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IIR 14-288 – HSR&D Study

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IIR 14-288
An RCT of a Primary Care-Based PTSD Intervention: Clinician-Supported PTSD Coach
Eric R Kuhn PhD
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: October 2016 - September 2020

BACKGROUND/RATIONALE:
PTSD is highly prevalent in Veterans seen in VA primary care; however, there is a lack of evidence-based brief PTSD interventions that can be delivered in this setting. Therefore, Veterans with PTSD are offered referrals to specialty MH care where evidence-based psychotherapies are available. Unfortunately, many patients refuse such referrals or if accepted, infrequently attend enough sessions to receive adequate treatment. Consequently, a significant gap exists between need for and engagement in effective PTSD treatment for Veterans seen exclusively in VA primary care. Innovative technology could help address this need by increasing access to and quality of PTSD treatment. VA's National Center for PTSD has developed PTSD Coach, an evidence-informed self-management mobile app that offers PTSD psycho-education, symptom monitoring, coping skills, and links to social support and professional resources. While, substantial evidence exists that technology-based self-management programs for MH conditions are effective, self-management programs when used alone are often underutilized. Interventions that include clinician support increase treatment utilization and effectiveness. Therefore, we have developed a treatment package that combines mobile technology with clinician support. Pilot data indicate participation in CS PTSD Coach leads to clinically significant reductions in PTSD symptoms and increased engagement in specialty MH care.

OBJECTIVE(S):
The primary objective of this research is to conduct a randomized controlled trial (RCT) of Clinician-Supported PTSD Coach in VA primary care with Veterans with clinically significant PTSD symptoms. The specific aims are to 1) investigate the impact of CS PTSD Coach on PTSD symptom severity, 2) investigate the impact of CS PTSD Coach on engagement in two sessions of specialty mental health care, and 3) investigate patient and provider satisfaction with CS PTSD Coach. We also aim to explore potential mediators (i.e., objective app use, coping self-efficacy) and moderators (i.e., baseline PTSD symptom severity, comorbid psychiatric symptoms) of outcomes. We will also explore trajectories of PTSD symptom change over the four month follow-up period to examine if engagement in specialty MH treatment and continued app use interact with symptom change.

METHODS:
Research Design and Methods - This is a four-year, two-site, two-arm RCT that will compare CS PTSD Coach to a standard referral to a Primary Care Mental Health Integration (PC-MHI) provider. CS PTSD Coach consists of four 20-30 minute sessions (in-person or via phone) over eight weeks focused on instructions for app use, setting symptom reductions goals, and assigning specific PTSD Coach activities (e.g., assessments, management strategies, psycho-educational readings) for the participant to complete between sessions. Participants will be VA primary care patients with clinically significant PTSD symptoms (N = 260). Assessments will include well-established clinical interviews and self-report measures that will take place at pre-treatment (baseline), post-treatment, and at 16- and 24-week follow-up. The study will also use VHA administrative data to assess MH treatment engagement, objective app usage data to assess app use, and qualitative methodology to assess CS PTSD Coach participant satisfaction.

FINDINGS/RESULTS:
The project is in the data collection phase so no findings to report at this time.

IMPACT:
The long term goal of this study is to establish effective, innovative, easily disseminated mobile health interventions for Veterans with PTSD. Bringing CS PTSD Coach into primary care could be an initial step in a stepped-care approach to provide patient-centered treatment that facilitates shared decision making on treatment options, reduces PTSD symptoms, and prepares Veterans for more intensive treatments, if needed. If this treatment is found to be effective at reducing PTSD symptoms and increasing use of MH care, it will provide a tremendous positive impact on Veterans with PTSD seen in VA primary care.

PUBLICATIONS:

