Access and engagement in evidence-based psychotherapies for Veterans are high priorities for the Veterans Health Administration (VHA), especially the Office of Rural Health (ORH) and the office of Mental Health Services (MHS). SmartPhone applications are an emerging technology with a vast potential to extend the reach of traditional in-person psychotherapy by allowing increased digital access to providers and self- management tools. Due to the relatively recent development of this technology, there are no data on the effectiveness of SmartPhone-delivered psychotherapy. Preliminary data on acceptability and satisfaction are promising, suggesting a need for further research. The National Center for PTSD in collaboration with the National Center for Telehealth &Technology (T2) recently completed the development of an app called Moving Forward, a Veteran-friendly adaptation of Problem Solving Therapy (PST), an evidence based therapy available through Primary Care Integration Clinics (PC-MHI). In partnership with MHS, this proposed pilot project will gather preliminary data on the effectiveness and acceptability of Moving Forward and provide timely feedback to the app creators. Participants will include 40 Veterans diagnosed with an anxiety or mood disorder interested in obtaining mental health treatment in PC-MHI. Participants will be randomly assigned to receive 6 sessions of either PST augmented by the Moving Forward app or 6 session of PST alone. Participants will complete assessments at baseline, 6 weeks and 12 weeks. We propose 3 specific hypotheses. In hypothesis 1, we predict an effect size e 0.3 will be observed when comparing scores on the PSSU (homework completion), and CSQ8 (satisfaction) at 6 and 12 weeks for patients randomized to PST plus the Moving Forward app compared to patients randomized to PST alone. In hypothesis 2, we predict an effect size e 0.3 will be observed when comparing change scores on the SPSI (problem solving style) at 6 and 12 weeks for patients randomized to PST plus the Moving Forward app compared to patients randomized to PST alone. In hypothesis 3, we predict an effect size e 0.3 will be observed when comparing change scores on the DASS composite score (depression, anxiety and stress) and SF-12 (health-related quality of life) at 6 and 12 weeks for patients randomized to PST plus the Moving Forward app compared to patients randomized to PST alone. Key informant interviews will provide qualitative feedback on the Moving Forward app which we will share with our partners at MHS. The proposed project is important to the VA mission to improve access for all Veterans particularly those who face barriers to engagement in traditional face-to-face treatment. The proposed research addresses one of three primary focus areas of the Office of Research and Development (Access), two of HSR&D's research priorities (Access/Rural Health and Mental Health), and three of Secretary Shinseki's Transformational Initiatives for the 21st Century including improving: 1) access to care, 2) mental health, and 3) patient-centeredness. This proposed work is innovative as it focuses on a rapidly emerging mobile technology that has great potential to improve access and engagement in mental health service delivery. To date, there have been no randomized effectiveness trials that have examined SmartPhone apps for mental health service delivery. The project is also timely as there is a temporary moratorium (imposed by the Office of Information Technology) on app dissemination within VHA, presenting an opportunity to study Moving Forward prior to its release. At the completion of this project, we expect that the work proposed in Aim 1 and 2 will highlight the clinical value of the Moving Forward app, which will inform both VA policy makers and the scientific community at large about the utility of SmartPhone technology in mental health care delivery. We also expect that Aim 3 will provide our partners at MHS with helpful feedback on the Moving Forward app design and future app development.
This project will be the first to evaluate the Moving Forward app in VA. Identifying an effective treatment for anxiety and depression in primary care is imperative within VHA as they are both common, chronic, and debilitating conditions associated with a number of personal and health-related costs. In close partnership with app developers at MHS, a major contribution of this research is the actionable feedback on the acceptability, feasibility and effectiveness of augmenting traditional PST with the Moving Forward app for future app development. If effectiveness can be established, Moving Forward has the potential for integration into the larger continuum of care for depression and anxiety in PC-MHI (e.g., care management, co-located collaborative care). Lastly, this pilot project will provide preliminary data for future research on SmartPhone technology. Veteran feedback on treatment components, ease of executing the study successfully and preliminary effect size calculations, will inform the design of the larger project.
