MILITARY MEDICINE, 179, 8:865. 2014

Review of Mobile Health Technology for Military Mental Health Jay H. Shore, MD, MPH*; M att Aldag, P hD f; COL Francis L. McVeigh, MS USA (Ret.)t; CAPT Ronald L. Hoover, MSC USNR (Ret.)§; Robert Ciulla, PhD/l; Ashley Fisher, M A f

ABSTRACT Mental health problems pose challenges for military veterans, returning service members, and military family members including spouses and children. Challenges to meeting mental health needs include improving access to care and improving quality of care. Mobile Health, or “mHealth,” can help meet these needs in the garrison and civilian environments. mHealth brings unique capabilities to health care provision through the use of mobile device technologies. This report identifies high-priority mHealth technology development considerations in two categories. First, priority considerations specific to mental health care provision include safety, privacy, evidence-based practice, efficacy studies, and temperament. Second, priority considerations broadly applicable to mHealth include security, outcomes, ease of use, carrier compliance, hardware, provider perspectives, data volume, population, regulation, com­ mand policy, and reimbursement. Strategic planning for the advancement of these priority considerations should be coordinated with stated Department of Defense capability needs to maximize likelihood of adoption. This report also summarizes three leading, military programs focused on mHealth projects in mental health, The Telemedicine and Advanced Technology Research Center, The Military Operational Medicine Research Program, United States Army Medical Research and Materiel Command, and The National Center for Telehealth and Technology.

INTRODUCTION Mental health problems pose challenges for many veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Psychological assessments of military ser­ vice members months following return from deployment indicate a notable burden of post-traumatic stress disorder (PTSD), depression, suicidal ideation, and alcohol/substance abuse.1"3 Mental health problems are also associated with traumatic brain injury (TBI),4 a significant long-term health concern associated with combat-related military deployment.5 Families of service members also face mental health chal­ lenges. Military spouses exhibit significant psychological problems associated with deployment.6'7 Studies of children in military families have found that depression, emotional problems, and behavioral problems increase when a parent is deployed.8,9 Critical mental health needs exist for returning service members and military families readjusting to postdeployment life in garrison and civilian environments. Recent efforts by the Department of Defense (DoD) and Veterans Administra­ tion (VA) have begun to identify and address ongoing chal­ lenges to meeting these needs.5,10"12 Key challenges include improving access to care and improving quality of care.

*Telemedicine and Advanced Technology Research Center (TATRC), Nighthorse Campbell Native Health Building, 13055 East 17th Avenue. Room 347, Aurora, CO 80045. fBooz Allen Hamilton, One Preserve Parkway, Rockville, MD 20852. ^Telemedicine and Advanced Technology Research Center (TATRC), MCMR-TT, 1054 Patchel Street, Fort Detrick, MD 21702. §Military Operational Medicine Research Program (MOMRP), MCMRRTO, 504 Scott Street, Building 722, Fort Detrick, MD 21702. ^National Center for Telehealth and Technology (T2), OMAMC, 9933 West Hayes Street, Joint Base Lewis-McChord, Tacoma, WA 98431. doi: 10.7205/MILMED-D-13-00429

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MOBILE HEALTH Mobile Health, or “mHealth,” can help meet ongoing mental health needs of military service members and their families in civilian environments and in military treatment facilities that are not in the Theaters of War. mHealth is the use of mobile communications technology, including cellular phones, smart phones, personal digital assistant, and tablets, to deliver health care services. mHealth is defined by the National Insti­ tutes of Health as “the use of mobile and wireless devices to improve health outcomes, health care services and health research.”1’ mHealth is a geographically mobile form of tele­ medicine, which is defined as the “use of medical information exchanged from one site to another via electronic communi­ cations to improve patients’ health status.”14 Worldwide development and adoption of mobile tech­ nology is spurring dramatic growth of mHealth as a platform to deliver numerous intervention strategies for a range of health conditions.15 The majority of global technology-based health program innovations are focused on mobile phones, as opposed to computers, radio, or television.16 In 2010, there were more than 7,000 documented smartphone health appli­ cations.17 Experts estimate that there are over 13,600 healthrelated applications in Apple’s App Store, more than 700 of which are dedicated to mental health.18 Clinical research and technology experts are developing mHealth applications and technology specifically for mental health needs. Approaches include administration of mental health questionnaires19 and delivery of cognitive behavioral therapy (CBT).20 Other strategies incorporate mHealth appli­ cations with wearable physiological sensors to monitor a user’s physiological activity.21"23 In recognition that military service members are active users of personal technology,24 multiple DoD organizations are developing mHealth technology for the mental health

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needs of service members and veterans. The Telemedicine and Advanced Technology Research Center (TATRC) is investing funding and personnel to develop mHealth tech­ nologies, systems, and applications2'1 (Table I). In keeping with its mission to “provide telehealth solutions” and “pro­ mote innovative medical technologies,” TATRC has been managing mHealth initiatives for over 10 years.26 TATRC is establishing a mobile Health Applications Laboratory (mHAL) to develop new mHealth technology, integrate new and existing technologies with electronic and personal health records, and support mobile development standards. The Military Operational Medicine Research Program (MOMRP), United States Army Medical Research and Materiel Command manages research aimed at developing “effective counter­ measures against stressors to maximize health, performance and well-being” of service members including psychological health and resilience.27 MOMRP funds and oversees studies in collaboration with military, university, and industry labo­ ratories to evaluate effectiveness of mHealth technologies, including those designed to address mental health (Table II). The National Center for Telehealth and Technology (T2) is dedicated toward the “development of telehealth and tech­ nology solutions for psychological health and traumatic brain injury.”28 In keeping with its mission to “lead innovation of health technology solutions,”29 T2 is developing numerous mHealth applications dedicated to mental health and resilience (Table III).

uled needs of an urgent or emergent nature. mHealth also facilitates communication channels linking providers to pro­ viders (for consultative or administrative needs), patients to patients (for peer support needs), as well as patient and pro­ viders to the medical system (for medical record retrieval or appointment scheduling).

