Mobile applications may be the future of veteran mental health support but do veterans know yet? A survey of app knowledge and use

Provider and patient barriers and facilitators to integration of digital mental health applications in routine clinical care

BACKGROUND

The limited accessibility of mental healthcare providers highlights the need for innovative approaches to provide effective and efficient care. Digital mental health applications (DMHAs) can improve patient access to evidence-based treatments and reduce burden on the healthcare system. Here, we examined the provider and patient barriers and facilitators to integration of DMHAs in a healthcare system.

METHODS

Patients (n = 57) and providers (n = 100) were recruited from a large healthcare system over five months. Participants completed a survey assessing attitudes towards DMHAs, and perceived facilitators and barriers to adoption and utilization of DMHAs in mental healthcare.

RESULTS

DMHA credibility was a key facilitator for provider adoption, while usability and accessibility were identified as key facilitators for patient utilization. Provider barriers included patient cost/provider reimbursement, limited knowledge, perceived limits to credibility, patient outcome enhancement, and personalization of DMHAs for patient needs. Patients identified privacy concerns as the top barrier for using DMHAs.

LIMITATIONS

The self-report survey nature of this study, modest sample size, and majority of sample identifying as White and upper middle class make results subject to biases and limitations. Given the potential of DMHAs to address disparities in access to mental healthcare, more research is needed including populations who are at greatest risk.

CONCLUSIONS

Findings provide new insights to inform the development of intervention strategies to improve the integration of DMHAs within healthcare systems. Additional research examining key stakeholders at different levels of care is critical to address barriers, optimize facilitators, and develop roadmaps for best-practice use in healthcare systems.

Mobile mental health application use, and app feature preferences among individuals with mental disorders in Ethiopia: A cross-sectional survey

BACKGROUND

Mobile health applications have been shown to assist in the treatment of mental illnesses, yet their potential remains underutilized. As supportive care, mental health applications use may be useful tools in improving mental health literacy and treatment outcomes, but patients' use of and interest in using these apps have not been studied in low-income countries like Ethiopia. This study explores the determinants of patients' mental health app use interests and app feature preferences.

METHODS

A cross-sectional study was conducted with 419 outpatient individuals with mental health disorders at Amanuel Mental Specialized Hospital, Ethiopia, between October and November 2023, using a convenience sampling method. Patients' self-reported mental health app use, interests, attitudes, and app feature preferences were collected. A multivariate logistic regression model was used to identify the associated factors.

RESULTS

Overall prevalence of not interested, somewhat interested, interested, and extremely interested in mental health app use was 5.3 %, 16.9 %, 27.7 %, and 50.1 % respectively. The proportion of current mental health apps use was low (21.2 %). Current mental health app use is associated with living in an urban area (AOR = 6.69, CI: 3.19-14) and having a higher education level (4.12 (2.02-8.04). Furthermore, app features such as psychoeducation, symptom tracking, and self-management techniques ranked as the most preferred app features.

CONCLUSIONS

Most study participants were interested in using mental health apps, but only about one in four were using mental health apps. This suggests promise for their utility in the Ethiopian context. App developers and policymakers should consider rural residents', lower educational levels, and patient app preferences when developing these applications.

The Virtual Hope Box mobile application: A systematic review of the literature

INTRODUCTION

The Virtual Hope Box (VHB) mobile application is an adapted version of the conventional hope box intervention that is used in several evidence-based treatments for suicide behaviors. The VHB is an award-winning app developed by a collaboration between the Departments of Defense and Veterans Affairs. Multiple studies have assessed the utility and effectiveness of the VHB for use in suicide prevention, but no reviews of the literature have been conducted.

METHODS

Authors performed a review of the literature using PsycINFO, EBSCOhost, and PubMed. 15 articles were ultimately included.

RESULTS

Results were categorized into three areas: (1) efficacy and effectiveness, (2) feasibility, awareness, and usage in high-risk populations, and (3) implementation approaches to increase use among patients and providers. Existing evidence for the VHB supports its feasibility and acceptability, especially among military and veteran populations. Only one study investigated effectiveness in a randomized control trial. Although the VHB developers have disseminated the app nationally, low adoption rates among veteran patients and VA providers remain. Studies found that educational implementation strategies can improve utilization rates.

CONCLUSIONS

Future research should examine suicide behaviors as outcomes, approaches to incorporating the VHB into treatment, and a range of populations.

