Mental and Behavioral Health Apps for Service Members, Veterans, and Providers
Julia E. Hoffman
More than half of US adults carry smartphones (Nielsen, 2013) allowing them to communicate via voice, text, and email, browse the Internet, consume various types of media, and run powerful software applications (apps). Apps can offer health-related resources such as health tips, self-assessments, appointment reminders, treatment tools, and real-time interaction with providers and supporters. In collaboration with partners, the VA National Center for PTSD is developing apps to address common mental and behavioral health issues facing veterans and civilians.
Our first app, PTSD Coach (Hoffman, Wald et al., 2011) was released in April of 2011 for self-management of PTSD symptoms. It was developed in partnership with the DoD’s National Center for Telehealth & Technology (T2) and draws upon evidence-based treatments (EBTs) for PTSD. Key features of the app include information about PTSD and related conditions, types of available treatment, and information on how to find care. The app includes a well-validated PTSD self-report measure (the PTSD Checklist [PCL]; Weathers et al., 1993) with possibilities for feedback and graphing of scores over time. It also includes such self-management skills as relaxation exercises, behavioral activation, coping with trauma triggers, self-coaching, and one-tap access to crisis resources, personal support contacts, and professional mental health care services. As of April 2013, iOS and Android versions of PTSD Coach have been downloaded over 100,000 times in 74 countries and the app has been versioned by various countries to suit their populations.
Apps are also being built to support face-to-face EBTs for PTSD and common co-occurring problems like insomnia and smoking. Whenever possible, treatment developers and expert clinicians participate to identify implementation challenges of the protocol defining an ideal feature set for the companion app. PE Coach (Reger et al., In Press), an exemplar of such efforts, is for patients undergoing Prolonged Exposure (PE) therapy (Foa, Hembree, & Rothbaum, 2007) for PTSD. It was designed to improve homework completion, protocol adherence, and execution of tasks required to maximize benefits from PE. It was developed with the DoD’s T2 and Center for Deployment Psychology (CDP) in collaboration with PE’s creators (Edna Foa & Barbara Rothbaum). Released in early 2012 for Android and iOS, it hadover 10,000 downloads in 42 countries as of April 2013.
The PE protocol includes psychoeducation about PTSD, breathing retraining to reduce anxiety, and two forms of exposure (in vivo and imaginal) to help patients overcome avoidance and emotionally process their trauma memory to alleviate PTSD symptoms. It includes exposure assignments with monitoring of distress and audio-recording sessions for patients to listen to as homework. PE Coach seeks to improve these practices and replaces paper-based assessments, handouts, and homework tracking forms. Using audio-visual presentations, it provides enhanced psychoeducation and breathing retraining. The app allows patients to construct a fear hierarchy and then select and rate their distress on in vivo exposure exercises. Imaginal exposure homework (e.g., listening to recordings of the in-session trauma recounting) can also be rated and saved. Finally, the app administers the PCL allowing for symptom tracking over sessions. The app provides additional advantages by exploiting existing smartphone features to allow users to set reminders for homework and appointments as well as storing provider contact and appointment information.
PFA Mobile (Hoffman et al., 2012) is an app for mental health providers and other response workers who deliver Psychological First Aid (PFA; Brymer et al., 2006) to affected populations shortly after disasters and emergencies. It was jointly developed with the National Child Traumatic Stress Network (NCTSN) and DoD’s T2. PFA treatment developers and trainers participated in designing the app, focusing on implementation challenges faced by providers. As disaster response typically occurs in chaotic environments, it can be difficult to assess survivors’ needs, especially when availability of qualified providers is limited. PFA Mobile was designed to assist in providing high quality psychological care in these circumstances by offering a compact comprehensive tool for connecting survivors with services. The app is not intended to replace PFA training but to reinforce learning and to supplement resources used before, during, and after a disaster response. An iOS version of the app is currently available and the complete Android version will be released shortly.
PFA Mobile offers several functions including a just-in-time refresher of PFA’s core actions and connecting these with examples and intervention suggestions; it also provides guidance for intervention strategies for survivor-specific needs. This includes tailored information on how to address survivor distress such as anger, parenting concerns, and sleep issues across age groups. There are mentor tips describing how to implement PFA in real-world situations. A self-assessment for responders is also included to determine their own readiness to conduct PFA based on contextual and personal variables. Anonymous assessment and tracking of survivors' needs afford simplified data collection and easy referrals.