Improve Compliance mHealth can help users take full advantage of existing health care opportunities. mHealth can deliver appointment reminders that help ensure patients attend scheduled meetings with their doctor or therapist; provide directions, local public transporta­ tion information, and access to transportation assistance pro­ grams; and deliver medication reminders to ensure treatment compliance with prescription and nonprescription medication.

Enrich Health Information

MOBILE HEALTH CAPABILITIES Unique characteristics of personal mobile devices confer unique capabilities to mHealth (Table I). Mobile devices are typically within a user’s reach throughout much of the day (and night). They are often continuously powered and func­ tioning (i.e., always “on”). These characteristics enable a more continuous proximity between users and mobile devices as compared to that between users and traditional technologies. Some mobile health devices can also determine the user’s geographic location, which introduces a useful component for customized health information delivery. These unique capa­ bilities provide new ways for mHealth to help provide access to care and improve quality of care through enhancing com­ munication, improving compliance, enriching the available health care data, and encouraging patient engagement.

mHealth technology enables the acquisition of new types of health information. For example, users can fill out self-report emotional questionnaires and/or cognitive assessments on a regular basis. Physiological data such as heart rate, breathing rate, or skin conductance measures can be recorded by wireless sensors on the body of the user. Global Positioning System (GPS) capabilities enabled by mobile devices also allow infor­ mation about location and movement to be incorporated into assessment and treatment modules. These additional types of health infonnation can be analyzed by software on the mobile device and sent electronically to care providers to aid diag­ nosis, evaluation, and intervention management. Given the “always on” nature of mobile technology and the fact that users are often within reach of their mobile devices throughout the day, mHealth can collect health data during new time periods as well. Health information can be collected between face-to-face appointments and sent to a provider automatically. mHealth devices can also collect information passively, while the patient is occupied by unre­ lated activities of everyday life or even while sleeping. Since mHealth devices are more seamlessly connected to electronic networks and systems, the technology has the potential for Electronic Health Record (EHR) integration. Information generated and/or processed by mHealth devices and applications can be “written” directly to existing EHR platforms to aid diagnosis and record-keeping needs.

Enhance Communication

Encourage Patient Engagement

mHealth technology provides new communication channels (e.g., short message service [SMS] or text messaging) between patient and provider. mHealth also improves the continuity of access to new and existing communications channels (e.g., phone, email, and instant messaging) by reducing the need for users to rely on a hard-wired phone line or desktop computer. More continuous communication access facilitates “betweenappointment” correspondence allowing providers to address questions that do not require office visits, as well as unsched­

Given that mobile devices are accessed by users on a regu­ lar and frequent basis, considerable opportunities exist to increase patient engagement with health care through these devices. mHealth can deliver health information directly to patients at different degrees of customization. Information can include specific instructions about enacting interventions or self-help modules. Users can also utilize mHealth applica­ tions to create action plans to track and follow treatment progress. Additionally, the anonymity of mHealth utilization

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Review ofmHealth Technology for Military Mental Health TABLE 1. Project Title: (Status)

TATRC mHealth Project Catalog

Mental Health Condition

mHAL: {In Development)

General M ental Health

mCare: (A vailable)

General M ental Health

iOS AHLTA-M obile Prim e (iAMP): (In Development)

General M ental Health

A Personal Affective Therapist for Rehabilitation of Individuals with Cognitive Im pairm ents (PATRICIA): (In Development)

General M ental Health

Remote Exercises for Learning Anger and Excitation Management (RELAX): (In Development)

Anger, Stress

Project Description m HAL consists o f facilities and expertise dedicated to fostering the developm ent o f mhealth applications and technologies. mHAL has 3 primary focus areas including (I) in-theatre, (2) garrison, and (3) global. The prim ary tenet o f mHAL is to integrate technology with the MHS EHR while supporting and im plem enting m obile technology developm ent standards. mHAL capabilities include software developm ent, acting as a clearing house, staff support, technology evaluation, and supporting various health and operational communities. m Care is a cell phone-based text m essaging system enabling an additional channel of bidirectional com m unication between patient and provider outside o f physical visits in the doctor’s office. Il is designed to improve com m unication between National Guard Reservists and health providers at Community Based W arrior Transition Units (CBW TU). m Care sends autom ated m essages (e.g., appointm ent reminders, announcem ents, and health/wellness tips) and supports secure text m essaging between patients and case m anagers. mCare received one of the A rm y’s 2010s Greatest Inventions Awards. m Care has been certified with the 4 m ajor nationwide carriers (Verizon, AT&T, Sprint, and T-M obile) and is available on Android, iPhone, Blackberry, and regional pay-as-you-go phones (Boost, Virgin M obile, and Metro PCS). The mCare Clinical Outcom es study, scheduled to conclude in F all 2012, will assess patient-provider com m unication rates, symptom severity, and user satisfaction. iAMP is a m obile application designed to provide direct access to the Armed Forces Health Longitudinal Technology Application (AHLTA) outpatient EHR, bypassing current infrastructure limitations that require login from a m ilitary treatm ent facility or access through limited rem ote connectivity. This application would enable providers to obtain read-only access to patient inform ation required for delivering quality care, such as dem ographics, diagnostic tests, m edications, laboratory results, and allergies. iAM P is currently an early stage prototype accessing fictitious patient data on the TATRC Clinical Data Repository. iAM P is designed for use in iOS devices (iPad and iPhone). PATRICIA is a smartphone application utilizing an avatar to provide motivational feedback to users during exercise. The application is coupled to wearable sensors that record the users heart rate, respiration, skin tem perature, acceleration and, location (via GPS) during exercise. The application’s software perform s real-tim e analysis o f this physiological inform ation and delivers encouragem ent and instructions via audio (synthesized speech) and video (expressive 3D avatar in the form of a virtual exercise therapist). PATRICIA allows health providers to track and m onitor the users exercise perform ance and also allows users to share progress on social networking sites. The prim ary intended end-users of the technology are those in the military rehabilitation environm ent. RELAX is a m obile device application designed to aid anger m anagem ent using m ultiple components. First, it enables users to implement an existing evidence-based CBT intervention. RELAX also enables direct com m unication between user and therapist through web-based messaging. The application collects self-reported inform ation about emotional state from the user, as well as physiological data recorded by wearable sensors. RELAX analyses and reports this inform ation to the provider to assist therapist-directed feedback and direction. RELA X is designed for use in iOS devices (iPad and iPhone). ( continued,

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Review ofmHealth Technology for Military Mental Health TA B LE I.

