Noise is a widespread harmful environmental stressor that burdens large urban populations globally. Exposure to environmental noise at elevated levels increases annoyance and disturbance, posing substantial risks to both mental and physical health. While the dangers of noise exposure have been widely recognized, the quantitative relationship between noise exposure and psychological response is not well translated to the environmental noise community. This study attempts to estimate people's annoyance generated by exhaust ventilation noise in a residential community through field measurements and theoretical exposure modeling. The sound pressure levels (SPLs) were sampled at multiple points first, and then a double-layer sound insulation strategy was implemented to reduce the noise levels. Acoustic computations show that the percentage of highly annoyed population in building A before and after duct-borne noise treatment were 11.6% 9.8%, demonstrating reasonable alleviation of noise annoyance and voluntary compliance with the WHO health-based guidelines. Moreover, issues in current environmental noise regulations and their implementation were pointed out, offering suggestions for potential improvements in local legislation. Finally, the methodology and recommendations presented in this study can assist environmental health professionals and policymakers in their efforts to alleviate noise annoyance and develop informative noise control guidelines in the future.

BACKGROUND: Investigation of the neural substrates of post-traumatic stress disorder (PTSD) in military personnel using whole-brain approaches remains scarce, hindering the development of circuit-based neuromodulatory interventions. OBJECTIVES: This study aimed to identify potential associations between clinical symptoms and whole-brain resting-state functional connectivity with magnetic resonance imaging in military personnel with adulthood-onset war-related PTSD. METHODS: Thirty-seven soldiers from the Canadian Armed Forces with moderate to severe treatment-resistant PTSD participated in this study. We assessed PTSD, anxiety and depressive symptoms, quality of life, and time since trauma. We characterized the whole-brain functional connectome using independent component analysis and regions of interest (ROI)-to-ROI connectivity, as well as its topology using graph theory. RESULTS: Greater severity of PTSD and anxiety symptoms was associated with lower connectivity ( < 0) between the default mode network (DMN) and frontoparietal network. Greater severity of PTSD symptoms was also associated with a higher nodal clustering coefficient of the inferior parietal lobule from the DMN. Greater severity of anxiety symptoms and longer time since trauma was the only clinical variables that correlated with higher connectivity patterns, all involving the visual networks (the frontoparietal-visual, the visual-DMN, and within-visual networks). CONCLUSIONS: This work contributes to identifying brain targets for the development of personalized neuromodulatory interventions. In particular, the DMN may be a promising target to alleviate PTSD symptoms, and the visual network may be a target to treat comorbid anxiety symptoms.

BACKGROUND: Antidepressants (ADs) are an essential depression treatment option, but may cause side effects that affect treatment outcome, patient function, and quality of life. AD side effect assessment may be insufficient in both clinical trials and practice, potentially distorting the understanding of their prevalence and tolerability. We examined AD self-reported side effects (SRSEs) in psychiatric settings. METHODS: We evaluated AD SRSEs in 128 psychiatric out- and inpatients from the Pharmacoepidemiology and Pharmacogenetics of Antidepressant Treatment for Depressive Disorders (PEGAD) study at baseline, two- and eight weeks, using the Antidepressant Side-Effect Checklist (ASEC), and the Frequency, Intensity, and Burden of Side Effects Rating (FIBSER) scale. RESULTS: Predominantly mild to moderate SRSEs with a low burden on daily activities were reported by over 90% at each evaluation, and 45% of study completers reported occasional severe side effects. Nonetheless, only 6.5% of study completers consequently discontinued their AD, and symptom attribution to the ADs varied, indicating different perceived reasons for SRSEs. Depression severity was the main predictor of SRSEs, and higher depression, anxiety, and age predicted functional impairment. CONCLUSIONS: When systematically evaluated, most antidepressant-treated patients with depression report multiple perceived side effects, some rated severe, that rarely result in discontinuation of their pharmacotherapy. Patients often attribute potential side effects to factors other than pharmacotherapy, and SRSEs affect overall functioning less than depression itself. Our findings highlight the difficulty of reliably ascertaining causes of perceived side effects in the absence of mechanistic biomarkers.

INTRODUCTION: Chronic hepatitis C virus (HCV) infection is common among imprisoned people. We aimed to assess HCV treatment uptake and associated factors before and after imprisonment among incarcerated individuals with chronic HCV infection. METHODS: Newly incarcerated individuals in six Norwegian prisons were consecutively included in 2018-2019 and tested for HCV infection. The cohort was linked to national registries for HCV notification status and treatment dispensations. Treatment initiation was defined as dispensation of ≥1 pack (28 days) of HCV treatment. RESULTS: Among 110 individuals with previous or current chronic HCV infection, the median age was 37 years, 79.1% male and 97.2% had ever injected drugs. Chronic HCV infection had been diagnosed in 88 persons before incarceration, of whom 34 (38.6%; 95% CI 28.4-49.6) had already initiated treatment. Among 76 with detectable HCV RNA at inclusion, 62 (81.6%; 95% CI 71.0-89.5) received treatment after incarceration, with a median time to treatment of 5.1 months. Treatment rates increased from 10.6/100 PY (95% CI 7.4-14.9) in the period before incarceration to 79.4/100 PY (95% CI 60.9-101.8) after incarceration. Following incarceration, time to treatment was shorter among individuals with sentence length ≥3 months than among those on remand or with shorter sentences (aHR 1.93; 95% CI 1.10-3.41;  < 0.001). Treatment completion was observed in 57 of 62 (91.9%) participants who initiated treatment after incarceration. CONCLUSION: HCV treatment uptake following incarceration was high, particularly among those with long sentences. HCV testing in prison should be followed by immediate treatment initiation, regardless of incarceration status and sentence length.

