Interactive Journal of Medical Research

Modeling Frailty Risk Based on Biochemical and Hematological Parameters Using Multiple and Logistic Regression: Cross-Sectional Analysis of the Toledo Study for Healthy Aging

2026-10-30T20:30:26-04:00

Background: Frailty is a complex syndrome characterized by diminished physiological reserves, resulting in increased vulnerability among older adults. Scalable tools that leverage routinely collected laboratory data could enable earlier risk stratification in aging populations. Objective: The aim of the study is to model frailty risk using Frailty Trait Scale (FTS)-12 scores and biochemical or hematological parameters, and to examine sex-specific patterns in predictors and performance. Methods: This study analyzed data from a population-based cohort of 1485 individuals aged 65 years or older, drawn from the Toledo Study for Healthy Aging (TSHA). Multiple and logistic regression analyses were used to investigate the relationships between biochemical and hematological parameters, and the FTS-12 score. Predictive models were developed separately for female and male participants, incorporating both single and composite risk factors. Model performance was evaluated using correlation coefficients, coefficients of determination, Akaike information criterion, log-likelihood values, and receiver operating characteristic curves, which summarize how well the models distinguish between higher and lower frailty risk. Results: The regression models accounted for approximately 40% of the variability in FTS-12 scores, revealing distinct risk factors for each sex. Gamma-glutamyl transferase, albumin, and age were kept as key predictors in the selected models. Several composite risk factor functions were also significantly associated with the FTS-12 score. Correlations between observed and predicted FTS-12 scores were moderately strong, with values of 0.621 (<.001) for female participants and 0.615 (<.001) for male participants. Logistic regression models showed moderate-to-good discriminative performance for high frailty probability, achieving receiver operating characteristic area under the curve values of 0.799 for female participants and 0.824 for male participants. Conclusions: This analysis is an exploratory proof-of-concept study, and the developed models do not constitute validated clinical prediction tools. Routine laboratory profiles demonstrate moderate, sex-specific predictive performance for FTS-12–defined frailty and may, in principle, complement comprehensive geriatric assessment by facilitating the early identification of patients who could benefit from further evaluation and closer clinical follow-up. External validation in independent cohorts is required before any clinical use, alongside longitudinal designs with repeated biomarker measures and integration of additional biological layers, to enhance generalizability and confirm clinical utility. Within these limits, the analysis highlights the potential of routine laboratory data to support digitally enabled frailty screening and workflow-integrated risk stratification in primary care and remote geriatric care settings.

Impact of a New Virtual Health Humanities Approach for Collaborative Online International Learning: Mixed Methods Study

2026-10-28T13:00:27-04:00

Background: This study presents a novel virtual health-humanities approach to collaborative online international learning, developed and delivered between 2023 and 2025. The approach, which we describe for the purposes of this study as a “Health Humanities Global Classroom” (HHGC), aimed to raise health professions students’ awareness of intercultural perspectives, potentially fostering more interculturally attuned health professionals. In the HHGC, students across 3 international universities participated synchronously in a virtual object-based learning seminar using shared teaching expertise and digitized artworks and museum objects drawn from the universities’ diverse art and cultural collections. Objective: This mixed methods research study aimed to assess the HHGC’s impact on encouraging a deeper awareness of intercultural perspectives in participants. Methods: A mixed methods study was conducted, involving 58 health professions students from universities in Australia, Singapore, and Hong Kong in February 2025 and March 2025. All students participated in a 2-hour online seminar with the theme of global health and well-being, during which they undertook guided exploration of virtual museum objects and artworks. Data on students’ seminar experiences were collected through presurveys and postsurveys, written reflections created during the seminar, and online focus groups conducted immediately afterward. Results: All 58 students participated in the focus groups. Among the participants, 84% (49/58) completed the postseminar survey; 96% (47/49) agreed that the seminar increased their awareness of how they communicate and exchange meanings with peers from diverse cultures; 98% (48/49) agreed that engaging with the museum objects in the seminar with peers heightened their awareness of diverse perspectives; and 86% (42/49) agreed that the seminar increased their awareness of local health in interprofessional contexts. Four primary themes were identified through qualitative analysis, including (1) key learning outcomes (intercultural, analytical, and empathic capacities, and knowledge acquired), (2) enabling factors (pedagogy, environment, and peer interaction), (3) barriers to learning (pedagogical approach, learning resources, time factors, and virtual constraints), and (4) novel and distinctive experiences (international, arts-integrated learning). Conclusions: This study provides early evidence for an innovative and accessible pedagogical approach. The HHGC is promising as a valuable educational activity, with positive student engagement in a safe environment for intercultural dialogue mediated by virtual museum objects and artworks. This approach may be useful to enhance participants’ awareness of cultural humility.

