@Article{info:doi/10.2196/66115, author="Westerveld, M. Myrna and van der Mheen, Malindi and Knipschild, Rik and Maijer, Kim and de Keizer-Altink, E. Marieke and Albisser, Nina and Hoekstra, E. Marielle J. and Timmermans-Jansen, Anne and Zijp, Rosa and Krabbendam, A. Anne and van Steensel, A?(Bonny) Francisca J. and Kan, Kees-Jan and Huyser, Chaim and Staal, G. Wouter and Utens, J. Elisabeth M. W. and Lindauer, L. Ram{\'o}n J.", title="Short- and Long-Term Effectiveness of Brief Intensive Trauma Treatment for Adolescents With Posttraumatic Stress Disorder and Their Caregivers: Protocol for a Multicenter Randomized Controlled Trial", journal="JMIR Res Protoc", year="2025", month="Apr", day="30", volume="14", pages="e66115", keywords="brief intensive trauma treatment", keywords="adolescents", keywords="stress disorder", keywords="post-traumatic", keywords="adverse childhood experiences", keywords="eye movement desensitization reprocessing", keywords="trauma-focused cognitive behavioral therapy", keywords="Caribbean", keywords="randomized controlled trials", keywords="multicenter studies", abstract="Background: Childhood trauma is pervasive, with approximately 50\% of adolescents experiencing at least one potentially traumatic event before adulthood. Eight percent to 33\% of potentially traumatic event--exposed adolescents develop posttraumatic stress disorder (PTSD), which can cause extreme suffering and coincides with numerous comorbid illnesses and high-risk behaviors. PTSD can be effectively treated in adolescents through weekly sessions of eye movement desensitization and reprocessing or trauma-focused cognitive behavioral therapy. Despite the availability of these treatments, numerous severely traumatized adolescents do not receive available treatment options due to high treatment avoidance. In adolescents who receive care, a large group of youth does not experience a sufficient symptom decrease after regular treatment. In addition, dropout rates during prolonged treatment are substantial, varying between 10\% and 30\%. This underscores the need for innovative and brief trauma treatment. Pilot studies indicate that Brief Intensive Trauma Treatment (BITT) can be a safe and effective treatment for adolescents with PTSD. However, randomized controlled trials on its effectiveness are crucial and urgently needed. Objective: This is the first study to test the effectiveness of a 1-week BITT in adolescents with PTSD and comorbid symptoms and their caregivers. Methods: This multicenter, single-blinded randomized controlled trial will be conducted in 4 youth care centers in the European and Caribbean Netherlands: Levvel, Karakter, Fornhese-GGz Centraal, and Mental Health Caribbean (Bonaire). We will randomize adolescents (12-18 years old) with PTSD to a BITT (n=50) or waitlist control group (WLCG; n=50). BITT comprises 1-week (ie, 5 consecutive workdays) intensive trauma treatment, encompassing daily 90-minute manualized sessions of trauma-focused cognitive behavioral therapy and eye movement desensitization and reprocessing. The day begins and ends with psychomotor therapy. Caregivers receive daily parental counseling sessions consisting of psychoeducation and social support skill training. We will conduct measurements at similar intervals for both groups: at baseline; directly after BITT or WLCG; and at 3, 6, and 9 months' follow-up. The WLCG will receive BITT after the 3-month follow-up assessment. We will assess all study parameters using digital or face-to-face questionnaires and semistructured interviews. We will assess the primary outcome PTSD symptoms using the Child and Adolescent Trauma Screen 2 (CATS-2) and the Clinician-Administered PTSD Scale for DSM-5 (Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition])-Child/Adolescent Version (CAPS-CA-5). Results: As of September 2022, we enrolled 104 participants. Data will be collected until December 2025. Results are expected to be published in the summer of 2026. Conclusions: This first, innovative study on BITT's effectiveness may enhance treatment outcomes for PTSD by preventing dropout, reducing avoidance, shortening therapy duration, and empowering therapists by working together intensively. This research will provide valuable insights across cultures for treating severely traumatized adolescents who do not benefit sufficiently from regular treatment. Trial Registration: ClinicalTrials.gov NCT06143982, http://clinicaltrials.gov/ct2/show/NCT06143982 International Registered Report Identifier (IRRID): DERR1-10.2196/66115 ", doi="10.2196/66115", url="https://www.researchprotocols.org/2025/1/e66115" } @Article{info:doi/10.2196/69829, author="Meyerson, E. Beth and Davis, Alissa and Crosby, A. Richard and Linde-Krieger, B. Linnea and Brady, R. Benjamin and Carter, A. Gregory and Mahoney, N. Arlene and Frank, David and Rothers, Janet and Coffee, Zhanette and Deuble, Elana and Ebert, Jonathon and Jablonsky, F. Mary and Juarez, Marlena and Lee, Barbara and Lorenz, M. Heather and Pava, D. Michael and Tinsely, Kristen and Yousaf, Sana", title="Methadone Patient Access to Collaborative Treatment: Protocol for a Pilot and a Randomized Controlled Trial to Establish Feasibility of Adoption and Impact on Methadone Treatment Delivery and Patient Outcomes", journal="JMIR Res Protoc", year="2025", month="Apr", day="15", volume="14", pages="e69829", keywords="methadone", keywords="implementation", keywords="patient-centered treatment", keywords="opioid use disorder", keywords="posttraumatic stress symptoms", keywords="vicarious trauma", abstract="Background: Access to methadone treatment can reduce opioid overdose death by up to 60\%, but US patient outcomes are suboptimal. Federally allowed methadone treatment accommodations during the COVID-19 public health emergency were not widely adopted. It is likely that staff-level characteristics such as trauma symptoms influence the adoption of treatment innovation. Objective: Methadone Patient Access to Collaborative Treatment (MPACT) is a 2-phased project (pilot and field trial) to develop and test a staff-level, multimodal intervention to increase staff adoption of low-barrier, patient-centered methadone treatment practices and ultimately improve treatment retention and patient outcomes. Methods: A pilot and national trial will measure implementation feasibility, acceptability, and effects of the MPACT intervention on treatment practice change, clinic culture, patient retention, and patient posttraumatic stress symptoms (PTSS). The pilot will be a single-arm 5.5-month pilot study of MPACT conducted in 2 Arizona methadone treatment clinics (rural and urban) among 100 patients and 22 staff. The national trial will be a 20-month cluster randomized trial conducted among 30 clinics, 600 patients (20 per clinic), and 480 staff (18 per clinic). Data will be gathered by staff and patient surveys and patient chart review. The primary study outcome is increased patient methadone treatment retention measured as (1) time to first treatment interruption from study enrollment; (2) active in treatment at enrollment, day 30, 60, 90, and 120; and (3) continuous days in treatment during the study period. Secondary study outcomes include reductions in vicarious trauma and PTSS among enrolled opioid treatment program staff and PTSS among enrolled patients. Results: The pilot study was funded by the National Institute on Drug Abuse (award R61DA059889, funded September 2023), and the field trial will be funded under the associated R33 mechanism in September 2025. The pilot study was completed in March 2025. The randomized controlled trial will begin in December 2025. Both the pilot and trial have been approved by the University of Arizona Human Subjects Protection Program and have been registered with the clinical trials network. Conclusions: The MPACT study will provide a foundation for an evidence-based, staff-level intervention aimed at improving patient retention in methadone treatment. Future studies should examine the individual components of MPACT to determine their differential contributions to the primary outcome of patient methadone treatment retention and to secondary outcomes of staff and patient reduction in stress symptoms. Trial Registration: ClinicalTrials.gov NCT06513728; https://clinicaltrials.gov/study/NCT06513728 and ClinicalTrials.gov NCT06556602; https://clinicaltrials.gov/study/NCT06556602 International Registered Report Identifier (IRRID): DERR1-10.2196/69829 ", doi="10.2196/69829", url="https://www.researchprotocols.org/2025/1/e69829", url="http://www.ncbi.nlm.nih.gov/pubmed/40105313" } @Article{info:doi/10.2196/57789, author="Thell, Maria and Edvardsson, Kerstin and Aljeshy, Reem and Ibrahim, Kalid and Warner, Georgina", title="A Trauma Support App for Young People: Co-design and Usability Study", journal="JMIR Form Res", year="2025", month="Mar", day="18", volume="9", pages="e57789", keywords="co-design", keywords="young people", keywords="trauma", keywords="app development", keywords="usability testing", abstract="Background: One of the most common reasons young people with mental health issues, such as posttraumatic stress disorder, do not seek help is stigma, which digital support tools could help address. However, there is a lack of trauma support apps specifically designed for young people. Involving the target group in such projects has been shown to produce more engaging and effective results. Objective: This study aimed to apply a child rights--based participatory approach to develop a trauma support app with young people. Methods: Seven young people (aged 14-19 years; 3 males and 4 females) with experiences of trauma were recruited as coresearchers. A child rights--based framework guided the working process. The app was developed through a series of Design Studio workshops and home assignments, using the manualized intervention Teaching Recovery Techniques as the foundation for its content. The coresearchers were trained in research methodology and conducted usability testing with other young people (n=11) using the think-aloud method, the System Usability Scale (SUS), and qualitative follow-up questions. Results: A functional app prototype was developed using a no-code platform, incorporating various trauma symptom management techniques. These techniques covered psychoeducation, normalization, relaxation, and cognitive shifting, presented in multiple formats, including text, audio, and video. The contributions of the coresearchers to the design can be categorized into 3 areas: mechanics (rules and interactions shaping the app's structure), dynamics (user-visible elements, such as the outcome when pressing a button), and aesthetics (the emotional responses the app aimed to evoke in users during interaction). Beyond influencing basic aesthetics, the coresearchers placed significant emphasis on user experience and the emotional responses the app could evoke. SUS scores ranged from 67.5 to 97.5, with the vast majority exceeding 77.5, indicating good usability. However, usability testing revealed several issues, generally of lower severity. For instance, video content required improvements, such as reducing light flickering in some recordings and adding rewind and subtitle selection options. Notably, the feature for listening to others' stories was removed to minimize emotional burden, shifting the focus to text formats with more context. Conclusions: Young people who have experienced trauma can actively participate in the cocreation of a mental health intervention, offering valuable insights into the needs and preferences of their peers. Applying a child rights--based framework to their involvement in a research project supported the fulfillment of the Convention on the Rights of the Child Article 12. ", doi="10.2196/57789", url="https://formative.jmir.org/2025/1/e57789" } @Article{info:doi/10.2196/65228, author="Isaac, Fadia and Klein, Britt and Nguyen, Huy and Watson, Shaun and Kennedy, A. Gerard", title="Digital Cognitive Behavioral Therapy--Based Treatment for Insomnia, Nightmares, and Posttraumatic Stress Disorder Symptoms in Survivors of Wildfires: Pilot Randomized Feasibility Trial", journal="JMIR Hum Factors", year="2025", month="Mar", day="14", volume="12", pages="e65228", keywords="insomnia", keywords="nightmares", keywords="posttraumatic stress disorder", keywords="PTSD", keywords="wildfires", keywords="cognitive behavioral therapy for insomnia", keywords="CBTi", keywords="exposure, relaxation, and rescripting therapy", keywords="ERRT", keywords="Sleep Best-i", keywords="mobile health", keywords="mHealth", keywords="digital health", keywords="computer", keywords="eHealth", keywords="bushfires", abstract="Background: Symptoms of insomnia, nightmares, and trauma are highly prevalent. However, there are significant barriers to accessing evidence-based treatments for these conditions, leading to poor mental health outcomes. Objective: This pilot trial evaluated the feasibility of a 4-week, digital self-paced intervention combining cognitive behavioral therapy for insomnia and exposure, relaxation, and rescripting therapy for nightmares in survivors of wildfires from Australia, Canada, and the United States. Methods: Study participants were recruited between May 2023 and December 2023 through social media platforms, workshops, conferences, and radio interviews. Participants had to meet at least one of the following criteria: a score of ?8 on the Insomnia Severity Index, a score of ?3 on the Nightmare Disorder Index, or a score of ?31 on the PTSD Checklist for DSM-5. In total, 30 survivors of wildfires were allocated to either the treatment group (n=16, 53\%) or the waitlist control group (n=14, 47\%) in a sequential manner. Participants' ages ranged from 18 to 79 years, with a mean age of 52.50 (SD 16.26) years. The cohort consisted of 63\% (19/30) female and 37\% (11/30) male participants. Participants also completed self-report secondary outcome measures, including the Generalized Anxiety Disorder--7, the Patient Health Questionnaire--9, and the Pittsburgh Sleep Quality Index, via the HealthZone digital platform. Assessments were conducted at baseline, the posttreatment time point, and the 3-month follow-up, with the waitlist group undergoing an additional assessment at the pretreatment time point, after 4 weeks of waiting and before crossing over to treatment. This study used intention-to-treat analysis as a primary analysis and per-protocol analysis as a secondary analysis. Results: Mixed-effects linear regression models and difference-in-differences analyses were used to assess the intervention's effects. The intention-to-treat analysis revealed significant improvements over time (main effect of time), with a 1.64-point reduction (P=.001) on the Nightmare Disorder Index and 10.64-point reduction (P=.009) on the PTSD Checklist for DSM-5 at the postintervention time point. No significant changes were observed in insomnia symptoms. On the secondary measures, there was an interaction effect of condition {\texttimes} time, with a 2.22-point reduction (P<.001) on the Pittsburgh Sleep Quality Index, and a main effect of time, with a 6.48-point reduction (P<.001) on the Patient Health Questionnaire--9. No changes were detected on the Generalized Anxiety Disorder--7. The per-protocol analysis yielded comparable results for both the primary and secondary measures. Conclusions: The findings of this pilot trial demonstrated a reduction in nightmares and trauma symptoms. Future research studies should aim at evaluating the intervention in a more definitive trial with a larger sample size. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12623000415606; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=385054 ", doi="10.2196/65228", url="https://humanfactors.jmir.org/2025/1/e65228" } @Article{info:doi/10.2196/64615, author="Whittaker, Spence and Rasmussen, Susan and Cogan, Nicola and Tse, Dwight and Martin, Bethany and Andriessen, Karl and Shiramizu, Victor and Krysinska, Karolina and Levi-Belz, Yossi", title="Posttraumatic Growth Among Suicide-Loss Survivors: Protocol for an Updated Systematic Review and Meta-Analysis", journal="JMIR Res Protoc", year="2025", month="Feb", day="14", volume="14", pages="e64615", keywords="posttraumatic growth", keywords="suicide-loss survivors", keywords="trauma", keywords="systematic review", keywords="meta-analysis", keywords="posttraumatic", keywords="suicidal", keywords="meta-analysis protocol", keywords="traumatic impacts", keywords="bereaved survivor", keywords="social support", keywords="bereavement", keywords="data collection", keywords="sociodemographic", keywords="psychological", keywords="databases", abstract="Background: Losing a loved one to suicide is an event that can have strong and potentially traumatic impacts on the lives of the bereaved survivors, especially regarding their grief, which can be complicated. These bereaved individuals are also less likely to receive social support following their bereavement. However, besides these adverse impacts, growing evidence supports the concept of posttraumatic growth following suicide bereavement. Posttraumatic growth is the personal improvement that occurs as a consequence of experiencing a traumatic or extremely challenging event or crisis. Only 1 systematic review and meta-analysis on posttraumatic growth following suicide bereavement has been conducted; this protocol is for the planned systematic review and meta-analysis update of the original systematic review and meta-analysis, as the original review collected its data in 2018. Objective: This review aims to investigate demographic characteristics, correlational relationships, and facilitative factors of posttraumatic growth in individuals bereaved by suicide. In addition, as this is an update of a previous systematic review and meta-analysis, we aim to compare our findings with the original review and to identify any similarities or differences. Methods: This protocol outlines the planned procedures of the updated systematic review and meta-analysis. MEDLINE, PsycINFO, Embase, CINAHL, Scopus, and Web of Science (Core Collection) were examined, and the search results were imported to Covidence, where title and abstract screenings and full-text screenings occurred. The inclusion and exclusion criteria for this updated review match those in the original review: (1) the study population must contain participants bereaved by suicide, (2) the study data must be quantitative, and (3) the study must report data on posttraumatic or stress-related growth. The original review conducted its search before 2019; thus, this updated review searched databases for the timeframe of January 2019 to January 2024. The updated meta-analysis will synthesize data from both the original and updated reviews to examine trends over time. The Newcastle-Ottawa Scale (NOS) will be used to assess publication quality. Random-effects meta-analyses will be conducted using RStudio (R Foundation for Statistical Computing). Results: The review was funded in October 2023 and is currently in progress. Results are expected to be finalized in October 2024. There are 21 articles that have been included in the review and are being analyzed at this time. We aim to submit the full article for publication in December 2024. Conclusions: The results of this updated systematic review and meta-analysis will be used to examine key relationships and findings regarding posttraumatic growth in individuals bereaved by suicide. The discussion will also investigate the findings of this updated review in comparison to the findings of the original review. Any differences would be highlighted. Limitations of the current review will be discussed, such as the quality of the articles included. Trial Registration: PROSPERO CRD42024485421; https://tinyurl.com/3hzpnzr3 International Registered Report Identifier (IRRID): DERR1-10.2196/64615 ", doi="10.2196/64615", url="https://www.researchprotocols.org/2025/1/e64615" } @Article{info:doi/10.2196/60708, author="de Vries, Jaap Herman and Delahaij, Roos and van Zwieten, Marianne and Verhoef, Helen and Kamphuis, Wim", title="The Effects of Self-Monitoring Using a Smartwatch and Smartphone App on Stress Awareness, Self-Efficacy, and Well-Being--Related Outcomes in Police Officers: Longitudinal Mixed Design Study", journal="JMIR Mhealth Uhealth", year="2025", month="Jan", day="28", volume="13", pages="e60708", keywords="wearable electronic devices", keywords="ecological momentary assessment", keywords="psychological stress", keywords="psychological well-being", keywords="awareness", keywords="self-efficacy", keywords="occupational medicine", keywords="emergency responders", keywords="well-being", keywords="psychological", keywords="efficacy", keywords="stress", keywords="wearables", keywords="wearable device", keywords="smartwatch", keywords="smartphone app", keywords="app", keywords="sensor", keywords="sensor technology", keywords="police officers", keywords="questionnaire", keywords="stress awareness", keywords="stress management", abstract="Background: Wearable sensor technologies, often referred to as ``wearables,'' have seen a rapid rise in consumer interest in recent years. Initially often seen as ``activity trackers,'' wearables have gradually expanded to also estimate sleep, stress, and physiological recovery. In occupational settings, there is a growing interest in applying this technology to promote health and well-being, especially in professions with highly demanding working conditions such as first responders. However, it is not clear to what extent self-monitoring with wearables can positively influence stress- and well-being--related outcomes in real-life conditions and how wearable-based interventions should be designed for high-risk professionals. Objective: The aim of this study was to investigate (1) whether offering a 5-week wearable-based intervention improves stress- and well-being--related outcomes in police officers and (2) whether extending a basic ``off-the-shelf'' wearable-based intervention with ecological momentary assessment (EMA) questionnaires, weekly personalized feedback reports, and peer support groups improves its effectiveness. Methods: A total of 95 police officers from 5 offices participated in the study. The data of 79 participants were included for analysis. During the first 5 weeks, participants used no self-monitoring technology (control period). During the following 5 weeks (intervention period), 41 participants used a Garmin Forerunner 255 smartwatch with a custom-built app (comparable to that of the consumer-available wearable), whereas the other 38 participants used the same system, but complemented by daily EMA questionnaires, weekly personalized feedback reports, and access to peer support groups. At baseline (T0) and after the control (T1) and intervention (T2) periods, questionnaires were administered to measure 15 outcomes relating to stress awareness, stress management self-efficacy, and outcomes related to stress and general well-being. Linear mixed models that accounted for repeated measures within subjects, the control and intervention periods, and between-group differences were used to address both research questions. Results: The results of the first analysis showed that the intervention had a small (absolute Hedges g=0.25?0.46) but consistent effect on 8 of 15 of the stress- and well-being--related outcomes in comparison to the control group. The second analysis provided mixed results; the extended intervention was more effective than the basic intervention at improving recovery after work but less effective at improving self-efficacy in behavior change and sleep issues, and similarly effective in the remaining 12 outcomes. Conclusions: Offering a 5-week wearable-based intervention to police officers can positively contribute to optimizing their stress-related, self-efficacy, and well-being--related outcomes. Complementing the basic ``off-the-shelf'' wearable-based intervention with additional EMA questionnaires, weekly personalized feedback reports, and peer support groups did not appear to improve the effectiveness of the intervention. Future work is needed to investigate how different aspects of these interventions can be tailored to specific characteristics and needs of employees to optimize these effects. ", doi="10.2196/60708", url="https://mhealth.jmir.org/2025/1/e60708" } @Article{info:doi/10.2196/64258, author="Lopez, M. Cristina and Moreland, D. Angela and Amaya, Stephanie and Bisca, Erin and Mujica, Christin and Wilson, Tayler and Baker, Nathaniel and Richey, Lauren and Eckard, Ross Allison and Resick, A. Patricia and Safren, A. Steven and Danielson, Kmett Carla", title="Assessment, Decision, Adaptation, Production, Topical Experts-Integration, Training, and Testing (ADAPT-ITT) Framework to Tailor Evidence-Based Posttraumatic Stress Disorder Treatment for People With HIV to Enhance Engagement and Adherence: Qualitative Results from a Feasibility Randomized Controlled Trial", journal="JMIR Form Res", year="2025", month="Jan", day="16", volume="9", pages="e64258", keywords="PTSD", keywords="HIV", keywords="adherence", keywords="minoritized populations", keywords="adaptation", keywords="evidence-based", keywords="treatment", keywords="engagement", keywords="posttraumatic stress disorder", keywords="stress", keywords="trauma", keywords="antiretroviral therapy", keywords="therapy", keywords="symptoms", keywords="acceptability", keywords="self-efficacy", abstract="Background: Individuals with co-occurring posttraumatic stress disorder (PTSD) and HIV are at high-risk for negative HIV-related outcomes, including low adherence to antiretroviral therapy, faster disease progression, more hospitalizations, and almost twice the rate of death. Despite high rates of PTSD in persons with HIV (PWH) and poor HIV-related health outcomes associated with PTSD, an effective evidence-based treatment for PTSD symptoms in PWH does not exist. Objective: This study aimed to describe the adaptation and theater testing of an evidence-based intervention designed for people with co-occurring PTSD and HIV. Methods: The Assessment, Decision, Adaptation, Production, Topical experts-integration, Training, and Testing (ADAPT-ITT) framework guided the formative process used to modify an evidence-based PTSD treatment (cognitive processing therapy; CPT) to meet the unique needs of PWH experiencing PTSD. With the integration of Life-Steps for Medication Adherence (Life-Steps), the adapted protocol (CPT-Life-Steps for integration of adherence; CPT-L) targeted HIV-related stigma and HIV medication adherence within a trauma-informed framework. Theater testing was completed with 7 participants to evaluate acceptability of CPT-L for PWH. The qualitative data (N=54 recordings) used to evaluate and adapt CPT-L emerged from individual interviews conducted with participants after each therapy session as well as exit interviews conducted at posttreatment data collection. Results: After challenging stigma-related appraisals, participants expressed feeling less constrained by maladaptive thoughts. These shifts translated to increased self-efficacy with both HIV-related care and mental health. Conclusions: These results indicate that trauma-informed work with PWH should consider the impact of HIV on trauma-related stuck points, intersecting identities (including living with HIV), and challenging internalized stigma. Findings provide evidence that CPT-L is acceptable and effective in addressing internalized HIV stigma that impacts PTSD symptom maintenance and HIV treatment engagement. Trial Registration: ClinicalTrials.gov; NCT05275842; https://clinicaltrials.gov/study/NCT05275842?id=NCT05275842\&rank=1 International Registered Report Identifier (IRRID): RR2-10.1016/j.conctc.2023.101150 ", doi="10.2196/64258", url="https://formative.jmir.org/2025/1/e64258" } @Article{info:doi/10.2196/63777, author="Segal, Hila and Benis, Arriel and Saar, Shirley and Shachar-Lavie, Iris and Fennig, Silvana", title="Digital Platform for Pediatric Mental Health Support During Armed Conflicts: Development and Usability Study", journal="JMIR Form Res", year="2024", month="Dec", day="26", volume="8", pages="e63777", keywords="pediatric mental health", keywords="digital platform", keywords="pediatricians", keywords="prevention", keywords="early intervention", abstract="Background: The prevalence of mental health disorders among children and adolescents presents a significant public health challenge. Children exposed to armed conflicts are at a particularly high risk of developing mental health problems, necessitating prompt and robust intervention. The acute need for early intervention in these situations is well recognized, as timely support can mitigate long-term negative outcomes. Pediatricians are particularly suited to deliver such interventions due to their role as primary health care providers and their frequent contact with children and families. However, barriers such as limited training and resources often hinder their ability to effectively address these issues. Objectives: This study aimed to describe the rapid development of a digital mental health tool for community pediatricians, created in response to the urgent need for accessible resources following the October 7th terror attack in Israel. The goal was to create a comprehensive resource that addresses a wide range of emotional and behavioral challenges in children and adolescents, with a particular focus on those affected by armed conflict and significant trauma exposure. In addition, the study aimed to evaluate the platform's usability and relevance through feedback from primary users, thereby assessing its potential for implementation in pediatric practice. Methods: A digital platform was developed using a collaborative approach that involved pediatricians and mental health professionals from various hospital clinics. The initial framework for the modules was drafted based on key emotional and behavioral issues identified through prior research. Following this, the detailed content of each module was cocreated with input from specialized mental health clinics within the hospital, ensuring comprehensive and practical guidance for community pediatricians. A focus group of 7 primary users, selected for their relevant hospital and community roles, provided feedback on the platform's user experience, content relevance, and layout. The evaluation was conducted using a structured questionnaire complemented by qualitative comments. Results: Fifteen detailed modules were created, each providing information, including anamnesis, initial intervention strategies, parental guidance, and referral options. The focus group feedback demonstrated high satisfaction, indicating a very good user experience (mean 4.57, SD 0.53), content relevance (mean 4.71, SD 0.48), and layout suitability (mean 4.66, SD 0.52). Specific feedback highlighted the value of concise, actionable content and the inclusion of medication information. Participants expressed a strong willingness to regularly use the platform in their practice (mean 4.40, SD 0.53), suggesting its potential for broad application. Conclusions: This study demonstrates the effectiveness of a collaborative development process in creating a digital tool that addresses the mental health needs of children in crisis situations. The positive feedback from pediatricians indicated that the platform has the potential to become a valuable resource for early recognition, crisis intervention, and parental support in community pediatric settings. Future research will focus on broader implementation and assessing the platform's impact on clinical outcomes. ", doi="10.2196/63777", url="https://formative.jmir.org/2024/1/e63777" } @Article{info:doi/10.2196/55562, author="Kubickova, Veronika and Steel, Craig and Moulds, L. Michelle and Kanstrup, Marie and Beer, Sally and Darwent, Melanie and Keating, Liza and Holmes, A. Emily and Iyadurai, Lalitha", title="Reducing the Number of Intrusive Memories of Work-Related Traumatic Events in Frontline Health Care Staff During the COVID-19 Pandemic: Case Series", journal="JMIR Hum Factors", year="2024", month="Nov", day="18", volume="11", pages="e55562", keywords="intrusive memories", keywords="digital intervention", keywords="psychological trauma", keywords="remote delivery", keywords="health care staff", keywords="COVID-19", keywords="case series", abstract="Background: Frontline health care staff are frequently exposed to traumatic events as part of their work. Although this study commenced before the emergence of COVID-19, levels of exposure were heightened by the pandemic. Many health care staff members report intrusive memories of such events, which can elicit distress, affect functioning, and be associated with posttraumatic stress disorder symptoms in the long term. We need evidence-based interventions that are brief, preventative, nonstigmatizing, suitable for the working lives of frontline health care staff, and effective for repeated trauma exposure. A brief, guided imagery-competing task intervention involving a trauma reminder cue and Tetris gameplay may hold promise in this regard, given evidence that it can prevent and reduce the number of intrusive memories following trauma across various settings. Objective: This case series aims to investigate the impact of a brief imagery-competing task intervention on the number of intrusive memories, general functioning, and symptoms of posttraumatic stress, anxiety, and depression, and examine the feasibility and acceptability of the intervention for UK National Health Service frontline health care staff. The intervention was delivered with guidance from a clinical psychologist. Methods: We recruited 12 clinical staff from the UK National Health Service, specifically from emergency departments, the intensive care unit, and the ambulance service. We evaluated the intervention using an AB single-case experimental design, where the baseline (A) was the monitoring-only phase and the postintervention (B) period was the time after the intervention was first administered. Methods were adapted once the COVID-19 pandemic began. Results: There was a decrease (59\%) in the mean number of intrusive memories per day from baseline (mean 1.29, SD 0.94) to postintervention (mean 0.54, SD 0.51). There was a statistically significant reduction in the number of intrusive memories from baseline to postintervention, as shown by an aggregated omnibus analysis with a small effect size ($\tau$-U=--0.38; P<.001). Depression, anxiety, and posttraumatic stress symptoms all significantly reduced from preintervention to postintervention. Participants also reported improvements in functioning based on both quantitative and qualitative measures. The intervention was feasible to deliver and rated as acceptable by participants. Conclusions: These preliminary findings suggest that this brief therapist-guided imagery-competing task intervention offers a potential approach to mitigating the impact of work-related traumatic events in frontline health care staff, both during a pandemic and beyond. Randomized controlled trials will be an important next step. ", doi="10.2196/55562", url="https://humanfactors.jmir.org/2024/1/e55562" } @Article{info:doi/10.2196/56437, author="Reilly, D. Erin and Kelly, M. Megan and Grigorian, L. Hannah and Waring, E. Molly and Quigley, S. Karen and Hogan, P. Timothy and Heapy, A. Alicia and Drebing, E. Charles and Volonte, Matias and Kathawalla, Ummul-Kiram and Robins, E. Hannah and Bernice, Katarina and Bickmore, Timothy", title="Virtual Coach--Guided Online Acceptance and Commitment Therapy for Chronic Pain: Pilot Feasibility Randomized Controlled Trial", journal="JMIR Form Res", year="2024", month="Nov", day="8", volume="8", pages="e56437", keywords="chronic pain", keywords="randomized controlled trial", keywords="usability", keywords="acceptance and commitment therapy", keywords="embodied conversational agent", keywords="veterans", abstract="Background: Veterans are disproportionately affected by chronic pain, with high rates of pain diagnoses (47\%-56\%) and a 40\% higher rate of prevalence of severe pain than nonveterans. This is often accompanied by negative functional outcomes and higher mortality. Combined with research suggesting medical treatments for chronic pain are often insufficient, there is an urgent need for nonmedical pain self-management programs. An interactive online platform to deliver an efficacious treatment for chronic pain such as acceptance and commitment therapy (ACT) could be a valuable option to assist veterans with pain care at home. Objective: This study aims to evaluate the virtual coach--guided Veteran ACT for Chronic Pain (VACT-CP) online program compared to a waitlist and treatment as usual (WL+TAU) control group through a small pilot feasibility randomized controlled trial. The primary aim was to evaluate the feasibility and acceptability of VACT-CP and study procedures, such as ease of recruitment, treatment receptivity, attrition and retention, sustained participation, system usability, and assessment of trial procedures. Secondary aims explored differences in the VACT-CP and WL+TAU groups on pre- and posttest (week 7) outcome measures for pain, mental health, functioning, and ACT processes. Methods: Veterans with chronic pain were recruited and randomized to either the VACT-CP (n=20) or the WL+TAU (n=22) group in a parallel group trial design. Self-report surveys were administered to participants at baseline (week 0), at the intervention midpoint (week 3), immediately after the intervention (week 7), and at the 1-month follow-up (week 11). We used Wilcoxon signed rank tests with the intention-to-treat sample to describe changes in secondary outcomes from pre- to postintervention within each group. Results: Study procedures showed good feasibility related to recruitment, enrollment, randomization, and study completion rates. Participants reported that VACT-CP was easy to use (System Usability Scale: mean 79.6, SD 12.8; median 82.5, IQR 70-87.5); they completed an average of 5 of the 7 total VACT-CP modules with high postintervention satisfaction rates. Qualitative feedback suggested a positive response to program usability, content tailoring, veteran centeredness, and perceived impact on pain management. Although the pilot feasibility trial was not powered to detect differences in clinical outcomes and significant findings should be interpreted with caution, the VACT-CP group experienced significant increases in chronic pain acceptance (P<.001) and decreases in depressive symptoms (P=.03). Conclusions: VACT-CP showed encouraging evidence of feasibility, usability, and acceptance, while also providing promising initial results in improving a key process in ACT for chronic pain---chronic pain acceptance---after online program use. A full-scale efficacy trial is needed to assess changes in clinical outcomes. Trial Registration: ClinicalTrials.gov NCT03655132; http://clinicaltrials.gov/ct2/show/NCT03655132 International Registered Report Identifier (IRRID): RR2-10.2196/45887 ", doi="10.2196/56437", url="https://formative.jmir.org/2024/1/e56437" } @Article{info:doi/10.2196/49761, author="Woolard, Alix and Paciente, Rigel and Munro, Emily and Wickens, Nicole and Wells, Gabriella and Ta, Daniel and Mandzufas, Joelie and Lombardi, Karen", title="\#TraumaTok---TikTok Videos Relating to Trauma: Content Analysis", journal="JMIR Form Res", year="2024", month="Nov", day="7", volume="8", pages="e49761", keywords="trauma", keywords="traumatic events", keywords="traumatic stress", keywords="TikTok", keywords="public health", keywords="social media", keywords="content analysis", abstract="Background: Experiencing a traumatic event can significantly impact mental and emotional well-being. Social media platforms offer spaces for sharing stories, seeking support, and accessing psychoeducation. TikTok (ByteDance), a rapidly growing social media platform, is increasingly used for advice, validation, and information, although the content of this requires further study. Research is particularly needed to better understand TikTok content relating to trauma and the potential implications for young viewers, considering the distressing nature of the subject and the possibility of users experiencing vicarious trauma through exposure to these videos. Objective: This study aims to explore the content of trauma-related videos on TikTok, focusing on hashtags related to trauma. Specifically, this study analyzes how TikTok videos present information, advice, stories, and support relating to trauma. Methods: A quantitative cross-sectional descriptive content analysis was performed on TikTok in December 2022. A total of 5 hashtags related to trauma were selected: \#trauma, \#traumatized, \#traumatok, \#traumatic, and \#traumabond, with the top 50 videos from each hashtag analyzed (total N=250 videos). A standardized codebook was developed inductively to analyze the content of the videos, while an existing generic codebook was used to collect the video features (eg, age of people in the video) and metadata (likes, comments, and shares) for each video. Results: A total of 2 major content themes were identified, which were instructional videos (54/250, 21.6\%) and videos disclosing personal stories (168/250, 67.3\%). The videos garnered significant engagement, with a total of 296.6 million likes, 2.3 million comments, and 4.6 million shares, indicating that users find this content engaging and useful. Alarmingly, only 3.7\% (9/250) of videos included a trigger warning, despite many featuring highly distressing stories that young people and those with trauma may be exposed to. Conclusions: The study highlights the potential risks of vicarious trauma due to trauma dumping without trigger warnings on TikTok, and the need for further research to assess the accuracy of advice and information in these videos. However, it also underscores the platform's potential to foster social connections, provide validation, and reduce stigma around mental health issues. Public health professionals should leverage social media to disseminate accurate mental health information, while promoting user education and content moderation to mitigate potential harms. People often use social media, such as TikTok to share advice, stories, and support around mental health, including their experiences with trauma. Out of 250 videos, most were either giving advice (54/250, 21.6\%) or sharing personal experiences (168/250, 67.3\%). The study found many videos lacked warnings about upsetting content, which could potentially harm young viewers or people suffering from trauma. While TikTok can help people feel connected and reduce the stigma around mental health, it is important to seek support from professionals when needed. ", doi="10.2196/49761", url="https://formative.jmir.org/2024/1/e49761" } @Article{info:doi/10.2196/53744, author="Paltell, C. Katherine and Duffecy, Jennifer and Maki, M. Pauline and Edalatian Zakeri, Shiva and Vujanovic, A. Anka and Berenz, C. Erin", title="Web-Based Intervention (SunnysideFlex) to Promote Resilience to Posttraumatic Stress Disorder Symptoms During Pregnancy: Development and Pilot Study", journal="JMIR Form Res", year="2024", month="Nov", day="1", volume="8", pages="e53744", keywords="trauma", keywords="posttraumatic stress disorder", keywords="pregnancy", keywords="perinatal", keywords="web-based intervention", keywords="stress", keywords="postpartum", keywords="depression", keywords="child health", keywords="treatment", keywords="behavioral therapy", keywords="SunnysideFlex", abstract="Background: Approximately 4\% to 8\% of pregnant individuals meet the criteria for current posttraumatic stress disorder (PTSD), a known risk factor for a multitude of adverse maternal and child health outcomes. However, PTSD is rarely detected or treated in obstetric settings. Moreover, available prenatal PTSD treatments require in-person services that are often inaccessible due to barriers to care. Thus, web-based interventions offer great potential in extending PTSD treatment to high-risk pregnant individuals by providing affordable, accessible care. However, there are currently no web-based interventions designed specifically for the treatment of PTSD symptoms during pregnancy. Objective: This study aims to develop and pilot a 6-week, web-based, cognitive behavioral therapy intervention for PTSD, SunnysideFlex, in a sample of 10 pregnant women with current probable PTSD. Consistent with established guidelines for developing and testing novel interventions, the focus of this pilot study was to evaluate the initial feasibility and acceptability of the SunnysideFlex intervention and preintervention to postintervention changes in PTSD and depression symptoms. This approach will allow for early refinement and optimization of the SunnysideFlex intervention to increase the odds of success in a larger-scale clinical trial. Methods: The SunnysideFlex intervention adapted an existing web-based platform for postpartum depression, Sunnyside for Moms, to include revised, trauma-focused content. A total of 10 pregnant women in weeks 16 to 28 of their pregnancy who reported lifetime interpersonal trauma exposure (ie, sexual or physical assault) and with current probable PTSD (scores ?33 per the PTSD checklist for DSM-5) were enrolled in the SunnysideFlex intervention. Assessments took place at baseline and 6 weeks (postintervention). Results: All participants were retained through the postintervention assessment period. Engagement was high; participants on average accessed 90\% of their lessons, logged on to the platform at least weekly, and reported a generally positive user experience. Moreover, 80\% (8/10) of participants demonstrated clinically meaningful reductions in PTSD symptoms from baseline to postintervention, and 50\% (5/10) of participants no longer screened positive for probable PTSD at postintervention. Most (6/10, 60\%) of the participants maintained subclinical depression symptoms from baseline to postintervention. Conclusions: Findings from this small pilot study indicate that SunnysideFlex may be a feasible and acceptable mechanism for delivering PTSD intervention to high-risk, trauma-exposed pregnant women who might otherwise not have opportunities for services. Larger-scale trials of the intervention are necessary to better understand the impact of SunnysideFlex on PTSD symptoms during pregnancy and the postpartum period. ", doi="10.2196/53744", url="https://formative.jmir.org/2024/1/e53744", url="http://www.ncbi.nlm.nih.gov/pubmed/39485381" } @Article{info:doi/10.2196/53683, author="Oliveira, Joana and Aires Dias, Joana and Correia, Rita and Pinheiro, Raquel and Reis, V{\'i}tor and Sousa, Daniela and Agostinho, Daniel and Sim{\~o}es, Marco and Castelo-Branco, Miguel", title="Exploring Immersive Multimodal Virtual Reality Training, Affective States, and Ecological Validity in Healthy Firefighters: Quasi-Experimental Study", journal="JMIR Serious Games", year="2024", month="Oct", day="24", volume="12", pages="e53683", keywords="virtual reality", keywords="firefighter", keywords="training", keywords="posttraumatic stress disorder", keywords="PTSD", keywords="emotion", keywords="situational awareness", keywords="engagement", keywords="ecological validity", keywords="multivariate approach", abstract="Background: Firefighters face stressful life-threatening events requiring fast decision-making. To better prepare for those situations, training is paramount, but errors in real-life training can be harmful. Virtual reality (VR) simulations provide the desired realism while enabling practice in a secure and controlled environment. Firefighters' affective states are also crucial as they are a higher-risk group. Objective: To assess the impact on affective states of 2 simulated immersive experiences in a sample of healthy firefighters (before, during, and after the simulation), we pursued a multivariate approach comprising cognitive performance, situational awareness, depression, anxiety, stress, number of previous adverse events experienced, posttraumatic stress disorder (PTSD) severity, and emotions. The efficacy and ecological validity of an innovative VR haptic system were also tested, exploring its impact on performance. Methods: In collaboration with the Portuguese National Fire Service School, we exposed 22 healthy firefighters to 2 immersive scenarios using the FLAIM Trainer VR system (neutral and arousing scenarios) while recording physiological data in a quasi-experimental study. Baseline cognitive performance, depression, anxiety, stress, number of adverse events, and severity of PTSD symptoms were evaluated. Positive and negative affective states were measured before, between, and after each scenario. Situational awareness, sense of presence, ecological validity, engagement, and negative effects resulting from VR immersion were tested. Results: Baseline positive affect score was high (mean 32.4, SD 7.2) and increased after the VR tasks (partial $\eta$2=0.52; Greenhouse-Geisser F1.82,32.78=19.73; P<.001). Contrarily, mean negative affect score remained low (range 11.0-11.9) throughout the study (partial $\eta$2=0.02; Greenhouse-Geisser F2.13,38.4=0.39; P=.69). Participants' feedback on the VR sense of presence was also positive, reporting a high sense of physical space (mean score 3.9, SD 0.8), ecological validity (mean score 3.8, SD 0.6), and engagement (mean score 3.8, SD 0.6). Engagement was related to the number of previously experienced adverse events (r=0.49; P=.02) and positive affect (after the last VR task; r=0.55; P=.02). Conversely, participants reported few negative effects (mean score 1.7, SD 0.6). The negative effects correlated positively with negative affect (after the last VR task; r=0.53; P=.03); and avoidance (r=0.73; P<.001), a PTSD symptom, controlling for relevant baseline variables. Performance related to situational awareness was positive (mean 46.4, SD 34.5), although no relation was found to metacognitively perceived situational awareness (r=--0.12; P=.59). Conclusions: We show that VR is an effective alternative to in-person training as it was considered ecologically valid and engaging while promoting positive emotions, with few negative repercussions. This corroborates the use of VR to test firefighters' performance and situational awareness. Further research is needed to ascertain that firefighters with PTSD symptomatology are not negatively affected by VR. This study favors the use of VR training and provides new insights on its emotional and cognitive impact on the trainee. ", doi="10.2196/53683", url="https://games.jmir.org/2024/1/e53683", url="http://www.ncbi.nlm.nih.gov/pubmed/39446479" } @Article{info:doi/10.2196/57322, author="Haun, N. Jolie and Fowler, A. Christopher and Venkatachalam, H. Hari and Alman, C. Amy and Ballistrea, M. Lisa and Schneider, Tali and Benzinger, C. Rachel and Melillo, Christine and Alexander, B. Neil and Klanchar, Angel S. and Lapcevic, A. William and Bair, J. Matthew and Taylor, L. Stephanie and Murphy, L. Jennifer and French, D. Dustin", title="Outcomes of a Remotely Delivered Complementary and Integrative Health Partnered Intervention to Improve Chronic Pain and Posttraumatic Stress Disorder Symptoms: Randomized Controlled Trial", journal="J Med Internet Res", year="2024", month="Oct", day="18", volume="26", pages="e57322", keywords="posttraumatic stress disorder", keywords="PTSD", keywords="pain", keywords="veteran", keywords="attrition", keywords="complementary and integrative health", keywords="CIH", keywords="randomized controlled trial", keywords="chronic pain", keywords="remote intervention", keywords="dyad", keywords="mobile health", abstract="Background: Nonpharmacological interventions for veterans are needed to help them manage chronic pain and posttraumatic stress disorder (PTSD) symptoms. Complementary and integrative health (CIH) interventions such as Mission Reconnect (MR) seek to provide veterans with the option of a partnered, self-directed intervention that teaches CIH skills remotely to support symptom management. Objective: The purpose of this study was to describe the physical, psychological, and social outcomes of a self-directed mobile- and web-based CIH intervention for veterans with comorbid chronic pain and PTSD and their partners and qualitatively examine their MR user experience. Methods: A sample of veteran-partner dyads (n=364) were recruited to participate in a mixed methods multisite waitlist control randomized controlled trial to measure physical, psychological, and social outcomes, with pain as the primary outcome and PTSD, depression, stress, sleep, quality of life, and relationships as secondary outcomes. Linear mixed models were constructed for primary and secondary patient-reported outcomes. The quantitative analysis was triangulated using qualitative interviews from a subsample of dyads (n=35) to examine participants' perceptions of their program experience. Results: Dyads were randomized to 2 groups: intervention (MR; 140/364, 38.5\%) and waitlist control (136/364, 37.4\%). No significant change was observed in overall pain, sleep, PTSD, quality of life, relationship satisfaction, overall self-compassion, or compassion for others. A significant reduction in pain interference in mood (P=.008) and sleep (P=.008) was observed among the veteran MR group that was not observed in the waitlist control group. We also observed a positive effect of the MR intervention on a reduction in negative affect associated with pain (P=.049), but this effect did not exceed the adjusted significance threshold (P=.01). Significant improvements were also observed for partners in