BACKGROUND: Functional movement disorder (FMD), a subtype of functional neurological disorder, is a complex neuropsychiatric syndrome characterized by inconsistent and incongruent motor symptoms. Despite its relatively high prevalence, FMD remains associated with delayed diagnosis, significant disability, and limited evidence to guide individualized treatment. The Calgary FMD Clinic employs an integrated neurological-psychiatric assessment model, and its registry offers an opportunity to describe characteristics of FMD. OBJECTIVES: To describe baseline demographic and clinical features of patients enrolled in the Calgary FMD Registry with particular attention to prior healthcare utilization and neuropsychiatric risk factors. METHODS: This prospective registry-based cohort study includes patients with clinically established FMD evaluated by a neurologist and neuropsychiatrist at a tertiary center in Calgary, Canada. Standardized data collection encompasses demographics, motor and non-motor symptoms, psychiatric comorbidities, healthcare utilization, and validated outcome measures assessing symptom severity and impact. Descriptive and comparative statistics were performed between FMD phenotypes. RESULTS: Seventy-seven participants were enrolled between April 2024 and April 2025. The cohort was predominantly female (n = 45, 58%), with median age of 43 years and median diagnostic delay of 12 months. Episodic presentations were more common (n = 44, 57%), while constant phenotypes demonstrated greater symptom burden and disability. Fatigue and anxiety were highly endorsed among both groups. CONCLUSION: The Calgary FMD Registry employs a unique neurological-psychiatric assessment model to characterize FMD phenotypes and neuropsychiatric correlates. This dataset provides a relative representation of the Canadian FMD population who are considered for intensive rehabilitation, with the intention to inform stratified rehabilitation and treatment pathways.

Obstetric violence is linked to postpartum depression, yet the mechanisms underlying this relationship remain underexplored. This study examined perceived partner support as a mediating mechanism among 535 women who had given birth within the past 18 months. Results indicated that obstetric violence was associated with higher postpartum depression and lower perceived partner support. Perceived partner support was negatively related to depression. Mediation analyses showed that perceived partner support partially mediated the association between obstetric abuse and violence and postpartum depression and fully mediated the link between perceived obstetric violence and postpartum depression. These findings suggest that obstetric violence may contribute to depressive symptoms partly by undermining women's perceptions of partner support.

BACKGROUND: Medical trainee mistreatment remains a widespread challenge in graduate medical education, contributing to burnout, depression, and workforce attrition. Graduate medical education programs have sought to create safer learning environments by fostering programmatic openness-climates perceived as transparent, welcoming, and supportive. Yet it remains unclear how such programmatic conditions interact with individual experiences of belonging to shape wellbeing. Drawing on ecological systems theory, we examine how programmatic openness and trainee belonging interact to mitigate trainee mistreatment during residency. METHODS: We conducted an anonymous online survey (Dec 2023-Jan 2024) at three large US teaching sites with 62 GME programs. Scales with robust validity evidence measured perceived programmatic openness, individual belonging, perceived mistreatment, burnout, and social support. We built a latent moderation model, encompassing both confirmatory factor analysis and latent interaction effects. We examined how programmatic openness moderated trainee perceived mistreatment while controlling for social support and trainee demographics. RESULTS: Of 675 eligible trainees, 266 responded (39.4%). Measurement models demonstrated good fit, supporting construct validity. Both programmatic openness and belonging were protective against perceived mistreatment, which was strongly associated with burnout. Residents' belonging to the training program was significantly associated with low burnout, even after accounting for social support. Moderation analyses revealed that programmatic openness most strongly buffered mistreatment among trainees who experienced low belonging, with diminished effects at higher belonging levels. CONCLUSION: Findings revealed a compensatory effect, suggesting the beneficial effects of programmatic openness were especially crucial among trainees who experienced low individual belonging. This finding aligns with the ecological system theory, which posits that supportive environments may mitigate individual-level vulnerabilities. Both burnout and perceived mistreatment were at its lowest when programmatic openness and individual belonging were both present. This underscores the need for residency programs to foster both openness and belonging as core strategies to support trainee wellbeing.

OBJECTIVE: Mealtimes are associated with heightened distress among individuals with eating disorders (EDs) and are frequently accompanied by ritualized eating behaviors that maintain psychopathology. In inpatient settings, post-meal rest is commonly prescribed to prevent compensatory behaviors. Yet, enforced inactivity may exacerbate anxiety and ritual engagement. This study used ecological momentary assessment (EMA) to examine whether structured light post-meal activity is associated with a reduced likelihood of ritualized eating behaviors in an inpatient ED sample. METHOD: Participants were 33 inpatients who completed a 2-week counterbalanced within-subject crossover protocol, consisting of 1 week of standard post-meal rest and 1 week allowing structured light post-meal activity. EMA prompts were delivered six times daily. Ritualized eating behaviors were assessed following reported eating episodes and coded dichotomously. A binomial generalized linear mixed-effects model with random intercepts for participants tested whether the likelihood of ritualized eating behaviors differed between conditions. RESULTS: Participants completed 1503 EMA prompts (81.3% compliance). Across 1192 meal-related assessments, ritualized eating behaviors were reported in 30.8% of prompts during the rest condition and 24.2% during the post-meal activity condition, with substantial variability across individuals. Participants were significantly less likely to engage in ritualized eating behaviors during weeks allowing post-meal activity compared with rest-only weeks (B = -0.70, SE = 0.19, p = 0.0002), corresponding to an ~50% reduction in odds. DISCUSSION: The findings suggest that supervised post-meal movement may help interrupt ritual engagement during a high-risk period and demonstrate the utility of EMA for examining behavioral mechanisms in inpatient care.

