{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,28]],"date-time":"2026-10-28T20:16:52Z","timestamp":1793218612130,"version":"4.5.0"},"reference-count":41,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2025,5,29]],"date-time":"2025-05-29T00:00:00Z","timestamp":1748476800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100012542","name":"Dalin Tzu Chi Hospital","doi-asserted-by":"publisher","award":["DTCRD112-I-21"],"award-info":[{"award-number":["DTCRD112-I-21"]}],"id":[{"id":"10.13039\/501100012542","id-type":"DOI","asserted-by":"publisher"}]},{"name":"National Science and Technology Council","award":["NSTC-113-2314-B-303-008"],"award-info":[{"award-number":["NSTC-113-2314-B-303-008"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: Extant research on the relationship between fatigue and depression in people with rheumatic diseases portrays a divergent picture. While caring for persons with this medical condition, one issue that represents individual confidence in carrying out specific tasks, namely self-efficacy level, has attracted significant attention. Yet, the information regarding whether self-efficacy may pose a clue linking these two major symptoms is still unknown. The aim of this study, therefore, is to examine whether self-efficacy mediates the association between fatigue and depressive symptoms among persons with rheumatoid arthritis (RA). Materials and Method: A cross-sectional study of 224 females with RA from a hospital in Taiwan was conducted between January and October 2023. We then distributed anonymous self-reported questionnaires instructing participants to provide information on their demographic characteristics, levels of fatigue, self-efficacy, and depressive symptoms. The bootstrap via PROCESS macro in SPSS was executed to analyze if self-efficacy would mediate the effect of fatigue on emergence of depressive symptoms. Results: For those participants captured at baseline, a negative association was noted between fatigue and self-efficacy, as well as between self-efficacy and depressive symptoms. Results of the mediation analysis revealed a remarkable indirect effect of fatigue on depressive symptoms through self-efficacy, with a regression coefficient of 0.21 (95% confidence intervals: 0.06\u20130.37). Conclusions: This work extends current understanding of the roles that fatigue and self-efficacy play in predicting depression among people with RA and further clarified the potential mediating role of self-efficacy in buffering against depressive symptomatology. Interventions that extend from the management of fatigue and further incorporate the improvement of self-efficacy sense into the stereotypical therapy should greatly mitigate the distressing symptoms for patients with RA.<\/jats:p>","DOI":"10.3390\/medicina61061013","type":"journal-article","created":{"date-parts":[[2025,5,29]],"date-time":"2025-05-29T03:30:19Z","timestamp":1748489419000},"page":"1013","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Mediating Role of Self-Efficacy in the Association Between Fatigue and Depressive Symptoms in Females with Rheumatoid Arthritis"],"prefix":"10.3390","volume":"61","author":[{"given":"I-Yu","family":"Hsiao","sequence":"first","affiliation":[{"name":"Department of Nursing, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi 62247, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5149-1717","authenticated-orcid":false,"given":"Hanoch","family":"Livneh","sequence":"additional","affiliation":[{"name":"Rehabilitation Counseling Program, Portland State University, Portland, OR 97207-0751, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chieh-Tsung","family":"Yen","sequence":"additional","affiliation":[{"name":"Department of Neurology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi 62247, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9051-0351","authenticated-orcid":false,"given":"Ming-Chi","family":"Lu","sequence":"additional","affiliation":[{"name":"Division of Allergy, Immunology and Rheumatology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi 62247, Taiwan"},{"name":"School of Medicine, Tzu Chi University, Hualien 97004, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wei-Jen","family":"Chen","sequence":"additional","affiliation":[{"name":"Department of Chinese Medicine, Dalin Tzuchi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi 62247, Taiwan"},{"name":"Graduate Institute of Sports Science, National Taiwan Sport University, Taoyuan 333325, Taiwan"},{"name":"School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien 97004, Taiwan"},{"name":"Center of Sports Medicine, Dalin Tzuchi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi 62247, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9865-7101","authenticated-orcid":false,"given":"Tzung-Yi","family":"Tsai","sequence":"additional","affiliation":[{"name":"Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan 70428, Taiwan"},{"name":"Department of Medical Research, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi 62247, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,5,29]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1822","DOI":"10.1038\/s41591-019-0675-0","article-title":"Chronic inflammation in the etiology of disease across the life span","volume":"25","author":"Furman","year":"2019","journal-title":"Nat. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1360","DOI":"10.1001\/jama.2018.13103","article-title":"Diagnosis and management of rheumatoid arthritis: A review","volume":"320","author":"Aletaha","year":"2018","journal-title":"JAMA"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"945","DOI":"10.1016\/j.autrev.2018.03.017","article-title":"The link between immunity, autoimmunity and endometriosis: A literature update","volume":"17","author":"Zhang","year":"2018","journal-title":"Autoimmun. Rev."