the affection (P=.007) and conflict (P=.001) subdomains of the consensus and satisfaction domains. In contrast to quantitative results, qualitative data indicated that intervention impacts included improved sleep and reduced pain, anxiety, and stress and, in contrast to the survey data, overall improvement in PTSD symptoms and social relationships. Participants' overall impressions of MR highlight usability and navigation, perceptions on packaging and content, and barriers to and facilitators of MR use. Conclusions: Adjunctive CIH-based modalities can be delivered using web and mobile apps but should be developed and tailored using established best practices. MR may be beneficial for veterans with pain and PTSD and their partners. Further pragmatic trials and implementation efforts are warranted. Trial Registration: ClinicalTrials.gov NCT03593772; https://clinicaltrials.gov/study/NCT03593772 International Registered Report Identifier (IRRID): RR2-10.2196/13666 ", doi="10.2196/57322", url="https://www.jmir.org/2024/1/e57322", url="http://www.ncbi.nlm.nih.gov/pubmed/39422992" } @Article{info:doi/10.2196/52130, author="Ong, E. Laura and Speicher, Sarah and Villasenor, Diana and Kim, Jamie and Jacobs, Adam and Macia, S. Kathryn and Cloitre, Marylene", title="Brief Peer-Supported Web-Based Skills Training in Affective and Interpersonal Regulation (BPS webSTAIR) for Trauma-Exposed Veterans in the Community: Randomized Controlled Trial", journal="J Med Internet Res", year="2024", month="Oct", day="2", volume="26", pages="e52130", keywords="posttraumatic stress disorder", keywords="PTSD", keywords="depression", keywords="depressive symptoms", keywords="veterans", keywords="veterans health", keywords="mHealth", keywords="mobile health", keywords="peer support", keywords="peer-to-peer", keywords="transdiagnostic", keywords="mental health", keywords="mental health services", keywords="community", keywords="emotion regulation", keywords="interpersonal regulation", keywords="mHealth program", abstract="Background: Peer-supported mobile health (mHealth) programs hold the promise of providing a low-burden approach to increasing access to care and improving mental health. While peer support has been shown to improve engagement in care, there is limited investigation into the impact of peers on symptom outcomes. Trauma-exposed populations frequently endure co-occurring posttraumatic stress and depressive symptoms as well as difficulties in day-to-day functioning. This study evaluated the potential benefits of a peer-supported, transdiagnostic mHealth program on symptom outcomes and functioning. Objective: This randomized controlled trial tested the effectiveness of Brief Peer-Supported (BPS) web-based Skills Training in Affective and Interpersonal Regulation (webSTAIR), a 6-module transdiagnostic digital program derived from Skills Training in Affective and Interpersonal Regulation and compared to waitlist control in a community sample of veterans who screened positive for either posttraumatic stress disorder (PTSD) or depression. Methods: A total of 178 veterans were enrolled in this study using a 2:1 randomization scheme with 117 assigned to BPS webSTAIR and 61 assigned to waitlist control. PTSD and depressive symptoms as well as emotion regulation and psychosocial functioning were assessed at pretreatment, posttreatment, and 8-week follow-up time points. Mixed-effects models were used to assess change in outcome measures across time points. Exploratory analyses were conducted to determine whether the type and number of peer interactions influenced outcomes. Results: Significant interaction effects were observed for all outcomes such that participants randomized to BPS webSTAIR reported significantly greater improvement at the posttreatment time point compared to waitlist control with moderate effect sizes for PTSD (d=0.48), depression (d=0.64), emotion regulation (d=0.61), and functional impairment (d=0.61); gains were maintained at 8-week follow-up. An initial cohort of participants who were required to engage with a peer coach to progress through the modules interacted more frequently with peers but completed fewer modules compared to a later cohort for whom peer engagement was optional. Overall, those who completed more modules reported greater improvement in all outcomes. Conclusions: BPS webSTAIR was effective in improving PTSD and depression symptoms, emotion regulation, and psychosocial functioning in community veterans. Peer-supported, transdiagnostic mHealth programs may be a particularly efficient, effective, and low-burden approach to improving mental health among trauma-exposed populations. Investigation of peer-supported programs among other populations is necessary to evaluate the generalizability of the findings. Analyses comparing peer support that was required versus optional indicated that some veterans may not need or want peer support. Future research should evaluate how best to deliver peer support and for whom it is most beneficial. If successful, peer-supported tech programs may increase the Veteran Affairs workforce as well as improve veteran mental health services and outcomes. Trial Registration: ClinicalTrials.gov NCT04286165; https://clinicaltrials.gov/study/NCT04286165 ", doi="10.2196/52130", url="https://www.jmir.org/2024/1/e52130", url="http://www.ncbi.nlm.nih.gov/pubmed/39012722" } @Article{info:doi/10.2196/43563, author="Lerner, Ivan and Chariot, Patrick and Lef{\`e}vre, Thomas", title="Functional Impairment in Individuals Exposed to Violence Based on Electronical Forensic Medical Record Mining and Their Profile Identification: Controlled Observational Study", journal="JMIR Public Health Surveill", year="2024", month="Sep", day="27", volume="10", pages="e43563", keywords="reproducibility", keywords="interpersonal violence", keywords="functional impairment", keywords="psychological trauma", keywords="clustering", keywords="intimate partner violence", abstract="Background: Little is known about the functional consequences of violence when directly assessed as a primary outcome, and even less about how consistently these consequences are evaluated in a judicial context. The World Health Organization (WHO) highlighted the importance of a functional approach to health in 2001 with the release of the International Classification of Functioning, Disability, and Health (ICF). In most European countries, forensic physicians assess individuals exposed to violence to evaluate the outcomes of violence, providing certified medical evidence for magistrates' sentencing decisions. This evaluation involves a mix of objective, subjective, and contextual elements, such as reported symptoms of fear, pain, and details of the assault. Quantifying these subjective elements with scales could enhance their interpretation and application in a judicial context. Objective: This study aims to (1) characterize and (2) assess 6 scales measuring subjective elements of functional impairment among individuals exposed to violence. Methods: We conducted a retrospective study that included individuals exposed to violence examined in a French department of forensic medicine over 12 months. A typology of violence encountered in medical settings was built based on the mining of electronic health records and the use of pattern recognition algorithms. The optimal number of violence types was determined using a robust and stable clustering approach, involving sample resampling and a multimetric scheme. Patients were then paired according to their homogeneous profiles, and the intra- and interrater reproducibility of the scales was evaluated. Results: All pain, fear, and life threat scales were significantly associated with higher functional impairment, suggesting that these measures contribute to the overall assessment of functional impairment. The intra- and interrater reproducibility of scales among similar situations of violence was measured, ranging from mild to good, with coefficients of concordance between 0.46-0.66 and 0.43-0.66, respectively. Individuals reporting intimate partner violence showed higher scores in both fear and perception of a life threat during the assault and medical interview, while individuals reporting battery by multiple unknown assailants presented higher scores only in perception of a life threat during the assault. We identified 5 remarkably stable profiles of situations of violence, consistent with clinical practice. Conclusions: Pain, fear, and life threat scales were related to functional impairment according to expert knowledge and demonstrated fair reproducibility under real-life conditions for similar situations of violence. Subjective elements related to functional impairment in individuals exposed to violence can be quantified using Likert scales during medical interviews. ", doi="10.2196/43563", url="https://publichealth.jmir.org/2024/1/e43563", url="http://www.ncbi.nlm.nih.gov/pubmed/39331422" } @Article{info:doi/10.2196/59089, author="Ferguson, M. Jacqueline and Van Campen, James and Slightam, Cindie and Greene, Liberty and Heyworth, Leonie and Zulman, M. Donna", title="Evaluation of the Veterans Health Administration's Digital Divide Consult for Tablet Distribution and Telehealth Adoption: Cohort Study", journal="J Med Internet Res", year="2024", month="Sep", day="9", volume="26", pages="e59089", keywords="veterans", keywords="health care access", keywords="video-based care", keywords="telehealth", keywords="barriers to care", keywords="telemedicine", abstract="Background: Video telehealth offers a mechanism to help Veterans Health Administration (VHA) patients overcome health care access barriers; however, many veterans lack a suitable device and sufficient internet connectivity. To address disparities in technology access, VHA established a Connected Device Program that offers veterans loaned video-capable tablets and internet service. In 2020, VHA introduced a national Digital Divide Consult to facilitate and standardize referrals for this resource. Objective: We sought to evaluate the reach and impact of VHA's Connected Device Program, leveraging Digital Divide Consult data to determine whether resources are supporting veterans with health care needs and access barriers. Methods: We examined the reach of VHA's Connected Device Program using national secondary data from VHA's electronic health records among 119,926 tablet recipients who received a tablet (April 1, 2020, to February 28, 2023) and 683,219 veterans from the general VHA population. We assessed changes in tablet recipients' demographic and clinical characteristics before and after implementation of the Digital Divide Consult compared with the general VHA population. We examined the impact of tablets and the consult on adoption of telehealth (ie, video visit use and number of visits) adjusting for differences between tablet recipients and the general VHA population. Finally, we evaluated consult implementation by assessing the use of video-based services by tablet referral reason. Results: Common reasons for tablet referral included mental health diagnoses (50,367/79,230, 63.9\%), distance from a VHA facility >30 miles (17,228/79,230, 21.7\%), and social isolation (16,161/79,230, 20.4\%). Moreover, 63.0\% (49,925/79,230) of individuals who received a tablet after implementation of the Digital Divide Consult had a video visit in the first 6 months of tablet receipt. Some consult reasons were associated with a higher-than-average percentage of video telehealth use, including enrollment in evidence-based mental health programs (74.8\% [830/1100] with video use), living >30 miles from a VHA facility (68.3\% [10,557/17,228] with video use), and having a mental health diagnosis (68.1\% [34,301/50,367] with video use). Tablet recipients had nearly 3 times the likelihood of having a video visit within a month once provided a tablet compared to the general VHA population, with an adjusted risk ratio of 2.95 (95\% CI 2.91-2.99) before consult implementation and 2.73 (95\% CI 2.70-2.76) after consult implementation. Analyses of telehealth adoption suggested that veterans receiving tablets for mental health care and evidence-based programs have higher rates of video visits, while those who are homebound or receiving tablets for hospice have higher rates of nonuse. Conclusions: This evaluation of VHA's Connected Device Program suggests that tablets are facilitating video-based care among veterans with complex needs. Standardization of referrals through the Digital Divide Consult has created opportunities to identify groups of tablet recipients with lower telehealth adoption rates who might benefit from a targeted intervention. ", doi="10.2196/59089", url="https://www.jmir.org/2024/1/e59089", url="http://www.ncbi.nlm.nih.gov/pubmed/39250183" } @Article{info:doi/10.2196/49393, author="Davis, Adrian C. and Miller, Madeleine and McLean, P. Carmen", title="The Impact of User Engagement With Exposure Components on Posttraumatic Stress Symptoms in an mHealth Mobile App: Secondary Analysis of a Randomized Controlled Trial", journal="JMIR Mhealth Uhealth", year="2024", month="Jul", day="18", volume="12", pages="e49393", keywords="posttraumatic stress disorder", keywords="PTSD", keywords="mHealth apps", keywords="user engagement", keywords="mHealth interventions", keywords="digital interventions", keywords="veterans", abstract="Background: Mobile mental health apps are a cost-effective option for managing mental health problems, such as posttraumatic stress disorder (PTSD). The efficacy of mobile health (mHealth) apps depends on engagement with the app, but few studies have examined how users engage with different features of mHealth apps for PTSD. Objective: This study aims to examine the relationship between app engagement indices and PTSD symptom reduction using data from an unblinded pilot randomized controlled trial of ``Renew'' (Vertical Design), an exposure-based app for PTSD with and without coaching support. Because exposure is an effective approach for treating PTSD, we expected that engagement with exposure activities would be positively related to symptom reduction, over and above overall app usage. Methods: Participants were veterans (N=69) with clinically significant PTSD symptoms who were recruited online using Facebook advertisements and invited to use the Renew app as often as they wanted over a 6-week period. Participants completed screening and assessments online but provided informed consent, toured the app, and completed feedback interviews via telephone. We assessed users' self-reported PTSD symptoms before and after a 6-week intervention period and collected app usage data using a research-instrumented dashboard. To examine overall app engagement, we used data on the total time spent in the app, the number of log-in days, and the number of points that the user gained in the app. To examine engagement with exposure components, we used data on total time spent completing exposure activities (both in vivo and imaginal), the number of in vivo exposure activities completed, and the number of characters written in response to imaginal exposure prompts. We used hierarchical regression analyses to test the effect of engagement indices on change in PTSD symptoms. Results: Usage varied widely. Participants spent an average of 166.09 (SD 156.52) minutes using Renew, over an average of 14.7 (SD 10.71) mean log-in days. Engagement with the exposure components of the app was positively associated with PTSD symptom reduction (F6,62=2.31; P=.04). Moreover, this relationship remained significant when controlling for overall engagement with the app ($\Delta$F3,62=4.42; P=.007). The number of characters written during imaginal exposure ($\beta$=.37; P=.009) and the amount of time spent completing exposure activities ($\beta$=.36; P=.03) were significant contributors to the model. Conclusions: To our knowledge, this is the first study to show a relationship between symptom improvement and engagement with the active therapeutic components of an mHealth app (ie, exposure) for PTSD. This relationship held when controlling for overall app use, which suggests that it was engagement with exposure, specifically, that was associated with symptom change. Future work to identify ways of promoting greater engagement with self-guided exposure may help improve the effectiveness of mHealth apps for PTSD. Trial Registration: ClinicalTrials.gov NCT04155736; https://clinicaltrials.gov/ct2/show/NCT04155736 ", doi="10.2196/49393", url="https://mhealth.jmir.org/2024/1/e49393" } @Article{info:doi/10.2196/58390, author="Adrien, Vladimir and Bosc, Nicolas and Peccia Galletto, Claire and Diot, Thomas and Claverie, Damien and Reggente, Nicco and Trousselard, Marion and Bui, Eric and Baubet, Thierry and Schoeller, F{\'e}lix", title="Enhancing Agency in Posttraumatic Stress Disorder Therapies Through Sensorimotor Technologies", journal="J Med Internet Res", year="2024", month="Jul", day="1", volume="26", pages="e58390", keywords="posttraumatic stress disorder", keywords="PTSD", keywords="agency", keywords="proprioception", keywords="trauma", keywords="self-control", keywords="sensorimotor technology", keywords="enactive perspective", keywords="peritraumatic dissociation", keywords="proprioceptive reafferent fibers", keywords="gesture sonification devices", doi="10.2196/58390", url="https://www.jmir.org/2024/1/e58390", url="http://www.ncbi.nlm.nih.gov/pubmed/38742989" } @Article{info:doi/10.2196/57146, author="Baillie Abidi, Catherine and Patten, San and Houle, A. Stephanie and Hoffer, Ken and Reeves, Kathryn and B{\'e}langer, St{\'e}phanie and Nazarov, Anthony and Wells, Samantha", title="Canadian Armed Forces Veterans' Perspectives on the Effects of Exposure to Children in Armed Conflict During Military Service: Protocol for a Qualitative Study", journal="JMIR Res Protoc", year="2024", month="Jun", day="14", volume="13", pages="e57146", keywords="moral injury", keywords="mental health", keywords="Canadian Armed Forces Veterans", keywords="children", keywords="deployments", keywords="conflicts", keywords="military culture", keywords="trauma-informed research", keywords="people-centered research", keywords="participatory action research", abstract="Background: The mental health of military personnel has garnered increased attention over the last few decades; however, the impacts of perpetuating, observing, or failing to prevent acts that transgress deeply held moral standards, referred to as moral injuries, are less understood, particularly in relation to encounters with children during deployment. This paper describes a multiphased research protocol that centers around the lived experiences of Canadian Armed Forces (CAF) Veterans to understand how encounters with children during military deployments impact the well-being and mental health of military personnel. Objective: This study has four objectives: (1) highlight the lived experiences of CAF Veterans who encountered children during military deployments; (2) improve understanding of the nature of experiences that military personnel faced that related to observing or engaging with children during military service; (3) improve understanding of the mental health impacts of encountering children during military service; and (4) use participatory action research (PAR) to develop recommendations for improving preparation, training, and support for military personnel deployed to contexts where encounters with children are likely. Methods: The research project has 2 main phases where phase 1 includes qualitative interviews with CAF Veterans who encountered children during military deployments and phase 2 uses PAR to actively engage Canadian Veterans with lived experiences of encountering children during military deployments, as well as health professionals and researchers to identify recommendations to better address the mental health effects of these encounters. Results: As of January 26, 2024, a total of 55 participants and research partners have participated in the 2 phases of the research project. A total of 16 CAF Veterans participated in phase 1 (qualitative interviews), and 39 CAF Veterans, health professionals, and researchers participated in phase 2 (PAR). The results for phase 1 have been finalized and are accepted for publication. Data collection and analysis are ongoing for phase 2. Conclusions: Prioritizing and valuing the experiences of CAF Veterans has deepened our understanding of the intricate nature and impacts of potentially morally injurious events involving children during military deployments. Together with health professionals and researchers, the PAR approach empowers CAF Veterans to articulate important recommendations for developing and improving training and mental health support. This support is crucial not only during the deployment cycle but also throughout the military career, helping lessen the effects of moral injury among military personnel. International Registered Report Identifier (IRRID): DERR1-10.2196/57146 ", doi="10.2196/57146", url="https://www.researchprotocols.org/2024/1/e57146", url="http://www.ncbi.nlm.nih.gov/pubmed/38874998" } @Article{info:doi/10.2196/49929, author="Ezeonu, Alexandra Nwamaka and Hertelendy, J. Attila and Adu, Kofi Medard and Kung, Y. Janice and Itanyi, Uchenna Ijeoma and Dias, Luz Raquel da and Agyapong, Belinda and Hertelendy, Petra and Ohanyido, Francis and Agyapong, Opoku Vincent Israel and Eboreime, Ejemai", title="Mobile Apps to Support Mental Health Response in Natural Disasters: Scoping Review", journal="J Med Internet Res", year="2024", month="Apr", day="17", volume="26", pages="e49929", keywords="mental health", keywords="disasters", keywords="mobile health", keywords="mHealth", keywords="application", keywords="applications", keywords="app", keywords="apps", keywords="smartphone", keywords="stress", keywords="psychological", keywords="traumatic", keywords="disaster", keywords="hazard", keywords="hazards", keywords="emergency", keywords="psychological trauma", keywords="mobile apps", keywords="trauma", keywords="scoping", keywords="review methods", keywords="review methodology", keywords="mobile phone", abstract="Background: Disasters are becoming more frequent due to the impact of extreme weather events attributed to climate change, causing loss of lives, property, and psychological trauma. Mental health response to disasters emphasizes prevention and mitigation, and mobile health (mHealth) apps have been used for mental health promotion and treatment. However, little is known about their use in the mental health components of disaster management. Objective: This scoping review was conducted to explore the use of mobile phone apps for mental health responses to natural disasters and to identify gaps in the literature. Methods: We identified relevant keywords and subject headings and conducted comprehensive searches in 6 electronic databases. Studies in which participants were exposed to a man-made disaster were included if the sample also included some participants exposed to a natural hazard. Only full-text studies published in English were included. The initial titles and abstracts of the unique papers were screened by 2 independent review authors. Full texts of the selected papers that met the inclusion criteria were reviewed by the 2 independent reviewers. Data were extracted from each selected full-text paper and synthesized using a narrative approach based on the outcome measures, duration, frequency of use of the mobile phone apps, and the outcomes. This scoping review was reported according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). Results: Of the 1398 papers retrieved, 5 were included in this review. A total of 3 studies were conducted on participants exposed to psychological stress following a disaster while 2 were for disaster relief workers. The mobile phone apps for the interventions included Training for Life Skills, Sonoma Rises, Headspace, Psychological First Aid, and Substance Abuse and Mental Health Services Administration (SAMHSA) Behavioural Health Disaster Response Apps. The different studies assessed the effectiveness or efficacy of the mobile app, feasibility, acceptability, and characteristics of app use or predictors of use. Different measures were used to assess the effectiveness of the apps' use as either the primary or secondary outcome. Conclusions: A limited number of studies are exploring the use of mobile phone apps for mental health responses to disasters. The 5 studies included in this review showed promising results. Mobile apps have the potential to provide effective mental health support before, during, and after disasters. However, further research is needed to explore the potential of mobile phone apps in mental health responses to all hazards. ", doi="10.2196/49929", url="https://www.jmir.org/2024/1/e49929", url="http://www.ncbi.nlm.nih.gov/pubmed/38520699" } @Article{info:doi/10.2196/48525, author="Austin, Tara and Smith, Jennifer and Rabin, Borsika and Lindamer, Laurie and Pittman, James and Justice, Staley and Twamley, W. Elizabeth and Lantrip, Crystal", title="The Effects of a Single-Session Virtual Rumination Intervention to Enhance Cognitive Functioning in Veterans With Subjective Cognitive Symptoms: Multimethod Pilot Study", journal="JMIR Form Res", year="2024", month="Apr", day="12", volume="8", pages="e48525", keywords="army", keywords="cognition", keywords="cognitive", keywords="emotion regulation", keywords="memory symptoms", keywords="memory", keywords="military", keywords="rumination", keywords="subjective cognitive decline", keywords="telehealth", keywords="telemedicine", keywords="veteran", keywords="worry", abstract="Background: Subjective cognitive concerns (SCCs) entail perceived difficulties in thinking or memory, often reported without substantial objective evidence of cognitive impairment. These concerns are prevalent among individuals with a history of brain injuries, neurological conditions, or chronic illnesses, contributing to both psychological distress and functional limitations. They are increasingly considered to be a risk factor for future objective decline. A considerable number of individuals reporting SCCs also exhibit mental health symptoms, such as a history of trauma, depression, or anxiety. Interventions that address modifiable emotional and cognitive factors related to SCC could improve functioning and quality of life. Therefore, the use of emotion regulation strategies, especially those directed at minimizing rumination, could serve as a promising focus for interventions aimed at mitigating subjective cognitive concerns in veteran populations. Objective: This pilot study explored the feasibility, acceptability, and preliminary efficacy of a brief, 1-session emotion regulation intervention called ``Worry Less, Remember More.'' The Worry Less, Remember More intervention was designed to reduce rumination and improve subjective cognitive functioning in veterans with subjective cognitive changes (N=15). Methods: We randomized 15 veterans to either the active telehealth condition or waitlist control and completed the intervention. Participants were aged between 31 and 67 (mean 49.5, SD 10.1) years, and the sample was primarily male (12/15, 83\%) and White (10/15, 67\%). The most common diagnoses were posttraumatic stress disorder and depression. Following the intervention, veteran input was sought through semistructured interviews with a subset of 12 participants, examining feasibility, acceptability, and perceived efficacy. Preliminary efficacy was also measured using pre- and postintervention self-report measures. Results: Veterans reported that this intervention was acceptable, with 92\% (11/12) of the sample reporting that they benefited from the intervention and would recommend the intervention to others with similar difficulties. Semistructured interviews revealed difficulties with feasibility, including problems with the remote consenting process, forgetting appointments, and needing additional strategies to remember to consistently use the interventions. The intervention improved self-reported cognitive symptoms on quantitative measures but did not improve self-reported rumination. Conclusions: This pilot study establishes the preliminary feasibility, acceptability, and efficacy of the Worry Less, Remember More intervention for veterans with subjective cognitive symptoms. Future iterations of the intervention may benefit from simplifying the electronic consent process, providing reminders for appointments, and incorporating compensatory cognitive strategies to assist with using the telehealth system, as well as applying the strategies learned in the intervention. While future research is needed with larger samples, including nonveteran populations, the intervention may also be a useful clinical tool to bridge care between neuropsychology clinics and mental health treatment. ", doi="10.2196/48525", url="https://formative.jmir.org/2024/1/e48525", url="http://www.ncbi.nlm.nih.gov/pubmed/38608264" } @Article{info:doi/10.2196/47458, author="Patel, Priya and Brown, Susan and Guo, Boliang and Holmes, A. Emily and Iyadurai, Lalitha and Kingslake, Jonathan and Highfield, Julie and Morriss, Richard", title="Using a Novel Gameplay Intervention to Target Intrusive Memories After Work-Related Trauma: Iterative Qualitative Analysis of Intensive Care Unit Staff Experiences", journal="JMIR Form Res", year="2024", month="Feb", day="29", volume="8", pages="e47458", keywords="intensive care", keywords="posttraumatic stress disorder", keywords="PTSD", keywords="qualitative research", keywords="intervention study", keywords="health care professionals", keywords="digital intervention", keywords="staff well-being", keywords="pandemic", keywords="intrusive memories", keywords="work-related trauma", keywords="mobile phone", abstract="Background: Many intensive care unit (ICU) staff experience intrusive memories following work-related traumatic events, which can lead to long-term mental health outcomes and impact work functioning. There is a need for interventions that target intrusive memories in this population; however, factors such as mental health stigma and difficulty in fitting interventions into busy schedules can pose barriers. The Brief Gameplay Intervention For National Health Service Intensive Care Unit Staff Affected By COVID-19 Trauma (GAINS) study tested a brief, digital imagery-competing task intervention (including computer gameplay) with the aim of reducing the recurrence of intrusive memories, which holds promise for overcoming some of these barriers. Objective: This substudy aims to explore barriers and facilitators to the uptake and practical use of the intervention by ICU staff, along with its acceptability, and iteratively explore the impact of intervention optimizations to further refine the intervention. Methods: The GAINS study is a randomized controlled trial comparing access to a brief digital imagery-competing task intervention for 4 weeks with usual care followed by delayed access to the intervention. The participants were ICU staff who worked during the COVID-19 pandemic and experienced intrusive memories. All participants were sent a questionnaire at 4 weeks to gather data about intervention acceptability. Nested within the randomized controlled trial, a subset of 16 participants was interviewed, and data were analyzed using thematic analysis drawing from a framework approach. Results: Both quantitative and qualitative data indicated high acceptability of the intervention. Intervention use data show that, on average, staff were able to target approximately 73\% (3.64/4.88) of their intrusive memories and engaged with the Tetris component for the full 20 minutes per session. Overall, on the acceptability questionnaire, staff found the intervention easy to use, helpful, and highly acceptable. The interviews generated four themes: approach to the intervention, positives of the intervention, negatives of the intervention, and improvements and optimizations. Findings highlighted barriers that ICU staff experienced: stigma, feeling weak for seeking help, not wanting colleagues to know they were struggling, and skepticism. However, they provided suggestions on how barriers could be overcome and discussed the advantages of the intervention when compared with other treatments. Although participants described many positive aspects of the intervention, such as being easy to use, enjoyable, and leading to a reduction in the frequency or intensity of intrusive memories, they also raised practical issues for implementation. Conclusions: The intervention has the potential to overcome stigma and reduce the frequency of intrusive memories after traumatic events among ICU staff. Further refinement is needed to improve the adoption and reach of this intervention. A limitation is that we could not interview the National Health Service staff who were unable or unwilling to take part in the trial. ", doi="10.2196/47458", url="https://formative.jmir.org/2024/1/e47458", url="http://www.ncbi.nlm.nih.gov/pubmed/38421698" } @Article{info:doi/10.2196/55560, author="Lawrence-Sidebottom, Darian and Huffman, Goodgame Landry and Beam, Brenna Aislinn and Guerra, Rachael and Parikh, Amit and Roots, Monika and Huberty, Jennifer", title="Rates of Trauma Exposure and Posttraumatic Stress in a Pediatric Digital Mental Health Intervention: Retrospective Analysis of Associations With Anxiety and Depressive Symptom Improvement Over Time", journal="JMIR Pediatr Parent", year="2024", month="Feb", day="27", volume="7", pages="e55560", keywords="collaborative care model", keywords="telehealth", keywords="childhood trauma", keywords="DMHI", keywords="digital health", keywords="mental health", keywords="telemedicine", keywords="trauma", keywords="traumatic", keywords="pediatric", keywords="pediatrics", keywords="paediatric", keywords="paediatrics", keywords="child", keywords="children", keywords="youth", keywords="adolescent", keywords="adolescents", keywords="teen", keywords="teens", keywords="teenager", keywords="teenagers", keywords="retrospective", keywords="anxiety", keywords="depression", keywords="depressive", keywords="co-occurring", keywords="comorbid", keywords="comorbidity", keywords="comorbidities", keywords="association", keywords="associations", keywords="correlation", keywords="correlations", keywords="correlate", abstract="Background: More than 2 out of 3 children and adolescents in the United States experience trauma by the age of 16 years. Exposure to trauma in early life is linked to a range of negative mental health outcomes throughout the lifespan, particularly co-occurring symptoms of posttraumatic stress (PTS), anxiety, and depression. There has been an increasing uptake of digital mental health interventions (DMHIs) among youths, particularly for anxiety and depression. However, little is known regarding the incidence of trauma exposure and PTS symptoms among youths participating in DMHIs and whether PTS symptoms impact anxiety and depressive symptom treatment response. Moreover, it is unclear whether participation in a DMHI for anxiety and depressive symptoms is associated with secondary effects on PTS symptoms among trauma-exposed youths. Objective: This study aims to use retrospective data from youths participating in a DMHI to (1) characterize rates of trauma, PTS, and comorbid anxiety and depressive symptoms; (2) determine whether trauma exposure and elevated PTS symptoms impact the improvement of comorbid anxiety and depressive symptoms throughout participation in care; and (3) determine whether participation in a non--posttraumatic DMHI is linked to reductions in PTS symptoms. Methods: This study was conducted using retrospective data from members (children ages 6 to 12 years) involved in a pediatric collaborative care DMHI. Participating caregivers reported their children's trauma exposure. PTS, anxiety, and depressive symptom severity were measured monthly using validated assessments. Results: Among eligible participants (n=966), 30.2\% (n=292) reported at least 1 traumatic event. Of those with trauma exposure and elevated symptoms of PTS (n=119), 73\% (n=87) exhibited elevated anxiety symptoms and 50\% (n=59) exhibited elevated depressive symptoms. Compared to children with no trauma, children with elevated PTS symptoms showed smaller reductions per month in anxiety but not depressive symptoms (anxiety: F2,287=26.11; P<.001). PTS symptoms also decreased significantly throughout care, with 96\% (n=79) of participants showing symptom reductions. Conclusions: This study provides preliminary evidence for the frequency of trauma exposure and comorbid psychiatric symptoms, as well as variations in treatment response between trauma-exposed and nontrauma-exposed youths, among participants in a pediatric collaborative care DMHI. Youths with traumatic experiences may show increased psychiatric comorbidities and slower treatment responses than their peers with no history of trauma. These findings deliver compelling evidence that collaborative care DMHIs may be well-suited to address mental health symptoms in children with a history of trauma while also highlighting the critical need to assess symptoms of PTS in children seeking treatment. ", doi="10.2196/55560", url="https://pediatrics.jmir.org/2024/1/e55560", url="http://www.ncbi.nlm.nih.gov/pubmed/38412001" } @Article{info:doi/10.2196/49557, author="Hahn, Christine and Tilstra-Ferrell, Emily and Salim, Selime and Goodrum, Nada and Rheingold, Alyssa and Gilmore, K. Amanda and Barber, Sara and Moreland, Angela", title="Web-Based Screening, Brief Intervention, and Referral to Treatment for Traumatic Stress and Alcohol Misuse Among Survivors of Sexual Assault and Intimate Partner Violence: Usability and Acceptability Study", journal="JMIR Form Res", year="2024", month="Feb", day="15", volume="8", pages="e49557", keywords="screening, brief intervention, and referral to treatment", keywords="brief intervention", keywords="intimate partner violence", keywords="sexual assault", keywords="substance use", keywords="alcohol use", keywords="mobile phone", abstract="Background: Recent survivors of intimate partner violence (IPV) and sexual assault (SA) are at a high risk for traumatic stress and alcohol misuse. IPV and SA survivors face barriers to services for traumatic stress and alcohol misuse and have low service utilization rates. One way to increase access to services for this population is the use of web-based screening, brief intervention, and referral to treatment (SBIRT), an evidence-informed approach for early identification of traumatic stress and alcohol and drug misuse and connecting individuals to treatment. Objective: This study aims to assess the usability and acceptability of a web-based SBIRT called CHAT (Choices For Your Health After Trauma) tailored to address traumatic stress and alcohol misuse following past-year IPV, SA, or both. Methods: Phase 1 involved gathering feedback about usability and acceptability from focus groups with victim service professionals (22/52, 42\%) and interviews with past-year survivors of IPV, SA, or both (13/52, 25\%). Phase 2 involved gathering feedback about the acceptability of an adapted version of CHAT in an additional sample of recent survivors (17/52, 33\%). Survey data on history of IPV and SA, posttraumatic stress disorder symptoms, alcohol and drug use, and service use were collected from survivors in both phases to characterize the samples. Qualitative content and thematic analyses of the interviews and focus group data were conducted using a coding template analysis comprising 6 a priori themes (usability, visual design, user engagement, content, therapeutic persuasiveness, and therapeutic alliance). Results: Six themes emerged during the focus groups and interviews related to CHAT: usability, visual design, user engagement, content, therapeutic persuasiveness, and therapeutic alliance. Phase 1 providers and survivors viewed CHAT as acceptable, easy to understand, and helpful. Participants reported that the intervention could facilitate higher engagement in this population as the web-based modality is anonymous, easily accessible, and brief. Participants offered helpful suggestions for improving CHAT by updating images, increasing content personalization, reducing text, and making users aware that the intervention is confidential. The recommendations of phase 1 participants were incorporated into CHAT. Phase 2 survivors viewed the revised intervention and found it highly acceptable (mean 4.1 out of 5, SD 1.29). A total of 4 themes encapsulated participant's favorite aspects of CHAT: (1) content and features, (2) accessible and easy to use, (3) education, and (4) personalization. Six survivors denied disliking any aspect. The themes on recommended changes included content and features, brevity, personalization, and language access. Participants provided dissemination recommendations. Conclusions: Overall, CHAT was acceptable among victim service professionals and survivors. Positive reactions to CHAT show promise for future research investigating the efficacy and potential benefit of CHAT when integrated into services for people with traumatic stress and alcohol misuse after recent IPV and SA. ", doi="10.2196/49557", url="https://formative.jmir.org/2024/1/e49557", url="http://www.ncbi.nlm.nih.gov/pubmed/38358791" } @Article{info:doi/10.2196/47175, author="Le Barbenchon, Emmanuelle and Trousselard, Marion and Pellissier, Sonia and Moisseron-Baud{\'e}, Mathilde and Chachignon, Philippine and Bouny, Pierre and Tour{\'e} Cuq, Emma and Jacob, Sandrine and Vigier, C{\'e}cile and Hidalgo, Maud and Claverie, Damien and Duffaud, M. Anais", title="Implementation of a Primary Prevention Program for Posttraumatic Stress Disorder in a Cohort of Professional Soldiers (PREPAR): Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2024", month="Jan", day="26", volume="13", pages="e47175", keywords="posttraumatic stress disorder, military, primary prevention, biopsychosocial, resilience, coping, stigma, biophysiology", keywords="PTSD", keywords="implementation", keywords="soldier", keywords="veterans", keywords="prevention program", abstract="Background: Posttraumatic stress disorder (PTSD) is a psychiatric disorder that can manifest after a traumatic event where the individual perceives a threat to his or her life or that of others. Its estimated prevalence in the European population is 0.7\% to 1.9\%. According to the ``dose-response'' model, individuals who are most exposed to traumatic events are most at risk of developing PTSD. Hence, it is unsurprising that studies have observed a higher prevalence among the military population, ranging from 10\% to 18\%, or even up to 45\%. This project's overall goal is to evaluate the primary prevention actions that can strengthen the resilience of at-risk professionals, notably military personnel, in the short term, with the medium- to long-term aim of preventing the occurrence of PTSD and improving the patient's prognosis. Objective: This study's objectives are (1) to design a primary prevention program for PTSD, tailored to the studied military population and compatible with operational constraints; and (2) to implement and validate the Primary Prevention of Posttraumatic Stress Disorder in Military Professionals (PREPARE) program in the short term with operational personnel belonging to the French Mountain Infantry Brigade. Methods: This is a single-center, prospective, randomized, parallel-group controlled cohort study. The cohort is divided into 2 groups: the nonintervention group receives no training, and the intervention group follows a dedicated prevention program (structured into 8 workshops and 2 debriefing and practice reinforcement workshops). Each participant is evaluated 4 times (at inclusion, +4 months, +6 months, and +12 months). During each visit, participants complete several psychosocial questionnaires (which take 15-80 minutes to complete). Samples (a 30-mL blood sample and three 5-mL saliva samples) are collected on 3 occasions: at inclusion, +4 months, and +12 months. Emotional reactivity (electrocardiogram and electrodermal activity) is measured before, during, and after the classic and the emotional Stroop task. Results: The project is currently ongoing, and results are expected to be published by the end of 2024. Conclusions: The study adopts an integrative approach to the processes that play a role in the risk of developing PTSD. Our biopsychosocial perspective makes it possible to target levers related to factors specific to the individual and socio-professional factors. The following dimensions are addressed: (1) biophysiology (by studying markers of the neurobiological stress response, wear and tear, and vulnerability phenomena and reinforcing the flexibility of the autonomic nervous system), (2) psychology (by facilitating and measuring the development of flexible coping strategies to deal with stress and evaluating the moderating role of the individual's sense of duty in the development of PTSD), and (3) social (by facilitating community strategies aimed at reducing stigmatization and supporting the use of care by professionals in difficulty, in the institutional context). Trial Registration: ClinicalTrials.gov NCT05094531; https://clinicaltrials.gov/study/NCT05094531 International Registered Report Identifier (IRRID): DERR1-10.2196/47175 ", doi="10.2196/47175", url="https://www.researchprotocols.org/2024/1/e47175", url="http://www.ncbi.nlm.nih.gov/pubmed/38277204" } @Article{info:doi/10.2196/51838, author="Greene, Talya and Contractor, A. Ateka and Dicker-Oren, Daniela Sheila and Fentem, Andrea and Sznitman, R. Sharon", title="The Effects of the Processing of Positive Memories Technique on Posttrauma Affect and Cognitions Among Survivors of Trauma: Protocol for a Daily Diary Study", journal="JMIR Res Protoc", year="2024", month="Jan", day="12", volume="13", pages="e51838", keywords="affect", keywords="case series design", keywords="cognitions", keywords="experience sampling", keywords="intensive longitudinal assessment", keywords="positive autobiographical memories", keywords="posttrauma health", keywords="posttraumatic stress disorder", keywords="trauma survivors", abstract="Background: The Processing of Positive Memories Technique (PPMT) is a promising new treatment approach for posttraumatic stress disorder (PTSD), which involves detailed narration and processing of specific positive autobiographical memories. Indeed, preliminary case-series studies have found reductions in PTSD symptoms, negative affect, and negative cognitions among survivors of trauma who have received PPMT. However, PPMT's effects have not been investigated at the daily level. In this study, we describe the protocol for a study that will examine the daily-level impacts of PPMT in a trauma-exposed, nonclinical community sample. Objective: This study uses an innovative research protocol that combines case-series design and daily diary approaches to examine changes in daily affect, daily cognitions, and daily PTSD symptoms pre- and post-PPMT. We hypothesize that at the daily level, in comparison to their own pre-PPMT levels, following the PPMT intervention, participants will report (1) a lower count of endorsed daily PTSD symptoms, (2) increases in daily positive affect and decreases in daily negative affect, (3) increases in positive affect reactivity to daily positive events, and (4) decreases in daily posttrauma cognitions. Methods: We are currently recruiting participants (target n=70) from a metroplex in the southwest United States. Following a screening survey, eligible participants complete a preintervention baseline survey, followed by 21 daily surveys in their natural environments. Then, they receive 4 PPMT sessions on a weekly basis. After the conclusion of the PPMT intervention, participants complete a postintervention outcome survey and 21 daily surveys. To compare daily affect, daily cognitions, and daily PTSD symptoms before and after PPMT, we will use the daily diary report data and conduct multilevel random intercepts and slopes linear regression models. Results: Data collection was initiated in March 2022 and is expected to end by June 2024. As of November 28, 2023, a total of 515 participants had consented to the study in the screening phase. No analyses will be conducted until data collection has been completed. Conclusions: Study findings could clarify whether deficits in positive autobiographical memory processes may also characterize PTSD alongside deficits in traumatic memory processes. Furthermore, PPMT could be an additional therapeutic tool for clinicians to help clients reduce posttraumatic distress in their everyday lives. International Registered Report Identifier (IRRID): DERR1-10.2196/51838 ", doi="10.2196/51838", url="https://www.researchprotocols.org/2024/1/e51838", url="http://www.ncbi.nlm.nih.gov/pubmed/38214953" } @Article{info:doi/10.2196/34346, author="Bogdanski, Erin", title="The Effects of Virtual Reality Telemedicine With Pediatric Patients Diagnosed With Posttraumatic Stress Disorder: Exploratory Research Method Case Report", journal="JMIR Form Res", year="2023", month="Dec", day="22", volume="7", pages="e34346", keywords="virtual reality", keywords="psychology", keywords="neuroscience", keywords="behavioral health", keywords="telehealth", keywords="eHealth", keywords="telemedicine", keywords="trauma", keywords="traumatic", keywords="PTSD", keywords="posttraumatic stress disorder", keywords="mental health", keywords="mental condition", keywords="mental illness", keywords="cognitive behavioral therapy", keywords="CBT", keywords="avatar", keywords="case study", keywords="pediatric", keywords="child", keywords="youth", keywords="psychiatric disorder", abstract="Background: Trauma-focused cognitive behavioral therapy (TF-CBT) strategies are common interventions to treat child trauma and a posttraumatic stress disorder (PTSD) diagnosis in children with histories of sexual and physical abuse. With the advent of COVID-19, the disruption of child development combined with intense exposure to technology and screen time indicate a need for delivering other novel approaches to treat pediatric PTSD. Virtual reality (VR) has been used with evidence-based TF-CBT as an intervention in lab-based settings, but never as telehealth. Such technologies, including a VR head-mounted device (HMD) programmed with novel TheraVR software, for psychotherapy and treating trauma-related symptoms could redefine how pediatric populations respond to treatment. Objective: The aim of this exploratory single-case study was to reflect symptom improvement and patient engagement using VR as telehealth. Methods: The patient was a 10-year-old girl of Middle Eastern descent diagnosed?with trauma and comorbid medical conditions. The patient was in divorced joint parental custody and a Child Protective Services report was made with referral for therapy. Night terrors, hallucinations, depression, anxiety, isolation, and encopresis symptoms were assessed at the beginning of treatment. Clinical analysis met the criteria for a diagnosis of early onset PTSD, which was treated over the course of 7 months using TF-CBT. A cross-analysis design was used to compare improved effectiveness in treatment and patient outcomes when moving from delivery of care with telehealth using desktop and tablet synchronous technology to 2D VR desktop telehealth with TheraVR software and subsequently HMD VR telehealth with TheraVR software. Sessions were conducted in private practice providing psychotherapy for remote patient care, collateral care with the family, and coordination of clinical care with the patient's pediatrician. Safety and protocols for reducing triggers were clinically monitored by the provider. Results: Over the course of treatment, and moving from standard telehealth to 2D VR to TheraVR with a standalone HMD, there was a significant reduction in PTSD symptoms. The transfer from using the standard video conferencing with face-to-face video to using customizable avatar technology with an assigned scene environment presented an increase in patient retention and follow-through with the treatment goals. The continuous use of delivery of care using VR with the TheraVR software demonstrated breakthrough clinical observations where the patient devised her own interventions for coping with mood, emotional regulation, and negative cognitive processes using the 10 different VR environments. Conclusions: This study shows the potential efficacy in using VR specifically for younger populations as a better modality of pediatrics care, while improving engagement with the provider through telehealth. These findings suggest the value of further research through larger clinical trials including pediatric patients diagnosed with severe trauma or trauma-related symptoms to assess the effectiveness of TheraVR software. ", doi="10.2196/34346", url="https://formative.jmir.org/2023/1/e34346", url="http://www.ncbi.nlm.nih.gov/pubmed/38133920" } @Article{info:doi/10.2196/48689, author="Stein, Jana and V{\"o}hringer, Max and Wagner, Birgit and Stammel, Nadine and Nesterko, Yuriy and B{\"o}ttche, Maria and Knaevelsrud, Christine", title="Exposure Versus Cognitive Restructuring Techniques in Brief Internet-Based Cognitive Behavioral Treatment for Arabic-Speaking People With Posttraumatic Stress Disorder: Randomized Clinical Trial", journal="JMIR Ment Health", year="2023", month="Dec", day="13", volume="10", pages="e48689", keywords="posttraumatic stress", keywords="posttraumatic stress disorder", keywords="PTSD", keywords="Middle East", keywords="North Africa", keywords="Arabic", keywords="Arabic-speaking