Geri-Mobile Health: Feasibility of a VA Mental Health Mobile Apps Coaching Program for Older Veterans

OBJECTIVES

This program evaluation examined the feasibility, acceptability, and preliminary effects of an individualized coaching program to help older Veterans use VA mental health mobile apps to address mental health and well-being goals.

METHODS

The program delivers individual technical and clinical support to facilitate the use of mobile devices and VA apps. Participants completed assessments of mobile device proficiency, app use frequency, app comfort, quality of life, and mental health symptoms (completed by a subset, n = 11) pre- and post-participation.

RESULTS

Of 24 enrollees, 17 completed the program and received an average of 7.58 (SD = 2.87) sessions including the initial assessment. Mobile device proficiency (t (16) = -3.80, p = .002) and number of days/week apps were used (t (16) = -2.34, p = .032) increased significantly from pre- to post-participation. Depressive and anxiety scores decreased significantly (t (10) = 3.16, p = .010; t (10) = 3.29, p = .008) among the subset completing those measures. Overall satisfaction was high; 100% reported they would recommend the program.

CONCLUSIONS

Findings suggest the program is feasible, highly acceptable, and increases mobile device proficiency and use of apps.

CLINICAL IMPLICATIONS

Coaching programs can equip older adults with the skills to use mental health apps.

Acceptance and commitment therapy for co-occurring gambling disorder and posttraumatic stress disorder in veterans: a narrative review

Background: PTSD and gambling disorder (GD) are frequently comorbid. Gambling may provide escape-based coping for the emotions experienced by PTSD sufferers. Military personnel may be at increased risk of PTSD and/or GD. Acceptance and Commitment Therapy (ACT) has been found to improve both PTSD and GD outcomes, yet research into the potential effectiveness of ACT for PTSD and/GD in veterans is scarce.Objective: This review aimed to systematically assess and describe the evidence relating to the use of ACT and acceptance-based therapy for military populations with PTSD and/or GD.Method: Six databases were searched. Selection criteria included studies that featured the armed forces/military, delivered ACT/acceptance-based therapy, and aimed to improve PTSD and/or GD outcomes. A narrative synthesis approach was adopted.Results: From 1,117 results, 39 studies were fully screened and 14 met inclusion criteria. All studies originated from the USA and 9 were associated with United States Department of Veterans Affairs. Therapy use within each study produced an improvement in PTSD and/or GD, yet only one study examined GD and no studies considered comorbid PTSD/GD. The broad range of study designs made it difficult to compare the findings or make generalisations from the collective results. It is unclear which method of ACT delivery is superior (app-based, telehealth, face-to-face, groups, one-to-one, manualised, or unstructured), or what the true effect size is of ACT for PTSD and/or GD.Conclusions: These preliminary findings are promising, yet more research is needed on the delivery format and content of ACT sessions, and whether findings generalise beyond USA-recruited military samples. The cost-effectiveness of remote-based ACT also warrants investigation.HIGHLIGHTS Among veterans, psychological interventions such as Acceptance and Commitment Therapy (ACT) may be effective for Post-Traumatic Stress Disorder (PTSD) and/or Gambling Disorder (GD).There is a paucity of evidence on ACT approaches for treating PTSD and GD in veterans.Further work is needed on context-specific delivery (in-person vs. group), method of ACT intervention (manualised vs unstructured, digital therapeutics) with non-US samples.

Automated Text Messaging During COVID-19: Patient Feedback to Increase Adoption

Automated text messaging interventions can effectively improve self-care and were used to support the U.S. Veterans Health Administration's (VHA) public health outreach during the COVID pandemic. Currently, significant gaps exist in knowledge about VHA patients' texting protocol preferences that may impact user receptivity, engagement, and effectiveness. This study qualitatively evaluated patient suggestions to improve two VHA Covid-related texting interventions and preferences for future text message protocols. We reviewed cross-sectional type-written survey responses from patients receiving either the "Coronavirus Precautions" or the "Coping During COVID" multi-week text protocols. Two team members independently and inductively coded all responses allowing for an upward abstraction of qualitative data. Nine hundred five patients (72.8% male) responded to the open-response item questions targeted by this research. An item that sought feedback to improve protocol acceptability generated thirteen distinct descriptive categories (inter-rater reliability 83.5%). Codable feedback showed, for example, that patients desired to manipulate message frequency and to have a more sophisticated interaction with messages. Patients' suggestions for future automated text messaging protocols yielded nine distinct topic areas. Patients offered suggestions that may impact receptivity and engagement of future automated text message protocols, particularly as they relate to outreach during a public health crisis. In addition, patients offered specific topics they would like to see in future text message protocols. We discuss how the findings can be used to increase engagement in current and post-pandemic public health interventions.