Impact of Elevated Blood Pressure Targets on Splanchnic Ischemia and Mortality in Septic Resuscitation: Systematic Review

2026-10-27T11:00:30-04:00

Background: Sepsis causes deaths worldwide each day, with hemodynamic resuscitation being central to management. Guidelines recommend a 65-mm Hg mean arterial pressure (MAP) target, yet the evidence for elevated targets remains fragmented across mortality, renal, and splanchnic outcomes. Objective: This review aims to comprehensively appraise the impact of elevated MAP targets on splanchnic ischemia, mortality, and organ-specific outcomes in septic resuscitation. Methods: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines, we systematically searched PubMed, the Cochrane Library, and Google Scholar for studies comparing MAP targets in septic shock. Risk of bias was assessed using the Cochrane Risk of Bias 2 (RoB 2; randomized controlled trials [RCTs]) and the Newcastle-Ottawa Scale (nonrandomized studies). The findings were synthesized narratively according to the Synthesis Without Meta-Analysis guidelines, with random-effects meta-analysis for mortality outcomes. Evidence certainty was graded using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Results: From 3254 records, 11 studies (2895 patients; 4 RCTs, 7 nonrandomized) met the inclusion criteria. Pooled 90-day mortality across 3 trials showed a nonsignificant trend toward higher mortality with elevated MAP targets (320/720, 44.4% vs 280/722, 38.8%; OR 1.31, 95% CI 0.97‐1.77). Pooled 28- or 30-day mortality showed a similar nonsignificant trend (OR 1.25, 95% CI 0.98‐1.61), which was robust to sensitivity analysis. Narratively, mortality findings across nonpooled observational studies were inconsistent; some linked low MAP to higher death risk, and others found no significant association. Renal outcomes were inconsistent, with some studies showing reduced renal replacement therapy or improved acute kidney injury recovery at higher targets, particularly in hypertensive or cirrhotic subgroups. Elevated MAP targets consistently increased vasopressor exposure and were associated with more arrhythmias and fewer organ support–free days. No study reported splanchnic ischemia as a discrete outcome; mesenteric ischemia rates were low and similar between arms. Overall certainty of evidence was very low. Conclusions: Higher MAP targets show no clear mortality or splanchnic perfusion benefit and may increase overall harm, though select subgroups, chronic hypertension, and cirrhosis, may benefit, supporting individualized, risk-stratified MAP targeting over uniformly elevated-target strategies.

Intravenous N-Acetylcysteine in Patients With Dengue Fever With Marked Aminotransferase Elevation: Prospective Comparative Study