people", keywords="internet", keywords="internet-based", keywords="exposure", keywords="cognitive restructuring", keywords="randomized clinical trial", keywords="RCT", keywords="cognitive behavioral therapy", keywords="CBT", keywords="cognitive behavioral treatment", abstract="Background: Cognitive behavioral interventions delivered via the internet are demonstrably efficacious treatment options for posttraumatic stress disorder (PTSD) in underserved, Arabic-speaking populations. However, the role of specific treatment components remains unclear, particularly in conflict-affected areas of the Middle East and North Africa. Objective: This study aims to evaluate 2 brief internet-based treatments in terms of efficacy, including change in PTSD symptom severity during treatment. Both treatments were developed in line with Interapy, an internet-based, therapist-assisted cognitive behavioral therapy protocol for PTSD and adapted to the specific research question. The first treatment comprised self-confrontation and social sharing (exposure treatment; 6 sessions); the second comprised cognitive restructuring and social sharing (cognitive restructuring treatment; 6 sessions). The 2 treatments were compared with each other and with a waitlist control group. Methods: In total, 365 Arabic-speaking participants from the Middle East and North Africa (mean age 25.49, SD 6.68 y) with PTSD were allocated to cognitive restructuring treatment (n=118, 32.3\%), exposure treatment (n=122, 33.4\%), or a waitlist control group (n=125, 34.2\%) between February 2021 and December 2022. PTSD symptom severity, posttraumatic maladaptive cognitions, anxiety, depressive and somatoform symptom severity, and quality of life were assessed via self-report at baseline and after treatment or waiting time. PTSD symptom severity was also measured throughout treatment or waiting time. Treatment satisfaction was assessed after treatment completion. Treatment use and satisfaction were compared between the 2 treatment conditions using appropriate statistical tests (eg, chi-square and Welch tests). Multiple imputation was performed to address missing data and evaluate treatment-associated changes. These changes were analyzed using multigroup change modeling in the completer and intention-to-treat samples. Results: Overall, 200 (N=240, 83.3\%) participants started any of the treatments, of whom 123 (61.5\%) completed the treatment. Treatment condition was not significantly associated with the proportion of participants who started versus did not start treatment (P=.20) or with treatment completion versus treatment dropout (P=.71). High treatment satisfaction was reported, with no significant differences between the treatment conditions (P=.48). In both treatment conditions, PTSD, anxiety, depressive and somatoform symptom severity, and posttraumatic maladaptive cognitions decreased, and quality of life improved significantly from baseline to the posttreatment time point (P?.001 in all cases). Compared with the baseline assessment, overall PTSD symptom severity decreased significantly after 4 sessions in both treatment conditions (P<.001). Moreover, both treatment conditions were significantly superior to the waitlist control group regarding overall PTSD symptom severity (P<.001) and most other comorbid mental health symptoms (P<.001 to P=.03). Differences between the 2 conditions in the magnitude of change for all outcome measures were nonsignificant. Conclusions: Internet-based cognitive behavioral treatments for PTSD focusing primarily on either self-confrontation or cognitive restructuring are applicable and efficacious for Arabic-speaking participants. Trial Registration: German Clinical Trials Register DRKS00010245; https://drks.de/search/de/trial/DRKS00010245 ", doi="10.2196/48689", url="https://mental.jmir.org/2023/1/e48689", url="http://www.ncbi.nlm.nih.gov/pubmed/38090792" } @Article{info:doi/10.2196/47233, author="Li, Jiaqi and Jin, Yu and Xu, Shicun and Wilson, Amanda and Chen, Chang and Luo, Xianyu and Liu, Yuhang and Ling, Xi and Sun, Xi and Wang, Yuanyuan", title="Effects of Bullying on Anxiety, Depression, and Posttraumatic Stress Disorder Among Sexual Minority Youths: Network Analysis", journal="JMIR Public Health Surveill", year="2023", month="Nov", day="1", volume="9", pages="e47233", keywords="sexual minority youths", keywords="bullying victimization", keywords="anxiety", keywords="depression", keywords="posttraumatic stress disorder", keywords="network analysis", keywords="Bayesian network", abstract="Background: Bullying victimization is highly prevalent among sexual minority youths, particularly in educational settings, negatively affecting their mental health. However, previous studies have scarcely explored the symptomatic relationships among anxiety, depression, and posttraumatic stress disorder (PTSD) among sexual minority youths who experienced bullying on college campuses. Objective: The objectives of our study were to (1) characterize the anxiety-depression-PTSD network structures of gay or lesbian, bisexuals, and other sexual minority youths previously bullied on college campuses; and (2) compare symptomatic associations in the anxiety-depression-PTSD networks among bullied sexual minority youths and heterosexual youths' groups. Methods: This cross-sectional study recruited college participants from Jilin Province, China. Data were analyzed using a subset of the data extracted after screening for sexual orientation and history of bullying victimization. Sexual minority youths were then divided into 3 subgroups: gay or lesbian (homosexual), bisexual, and other. Mental health symptom severity was assessed using scales: the 7-item Generalized Anxiety Disorder Scale measuring anxiety, the 9-item Patient Health Questionnaire measuring depression, and the 10-item Trauma Screening Questionnaire measuring PTSD symptoms. Combining the undirected and Bayesian network analyses, the anxiety-depression-PTSD networks were compared among sexual minority youths subgroups, and the difference between heterosexual youths and sexual minority youths was investigated. Chi-square tests were used to compare the difference in categorical variables, while independent-sample t tests were run on continuous variables. Results: In this large-scale sample of 89,342 participants, 12,249 identified as sexual minority youths, of which 1603 (13.1\%, 95\% CI 12.5\%-13.7\%) reported being bullied on college campuses in the past year. According to the expected influence (EI) and bridge expected influence (bEI) index, in the global network structure of anxiety, depression, and PTSD, sad mood (EI=1.078, bEI=0.635) and irritability (EI=1.077, bEI=0.954) were identified as central and bridge symptoms; emotional cue reactivity (EI=1.015) was a central symptom of PTSD in this global network. In the anxiety-depression-PTSD Bayesian network, anhedonia had the highest prediction priority for activating other symptoms; and feeling afraid linked symptoms from anxiety to the PTSD community. Compared to their heterosexual counterparts, sexual minority youths exhibited a stronger association between difficulty concentrating and appetite. The ``sad mood-appetite'' edge was strongest in the gay or lesbian network; the ``irritability-exaggerated startle response'' edge was strongest in the bisexual network. Conclusions: For the first time, this study identified the most central and bridge symptoms (sad mood and irritability) within the depression-anxiety-PTSD network of sexual minority youths with past bullying-victim experiences on college campuses. Emotional cue reactivity, anhedonia, and feeling afraid were other vital symptoms in the comorbid network. Symptomatic relationships existed showing heterogeneity in bullied heterosexual youths and sexual minority youth networks, which also was present within the sexual minority youth subgroups. Consequently, refined targeted interventions are required to relieve anxiety, depression, and PTSD symptoms. ", doi="10.2196/47233", url="https://publichealth.jmir.org/2023/1/e47233", url="http://www.ncbi.nlm.nih.gov/pubmed/37910159" } @Article{info:doi/10.2196/46652, author="Fedele, Emma and Trousset, Victor and Schalk, Thibault and Oliero, Juliette and Fovet, Thomas and Lefevre, Thomas", title="Identification of Psycho-Socio-Judicial Trajectories and Factors Associated With Posttraumatic Stress Disorder in People Over 15 Years of Age Who Recently Reported Sexual Assault to a Forensic Medical Center: Protocol for a Multicentric Prospective Study Using Mixed Methods and Artificial Intelligence", journal="JMIR Res Protoc", year="2023", month="Oct", day="16", volume="12", pages="e46652", keywords="sexual violence", keywords="posttraumatic stress disorder", keywords="functional outcomes", keywords="risk factors", keywords="artificial intelligence", keywords="trajectory", keywords="longitudinal", keywords="mixed methods", keywords="sexual assault", keywords="mental health", keywords="cohort study", keywords="PTSD", keywords="innovative", abstract="Background: Sexual assault (SA) can lead to a range of adverse effects on physical, sexual, and mental health, as well as on one's social life, financial stability, and overall quality of life. However, not all people who experience SA will develop negative functional outcomes. Various risk and protective factors can influence psycho-socio-judicial trajectories. However, how these factors influence trauma adaptation and the onset of early posttraumatic stress disorder (PTSD) is not always clear. Objective: Guided by an ecological framework, this project has 3 primary objectives: (1) to describe the 1-year psycho-socio-judicial trajectories of individuals recently exposed to SA who sought consultation with a forensic practitioner; (2) to identify predictive factors for the development of PTSD during the initial forensic examination using artificial intelligence; and (3) to explore the perceptions, needs, and experiences of individuals who have been sexually assaulted. Methods: This longitudinal multicentric cohort study uses a mixed methods approach. Quantitative cohort data are collected through an initial questionnaire completed by the physician during the first forensic examination and through follow-up telephone questionnaires at 6 weeks, 3 months, 6 months, and 1 year after the SA. The questionnaires measure factors associated with PTSD, mental, physical, social, and overall functional outcomes, as well as psycho-socio-judicial trajectories. Cohort participants are recruited through their forensic examination at 1 of the 5 participating centers based in France. Eligible participants are aged 15 or older, have experienced SA in the last 30 days, are fluent in French, and can be reached by phone. Qualitative data are gathered through semistructured interviews with cohort participants, individuals who have experienced SA but are not part of the cohort, and professionals involved in their psycho-socio-judicial care. Results: Bivariate and multivariate analyses will be conducted to examine the associations between each variable and mental, physical, social, and judicial outcomes. Predictive analyses will be performed using multiple prediction algorithms to forecast PTSD. Qualitative data will be integrated with quantitative data to identify psycho-socio-judicial trajectories and enhance the prediction of PTSD. Additionally, data on the perceptions and needs of individuals who have experienced SA will be analyzed independently to gain a deeper understanding of their experiences and requirements. Conclusions: This project will collect extensive qualitative and quantitative data that have never been gathered over such an extended period, leading to unprecedented insights into the psycho-socio-judicial trajectories of individuals who have recently experienced SA. It represents the initial phase of developing a functional artificial intelligence tool that forensic practitioners can use to better guide individuals who have recently experienced SA, with the aim of preventing the onset of PTSD. Furthermore, it will contribute to addressing the existing gap in the literature regarding the accessibility and effectiveness of support services for individuals who have experienced SA in Europe. This comprehensive approach, encompassing the entire psycho-socio-judicial continuum and taking into account the viewpoints of SA survivors, will enable the generation of innovative recommendations for enhancing their care across all stages, starting from the initial forensic examination. International Registered Report Identifier (IRRID): DERR1-10.2196/46652 ", doi="10.2196/46652", url="https://www.researchprotocols.org/2023/1/e46652", url="http://www.ncbi.nlm.nih.gov/pubmed/37843900" } @Article{info:doi/10.2196/49678, author="Haun, N. Jolie and Venkatachalam, H. Hari and Fowler, A. Christopher and Alman, C. Amy and Ballistrea, M. Lisa and Schneider, Tali and Benzinger, C. Rachel and Melillo, Christine and Alexander, B. Neil and Klanchar, Angelina S. and Lapcevic, William and French, D. Dustin", title="Mobile and Web-Based Partnered Intervention to Improve Remote Access to Pain and Posttraumatic Stress Disorder Symptom Management: Recruitment and Attrition in a Randomized Controlled Trial", journal="J Med Internet Res", year="2023", month="Oct", day="3", volume="25", pages="e49678", keywords="PTSD", keywords="pain", keywords="veteran", keywords="attrition", keywords="CIH", keywords="randomized controlled trial", keywords="chronic pain", keywords="remote intervention", keywords="dyad", keywords="mobile health", abstract="Background: Increasing access to nonpharmacological interventions to manage pain and posttraumatic stress disorder (PTSD) is essential for veterans. Complementary and integrative health (CIH) interventions can help individuals manage symptom burden with enhanced accessibility via remotely delivered health care. Mission Reconnect (MR) is a partnered, self-directed intervention that remotely teaches CIH skills. Objective: The purpose of this paper is to describe the recruitment, onboarding phase, and attrition of a fully remote randomized controlled trial (RCT) assessing the efficacy of a self-directed mobile and web-based intervention for veterans with comorbid chronic pain and PTSD and their partners. Methods: A total of 364 veteran-partner dyads were recruited to participate in a mixed methods multisite waitlist control RCT. Qualitative attrition interviews were conducted with 10 veterans with chronic pain and PTSD, and their self-elected partners (eg, spouse) who consented but did not begin the program. Results: At the point of completing onboarding and being randomized to the 2 treatment arms, of the 364 recruited dyads, 97 (26.6\%) failed to complete onboarding activities. Reported reasons for failure to complete onboarding include loss of self-elected partner buy-in (n=8, 8\%), difficulties with using remote data collection methods and interventions (n=30, 31\%), and adverse health experiences unrelated to study activities (n=23, 24\%). Enrolled veterans presented at baseline with significant PTSD symptom burden and moderate-to-severe pain severity, and represented a geographically and demographically diverse population. Attrition interviews (n=10) indicated that misunderstanding MR including the intent of the intervention or mistaking the surveys as the actual intervention was a reason for not completing the MR registration process. Another barrier to MR registration was that interviewees described the mailed study information and registration packets as too confusing and excessive. Competing personal circumstances including health concerns that required attention interfered with MR registration. Common reasons for attrition following successful MR registration included partner withdrawal, adverse health issues, and technological challenges relating to the MR and electronic data collection platform (Qualtrics). Participant recommendations for reducing attrition included switching to digital forms to reduce participant burden and increasing human interaction throughout the registration and baseline data collection processes. Conclusions: Challenges, solutions, and lessons learned for study recruitment and intervention delivery inform best practices of delivering remote self-directed CIH interventions when addressing the unique needs of this medically complex population. Successful recruitment and enrollment of veterans with chronic pain and PTSD, and their partners, to remote CIH programs and research studies requires future examination of demographic and symptom-associated access barriers. Accommodating the unique needs of this medically complex population is essential for improving the effectiveness of CIH programs. Disseminating lessons learned and improving access to remotely delivered research studies and CIH programs is paramount in the post--COVID-19 climate. Trial Registration: ClinicalTrials.gov NCT03593772; https://clinicaltrials.gov/ct2/show/NCT03593772 ", doi="10.2196/49678", url="https://www.jmir.org/2023/1/e49678", url="http://www.ncbi.nlm.nih.gov/pubmed/37788078" } @Article{info:doi/10.2196/51324, author="Sayer, A. Nina and Nelson, B. David and Gradus, L. Jaimie and Sripada, K. Rebecca and Murdoch, Maureen and Teo, R. Alan and Orazem, J. Robert and Cerel, Julie", title="The Effects of Suicide Exposure on Mental Health Outcomes Among Post-9/11 Veterans: Protocol for an Explanatory, Sequential, Mixed Methods Study", journal="JMIR Res Protoc", year="2023", month="Sep", day="26", volume="12", pages="e51324", keywords="veterans", keywords="suicide", keywords="death", keywords="posttraumatic stress disorder", keywords="bereavement", keywords="health services", abstract="Background: The toll associated with suicide goes well beyond the individual who died. This study focuses on a risk factor for veteran suicide that has received little previous empirical attention---exposure to the suicide death of another person. Objective: The study's primary objective is to describe the mental health outcomes associated with suicide exposure among veterans who served on active duty after September 2001 (``post-9/11''). The secondary objective is to elucidate why some veterans develop persistent problems following suicide exposure, whereas others do not. Methods: This is an explanatory, sequential, mixed methods study of a nationally representative sample of post-9/11 veterans enrolled in Department of Veterans Affairs (VA) health care. Our sampling strategy was designed for adequate representation of female and American Indian and Alaska Native veterans to allow for examination of associations between suicide exposure and outcomes within these groups. Primary outcomes comprise mental health problems associated with trauma and loss (posttraumatic stress disorder and prolonged grief disorder) and suicide precursors (suicidal ideation, attempts, and planning). Data collection will be implemented in 3 waves. During wave 1, we will field a brief survey to a national probability sample to assess exposure history (suicide, other sudden death, or neither) and exposure characteristics (eg, closeness with the decedent) among 11,400 respondents. In wave 2, we will include 39.47\% (4500/11,400) of the wave-1 respondents, stratified by exposure history (suicide, other sudden death, or neither), to assess health outcomes and other variables of interest. During wave 3, we will conduct interviews with a purposive subsample of 32 respondents exposed to suicide who differ in mental health outcomes. We will supplement the survey and interview data with VA administrative data identifying diagnoses, reported suicide attempts, and health care use. Results: The study began on July 1, 2022, and will end on June 30, 2026. This is the only national, population-based study of suicide exposure in veterans and the first one designed to study differences based on sex and race. Comparing those exposed to suicide with those exposed to sudden death for reasons other than suicide (eg, combat) and those unexposed to any sudden death may allow for the identification of the common and unique contribution of suicide exposure to outcomes and help seeking. Conclusions: Integrating survey, qualitative, and VA administrative data to address significant knowledge gaps regarding the effects of suicide exposure in a national sample will lay the foundation for interventions to address the needs of individuals affected by a suicide death, including female and American Indian and Alaska Native veterans. International Registered Report Identifier (IRRID): DERR1-10.2196/51324 ", doi="10.2196/51324", url="https://www.researchprotocols.org/2023/1/e51324", url="http://www.ncbi.nlm.nih.gov/pubmed/37751271" } @Article{info:doi/10.2196/45969, author="Stathakarou, Natalia and Kononowicz, A. Andrzej and Swain, Cara and Karlgren, Klas", title="Game Elements in the Design of Simulations in Military Trauma Management Training: Protocol for a Systematic Review", journal="JMIR Res Protoc", year="2023", month="Sep", day="8", volume="12", pages="e45969", keywords="gamification", keywords="game elements", keywords="military medicine", keywords="trauma", keywords="medical education", keywords="military training", keywords="systematic review", keywords="game", keywords="gaming", keywords="simulation", abstract="Background: Military trauma teams are commonly operating in civilian hospitals during peacetime; in a war situation they must adjust their practices to the austere conditions. Simulations can replicate austere conditions to allow training in a safe environment that tolerates errors. Gamification, understood as the use of game elements to motivate and engage learners in nongame contexts, is gaining interest in medical education and military training. Applying game elements in the design of military trauma management simulations has the potential to provide learners with active learning opportunities and prepare them for providing medical services under austere conditions. Although gamification is known for its engaging and motivational benefits, there are controversies about its pedagogical value. The controversies can be attributed to the fact that various gamification strategies may consist of a different combination of game elements, leading to different outcomes. Objective: This systematic review aims to understand how game elements are used in the design of simulations in military trauma management training and their reported outcomes. Methods: We have designed a search strategy for the purpose of the review. Two researchers will independently assess the identified studies based on the defined inclusion and exclusion criteria. The selection process will be represented using a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram. The search will be repeated and updated as necessary prior to publication of the review. Two reviewers will independently extract and manage the data for each of the articles using a structured data extraction form. Any disagreement that arises between reviewers will be resolved through discussion, and a third review author will be consulted when needed. We are going to conduct a thematic synthesis of the extracted game element descriptions. The results are going to be presented in a diagrammatic or tabular form, alongside a narrative summary. The quality of the studies will be assessed. Results: We implemented and tested the developed search strategy in May 2023. We retrieved 1168 study abstracts, which were reduced to 630 abstracts after deduplication. We have piloted the screening on 20\% (126/630) of the identified abstracts in groups of 2 reviewers. Conclusions: Although gamification has the potential to motivate learners in various ways, there is a lack of understanding about specific game elements and how they can inform instructional design in different contexts. Our findings will increase the understanding of how game elements are used in the design of simulations in military trauma management training and, thus, contribute to more effective development of future simulations. International Registered Report Identifier (IRRID): DERR1-10.2196/45969 ", doi="10.2196/45969", url="https://www.researchprotocols.org/2023/1/e45969", url="http://www.ncbi.nlm.nih.gov/pubmed/37682596" } @Article{info:doi/10.2196/46343, author="Esener, Yildiz and McCall, Terika and Lakdawala, Adnan and Kim, Heejun", title="Seeking and Providing Social Support on Twitter for Trauma and Distress During the COVID-19 Pandemic: Content and Sentiment Analysis", journal="J Med Internet Res", year="2023", month="Aug", day="31", volume="25", pages="e46343", keywords="COVID-19", keywords="social support", keywords="trauma", keywords="distress", keywords="posttraumatic stress disorder", keywords="PTSD", keywords="Twitter", keywords="social media", keywords="mental health", abstract="Background: The COVID-19 pandemic can be recognized as a traumatic event that led to stressors, resulting in trauma or distress among the general population. Social support is vital in the management of these stressors, especially during a traumatic event, such as the COVID-19 pandemic. Because of the limited face-to-face interactions enforced by physical distancing regulations during the pandemic, people sought solace on social media platforms to connect with, and receive support from, one another. Hence, it is crucial to investigate the ways in which people seek and offer support on social media for mental health management. Objective: The research aimed to examine the types of social support (eg, emotional, informational, instrumental, and appraisal) sought and provided for trauma or distress on Twitter during the COVID-19 pandemic. In addition, this study aimed to gain insight into the difficulties and concerns of people during the pandemic by identifying the associations between terms representing the topics of interest related to trauma or distress and their corresponding sentiments. Methods: The study methods included content analysis to investigate the type of social support people sought for trauma or distress during the pandemic. Sentiment analysis was also performed to track the negative and positive sentiment tweets posted between January 1, 2020, and March 15, 2021. Association rule mining was used to uncover associations between terms and sentiments in tweets. In addition, the research used Kruskal-Wallis and Mann-Whitney U tests to determine whether the retweet count and like count varied based on the social support type. Results: Most Twitter users who indicated trauma or distress sought emotional support. Regarding sentiment, Twitter users mostly posted negative sentiment tweets, particularly in January 2021. An intriguing observation was that wearing masks could trigger and exacerbate trauma or distress. The results revealed that people mostly sought and provided emotional support on Twitter regarding difficulties with wearing masks, mental health status, financial hardships, and treatment methods for trauma or distress. In addition, tweets regarding emotional support received the most endorsements from other users, highlighting the critical role of social support in fostering a sense of community and reducing the feelings of isolation during the pandemic. Conclusions: This study demonstrates the potential of social media as a platform to exchange social support during challenging times and to identify the specific concerns (eg, wearing masks and exacerbated symptoms) of individuals with self-reported trauma or distress. The findings provide insights into the types of support that were most beneficial for those struggling with trauma or distress during the pandemic and may inform policy makers and health organizations regarding better practices for pandemic response and special considerations for groups with a history of trauma or distress. ", doi="10.2196/46343", url="https://www.jmir.org/2023/1/e46343", url="http://www.ncbi.nlm.nih.gov/pubmed/37651178" } @Article{info:doi/10.2196/42862, author="Manuel, K. Jennifer and Purcell, Natalie and Abadjian, Linda and Cardoos, Stephanie and Yalch, Matthew and Hill, Coleen and McCarthy, Brittan and Bertenthal, Daniel and McGrath, Sarah and Seal, Karen", title="Virtual Worlds Technology to Enhance Training for Primary Care Providers in Assessment and Management of Posttraumatic Stress Disorder Using Motivational Interviewing: Pilot Randomized Controlled Trial", journal="JMIR Med Educ", year="2023", month="Aug", day="28", volume="9", pages="e42862", keywords="primary care", keywords="posttraumatic stress disorder", keywords="PTSD", keywords="motivational interviewing", keywords="virtual training", keywords="training", keywords="virtual", keywords="stress", keywords="disorder", keywords="treatment", keywords="patient", keywords="assessment", keywords="communication", keywords="feasibility", keywords="acceptability", keywords="efficacy", abstract="Background: Many individuals with posttraumatic stress disorder (PTSD) first present to primary care rather than specialty mental health care. Primary care providers often lack the training required to assess and treat patients with PTSD. Virtual trainings have emerged as a convenient and effective way of training primary care providers in PTSD assessment and communication methods (ie, motivational interviewing [MI]). Objective: The aim of this study was to conduct a pilot randomized controlled trial of a synchronous Virtual Worlds (VW; a virtual world where learners were immersed as avatars) training versus an asynchronous web-based training on PTSD and MI, comparing the feasibility, acceptability, usability, and preliminary efficacy of 2 different training platforms among primary care providers. Methods: Participating primary care providers were randomized to a VW and a web-based PTSD training. Outcomes were collected at baseline, posttraining, and 90-days follow-up. Standardized patient interviews measured participants' communication skills in assessing and managing patients with PTSD symptoms. Results: Compared to the web-based training, the VW training platform achieved larger learning gains in MI (ie, partnership and empathy) and in discussing pharmacotherapy and psychotherapy for PTSD. Both VW and web-based trainings led to increases in PTSD knowledge and primary care providers' self-confidence. Conclusions: The asynchronous web-based PTSD training improved PTSD-related knowledge and self-confidence but was not as effective as the VW immersive experience in teaching MI or clinical management. Because VW training is synchronous and new for many learners, it required more time, facilitation, and technical support. As computer technology improves, VW educational interventions may become more feasible, particularly in teaching clinical skills. Trial Registration: ClinicalTrials.gov NCT03898271; https://tinyurl.com/mu479es5 ", doi="10.2196/42862", url="https://mededu.jmir.org/2023/1/e42862", url="http://www.ncbi.nlm.nih.gov/pubmed/37639299" } @Article{info:doi/10.2196/42803, author="Rawat, Singh Bhanu Pratap and Reisman, Joel and Pogoda, K. Terri and Liu, Weisong and Rongali, Subendhu and Aseltine Jr, H. Robert and Chen, Kun and Tsai, Jack and Berlowitz, Dan and Yu, Hong and Carlson, F. Kathleen", title="Intentional Self-Harm Among US Veterans With Traumatic Brain Injury or Posttraumatic Stress Disorder: Retrospective Cohort Study From 2008 to 2017", journal="JMIR Public Health Surveill", year="2023", month="Jul", day="24", volume="9", pages="e42803", keywords="self-harm", keywords="suicide", keywords="suicide attempt", keywords="suicidal ideation", keywords="veteran", keywords="suicidal", keywords="brain injury", keywords="trauma", keywords="posttraumatic stress disorder", keywords="PTSD", keywords="big data", keywords="prevalence", keywords="correlation", keywords="risk factor", keywords="traumatic brain injury", keywords="TBI", abstract="Background: Veterans with a history of traumatic brain injury (TBI) and/or posttraumatic stress disorder (PTSD) may be at increased risk of suicide attempts and other forms of intentional self-harm as compared to veterans without TBI or PTSD. Objective: Using administrative data from the US Veterans Health Administration (VHA), we studied associations between TBI and PTSD diagnoses, and subsequent diagnoses of intentional self-harm among US veterans who used VHA health care between 2008 and 2017. Methods: All veterans with encounters or hospitalizations for intentional self-harm were assigned ``index dates'' corresponding to the date of the first related visit; among those without intentional self-harm, we randomly selected a date from among the veteran's health care encounters to match the distribution of case index dates over the 10-year period. We then examined the prevalence of TBI and PTSD diagnoses within the 5-year period prior to veterans' index dates. TBI, PTSD, and intentional self-harm were identified using International Classification of Diseases diagnosis and external cause of injury codes from inpatient and outpatient VHA encounters. We stratified analyses by veterans' average yearly VHA utilization in the 5-year period before their index date (low, medium, or high). Variations in prevalence and odds of intentional self-harm diagnoses were compared by veterans' prior TBI and PTSD diagnosis status (TBI only, PTSD only, and comorbid TBI/PTSD) for each VHA utilization stratum. Multivariable models adjusted for age, sex, race, ethnicity, marital status, Department of Veterans Affairs service-connection status, and Charlson Comorbidity Index scores. Results: About 6.7 million veterans with at least two VHA visits in the 5-year period before their index dates were included in the analyses; 86,644 had at least one intentional self-harm diagnosis during the study period. During the periods prior to veterans' index dates, 93,866 were diagnosed with TBI only; 892,420 with PTSD only; and 102,549 with comorbid TBI/PTSD. Across all three VHA utilization strata, the prevalence of intentional self-harm diagnoses was higher among veterans diagnosed with TBI, PTSD, or TBI/PTSD than among veterans with neither diagnosis. The observed difference was most pronounced among veterans in the high VHA utilization stratum. The prevalence of intentional self-harm was six times higher among those with comorbid TBI/PTSD (6778/58,295, 11.63\%) than among veterans with neither TBI nor PTSD (21,979/1,144,991, 1.92\%). Adjusted odds ratios suggested that, after accounting for potential confounders, veterans with TBI, PTSD, or comorbid TBI/PTSD had higher odds of self-harm compared to veterans without these diagnoses. Among veterans with high VHA utilization, those with comorbid TBI/PTSD were 4.26 (95\% CI 4.15-4.38) times more likely to receive diagnoses for intentional self-harm than veterans with neither diagnosis. This pattern was similar for veterans with low and medium VHA utilization. Conclusions: Veterans with TBI and/or PTSD diagnoses, compared to those with neither diagnosis, were substantially more likely to be subsequently diagnosed with intentional self-harm between 2008 and 2017. These associations were most pronounced among veterans who used VHA health care most frequently. These findings suggest a need for suicide prevention efforts targeted at veterans with these diagnoses. ", doi="10.2196/42803", url="https://publichealth.jmir.org/2023/1/e42803", url="http://www.ncbi.nlm.nih.gov/pubmed/37486751" } @Article{info:doi/10.2196/44790, author="Shaker, Abbas Ali and Austin, F. Stephen and Storeb{\o}, Jakob Ole and Schaug, Perrine Julie and Ayad, Alaa and S{\o}rensen, Aasted John and Tarp, Kristine and Bechmann, Henrik and Simonsen, Erik", title="Psychiatric Treatment Conducted via Telemedicine Versus In-Person Modality in Posttraumatic Stress Disorder, Mood Disorders, and Anxiety Disorders: Systematic Review and Meta-Analysis", journal="JMIR Ment Health", year="2023", month="Jul", day="5", volume="10", pages="e44790", keywords="telemedicine", keywords="telepsychiatry", keywords="video consultation", keywords="mobile health", keywords="mHealth", keywords="eHealth", keywords="COVID-19", keywords="synchronous technology", keywords="anxiety", keywords="psychiatry", keywords="patient satisfaction", keywords="depression", keywords="posttraumatic stress disorder", keywords="PTSD", abstract="Background: Telemedicine has played a vital role in providing psychiatric treatment to patients during the rapid transition of services during the COVID-19 pandemic. Furthermore, the use of telemedicine is expected to expand within the psychiatric field. The efficacy of telemedicine is well described in scientific literature. However, there is a need for a comprehensive quantitative review that analyzes and considers the different clinical outcomes and psychiatric diagnoses. Objective: This paper aimed to assess whether individual psychiatric outpatient treatment for posttraumatic stress disorder, mood disorders, and anxiety disorders in adults using telemedicine is equivalent to in-person treatment. Methods: A systematic search of randomized controlled trials was conducted using recognized databases for this review. Overall, 4 outcomes were assessed: treatment efficacy, levels of patient satisfaction, working alliance, and attrition rate. The inverse-variance method was used to summarize the effect size for each outcome. Results: A total of 7414 records were identified, and 20 trials were included in the systematic review and meta-analysis. The trials included posttraumatic stress disorder (9 trials), depressive disorder (6 trials), a mix of different disorders (4 trials), and general anxiety disorder (1 trial). Overall, the analyses yielded evidence that telemedicine is comparable with in-person treatment regarding treatment efficacy (standardized mean difference ?0.01, 95\% CI ?0.12 to 0.09; P=.84; I2=19\%, 17 trials, n=1814), patient satisfaction mean difference (?0.66, 95\% CI ?1.60 to 0.28; P=.17; I2=44\%, 6 trials, n=591), and attrition rates (risk ratio 1.07, 95\% CI 0.94-1.21; P=.32; I2=0\%, 20 trials, n=2804). The results also indicated that the working alliance between telemedicine and in-person modalities was comparable, but the heterogeneity was substantial to considerable (mean difference 0.95, 95\% CI ?0.47 to 2.38; P=.19; I2=75\%, 6 trials, n=539). Conclusions: This meta-analysis provided new knowledge on individual telemedicine interventions that were considered equivalent to in-person treatment regarding efficacy, patient satisfaction, working alliance, and attrition rates across diagnoses. The certainty of the evidence regarding efficacy was rated as moderate. Furthermore, high-quality randomized controlled trials are needed to strengthen the evidence base for treatment provided via telemedicine in psychiatry, particularly for personality disorders and a range of anxiety disorders where there is a lack of studies. Individual patient data meta-analysis is suggested for future studies to personalize telemedicine. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021256357; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=256357 ", doi="10.2196/44790", url="https://mental.jmir.org/2023/1/e44790", url="http://www.ncbi.nlm.nih.gov/pubmed/37277113" } @Article{info:doi/10.2196/44400, author="Dworkin, R. Emily and Schallert, Macey and Lee, M. Christine and Kaysen, Debra", title="mHealth Early Intervention to Reduce Posttraumatic Stress and Alcohol Use After Sexual Assault (THRIVE): Feasibility and Acceptability Results From a Pilot Trial", journal="JMIR Form Res", year="2023", month="Jul", day="4", volume="7", pages="e44400", keywords="mobile health", keywords="mHealth", keywords="mobile apps", keywords="prevention", keywords="alcohol use", keywords="trauma", keywords="sexual violence", keywords="rape", keywords="mobile phone", abstract="Background: Sexual assault is associated with increased risk for both posttraumatic stress (PTS) and alcohol misuse. Mobile health interventions have shown promise in addressing PTS and substance use in trauma survivors and might be a promising strategy in extending the reach of early interventions to individuals who have recently experienced trauma. Objective: This study assesses the feasibility and acceptability of THRIVE, a mobile health early intervention for recent survivors of sexual assault involving a cognitive behavioral app used daily over 21 days with weekly telephone coaching. Methods: Twenty adult female survivors of past--10-week sexual assault with elevated PTS and alcohol use were randomized to receive the THRIVE intervention as part of a pilot randomized controlled trial. We sought to understand feasibility by examining rates of completion of intervention activities and testing changes in participants' self-reported knowledge of key intervention concepts from baseline to after the intervention. We assessed acceptability by collecting self-report ratings of satisfaction with the intervention and app usability in a follow-up survey. The coach took notes during coaching calls to track call content and record participant feedback; these notes were qualitatively analyzed to elaborate on the aforementioned domains. Results: Feasibility was demonstrated by moderate rates of activity completion: all participants at least opened the app, 19 (95\%) of the 20 participants completed at least 1 cognitive behavioral exercise, and 16 (80\%) of the 20 participants attended all 4 coaching calls. Participants completed cognitive behavioral exercises on an average of 10.40 (SD 6.52) out of 21 days. The coaching call notes documented participant comments that app-generated reminders increased completion rates. Feasibility was also demonstrated by the finding that knowledge changes occurred from baseline to after the intervention; this indicated that THRIVE was successful in conveying key concepts. Acceptability was demonstrated by high participant ratings of THRIVE's usability; the ratings corresponded to a B+ usability grade. The coaching call notes documented that usability was increased by the coaching calls, the app exercises' clarity, and the app exercises' inclusion of suggestions; however, the coaching call notes also documented that some of the participants found aspects of the app exercises to be difficult or confusing. Acceptability was also demonstrated by participant ratings of satisfaction: most of the participants (15/16, 94\%) rated the app as either moderately helpful or very helpful. The coaching call notes documented that the cognitive behavioral activity modules were seen as appealing and that the positive impact of the intervention contributed to participants' satisfaction. Conclusions: These findings suggest that THRIVE is feasible and acceptable to survivors of recent sexual assault and that further testing of THRIVE is warranted. Trial Registration: ClinicalTrials.gov NCT03703258; https://clinicaltrials.gov/ct2/show/NCT03703258 ", doi="10.2196/44400", url="https://formative.jmir.org/2023/1/e44400", url="http://www.ncbi.nlm.nih.gov/pubmed/37402144" } @Article{info:doi/10.2196/46842, author="Abdulai, Abdul-Fatawu and Naghdali, Hasti and Tekie Ghirmay, Eden and Adam, Fuseini and Bawafaa, Eunice", title="Trauma-Informed Care in Digital Health Technologies: Protocol for a Scoping Review", journal="JMIR Res Protoc", year="2023", month="Jun", day="23", volume="12", pages="e46842", keywords="clinical intervention", keywords="digital health technologies", keywords="digital health", keywords="psychological trauma", keywords="stress", keywords="trauma", keywords="trauma-informed care", abstract="Background: The use of digital health technologies is becoming increasingly common across the globe as they offer immense potential to enhance health care delivery by promoting accessibility, flexibility, and personalized care, connecting patients to health care professionals, and offering more efficient services and treatments to remote residents. At the same time, there is an increasing recognition of how digital health can inadvertently foment psychological trauma. This phenomenon has led to the adoption of trauma-informed care in designing and deploying digital health technologies. However, how trauma-informed care is defined and characterized, and the various trauma-informed care strategies used in designing and deploying digital health technologies remain unexplored. Objective: This scoping review aims to explore and synthesize the literature on how trauma-informed care is defined and characterized in digital health and the various trauma-informed care principles, strategies, or recommendations used in designing and deploying digital health. Methods: This review will draw on the Joanna Briggs Institute's updated methodological guidance for scoping reviews. A search will be conducted on CINAHL, PubMed, Embase, Compendex Engineering Village, Web of Science, Scopus, and PsycINFO. This review will consider published research studies and unpublished work (gray literature). Studies will be included if they applied trauma-informed care in designing or deploying digital health for patients across all geographical locations or provide trauma-informed recommendations on how web developers should develop digital health. Studies will be limited to publications within the past 10 years and studies in all languages will be considered. Two independent reviewers will screen the titles and abstracts, and then perform a full-text review. Data will be extracted into a data extraction tool developed for this study. Results: The scoping review was undergoing a full search as of April 2023. The main results will synthesize the peer-reviewed and gray literature on adopting trauma-informed care practices in digital health research and development. The study is expected to be completed by December 2023 and the results are expected to be published in a peer-reviewed journal. Conclusions: This review is expected to provide the knowledge base on the adoption of trauma-informed care in designing and deploying digital health. This knowledge can lead to more engaging, and likely, more effective digital health interventions that have less potential for harm. A synthesis of the various trauma-informed care strategies in digital health will also provide a trauma-informed language by enabling researchers and digital health developers to consider trauma as a critical factor in each stage of the design process. International Registered Report Identifier (IRRID): DERR1-10.2196/46842 ", doi="10.2196/46842", url="https://www.researchprotocols.org/2023/1/e46842", url="http://www.ncbi.nlm.nih.gov/pubmed/37351935" } @Article{info:doi/10.2196/45894, author="Han, Jeong Hee and Mendu, Sanjana and Jaworski, K. Beth and Owen, E. Jason and Abdullah, Saeed", title="Preliminary Evaluation of a Conversational Agent to Support Self-management of Individuals Living With Posttraumatic Stress Disorder: Interview Study With Clinical Experts", journal="JMIR Form Res", year="2023", month="May", day="29", volume="7", pages="e45894", keywords="conversational agent", keywords="PTSD", keywords="self-management", keywords="clinical experts", keywords="evaluation", keywords="support system", keywords="mental health", keywords="trauma", abstract="Background: Posttraumatic stress disorder (PTSD) is a serious public health concern. However, individuals with PTSD often do not have access to adequate treatment. A conversational agent (CA) can help to bridge the treatment gap by providing interactive and timely interventions at scale. Toward this goal, we have developed PTSDialogue---a CA to support the self-management of individuals living with PTSD. PTSDialogue is designed to be highly interactive (eg, brief questions, ability to specify preferences, and quick turn-taking) and supports social presence to promote user engagement and sustain adherence. It includes a range of support features, including psychoeducation, assessment tools, and several symptom management tools. Objective: This paper focuses on the preliminary evaluation of PTSDialogue from clinical experts. Given that PTSDialogue focuses on a vulnerable population, it is critical to establish its usability and acceptance with clinical experts before deployment. Expert feedback is also important to ensure user safety and effective risk management in CAs aiming to support individuals living with PTSD. Methods: We conducted remote, one-on-one, semistructured interviews with clinical experts (N=10) to gather insight into the use of CAs. All participants have completed their doctoral degrees and have prior experience in PTSD care. The web-based PTSDialogue prototype was then shared with the participant so that they could interact with different functionalities and features. We encouraged them to ``think aloud'' as they interacted with the prototype. Participants also shared their screens throughout the interaction session. A semistructured interview script was also used to gather insights and feedback from the participants. The sample size is consistent with that of prior works. We analyzed interview data using a qualitative interpretivist approach resulting in a bottom-up thematic analysis. Results: Our data establish the feasibility and acceptance of PTSDialogue, a supportive tool for individuals with PTSD. Most participants agreed that PTSDialogue could be useful for supporting self-management of individuals with PTSD. We have also assessed how features, functionalities, and interactions in PTSDialogue can support different self-management needs and strategies for this population. These data were then used to identify design requirements and guidelines for a CA aiming to support individuals with PTSD. Experts specifically noted the importance of empathetic and tailored CA interactions for effective PTSD self-management. They also suggested steps to ensure safe and engaging interactions with PTSDialogue. Conclusions: Based on interviews with experts, we have provided design recommendations for future CAs aiming to support vulnerable populations. The study suggests that well-designed CAs have the potential to reshape effective intervention delivery and help address the treatment gap in mental health. ", doi="10.2196/45894", url="https://formative.jmir.org/2023/1/e45894", url="http://www.ncbi.nlm.nih.gov/pubmed/37247220" } @Article{info:doi/10.2196/33492, author="Andersen, Pizarro Judith and Di Nota, Maria Paula and Alavi, Nazanin and Anderson, Gregory and Bennell, Craig and McGregor, Carolyn and Ricciardelli, Rosemary and Scott, Caroline Sarah and Shipley, Peter and Vincent, Lise Michelle", title="A Biological Approach to Building Resilience and Wellness Capacity Among Police Exposed to Posttraumatic Stress Injuries: Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2023", month="May", day="24", volume="12", pages="e33492", keywords="posttraumatic stress injuries", keywords="autonomic modulation training", keywords="resilience", keywords="wellness promotion", keywords="public safety personnel", keywords="police", keywords="heart rate variability", keywords="heart rate variability biofeedback", keywords="respiratory sinus arrhythmia", abstract="Background: Law enforcement officers are routinely exposed to hazardous, disturbing events that can impose severe stress and long-term psychological trauma. As a result, police and other public safety personnel (PSP) are at increased risk of developing posttraumatic stress injuries (PTSIs) and disruptions to the autonomic nervous system (ANS). ANS functioning can be objectively and noninvasively measured by heart rate (HR), heart rate variability (HRV), and respiratory sinus arrhythmia (RSA). Traditional interventions aimed at building resilience among PSP have not adequately addressed the physiological ANS dysregulations that lead to mental and physical health conditions, as well as burnout and fatigue following potential psychological trauma. Objective: In this study, we will investigate the efficacy of a web-based Autonomic Modulation Training (AMT) intervention on the following outcomes: (1) reducing self-reported symptoms of PTSI, (2) strengthening ANS physiological resilience and wellness capacity, and (3) exploring how sex and gender are related to baseline differences in psychological and biological PTSI symptoms and response to the AMT intervention. Methods: The study is comprised of 2 phases. Phase 1 involves the development of the web-based AMT intervention, which includes 1 session of baseline survey measures, 6 weekly sessions that integrate HRV biofeedback (HRVBF) training with meta-cognitive skill practice, and 1 session of follow-up survey measures. Phase 2 will use a cluster randomized control design to test the effectiveness of AMT on the following prepost outcomes: (1) self-report symptoms of PTSI and other wellness measures; (2) physiological indicators of health and resilience including resting HR, HRV, and RSA; and (3) the influence of sex and gender on other outcomes. Participants will be recruited for an 8-week study across Canada in rolling cohorts. Results: The study received grant funding in March 2020 and ethics approval in February 2021. Due to delays related to COVID-19, phase 1 was completed in December 2022, and phase 2 pilot testing began in February 2023. Cohorts of 10 participants in the experimental (AMT) and control (prepost assessment only) groups will continue until a total of 250 participants are tested. Data collection from all phases is expected to conclude in December 2025 but may be extended until the intended sample size is reached. Quantitative analyses of psychological and physiological data will be conducted in conjunction with expert coinvestigators. Conclusions: There is an urgent need to provide police and PSP with effective training that improves physical and psychological functioning. Given that