Journal Articles

  1. Owen JE, Kuhn E, Jaworski BK, McGee-Vincent P, Juhasz K, Hoffman JE, Rosen C. VA mobile apps for PTSD and related problems: public health resources for veterans and those who care for them. mHealth. 2018 Jul 26; 4:28.
  2. Kuhn E, van der Meer C, Owen JE, Hoffman JE, Cash R, Carrese P, Olff M, Bakker A, Schellong J, Lorenz P, Schopp M, Rau H, Weidner K, Arnberg FK, Cernvall M, Iversen T. PTSD Coach around the world. mHealth. 2018 May 25; 4:15.
  3. Yu JS, Kuhn ER, Miller KE, Taylor M. Smartphone apps for insomnia: examining existing apps' usability and adherence to evidence-based principles for insomnia management. Translational behavioral medicine. 2018 Mar 21; iby014:https://doi.org/10.1093/tbm/iby014.
  4. Miller KE, Kuhn E, Owen JE, Taylor K, Yu JS, Weiss BJ, Crowley JJ, Trockel M. Clinician Perceptions Related to the Use of the CBT-I Coach Mobile App. Behavioral sleep medicine. 2019 Jul 1; 17(4):481-491.
  5. Reger GM, Browne KC, Campellone TR, Simons CE, Kuhn E, Fortney JC, Sayre G, Reisinger HS. Barriers and Facilitators to Mobile Application Use During PTSD Treatment: Clinician Adoption of PE Coach. Professional Psychology, Research and Practice. 2017 Dec 1; 48(6):510-517.
  6. Herbst E, Pennington D, Kuhn E, McCaslin SE, Delucchi K, Batki SL, Dickter B, Carmody T. Mobile Technology for Treatment Augmentation in Veteran Smokers With Posttraumatic Stress Disorder. American journal of preventive medicine. 2018 Jan 1; 54(1):124-128.
  7. Gould CE, Zapata AML, Bruce J, Bereknyei Merrell S, Wetherell JL, O'Hara R, Kuhn E, Goldstein MK, Beaudreau SA. Development of a video-delivered relaxation treatment of late-life anxiety for veterans. International psychogeriatrics. 2017 Oct 1; 29(10):1633-1645.
  8. Kuhn E, Schwarz EI, Bratton DJ, Rossi VA, Kohler M. Effects of CPAP and Mandibular Advancement Devices on Health-Related Quality of Life in OSA: A Systematic Review and Meta-analysis. Chest. 2017 Apr 1; 151(4):786-794.
  9. Morland LA, Greene CJ, Rosen CS, Kuhn E, Hoffman J, Sloan DM. Telehealth and eHealth interventions for posttraumatic stress disorder. Current opinion in psychology. 2017 Apr 1; 14:102-108.
  10. Kuhn E, Kanuri N, Hoffman JE, Garvert DW, Ruzek JI, Taylor CB. A randomized controlled trial of a smartphone app for posttraumatic stress disorder symptoms. Journal of consulting and clinical psychology. 2017 Mar 1; 85(3):267-273.
  11. Possemato K, Kuhn E, Johnson EM, Hoffman JE, Brooks E. Development and refinement of a clinician intervention to facilitate primary care patient use of the PTSD Coach app. Translational behavioral medicine. 2017 Mar 1; 7(1):116-126.
  12. Possemato K, Kuhn E, Johnson EM, Hoffman JE, Brooks E. Erratum to: Development and refinement of a clinician intervention to facilitate primary care patient use of the PTSD Coach app. Translational behavioral medicine. 2017 Mar 1; 7(1):127.
  13. Smith SK, Kuhn E, O'Donnell J, Koontz BF, Nelson N, Molloy K, Chang J, Hoffman J. Cancer distress coach: Pilot study of a mobile app for managing posttraumatic stress. Psycho-oncology. 2018 Jan 1; 27(1):350-353.
  14. Laha SS, Naik AR, Kuhn ER, Alvarez M, Sujkowski A, Wessells RJ, Jena BP. Nanothermometry Measure of Muscle Efficiency. Nano letters. 2017 Feb 8; 17(2):1262-1268.
  15. Rosen CS, Eftekhari A, Crowley JJ, Smith BN, Kuhn E, Trent L, Martin N, Tran T, Ruzek JI. Maintenance and Reach of Exposure Psychotherapy for Posttraumatic Stress Disorder 18 Months After Training. Journal of traumatic stress. 2017 Feb 1; 30(1):63-70.
  16. Ruzek JI, Kuhn E, Jaworski BK, Owen JE, Ramsey KM. Mobile mental health interventions following war and disaster. mHealth. 2016 Sep 29; 2:37.
  17. Ruzek JI, Eftekhari A, Rosen CS, Crowley JJ, Kuhn E, Foa EB, Hembree EA, Karlin BE. Effects of a comprehensive training program on clinician beliefs about and intention to use prolonged exposure therapy for PTSD. Psychological trauma : theory, research, practice and policy. 2016 May 1; 8(3):348-55.
Center Products

  1. Kuhn ER, Jaworski BK, Owen JE, McCaslin SE, Ramsey KM, Hoffman JE. Insomnia Coach mobile application. 2018 Jan 1. Available from: https://itunes.apple.com/us/app/insomnia-coach/id1341944736.
  2. Hoffman JE, Jaworski BK, Ramsey KM, Ruzek JI, Taylor K, Carlson EB, Schievelbein L, Kuhn ER, Owen JE, Vigil Dombeck MJ. Trauma Recovery Coach mobile application. 2017 Oct 1. Available from: https://itunes.apple.com/us/app/trauma-recovery/id1292950621?mt=8.


DRA: Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Efficacy/Effectiveness Clinical Trial, TRL - Applied/Translational
Keywords: Cognitive Therapy, PTSD, Utilization
MeSH Terms: none