McKaylee Robertson

Background: Alcohol consumption is a modifiable risk factor linked to anxiety and depression, yet the population-level impact of reducing alcohol use on the prevalence of anxiety and depression symptoms remains unclear. Prior studies are limited by methodological challenges including health-related selection into abstinence, time-varying confounding and reverse causation. Methods: We used data from 2,813 participants without documented underlying health conditions in a U.S. national longitudinal cohort (September 2021-December 2023) and applied the parametric g-formula within a target trial emulation framework to estimate the effect of a hypothetical intervention reducing alcohol consumption to low-risk levels on the prevalence of moderate-to-severe anxiety (GAD-7 ≥10) and depression (PHQ-8 ≥10) symptoms. The intervention set moderate- and high-risk drinking to low-risk at each follow-up, while leaving abstinent and low-risk drinking unchanged. Models adjusted for time-varying and baseline covariates, with uncertainty estimated using bootstrap resampling. Results: Under the natural course, the estimated prevalence of moderate-to-severe depressive symptoms was 12.67% (95% CI: 12.17, 13.23), compared to 12.77% (95% CI: 12.26, 13.29) under the intervention (risk difference: 0.10 percentage points; 95% CI: -0.22, 0.50). For anxiety symptoms, prevalence was 10.40% (95% CI: 8.89, 11.89) under the natural course and 10.25% (95% CI: 8.76, 11.98) under the intervention (risk difference: -0.15 percentage points; 95% CI: -0.68, 0.35). Conclusions: Under a hypothetical population-wide intervention reducing alcohol consumption to low-risk levels, differences in the prevalence of moderate or severe anxiety and depression symptoms were near null. These findings suggest that reducing alcohol use alone may be insufficient to meaningfully shift the population-wide burden of common mental health disorders.

Background: Alcohol use and physical activity are common, interrelated behaviors with opposing associations to mental health, yet little is known about their joint relationship with anxiety and depression. This study evaluated whether the association between alcohol use and anxiety and/or depression symptoms differed by physical activity level in a large U.S. longitudinal cohort. Methods: Using data from 5,152 adults in the CHASING COVID Cohort (2021-2023), alcohol use was categorized as low-, moderate-, or high-risk based on repeated AUDIT-C assessments, and physical activity was classified as active versus sedentary using items adapted from the 2023 Behavioral Risk Factor Surveillance System. Moderate to severe symptoms of anxiety/depression, assessed subsequent to the exposure assessment period, was defined as a PHQ-8 or GAD-7 score ≥10. Log-binomial regression estimated adjusted risk ratios (aRRs) for associations between alcohol use and anxiety/depression symptoms within strata of physical activity. Effect modification by physical activity was evaluated on the additive and multiplicative scales. Analyses were repeated among healthier participants without chronic conditions or poor self-rated health to reduce sick-quitter bias (N=3,141). Results: Most participants had low-risk or no alcohol use (70.3%), followed by moderate-risk (21.9%) and high-risk use (7.8%); 29.5% were sedentary. Sedentary participants had higher risk of moderate to severe anxiety/depression symptoms than active participants across alcohol use levels overall and in the healthier subsample. In the overall sample, active participants with high-risk alcohol use had elevated risk compared with active participants with low-risk or no alcohol use (aRR = 1.44, 95% CI: 1.15-1.80) and physical activity did not modify the association between alcohol use and anxiety/depression symptoms on either scale. Among healthier participants, risk was highest among sedentary participants with moderate-risk alcohol use compared with active participants with low-risk or no alcohol use (aRR = 1.92, 95% CI: 1.50-2.45); physical activity modified the association between moderate-risk alcohol use and moderate to severe anxiety/depression symptoms on the additive scale (RERI = 0.61, p=0.013) and multiplicative scales (ratio of aRRs = 1.49, p=0.001). Conclusions: Among healthier adults, physical activity modified the association between moderate alcohol use and symptoms of anxiety or depression on additive and multiplicative scales. Findings suggest sedentary behavior may amplify mental health vulnerability associated with moderate drinking; future studies are warranted to clarify these relationships, including those with larger numbers of high-risk drinkers.