help-seeking for PTSI is reduced among these occupational groups, AMT is a promising intervention that can be completed in the privacy of one's home. Importantly, AMT is a novel program that uniquely addresses the underlying physiological mechanisms that support resilience and wellness promotion and is tailored to the occupational demands of PSP. Trial Registration: ClinicalTrials.gov NCT05521360; https://clinicaltrials.gov/ct2/show/NCT05521360 International Registered Report Identifier (IRRID): PRR1-10.2196/33492 ", doi="10.2196/33492", url="https://www.researchprotocols.org/2023/1/e33492", url="http://www.ncbi.nlm.nih.gov/pubmed/37223981" } @Article{info:doi/10.2196/38552, author="Babaei, Nazanin and Kerry, Camrie and Goode, Kisha and Dang, Kevin and Mirzadeh, Parsa and Pirbaglou, Meysam and Kirk, A. Megan and Ritvo, Paul", title="Clinical Assessment of Eye Movement Desensitization and Reprocessing in Memory Distress: Protocol for a Double-Blinded Randomized Controlled Trial", journal="JMIR Res Protoc", year="2023", month="May", day="12", volume="12", pages="e38552", keywords="EMDR variants", keywords="eye movement desensitization reprocessing", keywords="flash technique-EMDR", keywords="posttraumatic stress disorder", abstract="Background: Exposures to ``traumatic'' events are widespread and can cause posttraumatic stress disorder (PTSD). Cognitive behavioral therapy and eye movement desensitization and reprocessing (EMDR) are frequently used and validated behavioral PTSD treatments. Despite demonstrated effectiveness, highly upsetting memory reactions can be evoked, resulting in extensive distress and, sometimes, treatment dropout. In recent years, multiple treatment approaches have aimed at reducing such upsetting memory reactions to traumatic memories while therapeutic progress proceeds. One of these methods, the flash technique (FT), a modification of standard EMDR (S-EMDR), appears effective in distressing memory reduction. This study will examine FT-EMDR and S-EMDR efficacies when both methods are delivered via web-based video. Objective: This study aims to assess the relative efficacy of (web-based) FT-EMDR versus S-EMDR in reducing the PTSD symptoms, anxieties, and depression associated with traumatic memories at postintervention and 1-month follow-up. Methods: This double-blinded, web-based, 2-arm randomized controlled trial will employ self-report outcomes. A total of 90 participants will be identified from the web-based CloudResearch platform and randomly allocated to the experimental or comparison group. Inclusion criteria are as follows: (1) approved for engagement by the CloudResearch platform; (2) 25-60 years of age; (3) residing in Canada or the United States; (4) a recalled disturbing memory of an event >2 years ago that has not repeated and was moderately or more upsetting during occurrence; (5) memory moderately or more upsetting at baseline and not linked to an earlier memory that is equally or more than equally disturbing. Exclusion criteria are bipolar disorder, borderline personality disorder, obsessive-compulsive disorder, schizophrenia, substance abuse or addiction in the past 3 months, suicidal ideation, and suicide attempt in the past 6 months. Interventions include guided video instruction of full FT or guided video of EMDR. Outcome measures are as follows: Primary outcome is PTSD symptoms that are measured by the PTSD Checklist for DSM-5 (Diagnostic and Statistical Manual of Mental Disorders-5) at 1-month follow-up. Secondary outcomes are State Anxiety subscale of State-Trait Anxiety Inventory at baseline, postintervention, and 1-month follow-up; Trait Anxiety subscale of State-Trait Anxiety Inventory; depression (Patient Health Questionnaire-9); and Positive and Negative Affect Schedule measured at 1-month follow-up. Results: If, at 1-month follow-up, the web-based FT-EMDR intervention is more effective in reducing PTSD symptoms (as measured by the PTSD Checklist for DSM-5) than EMDR, it may help reduce traumatic memory distress in multiple contexts. Conclusions: This randomized controlled trial will advance current understandings of PTSD symptoms and interventions that target traumatic memory--related distress. Trial Registration: ClinicalTrials.gov NCT05262127; https://clinicaltrials.gov/ct2/show/NCT05262127 ", doi="10.2196/38552", url="https://www.researchprotocols.org/2023/1/e38552", url="http://www.ncbi.nlm.nih.gov/pubmed/37171869" } @Article{info:doi/10.2196/44776, author="Haun, N. Jolie and Nakase-Richardson, Risa and Melillo, Christine and Kean, Jacob and Benzinger, C. Rachel and Schneider, Tali and Pugh, V. Mary Jo", title="Traumatic Brain Injury Intensive Evaluation and Treatment Program: Protocol for a Partnered Evaluation Initiative Mixed Methods Study", journal="JMIR Res Protoc", year="2023", month="May", day="9", volume="12", pages="e44776", keywords="service member", keywords="rehabilitation", keywords="traumatic brain injury", keywords="TBI", keywords="posttraumatic stress disorder", keywords="PTSD", keywords="pain", keywords="military", keywords="brain injury", keywords="trauma", keywords="traumatic", keywords="participatory", keywords="recovery", keywords="veteran", keywords="implementation", keywords="service delivery", keywords="protocol", keywords="treatment program", keywords="health care implementation", keywords="Consolidated Framework for Implementation Research", keywords="CFIR", keywords="cognitive", keywords="cognition", keywords="brain", keywords="script", keywords="Bayesian", keywords="network analysis", keywords="directed acyclic graph", keywords="effect size", keywords="missing data", keywords="inpatient", keywords="modality", abstract="Background: The traumatic brain injury (TBI) Intensive Evaluation and Treatment Program (IETP) is an innovative modality for delivering evidence-based treatments in a residential, inpatient format to special operational forces service members and veterans with mild TBI. IETPs provide bundled evidence-based assessment, treatment, referral, and case management in concordance with the existing guidelines for mild TBI and commonly co-occurring comorbidities. To date, there has been no formal characterization or evaluation of the IETP to understand the determinants of implementation across the system of care. The goal of our partnered evaluation initiative (PEI) with an operational partner, the Physical Medicine and Rehabilitation National Program Office, is to facilitate the full implementation of the IETP across all 5 Veterans Health Administration TBI--Centers of Excellence (TBI-COE) and to inform minimum standards while supporting the unique characteristics of each site. Objective: This IETP partnered evaluation will describe each of the 5 TBI-COE IETP services and state of implementation to identify opportunities for adaptation and scale, characterize the relationship between patient characteristics and clinical services received, evaluate the outcomes for participants in the IETP, and inform ongoing implementation and knowledge translation efforts to support IETP expansion. In alignment with the goals of the protocol, ineffective treatment components will be targeted for deimplementation. Methods: A 3-year concurrent mixed methods evaluation using a participatory approach in collaboration with the operational partner and TBI-COE site leadership will be conducted. Qualitative observations, semistructured focus groups, and interviewing methods will be used to describe IETP, stakeholder experiences and needs, and suggestions for IETP implementation. Quantitative methods will include primary data collection from patients in the IETP at each site to characterize long-term outcomes and patient satisfaction with treatment and secondary data collection to quantitatively characterize patient-level and care system--level data. Finally, data sets will be triangulated to share data findings with partners to inform ongoing implementation efforts. Results: Data collection began in December 2021 and is currently ongoing. The results and deliverables will inform IETP characterization, evaluation, implementation, and knowledge translation. Conclusions: The results of this evaluation seek to provide an understanding of the determinants affecting the implementation of IETPs. Service member, staff, and stakeholder insights will inform the state of implementation at each site, and quantitative measures will provide options for standardized outcome measures. This evaluation is expected to inform national Physical Medicine and Rehabilitation Office policies and processes and knowledge translation efforts to improve and expand the IETP. Future work may include cost evaluations and rigorous research, such as randomized controlled trials. International Registered Report Identifier (IRRID): DERR1-10.2196/44776 ", doi="10.2196/44776", url="https://www.researchprotocols.org/2023/1/e44776", url="http://www.ncbi.nlm.nih.gov/pubmed/37159250" } @Article{info:doi/10.2196/39894, author="McGuire, P. Adam and Howard, Nguyen Binh An and Erickson, M. Thane and Creech, K. Suzannah", title="Moral Elevation Online Intervention for Veterans Experiencing Distress Related to Posttraumatic Stress Disorder and Moral Injury (MOVED): Pilot Trial of a 4-Week Positive Psychology Web-Based Intervention", journal="JMIR Form Res", year="2023", month="Mar", day="24", volume="7", pages="e39894", keywords="moral elevation", keywords="web-based intervention", keywords="pilot study", keywords="veterans", keywords="posttraumatic stress disorder", keywords="PTSD", keywords="moral injury", abstract="Background: Veterans with posttraumatic stress disorder (PTSD) and moral injury can encounter several barriers to treatment, including limited access to care and low engagement with therapy. Furthermore, most treatment approaches focus on alleviating distress rather than cultivating positive experiences that could facilitate trauma recovery. A potential way to address these issues is through moral elevation: feeling uplifted and inspired by others' virtuous actions. Objective: This study aimed to examine the feasibility and acceptability of a novel, web-based moral elevation intervention for veterans with PTSD symptoms and moral injury distress (Moral Elevation Online Intervention for Veterans Experiencing Distress Related to PTSD and Moral Injury [MOVED]). This mixed methods study also examined potential changes in PTSD symptoms, moral injury distress, quality of life, and prosocial behavior. Methods: In this pilot trial, 48 participants were randomized to a MOVED or control condition (24 participants per condition). Both conditions included 8 sessions and lasted 1 month. The MOVED intervention and all survey components across both conditions were administered online. Participants completed self-report measures that assessed PTSD symptoms, moral injury distress, quality of life, and prosocial behavior at baseline and follow-up. Veterans in the MOVED condition also completed individual qualitative interviews at follow-up. We coded qualitative responses to interviews and identified emergent themes. Results: Findings suggest the MOVED intervention was largely feasible, with evidence for moderate-to-high levels of participation, engagement, and retention in MOVED sessions. Both quantitative and qualitative results suggest veterans found MOVED to be acceptable and satisfactory at the overall treatment level. Furthermore, participants reported high scores for helpfulness and engagement at the session level. Veterans who completed MOVED reported large within-person decreases in PTSD symptoms (Cohen d=1.44), approximately twice that of veterans in the control condition (Cohen d=0.78). Those in MOVED also reported medium-sized increases in physical (Cohen d=0.71) and psychological domains of quality of life (Cohen d=0.74), compared with no meaningful changes in the control condition. Unexpectedly, MOVED veterans reported no decrease in moral injury distress, whereas veterans in the control condition endorsed a medium-sized decrease in the total score. There were no changes in prosociality for either condition. Qualitative feedback further supported high levels of perceived acceptability and satisfaction and positive treatment outcomes across a range of domains, including behaviors, cognitions, emotions, and social functioning. Veterans also recommended adaptations to enhance engagement and maximize the impact of intervention content. Conclusions: Overall, findings indicate that veterans with PTSD and moral injury distress were interested in an intervention based on exposure to and engagement with experiences of moral elevation. After further research and refinement guided by future trials, veterans may benefit from this novel approach, which may enhance treatment outcomes and increase treatment accessibility for those in need of additional trauma-focused care. ", doi="10.2196/39894", url="https://formative.jmir.org/2023/1/e39894", url="http://www.ncbi.nlm.nih.gov/pubmed/36961494" } @Article{info:doi/10.2196/40145, author="Tan, Leona and Deady, Mark and Mead, Olivia and Foright, M. Rebecca and Brenneman, M. Eric and Yeager, R. Jamie and Bryant, A. Richard and Harvey, B. Samuel", title="Web-Based Mind-Body Tactical Resilience Training Program for First Responders: Pre-Post Study Assessing Feasibility, Acceptability, and Usability", journal="JMIR Form Res", year="2023", month="Feb", day="1", volume="7", pages="e40145", keywords="resilience training", keywords="first responders", keywords="web-based intervention", keywords="mental health", keywords="mind-body", keywords="posttraumatic stress disorder", keywords="PTSD", keywords="prevention", abstract="Background: First responders report elevated rates of mental disorders, including posttraumatic stress disorder (PTSD), yet many are reluctant to seek care. Preventative resilience training programs attempt to proactively address this issue, and there is evidence showing promise for programs targeting cognitive processes. However, these programs rarely address the physical health conditions associated with PTSD. There is emerging evidence of mind-body exercise training improving PTSD symptoms as well as its associated physical health symptoms. However, the feasibility and acceptability of delivering a web-based mind-body resilience training among first responders are not yet known. Objective: This study aimed to evaluate the feasibility, usability, and acceptability of a web-based mind-body tactical resilience training program designed for first responders. In addition, we explored the preliminary effectiveness of the training program on mental health outcomes, adaptive cognitive strategies, and work productivity. Methods: A total of 42 first responders based in the United States enrolled in the web-based training program. Participants were administered web-based surveys before enrolling in the 6-week web-based program and at the end of the program. The primary outcomes of feasibility were measured using the number of training hours, program adherence rates, and self-reported data on frequency of practice. Acceptability and usability were measured using self-reported data. Secondary outcomes were symptoms of PTSD, psychological distress, emotion regulation, stress mindset, psychological preparedness, and work performance. Results: Overall, the training program was feasible based on the median number of training hours spent on the web-based program (7.57 hours out of an expected total of 6 to 9 hours), and 55\% (23/42) of the enrolled participants completed more than half of the program. Although acceptability, usability, and frequency of practice were rated as high, this was based on only 29\% (12/42) of the respondents who provided follow-up data. Secondary outcomes showed a significant improvement in the adaptive cognitive strategy of the stress mindset, with a mean difference of --5.42 (SD 4.81; 95\% CI ?8.475 to ?2.358; t11=?3.898; P=.002). All other secondary outcomes were not significant. However, the secondary outcomes were exploratory only, and this study was neither designed nor powered to adequately assess efficacy. Conclusions: These findings suggest that a mind-body tactical resilience training program delivered in a web-based format is feasible and acceptable among first responders; however, further refinements may be required to improve adherence rates. Further research using a larger, more rigorous trial design is warranted to examine the effectiveness of this type of training as a possible prevention or treatment strategy for this population. ", doi="10.2196/40145", url="https://formative.jmir.org/2023/1/e40145", url="http://www.ncbi.nlm.nih.gov/pubmed/36724011" } @Article{info:doi/10.2196/37225, author="Ettore, Eric and M{\"u}ller, Philipp and Hinze, Jonas and Riemenschneider, Matthias and Benoit, Michel and Giordana, Bruno and Postin, Danilo and Hurlemann, Rene and Lecomte, Amandine and Musiol, Michel and Lindsay, Hali and Robert, Philippe and K{\"o}nig, Alexandra", title="Digital Phenotyping for Differential Diagnosis of Major Depressive Episode: Narrative Review", journal="JMIR Ment Health", year="2023", month="Jan", day="23", volume="10", pages="e37225", keywords="depression", keywords="bipolar disorder", keywords="posttraumatic stress disorder", keywords="differential diagnosis", keywords="digital phenotyping", keywords="speech analysis", keywords="nonverbal behavior", keywords="physiological measures", keywords="mental health", keywords="clinical interview", keywords="diagnosis", keywords="mental disorder", keywords="interview", keywords="digital health", keywords="psychotrauma", keywords="digital", keywords="information", abstract="Background: Major depressive episode (MDE) is a common clinical syndrome. It can be found in different pathologies such as major depressive disorder (MDD), bipolar disorder (BD), posttraumatic stress disorder (PTSD), or even occur in the context of psychological trauma. However, only 1 syndrome is described in international classifications (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5]/International Classification of Diseases 11th Revision [ICD-11]), which do not take into account the underlying pathology at the origin of the MDE. Clinical interviews are currently the best source of information to obtain the etiological diagnosis of MDE. Nevertheless, it does not allow an early diagnosis and there are no objective measures of extracted clinical information. To remedy this, the use of digital tools and their correlation with clinical symptomatology could be useful. Objective: We aimed to review the current application of digital tools for MDE diagnosis while highlighting shortcomings for further research. In addition, our work was focused on digital devices easy to use during clinical interview and mental health issues where depression is common. Methods: We conducted a narrative review of the use of digital tools during clinical interviews for MDE by searching papers published in PubMed/MEDLINE, Web of Science, and Google Scholar databases since February 2010. The search was conducted from June to September 2021. Potentially relevant papers were then compared against a checklist for relevance and reviewed independently for inclusion, with focus on 4 allocated topics of (1) automated voice analysis, behavior analysis by (2) video and physiological measures, (3) heart rate variability (HRV), and (4) electrodermal activity (EDA). For this purpose, we were interested in 4 frequently found clinical conditions in which MDE can occur: (1) MDD, (2) BD, (3) PTSD, and (4) psychological trauma. Results: A total of 74 relevant papers on the subject were qualitatively analyzed and the information was synthesized. Thus, a digital phenotype of MDE seems to emerge consisting of modifications in speech features (namely, temporal, prosodic, spectral, source, and formants) and in speech content, modifications in nonverbal behavior (head, hand, body and eyes movement, facial expressivity, and gaze), and a decrease in physiological measurements (HRV and EDA). We not only found similarities but also differences when MDE occurs in MDD, BD, PTSD, or psychological trauma. However, comparative studies were rare in BD or PTSD conditions, which does not allow us to identify clear and distinct digital phenotypes. Conclusions: Our search identified markers from several modalities that hold promise for helping with a more objective diagnosis of MDE. To validate their potential, further longitudinal and prospective studies are needed. ", doi="10.2196/37225", url="https://mental.jmir.org/2023/1/e37225", url="http://www.ncbi.nlm.nih.gov/pubmed/36689265" } @Article{info:doi/10.2196/40496, author="Besterman-Dahan, Karen and Hathaway, A. Wendy and Chavez, Margeaux and Bradley, Sarah and Orozco, Tatiana and Panaite, Vanessa and Lind, Jason and Berumen, Jessica", title="Multisite Agricultural Veterans Affairs Farming and Recovery Mental Health Services (VA FARMS) Pilot Program: Protocol for a Responsive Mixed Methods Evaluation Study", journal="JMIR Res Protoc", year="2023", month="Jan", day="6", volume="12", pages="e40496", keywords="veteran", keywords="evaluation", keywords="farming", keywords="farm", keywords="agriculture", keywords="nature", keywords="agricultural", keywords="mental health", keywords="mental health services", keywords="support", keywords="vocation", keywords="gardening", keywords="training", keywords="nature-based therapy", keywords="pilot program", keywords="posttraumatic stress disorder", keywords="PTSD", keywords="rehabilitation", keywords="reintegration", abstract="Background: Veterans Affairs Farming and Recovery Mental Health Services (VA FARMS) is an innovative pilot program to provide supportive resources for veterans with interests in agricultural vocations. Implemented at 10 pilot sites, VA FARMS will provide mental health services and resources for veterans while supporting training in gardening and agriculture. As each pilot site project has unique goals, outreach strategies, and implementation efforts based on the local environment and veteran population, evaluating the pilot program provides a unique challenge for evaluators. This paper describes the protocol to evaluate VA FARMS, which was specifically designed to enable site variation by providing both site-specific and cross-site understanding of site implementation processes and outcomes. Objective: The objectives of this paper are to (1) describe the protocol used for evaluating VA FARMS, as an innovative Department of Veterans Affairs (VA) agriculturally based, mental health, and employment pilot program serving veterans at 10 pilot sites across the Veterans Health Administration enterprise; and (2) provide guidance to other evaluators assessing innovative programs. Methods: This evaluation uses the context, inputs, process, product (CIPP) model, which evaluates a program's content and implementation to identify strengths and areas for improvement. Data collection will use a concurrent mixed methods approach. Quantitative data collection will involve quarterly program surveys, as well as three individual veteran participant surveys administered upon the veteran's entrance and exit of the pilot program and 3 months postexit. Quantitative data will include baseline descriptive statistics and follow-up statistics on veteran health care utilization, health care status, and agriculture employment status. Qualitative data collection will include participant observation at each pilot site, and interviews with participants, staff, and community stakeholders. Qualitative data will provide insights about pilot program implementation processes, veterans' experiences, and short-term participation outcomes. Results: Evaluation efforts began in December 2018 and are ongoing. Between October 2018 and September 2020, 494 veterans had enrolled in VA FARMS and 1326 veterans were reached through program activities such as demonstrations, informational presentations, and town-hall discussions. A total of 1623 community members and 655 VA employees were similarly reached by VA FARMS programming during that time. Data were collected between October 2018 and September 2020 in the form of 336 veteran surveys, 30 veteran interviews, 27 staff interviews, and 11 community partner interviews. Data analysis is expected to be completed by October 2022. Conclusions: This evaluation protocol will provide guidance to other evaluators assessing innovative programs. In its application to the VA FARMS pilot, the evaluation aims to add to existing literature on nature-based therapies and the rehabilitation outcomes of agricultural training programs for veterans. Results will provide programmatic insights on the implementation of pilot programs, along with needed improvements and modifications for the future expansion of VA FARMS and other veteran-focused agricultural programs. International Registered Report Identifier (IRRID): DERR1-10.2196/40496 ", doi="10.2196/40496", url="https://www.researchprotocols.org/2023/1/e40496", url="http://www.ncbi.nlm.nih.gov/pubmed/36607716" } @Article{info:doi/10.2196/42053, author="van Stolk-Cooke, Katherine and Wielgosz, Joseph and Hallenbeck, Wu Haijing and Chang, Andrew and Rosen, Craig and Owen, Jason and Kuhn, Eric", title="The PTSD Family Coach App in Veteran Family Members: Pilot Randomized Controlled Trial", journal="JMIR Form Res", year="2023", month="Jan", day="5", volume="7", pages="e42053", keywords="posttraumatic stress disorder", keywords="PTSD", keywords="veterans", keywords="family", keywords="mobile apps", abstract="Background: Posttraumatic stress disorder (PTSD) among US military veterans can adversely impact their concerned significant others (CSOs; eg, family members and romantic partners). Mobile apps can be tailored to support CSO mental health through psychoeducation, coping skills, and stress monitoring. Objective: This study assessed the feasibility, acceptability, and potential efficacy of PTSD Family Coach 1.0, a free, publicly available app that includes psychoeducation, stress management tools, self-assessments, and features for connecting to alternative supports, compared with a psychoeducation-only version of the app for cohabitating CSOs of veterans with PTSD. Methods: A total of 200 participants with an average age of 39 (SD 8.44) years, primarily female (193/200, 97\%), and White (160/200, 80\%) were randomized to self-guided use of either PTSD Family Coach 1.0 (n=104) or a psychoeducation-only app (n=96) for 4 weeks. Caregiver burden, stress, depression, anxiety, beliefs about treatment, CSO self-efficacy, and relationship functioning assessed using measures of dyadic adjustment, social constraints, and communication danger signs were administered via a web survey at baseline and after treatment. User satisfaction and app helpfulness were assessed after treatment. Data were analyzed using linear mixed methods. Results: Overall, 50.5\% (101/200) of randomized participants used their allocated app. Participants found PTSD Family Coach 1.0 somewhat satisfying (mean 4.88, SD 1.11) and moderately helpful (mean 2.99, SD 0.97) to use. Linear mixed effects models revealed no significant differences in outcomes by condition for caregiver burden (P=.45; Cohen d=0.1, 95\% CI ?0.2 to 0.4), stress (P=.64; Cohen d=0.1, 95\% CI ?0.4 to 0.6), depression (P=.93; Cohen d= 0.0, 95\% CI ?0.3 to 0.3), anxiety (P=.55; Cohen d=?0.1, 95\% CI ?0.4 to 0.2), beliefs about treatment (P=.71; Cohen d=0.1, 95\% CI ?0.2 to 0.3), partner self-efficacy (P=.59; Cohen d=?0.1, 95\% CI ?0.4 to 0.2), dyadic adjustment (P=.08; Cohen d=?0.2, 95\% CI ?0.5 to 0.0), social constraints (P=.05; Cohen d=0.3, 95\% CI 0.0-0.6), or communication danger signs (P=.90; Cohen d=?0.0, 95\% CI ?0.3 to 0.3). Post hoc analyses collapsing across conditions revealed a significant between-group effect on stress for app users versus nonusers ($\beta$=?3.62; t281=?2.27; P=.02). Conclusions: Approximately half of the randomized participants never used their allocated app, and participants in the PTSD Family Coach 1.0 condition only opened the app approximately 4 times over 4 weeks, suggesting limitations to this app version's feasibility. PTSD Family Coach 1.0 users reported moderately favorable impressions of the app, suggesting preliminary acceptability. Regarding efficacy, no significant difference was found between PTSD Family Coach 1.0 users and psychoeducation app users across any outcome of interest. Post hoc analyses suggested that app use regardless of treatment condition was associated with reduced stress. Further research that improves app feasibility and establishes efficacy in targeting the domains most relevant to CSOs is warranted. Trial Registration: ClinicalTrials.gov NCT02486705; https://clinicaltrials.gov/ct2/show/NCT02486705 ", doi="10.2196/42053", url="https://formative.jmir.org/2023/1/e42053", url="http://www.ncbi.nlm.nih.gov/pubmed/36602852" } @Article{info:doi/10.2196/38951, author="McLean, Carmen and Davis, Adrian C. and Miller, Madeleine and Ruzek, Josef and Neri, Eric", title="The Effects of an Exposure-Based Mobile App on Symptoms of Posttraumatic Stress Disorder in Veterans: Pilot Randomized Controlled Trial", journal="JMIR Mhealth Uhealth", year="2022", month="Nov", day="4", volume="10", number="11", pages="e38951", keywords="posttraumatic stress disorder", keywords="veteran's health", keywords="exposure therapy", keywords="cognitive behavioral therapy", keywords="mHealth", keywords="mobile apps", keywords="self-management", abstract="Background: Barriers to accessing in-person care can prevent veterans with posttraumatic stress disorder (PTSD) from receiving trauma-focused treatments such as exposure therapy. Mobile apps may help to address unmet need for services by offering tools for users to self-manage PTSD symptoms. Renew is a mobile mental health app that focuses on exposure therapy and incorporates a social support function designed to promote user engagement. Objective: We examined the preliminary efficacy of Renew with and without support from a research staff member compared with waitlist among 93 veterans with clinically significant PTSD symptoms. We also examined the impact of study staff support on participant engagement with the app. Methods: In a pilot randomized controlled trial, we compared Renew with and without support from a research staff member (active use condition) with waitlist (delayed use condition) over 6 weeks. Participants were recruited through online advertisements. The Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) was used to measure PTSD symptoms at pre, post, and 6-week follow-up. Usage data were collected to assess engagement with Renew. Results: Results indicated a small effect size (d=--0.39) favoring those in the active use conditions relative to the delayed use condition, but the between-group difference was not significant (P=.29). There were no differences on indices of app engagement between the 2 active use conditions. Exploratory analyses found that the number of support persons users added to the app, but not the number of support messages received, was positively correlated with app engagement. Conclusions: Findings suggest Renew may hold promise as a self-management tool to reduce PTSD symptoms in veterans. Involving friends and family in mobile mental health apps may help bolster engagement with no additional cost to public health systems. Trial Registration: ClinicalTrials.gov NCT04155736; https://clinicaltrials.gov/ct2/show/NCT04155736 ", doi="10.2196/38951", url="https://mhealth.jmir.org/2022/11/e38951", url="http://www.ncbi.nlm.nih.gov/pubmed/36331540" } @Article{info:doi/10.2196/38223, author="Pinto, V. Janaina and Hunt, Caroline and O'Toole, Brian", title="Advancing Posttraumatic Stress Disorder Diagnosis and the Treatment of Trauma in Humanitarian Emergencies via Mobile Health: Protocol for a Proof-of-Concept Nonrandomized Controlled Trial", journal="JMIR Res Protoc", year="2022", month="Jun", day="15", volume="11", number="6", pages="e38223", keywords="posttraumatic stress disorder", keywords="PTSD", keywords="trauma", keywords="humanitarian", keywords="emergencies", keywords="mobile health", keywords="mHealth", keywords="technology", keywords="neuroscience", keywords="electrophysiology", keywords="electroencephalogram", keywords="EEG", keywords="cognition", keywords="health system", keywords="biometric", keywords="health application", keywords="mental health", keywords="health intervention", keywords="mobile phone", abstract="Background: Decentralized health systems in low- and middle-income countries (LMICs) affected by humanitarian crises lack resources and a qualified workforce to attend to the overwhelming demand for mental health care in emergencies. Innovative approaches that are safe, cost-effective, and scalable are needed to address the burden of traumatic stress caused by emergencies. High mobile phone ownership rates combined with the precision of neural, cognitive, and biometric measures of trauma and their feasible integration with artificial intelligence makes digital app interventions a promising pathway to promote precision diagnosis and high-impact care. Objective: This study aimed to advance methods for the objective diagnosis and treatment of trauma in emergencies across LMICs by examining neural, cognitive, and biometric markers and the efficacy of the eResilience app, a neuroscience-informed mobile health mental health app intervention, via changes in clinical symptomatology, cognitive performance, and brain activity. Methods: Trauma-exposed African refugees residing in Australia were selected for this study. A research software version of the eResilience app with advanced monitoring capabilities was designed for this trial. Participants completed the eResilience app at home during a 7-day period. Clinical, cognitive, and electrophysiological data were collected at baseline, along with posttest measurements to examine biomarkers of trauma and the efficacy of the proposed digital intervention for the treatment of trauma and its potential outcomes, including depression, anxiety, physical symptoms, self-harm, substance misuse, and cognitive impairment. In addition, biofeedback, well-being, and subjective stress data points were collected via the app during the treatment week, followed by clinical interviews at 1, 3, 6, and 12 months after the intervention. Results: Data collection was conducted between 2018 and 2020. A total of 100 participants exposed to war were screened; 75 (75\%) were enrolled and assigned to a trauma-exposed control (38/75, 51\%) or posttraumatic stress disorder condition (37/75, 49\%); and 70 (70\%) completed all baseline, treatment, and posttest assessments. A total of 89\% (62/70) of those who completed the intervention opted to enroll in the 3-, 6-, and 12-month follow-ups. Data collection is complete. As of May 2022, the results of all proposed analyses are being prepared for publication. If proven efficacious, this proof-of-concept clinical trial will inform fully powered randomized clinical trials in LMICs to further develop artificial intelligence--powered, app-based diagnostic and prognostic features and determine the app's cross-cultural efficacy for the treatment of trauma in emergency settings. Conclusions: This protocol provides researchers with a comprehensive background of the study rationale, a detailed guideline for replication studies interested in examining the feasibility and efficacy of the eResilience app across varied demographics, and a robust framework for investigating low-cost objective diagnostic markers in mental health interventions. Methodological limitations and suggestions are also provided. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12616001205426; https://tinyurl.com/yckwc4d7 International Registered Report Identifier (IRRID): RR1-10.2196/38223 ", doi="10.2196/38223", url="https://www.researchprotocols.org/2022/6/e38223", url="http://www.ncbi.nlm.nih.gov/pubmed/35596546" } @Article{info:doi/10.2196/35048, author="Yeager, M. Carolyn and Benight, C. Charles", title="Engagement, Predictors, and Outcomes of a Trauma Recovery Digital Mental Health Intervention: Longitudinal Study", journal="JMIR Ment Health", year="2022", month="May", day="2", volume="9", number="5", pages="e35048", keywords="engagement", keywords="digital health", keywords="digital mental health intervention", keywords="social cognitive theory", keywords="SCT", keywords="self-efficacy", keywords="outcome expectations", keywords="trauma", keywords="posttraumatic stress disorder", keywords="PTSD", abstract="Background: Worldwide, exposure to potentially traumatic events is extremely common, and many individuals develop posttraumatic stress disorder (PTSD) along with other disorders. Unfortunately, considerable barriers to treatment exist. A promising approach to overcoming treatment barriers is a digital mental health intervention (DMHI). However, engagement with DMHIs is a concern, and theoretically based research in this area is sparse and often inconclusive. Objective: The focus of this study is on the complex issue of DMHI engagement. On the basis of the social cognitive theory framework, the conceptualization of engagement and a theoretically based model of predictors and outcomes were investigated using a DMHI for trauma recovery. Methods: A 6-week longitudinal study with a national sample of survivors of trauma was conducted to measure engagement, predictors of engagement, and mediational pathways to symptom reduction while using a trauma recovery DMHI (time 1: N=915; time 2: N=350; time 3: N=168; and time 4: N=101). Results: Confirmatory factor analysis of the engagement latent constructs of duration, frequency, interest, attention, and affect produced an acceptable model fit ($\chi$22=8.3; P=.02; comparative fit index 0.973; root mean square error of approximation 0.059; 90\% CI 0.022-0.103). Using the latent construct, the longitudinal theoretical model demonstrated adequate model fit (comparative fit index 0.929; root mean square error of approximation 0.052; 90\% CI 0.040-0.064), indicating that engagement self-efficacy ($\beta$=.35; P<.001) and outcome expectations ($\beta$=.37; P<.001) were significant predictors of engagement (R2=39\%). The overall indirect effect between engagement and PTSD symptom reduction was significant ($\beta$=--.065; P<.001; 90\% CI --0.071 to --0.058). This relationship was serially mediated by both skill activation self-efficacy ($\beta$=.80; P<.001) and trauma coping self-efficacy ($\beta$=.40; P<.001), which predicted a reduction in PTSD symptoms ($\beta$=?.20; P=.02). Conclusions: The results of this study may provide a solid foundation for formalizing the nascent science of engagement. Engagement conceptualization comprised general measures of attention, interest, affect, and use that could be applied to other applications. The longitudinal research model supported 2 theoretically based predictors of engagement: engagement self-efficacy and outcome expectancies. A total of 2 task-specific self-efficacies---skill activation and trauma coping---proved to be significant mediators between engagement and symptom reduction. Taken together, this model can be applied to other DMHIs to understand engagement, as well as predictors and mechanisms of action. Ultimately, this could help improve the design and development of engaging and effective trauma recovery DMHIs. ", doi="10.2196/35048", url="https://mental.jmir.org/2022/5/e35048", url="http://www.ncbi.nlm.nih.gov/pubmed/35499857" } @Article{info:doi/10.2196/33080, author="Cloitre, Marylene and Amspoker, Bush Amber and Fletcher, L. Terri and Hogan, B. Julianna and Jackson, Christie and Jacobs, Adam and Shammet, Rayan and Speicher, Sarah and Wassef, Miryam and Lindsay, Jan", title="Comparing the Ratio of Therapist Support to Internet Sessions in a Blended Therapy Delivered to Trauma-Exposed Veterans: Quasi-experimental Comparison Study", journal="JMIR Ment Health", year="2022", month="Apr", day="27", volume="9", number="4", pages="e33080", keywords="PTSD", keywords="depression", keywords="veterans", keywords="blended therapy", keywords="iCBT", keywords="web-based", keywords="webSTAIR", keywords="noninferiority", keywords="mental health", keywords="digital health", abstract="Background: Blended models of therapy, which incorporate elements of both internet and face-to-face methods, have been shown to be effective, but therapists and patients have expressed concerns that fewer face-to-face therapy sessions than self-guided internet sessions may be associated with lower therapeutic alliance, lower program completion rates, and poorer outcomes. Objective: A multisite quasi-experimental comparison study with a noninferiority design implemented in routine clinical care was used to assess webSTAIR, a 10-module blended therapy derived from STAIR (skills training in affective and interpersonal regulation) for trauma-exposed individuals delivered with 10 weekly therapist sessions (termed Coach10) compared to 5 biweekly sessions (Coach5). It was hypothesized that Coach5 would be as good as Coach10 in a range of outcomes. Methods: A total of 202 veterans were enrolled in the study with 101 assigned to Coach5 and 101 to Coach10. Posttraumatic stress disorder (PTSD) symptoms, depression, emotion regulation, interpersonal problems, and social functioning measures were collected pre-, mid-, and posttreatment, and at a 3-month follow-up. Noninferiority analyses were conducted on symptom outcome measures. Comparisons were made of continuous and categorical measures regarding participant and therapist activities. Results: Participants reported moderate to severe levels of baseline PTSD, depression, or both. Significant reductions were obtained in all symptom measures posttreatment and at the 3-month follow up. Coach5 was not inferior to Coach10 in any outcome. Therapeutic alliance was at an equivalently high level across the 2 treatment conditions; completion rates and web usage were similar. Total session time was substantially less for the Coach5 therapists than the Coach10 therapists. Both programs were associated with a low, but equal number of therapist activities related to scheduling and crisis or motivational sessions. Conclusions: A blended model delivered with 5 sessions of therapist support was noninferior to 10 sessions in individuals with moderate to severe symptoms. Future studies identifying patient characteristics as moderators of outcomes with high versus low doses of therapist support will help create flexible, technology-based intervention programming. ", doi="10.2196/33080", url="https://mental.jmir.org/2022/4/e33080", url="http://www.ncbi.nlm.nih.gov/pubmed/35475777" } @Article{info:doi/10.2196/30680, author="Obuobi-Donkor, Gloria and Eboreime, Ejemai and Bond, Jennifer and Phung, Natalie and Eyben, Scarlett and Hayward, Jake and Zhang, Yanbo and MacMaster, Frank and Clelland, Steven and Greiner, Russell and Jones, Chelsea and Cao, Bo and Br{\'e}mault-Phillips, Suzette and Wells, Kristopher and Li, Xin-Min and Hilario, Carla and Greenshaw, J. Andrew and Agyapong, Opoku Vincent Israel", title="An E--Mental Health Solution to Prevent and Manage Posttraumatic Stress Injuries Among First Responders in Alberta: Protocol for the Implementation and Evaluation of Text Messaging Services (Text4PTSI and Text4Wellbeing)", journal="JMIR Res Protoc", year="2022", month="Apr", day="25", volume="11", number="4", pages="e30680", keywords="posttraumatic stress injury", keywords="first responders", keywords="messaging", keywords="mobile phone", keywords="text-based intervention", keywords="Text4PTSI", keywords="Text4Wellbeing", abstract="Background: First responders are confronted with traumatic events in their work that has a substantial toll on their psychological health and may contribute to or result in posttraumatic stress injuries (PTSIs) for many responders. Persons with a PTSI usually seek management therapies. Evidence indicates that digital delivery of these therapies is an innovative, efficient, and effective way to improve PTSI symptoms as an adjunct to in-person delivery. Objective: This project aims to implement and provide accessible, convenient, and economical SMS text messaging services, known as Text4PTSI and Text4Wellbeing, to first responders in Alberta, Canada; to prevent and improve the symptoms of PTSI among first responders; and to improve their overall quality of life. We will evaluate posttraumatic symptoms and the impact of Text4PTSI and Text4Wellbeing on stress, anxiety, and depression in relation to the correspondents' demographic backgrounds. Methods: First responders who subscribe to Text4PTSI or Text4Wellbeing receive daily supportive and psychoeducational SMS text messages for 6 months. The SMS text messages are preprogrammed into an online software program that delivers messages to subscribers. Baseline and follow-up data are collected through online questionnaires using validated scales at enrollment, 6 weeks, 12 weeks, and 24 weeks (end point). In-depth interviews will be conducted to assess satisfaction with the text-based intervention. Results: We hypothesize that participants who enroll in this program will have improved PTSI symptoms; increased or improved quality of life; and significant reduction in associated stress, depression, and anxiety symptoms, among other psychological concerns. Improvement will be determined in comparison to established baseline parameters. Conclusions: This research will be beneficial for practitioners and will inform policy-making and decision-making regarding psychological interventions for PTSI. Lessons from this study will inform the scale-up of the intervention, a cost-effective, zero contact therapeutic option to manage PTSI. International Registered Report Identifier (IRRID): PRR1-10.2196/30680 ", doi="10.2196/30680", url="https://www.researchprotocols.org/2022/4/e30680", url="http://www.ncbi.nlm.nih.gov/pubmed/35468094" } @Article{info:doi/10.2196/33681, author="Jones, Chelsea and Miguel Cruz, Antonio and Smith-MacDonald, Lorraine and Brown, G. Matthew R. and Vermetten, Eric and Br{\'e}mault-Phillips, Suzette", title="Technology Acceptance and Usability of a Virtual Reality Intervention for Military Members and Veterans With Posttraumatic Stress Disorder: Mixed Methods Unified Theory of Acceptance and Use of Technology Study", journal="JMIR Form Res", year="2022", month="Apr", day="21", volume="6", number="4", pages="e33681", keywords="PTSD", keywords="UTAUT", keywords="technology acceptance model", keywords="trauma", keywords="mental health", keywords="therapy", keywords="rehabilitation", keywords="digital health", keywords="psychotherapy", keywords="military", keywords="veteran", keywords="3MDR", keywords="technology acceptability", keywords="technology acceptance", keywords="Canadian Armed Forces", keywords="virtual reality", abstract="Background: Military members and veterans exhibit higher rates of injuries and illnesses such as posttraumatic stress disorder (PTSD) because of their increased exposure to combat and other traumatic scenarios. Novel treatments for PTSD are beginning to emerge and increasingly leverage advances in gaming and other technologies, such as virtual reality. Without assessing the degree of technology acceptance and perception of usability to the end users, including the military members, veterans, and their attending therapists and staff, it is difficult to determine whether a technology-based treatment will be used successfully in wider clinical practice. The Unified Theory of Acceptance and Use of Technology model is commonly used to address the technology acceptance and usability of applications in 5 domains. Objective: Using the Unified Theory of Acceptance and Use of Technology model, the purpose of this study was to determine the technology acceptance and usability of multimodal motion-assisted memory desensitization and reconsolidation (3MDR) on a virtual reality system in the primary user group (military members and veterans with treatment-resistant PTSD, 3MDR therapists, and virtual reality environment operators). Methods: This mixed methods embedded pilot study included military members (n=3) and veterans (n=8) with a diagnosis of combat-related PTSD, as well as their therapists (n=13) and operators (n=5) who completed pre-post questionnaires before and on completion of 6 weekly sessions of 3MDR. A partial least squares structural equation model was used to analyze the questionnaire results. Qualitative data from the interviews were assessed using thematic analysis. Results: Effort expectancy, which was the most notable predictor of behavioral intention, increased after a course of 3MDR with the virtual reality system, whereas all other constructs demonstrated no significant change. Participants' expectations of the technology were met, as demonstrated by the nonsignificant differences in the pre-post scores. The key qualitative themes included feasibility and function, technical support, and tailored immersion. Conclusions: 3MDR via a virtual reality environment appears to be a feasible, usable, and accepted technology for delivering 3MDR to military members and veterans who experience PTSD and 3MDR therapists and operators who facilitate their treatment. ", doi="10.2196/33681", url="https://formative.jmir.org/2022/4/e33681", url="http://www.ncbi.nlm.nih.gov/pubmed/35451971" } @Article{info:doi/10.2196/21111, author="Wiegersma, Sytske and Hidajat, Maurice and Schrieken, Bart and Veldkamp, Bernard and Olff, Miranda", title="Improving Web-Based Treatment Intake for Multiple Mental and Substance Use Disorders by Text Mining and Machine Learning: Algorithm Development and Validation", journal="JMIR Ment Health", year="2022", month="Apr", day="11", volume="9", number="4", pages="e21111", keywords="supervised text classification", keywords="multi-class classification", keywords="screening", keywords="mental health disorders", keywords="computerized CBT", keywords="automated intake and referral", abstract="Background: Text mining and machine learning are increasingly used in mental health care practice and research, potentially saving time and effort in the diagnosis and monitoring of patients. Previous studies showed that mental disorders can be detected based on text, but they focused on screening for a single predefined disorder instead of multiple disorders simultaneously. Objective: The aim of this study is to develop a Dutch multi-class text-classification model to screen for a range of mental disorders to refer new patients to the most suitable treatment. Methods: On the basis of textual responses of patients (N=5863) to a questionnaire currently used for intake and referral, a 7-class classifier was developed to distinguish among anxiety, panic, posttraumatic stress, mood, eating, substance use, and somatic symptom disorders. A linear support vector machine was fitted using nested cross-validation grid search. Results: The highest classification rate was found for eating disorders (82\%). The scores for panic (55\%), posttraumatic stress (52\%), mood (50\%), somatic symptom (50\%), anxiety (35\%), and substance use disorders (33\%) were lower, likely because of overlapping symptoms. The overall classification accuracy (49\%) was reasonable for a 7-class classifier. Conclusions: A classification model was developed that could screen text for multiple mental health disorders. The screener resulted in an additional outcome score that may serve as input for a formal diagnostic interview and referral. This may lead to a more efficient and standardized intake process. ", doi="10.2196/21111", url="https://mental.jmir.org/2022/4/e21111", url="http://www.ncbi.nlm.nih.gov/pubmed/35404261" } @Article{info:doi/10.2196/27402, author="Fidel Kinori, Guila Sara and Carot-Sans, Gerard and Cuartero, Andr{\'e}s and Valero-Bover, Dami{\`a} and Roma Monfa, Rosa and Garcia, Elisabet and P{\'e}rez Sust, Pol and Blanch, Jordi and Piera-Jim{\'e}nez, Jordi and Ramos-Quiroga, Antoni Josep", title="A Web-Based App for Emotional Management During the COVID-19 Pandemic: Platform Development and Retrospective Analysis of its Use Throughout Two Waves of the Outbreak in Spain", journal="JMIR Form Res", year="2022", month="Mar", day="31", volume="6", number="3", pages="e27402", keywords="web-based app", keywords="emotional management", keywords="lockdown", keywords="COVID-19", keywords="posttraumatic stress disorder", keywords="anxiety", keywords="quarantine", keywords="PTSD", keywords="app", keywords="emotion", keywords="development", keywords="platform", keywords="retrospective", keywords="usage", keywords="utilization", abstract="Background: Quarantines and nationwide lockdowns implemented for containing the spread of the COVID-19 pandemic may lead to distress and increase the frequency of anxiety and depression symptoms among the general population. During the nationwide lockdown of the first wave of the COVID-19 outbreak in Spain, we developed and launched a web-based app to promote emotional self-care in the general population and facilitate contact with health care professionals. Objective: This study aimed to describe a web-based app and analyze its utilization pattern throughout 2 successive waves of the COVID-19 outbreak in Spain. Methods: Our web-based app targeted all individuals aged 18 years or more and was designed by adapting the contents of a mobile app for adjuvant treatment of posttraumatic stress disorder (ie, the PTSD Coach app) to the general population and the pandemic or lockdown scenario. We retrospectively assessed the utilization pattern of the web-based app using data systematically retrieved from Google Analytics. Data were grouped into 3 time periods, defined using Joinpoint