Academic Appointments


  • Associate Professor - University Medical Line, Psychiatry and Behavioral Sciences

Administrative Appointments


  • Co-Chair, Stanford Mental Health Technology and Innovation Hub (2019 - Present)
  • Member, A&P Committee for CE (Affiliated) Faculty, Dept. of Psychiatry and Behavioral Sciences (2022 - Present)
  • Member, A&P Committee for CE Faculty, Dept. of Psychiatry and Behavioral Sciences (2021 - 2022)
  • Member, VA CE-Affiliate A&P Subcommittee (2017 - 2022)
  • Co-Chair, Stanford/VA Behavioral Telehealth and Technology (BTHAT) Workgroup (2015 - 2019)

Honors & Awards


  • Annual Chairman's Awards Unsung Hero Award, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine (2022)
  • Award for Outstanding Contributions to Practice in Trauma Psychology, Division 56, Trauma Psychology, American Psychological Association (2021)
  • Finalist for the Excellence.Gov Awards, American Council for Technology and the Industry Advisory Council (2014)
  • Official Honoree: Health & Fitness, The 18th Annual Webby Awards (2014)
  • Peer Group Award: National Center for PTSD Mobile Apps Team, Office of Patient Care Services, US Department of Veterans Affairs (2012)
  • President's Award for the Advancement of Telemedicine, American Telemedicine Association (2012)
  • Chairman’s Award for Advancement in Accessibility, Federal Communications Commission (2011)

Professional Education


  • Postdoctoral Fellowship, VA Special Research Fellowship (APA Accredited) Sierra Pacific Mental Illness Research, Education, Clinical Center (MIRECC), VAPAHCS/ Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Clinical Psychology (2006)
  • Ph.D., University at Albany, State University of New York (SUNY), Clinical Psychology (2004)
  • MA, University at Albany, State University of New York (SUNY), Psychology (2002)
  • Post-Baccalaureate Studies, University at Albany, State University of New York (SUNY), Psychology and Computer Science (1997)
  • BA, University at Albany, State University of New York (SUNY), United States History (major), Anthropology (minor) (1991)

All Publications


  • Peer-Supported Mobile Mental Health for Veterans in Primary Care: A Pilot Study PSYCHOLOGICAL SERVICES Blonigen, D. M., Montena, A. L., Smith, J., Hedges, J., Kuhn, E., Carlson, E. B., Owen, J., Wielgosz, J., Possemato, K. 2022

    Abstract

    One in four veteran primary care patients suffers from a mental health condition; however, most do not receive any treatment for these problems. Mobile health (mHealth) can overcome barriers to care access, but poor patient engagement limits the effectiveness and implementation of these tools. Peers may facilitate patient engagement with mHealth. We designed a protocol for peers to support implementation of mobile mental health tools in primary care and tested the feasibility, acceptability, and clinical utility of this approach. Thirty-nine patients across two Veterans Affairs sites who screened positive for depression during a primary care visit and were not currently in mental health treatment were enrolled. Participants were scheduled for four phone sessions with a peer over 8 weeks and introduced to five mobile apps for a range of transdiagnostic mental health issues (stress, low mood, sleep problems, anger, and trauma). Pre/post phone interviews using quantitative and qualitative approaches assessed participants' self-reported app use, satisfaction with the intervention, symptom change (stress, anxiety, depression, insomnia), and progress with personal health goals. On average, patients reported using 3.04 apps (SD = 1.46). Per the Client Satisfaction Questionnaire, global satisfaction with the intervention was high (M = 25.71 out of 32, SD = 3.95). Pre to post participants reported significant improvements in their level of stress, based on a quantitative measure (p = .008), and 87% reported progress on at least one personal health goal. Findings support the feasibility, acceptability, and clinical utility of peer-supported mobile mental health for veterans in primary care. A randomized controlled trial of an adaptive version of this intervention is recommended. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

    View details for DOI 10.1037/ser0000709

    View details for Web of Science ID 000853574700001

    View details for PubMedID 36107676

  • A Pilot Randomized Controlled Trial of the Insomnia Coach Mobile App to Assess Its Feasibility, Acceptability, and Potential Efficacy. Behavior therapy Kuhn, E., Miller, K. E., Puran, D., Wielgosz, J., YorkWilliams, S. L., Owen, J. E., Jaworski, B. K., Hallenbeck, H. W., McCaslin, S. E., Taylor, K. L. 2022; 53 (3): 440-457

    Abstract

    Insomnia is highly prevalent among military veterans but access to cognitive-behavioral therapy for insomnia (CBT-I) is limited. Thus, this study examined the feasibility, acceptability, and potential efficacy of Insomnia Coach, a CBT-I-based, free, self-management mobile app. Fifty U.S. veterans, who were mostly male (58%) and mean age 44.5 (range = 28-55) years with moderate insomnia symptoms were randomized to Insomnia Coach (n = 25) or a wait-list control condition (n = 25) for 6 weeks. Participants completed self-report measures and sleep diaries at baseline, posttreatment, and follow-up (12 weeks postrandomization), and app participants (n = 15) completed a qualitative interview at posttreatment. Findings suggest that Insomnia Coach is feasible to use, with three quarters of participants using the app through 6 weeks and engaging with active elements. For acceptability, perceptions of Insomnia Coach were very favorable based on both self-report and qualitative interview responses. Finally, for potential efficacy, at posttreatment, a larger proportion of Insomnia Coach (28%) than wait-list control participants (4%) achieved clinically significant improvement (p = .049) and there was a significant treatment effect on daytime sleep-related impairment (d = -0.6, p = .044). Additional treatment effects emerged at follow-up for insomnia severity (d = -1.1, p = .001), sleep onset latency (d = -0.6, p = .021), global sleep quality (d = -0.9, p = .002), and depression symptoms (d = -0.8, p = .012). These findings provide preliminary evidence that among veterans with moderate insomnia symptoms, a CBT-I-based self-management app is feasible, acceptable, and promising for improving insomnia severity and other sleep-related outcomes. Given the vast unmet need for insomnia treatment in the population, Insomnia Coach may provide an easily accessible, convenient public health intervention for individuals not receiving care.

    View details for DOI 10.1016/j.beth.2021.11.003

    View details for PubMedID 35473648

  • The Role of Posttraumatic Stress Symptoms on Pain Catastrophizing among Acutely Injured Patients Pacella-LaBarbara, M. L., Plaitano, E., Suffoletto, B., Kuhn, E., Jaramillo, S., Repine, M., Germain, A., Callaway, C. CHURCHILL LIVINGSTONE. 2022: 52-53
  • VA MHEALTH RESOURCES FOR ADDRESSING AND RESEARCHING BEHAVIORAL HEALTH ISSUES OF VETERANS Kuhn, E., Owen, J., Stanley, L., Hallenbeck, H., Blonigen, D., Wielgosz, J. OXFORD UNIV PRESS INC. 2022: S598
  • PTSD Coach Version 3.1: A Closer Look at the Reach, Use, and Potential Impact of This Updated Mobile Health App in the General Public. JMIR mental health Hallenbeck, H. W., Jaworski, B. K., Wielgosz, J., Kuhn, E., Ramsey, K. M., Taylor, K., Juhasz, K., McGee-Vincent, P., Mackintosh, M., Owen, J. E. 2022; 9 (3): e34744

