Tag: Anxiety

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Trajectories of Persistent Exposure to Self-Harm–Encouraging Websites and Subsequent Mental Health Outcomes in US Youth: Longitudinal Cohort Study

Background: Self-harm, including suicidal thoughts, self-injurious behavior, and disordered eating, is a major public health concern among adolescents and young adults. Youth increasingly encounter self-harm–related content online, including websites that explicitly encourage harmful behaviors. Although exposure to such content has been linked to poorer mental health, most research is cross-sectional and has not examined longitudinal exposure trajectories. Whether persistent exposure represents a distinct digital risk pattern remains unclear. Objective: This study examined longitudinal trajectories and correlates of exposure to self-harm–encouraging websites over 1 year and tested whether persistent exposure was associated with subsequent suicidal ideation, self-injury, and disordered eating. Methods: We analyzed data from 2197 US youth aged 13 to 22 years who completed waves 2 and 4 of Project Lift Up, a national longitudinal cohort study. Website exposure was categorized into 4 trajectories: none, desist (wave 2 only), new (wave 4 only), and persistent (both waves). Categories reflected reported exposure at the 2 assessment waves rather than the frequency or continuity of website use between assessments. Logistic regression models estimated associations between exposure trajectory and wave 4 suicidal ideation, self-injury, and disordered eating, restricting analyses to participants without the respective outcome at wave 2. Models were adjusted for demographics and wave 2 depression or anxiety symptoms and other mental health indicators. Results: Overall, 26.5% (583/2197) reported exposure to self-harm–encouraging websites at wave 2, and 18.5% (407/2197) reported persistent exposure. Privacy concerns, embarrassment, curiosity, and lack of offline support were associated with greater odds of persistence (adjusted odds ratios [aORs] 1.84‐3.23), whereas accidental exposure was associated with lower odds of persistence (aOR 0.28, 95% CI 0.19‐0.41). Compared with no exposure, persistent exposure was associated with higher odds of suicidal ideation (aOR 1.88, 95% CI 1.24‐2.86; =.003), self-injury (aOR 3.14, 95% CI 2.05‐4.80; <.001), and disordered eating (aOR 2.46, 95% CI 1.54‐3.93; <.001). Adjusted predicted probabilities showed a graded pattern, with persistent exposure associated with the highest predicted probabilities (suicidal ideation: 33.4% vs 21.3%; self-injury: 25.7% vs 10.2%; disordered eating: 11.7% vs 5.3%). New exposure was associated with increased odds of self-injury (aOR 2.32, 95% CI 1.30‐4.15; =.004) but was not significantly associated with suicidal ideation or disordered eating. The desist trajectory was not significantly associated with outcomes. Conclusions: Persistent exposure to self-harm–encouraging websites may represent a distinct digital risk pattern associated with higher subsequent odds of suicidal ideation, self-injury, and disordered eating. Assessing patterns of repeated website exposure and youths’ motivations for seeking this content—not merely whether exposure occurred—may improve the identification of youth at heightened risk and inform digital prevention and clinical intervention strategies.
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Effectiveness and Usability of Digital Slow Breathing and Detached Mindfulness Interventions in Late Adolescents: Mixed Methods Study

Background: Many adolescents experience elevated stress and anxiety; yet, access to effective psychological support is limited. Brief digital mental health interventions, such as slow breathing (SB) and detached mindfulness (DM), offer a potentially scalable approach to promoting emotion regulation in daily life. Objective: This study aimed to investigate whether 1 week of daily practice with a SB or DM intervention reduced stress, anxiety, and negative metacognitive beliefs in youth, and explored participants’ experiences to inform the development of accessible, youth-tailored digital interventions. Methods: A mixed method approach was used, including quantitative and qualitative data. A total of 147 university students between 16 and 19 years old were randomly allocated to the DM (n=49), SB (n=49), or passive control group (n=49). Participants who were allocated to DM or SB practiced the intervention for 1 week. Stress, anxiety, and negative metacognitive beliefs were assessed at pre- and postintervention using self-report questionnaires. The quantitative data were analyzed with linear mixed-effects models, and we explored daily changes in intervention effect. After posttest, participants were invited to focus groups to evaluate their experience with the interventions (n=37). The qualitative data were analyzed with a content analysis. Results: Our results showed that a week-long DM intervention significantly reduced stress compared with the control condition. No other differences emerged for the main outcomes on pre- and postmeasurements. However, in the SB group, higher perceived usability was associated with greater reductions in stress. Qualitative findings showed that both interventions were viewed as calming, easy to use, and acceptable, while also highlighting challenges such as maintaining motivation and integrating the exercises into daily routines. Conclusions: This study provides early formative evidence that brief digital interventions such as SB and DM are feasible and usable, with preliminary indication that DM intervention may support short-term stress reduction. Future research should focus on enhancing motivation and sustained engagement to maximize the effectiveness of digital mental health tools for late adolescents. Trial Registration: OSF Registries osf.io/vu56y; https://osf.io/vu56y/overview
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Neural mechanisms of uncertain decision-making in anxious adolescents: an EEG study based on the balloon analogue risk task

