Health disparities in the United States are not produced by single risk factors but by interacting social and biological conditions that cluster within structurally marginalized communities. Poverty, violence, and poor physical and mental health form a reinforcing system of disadvantage that traditional healthcare models—organized around isolated diseases—are poorly equipped to address. This perspective examines these dynamics through a syndemic framework, which conceptualizes co-occurring conditions as mutually interacting epidemics intensified by social inequality. Drawing on interdisciplinary evidence from public health, medicine, and social science, we describe how poverty-related stressors such as housing instability, food insecurity, and barriers to healthcare intersect with exposure to interpersonal and structural violence to amplify risks for depression, posttraumatic stress disorder, chronic disease, and premature mortality. These interactions produce compounded health burdens that are disproportionately experienced by marginalized populations. Despite increasing attention to social determinants of health, current healthcare responses remain fragmented. Health systems frequently identify risks through screening for social needs or trauma exposure but lack the institutional infrastructure, reimbursement mechanisms, and cross-sector partnerships required to address them effectively. We argue that advancing health equity requires moving beyond additive models of care coordination toward syndemic-informed healthcare systems that intervene simultaneously on clustered conditions and their shared upstream drivers. We outline key priorities for practice, policy, and research, including linking screening to actionable care pathways, strengthening partnerships between healthcare and social service systems, and expanding workforce training to include structural and syndemic competency.
Establishing standards of care for forensic mental health: an international Delphi consensus-building study
ObjectivesThe present study aimed to establish a consensus on a definition of forensic mental health systems and services, and to identify principles and components of forensic mental health systems.MethodsA Delphi consensus-building process was employed among 23 experts in forensic mental health, defined by lived experience of forensic mental health services, professional, clinical or management practice in forensic settings, or academic research in the field. Items were rated on a 9-point Likert scale, with consensus defined as ≥75% of panelists rating an item between 7 and 9. Across three Delphi rounds, items were revised, merged, or added based on participant feedback. Data were collected anonymously using LimeSurvey, with reminders sent to maximize participation, followed by a structured consensus meeting to resolve remaining areas of disagreement.ResultsThe final consensus statement comprises three components: (1) a definition of forensic mental health services; (2) a general statement including 12 guiding principles; and (3) 43 core components organized across 10 thematic domains addressing models of care, pathways and processes, programs and activities, physical health, service user and peer involvement, evaluation and improvement, service integration, safe environments, restrictive practices, and other system-level considerations. While all items achieved consensus at the consensus meeting, areas of sustained discussion related to the integration of cultural expertise, the inclusion of a lived experience workforce, and the distinction between descriptive and aspirational elements of forensic mental health services.ConclusionsThis international consensus statement provides a structured framework for understanding forensic mental health systems. By articulating shared principles and core components while allowing flexibility across jurisdictions, the framework offers a foundation to support service development and evaluation across diverse jurisdictions.
AI-Assisted 4-Week Psychodynamic Therapy and Cognitive Behavioral Therapy Via Smartphone for Social Anxiety: A Randomized Pilot Study (STePS-Ai)
Conditions: Social Anxiety Disorder (SAD)
Interventions: Behavioral: Ai chatbot
Sponsors: Stockholm University
Active, not recruiting
Interventions: Behavioral: Ai chatbot
Sponsors: Stockholm University
Active, not recruiting
[Comment] Youth mental health in central Asia: research needs
Little research has been published on mental health difficulties in young people (aged 10–24 years) living in central Asia,1 a region comprising Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan. As researchers and representatives from academic, non-governmental, governmental, and UN organisations working in Kyrgyzstan and Uzbekistan and beyond, we are noting an increasing number of young people reporting emotional and behavioural symptoms in central Asia in published articles2 and from our own observations.
