Proposing a standardized, step-by-step model for creating post-traumatic stress disorder (PTSD) related mobile mental health apps in a framework based on technical and medical norms

The development of a smartphone app to enhance post-traumatic stress disorder treatment in high-risk workers

Objective

Post-traumatic stress disorder (PTSD) is highly prevalent in certain populations. However, evidence indicates that many individuals do not respond to treatment. Digital supports hold promise for increasing service provision and engagement but there is a lack of evidence on blended care options and still less research guiding the development of such tools. This study details the development and overarching framework used to build a smartphone app to support PTSD treatment.

Methods

The app was developed in line with the Integrate, Design, Assess, and Share (IDEAS) framework for the development of digital health interventions and involved clinicians (n=3), frontline worker clients (n=5) and trauma-exposed frontline workers (n=19). Integrated iterative rounds of testing were conducted via in-depth interviews, surveys, prototype testing and workshops, alongside app and content development.

Results

Clinicians and frontline workers both expressed a clear preference for the app to augment but not replace face-to-face therapy, with the aim of increasing between-session support, and facilitating homework completion. Content was adapted for app delivery from manualised therapy (trauma-focused cognitive behavioural therapy (CBT). Prototype versions of the app were well received, with both clinicians and clients reporting the app was easy to use, understandable, appropriate and highly recommendable. System Usability Scale (SUS) scores were on average in the excellent range (82/100).

Conclusions

This is one of the first studies to document the development of a blended care app designed specifically to augment clinical care for PTSD, and the first within a frontline worker population. Through a systematic framework with active end user consultation, a highly usable app was built to undergo subsequent evaluation.

Designing, Developing, Evaluating, and Implementing a Smartphone-Delivered, Rule-Based Conversational Agent (DISCOVER): Development of a Conceptual Framework

BACKGROUND

Conversational agents (CAs), also known as chatbots, are computer programs that simulate human conversations by using predetermined rule-based responses or artificial intelligence algorithms. They are increasingly used in health care, particularly via smartphones. There is, at present, no conceptual framework guiding the development of smartphone-based, rule-based CAs in health care. To fill this gap, we propose structured and tailored guidance for their design, development, evaluation, and implementation.

OBJECTIVE

The aim of this study was to develop a conceptual framework for the design, evaluation, and implementation of smartphone-delivered, rule-based, goal-oriented, and text-based CAs for health care.

METHODS

We followed the approach by Jabareen, which was based on the grounded theory method, to develop this conceptual framework. We performed 2 literature reviews focusing on health care CAs and conceptual frameworks for the development of mobile health interventions. We identified, named, categorized, integrated, and synthesized the information retrieved from the literature reviews to develop the conceptual framework. We then applied this framework by developing a CA and testing it in a feasibility study.

RESULTS

The Designing, Developing, Evaluating, and Implementing a Smartphone-Delivered, Rule-Based Conversational Agent (DISCOVER) conceptual framework includes 8 iterative steps grouped into 3 stages, as follows: design, comprising defining the goal, creating an identity, assembling the team, and selecting the delivery interface; development, including developing the content and building the conversation flow; and the evaluation and implementation of the CA. They were complemented by 2 cross-cutting considerations-user-centered design and privacy and security-that were relevant at all stages. This conceptual framework was successfully applied in the development of a CA to support lifestyle changes and prevent type 2 diabetes.

CONCLUSIONS

Drawing on published evidence, the DISCOVER conceptual framework provides a step-by-step guide for developing rule-based, smartphone-delivered CAs. Further evaluation of this framework in diverse health care areas and settings and for a variety of users is needed to demonstrate its validity. Future research should aim to explore the use of CAs to deliver health care interventions, including behavior change and potential privacy and safety concerns.

Sports injury and stressor-related disorder in competitive athletes: a systematic review and a new framework

BACKGROUND

For professional athletes, sports injury has been considered one of the most influential factors determining their athletic careers' duration and quality. High-intensity training and competitiveness of the sports competition are perhaps critical causes of sports-related stress. This article reviews the relevant research on sports injuries and stressor-related disorders. Further, it explores the following three issues in depth: (1) Do physical injuries caused by competitive sports lead to acute or posttraumatic stress disorder for athletes? What are the abnormal stress responses? (2) What diagnoses are currently available for sports injury related traumatic stress disorder? (3) What kinds of psychological rehabilitation are available for trauma-related symptoms in sports injury? How efficient are they in alleviating these symptoms?

