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Source publication
In the present systematic review, we summarize the feasibility, usability, efficacy, and effectiveness of mental health-related apps created by the Veterans Affairs (VA) or the Department of Defense (DoD). Twenty-two articles were identified, reporting on 8 of the 20 VA/DoD mental health self-management and treatment companion apps. Review inclusio...
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Citations
... These apps are free to the public, evidence-informed, and do not collect or share identifiable data (Owen et al., 2018). While evidence for the efficacy of specific apps for mental health is limited, VA's MH apps have a growing research base supporting their acceptability, feasibility, and effectiveness (see Bröcker et al., 2023;Gould et al., 2019;Kuhn et al., 2017). ...
The U.S. Department of Veterans Affairs (VA) developed evidence-informed mental health mobile applications (MH apps) to supplement treatment and serve as self-care resources for veterans. However, lack of awareness and understanding of how to integrate MH apps into care pose barriers to uptake. The VA Mobile Mental Health Apps Project was conducted from 2019 to 2021 to train and support VA health care staff in integrating VA MH apps into practice using implementation facilitation. Interdisciplinary staff (N = 1,110) from 19 VA sites, led by local site champions, and supported by project Facilitators, participated. The training phase successfully equipped staff with key knowledge and skills for MH app integration (McGee-Vincent et al., 2023), but training is not sufficient for practice change (Schueller & Torous, 2020). The current article summarizes results from a mixed methods evaluation of the preimplementation planning and active implementation phases of the project. Survey data from 3-month posttraining (n = 362) and qualitative interview data (n = 27) assessed within the Consolidated Framework for Implementation Research (Damschroder et al., 2022b) were analyzed to highlight facilitators and barriers to implementation. Results showed positive perceptions, meaningful adoption, and expanded reach of MH apps for veterans by staff across VA. Given that the project was well-received and perceived to be sustainable, the adaptability of the innovation and implementation model, and the relatively limited number of perceived barriers, this project may serve as a model for other practice changes.
... The overall literature has recently expanded to better demonstrate the utility of specific apps in mental health treatment [11,12] with the delay in evidence impacting their wider deployment. Notably, the US Department of Veterans Affairs (VA) has developed a library of apps targeted at Veteran mental health treatment, efforts birthed from initial joint development work between the VA and US Department of Defense [13]. Arising from the Iraq conflict virtual reality exposure therapy for combat related posttraumatic stress disorder (PTSD) generated excitement and some encouraging evidence [14,15] but has yet to achieve systematic usage due to a host of implementation issues including cost, evidence, technical, clinical and administrative integration challenges. ...
Purpose of Review
Medicine and specifically mental health have been affected by emerging technologies advancing mental health treatment while at the same time bringing new challenges and stressors to the battlefield, military systems, and the warfighter.
Recent Findings
This article reviews the evolving positive and negative impacts of technology on combat mental health and treatment. A history of technology and military mental health concerns and services is followed by an overview of present benefits and risks. The conflict in Ukraine, the Russo-Ukraine War, is used to illustrate the current state-of-affairs with examples of the use, deployment, and consequence of technology on battlefield mental health.
Summary
Models need to be developed that assess specific battlefield environments and then selected and appropriately paired with available resources, technology, infrastructure, and workforce for mental health services at the individual and systems level, while understanding the impact of the changing battlefield ton mental health.
... In FY 2022, work continued to establish Clinical Resource Hubs to support telehealth in all VA regional networks. The VHA has also developed mobile apps that can be used as selfhelp tools or to support the implementation of EBP protocols such as cognitive behavioral therapy for insomnia, cognitive processing therapy, and prolonged exposure (Gould et al., 2019). ...
Recently, Dodge et al. (2024) published an article in American Psychologist offering recommendations to the mental health field for changing from an individual-level to a population-level focus. These recommendations included scaling up evidence-based programs, innovating and evaluating population-level interventions, and creating a primary system of care to promote mental health and well-being. For the past 2 decades, the Veterans Health Administration has been successfully engaged in these activities. In this commentary, we describe some of these ongoing efforts to demonstrate that Dodge et al.’s (2024) recommendations are indeed feasible with the proper infrastructure and resources and that the Veterans Health Administration’s efforts can serve as a model for the field.
... This intervention-Breathing, Relaxation, and Education for Anxiety Treatment in the Home Environment (BREATHE)-is organized with weekly video lessons, daily practice videos, and telephone coaching to encourage adherence to the practices. It was initially tested in a proof-of-concept study comparing the 4-week BREATHE intervention to a waitlist control in older adults with anxiety disorders [14]. The BREATHE intervention was found to be superior to the waitlist control in reducing anxiety, depressive, and somatic symptoms; however, the attrition in BREATHE (35%) warranted further investigation. ...