regression analysis of COVID-19 incidence in our area: first wave, between-wave period, and second wave. Results: The resulting web-based app, named gesioemocional.cat, maintains the navigation structure of the PTSD Coach app, with three main modules: tools for emotional self-care, a self-assessment test, and professional resources for on-demand contact. The self-assessment test combines the Patient Health Questionnaire-2 and the 7-item Generalized Anxiety Disorder scale and offers professional contact in the advent of a high level of depression and anxiety; contact is prioritized in accordance with a screening questionnaire administered at the time of obtaining individual consent to be contacted. The tools for emotional self-care can be accessed either on-demand or symptom-driven. The utilization analysis showed a high number of weekly accesses during the first wave. In this period, press releases regarding critical events of the pandemic progression and government decisions on containment measures were followed by a utilization peak, irrespective of the sense (ie, positive or negative) of the information. Positive information pieces (eg, relaxation of containment measures due to a reduction of COVID-19 cases) resulted in a sharp increase in utilization immediately after information release, followed by a successive decline in utilization. The second wave was characterized by a lower and less responsive utilization of the web-based app. Conclusions: mHealth tools may help the general population cope with stressful conditions associated with the pandemic scenario. Future studies shall investigate the effectiveness of these tools among the general population---including individuals without diagnosed mental illnesses---and strategies to reach as many people as possible. ", doi="10.2196/27402", url="https://formative.jmir.org/2022/3/e27402", url="http://www.ncbi.nlm.nih.gov/pubmed/35142638" } @Article{info:doi/10.2196/34744, author="Hallenbeck, Wu Haijing and Jaworski, K. Beth and Wielgosz, Joseph and Kuhn, Eric and Ramsey, M. Kelly and Taylor, Katherine and Juhasz, Katherine and McGee-Vincent, Pearl and Mackintosh, Margaret-Anne and Owen, E. Jason", title="PTSD Coach Version 3.1: A Closer Look at the Reach, Use, and Potential Impact of This Updated Mobile Health App in the General Public", journal="JMIR Ment Health", year="2022", month="Mar", day="29", volume="9", number="3", pages="e34744", keywords="posttraumatic stress disorder", keywords="trauma", keywords="mental health", keywords="mHealth", keywords="mobile app", keywords="public health", keywords="self-management", keywords="mobile phone", abstract="Background: With widespread smartphone ownership, mobile health apps (mHealth) can expand access to evidence-based interventions for mental health conditions, including posttraumatic stress disorder (PTSD). Research to evaluate new features and capabilities in these apps is critical but lags behind app development. The initial release of PTSD Coach, a free self-management app developed by the US Departments of Veterans Affairs and Defense, was found to have a positive public health impact. However, major stakeholder-driven updates to the app have yet to be evaluated. Objective: We aimed to characterize the reach, use, and potential impact of PTSD Coach Version 3.1 in the general public. As part of characterizing use, we investigated the use of specific app features, which extended previous work on PTSD Coach. Methods: We examined the naturalistic use of PTSD Coach during a 1-year observation period between April 20, 2020, and April 19, 2021, using anonymous in-app event data to generate summary metrics for users. Results: During the observation period, PTSD Coach was broadly disseminated to the public, reaching approximately 150,000 total users and 20,000 users per month. On average, users used the app 3 times across 3 separate days for 18 minutes in total, with steep drop-offs in use over time; a subset of users, however, demonstrated high or sustained engagement. More than half of users (79,099/128,691, 61.46\%) accessed one or more main content areas of the app (ie, Manage Symptoms, Track Progress, Learn, or Get Support). Among content areas, features under Manage Symptoms (including coping tools) were accessed most frequently, by over 40\% of users (53,314/128,691, 41.43\% to 56,971/128,691, 44.27\%, depending on the feature). Users who provided initial distress ratings (56,971/128,691, 44.27\%) reported relatively high momentary distress (mean 6.03, SD 2.52, on a scale of 0-10), and the use of a coping tool modestly improved momentary distress (mean ?1.38, SD 1.70). Among users who completed at least one PTSD Checklist for DSM-5 (PCL-5) assessment (17,589/128,691, 13.67\%), PTSD symptoms were largely above the clinical threshold (mean 49.80, SD 16.36). Among users who completed at least two PCL-5 assessments (4989/128,691, 3.88\%), PTSD symptoms decreased from the first to last assessment (mean ?4.35, SD 15.29), with approximately one-third (1585/4989, 31.77\%) of these users experiencing clinically significant improvements. Conclusions: PTSD Coach continues to fulfill its mission as a public health resource. Version 3.1 compares favorably with version 1 on most metrics related to reach, use, and potential impact. Although benefits appear modest on an individual basis, the app provides these benefits to a large population. For mHealth apps to reach their full potential in supporting trauma recovery, future research should aim to understand the utility of individual app features and identify strategies to maximize overall effectiveness and engagement. ", doi="10.2196/34744", url="https://mental.jmir.org/2022/3/e34744", url="http://www.ncbi.nlm.nih.gov/pubmed/35348458" } @Article{info:doi/10.2196/31308, author="du Plessis, San{\'e} and Oni, K. Ibukunoluwa and Lapointe, P. Andrew and Campbell, Christina and Dunn, F. Jeff and Debert, T. Chantel", title="Treatment of Persistent Postconcussion Syndrome With Repetitive Transcranial Magnetic Stimulation Using Functional Near-Infrared Spectroscopy as a Biomarker of Response: Protocol for a Randomized Controlled Clinical Trial", journal="JMIR Res Protoc", year="2022", month="Mar", day="22", volume="11", number="3", pages="e31308", keywords="concussion", keywords="mild traumatic brain injury", keywords="persistent postconcussion syndrome", keywords="repetitive transcranial magnetic stimulation", keywords="functional near-infrared spectroscopy", keywords="traumatic brain injury", keywords="TBI", keywords="brain injury", keywords="brain", keywords="symptom burden", keywords="mental health", keywords="quality of life", keywords="neuroscience", keywords="neurology", abstract="Background: Approximately one-third of all concussions lead to persistent postconcussion syndrome (PPCS). Repetitive transcranial magnetic stimulation (rTMS) is a form of noninvasive brain stimulation that has been extensively used to treat refractory major depressive disorder and has a strong potential to be used as a treatment for patients with PPCS. Functional near-infrared spectroscopy (fNIRS) has already been used as a tool to assess patients with PPCS and may provide insight into the pathophysiology of rTMS treatment in patients with PPCS. Objective: The primary objective of this research is to determine whether rTMS treatment improves symptom burden in patients with PPCS compared to sham treatment using the Rivermead postconcussion symptom questionnaire. The secondary objective is to explore the neuropathophysiological changes that occur following rTMS in participants with PPCS using fNIRS. Exploratory objectives include determining whether rTMS treatment in participants with PPCS will also improve quality of life, anxiety, depressive symptoms, cognition, posttraumatic stress, and function secondary to headaches. Methods: A total of 44 adults (18-65 years old) with PPCS (>3 months to 5 years) will participate in a double-blind, sham-controlled, concealed allocation, randomized clinical trial. The participants will engage in either a 4-week rTMS treatment protocol or sham rTMS protocol (20 treatments). The left dorsolateral prefrontal cortex will be located through Montreal Neurologic Institute coordinates. The intensity of the rTMS treatment over the left dorsolateral prefrontal cortex will be 120\% of resting motor threshold, with a frequency of 10 Hz, 10 trains of 60 pulses per train (total of 600 pulses), and intertrain interval of 45 seconds. Prior to starting the rTMS treatment, participant and injury characteristics, questionnaires (symptom burden, quality of life, depression, anxiety, cognition, and headache), and fNIRS assessment will be collected. Repeat questionnaires and fNIRS will occur immediately after rTMS treatment and at 1 month and 3 months post rTMS. Outcome parameters will be analyzed by a 2-way (treatment {\texttimes} time) mixed analysis of variance. Results: As of May 6, 2021, 5 participants have been recruited for the study, and 3 have completed the rTMS protocol. The estimated completion date of the trial is May 2022. Conclusions: This trial will expand our knowledge of how rTMS can be used as a treatment option of PPCS and will explore the neuropathophysiological response of rTMS through fNIRS analysis. Trial Registration: ClinicalTrials.gov NCT04568369; https://clinicaltrials.gov/ct2/show/NCT04568369 International Registered Report Identifier (IRRID): DERR1-10.2196/31308 ", doi="10.2196/31308", url="https://www.researchprotocols.org/2022/3/e31308", url="http://www.ncbi.nlm.nih.gov/pubmed/35315783" } @Article{info:doi/10.2196/26479, author="Kirk, A. Megan and Taha, Bilal and Dang, Kevin and McCague, Hugh and Hatzinakos, Dimitrios and Katz, Joel and Ritvo, Paul", title="A Web-Based Cognitive Behavioral Therapy, Mindfulness Meditation, and Yoga Intervention for Posttraumatic Stress Disorder: Single-Arm Experimental Clinical Trial", journal="JMIR Ment Health", year="2022", month="Feb", day="28", volume="9", number="2", pages="e26479", keywords="posttraumatic stress disorder", keywords="cognitive therapy", keywords="internet delivery", keywords="pupillometry", keywords="psychophysiology", keywords="PTSD", keywords="therapy", keywords="cognitive behavioral therapy", keywords="mindfulness", keywords="intervention", abstract="Background: Posttraumatic stress disorder (PTSD) is a debilitating, undertreated condition. The web-based delivery of cognitive behavioral therapy supplemented with mindfulness meditation and yoga is a viable treatment that emphasizes self-directed daily practice. Objective: This study aims to examine the effectiveness of a web-based cognitive behavioral therapy, mindfulness, and yoga (CBT-MY) program designed for daily use. Methods: We conducted an 8-week, single-arm, experimental, registered clinical trial on adults reporting PTSD symptoms (n=22; aged 18-35 years). Each participant received web-based CBT-MY content and an hour of web-based counseling each week. Pre-post outcomes included self-reported PTSD symptom severity, depression, anxiety, chronic pain, and mindfulness. Pre-post psychophysiological outcomes included peak pupil dilation (PPD) and heart rate variability (HRV). HRV and PPD were also compared with cross-sectional data from a non-PTSD comparison group without a history of clinical mental health diagnoses and CBT-MY exposure (n=46). Results: Pre-post intention-to-treat analyses revealed substantial improvements in PTSD severity (d=1.60), depression (d=0.83), anxiety (d=0.99), and mindfulness (d=0.88). Linear multilevel mixed models demonstrated a significant pre-post reduction in PPD (B=?0.06; SE=0.01; P<.001; d=0.90) but no significant pre-post change in HRV (P=.87). Overall, participants spent an average of 11.53 (SD 22.76) min/day on self-directed mindfulness practice. Conclusions: Web-based CBT-MY was associated with clinically significant symptom reductions and significant PPD changes, suggesting healthier autonomic functioning. Future randomized controlled trials are needed to further examine the gains apparent in this single-arm study. Trial Registration: ClinicalTrials.gov NCT03684473; https://clinicaltrials.gov/ct2/show/NCT03684473 ", doi="10.2196/26479", url="https://mental.jmir.org/2022/2/e26479", url="http://www.ncbi.nlm.nih.gov/pubmed/34499613" } @Article{info:doi/10.2196/33704, author="Houben-Wilke, Sarah and Go{\"e}rtz, MJ Yvonne and Delbressine, M. Jeannet and Vaes, W. Anouk and Meys, Roy and Machado, VC Felipe and van Herck, Maarten and Burtin, Chris and Posthuma, Rein and Franssen, ME Frits and Vijlbrief, Herman and Spies, Yvonne and van 't Hul, J. Alex and Spruit, A. Martijn and Janssen, JA Daisy", title="The Impact of Long COVID-19 on Mental Health: Observational 6-Month Follow-Up Study", journal="JMIR Ment Health", year="2022", month="Feb", day="24", volume="9", number="2", pages="e33704", keywords="SARS-CoV-2", keywords="corona", keywords="COVID-19", keywords="post-traumatic stress disorder", keywords="anxiety", keywords="depression", keywords="PASC", abstract="Background: The psychological impact of COVID-19 can be substantial. However, knowledge about long-term psychological outcomes in patients with COVID-19 is scarce. Objective: In this longitudinal, observational study, we aimed to reveal symptoms of posttraumatic stress disorder (PTSD) and symptoms of anxiety and depression up to 6 months after the onset of COVID-19--related symptoms in patients with confirmed COVID-19 and persistent complaints. To demonstrate the impact in nonhospitalized patients, we further aimed to compare these outcomes between nonhospitalized and hospitalized patients. Methods: Demographics, symptoms of PTSD (Trauma Screening Questionnaire [TSQ] ?6 points) and symptoms of anxiety and depression (Hospital Anxiety and Depression Scale [HADS] ?8 points) were assessed at 3 and 6 months after the onset of COVID-19--related symptoms in members of online long COVID-19 peer support groups. Results: Data from 239 patients with confirmed COVID-19 (198/239, 82.8\% female; median age: 50 [IQR 39-56] years) were analyzed. At the 3-month follow-up, 37.2\% (89/239) of the patients had symptoms of PTSD, 35.6\% (85/239) had symptoms of anxiety, and 46.9\% (112/239) had symptoms of depression, which remained high at the 6-month follow-up (64/239, 26.8\%, P=.001; 83/239, 34.7\%, P=.90; 97/239, 40.6\%, P=.08, respectively; versus the 3-month follow-up). TSQ scores and HADS anxiety and depression scores were strongly correlated at the 3- and 6-month follow-ups (r=0.63-0.71, P<.001). Symptoms of PTSD, anxiety, and depression were comparable between hospitalized (n=62) and nonhospitalized (n=177) patients. Conclusions: A substantial percentage of patients with confirmed COVID-19 and persistent complaints reported symptoms of PTSD, anxiety, or depression 3 and 6 months after the onset of COVID-19--related symptoms. The prevalence rates of symptoms of PTSD, anxiety, and depression were comparable between hospitalized and nonhospitalized patients and merely improved over time. Health care professionals need to be aware of these psychological complications and intervene on time in post-COVID-19 patients with persistent complaints. Trial Registration: Netherlands Trial Register NTR8705; https://www.trialregister.nl/trial/8705. ", doi="10.2196/33704", url="https://mental.jmir.org/2022/2/e33704", url="http://www.ncbi.nlm.nih.gov/pubmed/35200155" } @Article{info:doi/10.2196/26736, author="van Loenen, Inge and Scholten, Willemijn and Muntingh, Anna and Smit, Johannes and Batelaan, Neeltje", title="The Effectiveness of Virtual Reality Exposure--Based Cognitive Behavioral Therapy for Severe Anxiety Disorders, Obsessive-Compulsive Disorder, and Posttraumatic Stress Disorder: Meta-analysis", journal="J Med Internet Res", year="2022", month="Feb", day="10", volume="24", number="2", pages="e26736", keywords="anxiety disorders", keywords="virtual reality", keywords="virtual reality exposure therapy", keywords="cognitive behavioral therapy", keywords="meta-analysis", keywords="mobile phone", abstract="Background: In recent years, virtual reality exposure--based cognitive behavioral therapy (VRE-CBT) has shown good treatment results in (subclinical) anxiety disorders and seems to be a good alternative to exposure in vivo in regular cognitive behavioral therapy (CBT). However, previous meta-analyses on the efficacy of VRE-CBT on anxiety disorders have included studies on specific phobias and subthreshold anxiety; therefore, these results may not be generalizable to patients with more severe and disabling anxiety disorders. Objective: The objective of our study is to determine the efficacy of VRE-CBT on more severe anxiety disorders, excluding specific phobias and subthreshold anxiety disorders. Meta-analyses will be conducted to examine the efficacy of VRE-CBT versus waitlist and regular CBT. Our secondary objectives are to examine whether the efficacy differs according to the type of anxiety disorder, type of recruitment, and type of VRE-CBT (virtual reality exposure either with or without regular CBT). Furthermore, attrition in VRE-CBT and CBT will be compared. Methods: Studies published until August 20, 2020, were retrieved through systematic literature searches in PubMed, PsycINFO, and Embase. We calculated the effect sizes (Hedges g) for the difference between the conditions and their 95\% CIs for posttest and follow-up measurements in a random effects model. A separate meta-analysis was performed to compare attrition between the VRE-CBT and CBT conditions. Results: A total of 16 trials with 817 participants were included. We identified 10 comparisons between VRE-CBT and a waitlist condition and 13 comparisons between VRE-CBT and a CBT condition. With regard to risk of bias, information on random sequence generation, allocation concealment, and risk of bias for selective outcome reporting was often absent or unclear. The mean effect size of VRE-CBT compared with waitlist (nco=10) was medium and significant, favoring VRE-CBT (Hedges g=?0.490, 95\% CI ?0.82 to ?0.16; P=.003). The mean effect size of VRE-CBT compared with CBT (nco=13) was small and nonsignificant, favoring CBT (Hedges g=0.083, 95\% CI ?0.13 to 0.30; P=.45). The dropout rates between VRE-CBT and CBT (nco=10) showed no significant difference (odds ratio 0.79, 95\% CI 0.49-1.27; P=.32). There were no indications of small study effects or publication bias. Conclusions: The results of our study show that VRE-CBT is more effective than waitlist and as effective as CBT in the treatment of more severe anxiety disorders. Therefore, VRE-CBT may be considered a promising alternative to CBT for patients with more severe anxiety disorders. Higher-quality randomized controlled trials are needed to verify the robustness of these findings. ", doi="10.2196/26736", url="https://www.jmir.org/2022/2/e26736", url="http://www.ncbi.nlm.nih.gov/pubmed/35142632" } @Article{info:doi/10.2196/30975, author="Bouldin, D. Erin and Delgado, Roxana and Peacock, Kimberly and Hale, Willie and Roghani, Ali and Trevino, Y. Amira and Viny, Mikayla and Wetter, W. David and Pugh, Jo Mary", title="Military Injuries---Understanding Posttraumatic Epilepsy, Health, and Quality-of-Life Effects of Caregiving: Protocol for a Longitudinal Mixed Methods Observational Study", journal="JMIR Res Protoc", year="2022", month="Jan", day="5", volume="11", number="1", pages="e30975", keywords="epilepsy", keywords="military personnel", keywords="veterans", keywords="caregiver", keywords="traumatic brain injury", keywords="quality of life", keywords="health status", keywords="longitudinal studies", keywords="ecologic momentary assessment", keywords="qualitative research", abstract="Background: Veterans with posttraumatic epilepsy (PTE), particularly those with comorbidities associated with epilepsy or traumatic brain injury (TBI), have poorer health status and higher symptom burden than their peers without PTE. One area that has been particularly poorly studied is that of the role of caregivers in the health of veterans with PTE and the impact caring for someone with PTE has on the caregivers themselves. Objective: In this study, we aim to address the following: describe and compare the health and quality of life of veterans and caregivers of veterans with and without PTE; evaluate the change in available supports and unmet needs for services among caregivers of post-9/11 veterans with PTE over a 2-year period and to compare support and unmet needs with those without PTE; and identify veteran and caregiver characteristics associated with the 2-year health trajectories of caregivers and veterans with PTE compared with veterans without PTE. Methods: We conducted a prospective cohort study of the health and quality of life among 4 groups of veterans and their caregivers: veterans with PTE, nontraumatic epilepsy, TBI only, and neither epilepsy nor TBI. We will recruit participants from previous related studies and collect information about both the veterans and their primary informal caregivers on health, quality of life, unmet needs for care, PTE and TBI symptoms and treatment, relationship, and caregiver experience. Data sources will include existing data supplemented with primary data, such as survey data collected at baseline, intermittent brief reporting using ecological momentary assessment, and qualitative interviews. We will make both cross-sectional and longitudinal comparisons, using veteran-caregiver dyads, along with qualitative findings to better understand risk and promotive factors for quality of life and health among veterans and caregivers, as well as the bidirectional impact of caregivers and care recipients on one another. Results: This study was approved by the institutional review boards of the University of Utah and Salt Lake City Veterans Affairs and is under review by the Human Research Protection Office of the United States Army Medical Research and Development Command. The Service Member, Veteran, and Caregiver Community Stakeholders Group has been formed and the study questionnaire will be finalized once the panel reviews it. We anticipate the start of recruitment and primary data collection by January 2022. Conclusions: New national initiatives aim to incorporate the caregiver into the veteran's treatment plan; however, we know little about the impact of caregiving---both positive and negative---on the caregivers themselves and on the veterans for whom they provide care. We will identify specific needs in this understudied population, which will inform clinicians, patients, families, and policy makers about the specific impact and needs to equip caregivers in caring for veterans at home. International Registered Report Identifier (IRRID): PRR1-10.2196/30975 ", doi="10.2196/30975", url="https://www.researchprotocols.org/2022/1/e30975", url="http://www.ncbi.nlm.nih.gov/pubmed/34989689" } @Article{info:doi/10.2196/29661, author="Zuelke, E. Andrea and Luppa, Melanie and L{\"o}bner, Margrit and Pabst, Alexander and Schlapke, Christine and Stein, Janine and Riedel-Heller, G. Steffi", title="Effectiveness and Feasibility of Internet-Based Interventions for Grief After Bereavement: Systematic Review and Meta-analysis", journal="JMIR Ment Health", year="2021", month="Dec", day="8", volume="8", number="12", pages="e29661", keywords="grief", keywords="systematic review", keywords="meta-analysis", keywords="internet-based", keywords="online therapy", abstract="Background: Although grief and its symptoms constitute a normal reaction to experiences of loss, some of those affected still report elevated levels of distress after an extended period, often termed complicated grief. Beneficial treatment effects of face-to-face therapies, for example, grief counseling or cognitive behavioral therapy against complicated grief, have been reported. Evaluations of internet- and mobile-based interventions targeting symptoms of grief in bereaved individuals with regard to objective quality criteria are currently lacking. Objective: We aim to conduct a systematic review and meta-analysis on the effectiveness and feasibility of internet- and mobile-based interventions against symptoms of grief after bereavement. Methods: We conducted systematic literature searches of randomized controlled trials or feasibility studies published before January 9, 2020, following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, in PubMed, PsycINFO, Web of Science Core Collection, and the Cochrane Library. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations system. We further assessed aspects of feasibility and rated quality of interventions using criteria suggested by an expert panel on mental health care (German Association for Psychiatry, Psychotherapy, and Psychosomatics). A random-effects meta-analysis was conducted to assess between-group effect sizes. Results: In total, 9 trials (N=1349) were included. Of these, 7 studies were analyzed meta-analytically. Significant effects were found for symptoms of grief (g=0.54, 95\% CI 0.32-0.77), depression (g=0.44, 95\% CI 0.20-0.68), and posttraumatic stress (g=0.82, 95\% CI 0.63-1.01). Heterogeneity was moderate for grief and depression (I2=48.75\% and 55.19\%, respectively) and low for posttraumatic stress symptoms (I2=0\%). The overall quality of evidence was graded low (grief and depression) to moderate (posttraumatic stress). User satisfaction with the interventions was high, as was the quality of the interventions assessed using objective quality criteria. Conclusions: Internet- or mobile-based interventions might constitute an effective treatment approach against symptoms of grief in bereaved adults. However, the small sample sizes and limited number of studies included in the review warrant further investigation. Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO) CRD42012002100; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=131428 ", doi="10.2196/29661", url="https://mental.jmir.org/2021/12/e29661", url="http://www.ncbi.nlm.nih.gov/pubmed/34889769" } @Article{info:doi/10.2196/33599, author="Zong, Hui and Hu, Binyang and Han, Yang and Li, Zuofeng and Zhang, Xiaoyan", title="Prevalence and Temporal Trends Analysis of Screening and Diagnostic Instruments in Posttraumatic Stress Disorder: Text Mining Study", journal="JMIR Ment Health", year="2021", month="Nov", day="17", volume="8", number="11", pages="e33599", keywords="posttraumatic stress disorder", keywords="instruments", keywords="prevalence", keywords="clinical trials", keywords="text mining", abstract="Background: Various instruments for patient screening and diagnosis have been developed for and applied in posttraumatic stress disorder (PTSD). Objective: This study comprehensively investigates the prevalence and temporal trends of the most widely used instruments in PTSD-related studies. Methods: A total of 1345 files of registered clinical trials from ClinicalTrials.gov and 9422 abstracts from the PubMed database from 2005 to 2020 were downloaded for this study. The instruments applied in clinical trials were manually annotated, and instruments in abstracts were recognized using exact string matching. The prevalence score of an instrument in a certain period was calculated as the number of studies divided by the number of instances of the instrument. By calculating the yearly prevalence index of each instrument, we conducted a trends analysis and compared the trends in index change between instruments. Results: A total of 4178 instrument synonyms were annotated, which were mapped to 1423 unique instruments. In the 16 years from 2005 to 2020, only 10 instruments were used more than once per year; the 4 most used instruments were the PTSD Checklist, the Clinician-Administered PTSD Disorder Scale, the Patient Health Questionnaire, and the Beck Depression Inventory. There were 18 instruments whose yearly prevalence index score exceeded 0.1 at least once during the 16 years. The changes in trends and time points of partial instruments in clinical trials and PubMed abstracts were highly consistent. The average time duration of a PTSD-related trial was 1495.5 days or approximately 4 years from submission to ClinicalTrial.gov to publication in a journal. Conclusions: The application of widely accepted and appropriate instruments can help improve the reliability of research results in PTSD-related clinical studies. With extensive text data obtained from real clinical trials and published articles, we investigated and compared the usage of instruments in the PTSD research community. ", doi="10.2196/33599", url="https://mental.jmir.org/2021/11/e33599", url="http://www.ncbi.nlm.nih.gov/pubmed/34666307" } @Article{info:doi/10.2196/29873, author="Thorarinsdottir, Kristjana and Holmes, A. Emily and Hardarson, Johann and Hedinsdottir, Unnur and Kanstrup, Marie and Singh, Laura and Hauksdottir, Arna and Halldorsdottir, Thorhildur and Gudmundsdottir, Berglind and Valdimarsdottir, Unnur and Thordardottir, Bjork Edda and Gamble, Beau and Bjornsson, Andri", title="Reducing Intrusive Memories of Childhood Trauma Using a Visuospatial Intervention: Case Study in Iceland", journal="JMIR Form Res", year="2021", month="Nov", day="4", volume="5", number="11", pages="e29873", keywords="psychological trauma", keywords="intrusive memories", keywords="case report", keywords="visuospatial interference task", keywords="Tetris gameplay", keywords="mental imagery", keywords="mobile phone", abstract="Background: Additional interventions are needed for survivors of psychological trauma because of several barriers to and limitations of existing treatment options (eg, need to talk about the trauma in detail). Case studies are an important step in exploring the development of novel interventions, allowing detailed examination of individual responses to treatment over time. Here, we present a case study that aims to test a novel intervention designed to disrupt memory reconsolidation, taking a single-symptom approach by focusing on intrusive memories of a traumatic event. Objective: This study aims to examine a novel brief cognitive intervention to reduce the number of intrusive memories of trauma in an Icelandic setting and to extend previous studies by examining long-term effects for up to 3 months. The intervention was guided by a clinical psychologist and comprised a brief memory reminder, followed by Tetris gameplay with mental rotation, targeting one memory at a time in each session. Methods: This was a single case study in Iceland with a woman in her 50s (drawn from an epidemiological study of trauma) with subthreshold posttraumatic stress disorder and a diagnosis of obsessive-compulsive disorder and social anxiety disorder. The participant had four different intrusive memories from a traumatic event that happened in her childhood. The primary outcome was the change in the number of intrusive memories from baseline to intervention phase and to follow-ups. The number of intrusions was monitored in a daily diary for 4 weeks preintervention, 8 weeks during the intervention, and 1 week at 1-month and 3-month follow-ups. Intrusions were targeted one by one over six intervention sessions, creating four repetitions of an AB design (ie, length of baseline A and intervention phase B varied for each memory). We examined changes in both the total number of intrusions (summed across all four memories) and individually for each memory. In addition, we explored whether having fewer intrusive memories would have an impact on functioning, posttraumatic stress, and depression or anxiety symptoms. Results: The total number of intrusions per week was 12.6 at baseline, 6.1 at the intervention phase (52\% reduction from baseline), 3.0 at the 1-month follow-up (76\% reduction), and 1.0 at the 3-month follow-up (92\% reduction). Reductions in the symptoms of posttraumatic stress and depression were observed postintervention. Sleep, concentration, stress, and functioning improved. The participant considered the gameplay intervention acceptable and helpful in that she found that the memories disappeared while she was playing. Conclusions: This guided brief cognitive intervention reduced the number of intrusive memories over the intervention phase and follow-ups. The brief memory reminder was well tolerated, removing the need to discuss trauma in detail. The next steps require an extension to more cases and exploring remote delivery of the intervention. ", doi="10.2196/29873", url="https://formative.jmir.org/2021/11/e29873", url="http://www.ncbi.nlm.nih.gov/pubmed/34734830" } @Article{info:doi/10.2196/30711, author="Winkler, Olga and Dhaliwal, Raman and Greenshaw, Andrew and O'Shea, Katie and Abba-Aji, Adam and Chima, Chidi and Purdon, E. Scot and Burback, Lisa", title="Web-Based Eye Movement Desensitization and Reprocessing for Adults With Suicidal Ideation: Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2021", month="Nov", day="4", volume="10", number="11", pages="e30711", keywords="suicide", keywords="trauma", keywords="eye movement desensitization and reprocessing (EMDR)", keywords="telemedicine", keywords="psychotherapy", keywords="digital health", keywords="eHealth", keywords="remote delivery", keywords="virtual care", abstract="Background: Adversity and traumatic experiences increase the likelihood of suicidal thoughts and behaviors. Eye Movement Desensitization and Reprocessing (EMDR) is an evidence-based, trauma-focused psychotherapy that desensitizes painful memories, so that reminders in the present no longer provoke overwhelming emotional responses. Preliminary evidence suggests that EMDR can be used as an acute intervention in suicidal patients, including those with major depressive disorder. In addition, because of social distancing restrictions during the COVID-19 pandemic, clinicians have been using EMDR on the web and, in the absence of formal evaluations of web-based EMDR, informal reports indicate good results. Objective: The primary aim of this randomized controlled trial is to investigate whether remotely delivered EMDR (targeting experiences associated with suicidal thinking) reduces suicidal thoughts. Secondary aims include examining the impact of remotely delivered EMDR on symptoms of depression, anxiety, posttraumatic stress, emotional dysregulation, and dissociation. We will also report on adverse events in the EMDR group to explore whether targeting suicidal ideation with EMDR is safe. Finally, we will compare dropout rates between the treatment groups. Methods: In this randomized controlled trial, 80 adults who express suicidal ideation and meet the study criteria will receive either 12 sessions of twice weekly EMDR plus treatment as usual or treatment as usual alone. EMDR sessions will focus on the most distressing and intrusive memories associated with suicidal ideation. Data for primary and secondary objectives will be collected at baseline, 2 months, and 4 months after enrollment. A subsequent longer-term analysis, beyond the scope of this protocol, will examine differences between the groups with respect to the number of posttreatment emergency room visits, hospitalizations, and overall health care use in the year before and after therapy. Results: The protocol was approved by the University of Alberta Research Health Ethics Board (protocol ID Pro00090989). Funding for this study was provided by the Mental Health Foundation (grant RES0048906). Recruitment started in May 2021, with a projected completion date of March 2023. Conclusions: The results of this trial will contribute to knowledge on whether web-based delivery of EMDR is a safe and effective treatment for reducing suicidal ideation and potentially reducing the incidence of suicide attempts in this patient population. Trial Registration: ClinicalTrials.gov NCT04181047; https://clinicaltrials.gov/ct2/show/NCT04181047 International Registered Report Identifier (IRRID): DERR1-10.2196/30711 ", doi="10.2196/30711", url="https://www.researchprotocols.org/2021/11/e30711", url="http://www.ncbi.nlm.nih.gov/pubmed/34734835" } @Article{info:doi/10.2196/33151, author="Liu, W. Jenny J. and Nazarov, Anthony and Easterbrook, Bethany and Plouffe, A. Rachel and Le, Tri and Forchuk, Callista and Brandwood, Alec and St Cyr, Kate and Auger, Edouard and Balderson, Ken and Bilodeau, Mathieu and Burhan, M. Amer and Enns, W. Murray and Smith, Patrick and Hosseiny, Fardous and Dupuis, Gabrielle and Roth, Maya and Mota, Natalie and Lavoie, Vicky and Richardson, Don J.", title="Four Decades of Military Posttraumatic Stress: Protocol for a Meta-analysis and Systematic Review of Treatment Approaches and Efficacy", journal="JMIR Res Protoc", year="2021", month="Oct", day="25", volume="10", number="10", pages="e33151", keywords="military personnel", keywords="psychotherapy", keywords="pharmacotherapy", keywords="stress disorders", keywords="posttraumatic", keywords="meta-analysis", keywords="systematic review", keywords="therapy", keywords="stress", keywords="disorder", keywords="posttraumatic stress disorder", keywords="review", keywords="treatment", keywords="efficacy", keywords="military", keywords="Canada", keywords="veteran", abstract="Background: Over 85\% of active members of the Canadian Armed Forces have been exposed to potentially traumatic events linked to the development of posttraumatic stress disorder (PTSD). At the time of transition to civilian life, as high as 1 in 8 veterans may be diagnosed with PTSD. Given the high prevalence of PTSD in military and veteran populations, the provision of effective treatment considering their unique challenges and experiences is critical for mental health support and the well-being of these populations. Objective: This paper presents the protocol for a meta-analysis and systematic review that will examine the effectiveness of treatment approaches for military-related PTSD. Methods: This PROSPERO-preregistered meta-analysis is being conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and Cochrane guidelines. A comprehensive search of the literature was conducted using the databases PsycInfo, Medline, Embase, CINAHL, and ProQuest Dissertation \& Theses. Effect sizes will be computed based on changes in PTSD symptom scores over time across studies using validated PTSD scales. A multilevel meta-analysis will examine the overall effects, between-study effects, and within-study effects of available evidence for PTSD treatments in military populations. Effect sizes will be compared between pharmacotherapeutic, psychotherapeutic, and alternative/emerging treatment interventions. Finally, meta-regression and subgroup analyses will explore the moderating roles of clinical characteristics (eg, PTSD symptom clusters), treatment approaches (eg, therapeutic orientations in psychotherapy and alternative therapies and classifications of drugs in pharmacotherapy), as well as treatment characteristics (eg, length of intervention) on treatment outcomes. Results: The literature search was completed on April 14, 2021. After the removal of duplicates, a total of 12,002 studies were screened for inclusion. As of July 2021, title and abstract screening has been completed, with 1469 out of 12,002 (12.23\%) studies included for full-text review. Full review is expected to be completed in the summer of 2021, with initial results expected for publication by early winter of 2021. Conclusions: This meta-analysis will provide information on the current state of evidence on the efficacy and effectiveness of various treatment approaches for military-related PTSD and identify factors that may influence treatment outcomes. The results will inform clinical decision-making for service providers and service users. Finally, the findings will provide insights into future treatment development and practice recommendations to better support the well-being of military and veteran populations. Trial Registration: PROSPERO CRD42021245754; https://tinyurl.com/y9u57c59 International Registered Report Identifier (IRRID): DERR1-10.2196/33151 ", doi="10.2196/33151", url="https://www.researchprotocols.org/2021/10/e33151", url="http://www.ncbi.nlm.nih.gov/pubmed/34694228" } @Article{info:doi/10.2196/25622, author="Hendrikx, Josephine Laura and Murphy, Dominic", title="Supporting the Mental Health Needs of Military Partners Through the Together Webinar Program: Pilot Randomized Controlled Trial", journal="JMIR Ment Health", year="2021", month="Oct", day="12", volume="8", number="10", pages="e25622", keywords="mental health support", keywords="online group-based support", keywords="military partners", abstract="Background: Despite an increased risk of psychological difficulties, there remains a lack of evidence-based support for the mental health needs of military partners. Objective: This study aims to investigate whether the Together Webinar Programme (TTP-Webinar), a 6-week structured, remote access group intervention would reduce military partners' experience of common mental health difficulties and secondary trauma symptoms. Methods: A pilot randomized controlled trial was used to compare the TTP-Webinar intervention with a waitlist control. The sample was UK treatment-seeking veterans engaged in a mental health charity. A total of 196 military partners (1 male and 195 females; aged mean 42.28, SD 10.82 years) were randomly allocated to the intervention (n=97) or waitlist (n=99) condition. Outcome measures were self-reported measures of common mental health difficulties, secondary trauma symptoms, and overall quality of life rating. Results: Compared with the waitlist, military partners in the TTP-Webinar had reduced common mental health difficulties (P=.02) and secondary trauma symptoms (P=.001). However, there was no difference in quality-of-life ratings (P=.06). Conclusions: The results suggest that TTP-Webinar is an effective intervention to support the mental health difficulties of military partners. This study provides promising evidence that webinars may be an appropriate platform for providing group-based support. Trial Registration: ClinicalTrials.gov NCT05013398; https://clinicaltrials.gov/ct2/show/NCT05013398 ", doi="10.2196/25622", url="https://mental.jmir.org/2021/10/e25622", url="http://www.ncbi.nlm.nih.gov/pubmed/34636734" } @Article{info:doi/10.2196/32663, author="Liu, W. Jenny J. and Nazarov, Anthony and Plouffe, A. Rachel and Forchuk, A. Callista and Deda, Erisa and Gargala, Dominic and Le, Tri and Bourret-Gheysen, Jesse and Soares, Vanessa and Nouri, S. Maede and Hosseiny, Fardous and Smith, Patrick and Roth, Maya and MacDougall, G. Arlene and Marlborough, Michelle and Jetly, Rakesh and Heber, Alexandra and Albuquerque, Joy and Lanius, Ruth and Balderson, Ken and Dupuis, Gabrielle and Mehta, Viraj and Richardson, Don J.", title="Exploring the Well-being of Health Care Workers During the COVID-19 Pandemic: Protocol for a Prospective Longitudinal Study", journal="JMIR Res Protoc", year="2021", month="Sep", day="27", volume="10", number="9", pages="e32663", keywords="COVID-19", keywords="health care worker", keywords="pandemic", keywords="mental health", keywords="wellbeing", keywords="survey", keywords="design", keywords="longitudinal", keywords="prospective", keywords="protocol", keywords="challenge", keywords="impact", keywords="distress", keywords="perception", abstract="Background: Health care workers (HCWs) have experienced several stressors associated with the COVID-19 pandemic. Structural stressors, including extended work hours, redeployment, and changes in organizational mandates, often intersect with interpersonal and personal stressors, such as caring for those with COVID-19 infections; worrying about infection of self, family, and loved ones; working despite shortages of personal protective equipment; and encountering various difficult moral-ethical dilemmas. Objective: The paper describes the protocol for a longitudinal study seeking to capture the unique experiences, challenges, and changes faced by HCWs during the COVID-19 pandemic. The study seeks to explore the impact of COVID-19 on the mental well-being of HCWs with a particular focus on moral distress, perceptions of and satisfaction with delivery of care, and how changes in work structure are tolerated among HCWs providing clinical services. Methods: A prospective longitudinal design is employed to assess HCWs' experiences across domains of mental health (depression, anxiety, posttraumatic stress, and well-being), moral distress and moral reasoning, work-related changes and telehealth, organizational responses to COVID-19 concerns, and experiences with COVID-19 infections to self and to others. We recruited HCWs from across Canada through convenience snowball sampling to participate in either a short-form or long-form web-based survey at baseline. Respondents to the baseline survey are invited to complete a follow-up survey every 3 months, for a total of 18 months. Results: A total of 1926 participants completed baseline surveys between June 26 and December 31, 2020, and 1859 participants provided their emails to contact them to participate in follow-up surveys. As of July 2021, data collection is ongoing, with participants nearing the 6- or 9-month follow-up periods depending on their initial time of self-enrollment. Conclusions: This protocol describes a study that will provide unique insights into the immediate and longitudinal impact of the COVID-19 pandemic on the dimensions of mental health, moral distress, health care delivery, and workplace environment of HCWs. The feasibility and acceptability of implementing a short-form and long-form survey on participant engagement and data retention will also be discussed. International Registered Report Identifier (IRRID): DERR1-10.2196/32663 ", doi="10.2196/32663", url="https://www.researchprotocols.org/2021/9/e32663", url="http://www.ncbi.nlm.nih.gov/pubmed/34477557" } @Article{info:doi/10.2196/28736, author="Plomecka, Martyna and Gobbi, Susanna and Neckels, Rachael and Radzinski, Piotr and Skorko, Beata and Lazzeri, Samuel and Almazidou, Kristina and Dedic, Alisa and Bakalovic, Asja and Hrustic, Lejla and Ashraf, Zainab and Es Haghi, Sarvin and Rodriguez-Pino, Luis and Waller, Verena and Jabeen, Hafsa and Alp, Beyza A. and Behnam, Mehdi and Shibli, Dana and Baranczuk-Turska, Zofia and Haq, Zeeshan and Qureshi, Salah and Strutt, M. Adriana and Jawaid, Ali", title="Factors Associated With Psychological Disturbances During the COVID-19 Pandemic: Multicountry Online Study", journal="JMIR Ment Health", year="2021", month="Aug", day="19", volume="8", number="8", pages="e28736", keywords="COVID-19", keywords="pandemic", keywords="mental health", keywords="depression", keywords="posttraumatic stress disorder", keywords="general psychological disturbance", keywords="global", abstract="Background: Accumulating evidence suggests that the COVID-19 pandemic has negatively impacted the mental health of individuals. However, the susceptibility of individuals to be impacted by the pandemic is variable, suggesting potential influences of specific factors related to participants' demographics, attitudes, and practices. Objective: We aimed to identify the factors associated with psychological symptoms related to the effects of the first wave of the pandemic in a multicountry cohort of internet users. Methods: This study anonymously screened 13,332 internet users worldwide for acute psychological symptoms related to the COVID-19 pandemic from March 29 to April 14, 2020, during the first wave of the pandemic amidst strict lockdown conditions. A total of 12,817 responses were considered valid. Moreover, 1077 participants from Europe were screened a second time from May 15 to May 30, 2020, to ascertain the presence of psychological effects after the ease down of restrictions. Results: Female gender, pre-existing psychiatric conditions, and prior exposure to trauma were identified as notable factors associated with increased psychological symptoms during the first wave of COVID-19 (P<.001). The same factors, in addition to being related to someone who died due to COVID-19 and using social media more than usual, were associated with persistence of psychological disturbances in the limited second assessment of European participants after the restrictions had relatively eased (P<.001). Optimism, ability to share concerns with family and friends like usual, positive prediction about COVID-19, and daily exercise were related to fewer psychological symptoms in both assessments (P<.001). Conclusions: This study highlights the significant impact of the COVID-19 pandemic at the worldwide level on the mental health of internet users and elucidates prominent associations with their demographics, history of psychiatric disease risk factors, household conditions, certain personality traits, and attitudes toward COVID-19. ", doi="10.2196/28736", url="https://mental.jmir.org/2021/8/e28736", url="http://www.ncbi.nlm.nih.gov/pubmed/34254939" } @Article{info:doi/10.2196/26369, author="Smith-MacDonald, Lorraine and Jones, Chelsea and Sevigny, Phillip and White, Allison and Laidlaw, Alexa and Voth, Melissa and Mikolas, Cynthia and Heber, Alexandra and Greenshaw, J. Andrew and Br{\'e}mault-Phillips, Suzette", title="The Experience of Key Stakeholders During the Implementation and Use of Trauma Therapy via Digital Health for Military, Veteran, and Public Safety Personnel: Qualitative Thematic Analysis", journal="JMIR Form Res", year="2021", month="Aug", day="12", volume="5", number="8", pages="e26369", keywords="trauma", keywords="mental health", keywords="telemedicine", keywords="therapy", keywords="rehabilitation", keywords="digital health", keywords="psychotherapy", keywords="military", keywords="veteran", keywords="first responder", keywords="public safety personnel", keywords="teletherapy", keywords="telepsychiatry", keywords="mobile phone", abstract="Background: Exposure to occupational stressors and potentially psychologically traumatic events experienced by public safety personnel (eg, paramedics, police, fire, and correctional officers), military members, and veterans can lead to the development of posttraumatic stress injuries and other mental health disorders. Providing emergency services during COVID-19 has intensified the challenges. Owing to COVID-19 restrictions, mental health service providers offering support to these populations have had to rapidly pivot to use digital versus in-person methods of service delivery. Objective: This paper aims to explore the experience of mental health service providers regarding digital health service delivery, including the current state of digital mental health service delivery, barriers to and facilitators of the use of digital health for mental health service delivery experienced during the pandemic, and recommendations for implementing and integrating digital health into regular mental health service delivery. Methods: This embedded mixed-methods study included questionnaires and focus groups with key stakeholders (N=31) with knowledge and experience in providing mental health services. Data analysis included descriptive, quantitative, and qualitative thematic analyses. Results: The following three themes emerged: being forced into change, daring to deliver mental health services using digital health, and future possibilities offered by digital health. In each theme, participants' responses reflected their perceptions of service providers, organizations, and clients. The findings offer considerations regarding for whom and at what point in treatment digital health delivery is appropriate; recommendations for training, support, resources, and guidelines for digitally delivering trauma therapy; and a better understanding of factors influencing mental health service providers' perceptions and acceptance of digital health for mental health service delivery. Conclusions: The results indicate the implementation of digital health for mental health service delivery to military members, public safety personnel, and veterans. As the COVID-19 pandemic continues, remote service delivery methods for trauma therapy are urgently needed to support the well-being of those who have served and continue to serve. ", doi="10.2196/26369", url="https://formative.jmir.org/2021/8/e26369", url="http://www.ncbi.nlm.nih.gov/pubmed/34387549" } @Article{info:doi/10.2196/30813, author="Petrinec, B. Amy and Hughes, W. Joel and Zullo, D. Melissa and Wilk, Cindy and George, L. Richard", title="Smartphone Delivery of Cognitive Behavioral Therapy for Postintensive Care Syndrome-Family: Protocol for a Pilot Study", journal="JMIR Res Protoc", year="2021", month="Aug", day="4", volume="10", number="8", pages="e30813", keywords="postintensive care syndrome-family", keywords="mobile health app", keywords="cognitive behavioral therapy", keywords="mobile phone", abstract="Background: Family members of critically ill patients experience symptoms of postintensive care syndrome-family (PICS-F), including anxiety, depression, and posttraumatic stress disorder. Postintensive care syndrome-family reduces the quality of life of the families of critically ill patients and may impede the recovery of such patients. Cognitive behavioral therapy has become a first-line nonpharmacological treatment of many psychological symptoms and disorders, including anxiety, depression, and posttraumatic stress. With regard to managing mild-to-moderate symptoms, the delivery of cognitive behavioral therapy via mobile technology without input from a clinician has been found to be feasible and well accepted, and its efficacy rivals that of face-to-face therapy. Objective: The purpose of our pilot study is to examine the efficacy of using a smartphone mobile health (mHealth) app to deliver cognitive behavioral therapy and diminish the severity and prevalence of PICS-F symptoms in family members of