Determinants of Digital Health Literacy Among Patients With Serious Mental Illness: Cross-Sectional Survey
Background: Individuals with serious mental illness increasingly use digital devices and the internet to access health information and services but often face challenges when navigating digital tools, which may limit the benefits they receive from online health resources and digital health care services. Objective: The objective of our study was to assess digital health literacy among individuals with serious mental illness and identify factors influencing this literacy. Methods: Participants were recruited, using convenience sampling, from 2 psychiatric clinics, 1 day-care center, and 4 halfway houses in Taipei, Taiwan, between May 2024 and February 2025. Self-reported data were collected using a survey that incorporated the eHealth Literacy Scale, the Attitudes Toward Computer/Internet Questionnaire, and the Mobile Device Proficiency Questionnaire. Generalized linear modeling was applied to identify factors associated with digital health literacy. Results: Among 255 participants included in the analysis, 83.5% (n=213) reported owning at least 1 digital device. Digital health literacy was significantly lower among individuals who reported greater perceived difficulty in using digital tools (=−1.533, 95% CI −2.350 to −0.717; <.001) and higher distrust in online information (=−0.986, 95% CI −1.916 to −0.056; =.04). By contrast, greater mobile device proficiency (=0.144, 95% CI 0.008‐0.281; =.04) and self-efficacy (=1.777, 95% CI 0.376‐3.177; =.01) were positively associated with digital health literacy. Conclusions: Despite widespread device ownership, digital health literacy was varied and generally suboptimal among patients with serious mental illness. Perceived difficulty and distrust emerged as major barriers; proficiency and self-efficacy facilitated higher literacy. These findings highlight the need for mental health professionals to integrate tailored digital skills training, confidence-building strategies, and ongoing support into digital health interventions for individuals with serious mental illnesses.
Development of a Contextualized, Research-Based Flemish Assessment Framework for Digital Care, Assistance, and Support: Delphi Study
<strong>Background:</strong> The rapid evolution of digital technologies has transformed health, mental health, and social care, offering new modalities of digital care, assistance, and support through web-based platforms, mobile apps, extended reality, wearables, and artificial intelligence systems. Despite this proliferation, there is little consensus on what constitutes “high-quality” digital care. Challenges persist regarding data security, interoperability, accessibility, sustainability, and professional competence, whereas existing standards and regulations provide fragmented guidance. <strong>Objective:</strong> This study aimed to develop a contextualized, consensus-based quality assessment framework for digital care, assistance, and support in Flanders, Belgium. For this purpose, perspectives across technology, organizational processes, and professional competencies were integrated. <strong>Methods:</strong> The study used a multiphase design comprising (1) 10 expert interviews with Flemish government officials; (2) a narrative literature review of 303 peer-reviewed and gray literature sources; (3) a 3-round Delphi study with 50 experts across 5 domains (end users, facilitators, technology developers, deontology and ethics experts, and digital inclusion and media literacy experts); and (4) 4 complementary focus groups and 3 interviews with specialists in artificial intelligence, regulation, social work, mental health, and IT. The Delphi rounds gathered iterative feedback through open-ended elicitation, structured rating, and classification of quality criteria. Quantitative data were analyzed using descriptive statistics, whereas qualitative feedback was subjected to thematic analysis. <strong>Results:</strong> A total of 50 experts participated in round 1, a total of 40 (80%) participated in round 2, and 27 (54%) participated in round 3. Round 1 generated 577 unique quality criteria, consolidated into 26 clusters organized under 3 pillars: technology, organization, and professional competencies. The relative importance across pillars was balanced (mean score 37.29, SD 12.38 for technology; 33.33, SD 10.39 for professional competencies; and 29.80, SD 10.45 for organizations). Accessibility, reliability, and safety ranked highest for the technology; vision, quality monitoring, and infrastructure ranked highest for organization; and support, digital competencies, and ethics ranked highest for professional competencies. The finalized framework included 112 criteria, of which 35 (31.3%) were designated as optional and 77 (68.8%) were designated as minimum requirements. Focus groups and interviews validated the framework’s comprehensiveness and usability, emphasizing proportional implementation, user centrality, and alignment with European Union regulations. Stakeholders highlighted the need for tools, training, and governance mechanisms to ensure adoption and sustainability. <strong>Conclusions:</strong> This study produced a codeveloped, context-sensitive quality assessment framework that balances technological robustness, organizational readiness, and professional competence in digital care, assistance, and support. The framework can serve both as a quality safeguard and a developmental road map. Accompanying self-assessment and governance tools enhance practical applicability. Implementation success will depend on governmental support, resource allocation, and structured feedback loops. Future research should pilot the framework in real-world settings, assess its impact, and establish mechanisms for continuous updates to maintain relevance in a rapidly evolving digital landscape. <strong>Trial Registration:</strong>