    Abstract

    BACKGROUND: With widespread smartphone ownership, mobile health apps (mHealth) can expand access to evidence-based interventions for mental health conditions, including posttraumatic stress disorder (PTSD). Research to evaluate new features and capabilities in these apps is critical but lags behind app development. The initial release of PTSD Coach, a free self-management app developed by the US Departments of Veterans Affairs and Defense, was found to have a positive public health impact. However, major stakeholder-driven updates to the app have yet to be evaluated.OBJECTIVE: We aimed to characterize the reach, use, and potential impact of PTSD Coach Version 3.1 in the general public. As part of characterizing use, we investigated the use of specific app features, which extended previous work on PTSD Coach.METHODS: We examined the naturalistic use of PTSD Coach during a 1-year observation period between April 20, 2020, and April 19, 2021, using anonymous in-app event data to generate summary metrics for users.RESULTS: During the observation period, PTSD Coach was broadly disseminated to the public, reaching approximately 150,000 total users and 20,000 users per month. On average, users used the app 3 times across 3 separate days for 18 minutes in total, with steep drop-offs in use over time; a subset of users, however, demonstrated high or sustained engagement. More than half of users (79,099/128,691, 61.46%) accessed one or more main content areas of the app (ie, Manage Symptoms, Track Progress, Learn, or Get Support). Among content areas, features under Manage Symptoms (including coping tools) were accessed most frequently, by over 40% of users (53,314/128,691, 41.43% to 56,971/128,691, 44.27%, depending on the feature). Users who provided initial distress ratings (56,971/128,691, 44.27%) reported relatively high momentary distress (mean 6.03, SD 2.52, on a scale of 0-10), and the use of a coping tool modestly improved momentary distress (mean -1.38, SD 1.70). Among users who completed at least one PTSD Checklist for DSM-5 (PCL-5) assessment (17,589/128,691, 13.67%), PTSD symptoms were largely above the clinical threshold (mean 49.80, SD 16.36). Among users who completed at least two PCL-5 assessments (4989/128,691, 3.88%), PTSD symptoms decreased from the first to last assessment (mean -4.35, SD 15.29), with approximately one-third (1585/4989, 31.77%) of these users experiencing clinically significant improvements.CONCLUSIONS: PTSD Coach continues to fulfill its mission as a public health resource. Version 3.1 compares favorably with version 1 on most metrics related to reach, use, and potential impact. Although benefits appear modest on an individual basis, the app provides these benefits to a large population. For mHealth apps to reach their full potential in supporting trauma recovery, future research should aim to understand the utility of individual app features and identify strategies to maximize overall effectiveness and engagement.

    View details for DOI 10.2196/34744

    View details for PubMedID 35348458

  • Barriers and facilitators to peer-supported implementation of mental health applications with veterans in primary care Journal of Technology in Behavioral Science Montena, A. L., Possemato, K., Kuhn, E., Carlson, E. B., McGovern, M., Smith, J., Blonigen, D. 2022; 7 (1): 1-12
  • Using Peers to Increase Veterans' Engagement in a Smartphone Application for Unhealthy Alcohol Use: A Pilot Study of Acceptability and Utility PSYCHOLOGY OF ADDICTIVE BEHAVIORS Blonigen, D. M., Harris-Olenak, B., Kuhn, E., Timko, C., Humphreys, K., Smith, J. S., Dulin, P. 2021; 35 (7): 829-839

    Abstract

    Mobile apps can only increase access to alcohol treatment if patients actively engage with them. Peers may be able to facilitate such engagement by providing supportive accountability and instruction and encouragement for app use. We developed a protocol for peers to support engagement in the Stand Down app for unhealthy alcohol use in veterans and tested the acceptability and utility of the protocol. Thirty-one veteran primary care patients who screened positive for unhealthy alcohol use and were not currently in addiction treatment were given access to Stand Down for four weeks and concurrently received weekly phone support from a Department of Veterans Affairs peer specialist to facilitate engagement with the app. App usage was extracted daily, and pre/post treatment assessments measured changes in drinking patterns, via the Timeline Followback interview, and satisfaction with care, via quantitative and qualitative approaches. A priori benchmarks for acceptability were surpassed: time spent in the app (M = 93.89 min, SD = 92.1), days of app use (M = 14.05, SD = 8.0), and number of daily interviews completed for tracking progress toward a drinking goal (M = 12.64, SD = 9.7). Global satisfaction, per the Client Satisfaction Questionnaire, was high (M = 26.4 out of 32, SD = 4.5). Pre to post, total standard drinks in the prior 30 days (MPre = 142.7, MPost = 85.6), Drinks Per Drinking Day (MPre = 5.4, MPost = 4.0), and Percent Heavy Drinking Days (MPre = 35.3%, MPost = 20.1%) decreased significantly (ps < .05). Findings indicate that Peer-Supported Stand Down is highly acceptable to veteran primary care patients and may help reduce drinking in this population. A larger controlled trial of this intervention is warranted. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

    View details for DOI 10.1037/adb0000598

    View details for Web of Science ID 000716306700007

    View details for PubMedID 32597665

    View details for PubMedCentralID PMC7769861

  • The Role of Specific Sources of Social Support on Postinjury Psychological Symptoms REHABILITATION PSYCHOLOGY Brienza, A., Suffoletto, B. P., Kuhn, E., Germain, A., Jaramillo, S., Repine, M., Callaway, C. W., Pacella-LaBarbara, M. L. 2021; 66 (4): 600-610

    Abstract

    The role of perceived social support from specific sources (e.g., families, friends, and significant others) on the development of postinjury posttraumatic stress disorder (PTSD) and associated psychological symptoms (e.g., depression and anxiety) remains relatively unexplored. We examined the predictive role of social support from specific sources on psychological symptoms among emergency department (ED) patients following motor vehicle crash (MVC). Research Methods/Design: Sixty-three injured patients (63.5% female; 37 years old on average) with moderately painful complaints were recruited in the EDs of two Level-1 trauma centers within 24 hr post-MVC. In the ED, participants completed surveys of baseline psychological symptoms and perceived social support; follow-up surveys were completed at 90 days postinjury.Most of the sample (84.1%) was discharged home from the ED with predominantly mild injuries and did not require hospitalization. After adjusting for race, sex, age, and baseline symptoms, hierarchical regression analyses demonstrated that lower perceived social support in the ED predicted higher PTSD symptoms and depressive symptoms (but not anxiety) at 90 days. This effect seemed to be specific to significant others and friends but not family.MVC-related injuries are robust contributors to psychological sequelae. These findings extend prior work by highlighting that perceived social support, particularly from significant others and friends, provides unique information regarding the development of psychological symptoms following predominantly mild MVC-related injuries. This data may serve to inform recovery expectations. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

    View details for DOI 10.1037/rep0000388

    View details for Web of Science ID 000725826700032

    View details for PubMedID 34398631

    View details for PubMedCentralID PMC8648976

  • A SMART approach to optimizing delivery of an mHealth intervention among cancer survivors with posttraumatic stress symptoms CONTEMPORARY CLINICAL TRIALS Smith, S. K., Somers, T. J., Kuhn, E., Laber, E., Sung, A. D., Syrjala, K. L., Feger, B., Kelleher, S. A., Majestic, C., Gebert, R., LeBlanc, M., Owen, J. E., Applebaum, A. J. 2021; 110: 106569

    Abstract

    Many cancer survivors who received intensive treatment such as hematopoietic stem cell transplantation (HCT) experience posttraumatic stress disorder (PTSD) symptoms. PTSD is associated with lower quality of life and other symptoms that require clinical treatment. The iterative treatment decisions that happen in clinical practice are not adequately represented in traditional randomized controlled trials (RCT) of PTSD treatments. The proposed stepped-care SMART design allows for evaluation of initial response to the Cancer Distress Coach mobile app; adaptive stepped-care interventions; and precision treatment strategies that tailor treatment selection to patient characteristics.HCT survivors (N = 400) reporting PTSD symptoms are being recruited at two cancer centers and randomly assigned to: 1) Cancer Distress Coach app or 2) Usual Care. The app includes educational and cognitive behavioral therapy (CBT)-based activities. Four weeks post-randomization, participants re-rate their PTSD symptoms and, based on intervention response, non-responders are re-randomized to receive video-conferenced sessions with a therapist: 3) coaching sessions in using the mobile app; or 4) CBT specific to HCT survivors. Participants complete outcome measures of PTSD, depression, and anxiety after Months 1, 3, and 6. Participant characteristics moderating intervention responses will be examined.This novel adaptive trial design will afford evidence that furthers knowledge about optimizing PTSD interventions for HCT survivors. To our knowledge, this study is the first SMART design evaluating PTSD symptom management in cancer survivors. If successful, it could be used to optimize treatment among a range of cancer and other trauma survivors.

