Evidence indicates that the COVID-19 pandemic has led to an increase in self-harm among adolescents; however, little is known about the trends in prevalence after the end of the pandemic.

This retrospective cross-sectional database study evaluates changes in the prevalence and clinical characteristics of self-harm among adolescents who sought attention from the emergency service of the largest children’s psychiatric hospital in Mexico before, during and after the COVID-19 pandemic.

After comparing the clinical characteristics of self-harm between the three periods, we calculated the monthly prevalence of self-harm among patients (n = 3520) visiting the hospital’s emergency psychiatric services over a period of 58 months. Using joinpoint regression, we evaluated temporal trends in self-harm prevalence.

Affective disorders and hitting as a method of self-harm were more frequent during and after the pandemic in comparison with the pre-pandemic period. The prevalence of self-harm diminished from March 2019 to March 2023, a trend followed by an increase coinciding with the end of the pandemic and the return to normal activities.

The significant increase in prevalence observed after the end of the pandemic suggests a long-term impact on mental health of adolescents. This underscores the need for monitoring this population during post-pandemic years to provide timely interventions.

Second-generation antipsychotics (SGAs) can cause corrected QT interval (QTc) prolongation as a side-effect. This may limit their clinical use and pose safety concerns for patients.

To analyse the risk of QTc prolongation associated with eight second-generation antipsychotics and observe the timing characteristics of QTc prolongation events and subsequent changes in medication strategies.

Using data from the hospital information system of a large mental health centre, this retrospective cohort study included 5130 patients (median follow-up: 141.2 days) treated between 2007 and 2019. A marginal structural Cox model was used to compare the hazard ratios for QTc prolongation associated with various SGAs.

The mean age of the cohort was 35.54 years (s.d. = 14.22), and 47.8% (N = 2454) were male. Ziprasidone, amisulpride and olanzapine were the only SGAs associated with QTc prolongation. Ziprasidone presented the highest risk (hazard ratio 1.72, 95% CI: 1.03–2.85, adjusted P = 0.03), followed by amisulpride (hazard ratio 1.56, 95% CI: 1.04–2.34, adjusted P = 0.03) and olanzapine (hazard ratio 1.40, 95% CI: 1.02–1.94, adjusted P = 0.04).

Ziprasidone, amisulpride and olanzapine are associated with increased risk of QTc prolongation. Regular electrocardiogram monitoring is recommended when clinicians prescribe such drugs.

Subjective cognitive decline (SCD) is defined as self-reported increase in confusion or memory loss. There is limited research on the interplay between rural–urban residence and education on SCD.

Examine rural–urban differences in SCD, and whether education moderates this relationship.

Respondents aged ≥45 years were queried about SCD in the 2022 Behavioral Risk Factor Surveillance System data, creating a sample size of 63 890. A logistic regression analysed the association between rural–urban residence and SCD, and moderation was tested by an interaction with education.

SCD was more common among rural (12.0%) compared with urban (10.7%) residents. Rural residence was associated with 9% significantly higher odds of SCD compared with urban residence after adjusting for sociodemographic and health covariates (adjusted odds ratio (aOR) = 1.09, P = 0.01). There was a negative relationship between education level and SCD, including the association of college degree with 15% lower odds of SCD compared with less than high school degree (aOR = 0.85, P < 0.01). Education was a significant moderator, with higher education associated with lower odds of SCD for urban, but not rural, residents.

Rural setting and lower education were associated with higher odds of SCD, but higher education was protective for only urban residents. These results indicate that higher education may be a gateway for more opportunities and resources in urban settings, with cascading impacts on cognition. Future research should examine reasons for the diverging cognitive benefits from education depending on rural–urban residence.

Alcohol use in autism spectrum disorder (ASD) is under-researched. Previous reviews have explored substance use as a whole, but this neglects individual characteristics unique to different substances. Alcohol use in non-clinical samples is associated with diverse responses. To advance practice and policy, an improved understanding of alcohol use among people with ASD is crucial to meet individual needs.

This was a narrative systematic review of the current literature on the association between alcohol use and ASD, focusing on aetiology (biological, psychological, social and environmental risk factors) and implications (consequences and protective factors) of alcohol use in autistic populations who utilise clinical services. We sought to identify priority research questions and offer policy and practice recommendations.

PROSPERO Registration: CRD42023430291. The search was conducted across five databases: CINAHL, EMBASE, MEDLINE, PsychINFO and Global Health. Included studies explored alcohol use and ASD within clinical samples.