Evaluation of a Psychoeducational Group to Expand Mobile Application Knowledge and Use in a Veteran Residential Treatment Program

Despite the availability of free, evidence-informed mental health mobile applications (apps) to support Veterans and Service Members, interventions are needed to ensure patients are aware of the developed resources. A psychoeducational group was developed and evaluated by a quality improvement project in the context of a Department of Veterans Affairs residential treatment program. Four weekly group sessions introduced 82 Veterans to two similarly themed apps at each group and supported Veteran installation, introduction to the clinical subject matter, app orientation and demonstration, and device/app troubleshooting. Although 94% owned a smartphone, prior to the group, seven of eight apps introduced during the group had been used by fewer than 10% of participants. Following group participation, the proportion of participants agreeing that they were comfortable using mental health apps increased from 33% at baseline to 75%. Similarly, relative to 54% of participants at baseline who agreed that they were aware of available mental health mobile applications, the proportion rose to 89% after the group. Most participants rated three apps as "helpful" or "very helpful" (Breath2Relax, Mindfulness Coach, and PTSD Coach) and most participants reported they were likely to use these apps in the future. Results and qualitative feedback identified needed improvements to the group, including the replacement of some featured apps and the inclusion of automated app usage metrics. Well-designed implementation studies of dissemination strategies are needed to inform best practices for the adoption of these promising interventions.

Training Staff Across the Veterans Affairs Health Care System to Use Mobile Mental Health Apps: A National Quality Improvement Project

BACKGROUND

The National Center for PTSD, within the Department of Veterans Affairs (VA), has developed a suite of free, publicly available, evidence-informed apps that can reach an increasing number of veterans and bridge gaps in care by providing resources to those who are not engaged in mental health treatment. To expand the reach of these apps, staff across VA service lines learned about these apps, their features and limitations, and how to introduce them to veterans.

OBJECTIVE

This study aimed to develop, disseminate, and evaluate a training for multidisciplinary staff as part of a national quality improvement project to increase the reach of mobile mental health apps as a resource for veterans.

METHODS

Sites from all of VA's 18 geographic regions enrolled in this project. At each site, a minimum of 25 VA staff members who had direct contact with veterans, including staff from the mental health service line and all other service lines, were recruited to participate. Training included a 3-hour multidisciplinary core module, and a 1-hour clinical integration module designed specifically for mental health clinicians. Owing to the COVID-19 pandemic, the trainings were adapted to a live, web-based format. Pre- and posttraining surveys assessed program reach (ie, participants enrolled per site), satisfaction, and effectiveness of the training as measured by changes in knowledge, basic skills, and behavioral intentions to use apps with veterans.

RESULTS

A total of 1110 participants representing 34 disciplines at 19 VA sites completed the training. Overall, 67% (743/1109) of participants were mental health staff members. Sites averaged 58.4 participants (SD 36.49, median [IQR] 51). Most (961/1024, 93.85%) participants were satisfied with the training and reported that they (941/1018, 92.44%) would recommend it to others. App knowledge scores significantly increased from pretraining (mean 80.8% correct, SD 15.77%) to posttraining (mean 91.1% correct, SD 9.57%; P<.001). At posttraining, participants also reported greater confidence in their ability to show veterans how to download (z=-13.86; P<.001) and use VA mental health apps (z=-15.13; P<.001). There was near universal endorsement by staff for their intentions to recommend apps to veterans as well as their ability to think of at least one specific veteran to whom they could recommend an app. Staff also reported a strong motivation to encourage other VA staff to share apps with veterans.

CONCLUSIONS

The training far exceeded the initial goals for staff recruitment and training for all three metrics. Overall, 33% (366/1109) of participants came from service lines outside of mental health, indicating the feasibility of introducing these mental health resources during medical appointments and in other contexts.

Regulatory considerations to keep pace with innovation in digital health products

Rapid innovation and proliferation of software as a medical device have accelerated the clinical use of digital technologies across a wide array of medical conditions. Current regulatory pathways were developed for traditional (hardware) medical devices and offer a useful structure, but the evolution of digital devices requires concomitant innovation in regulatory approaches to maximize the potential benefits of these emerging technologies. A number of specific adaptations could strengthen current regulatory oversight while promoting ongoing innovation.

