Research Appraisals
Evidence-based critical appraisals of the latest medical research, systematically evaluated using Oxford CEBM methodology.
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JMIR formative research
Cultural Relevance and Acceptability of Cognitive Behavioral Therapy Techniques Adapted by AI or a Human Psychologist: Experimental Study
BACKGROUND: Evidence-based psychological interventions are usually not accessed by marginalized groups such as refugees. Culturally adapted psychological interventions have reported larger effect sizes than nonadapted psychological interventions. However, the cultural adaptation of interventions is a lengthy process, entailing a challenge. One potential solution to overcome this challenge is the use of artificial intelligence (AI). OBJECTIVE: The aim of this study was to investigate and compare the perceived cultural relevance and acceptability of 2 common cognitive behavioral therapy (CBT) techniques when translated and culturally adapted by AI versus a human psychologist. METHODS: In a 2×2 factorial design, the text generator type (AI vs human psychologist) and the CBT technique (cognitive restructuring vs behavior modification) were compared. CBT technique texts translated and culturally adapted either by AI or by a human psychologist were blindly rated using the Cultural Relevance Questionnaire and the Theoretical Framework of Acceptability. Raters were Arabic-speaking refugees and immigrants, aged between 18 and 69 years, residing in Sweden, Denmark, and Germany. Raters were randomly allocated to 1 of 4 conditions. Each condition consisted of 2 stimuli. Two-factor between-subject design analyses were used to analyze the data. RESULTS: A significant main effect of the text generator domain type (P=.02; η²=0.045) was found in the first rating, with texts adapted by the AI domain perceived as more culturally relevant than those adapted by the human domain. No significant main effect of the CBT technique was found in the first rating (P=.10; η²=0.022). There were no differences in the second rating. Regarding acceptability, no significant main effects of text generator domain type (P=.09; η²=0.024) or the CBT technique (P=.88; η²=0.001) were found in either of the ratings. CONCLUSIONS: CBT technique materials adapted by AI may be perceived as similarly culturally relevant as those adapted by a human psychologist. This finding implies the potential to accelerate the cultural adaptation of psychological interventions. However, AI still needs to be used with caution and in accordance with rigorous safety standards and robust frameworks.
11 May 2026
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Delusional Experiences Emerging From AI Chatbot Interactions or "AI Psychosis"
The integration of artificial intelligence (AI) into daily life has introduced unprecedented forms of human-machine interaction, prompting psychiatry to reconsider the boundaries between environment, cognition, and technology. This Viewpoint reviews the concept of "AI psychosis," which is a framework to understand how sustained engagement with conversational AI systems might trigger, amplify, or reshape psychotic experiences in vulnerable individuals. Drawing from phenomenological psychopathology, the stress-vulnerability model, cognitive theory, and digital mental health research, the paper situates AI psychosis at the intersection of predisposition and algorithmic environment. Rather than defining a new diagnostic entity, it examines how immersive and anthropomorphic AI technologies may modulate perception, belief, and affect, altering the prereflective sense of reality that grounds human experience. The argument unfolds through 4 complementary lenses. First, within the stress-vulnerability model, AI acts as a novel psychosocial stressor. Its 24-hour availability and emotional responsiveness may increase allostatic load, disturb sleep, and reinforce maladaptive appraisals. Second, the digital therapeutic alliance, a construct describing relational engagement with digital systems, is conceptualized as a double-edged mediator. While empathic design can enhance adherence and support, uncritical validation by AI systems may entrench delusional conviction or cognitive perseveration, reversing the corrective principles of cognitive-behavioral therapy for psychosis. Third, disturbances in theory of mind offer a cognitive pathway: individuals with impaired or hyperactive mentalization may project intentionality or empathy onto AI, perceiving chatbots as sentient interlocutors. This dyadic misattribution may form a "digital folie à deux," where the AI becomes a reinforcing partner in delusional elaboration. Fourth, emerging risk factors, including loneliness, trauma history, schizotypal traits, nocturnal or solitary AI use, and algorithmic reinforcement of belief-confirming content may play roles at the individual and environmental levels. Building on this synthesis, we advance a translational research agenda and five domains of action: (1) empirical studies using longitudinal and digital-phenotyping designs to quantify dose-response relationships between AI exposure, stress physiology, and psychotic symptomatology; (2) integration of digital phenomenology into clinical assessment and training; (3) embedding therapeutic design safeguards into AI systems, such as reflective prompts and "reality-testing" nudges; (4) creation of ethical and governance frameworks for AI-related psychiatric events, modeled on pharmacovigilance; and (5) development of environmental cognitive remediation, a preventive intervention aimed at strengthening contextual awareness and reanchoring experience in the physical and social world. By applying empirical rigor and therapeutic ethics to this emerging interface, clinicians, researchers, patients, and developers can transform a potential hazard into an opportunity to deepen understanding of human cognition, safeguard mental health, and promote responsible AI integration within society.
1 Dec 2025
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