A total of 22 studies was included in the final review. The pooled prevalence of alcohol use disorder in ASD was 1.6% and 16.1% in large population registers and clinical settings, respectively. Four components were identified as possible aetiological risk factors: age, co-occurring conditions, gender and genetics. We identified ten implications for co-occurring alcohol use disorder in ASD, summarised as a concept map.

Emerging trends in the literature suggest direction and principles for research and practice. Future studies should use a standardised methodological approach, including psychometrically validated instruments and representative samples, to inform policy and improve the experience for autistic populations with co-occurring alcohol use.

A systematic review/meta-analysis synthesising the existing evidence regarding the prevalence of loneliness and social isolation among individuals with mild cognitive impairment (MCI) or dementia is lacking.

A systematic review and meta-analysis was conducted to investigate the prevalence and factors associated with loneliness and social isolation among individuals with MCI or dementia.

A search was conducted in five established electronic databases. Observational studies reporting prevalence and, where available, factors associated with loneliness/isolation among individuals with MCI and individuals with dementia, were included. Important characteristics of the studies were extracted.

Out of 7427 records, ten studies were included. The estimated prevalence of loneliness was 38.6% (95% CI 3.7–73.5%, I2 = 99.6, P < 0.001) among individuals with MCI. Moreover, the estimated prevalence of loneliness was 42.7% (95% CI 33.8–51.5%, I² = 90.4, P < 0.001) among individuals with dementia. The estimated prevalence of social isolation was 64.3% (95% CI 39.1–89.6%, I² = 99.6, P < 0.001) among individuals with cognitive impairment. Study quality was reasonably high. It has been found that living alone and more depressive symptoms are associated with a higher risk of loneliness among individuals with dementia.

Social isolation, and in particular loneliness, are significant challenges for individuals with MCI and dementia. This knowledge can contribute to supporting successful ageing among such individuals. Future research in regions beyond Asia and Europe are clearly required. In addition, challenges such as chronic loneliness and chronic social isolation should be examined among individuals with MCI or dementia.

Family and friends (family carers) provide substantial support to those with mental ill health, often affecting their own well-being. Subsequently, family carers have their own recovery journeys. Research highlights numerous benefits of attending Recovery Colleges, but whether these apply for family carers remains unexplored.

We aimed to explore family carers’ experiences of attending Recovery Colleges across England, to understand current provision and how this might better include and support family carers.

Together with lived experience researchers, this qualitative focus group study used collaborative thematic analysis of online focus groups and interviews with family carers and Recovery College staff from across England.

We generated six superordinate themes: ‘The “carer” identity is not clearcut’, ‘Recovery ethos applies to family carers too’, ‘Power of lived experience’, ‘Educational focus is appealing’, ‘Family carers deserve recognition and provision’ and ‘Reaching out and fitting around family carers’. Attending Recovery Colleges developed family carers understandings and gave them skills to navigate services and support themselves and others, which furthered their own recovery journeys. Shared learning spaces were helpful, but participants felt these were not always oriented to include family carers. Our findings revealed ways Recovery Colleges could increase their relevance and accessibility to family carers.

The unique characteristics of Recovery Colleges suited the recovery needs of family carers. However, more resources are needed to develop this potential and reach more family carers. Family carer co-researchers enriched our findings, and discussions with the Recovery College community furthered our recommendations for practice.

A lifetime history of non-suicidal self-injury (NSSI) is a risk factor for subsequent behavioural and emotional problems, including depression, aggression and heightened emotional reactivity. Traumatic experiences, which are frequently reported by individuals with NSSI, also show predictive links to these mental health problems. However, the exact connections between these areas and their subdomains remain unclear.

To explore in detail the relationships of specific characteristics of NSSI (e.g. termination in adolescence, duration, frequency, reinforcement mechanisms) and various types of traumatic experience (emotional, physical, sexual) with distinct aspects of emotional reactivity (sensitivity, intensity, persistence), aggression (behavioural, cognitive, affective) and severity of depression in university students.

Via online survey, 150 university students aged 18 to 25 years, who had self-injured at least once, provided information on NSSI, and completed questionnaires including the Childhood Trauma Questionnaire, Patient Health Questionnaire, Emotion Reactivity Scale, and Aggression Questionnaire. Regression analyses were conducted to determine risk factors linked to increased depression scores, aggression and emotional reactivity. The study was pre-registered in the German Clinical Trials Register (DRKS00023731).

