preliminary pilot test of sms to track ptsd symptoms after a traumatic injury matthew price ken...
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Preliminary pilot test of SMS to track PTSD symptoms
after a traumatic injuryMatthew Price
Ken Ruggiero, Pamela Ferguson, Sachin Patel,
Frank Treiber, Samir Fakhry
Psychiatric Diagnosis After A Traumatic Injury
≥1 Diagnosis First MH Condition
PTSD Depression Substance Use Disorder
0%
10%
20%
30%
40%
50%
31%
22% 22%16%
10%
Zatzick et al., 2007; Bryant et al., 2010
Obtaining Mental Health Treatment After an Injury
0%
20%
40%41%
28% 33%21%
12%0%
Wang et al., 2005; Bryant et al., 2010
Challenges to Post Trauma Mental Health Care
• PTSD symptoms must last > 1 month• Depression symptoms must last > 2 weeks• Average inpatient stay is 9 days
Mental health conditions not apparent in acute care
• Self-help strategies are beneficial shortly after the trauma• Person-level resources may be sufficient (e.g. social support, home environment)
Unclear if patients need comprehensive mental health care
• Patients “out of the system” once they leave hospital• Most patients are referred to primary care doctor for continued follow up, but only 50% have a PCP
• Mental health care is silo’ed
Follow up systems are limited
Two Birds With One Innovation
• Technology-based strategies have the potential to overcome many of these significant barriers
• Immense Reach1,2: 94% of adults use the internet & own a cell phone3
• 23.6% of psychologists reported technology will be included in clinical services by 20324
• 22.4% indicated that evidence-based practices will be included in clinical services by 2032
1Koepsell, Zatzick, Rivara, 2011 ; 2Bryant, 2007; 3Pew Internet & American Life Project, 2012; 4Prinstein et al., 2012
Mobile Phones as Gateway for Continued Assessment & Care
Cell Phone Ownership Smartphone Ownership Access Internet via Mobile
0%
20%
40%
60%
80%
100%
African Americans Latinos Whites MAWs
Price et al., 2013 Pew Internet & American Life Project, August 2013
Connecting to Help After Trauma (CHAT)
• Mobile phone based assessment protocol
• Daily assessments of symptoms of recovery
• Monitoring of symptoms can facilitate the recovery process
• Lower cost and broad reach (90% cell phone ownership)
• Aims:
• Better understand process of recovery
• Evaluate use of SMS protocol
• Determine the ease with which providers can Rx
Price et al., 2014
Approach: 15 Days of SMS
In Hospital
• Assessed for PTSD, Depression, Social Functioning
• Oriented to text responses
15 days post discharge
• Daily text sent that assessed 1 of 5 domains
• Avoidance, Hyperarousal, Re-experiencing, Social Functioning, Pain
1-Mont
h3-
Month
• Re-assessed for PTSD, Depression, Disability, Social Functioning
Domain Item
Social Support
How supported, close, and/or connected to friends &family have you felt today? (1=not at all; 7 =completely)
Hypervigiliance
How much did you feel overly alert, jumpy, and/or have difficulty concentrating today? (1=not at all; 7=all the time)
Avoidance How much have you avoided people, places or activities that may remind you of the trauma today? (1=not at all; 7=completely)
Re-experiencing
How often did you have negative memories or thoughts about the trauma today? (1=none at all; 7=a lot)
Pain How much physical pain were you in today? (1=none; 10=a lot)
Planned Missingness Design
Participant
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6
1 Pain SS Hyperarousal
Reexperiencing
Avoidance Pain
2 SS Hyperarousal
Reexperiencing
Avoidance Pain SS
3 Hyperarousal
Reexperiencing
Avoidance Pain SS Hyperarousal
4 Reexperiencing
Avoidance Pain SS Hyperarousal
Reexperiencing
5 Avoidance Pain SS Hyperarousal
Reexperiencing
Avoidance
6 Pain SS Hyperarousal
Reexperiencing
Avoidance Pain
7 SS Hyperarousal
Reexperiencing
Avoidance Pain SS
8 Hyperarousal
Reexperiencing