METHODS

The study searched electronic databases, including PubMed, MEDLINE, CINAHL, etc. And reference lists of included papers were also screened. Two researchers selected the literature strictly according to the inclusion criteria and sorted them out. Based on the proved conclusions, the study established a new framework to manage traumatic stress disorders after the injury occurred.

RESULTS

16 articles were included in the study. (Q1: N = 10; Q2: N = 3; Q3: N = 3 ) The findings of this review suggested that athletes who suffer from sports injuries are more likely to experience abnormal physiological or psychological stress responses, which may become a massive challenge for athletes to continue their sports careers at a competitive level. However, there is a minimal understanding of addressing sports injury-related traumatic stress disorder from a biological perspective. Thus, it is challenging to build a scientific basis for diagnosis, screening, and treatment. In addition, the current diagnostic tool for athletes stress disorder still heavily relies on subjective measurement, and the treatment plan is not different from that of the general population.

CONCLUSIONS

It highlighted that sports-related stress disorder could be the greatest challenge to return to competition for injured athletes. The present study indicated the importance of systematically identifying the symptoms of sports-related stress disorder and improving the current diagnosis and treatment system.

Low-Intensity Interventions and EMDR Therapy

Unlike high-intensity treatment, in which clients have face-to-face contact with a mental health specialist, clients in low-intensity treatment have limited or no contact with a specialist. Instead, their treatment is usually provided through self-help procedures, which are delivered via (guided) computer programs, books, or “mHealth" apps. Other treatments sometimes considered low-intensity are brief treatments, group therapy, and interventions delivered by nonspecialists. Advantages include effectiveness, accessibility, efficiency, and affordability. Concerns related to safety, engagement, and adherence to self-help programs may be addressed by (asynchronous) therapist guidance. This article describes low-intensity treatments and their relevance for eye movement desensitization and reprocessing (EMDR) therapy. Hundreds of randomized controlled trials (RCTs) have found self-help interventions to be efficacious, with many producing the same level of results as the traditional face-to-face procedure. Guided self-help cognitive behavioral therapy is recommended for the treatment of posttraumatic stress disorder in the guidelines of both the National Institute for Health and Care Excellence and International Society of Traumatic Stress Studies. Only three self-help-EMDR RCTs have been conducted. This author advocates for reconceptualizing EMDR group therapy as “guided self-help-EMDR therapy,” because it is a highly manualized, heavily scripted treatment in which the client works independently on their own material. In this respect, it offers an excellent template for the future development of efficacious low-intensity EMDR interventions. Developing safe, easy-to-use, affordable, and readily available low-intensity interventions will make effective EMDR treatment available to many millions of people around the world.

Framework for the Design Engineering and Clinical Implementation and Evaluation of mHealth Apps for Sleep Disturbance: Systematic Review

BACKGROUND

Mobile health (mHealth) apps offer a scalable option for treating sleep disturbances at a population level. However, there is a lack of clarity about the development and evaluation of evidence-based mHealth apps.

OBJECTIVE

The aim of this systematic review was to provide evidence for the design engineering and clinical implementation and evaluation of mHealth apps for sleep disturbance.

METHODS

A systematic search of studies published from the inception of databases through February 2020 was conducted using 5 databases (MEDLINE, Embase, Cochrane Library, PsycINFO, and CINAHL).

RESULTS

A total of 6015 papers were identified using the search strategy. After screening, 15 papers were identified that examined the design engineering and clinical implementation and evaluation of 8 different mHealth apps for sleep disturbance. Most of these apps delivered cognitive behavioral therapy for insomnia (CBT-I, n=4) or modified CBT-I (n=2). Half of the apps (n=4) identified adopting user-centered design or multidisciplinary teams in their design approach. Only 3 papers described user and data privacy. End-user acceptability and engagement were the most frequently assessed implementation metrics. Only 1 app had available evidence assessing all 4 implementation metrics (ie, acceptability, engagement, usability, and adherence). Most apps were prototype versions (n=5), with few matured apps. A total of 6 apps had supporting papers that provided a quantitative evaluation of clinical outcomes, but only 1 app had a supporting, adequately powered randomized controlled trial.

CONCLUSIONS

This is the first systematic review to synthesize and examine evidence for the design engineering and clinical implementation and evaluation of mHealth apps for sleep disturbance. The minimal number of apps with published evidence for design engineering and clinical implementation and evaluation contrasts starkly with the number of commercial sleep apps available. Moreover, there appears to be no standardization and consistency in the use of best practice design approaches and implementation assessments, along with very few rigorous efficacy evaluations. To facilitate the development of successful and evidence-based apps for sleep disturbance, we developed a high-level framework to guide researchers and app developers in the end-to-end process of app development and evaluation.