Childhood emotional abuse contributed to emotional reactivity, aggression and depressive symptom severity (β = 0.33–0.51). Risk factors for sustained NSSI beyond adolescence included increased automatic positive reinforcement (odds ratio: 2.24).

Childhood emotional abuse significantly contributes to emotional and behavioural problems and needs to be considered in NSSI therapy. NSSI was found to persist into adulthood when used as an emotion regulation strategy.

Research shows initial COVID-19 lockdowns increased population mental distress. Yet, the mental health impact of repeated lockdowns in England remains unknown.

To: (a) explore changes in population mental health symptoms over the COVID-19 pandemic period (March 2020 to March 2021) in England, comparing this with trends from a decade before (2009–2019) as well as after (2021–2023); (b) compare the mental health impact of each of the three lockdowns in England with periods of eased restrictions, determining who was most affected; (c) examine the impact of demographics and distinct time periods on the prevalence of mental health symptoms.

A secondary analysis of a national longitudinal cohort study, utilising data from Waves 1–13 of the UK Household Longitudinal Study and from Waves 1–9 of the COVID-19 Survey. Mental health was assessed using the 12-item General Health Questionnaire. Student t-tests and logistical regressions were conducted.

There was a significant increase in the prevalence of self-reported symptoms of mental health during England's pandemic period, encompassing three lockdowns, compared with the average of rates from 10 years before. Rates of reported mental health symptoms were not significantly different across each lockdown, but were significantly higher than pre-pandemic rates, declining with eased restrictions. Rates from the end of lockdown to May 2023 revealed elevated mental health symptoms compared with pre-pandemic. Elevated symptoms were observed for women, people homeworking, those with health conditions, individuals aged 30–45 years and those experiencing loneliness.

Repeated lockdowns in England had a substantial impact on mental health, indicating requirements for ongoing mental health support.

Adolescence is the peak life stage for the development of mental illness. Whole-school approaches to mental health and well-being, modelled on the World Health Organization’s Health-Promoting Schools Framework, hold vast potential in this developmentally sensitive period. However, the evidence base for these interventions is inconclusive.

Our study examines the effectiveness of The Resilience Project School Partnership Program, a whole-school intervention involving students, teachers and parents, centred around concepts of gratitude, empathy, emotional literacy and mindfulness.

A quasi-experimental study with an intervention and a control arm was used to evaluate the programme in 40 149 students across 102 schools in 2023. Data collected included sociodemographic information and outcomes derived from validated scales, comprising life satisfaction, hope, coping skills, anxiety and depression. Intervention schools were stratified by the number of years they had implemented the programme, and mixed-effects regression models were used to evaluate the programme.

After adjusting for confounders, participants at schools who had been implementing the programme for 6 years or longer demonstrated significantly better outcomes across all five domains (life satisfaction: B = 0.627, 95% CI 0.465–0.789; hope: B = 2.135, 95% CI 0.895–3.347; coping skills: B = 0.438, 95% CI 0.250–0.625; anxiety: odds ratio = 0.658, 95% CI 0.559–0.774; depression: odds ratio = 0.534, 95% CI 0.459–0.620). Only depression was significantly lower among participants at schools in their fourth or fifth year of implementing the programme (odds ratio = 0.941, 95% CI 0.935–0.948).

Our findings indicate that whole-school interventions may require long-term investment to realise their potential and highlight implementation duration as an important consideration for future evaluations of whole-school interventions.

Research suggests that those caring for a loved one with an eating disorder in the UK report unmet needs and highlight areas for improvement. More research is needed to understand these experiences on a wider, national scale.

To disseminate a national survey for adults who had experience caring for a loved one with an eating disorder in the UK, informed by the findings of a smaller scale, qualitative study with parents, siblings and partners in the UK.

A cross-sectional web-based survey was disseminated to adults who had experience caring for a loved one with an eating disorder in the UK.

A total of 360 participants completed the survey. Participants described experiences of care received in both children and young people's, and adult services. Those receiving care from children and young people's services generally reported more timely care, greater involvement in care and more confidence managing their loved one's symptoms post-discharge. In both settings, participants identified a number of areas for improvement, including more timely access to care, improved transition processes and discharge planning, and increased involvement in their loved one's care.

This survey captures the experiences of individuals caring for a loved one with an eating disorder in the UK. There are identified discrepancies between experiences of care in children and young people services compared with adult services. Clinical implications and recommendations for improvement are discussed, including improved transition and discharge processes, increased involvement of and/or support for carers themselves, and more timely access to support services for the unwell individual.