Avoidance Pain SS Hyperarousal
9 Reexperiencing
Avoidance Pain SS Hyperarousal
Reexperiencing
10 Avoidance Pain SS Hyperarousal
Reexperiencing
Avoidance
Patients identified = 87Total Declined = 11• Declined due to concern about texts = 2• Declined due to concern about research = 9Excluded = 12• In police custody = 3• Suicidal = 1• Non-English speaking = 4• Did not have a cell phone = 4Could not approach = 18Discharged prior to contact = 15
Patients enrolled = 31
Removed due to hospital stay > 15 days = 2
Completed 1 month follow-up = 22
Completed 3 month follow-up = 21
Lost to follow-up = 7
Lost to follow-up = 1
Valid sample = 29
Consort Diagram
Response Rates
Adherence Mean Response rate
Response rate > 75%
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
82.80%
63.10%
41.70%
Response Rates and Symptoms
• Increased distress in hospital associated with more frequent responding (r = 0.67, p < 0.01)
• Subsequent symptoms of PTSD, depression, or disability not correlated however (p’s = 0.09 to 0.85)
• Response rates did not differ between those who developed PTSD and those who did not (p = 0.21)
• However, those with PTSD 3 months later replied to 10 messages whereas those without replied to 7 messages
• 72.2% felt 1 per day was good, but 27.8% wanted them every other day
• Those that wanted daily messages had higher PTSD, Depression, and Disability at follow up assessments
Participants’ Thoughts About SMS Interaction
• “My family didn’t want to talk about it… I felt like I had someone to talk to about the experience with the texts.”
• “Someone cared, was concerned, and worried about me… You were concerned about my recovery.”
• “I knew that every day at 7 someone was there to talk to me. It felt that someone everyday really cared about me...”
What do post-trauma symptom trajectories look like?
“Approximately 80% of projects that use technology-based assessments fail to collect data due to technical errors” –S. Shiffman
Conclusions• Trauma patients replied
• And they enjoyed it
• Rates of responding were unrelated to subsequent symptoms
• But that is to be expected given recent evidence1
• Effect size for repeated assessments is small (12%)2
• Technology limited in what could be assessed
• Data on daily symptom changes were not available
• Single messages were sent
• Wanted personalized feedback from their texts
• Variable schedules of messaging were preferred 1Donkin et al., 2013, 2Tarrier 1999
Mobile Applications for Monitoring• Mobile applications offer greater flexibility for treatment and
research
• Developed a mobile application for symptom monitoring with team at UVM
Usability Evaluation (Ongoing)
• Determining the features and components that are of interest to a mobile monitoring system
• 5 users can identify 80% of the problems (20 can find 95%)1
• Employing agile development process
• Findings (thus far) indicate
• Prefer 2-way communication
• Free responses
• Feedback after completing a set of questions
• Do not want technology to replace personal interaction with providers1Faulkner 2003
Mobile Assessment After Trauma – Pilot (Underway)
• Putting app into use in the coming week with Fletcher Allen patients recruited through EMRAP
• Mobile application monitors for 4-weeks post discharge
• 2x per day for 7 days
• 1x per day for 21 days
• Opportunity to quit after each week
• Larger assessments at 1-week, 1-month, and 3-months
• Aims to determine which symptoms develop first and understand the role of cues in leading to symptoms
Abbreviated List of Acknowledgements
•
• Kenneth J. Ruggiero, PhD
• Trauma Center
• Samir Fakhry, MD
• Pamela Ferguson, PhD
• Debbie Coulliard, RN
• TACHL
• Frank Treiber, PhD
• Sachin Patel, MBA
• CREST
• Anna Bellard
• Sara Brennan
• Andrew Brown
• Annie Maheux
• Rachel Merriam
• Anna Myers
• Hanna Ward
• Tyler Sawyer
• Madison Harris
• Chris Skalka, PhD