Continued

Project Title:

(Status) Remote Anger and Stress M anagem ent (M-SAT):

Mental Health Condition Anger, Stress

(In Development)

Integrated Novel Solution for PTSD Intervention and Remote Engagem ent (INSPIRE):

Anger, Stress

(In Development)

Anger and Stress Management Tool (ASMAT)

Anger, Stress

(In Development)

Custom ized Anger Level Management (CALM):

Anger, Stress

(In Development)

Remote PTSD monitoring and diagnosis using an autom ated system:

PTSD

(In Development)

Virtual Reality and Cellular Phones as a Com plem entary Intervention for Veterans with PTSD and Substance Use Disorders:

PTSD and Substance Abuse

(In Development)

A Conversational Independent Living Assistant for Cognitive Impairments:

(In Development)

Mild Cognitive Impairm ent

Project Description M -SAT is a m obile device application for stress and anger managem ent. It is designed to create a patient-provider com m unications portal and perform real-tim e analysis of physiological inform ation to inform provider feedback to the patient. M-SAT will enable wireless recording of galvanic skin response and heart rate. A software suite designed to track patient-specific PTSD sym ptom s will offer providers accounts o f the patient’s stress- and/or anger-related experiences in between therapy sessions. INSPIRE utilizes a 2-com ponent approach for m anagem ent of PTSD-related anger and stress. First, users receive instruction about how to practice Transcendental M editation (TM ), a hom e-based intervention method yielding psychological benefits including the reduction of depression and anxiety. The INSPIRE mobile device application assists with the m aintenance of TM and provides remote psychological monitoring. INSPIRE utilizes a num ber of technologies, including a virtual therapist for m otivation and encouragem ent, and a voice-based tele-PTSD m onitor and recording o f galvanic skin response with a wrist-worn sensor. The Remote Anger and Stress M anagem ent project will adapt a DARPA-funded m obile “eLearning” application being developed for a Stress Resilience Training System to aid service members coping with postdeploym ent psychological health issues outside the clinical setting. The project will couple this mobile platform to evidence-based anger m anagem ent and stress treatm ent interventions. CALM is a mobile device application for stress and anger managem ent. It is designed as a self-paced and therapist-assisted toolkit. CALM consists of 4 interconnected components: (1) rem ote physiological m onitoring, (2) individually tailored appraisal/coping strategies, (3) social support, and (4) virtual coaching. The Remote PTSD m onitoring and diagnosis using an automated system project aim s to develop voice analysis software to screen and identify individuals at risk for PTSD. This software will be im plem ented on a TCP/IP network, which can be directly deployed into internet, a Local Area Network (LAN) or use on a mobile device. This clinical study, at Duke University, seeks to investigate the effectiveness of using cell phones in conjunction with virtual reality (VR) as a substance use intervention in veterans with PTSD. Following the use o f VR as an exposure platform to extinguish cravings to drug-related cues, extinction rem inders are delivered to the user via m obile phone to transfer learning effects from exposure/extinction in the clinic to adaptive responses in high-risk contexts for drug use in everyday life. TATRC developing this project in collaboration with MOMRP. This project aim s to extend Planning and Execution Assistant T rainer (PEAT), which is a m obile system currently in use by the VA to assist users with planning and executing daily activities, m onitoring progress and replanning when changes occur, to use wireless biosensors, a conversational interface and plug-in therapy modules. A key innovation is the developm ent of a conversational caregiver agent which interacts with the user as if it were a hum an caregiver speaking w ith the user while m onitoring their behavior.

(continued)

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Review of mHealth Technology for Military Mental Health

TABLE I. Project Title: (Status)

Continued

M ental Health Condition

Project Description

Naturalistic Neurocognitive Assessm ent Using M obile Gam ing Platforms: Neuroracer: (In Development)

Mild Cognitive Im pairm ent

New M obile Gam e-based Application for Reliable Neurocognitive Assessm ent: Cognizen: (In Development)

M ild Cognitive Impairment

N euroracer is an Android-based cell-phone gam e that is an engaging, realistic driving video game, perm itting the assessment o f increasingly com plex neurocognitive assessm ent m etrics, serial reassessment against individual baselines, early detection o f deficit onset, facilitates next-level assessm ent and intervention This developm ent will build upon CogniZen, an existing gam e-based platform sponsored by the U.S. Arm y M edical Research and M ateriel Com m and, designed specifically for the rehabilitation and improvement of cognitive functioning for individuals with cognitive impairments. In the proposed effort, CogniZen will be extended to becom e a mobile application for the reliable and unobtrusive assessm ent of cognitive perform ance in real world settings, without the involvem ent o f a trained administrator. They will utilize an innovative approach by transforming cognitive assessm ent tests into core gam e m echanics.