Early tinnitus burden and subjective hearing are candidate markers of 2-year quality of life after cochlear implantation in single-sided deafness
BackgroundCochlear implantation is a common treatment for adults with single-sided deafness (SSD), but patient-reported benefits vary. The relationships among tinnitus burden, perceived hearing ability, psychological distress, disease-specific health-related quality of life, and whether early postoperative outcomes predict later results are not well understood.ObjectiveThis study explores how disease-specific quality of life relates to tinnitus burden, hearing, stress, depression, and anxiety after cochlear implantation in SSD. It also seeks early markers linked to 2-year outcomes.MethodsThis secondary complete-case analysis was based on a previously reported prospective longitudinal SSD cohort. Of 70 adults with postlingual SSD, 36 (51.4%) had complete Nijmegen Cochlear Implant Questionnaire (NCIQ) data at baseline and at 6 months, 1 year, and 2 years after unilateral cochlear implantation and were included. Additional measures included the Tinnitus Questionnaire (TQ), Oldenburg Inventory (OI), PerceivFed Stress Questionnaire (PSQ), General Depression Scale (ADS-L), Generalized Anxiety Disorder 7-item scale (GAD-7), and Freiburg Monosyllable Test (FMT) at 65 dB. Timepoint-specific correlations with the NCIQ were analyzed using Spearman’s rank correlations. Exploratory multivariable analyses employed linear regression on rank-transformed variables to assess whether baseline and 6-month patient-reported profiles were associated with 2-year NCIQ outcomes. Longitudinal within-patient comparisons were conducted as a secondary descriptive analysis.ResultsHigher NCIQ scores were linked to lower tinnitus burden and better hearing across all assessments. Associations with depression and anxiety persisted, while connections with perceived stress emerged after surgery. At baseline, higher tinnitus burden was associated with lower 2-year NCIQ scores. At 6 months, higher tinnitus is still associated with lower 2-year NCIQ scores, whereas better hearing is associated with higher 2-year NCIQ scores. Early postoperative improvement was followed by stabilization over 2 years.ConclusionImprovement in health-related quality of life after cochlear implantation in adults with SSD is complex and extends beyond hearing alone. Tinnitus was the most consistent negative factor, while improved subjective hearing at 6 months was associated with better outcomes at 2 years. These results support a structured, multidimensional approach to patient-reported follow-up after cochlear implantation in SSD and suggest that early postoperative patient-reported status may serve as an early candidate marker for later quality-of-life outcomes.
Direct and indirect associations of hypochondriasis with suicidality in psychiatric outpatients: mediating roles of anxiety and depression
IntroductionAlthough both hypochondriasis and suicidality are common in psychiatric patients and related to anxiety and depression, their association in psychiatric patients remains unclear. This study investigated the direct association of hypochondriasis with suicidality and the indirect associations via anxiety and depression in psychiatric patients.MethodsClinical records of 5484 psychiatric outpatients were reviewed. Hypochondriasis, Suicidality, Anxiety, and Depression were evaluated using the hypochondriasis item of the Hamilton Depression Rating Scale, the suicidality item of the 17-item Hamilton Depression Rating Scale (HAM-D17), the Hamilton Anxiety Rating Scale (HAM-A), and the 6-item subscale of the Hamilton Depression Rating Scale (HAM-D6), respectively. The associations among Hypochondriasis, Suicidality, Anxiety, and Depression were examined using a parallel mediation model. The model was estimated using the lavaan package in R with 10, 000 bootstrap resamples, adjusted for age and sex. Moderation by age and sex was also investigated.ResultsSignificant positive indirect associations via Anxiety (point estimate = 0.05, 95% CI [0.03, 0.06]) and Depression (point estimate = 0.17, 95% CI [0.15, 0.19]) were observed between Hypochondriasis and Suicidality. Conversely, the direct association between Hypochondriasis and Suicidality was also significant but in a negative direction (B = −0.16, p <.001). As the total indirect association was stronger than the direct association, the total association of Hypochondriasis with Suicidality was significantly positive (B = 0.05, p = 0.002). The negative direct association of Hypochondriasis with Suicidality was significantly stronger in younger patients (interaction term = 0.004, p <.001).ConclusionAnxiety and depression mediated the association between hypochondriasis and increased suicidality. In contrast, hypochondriasis was associated with decreased suicidality after accounting for the mediators. As the indirect association was stronger than the direct association, hypochondriasis was associated with increased suicidality overall. The direct association between hypochondriasis and decreased suicidality was stronger in younger patients.