Scientific Publication Patterns of Mobile Technologies and Apps for Posttraumatic Stress Disorder Treatment: Bibliometric Co-Word Analysis

Background

Mobile apps are viewed as a promising opportunity to provide support for patients who have posttraumatic stress disorder (PTSD). The development of mobile technologies and apps shows similar trends in PTSD treatment. Therefore, this emerging research field has received substantial attention. Consequently, various research settings are planned for current and further studies.

Objective

The aim of this study was to explore the scientific patterns of research domains related to mobile apps and other technologies for PTSD treatment in scholarly publications, and to suggest further studies for this emerging research field.

Methods

We conducted a bibliometric analysis to identify publication patterns, most important keywords, trends for topicality, and text analysis, along with construction of a word cloud for papers published in the last decade (2010 to 2019). Research questions were formulated based on the relevant literature. In particular, we concentrated on highly ranked sources. Based on the proven bibliometric approach, the data were ultimately retrieved from the Web of Science Core Collection (Clarivate Analytics).

Results

A total of 64 studies were found concerning the research domains. The vast majority of the papers were written in the English language (63/64, 98%) with the remaining article (1/64, 2%) written in French. The articles were written by 323 authors/coauthors from 11 different countries, with the United States predominating, followed by England, Canada, Italy, the Netherlands, Australia, France, Germany, Mexico, Sweden, and Vietnam. The most common publication type was peer-reviewed journal articles (48/64, 75%), followed by reviews (8/64, 13%), meeting abstracts (5/64, 8%), news items (2/64, 3%), and a proceeding (1/64, 2%). There was a mean of 6.4 papers published per year over the study period. There was a 100% increase in the number of publications published from 2016 to 2019 with a mean of 13.33 papers published per year during this latter period.

Conclusions

Although the number of papers on mobile technologies for PTSD was quite low in the early period, there has been an overall increase in this research domain in recent years (2016-2019). Overall, these findings indicate that mobile health tools in combination with traditional treatment for mental disorders among veterans increase the efficiency of health interventions, including reducing PTSD symptoms, improving quality of life, conducting intervention evaluation, and monitoring of improvements. Mobile apps and technologies can be used as supportive tools in managing pain, anger, stress, and sleep disturbance. These findings therefore provide a useful overview of the publication trends on research domains that can inform further studies and highlight potential gaps in this field.

E-health applications in the field of traumatic stress

E-health offers great potential in the field of traumatic stress to deliver training, assessment, prevention, and treatment of adverse outcomes after trauma worldwide. In order to encourage research on E-health applications in the field of traumatic stress, this current special issue of the European Journal of Psychotraumatology presents a series of papers divided into three emergent topics: I) development of digital interventions, II) the use of digital interventions to foster self-management and deliver therapy, and III) digital methods to improve prediction, assessment, and monitoring of post-trauma outcomes. These studies show acceptance of the tools by various end-user groups and improvements of current research and clinical practices, but also areas for improvement regarding the development process and making even better use of technological capabilities of E-Health. We propose three general themes to accelerate the quality of e-Health interventions and studies in this area in the coming years: optimizing user engagement and adherence, conducting more (innovative) research, and increasing implementation and dissemination activities. This issue appears in the midst of the COVID-19 pandemic. It is exactly at times like these that we need effective online interventions and we see an enormous increase in the use of e-Health. We hope this issue will contribute to help those affected and to serve the community worldwide.

Connected Mental Health: Systematic Mapping Study

BACKGROUND

Although mental health issues constitute an increasing global burden affecting a large number of people, the mental health care industry is still facing several care delivery barriers such as stigma, education, and cost. Connected mental health (CMH), which refers to the use of information and communication technologies in mental health care, can assist in overcoming these barriers.

OBJECTIVE

The aim of this systematic mapping study is to provide an overview and a structured understanding of CMH literature available in the Scopus database.

METHODS

A total of 289 selected publications were analyzed based on 8 classification criteria: publication year, publication source, research type, contribution type, empirical type, mental health issues, targeted cohort groups, and countries where the empirically evaluated studies were conducted.

RESULTS

The results showed that there was an increasing interest in CMH publications; journals were the main publication channels of the selected papers; exploratory research was the dominant research type; advantages and challenges of the use of technology for mental health care were the most investigated subjects; most of the selected studies had not been evaluated empirically; depression and anxiety were the most addressed mental disorders; young people were the most targeted cohort groups in the selected publications; and Australia, followed by the United States, was the country where most empirically evaluated studies were conducted.