can be a potential means of combating stigma, a major barrier to obtaining mental health care. mHEALTH DEVELOPMENT CONSIDERATIONS FOR MENTAL HEALTH Provision of mental health care has unique characteristics that should be taken into consideration when developing mHealth applications that deliver mental health services. These characteristics include safety, privacy, evidence base, and temperament. Prioritization of development consider­ ations, which represent areas of continuing research need, can vary across different mHealth applications and/or intended mental health conditions. Safety mHealth applications and technologies should evaluate the need to establish a direct line of communication between users and care providers in times of crisis. Because emergent or urgent needs can arise unexpectedly for mental health patients, the ability to connect immediately with another human being in real-time who can provide help could be important. This could include contacting service hotlines, a patient’s therapist, substance abuse counselor, peer support, or local medical emergency services. mHealth developers should make every effort to ensure that users are fully informed and aware of the capabilities, risks, and limitations of a particular application or tech­ nology. Accurate expectations need to be defined for what benefit can be derived from a particular technology or appli­ cation so that users look for things they need in places where they can find them— especially in urgent or in emergent con­ ditions. The American Psychological Association Code of Ethics requires, as part of the informed consent process, that mental health care consumers be fully informed about capa­ bilities and limitations of interventions administered by pro­ viders. Potential approaches for informing users include End

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User License Agreements for stand-alone applications and for applications integrated into specific treatment incorpora­ tion into an informed consent processes. Privacy Protection of records and information is particularly impor­ tant given the existing stigma toward mental health in civilian30 and military populations .31'32 Information about a service member’s mental health status can affect disability claims, civilian employment eligibility, and legal hearings (e.g., child custody). Privacy is a major design priority for mobile health technologies and applications that generate, analyze, and transmit mental health information. Evidence Base Few of the existing mHealth technologies or applications dedi­ cated to mental health or substance abuse utilize evidencebased interventions .33'34 Incorporation of new or existing evidence-based practices into the fundamental design of mHealth applications and technologies for mental health and substance abuse would represent a meaningful differentiator from available products leading to greater efficacy and ulti­ mately greater adoption. In evaluating evidence of new mHealth technologies, it is important to make the distinction between the content, which may or may not be drawn from an evidence-based intervention, and the delivery system which maybe novel in order to clearly establish the data supporting a “new” application. Efficacy Ongoing efforts to study the efficacy of mHealth applica­ tions and technologies are helping to build the evidence base needed for incorporation into product design. Existing mHealth interventions have a positive impact on patient outcomes for mental health assessment,33 mood ,36 depres­ sion , ’7 anxiety, and smoking.38 Investigators are continuing

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Review ofmHealth Technology for Military Mental Health TABLE II. Project Title: (Status)

MOMRP mHealth Project Catalog

Mental Health Condition

Usability and Utility o f a Virtual Hope Box (VHB) for Reducing Suicidal Ideation: (In Developm ent)

Suicidal Ideation

Military Continuity Project: {In Developm ent)

Suicidal Ideation

Virtual Reality and Cellular Phones as a Com plem entary Intervention for Veterans with PTSD and Substance Use Disorders (2) (In Development)

PTSD and Substance Abuse

Intelligent PTSD Classification and Treatm ent-Augm entation Technology: (In Development)

PTSD

PHIT for Duty: A Personal Health Intervention Tool (PHIT) for Psychological Health and TBI: (In Development)

Resilience

870

Project Description This project is a study designed to com pare the use o f VHB com pared to a conventional, physical Hope Box intervention technique. VHB is a m obile device application for suicidal ideation in which patients store im ages of m eaningful people and events. VHB is a virtual version o f the original, physical "Hope Box” where patients store items o f personal and meaningful significance. The VHB is being designed as a supplement to the physical Hope Box since the latter may not be easy or convenient for the individual to carry at all times. The VHB will also provide access for help, inspiring texts and relaxation tools. Phase 1 of the study will include prototype developm ent and usability testing. Phase 2 will be a proof of concept pilot com paring acceptability and utility o f VHB against the conventional physical Hope Box in clinical practice. M OM RP is developing this application in collaboration with T2. The Military Continuity Project is a randomized controlled trial designed to determ ine the effect of a text m essage-based intervention on suicidal ideation and/or suicidal behavior. The study will com pare use o f Continuity Contact via Texts (CCVT) to Treatm ent as Usual (TAU) in a cohort of 800 Service M em bers with suicidal ideation and/or suicidal behavior. This cohort consists o f 2 groups that receive either CC VT+TAU or TAU alone. The primary goal of this study is to test the hypothesis that after a 12-month follow-up, rates of suicidal ideation and suicidal behavior will be lower in the CCVT+TAU group com pared to the TAU only group. The secondary goal o f this study is to determ ine whether changes in suicidal ideation and suicidal behavior follow ing CCVT+TAU are influenced by feelings of “thwarted belongingness” and/or engagem ent in behavioral health services. This project is working to test a novel adjunctive intervention designed to com plem ent exposure-based therapies for com bat veterans with PTSD and comorbid substance abuse disorders. This intervention will use virtual reality as a platform to extinguish cravings to drug-related cues, and cellular phones as an extinction rem inder platform. The goal is to transfer the learning effects from exposure/extinction in the clinic to adaptive responses in high-risk contexts for drug use in everyday life. M O M RP is developing project in collaboration with TATRC. The objective of this project is to develop a technique for identifying PTSD through the use o f physiological monitoring. The technique uses a wrist m onitor to record physiological (heart rate, respiration), actigraphic (activity level), and voice (vocalized em otional outbursts) information that can be uploaded wirelessly to a centralized database. The project will test 3 groups of returning service members: (1) patients with a clinical diagnosis of PTSD, (2) patients with other diagnoses, and (3) controls. Participants will w ear the wrist m onitor for a 7-day period o f data collection and archiving. D ata will be analyzed via Stepwise D iscrim inant Analysis to determ ine the accuracy with which patients can be classified into the correct PTSD versus non-PTSD diagnostic category. The goal of PHIT for Duty is to develop a m obile device application or persona] health intervention tool (PHIT) enabling personal health assessm ent and self-help intervention (SHI) to help build resilience in healthy troops and support prevention in high-risk personnel with subclinical psychological symptoms. The project will first identify SHIs to assist individuals in dealing with psychological and physical consequences of combat' and operational stress. Then mobile device applications that deliver health assessm ent and SHI will be developed. Resulting PHIT for Duty application technologies will be validated through beta testing and pilot studies. Finally, the PHIT m ethodology will be studied in a random ized controlled trial with postdeployed personnel to evaluate its efficacy for prevention and operational utility in deployed personnel.

