Background
Psychological distress is highly prevalent in inflammatory arthritis (IA), including rheumatoid arthritis (RA), spondyloarthritis (SpA), and psoriatic arthritis (PsA), and is associated with worse clinical outcomes and quality of life. Recent evidence confirms that depression and anxiety are closely linked to disease activity and symptom burden in IA [1, p. 2]. Digital mental health interventions delivered via mobile applications demonstrate small-to-moderate improvements in psychological outcomes, particularly depending on engagement intensity [2, p. 140]. Sleep disturbances are also common and may contribute to inflammatory activation and symptom severity [3, p. 546].
Objective
To evaluate whether engagement with mental health and sleep coaching modules in a digital self-management application is associated with 12-week changes in psychological distress in IA patients.
Methods
This retrospective cohort study used real-world data from adults with RA, SpA, and PsA who use a mobile application that delivers a multimodal, guideline-based intervention through personalized "action plans". The primary outcome was the change in psychological distress, measured by the PHQ-4 (Patient Health Questionnaire-4), over 12 weeks. Secondary outcomes included SF-36 MCS (Short Form-36 Mental Component Summary), Pain (Vіsual Analog Score), and PGA (Patient Global Assessment). Engagement exposures included mental health dose, sleep dose, and action plan engagement. Linear regression models were adjusted for age, sex, diagnosis, and baseline values, with robust standard errors and inverse-probability weighting applied. Model assumptions were assessed using residual diagnostics, and statistical significance was defined at a two-sided p-value < 0.05. Continuous variables are presented as mean and standard deviation, and effect estimates are reported with 95% confidence intervals. All analyses were performed using validated statistical packages, ensuring reproducibility of the results.
Results
Baseline PHQ-4 data were available for 1,885 participants, while the analytic sample for the primary outcome included 467 participants with paired measurements. Baseline distress was moderate (mean 4.11, SD 2.71). Over 12 weeks, mean changes were small: ΔPHQ-4 −0.26 (SD 2.45), ΔMCS +1.03 (SD 18.54), ΔPain −1.91 (SD 23.94), and ΔPGA −3.33 (SD 24.48).
Higher engagement with mental health modules was significantly associated with a greater reduction in distress (β = −1.43, 95% CI −2.15 to −0.71; p = 0.000093). Sleep module engagement showed no significant association (β = 0.56, 95% CI −0.18 to 1.30; p = 0.14). Participants who completed at least one mental action plan demonstrated greater improvement (ΔPHQ-4: -0.56 vs +0.31), with a between-group difference of −0.87 (p = 0.0003). The observed association remained directionally consistent across subgroups defined by diagnosis and baseline distress levels. This suggests that the effect of engagement is not limited to a specific IA subtype.
A higher proportion of mental action plans was also associated with improved outcomes (β = −1.78 per 10 percentage points; 95% CI −2.60 to −0.96; p = 0.00002), supporting a dose–response relationship. No significant associations were observed for SF-36 MCS, pain, or PGA. These associations remained consistent in sensitivity analyses using alternative model specifications. Additionally, weighting procedures improved covariate balance, supporting the robustness of the observed associations. The magnitude of effect suggests that engagement-related differences exceed the average cohort-level change, indicating heterogeneity of response. Notably, confidence intervals remained narrow, supporting the precision of the estimates.
Conclusions
Greater engagement with mental health modules and action plans is associated with reduced psychological distress in IA patients, while effects on pain and global assessment were not observed. These findings support the use of targeted digital psychological interventions in IA and highlight the importance of patient engagement. These results may inform future design of personalized digital interventions targeting psychological outcomes.
References
1. Vestergaard S. B., Lie E., Hammer H. B. et al. Prevalence of anxiety and depression and the association with patient-reported outcomes and comorbidities in inflammatory arthritis: a cross-sectional study. RMD Open. 2024. Vol. 10, No. 1. Art. e003412. DOI: 10.1136/rmdopen-2023-003412.
2. Linardon J., Torous J., Firth J., Cuijpers P., Messer M., Fuller-Tyszkiewicz M. Current evidence on the efficacy of mental health smartphone apps for symptoms of depression and anxiety: a meta-analysis of 176 randomized controlled trials. World Psychiatry. 2024. Vol. 23, No. 1. P. 139–149. DOI: 10.1002/wps.21183.
3. Irwin M. R., Straub R. H., Smith M. T. Heat of the night: sleep disturbance activates inflammatory mechanisms and induces pain in rheumatoid arthritis. Nature Reviews Rheumatology. 2023. Vol. 19, No. 9. P. 545–559. DOI: 10.1038/s41584-023-00997-3.
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