BackgroundAdolescence is marked by heightened vulnerability to anxiety which can impair decision-making under uncertainty. The underlying neural oscillatory network-level mechanisms in anxious adolescents require further elucidation.MethodsWe recruited 40 adolescents (20 adolescents with clinically diagnosed anxiety disorders, 20 matched controls). Participants performed a gain/loss version of the Balloon Analogue Risk Task (BART) during EEG recording. Behavioral data, time-frequency EEG power in beta (13–30 Hz) and theta (4–7 Hz) bands, and phase-based functional connectivity were analyzed.ResultsAnxious adolescents exhibited significant behavioral avoidance, reflected in fewer pump attempts and lower BART scores compared to controls. EEG analysis revealed elevated beta-band power during gain decisions and enhanced beta-band occipito-temporal connectivity in the anxious group. In loss contexts, anxious adolescents showed increased theta-band parieto-temporal connectivity.ConclusionsAdolescent anxiety is associated with a generalized avoidance pattern during uncertain decision-making, characterized by distinct neural dynamics. Beta-band changes in gain contexts may reflect heightened vigilance, while theta-band connectivity in loss contexts may indicate amplified threat monitoring. These neural signatures may represent candidate neurophysiological signatures of anxiety-related alterations in decision-making under uncertainty, warranting further validation in longitudinal and predictive studies.
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Efficacy of a personalized, response-based transdiagnostic intervention for emotional disorders delivered via the Internet: a protocol for an adaptive randomized controlled trial

One of the main challenges in clinical psychotherapy is disseminating effective psychological treatments to the millions who need them but lack access. Transdiagnostic interventions, particularly those delivered online, can help bridge this treatment gap. However, these interventions, often provided as a “one-size-fits-all” approach, do not tailor to individual patient needs. Therefore, it is essential to identify which patients benefit from these treatments and who require more intensive interventions. This randomized controlled trial (RCT) aims to evaluate the effects of an Internet-based transdiagnostic intervention (UJI Online Transdiagnostic Protocol/Transversal) for emotional disorders, adapted to patients’ response. Three hundred sixty-six adults with clinically significant symptoms of anxiety and depression (ODSIS ≥ 7 and/or OASIS ≥ 8) and without suicidal ideation or a severe mental disorder participated. After having completed the first three modules, patients will be randomized based on their symptomatic response. Early responders will either continue with the original intervention—12 self-administered modules—or discontinue treatment. Non-early responders will receive a blended format—including two therapist-led videoconference sessions—or continue with the original intervention. Multilevel models will be used to analyze the data. The primary expected result is that the blended format will improve treatment outcomes for non-early responders compared to the self-applied format. Moreover, it is expected that discontinuing treatment for early responders will be as effective as continuing it until completion. The findings are expected to inform clinical practice by highlighting the importance of assessing symptomatic response throughout treatment, especially in its early phases, to better tailor interventions to the needs of different patient groups.Clinical trial registrationhttp://www.chictr.org.cn, identifier NCT07051148.
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Body image dissatisfaction and emotional eating across age and weight status: a comparative cross-sectional study

