Mental vulnerability, family dysfunction, and digital exposure: Overlooked burdens in populations with noncommunicable chronic diseases

Abstract

In this article, we comment on the recent network analysis by Li et al, which explores depression, anxiety, and their associated factors in individuals with noncommunicable chronic diseases (NCDs). We highlight three often-overlooked domains in this population: Mental vulnerability (depression, anxiety, fatigue, nervousness), dysfunction in family functioning (family health, intimate partner violence), and digital exposure (media exposure, problematic internet use), and examine their dynamic interrelations within a psychosocial network framework. The findings reveal a complex system in which emotional dysregulation, family relational adversity, and digital behaviors mutually reinforce one another to heighten psychiatric risk. Notably, traditional demographic factors such as gender, ethnicity, and residence had minimal impact on overall network strength. We argue that these interconnected domains represent modifiable yet underrecognized targets for mental health intervention among medically vulnerable populations. Strategies that promote emotional resilience, strengthen family systems, and enhance digital literacy may play a pivotal role in disrupting maladaptive network pathways and improving quality of life for individuals with NCDs. Future research should prioritize longitudinal and multimodal designs to clarify causal mechanisms and support tailored, systems-level psychosocial interventions.

Key Words: Noncommunicable chronic diseases; Mental vulnerability; Family dysfunction; Digital exposure; Intervention strategies

Core Tip: This commentary underscores the dynamic interplay among emotional vulnerability, family dysfunction, and digital exposure in individuals with noncommunicable chronic diseases. By identifying these psychosocial factors as modifiable and transdiagnostic intervention targets, the article advocates for integrative strategies emotional resilience training, family-based support, and digital literacy enhancement to disrupt reinforcing risk pathways and improve mental health outcomes in medically vulnerable populations.

INTRODUCTION

Noncommunicable chronic diseases (NCDs), such as cardiovascular disease, diabetes, and cancer, represent a leading global health burden[1]. According to a 2022 report by the World Health Organization, chronic diseases account for over 17 million deaths worldwide each year[2]. In China, the prevalence of NCDs has risen sharply between 1992 and 2012, making them the primary cause of mortality among the Chinese population[3]. Beyond their physical consequences, individuals with NCDs frequently experience significant psychological distress, including depression and anxiety, which profoundly undermine both quality of life and treatment adherence[4,5]. While prior research has examined biomedical and demographic determinants of mental health in this population[6], far less attention has been devoted to key psychosocial domains that may exert similarly profound effects.

Li et al[7] conducted a cross-sectional survey of 6182 Chinese individuals with NCDs using data from the psychology and behavior investigation of Chinese residents. Through network analysis, they identified core psychosocial factors in individuals with NCDs (e.g., media exposure, family health, problematic internet use, intimate partner violence, anxiety, nervousness, low energy) as well as bridge factors (e.g., media exposure, problematic internet use, intimate partner violence), and proposed interventions targeting these key symptoms. Notably, this study represents the first preliminary investigation of the network relationships among these key psychosocial domains namely, mental vulnerability (e.g., emotional dysregulation, fatigue), family dysfunction (e.g., family conflict, intimate partner violence), and digital exposure (e.g., media consumption, problematic internet use) highlighting their potential interconnections. However, the interactions among these domains remain insufficiently explored, and to date, no other study has systematically examined their interrelationships in NCD populations.

In this commentary, we argue that these domains constitute modifiable psychosocial burdens in individuals with NCDs, and that addressing their interconnections may provide valuable targets for interventions aimed at improving psychological outcomes. By highlighting their interdependence within a dynamic network framework, we call for greater attention to these domains in both research and intervention development. Specifically, we examine: (1) The unique roles of these domains in shaping psychological outcomes among individuals with NCDs; (2) The interactions among these domains and their reinforcing nature within psychosocial networks; (3) Potential intervention strategies that target these interconnected domains; and (4) Limitations of the current evidence and directions for future research. Through this synthesis, we aim to promote a more integrative and actionable understanding of psychosocial determinants of mental health in NCD populations.

MENTAL VULNERABILITY IN INDIVIDUALS WITH NCDS

On the one hand, preexisting psychological vulnerabilities including heightened sensitivity to emotional distress, impaired affect regulation, and maladaptive coping styles may predispose individuals to worse psychological outcomes once they are diagnosed with a NCD. Such vulnerabilities can arise from prior psychiatric conditions (e.g., history of depression or anxiety disorders), early-life adversity, or enduring personality traits such as high neuroticism[8,9]. Evidence indicates that these factors amplify emotional reactivity to health-related stressors, increase perceived illness threat, and reduce the capacity to adaptively cope with chronic symptoms[10,11]. Neurobiological mechanisms, including preexisting dysregulation of the hypothalamic-pituitary-adrenal axis and altered inflammatory profiles, may further heighten susceptibility to mental distress when confronted with the demands of managing an NCD[12,13]. However, the literature on NCDs has paid relatively little attention to how such baseline vulnerabilities shape the trajectory of psychological adjustment, representing a critical gap in the understanding of the heterogeneity of mental health outcomes in these populations.