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"12234","DOI":"10.1111\/jcmm.15803","article-title":"Immunomodulatory effects of berberine on the inflamed joint reveal new therapeutic targets for rheumatoid arthritis management","volume":"24","author":"Shen","year":"2020","journal-title":"J. Cell. Mol. Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"160","DOI":"10.4172\/2155-9899.1000160","article-title":"Intracellular signaling pathways in rheumatoid arthritis","volume":"4","author":"Malemud","year":"2013","journal-title":"J. Clin. Cell. Immunol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"2136","DOI":"10.1093\/rheumatology\/ket169","article-title":"The prevalence of depression in rheumatoid arthritis: A systematic review and meta-analysis","volume":"52","author":"Matcham","year":"2013","journal-title":"Rheumatology"},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Lu, M.C., Guo, H.R., Lin, M.C., Livneh, H., Lai, N.S., and Tsai, T.Y. (2016). Bidirectional associations between rheumatoid arthritis and depression: A nationwide longitudinal study. Sci. Rep., 6.","DOI":"10.1038\/srep20647"},{"key":"ref_8","first-page":"1013","article-title":"Comorbid depression is an independent risk factor for mortality in patients with rheumatoid arthritis","volume":"32","author":"Ang","year":"2005","journal-title":"J. Rheumatol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"743","DOI":"10.3899\/jrheum.080670","article-title":"Hidden cost of rheumatoid arthritis (RA): Estimating cost of comorbid cardiovascular disease and depression among patients with RA","volume":"36","author":"Joyce","year":"2009","journal-title":"J. Rheumatol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"e014233","DOI":"10.1136\/bmjopen-2016-014233","article-title":"Does depression increase the risk of stroke in patients with rheumatoid arthritis? A population-based cohort study","volume":"7","author":"Tsai","year":"2017","journal-title":"BMJ Open"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1260","DOI":"10.1136\/ard-2023-224514","article-title":"2023 EULAR recommendations for the management of fatigue in people with inflammatory rheumatic and musculoskeletal diseases","volume":"83","author":"Dures","year":"2024","journal-title":"Ann. Rheum. Dis."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"591","DOI":"10.3390\/clinpract12040062","article-title":"The Assessment of Fatigue in Rheumatoid Arthritis Patients and Its Impact on Their Quality of Life","volume":"12","author":"Dar","year":"2022","journal-title":"Clin. Pract."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"3737","DOI":"10.1093\/rheumatology\/keab947","article-title":"Fatigue in early rheumatoid arthritis: Data from the Early Rheumatoid Arthritis Network","volume":"61","author":"Ifesemen","year":"2021","journal-title":"Rheumatology"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"274","DOI":"10.1016\/j.bbi.2018.05.012","article-title":"The association of disease activity, pro-inflammatory cytokines, and neurotrophic factors with depression in patients with rheumatoid arthritis","volume":"73","author":"Cheon","year":"2018","journal-title":"Brain Behav. Immun."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1705","DOI":"10.1007\/s00296-016-3559-3","article-title":"Prevalence and risk factors of anxiety and depression in patients with systemic lupus erythematosus in Southwest China","volume":"36","author":"Xie","year":"2016","journal-title":"Rheumatol. Int."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"143","DOI":"10.1016\/j.ejpsy.2022.04.002","article-title":"Inflammatory biomarkers associated with depression, anxiety, and\/or fatigue in primary Sj\u00f6gren\u2019s syndrome\u2014A systematic review","volume":"36","author":"Miglianico","year":"2022","journal-title":"Eur. J. Psychiatry"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1199","DOI":"10.1037\/a0029773","article-title":"Longitudinal relationships between fatigue and depression in cancer patients with depression and\/or pain","volume":"32","author":"Brown","year":"2013","journal-title":"Health Psychol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1278","DOI":"10.1136\/annrheumdis-2021-220249","article-title":"2021 EULAR recommendations for the implementation of self-management strategies in patients with inflammatory arthritis","volume":"80","author":"Nikiphorou","year":"2021","journal-title":"Ann. Rheum. Dis."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1111\/nhs.12022","article-title":"Self-efficacy, self-care behavior, anxiety, and depression in Taiwanese with type 2 diabetes: A cross-sectional survey","volume":"15","author":"Wu","year":"2013","journal-title":"Nurs. Health Sci."},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Hsiao, I.Y., Livneh, H., Chen, W.J., Lu, M.C., and Tsai, T.Y. (2024). An exploration of self-efficacy and its associated factors among rheumatoid arthritis patients in Taiwan. Medicina, 60.","DOI":"10.3390\/medicina60101653"},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Qomi, M., Rakhshan, M., Ebrahimi Monfared, M., and Khademian, Z. (2023). The effect of distance nurse-led fatigue management on fatigue, sleep quality, and self-efficacy in patients with multiple sclerosis: A quasi-experimental study. BMC Neurol., 23.","DOI":"10.1186\/s12883-023-03115-8"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"2569","DOI":"10.1002\/art.27584","article-title":"2010 Rheumatoid arthritis classification criteria: An American College of Rheumatology\/European League Against Rheumatism collaborative initiative","volume":"62","author":"Aletaha","year":"2010","journal-title":"Arthritis Rheum."