Rheumatic disease patients know little about mental health care yet hold positive attitudes

Patients with immune-mediated and inflammatory rheumatic diseases in China carry a heavy psychological burden but know remarkably little about mental health care, according to a multicenter cross-sectional study published in Frontiers in Public Health. Across six tertiary hospitals, researchers found that patients scored poorly on knowledge of mental health and psychological interventions, held generally positive attitudes toward such care, and yet rarely engaged in proactive mental health practices. The gap between what patients feel and what they do emerged as the study’s central finding, and the analysis pointed to knowledge and attitude as the main levers associated with whether patients actually act to protect their psychological wellbeing.

The study, conducted between July and December 2023 in the rheumatology and immunology departments of six tertiary Grade A hospitals, recruited adult patients with conditions including rheumatoid arthritis, systemic lupus erythematosus, Sjögren’s syndrome, systemic sclerosis, inflammatory myopathies, vasculitis, ankylosing spondylitis, gout, and other connective tissue diseases. From 916 questionnaire records collected, the researchers excluded 79 with incomplete key sections, 33 lacking consent for research use, and 132 with malformed or implausible sleep-time data that prevented valid scoring of the Pittsburgh Sleep Quality Index. That left 672 valid questionnaires in the final analytical dataset. Among these patients, 499, or 74.26 percent, were female, and the mean age was 44.86 years with a standard deviation of 15.54. Systemic lupus erythematosus was the most common diagnosis at 24.11 percent, followed by rheumatoid arthritis at 18.01 percent, Sjögren’s syndrome at 11.16 percent, and gout at 9.38 percent.

To measure knowledge, attitudes, and practices, the team used a self-designed questionnaire developed in Chinese with input from rheumatologists, psychologists, and nurses, refined through two rounds of expert consultation and piloted in 31 patients. The knowledge domain contained nine items scored from 0 to 2 each, for a possible total of 0 to 18. The attitude and practice domains each contained six items rated on five-point scales, with possible totals of 6 to 30. Consistent with previous knowledge-attitude-practice studies, scores above 70 percent of the maximum were defined as adequate knowledge, positive attitude, or proactive practice. The questionnaire showed strong internal consistency in the sample, with an overall Cronbach’s alpha of 0.904 and subscale values of 0.938 for knowledge, 0.920 for attitude, and 0.769 for practice. Confirmatory factor analysis supported the theoretical three-factor structure with good fit indices.

The results revealed a striking imbalance across the three domains. The mean knowledge score was 5.65 out of a possible 18, well below the adequacy threshold, while the mean attitude score was 23.03 out of 30, above the cutoff for a positive attitude. The mean practice score was 18.41 out of 30, falling short of the proactive-practice threshold. In other words, patients demonstrated inadequate knowledge, positive attitudes, and inactive practice toward mental health and psychological interventions. Item-level responses sharpened this picture. Most patients knew that someone suspecting psychological problems should consult a psychologist or psychiatrist, endorsed by 71.13 percent, and 60.57 percent knew that mental illnesses and psychological issues can be prevented, controlled, and improved through psychological interventions. But 59.38 percent did not know that family members of patients with these rheumatic diseases are more in need of psychological interventions than the general population, and 58.93 percent did not know the same about the patients themselves.

Practice patterns told a similar story of selective engagement. On the positive side, 41.22 percent of respondents always ensured sufficient sleep, 39.73 percent always maintained a regular diet and balanced nutrition, and 26.64 percent always kept an optimistic mindset. Yet 41.90 percent reported never taking the initiative to use psychological scales to assess their own mental health status, and 33.04 percent never actively learned about psychological interventions. The authors noted that the practice dimension spans a broad construct, from general self-management behaviors to specific engagement with formal psychological services, and suggested that patients may not view structured mental health assessment as part of routine care for their rheumatologic disease.

Beyond the headline scores, the study examined which factors were independently associated with each domain using multivariable logistic regression with an a priori confounder selection strategy, forcing clinically predefined variables including age, sex, education, income, disease type, and disease duration into all models. For adequate knowledge, none of the predefined clinical variables showed a statistically significant independent association after adjustment. For positive attitude, each one-point increase in knowledge score was associated with a 15.7 percent increase in the odds of a positive attitude, and each additional year of age was associated with a 1.8 percent decrease in those odds. For proactive practice, knowledge, attitude, and age were all independently associated: each one-point increase in knowledge raised the odds of proactive practice by 13.3 percent, each one-point increase in attitude raised them by 11.5 percent, and each additional year of age raised them by 2.3 percent.