Background
Older veterans with anxiety disorders encounter multiple barriers to receiving mental health services, including transportation difficulties, physical limitations, and limited access to providers trained to work with older persons. To address both accessibility and the shortage of available providers, evidence-based treatments that can be delivered via guided self-management modalities are a potential solution.
Objective
This study aims to determine the feasibility and acceptability of a randomized controlled trial of 2 guided self-management interventions. This study compared the treatment effects of these 2 interventions (relaxation and health psychoeducation) on anxiety symptom severity and functioning in older veterans with anxiety disorders. Our exploratory aims examined factors related to home practices and treatment engagement and perceptions of the practices.
Methods
Participants were randomized to one of two video-delivered interventions: (1) Breathing, Relaxation, and Education for Anxiety Treatment in the Home Environment (BREATHE)—breathing and progressive relaxation or (2) Healthy Living for Reduced Anxiety—psychoeducation about lifestyle changes. Telephone coaching calls were conducted weekly. Measures of anxiety, depression, and functioning were obtained at baseline, week 4 (end of treatment), week 8, and week 12. Participants completed a semistructured interview at week 12. Analyses included descriptive statistics to summarize measures of intervention engagement; mixed-effects models to characterize symptom change, and qualitative analyses.
Results
Overall, 56 participants (n=48, 86% men; n=23, 41% from ethnic or racial minority groups; mean age 71.36, SD 6.19 y) were randomized. No difference in retention between study arms was found. The Healthy Living group (29/56, 52%) completed significantly more lessons (mean 3.68, SD 0.86) than the BREATHE group (27/56, 48%; mean 2.85, SD 1.43; t53=2.60; P=.01) but did not differ in completion of coaching calls. In the BREATHE group, greater baseline anxiety scores (r=–0.41; P=.03) and greater severity of medical comorbidity (r=–0.50; P=.009) were associated with fewer completed practices. There was no effect of intervention on change in total anxiety scores or functioning. For specific anxiety subtypes, Healthy Living produced a greater decline in somatic anxiety compared with BREATHE. Qualitative analyses found barriers to practicing, including difficulty setting time aside to practice, forgetting, or having other activities that interfered with BREATHE practices. Some participants described adapting their practice routine to fit their daily lives; some also used relaxation skills in everyday situations.
Conclusions
These findings suggest that a larger randomized controlled trial of guided self-management approaches to treating late-life anxiety is feasible; however, BREATHE was not effective in reducing anxiety compared with Healthy Living. Possible contributing factors may have been the reliance on a single technique. Progressive relaxation was reported to be enjoyable for most participants, but maintaining home practices was challenging. Those with milder anxiety severity and fewer health problems were better able to adhere to practices.
Trial Registration
ClinicalTrials.gov NCT02400723; https://clinicaltrials.gov/study/NCT02400723
... Last, these results should not be misconstrued as evidence of efficacy due to potential bias and lack of a suitable comparator. Efficacy of mental health IMIs is generally a gap in the literature (Gould et al., 2019). ...
Objective: While mobile delivery can help increase access to evidence-based treatment for veterans with posttraumatic stress disorder (PTSD), feasibility and acceptability are of concern with the potential for high attrition rates and limited participation. The Mantram Repetition Program (MRP), a meditation-focused approach with documented efficacy for reducing symptoms of PTSD and insomnia, was adapted as a brief, mobile-delivered MRP (mMRP) training. This study assessed implementation indicators of mMRP and compared self-directed users of mMRP versus users who received additional text message support. Method: Thirty-six veterans with clinically significant PTSD symptoms (Mage = 50.50 years; 83.3% male; 72.2% White; 88.9% heterosexual) completed four weekly training video modules. Participants completed questions related to program satisfaction, mantram repetition use, clinical measures, and a 30-min individual interview. Results: Participants reported using their mantram between 4 and 5 days per week. Participants indicated that mMRP was generally acceptable, appropriate, and feasible across quantitative and qualitative data. On clinical measures, change from pre- to postintervention was significant for the brief symptom screen, PTSD symptoms, and Personal Health Inventory but not for depression or insomnia symptoms. No significant differences were found between the self-directed and supported conditions; however, data suggest that participants primarily engaged with the support for administrative needs. Qualitative data highlighted suggestions for mMRP improvement, including alternative methods for receiving support and more content on how to use the skills taught. Conclusions: Findings suggest that mMRP can be delivered in a brief format, with veterans learning and using mantram repetition. Developing additional ways of individualizing the mMRP and further testing are warranted.