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Review ofmHealth Technology for Military Mental Health TABLE III.

T2 mHealth Project Catalog

Project Title:

(Status) Co-Occurring Conditions Toolkit:

M ental Health Condition General Mental Health

(Available)

LifeArmor:

General Mental Health

(Available)

T2 M oodTracker:

General Mental Health

(Available)

Positive Activity Jackpot:

General Mental Health

(Available)

BioZen: (.Available )

General Mental H ealth

Navy Leaders’ Guide to Managing Sailors in Distress:

General Mental Health

(In Development)

M obile Screener:

General Mental Health

(Available)

SMS Gateway:

General Mental Health

(Available)

Daily Diary:

General M ental Health

(In Development)

At Ease M ilitary Kids Connect Game:

General M ental Health

(In Development)

Goal Setting App (nam e TBD)

General Mental Health

(In Development)

Project Description This Toolkit is a m obile application that provides an electronic version of the DCoE Co-occurring Conditions Toolkit (CCT). It includes the entire contents o f the 132-page spiral-bound CCT, and adds enhancements such as interactive decision trees to aid in the identification o f appropriate interventions and tim ing o f services. The application also incorporates VA/DoD Evidence-B ased Clinical Practice Guidelines (CPGs) for the m anagem ent o f concussions and rnTBI, together with CPGs targeting com m on co-occurring conditions such as PTSD, depression, and substance use. The application is available on iPhone and Android platforms. LifeArmor is a mobile application that provides access to information about 17 health topics, including sleep, depression, relationship issues, and post-traum atic stress. Users can perform self-assessm ents to m easure and track symptoms. Tools are also available to assist with m anaging specific problems. LifeArm or includes videos relevant to each health topic that provide personal stories from other service m em bers, veterans, and m ilitary fam ily m embers. The application is available on iPhone and Android platforms. T2 M oodTracker is a mobile application allowing users to self-monitor, track, and reference their em otional experience over a period of days, weeks, and m onths using a visual analog rating scale. Users can m onitor em otional experiences associated with com m on deploym ent-related behavioral health issues such as post-traum atic stress, brain injury, life stress, depression, and anxiety. The application is available on iPhone and Android platforms. Positive Activity Jackpot is a mobile application enabling users to identify nearby enjoyable activities or pleasant diversions. The application utilizes augmented reality technology to combine GPS and camera phone information. It also uses a professional behavioral health therapy called “pleasant event scheduling” to help overcome depression. Positive Activity Jackpot is available on the Android platform. BioZen is a mobile application providing users with real-time biofeedback data from multiple wearable body sensors. The application monitors and displays a range of biophysiological signals including electroencephalography (EEG), electromyography (EMG), galvanic skin response (GSR), electrocardiogram (ECG or EKG), respiratory rate, and temperature. BioZen is available on the Android platform. The Navy L eaders’ Guide to M anaging Sailors in Distress is a mobile application providing access to key content from the web-based Navy L eader’s Guide in an easy-to-use format in areas without internet access. Users will also have the ability to connect imm ediately with em ergency resources. The application is designed for iOS and Android platforms. Mobile Screener is a mobile surveillance app designed for use in the field and between clinic sessions. Users will be presented with assessment questions. Based upon input, certain endorsed responses will trigger the presentation of up to four measures of sleep, anger, suicide ideation and TBI-related symptoms. The application scores the measures and presents scores and brief interpretive statements to the user. The SMS Gateway project is designed to provide crisis numbers, health tips, and other health intervention processes to users in the form o f SMS m essages via smartphone or mobile devices. Users will register for SMS service and receive messages based on user input. Daily Diary is a m obile app enabling daily diary assessments and the use o f the Ecological M om entary Assessment methodology. Assessments can be self-reported by users or com pleted by providers. The app is designed to increase ease-of-use and survey com pletion while reducing the potential for data loss. The At Ease M ilitary Kids Connect Game is a m obile application version o f Mood Match, an existing web-based game found on M ilitaryKidsConnect.org. The application is com posed of a “match three” puzzle gam e where users m atch at least three of an object in a grid. Players progress through m ultiple levels to achieve their highest score. Psychological content is delivered during level changes in the form o f stress tips related to the gam e play. This application is being designed for the Android platform. The Goal Setting app will allow users to set individual behavior change goals via m obile device or a web-based interface and then share progress with a specific group of family m em bers or friends. This application is being developed for deploym ent on iOS. Android and web as part of the MHS Healthy Base initiative.

(continued)

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Review ofmHealth Technology fo r Military Mental Health TABLE III. Project Title: (Status) PE Coach: (.Available)

PTSD Coach: (Available)

CPT Coach: (In Development)

Tactical Breather: (Available)

Problem Solving (name TBD): (In Development)

Breathe2Relax: (Available)

Provider Resilience: (Available) DCoE Substance Use Disorder Toolkit: (In Development)

Virtual Hope Box: (In Development)