Structural equation modeling reinforced these statistical relationships. The model showed a significant direct path from knowledge to attitude, a direct path from knowledge to practice, and a direct path from attitude to practice, along with a significant indirect association of knowledge with practice mediated through attitude. Sensitivity analyses using multiple linear regression with the continuous scores produced consistent results. Correlation analysis added a mental health dimension: knowledge, attitude, and practice were all positively correlated with one another, while practice was negatively correlated with anxiety symptoms, depressive symptoms, and sleep disturbance. Patients who engaged in more proactive mental health practices tended to report fewer symptoms, though the cross-sectional design cannot establish whether better practice leads to fewer symptoms, whether symptoms reduce the capacity to engage in healthy behaviors, or both.

The symptom burden in the sample was substantial. Mean scores were 35.54 on the Self-Rating Anxiety Scale, 39.35 on the Self-Rating Depression Scale, and 7.08 on the Pittsburgh Sleep Quality Index, with higher scores indicating more severe symptoms or poorer sleep. The authors emphasized that these instruments are validated screening tools rather than diagnostic instruments for formal psychiatric disorders. Sociodemographic patterns also emerged in the unadjusted comparisons: knowledge scores differed significantly by education level, employment status, residence, and monthly per capita household income, with urban residents, more educated patients, and higher-income patients scoring higher. After adjustment, however, specific disease types were generally not independent predictors of knowledge, attitude, or practice, suggesting that the identified gaps in mental health literacy are relatively universal across the spectrum of immune-mediated and inflammatory rheumatic diseases in this cohort.

The authors placed their findings in the context of mental health stigma, access barriers, and literacy challenges in China, noting that psychological problems are often perceived as a source of shame, that the term psychological intervention may be unfamiliar or associated mainly with severe psychiatric illness, and that access to mental health professionals remains uneven between urban and rural areas. They suggested that rheumatology teams could incorporate brief validated mental health screening into regular visits, distribute educational materials, and use non-stigmatizing language to normalize mental health assessment as part of chronic disease management. The researchers were careful to frame these as directions for future work rather than proven benefits: the findings highlight key areas for future health-services research and the hypothesis that targeted educational and psychological programs could enhance patient engagement, which should be tested in rigorous longitudinal and interventional studies.

The study’s limitations are important for interpreting its conclusions. The cross-sectional design precludes causal inference about the relationships among knowledge, attitudes, practices, and symptoms. The sampling combined stratified selection of tertiary hospitals with convenience sampling of patients within each site, so patients attending large tertiary centers may differ from those treated in secondary or community settings, limiting generalizability, particularly to rural or underresourced areas. All data were self-reported and subject to recall and social desirability bias, and test-retest reliability of the newly developed questionnaire could not be assessed without follow-up. The number of hospitals was limited and all were tertiary Grade A institutions, leaving system-level factors such as local mental health resources and regional policy differences unexamined. Even so, the study offers a detailed empirical map of where mental health literacy breaks down in this population: patients largely recognize the importance of psychological care and express willingness to seek help, but they do not see themselves or their families as being at elevated need, and they rarely take concrete steps to learn about or access psychological support.

Subject of Research: Knowledge, attitudes, and practices toward mental health and psychological interventions among patients with immune-mediated and inflammatory rheumatic diseases in China

Article Title: Knowledge, attitude and practice of patients with immune-mediated and inflammatory rheumatic diseases towards mental health and psychological interventions

Article References: Li, S., Wang, X., Liu, H., Liu, M., Liu, Y., Sun, Y., Tao, D., Tian, B., & Wang, F. (2026). Knowledge, attitude and practice of patients with immune-mediated and inflammatory rheumatic diseases towards mental health and psychological interventions. Frontiers in Public Health, 14, Article 1959054. https://doi.org/10.3389/fpubh.2026.1959054

Image Credits: AI Generated

DOI: 10.3389/fpubh.2026.1959054

Keywords: rheumatic diseases, mental health, psychological interventions, knowledge attitude practice, cross-sectional study, China, rheumatoid arthritis, systemic lupus erythematosus, anxiety, depression, health education, patient survey