Exposure to maternal mental illness during foetal development may lead to altered development, resulting in permanent changes in offspring functioning.

To assess whether there is an association between prenatal maternal psychiatric disorders and offspring behavioural problems in early childhood, using linked health administrative data and the Australian Early Development Census from New South Wales, Australia.

The sample included all mother–child pairs of children who commenced full-time school in 2009 in New South Wales, and met the inclusion criteria (N = 69 165). Univariable logistic regression analysis assessed unadjusted associations between categories of maternal prenatal psychiatric disorders with indicators of offspring behavioural problems. Multivariable logistic regression adjusted the associations of interest for psychiatric categories and a priori selected covariates. Sensitivity analyses included adjusting the final model for primary psychiatric diagnoses and assessing association of interest for effect modification by child's biological gender.

Children exposed in the prenatal period to maternal psychiatric disorders had greater odds of being developmentally vulnerable in their first year of school. Children exposed to maternal anxiety disorders prenatally had the greatest odds for behavioural problems (adjusted odds ratio 1.98; 95% CI 1.43–2.69). A statistically significant interaction was found between child biological gender and prenatal hospital admissions for substance use disorders, for emotional subdomains, aggression and hyperactivity/inattention.

Children exposed to prenatal maternal mental illness had greater odds for behavioural problems, independent of postnatal exposure. Those exposed to prenatal maternal anxiety were at greatest risk, highlighting the need for targeted interventions for, and support of, families with mental illness.

The school–vacation cycle may have impacts on the psychological states of adolescents. However, little evidence illustrates how transition from school to vacation impacts students’ psychological states (e.g. depression and anxiety).

To explore the changing patterns of depression and anxiety symptoms among adolescent students within a school–vacation transition and to provide insights for prevention or intervention targets.

Social demographic data and depression and anxiety symptoms were measured from 1380 adolescent students during the school year (age: 13.8 ± 0.88) and 1100 students during the summer vacation (age: 14.2 ± 0.93) in China. Multilevel mixed-effect models were used to examine the changes in depression and anxiety levels and the associated influencing factors. Network analysis was used to explore the symptom network structures of depression and anxiety during school and vacation.

Depression and anxiety symptoms significantly decreased during the vacation compared to the school period. Being female, higher age and with lower mother's educational level were identified as longitudinal risk factors. Interaction effects were found between group (school versus vacation) and the father's educational level as well as grade. Network analyses demonstrated that the anxiety symptoms, including ‘Nervous’, ‘Control worry’ and ‘Relax’ were the most central symptoms at both times. Psychomotor disturbance, including ‘Restless’, ‘Nervous’ and ‘Motor’, bridged depression and anxiety symptoms. The central and bridge symptoms showed variation across the school vacation.

The school–vacation transition had an impact on students’ depression and anxiety symptoms. Prevention and intervention strategies for adolescents’ depression and anxiety during school and vacation periods should be differentially developed.

There is an urgent need to understand explanatory factors of poor mental health before (pre-) and during (peri-) the COVID-19 pandemic in university students, especially those from underrepresented and minority groups.

To examine potential differences and explanatory factors for psychological distress, clinical risk and impact of problems on academic outcomes pre- and peri-pandemic in university students.

A repeated cross-sectional design was used with routine data between August 2018 and July 2022 at the registration stage from a student counselling and mental health service at a UK university. Wilcoxon signed-rank tests were used to examine pre- and peri-pandemic differences in outcomes. Unadjusted and adjusted linear regression models were conducted to assess potential explanatory factors for poor outcomes.

A total of 9517 university students had completed sociodemographic and outcome data and were included in analysis. Psychological distress and impact of problems on academic outcomes were not significantly different between pre- and peri-pandemic groups. Clinical risk was significantly higher in the pre-pandemic than peri-pandemic group. Potential explanatory factors for poorer outcomes included being younger, female or non-binary/genderqueer, sexual minority, from a minority ethnic group, having home fee status and having a disability registration.

Poor student mental health profiles and related explanatory factors may not have changed drastically between pre- and peri-pandemic. Longitudinal methods and intersectional approaches should be used in future research. Further understanding of how universities and student mental health services can most efficiently and effectively support the mental health of university students is crucially warranted.

Co-occurring self-harm and aggression (dual harm) is particularly prevalent among forensic mental health service (FMHS) patients. There is limited understanding of why this population engages in dual harm.