... After reviewing the content and quality of 69 PTSD-focused applications (apps), Sander et al. (2020) highlighted the freely available PTSD Coach app as a promising treatment option with positive quality ratings. The PTSD Coach app forms part of a 20 mental health-related apps suite developed by the Veterans Affairs of the United States Department of Defence and is available for both Android and iOS users (Gould et al., 2019;United States Department of Veterans Affairs, 2022). The PTSD Coach app includes trauma and PTSD psychoeducation, tools to manage and track PTSD symptoms, and support resources (visit https:// www.ptsd.va.gov/appvid/mobile/ptsdcoach_app.asp for further information). ...
... The lack of family involvement mentioned reiterates that PTSD affects both the family and the trauma-exposed individual. To this end, the PTSD Family Coach app was developed to assist families of those affected by PTSD (Gould et al., 2019). Participants' dislike of detailed enquiry about the experiences of trauma was likely in reference to the monitoring sessions with the psychologist rather than the intervention or the app itself (Bröcker et al., 2024). ...
We explored participants’ experiences of a counsellor-supported PTSD Coach mobile application intervention (PTSD Coach-CS) in a randomised controlled trial. PTSD Coach-CS participants, who received the intervention and self-completed a custom-designed questionnaire at intervention completion were included (n = 25; female = 20; ages 19–59; isiXhosa = 22). This questionnaire comprised questions regarding the feasibility, acceptability and potential impact of the PTSD Coach-CS intervention, and general psychological support in our setting. Data were analysed using Braun and Clarke’s thematic analysis. Three main themes emerged. (i) Participants’ largely positive experiences of treatment procedures included the safe space created by the counsellor support in combination with the PTSD Coach application, allowing them to learn about and understand their lived experiences, and to accept their PTSD diagnoses. (ii) Positive perceptions of the PTSD Coach application, yet raising important concerns (e.g., lack of family involvement) for future consideration. (iii) Intervention-specific and systemic treatment barriers (e.g., stigma) providing important information to inform and increase the usefulness of the PTSD Coach-CS intervention. The findings suggest that the PTSD Coach-CS intervention may help address the need for access to suitable care for South African adults with PTSD. Some contextual barriers must be considered in further intervention implementation.
... Yet, the breadth of health apps suggests significant demand for funding and other challenges potentially hindering quality research. For example, the VA has developed and implemented a robust suite of health apps grounded in a strong theoretical evidence base, yet a review of research on the VA health apps found research was quite limited (Gould et al., 2019). Thus, it is important for clinical researchers to invest increased efforts in evaluating health apps with priority given to those focused on highdemand, low-resource, evidenced-based treatments such as CBT-I. ...
Cognitive behavioral therapy for insomnia (CBT-I) is the recommended treatment for insomnia, yet multiple barriers limit utilization. Digital CBT-I may present a solution, though related reviews have focused on Internet-based delivery rather than app use. The high utilization of health apps and prevalence of sleep apps indicate the need to equip clinicians with app-specific research. Toward this end, we reviewed efficacy and quality data on self-management CBT-I smartphone apps, revealing efficacy research on eleven apps, five of which were publicly available. While preliminary, these efficacy studies showed consistent positive findings. When examining quantitative quality indicators for the five publicly available apps, two had consistent data. Overall, two apps, CBTi Coach and Insomnia Coach, had positive, empirical findings across all efficacy and quality assessment approaches. We provide recommendations to guide clinician decision making regarding CBT-I self-management apps based on the literature and publicly available methods of app evaluations.
... Lastly, the VA has also bridged gaps in care by developing over 20 interventional smartphone apps in partnership with the National Center for PTSD (e.g., PTSD Coach) [66][67][68]. These apps provide psychoeducation, symptom tracking, and coping tools for PTSD and other related mental health concerns, free of cost. ...
... These apps provide psychoeducation, symptom tracking, and coping tools for PTSD and other related mental health concerns, free of cost. VA mental health apps have been shown to be sufficiently feasible for veteran use and acceptable to veterans, with preliminary evidence of efficacy and effectiveness (particularly for PTSD Coach) [66]. These VA apps do not provide PE or CPT protocols themselves. ...