On the other hand, psychological consequences secondary to NCD onset also contribute substantially to mental vulnerability. These include illness-related fatigue[14,15], prognostic uncertainty[16,17], functional limitations[18,19], and perceived social stigma[18,20]. For example, individuals with diabetes may experience guilt and shame associated with lifestyle-related attributions[21], while those with cancer often endure existential distress linked to mortality salience and identity disruption[22]. Such illness-driven stressors can precipitate emotion dysregulation defined as difficulty modulating emotional responses in accordance with contextual demands which is consistently associated with poorer self-care, lower treatment adherence, and worsened clinical outcomes[23]. Over time, these maladaptive patterns can impair executive functioning[24,25], goal-directed behavior[26], and interpersonal relationships[27], creating a reinforcing cycle of psychosocial and physical decline.

DYSFUNCTION IN FAMILY FUNCTIONING AMONG INDIVIDUALS WITH NCDS

Family functioning plays a pivotal role in shaping the psychosocial trajectory of individuals living with NCDs. Two critical yet underrecognized domains of dysfunction family health[28,29] and intimate partner violence[30] have emerged as salient contributors to emotional burden, behavioral dysregulation, and poor clinical outcomes in this population.

On the one hand, family dysfunction can lead to or exacerbate psychological distress among individuals with NCDs. Family health, which is conceptualized as the system-level capacity of the family to adapt, communicate, and maintain cohesion in the face of adversity, is frequently compromised in households affected by chronic illness[31]. The persistent demands of disease management ranging from treatment complexity to financial strain can erode family resilience, increase relational conflict, and diminish collective problem-solving abilities[32]. Studies have shown that poor family functioning is associated with reduced treatment adherence, heightened psychological distress, and accelerated disease progression across various NCDs[33]. Moreover, in pediatric and adolescent populations, impaired family functioning has been linked to emotional dysregulation, school difficulties, and diminished quality of life[34].

On the other hand, the presence of NCDs and the chronic stressors they impose can in turn undermine family functioning. Intimate partner violence presents a more insidious yet pervasive form of family dysfunction[30]. Individuals with NCDs particularly women and those from marginalized communities face an elevated risk of intimate partner violence, which may be both a consequence and a driver of poor health[30]. Intimate partner violence undermines psychological safety, disrupts care routines, and is strongly associated with depression, anxiety, substance use, and suicidal ideation[35]. Chronic health conditions such as cancer[36,37] and autoimmune disorders[38] have been independently associated with higher intimate partner violence prevalence, suggesting a bidirectional pathway wherein illness exacerbates relationship vulnerability and vice versa. Notably, the experience of intimate partner violence also contributes to internalized stigma, healthcare avoidance, and mistrust of medical systems, all of which compound disparities in care access and health outcomes[39,40].

DIGITAL EXPOSURE IN INDIVIDUALS WITH NCDS

The growing ubiquity of digital technologies has profoundly reshaped daily routines, particularly among individuals living with NCDs. Digital exposure encompassing both beneficial engagement (e.g., health information seeking, telemedicine use)[41,42] and potentially harmful use (e.g., excessive screen time, problematic internet use)[43,44] has emerged as a critical but underexplored determinant of mental and physical health in this population.

On the one hand, digital tools offer unprecedented opportunities for individuals with NCDs to access health resources, manage chronic conditions, and maintain social connectedness, especially amid mobility restrictions or limited in-person services[45,46]. Studies have shown that digital health platforms can improve medication adherence, enable remote symptom tracking, and facilitate behavioral interventions for lifestyle modification[46,47].

On the other hand, excessive or dysregulated digital exposure may exacerbate health vulnerabilities. High levels of screen time are associated with various chronic diseases, such as diabetes and cardiovascular conditions[48,49]. Moreover, problematic internet use, particularly among adolescents and young adults with NCDs, is increasingly linked to emotional dysregulation[50], loneliness[51], and depressive symptoms[52]. For individuals with comorbid mental health disorders such as anxiety or post-traumatic stress digital overexposure may reinforce avoidance coping, reduce real-world engagement, and contribute to worsening psychological distress[51,53].

