Can AI Help You Get Over Your Breakup? One Session with a Belief-Reframing Chatbot Shows Sustained Distress Reduction

AI chatbots are increasingly used for health advice, but their performance in psychiatric triage remains undercharacterized. Psychiatric triage is particularly challenging because urgency must often be inferred from thoughts, behavior, and context rather than from objective findings. We evaluated the performance of 15 frontier AI chatbots on psychiatric triage from realistic single-message disclosures using 112 clinical vignettes, each paired with 1 of 4 original benchmark triage labels: A, routine; B, assessment within 1 week; C, assessment within 24 to 48 hours; and D, emergency care now. Vignettes covered 9 psychiatric presentation clusters and 9 focal risk dimensions, organized into 28 presentation-by-risk groups. Each group contributed 4 distinct vignettes, with 1 vignette at each triage level. Each vignette was rendered as a realistic human-authored conversational query, and the AI chatbots were tasked with assigning a triage label from that disclosure. Emergency under-triage occurred in 23 of 410 level D trials (5.6%), and all under-triaged emergencies were reassigned to level C urgency. Across target models, average accuracy ranged from 42.0% to 71.8%. Accuracy was highest for level D vignettes (94.3%) and lowest for level B vignettes (19.7%). Mean signed ordinal error was positive (+0.47 triage levels), indicating net over-triage. Dispersion was highest around the middle triage levels. All results were confirmed relative to clinician consensus labels from 50 medical doctors. When presented with user messages containing sufficient clinical information, frontier AI chatbots thus recognized psychiatric emergencies as requiring urgent medical assessment with near-zero error rates, yet showed marked over-triage for low and intermediate risk presentations.

Cognitive behavioural therapy is widely used to help patients understand and manage psychological distress. It is often delivered through spoken conversation, where therapists attend not only to what patients say, but also to how they say it, because these cues can help therapists decide how to respond and adapt treatment. Progress in building AI systems for CBT remains largely limited to text, partly because most available datasets are text based and shareable spoken CBT data are scarce under ethical and privacy constraints. This creates a blind spot because text based models and evaluations cannot capture the mismatch between the transcript and the patient's voice, even though therapists often rely on this mismatch to understand patient distress. We introduce CBT-Audio, a dataset for evaluating patient distress estimation from spoken CBT sessions with audio language models. CBT-Audio contains 1,802 patient turns from 96 publicly available CBT recordings, with turn-level distress labels validated on an experts-annotated subset. We evaluate 10 open source audio language models under three input conditions, where models receive only patient audio, only the transcript, or both audio and transcript. Our results show that audio can provide useful information beyond text, especially when combined with transcripts. Adding audio to transcript input improves distress estimation over using the transcript alone in 8 of 10 model families, with significant gains in 4, and case studies show the clearest benefit when verbal content and vocal delivery diverge. CBT-Audio makes spoken patient behaviour measurable for AI evaluation in CBT-related tasks and supports future work on audio language models for mental health interaction.

LLM chatbots increasingly serve as a first source of support for people in psychological distress, including those whose distress is entangled with delusional beliefs. Prior work on LLM mental-health safety largely evaluates general therapeutic quality or single-turn crisis detection, leaving unclear how models behave when distress is intertwined with delusion over sustained conversations. We address this gap with matched multi-turn simulations, across clinically grounded personas and six LLMs, that pair each delusional conversation with a distress-only control to isolate the effect of delusional framing. This reveals a recognition-intervention gap: models detect distress at comparable rates regardless of framing, yet sharply fail to act on it once distress is embedded in delusion, with safety interventions suppressed by up to 4.5x. The failure tracks accumulated acceptance of the user's premises rather than emotional validation. Worse, the intuitive fix of prompting models to assess user distress backfires under delusional framing; only delusion-aware prompting with explicit response guidance closes the gap, and even this depends on a delusion classifier that is itself unreliable on the most vulnerable models. Safe deployment therefore requires treating delusional framing as a distinct risk signal that overrides conversational accommodation.