2026-10-05T16:30:17-04:00

Background: Dengue fever can lead to significant hepatic involvement and marked aminotransferase elevation and is associated with increased morbidity and prolonged hospitalization. N-acetylcysteine (NAC) has been proposed as a supportive therapy for dengue-induced liver injury. However, prospective comparative evidence from endemic regions such as Vietnam remains limited. Objective: This study aimed to evaluate the association between intravenous NAC administration and clinical outcomes (primarily length of hospital stay), as well as the secondary effects of NAC on liver transaminase levels (posttreatment aspartate aminotransferase [AST] and alanine aminotransferase [ALT] and their changes from baseline) and platelet recovery in patients with dengue fever with marked aminotransferase elevation (AST or ALT ≥400 U/L). Methods: A prospective, nonrandomized comparative study was conducted at the Department of Tropical Diseases, Viet Tiep Hospital, Hai Phong, Vietnam, from June to December 2024. A total of 128 adult patients with laboratory-confirmed dengue fever and marked aminotransferase elevation (AST and/or ALT ≥400 U/L) were enrolled. Treatment allocation was not randomized and was determined by the treating physicians based on aminotransferase elevation and overall clinical condition. Patients received either intravenous NAC (100 mg per kilogram per day) plus standard supportive care (NAC group; n=68) or standard care alone (non-NAC group; n=60). The primary outcome was length of hospital stay. Secondary outcomes included liver transaminase levels and platelet recovery at discharge. Results: Baseline AST, ALT, bilirubin, and international normalized ratio values were broadly comparable between groups, although several clinical and hematological characteristics differed at baseline. The NAC group had a significantly shorter hospital stay (mean 5.01, SD 1.28 vs 6.12, SD 1.25 days; P<.001). The AST and ALT levels were significantly lower in the NAC group (AST: mean 154.83, SD 67.22 vs 184.62, SD 79.88 U/L and P=.02; ALT: mean 113.09, SD 33.31 vs 156.35, SD 73.66 U/L and P=.004). The posttreatment platelet count was significantly higher in the NAC group (median 31.50, IQR 19.00-50.15 G/L vs 17.00, IQR 8.75-36.23 G/L; P=.001). The median increase in platelet count was also greater in the NAC group (15.05, IQR 7.05-26.10 G/L vs 6.95, IQR 4.22-15.43 G/L; P=.001). No severe infusion-related adverse events were documented during the study period. Conclusions: In this prospective, nonrandomized comparative study, intravenous NAC administration was associated with shorter hospitalization and lower posttreatment aminotransferase levels in adult patients with dengue fever and marked aminotransferase elevation. No severe infusion-related adverse events were documented during the study period. However, the nonrandomized design and potential for confounding limit causal inference. Larger, multicenter randomized controlled trials are warranted to clarify the therapeutic role of NAC in dengue-related hepatic complications.

Design, Facilitation, and Evaluation of Tabletop Exercises for Prehospital Mass Casualty Preparedness: Scoping Review

2026-10-05T15:45:03-04:00

Background: Tabletop exercises (TTXs) are commonly used to enhance prehospital readiness for mass casualty incidents (MCIs). However, evidence on their design, facilitation, and evaluation remains scattered. TTXs simulate organized interactions at 3 levels: among individual responders and response protocols, within interdisciplinary teams, and across organizations and systems. While existing reviews cover tabletop simulation generally, they do not specifically focus on the prehospital MCI interface or assess whether evaluation methods match the exercise objectives. Objective: This scoping review aimed to explore how TTXs are designed, facilitated, and evaluated in prehospital MCI preparedness. It classified outcomes using the Kirkpatrick Evaluation Model and analyzed how evaluation methods align with the purpose of each exercise. Methods: We performed a scoping review following Arksey and O’Malley’s framework, with enhancements from Levac et al, along with PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) and PRISMA-S (PRISMA Extension for Reporting Literature Searches) guidelines. Searches across PubMed, Embase, Scopus, PsycINFO, CINAHL, the Cochrane Library, ClinicalTrials.gov, Google Scholar, and references were limited to English peer-reviewed and gray literature published from 2015 to May 2026. Eligible studies focused on TTXs related to prehospital disaster or MCI preparedness and reported measurable educational, clinical, or system outcomes. The review protocol was registered beforehand on Protocols.io. Two reviewers (PP and AA) independently screened records, extracted data, and classified outcomes using Kirkpatrick levels, with an added level 2+ (Applied Learning) category for structured performance evaluation during exercises. Results: Thirteen studies from 9 countries were included. They were categorized into a preliminary 3-tier typology called the TTX Design Spectrum, representing increasing levels of interaction: algorithm-rehearsal exercises (n=2) focused on individual responders’ interaction with triage protocols, scenario-based decision-training exercises (n=7) aimed at multidisciplinary team decision-making under realistic conditions, and systems integration exercises (n=4) centered on interagency coordination and system-level preparedness. Facilitation varied by exercise purpose, from standardized assessment-focused approaches to expert-led and multidisciplinary facilitation. Evaluation primarily targeted Kirkpatrick level 1: Reaction (n=10), level 2: Learning (n=10), and level 2+ (Applied Learning) (n=8), with fewer studies examining level 3: Behavior (n=2) or level 4: Results (n=3). Operational frameworks were reported more consistently than formal educational design or assessment frameworks. Additionally, natural disaster scenarios and evidence from resource-limited settings were underrepresented. Conclusions: TTXs for prehospital MCI preparedness should be viewed as a collection of related exercise types rather than a single, uniform intervention. This review introduces an initial typology called the TTX Design Spectrum, along with the level 2+ (Applied Learning) classification, which operationalizes the distinction between in-training performance and behavioral transfer. These tools aim to help align exercise purpose, facilitation, and evaluation strategies. Future research should focus on validating this typology, enhancing follow-up assessments of behavioral transfer, and adapting TTX design for natural disaster and resource-limited settings.