Notably, the adverse effects of digital technologies are not uniform and cannot be solely explained by metrics such as duration of use. Instead, their impact is shaped by the sociocultural milieu, the type and purpose of digital engagement, and individual vulnerability factors. Consequently, findings across studies remain inconsistent, with some reporting benefits and others documenting harm. Furthermore, as digital ecosystems rapidly evolve, knowledge gaps are widening. While the psychological effects of social media use are relatively well studied, little is known about emerging technologies such as the metaverse and their potential implications for individuals with NCDs. Addressing these gaps requires nuanced, culturally sensitive, and forward-looking research to provide a balanced understanding of digital exposure in this vulnerable population.

In addition to its psychological effects, digital engagement can directly influence the treatment, rehabilitation, and functional outcomes of individuals with NCDs. Telemedicine platforms, remote monitoring applications, and digital health education tools have been shown to enhance medication adherence, support rehabilitation programs, and improve overall quality of life[54]. Appropriate digital use can facilitate behavioral interventions, enable timely symptom tracking, and promote self-management of chronic conditions. At a physiological level, maladaptive or stress-inducing digital exposure may affect neuroendocrine pathways, including the hypothalamic-pituitary-adrenal axis, and modulate inflammatory responses, linking digital behaviors with both mental and physical health outcomes[55]. These findings highlight the dual role of digital exposure as both a potential therapeutic adjunct and a source of risk, underscoring the need for careful, individualized guidance and culturally sensitive interventions.

INTERACTIONS AMONG DIGITAL EXPOSURE, MENTAL VULNERABILITY, AND DYSFUNCTION IN FAMILY FUNCTIONING IN INDIVIDUALS WITH NCDS

The interplay between digital exposure, mental vulnerability, and dysfunctional family functioning may exacerbate psychosocial and health outcomes in individuals with NCDs. These interactions are not merely additive but also mutually reinforcing, creating a complex cycle of risk.

Interaction between mental vulnerability and family dysfunction

Mental vulnerability can both stem from and contribute to family dysfunction[56,57]. Individuals with NCDs who experience high levels of psychological distress often report impaired family communication, reduced emotional support, and increased conflict[33]. Conversely, living in an unsupportive or hostile family environment may heighten feelings of helplessness, stress, and emotional instability, creating a bidirectional feedback loop that aggravates both mental and physical health symptoms[35,58].

Interaction between family dysfunction and digital exposure

Family dysfunction can significantly influence digital media usage patterns. In families marked by poor cohesion, limited supervision, or high levels of conflict, individuals especially adolescents may resort to excessive screen use or problematic internet behaviors as a form of escapism or passive coping[59]. While this compensatory digital engagement may provide temporary distraction, it can also disrupt sleep[60], reduce physical activity, and interfere with social interactions[60,61], which may indirectly exacerbate existing family tension.

Interaction between mental vulnerability and digital exposure

Digital exposure and mental vulnerability often reinforce each other in a maladaptive cycle. Individuals with high psychological burden may use digital platforms to avoid emotional discomfort or to seek online validation, potentially exacerbating symptoms of anxiety, depression, and social withdrawal[62-64]. Problematic internet use has been linked to poorer emotional regulation and increased loneliness in youth and adults with NCDs[62,63,65]. Over time, this cycle may intensify digital dependence and impede real-world engagement, thereby worsening clinical outcomes.

The interaction between psychosocial imbalance and chronic physical illness

The interaction between digital exposure, mental vulnerability, and family dysfunction represent a core manifestation of psychosocial imbalance in individuals with NCDs. This triadic interplay not only reflects disturbances in psychological well-being but also exerts a reciprocal influence on the progression and management of chronic physical illnesses, ultimately compromising self-regulation, treatment adherence, and health outcomes in individuals with NCDs (Figure 1).

Figure 1 The interaction between psychosocial imbalance (mental vulnerability, family dysfunction, and digital exposure) and chronic physical illness.

INTERVENTIONS

Individual-level interventions

For people living with NCDs, individual-level interventions are critical to improving psychological well-being, disease management, and overall quality of life. Key strategies include enhancing digital health literacy to improve access to and use of health information, particularly for older adults[66,67]; implementing cognitive-behavioral therapy to alleviate anxiety and depression while promoting adaptive coping[68]; delivering mindfulness-based stress reduction programs to reduce stress and enhance emotional regulation[69]; and providing emotion regulation training to strengthen resilience and self-management[70]. Together, these interventions target both psychological vulnerabilities and behavioral skills, supporting better mental health outcomes and more effective chronic disease management.