872

Mental Health Condition

Continued Project Description

PTSD

PE Coach is a mobile application designed to support tasks associated with prolonged exposure treatment for PTSD. It includes audio recording capability for easy playback after therapeutic sessions, tools to support patient tasks between sessions, and visual displays of symptom reduction over time. Additionally, PE Coach is integrated with smartphone calendar functionality to encourage patient recall and session attendance. The application was developed in collaboration with the VA National Center for PTSD (VA NCPTSD) and is available on iPhone and Android platforms. PTSD PTSD Coach is a mobile application designed to assist users experiencing symptoms of PTSD. It is intended to be used as an adjunct to psychological treatment but can also serve as a stand-alone education tool. Key features of PTSD Coach include self-assessments, management of symptoms, identifying appropriate mental health resources, and general education topics. The application was developed in collaboration with the VA NCPTSD and is available on iPhone and Android platforms. PTSD CPT Coach is a mobile application designed to help users manage symptoms of stress-related trauma. It will provide information about PTSD and effective treatments, as well as tools for screening, symptom tracking, and symptom management. CPT Coach is intended for use in conjunction with professional therapy and will provide direct links to support and help. Stress Tactical Breather is a mobile application that can be used to gain control over physiological and psychological responses to stress. Through repetitive practice and training, users gain control of heart rate, emotions, concentration, and other responses to stressful situations. Tactical Breather is available on iPhone and Android platforms. Stress This mobile application is intended to teach users how stress impacts problem solving ability and provide practical tools for dealing with stress. Designed for the iOS platform, the application is designed to be used as a stand-alone product as well as an adjunct to a web-based program. T2 is developing this app in collaboration with the VA NCPTSD. Mood Stabilization, Anger Breathe2Relax is a mobile application for stress management. It coaches users Control, Anxiety through diaphragmatic breathing exercises and enables recording of stress level Management on a “visual analog scale” with a simplified graphical user interface. Built on the iPhone and Android mobile application platform, Breathe2Relax utilizes graphics, animation, narration, and videos to deliver content. Resilience Provider Resilience is a self-care tool for health care providers experiencing compassion fatigue. The application is designed to provide behavior management techniques, a leave time tracker, and a resilience progress tracker. Substance Abuse The DCoE Substance Use Disorder Toolkit is a mobile application modeled after the Department of Veterans Affairs/DoD Clinical Practice Guideline for the Management of Substance Use toolkits. It is designed to provide features that are not available on hard copy or PDF versions of the toolkit. These features would allow providers to select symptoms with which the patient presents, filter through decision trees, and provide the recommended treatment plans to include pharmacologic (drug name, dose, side effects, special considerations, and warnings) and nonpharmacologic interventions. Suicide Prevention Virtual Hope Box (VHB) is a mobile device application for suicidal ideation in which patients store images of meaningful people and events. VHB is a virtual version of the original, physical “Hope Box” where patients store items of personal significance that serve as reminders that life is meaningful and worth living. The VHB is being designed as a supplement to the physical Hope Box, since use of the latter may not be easy or convenient for the individual to carry at all times. The VHB will also provide access for help, inspiring texts, and relaxation tools. VHB will provide 4 core features: (1) “Distract Me” includes absorbing games that help to divert a user’s attention away from distressing thoughts; (2) “Inspire Me” provides inspirational quotes; (3) “Relax Me” offers stress-reduction exercises; and (4) “Coping Cards” teach positive-thinking strategies. T2 is developing this application in collaboration with MOMRP.

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Review o f mHealth Technology for Military Mental Health

to evaluate mHealth applications for major depressive dis­ order,39 schizophrenia,40 depression, and anxiety.41 Sustained support of efficacy research is warranted, particularly studies that compare the use of mHealth to traditional treatment. Future work should attempt to understand the optimal match­ ing between a mHealth application’s efficacy in the context of the intended population/disorder it is targeted for, espe­ cially considering the ubiquitous availability of certain mHealth applications. Table IV presents a more detailed overview of these studies and their results. Condition-Appropriate Temperament Although there is scarce data from the literature, design of mHealth applications and technologies for mental health con­ ditions will likely need to considerate of user perspective and attempt to strike the appropriate tone. For example, graphical user interfaces consisting of bright colors, lively game-like sound effects, and enthusiastic language may not be appro­ priate for suicide prevention applications. While ease of use is a critical design concept for mHealth applications as well (see below), understanding the role of striking the appropri­ ate temperament will likely be important for mental health applications to maximize utilization and effectiveness. There­ fore, more studies are needed on both the impact of design elements on users and specifically pairing of tone/perspective with populations and conditions. GENERAL mHEALTH DEVELOPMENT CONSIDERATIONS Provision of health care services to military service members across both primary care and specialty environments has characteristics that merit consideration when developing mHealth technologies or applications for delivery of care. These characteristics include security, outcomes, ease of use, carrier compliance, hardware, provider perspectives, data volume, population, regulation, command policy, and reimbursement policy. Security Protection of data is a major issue for the development of mHealth technology and wireless medical sensor net­ works.42,43 Security of health data, whether at rest upon a single device or in transit between devices, is needed to protect the privacy of patients and providers. Numerous data security approaches for mHealth exist, including tiered architecture44 and authentication protocols.45 Outcomes mHealth technology developers should begin to cultivate metrics for evaluation of relevant and desired outcomes. Out­ comes can include efficacy, usability, usage, etc. Where pos­ sible and appropriate, efforts should be made to standardize across technology platforms and/or health conditions and use widely accepted outcomes for disease processes used in

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mental health research to ascertain the clinical relevancy or efficacy. Ease-of-Use Usability testing is a critical component of technology design to maximize utilization and effectiveness. Usability testing of health technology can require specific methodo­ logical approaches.46,47 In 2011, T2 launched a Technology Enhancement Center that manages a user-centered approach to designing and testing mHealth technologies.29,48 Carrier Compliance mHealth applications and technologies designed for the non-Theaters of War settings must be compatible with the multiple commercial cellular providers available to users (Verizon, AT&T, Sprint, T-Mobile). Different providers have different payment policies and technical/software require­ ments that must be met for application execution. mHealth developers should take into account the time and resources required to achieve compliance with multiple earners when determining budgets and timelines. Hardware Personal mobile devices have different levels of sophistica­ tion and capabilities. The vast majority of mobile devices can send and receive SMS messages. Features such as video playback, GPS, and data processing applications require more advanced, and therefore more costly, mobile devices (e.g., iOS platforms). Since many service members do not use expensive mobile devices, mHealth development should carefully weigh trade-offs between sophistication and availability. mHealth application design should take into account the capabilities and limitations of available platforms, and where possible ensure benefit even to users of low-end devices. Hardware sophistication and user adoption will be dynamic as mobile technologies continue to evolve rapidly over the next several years. Smartphone ownership in American adults increased from 35% to 46% between May 2011 and March 2012 49 Development directors and policy makers will need to determine what resources to dedicate to less sophisticated technologies that would be of benefit to users in the short term, but would be potentially rendered obsolete, and there­ fore unused, in the longer term. Provider Perspectives Some mHealth applications and technologies are designed to improve health care communication channels by linking users to providers or provider offices. For these technolo­ gies, providers must also be considered users with their usability needs incorporated into design. For example, the impact of direct patient-provider electronic messaging on physician acceptance, productivity, and liability is being evalu­ ated broadly within the health care system.50-52 mHealth

