Highlights
– A self-guided digital psychological program reduced psychological distress (HADS) at 3 months versus treatment-as-usual in people with rheumatoid arthritis, psoriatic arthritis, or systemic lupus erythematosus.
– Effect size for distress was medium-to-large (Cohen d = -0.71); quality of life improved modestly (Cohen d = 0.49).
– A higher proportion of participants randomized to the intervention experienced clinically meaningful improvements in distress and quality of life; no intervention-related adverse events were reported.
Background: disease burden and unmet need
People living with inflammatory rheumatic diseases (IRDs) such as rheumatoid arthritis (RA), psoriatic arthritis (PsA), and systemic lupus erythematosus (SLE) face not only joint and systemic manifestations but also elevated rates of psychological distress, anxiety, and depression. Psychological comorbidity adversely affects quality of life, self-management, adherence to therapy, and may contribute to pain amplification and greater perceived disability. Despite this, timely access to psychological therapies is often limited by workforce shortages, geographic barriers, stigma, and competing demands of chronic disease management. Digital psychological interventions promise scalable, low-threshold support that can be integrated alongside standard rheumatology care, but evidence specifically in IRD populations has been limited.
Study design
This pilot randomized clinical trial (Knitza et al., JAMA Network Open 2025) enrolled adults (≥18 years) across Germany from February 22 to June 4, 2024. Eligibility required a diagnosis of RA, PsA, or SLE plus self-reported psychological distress and reduced quality of life. A total of 102 participants (mean age 47.2 years; 90.2% female) were randomized to a self-guided digital psychological intervention (n = 52) or treatment-as-usual (n = 50). The intervention was delivered without therapist support. Primary endpoints were change from baseline to 3 months in psychological distress measured by the German version of the Hospital Anxiety and Depression Scale (HADS) and quality of life measured by the Assessment of Quality of Life–8 Dimensions (AQoL-8D). Secondary endpoints included self-efficacy, health literacy, perceived stress, functional impairment, and domain-specific measures of depression and anxiety. The trial is registered at the German Clinical Trials Register (DRKS00032862).
Key findings and interpretation
The intervention group experienced a statistically and clinically meaningful reduction in psychological distress at 3 months compared with treatment-as-usual. The reported least-squares mean difference in HADS change was -3.60 (SE 1.07; 95% CI -5.73 to -1.47; P < .001), corresponding to a Cohen d of -0.71. In practical terms, this reflects a medium-to-large treatment effect on distress over a 3-month period for a self-guided digital program.
Quality of life (AQoL-8D) also improved in the intervention arm: least-squares mean difference 0.04 (SE 0.02; 95% CI 0.00 to 0.09; P = .047), Cohen d = 0.49, a moderate effect size. Although the absolute AQoL change was numerically small, the between-group comparison reached statistical significance and the effect size suggests a meaningful patient-centered benefit.
Clinically meaningful responder analyses favored the digital intervention. A significantly larger proportion of participants randomized to the intervention achieved a predefined clinically meaningful improvement in psychological distress (29/49 [59.2%] vs 17/50 [34.0%]; P = .02) and in quality of life (27/49 [55.1%] vs 16/50 [32.0%]; P = .03) than controls. Secondary outcomes—self-efficacy, health literacy, perceived stress, depression and anxiety symptom scales—showed a similar pattern of improvement in the intervention group, with the exception of functional impairment where no significant between-group difference was found.
No intervention-related adverse events were reported during the 3-month follow-up.
Clinical significance and effect sizes
The observed HADS effect (d = -0.71) is consistent with a moderate-to-large clinical impact for a self-guided digital intervention and compares favorably with many brief psychosocial interventions in chronic illness. The AQoL effect (d = 0.49) indicates a moderate improvement in health-related quality of life domains measured by that instrument. Importantly, more than half of participants in the intervention arm achieved clinically meaningful improvements in distress and QoL, supporting potential relevance at the individual patient level.