    View details for DOI 10.1016/j.cct.2021.106569

    View details for Web of Science ID 000701978900006

    View details for PubMedID 34536584

    View details for PubMedCentralID PMC8595815

  • Digital Clinics and Mobile Technology Implementation for Mental Health Care CURRENT PSYCHIATRY REPORTS Connolly, S. L., Kuhn, E., Possemato, K., Torous, J. 2021; 23 (7): 38

    Abstract

    Interest in digital mental health, especially smartphone apps, has expanded in light of limited access to mental health services and the need for remote care during COVID-19. Digital clinics, in which apps are blended into routine care, offer a potential solution to common implementation challenges including low user engagement and lack of clinical integration of apps.While the number of mental health apps available in commercial marketplaces continues to rise, there are few examples of successful implementation of these apps into care settings. We review one example of a digital clinic created within an academic medical center and another within the Department of Veterans Affairs. We then discuss how implementation science can inform new efforts to effectively integrate mental health technologies across diverse use cases. Integrating mental health apps into care settings is feasible but requires careful attention to multiple domains that will influence implementation success, including characteristics of the innovation (e.g., utility and complexity of the app), the recipients of the technology (e.g., patients and clinicians), and context (e.g., healthcare system buy-in, reimbursement, and regulatory policies). Examples of effective facilitation strategies that can be utilized to improve implementation efforts include co-production of technology involving all end users, specialized trainings for staff and patients, creation of new team members to aid in app usage (e.g., digital navigators), and re-design of clinical workflows.

    View details for DOI 10.1007/s11920-021-01254-8

    View details for Web of Science ID 000648273800001

    View details for PubMedID 33961135

    View details for PubMedCentralID PMC8103883

  • Effects of Mobile App-Based Intervention for Depression in Middle-Aged and Older Adults: Mixed Methods Feasibility Study. JMIR formative research Gould, C. E., Carlson, C., Ma, F., Forman-Hoffman, V., Ranta, K., Kuhn, E. 2021; 5 (6): e25808

    Abstract

    BACKGROUND: Digital mental health interventions may help middle-aged and older adults with depression overcome barriers to accessing traditional care, but few studies have investigated their use in this population.OBJECTIVE: This pilot study examines the feasibility, acceptability, and potential efficacy of the Meru Health Program, an 8-week mobile app-delivered intervention.METHODS: A total of 20 community-dwelling middle-aged and older adults (age: mean 61.7 years, SD 11.3) with elevated depressive symptoms participated in a single-arm pilot study investigating the Meru Health Program, an app-delivered intervention supported by remote therapists. The program primarily uses mindfulness and cognitive behavioral skills to target depressive symptoms. A semistructured interview was completed at the baseline to establish current psychiatric diagnoses. Depressive symptoms were measured using the Patient Health Questionnaire and Patient-Reported Outcomes Measurement Information System (PROMIS) depression measures. Anxiety symptoms were measured using the Generalized Anxiety Disorder Scale and the PROMIS Anxiety measure. User experience and acceptability were examined through surveys and qualitative interviews.RESULTS: In total, 90% (18/20) of the participants completed the program, with 75% (15/20) completing at least 7 of the 8 introductory weekly lessons. On average, participants completed 60 minutes of practice and exchanged 5 messages with their therapists every week. The app was rated as helpful by 89% (17/19) participants. Significant decreases in depressive (P=.03) and anxiety symptom measures (P=.01) were found; 45% (9/20) of participants showed clinically significant improvement in either depressive symptoms or anxiety symptoms.CONCLUSIONS: The findings suggest that the commercially available Meru Health Program may be feasible, acceptable, and potentially beneficial to middle-aged and older adults. Although larger controlled trials are needed to demonstrate efficacy, these findings suggest that digital health interventions may benefit adults of all ages.

    View details for DOI 10.2196/25808

    View details for PubMedID 34185000

  • A Pilot Randomized Controlled Trial of the PTSD Coach App Following Motor Vehicle Crash-related Injury ACADEMIC EMERGENCY MEDICINE Pacella-LaBarbara, M. L., Suffoletto, B. P., Kuhn, E., Germain, A., Jaramillo, S., Repine, M., Callaway, C. W. 2020

    Abstract

    Posttraumatic stress disorder (PTSD) symptoms (PTSS) are common after minor injuries and can impair recovery. We sought to understand whether an evidence-based mobile phone application with self-help tools (PTSD Coach) could be useful to improve recovery after acute trauma among injured emergency department (ED) patients. This pilot study examined the feasibility, acceptability, and potential benefit of using PTSD Coach among acutely injured motor vehicle crash (MVC) patients.From September 2017 to September 2018, we recruited adult patients within 24 hours post-MVC from the EDs of two Level I trauma centers in the United States. We randomly assigned 64 injured adults to either the PTSD Coach (n = 33) or treatment as usual (TAU; n = 31) condition. We assessed PTSS and associated symptoms at 1 month (83% retained) and 3 months (73% retained) postenrollment.Enrollment was feasible (74% of eligible subjects participated) but usability and engagement were low (67% used PTSD Coach at least once, primarily in week 1); 76% of those who used it rated the app as moderately to extremely helpful. No differences emerged between groups in PTSS outcomes. Exploratory analyses among black subjects (n = 21) indicated that those in the PTSD Coach condition (vs. TAU) reported marginally lower PTSS (95% CI = -0.30 to 37.77) and higher PTSS coping self-efficacy (95% CI = -58.20 to -3.61) at 3 months.We demonstrated feasibility to recruit acutely injured ED patients into an app-based intervention study, yet mixed evidence emerged for the usability and benefit of PTSD Coach. Most patients used the app once and rated it favorably in regard to satisfaction with and helpfulness, but longitudinal engagement was low. This latter finding may explain the lack of overall effects on PTSS. Additional research is warranted regarding whether targeting more symptomatic patients and the addition of engagement and support features can improve efficacy.

    View details for DOI 10.1111/acem.14000

    View details for Web of Science ID 000533683900001

    View details for PubMedID 32339359

  • AN EXPLORATION OF RACIAL DIFFERENCES IN A PILOT RANDOMIZED CONTROLLED TRIAL OF THE PTSD COACH APP AFTER CRASH-RELATED INJURY Pacella-LaBarbara, M., Suffoletto, B., Kuhn, E., Germain, A., Jaramillo, S., Repine, M., Callaway, C. OXFORD UNIV PRESS INC. 2020: S50
  • TECHNOLOGY AND TELEPHONE-BASED SMOKING CESSATION TREATMENT FOR VETERANS WITH POSTTRAUMATIC STRESS DISORDER Herbst, E., Kausen, A., Daryani, S., Rossi, N., Hopkins, L., Manuel, J., Wheeler, T., Cano, M., Carroll, C., Zhou, H., Kuhn, E., McCaslin, S., Tsoh, J. Y. OXFORD UNIV PRESS INC. 2020: S660
  • Development of a mobile app for family members of Veterans with PTSD: identifying needs and modifiable factors associated with burden, depression, and anxiety JOURNAL OF FAMILY STUDIES Owen, J. E., Jaworski, B. K., Kuhn, E., Hoffman, J. E., Schievelbein, L., Chang, A., Ramsey, K., Rosen, C. 2020; 26 (2): 286–307
  • A Qualitative Examination of Stay Quit Coach, A Mobile Application for Veteran Smokers With Posttraumatic Stress Disorder NICOTINE & TOBACCO RESEARCH Herbst, E., McCaslin, S. E., Daryani, S., Laird, K. T., Hopkins, L. B., Pennington, D., Kuhn, E. 2020; 22 (4): 560-568