BACKGROUND: Colorectal cancer (CRC) survival is improving, yet long-term survivors remain at risk for cancer- and treatment-related late effects, which may emerge many years after diagnosis and treatment. We aimed to summarize evidence on late effects and their risk factors reported ≥5 years after CRC diagnosis, compared to cancer-free controls. METHODS: The literature search for this scoping review was conducted in PubMed, EMBASE and Web of Science from inception to November 18, 2025. Primary research studies investigating late effects and providing relative risks estimates specifically ≥5 years after diagnosis were included. Risk of bias was assessed with the Newcastle-Ottawa-Scale. The study was registered with Open Science Framework, 10.17605/OSF.IO/JY6DX. RESULTS: We identified nine observational studies that reported relative risks estimates for late effects. Seven studies had a low risk of bias and two were at moderate risk. The most frequently investigated late effect was incidence of diabetes (five studies). The highest relative risks were reported for immunity disorders (5 to 10 years hazard ratio (HR) 4.56, 99%CI[1.36-15.31]), depression (>5 years HR 2.65, 95%CI[1.61-4.36]) and nutritional deficiency (5 to 10 years HR 1.69, 99%CI[1.38-2.08). Comorbidities at diagnosis, age at diagnosis and treatment were the most common risk factors associated with late effects. CONCLUSIONS: This scoping review found that even ≥5 years after diagnosis late effects requiring treatment are considerably more common among CRC survivors than cancer-free controls. The small number of studies and the broad spectrum of identified late effects highlight the need for extensive research to characterize late effects to improve long-term survivorship care.

BACKGROUND: Omega-3 polyunsaturated fatty acids (PUFAs) play important roles in cardiometabolic and mental health, and the dietary omega-6/omega-3 ratio has emerged as a key determinant of inflammatory and psychological outcomes. Despite generally low omega-3 intake in Iran, little is known about how dietary fatty acid patterns relate to mental health in young adults, who may be particularly vulnerable due to nutritional constraints and high rates of depressive symptoms. Moreover, prior studies in Iran have not simultaneously examined omega-3 intake, the omega-6/omega-3 ratio, BMI, and depressive symptoms within the same analytical framework. OBJECTIVE: This cross-sectional study aims to investigate the associations between the intake of omega-6 and omega-3 fatty acids, the omega-6:3 ratio, body mass index, and depressive symptoms in young Iranian adults. METHODS: Dietary data on omega-3 and omega-6 fatty acids were obtained through semi-quantitative food-frequency questionnaire (FFQ). The Beck Depression Inventory-II (BDI-II) was used to measure depressive symptom. We applied logistic regression to assess the relationships between variables. RESULTS: A total of 440 university students aged 18-30 years were included. After adjustment for age, sex, and total energy intake, higher BMI was associated with greater odds of depressive symptoms (OR: 1.11; 95% CI: 1.04-1.20). Compared with the lowest quintile, participants in the highest quintile of omega-3 intake had lower odds of depressive symptoms (OR: 0.34; 95% CI: 0.17-0.71). In contrast, a higher omega-6/omega-3 ratio was associated with greater odds of depressive symptoms, with nearly tenfold higher odds observed in the highest versus lowest quintile (OR: 9.94; 95% CI: 3.89-25.43). CONCLUSION: Higher omega-3 intake was associated with lower odds of depressive symptoms, whereas higher BMI and a greater omega-6/omega-3 ratio were associated with higher odds. These findings suggest that dietary fatty-acid balance and body weight may be relevant correlates of mental health in young adults. Prospective and interventional studies are needed to clarify causal relationships.

BACKGROUND: Moral injury (MI) and negative emotions (NE) are core psychological issues that severely impair the mental health and professional competence of medical staff, while emotion regulation serves as a crucial psychological resource for coping with occupational psychological distress. However, the latent severity profiles of MI among medical staff, as well as the differential mediating effects of emotion regulation strategies, i.e., cognitive reappraisal (CR) and expressive suppression (ES), between MI and negative emotion (NE) remain unexplored. OBJECTIVE: This study aimed to identify the latent subtypes of MI among medical staff via latent profile analysis and to explore the mediating role of CR and ES between MI and NE, so as to provide empirical evidence for formulating targeted psychological intervention strategies for medical staff. METHODS: This was a cross-sectional survey. 1001 medical staff were enrolled via a convenience sampling method. Questionnaires were used to assess MI, anxiety, depression and emotion regulation among medical staff, with latent profile analysis applied for subgroup identification. The relationships among variables were analyzed using Pearson correlation analysis and mediation analysis. RESULTS: Three profiles of MI were identified and designated as the low injury profile (62.84%), emotion injury profile (25.27%), and value injury profile (11.89%). MI correlated positively with NE (r = 0.38-0.41) and negatively with CR (r = -0.19). Overall, CR had mediated MI-NE associations, while ES did not. Critically, profile‑specific mediation showed that ES had mediated effects in value injury profile, whereas CR partially mediated effects in emotion injury profile. CONCLUSION: To mitigate negative emotions in medical staff, administrators should account for individual differences in MI profiles. For the emotion injury profile, prioritize CR to restructure self-blame. For value injury profile, focus on reducing ES and fostering healthy emotional expression. Tailoring emotion regulation strategies to specific MI profiles is essential to safeguard staff mental health and care quality.

