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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.
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.
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.
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.
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.
Recent technological advances have resulted in the development of emerging mobile health (mHealth) apps. mHealth apps include a wide range of applications such as educational materials and self-management platforms, health care–specific tools for managing the therapeutic process, health and preventative behavior, patient and patient-provider roles and relationships, challenges of daily life, and crisis situations. In addition, many of these apps are free and can help to reduce barriers to access, as they are able to provide the assistance to patients at any given time, whereas speaking with a clinician requires an appointment, traveling to the facility, and financial considerations. mHealth apps have thus far been successfully implemented across a wide range of medical disciplines, including dermatology [
PTSD is a prevalent mental health issue that commonly occurs after a person has experienced a traumatic event, which can include being threatened with death or experiencing the death of others (eg, death of a family member or a friend), sexual violence, or serious injury [
Current PTSD treatments are divided into two categories that are not mutually exclusive: (1) pharmacotherapy and (2) psychotherapy. Studies suggest psychotherapy is more effective than pharmacotherapy [
Despite the efficacy of current PTSD therapies, significant challenges still exist in access to treatment, particularly for veterans, that may influence both treatment-seeking behavior and adherence to treatment [
mHealth apps have the potential to help improve access to care [
The goal of PTSD apps should be to aid in the treatment and monitoring of trauma survivors with PTSD and to provide both patients and clinicians with timely remote feedback that can supplement or enhance current therapies [
This study consists of two parts: (1) a review of publically available PTSD apps, which includes more detailed information about the three most prevalent apps used and (2) a scoping literature review performed using systematic methods. The purpose of part 1 is to determine the availability of PTSD apps, and the purpose of part 2 is to determine the usage and efforts toward validation of such mHealth apps.
Health care providers’ mobile app websites (eg, the Department of Veterans Affairs [VA] App Store), commercial app stores (eg, Apple App Store, Google Play Store), websites that aggregated or listed mental health apps, websites that provide app ratings, Web communities supporting veterans, and Google were used to search keywords relating to [post-traumatic stress disorder” OR “PTSD”], [“veterans”], and words relating to PTSD treatment (eg, [“insomnia”]). The search was performed from January 2016 to August 2016. Data on available apps were collected from the following websites: Apple App Store [
Apps were categorized according to clinical focus (ie, mental health disorder, PTSD symptom, or clinical treatment modality) and for each type of app utility used (eg, education and exercises). Each app was assigned to one primary clinical focus but could contain more than one app utility. For example, Acceptance and Commitment Therapy (ACT) Coach included mindfulness exercises, but the primary focus of this app is specific to a VA-recognized evidence-based treatment for PTSD. Apps may use several utilities. For example, PE Coach included multiple utilities such as educational materials and exercises. Apps within each clinical focus and app utility categories were tallied to determine frequency. The following information for each app was also collected to determine feasibility and acceptability: average user ratings, number of user ratings, availability to iPhone operating system (henceforth iOS) (Apple, Cupertino, CA) and/or Android (Google, Mountain View, CA) operating systems (henceforth Android), minimum iOS and/or Android requirements, and cost to download.
The app search did not reveal information on how the apps were designed and evaluated, or whether studies had analyzed their usability. A scoping literature review [
A combination of keywords relating to [“post-traumatic stress disorder” OR “PTSD”] AND [“mobile applications” OR “mHealth”] was used to search within Google Scholar and the Texas A&M EBSCOHost Research Databases such as MEDLINE, ABI/INFORM Complete, and Academic Search Complete. The Google Scholar database search was completed on March 16, 2016, with a total of 1850 results. The search using other databases did not result in any new results. The search only included journals written in English and published in or after 2011, as this is the year in which PTSD Coach, the first of the VA PTSD mobile apps, first appeared on the app store. The following inclusion criteria were then used to narrow the scope of the papers obtained through the search: the paper reviewed or validated an existing PTSD app (eg, feasibility studies, randomized clinical trials, usability testing, etc), the paper detailed the development of a new app for the detection or treatment of PTSD, or the paper was a case study using PTSD apps.
The following section first details the results from the review of publically available PTSD apps and then the scoping literature review.
A total of 201 apps were chosen for the study, all of which were available for iOS or Android. Apps were categorized based on their primary focus or purpose, which fell into six distinct groups. These were as follows: (1) PTSD evidence-based treatment (EBT), which included apps specific to a VA-recognized EBT for PTSD [
The total number of 201 apps chosen included duplicate apps between operating systems; for example, PTSD Coach was available for both iOS and Android, so it was counted twice. When duplicates were removed, the total number of apps was 81. Across all categories, apps related to mindfulness and relaxation were the most frequently available (approximately 29.9%, 60/201) followed by PTSD-specific apps (approximately 22.4%, 45/201).