The United States Department of Veterans Affairs (VA) uses a systematized approach for disseminating evidence-based, trauma-focused psychotherapies for post-traumatic stress disorder (PTSD). Within this approach, veterans with PTSD must often choose between Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), each delivered in their standard protocols. Many veterans have been greatly helped by this approach. Yet limiting trauma-focused therapy to these two options leaves the VA unable to fully address the needs of a variety of veterans. This limitation , among other factors, contributes to the suboptimal attrition rates within the VA. The present review proposes solutions to address treatment barriers that are both practical (such as time and travel constraints) and psychological (such as resistance to trauma exposure). By reducing barriers, attrition may lessen. Proposed countermeasures against practical barriers include intensive protocols, shortened sessions, telehealth, smartphone application delivery, or any combination of these methods. Countermeasures against psychological barriers include alternative evidence-based treatment programs (such as Acceptance and Commitment Therapy), intensive protocols for exposure-based treatments, and the integration of components from complementary treatments to facilitate PE and CPT (such as Motivational Interviewing or family therapy). By further tailoring treatment to veterans' diverse needs, these additions may reduce attrition in VA services for PTSD.
... Accumulating evidence suggests that U.S. veterans are open to using apps to support health, and mental health apps developed by the VA and the Defense (DoD) have been found to be both feasible and acceptable (Gould et al., 2019;Hogan et al., 2022). With respect to the suite of apps developed by the VA's National Center for PTSD to address the self-management of mental health and wellbeing, there is a growing evidence base to suggest they can be of use for PTSD Kuhn et al., 2014Kuhn et al., , 2017Miner et al., 2016;Owen et al., 2015;Possemato et al., 2016), COVIDrelated stress , sleep problems (Koffel et al., 2018;Kuhn et al., 2022;Reilly et al., 2019), and the practice of mindfulness (Kozlov et al., 2020(Kozlov et al., , 2022. ...
U.S. veterans have historically experienced more mental health concerns as compared to the general population, yet face a variety of barriers to accessing care. Evidence-based and accessible resources, such as mobile apps, are needed to respond to the unique needs of a diverse veteran population. The U.S. Department of Veterans Affairs (VA’s) National Center for Posttraumatic Stress Disorder has created a one-of-a-kind portfolio of mental health apps to target the needs of veterans and support the self-management of common concerns related to posttraumatic stress disorder. Using data from a nationally representative sample of U.S. veterans, the present study sought to examine how veterans perceived the importance of making each self-management app available to other Veterans; factors impacting veterans’ intent to try each app; and actual uptake of each app. Results revealed that while 46.7%–75.0% of veterans reported that the apps are important for veterans, 5.8%–19.2% reported that they would be likely to download the apps, and only 5.0% reported having ever used any of them. Veterans who used any of the apps were more likely to be employed, have served two or more deployments, be married or partnered, use the VA as their primary source of health care, had more medical conditions, and were less likely to identify as Black. With respect to future app use, Black veterans were to 2–5 times more likely than White veterans to indicate a desire to download each of the apps. Other variables that showed consistent associations with increased likelihood of app download included greater smartphone utilization, being married or having a partner, lower household income, and history of mental health treatment. Implications of these results for the broader dissemination of mental health apps and promotion of their uptake are discussed.
... This is a stark departure from previous attempts to create chatbots to support mental health. Unlike companion AIs, these apps (e.g., Woebot, Wysa, Koa Health) tend to leverage rule-based retrieval dialog models that select appropriate responses from a dataset of pre-scripted responses (Bendig et al. 2019;Boucher et al. 2021;Gould et al. 2019;Kretzschmar et al. 2019;Sweeney et al. 2021;Vaidyam et al. 2019). Using pre-scripted responses provides guardrails on what the chatbot can say, with one review concluding that such apps are safe to use (Abd-Alrazaq et al. 2020). ...
Chatbots are now able to engage in sophisticated conversations with consumers. Due to the ‘black box’ nature of the algorithms, it is impossible to predict in advance how these conversations will unfold. Behavioral research provides little insight into potential safety issues emerging from the current rapid deployment of this technology at scale. We begin to address this urgent question by focusing on the context of mental health and “companion AI”: applications designed to provide consumers with synthetic interaction partners. Studies 1a and 1b present field evidence: actual consumer interactions with two different companion AIs. Study 2 reports an extensive performance test of several commercially available companion AIs. Study 3 is an experiment testing consumer reaction to risky and unhelpful chatbot responses. The findings show that (1) mental health crises are apparent in a non‐negligible minority of conversations with users; (2) companion AIs are often unable to recognize, and respond appropriately to, signs of distress; and (3) consumers display negative reactions to unhelpful and risky chatbot responses, highlighting emerging reputational risks for generative AI companies.