BackgroundObesity in older adults is associated with significant medical, functional, and psychological consequences, including body image dissatisfaction and maladaptive eating behaviors such as emotional eating. Although these associations have been extensively studied in younger populations, limited evidence is available in older adults with obesity. This study aimed to examine differences in body dissatisfaction by age and weight status and its association with emotional eating in adults and older adults with obesity.Methods108 participants were included and divided into four subgroups based on age and weight status. Body dissatisfaction was assessed using the Body Uneasiness Test (BUT-A). Emotional eating was evaluated using the Emotional Eating subscale of the Dutch Eating Behaviour Questionnaire (EE-DEBQ). Two-way ANOVAs were conducted to examine the effects of age, weight status, and their interaction on body dissatisfaction, while Pearson correlations were used to assess associations between body dissatisfaction and emotional eating.ResultsThe analysis showed significant main effects of both age and weight status on global body dissatisfaction, with higher BUT-GSI scores observed in adults than in older adults and in participants with obesity compared with normal-weight individuals. Across all BUT dimensions, participants with obesity reported higher levels of body image concerns, avoidance, compulsive self-monitoring, and depersonalization. Significant age × weight status interactions emerged for weight phobia and body image concerns. Age significantly affected body image concerns and avoidance. Positive correlations between body dissatisfaction and emotional eating were found in adults with obesity (r=0.443, p=0.024) and older adults with obesity (r=0.480, p=0.004), as well as in normal-weight adults (r=0.573, p=0.001).ConclusionThe findings highlight the significant role of both ageing and obesity in shaping body image experiences.
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A comparative study of traditional Chinese mind-body therapies on sleep quality, mental health, and quality of life in patients with sleep disorders: a network meta-analysis based on randomized controlled trials

BackgroundSleep disorders are a common clinical condition characterized primarily by difficulty falling asleep, trouble maintaining sleep, and impaired daytime functioning, with a high prevalence among adults. This condition can lead to a persistent decline in sleep quality, trigger mental health issues such as anxiety and depression, and ultimately reduce overall quality of life. Traditional Chinese mind-body exercise therapies are considered potentially effective non-pharmacological interventions due to their low risk, high accessibility, and dual mind-body regulation effects. However, the relative efficacy of different exercise therapies on sleep quality, mental health, and quality of life in patients with sleep disorders remains unclear. This study employed a web-based meta-analysis to systematically evaluate the effects of three interventions—Tai Chi, Baduanjin, and Tai Chi combined with transcranial magnetic stimulation—on three outcome measures and to rank their efficacy, aiming to provide evidence-based support for clinical decision-making.MethodsThis study conducted a systematic search of the PubMed, Embase, Web of Science, Cochrane, EBSCO, and CNKI databases and included 18 randomized controlled trials that met the inclusion criteria. Outcome measures included sleep quality, mental health, and quality of life. A network meta-analysis using a random-effects model was performed to calculate standardized mean differences and 95% confidence intervals, and the cumulative ranking probability curve area was used to rank the efficacy of the interventions.ResultThis study included a total of 18 randomized controlled trials. Regarding sleep quality, TCCWTMS yielded the best results (SMD = −1.15, 95% CI [−2.07, −0.22]). Regarding mental health, only the Tai Chi intervention achieved statistical significance (SMD = 0.64, 95% CI [0.07, 1.21], P = 0.03); although Baduanjin ranked first in the SUCRA ranking (92.6%), pairwise comparisons did not reach statistical significance (P = 0.07). Regarding quality of life, both Tai Chi (SMD = -0.47, 95% CI [-0.71, -0.24], P < 0.0001) and Baduanjin (SMD = -0.57, 95% CI [-0.91, -0.23], P = 0.001) were significantly effective. There were significant heterogeneous differences in the efficacy of the three interventions across different outcome measures.ConclusionThis study indicates that the TCCWTMS is the most effective intervention for improving sleep quality in patients with sleep disorders. Regarding quality of life, both Baduanjin and Tai Chi demonstrated significant effects, with Baduanjin showing superior efficacy. Regarding mental health, the current evidence is insufficient to determine the optimal intervention strategy. There are significant differences in the efficacy of the three interventions across various outcome measures; clinical decisions can be made by selecting the appropriate intervention based on the patient’s score needs.Systematic review registrationhttps://www.crd.york.ac.uk/PROSPERO/view/CRD420261415202, identifier CRD420261415202.
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School refusal behavior in children and adolescents: a concept analysis