CONCLUSIONS

CMH is a promising research field to present novel approaches to assist in the management, treatment, and diagnosis of mental health issues that can help overcome existing mental health care delivery barriers. Future research should be shifted toward providing evidence-based studies to examine the effectiveness of CMH solutions and identify related issues.

Treating Psychological Trauma in the Midst of COVID-19: The Role of Smartphone Apps

With the COVID-19 pandemic confronting health systems worldwide, medical practitioners are treating a myriad of physical symptoms that have, sadly, killed many thousands of people. There are signs that the public is also experiencing psychological trauma as they attempt to navigate their way through the COVID-19 restrictions impinging on many aspects of society. With unprecedented demand for health professionals' time, people who are unable to access face-to-face assistance are turning to smartphone apps to help them deal with symptoms of trauma. However, the evidence for smartphone apps to treat trauma is limited, and clinicians need to be aware of the limitations and unresolved issues involved in using mental health apps.

'Help for trauma from the app stores?' A systematic review and standardised rating of apps for Post-Traumatic Stress Disorder (PTSD)

Background: Mobile health applications (apps) are considered to complement traditional psychological treatments for Post-Traumatic Stress Disorder (PTSD). However, the use for clinical practice and quality of available apps is unknown. Objective: To assess the general characteristics, therapeutic background, content, and quality of apps for PTSD and to examine their concordance with established PTSD treatment and self-help methods. Method: A web crawler systematically searched for apps targeting PTSD in the British Google Play and Apple iTunes stores. Two independent researchers rated the apps using the Mobile App Rating Scale (MARS). The content of high-quality apps was checked for concordance with psychological treatment and self-help methods extracted from current literature on PTSD treatment. Results: Out of 555 identified apps, 69 met the inclusion criteria. The overall app quality based on the MARS was medium (M = 3.36, SD = 0.65). Most apps (50.7%) were based on cognitive behavioural therapy and offered a wide range of content, including established psychological PTSD treatment methods such as processing of trauma-related emotions and beliefs, relaxation exercises, and psychoeducation. Notably, data protection and privacy standards were poor in most apps and only one app (1.4%) was scientifically evaluated in a randomized controlled trial. Conclusions: High-quality apps based on established psychological treatment techniques for PTSD are available in commercial app stores. However, users are confronted with great difficulties in identifying useful high-quality apps and most apps lack an evidence-base. Commercial distribution channels do not exploit the potential of apps to complement the psychological treatment of PTSD.

Ecological momentary assessment in posttraumatic stress disorder and coping. An eHealth study protocol

Background: It is well known from cross-sectional studies that individual coping strategies significantly influence the pathogenesis of posttraumatic stress disorder (PTSD). Equally, undisputed is the role of biological processes, e.g. of the so-called 'stress hormone' cortisol for the trajectory of PTSD. Ecological momentary assessment (EMA), the repeated collection of self-reported momentary states via smartphones, is ideal for shedding light upon symptom fluctuations and coping strategies. EMA may also constitute a promising approach to provide closer associations to biomarkers than retrospective self-report. The mobile application 'CoachPTBS', created to facilitate transition into health-care systems, bridges waiting periods for trauma-specific psychotherapy. CoachPTBS offers tools akin to EMA that could elucidate coping with stress symptoms. Moreover, the app's self-management tools may improve coping strategies. However, these processes have never been examined in a combined, longitudinal fashion. Objective: The aim of the current study is to assess symptom fluctuations, coping strategies and long-term endocrine correlates of PTSD by a longitudinal, multimodal approach, combining traditional, online and EMA self-report with hair cortisol data and CoachPTBS as a possible novel mHealth tool. Method: 120 participants waiting for PTSD psychotherapy will be randomly grouped. After in-situ assessment and hair sample collection, 40 will receive CoachPTBS, using it daily throughout 4 weeks. A parallel group of 40 will participate in EMA, completing daily questionnaires on symptoms and coping. In between, online surveys will be conducted. After 6 weeks, a final interview and another hair sample collection will follow. Comparisons between these groups and waitlist-control, also consisting of 40 PTSD participants, and 40 non-traumatized participants assessed via EMA regarding aversive emotions and coping are planned. Discussion: Novel insights into the interplay of biological and coping strategies in PTSD are expected due to the innovative multimodal study design. Results will further explore benefits of eHealth tools on coping with PTSD.