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Review ofmHealth Technology for Military Men tal Health TABLE IV. Author(s) (Year)

Study Title

Outcomes in mHealth Technology for Mental Health Literature Study Purpose

Abroms e ta l (2011)

iPhone Apps for Smoking Cessation: a content analysis

To examine the content of 47 iPhone applications (apps) for smoking cessation distributed through the iTunes store as of June 2009.

Cohn e ta l (2011)

Promoting behavior change from alcohol use through mobile technology: the future of ecological momentary assessment

Reid e t a l (2011)

A mobile phone application for the assessment and management of youth mental health problems in primary care: a randomised controlled trial

Morris et al (2010)

Mobile therapy: case study evaluations of a cell phone application for emotional self-awareness

To examine currently available mobile smartphone apps utilizing principles of ecological momentary assessment (i.e., selfmonitoring) to promote positive behavior change, alcohol harm reduction, psycho-education about alcohol use, or abstinence from alcohol. To examine benefits of the “mobiletype” program, a mental health assessment and management mobile phone application. “mobiletype” monitors mood, stress, coping strategies, activities, eating, sleeping, exercise patterns, and alcohol and cannabis use on a daily basis. The application transmits this information to general practitioners via a secure website in summary format for medical review. To examine the potential of mobile phone technologies to broaden access to CBT techniques and to provide “in-the-moment support.” A mobile app was developed with touch screen scales for mood reporting and therapeutic exercises for cognitive reappraisal and physical relaxation.

Study M ethodology Each app was independently coded by 2 reviewers for its (1) approach to smoking cessation, (2) adherence to the U.S. Public Health Service’s 2008 Clinical Practice Guidelines for Treating Tobacco Use and Dependence, and (3) frequency of downloads.

Qualitative analysis of data from iTunes for Apple iPhone. The analysis examined the number of available apps directly addressing alcohol use and consumption, alcohol treatment, or recovery, and whether these apps incorporated empirically based components of alcohol treatment.

Study Outcome Adherence to established smoking cessation guidelines was rare. Analysis indicated that only 11.3% o f iPhone apps strongly followed a given guideline. Among app types, calculator apps were most adherent to guidelines, whereas calendar apps were least adherent. The authors recommend that current apps be revised and future apps be developed around evidence-based practices for smoking cessation. Few apps addressed alcohol-use behavior change or recovery. Aside from tracking drinking consumption, a minority utilized empirically based components of alcohol treatment. Some apps claimed to serve as an intervention without provided empirical evidence.

This randomized controlled trial included 114 participants (n = 68 intervention group, n = 46 comparison group) ages 14 to 24 referred from both ruraland metropolitan practices in the primary care setting. Participants completed pre-, post-, and 6-week post-test measures of the Depression, Anxiety, Stress Scale, and an Emotional Self Awareness (ESA) Scale.

Monitoring mental health symptoms appears to increase ESA and implementing a mental health program in primary care and providing frequent reminders, clinical resources, and support to general practitioners s substantially improved mental health outcomes for the sample as a whole.

This was a 1-month field study with 8 employees recruited from a large corporation who had reported significant stress during an employee health assessment. Participants would use the app as needed and during weekly open-ended interviews, participants discussed their use of the device and responded to longitudinal views of their data.

Interview narratives suggest that participants applied the mood scales and therapeutic content in ways that helped them initiate meaningful personal change. There was also a willingness among participants to utilize the app when experiencing intense emotions. Overall, this preliminary study pointed to potential promises of coupling experience sampling tools with mobile therapies to encourage self-awareness and coping in daily life.

(continued)

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Review of mHealth Technology for Military Mental Health TABLE IV. Author(s) (Year)

Study Title

Study Purpose

Continued Study Methodology

Study Outcome

Bums e ta l (2011)

Harnessing context sensing to develop a mobile intervention for depression

To investigate the technical feasibility, functional reliability, and patient satisfaction with Mobilyze!, a mobile phone- and internet-based intervention including ecological momentary intervention and context sensing.

Eight adults with major depressive disorder were enrolled in a single-arm pilot study to receive Mobilyze! and complete clinical assessments for 8 weeks.

Kittler et al (2004)

Primary care physician attitudes towards using a secure web-based portal designed to facilitate electronic communication with patients

To assess physician attitudes toward electronic communication with patients 6 months after the implementation Patient Gateway, an app allowing patients access to their medical records and facilitates online communication with medical practices

A paper-based survey was completed by 24 primary care physicians in a single integrated delivery system.

Liederman et al (2005)

Patient-physician web messaging. The impact on message volume and satisfaction

To measure the effects of patient-physician web messaging on primary care practices.

Retrospective analysis of physicians message volume and a patient survey of (n = 5,971) across 16 community primary care clinics in the Sacramento, CA region.

Strachan et al (2012)

An integrated approach to delivering exposure-based treatment for symptoms of PTSD and depression in OIF/OEF veterans: preliminary findings

To review an ongoing clinical trial comparing home-based telehealth application of a brief, behavioral treatment (Behavioral Activation and Therapeutic Exposure; BA-TE) for veterans with PTSD to the standard, in-person application of the same treatment.

This study included 31 OIF/OEF military personnel with PTSD symptoms who completed the 8-session BA-TE treatment protocol.