    Abstract

    Smoking is a lethal public health problem that is common in US military veterans, particularly those with posttraumatic stress disorder (PTSD). Mobile applications (apps) to promote smoking cessation are a scalable and low-cost approach that may facilitate treatment engagement.This qualitative study examined the acceptability, user experience, and perceptions of a smoking cessation app, Stay Quit Coach (SQC), when incorporated into evidence-based smoking cessation treatment. US military veterans with PTSD who smoked at least five cigarettes per day for 15 of the past 30 days and stated an interested in cessation were eligible to participate. Participants' baseline comfort levels with mobile technology was measured using the Perceptions of Mobile Phone Interventions Questionnaire-Patient version (PMPIQ-P). At treatment end, semi-structured qualitative interviews were conducted.Twenty participants were enrolled and 17 (85.0%) participated in the qualitative interview at treatment end. PMPIQ-P scores at baseline ranged from 4.97 to 5.25 (SDs = 0.73-1.04), reflecting moderately high comfort with mobile technology among participants. Qualitative analyses indicated that most participants: (1) endorsed mobile technology as an appealing format for smoking cessation treatment, due to convenience and instantaneous access; and (2) expressed highest perceived helpfulness for interactive app features. Recommendations to improve SQC clustered into four thematic areas: (1) increasing personalization, (2) including more self-tracking features, (3) increasing visual cues, and (4) sharing progress with peers.SQC was perceived as an acceptable and useful tool to support smoking cessation in a sample of veteran smokers with PTSD. Qualitative data provided valuable insights that can inform the continued development of SQC and other apps for smoking cessation.Given the high lethality associated with cigarette smoking, it is crucial to identify scalable, low-risk strategies to promote smoking cessation, particularly in high-risk populations. Mobile technology is a promising approach that can be used to augment evidence-based smoking cessation treatment. Results of this qualitative study support the use of the SQC mobile app when incorporated into evidence-based smoking cessation treatment for veterans with PTSD and provide future directions for refinement of the SQC app. These findings also highlight the importance of using a patient-centered approach in designing apps intended for a clinical population.

    View details for DOI 10.1093/ntr/ntz037

    View details for Web of Science ID 000546967300015

    View details for PubMedID 30874289

  • Mobile Intervention for Depression Benefits Middle Aged and Older Adults Carlson, C., Kuhn, E., Nazem, S., Gould, C. WILEY. 2020: S255-S256
  • From "Step Away" to "Stand Down": Tailoring a Smartphone App for Self-Management of Hazardous Drinking for Veterans JMIR MHEALTH AND UHEALTH Blonigen, D., Harris-Olenak, B., Kuhn, E., Humphreys, K., Timko, C., Dulin, P. 2020; 8 (2): e16062

    Abstract

    US military veterans who screen positive for hazardous drinking during primary care visits may benefit from a mobile app. Step Away is an evidence-based mobile intervention system for the self-management of hazardous drinking. However, Step Away was not designed for veterans, and differences between veterans and civilians could limit the reach and effectiveness of the app with this population.The primary objective of this study was to repurpose Step Away to address the needs and preferences of the veteran primary care population. The Method for Program Adaptation through Community Engagement (M-PACE) model was used to guide the adaptation process. This model can serve as a generalizable approach that other researchers and intervention developers can follow to systematically tailor mobile health tools for a new population.Veteran patients who screened positive for hazardous drinking during a primary care visit (n=12) and peer providers employed by the US Veterans Health Administration (n=11) were recruited to systematically review Step Away and provide feedback on its content and presentation via Web-based surveys and a semistructured interview. Participant feedback was reviewed through an iterative process by key stakeholders who adjudicated which suggested modifications to the app could enhance engagement and effectiveness with veterans while maintaining program integrity.Usability ratings of the individual modules of Step Away were uniformly positive across patients and peers, as was the perceived utility of the app overall. Personalized feedback on the health consequences and costs of drinking, options for customization, and the measurement-based care capabilities of the app were viewed as facilitators of engagement. Conversely, lengthy text, small font, and a lack of interactive features were viewed as potential barriers with the older primary care population. Modifications to create a veteran version of the app (Stand Down: Think Before You Drink) included altering the appearance of the app to incorporate more veteran-centric content, adding links and options for resources and activities for veterans, and reducing the amount of text and adding veteran-specific references and common concerns and triggers for drinking in this population.The M-PACE model provided a systematic approach to repurpose Step Away to fit the needs and preferences of veteran primary care patients who engage in hazardous drinking. Stand Down may serve as an innovative, low-cost means of expanding access to care for veterans who engage in hazardous drinking.

    View details for DOI 10.2196/16062

    View details for Web of Science ID 000513519300001

    View details for PubMedID 32053118

    View details for PubMedCentralID PMC7055774

  • Advances in PTSD treatment delivery: The role of digital technology in PTSD treatment Current Treatment Options in Psychiatry Kuhn, E., Owen, J. E. 2020
  • Technology Use and Preferences for Mental Health Self-Management Interventions among Older Veterans. International journal of geriatric psychiatry Gould, C. E., Loup, J., Kuhn, E., Beaudreau, S. A., Ma, F., Goldstein, M. K., Wetherell, J. L., Zapata, A. M., Choe, P., O'Hara, R. 2019

    Abstract

    OBJECTIVES: The United States Department of Veterans Affairs offers numerous technology-delivered interventions to self-manage mental health problems. It is unknown, however, what barriers older military veterans face to using these technologies and how willing they would be to use technologies for mental health concerns.METHODS: Seventy-seven veterans (Mage =69.16years; SD=7.10) completed interviews in a concurrent mixed methods study. Interviewers asked about technology ownership and described four modalities of delivering self-management interventions: printed materials, DVDs, Internet, and mobile apps. Interviewers obtained feedback about each modality's benefits, barriers, and facilitators. Participants ranked their self-management modalities preferences alone and compared with counseling. Multi-variable adjusted logistic regression and qualitative analyses were conducted to investigate the reasons contributing to preferences.RESULTS: Most reported owning a computer (84.4%), having home Internet (80.5%), and a smartphone (70.1%). Participants preferred printed materials (35.1%) over mobile apps (28.6%), Internet (24.7%), and DVDs (13.0%). Lower computer proficiency was associated with preferring DVDs; higher proficiency was associated with Internet and mobile interventions. Residing in an urban area was associated with mobile apps. When counseling was an option, 66% identified this as their first preference. Qualitative findings showed veterans' desire for information, training, and provider support with technology.CONCLUSIONS: Older veterans reported high technology ownership rates, but varied preferences for self-management interventions. Notably, two-thirds preferred some form of technology, which points to the importance of ensuring that providers offer existing technology-delivered interventions to older veterans. Veterans' strong preference for counseling emphasizes the need for human support alongside self-management. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/gps.5252

    View details for PubMedID 31854029

  • A Pilot Trial of Online Training for Family Well-Being and Veteran Treatment Initiation for PTSD. Military medicine Erbes, C. R., Kuhn, E., Polusny, M. A., Ruzek, J. I., Spoont, M., Meis, L. A., Gifford, E., Weingardt, K. R., Campbell, E. H., Oleson, H., Taylor, B. C. 2019

    Abstract

    INTRODUCTION: Family members are important supports for veterans with Posttrauamtic Stress Disroder (PTSD), but they often struggle with their own distress and challenges. The Veterans Affairs-Community Reinforcement and Family Training (VA-CRAFT) website was designed to teach family members of veterans with PTSD effective ways to interact with their veterans to encourage initiation of mental health services as well as to care for themselves and improve their relationships. This article presents a pilot investigation of VA-CRAFT.MATERIALS AND METHOD: Spouse/partners of veterans who had screened positive for PTSD but were not in mental health treatment were randomized to either use the VA-CRAFT website (n=22) or to a waitlist control condition (n=19) for 3months. Veteran mental health service initiation was assessed posttreatment. Spouse/partner distress, caregiver burden, quality of life, and relationship quality were assessed pre and posttreatment. The study was approved by the Minneapolis VA Health Care System Institutional Review Board (IRB).RESULTS: Differences between groups on veteran treatment initiation were small (Phi=0.17) and not statistically significant. VA-CRAFT participants reported large and statistically significantly greater decreases in overall caregiver burden (eta2=0.10) and objective caregiver burden (eta2=0.14) than control participants. Effects were larger for those with greater initial distress. Effects sizes for other partner outcomes were negligible (eta2=0.01) to medium (eta2=0.09) and not statistically significant. Postintervention interviews suggested that only 33% of the VA-CRAFT participants talked with their veterans about starting treatment for PTSD during the trial.CONCLUSION: Results from this pilot trial suggest that VA-CRAFT holds initial promise in reducing caregiver burden and as such it could be a useful resource for family members of veterans with PTSD. However, VA-CRAFT does not enhance veteran treatment initiation. It may benefit from enhancements to increase effectiveness and caregiver engagement.