Our development and dissemination efforts run parallel to our ongoing research and program evaluation. We are evaluating our apps for their feasibility and user satisfaction and conducting studies on factors related to their clinical adoption and efficacy. For example, we examined user satisfaction, perceived helpfulness, and usage patterns of PTSD Coach in veterans in PTSD treatment (Kuhn, Greene et al., 2013). Participants reported high satisfaction with the app and perceived it as being moderately to very helpful in managing acute distress, PTSD symptoms, and helping with sleep. They also reported that the app helped them to learn more about PTSD and to explain it to family and friends.
To understand if providers would be willing to use PE Coach before its release, VA PE providers’ perceptions of the primary functions of the app were assessed (Kuhn, Eftekhari et al., 2013). Overall, providers believed that the app would offer relative advantages to existing PE practices, would not be too complex to use, and would be compatible with their and their patients’ values and needs. Provider characteristics, such as being younger, owning a smartphone, and having already used apps in care (i.e., early adopters) were related to more favorable perceptions of the app. Being a smartphone owner, perceiving that the app would provide relative advantages, and would not be too complex to use predicted intention to use the app if it were available.
We currently have two randomized controlled trials of PTSD Coach underway. One examines the efficacy of the app at reducing PTSD symptoms, increasing coping self-efficacy, and transferring knowledge of PTSD in a community sample of trauma survivors with elevated PTSD symptoms. The other examines the effects of PTSD Coach on treatment engagement in asample of VA PTSD patients just beginning outpatient PTSD specialty care.
Our publicly available apps are unconnected; they do not transmit or receive data. The potential for apps to improve veterans’ mental and behavioral health in the future could be vastly improved by having connected apps capable of sending and receiving data. Connected apps could securely share data with the patient’s electronic health record, personal health record, or a secure clinical or research server. These data could also be accessed through a clinician website (dashboard) where they would be synthesized and visualized providing rich patient information to inform care. Research and limited demonstration pilots are underway to test connected versions of our apps; however, realizing any potential benefits will require compliance with applicable ethical and legal requirements.
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Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J., Steinberg, A., Vernberg, E., & Watson, P., (2006). Psychological First Aid: Field Operations Guide (2nd ed.). National Child Traumatic Stress Network and National Center for PTSD. Retrieved from http://www.ptsd.va.gov/professional/manuals/manual-pdf/pfa/PFA_V2.pdf
Foa, E. B., Hembre, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences, a therapists guide. New York: Oxford University Press.
Hoffman, J.E., Brymer, M.J., Watson, P.J., Kim, H.C., Ruzek, J.I., Wald, L.J., Kuhn, E., Greene, C., & Weingardt, K. (2012). PFA Mobile (Version 1.0) [Mobile application software]. Retrieved from http://itunes.apple.com .
Hoffman, J.E., Wald, L.J., Kuhn, E., Greene, C., Ruzek, J.I., & Weingardt, K. (2011). PTSD Coach (Version 1.0). [Mobile application software]. Retrieved from http://itunes.apple.com.
Kuhn, E., Eftekhari, A., Hoffman, J. E., Crowley, J. J., Ramsey K M, & Ruzek J. I. (2013). Clinician Perceptions of Using a Smartphone App with Prolonged Exposure Therapy. Manuscript submitted for publication.
Kuhn, E., Greene C., Hoffman, J. E., Nguyen, T., Wald, L., Schmidt, J., Ramsey, K. M., & Ruzek, J. I. (2013). A preliminary evaluation of PTSD Coach, a smartphone app for posttraumatic stress symptoms. Manuscript submitted for publication.
Nielsen. (2013, February). The Mobile Consumer: A Global Snapshot. Retrieved from Nielsen website: http://www.nielsen.com/us/en/reports/2013/mobile-consumer-report-february-2013.html
Reger, G. M., Riggs, D., Rothbaum, B. O., Ruzek, J. I., Hoffman, J., & Kuhn, E. (in press). A “PE Coach” Smartphone Application: An Innovative Approach to Improving Implementation, Fidelity, and Homework Compliance for Prolonged Exposure. Psychological Services.
Weathers, F., Litz, B., Herman, D., Huska, J., & Keane, T. (1993, October). The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Paper presented at the Annual Convention of the International Society for Traumatic Stress Studies, San Antonio, TX.