BACKGROUND: Pancreaticoduodenectomy (PD) can lead to major trauma in terms of patients' mental health, including severe postoperative depression. This study aimed to investigate the effects of supplementing patient-controlled analgesia with low-dose esketamine on postoperative depression among patients undergoing PD. METHODS: Eighty patients who were scheduled for PD were randomly assigned to either the control or esketamine groups. The control group received 2 µg/kg of sufentanil for patient-controlled analgesia (PCIA), whereas the esketamine group received a combination of 1.5 mg/kg esketamine and 2 µg/kg sufentanil. The primary outcome was the incidence of depression on the third postoperative day. The secondary outcomes included the Hamilton Depression Scale (HAMD-17) scores on the first, second, third, and fifth postoperative days; the severity of postoperative pain; the analgesic dosage; the incidence of postoperative adverse effects; the concentrations of plasma 5-hydroxytryptamine (5-HT), brain-derived neurotrophic factor (BDNF), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α); and the one-year survival rate. RESULTS: The incidence of depression on the third postoperative day did not differ significantly between the two groups (47.1% vs. 42.9%, P = 0.726). However, the change in the HAMD-17 score between baseline and the fifth postoperative day was significantly lower in the esketamine group (P = 0.029). The number of PCIA button presses was significantly lower in the esketamine group than in the control group (9.32 ± 6.48 vs. 6.54 ± 4.39, P = 0.040), and opioid usage was also significantly lower in the esketamine group (114.9 ± 23.32 vs. 100.9 ± 25.72, P = 0.021). Furthermore, esketamine decreased the plasma concentration of IL-6 on the first postoperative day (P < 0.05) and that of TNF-α on the fifth postoperative day (P < 0.05). CONCLUSION: The postoperative administration of esketamine may reduce the need for analgesics among patients undergoing PD, alleviate peripheral inflammation, and potentially improve postoperative depressive symptoms. TRIAL REGISTRATION: This trial was registered at http://www.chictr.org.cn (ChiCTR2200066303, Principal investigator: Yinqing Yin, Date of registration: 2022-11-30).

BACKGROUND: South Asia has the highest rates of suicide fatalities among women globally. Existing suicide prevention interventions are largely based on Western-informed risk reduction programs and theories. This pilot trial aims to test the acceptability and feasibility of a co-designed suicide prevention program for peri-rural Pakistani women called the Khushal Pur-Umeed Zindagi (KPZ, خوشحال پُرامید زندگی پروگرام), compared to enhanced usual care (EUC). The study seeks to innovate suicide prevention by grounding interventions in decolonized frameworks, leveraging peer mothers, and developing robust health system integration strategies. METHODS: We will conduct a two-arm, mixed-methods, hybrid type 2, stratified pilot cluster randomized controlled trial in peri-rural areas of the Islamabad Capital Territory (ICT). KPZ is a decolonized, culturally salient brief intervention combining narrative-based safety planning and contact follow-up, delivered by peer mothers over 6 months. EUC entails the WHO Mental Health Gap Action Programme (mhGAP) suicide prevention module, along with referral support delivered through Primary Health Care (PHC) by Medical Officers (n = 2) and Lady Health Worker teams (n = 11). KPZ is integrated into the PHC system and is implemented through close collaboration between peer mothers (delivery agents) and the government-employed LHWs. A cohort of peer mothers (n = 11), identified from the same communities as participants, will be trained and supervised for the study duration. We will enroll 50 women aged 18-45 with a child under 3 years who report suicidal ideation and will conduct follow-ups at 3- and 6-months post-recruitment. Qualitative interviews with trial participants and periodic reflections from peer mothers will be conducted iteratively over 6 months. A mixed-methods approach will be used to assess both clinical and implementation outcomes. Primary clinical outcomes include suicidal ideation severity and suicidal behaviors. Implementation outcomes include feasibility, acceptability, fidelity, appropriateness, and peer mothers' competence. Secondary outcomes assess additional clinical domains (depression, anxiety) and culturally relevant constructs (moral injury, cultural suicide cognitions). DISCUSSION: This pilot trial will provide evidence on the feasibility and acceptability of integrating a decolonized, peer-delivered suicide prevention program for women into the existing Pakistani health system. The findings have the potential for large-scale public health impact by improving the availability, accessibility, and quality of culturally appropriate suicide prevention interventions in resource-constrained and complex environments. Results will inform a larger definitive trial of a community-initiated suicide prevention program in Pakistan. TRIAL REGISTRATION: NCT06208293.