Apps were further analyzed for content and utilities, which included the following: (1) educational information, which included educational material regarding PTSD, PTSD treatment, or common symptoms of PTSD; (2) exercises, which included either skills training or practice components; (3) symptom tracking, which included tools to track severity of symptoms of PTSD, whether or not the app was related to PTSD (eg, tracking sleep); (4) connections to outside professional support, which provided methods of contacting outside professional support, and this included direct contact options (eg, send a message through the app) or providing contact information (eg, phone number); (5) connections to outside peer support, which included content for individuals with PTSD for communication with local or online peer support; and (6) components specific to treatment integration, which included content designed to be integrated into ongoing in-person treatment with a therapist. An example of treatment integration content included patients’ ability to audio-record in-person therapy sessions and replay them outside of therapy as part of a treatment homework assignment (
Across utilities, in-app exercises (eg, guided breathing) were the most commonly provided app function and were especially dominant across apps related to mindfulness and relaxation. All apps that were directly related to an EBT for PTSD included exercise components, and apps specific to PTSD commonly utilized both education and exercise components. Both PTSD-specific and mindfulness and relaxation app categories had at least one app to provide for one or more of all measured utility categories. All app categories included at least one app that provided education.
Building on this work, app accessibility was measured in two ways: (1) technological access, defined as the minimum operating system and memory required to use the app, with lower operating systems and less memory requirements having better accessibility and (2) financial access, defined as the cost of downloading the app, with lower costs having better accessibility. With respect to
The app categories grouped by the type of operating system.
Type of operating system | PTSDa EBTb | PTSD-specific | MH variety | Mindful and relax | Anger | Insomnia | Total |
iPhone operating system (iOS) only | 8 | 12 | 8 | 22 | 4 | 12 | 66 |
Android only | 7 | 14 | 5 | 16 | 4 | 8 | 54 |
Both iOS and Android | 12 | 19 | 8 | 22 | 8 | 12 | 81 |
Total | 27 | 45 | 21 | 60 | 16 | 32 | 201 |
aPosttraumatic stress disorder.
bEvidence-based treatment.
cMH: mental health.
The app tallies for different utility categories (utilities are not mutually exclusive).
App categories (total from search) | Education | Exercises | Tracking | Professional support | Peer support | Treatment integration | Other |
PTSDa EBTb (27) | 5 | 12 | 4 | 2 | 0 | 2 | 2 |
PTSD-specific (45) | 13 | 12 | 5 | 4 | 2 | 0 | 9 |
MH variety (21) | 2 | 5 | 5 | 0 | 1 | 0 | 8 |
Mindful and relax (60) | 7 | 22 | 7 | 2 | 3 | 0 | 19 |
Anger (16) | 5 | 7 | 2 | 0 | 0 | 0 | 2 |
Insomnia (32) | 3 | 11 | 3 | 0 | 1 | 0 | 14 |
Total | 35 | 69 | 26 | 8 | 7 | 2 | 54 |
aPosttraumatic stress disorder.
bEvidence-based treatment.
For example, an Apple phone with 8 GB of space may not be able to download an upgrade that requires over 4 GB of available space. Regarding
Three mHealth apps reviewed in this search appeared dominant among users (most downloads), all of which were developed by the Department of Veterans Affairs for trauma survivors with PTSD: PTSD Coach (261,045 total downloads), PE Coach (49,453 total downloads), and CPT Coach (11,689 total downloads). Download counts were reported by J Worthen from the National Center for Telehealth and Technology (September 12, 2016). These apps can be divided into two categories based on their intended use: (1) as a stand-alone app for the self-management of symptoms (ie, PTSD Coach) or (2) in conjunction with a PTSD EBT through a health care provider (ie, PE Coach and CPT Coach). PE Coach and CPT Coach are the only apps designed thus far explicitly for integration with standard treatment.
PTSD Coach (left), PE Coach (middle), CPT Coach (right).
PTSD Coach (
Of the 201 apps collected, only 2 were designed explicitly for integration with standard treatment for PTSD: PE Coach (with PE therapy;
A total of 1850 papers were found. The 28 papers fitting the inclusion criteria are listed in
The first category “Veteran population” refers to papers that specifically mention PTSD apps in reference to the veteran populations (as opposed to the general population). “Benefit analysis” contains the papers that focus on the perception or evaluation of app, or with the potential benefits of apps to the population. “Age concern” includes the papers that discuss potential barriers to older populations, or the appeal of mHealth apps to the younger populations. “Usage and adoption” refers to papers that specifically mention how the users have interacted with the apps, particularly those that contain analytics on the use of apps, such as statistics about downloads, how often users return to the app after the initial download, and the number of users who download the app specifically as part of their treatment for PTSD. The final category “HFE considerations” (ie, human factors and ergonomics) contains the papers that mention app design concerns, including usability of apps, user satisfaction, and acceptability of apps, or other HFE analysis beyond that in the previous categories.
Although all the papers listed in
Three studies examined PE Coach. Reger et al [
Three studies examined PTSD Coach, all of which were more analytical than those that examined PE Coach. Both Kuhn et al [
The 28 papers meeting the inclusion criteria. The headers are the categories of gaps identified. An “X” in the column indicates that the papers worked to address this gap.