Background: Observational studies frequently report a J- or U- shaped association between alcohol use and anxiety and depression, with moderate drinkers appearing to have lower risk than abstainers. However, this pattern may be driven in part by confounding due to health-related selection into abstinence or low-risk drinking (sick-quitter bias), whereby individuals reduce or stop drinking in response to declining health that is independently associated with worse mental health outcomes. We aimed to evaluate whether this association reflects a causal effect or residual confounding driven by sick-quitter bias. Methods: We analyzed data from 4,673 participants in the CHASING COVID Cohort, a U.S. longitudinal study with repeated measures from September 2021 through December 2023. Alcohol use was assessed at five timepoints using the AUDIT-C and categorized as abstinent, low-risk, moderate-risk, or high/severe-risk. Using a target trial emulation framework, we estimated the effects of sustained alcohol use strategies on anxiety and depression symptom severity (GAD-7 and PHQ-8) at follow-up. Artificial censoring and stabilized inverse probability weighting were applied to account for time-varying confounding and loss to follow-up. To assess the role of sick-quitter bias, we compared the abstinent versus moderate-risk contrast across strata of health status at time zero. Results: In the full sample, a J-shaped pattern was observed, with moderate-risk drinkers having the lowest predicted symptom scores. The abstinent versus moderate-risk symptom score contrast was 1.38 for depression (PHQ-8: 95% CI: 0.65, 2.14), and 0.95 for anxiety (GAD-7: 95% CI 0.24, 1.65). Among participants without underlying conditions or poor self-rated health, this pattern attenuated, with contrasts near zero for both outcomes. In contrast, the J-shaped pattern was amplified among participants with poorer baseline health, with abstinent versus moderate-risk contrasts of 3.31 for depression (95% CI: 2.14, 4.32) and 2.83 for anxiety (95% CI: 1.61, 3.86). High-risk drinking was consistently associated with higher symptom scores across all analyses. Conclusions: The J-shaped pattern between alcohol use and anxiety and depression symptoms observed in the full cohort was attenuated among participants without poorer baseline health, consistent with sick-quitter bias. Findings underscore the importance of addressing confounding due to declining health in observational alcohol research and caution against interpreting moderate drinking as beneficial for symptoms of anxiety and depression.

During the 2025-26 respiratory virus season, changes to COVID-19 vaccine eligibility, recommendations, and communication may have made vaccination follow-through especially challenging. Under-vaccination may reflect not only lack of willingness, but also breakdowns between willingness and uptake. We analyzed data from 3,390 adults in the CHASING COVID Cohort who completed assessments in August 2025 and March 2026 to examine gaps between vaccine willingness and subsequent influenza and COVID-19 vaccination. Vaccine willingness was defined using prior-season vaccination and stated intention to vaccinate during the 2025-26 respiratory virus season. In August 2025, 73% of participants were influenza vaccine willing and 68% were COVID-19 vaccine willing. Among vaccine-willing participants, 17% and 39% were unvaccinated for influenza and COVID-19, respectively, by March 2026. Absence of prior-season vaccination was the strongest predictor of not vaccinating for influenza and COVID-19, respectively (aRR [95% CI]: 4.04 [3.44-4.74]; 3.01 [2.72-3.34]). Non-vaccination was also associated with food insecurity (1.99 [1.66-2.37]; 1.47 [1.33-1.63]), any healthcare barrier (1.89 [1.57-2.28]; 1.51 [1.36-1.67]), and being not at all confident in vaccine safety (2.95 [2.15-4.05]; 2.21 [1.88-2.59]). Trajectory analyses suggested willingness-uptake gaps reflected incomplete follow-through on intentions and discontinuation among some prior vaccinators. Commonly reported reasons among vaccine-willing non-vaccinators included difficulty finding a convenient time, place, or appointment and, for COVID-19, lack of healthcare provider recommendation. Findings among non-vaccinated adults with prior or stated openness to vaccinate highlight missed opportunities and suggest avenues to improve coverage through strategies that reinforce vaccine confidence, reduce access and logistical barriers, and make vaccination easier to complete.