BACKGROUND: Adolescence is a crucial developmental stage characterized by rapid biological, psychological, and social changes, that increase vulnerability to mental health issues. Nearly half of all mental health conditions have their onset during this period and are influenced by individual, family, and environmental factors. Schools play a key role in promoting mental well-being among adolescents due to their accessibility and reach. While school-based mental health prevention interventions have shown positive outcomes in high-income countries, evidence from low- and middle-income countries (LMICs) is limited. This study aimed to assess the feasibility and acceptability of Health Action in Schools for a Thriving Adolescent Generation (HASHTAG), a comprehensive school-based intervention for adolescents aged 13-16 years in Nepal. METHODS: A feasibility cluster-randomized controlled trial was conducted in four secondary schools in Morang district, Nepal. Adolescents completed surveys at baseline and at a 3-month follow-up to evaluate mental well-being, emotional and behavioral outcomes, social support, school climate, and functioning. The intervention comprised two components: Thriving Environment in Schools (TES), implemented over three months and Thriving Together (TT), delivered through six weekly sessions. Quantitative data were collected electronically and analyzed descriptively. Qualitative data were gathered through focus group discussions and in-depth interviews with adolescents, teachers, and facilitators to explore implementation experiences and were analyzed thematically. RESULTS: Both the TES and TT components were well received, with TT sessions achieving an average attendance rate exceeding 70%, and being delivered as planned by trained facilitators, indicating good acceptability and feasibility. Explanatory analysis suggested a positive trend in anxiety outcomes in the intervention group while, social support showed a modest increase. Other outcomes showed small, non-significant changes. Qualitative findings highlighted perceived benefits such as improvements in school cleanliness, staff-student relationships, bullying and discrimination reduction, and positive social and behavioral changes. Participants found breathing exercises, games, the workbook, and the 'feeling box' particularly helpful. Implementation challenges included limited space, logistical constraints, COVID-19 related disruptions, and session length. CONCLUSION: HASHTAG demonstrated feasibility and accessibility as a school-based intervention for adolescents in Nepal, with preliminary indications of potential benefits. Addressing identified implementation challenges will be important for optimizing delivery in future studies. A fully powered randomized controlled trial is warranted to evaluate effectiveness.

BACKGROUND: The construct of borderline personality disorder (BPD) remains contentious, with some arguing that it embraces too much pathology to be of any real value as a clinical diagnosis. Examining BPD's comorbidity is key to understanding its heterogeneous vs. homogeneous nature. METHODS: This study aimed to uncover differences in patterns of symptoms and their severity between 3 groups of patients a with a DSM-5 diagnosis of BPD: (i) those with a single borderline diagnosis; (ii) those with a dual diagnosis of BPD and antisocial personality disorder (ASPD); those with a dual diagnosis of BPD and narcissistic personality disorder (NPD). Groups were compared in terms of: (i) borderline symptom severity; (ii) self-report measures of emotional dysregulation, suicidality, and identity disturbance; (iii) DSM-defined borderline symptom profiles. Network analysis assessed whether a stable and reproducible structure of symptoms could be seen across all three groups and whether groups differed in symptom prevalence. RESULTS: Results of network analyses showed that the three groups shared the same symptom structure but differed systematically in which symptoms were most strongly endorsed: identity/interpersonal dysfunction in BPD, affective/behavioural dysregulation in BPD+ASPD, and a mixed/intermediate profile in BPD + NPD. BPD+ASPD showed the greatest severity of borderline symptoms, greatest emotional dysregulation, and highest impulsiveness and anger. The BPD group showed the highest identity disturbance and suicidality, BPD + NPD the lowest. In their symptom profiles, BPD were more likely to meet criteria for fear of abandonment, unstable relationships, identity disturbance and suicidality, while BPD+ASPD were more likely to meet criteria for impulsivity, affective instability, and anger control difficulty. The three groups differed on measures of identity and interpersonal relationships, supporting the idea that PD reflects disturbances of relationality. CONCLUSION: Results highlight that BPD can manifest in different ways that depend on its comorbidity. These differences require treatment to be tailored to the individual patient, with a focus on identity/interpersonal dysfunction when BPD presents alone, and on affective/behavioural dysregulation when BPD co-occurs with ASPD.

BACKGROUND: Contentious debate persists over whether the stigma of borderline personality disorder (BPD) stems from the diagnostic label itself or the behaviours commonly associated with it. At the same time, it remains unclear whether old age identities exacerbate such stigma, raising concerns surrounding the quality of care experienced by the burgeoning population of older adults-both diagnosed and undiagnosed-presenting to mental health services with BPD symptoms. METHOD: Using a 2 × 2 between-subjects experimental design, participants were randomized equally to one of four conditions varying by age (27 vs. 70 years) and diagnostic label (BPD vs. no diagnosis). The study used two-way independent-measures ANOVAs to examine 242 clinical psychology trainees' treatment beliefs, as well as their cognitive, emotional and behavioural reactions to a vignette character presenting with BPD symptoms. RESULTS: Contrary to expectations, participants reported more favourable treatment beliefs about patients with a BPD diagnosis relative to undiagnosed patients with identical BPD symptoms, as indicated by more positive beliefs about their therapeutic relationships, and more conviction in their treatability. Additionally, participants anticipated that they would exhibit more infantilising behaviours (i.e., child-like speech patterns) toward older adult patients than toward younger patients, independent of diagnostic label. CONCLUSIONS: A BPD diagnostic label can improve clinical psychology trainees' expectations about the treatability of affected individuals and may have a positive influence on beliefs about the therapeutic relationship with younger adult patients in particular. Thus, the label may now be less stigmatising among current clinical psychology trainees compared to previous generations.