    View details for DOI 10.1093/milmed/usz326

    View details for PubMedID 31621884

  • Clinician Perceptions Related to the Use of the CBT-I Coach Mobile App BEHAVIORAL SLEEP MEDICINE Miller, K. E., Kuhn, E., Owen, J. E., Taylor, K., Yu, J. S., Weiss, B. J., Crowley, J. J., Trockel, M. 2019; 17 (4): 481–91
  • Mobile App Use for Insomnia Self-Management: Pilot Findings on Sleep Outcomes in Veterans INTERACTIVE JOURNAL OF MEDICAL RESEARCH Reilly, E. D., Robinson, S. A., Petrakis, B., Kuhn, E., Pigeon, W. R., Wiener, R., Mclnnes, D., Quigley, K. S. 2019; 8 (3): e12408

    Abstract

    Sleep disturbance is a major health concern among US veterans who have served since 2001 in a combat theater in Iraq or Afghanistan. We report subjective and objective sleep results from a pilot trial assessing self-management-guided use of a mobile app (CBT-i Coach, which is based on cognitive behavioral therapy for insomnia) as an intervention for insomnia in military veterans.The primary aim of this study was to evaluate changes in subjective and objective sleep outcomes from pre to postintervention.Subjective outcomes included the Insomnia Severity Index, the Pittsburgh Sleep Quality Inventory, and sleep-related functional status. A wearable sleep monitor (WatchPAT) measured objective sleep outcomes, including sleep efficiency, percent rapid eye movement (REM) during sleep, sleep time, and sleep apnea. A total of 38 participants were enrolled in the study, with 18 participants being withdrawn per the protocol because of moderate or severe sleep apnea and 9 others who dropped out or withdrew. Thus, 11 participants completed the full 6-week CBT-i Coach self-management intervention (ie, completers).Completer results indicated significant changes in subjective sleep measures, including reduced reports of insomnia (Z=-2.68, P=.007) from pre (mean 16.63, SD 5.55) to postintervention (mean 12.82, SD 3.74), improved sleep quality (Z=-2.37, P=.02) from pre (mean 12.82, SD 4.60) to postintervention (mean 10.73, SD 3.32), and sleep-related functioning (Z=2.675, P=.007) from pre (mean 13.86, SD 3.69) to postintervention (mean 15.379, SD 2.94). Among the objective measures, unexpectedly, objective sleep time significantly decreased from pre to postintervention (χ22=7.8, P=.02). There were no significant changes in percent REM sleep or sleep efficiency.These findings suggest that the CBT-i Coach app can improve subjective sleep and that incorporating objective sleep measures into future, larger clinical trials or clinical practice may yield important information, particularly by detecting previously undetected sleep apnea.ClinicalTrials.gov NCT02392000; http://clinicaltrials.gov/ct2/show/NCT02392000.

    View details for DOI 10.2196/12408

    View details for Web of Science ID 000488621100002

    View details for PubMedID 31342904

    View details for PubMedCentralID PMC6685127

  • Use and Perceptions of Mobile Apps for Patients Among VA Primary Care Mental and Behavioral Health Providers PROFESSIONAL PSYCHOLOGY-RESEARCH AND PRACTICE Miller, K. E., Kuhn, E., Yu, J., Owen, J. E., Jaworski, B. K., Taylor, K., Blonigen, D. M., Possemato, K. 2019; 50 (3): 204–9

    View details for DOI 10.1037/pro0000229

    View details for Web of Science ID 000468985200007

  • INTEGRATING MOBILE-BASED APPLICATIONS WITH PEER SUPPORT TO REDUCE HAZARDOUS DRINKING AMONG VETERANS IN PRIMARY CARE: A STUDY OF ACCEPTABILITY AND UTILITY Blonigen, D. M., Joshi, G., Harris-Olenak, B., Kuhn, E., Timko, C., Humphreys, K., Dulin, P. WILEY. 2019: 138A
  • Customizing a Clinical App to Reduce Hazardous Drinking Among Veterans in Primary Care PSYCHOLOGICAL SERVICES Blonigen, D. M., Harris-Olenak, B., Haber, J., Kuhn, E., Timko, C., Humphreys, K., Dulin, P. L. 2019; 16 (2): 250–54

    Abstract

    Within the Veterans Health Administration (VHA), 15-30% of patients seen in primary care are identified as hazardous drinkers, yet the vast majority of these patients receive no intervention. Time constraints on providers and patient-level barriers to in-person treatment contribute to this problem. The scientific literature provides a compelling case that mobile-based interventions can reduce hazardous drinking and underscores the role of peer support in behavioral change. Here, we describe the benefits of using a clinical app-Step Away-to treat hazardous drinking among VHA primary care patients as well as an approach to customizing the app to maximize its engagement and effectiveness with this population. We highlight the value of integrating use of Step Away with telephone support from a trained VHA peer support specialist. This type of integrated approach may provide the key therapeutic components necessary to generate an effective and easily implemented alcohol use intervention that can be made available to VHA primary care patients who screen positive for hazardous drinking but are unwilling or unable to attend in-person treatment. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

    View details for DOI 10.1037/ser0000300

    View details for Web of Science ID 000466773000010

    View details for PubMedID 30407060

  • Veterans Affairs and the Department of Defense Mental Health Apps: A Systematic Literature Review PSYCHOLOGICAL SERVICES Gould, C. E., Kok, B. C., Ma, V. K., Zapata, A. L., Owen, J. E., Kuhn, E. 2019; 16 (2): 196–207

    Abstract

    In the present systematic review, we summarize the feasibility, usability, efficacy, and effectiveness of mental health-related apps created by the Veterans Affairs (VA) or the Department of Defense (DoD). Twenty-two articles were identified, reporting on 8 of the 20 VA/DoD mental health self-management and treatment companion apps. Review inclusion criteria were studies that reported original data on the usability, acceptability, feasibility, efficacy, and effectiveness, or attitudes toward the app. We collected data from each article regarding type of study, sample size, participant population, follow-up period, measures/assessments, and summary of findings. The apps have been tested with patients seeking treatment, patients with elevated mental health symptoms, and clinicians. The strongest area of support for the apps is regarding evidence of their feasibility and acceptability. Research support for efficacy and effectiveness of the apps is scarce with exceptions for two apps (PTSD Coach, Virtual Hope Box). Until more evidence accumulates, clinicians should use their judgment and be careful not to overstate the potential benefits of the apps. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

    View details for DOI 10.1037/ser0000289

    View details for Web of Science ID 000466773000003

    View details for PubMedID 30431306

  • THE UTILITY OF PTSD SYMPTOMS AND PAIN CATASTROPHIZING IN PREDICTING ACUTE PAIN AMONG EMERGENCY DEPARTMENT PATIENTS INJURED IN A MOTOR VEHICLE-RELATED ACCIDENT Pacella-LaBarbara, M. L., Germain, A., Suffoletto, B., Kuhn, E., Callaway, C. L. LIPPINCOTT WILLIAMS & WILKINS. 2019: A60
  • A Randomized Controlled Trial of the PTSD Coach Mobile Health App at Reducing Pain and Psychological Symptoms among Injured Emergency Department Patients: Preliminary Results PaceIla, M., Germain, A., Suffoletto, B., Kuhn, E., Jaramillo, S., Caaway, C. CHURCHILL LIVINGSTONE. 2019: S13
  • Smartphone apps for insomnia: examining existing apps' usability and adherence to evidence-based principles for insomnia management TRANSLATIONAL BEHAVIORAL MEDICINE Yu, J. S., Kuhn, E., Miller, K. E., Taylor, K. 2019; 9 (1): 110–19

