Preliminary pilot test of SMS to track PTSD symptoms after a traumatic injury Matthew Price Ken Ruggiero, Pamela Ferguson, Sachin Patel, Frank Treiber, Samir Fakhry

Psychiatric Diagnosis After A Traumatic Injury Zatzick et al., 2007; Bryant et al., 2010

Obtaining Mental Health Treatment After an Injury 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 Reach 1,2 : 94% of adults use the internet & own a cell phone % of psychologists reported technology will be included in clinical services by % indicated that evidence-based practices will be included in clinical services by Koepsell, Zatzick, Rivara, 2011 ; 2Bryant, 2007; 3 Pew Internet & American Life Project, 2012; 4 Prinstein et al., 2012

Mobile Phones as Gateway for Continued Assessment & Care 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-Month 3-Month Re-assessed for PTSD, Depression, Disability, Social Functioning DomainItem Social SupportHow supported, close, and/or connected to friends &family have you felt today? (1=not at all; 7 =completely) HypervigilianceHow much did you feel overly alert, jumpy, and/or have difficulty concentrating today? (1=not at all; 7=all the time) AvoidanceHow much have you avoided people, places or activities that may remind you of the trauma today? (1=not at all; 7=completely) Re-experiencingHow often did you have negative memories or thoughts about the trauma today? (1=none at all; 7=a lot) PainHow much physical pain were you in today? (1=none; 10=a lot)

Planned Missingness Design ParticipantDay 1Day 2Day 3Day 4Day 5Day 6 1PainSSHyperarousalReexperiencingAvoidancePain 2SSHyperarousalReexperiencingAvoidancePainSS 3HyperarousalReexperiencingAvoidancePainSSHyperarousal 4ReexperiencingAvoidancePainSSHyperarousalReexperiencing 5AvoidancePainSSHyperarousalReexperiencingAvoidance 6PainSSHyperarousalReexperiencingAvoidancePain 7SSHyperarousalReexperiencingAvoidancePainSS 8HyperarousalReexperiencingAvoidancePainSSHyperarousal 9ReexperiencingAvoidancePainSSHyperarousalReexperiencing 10AvoidancePainSSHyperarousalReexperiencingAvoidance

Patients identified = 87 Total Declined = 11 Declined due to concern about texts = 2 Declined due to concern about research = 9 Excluded = 12 In police custody = 3 Suicidal = 1 Non-English speaking = 4 Did not have a cell phone = 4 Could not approach = 18 Discharged 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

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 evidence 1 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 1 Donkin et al., 2013, 2 Tarrier 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 providers 1 Faulkner 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

Thank You For Your Time!