mHealth Apps for Vets Are a Complicated Necessity

Military service taxes both body and mind, and veterans are disproportionately affected by both chronic pain and post-traumatic stress disorder (PTSD).

More than 20 million veterans live in the United States. But the Department of Veterans Affairs’ (VA) health system is facing widespread staff shortages. Because of this, telehealth and mobile health (mHealth) solutions are expected to play a larger role in post-deployment care. Digital tools that address the complex conditions facing veterans, however, are not easy to create.

Two new studies published by Journal of Medical Internet Research illustrate the issue.

Researchers from Pro-Change Behavior Systems and the VA collaborated to develop and pilot a pain self-management application for veterans. The app, Health eRide: Your Journey to Managing Pain, was designed to be a “theoretically grounded, mobile-optimized, Internet-based, interactive pain self-management program for veterans with chronic musculoskeletal pain.”

It relied on gamification to encourage cognitive and behavioral pain-coping skills. It delivered periodic “report cards” to veterans, assessing how well they adhered to safe coping methods. It also offered optional SMS text reminders to maintain activity.

The study quantified pain on the typical 11-point scale (0-10), asking respondents about their current pain level, usual level of pain in the past week, and best level of pain in the past week. From those scores, the researchers created benchmarks for change over time.

The app’s usability was rated “slightly below the mean for digital programs,” but it still showed promise. A total of 44 veterans completed the full 30-day period and follow-up assessment: 41% reported experiencing “slight but noticeable improvement,” 11% experienced “definite improvement,” and 16% said they saw “considerable improvement” in their chronic pain. The remaining 32% reported no noticeable change.

Veterans also described a modest reduction in PTSD symptoms, although it was not clinically significant. Chronic pain and PTSD are often comorbid, and the authors concluded that applications which also address mental health conditions may be more successful in managing pain.

A separate study, on the other hand, found most of the available PTSD treatment applications insufficient.

“The emergence of [mHealth] apps has the potential to bridge many of [the] access gaps by providing remote resources and monitoring,” the authors wrote, emphasizing the discrete nature of mobile applications for treatment and their potential to enhance clinician-patient relationships.

The multidisciplinary team, led by Carolina Rodriguez-Paras of Texas A&M University, found 201 PTSD treatment apps across the major app stores. Most, however, lacked efficacy evidence and clinical integration.

Three apps dominated the field. The VA developed all of them: PTSD Coach, PE Coach, and CPT Coach. PTSD Coach is a standalone app, and the other 2 are adjuncts to clinical care. The researchers found little information about how the applications came about, writing that the lack of documentation of the design and testing process was “less rigorous compared with traditional validation procedures set out by the US Food and Drug Administration.”

Applications in the study “reside solely on the smartphone and involve no data communication with any hospital system.” The investigators considered that lack of integration problematic, hypothesizing that it could be attributed it to regulation and data security concerns.

New technology like wearable sensors could track activity and physiological changes to inform diagnosis, monitoring, and optimizing of treatment, which could “contribute significantly to ongoing therapies.” Until the clinical integration and validation problems are solved, the authors argued, the true potential of mHealth apps for veterans with PTSD will remain unknown.