This work aims to explore FMHS patients’ experiences of dual harm and how they make sense of this behaviour, with a focus on the role of emotions.

Participants were identified from their participation in a previous study. Sixteen FMHS patients with a lifetime history of dual harm were recruited from two hospitals. Individuals participated in one-to-one, semi-structured interviews where they reflected on past and/or current self-harm and aggression. Interview transcripts were analysed using reflexive thematic analysis.

Six themes were generated: self-harm and aggression as emotional regulation strategies, the consequences of witnessing harmful behaviours, relationships with others and the self, trapped within the criminal justice system, the convergence and divergence of self-harm and aggression, and moving forward as an FMHS patient. Themes highlighted shared risk factors of dual harm across participants, including emotional dysregulation, perceived lack of social support and witnessing harmful behaviours. Participants underlined the duality of their self-harm and aggression, primarily utilising both to regulate negative emotions. These behaviours also fulfilled distinct purposes at times (e.g. self-harm as punishment, aggression as defence). The impact of contextual factors within FMHSs, including restrictive practices and institutionalisation, were emphasised.

Findings provide recommendations that can help address dual harm within forensic settings, including (a) transdiagnostic, individualised approaches that consider the duality of self-harm and aggression; and (b) cultural and organisational focus on recovery-centred practice.

Knowledge on efficient approaches to the provision of post-disaster psychosocial care is urgently needed. To prevent unmet healthcare needs, proactive follow-up by municipal contact persons was recommended for survivors of the Utøya youth camp attack in Norway.

To examine characteristics of the survivors by whether or not they had a contact person in the early (0–5 months), intermediary (5–15 months) and long-term (20–32 months) aftermath of the attack, and to describe the survivors’ experiences with the contact person.

We analysed data from three waves of interviews with survivors conducted 4–5, 14–15 and 30–32 months after the attack, as well as register-based data on the use of mental health services from 3 years before until 3 years after the attack.

Survivors with a contact person early post-attack were less likely to receive care from mental health services concurrently or to have anxiety/depression symptoms subsequently compared with survivors without a contact person in the same period. Survivors with a contact person in the intermediary aftermath were more satisfied with the overall help they received, but also more likely to have long-term anxiety/depression symptoms. Survivors with a contact person in the long term were more likely to be financially disadvantaged. Approximately half of the survivors with a contact person found this highly or very highly useful, whereas one-third found it of little use or not at all useful.

The proactive outreach reached survivors across sociodemographic characteristics during the recommended first year of follow-up, which could be conducive to prevention of unmet healthcare needs. Still, there was considerable variation in the perceived usefulness and duration of the follow-up.

Women’s authorship position in science, technology, engineering, mathematics and medicine research reflects career progression, especially the transition from first to last (usually senior) author. Employment of women in mental health sciences has increased, and so should have had an impact on the change to senior author position.

To identify if first or last women’s authorship has changed, and mental health has better representation.

We investigated women’s authorship position in a systematic review and meta-analyses, following PRISMA guidelines and using random-effects regression analyses.

We identified 149 studies with sampling periods from 1975 to 2020 (excluding potential COVID-19 pandemic effects) that showed a large variation of women authors, and found an average proportion for first (26.2%) and last (16.1%) author position. In mental health (psychology and psychiatry), there was a higher representation, with 40% first author and 36.7% last author position, whereas medicine was 25.9% and 19.5%, respectively. The rate of change for psychology and psychiatry women authors was also higher every 10 years: 8.56% (95% CI 6.44–10.69%) for first and 6.86% (95% CI 4.57–9.15%) for last author, and rate was 2.35% higher for first author and 2.65% higher for last author than in medicine. Different methods of classifying gender and identification method did not affect our results.

Although mental health topics seem to fare better, our comprehensive review highlighted that the proportions of women first compared with last authors shows the same leaky pipeline as in other analyses, so we cannot be complacent about gender equality and career progression.

Differences in social behaviours are common in young people with neurodevelopmental conditions (NDCs). Recent research challenges the long-standing hypothesis that difficulties in social cognition explain social behaviour differences.

We examined how difficulties regulating one's behaviour, emotions and thoughts to adapt to environmental demands (i.e. dysregulation), alongside social cognition, explain social behaviours across neurodiverse young people.