Predicting Uptake of the COVID Coach App Among US Military Veterans: Funnel Analysis Using a Probability-Based Panel

BACKGROUND

Although the COVID-19 pandemic has not led to a uniform increase of mental health concerns among older adults, there is evidence to suggest that some older veterans did experience an exacerbation of preexisting mental health conditions, and that mental health difficulties were associated with a lack of social support and increasing numbers of pandemic-related stressors. Mobile mental health apps are scalable, may be a helpful resource for managing stress during the pandemic and beyond, and could potentially provide services that are not accessible due to the pandemic. However, overall comfort with mobile devices and factors influencing the uptake and usage of mobile apps during the pandemic among older veterans are not well known. COVID Coach is a free, evidence-informed mobile app designed for pandemic-related stress. Public usage data have been evaluated; however, the uptake and usage of the app among older veterans have not been explored.

OBJECTIVE

The purpose of this study was to characterize smartphone ownership rates among US veterans, identify veteran characteristics associated with downloading and use of COVID Coach, and characterize key content usage within the app.

METHODS

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study (NHRVS), which surveyed a nationally representative, prospective cohort of 3078 US military veterans before and 1 year into the pandemic. The NHRVS sample was drawn from KnowledgePanel, a research panel of more than 50,000 households maintained by Ipsos, Inc. The median time to complete the survey was nearly 32 minutes. The research version of COVID Coach was offered to all veterans who completed the peripandemic follow-up assessment on a mobile device (n=814; weighted 34.2% of total sample). App usage data from all respondents who downloaded the app (n=34; weighted 3.3% of the mobile completers sample) were collected between November 14, 2020, and November 7, 2021.

RESULTS

We found that most US veterans (81.5%) own smartphones, and that veterans with higher education, greater number of adverse childhood experiences, higher extraversion, and greater severity of pandemic-related posttraumatic stress disorder symptoms were more likely to download COVID Coach. Although uptake and usage of COVID Coach were relatively low (3.3% of eligible participants, n=34), 50% of the participants returned to the app for more than 1 day of use. The interactive tools for managing stress were used most frequently.

CONCLUSIONS

The COVID-19 pandemic has increased the need for and creation of digital mental health tools. However, these resources may require tailoring for older veteran populations. Future research is needed to better understand how to optimize digital mental health tools such as apps to ensure uptake and usage among older adults, particularly those who have experienced traumas across the lifespan.

FOCUS mHealth Intervention for Veterans With Serious Mental Illness in an Outpatient Department of Veterans Affairs Setting: Feasibility, Acceptability, and Usability Study

BACKGROUND

Veterans with serious mental illnesses (SMIs) face barriers to accessing in-person evidence-based interventions that improve illness management. Mobile health (mHealth) has been demonstrated to be feasible, acceptable, effective, and engaging among individuals with SMIs in community mental health settings. mHealth for SMIs has not been tested within the Department of Veterans Affairs (VA).

OBJECTIVE

This study examines the feasibility, acceptability, and preliminary effectiveness of an mHealth intervention for SMI in the context of VA outpatient care.

METHODS

A total of 17 veterans with SMIs were enrolled in a 1-month pilot trial of FOCUS, a smartphone-based self-management intervention for SMI. At baseline and posttest, they completed measures examining symptoms and functional recovery. The participants provided qualitative feedback related to the usability and acceptability of the intervention.

RESULTS

Veterans completed on an average of 85.0 (SD 96.1) interactions with FOCUS over the 1-month intervention period. They reported high satisfaction, usability, and acceptability, with nearly all participants (16/17, 94%) reporting that they would recommend the intervention to a fellow veteran. Clinicians consistently reported finding mHealth-related updates useful for informing their care. Qualitative feedback indicated that veterans thought mHealth complemented their existing VA services well and described potential opportunities to adapt FOCUS to specific subpopulations (eg, combat veterans) as well as specific delivery modalities (eg, groups). In the 1-month period, the participants experienced small improvements in self-assessed recovery, auditory hallucinations, and quality of life.

CONCLUSIONS

The FOCUS mHealth intervention is feasible, acceptable, and usable among veterans. Future work should develop and examine VA-specific implementation approaches of FOCUS for this population.