AI-Assisted Mindfulness Intervention in Emotional Distress

The GAD-7 is a 7-item self-report questionnaire used to assess the severity of anxiety symptoms over the past 2 weeks. Each item is rated on a 4-point scale from 0 ("not at all") to 3 ("nearly every day"), with total scores ranging from 0 to 21. Higher scores indicate greater anxiety severity. The GAD-7 has demonstrated good reliability and validity in both clinical and general populations (Spitzer et al., 2006).

The PHQ-9 is a 9-item self-report questionnaire used to assess the severity of depressive symptoms over the past 2 weeks. Each item is rated on a 4-point scale from 0 ("not at all") to 3 ("nearly every day"), with total scores ranging from 0 to 27. Higher scores indicate greater depression severity. The PHQ-9 has demonstrated good reliability and validity in both clinical and general populations (Kroenke et al., 2001).

TIC-P is a widely used health economic instrument in mental health research for assessing psychiatric healthcare use and societal costs, including service utilization, medication use, and productivity losses (Bouwmans et al., 2013). In this study, TIC-P will be used to record healthcare resource consumption during the trial, including outpatient visits, medication costs, and other healthcare-related expenditures. To capture healthcare utilization more comprehensively, a self-developed healthcare utilization questionnaire will also be administered.

This is one of the most widely used instruments in health economic evaluation for measuring health-related quality of life and includes five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression, each with five response levels (Devlin & Brooks, 2017; Herdman et al., 2011). The health utility values derived from EQ-5D-5L will be used to calculate Quality-Adjusted Life Years (QALYs) for cost-utility analysis (Drummond et al., 2015; Group, 1990).

Resilience will be measured using the Connor-Davidson Resilience Scale (CD-RISC), one of the most widely used instruments for assessing the ability to cope with stress and adversity, with good reliability and validity (Connor & Davidson, 2003).

Perceived stress will be measured using the Perceived Stress Scale (PSS), a widely used instrument that assesses individuals' subjective appraisal of stress over a recent period (Cohen et al., 1983).

Life satisfaction will be measured using the Satisfaction With Life Scale (SWLS), which assesses individuals' cognitive evaluation of their overall life circumstances and has sound psychometric properties (Diener et al., 1985).

Sleep status will be assessed using the Insomnia Severity Index (ISI), a brief 7-item self-report scale widely used in clinical and digital health research to assess the severity of insomnia symptoms and their impact on daily functioning (Bastien et al., 2001; Morin et al., 2011).

The OASIS is a 5-item self-report measure designed to assess the frequency and severity of anxiety symptoms, as well as the extent of anxiety-related functional impairment and avoidance, over the past week. Each item is rated on a 5-point scale from 0 to 4, with total scores ranging from 0 to 20. Higher scores indicate greater overall anxiety severity and impairment. The OASIS has demonstrated good reliability and validity in both clinical and nonclinical samples (Norman et al., 2006).

The ODSIS is a 5-item self-report measure designed to assess the frequency and severity of depressive symptoms, as well as depression-related functional impairment and avoidance, over the past week. Each item is rated on a 5-point scale from 0 to 4, with total scores ranging from 0 to 20. Higher scores indicate greater overall depression severity and impairment. The ODSIS has demonstrated good reliability and validity in both clinical and nonclinical samples (Bentley et al., 2014).

Mindfulness will be assessed using the Five Facet Mindfulness Questionnaire (FFMQ). The FFMQ measures trait mindfulness across five dimensions: observing, describing, acting with awareness, nonjudging of inner experience, and nonreactivity to inner experience. It is one of the most widely used instruments in mindfulness research and has demonstrated good reliability and validity (Baer et al., 2006). In this study, the total FFMQ score and its subscale scores will be analyzed as exploratory continuous variables

The Engaging in Life Scale will be used to assess the degree to which individuals engage in key life domains such as work, study, social interaction, and sleep, and is an important tool for evaluating levels of engagement in life (Chen et al., 2026).

Distress tolerance will be assessed using the Distress Tolerance Scale (DTS), which measures individuals' capacity to tolerate negative emotional experiences and their regulatory responses to emotional distress (Simons & Gaher, 2005).

The Discomfort Intolerance Scale (DIS) will be used to assess tolerance of unpleasant bodily sensations, which has been widely applied in anxiety disorder and emotion regulation research (Schmidt et al., 2006).

The Excessive Emotional Behavior Scale (EEBS) will be used to assess excessive emotion-driven and avoidant behaviors under negative affective states, thereby providing a more comprehensive assessment of this psychological process (Zhang et al., 2026).

The Brief Experiential Avoidance Questionnaire (BEAQ) will be used to further assess experiential avoidance as a core process (Gámez et al., 2014).

Cognitive flexibility will be measured using the Cognitive Flexibility Inventory (CFI), which assesses individuals' ability to shift cognitive frameworks, generate alternative explanations, and adopt adaptive thinking strategies under stress (Dennis & Vander Wal, 2010).

To evaluate the role of AI support in the intervention, the following behavioral data will be recorded: number of interactions with the AI assistant, number of personalized feedback responses, and daily duration of use. Associations between these variables and intervention outcomes will then be analyzed.

To assess the scalability of iMIED in real-world settings, the following indicators will be measured: intervention completion rate, average usage frequency, participant adherence (proportion of exercises completed), and user satisfaction.

Satisfaction will be measured using the Client Satisfaction Questionnaire (CSQ-8), an 8-item instrument assessing participants' overall satisfaction with the intervention service (Attkisson & Zwick, 1982).

To evaluate the safety of the intervention, this study will record adverse events (AEs) and serious adverse events (SAEs) occurring during the study period. These events will be defined, documented, and reported in accordance with international clinical trial guidelines, and will be descriptively analyzed with respect to the time of occurrence, severity, relationship to the intervention, and outcomes, in order to comprehensively assess the safety and acceptability of iMIED (Guideline, 1994).