Participants were satisfied with the phone application and improved significantly on self-reported depressive symptoms. Participants also became less likely to meet criteria for major depressive disorder diagnosis. Comorbid anxiety symptoms also decreased. However, for states rated on scales (e.g., mood), predictive capability was poor. Physicians’ fears about being overwhelmed with messages were not realized. Although physicians were generally enthusiastic about the application, none used it to communicate directly with patients. Over three-quarters of respondents indicated that they would be more enthusiastic about electronic communication with patients if this time were compensated. Patients expressed overwhelming satisfaction with web-messaging, whereas provider satisfaction was more moderate. Both populations found the system easy to use. Patient satisfaction correlated strongly with provider response time and provider/staff satisfaction with computer skills Results provide preliminary evidence that a brief therapeutic protocol, inclusive of BA and exposure components, may reduce symptoms of PTSD, depression, and anxiety in OIF/OEF military personnel and that this treatment may be effectively delivered via home-based telehealth.

technologies requiring significant provider participation should be designed with provider needs in mind and pro­ viders should be involved in the developm ent process. Alert systems need to be in place such that the level of response time is determ ined and clinically appropriate personnel are notified within a designated time frame.

not overwhelmed by increased data management (including triage, filtering, and storage) and patient communication demands. Legal consequences should also be taken into consideration since a more ubiquitous existence of health data may place a greater burden on physicians or the health care system to react to potentially diagnostic or emergent patient information.

D a ta V o lu m e

Technology developers and health policy makers need to address potential challenges manifested by the increasing amount of data generated by mHealth. Measures need to be taken to ensure providers and health care systems are

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P o p u la tio n

Developers of military health technology, including mHealth, should be vigilant of the ethical issues surrounding the appli­ cation of novel techniques to active duty member populations

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with demonstrated health needs. Developers should also con­ sider when the health needs of the active duty member popu­ lation are unique from civilian population needs to determine when military-specific solutions are required. Cultural issues (e.g., gender, ethnicity) need to be taken into account as well.

Regulation Technology developers should consider pending regulation of mHealth technology by the U.S. Food and Drug Adminis­ tration (FDA). Current guidelines53 are under develop­ ment and open for public comment. When final FDA rules are released, existing mHealth applications may have to be taken “off the shelf’ for evaluation of compliance and, if necessary, modification to meet compliance specifica­ tions. Strategies for mHealth developers to reduce risk of FDA regulation include avoidance of unnecessary medical claims in promotional materials and subcontracting highrisk components.54

Command Policy Command policy constraints are an often-cited challenge to development and implementation of mHealth and telehealth technology. Gamering Command buy-in and approval nec­ essarily requires adequate and thorough demonstration of safety, security, and effectiveness. However, over the years, leaders in the DoD have developed the technology and infrastructure necessary to support telemedicine55 for health specialties such as orthopedics56 and ocular care.'7 DoD telemedicine programs have also been dedicated to mental health,58 although cost savings and effectiveness are still being evaluated.59 The VA has also extensively imple­ mented telemedicine programs,60 including those for mental health.61,62 Implementation of telehealth has enabled the development of mHealth approaches in the Military Health Service (MHS).63,64 Second in importance to command sup­ port is the identification of local clinical champions who will support the adoption and sustainment of mHealth initiatives.

Reimbursement Policy Federal policy is shifting to encourage the use of telemedi­ cine for military service members and veterans. The recent Service Members Telemedicine & E-Health Portability (STEP) Act65 proposed bypassing individual state licensing require­ ments and removes financial disincentives to providing care via telemedicine across state lines. The 2012 National Defense Authorization Act incorporated provisions of the STEP Act, allowing reimbursement of telemedicine services to licensed medical professionals when providing care to members of the Armed Forces. DoD implementation guidelines are being developed and will soon be disseminated to put the new poli­ cies in place. The Veterans E-Health & Telemedicine Support Act,66 which was recently introduced into legislation in 2012, would allow equivalent reimbursement rules for licensed care provision to veterans via telemedicine.

876

Innovation mHealth is a rapidly evolving field of technology and leading developers are cultivating new design consideration to opti­ mize the delivery of health services via personal mobile devices. For example, automatic delivery or analysis of infor­ mation via mHealth technology could reduce cost as well as potentially increase consistency and reliability. For exam­ ple, appointment reminders delivered to patients by SMS or voice recording could be generated by electronic scheduling systems instead of administrative staff. Additionally, mHealth applications could be customized to individual users, which may enhance usability and overall effectiveness for patients, providers, or both. mHealth developers are also sharing tech­ nical solutions to promote growth of the field. For example, T2 is working to identify, package, and share software module components that can be adapted to prototype tech­ nologies being developed by colleagues and collaborators. CONCLUSIONS Given the rapid pace of technology innovation, the scale of current health care needs, the abundant capabilities of mobile technology, and the numerous development con­ siderations discussed herein, opportunity exists to make positive contributions to the advancement of mHealth for mental health. Central to these efforts will be embedding rigorous evaluation and outcome studies that delineate the properties of mHealth applications for mental health includ­ ing strengths, benefits, and limitations. This information will be critical in discerning which applications and platforms best address mental health issues for service members and their families and which should be propagated for wide­ spread use and dissemination. Strategic planning efforts by DoD, as well as private and public partners, dedicated to mHealth applications for military service members and military families need to synchronize with stated DoD capability needs. mHealth initiatives that are aligned and coordinated with DoD needs will have the greater chances for realization, execution, and achieving their current promise for supporting the mental health care issues confronting service members and their communities. ACKNOWLEDGMENTS The authors are grateful for the valuable contributions of Holly Pavliscsak (TATRC), Jeanette Rasche Little (TATRC), Dave Williams (TATRC), Charles Peterson (TATRC), Eva Lai (TATRC), COL (Ret.) Ronald Poropatich (TATRC), Mark Jeffrey (Integrated Clinical Systems), Steve Steffensen (U.S. Army Office of the Surgeon General), and Julie Kinn (T2) in support of this manuscript. This work was supported by the Telemedicine and Advanced Technology Research Center (TATRC).

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