    View details for DOI 10.1093/tbm/iby014

    View details for Web of Science ID 000492961800011

  • Smartphone apps for insomnia: examining existing apps' usability and adherence to evidence-based principles for insomnia management. Translational behavioral medicine Yu, J. S., Kuhn, E., Miller, K. E., Taylor, K. 2019; 9 (1): 110–19

    Abstract

    Insomnia affects up to 22% of the U.S. adult population. The use of mobile health applications (mHealth apps) has been posited as one way to increase access to evidence-based interventions for insomnia, such as cognitive behavioral therapy for insomnia (CBT-I). The purpose of the current study was to summarize the availability of mHealth apps that focus on providing users with the behavioral and/or cognitive skills to manage insomnia, assess their adherence to evidence-based principles, and examine their usability. The terms "insomnia," "insomnia treatment," and "sleep treatment" were used to search the Apple iTunes and Google Play stores in November 2016. Social network query within the authors' professional networks was also conducted. Apps that met inclusion criteria for the study were downloaded and reviewed by the research team for their general characteristics; inclusion of CBT-I skills, strategies, and principles; and aesthetics and usability. Of the 357 apps initially found, 12 met criteria for further review. Overall, the apps were moderately adherent to CBT-I principles, with a mean app score of 1.44 out of 3.00, and moderately usable, with a mean usability score of 3.54 out of 5.00. Few apps currently exist that utilize evidence-based principles to help users practice the behavioral and cognitive skills shown to manage insomnia. Thus, there are exciting opportunities for clinicians, researchers, and mHealth experts to develop effective apps that can help ease the public health burden of insomnia.

    View details for PubMedID 30590862

  • VA mobile apps for PTSD and related problems: public health resources for veterans and those who care for them. mHealth Owen, J. E., Kuhn, E., Jaworski, B. K., McGee-Vincent, P., Juhasz, K., Hoffman, J. E., Rosen, C. 2018; 4: 28

    Abstract

    Many public health agencies, including the U.S. Department of Veterans Affairs (VA), have identified the use of mobile technologies as an essential part of a larger strategy to address major public health challenges. The VA's National Center for PTSD (NCPTSD), in collaboration with VA's Office of Mental Health and Suicide Prevention and the Defense Health Agency inside the U.S. Department of Defense (DoD), has been involved in the development, evaluation, and testing of 15 mobile apps designed specifically to address the needs and concerns of veterans and others experiencing symptoms of posttraumatic stress disorder (PTSD). These applications include seven treatment-companion apps (designed to be used with a provider, in conjunction with an evidence-based therapy) and eight self-management apps (designed to be used independently or as an adjunct or extender of traditional care). There is growing evidence for the efficacy of several of these apps for reducing PTSD and other symptoms, and studies of providers demonstrate that the apps are engaging, easy-to-use, and provide a relative advantage to traditional care without apps. While publicly available apps do not collect or share personal data, VA has created research-enabled versions of many of its mental health apps to enable ongoing product enhancement and continuous measurement of the value of these tools to veterans and frontline providers. VA and DoD are also collaborating on provider-based implementation networks to enable clinicians to optimize implementation of mobile technologies in care. Although there are many challenges to developing and integrating mHealth into care, including cost, privacy, and the need for additional research, mobile mental health technologies are likely here to stay and have the potential to reach large numbers of those with unmet mental health needs, including PTSD-related concerns.

    View details for DOI 10.21037/mhealth.2018.05.07

    View details for PubMedID 30148141

    View details for PubMedCentralID PMC6087876

  • Leveraging routine clinical materials and mobile technology to assess CBT fidelity: the Innovative Methods to Assess Psychotherapy Practices (imAPP) study IMPLEMENTATION SCIENCE Stirman, S., Marques, L., Creed, T. A., Gutner, C. A., DeRubeis, R., Barnett, P. G., Kuhn, E., Suvak, M., Owen, J., Vogt, D., Jo, B., Schoenwald, S., Johnson, C., Mallard, K., Beristianos, M., La Bash, H. 2018; 13: 69

    Abstract

    Identifying scalable strategies for assessing fidelity is a key challenge in implementation science. However, for psychosocial interventions, the existing, reliable ways to test treatment fidelity quality are often labor intensive, and less burdensome strategies may not reflect actual clinical practice. Cognitive behavioral therapies (CBTs) provide clinicians with a set of effective core elements to help treat a multitude of disorders, which, evidence suggests, need to be delivered with fidelity to maximize potential client impact. The current "gold standard" for rating CBTs is rating recordings of therapy sessions, which is extremely time-consuming and requires a substantial amount of initial training. Although CBTs can vary based on the target disorder, one common element employed in most CBTs is the use of worksheets to identify specific behaviors and thoughts that affect a client's ability to recover. The present study will develop and evaluate an innovative new approach to rate CBT fidelity, by developing a universal CBT scoring system based on worksheets completed in therapy sessions.To develop a scoring system for CBT worksheets, we will compile common CBT elements from a variety of CBT worksheets for a range of psychiatric disorders and create adherence and competence measures. We will collect archival worksheets from past studies to test the scoring system and assess test-retest reliability. To evaluate whether CBT worksheet scoring accurately reflects clinician fidelity, we will recruit clinicians who are engaged in a CBT for depression, anxiety, and/or posttraumatic stress disorder. Clinicians and clients will transmit routine therapy materials produced in session (e.g., worksheets, clinical notes, session recordings) to the study team after each session. We will compare observer-rated fidelity, clinical notes, and fidelity-rated worksheets to identify the most effective and efficient method to assess clinician fidelity. Clients will also be randomly assigned to either complete the CBT worksheets on paper forms or on a mobile application (app) to learn if worksheet format influences clinician and client experience or differs in terms of reflecting fidelity.Scoring fidelity using CBT worksheets may allow clinics to test fidelity in a short and effective manner, enhancing continuous quality improvement in the workplace. Clinicians and clinics can use such data to improve clinician fidelity in real time, leading to improved patient outcomes.ClinicalTrials.gov NCT03479398 . Retrospectively registered March 20, 2018.

    View details for PubMedID 29789017

  • A randomized controlled pilot study of CBT-I Coach: Feasibility, acceptability, and potential impact of a mobile phone application for patients in cognitive behavioral therapy for insomnia HEALTH INFORMATICS JOURNAL Koffel, E., Kuhn, E., Petsoulis, N., Erbes, C. R., Anders, S., Hoffman, J. E., Ruzek, J. I., Polusny, M. A. 2018; 24 (1): 3-13

    Abstract

    There has been growing interest in utilizing mobile phone applications (apps) to enhance traditional psychotherapy. Previous research has suggested that apps may facilitate patients' completion of cognitive behavioral therapy for insomnia (CBT-I) tasks and potentially increase adherence. This randomized clinical trial pilot study ( n = 18) sought to examine the feasibility, acceptability, and potential impact on adherence and sleep outcomes related to CBT-I Coach use. All participants were engaged in CBT-I, with one group receiving the app as a supplement and one non-app group. We found that patients consistently used the app as intended, particularly the sleep diary and reminder functions. They reported that it was highly acceptable to use. Importantly, the app did not compromise or undermine benefits of cognitive behavioral therapy for insomnia and patients in both groups had significantly improved sleep outcomes following treatment.

    View details for DOI 10.1177/1460458216656472

    View details for Web of Science ID 000424053900001

    View details for PubMedID 27354394

  • PTSD Coach around the world. mHealth Kuhn, E., van der Meer, C., Owen, J. E., Hoffman, J. E., Cash, R., Carrese, P., Olff, M., Bakker, A., Schellong, J., Lorenz, P., Schopp, M., Rau, H., Weidner, K., Arnberg, F. K., Cernvall, M., Iversen, T. 2018; 4: 15

    Abstract

    Posttraumatic stress disorder (PTSD) is a global public health problem. Unfortunately, many individuals with PTSD do not receive professional care due to a lack of available providers, stigma about mental illness, and other concerns. Technology-based interventions, including mobile phone applications (apps) may be a viable means of surmounting such barriers and reaching and helping those in need. Given this potential, in 2011 the U.S Veterans Affairs National Center for PTSD released PTSD Coach, a mobile app intended to provide psycho-education and self-management tools for trauma survivors with PTSD symptoms. Emerging research on PTSD Coach demonstrates high user satisfaction, feasibility, and improvement in PTSD symptoms and other psychosocial outcomes. A model of openly sharing the app's source code and content has resulted in versions being created by individuals in six other countries: Australia, Canada, The Netherlands, Germany, Sweden, and Denmark. These versions are described, highlighting their significant adaptations, enhancements, and expansions to the original PTSD Coach app as well as emerging research on them. It is clear that the sharing of app source code and content has benefited this emerging PTSD Coach community, as well as the populations they are targeting. Despite this success, challenges remain especially reaching trauma survivors in areas where few or no other mental health resources exist.