critically ill patients. Methods: For our pilot study, 60 family members of critically ill patients will be recruited. A repeated-measures longitudinal study design that involves the randomization of participants to 2 groups (the control and intervention groups) will be used. The intervention group will receive cognitive behavioral therapy, which will be delivered via a smartphone mHealth app. Bandura's social cognitive theory and an emphasis on mental health self-efficacy form the theoretical framework of the study. Results: Recruitment for the study began in August 2020. Data collection and analysis are expected to be completed by March 2022. Conclusions: The proposed study represents a novel approach to the treatment of PICS-F symptoms and is an extension of previous work conducted by the research team. The study will be used to plan a fully powered randomized controlled trial. Trial Registration: ClinicalTrials.gov NCT04316767; https://clinicaltrials.gov/ct2/show/NCT04316767 International Registered Report Identifier (IRRID): DERR1-10.2196/30813 ", doi="10.2196/30813", url="https://www.researchprotocols.org/2021/8/e30813", url="http://www.ncbi.nlm.nih.gov/pubmed/34346900" } @Article{info:doi/10.2196/26852, author="Riisager, G. Lisa H. and Christensen, Bryde Anne and Scharff, Bernt Frederik and Arendt, P. Ida-Marie T. and Ismail, Israa and Lau, Engelbrecht Marianne and Moeller, Bjerrum Stine", title="Patients' Experiences of Using a Self-help App for Posttraumatic Stress Disorder: Qualitative Study", journal="JMIR Form Res", year="2021", month="Aug", day="4", volume="5", number="8", pages="e26852", keywords="app", keywords="PTSD", keywords="mHealth", keywords="qualitative analysis", keywords="patient experience", keywords="posttraumatic stress disorder", keywords="thematic analysis", keywords="smartphone", keywords="intervention", keywords="mobile phone", abstract="Background: Posttraumatic stress disorder (PTSD) is a common disorder that requires more treatment options. Mobile health (mHealth) app interventions are promising for patients with PTSD, as they can provide easily accessible support, strategies, and information. However, knowledge about mHealth interventions is sparse and primarily based on quantitative studies. Objective: The aim of this study is to qualitatively explore the experiences of patients with PTSD with regard to using an mHealth app as a stand-alone intervention before commencing psychotherapeutic treatment. Methods: We conducted semistructured interviews with 14 participants 6 weeks after they received the app. The participants were all referred to PTSD treatment and were waiting to commence psychotherapeutic treatment. During this waiting time, the participants had no contact with the health staff. Interviews were transcribed and were analyzed using thematic analysis. Results: A total of 3 themes were identified---the use of app, being a patient, and the overall evaluation of the app. The use of the app was described with the subtheme of habits, and the theme of being a patient included the subthemes of having negative experiences with the app and being a part of a research project. The use of the app encompassed how psychological factors and technical problems could interfere with the use of the app. The theme of being a patient depicted that the waiting time before starting treatment was long, and a subgroup of patients experienced feeling worse during this time, which they partly attributed to using the app. Several suggestions for change have been described in the overall evaluation of the app. Conclusions: The findings in this study revealed that emotional arousal influenced the use of the app and that it was difficult for participants to establish a habit of using the app, thus reflecting the importance of supporting habit formation when implementing an mHealth app in mental health care services. This study makes an important contribution to the field of mHealth research, as it revealed that some participants had negative experiences resulting from using the app, thus reflecting the potential harm of having an mHealth app without the support of a clinician. It is therefore recommended to use a blended care treatment or an approach in which mental health care professionals prescribe an mHealth app for relevant patients to avoid increased suicidal risk. ", doi="10.2196/26852", url="https://formative.jmir.org/2021/8/e26852", url="http://www.ncbi.nlm.nih.gov/pubmed/34346896" } @Article{info:doi/10.2196/30334, author="Philipp-Muller, Emile Aaron and Reshetukha, Taras and Vazquez, Gustavo and Milev, Roumen and Armstrong, Dawn and Jagayat, Jasleen and Alavi, Nazanin", title="Combining Ketamine and Internet-Based Cognitive Behavioral Therapy for the Treatment of Posttraumatic Stress Disorder: Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2021", month="Jul", day="20", volume="10", number="7", pages="e30334", keywords="mental health", keywords="PTSD", keywords="psychotherapy", keywords="cognitive behavioral therapy", keywords="online", keywords="internet", keywords="electronic", keywords="virtual", keywords="mental health care", keywords="ketamine", abstract="Background: Over one third of patients with posttraumatic stress disorder (PTSD) do not respond to current interventions. Ketamine presents a potential treatment option; however, its effects are temporary. Administering ketamine alongside psychotherapy is one potential means of prolonging its effects; however, only a few studies have investigated this treatment method to date, and none have tested ketamine with internet-based or electronically delivered cognitive behavioral therapy (e-CBT). Objective: This open-label randomized controlled trial aims to assess the efficacy of a combined treatment method of subanesthetic intravenous ketamine and e-CBT for treating patients with PTSD. Methods: In total, 20 patients with refractory PTSD recruited from a community clinic will be randomly assigned to either an experimental group (n=10), receiving a combination of ketamine and therapist-administered e-CBT over 14 weeks, or a waitlist control group (n=10), receiving the experimental treatment after 14 weeks. Both groups will be assessed for the symptoms of PTSD and comorbid disorders before treatment, at two midway points, and at the end of the experiment. Results: PTSD symptoms of participants in the experimental group are expected to improve significantly more than those of participants in the waitlist control group (P=.05) with a large effect size ($\eta$2=0.14). Conclusions: This is the first study to assess the relationship between e-CBT and ketamine and their combined ability to treat refractory PTSD. If successful, this study will open web-based, asynchronous therapeutic options for patients with PTSD and will provide new insights into the functional role of glutamate in trauma-related disorders as well as in learning, memory, and fear extinction. Trial Registration: ClinicalTrials.gov NCT04771767; https://clinicaltrials.gov/ct2/show/NCT04771767. International Registered Report Identifier (IRRID): PRR1-10.2196/30334 ", doi="10.2196/30334", url="https://www.researchprotocols.org/2021/7/e30334", url="http://www.ncbi.nlm.nih.gov/pubmed/34092549" } @Article{info:doi/10.2196/24623, author="Yang, Xue and Yip, K. Benjamin H. and Mak, P. Arthur D. and Zhang, Dexing and Lee, P. Eric K. and Wong, S. Samuel Y.", title="The Differential Effects of Social Media on Depressive Symptoms and Suicidal Ideation Among the Younger and Older Adult Population in Hong Kong During the COVID-19 Pandemic: Population-Based Cross-sectional Survey Study", journal="JMIR Public Health Surveill", year="2021", month="May", day="25", volume="7", number="5", pages="e24623", keywords="social media", keywords="depression", keywords="suicidal ideation", keywords="social loneliness", keywords="posttraumatic stress", keywords="suicide", keywords="mental health", keywords="COVID-19", keywords="loneliness", keywords="age", keywords="mediation", abstract="Background: Social media has become a ubiquitous part of daily life during the COVID-19 pandemic isolation. However, the role of social media use in depression and suicidal ideation of the general public remains unclear. Related empirical studies were limited and reported inconsistent findings. Little is known about the potential underlying mechanisms that may illustrate the relationship between social media use and depression and suicidal ideation during the COVID-19 pandemic. Objective: This study tested the mediation effects of social loneliness and posttraumatic stress disorder (PTSD) symptoms on the relationship between social media use and depressive symptoms and suicidal ideation, as well as the moderation effect of age on the mediation models. Methods: We administered a population-based random telephone survey in May and June 2020, when infection control measures were being vigorously implemented in Hong Kong. A total of 1070 adults (658 social media users and 412 nonusers) completed the survey. Structural equation modeling (SEM) and multigroup SEM were conducted to test the mediation and moderation effects. Results: The weighted prevalence of probable depression was 11.6\%; 1.6\% had suicidal ideation in the past 2 weeks. Both moderated mediation models of depressive symptoms ($\chi$262=335.3; P<.05; comparative fit index [CFI]=0.94; nonnormed fit index [NNFI]=0.92; root mean square error of approximation [RMSEA]=0.06) and suicidal ideation ($\chi$234=50.8; P<.05; CFI=0.99; NNFI=0.99; RMSEA=0.02) showed acceptable model fit. There was a significantly negative direct effect of social media use on depressive symptoms among older people ($\beta$=--.07; P=.04) but not among younger people ($\beta$=.04; P=.55). The indirect effect via PTSD symptoms was significantly positive among both younger people ($\beta$=.09; P=.02) and older people ($\beta$=.10; P=.01). The indirect effect via social loneliness was significant among older people ($\beta$=--.01; P=.04) but not among younger people ($\beta$=.01; P=.31). The direct effect of social media use on suicidal ideation was not statistically significant in either age group (P>.05). The indirect effects via PTSD symptoms were statistically significant among younger people ($\beta$=.02; P=.04) and older people ($\beta$=.03; P=.01). Social loneliness was not a significant mediator between social media use and suicidal ideation among either age group (P>.05). Conclusions: Social media may be a ``double-edged sword'' for psychosocial well-being during the COVID-19 pandemic, and its roles vary across age groups. The mediators identified in this study can be addressed by psychological interventions to prevent severe mental health problems during and after the COVID-19 pandemic. ", doi="10.2196/24623", url="https://publichealth.jmir.org/2021/5/e24623", url="http://www.ncbi.nlm.nih.gov/pubmed/33835937" } @Article{info:doi/10.2196/26078, author="Jones, Chelsea and Miguel-Cruz, Antonio and Br{\'e}mault-Phillips, Suzette", title="Technology Acceptance and Usability of the BrainFx SCREEN in Canadian Military Members and Veterans With Posttraumatic Stress Disorder and Mild Traumatic Brain Injury: Mixed Methods UTAUT Study", journal="JMIR Rehabil Assist Technol", year="2021", month="May", day="13", volume="8", number="2", pages="e26078", keywords="NCAT", keywords="PTSD", keywords="cognitive assessment", keywords="cognition", keywords="executive function", keywords="technology acceptance", keywords="UTAUT", keywords="Canadian Armed Forces", keywords="mTBI", keywords="concussion", keywords="digital health", keywords="neuropsychology", keywords="neurology", keywords="post concussive symptoms", keywords="military", abstract="Background: Canadian Armed Forces service members (CAF-SMs) and veterans exhibit higher rates of injuries and illnesses, such as posttraumatic stress disorder (PTSD) and traumatic brain injury, which can cause and exacerbate cognitive dysfunction. Computerized neurocognitive assessment tools have demonstrated increased reliability and efficiency compared with traditional cognitive assessment tools. Without assessing the degree of technology acceptance and perceptions of usability to end users, it is difficult to determine whether a technology-based assessment will be used successfully in wider clinical practice. The Unified Theory of Acceptance and Use of Technology model is commonly used to address the technology acceptance and usability of applications in five domains. Objective: This study aims to determine the technology acceptance and usability of a neurocognitive assessment tool, which was titled BrainFx SCREEN, among CAF-SMs and veterans with PTSD by using the Unified Theory of Acceptance and Use of Technology model. Methods: This mixed methods embedded pilot study included CAF-SMs and veterans (N=21) aged 18-60 years with a diagnosis of PTSD who completed pre- and postquestionnaires on the same day the BrainFx SCREEN was used. A partial least squares structural equation model was used to analyze the questionnaire results. Qualitative data were assessed using thematic analysis. Results: Facilitating conditions, which were the most notable predictors of behavioral intention, increased after using the BrainFx SCREEN, whereas effort expectancy decreased. Performance expectancy, effort expectancy, and social interaction were not factors that could predict behavioral intention. Participants who reported a previous mild traumatic brain injury were significantly more likely to report current symptoms of cognitive impairment. The BrainFx SCREEN is a feasible, usable, and accepted assessment tool for CAF-SMs and veterans who experience PTSD. Conclusions: As military health care systems integrate technological innovations to improve the services and care provided, research must continue to address the acceptability and use of these novel assessments and interventions. ", doi="10.2196/26078", url="https://rehab.jmir.org/2021/2/e26078", url="http://www.ncbi.nlm.nih.gov/pubmed/33983125" } @Article{info:doi/10.2196/27610, author="Hadjistavropoulos, D. Heather and McCall, C. Hugh and Thiessen, L. David and Huang, Ziyin and Carleton, Nicholas R. and Dear, F. Blake and Titov, Nickolai", title="Initial Outcomes of Transdiagnostic Internet-Delivered Cognitive Behavioral Therapy Tailored to Public Safety Personnel: Longitudinal Observational Study", journal="J Med Internet Res", year="2021", month="May", day="5", volume="23", number="5", pages="e27610", keywords="internet", keywords="cognitive behavior therapy", keywords="anxiety", keywords="depression", keywords="posttraumatic stress disorder", keywords="public safety personnel", keywords="CBT", keywords="internet-based cognitive behavioral therapy", keywords="ICBT", keywords="PTSD", keywords="outcome", keywords="diagnosis", keywords="longitudinal", keywords="observational", keywords="literature", keywords="effectiveness", abstract="Background: Canadian public safety personnel (PSP) experience high rates of mental health disorders and face many barriers to treatment. Internet-delivered cognitive behavioral therapy (ICBT) overcomes many such barriers, and is effective for treating depression, anxiety, and posttraumatic stress disorder (PTSD) symptoms. Objective: This study was designed to fill a gap in the literature regarding the use of ICBT tailored specifically for PSP. We examined the effectiveness of a tailored ICBT program for treating depression, anxiety, and PTSD symptoms among PSP in the province of Saskatchewan. Methods: We employed a longitudinal single-group open-trial design (N=83) with outcome measures administered at screening and at 8 weeks posttreatment. Data were collected between December 5, 2019 and September 11, 2020. Primary outcomes included changes in depression, anxiety, and PTSD symptoms. Secondary outcomes included changes in functional impairment; symptoms of panic, social anxiety, and anger; as well as treatment satisfaction, working alliance, and program usage patterns. Results: Clients reported large symptom reductions on measures of depression and anxiety, as well as moderate reductions on measures of PTSD and secondary symptoms, except for social anxiety. Most clients who reported symptoms above clinical cut-offs on measures of depression, anxiety, and PTSD during screening experienced clinically significant symptom reductions. Results suggested good engagement, treatment satisfaction, and working alliance. Conclusions: Tailored, transdiagnostic ICBT demonstrated promising outcomes as a treatment for depression, anxiety, and PTSD among Saskatchewan PSP and warrants further investigation. Trial Registration: Clinicaltrials.gov NCT04127032; https://www.clinicaltrials.gov/ct2/show/NCT04127032 ", doi="10.2196/27610", url="https://www.jmir.org/2021/5/e27610", url="http://www.ncbi.nlm.nih.gov/pubmed/33949959" } @Article{info:doi/10.2196/26360, author="Jones, Chelsea and Harasym, Jessica and Miguel-Cruz, Antonio and Chisholm, Shannon and Smith-MacDonald, Lorraine and Br{\'e}mault-Phillips, Suzette", title="Neurocognitive Assessment Tools for Military Personnel With Mild Traumatic Brain Injury: Scoping Literature Review", journal="JMIR Ment Health", year="2021", month="Feb", day="22", volume="8", number="2", pages="e26360", keywords="military", keywords="rehabilitation", keywords="head injury", keywords="posttraumatic stress disorder", keywords="cognition", keywords="neurocognitive assessment tool", keywords="traumatic brain injury", keywords="assessment", keywords="brain concussion", keywords="mobile phone", abstract="Background: Mild traumatic brain injury (mTBI) occurs at a higher frequency among military personnel than among civilians. A common symptom of mTBIs is cognitive dysfunction. Health care professionals use neuropsychological assessments as part of a multidisciplinary and best practice approach for mTBI management. Such assessments support clinical diagnosis, symptom management, rehabilitation, and return-to-duty planning. Military health care organizations currently use computerized neurocognitive assessment tools (NCATs). NCATs and more traditional neuropsychological assessments present unique challenges in both clinical and military settings. Many research gaps remain regarding psychometric properties, usability, acceptance, feasibility, effectiveness, sensitivity, and utility of both types of assessments in military environments. Objective: The aims of this study were to explore evidence regarding the use of NCATs among military personnel who have sustained mTBIs; evaluate the psychometric properties of the most commonly tested NCATs for this population; and synthesize the data to explore the range and extent of NCATs among this population, clinical recommendations for use, and knowledge gaps requiring future research. Methods: Studies were identified using MEDLINE, Embase, American Psychological Association PsycINFO, CINAHL Plus with Full Text, Psych Article, Scopus, and Military \& Government Collection. Data were analyzed using descriptive analysis, thematic analysis, and the Randolph Criteria. Narrative synthesis and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews) guided the reporting of findings. The psychometric properties of NCATs were evaluated with specific criteria and summarized. Results: Of the 104 papers, 33 met the inclusion criteria for this scoping review. Thematic analysis and NCAT psychometrics were reported and summarized. Conclusions: When considering the psychometric properties of the most commonly used NCATs in military populations, these assessments have yet to demonstrate adequate validity, reliability, sensitivity, and clinical utility among military personnel with mTBIs. Additional research is needed to further validate NCATs within military populations, especially for those living outside of the United States and individuals experiencing other conditions known to adversely affect cognitive processing. Knowledge gaps remain, warranting further study of psychometric properties and the utility of baseline and normative testing for NCATs. ", doi="10.2196/26360", url="https://mental.jmir.org/2021/2/e26360", url="http://www.ncbi.nlm.nih.gov/pubmed/33616538" } @Article{info:doi/10.2196/23712, author="Gamble, Beau and Depa, Katherine and Holmes, A. Emily and Kanstrup, Marie", title="Digitalizing a Brief Intervention to Reduce Intrusive Memories of Psychological Trauma: Qualitative Interview Study", journal="JMIR Ment Health", year="2021", month="Feb", day="22", volume="8", number="2", pages="e23712", keywords="digital intervention", keywords="remote delivery", keywords="intrusive memories", keywords="psychological trauma", keywords="qualitative feedback", keywords="cognitive science", keywords="posttraumatic stress disorder", abstract="Background: The COVID-19 pandemic has escalated the global need for remotely delivered and scalable interventions after psychological trauma. A brief intervention involving a computer game as an imagery-competing task has shown promising results for reducing the number of intrusive memories of trauma---one of the core clinical symptoms of posttraumatic stress disorder. To date, the intervention has only been delivered face-to-face. To be tested and implemented on a wider scale, digital adaptation for remote delivery is crucial. An important first step is to develop digitalized intervention materials in a systematic way based on feedback from clinicians, researchers, and students in preparation for pilot testing with target users. Objective: The first aim of this study is to obtain and analyze qualitative feedback on digital intervention materials, namely two animated videos and two quizzes that explain the target clinical symptoms and provide intervention instructions. The second aim is to refine the digitalized materials based on this feedback. Methods: We conducted semistructured interviews with 12 participants who had delivered or had knowledge of the intervention when delivered face-to-face. We obtained in-depth feedback on the perceived feasibility of using the digitalized materials and suggestions for improvements. Interviews were assessed using qualitative content analysis, and suggested improvements were evaluated for implementation using a systematic method of prioritization. Results: A total of three overarching themes were identified from the data. First, participants were highly positive about the potential benefits of using these digital materials for remote delivery, reporting that the videos effectively conveyed key concepts of the symptom and its treatment. Second, some modifications to the materials were suggested for improving clarity. On the basis of this feedback, we made nine specific changes. Finally, participants raised some key challenges for remote delivery, mainly in overcoming the lack of real-time communication during the intervention. Conclusions: Clinicians, researchers, and clinical psychology students were overall confident in the use of digitalized materials to remotely deliver a brief intervention to reduce intrusive memories of trauma. Guided by participant feedback, we identified and implemented changes to refine the intervention materials. This study lays the groundwork for the next step: pilot testing remote delivery of the full intervention to trauma survivors. ", doi="10.2196/23712", url="https://mental.jmir.org/2021/2/e23712", url="http://www.ncbi.nlm.nih.gov/pubmed/33616540" } @Article{info:doi/10.2196/24807, author="R{\"o}hr, Susanne and Jung, U. Franziska and Pabst, Alexander and Grochtdreis, Thomas and Dams, Judith and Nagl, Michaela and Renner, Anna and Hoffmann, Rahel and K{\"o}nig, Hans-Helmut and Kersting, Anette and Riedel-Heller, G. Steffi", title="A Self-Help App for Syrian Refugees With Posttraumatic Stress (Sanadak): Randomized Controlled Trial", journal="JMIR Mhealth Uhealth", year="2021", month="Jan", day="13", volume="9", number="1", pages="e24807", keywords="app", keywords="cost-utility analysis", keywords="mHealth", keywords="posttraumatic stress", keywords="PTSD", keywords="quality-adjusted life years", keywords="randomized controlled trial", keywords="refugees", keywords="stimga", keywords="Syrian refugees", keywords="usability", abstract="Background: Syrian refugees residing in Germany often develop posttraumatic stress as a result of the Syrian civil war, their escape, and postmigration stressors. At the same time, there is a lack of adequate treatment options. The smartphone-based app Sanadak was developed to provide cognitive behavioral therapy--based self-help in the Arabic language for Syrian refugees with posttraumatic stress. Objective: The aim of this study was to evaluate the effectiveness and cost-effectiveness of the app. Methods: In a randomized controlled trial, eligible individuals were randomly allocated to the intervention group (IG; app use) or control group (CG; psychoeducational reading material). Data were collected during structured face-to-face interviews at 3 assessments (preintervention/baseline, postintervention/after 4 weeks, follow-up/after 4 months). Using adjusted mixed-effects linear regression models, changes in posttraumatic stress and secondary outcomes were investigated as intention-to-treat (ITT) and per-protocol (PP) analysis. Cost-effectiveness was evaluated based on adjusted mean total costs, quality-adjusted life years (QALYs), and cost-effectiveness acceptability curves using the net benefit approach. Results: Of 170 screened individuals (aged 18 to 65 years), 133 were eligible and randomized to the IG (n=65) and CG (n=68). Although there was a pre-post reduction in posttraumatic stress, ITT showed no significant differences between the IG and CG after 4 weeks (Posttraumatic Diagnostic Scale for DSM-5, Diff --0.90, 95\% CI --0.24 to 0.47; P=.52) and after 4 months (Diff --0.39, 95\% CI --3.24 to 2.46; P=.79). The same was true for PP. Regarding secondary outcomes, ITT indicated a treatment effect for self-stigma: after 4 weeks (Self-Stigma of Mental Illness Scale/SSMIS--stereotype agreement: d=0.86, 95\% CI 0.46 to 1.25; stereotype application: d=0.60, 95\% CI 0.22 to 0.99) and after 4 months (d=0.52, 95\% CI 0.12 to 0.92; d=0.50, 95\% CI 0.10 to 0.90), the IG showed significantly lower values in self-stigma than the CG. ITT showed no significant group differences in total costs and QALYs. The probability of cost-effectiveness was 81\% for a willingness-to-pay of {\texteuro}0 per additional QALY but decreased with increasing willingness-to-pay. Conclusions: Sanadak was not more effective in reducing mild to moderate posttraumatic stress in Syrian refugees than the control condition nor was it likely to be cost-effective. Therefore, Sanadak is not suitable as a standalone treatment. However, as the app usability was very good, no harms detected, and stigma significantly reduced, Sanadak has potential as a bridging aid within a stepped and collaborative care approach. Trial Registration: German Clinical Trials Register DRKS00013782; https://www.drks.de/drks\_web/navigate.do?navigationId=trial.HTML\&TRIAL\_ID=DRKS00013782 International Registered Report Identifier (IRRID): RR2-10.1186/s12888-019-2110-y ", doi="10.2196/24807", url="http://mhealth.jmir.org/2021/1/e24807/", url="http://www.ncbi.nlm.nih.gov/pubmed/33439140" } @Article{info:doi/10.2196/19391, author="Kulakli, Atik and Shubina, Ivanna", title="Scientific Publication Patterns of Mobile Technologies and Apps for Posttraumatic Stress Disorder Treatment: Bibliometric Co-Word Analysis", journal="JMIR Mhealth Uhealth", year="2020", month="Nov", day="26", volume="8", number="11", pages="e19391", keywords="posttraumatic stress disorder (PTSD)", keywords="mobile technologies", keywords="mobile apps", keywords="treatment", keywords="text analysis", keywords="co-word analysis", keywords="bibliometric", keywords="Web of Science", abstract="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. ", doi="10.2196/19391", url="http://mhealth.jmir.org/2020/11/e19391/", url="http://www.ncbi.nlm.nih.gov/pubmed/33242019" } @Article{info:doi/10.2196/19162, author="Coimbra, Messina Bruno and Yeh, Mary and D'Elia, Teresa Ana and Maciel, Rangel Mariana and Carvalho, Muniz Carolina and Milani, Carolina Ana and Mozzambani, Adriana and Juruena, Mario and Belangero, Iole Sintia and Jackowski, Parolin Andrea and Poyares, Dalva and Mello, Feijo Andrea and Mello, Feijo Marcelo", title="Posttraumatic Stress Disorder and Neuroprogression in Women Following Sexual Assault: Protocol for a Randomized Clinical Trial Evaluating Allostatic Load and Aging Process Acceleration", journal="JMIR Res Protoc", year="2020", month="Nov", day="18", volume="9", number="11", pages="e19162", keywords="PTSD", keywords="neuroprogression", keywords="allostatic load", keywords="sexual assault", keywords="trauma", keywords="thematic research", keywords="randomized clinical trial", keywords="aging", abstract="Background: Posttraumatic stress disorder (PTSD) is a prevalent, chronic, and severe disorder related to traumatic events. Women are disproportionately affected by PTSD than men and are more at risk in the occurrence of sexual assault victimization. Estimates suggest that 50\% of women develop PTSD following sexual assault and successful clinical management can be challenging. Growing evidence has implicated neural, immune, and endocrine alterations underpinning PTSD, but only few studies have assessed the evolution of acute PTSD in women. Objective: This study aims to measure whether the onset of PTSD is associated with accelerated aging in women following sexual assault. We hypothesize that the increase of allostatic load caused by PTSD leads to neuroprogression. We will implement a randomized clinical trial to compare responses to treatment with either interpersonal psychotherapy adapted for PTSD (IPT-PTSD) or the selective serotonin reuptake inhibitor sertraline. Methods: We will include women between 18 and 45 years of age, who experienced sexual assault from 1 to 6 months before the initial evaluation, and present with a Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) diagnosis of PTSD. Baseline evaluation will comprise clinical and psychometric assessments, structural and functional magnetic resonance imaging, neuropsychological testing, polysomnography, evaluation of immune and endocrine parameters, and genetic analyses. Age-matched female healthy controls will be included and subjected to the same evaluation. Patients will be randomized for treatment in 1 of the 2 arms of the study for 14 weeks; follow-up will continue until 1 year after inclusion via treatment as usual. The researchers will collect clinical and laboratory data during periodic clinical assessments up to 1-year follow-up. Results: Data collection started in early 2016 and will be completed by the end of the first semester of 2020. Analyses will be performed soon afterward, followed by the elaboration of several articles. Articles will be submitted in early 2021. This research project has obtained a grant from the Funda{\c{c}}{\~a}o de Amparo {\`a} Pesquisa do Estado de S{\~a}o Paulo (FAPESP 2014/12559-5). Conclusions: We expect to provide insight into the consequences of recent sexual assault exposure in women by investigating the degree of neuroprogression developing from an early stage of PTSD. We also expect to provide important evidence on the efficacy of a non-exposure psychotherapy (IPT-PTSD) to mitigate PTSD symptoms in recently sexually assaulted women. Further, we aim to obtain evidence on how treatment outcomes are associated with neuroprogression measures. Trial Registration: Brazilian Clinical Trials Registry RBR-3z474z; http://www.ensaiosclinicos.gov.br/rg/RBR-3z474z/ International Registered Report Identifier (IRRID): DERR1-10.2196/19162 ", doi="10.2196/19162", url="http://www.researchprotocols.org/2020/11/e19162/", url="http://www.ncbi.nlm.nih.gov/pubmed/33206061" } @Article{info:doi/10.2196/20620, author="Jones, Chelsea and Smith-MacDonald, Lorraine and Miguel-Cruz, Antonio and Pike, Ashley and van Gelderen, Marieke and Lentz, Liana and Shiu, Y. Maria and Tang, Emily and Sawalha, Jeffrey and Greenshaw, Andrew and Rhind, G. Shawn and Fang, Xin and Norbash, Adrian and Jetly, Rakesh and Vermetten, Eric and Br{\'e}mault-Phillips, Suzette", title="Virtual Reality--Based Treatment for Military Members and Veterans With Combat-Related Posttraumatic Stress Disorder: Protocol for a Multimodular Motion-Assisted Memory Desensitization and Reconsolidation Randomized Controlled Trial", journal="JMIR Res Protoc", year="2020", month="Oct", day="29", volume="9", number="10", pages="e20620", keywords="3MDR", keywords="posttraumatic stress disorder", keywords="military", keywords="veteran", keywords="psychotherapy", keywords="virtual reality", abstract="Background: Military members are at elevated risk of operational stress injuries, including posttraumatic stress disorder (PTSD) and moral injury. Although psychotherapy can reduce symptoms, some military members may experience treatment-resistant PTSD. Multimodular motion-assisted memory desensitization and reconsolidation (3MDR) has been introduced as a virtual reality (VR) intervention for military members with PTSD related to military service. The 3MDR intervention incorporates exposure therapy, psychotherapy, eye movement desensitization and reconsolidation, VR, supportive counselling, and treadmill walking. Objective: The objective of this study is to investigate whether 3MDR reduces PTSD symptoms among military members with combat-related treatment-resistant PTSD (TR-PTSD); examine the technology acceptance and usability of the Computer Assisted Rehabilitation ENvironment (CAREN) and 3MDR interventions by Canadian Armed Forces service members (CAF-SMs), veterans, 3MDR clinicians, and operators; and evaluate the impact on clinicians and operators of delivering 3MDR. Methods: This is a mixed-methods waitlist controlled crossover design randomized controlled trial. Participants include both CAF-SMs and veterans (N=40) aged 18-60 years with combat-related TR-PTSD (unsuccessful experience of at least 2 evidence-based trauma treatments). Participants will also include clinicians and operators (N=12) who have been trained in 3MDR and subsequently utilized this intervention with patients. CAF-SMs and veterans will receive 6 weekly 90-minute 3MDR sessions. Quantitative and qualitative data will be collected at baseline and at 1, 3, and 6 months postintervention. Quantitative data collection will include multiomic biomarkers (ie, blood and salivary proteomic and genomic profiles of neuroendocrine, immune-inflammatory mediators, and microRNA), eye tracking, electroencephalography, and physiological data. Data from outcome measures will capture self-reported symptoms of PTSD, moral injury, resilience, and technology acceptance and usability. Qualitative data will be collected from audiovisual recordings of 3MDR sessions and semistructured interviews. Data analysis will include univariate and multivariate approaches, and thematic analysis of treatment sessions and interviews. Machine learning analysis will be included to develop models for the prediction of diagnosis, symptom severity, and treatment outcomes. Results: This study commenced in April 2019 and is planned to conclude in April 2021. Study results will guide the further evolution and utilization of 3MDR for military members with TR-PTSD and will have utility in treating other trauma-affected populations. Conclusions: The goal of this study is to utilize qualitative and quantitative primary and secondary outcomes to provide evidence for the effectiveness and feasibility of 3MDR for treating CAF-SMs and veterans with combat-related TR-PTSD. The results will inform a full-scale clinical trial and stimulate development and adaptation of the protocol to mobile VR apps in supervised clinical settings. This study will add to knowledge of the clinical effectiveness of 3MDR, and provide the first comprehensive analysis of biomarkers, technology acceptance and usability, moral injury, resilience, and the experience of clinicians and operators delivering 3MDR. Trial Registration: ISRCTN Registry 11264368; http://www.isrctn.com/ISRCTN11264368. International Registered Report Identifier (IRRID): DERR1-10.2196/20620 ", doi="10.2196/20620", url="http://www.researchprotocols.org/2020/10/e20620/", url="http://www.ncbi.nlm.nih.gov/pubmed/33118957" } @Article{info:doi/10.2196/18447, author="Shakespeare-Finch, Jane and Alichniewicz, K. Karolina and Strodl, Esben and Brown, Kelly and Quinn, Catherine and Hides, Leanne and White, Angela and Gossage, Gabrial and Poerio, Loretta and Batras, Dimitri and Jackson, Samantha and Styles, Jess and Kavanagh, David", title="Experiences of Serving and Ex-Serving Members With the PTSD Coach Australia App: Mixed Methods Study", journal="J Med Internet Res", year="2020", month="Oct", day="8", volume="22", number="10", pages="e18447", keywords="PTSD", keywords="stress disorders, posttraumatic", keywords="self-management", keywords="evaluation, qualitative", keywords="health, veterans", keywords="armed forces personnel", abstract="Background: PTSD Coach Australia is an app for serving and ex-serving defense members and was adapted for the Australian context in 2013 from PTSD Coach, which was created in the United States. Objective: This study aimed to provide a user-centered evaluation of the app from the perspective of serving and ex-serving members of the Australian Defence Force. Methods: Qualitative data were collected in response to questions to participants in 1 of 5 workshops (n=29) or in telephone interviews (n=24). Quantitative data were collected using the user version of Mobile Apps Rating Scale (uMARS). Results: Analysis of the qualitative data demonstrated mixed support for the app. While some people found it extremely useful, especially as an adjunct to therapy, others pointed out limitations and cautioned against the app potentially triggering symptoms in people with PTSD. This perceived risk was usually found to stem from frustration with the app's functionality rather than its content. Participants spoke about the helpful and unhelpful aspects of the app and barriers to its use and made suggestions for improvement. Many participants encouraged its continued use and highlighted the need for it to be promoted more broadly, as many were not aware of it until they were invited to participate in this research. Conclusions: PTSD Coach Australia was seen in a positive light by some participants, but others thought it had too much text and the potential to trigger a traumatic response in users with PTSD. A need to update the app was also a common comment as was the need to increase awareness of the app's existence. ", doi="10.2196/18447", url="https://www.jmir.org/2020/10/e18447", url="http://www.ncbi.nlm.nih.gov/pubmed/33030438" } @Article{info:doi/10.2196/19716, author="van Herpen, Marjolein Merel and Boeschoten, A. Manon and te Brake, Hans and van der Aa, Niels and Olff, Miranda", title="Mobile Insight in Risk, Resilience, and Online Referral (MIRROR): Psychometric Evaluation of an Online Self-Help Test", journal="J Med Internet Res", year="2020", month="Sep", day="25", volume="22", number="9", pages="e19716", keywords="potentially traumatic events", keywords="mobile mental health", keywords="self-help", keywords="online", keywords="resilience", keywords="posttraumatic stress disorder", abstract="Background: Most people who experience a potentially traumatic event (PTE) recover on their own. A small group of individuals develops psychological complaints, but this is often not detected in time or guidance to care is suboptimal. To identify these individuals and encourage them to seek help, a web-based self-help test called Mobile Insight in Risk, Resilience, and Online Referral (MIRROR) was developed. MIRROR takes an innovative approach since it integrates both negative and positive outcomes of PTEs and time since the event and provides direct feedback to the user. Objective: The goal of this study was to assess MIRROR's use, examine its psychometric properties (factor structure, internal consistency, and convergent and divergent validity), and evaluate how well it classifies respondents into different outcome categories compared with reference measures. Methods: MIRROR was embedded in the website of Victim Support Netherlands so visitors could use it. We compared MIRROR's outcomes to reference measures of PTSD symptoms (PTSD Checklist for DSM-5), depression, anxiety, stress (Depression Anxiety Stress Scale--21), psychological resilience (Resilience Evaluation Scale), and positive mental health (Mental Health Continuum Short Form). Results: In 6 months, 1112 respondents completed MIRROR, of whom 663 also completed the reference measures. Results showed good internal consistency (interitem correlations range .24 to .55, corrected item-total correlations range .30 to .54, and Cronbach alpha coefficient range .62 to .68), and convergent and divergent validity (Pearson correlations range --.259 to .665). Exploratory and confirmatory factor analyses (EFA+CFA) yielded a 2-factor model with good model fit (CFA model fit indices: $\chi$219=107.8, P<.001, CFI=.965, TLI=.948, RMSEA=.065), conceptual meaning, and parsimony. MIRROR correctly classified respondents into different outcome categories compared with the reference measures. Conclusions: MIRROR is a valid and reliable self-help test to identify negative (PTSD complaints) and positive outcomes (psychosocial functioning and resilience) of PTEs. MIRROR is an easily accessible online tool that can help people who have experienced a PTE to timely identify psychological complaints and find appropriate support, a tool that might be highly needed in times like the coronavirus pandemic. ", doi="10.2196/19716", url="http://www.jmir.org/2020/9/e19716/", url="http://www.ncbi.nlm.nih.gov/pubmed/32975521" } @Article{info:doi/10.2196/17424, author="Norman, P. Kim and Govindjee, Anita and Norman, R. Seth and Godoy, Michael and Cerrone, L. Kimberlie and Kieschnick, W. Dustin and Kassler, William", title="Natural Language Processing Tools for Assessing Progress and Outcome of Two Veteran Populations: Cohort Study From a Novel Online Intervention for Posttraumatic Growth", journal="JMIR Form Res", year="2020", month="Sep", day="23", volume="4", number="9", pages="e17424", keywords="natural language analysis", keywords="emotional tone", keywords="personality", keywords="values", keywords="PTSD", keywords="military sexual trauma", keywords="online interventions", keywords="internet-based cognitive behavioral therapy", keywords="narrative therapy", keywords="mindfulness", abstract="Background: Over 100 million Americans lack affordable access to behavioral health care. Among these, military veterans are an especially vulnerable population. Military veterans require unique behavioral health services that can address military experiences and challenges transitioning to the civilian sector. Real-world programs to help veterans successfully transition to civilian life must build a sense of community, have the ability to scale, and be able to reach the many veterans who cannot or will not access care. Digitally based behavioral health initiatives have emerged within the past few years to improve this access to care. Our novel behavioral health intervention teaches mindfulness-based cognitive behavioral therapy and narrative therapy using peer support groups as guides, with human-facilitated asynchronous online discussions. Our study applies natural language processing (NLP) analytics to assess effectiveness of our online intervention in order to test whether NLP may provide insights and detect nuances of personal change and growth that are not currently captured by subjective symptom measures. Objective: This paper aims to study the value of NLP analytics in assessing progress and outcomes among combat veterans and military sexual assault survivors participating in novel online interventions for posttraumatic growth. Methods: IBM Watson and Linguistic Inquiry and Word Count tools were applied to the narrative writings of combat veterans and survivors of military sexual trauma who participated in novel online peer-supported group therapies for posttraumatic growth. Participants watched videos, practiced skills such as mindfulness meditation, told their stories through narrative writing, and participated in asynchronous, facilitated online discussions with peers. The writings, including online postings, by the 16 participants who completed the program were analyzed after completion of the program. Results: Our results suggest that NLP can provide valuable insights on shifts in personality traits, personal values, needs, and emotional tone in an evaluation of our novel online behavioral health interventions. Emotional tone analysis demonstrated significant decreases in fear and anxiety, sadness, and disgust, as well as increases in joy. Significant effects were found for personal values and needs, such as needing or desiring closeness and helping others, and for personality traits of openness, conscientiousness, extroversion, agreeableness, and neuroticism (ie, emotional range). Participants also demonstrated increases in authenticity and clout (confidence) of expression. NLP results were generally supported by qualitative observations and analysis, structured data, and course feedback. Conclusions: The aggregate of results in our study suggest that our behavioral health intervention was effective and that NLP can provide valuable insights on shifts in personality traits, personal values, and needs, as well as measure changes in emotional tone. NLP's sensitivity to changes in emotional tone, values, and personality strengths suggests the efficacy of NLP as a leading indicator of treatment progress. ", doi="10.2196/17424", url="https://formative.jmir.org/2020/9/e17424", url="http://www.ncbi.nlm.nih.gov/pubmed/32769074" } @Article{info:doi/10.2196/19881, author="Schuurmans, T. Angela A. and Nijhof, S. Karin and Scholte, Ron and Popma, Arne and Otten, Roy", title="Game-Based Meditation Therapy to Improve Posttraumatic Stress and Neurobiological Stress Systems in Traumatized Adolescents: Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2020", month="Sep", day="23", volume="9", number="9", pages="e19881", keywords="Adolescents", keywords="Autonomic nervous system", keywords="Cortisol", keywords="Meditation", keywords="Neurofeedback", keywords="Posttraumatic stress", keywords="Randomized controlled trial", keywords="Trauma", abstract="Background: Many adolescents in residential care have been exposed to prolonged traumatic experiences such as violence, neglect, or abuse. Consequently, they suffer from posttraumatic stress. This not only negatively affects psychological and behavioral outcomes (eg, increased anxiety, depression, and aggression) but also has adverse effects on physiological outcomes, in particular on their neurobiological stress systems. Although current evidence-based treatment options are effective, they have their limitations. An alternative to traditional trauma treatment is meditation-based treatment that focuses on stress regulation and relaxation. Muse is a game-based meditation intervention that makes use of adolescents' intrinsic motivation. The neurofeedback element reinforces relaxation abilities. Objective: This paper describes the protocol for a randomized controlled trial in which the goal is to examine the effectiveness of Muse (InteraXon Inc) in reducing posttraumatic stress and normalizing neurobiological stress systems in a sample of traumatized adolescents in residential care. Methods: This will be a multicenter, multi-informant, and multimethod randomized controlled trial. Participants will be adolescents (N=80), aged 10 to 18 years, with clinical levels of posttraumatic symptoms, who are randomized to receive either the Muse therapy sessions and treatment as usual (intervention) or treatment as usual alone (control). Data will be collected at 3 measurement instances: pretest (T1), posttest (T2), and at 2-month follow-up. Primary outcomes will be posttraumatic symptoms (self-report and mentor report) and stress (self-report) at posttest. Secondary outcomes will be neurobiological stress parameters under both resting and acute stress conditions, and anxiety, depression, and aggression at posttest. Secondary outcomes also include all measures at 2-month follow-up: posttraumatic symptoms, stress, anxiety, depression aggression, and neurobiological resting parameters. Results: The medical-ethical committee Arnhem-Nijmegen (NL58674.091.16) approved the trial on November 15, 2017. The study was registered on December 2, 2017. Participant enrollment started in January 2018, and the results of the study are expected to be published in spring or summer 2021. Conclusions: Study results will demonstrate whether game-based meditation therapy improves posttraumatic stress and neurobiological stress systems, and whether it is more effective than treatment as usual alone for traumatized adolescents. Trial Registration: Netherlands Trial Register NL6689 (NTR6859); https://www.trialregister.nl/trial/6689 International Registered Report Identifier (IRRID): DERR1-10.2196/19881 ", doi="10.2196/19881", url="http://www.researchprotocols.org/2020/9/e19881/", url="http://www.ncbi.nlm.nih.gov/pubmed/32965226" } @Article{info:doi/10.2196/22079, author="Jones, Chelsea and Miguel-Cruz, Antonio and Smith-MacDonald, Lorraine and Cruikshank, Emily and Baghoori, Delaram and Kaur Chohan, Avneet and Laidlaw, Alexa and White, Allison and Cao, Bo and Agyapong, Vincent and Burback, Lisa and Winkler, Olga and Sevigny, R. Phillip and Dennett, Liz and Ferguson-Pell, Martin and Greenshaw, Andrew and Br{\'e}mault-Phillips, Suzette", title="Virtual Trauma-Focused Therapy for Military Members, Veterans, and Public Safety Personnel With Posttraumatic Stress Injury: Systematic Scoping Review", journal="JMIR Mhealth Uhealth", year="2020", month="Sep", day="21", volume="8", number="9", pages="e22079", keywords="trauma", keywords="mental health", keywords="telemedicine", keywords="therapy", keywords="rehabilitation", keywords="digital health", keywords="psychotherapy", keywords="military", keywords="veteran", keywords="first responder", keywords="public safety personnel", keywords="teletherapy", keywords="telepsychiatry", keywords="mobile phone", abstract="Background: A necessary shift from in-person to remote delivery of psychotherapy (eg, teletherapy, eHealth, videoconferencing) has occurred because of the COVID-19 pandemic. A corollary benefit is a potential fit in terms of the need for equitable and timely access to mental health services in remote and rural locations. Owing to COVID-19, there may be an increase in the demand for timely, virtual delivery of services among trauma-affected populations, including public safety personnel (PSP; eg, paramedics, police, fire, correctional officers), military members, and veterans. There is a lack of evidence on the question of whether digital delivery of trauma-therapies for military members, veterans, and PSP leads to similar outcomes to in-person delivery. Information on barriers and facilitators and recommendations regarding digital-delivery is also scarce. Objective: This study aims to evaluate the scope and quality of peer-reviewed literature on psychotherapeutic digital health interventions delivered remotely to military members, veterans, and PSP and synthesize the knowledge of needs, gaps, barriers to, and facilitators for virtual assessment of and virtual interventions for posttraumatic stress injury. Methods: Relevant studies were identified using MEDLINE (Medical Literature Analysis and Retrieval System Online), EMBASE (Excerpta Medica dataBASE), APA (American Psychological Association) PsycINFO, CINAHL (Cumulative Index of Nursing and Allied Health Literature) Plus with Full Text, and Military \& Government Collection. For collation, analysis, summarizing, and reporting of results, we used the CASP (Critical Skills Appraisal Program) qualitative checklist, PEDro (Physiotherapy Evidence Database) scale, level of evidence hierarchy, PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews), and narrative synthesis. Results: A total of 38 studies were included in this review. Evidence for the effectiveness of digital delivery of prolonged exposure therapy, cognitive processing therapy, behavioral activation treatment with therapeutic exposure to military members, veterans, and PSP was rated level 1a, whereas evidence for cognitive behavioral therapy was conflicting. The narrative synthesis indicated that virtual delivery of these therapies can be as effective as in-person delivery but may reduce stigma and cost while increasing access to therapy. Issues of risk, safety, potential harm (ie, suicidality, enabling avoidance), privacy, security, and the match among the therapist, modality, and patient warrant further consideration. There is a lack of studies on the influences of gender, racial, and cultural factors that may result in differential outcomes, preferences, and/or needs. An investigation into other therapies that may be suitable for digital delivery is needed. Conclusions: Digital delivery of trauma therapies for military members, veterans, and PSP is a critical area for further research. Although promising evidence exists regarding the effectiveness of digital health within these populations, many questions remain, and a cautious approach to more widespread implementation is warranted. ", doi="10.2196/22079", url="http://mhealth.jmir.org/2020/9/e22079/", url="http://www.ncbi.nlm.nih.gov/pubmed/32955456" } @Article{info:doi/10.2196/15506, author="Betthauser, M. Lisa and Stearns-Yoder, A. Kelly