Nurse-Led Large Language Model Chatbot for Predicting and Preventing Complications After Coronary Artery Bypass Grafting: Protocol for a Randomized Controlled Trial.

The COVID-19 pandemic profoundly impacted global behavioral health, with significant implications for mental health, treatment seeking, and treatment capacity [,]. Consistent with a broad literature attesting to the linkage between natural disasters and increased rates of mental illness and treatment demand, the COVID-19 pandemic demonstrated outcomes similar to those seen after Hurricane Katrina (2005) [-] and the Baton Rouge flood (2016) [-] but on an international scale [,-]. In the United States, rates of depression and anxiety disorders increased 3-fold, with the burden of care falling largely on primary care settings that were swiftly overwhelmed by the rising demand [-]. Furthermore, health disparities research revealed that individuals experiencing greater socioeconomic impacts tended to demonstrate higher risk for developing depression [,]. Taken together, these findings highlight the need during periods of high community distress for effective remotely delivered population mental health approaches that readily target the most prevalent disorders among vulnerable populations (eg, depression) in anticipation of the expected increases in mental health treatment demand []. Within months of the COVID-19 pandemic’s onset in 2020, Cambridge Health Alliance (CHA), an extensive public safety-net health care system in the Metro Boston area, launched a remotely delivered online population mental health screening and stratified behavioral health care program, CHA MindWell (CHA-MW) []. CHA-MW aimed to reduce the mental health impacts of the COVID-19 pandemic on vulnerable populations both during and after the acute crisis. The CHA-MW team designed the program to accomplish this through remote screening and monitoring of mental health symptoms and by offering participants a variety of online mental wellness resources, individual check-ins with telehealth mental wellness counselors, and treatment referrals to standard telemental health care services based on the severity of the symptoms reported. Specifically, CHA-MW used Computer Adaptive Testing for Mental Health (CAT-MH) [,] to monitor participants’ mental health via regular dynamically adapted behavioral health surveys. A retrospective single-arm evaluation of the first year of CHA-MW implementation found significant reductions in depression (=−0.30), anxiety (=−0.27), and posttraumatic stress disorder (PTSD) (=−0.31) symptoms after 3‐6 months of program engagement during the COVID-19 pandemic []. Participants whose symptoms met or exceeded clinical thresholds at baseline displayed greater improvements in depression (=−0.42), anxiety (=−0.44), and PTSD (=−0.37) []. Having established CHA-MW as a basic population health monitoring and response program for reducing depression, anxiety, and PTSD, CHA sought to further address the need for remotely delivered mental health interventions by augmenting existing CHA-MW services with other evidence-based treatments for depression and pandemic-related distress. Mindfulness-Based Cognitive Therapy (MBCT) for depression [] was identified as a promising program for investigation based upon its demonstrated effectiveness for treating depression, anxiety, and stress, as well as its ability to be mildly adapted to meet present needs (eg, remote delivery and transdiagnostic focus) while maintaining fidelity to its theory and core techniques. As a cost-effective, evidence-based intervention for treatment and relapse prevention of depression, MBCT integrated mindfulness skills training with elements of cognitive therapy [,]. Several randomized controlled trials found that MBCT significantly reduced depression relapse rates compared with usual care [-]. Furthermore, MBCT had been found to be as effective for maintenance as antidepressant medication [,,], with some studies finding greater comparative effectiveness, particularly for patients with residual depression symptoms [,]. While MBCT was originally designed to prevent relapse in patients with remitted symptoms, several studies have demonstrated its effectiveness among patients with active depressive disorders or elevated depressive symptoms [-], with a recent meta-analysis finding that MBCT was as effective as other active treatments for people with current depressive symptoms []. MBCT was also found to be effective for treating anxiety [-] and stress [,] when delivered in online or virtual and in-person formats [,,].