Gut microbiota profiles in anorexia nervosa: associations with disease severity, BMI, and history of childhood trauma
Study objectivesEmerging evidence suggests a possible link between anorexia nervosa (AN) and alterations in the gut microbiota. This study aimed to characterize the gut microbiota profile in a cohort of Chinese female patients with AN.MethodA comparative analysis of the gut microbiota was conducted between 30 female patients with AN and 30 sex- and age-matched healthy controls (HCs). Fecal samples were collected for 16S rRNA gene sequencing analysis. All participants were assessed using the Eating Disorder Inventory (EDI) and the Childhood Trauma Questionnaire (CTQ). Bioinformatics analysis was performed using QIIME2, and statistical analyses were carried out with SPSS 26.0 and R software. Correlations between microbiota differences and body mass index (BMI), EDI, and CTQ were further investigated.ResultsThe analysis revealed differences in beta diversity and the abundances of specific microbial taxa between the two groups; however, no significant differences were observed in alpha diversity nor in the associations between gut microbiota and BMI, disease severity, or childhood trauma.ConclusionsThis study identified limited differences in the gut microbiota composition between patients with AN and HCs. Critically, no robust associations between gut microbiota and clinical features were found after rigorous multiple comparison correction. While nominal (uncorrected) correlations were observed between the specific microbiota and psychological traits, these results are exploratory and should be considered hypothesis-generating. They highlight a potential avenue for future research but require validation in larger, longitudinal cohorts to determine their reproducibility and biological significance.
Preoperative anxiety and depression symptoms are associated with poorer clinical outcomes following corrective surgery for adult equinocavovarus foot
PurposeThis study aimed to investigate the preoperative psychological status of adult patients with equinocavovarus foot deformity and to examine the association between preoperative anxiety/depressive symptoms and the clinical outcomes of corrective surgery in this population.MethodsA retrospective analysis was conducted on 103 adult patients who underwent corrective surgery for equinocavovarus foot at Xi’an Honghui Hospital between March 2014 and July 2023. Baseline data were collected. Patient psychological status, ankle-hindfoot function, pain, and quality of life were assessed preoperatively and at the final follow-up using the Hospital Anxiety and Depression Scale (HADS), the American Orthopedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, the Visual Analog Scale (VAS), and the 36-Item Short Form Health Survey (SF-36). Based on preoperative HADS scores, patients were categorized into an anxiety/depression group (Group A) and a non-anxiety/depression group (Group B). The two groups were compared with respect to baseline characteristics (gender, age, disease duration, BMI, follow-up duration), clinical outcomes, and the degree of improvement in all assessment metrics.ResultsA total of 83 patients completed the follow-up, among whom 38 (45.78%) exhibited preoperative anxiety/depression symptoms. No significant differences were found in baseline characteristics between the two groups (all P > 0.05). At the final follow-up, both groups showed significant improvement in VAS, AOFAS, SF-36 (PCS/MCS), and HADS (A/D) scores compared to their preoperative baselines (all P < 0.001). Intergroup comparisons revealed that Group A had significantly lower AOFAS and SF-36 (PCS/MCS) scores, and significantly higher VAS and HADS (A/D) scores than Group B, both preoperatively and at the final follow-up (all P < 0.001). Regarding the degree of improvement, Group A demonstrated a smaller magnitude of improvement in VAS (P < 0.01), AOFAS (P < 0.01), and SF-36 PCS (P < 0.001) compared to Group B. Conversely, Group A showed a greater improvement in SF-36 MCS and HADS (A/D) scores (all P < 0.001).ConclusionsWhile surgery improved all outcomes, patients with preoperative anxiety/depression exhibited persistently worse clinical scores. Their improvement profile was distinct: smaller gains in pain and physical function but greater mental health improvement. Addressing preoperative psychological status may optimize comprehensive outcomes.