BACKGROUND: Generalized Anxiety Disorder (GAD) is one of the most common mental disorders. Current treatments often emphasize symptom reduction while neglecting key factors such as emotional distress tolerance and medication adherence. Metacognitive Therapy (MCT) provides a distinct approach by targeting maladaptive metacognitive beliefs that sustain anxiety and worry. This study aimed to evaluate the effectiveness of MCT in improving emotional distress tolerance and medication adherence among patients with GAD, with the goal of facilitating its clinical use by psychologists and psychiatrists. METHOD: This study was conducted as a pilot randomized controlled trial with a pre-test/post-test design, comparing an intervention group to a waitlist control group. The sample included 32 outpatients aged 18-40 years diagnosed with GAD at Zareh Hospital's psychotherapy clinic. Participants were randomly assigned to an experimental group (n = 16) and a control group (n = 16). The experimental group received eight weekly sessions of Metacognitive Therapy (MCT), while the control group was placed on a waitlist and received no intervention during the study period. Data were collected using the Generalized Anxiety Disorder Scale, the Distress Tolerance Scale, and the Medication Adherence Measure. Data analysis was performed with SPSS version 26 using MANCOVA. RESULTS: Results showed that MCT significantly improved emotional distress tolerance. In the experimental group, the mean score increased from 30.94 ± 4.28 at pre-test to 52.75 ± 6.89 at post-test (95% CI for estimated marginal mean: 52.06-55.47), while in the control group the mean score changed from 32.63 ± 5.56 to 33.81 ± 6.73 (95% CI: 31.09-34.51). This difference was significant (F = 109.82, η²=0.80, P < 0.001). MCT also significantly improved medication adherence. In the experimental group, the mean score increased from 3.06 ± 1.88 to 7.81 ± 1.94 (95% CI: 7.38-8.64), whereas in the control group it changed from 3.50 ± 1.37 to 3.63 ± 1.54 (95% CI: 2.79-4.05). This difference was significant (F = 311.16, η²=0.92, P < 0.001). CONCLUSION: Conclusion Preliminary findings suggest that MCT may enhance both emotional and behavioral outcomes in GAD. If replicated in larger trials, its application in clinical practice could help mental health professionals address major challenges such as distress intolerance and poor medication adherence, potentially reducing patient distress and promoting long-term engagement in treatment. TRIAL REGISTRATION: Iranian Registry of Clinical Trials (IRCT), IRCT20231128060213N1, registered on 05 January 2024 (retrospectively registered).

BACKGROUND: Responding to system pressures, fragmentation, and growing project fatigue in primary care, this study examines how values-driven innovations (VDIs) can be successfully embedded and sustained by (1) defining what constitutes a values-driven innovation, (2) identifying strategies and mechanisms that support long-term implementation, and (3) co-developing evidence-based sustainability indicators with stakeholders. By integrating four complementary theoretical frameworks and examining the full lifecycle from conceptualization to long-term sustainment, it generates actionable insights to strengthen enduring, values-based transformation in primary care. METHODS AND ANALYSIS: This study uses a longitudinal, theory-informed, multi-stakeholder design. Over three years, we follow selected VDIs from conceptualization through long-term sustainment, using multiple data sources and repeated timepoints to capture dynamic implementation processes. An integrated conceptual framework: combining realist evaluation, the Dynamic Sustainability Framework, Consolidated Framework for Implementation Research, and Normalization Process Theory, guides all phases. The three-phase design includes: (1) defining VDI and mapping the innovation landscape; (2) conducting longitudinal case studies using document analysis, serial interviews, and questionnaires; and (3) co-creating an actionable sustainability model and monitoring indicators with stakeholders. Continuous reflexive practice, triangulation, and participatory engagement ensure rigor and relevance. DISCUSSION: Despite the analytical complexity of using multiple frameworks, this integration provides a comprehensive understanding of sustainability and contextual adaptation in primary care. ETHICS AND DISSEMINATION: The study protocol was approved by the Ethics Committee of the University of Antwerp (reference number 2025-7124).

BACKGROUND: Comorbid borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) predict poorer treatment outcomes. Available treatments for BPD and psychological trauma are often phase-based, first ensuring stabilization of dysregulated behaviors and emotions and later focusing on treating trauma. This study investigates the feasibility, acceptability, and preliminary efficacy of combining dialectical behavioral therapy group skills training (DBT-ST), consisting of mindfulness, emotion regulation, distress tolerance, and interpersonal-effectiveness skills, with eye movement desensitization and reprocessing (EMDR) individual therapy for patients with BPD and psychological trauma. METHODS: Forty-two participants with BPD and psychological trauma (40 females, mean age = 28.5, SD = 9.2) participated in the study. All participants underwent an initial 6-month DBT-ST group (phase 1), then those randomized to the experimental group received EMDR, and those in the control condition continued DBT-ST (phase 2). Feasibility and acceptability were assessed through qualitative interviews. Additionally, borderline personality disorder symptoms and trauma-related symptoms were measured as secondary clinical outcomes. Assessments were conducted at baseline, post phase 1, and post phase 2. RESULTS: Overall retention from baseline to post phase 2 was 62%. Descriptively, retention was 81.2% in the DBT-ST continuation group and 72.2% in the DBT-ST+EMDR group, though this difference was not statistically significant. Qualitative interviews suggested that the sequential design was acceptable, and that DBT-ST helped some participants feel more prepared for subsequent trauma-focused work, although these findings are based on a small qualitative subsample. Both conditions reduced BPD symptoms, while only the DBT-ST+EMDR condition significantly reduced dissociative symptoms from baseline to post phase 2. CONCLUSIONS: A definitive, fully powered randomized clinical trial is warranted to confirm these findings and optimize the integration of DBT-ST and EMDR. TRIAL REGISTRATION: Clinical Trials, NCT04856449. Registered on 08-04-2021.