Codeveloping a Clinical Pathway for Recurrent Clostridioides difficile Infection With Primary Care Providers: User-Centered Design Study

2026-09-30T13:45:12-04:00

Background: infection (CDI) is the most common cause of health care–associated infectious diarrhea; however, variability in laboratory testing results in uncertainty in diagnosis and clinical decision-making. Recurrent CDI (rCDI), defined as the return of infection following initial treatment, continues to present significant clinical challenges due to limited therapeutic options. Although health care providers are familiar with vancomycin as first-line therapy for CDI, many are less familiar with fecal microbiota transplantation (FMT), despite its recommendation in clinical guidelines for rCDI management. Consequently, primary care providers (PCPs) may experience uncertainty regarding diagnostic test interpretation, treatment selection, and referral for FMT, highlighting the need for practical clinical tools to support evidence-based management. Objective: This study will support the standardization of care and improve patient treatment experiences in Alberta by identifying barriers and facilitators encountered by PCPs in managing CDI and rCDI, using these findings to codevelop a provincial rCDI clinical pathway. Methods: This qualitative study investigated the codevelopment process of a provincial rCDI clinical pathway between the study team and intended end users. A draft pathway was developed by the study team comprising gastroenterology and infectious disease specialists, followed by an iterative end user–centered design approach. PCP participants completed 2 rounds of 60‐ to 90-minute virtual, one-on-one, semistructured interviews incorporating scenario-based usability testing with standardized clinical cases. Using a think-aloud approach, participants evaluated the pathway’s clarity, diagnostic decision-making, treatment recommendations, referral processes, and integration into clinical workflows. Feedback was analyzed using thematic analysis, informed iterative revisions were made to the pathway and accompanying user guide, and they were reevaluated in a second round of interviews. Results: Out of 30 invited PCPs, 3 (10%) participated in this study. During the first round of interviews, participants identified challenges interpreting PCR-positive vs toxin-positive test results, navigating the pathway layout, locating embedded hyperlinks, and understanding FMT referral processes. Iterative, feedback-driven revisions addressed these barriers by improving diagnostic guidance, simplifying navigation, increasing hyperlink visibility, and clarifying referral timing with a user guide. During the second round of interviews, all participants reported that modifications improved CDI test result interpretation, streamlined navigation, enhanced workflow integration, and increased confidence in applying the pathway to clinical scenarios. The final version of this pathway was well received for its clarity, readability, and clinical utility, and was viewed as a valuable educational resource for supporting evidence-based management of CDI. Conclusions: This study demonstrated the feasibility and value of codeveloping a provincial clinical pathway with physician partners for managing CDI and rCDI. The resulting tool was clear, practical, and aligned with primary care workflows. This iterative, user-centered design was useful for developing clinically relevant decision support tools. Future research should evaluate the pathway’s implementation and impact on physician practice, patient care, and clinical outcomes using quantitative and qualitative methods.

Factors Influencing Adherence to Digital Lifestyle Interventions for Adolescents: Systematic Review and Meta-Analysis of Attrition