Purpose The Prospective Respiratory Outcomes from Tracking and Evaluating Community-based TeSting study is a 2-year community-based, prospective cohort launched in 2024. The overall aim of the study is to better understand the burden and impact of acute and postacute COVID-19, influenza and respiratory syncytial virus (RSV) infections across the USA. Our key objectives are to measure the incidence and symptom burden of major respiratory viruses using home testing, measure incidence and risk factors for postacute symptoms of major respiratory viruses and investigate the impact of antivirals and vaccinations on acute and postacute symptoms of respiratory viruses. Participants Enrolment began in June 2024 using internet-based strategies. Eligible participants were adults aged ≥18 years who were US residents, English language proficient and had no known SARS-CoV-2, RSV or influenza infections in the 3 months before screening. We prioritised enrolment of individuals who were at high risk for severe SARS-CoV-2 outcomes. After enrolment, participants were prompted to report the presence or absence of respiratory symptoms weekly. When respiratory symptoms occurred, participants completed serial at-home multipathogen rapid antigen tests for SARS-CoV-2, RSV, influenza A and influenza B viruses, and daily symptom reporting, including timing and severity. A subset of participants provided self-collected nasopharyngeal and saliva samples for PCR testing. Following a positive test and acute symptom reporting for up to 29 days, participants were followed monthly for 6 months to capture postacute symptoms. Findings to date As of March 2025, 6206 people were enrolled in the cohort. The majority of the participants were over 50 years of age (61.4%), women (66.8%) and non-Hispanic white (75.2%), with a notable proportion having a college or postgraduate degree (68.4%) and an annual household income of >US$100 000 (40.7%). All 50 US states, the District of Columbia and Puerto Rico were represented in the cohort. Half of participants (51.8%) had received a COVID-19 vaccine in the year prior to enrolment, and 19.5% who had reported at least one SARS-CoV-2 infection had a history of antiviral use. A majority of the cohort (95.6%) had at least one underlying medical condition or risk factor for severe COVID-19. Nine-month retention (93.7%) and adherence to the study protocol among participants was high. As of 18 April 2025, 4537/6206 (73.1%) participants had reported respiratory symptoms within 10 days of onset, with a median time to report of 2 days after onset, and 3814/4537 (84.1%) conducting at least one valid rapid test. Of these 3814 participants, 489 (12.8%) had tested positive for SARS-CoV-2, 324 (8.5%) for influenza A, 22 (0.6%) for influenza B and 113 (2.9%) for RSV by study rapid or PCR tests. Future plans We enrolled a large, diverse cohort with a high proportion at risk for severe COVID-19. We have collected over 3000 person-years of data on symptoms, outcomes and risk factors for three major respiratory infections, with high participant retention and engagement through 9 months of data collection. Research priorities include characterising acute and postacute symptoms of major respiratory illnesses and assessing the impact of antivirals and vaccination on the development of severe symptoms.

Evidence-based strategies are needed to address the increasing healthcare system demands for people aging with HIV (PAWH). HIV case management models integrating access to primary care, specialty care, and supportive services represent a promising approach for healthy aging. We emulated a target trial comparing mortality outcomes through 36-month follow-up among people with HIV (PWH) enrolled in the New York City revised Care Coordination Program (CCR) versus a contemporaneous group of PWH who met CCR eligibility criteria but did not enroll in the CCR. To estimate the effect of the CCR on all-cause and cause-specific mortality, we used hazards regression with inverse probability of treatment weights controlling for clinical and demographic differences. From August 2018 to March 2021, 3040 individuals enrolled in the CCR. At enrollment, 43% of CCR enrollees were aged 50 years or older, 27% had a CD4 count <200 cells/µL, and 19% were diagnosed prior to 1996. In adjusted analyses, CCR enrollees had lower all-cause mortality (adjusted hazard ratio [aHR]: 0.71 [0.60–0.84]), driven primarily by reductions in HIV-related deaths. The effects on all-cause and HIV-related mortality were consistent among PAWH and younger PWH, among those lacking evidence of viral suppression (VS), and among those with lower CD4 counts (<350 cells/µL). The CCR appears to reduce all-cause and HIV-related mortality including among PWH at highest risk for poor outcomes. These findings suggest that integrated care coordination models—linking primary care, specialty care, and psychosocial services—offer survival benefits and multiple health outcomes improvements among PWH.

Food insecurity has increased in recent years, with inequities likely patterned by multiple, intersecting social identities/positions, such as educational attainment and race/ethnicity. Anxiety or depression symptoms may restrict material resources and increase food insecurity. Using an intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (I-MAIHDA) logistic model with random effects, we examined whether age, gender, race/ethnicity, and educational attainment inequities in persistent food insecurity are modified by symptoms of anxiety or depression. In a national cohort of U.S. adults (n=4,933) followed for over two years (2021-2023), 23% experienced persistent food insecurity, with a higher prevalence among those with anxiety or depression symptoms (49%). In the null model, 20% of variance in persistent food insecurity was attributable to intersectional social strata. Additive effects of social position explained 94% of between-stratum variance among adults without persistent symptoms and 99% among those with persistent symptoms of anxiety or depression. Predicted probabilities of food insecurity were highest among adults younger than 39 years, non-college-educated, identified as Black and Hispanic. Symptoms increased probabilities of persistent food insecurity by 14–38 percentage points. Findings highlight the importance of addressing food insecurity inequities tied to social positioning using universal proportionate interventions that integrate mental health support.