    View details for DOI 10.21037/mhealth.2018.05.01

    View details for PubMedID 29963560

  • everaging routine clinical materials and mobile technology to assess CBT fidelity: the Innovative Methods to Assess Psychotherapy Practices (imAPP) study Implementation Science Wiltsey Stirman, S., Marques, L., Creed, T. A., Gutner, C. A., DeRubeis, R., Barnett, P. G., Kuhn, E., Suvak, M., Owen, J., Vogt, D., Jo, B., Shoenwald, S., Johnson, C., Mallard, K., Beristianos, M., La Bash, H. 2018; 13
  • Cancer distress coach: Pilot study of a mobile app for managing posttraumatic stress. Psycho-oncology Smith, S. K., Kuhn, E., O'Donnell, J., Koontz, B. F., Nelson, N., Molloy, K., Chang, J., Hoffman, J. 2018; 27 (1): 350-353

    View details for DOI 10.1002/pon.4363

    View details for PubMedID 28032921

  • Mobile Technology for Treatment Augmentation in Veteran Smokers With Posttraumatic Stress Disorder AMERICAN JOURNAL OF PREVENTIVE MEDICINE Herbst, E., Pennington, D., Kuhn, E., McCaslin, S. E., Delucchi, K., Batki, S. L., Dickter, B., Carmody, T. 2018; 54 (1): 124-128

    Abstract

    The purpose of this study is to examine the feasibility and acceptability of incorporating a mobile application, Stay Quit Coach, into an integrated care smoking-cessation treatment protocol for veterans with posttraumatic stress disorder (PTSD).Participants included veteran smokers aged 18-69 years with PTSD. The integrated care protocol includes eight weekly PTSD-informed cognitive behavioral therapy sessions for smoking cessation, followed by monthly booster sessions and a prescription for standard smoking-cessation medications if desired. Participants used Stay Quit Coach as desired. Outcome measures at 3-month follow-up included: adherence (sessions attended), 30-day point-prevalence abstinence bioverified with carbon monoxide <6 parts per million, past-30 day mean daily cigarette use, exhaled carbon monoxide, nicotine dependence, and PTSD symptom severity. Repeated outcomes were analyzed with random-intercept linear mixed models. Data were collected in 2015-2016 and analyses were conducted in 2016-2017.Participants (n=20) were 95% male and 5% female; mean age 41.4 (SD=16.2) years. Thirteen participants (65%) attended all scheduled sessions, four (20%) did not adhere to the protocol on schedule, and three (15%) were lost to follow-up. At 3-month follow-up, six of 17 completers (35.3%) had bioverified 30-day point-prevalence abstinence. Nicotine dependence, carbon monoxide levels, and past 30-day cigarette use significantly decreased and PTSD symptoms were unchanged from baseline to follow-up. Participants self-reported using Stay Quit Coach 2.5 (SD=2.2) days/week; 15 of 17 (88.2%) reported using Stay Quit Coach <30 minutes/week; two of 17 (11.8%) reported using Stay Quit Coach 30-60 minutes/week.Although results must be interpreted with caution given the lack of control group and small sample size, findings indicate that integrating Stay Quit Coach into integrated care was feasible and acceptable.

    View details for DOI 10.1016/j.amepre.2017.08.016

    View details for Web of Science ID 000418763100021

    View details for PubMedID 29074319

  • Barriers and Facilitators to Mobile Application Use During PTSD Treatment: Clinician Adoption of PE Coach PROFESSIONAL PSYCHOLOGY-RESEARCH AND PRACTICE Reger, G. M., Browne, K. C., Campellone, T. R., Simons, C., Kuhn, E., Fortney, J. C., Sayre, G. G., Reisinger, H. 2017; 48 (6): 510-517

    View details for DOI 10.1037/pro0000153

    View details for Web of Science ID 000422905900014

  • Development of a video-delivered relaxation treatment of late-life anxiety for veterans. International psychogeriatrics Gould, C. E., Zapata, A. M., Bruce, J., Bereknyei Merrell, S., Wetherell, J. L., O'Hara, R., Kuhn, E., Goldstein, M. K., Beaudreau, S. A. 2017: 1-13

    Abstract

    Behavioral treatments reduce anxiety, yet many older adults may not have access to these efficacious treatments. To address this need, we developed and evaluated the feasibility and acceptability of a video-delivered anxiety treatment for older Veterans. This treatment program, BREATHE (Breathing, Relaxation, and Education for Anxiety Treatment in the Home Environment), combines psychoeducation, diaphragmatic breathing, and progressive muscle relaxation training with engagement in activities.A mixed methods concurrent study design was used to examine the clarity of the treatment videos. We conducted semi-structured interviews with 20 Veterans (M age = 69.5, SD = 7.3 years; 55% White, Non-Hispanic) and collected ratings of video clarity.Quantitative ratings revealed that 100% of participants generally or definitely could follow breathing and relaxation video instructions. Qualitative findings, however, demonstrated more variability in the extent to which each video segment was clear. Participants identified both immediate benefits and motivation challenges associated with a video-delivered treatment. Participants suggested that some patients may need encouragement, whereas others need face-to-face therapy.Quantitative ratings of video clarity and qualitative findings highlight the feasibility of a video-delivered treatment for older Veterans with anxiety. Our findings demonstrate the importance of ensuring patients can follow instructions provided in self-directed treatments and the role that an iterative testing process has in addressing these issues. Next steps include testing the treatment videos with older Veterans with anxiety disorders.

    View details for DOI 10.1017/S1041610217000928

    View details for PubMedID 28592349

  • Telehealth and eHealth interventions for posttraumatic stress disorder. Current opinion in psychology Morland, L. A., Greene, C. J., Rosen, C. S., Kuhn, E., Hoffman, J., Sloan, D. M. 2017; 14: 102-108

    Abstract

    This paper presents existing research describing how telehealth and eHealth technologies can be used to improve mental health services for trauma survivors, either by enhancing existing treatment approaches or as a stand-alone means of delivering trauma-relevant information and interventions. The potential ways in which telemedicine technologies aide in overcoming barriers to care is first addressed in terms of providing mental health treatment. We then outline how different telehealth and eHealth tools can be used for key therapeutic tasks, including the provision of self-guided interventions, remote delivery of psychotherapy, and augmentation of psychological treatments. We conclude by discussing key emergent issues that are shaping current and future use of telemedicine technologies as part of the continuum of care for trauma survivors.