2026-09-30T13:30:12-04:00

Background: Intervention studies frequently report that fewer than half of adolescent participants complete digital health interventions as intended, yet a systematic synthesis of the factors driving this low adherence across lifestyle domains is lacking. Understanding these factors is essential for informing the design of interventions that can sustain adherence and achieve meaningful behavioral outcomes. Objective: This systematic review identified and analyzed factors influencing adherence to digital health interventions targeting key adolescent lifestyle domains: physical activity, dietary habits, obesity management, alcohol consumption, and tobacco use. Methods: We systematically searched PubMed, PsycINFO, Embase, and CINAHL in March 2024, with the search updated in June 2026, for studies of digital interventions targeting adolescents (10‐19 years). Studies were included if they reported adherence outcomes. Data on intervention characteristics, user-related factors, and adherence outcomes were extracted and narratively synthesized using a framework distinguishing intervention-related and user-related factors across 3 evidence types (statistical, descriptive, and qualitative). Study-level attrition was additionally pooled in a random-effects meta-analysis. Results: A total of 116 studies, comprising 46,029 participants, were included. The average completion rate (binary measure) was 66.9% (SD 26%), while average adherence to individual intervention components was 55.2% (SD 25.5%). A meta-analysis of attrition across 108 comparisons yielded a pooled dropout of 16.9% (95% CI 13.6‐20.9), with very high between-study heterogeneity and no significant moderators. Consistently reported facilitators included personalization, user-friendly design, reminders, goal setting, gamification, and human support (particularly health coaching and parental involvement). The most common barriers were technical difficulties and poor system usability. Evidence regarding the effects of intervention duration and social components on adherence was inconsistent. Conclusions: Given that adolescents frequently underuse digital health interventions, completing only about half of intervention components on average, the effectiveness of these interventions is fundamentally constrained by adherence challenges. Adherence is primarily driven by user-centered design features and robust technical performance, while the impact of social and user-related factors varies by health domain and study context. Future research should adopt standardized adherence frameworks and reporting standards to enable meaningful cross-study comparisons and the development of evidence-based engagement strategies.

The Shifting Landscape of Natural Health Product Licensing in Canada: The e-Commerce Case of Stem Cell Supplements

2026-09-28T15:00:14-04:00

Natural health product (NHP) regulations have shifted in Canada, with the aim of reducing “red tape” and enabling market entry. This study assessed how many “stem cell” supplements for sale on Amazon.ca had Health Canada–required natural product number (NPN) licenses compared with vitamin D and “longevity” supplements. It also conducted a marketing overview analysis comparing the Amazon.ca discourse across the 3 product types. Findings show a gap in regulatory licensing compliance between “stem cell” supplements and vitamin D or “longevity” supplements. Marketing discourse also presented potential conflict with regulatory parameters. We discuss the impacts of loosening NHP regulations and the potential for products with weak evidentiary bases to enhance validation through NPN licensing.

Clinical Effectiveness and Cost-Effectiveness of Blended Treatment for Major Depression Compared With Treatment as Usual Within Routine Care in Europe: A Noninferiority Randomized Controlled Trial

2026-09-24T16:45:10-04:00

Background: Cognitive behavioral therapy (CBT) is an effective and widely used treatment for major depressive disorder (MDD). However, access is limited by long waiting lists and a shortage of trained therapists. Evidence-based guided and self-guided digital interventions can address these challenges, but their large-scale adoption in routine primary and specialized mental health care has been slow. Blended CBT (bCBT), combining face-to-face therapy with structured, guided digital treatment modules, may increase treatment capacity while maintaining the benefits of therapist support. Objective: The European Comparative Effectiveness Research on Internet-based Depression Treatment study, conducted across 9 European countries, is the first large-scale comparative bCBT study for MDD. The hypothesis was that bCBT is clinically noninferior and cost-effective when compared with treatment as usual (TAU), which mainly consisted of face-to-face CBT. Methods: A multisite randomized controlled trial was conducted with a noninferiority margin of =0.20. Main inclusion criteria were age ≥18 years, a diagnosis of MDD based on the Mini International Neuropsychiatric Interview, and a baseline Patient Health Questionnaire-9 (PHQ-9) score of ≥5. The primary outcome was the PHQ-9, with secondary outcomes including MDD remission at 12 months, therapeutic alliance, and costs. Intention-to-treat analyses were performed, and linear mixed modeling was used to assess intervention effects. Cost-effectiveness analyses were conducted from a health care perspective. Results: A total of 835 patients were included in the study. bCBT was shown to be noninferior to TAU on the primary PHQ-9 outcome during treatment (3 months after the baseline assessment, =−0.26, 95% CI −0.43 to −0.09), at 6 months (posttreatment, =−0.21, 95% CI −0.39 to−0.04), and at 12-month follow-up (=−0.01, 95% CI −0.19 to 0.17). Furthermore, the bCBT group had a significantly lower likelihood of experiencing an MDD episode at 12 months (odds ratio 0.67, 95% CI 0.45‐0.99). Subgroup analyses indicated that participants with and with no antidepressant use at baseline in both groups benefited equally from their treatment. Deterioration rates (Reliable Change Index) were below 5% in both groups. bCBT appeared acceptable for patients and therapists, with a strong working alliance in both groups. From a health care perspective, bCBT was not cost-effective at 12 months' assessment, as its total costs were not significantly lower than TAU. However, the probability that bCBT is cost-effective is high (0.95) at a willingness to pay (WTP) of €3800 per improvement in the PHQ-9 score, and 0.76 at a WTP of €10,000 per MDD case prevented (average 2017 exchange rate was €1=US $1.13). Conclusions: bCBT offers an effective and safe digitally supported alternative to face-to-face TAU for patients with MDD and their therapists in routine clinical care. From a health care perspective, its cost-effectiveness depends on policymakers’ WTP for the additional clinical benefits achieved. Trial Registration: ClinicalTrials.gov NCT02796573; https://clinicaltrials.gov/study/NCT02796573 and ClinicalTrials.gov NCT02542891; https://clinicaltrials.gov/study/NCT02542891 and German Clinical Trials Register DRKS00006866; https://drks.de/search/en/trial/DRKS00006866 and Netherlands Trials Register NTR4962; https://www.onderzoekmetmensen.nl/en/trial/25452 and ClinicalTrials.gov NCT02389660; https://clinicaltrials.gov/study/NCT02389660 and ClinicalTrials.gov NCT02361684; https://clinicaltrials.gov/study/NCT02361684 and ClinicalTrials.gov NCT02449447; https://clinicaltrials.gov/study/NCT02449447 and ClinicalTrials.gov NCT02410616; https://clinicaltrials.gov/study/NCT02410616 and ISRCTN Registry ISRCTN12388725; https://www.isrctn.com/ISRCTN12388725 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-016-1511-1