and McGarity, Suzanne and Smith, Victoria and Place, Skyler and Brenner, A. Lisa", title="Mobile App for Mental Health Monitoring and Clinical Outreach in Veterans: Mixed Methods Feasibility and Acceptability Study", journal="J Med Internet Res", year="2020", month="Aug", day="11", volume="22", number="8", pages="e15506", keywords="veterans", keywords="mobile app", keywords="smartphone", keywords="mental health", keywords="acceptability", keywords="feasibility", abstract="Background: Advances in mobile health (mHealth) technology have made it possible for patients and health care providers to monitor and track behavioral health symptoms in real time. Ideally, mHealth apps include both passive and interactive monitoring and demonstrate high levels of patient engagement. Digital phenotyping, the measurement of individual technology usage, provides insight into individual behaviors associated with mental health. Objective: Researchers at a Veterans Affairs Medical Center and Cogito Corporation sought to explore the feasibility and acceptability of an mHealth app, the Cogito Companion. Methods: A mixed methodological approach was used to investigate the feasibility and acceptability of the app. Veterans completed clinical interviews and self-report measures, at baseline and at a 3-month follow-up. During the data collection period, participants were provided access to the Cogito Companion smartphone app. The mobile app gathered passive and active behavioral health indicators. Data collected (eg, vocal features and digital phenotyping of everyday social signals) are analyzed in real time. Passive data collected include location via global positioning system (GPS), phone calls, and SMS text message metadata. Four primary model scores were identified as being predictive of the presence or absence of depression or posttraumatic stress disorder (PTSD). Veterans Affairs clinicians monitored a provider dashboard and conducted clinical outreach when indicated. Results: Findings suggest that use of the Cogito Companion app was feasible and acceptable. Veterans (n=83) were interested in and used the app; however, active use declined over time. Nonetheless, data were passively collected, and outreach occurred throughout the study period. On the Client Satisfaction Questionnaire--8, 79\% (53/67) of the sample reported scores demonstrating acceptability of the app (mean 26.2, SD 4.3). Many veterans reported liking specific app features (day-to-day monitoring) and the sense of connection they felt with the study clinicians who conducted outreach. Only a small percentage (4/67, 6\%) reported concerns regarding personal privacy. Conclusions: Feasibility and acceptability of the Cogito Corporation platform to monitor mental health symptoms, behaviors, and facilitate follow-up in a sample of veterans were supported. Clinically, platforms such as the Cogito Companion system may serve as useful methods to promote monitoring, thereby facilitating early identification of risk and mitigating negative psychiatric outcomes, such as suicide. ", doi="10.2196/15506", url="https://www.jmir.org/2020/8/e15506", url="http://www.ncbi.nlm.nih.gov/pubmed/32779572" } @Article{info:doi/10.2196/16654, author="Sadeghi, Mahnoosh and Sasangohar, Farzan and McDonald, D. Anthony", title="Toward a Taxonomy for Analyzing the Heart Rate as a Physiological Indicator of Posttraumatic Stress Disorder: Systematic Review and Development of a Framework", journal="JMIR Ment Health", year="2020", month="Jul", day="22", volume="7", number="7", pages="e16654", keywords="heart rate", keywords="statistics", keywords="PTSD", keywords="mental health", keywords="physiology", abstract="Background: Posttraumatic stress disorder (PTSD) is a prevalent psychiatric condition that is associated with symptoms such as hyperarousal and overreactions. Treatments for PTSD are limited to medications and in-session therapies. Assessing the way the heart responds to PTSD has shown promise in detecting and understanding the onset of symptoms. Objective: This study aimed to extract statistical and mathematical approaches that researchers can use to analyze heart rate (HR) data to understand PTSD. Methods: A scoping literature review was conducted to extract HR models. A total of 5 databases including Medical Literature Analysis and Retrieval System Online (Medline) OVID, Medline EBSCO, Cumulative Index to Nursing and Allied Health Literature (CINAHL) EBSCO, Excerpta Medica Database (Embase) Ovid, and Google Scholar were searched. Non--English language studies, as well as studies that did not analyze human data, were excluded. A total of 54 studies that met the inclusion criteria were included in this review. Results: We identified 4 categories of models: descriptive time-independent output, descriptive and time-dependent output, predictive and time-independent output, and predictive and time-dependent output. Descriptive and time-independent output models include analysis of variance and first-order exponential; the descriptive time-dependent output model includes a classical time series analysis and mixed regression. Predictive time-independent output models include machine learning methods and analysis of the HR-based fluctuation-dissipation method. Finally, predictive time-dependent output models include the time-variant method and nonlinear dynamic modeling. Conclusions: All of the identified modeling categories have relevance in PTSD, although the modeling selection is dependent on the specific goals of the study. Descriptive models are well-founded for the inference of PTSD. However, there is a need for additional studies in this area that explore a broader set of predictive models and other factors (eg, activity level) that have not been analyzed with descriptive models. ", doi="10.2196/16654", url="https://mental.jmir.org/2020/7/e16654", url="http://www.ncbi.nlm.nih.gov/pubmed/32706710" } @Article{info:doi/10.2196/17119, author="Karstoft, Karen-Inge and Tsamardinos, Ioannis and Eskelund, Kasper and Andersen, Bo S{\o}ren and Nissen, Ravnborg Lars", title="Applicability of an Automated Model and Parameter Selection in the Prediction of Screening-Level PTSD in Danish Soldiers Following Deployment: Development Study of Transferable Predictive Models Using Automated Machine Learning", journal="JMIR Med Inform", year="2020", month="Jul", day="22", volume="8", number="7", pages="e17119", keywords="decision support", keywords="machine learning", keywords="mental health", keywords="PTSD", keywords="military", keywords="screening", abstract="Background: Posttraumatic stress disorder (PTSD) is a relatively common consequence of deployment to war zones. Early postdeployment screening with the aim of identifying those at risk for PTSD in the years following deployment will help deliver interventions to those in need but have so far proved unsuccessful. Objective: This study aimed to test the applicability of automated model selection and the ability of automated machine learning prediction models to transfer across cohorts and predict screening-level PTSD 2.5 years and 6.5 years after deployment. Methods: Automated machine learning was applied to data routinely collected 6-8 months after return from deployment from 3 different cohorts of Danish soldiers deployed to Afghanistan in 2009 (cohort 1, N=287 or N=261 depending on the timing of the outcome assessment), 2010 (cohort 2, N=352), and 2013 (cohort 3, N=232). Results: Models transferred well between cohorts. For screening-level PTSD 2.5 and 6.5 years after deployment, random forest models provided the highest accuracy as measured by area under the receiver operating characteristic curve (AUC): 2.5 years, AUC=0.77, 95\% CI 0.71-0.83; 6.5 years, AUC=0.78, 95\% CI 0.73-0.83. Linear models performed equally well. Military rank, hyperarousal symptoms, and total level of PTSD symptoms were highly predictive. Conclusions: Automated machine learning provided validated models that can be readily implemented in future deployment cohorts in the Danish Defense with the aim of targeting postdeployment support interventions to those at highest risk for developing PTSD, provided the cohorts are deployed on similar missions. ", doi="10.2196/17119", url="http://medinform.jmir.org/2020/7/e17119/", url="http://www.ncbi.nlm.nih.gov/pubmed/32706722" } @Article{info:doi/10.2196/16372, author="Faruqui, Akhter Syed Hasib and Alaeddini, Adel and Chang, C. Mike and Shirinkam, Sara and Jaramillo, Carlos and NajafiRad, Peyman and Wang, Jing and Pugh, Jo Mary", title="Summarizing Complex Graphical Models of Multiple Chronic Conditions Using the Second Eigenvalue of Graph Laplacian: Algorithm Development and Validation", journal="JMIR Med Inform", year="2020", month="Jun", day="17", volume="8", number="6", pages="e16372", keywords="graphical models", keywords="graph summarization", keywords="graph Laplacian", keywords="disease network", keywords="multiple chronic conditions", abstract="Background: It is important but challenging to understand the interactions of multiple chronic conditions (MCC) and how they develop over time in patients and populations. Clinical data on MCC can now be represented using graphical models to study their interaction and identify the path toward the development of MCC. However, the current graphical models representing MCC are often complex and difficult to analyze. Therefore, it is necessary to develop improved methods for generating these models. Objective: This study aimed to summarize the complex graphical models of MCC interactions to improve comprehension and aid analysis. Methods: We examined the emergence of 5 chronic medical conditions (ie, traumatic brain injury [TBI], posttraumatic stress disorder [PTSD], depression [Depr], substance abuse [SuAb], and back pain [BaPa]) over 5 years among 257,633 veteran patients. We developed 3 algorithms that utilize the second eigenvalue of the graph Laplacian to summarize the complex graphical models of MCC by removing less significant edges. The first algorithm learns a sparse probabilistic graphical model of MCC interactions directly from the data. The second algorithm summarizes an existing probabilistic graphical model of MCC interactions when a supporting data set is available. The third algorithm, which is a variation of the second algorithm, summarizes the existing graphical model of MCC interactions with no supporting data. Finally, we examined the coappearance of the 100 most common terms in the literature of MCC to validate the performance of the proposed model. Results: The proposed summarization algorithms demonstrate considerable performance in extracting major connections among MCC without reducing the predictive accuracy of the resulting graphical models. For the model learned directly from the data, the area under the curve (AUC) performance for predicting TBI, PTSD, BaPa, SuAb, and Depr, respectively, during the next 4 years is as follows---year 2: 79.91\%, 84.04\%, 78.83\%, 82.50\%, and 81.47\%; year 3: 76.23\%, 80.61\%, 73.51\%, 79.84\%, and 77.13\%; year 4: 72.38\%, 78.22\%, 72.96\%, 77.92\%, and 72.65\%; and year 5: 69.51\%, 76.15\%, 73.04\%, 76.72\%, and 69.99\%, respectively. This demonstrates an overall 12.07\% increase in the cumulative sum of AUC in comparison with the classic multilevel temporal Bayesian network. Conclusions: Using graph summarization can improve the interpretability and the predictive power of the complex graphical models of MCC. ", doi="10.2196/16372", url="http://medinform.jmir.org/2020/6/e16372/", url="http://www.ncbi.nlm.nih.gov/pubmed/32554376" } @Article{info:doi/10.2196/15852, author="Leightley, Daniel and Pernet, David and Velupillai, Sumithra and Stewart, J. Robert and Mark, M. Katharine and Opie, Elena and Murphy, Dominic and Fear, T. Nicola and Stevelink, M. Sharon A.", title="The Development of the Military Service Identification Tool: Identifying Military Veterans in a Clinical Research Database Using Natural Language Processing and Machine Learning", journal="JMIR Med Inform", year="2020", month="May", day="25", volume="8", number="5", pages="e15852", keywords="natural language processing", keywords="machine learning", keywords="military personnel", keywords="electronic health care records", keywords="mental health", keywords="veteran", abstract="Background: Electronic health care records (EHRs) are a rich source of health-related information, with potential for secondary research use. In the United Kingdom, there is no national marker for identifying those who have previously served in the Armed Forces, making analysis of the health and well-being of veterans using EHRs difficult. Objective: This study aimed to develop a tool to identify veterans from free-text clinical documents recorded in a psychiatric EHR database. Methods: Veterans were manually identified using the South London and Maudsley (SLaM) Biomedical Research Centre Clinical Record Interactive Search---a database holding secondary mental health care electronic records for the SLaM National Health Service Foundation Trust. An iterative approach was taken; first, a structured query language (SQL) method was developed, which was then refined using natural language processing and machine learning to create the Military Service Identification Tool (MSIT) to identify if a patient was a civilian or veteran. Performance, defined as correct classification of veterans compared with incorrect classification, was measured using positive predictive value, negative predictive value, sensitivity, F1 score, and accuracy (otherwise termed Youden Index). Results: A gold standard dataset of 6672 free-text clinical documents was manually annotated by human coders. Of these documents, 66.00\% (4470/6672) were then used to train the SQL and MSIT approaches and 34.00\% (2202/6672) were used for testing the approaches. To develop the MSIT, an iterative 2-stage approach was undertaken. In the first stage, an SQL method was developed to identify veterans using a keyword rule--based approach. This approach obtained an accuracy of 0.93 in correctly predicting civilians and veterans, a positive predictive value of 0.81, a sensitivity of 0.75, and a negative predictive value of 0.95. This method informed the second stage, which was the development of the MSIT using machine learning, which, when tested, obtained an accuracy of 0.97, a positive predictive value of 0.90, a sensitivity of 0.91, and a negative predictive value of 0.98. Conclusions: The MSIT has the potential to be used in identifying veterans in the United Kingdom from free-text clinical documents, providing new and unique insights into the health and well-being of this population and their use of mental health care services. ", doi="10.2196/15852", url="http://medinform.jmir.org/2020/5/e15852/", url="http://www.ncbi.nlm.nih.gov/pubmed/32348287" } @Article{info:doi/10.2196/15587, author="Malgaroli, Matteo and Hull, Derrick Thomas and Wiltsey Stirman, Shannon and Resick, Patricia", title="Message Delivery for the Treatment of Posttraumatic Stress Disorder: Longitudinal Observational Study of Symptom Trajectories", journal="J Med Internet Res", year="2020", month="Apr", day="29", volume="22", number="4", pages="e15587", keywords="PTSD", keywords="telemedicine", keywords="messaging", keywords="textmessaging", keywords="psychotherapy", keywords="telehealth", keywords="digital health", abstract="Background: Individuals with posttraumatic stress disorder (PTSD) face symptoms that can hinder access to treatment, such as avoidance and guilt. Telemedicine offers a technological solution to increase access to mental health care and overcome barriers to treatment. Although an increasing body of literature focused on synchronous telehealth (eg, live video), no studies have examined the delivery of PTSD treatment via two-way multimedia messages (ie, texting or messaging). Objective: The aim of this study was to conduct a longitudinal observation of treatment for PTSD delivered using two-way asynchronous messaging. We also sought to identify individual and treatment characteristics that could predict the observed outcome differences. Methods: Outpatients diagnosed with PTSD (N=475) received interventions from licensed therapists, which were delivered via messaging once or more than once per day, 5 days a week for 12 weeks. PTSD symptoms were assessed every 3 weeks using the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-5. Trajectories of PTSD symptoms were identified using growth mixture modeling (GMM). Using logistic regression, the demographic, treatment, and messaging characteristics of patient groups that improved were compared with the characteristics of patient groups that did not improve. Results: The GMM identified 4 trajectories of PTSD symptoms: moderate improvement (197/475, 41.4\%), high symptoms (197/475, 41.4\%), chronic symptoms (61/475, 12.9\%), and acute improvement (20/475, 4.3\%). Patients with a clinically significant reduction in PTSD symptoms (231/475, 48.6\%) were more likely to communicate via video (odds ratio [OR] 1.01, 95\% CI 1.01-1.05; P=.03), have a higher working alliance with their therapist (OR 1.03, 95\% CI 1.01-1.05; P=.02), and be at their first treatment experience (OR 2.03, 95\% CI 1.18-3.54; P=.01). Treatment adherence was associated with greater therapeutic alliance (OR 1.07, 95\% CI 1.03-1.10; P<.001), education (OR 2.13, 95\% CI 1.13-4.03; P=.02), and more patient-generated messages per week (OR 1.08, 95\% CI 1.04-1.13; P<.001). Conclusions: Multimedia message delivery for PTSD treatment showed symptom-reduction rates similar to traditional forms of treatment delivery, suggesting further study of messaging as a treatment medium. Most patients completed an 8-week course, reflecting the acceptability of messaging interventions. Delivering treatment via two-way messaging offers increased opportunities for widespread access to mental health care. ", doi="10.2196/15587", url="http://www.jmir.org/2020/4/e15587/", url="http://www.ncbi.nlm.nih.gov/pubmed/32347814" } @Article{info:doi/10.2196/16423, author="Trail, Thomas and Friedman, Esther and Rutter, M. Carolyn and Tanielian, Terri", title="The Relationship Between Engagement in Online Support Groups and Social Isolation Among Military Caregivers: Longitudinal Questionnaire Study", journal="J Med Internet Res", year="2020", month="Apr", day="23", volume="22", number="4", pages="e16423", keywords="caregivers", keywords="family caregivers", keywords="social isolation", keywords="loneliness", keywords="depression", keywords="social support", keywords="online intervention", keywords="self-help groups", keywords="veterans health", abstract="Background: There is a lack of research on the effectiveness of online peer support groups for reducing social isolation and depressive symptoms among caregivers, and previous research has mixed results. Objective: This study aimed to test whether military caregivers who joined a new online peer support community or engaged with an existing online community experienced decreased perceived social isolation and improved depressive symptoms over 6 months. Methods: We conducted a longitudinal study of 212 military caregivers who had newly joined an online community and those who were members of other military caregiver groups. Multiple indicators of perceived social isolation and depressive symptoms were assessed at baseline and at 3 and 6 months. Results: Compared with caregivers in the comparison group, caregivers who joined the new group experienced less perceived social isolation at 3 months (eg, number of caregivers in social network [unstandardized regression coefficients] b=0.49, SE 0.19, 95\% CI 0.87 to 0.02), but this effect did not persist at 6 months. Those who engaged more with new or existing groups experienced less perceived social isolation over time (eg, number of caregivers in social network b=0.18, SE 0.06, 95\% CI 0.02 to 0.27), and this relationship was mediated by increased interactions with other military caregivers (95\% CI 0.0046 to 0.0961). Engagement with an online group was not associated with improvements in depressive symptoms. Conclusions: Online communities might help reduce social isolation when members engage with the group, but more intensive treatment is needed to improve depressive symptoms. ", doi="10.2196/16423", url="http://www.jmir.org/2020/4/e16423/", url="http://www.ncbi.nlm.nih.gov/pubmed/32324141" } @Article{info:doi/10.2196/14306, author="Tsanas, Athanasios and Woodward, Elizabeth and Ehlers, Anke", title="Objective Characterization of Activity, Sleep, and Circadian Rhythm Patterns Using a Wrist-Worn Actigraphy Sensor: Insights Into Posttraumatic Stress Disorder", journal="JMIR Mhealth Uhealth", year="2020", month="Apr", day="20", volume="8", number="4", pages="e14306", keywords="actigraphy", keywords="sleep", keywords="Geneactiv", keywords="posttraumatic stress disorder", keywords="wearable technology", abstract="Background: Wearables have been gaining increasing momentum and have enormous potential to provide insights into daily life behaviors and longitudinal health monitoring. However, to date, there is still a lack of principled algorithmic framework to facilitate the analysis of actigraphy and objectively characterize day-by-day data patterns, particularly in cohorts with sleep problems. Objective: This study aimed to propose a principled algorithmic framework for the assessment of activity, sleep, and circadian rhythm patterns in people with posttraumatic stress disorder (PTSD), a mental disorder with long-lasting distressing symptoms such as intrusive memories, avoidance behaviors, and sleep disturbance. In clinical practice, these symptoms are typically assessed using retrospective self-reports that are prone to recall bias. The aim of this study was to develop objective measures from patients' everyday lives, which could potentially considerably enhance the understanding of symptoms, behaviors, and treatment effects. Methods: Using a wrist-worn sensor, we recorded actigraphy, light, and temperature data over 7 consecutive days from three groups: 42 people diagnosed with PTSD, 43 traumatized controls, and 30 nontraumatized controls. The participants also completed a daily sleep diary over 7 days and the standardized Pittsburgh Sleep Quality Index questionnaire. We developed a novel approach to automatically determine sleep onset and offset, which can also capture awakenings that are crucial for assessing sleep quality. Moreover, we introduced a new intuitive methodology facilitating actigraphy exploration and characterize day-by-day data across 49 activity, sleep, and circadian rhythm patterns. Results: We demonstrate that the new sleep detection algorithm closely matches the sleep onset and offset against the participants' sleep diaries consistently outperforming an existing open-access widely used approach. Participants with PTSD exhibited considerably more fragmented sleep patterns (as indicated by greater nocturnal activity, including awakenings) and greater intraday variability compared with traumatized and nontraumatized control groups, showing statistically significant (P<.05) and strong associations (|R|>0.3). Conclusions: This study lays the foundation for objective assessment of activity, sleep, and circadian rhythm patterns using passively collected data from a wrist-worn sensor, facilitating large community studies to monitor longitudinally healthy and pathological cohorts under free-living conditions. These findings may be useful in clinical PTSD assessment and could inform therapy and monitoring of treatment effects. ", doi="10.2196/14306", url="http://mhealth.jmir.org/2020/4/e14306/", url="http://www.ncbi.nlm.nih.gov/pubmed/32310142" } @Article{info:doi/10.2196/13682, author="Hiratsuka, Y. Vanessa and Moore, Laurie and Avey, P. Jaedon and Dirks, G. Lisa and Beach, D. Barbara and Dillard, A. Denise and Novins, K. Douglas", title="An Internet-Based Therapeutic Tool for American Indian/Alaska Native Adults With Posttraumatic Stress Disorder: User Testing and Developmental Feasibility Study", journal="JMIR Form Res", year="2019", month="Nov", day="13", volume="3", number="4", pages="e13682", keywords="formative research", keywords="posttraumatic stress disorder", keywords="Web-based intervention", keywords="Indians, North American", abstract="Background: Posttraumatic stress disorder (PTSD) is a major public health concern among American Indian and Alaska Native populations. Primary care clinics are often the first point of contact for American Indian and Alaska Natives seeking health care and are feasible locations for trauma-focused interventions. Objective: Web-based therapeutic interventions have the potential to reduce PTSD symptoms by offering psychoeducation and symptom self-management tools. We investigated the feasibility of a culturally adapted Web-based therapeutic intervention in two American Indian and Alaska Native--serving primary care sites. We developed and tested a self-guided Web-based therapeutic intervention aimed at improving knowledge and awareness of, and provision of guidance, support, and symptom-management for, PTSD symptoms. Methods: A community-based participatory research process was used to refine adaptations to the veteran's administration's PTSD Coach Online, to develop new content, and to guide and interpret the results of the feasibility pilot. This process resulted in a 16-guide intervention ``Health is Our Tradition: Balance and Harmony after Trauma'' website. The feasibility pilot included 24 American Indian and Alaska Natives aged 18 years and older who scored positive on a primary care PTSD screener. Enrolled participants completed a demographic questionnaire, an experience with technology questionnaire, and baseline behavioral health measures. Once measures were complete, research staff described weekly text messages, minimum study expectations for website use, and demonstrated how to use the website. Feasibility measures included self-reported website use, ratings of satisfaction and perceived effectiveness, and website metrics. Feasibility of obtaining measures for an effectiveness trial was also assessed to include behavioral health symptoms and service utilization through self-report instruments and electronic health record queries. Self-reported measures were collected at enrollment and at 6 and 12 weeks post enrollment. Electronic health records were collected from 12 months before study enrollment to 3 months following study enrollment. Changes between enrollment and follow-up were examined with paired t tests, analysis of variance or logistic regression, or the Wilcoxon signed rank test for nonnormally distributed data. Results: The culturally adapted website and associated text message reminders were perceived as satisfactory and effective by participants with no differences by age or gender. The majority of participants (86\%, 19/24) reported use of the website at 6 weeks and nearly all (91\%, 20/22) at 12 weeks. At 6 weeks, 55\% (12/22) of participants reported using the website at the recommended intensity (at least three times weekly), dropping to 36\% (8/22) at 12 weeks. Participant use of modules varied from 8\% (2/24) to 100\% (24/24), with guide completion rates being greater for guides that were only psychoeducational in nature compared with guides that were interactive. There were no significant changes in patterns of diagnoses, screening, medications, or service utilization during exposure to the website. Conclusions: ``Health is Our Tradition: Balance and Harmony after Trauma'' shows promise for an effectiveness pilot. ", doi="10.2196/13682", url="http://formative.jmir.org/2019/4/e13682/", url="http://www.ncbi.nlm.nih.gov/pubmed/31719027" } @Article{info:doi/10.2196/12408, author="Reilly, D. Erin and Robinson, A. Stephanie and Petrakis, Ann Beth and Kuhn, Eric and Pigeon, R. Wilfred and Wiener, Soylemez Renda and McInnes, Keith D. and Quigley, S. Karen", title="Mobile App Use for Insomnia Self-Management: Pilot Findings on Sleep Outcomes in Veterans", journal="Interact J Med Res", year="2019", month="Jul", day="24", volume="8", number="3", pages="e12408", keywords="cognitive behavioral therapy", keywords="mobile apps", keywords="insomnia", keywords="sleep apnea", abstract="Background: Sleep disturbance is a major health concern among US veterans who have served since 2001 in a combat theater in Iraq or Afghanistan. We report subjective and objective sleep results from a pilot trial assessing self-management--guided use of a mobile app (CBT-i Coach, which is based on cognitive behavioral therapy for insomnia) as an intervention for insomnia in military veterans. Objective: The primary aim of this study was to evaluate changes in subjective and objective sleep outcomes from pre to postintervention. Methods: Subjective outcomes included the Insomnia Severity Index, the Pittsburgh Sleep Quality Inventory, and sleep-related functional status. A wearable sleep monitor (WatchPAT) measured objective sleep outcomes, including sleep efficiency, percent rapid eye movement (REM) during sleep, sleep time, and sleep apnea. A total of 38 participants were enrolled in the study, with 18 participants being withdrawn per the protocol because of moderate or severe sleep apnea and 9 others who dropped out or withdrew. Thus, 11 participants completed the full 6-week CBT-i Coach self-management intervention (ie, completers). Results: Completer results indicated significant changes in subjective sleep measures, including reduced reports of insomnia (Z=--2.68, P=.007) from pre (mean 16.63, SD 5.55) to postintervention (mean 12.82, SD 3.74), improved sleep quality (Z=--2.37, P=.02) from pre (mean 12.82, SD 4.60) to postintervention (mean 10.73, SD 3.32), and sleep-related functioning (Z=2.675, P=.007) from pre (mean 13.86, SD 3.69) to postintervention (mean 15.379, SD 2.94). Among the objective measures, unexpectedly, objective sleep time significantly decreased from pre to postintervention ($\chi$22=7.8, P=.02). There were no significant changes in percent REM sleep or sleep efficiency. Conclusions: These findings suggest that the CBT-i Coach app can improve subjective sleep and that incorporating objective sleep measures into future, larger clinical trials or clinical practice may yield important information, particularly by detecting previously undetected sleep apnea. Trial Registration: ClinicalTrials.gov NCT02392000;?http://clinicaltrials.gov/ct2/show/NCT02392000 ", doi="10.2196/12408", url="http://www.i-jmr.org/2019/3/e12408/", url="http://www.ncbi.nlm.nih.gov/pubmed/31342904" } @Article{info:doi/10.2196/13946, author="Wshah, Safwan and Skalka, Christian and Price, Matthew", title="Predicting Posttraumatic Stress Disorder Risk: A Machine Learning Approach", journal="JMIR Ment Health", year="2019", month="Jul", day="22", volume="6", number="7", pages="e13946", keywords="PTSD", keywords="machine learning", keywords="predictive algorithms", abstract="Background: A majority of adults in the United States are exposed to a potentially traumatic event but only a handful go on to develop impairing mental health conditions such as posttraumatic stress disorder (PTSD). Objective: Identifying those at elevated risk shortly after trauma exposure is a clinical challenge. The aim of this study was to develop computational methods to more effectively identify at-risk patients and, thereby, support better early interventions. Methods: We proposed machine learning (ML) induction of models to automatically predict elevated PTSD symptoms in patients 1 month after a trauma, using self-reported symptoms from data collected via smartphones. Results: We show that an ensemble model accurately predicts elevated PTSD symptoms, with an area under the curve (AUC) of .85, using a bag of support vector machines, naive Bayes, logistic regression, and random forest algorithms. Furthermore, we show that only 7 self-reported items (features) are needed to obtain this AUC. Most importantly, we show that accurate predictions can be made 10 to 20 days posttrauma. Conclusions: These results suggest that simple smartphone-based patient surveys, coupled with automated analysis using ML-trained models, can identify those at risk for developing elevated PTSD symptoms and thus target them for early intervention. ", doi="10.2196/13946", url="http://mental.jmir.org/2019/7/e13946/", url="http://www.ncbi.nlm.nih.gov/pubmed/31333201" } @Article{info:doi/10.2196/11909, author="Jones, Matthew and Denisova, Alena and Mitchell, Stephen and Owen, Tom", title="Acceptability of a Plasticity-Focused Serious Game Intervention for Posttraumatic Stress Disorder: User Requirements Analysis", journal="JMIR Serious Games", year="2019", month="Apr", day="16", volume="7", number="2", pages="e11909", keywords="PTSD", keywords="mobile applications", keywords="neuronal plasticity", keywords="cognitive behavioral therapy", abstract="Background: Trauma-focused cognitive behavioral therapy (TF-CBT) is a first-line treatment for posttraumatic stress disorder (PTSD). Despite a solid evidence base, TF-CBT response and attrition rates vary considerably. Plasticity-focused interventions, including the use of serious games, have the potential to improve TF-CBT response and treatment retention. Objective: The aim of this study was to assess the acceptability of a mobile phone--delivered plasticity-focused serious game to improve response to TF-CBT for PTSD, and carry out a user requirements analysis should the development of a prototype be warranted. Methods: We conducted 2 one-to-one interviews (n=2), one focus group involving service users who had received a diagnosis of PTSD (n=3) and one focus group involving psychological trauma service clinicians (n=4). Results: We found that the concept of a plasticity-focused mobile phone intervention for PTSD is acceptable to patients and clinicians. Service users and clinicians both believed that the usage should be guided by a therapist, and both contributed useful inputs regarding the audiovisual aspects of the proposed serious game. It was accepted that the game would not be suitable for all patients and that clinicians would need to appropriately prescribe the usage of the game. Conclusions: The findings highlight the acceptability of the proposed serious game and clarify the user requirements for such an intervention. It is the intention of the authors to carry out a user experience evaluation using a prototype serious game in a clinical population. ", doi="10.2196/11909", url="http://games.jmir.org/2019/2/e11909/", url="http://www.ncbi.nlm.nih.gov/pubmed/30990461" } @Article{info:doi/10.2196/jmir.9240, author="Tielman, L. Myrthe and Neerincx, A. Mark and Brinkman, Willem-Paul", title="Design and Evaluation of Personalized Motivational Messages by a Virtual Agent that Assists in Post-Traumatic Stress Disorder Therapy", journal="J Med Internet Res", year="2019", month="Mar", day="27", volume="21", number="3", pages="e9240", keywords="mental health", keywords="motivation", keywords="trust", keywords="user-computer interface", keywords="PTSD", keywords="computer assisted therapy", abstract="Background: Systems incorporating virtual agents can play a major role in electronic-mental (e-mental) health care, as barriers to care still prevent some patients from receiving the help they need. To properly assist the users of these systems, a virtual agent needs to promote motivation. This can be done by offering motivational messages. Objective: The objective of this study was two-fold. The first was to build a motivational message system for a virtual agent assisting in post-traumatic stress disorder (PTSD) therapy based on domain knowledge from experts. The second was to test the hypotheses that (1) computer-generated motivating messages influence users' motivation to continue with therapy, trust in a good therapy outcome, and the feeling of being heard by the agent and (2) personalized messages outperform generic messages on these factors. Methods: A system capable of generating motivational messages was built by analyzing expert (N=13) knowledge on what types of motivational statements to use in what situation. To test the 2 hypotheses, a Web-based study was performed (N=207). Participants were asked to imagine they were in a certain situation, specified by the progression of their symptoms and initial trust in a good therapy outcome. After this, they received a message from a virtual agent containing either personalized motivation as generated by the system, general motivation, or no motivational content. They were asked how this message changed their motivation to continue and trust in a good outcome as well as how much they felt they were being heard by the agent. Results: Overall, findings confirmed the first hypothesis, as well as the second hypothesis for the measure feeling of being heard by the agent. Personalization of the messages was also shown to be important in those situations where the symptoms were getting worse. In these situations, personalized messages outperformed general messages both in terms of motivation to continue and trust in a good therapy outcome. Conclusions: Expert input can successfully be used to develop a personalized motivational message system. Messages generated by such a system seem to improve people's motivation and trust in PTSD therapy as well as the user's feeling of being heard by a virtual agent. Given the importance of motivation, trust, and therapeutic alliance for successful therapy, we anticipate that the proposed system can improve adherence in e-mental therapy for PTSD and that it can provide a blueprint for the development of an adaptive system for persuasive messages based on expert input. ", doi="10.2196/jmir.9240", url="http://www.jmir.org/2019/3/e9240/", url="http://www.ncbi.nlm.nih.gov/pubmed/30916660" } @Article{info:doi/10.2196/10309, author="Benight, C. Charles and Shoji, Kotaro and Yeager, M. Carolyn and Weisman, Pamela and Boult, E. Terrance", title="Predicting Change in Posttraumatic Distress Through Change in Coping Self-Efficacy After Using the My Trauma Recovery eHealth Intervention: Laboratory Investigation", journal="JMIR Ment Health", year="2018", month="Nov", day="29", volume="5", number="4", pages="e10309", keywords="eHealth", keywords="posttraumatic stress disorder (PTSD)", keywords="coping self-efficacy (CSE)", keywords="trauma triggers", keywords="relaxation", keywords="digital behavior change interventions (DBCI)", keywords="internet", abstract="Background: Technology offers a unique platform for delivering trauma interventions (ie, eHealth) to support trauma-exposed populations. It is important to evaluate mechanisms of therapeutic change in reducing posttraumatic distress in eHealth for trauma survivors. Objective: This study evaluated a proactive, scalable, and individually responsive eHealth intervention for trauma survivors called My Trauma Recovery. My Trauma Recovery is an eHealth intervention aiming to support trauma survivors and consisting of 6 modules: relaxation, triggers, self-talk, professional help, unhelpful coping, and social support. It was designed to enhance trauma coping self-efficacy (CSE). We tested 3 hypotheses. First, My Trauma Recovery would decrease posttraumatic stress symptoms (PTSS). Second, My Trauma Recovery would increase CSE. And last, changes in CSE would be negatively correlated with changes in PTSS. Methods: A total of 92 individuals exposed to trauma (78/92, 85\% females, mean age 34.80 years) participated. Our study was part of a larger investigation and consisted of 3 sessions 1 week apart. Participants completed the baseline online survey assessing PTSS and CSE. Each session included completing assigned modules followed by the online survey assessing CSE. PTSS was remeasured at the end of the last module. Results: PTSS significantly declined from T1 to T9 (F1,90=23.63, P<.001, $\eta$2p=.21) supporting the clinical utility of My Trauma Recovery. Significant increases in CSE for sessions 1 and 2 (F8,83=7.51, P<.001) were found. No significant change in CSE was found during session 3 (N=92). The residualized scores between PTSS T1 and T9 and between CSE T1 and T9 were calculated. The PTSS residualized score and the CSE residualized score were significantly correlated, r=--.26, P=.01. Results for each analysis with a probable PTSD subsample were consistent. Conclusions: The findings of our study show that participants working through My Trauma Recovery report clinically lower PTSS after 3 weeks. The results also demonstrate that CSE is an important self-appraisal factor that increased during sessions 1 and 2. These improvements are correlated with reductions in PTSS. Thus, changes in CSE may be an important mechanism for reductions in PTSS when working on a self-help trauma recovery website and may be an important target for eHealth interventions for trauma. These findings have important implications for trauma eHealth interventions. ", doi="10.2196/10309", url="http://mental.jmir.org/2018/4/e10309/", url="http://www.ncbi.nlm.nih.gov/pubmed/30497992" } @Article{info:doi/10.2196/jmir.9795, author="Ennis, Naomi and Sijercic, Iris and Monson, M. Candice", title="Internet-Delivered Early Interventions for Individuals Exposed to Traumatic Events: Systematic Review", journal="J Med Internet Res", year="2018", month="Nov", day="14", volume="20", number="11", pages="e280", keywords="psychological trauma", keywords="secondary prevention", keywords="trauma and stressor-related disorders", keywords="internet", abstract="Background: Over 75\% of individuals are exposed to a traumatic event, and a substantial minority goes on to experience mental health problems that can be chronic and pernicious in their lifetime. Early interventions show promise for preventing trauma following psychopathology; however, a face-to-face intervention can be costly, and there are many barriers to accessing this format of care. Objective: The aim of this study was to systematically review studies of internet-delivered early interventions for trauma-exposed individuals. Methods: A literature search was conducted in PsycINFO and PubMed for papers published between 1991 and 2017. Papers were included if the following criteria were met: (1) an internet-based intervention was described and applied to individuals exposed to a traumatic event; (2) the authors stated that the intervention was intended to be applied early following trauma exposure or as a preventive intervention; and (3) data on mental health symptoms at pre-and postintervention were described (regardless of whether these were primary outcomes). Methodological quality of included studies was assessed using the Downs and Black checklist. Results: The interventions in the 7 studies identified were categorized as selected (ie, delivered to an entire sample after trauma regardless of psychopathology symptoms) or indicated (ie, delivered to those endorsing some level of posttraumatic distress). Selected interventions did not produce significant symptom improvement compared with treatment-as-usual or no intervention control groups. However, indicated interventions yielded significant improvements over other active control conditions on mental health outcomes. Conclusions: Consistent with the notion that many experience natural recovery following trauma, results imply that indicated early internet-delivered interventions hold the most promise in future prevention efforts. More studies that use rigorous methods and clearly defined outcomes are needed to evaluate the efficacy of early internet-delivered interventions. Moreover, basic research on risk and resilience factors following trauma exposure is necessary to inform indicated internet-delivered interventions. ", doi="10.2196/jmir.9795", url="https://www.jmir.org/2018/11/e280/", url="http://www.ncbi.nlm.nih.gov/pubmed/30429113" } @Article{info:doi/10.2196/10748, author="Connolly, L. Samantha and Miller, J. Christopher and Koenig, J. Christopher and Zamora, A. Kara and Wright, B. Patricia and Stanley, L. Regina and Pyne, M. Jeffrey", title="Veterans' Attitudes Toward Smartphone App Use for Mental Health Care: Qualitative Study of Rurality and Age Differences", journal="JMIR Mhealth Uhealth", year="2018", month="Aug", day="22", volume="6", number="8", pages="e10748", keywords="smartphone apps", keywords="mobile phone", keywords="mhealth", keywords="mental health", keywords="qualitative analysis", keywords="rurality", keywords="age", keywords="veterans", keywords="depression", keywords="anxiety disorders", keywords="posttraumatic stress disorder", keywords="PTSD", keywords="alcohol abuse", abstract="Background: Mental health smartphone apps provide support, skills, and symptom tracking on demand and come at minimal to no additional cost to patients. Although the Department of Veterans Affairs has established itself as a national leader in the creation of mental health apps, veterans' attitudes regarding the use of these innovations are largely unknown, particularly among rural and aging populations who may benefit from increased access to care. Objective: The objective of our study was to examine veterans' attitudes toward smartphone apps and to assess whether openness toward this technology varies by age or rurality. Methods: We conducted semistructured qualitative interviews with 66 veterans from rural and urban areas in Maine, Arkansas, and California. Eligible veterans aged 18 to 70 years had screened positive for postraumatic stress disorder (PTSD), alcohol use disorder, or major depressive disorder, but a history of mental health service utilization was not required. Interviews were digitally recorded, professionally transcribed, and coded by a research team using an established codebook. We then conducted a thematic analysis of segments pertaining to smartphone use, informed by existing theories of technology adoption. Results: Interviews revealed a marked division regarding openness to mental health smartphone apps, such that veterans either expressed strongly positive or negative views about their usage, with few participants sharing ambivalent or neutral opinions. Differences emerged between rural and urban veterans' attitudes, with rural veterans tending to oppose app usage, describe smartphones as hard to navigate, and cite barriers such as financial limitations and connectivity issues, more so than urban populations. Moreover, rural veterans more often described smartphones as being opposed to their values. Differences did not emerge between younger and older (?50) veterans regarding beliefs that apps could be effective or compatible with their culture and identity. However, compared with younger veterans, older veterans more often reported not owning a smartphone and described this technology as being difficult to use. Conclusions: Openness toward the use of smartphone apps in mental health treatment may vary based on rurality, and further exploration of the barriers cited by rural veterans is needed to improve access to care. In addition, findings indicate that older patients may be more open to integrating technology into their mental health care than providers might assume, although such patients may have more trouble navigating these devices and may benefit from simplified app designs or smartphone training. Given the strong opinions expressed either for or against smartphone apps, our findings suggest that apps may not be an ideal adjunctive treatment for all patients, but it is important to identify those who are open to and may greatly benefit from this technology. ", doi="10.2196/10748", url="http://mhealth.jmir.org/2018/8/e10748/", url="http://www.ncbi.nlm.nih.gov/pubmed/30135050" } @Article{info:doi/10.2196/10277, author="Abraham, H. Traci and Marchant-Miros, Kathy and McCarther, B. Michael and Craske, G. Michelle and Curran, M. Geoffrey and Kearney, K. Lisa and Greene, Carolyn and Lindsay, A. Jan and Cucciare, A. Michael", title="Adapting Coordinated Anxiety Learning and Management for Veterans Affairs Community-Based Outpatient Clinics: Iterative Approach", journal="JMIR Ment Health", year="2018", month="Aug", day="22", volume="5", number="3", pages="e10277", keywords="therapy", keywords="veterans", keywords="depression", keywords="anxiety disorders", keywords="posttraumatic stress disorder", keywords="PTSD", abstract="Background: A national priority at the US Department of Veterans Affairs (VA) is to increase the availability and accessibility of evidence-based psychotherapies (EBPs) across all VA medical facilities. Yet many veterans, particularly those who use remote outpatient VA clinics, still do not receive much needed evidence-based treatment. Strategies are needed for supporting mental health providers at rural VA community-based outpatient clinics (CBOCs) as they translate their clinical training to routine practice. The Coordinated Anxiety Learning Management (CALM) program is a computer-delivered program that supports the delivery of cognitive behavioral therapy (CBT) by providers in outpatient settings to patients with depression and anxiety, including posttraumatic stress disorder. Objective: The objectives of our study were to (1) adapt an existing computer-based program to rural VA CBOCs through feedback from key stakeholder focus groups; (2) develop a prototype of the adapted program; and (3) determine the adapted program's acceptability and feasibility. Mental health stakeholders included VA leaders (n=4) in the implementation of EBPs, VA experts (n=4) in CBT, VA CBOC mental health providers (n=8), and veterans (n=8) diagnosed with a mental health condition treated using the CALM program and receiving treatment in a VA CBOC. Methods: An iterative approach comprising 3 waves of focus group discussions was used to develop a modified prototype of CALM. Following each wave of focus group discussions, template analysis was used to rapidly communicate stakeholder recommendations and feedback to the design team. The original program was first adapted through a process of data collection, design modification, and product development. Next, a prototype was developed. Finally, the redesigned program was tested for acceptability and feasibility through a live demonstration. Results: Key stakeholders suggested modifications to the original CALM program that altered its modules' appearance by incorporating veteran-centric content. These modifications likely have no impact on the integrity of the original CALM program, but have altered its content to reflect better the demographic characteristics and experiences of rural veterans. Feedback from stakeholder groups indicates that changes will help VA patients identify with the program content, potentially enhancing their treatment engagement. Conclusions: The development model was effective for economically gathering actionable recommendations from stakeholders to adapt a computer-based program, and it can result in the development of an acceptable and feasible computer-delivered intervention. Results have implications for developing computer-based programs targeting behavior change more broadly and enhancing engagement in EBP. ", doi="10.2196/10277", url="http://mental.jmir.org/2018/3/e10277/", url="http://www.ncbi.nlm.nih.gov/pubmed/30135051" } @Article{info:doi/10.2196/games.9327, author="Grant, Sean and Spears, Asya and Pedersen, R. Eric", title="Video Games as a Potential Modality for Behavioral Health Services for Young Adult Veterans: Exploratory Analysis", journal="JMIR Serious Games", year="2018", month="Jul", day="26", volume="6", number="3", pages="e15", keywords="behavioral health", keywords="replication", keywords="veterans", keywords="video games", abstract="Background: Improving the reach of behavioral health services to young adult veterans is a policy priority. Objective: The objective of our study was to explore differences in video game playing by behavioral health need for young adult veterans to identify potential conditions for which video games could be used as a modality for behavioral health services. Methods: We replicated analyses from two cross-sectional, community-based surveys of young adult veterans in the United States and examined the differences in time spent playing video games by whether participants screened positive for behavioral health issues and received the required behavioral health services. Results: Pooling data across studies, participants with a positive mental health screen for depression or posttraumatic stress disorder (PTSD) spent 4.74 more hours per week (95\% CI 2.54-6.94) playing video games. Among participants with a positive screen for a substance use disorder, those who had received substance use services since discharge spent 0.75 more days per week (95\% CI 0.28-1.21) playing video games than participants who had not received any substance use services since discharge. Conclusions: We identified the strongest evidence that participants with a positive PTSD or depression screen and participants with a positive screen for a substance use disorder who also received substance use services since their discharge from active duty spent more time playing video games. Future development and evaluation of video games as modalities for enhancing and increasing access to behavioral health services should be explored for this population. ", doi="10.2196/games.9327", url="http://games.jmir.org/2018/3/e15/", url="http://www.ncbi.nlm.nih.gov/pubmed/30049668" } @Article{info:doi/10.2196/10078, author="Teo, R. Alan and Liebow, BL Samuel and Chan, Benjamin and Dobscha, K. Steven and Graham, L. Amanda", title="Reaching Those At Risk for Psychiatric Disorders and Suicidal Ideation: Facebook Advertisements to Recruit Military Veterans", journal="JMIR Ment