Expert commentary: strengths and limitations
Strengths of the trial include randomized allocation, use of validated patient-reported outcome measures, reporting of both continuous and responder analyses, and pragmatic recruitment across Germany. The self-guided format improves scalability and lowers per-patient delivery costs compared with therapist-led approaches.
However, the study has limitations typical of early-stage digital health trials. As presented in the summary, follow-up was limited to 3 months, leaving durability of benefit unknown. The sample was predominantly female (≈90%), which mirrors the higher prevalence of many IRDs in women but limits generalizability to men. The control condition was treatment-as-usual rather than an active digital comparator, so non-specific effects (expectancy, engagement) cannot be fully excluded. The summary did not report detailed adherence metrics, platform engagement, or attrition rates—important determinants of real-world effectiveness for self-guided programs. Objective measures of inflammatory disease activity (e.g., DAS28, CRP) were not reported in the provided summary; thus any downstream effects on disease activity or medication use remain unknown.
Finally, the trial population was recruited in Germany; differences in healthcare systems, availability of psychosocial care, and digital literacy may affect transportability to other settings.
Mechanistic plausibility
Psychological interventions (particularly cognitive behavioral approaches) may reduce distress through improving coping strategies, reducing maladaptive illness beliefs, enhancing self-efficacy, and decreasing stress-related physiological activation. In IRDs, improved mental health can translate into better self-management, pain coping, medication adherence, and engagement with rehabilitation—pathways that plausibly improve patient-reported quality of life even if short-term inflammatory markers remain unchanged.
Implications for practice and implementation
This pilot RCT provides encouraging evidence that a self-guided digital psychological intervention can reduce distress and improve quality of life for people with IRDs. For clinicians and healthcare services, key implementation considerations include:
- Identification: Routine screening for distress in rheumatology clinics (e.g., HADS or brief screening tools) can flag patients who may benefit from digital programs.
- Integration: Digital programs are best used as part of a stepped-care model—offering self-guided options for mild-to-moderate symptoms, with pathways to therapist-led care for non-responders or severe cases.
- Access and equity: Ensure programs are accessible across ages, languages, and digital literacy levels; provide alternatives for those without digital access.
- Monitoring: Capture engagement and outcomes to identify early non-responders and adverse events, and to support safety monitoring.
- Reimbursement and policy: Scaling such interventions will require reimbursement pathways and alignment with national digital health strategies.
Research gaps and next steps
Before broad adoption, confirmatory larger trials are needed that address important gaps: longer-term follow-up to assess durability, diverse and larger samples to test generalizability, active comparator arms to control for nonspecific effects, cost-effectiveness analyses, and measurement of downstream outcomes such as healthcare use, medication adherence, pain, and objective disease activity. Implementation science studies should explore strategies to optimize engagement and equity, and to integrate digital mental health into routine rheumatology workflows.
Conclusion
This pilot randomized clinical trial indicates that a self-guided digital psychological intervention can produce clinically meaningful reductions in psychological distress and moderate improvements in quality of life over 3 months among people with inflammatory rheumatic diseases. The findings support further, larger-scale evaluation and careful implementation research to determine how best to deploy such scalable interventions within comprehensive rheumatology care.
Funding and trial registration
Trial registration: German Clinical Trials Register (DRKS) identifier: DRKS00032862. Funding information and more detailed trial methods and disclosures are reported in the original publication (Knitza et al., JAMA Netw Open 2025).
References
1. Knitza J, Kraus J, Krusche M, et al. Digital Psychological Intervention for Inflammatory Rheumatic Diseases: A Pilot Randomized Clinical Trial. JAMA Netw Open. 2025;8(9):e2529892. PMID: 40924426 ; PMCID: PMC12421347 .
2. Matcham F, Rayner L, Steer S, Hotopf M. The prevalence of depression in rheumatoid arthritis: a systematic review and meta-analysis. Rheumatology (Oxford). 2013;52(12):2136-2148.