School refusal behavior (SRB) is increasingly recognized across educational, pediatric, and mental health settings, yet its conceptual boundaries remain unclear, and the term is frequently conflated with school refusal, truancy, school withdrawal, school exclusion, and broader school attendance problems. This study used Walker and Avant’s concept analysis method to clarify the meaning, defining attributes, antecedents, consequences, and empirical referents of SRB. PubMed, Web of Science, Scopus, and PsycINFO were searched for English-language literature published through January 2026, supplemented by Google Scholar and manual citation searching. A total of 100 sources were included and analyzed through iterative comparison of conceptual definitions, recurrent characteristics, contextual conditions, outcomes, and indicators used in research and practice. The analysis showed that SRB has evolved from earlier anxiety-centered descriptions toward a broader behavioral and functional construct. Four defining attributes were identified: difficulty initiating, sustaining, or completing school attendance or participation; young person–expressed attendance difficulty; aversive school-related experiences or emotional distress; and heterogeneous avoidance- or reinforcement-related maintaining functions. Antecedents were distributed across individual, family, peer and interpersonal, and school-contextual domains, while consequences extended across academic, psychological, social, family, and service-related domains and may accumulate over time. Empirical identification requires the integration of observable attendance patterns, emotional, behavioral, and somatic responses, functional assessment, and contextual information from young people, caregivers, and school personnel. Moving beyond the summary of existing definitions, this analysis proposes an integrative framework that distinguishes the observable form of attendance difficulty from its emotional presentation, maintaining functions, and ecological context. SRB is therefore best understood as a persistent or recurrent, young person–expressed pattern of disrupted school attendance or participation that is clinically meaningful but cannot be reduced to a single diagnosis, cause, or attendance threshold. By clarifying what constitutes SRB and how it differs from other forms of school attendance problems, this framework may support earlier recognition of emerging attendance difficulties, more comprehensive assessment of underlying needs, and better coordination among mental health professionals, families, and schools.
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Predicting multiple mental health outcomes in adolescents using explainable machine learning models

IntroductionAdolescent mental health problems, including depression, anxiety, and stress, are an increasing public health concern, yet the factors associated with different mental health outcomes may vary across domains. This study investigated shared and outcome-specific predictive features of depression, anxiety, perceived stress, and psychological well-being using explainable machine learning models.MethodsA cross-sectional study was conducted among 1,088 adolescents aged 13–18 years recruited from secondary schools in Wuhan, China, using multistage cluster sampling. Participants completed validated measures of emotional dysregulation, loneliness, social media addiction, self-esteem, sleep quality, academic stress, family support, physical activity, and mental health outcomes. Four algorithms—linear regression, support vector regression, Random Forest, and XGBoost—were trained using an 80/20 train-test split with five-fold cross-validation, and model performance was evaluated using test-set R², RMSE, and MAE. SHapley Additive exPlanations (SHAP) were used to examine feature contributions. To minimize target leakage, outcome-specific feature sets were used, with PSQI and RSES excluded from the depression model because of direct or substantial conceptual overlap with PHQ-9 content, and PSQI excluded from the well-being model because of overlap with WHO-5 content.ResultsXGBoost showed the strongest out-of-sample predictive performance across all four outcomes, explaining 49% of the variance in depression (R² = 0.49, 95% CI: 0.44–0.53; RMSE = 3.52; MAE = 2.81), 55% in anxiety (R² = 0.55, 95% CI: 0.50–0.59; RMSE = 3.04; MAE = 2.47), 60% in perceived stress (R² = 0.60, 95% CI: 0.56–0.64; RMSE = 3.71; MAE = 2.87), and 50% in psychological well-being (R² = 0.50, 95% CI: 0.45–0.54; RMSE = 3.38; MAE = 2.68).DiscussionEmotional dysregulation and loneliness were consistently among the most influential features, while academic stress, family support, social media addiction, self-esteem, and sleep quality showed outcome-specific contributions. SHAP rankings for the depression model were stable across five-fold cross-validation, with emotional dysregulation and loneliness consistently occupying the highest ranks.
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PROMATER: protocol for a randomized controlled trial of a digital self-guided intervention to promote perinatal mental health and reduce self-criticism