Health", year="2018", month="Jul", day="05", volume="5", number="3", pages="e10078", keywords="Facebook", keywords="social media", keywords="methodology", keywords="Veterans Affairs", keywords="veterans", abstract="Background: Younger military veterans are at high risk for psychiatric disorders and suicide. Reaching and engaging veterans in mental health care and research is challenging. Social media platforms may be an effective channel to connect with veterans. Objective: This study tested the effectiveness of Facebook advertisements in reaching and recruiting Iraq and Afghanistan-era military veterans in a research study focused on mental health. Methods: Facebook ads requesting participation in an online health survey ran for six weeks in 2017. Ads varied imagery and headlines. Validated instruments were used to screen for psychiatric disorders and suicidality. Outcomes included impressions, click-through rate, survey completion, and cost per survey completed. Results: Advertisements produced 827,918 impressions, 9,527 clicks, and 587 survey completions. Lack of enrollment in Veterans Affairs health care (193/587, 33\%) and positive screens for current mental health problems were common, including posttraumatic stress disorder (266/585, 45\%), problematic drinking (243/584, 42\%), major depression (164/586, 28\%), and suicidality (132/585, 23\%). Approximately half of the survey participants (285/587, 49\%) were recruited with just 2 of the 15 ads, which showed soldiers marching tied to an ``incentive'' or ``sharing'' headline. These 2 ads were also the most cost-effective, at US \$4.88 and US \$5.90 per participant, respectively. Among veterans with current suicidal ideation, the survey-taking image resulted in higher survey completion than the soldiers marching image (P=.007). Conclusions: Facebook advertisements are effective in rapidly and inexpensively reaching military veterans, including those at risk for mental health problems and suicidality, and those not receiving Veterans Affairs health care. Advertisement image and headlines may help optimize the effectiveness of advertisements for specific subgroups. ", doi="10.2196/10078", url="http://mental.jmir.org/2018/3/e10078/", url="http://www.ncbi.nlm.nih.gov/pubmed/29980498" } @Article{info:doi/10.2196/10415, author="Ng, Ada and Reddy, Madhu and Zalta, K. Alyson and Schueller, M. Stephen", title="Veterans' Perspectives on Fitbit Use in Treatment for Post-Traumatic Stress Disorder: An Interview Study", journal="JMIR Ment Health", year="2018", month="Jun", day="15", volume="5", number="2", pages="e10415", keywords="fitness trackers", keywords="patient generated health data", keywords="consumer health informatics", keywords="stress disorders, post-traumatic", keywords="PTSD", keywords="mental health", keywords="veterans", abstract="Background: The increase in availability of patient data through consumer health wearable devices and mobile phone sensors provides opportunities for mental health treatment beyond traditional self-report measurements. Previous studies have suggested that wearables can be effectively used to benefit the physical health of people with mental health issues, but little research has explored the integration of wearable devices into mental health care. As such, early research is still necessary to address factors that might impact integration including patients' motivations to use wearables and their subsequent data. Objective: The aim of this study was to gain an understanding of patients' motivations to use or not to use wearables devices during an intensive treatment program for post-traumatic stress disorder (PTSD). During this treatment, they received a complementary Fitbit. We investigated the following research questions: How did the veterans in the intensive treatment program use their Fitbit? What are contributing motivators for the use and nonuse of the Fitbit? Methods: We conducted semistructured interviews with 13 veterans who completed an intensive treatment program for PTSD. We transcribed and analyzed interviews using thematic analysis. Results: We identified three major motivations for veterans to use the Fitbit during their time in the program: increase self-awareness, support social interactions, and give back to other veterans. We also identified three major reasons certain features of the Fitbit were not used: lack of clarity around the purpose of the Fitbit, lack of meaning in the Fitbit data, and challenges in the veteran-provider relationship. Conclusions: To integrate wearable data into mental health treatment programs, it is important to understand the patient's perspectives and motivations in using wearables. We also discuss how the military culture and PTSD may have contributed to our participants' behaviors and attitudes toward Fitbit usage. We conclude with possible approaches for integrating patient-generated data into mental health treatment settings that may address the challenges we identified. ", doi="10.2196/10415", url="http://mental.jmir.org/2018/2/e10415/", url="http://www.ncbi.nlm.nih.gov/pubmed/29907556" } @Article{info:doi/10.2196/10048, author="Bauer, M. Amy and Hodsdon, Sarah and Bechtel, M. Jared and Fortney, C. John", title="Applying the Principles for Digital Development: Case Study of a Smartphone App to Support Collaborative Care for Rural Patients With Posttraumatic Stress Disorder or Bipolar Disorder", journal="J Med Internet Res", year="2018", month="Jun", day="06", volume="20", number="6", pages="e10048", keywords="mHealth", keywords="mental health", keywords="primary health care", keywords="rural health", keywords="post-traumatic stress disorders", keywords="PTSD", keywords="bipolar disorder", keywords="depression", abstract="Background: Despite a proliferation of patient-facing mobile apps for mental disorders, there is little literature guiding efforts to incorporate mobile tools into clinical care delivery and integrate patient-generated data into care processes for patients with complex psychiatric disorders. Objective: The aim of this study was to seek to gain an understanding of how to incorporate a patient-provider mobile health (mHealth) platform to support the delivery of integrated primary care--based mental health services (Collaborative Care) to rural patients with posttraumatic stress disorder and/or bipolar disorder. Methods: Using the Principles for Digital Development as a framework, we describe our experience designing, developing, and deploying a mobile system to support Collaborative Care. The system consists of a patient-facing smartphone app that integrates with a Web-based clinical patient registry used by behavioral health care managers and consulting psychiatrists. Throughout development, we engaged representatives from the system's two user types: (1) providers, who use the Web-based registry and (2) patients, who directly use the mobile app. We extracted mobile metadata to describe the early adoption and use of the system by care managers and patients and report preliminary results from an in-app patient feedback survey that includes a System Usability Scale (SUS). Results: Each of the nine Principles for Digital Development is illustrated with examples. The first 10 patients to use the smartphone app have completed symptom measures on average every 14 days over an average period of 20 weeks. The mean SUS score at week 8 among four patients who completed this measure was 91.9 (range 72.5-100). We present lessons learned about the technical and training requirements for integration into practice that can inform future efforts to incorporate health technologies to improve care for patients with psychiatric conditions. Conclusions: Adhering to the Principles for Digital Development, we created and deployed an mHealth system to support Collaborative Care for patients with complex psychiatric conditions in rural health centers. Preliminary data among the initial users support high system usability and show promise for sustained use. On the basis of our experience, we propose five additional principles to extend this framework and inform future efforts to incorporate health technologies to improve care for patients with psychiatric conditions: design for public health impact, add value for all users, test the product and the process, acknowledge disruption, and anticipate variability. ", doi="10.2196/10048", url="http://www.jmir.org/2018/6/e10048/" } @Article{info:doi/10.2196/mental.9449, author="Yeager, M. Carolyn and Shoji, Kotaro and Luszczynska, Aleksandra and Benight, C. Charles", title="Engagement With a Trauma Recovery Internet Intervention Explained With the Health Action Process Approach (HAPA): Longitudinal Study", journal="JMIR Ment Health", year="2018", month="Apr", day="10", volume="5", number="2", pages="e29", keywords="electronic health (eHealth)", keywords="engagement", keywords="trauma", keywords="stress disorders, post-traumatic", keywords="PTSD", keywords="Health Action Process Approach (HAPA)", keywords="outcome expectations", keywords="internet", keywords="digital health intervention", abstract="Background: There has been a growing trend in the delivery of mental health treatment via technology (ie, electronic health, eHealth). However, engagement with eHealth interventions is a concern, and theoretically based research in this area is sparse. Factors that influence engagement are poorly understood, especially in trauma survivors with symptoms of posttraumatic stress. Objective: The aim of this study was to examine engagement with a trauma recovery eHealth intervention using the Health Action Process Approach theoretical model. Outcome expectancy, perceived need, pretreatment self-efficacy, and trauma symptoms influence the formation of intentions (motivational phase), followed by planning, which mediates the translation of intentions into engagement (volitional phase). We hypothesized the mediational effect of planning would be moderated by level of treatment self-efficacy. Methods: Trauma survivors from around the United States used the eHealth intervention for 2 weeks. We collected baseline demographic, social cognitive predictors, and distress symptoms and measured engagement subjectively and objectively throughout the intervention. Results: The motivational phase model explained 48\% of the variance, and outcome expectations (beta=.36), perceived need (beta=.32), pretreatment self-efficacy (beta=.13), and trauma symptoms (beta=.21) were significant predictors of intention (N=440). In the volitional phase, results of the moderated mediation model indicated for low levels of treatment self-efficacy, planning mediated the effects of intention on levels of engagement (B=0.89, 95\% CI 0.143-2.605; N=115). Conclusions: Though many factors can affect engagement, these results offer a theoretical framework for understanding engagement with an eHealth intervention. This study highlighted the importance of perceived need, outcome expectations, self-efficacy, and baseline distress symptoms in the formation of intentions to use the intervention. For those low in treatment self-efficacy, planning may play an important role in the translation of intentions into engagement. Results of this study may help bring some clarification to the question of what makes eHealth interventions work. ", doi="10.2196/mental.9449", url="http://mental.jmir.org/2018/2/e29/", url="http://www.ncbi.nlm.nih.gov/pubmed/29636323" } @Article{info:doi/10.2196/resprot.9006, author="Visser, Eva and Gosens, Taco and Den Oudsten, Brenda and De Vries, Jolanda", title="Physical Trauma Patients with Symptoms of an Acute and Posttraumatic Stress Disorder: Protocol for an Observational Prospective Cohort Study", journal="JMIR Res Protoc", year="2018", month="Mar", day="29", volume="7", number="3", pages="e88", keywords="acute stress disorder", keywords="posttraumatic stress disorder", keywords="PTSD", keywords="ASD", keywords="trauma", keywords="injury", keywords="observational study", keywords="qualitative study", keywords="focus groups", abstract="Background: Injury, medical treatment, and rehabilitation can have major impacts on patients' wellbeing. About 25-33\% of the patients experience an acute stress disorder (ASD) or a posttraumatic stress disorder (PTSD) after injury. ASD is a relatively new diagnosis. Therefore, knowledge about patients' experiences, the course of ASD and PTSD, and who is at risk for developing ASD or PTSD is lacking. Objective: The aims of this multi-method study are to explore patients' experiences with injury (and their care) using a focus group study. Then, in the observational study, different courses of ASD, PTSD, and quality of life will be examined. In addition, this study will examine if these courses could be characterized by socio-demographic, clinical, and psychological variables. Consequently, a risk profile will be developed to determine which patients are at risk for developing ASD or PTSD during the 12 months after injury. Methods: Trauma patients treated in the shock room (in 2015) of the Elisabeth-TweeSteden Hospital will share their experiences with injury in the focus group study. Open, axial, and selective coding will be used to analyze the data. Concerning the observational study, patients treated in the shock room (during 2016 and 2017, Elisabeth-TweeSteden Hospital and Erasmus Medical Centre) will be asked to participate. The inclusion period is 12 months. Participants will complete the Impact of Event Scale-Revised, MINI-plus, the Hospital Anxiety and Depression Scale, and the World Health Organization Quality of Life-BREF after inclusion and at 3, 6, 9, and 12 months after injury. The NEO-Five Factor Inventory and the State-Trait Anxiety Inventory-Trait are completed after inclusion only. Repeated measures of latent class analysis and linear mixed models will be used to examine the research aims. Results: This project was funded in August 2015 by ZonMw. The results of the focus group study are expected in the first trimester of 2018. With regard to the observational study, recruitment is currently underway. Data collection will be completed in November 2018. The first results will be expected in the first trimester of 2019. Conclusions: This is the first multi-method study in trauma patients that examines patients' experiences (qualitative design) as well as psychological disorders (observational prospective). This study will contribute to necessary information on psychological consequences after injury. Moreover, it provides knowledge about which patients to include in future psychological intervention research. Finally, awareness in clinicians about the psychological consequences can be created, so they are able to act more effectively to provide patient-oriented care. Trial Registration: Netherlands Trial Registry NTR6258; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6258 (Archived by WebCite at http://www.webcitation.org/6xSCiO1bS) ", doi="10.2196/resprot.9006", url="http://www.researchprotocols.org/2018/3/e88/", url="http://www.ncbi.nlm.nih.gov/pubmed/29599104" } @Article{info:doi/10.2196/jmir.9007, author="Teo, R. Alan and Marsh, E. Heather and Liebow, L. Samuel B. and Chen, I. Jason and Forsberg, W. Christopher and Nicolaidis, Christina and Saha, Somnath and Dobscha, K. Steven", title="Help-Seeking on Facebook Versus More Traditional Sources of Help: Cross-Sectional Survey of Military Veterans", journal="J Med Internet Res", year="2018", month="Feb", day="26", volume="20", number="2", pages="e62", keywords="social media", keywords="social networking sites", keywords="internet", keywords="Facebook", keywords="service use", keywords="utilization", keywords="treatment-seeking", abstract="Background: The media has devoted significant attention to anecdotes of individuals who post messages on Facebook prior to suicide. However, it is unclear to what extent social media is perceived as a source of help or how it compares to other sources of potential support for mental health problems. Objective: This study aimed to evaluate the degree to which military veterans with depression use social media for help-seeking in comparison to other more traditional sources of help. Methods: Cross-sectional self-report survey of 270 adult military veterans with probable major depression. Help-seeking intentions were measured with a modified General Help-Seeking Questionnaire. Facebook users and nonusers were compared via t tests, Chi-square, and mixed effects regression models. Associations between types of help-seeking were examined using mixed effects models. Results: The majority of participants were users of social media, primarily Facebook (n=162). Mean overall help-seeking intentions were similar between Facebook users and nonusers, even after adjustment for potential confounders. Facebook users were very unlikely to turn to Facebook as a venue for support when experiencing either emotional problems or suicidal thoughts. Compared to help-seeking intentions for Facebook, help-seeking intentions for formal (eg, psychologists), informal (eg, friends), or phone helpline sources of support were significantly higher. Results did not substantially change when examining users of other social media, women, or younger adults. Conclusions: In its current form, the social media platform Facebook is not seen as a venue to seek help for emotional problems or suicidality among veterans with major depression in the United States. ", doi="10.2196/jmir.9007", url="http://www.jmir.org/2018/2/e62/", url="http://www.ncbi.nlm.nih.gov/pubmed/29483064" } @Article{info:doi/10.2196/mhealth.7318, author="Rodriguez-Paras, Carolina and Tippey, Kathryn and Brown, Elaine and Sasangohar, Farzan and Creech, Suzannah and Kum, Hye-Chung and Lawley, Mark and Benzer, K. Justin", title="Posttraumatic Stress Disorder and Mobile Health: App Investigation and Scoping Literature Review", journal="JMIR Mhealth Uhealth", year="2017", month="Oct", day="26", volume="5", number="10", pages="e156", keywords="posttraumatic stress disorders", keywords="PTSD", keywords="mobile health", keywords="mHealth", keywords="anxietys", abstract="Background: Posttraumatic stress disorder (PTSD) is a prevalent mental health issue among veterans. Access to PTSD treatment is influenced by geographic (ie, travel distance to facilities), temporal (ie, time delay between services), financial (ie, eligibility and cost of services), and cultural (ie, social stigma) barriers. Objective: The emergence of mobile health (mHealth) apps has the potential to bridge many of these access gaps by providing remote resources and monitoring that can offer discrete assistance to trauma survivors with PTSD and enhance patient-clinician relationships. In this study, we investigate the current mHealth capabilities relevant to PTSD. Methods: This study consists of two parts: (1) a review of publicly available PTSD apps designed to determine the availability of PTSD apps, which includes more detailed information about three dominant apps and (2) a scoping literature review performed using a systematic method to determine app usage and efforts toward validation of such mHealth apps. App usage relates to how the end users (eg, clinicians and patients) are interacting with the app, whereas validation is testing performed to ensure the app's purpose and specifications are met. Results: The results suggest that though numerous apps have been developed to aid in the diagnosis and treatment of PTSD symptoms, few apps were designed to be integrated with clinical PTSD treatment, and minimal efforts have been made toward enhancing the usability and validation of PTSD apps. Conclusions: These findings expose the need for studies relating to the human factors evaluation of such tools, with the ultimate goal of increasing access to treatment and widening the app adoption rate for patients with PTSD. ", doi="10.2196/mhealth.7318", url="http://mhealth.jmir.org/2017/10/e156/", url="http://www.ncbi.nlm.nih.gov/pubmed/29074470" } @Article{info:doi/10.2196/mental.5558, author="Simblett, Sara and Birch, Jennifer and Matcham, Faith and Yaguez, Lidia and Morris, Robin", title="A Systematic Review and Meta-Analysis of e-Mental Health Interventions to Treat Symptoms of Posttraumatic Stress", journal="JMIR Ment Health", year="2017", month="May", day="17", volume="4", number="2", pages="e14", keywords="e-Mental Health", keywords="PTSD", keywords="psychological treatment", keywords="systematic review", keywords="meta-analysis", abstract="Background: Posttraumatic stress disorder (PTSD) is a stress disorder characterized by unwanted intrusive re-experiencing of an acutely distressing, often life-threatening, event, combined with symptoms of hyperarousal, avoidance, as well as negative thoughts and feelings. Evidence-based psychological interventions have been developed to treat these symptoms and reduce distress, the majority of which were designed to be delivered face-to-face with trained therapists. However, new developments in the use of technology to supplement and extend health care have led to the creation of e-Mental Health interventions. Objective: Our aim was to assess the scope and efficacy of e-Mental Health interventions to treat symptoms of PTSD. Methods: The following databases were systematically searched to identify randomized controlled trials of e-Mental Health interventions to treat symptoms of PTSD as measured by standardized and validated scales: the Cochrane Library, MEDLINE, EMBASE, and PsycINFO (in March 2015 and repeated in November 2016). Results: A total of 39 studies were found during the systematic review, and 33 (N=3832) were eligible for meta-analysis. The results of the primary meta-analysis revealed a significant improvement in PTSD symptoms, in favor of the active intervention group (standardized mean difference=-0.35, 95\% confidence interval -0.45 to -0.25, P<.001, I2=81\%). Several sensitivity and subgroup analyses were performed suggesting that improvements in PTSD symptoms remained in favor of the active intervention group independent of the comparison condition, the type of cognitive behavioral therapy-based intervention, and the level of guidance provided. Conclusions: This review demonstrates an emerging evidence base supporting e-Mental Health to treat symptoms of PTSD. ", doi="10.2196/mental.5558", url="http://mental.jmir.org/2017/2/e14/", url="http://www.ncbi.nlm.nih.gov/pubmed/28526672" } @Article{info:doi/10.2196/jmir.6678, author="Place, Skyler and Blanch-Hartigan, Danielle and Rubin, Channah and Gorrostieta, Cristina and Mead, Caroline and Kane, John and Marx, P. Brian and Feast, Joshua and Deckersbach, Thilo and Pentland, ``Sandy'' Alex and Nierenberg, Andrew and Azarbayejani, Ali", title="Behavioral Indicators on a Mobile Sensing Platform Predict Clinically Validated Psychiatric Symptoms of Mood and Anxiety Disorders", journal="J Med Internet Res", year="2017", month="Mar", day="16", volume="19", number="3", pages="e75", keywords="mHealth", keywords="post-traumatic stress disorders", keywords="depression", keywords="behavioral symptoms", abstract="Background: There is a critical need for real-time tracking of behavioral indicators of mental disorders. Mobile sensing platforms that objectively and noninvasively collect, store, and analyze behavioral indicators have not yet been clinically validated or scalable. Objective: The aim of our study was to report on models of clinical symptoms for post-traumatic stress disorder (PTSD) and depression derived from a scalable mobile sensing platform. Methods: A total of 73 participants (67\% [49/73] male, 48\% [35/73] non-Hispanic white, 33\% [24/73] veteran status) who reported at least one symptom of PTSD or depression completed a 12-week field trial. Behavioral indicators were collected through the noninvasive mobile sensing platform on participants' mobile phones. Clinical symptoms were measured through validated clinical interviews with a licensed clinical social worker. A combination hypothesis and data-driven approach was used to derive key features for modeling symptoms, including the sum of outgoing calls, count of unique numbers texted, absolute distance traveled, dynamic variation of the voice, speaking rate, and voice quality. Participants also reported ease of use and data sharing concerns. Results: Behavioral indicators predicted clinically assessed symptoms of depression and PTSD (cross-validated area under the curve [AUC] for depressed mood=.74, fatigue=.56, interest in activities=.75, and social connectedness=.83). Participants reported comfort sharing individual data with physicians (Mean 3.08, SD 1.22), mental health providers (Mean 3.25, SD 1.39), and medical researchers (Mean 3.03, SD 1.36). Conclusions: Behavioral indicators passively collected through a mobile sensing platform predicted symptoms of depression and PTSD. The use of mobile sensing platforms can provide clinically validated behavioral indicators in real time; however, further validation of these models and this platform in large clinical samples is needed. ", doi="10.2196/jmir.6678", url="http://www.jmir.org/2017/3/e75/", url="http://www.ncbi.nlm.nih.gov/pubmed/28302595" } @Article{info:doi/10.2196/jmir.5594, author="Whealin, M. Julia and Jenchura, C. Emily and Wong, C. Ava and Zulman, M. Donna", title="How Veterans With Post-Traumatic Stress Disorder and Comorbid Health Conditions Utilize eHealth to Manage Their Health Care Needs: A Mixed-Methods Analysis", journal="J Med Internet Res", year="2016", month="Oct", day="26", volume="18", number="10", pages="e280", keywords="stress disorders, post-traumatic", keywords="telemedicine", keywords="electronic mail", keywords="social media", keywords="self-care", keywords="computer literacy", abstract="Background: Mental health conditions are prevalent among US veterans and pose a number of self-management and health care navigation challenges. Post-Traumatic Stress Disorder (PTSD) with comorbid chronic medical conditions (CMCs) is especially common, in both returning Iraq or Afghanistan and earlier war-era veterans. Patient-facing electronic health (eHealth) technology may offer innovative strategies to support these individuals' needs. Objective: This study was designed to identify the types of eHealth tools that veterans with PTSD and comorbid CMCs use, understand how they currently use eHealth technology to self-manage their unique health care needs, and identify new eHealth resources that veterans feel would empower them to better manage their health care. Methods: A total of 119 veterans with PTSD and at least one CMC who have used the electronic personal health record system of the US Department of Veterans Affairs (VA) responded to a mailed survey about their chronic conditions and preferences related to the use of technology. After the survey, 2 focus groups, stratified by sex, were conducted with a subgroup of patients to explore how veterans with PTSD and comorbid CMCs use eHealth technology to support their complex health care needs. Focus groups were transcribed verbatim and analyzed using standard content analysis methods for coding textual data, guided by the ``Fit between Individual, Task, and Technology'' framework. Results: Survey respondents had a mean age of 64.0 (SD 12.0) years, 85.1\% (97/114) were male, 72.4\% (84/116) were white, and 63.1\% (70/111) had an annual household income of < US \$50,000. Mean score on a measure of eHealth literacy was 27.7 (SD 9.8). Of the respondents, 44.6\% (50/112) used health-related technology 1 to 3 times per month and 21.4\% (24/112) used technology less than once per month. Veterans reported using technology most often to search for health information (78.9\%, 90/114), communicate with providers (71.1\%, 81/114), and track medications (64.9\%, 74/114). Five major themes emerged that describe how eHealth technology influences veterans with PTSD and comorbid CMCs: (1) interactions with social support, (2) condition management, (3) access to and communication with providers, (4) information access, and (5) coordination of care. Conclusions: The ``Fit between Individual, Task, and Technology'' model provided a useful framework to examine the clinical tasks that arose for veterans and their resourceful adoption of eHealth tools. This study suggests that veterans who use the Web are eager to incorporate eHealth technology into their care and self-management activities. Findings illustrate a number of ways in which the VA and eHealth technology developers can refine existing applications, develop new resources, and better promote tools that address challenges experienced by veterans with PTSD and comorbid CMCs. ", doi="10.2196/jmir.5594", url="http://www.jmir.org/2016/10/e280/", url="http://www.ncbi.nlm.nih.gov/pubmed/27784650" } @Article{info:doi/10.2196/jmir.5800, author="Kahn, R. Janet and Collinge, William and Soltysik, Robert", title="Post-9/11 Veterans and Their Partners Improve Mental Health Outcomes with a Self-directed Mobile and Web-based Wellness Training Program: A Randomized Controlled Trial", journal="J Med Internet Res", year="2016", month="Sep", day="27", volume="18", number="9", pages="e255", keywords="veterans", keywords="PTSD", keywords="moral injury", keywords="mind-body therapies", keywords="mindfulness", keywords="patient-centered care", keywords="compassion", keywords="Web-based program", keywords="reintegration", abstract="Background: Veterans with history of deployment in the Global War on Terror face significant and ongoing challenges with high prevalences of adverse psychological, physical, spiritual, and family impacts. Together, these challenges contribute to an emerging public health crisis likely to extend well into the future. Innovative approaches are needed that reach veterans and their family members with strategies they can employ over time in their daily lives to promote improved adjustment and well-being. Objective: The objective of this study was to evaluate effects of use of a Web-based, self-directed program of instruction in mind- and body-based wellness skills to be employed by Global War on Terror veterans and their significant relationship partners on mental health and wellness outcomes associated with postdeployment readjustment. Methods: We recruited 160 veteran-partner dyads in 4 regions of the United States (San Diego, CA; Dallas, TX; Fayetteville, NC; and New York, NY) through publicity by the Iraq and Afghanistan Veterans of America to its membership. Dyads were randomly allocated to 1 of 4 study arms: Mission Reconnect (MR) program alone, MR plus the Prevention and Relationship Enhancement Program (PREP) for Strong Bonds weekend program for military couples, PREP alone, and waitlist control. We administered a battery of standardized and investigator-generated instruments assessing mental health outcomes at baseline, 8 weeks, and 16 weeks. Dyads in the MR arms were provided Web-based and mobile app video and audio instruction in a set of mindfulness-related stress reduction and contemplative practices, as well as partner massage for reciprocal use. All participants provided weekly reports on frequency and duration of self-care practices for the first 8 weeks, and at 16 weeks. Results: During the first 8-week reporting period, veterans and partners assigned to MR arms used some aspect of the program a mean of 20 times per week, totaling nearly 2.5 hours per week, with only modest declines in use at 16 weeks. Significant improvements were seen at 8 and 16 weeks in measures of posttraumatic stress disorder, depression, sleep quality, perceived stress, resilience, self-compassion, and pain for participants assigned to MR arms. In addition, significant reductions in self-reported levels of pain, tension, irritability, anxiety, and depression were associated with use of partner massage. Conclusions: Both veterans and partners were able to learn and make sustained use of a range of wellness practices taught in the MR program. Home-based, self-directed interventions may be of particular service to veterans who are distant from, averse to, or prohibited by schedule from using professional services. Leveraging the partner relationship may enhance sustained use of self-directed interventions for this population. Use of the MR program appears to be an accessible, low-cost approach that supports well-being and reduces multiple symptoms among post-9/11 veterans and their partners. Trial Registration: Clinicaltrials.gov NCT01680419; https://clinicaltrials.gov/ct2/show/NCT01680419 (Archived by WebCite at http://www.webcitation.org/6jJuadfzj) ", doi="10.2196/jmir.5800", url="http://www.jmir.org/2016/9/e255/", url="http://www.ncbi.nlm.nih.gov/pubmed/27678169" } @Article{info:doi/10.2196/mhealth.3726, author="Frisbee, L. Kathleen", title="Variations in the Use of mHealth Tools: The VA Mobile Health Study", journal="JMIR Mhealth Uhealth", year="2016", month="Jul", day="19", volume="4", number="3", pages="e89", keywords="caregivers", keywords="telemedicine", keywords="stress (psychological)", keywords="veterans health", abstract="Background: Mobile health (mHealth) technologies exhibit promise for offering patients and their caregivers point-of-need tools for health self-management. This research study involved the dissemination of iPads containing a suite of mHealth apps to family caregivers of veterans who receive care from the Veterans Affairs (VA) Health Administration and have serious physical or mental injuries. Objective: The goal of the study was to identify factors and characteristics of veterans and their family caregivers that predict the use of mHealth apps. Methods: Veteran/family caregiver dyads (N=882) enrolled in VA's Comprehensive Assistance for Family Caregivers program were recruited to participate in an mHealth pilot program. Veterans and caregivers who participated and received an iPad agreed to have their use of the apps monitored and were asked to complete a survey assessing Caregiver Preparedness, Caregiver Traits, and Caregiver Zarit Burden Inventory baseline surveys. Results: Of the 882 dyads, 94.9\% (837/882) of caregivers were women and 95.7\% (844/882) of veteran recipients were men. Mean caregiver age was 40 (SD 10.2) years and mean veteran age was 39 (SD 9.15) years, and 39.8\% (351/882) lived in rural locations. Most (89\%, 788/882) of the caregivers were spouses. Overall, the most frequently used app was Summary of Care, followed by RX Refill, then Journal, Care4Caregivers, VA Pain Coach, and last, VA PTSD Coach. App use was significantly predicted by the caregiver being a spouse, increased caregiver computer skills, a rural living location, lower levels of caregiver preparedness, veteran mental health diagnosis (other than posttraumatic stress disorder), and veteran age. Conclusions: This mHealth Family Caregiver pilot project effectively establishes the VA's first patient-facing mHealth apps that are integrated within the VA data system. Use varied considerably, and apps that were most used were those that assisted them in their caregiving responsibilities. ", doi="10.2196/mhealth.3726", url="http://mhealth.jmir.org/2016/3/e89/", url="http://www.ncbi.nlm.nih.gov/pubmed/27436165" } @Article{info:doi/10.2196/mental.5697, author="G{\"o}rg, Nora and Priebe, Kathlen and Deuschel, Tilman and Sch{\"u}ller, Martin and Schriner, Friederike and Kleindienst, Nikolaus and Lud{\"a}scher, Petra and Schmahl, Christian and Bohus, Martin", title="Computer-Assisted In Sensu Exposure for Posttraumatic Stress Disorder: Development and Evaluation", journal="JMIR Ment Health", year="2016", month="Jun", day="08", volume="3", number="2", pages="e27", keywords="dissociative disorders", keywords="behavior therapy", keywords="posttraumatic stress disorder", keywords="technology", abstract="Background: Dissociative states during psychotherapy sessions reduce the benefit of exposure-based therapy for posttraumatic stress disorder (PTSD). Thus, in evidence-based therapeutic programs such as dialectical behavior therapy for PTSD (DBT-PTSD), therapists apply specific antidissociative skills to reduce dissociative features during in sensu exposure. In addition to therapist-guided sessions, exposure protocols often require that the patients listen to audio recordings of exposure sessions in self-management. The problem of how to prevent dissociative features during such self-administered exposure exercises has not been resolved yet. Hence, we developed the computer program MORPHEUS that supports the application of self-administered exposure exercises. MORPHEUS continuously monitors the level of dissociative states and offers state-related antidissociative skills. Objective: This study sought to examine the acceptance and feasibility of the MORPHEUS program. Methods: Patients who underwent 12 weeks of residential DBT-PTSD treatment used MORPHEUS during exposure exercises in self-management. After the treatment, they filled out evaluation questionnaires. Results: In sum, 26 patients receiving a 12-week standard DBT-PTSD program participated in this study; 2 participants could not be analyzed because of missing data. All the patients used MORPHEUS as often as it was required according to the DBT-PTSD treatment (2 to 5 times a week). The overall acceptance and feasibility as rated by the patients was high: for example, patients found the skills useful to block dissociation (mean 4.24 on a scale from 0 to 5, SD 0.24) and stated that they would use the program again (mean 4.72 on a scale from 0 to 5, SD 0.11). Furthermore, patients indicated that they would recommend MORPHEUS to a friend (mean 4.44 on a scale from 0 to 5, SD 0.12). In 82\% (32/39) of the cases, the use of antidissociative skills was related to a decrease in dissociation. In 18\% (5/39), dissociation remained unchanged or increased. Conclusions: The evaluative data suggest high acceptability and feasibility of MORPHEUS. Further studies should evaluate the effectiveness of the skills applied during the program. Trial Registration: World Health Organization International Clinical Trials Registry Platform: DRKS00006226; http://apps.who.int/trialsearch/Trial2.aspx?TrialID= DRKS00006226 (Archived by WebCite at http://www.webcitation.org/ 6hxuFbIUr) ", doi="10.2196/mental.5697", url="http://mental.jmir.org/2016/2/e27/", url="http://www.ncbi.nlm.nih.gov/pubmed/27277899" } @Article{info:doi/10.2196/mental.5023, author="Price, Matthew and Sawyer, Tyler and Harris, Madison and Skalka, Christian", title="Usability Evaluation of a Mobile Monitoring System to Assess Symptoms After a Traumatic Injury: A Mixed-Methods Study", journal="JMIR Mental Health", year="2016", month="Jan", day="11", volume="3", number="1", pages="e3", keywords="mobile phone", keywords="trauma", keywords="posttraumatic stress disorder", keywords="usability", abstract="Background: Victims of trauma are at high risk for mental health conditions such as posttraumatic stress disorder and depression. Regular assessment of mental health symptoms in the post-trauma period is necessary to identify those at greatest risk and provide treatment. The multiple demands of the acute post-trauma period present numerous barriers to such assessments. Mobile apps are a method by which to overcome these barriers in order to regularly assess symptoms, identify those at risk, and connect patients to needed services. Objective: The current study conducted a usability evaluation of a system to monitor mental health symptoms after a trauma. The system was developed to promote ease of use and facilitate quick transmission of data. Methods: A sample of 21 adults with a history of trauma completed a standardized usability test in a laboratory setting followed by a qualitative interview. Results: Usability testing indicated that the app was easy to use and that patients were able to answer several questions in less than 1 minute (mean [SD] 29.37 [7.53]; range 15-57). Qualitative analyses suggested that feedback should be included in such an app and recommendations for the type of feedback were offered. Conclusions: The results of the current study indicate that a mobile app to monitor post-trauma mental health symptoms would be well received by victims. Personalized feedback to the user was identified as critical to promote the usability of the software. ", doi="10.2196/mental.5023", url="http://mental.jmir.org/2016/1/e3/", url="http://www.ncbi.nlm.nih.gov/pubmed/26753673" } @Article{info:doi/10.2196/mental.3935, author="Owen, E. Jason and Jaworski, K. Beth and Kuhn, Eric and Makin-Byrd, N. Kerry and Ramsey, M. Kelly and Hoffman, E. Julia", title="mHealth in the Wild: Using Novel Data to Examine the Reach, Use, and Impact of PTSD Coach", journal="JMIR Mental Health", year="2015", month="Mar", day="25", volume="2", number="1", pages="e7", keywords="PTSD", keywords="trauma", keywords="mHealth", keywords="mental heatlh", keywords="mobile app", keywords="public health", keywords="self-management", abstract="Background: A majority of Americans (58\%) now use smartphones, making it possible for mobile mental health apps to reach large numbers of those who are living with untreated, or under-treated, mental health symptoms. Although early trials suggest positive effects for mobile health (mHealth) interventions, little is known about the potential public health impact of mobile mental health apps. Objective: The purpose of this study was to characterize reach, use, and impact of ``PTSD Coach'', a free, broadly disseminated mental health app for managing posttraumatic stress disorder (PTSD) symptoms. Methods: Using a mixed-methods approach, aggregate mobile analytics data from 153,834 downloads of PTSD Coach were analyzed in conjunction with 156 user reviews. Results: Over 60\% of users engaged with PTSD Coach on multiple occasions (mean=6.3 sessions). User reviews reflected gratitude for the availability of the app and being able to use the app specifically during moments of need. PTSD Coach users reported relatively high levels of trauma symptoms (mean PTSD Checklist Score=57.2, SD=15.7). For users who chose to use a symptom management tool, distress declined significantly for both first-time users (mean=1.6 points, SD=2.6 on the 10-point distress thermometer) and return-visit users (mean=2.0, SD=2.3). Analysis of app session data identified common points of attrition, with only 80\% of first-time users reaching the app's home screen and 37\% accessing one of the app's primary content areas. Conclusions: These findings suggest that PTSD Coach has achieved substantial and sustained reach in the population, is being used as intended, and has been favorably received. PTSD Coach is a unique platform for the delivery of mobile mental health education and treatment, and continuing evaluation and improvement of the app could further strengthen its public health impact. ", doi="10.2196/mental.3935", url="http://mental.jmir.org/2015/1/e7/", url="http://www.ncbi.nlm.nih.gov/pubmed/26543913" } @Article{info:doi/10.2196/jmir.3582, author="Knaevelsrud, Christine and Brand, Janine and Lange, Alfred and Ruwaard, Jeroen and Wagner, Birgit", title="Web-Based Psychotherapy for Posttraumatic Stress Disorder in War-Traumatized Arab Patients: Randomized Controlled Trial", journal="J Med Internet Res", year="2015", month="Mar", day="20", volume="17", number="3", pages="e71", keywords="posttraumatic stress disorders", keywords="Middle East", keywords="war", keywords="violence", keywords="cognitive therapy", keywords="mental health service", keywords="Internet", abstract="Background: In recent years, armed conflicts in the Middle East have resulted in high rates of exposure to traumatic events. Despite the increasing demand of mental health care provision, ongoing violence limits conventional approaches of mental health care provision. Internet-based interventions for posttraumatic stress disorder (PTSD) have proved feasible and effective in Western countries, but their applicability and efficacy in war and conflict regions remains unknown. Objective: This study investigated the efficacy of a cognitive behavioral Internet-based intervention for war-traumatized Arab patients, with focus on Iraq. Methods: A total of 159 individuals with PTSD participated in a parallel group randomized trial. Participants were randomly allocated by a computer-generated sequence to a treatment group (n=79) or a waiting list control group (n=80). The treatment group received 2 weekly 45-minute cognitive behavioral interventions via Internet over a 5-week period (10 sessions in total). The primary outcome was recovery from posttraumatic stress symptoms. Results: Posttraumatic stress symptoms were significantly reduced from baseline to posttreatment (intention-to-treat analysis) in the treatment group relative to the control group (F1,157=44.29, P<.001, d=0.92). Treatment effects were sustained at 3-month follow-up. Completer analysis indicated that 29 of 47 patients (62\%) in the treatment group had recovered from posttraumatic stress symptoms at posttreatment (reliable change and Posttraumatic Stress Diagnostic Scale score <20) versus 1 patient (2\%) in the control group (OR 74.19, 95\% CI 9.93-585.8, P<.001) indicating that the chance of recovering was 74.19 times higher in the treatment than in the control group. Conclusions: The results indicate, even in unstable and insecure settings with ongoing exposure to human rights violations through war and dictatorships, people with posttraumatic stress symptoms benefit from a cognitive behavioral treatment provided entirely through the Internet. This method of delivery could improve patients' access to humanitarian aid in the form of e-mental health services. Trial Registration: Australian New Zealand Clinical Trial Registry, ACTRN12611001019998; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=347505 (Archived by WebCite at http://www.webcitation.org/6Wto4HCdH). ", doi="10.2196/jmir.3582", url="http://www.jmir.org/2015/3/e71/", url="http://www.ncbi.nlm.nih.gov/pubmed/25799024" } @Article{info:doi/10.2196/jmir.3513, author="AL-Asadi, M. Ali and Klein, Britt and Meyer, Denny", title="Posttreatment Attrition and Its Predictors, Attrition Bias, and Treatment Efficacy of the Anxiety Online Programs", journal="J Med Internet Res", year="2014", month="Oct", day="14", volume="16", number="10", pages="e232", keywords="posttreatment attrition", keywords="posttreatment predictors", keywords="treatment efficacy", keywords="online therapy", keywords="e-mental health", keywords="cognitive behavioral therapy", keywords="Internet interventions", keywords="fully automated", keywords="self-help", keywords="Web treatment", keywords="generalized anxiety disorder", keywords="obsessive compulsive disorder", abstract="Background: Although relatively new, the field of e-mental health is becoming more popular with more attention given to researching its various aspects. However, there are many areas that still need further research, especially identifying attrition predictors at various phases of assessment and treatment delivery. Objective: The present study identified the predictors of posttreatment assessment completers based on 24 pre- and posttreatment demographic and personal variables and 1 treatment variable, their impact on attrition bias, and the efficacy of the 5 fully automated self-help anxiety treatment programs for generalized anxiety disorder (GAD), social anxiety disorder (SAD), panic disorder with or without agoraphobia (PD/A), obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD). Methods: A complex algorithm was used to diagnose participants' mental disorders based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision; DSM-IV-TR). Those who received a primary or secondary diagnosis of 1 of 5 anxiety disorders were offered an online 12-week disorder-specific treatment program. A total of 3199 individuals did not formally drop out of the 12-week treatment cycle, whereas 142 individuals formally dropped out. However, only 347 participants who completed their treatment cycle also completed the posttreatment assessment measures. Based on these measures, predictors of attrition were identified and attrition bias was examined. The efficacy of the 5 treatment programs was assessed based on anxiety-specific severity scores and 5 additional treatment outcome measures. Results: On average, completers of posttreatment assessment measures were more likely to be seeking self-help online programs; have heard about the program from traditional media or from family and friends; were receiving mental health assistance; were more likely to learn best by reading, hearing and doing; had a lower pretreatment Kessler-6 total score; and were older in age. Predicted probabilities resulting from these attrition variables displayed no significant attrition bias using Heckman's method and thus allowing for the use of completer analysis. Six treatment outcome measures (Kessler-6 total score, number of diagnosed disorders, self-confidence in managing mental health issues, quality of life, and the corresponding pre- and posttreatment severity for each program-specific anxiety disorder and for major depressive episode) were used to assess the efficacy of the 5 anxiety treatment programs. Repeated measures MANOVA revealed a significant multivariate time effect for all treatment outcome measures for each treatment program. Follow-up repeated measures ANOVAs revealed significant improvements on all 6 treatment outcome measures for GAD and PTSD, 5 treatment outcome measures were significant for SAD and PD/A, and 4 treatment outcome measures were significant for OCD. Conclusions: Results identified predictors of posttreatment assessment completers and provided further support for the efficacy of self-help online treatment programs for the 5 anxiety disorders. Trial Registration: Australian and New Zealand Clinical Trials Registry ACTRN121611000704998; http://www.anzctr.org.au/trial\_view.aspx?ID=336143 (Archived by WebCite at http://www.webcitation.org/618r3wvOG). ", doi="10.2196/jmir.3513", url="http://www.jmir.org/2014/10/e232/", url="http://www.ncbi.nlm.nih.gov/pubmed/25316533" } @Article{info:doi/10.2196/jmir.1918, author="Klein, Britt and Meyer, Denny and Austin, William David and Kyrios, Michael", title="Anxiety Online---A Virtual Clinic: Preliminary Outcomes Following Completion of Five Fully Automated Treatment Programs for Anxiety Disorders and Symptoms", journal="J Med Internet Res", year="2011", month="Nov", day="04", volume="13", number="4", pages="e89", keywords="eTherapy", keywords="Internet interventions", keywords="e-mental health", keywords="cognitive behavior therapy", keywords="generalized anxiety disorder", keywords="panic disorder", keywords="obsessive compulsive disorder", keywords="social anxiety disorder", keywords="posttraumatic stress disorder", keywords="self-help", keywords="fully automated", keywords="Web treatment", abstract="Background: The development of e-mental health interventions to treat or prevent mental illness and to enhance wellbeing has risen rapidly over the past decade. This development assists the public in sidestepping some of the obstacles that are often encountered when trying to access traditional face-to-face mental health care services. Objective: The objective of our study was to investigate the posttreatment effectiveness of five fully automated self-help cognitive behavior e-therapy programs for generalized anxiety disorder (GAD), panic disorder with or without agoraphobia (PD/A), obsessive--compulsive disorder (OCD), posttraumatic stress disorder (PTSD), and social anxiety disorder (SAD) offered to the international public via Anxiety Online, an open-access full-service virtual psychology clinic for anxiety disorders. Methods: We used a naturalistic participant choice, quasi-experimental design to evaluate each of the five Anxiety Online fully automated self-help e-therapy programs. Participants were required to have at least subclinical levels of one of the anxiety disorders to be offered the associated disorder-specific fully automated self-help e-therapy program. These programs are offered free of charge via Anxiety Online. Results: A total of 225 people self-selected one of the five e-therapy programs (GAD, n = 88; SAD, n = 50; PD/A, n = 40; PTSD, n = 30; OCD, n = 17) and completed their 12-week posttreatment assessment. Significant improvements were found on 21/25 measures across the five fully automated self-help programs. At postassessment we observed significant reductions on all five anxiety disorder clinical disorder severity ratings (Cohen d range 0.72--1.22), increased confidence in managing one's own mental health care (Cohen d range 0.70--1.17), and decreases in the total number of clinical diagnoses (except for the PD/A program, where a positive trend was found) (Cohen d range 0.45--1.08). In addition, we found significant improvements in quality of life for the GAD, OCD, PTSD, and SAD e-therapy programs (Cohen d range 0.11--0.96) and significant reductions relating to general psychological distress levels for the GAD, PD/A, and PTSD e-therapy programs (Cohen d range 0.23--1.16). Overall, treatment satisfaction was good across all five e-therapy programs, and posttreatment assessment completers reported using their e-therapy program an average of 395.60 (SD 272.2) minutes over the 12-week treatment period. Conclusions: Overall, all five fully automated self-help e-therapy programs appear to be delivering promising high-quality outcomes; however, the results require replication. Trial Registration: Australian and New Zealand Clinical Trials Registry ACTRN121611000704998; http://www.anzctr.org.au/trial\_view.aspx?ID=336143 (Archived by WebCite at http://www.webcitation.org/618r3wvOG) ", doi="10.2196/jmir.1918", url="http://www.jmir.org/2011/4/e89/", url="http://www.ncbi.nlm.nih.gov/pubmed/22057287" }