Burden of Insomnia Among Individuals With Major Depressive Disorder: Cross-Sectional Observational Study

2026-09-21T16:30:12-04:00

Background: Insomnia is a common and persistent symptom in major depressive disorder (MDD), associated with poorer outcomes and reduced quality of life (QoL). Despite its prevalence, recent patient-reported data on the burden of insomnia symptoms in MDD remains limited. Objective: This study aimed to assess the burden of insomnia among individuals with MDD experiencing insomnia symptoms (MDDIS) and its impact on patient-perceived disease burden and QoL. Methods: A noninterventional, cross-sectional online study was conducted from October 2022 to February 2023 in adults with self-reported MDD and insomnia symptoms, residing in the United States or 1 of 5 European countries (EU5: France, Germany, Italy, Spain, and the United Kingdom). Participants completed validated questionnaires (Patient Health Questionnaire-9 [PHQ-9] for depression severity and Insomnia Severity Index [ISI] for insomnia severity) and provided data on demographics, clinical history, treatment experience, and perceptions. Descriptive statistics were used to summarize results, and subgroup analyses were conducted based on depression status and severity. Results: Among 1250 participants (United States: 500; EU5: 750), most were cisgender women (United States: 363/500, 72%; EU5: 637/750, 85%), aged ~48 years, and on average 13.4 years in the United States and 11.2 years in EU5 had passed since being diagnosed with MDD. Around 60% (United States: 312/500; EU5: 439/750) reported having moderate to severe insomnia symptoms. Most had used antidepressants (United States: 460/500, 92%; EU5: 646/750, 86%) at least 40% (United States: 198/500; EU5: 343/750) in both regions reported using sleep-related medications (over-the-counter sleep aids, dual-purpose medication, or sleep-specific medication). However, insomnia symptoms persisted, with around half of participants reporting 8 to 15 insomnia nights over 2 weeks. Insomnia symptom severity differed significantly according to depression severity and current depressive episode status. Nearly all participants reported negative consequences for daily functioning, including irritability, cognitive impairment, and reduced productivity, and approximately two-thirds identified sleep disturbances as having a major impact on their daily lives. Satisfaction with current treatments, particularly their effectiveness on sleep, was low, and 65%‐71% (488/750-354/500) of participants expressed a desire for alternative therapies. Conclusions: Insomnia symptoms are highly prevalent and burdensome among patients with MDD, severely affecting daily life and perceived treatment success. Insomnia remains inadequately controlled despite high medication use. These findings emphasize the need for integrated treatment strategies targeting both mood and sleep symptoms. Given its role in depression relapse, suicidality, and treatment resistance, addressing insomnia symptoms in MDD should be a clinical priority.