BackgroundPerinatal mental health represents a significant public health concern given the high prevalence of mental disorders during pregnancy and the postpartum period and their impact on maternal well-being, mother-infant bonding, and child development. Emerging evidence identifies self-criticism as a transdiagnostic vulnerability factor associated with psychological distress in this period, while self-compassion has been recognized as an important protective factor. In Brazil, access to preventive perinatal mental health interventions remains limited. This paper describes the protocol of a randomized controlled trial (RCT) evaluating PROMATER – an online program designed to promote perinatal mental health by targeting self-criticism and self-compassion.MethodsA total of 130 pregnant women between 28 and 34 weeks of gestation will enroll in a two-arm RCT with a dismantling design. Participants will be randomized (1:1 ratio) to either the PROMATER intervention or to an active control group. Participants and data analysts will be blinded to group allocation. PROMATER consists of a 3-week program (6 modules) addressing maternal expectations, self-criticism, perinatal mental health, social support, self-compassion, and mindfulness and mother-infant bonding. The active control offers a structurally equivalent program covering the same topics, except for the modules specifically targeting these transdiagnostic processes. Primary outcomes are self-compassion, assessed via the compassionate self-responding (CSR) score of the Self-Compassion Scale, and self-criticism, operationalized through the uncompassionate self-responding (USR) score. Secondary outcomes include postpartum depression, anxiety, quality of life, social support, and mother-infant bonding. Assessments occur at baseline (T1), post-intervention (T2), and 3-month postpartum follow-up (T3). Data will be analyzed using Linear Mixed Models (LMM) following the Intention-to-Treat (ITT) principle.DiscussionEvaluating the effectiveness of a brief, accessible, online intervention has the potential to address the need for an evidence-based approach designed to promote maternal well-being during pregnancy and the postpartum period. The intervention is designed to maximize reach and minimize cost, with the potential to scale up and incorporate in routine perinatal care. The active control condition will allow examination of whether directly targeting self-criticism and self-compassion confers incremental benefit over structured perinatal psychoeducation alone.Systematic review registrationhttps://ensaiosclinicos.gov.br/, identifier RBR-99tjfz5.
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Association between first-trimester serum 25(OH)D and EPDS-positive postpartum depressive symptoms in women with gestational diabetes mellitus: a retrospective cohort study

IntroductionGestational diabetes mellitus (GDM) has been associated with an increased risk of postpartum depressive symptoms, while maternal vitamin D status may also be related to perinatal mood disturbances. This study investigated the association between first-trimester serum 25-hydroxyvitamin D [25(OH)D] concentrations and Edinburgh Postnatal Depression Scale (EPDS)-positive postpartum depressive symptoms in women with GDM.MethodsThis retrospective cohort study included 242 women with GDM. Prenatal depressive and anxiety symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), respectively. Sequential logistic regression models were adjusted for baseline maternal characteristics, prenatal PHQ-9 and GAD-7 scores, and glycated hemoglobin A1c (HbA1c).ResultsAmong 242 women, 69 had EPDS-positive postpartum depressive symptoms. Each 5-ng/mL increase in 25(OH)D was associated with lower odds of EPDS-positive symptoms in the crude model (OR 0.35, 95% CI 0.25–0.48) and after adjustment for baseline characteristics (adjusted OR 0.36, 95% CI 0.25–0.50). After additional adjustment for prenatal PHQ-9 and GAD-7 scores, the association was attenuated and was no longer statistically significant overall (adjusted OR 0.69, 95% CI 0.43–1.12; P = 0.134). Additional adjustment for HbA1c produced similar results. Exploratory stratified analyses using the full Model 2 covariate set showed no statistically significant associations within strata defined by pre-pregnancy BMI, hypertensive disorders of pregnancy, or insulin use, and no significant interactions were detected.DiscussionThese findings suggest that the overall association between first-trimester 25(OH)D and postpartum depressive symptoms was substantially influenced by prenatal mental health status and was not consistently demonstrated after comprehensive covariate adjustment.