Family-level interventions

At the family level, interventions aim to strengthen relational dynamics, caregiving support, and communication patterns that are critical for effectively managing of NCDs. Systemic family therapy can help families identify and modify maladaptive interaction patterns, enhance problem-solving, and improve cohesion in the face of chronic illness[71]. Parenting interventions and caregiver support programs provide practical skills and emotional guidance, reducing stress and burden for both patients and caregivers. Family-centered psychoeducation, including disease management, lifestyle adjustments, and coping strategies, can improve adherence to treatment regimens and reduce psychological distress[72]. These interventions not only target family dysfunction but also indirectly enhance individual well-being by creating a supportive home environment conducive to recovery and long-term disease management.

Population targeting and policy-level strategies

Given that NCDs disproportionately affect older adults who often face social isolation, loneliness, and reduced access to care population-level psychosocial interventions are both essential and timely. Digital interventions designed to reduce loneliness, such as videoconferencing with family or socially assistive robots, have shown promise in enhancing social connectedness and improving quality of life among older adults, although high-quality evidence remains unevenly distributed and further research is needed[73]. Policy-level strategies may include integrating funding for such digital platforms into aging and public health programs, training community social care workers to deliver psychosocial support, and addressing digital equity by ensuring that older adults have both the necessary devices and digital literacy[74]. Community-based models such as virtual group exercises can promote both physical engagement and social interaction, creating accessible psychosocial support for homebound seniors[75]. Moreover, randomized field studies demonstrate that mobile health platforms delivering self-management content improve behavioral outcomes and clinical markers in patients with chronic diseases, underscoring the feasibility of scalable digital psychosocial interventions[75]. Together, these population-targeted measures, which bridge policy, community infrastructure, and digital tools, constitute actionable, evidence-supported strategies to strengthen psychological resilience, social support, and functional health among older adults with NCDs.

Integration and systems-based approach

Although interventions at the individual, family, and population or policy levels have demonstrated efficacy, current research often treats these strategies in isolation, limiting their potential impact. A systems-based approach is needed to integrate these components into a coherent, multilevel framework. Network analysis offers a promising tool to identify central and bridge symptoms that sustain maladaptive feedback loops across psychological, familial, and social domains. Targeting these mechanisms may not only improve mental health outcomes but also enhance disease self-management and slow the progression of NCDs. Such an integrated, cross-diagnostic model underscores the value of transdisciplinary collaboration, ensuring that interventions address both biological and psychosocial determinants of health in a synergistic and sustainable manner.

LIMITATIONS AND FUTURE DIRECTIONS

While this conceptual synthesis highlights the complex interplay among digital exposure, mental vulnerability, and family dysfunction in individuals with NCDs, several limitations must be acknowledged. First, the existing empirical literature is largely cross-sectional, precluding definitive causal inferences and obscuring the temporal dynamics between psychosocial stressors and disease progression. Second, most studies rely on self-reported data, which are susceptible to recall bias and may underrepresent subclinical yet functionally significant disturbances. Third, the cultural and socioeconomic contexts that modulate these interactions remain underexplored, limiting the generalizability of current findings across diverse populations, particularly in low- and middle-income countries. Although prior work (e.g., Li et al[7]) suggests that traditional demographic variables such as gender, ethnicity, and residence exert limited influence on overall network strength, the broader role of sociocultural factors in shaping psychological distress and family dynamics cannot be dismissed.

Future research should prioritize longitudinal, multi-informant designs that integrate biological, behavioral, and digital biomarkers to capture real-time dynamics within and between psychosocial domains. Network-based analytical approaches offer particular promise in identifying transdiagnostic “bridge nodes” that connect digital exposure, affective symptoms, and relational dysfunction providing novel targets for intervention. Furthermore, intervention studies must move toward precision-based frameworks that tailor strategies to individual vulnerability profiles, accounting for developmental stage, digital habits, family system structure, and comorbidity patterns. Finally, cross-sectoral collaboration between health care, education, and digital technology sectors is essential for the scalable implementation of integrated interventions. Only through such multidimensional and contextually grounded approaches can we advance from descriptive mapping to transformative action in addressing the psychological burden associated with chronic disease.

CONCLUSION

This synthesis underscores the mental vulnerability, family dysfunction, and digital exposure experienced by individuals with NCDs, and explores their complex, reciprocal interactions within a dysfunctional psychosocial network. These domains should not be viewed as isolated risk factors, but as interconnected elements of a dynamic system reflecting the broader psychosocial burden embedded in chronic illness. Addressing this burden calls for a paradigm shift toward network-informed, system-level interventions that integrate mental health care, digital behavior regulation, and family support. Future research must adopt longitudinal, context-sensitive methodologies, while health policies should prioritize cross-sectoral integration to ensure comprehensive, equitable, and sustainable care for individuals living with NCDs.