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1002\/anr.1780320107","article-title":"Development and evaluation of a scale to measure perceived self-efficacy in people with arthritis","volume":"32","author":"Lorig","year":"1989","journal-title":"Arthritis Rheum."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"e042014","DOI":"10.1136\/bmjopen-2020-042014","article-title":"Psychometric evaluation of the Arthritis Self-Efficacy Scale in Chinese adults with rheumatic diseases: A cross-sectional study","volume":"11","author":"Tsai","year":"2021","journal-title":"BMJ Open"},{"key":"ref_25","first-page":"688","article-title":"Development of the Taiwanese depression questionnaire","volume":"23","author":"Lee","year":"2000","journal-title":"Chang Gung Med. J."},{"key":"ref_26","first-page":"369","article-title":"Comparing the use of the Taiwanese depression questionnaire and beck depression inventory for screening depression in patients with chronic pain","volume":"31","author":"Lee","year":"2008","journal-title":"Chang Gung Med. J."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Chiang, H.H., Livneh, H., Yen, M.L., Li, T.C., and Tsai, T.Y. (2013). Prevalence and correlates of depression among chronic kidney disease patients in Taiwan. BMC Nephrol., 14.","DOI":"10.1186\/1471-2369-14-78"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"e13443","DOI":"10.1111\/ijcp.13443","article-title":"The effectiveness of nurse-led case management for patients with rheumatoid arthritis in Taiwan","volume":"74","author":"Lu","year":"2020","journal-title":"Int. J. Clin. Pract."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"v3","DOI":"10.1093\/rheumatology\/kez351","article-title":"The impact of fatigue in rheumatoid arthritis and the challenges of its assessment","volume":"58","author":"Santos","year":"2019","journal-title":"Rheumatology"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"e001084","DOI":"10.1136\/rmdopen-2019-001084","article-title":"Management of fatigue in rheumatoid arthritis","volume":"6","author":"Pope","year":"2020","journal-title":"RMD Open"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"165","DOI":"10.1097\/MRR.0b013e3282fc0f93","article-title":"Reliability and validity of the visual analogue scale for disability in patients with chronic musculoskeletal pain","volume":"31","author":"Boonstra","year":"2008","journal-title":"Int. J. Rehabil. Res."},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Liu, N., Yan, W., Su, R., Zhang, L., Wang, X., Li, Z., Qin, D., and Peng, J. (2023). Research progress on rheumatoid arthritis-associated depression. Front. Behav. Neurosci., 16.","DOI":"10.3389\/fnbeh.2022.992223"},{"key":"ref_33","unstructured":"Hayes, A.F. (2022). Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach, Guilford Press."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"352","DOI":"10.1037\/prj0000199","article-title":"Self-Efficacy as a mediator of the relationship between social support and recovery in serious mental illness","volume":"39","author":"Thomas","year":"2016","journal-title":"Psychiatr. Rehabil. J."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"643","DOI":"10.3390\/covid3040046","article-title":"A mediation model of self-efficacy and depression between burnout and alcohol consumption among health workers during the COVID-19 pandemic","volume":"3","year":"2023","journal-title":"COVID"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"30","DOI":"10.1002\/nop2.382","article-title":"Promoting self-efficacy in patients with chronic disease beyond traditional education: A literature review","volume":"7","author":"Farley","year":"2020","journal-title":"Nurs. Open"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"2721","DOI":"10.1007\/s10067-024-07052-w","article-title":"Evidence for telemedicine heterogeneity in rheumatic and musculoskeletal diseases care: A scoping review","volume":"43","author":"Melis","year":"2024","journal-title":"Clin. Rheumatol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"2547","DOI":"10.1093\/rheumatology\/keae177","article-title":"Effectiveness of a novel digital patient education programme to support self-management of early rheumatoid arthritis: A randomized controlled trial","volume":"63","author":"Knudsen","year":"2024","journal-title":"Rheumatology"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1399","DOI":"10.1007\/s00296-021-04907-2","article-title":"Tele-health interventions to support self-management in adults with rheumatoid arthritis: A systematic review","volume":"41","author":"MacIver","year":"2021","journal-title":"Rheumatol. Int."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"561","DOI":"10.1093\/intqhc\/mzu071","article-title":"Integrated care programmes for adults with chronic conditions: A meta-review","volume":"26","author":"Berchtold","year":"2014","journal-title":"Int. J. Qual. Health Care"},{"key":"ref_41","first-page":"768","article-title":"The effect of rheumatoid arthritis\u2013associated autoantibodies on the incidence of cardiovascular events in a large inception cohort of early inflammatory arthritis","volume":"56","author":"Barra","year":"2017","journal-title":"Rheumatology"}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/61\/6\/1013\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T17:42:42Z","timestamp":1760031762000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/61\/6\/1013"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,5,29]]},"references-count":41,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2025,6]]}},"alternative-id":["medicina61061013"],"URL":"https:\/\/doi.org\/10.3390\/medicina61061013","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,5,29]]}}}