BACKGROUND: Traumatic brain injury is a major global health concern, with penetrating brain trauma representing an uncommon but highly lethal subset, especially in conflict-affected regions. Outcomes in penetrating brain trauma are strongly influenced by admission Glasgow Coma Scale (GCS), extent of structural injury, projectile characteristics, and imaging findings. Early expert assessment, rapid neuroimaging, and timely surgical intervention are critical for improving survival in selected patients although long‑term recovery often requires multidisciplinary rehabilitation. We report a rare case of penetrating brain trauma in a 14‑year‑old male who achieved complete neurological recovery following prompt and appropriate management. CASE PRESENTATION: A 14‑year‑old Syrian male presented with a penetrating gunshot injury to the left frontal region, arriving with a GCS of 10, left pupillary non-reactivity, periorbital ecchymosis, cerebrospinal fluid leak, and a depressed comminuted frontal fracture. Computed tomography imaging revealed multiple bone fragments penetrating the left frontal lobe, an anterior skull base fracture, pneumocephalus, contusions, and a bullet lodged in the right maxillary sinus. He underwent urgent left frontal craniectomy with removal of bone fragments, dural repair, and abdominal preservation of the bone flap. Postoperatively, his neurological status improved rapidly to a GCS of 15 within 12 h, with spontaneous resolution of cerebrospinal fluid leakage. The patient remained neurologically intact and was discharged with plans for subsequent neuropsychological follow-up and cranioplasty (refer to Graphical Abstract). CONCLUSION: This case highlights the importance of rapid assessment and timely intervention in penetrating brain trauma despite its high morbidity and mortality. The patient's full recovery from an initial GCS of 10 underscores the value of appropriate rehabilitation. Accurate projectile identification and avoidance of management delays are essential, and multidisciplinary collaboration may benefit selected cases.

BACKGROUND: Insomnia and depression frequently co-occur during adolescence, posing significant challenges to adolescent mental health. However, the direction of their association remains inconsistent in the literature and may show grade-specific patterns. Grounded in psychopathology network theory and informed by the developmental psychopathology perspective, this study examined symptom-level associations between insomnia and depression to better characterize these association patterns. METHODS: This study employed cross-lagged panel network analysis to explore symptom-level interactions between insomnia and depression from Grades 5 to 12, capturing both contemporaneous (within-timepoint) associations and temporal (cross-timepoint) predictive associations. A large cohort of 175,950 adolescents (M = 14.35, SD = 2.14; 52.72% female) completed the Insomnia Severity Index (ISI) and Patient Health Questionnaire-9 (PHQ-9) at two time points. RESULTS: The findings showed both relatively stable and grade-specific patterns of association between insomnia and depression. In the contemporaneous networks, Motor descriptively showed the highest strength centrality in most grades, although the symptom with the highest centrality differed in some grades. In the temporal networks, descriptive centrality results indicated that Sad Mood had the highest out-expected influence in most grades, except for Anhedonia in Grade 6 and 8 and Suicide in Grade 12; Daily Function descriptively had the highest in-expected influence in most grades, except for Fatigue in Grade 10 and 11. CONCLUSION: These findings highlight several symptoms in the insomnia-depression network, with some variation across grades. By moving beyond total-score approaches, this symptom-level perspective provides exploratory insights that may shed light on inconsistencies in prior findings regarding the directionality of the insomnia-depression association and offer a more nuanced understanding of insomnia-depression relationships during adolescence.

BACKGROUND: Fatigue is a highly disabling symptom of adolescent depression, yet little is known about prevalence, associated characteristics, nor how fatigue might change during psychological intervention. METHODS: An exploratory secondary analysis was conducted using trial data from 465 adolescents (aged 11-17 years old) diagnosed with major depressive disorder who were randomised to receive one of three psychological interventions. Fatigue was measured as a binary variable (fatigue status; fatigued versus non-fatigued). We explored the prevalence of fatigue, associated demographic and clinical characteristics, changes in fatigue following psychological intervention, and the impact of baseline fatigue on improvements in depression severity and psychosocial functioning. RESULTS: Clinically significant fatigue was self-reported by 73% of adolescents at baseline. From self-report and diagnostic interviews, fatigue status was consistently associated with older age and higher depression severity. Through self-report only, depressed adolescents were also more likely to be fatigued if they were an ethnic minority, had more comorbidities, and higher psychosocial impairment. Fatigue status significantly decreased across all timepoints, irrespective of treatment arm, and continued to decrease after treatment was terminated. Furthermore, fatigue did not significantly predict overall treatment response or differential response between arms in relation to depression severity and psychosocial functioning. However, up to a third of depressed adolescents still reported residual fatigue at 86-weeks follow-up. CONCLUSIONS: In this exploratory study, fatigue is commonly reported by depressed adolescents and consistently associated with older age and higher depression severity, which are characteristics that could aid identification. Fatigue may decrease when receiving evidence-based psychological interventions for adolescent depression, but a proportion are left with residual symptoms. Further research is warranted to expand on these tentative findings.

