Functional outcomes and naturalistic engagement with a purpose-built conversational AI for mental health (Ash)

Kristen M. Van Swearingen, Thomas D. Hull, Karthik V. Sarma, Caitlin A. Stamatis

Background: Conversational AI chatbots designed for mental health may offer an accessible, scalable avenue for supporting psychological well-being, yet prior evaluations have largely focused on clinical symptom reduction rather than broader indicators of day-to-day functioning, and have rarely monitored for potential harms such as inflated self-perception. Objective: We examined within-person change in psychological functioning indicators among real-world users of Ash, a purpose-built conversational AI for mental health support, over the first four weeks of use, and whether these changes were associated with engagement metrics. Methods: In this single-arm observational cohort study, new users (n = 1,284) completed in-app single-item measures of psychological functioning (life satisfaction, relationship satisfaction, sleep quality, behavioral activation), working alliance, and grandiosity (inflated self-perception), at baseline and Week 4. Paired-sample t-tests examined within-person change; ANCOVAs tested engagement-outcome associations at Week 4, controlling for baseline. Results: At baseline, participants reported below-average life satisfaction and fair sleep quality. Significant within-person improvements emerged across all functioning indicators and working alliance (ps < .001; d = 0.14-0.26), with no change in grandiosity. Active days, total sessions, and total minutes consistently predicted Week 4 psychological functioning and working alliance (ps <= .006; partial R^2 range: 0.58-2.15%; controlling for baseline), whereas user message volume did not. Conclusion: Findings provide preliminary data for the potential of evidence-based conversational AI to extend mental health support for broad psychological functioning, extending the existing literature beyond symptom-based outcomes.