Paper number and author name | Veteran population | Benefit analysis | Age concern | Usage and adoption | HFEa considerations | |
1 | Erbes et al [ |
X | X | X | X | X |
2 | Gravenhorst et al [ |
X | X | |||
3 | Chen et al [ |
X | ||||
4 | Kuhn et al [ |
X | X | X | X | X |
5 | Olff [ |
|||||
6 | Sloan et al [ |
X | ||||
7 | Owen et al [ |
X | X | X | X | |
8 | Kuhn et al [ |
X | X | X | ||
9 | Reger et al [ |
X | ||||
10 | McInnes et al [ |
X | X | X | ||
11 | Possemato et al [ |
X | X | |||
12 | Gratzer et al [ |
|||||
13 | Kuester et al [ |
|||||
14 | Luxton et al [ |
|||||
15 | Fletcher et al [ |
X | ||||
16 | Castro et al [ |
X | ||||
17 | Turvey et al [ |
|||||
18 | Kanuri et al [ |
X | ||||
19 | Baysari et al [ |
|||||
20 | Mohsenin et al [ |
|||||
21 | Driesenga et al [ |
X | ||||
22 | Proudfoot [ |
|||||
23 | Price et al [ |
X | ||||
24 | Kuhn et al [ |
X | X | X | ||
25 | Reger et al [ |
X | X | X | ||
26 | Olff et al [ |
X | X | |||
27 | Weingardt and Greene [ |
X | ||||
28 | Chan et al [ |
aHuman factors and ergonomics.
bPapers that provide more detailed analysis of a specific PTSD App (PE Coach or PTSD Coach).
To date, no papers exist that compare the stand-alone app (PTSD Coach) with the adjunctive apps (CPT Coach and PE Coach). Although PTSD Coach offers more information on PTSD and some therapy tools, both PE and CPT Coach contain information relevant for each clinical session. For example, these adjunctive apps may be able to improve treatment adherence by offering reminders on homework assignments due. Clinicians’ perceptions tend to be favorable toward implementing apps for PTSD treatment, such as PE Coach [
Some of this literature conceptualizes mHealth apps as a method for overcoming geographic and temporal access barriers to mental health care [
The goal of this review was to determine the availability and level of validation of PTSD apps. The mHealth app search indicated that a plethora of Android and iOS PTSD-specific apps are available. In addition, the app search showed that other PTSD-related apps such as relaxation, insomnia management, and anger management tools are available but may not be necessarily known to PTSD patients. Despite the availability of these tools, the scoping literature review suggested there was insufficient evidence on the validity of the apps. The literature review highlighted the need for additional studies on app dissemination and adoption [
Of the PTSD-related apps available, all of the VA’s apps including the three most-downloaded apps for PTSD treatment (PTSD Coach, CPT Coach, and PE Coach) are free to download. However, the results suggest many trauma survivors with PTSD, and even some practitioners, may not be aware that these apps exist [
This review found only 6 papers analyzing the usage or validation of specific PTSD-related apps [
The potential legal ramifications posed by mHealth apps center on scrutiny of data storage and remote communication with health care providers. The responsible party for these legal issues—whether it is the developer, the health care provider, the user, or some combination of the aforementioned—has yet to be determined [
Despite potential security issues and obstacles to apps’ dispersion among users, an abundance of calls for more studies on app dissemination and adoption [
Recent advances in wearable sensors provide an opportunity for future PTSD apps to utilize the features of activity trackers for tracking patients’ PTSD-related physiological changes, thus aiding in diagnosing, monitoring, and optimizing clinical treatment regimens. This has the potential to significantly contribute to on-going therapies. App-integrated information from wearable sensors could be used to inform patients of their current physiology and mental state or provide clinicians with information about the most viable treatment course or aid in remote care [
The mHealth app search centered around four main symptoms of PTSD (eg, intrusion, avoidance, negative alterations to mood and cognition, and changes in arousal and reactivity), which are common among mental health issues including PTSD. Apps specific to other mental conditions that may aid in PTSD were hence not included in this analysis. In addition, although we focused on stand-alone mobile apps, there are several mobile-responsive websites related to PTSD that were not included in this search. Although accessibility was assessed and discussed based on technical and financial access, future studies should investigate design for the disabled (eg, blind, cognitively impaired, deaf, and users with missing limbs). Although the literature review yielded only a small number of peer-reviewed publications relating to PTSD mobile apps, the combined results of the app search and review of literature shed light on the current state of mHealth apps to support PTSD patients.
This dual review highlights the availability and potential of PTSD app usage in increasing treatment adherence and quality. Results of this review suggest that current app development, however, lacks strong usability and validation components and that not enough apps are being developed to be integrated as treatment tools. 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.
Acceptance and Commitment Therapy
cognitive behavioral therapy
cognitive processing therapy
evidence-based treatment
human factors and ergonomics
mobile health
prolonged exposure therapy
posttraumatic stress disorder
Veterans Affairs
This research was funded by a Texas A&M Engineering Experiment Station (TEES) Grant and a Department of Veterans Affairs Career Development Award (CDA 11-246). The views expressed in this paper are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US Government. The authors would like to thank the members of the Applied Cognitive Ergonomics Laboratory at Texas A&M University for their insightful feedback.
None declared.