We analysed cross-sectional behavioural and cognitive data of 646 6- to 18-year-old typically developing young people and those with NDCs from the Province of Ontario Neurodevelopmental Network. Social behaviours and dysregulation were measured by the caregiver-reported Adaptive Behavior Assessment System Social domain and Child Behavior Checklist Dysregulation Profile, respectively. Social cognition was assessed by the Neuropsychological Assessment Affect-Recognition and Theory-of-Mind, Reading the Mind in the Eyes Test, and Sandbox continuous false-belief task scores. We split the sample into training (n = 324) and test (n = 322) sets. We investigated how social cognition and dysregulation explained social behaviours through principal component regression and hierarchical regression in the training set. We tested social cognition-by-dysregulation interactions, and whether dysregulation mediated the social cognition–social behaviours association. We assessed model fits in the test set.

Two social cognition components adequately explained social behaviours (13.88%). Lower dysregulation further explained better social behaviours (β = −0.163, 95% CI −0.191 to −0.134). Social cognition-by-dysregulation interaction was non-significant (β = −0.001, 95% CI −0.023 to 0.021). Dysregulation partially mediated the social cognition–social behaviours association (total effect: 0.544, 95% CI 0.370–0.695). Findings were replicated in the test set.

Self-regulation, beyond social cognition, substantially explains social behaviours across neurodiverse young people.

Clozapine-induced gastrointestinal hypomotility and constipation can result in severe and sometimes fatal gastrointestinal complications. Laxatives should be prophylactically prescribed with clozapine, but this is inconsistently achieved. Digital clinical decision support (CDS) alerts can promote safer prescribing.

To evaluate whether a CDS alert could promote timely laxative use with clozapine in hospital.

Retrospective in-patient prescribing data was used to compare co-prescribing of laxatives for first clozapine prescriptions pre-alert (January 2017–September 2019) and post-alert (September 2019–December 2023) implementation across 1194 hospital admissions where clozapine was prescribed. Regular non-bulking laxative and any laxative co-prescribing for first clozapine prescriptions within 24 h were assessed. Multivariable logistic regression was performed to determine the impact of alert implementation on laxative co-prescribing.

Of the 1194 admissions included, 449 admissions had clozapine prescribed pre-alert implementation and 745 admissions had post-alert implementation. Regular non-bulking laxative co-prescription occurred for 67.0% of first clozapine prescriptions pre-alert and 76.1% post-alert (P < 0.001). Any laxative co-prescription occurred for 87.3% of first clozapine prescriptions pre-alert and 96.5% post-alert (P < 0.001). Alert implementation was associated with increased likelihoods of regular non-bulking laxative co-prescribing (odds ratio, 1.341; 95% CI, 1.021–1.756; P = 0.035) and any laxative co-prescribing (odds ratio, 3.487; 95% CI, 2.135–5.838; P < 0.001) for first clozapine prescriptions within 24 h.

CDS alert implementation was associated with increased and earlier laxative co-prescribing for clozapine. Our findings suggest that a CDS alert is an effective tool for promoting timely laxative use with clozapine in hospital.

Action mechanisms of therapeutic alliance in stepped and digital interventions remain unclear.

(a) To compare the development of therapeutic alliance between psychosocial treatment as usual (PTAU) and a stepped digital intervention designed to prevent distress in cancer patients; (b) to analyse the level of agreement between patients’ and therapists’ therapeutic alliance ratings; and (c) to explore variables associated with therapeutic alliance in the digital intervention.

A multicentre randomised controlled trial with 184 newly diagnosed breast cancer women was conducted. Patients were assigned to digital intervention or PTAU. Therapeutic alliance was assessed at 3, 6 and 12 months after inclusion using the working alliance inventory for patients and therapists. Age, usability (system usability scale), satisfaction (visual analogue scale), type and amount of patient–therapist communication were analysed as associated variables.

Patients and therapists established high therapeutic alliance in the digital intervention, although significantly lower compared with PTAU. The development of patients’ therapeutic alliance did not differ between interventions, unlike that of the therapists. No agreement was found between patients’ and therapists’ therapeutic alliance ratings. Patients’ therapeutic alliance was associated with usability and satisfaction with app, whereas therapists’ therapeutic alliance was associated with satisfaction with monitoring platform.

A stepped digital intervention for cancer patients could develop and maintain strong therapeutic alliance. Neither the type nor amount of communication affected patients’ therapeutic alliance, suggesting that flexible and available digital communication fosters a sense of care and connection. The association between usability and satisfaction with digital tools highlights their importance as key therapeutic alliance components in digital settings.