BACKGROUND: Non-suicidal self-injury (NSSI) represents a significant public health concern among adolescents with mood disorders. While individual psychological distress is established as a risk factor, the impact of parent-adolescent emotional congruence/incongruence on NSSI remains underexplored. This study aimed to examine the associations between adolescent and parental psychological distress and adolescent NSSI, focusing on the effects of dyadic congruence and incongruence. METHODS: The study included 147 parent-adolescent dyads (94 girls, 53 boys; mean age = 15.18 years) with adolescents diagnosed with depression or bipolar disorder. Participants completed the Depression Anxiety Stress Scale (DASS-21) and the Self-Injurious Behavior Scale. Polynomial regression analysis and response surface analysis were employed to examine the effects of congruence and incongruence in psychological distress between parents and adolescents on adolescent NSSI. RESULTS: Adolescent psychological distress was positively associated with NSSI frequency (depression: r = 0.38, p < 0.001; anxiety: r = 0.42, p < 0.001; stress: r = 0.31, p < 0.001). Response surface analyses revealed that emotional incongruence between parents and adolescents significantly predicted higher levels of NSSI for all three dimensions of psychological distress. For anxiety specifically, a U-shaped curvilinear relationship emerged (a₄=0.29, p < 0.001), indicating that extreme incongruence in either direction was particularly detrimental. CONCLUSION: The current study highlights that beyond individual psychological distress, emotional incongruence between parents and adolescents represents a significant risk factor for NSSI in clinically depressed adolescents. This underscores the importance of family-based interventions that promote emotional understanding and co-regulation within parent-adolescent relationships to reduce NSSI risk in clinical populations.

OBJECTIVE: To investigate the prevalence of anxiety, depression, and sleep problems among specialized operation personnel on surface vessels, and to analyze their influencing factors. METHODS: A total of 600 participants were randomly selected. Basic demographic and occupational information was collected using a general information questionnaire. The Self-Rating Anxiety Scale (SAS), Self-Rating Depression Scale (SDS), and Pittsburgh Sleep Quality Index (PSQI) were administered to assess anxiety, depression, and sleep quality. RESULTS: Spearman correlation analysis indicated that anxiety symptoms was associated with years of service (r = 0.130, P = 0.001), family residence (r = -0.153, P < 0.001), and sleep quality (r = 0.199, P < 0.001). Depression symptoms was associated with parental relationship (r = -0.134, P = 0.001), family residence (r = -0.144, P < 0.001), and sleep quality (r = 0.122, P < 0.05). Binary logistic regression further showed that PSQI was associated with anxiety (OR = 2.187, P = 0.001). All PSQI subscales were correlated with SAS and SDS total scores (P < 0.05). CONCLUSION: Sleep and emotional problems are prevalent among specialized operation personnel on surface vessels. Greater attention should be given to the psychological health of subgroups at higher risk, such as older individuals, those with rural backgrounds, and those with longer years of service. Routine psychological screening is recommended for this population.

BACKGROUND: Suicidal ideation is a critical precursor to suicide and an important focus for early prevention. Police officers are frequently exposed to sustained operational and organisational stressors that may increase vulnerability to suicidal ideation. Although police suicide has attracted growing attention in Malaysia, empirical data on high-risk suicidal ideation and associated factors among Malaysian police personnel remain limited. This study aimed to determine the prevalence of high-risk suicidal ideation and its associated factors among police officers in a district in Sabah. METHODS: A cross-sectional study was conducted among 528 active-duty police officers from a district police headquarters and affiliated units in Sabah. Participants completed validated self-administered questionnaires assessing suicidal ideation (RSIS), depression (PHQ-9), anxiety (GAD-7), perceived stress (PSS-10), burnout (Copenhagen Burnout Inventory), police stress (Police Stress Questionnaire), resilience (Brief Resilience Scale), relationship quality (Relationship Dynamics Scale), substance use risk (ASSIST-Lite), and financial well-being (FWS), together with sociodemographic information. High-risk suicidal ideation was defined using the RSIS high-risk category. Descriptive statistics were used to estimate prevalence, and multiple logistic regression was used to examine associated factors. RESULTS: The prevalence of high-risk suicidal ideation was 10.8% (57/528; 95% CI: 8.4-13.7). Sedative use risk (AOR = 5.00; 95% CI: 1.90-13.05) and depression severity (AOR = 1.18; 95% CI: 1.11-1.25) were associated with higher odds of high-risk suicidal ideation. Higher financial well-being (AOR = 0.97; 95% CI: 0.96-0.99) and greater resilience (AOR = 0.36; 95% CI: 0.15-0.86) were associated with lower odds of high-risk suicidal ideation. CONCLUSIONS: Approximately one in ten police officers in this district met the threshold for high-risk suicidal ideation. These findings highlight the importance of early identification and targeted support in policing settings, particularly addressing depressive symptoms, sedative use risk, financial well-being, and resilience. Longitudinal research is needed to clarify temporal relationships.