    View details for DOI 10.1016/j.copsyc.2016.12.003

    View details for PubMedID 28813306

  • CLINICIAN PERCEPTIONS RELATED TO THE USE OF CBT-I COACH MOBILE APP Miller, K. E., Kuhn, E., Weiss, B., Owen, J., Crowley, J. J., Yu, J., Taylor, K. L., Trockel, M. OXFORD UNIV PRESS INC. 2017: A132-A133
  • A randomized controlled trial of a smartphone app for posttraumatic stress disorder symptoms. Journal of consulting and clinical psychology Kuhn, E., Kanuri, N., Hoffman, J. E., Garvert, D. W., Ruzek, J. I., Taylor, C. B. 2017; 85 (3): 267-273

    Abstract

    Posttraumatic stress disorder (PTSD) is highly prevalent in the population, but relatively few affected individuals receive treatment for it. Smartphone applications (apps) could help address this unmet need by offering sound psychoeducational information and evidence-based cognitive behavioral coping tools. We conducted a randomized controlled trial to assess the efficacy of a free, publicly available smartphone app (PTSD Coach) for self-management of PTSD symptoms.One hundred 20 participants who were an average of 39 years old, mostly women (69.2%) and White (66.7%), recruited primarily through online advertisements, were randomized to either a PTSD Coach (n = 62) or a waitlist condition (n = 58) for 3 months. Web-administered self-report measures of PTSD, PTSD symptom coping self-efficacy, depression, and psychosocial functioning were conducted at baseline, posttreatment, and 3 months following treatment.Following the intent-to-treat principle, repeated-measures analyses of variance (ANOVAs) revealed that at posttreatment, PTSD Coach participants had significantly greater improvements in PTSD symptoms (p = .035), depression symptoms (p = .005), and psychosocial functioning (p = .007) than did waitlist participants; however, at posttreatment, there were no significant mean differences in outcomes between conditions. A greater proportion of PTSD Coach participants achieved clinically significant PTSD symptom improvement (p = .018) than waitlist participants.PTSD Coach use resulted in significantly greater improvements in PTSD symptoms and other outcomes relative to a waitlist condition. Given the ubiquity of smartphones, PTSD Coach may provide a wide-reaching, convenient public health intervention for individuals with PTSD symptoms who are not receiving care. (PsycINFO Database Record

    View details for DOI 10.1037/ccp0000163

    View details for PubMedID 28221061

  • Development and refinement of a clinician intervention to facilitate primary care patient use of the PTSD Coach app TRANSLATIONAL BEHAVIORAL MEDICINE Possemato, K., Kuhn, E., Johnson, E. M., Hoffman, J. E., Brooks, E. 2017; 7 (1): 116-126

    Abstract

    Posttraumatic stress disorder (PTSD) is common and undertreated among Veterans Affairs (VA) primary care patients. A brief primary care intervention combining clinician support with a self-management mobile app (Clinician-Supported PTSD Coach, CS-PTSD Coach) may improve patient outcomes. This study developed and refined an intervention to provide clinician support to facilitate use of the PTSD Coach app and gathered VA provider and patient qualitative and quantitative feedback on CS-PTSD Coach to investigate preliminary acceptability and implementation barriers/facilitators. VA primary care providers and mental health leadership (N = 9) completed a survey and interview regarding implementation barriers and facilitators structured according to the Consolidated Framework for Implementation Research (CFIR). Clinicians who delivered CS-PTSD Coach (N = 3) and patients (N = 9) who received it provided feedback on the intervention and implementation process. CS-PTSD Coach has high provider and patient acceptability. Important implementation factors included that CS-PTSD Coach be compatible with the clinics' current practices, have low complexity to implement, be perceived to address patient needs, and have strong support from leadership. Diverse factors related to CS-PTSD Coach delivery facilitate implementation, provide an opportunity to problem-solve barriers, and improve integration of the intervention into primary care.

    View details for DOI 10.1007/s13142-016-0393-9

    View details for Web of Science ID 000399622700018

    View details for PubMedID 27234150

    View details for PubMedCentralID PMC5352634

  • Maintenance and Reach of Exposure Psychotherapy for Posttraumatic Stress Disorder 18 Months After Training. Journal of traumatic stress Rosen, C. S., Eftekhari, A., Crowley, J. J., Smith, B. N., Kuhn, E., Trent, L., Martin, N., Tran, T., Ruzek, J. I. 2017; 30 (1): 63-70

    Abstract

    This study examined aspects of clinicians' work environment that facilitated sustained use of prolonged exposure (PE) therapy. Surveys were completed by 566 U.S. Department of Veterans Affairs clinicians 6 and 18 months after intensive training in PE. The number of patients treated with PE at 18 months (reach) was modeled as a function of clinician demographics, clinician beliefs about PE, and work context factors. There were 342 clinicians (60.4%) who used PE at 6 and 18 months after training, 58 (10.2%) who used PE at 18 but not 6 months, 95 (16.7%) who used PE at 6 but not 18 months, and 71 (12.5%) who never adopted PE. Median reach was 12% of clinicians' appointments with patients with posttraumatic stress disorder. Reach was predicted by flow of interested patients (incident response ratio [IRR] = 1.21 to 1.51), PE's perceived effectiveness (IRR = 1.04 to 1.31), working in a PTSD specialty clinic (IRR = 1.06 to 1.26), seeing more patients weekly (IRR = 1.04 to 1.25), and seeing fewer patients in groups (IRR = 0.83 to 0.99). Most clinicians trained in PE sustained use of the treatment, but on a limited basis. Strategies to increase reach of PE should address organizational barriers and patient engagement.

    View details for DOI 10.1002/jts.22153

    View details for PubMedID 28103401

  • Technology-Based Blended Learning to Facilitate Psychiatry Resident Training in Prolonged Exposure (PE) Therapy for PTSD ACADEMIC PSYCHIATRY Kuhn, E., Hugo, E. 2017; 41 (1): 121-124

    View details for DOI 10.1007/s40596-016-0648-2

    View details for Web of Science ID 000392317100025

    View details for PubMedID 27921266

  • Clinician Perceptions Related to the Use of the CBT-I Coach Mobile App. Behavioral sleep medicine Miller, K. E., Kuhn, E. n., Owen, J. E., Taylor, K. n., Yu, J. S., Weiss, B. J., Crowley, J. J., Trockel, M. n. 2017: 1–11

    Abstract

    Clinicians' perceptions of CBT-I Coach, a patient-facing mobile app for cognitive-behavioral therapy for insomnia (CBT-I), are critical to its adoption and integration into practice. Diffusion of innovations theory emphasizes the influence of perceptions, including the relative advantage to current practice, the compatibility to clinicians' needs, the complexity, the innovation's trialability, and observability. This study intended to evaluate the use and perceptions of CBT-I Coach among Veterans Affairs (VA)-trained CBT-I clinicians.Clinicians (N = 108) were surveyed about their use, feedback, and perceptions of CBT-I Coach a year after the app became available.Overall perceptions of CBT-I Coach were favorable. Fifty percent of clinicians reported using CBT-I Coach, with 98% intending to continue use. The app was perceived to increase sleep diary completion and homework compliance. Clinicians viewed the app as providing accessibility to helpful tools and improving patient engagement. Of those not using the app, 83% endorsed intention to use it. Reasons for nonuse were lack of patient access to smart phones, not being aware of the app, not having time to learn it, and inability to directly access app data. Those who reported using CBT-I Coach had more favorable perceptions across all constructs (p < .01 - p < .001), except relative advantage, compared to nonusers. Users perceived it as less complex and more compatible with their practice than nonusers.Continued efforts are needed to increase adoption and enhance use of CBT-I Coach, as well as study if reported benefits can be evidenced more directly.

    View details for PubMedID 29120247

  • Post-training Beliefs, Intentions, and Use of Prolonged Exposure Therapy by Clinicians in the Veterans Health Administration ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH Ruzek, J. I., Eftekhari, A., Crowley, J., Kuhn, E., Karlin, B. E., Rosen, C. S. 2017; 44 (1): 123-132

    Abstract

    To examine how changes in beliefs during the training process predict adoption of prolonged exposure therapy (PE) by veterans health administration clinicians who received intensive training in this evidence-based treatment. Participants completed a 4-day PE workshop and received expert consultation as they used PE with two or more training cases. Participants were surveyed prior to the workshop, after the workshop, after case consultation (n = 1.034), and 6 months after training (n = 810). Hierarchical regression was used to assess how pre-training factors, and changes in beliefs during different stages of training incrementally predicted post-training intent to use PE and how many patients clinicians were treating with PE 6 months after training. Post-training intent to use PE was high (mean = 6.2, SD = 0.81 on a 1-7 scale), yet most participants treated only 1 or 2 patients at a time with PE. Pre-training factors predicted intent to use and actual use of PE. Changes in beliefs during the workshop had statistically significant yet modest effects on intent and use of PE. Changes in beliefs during case consultation had substantial effects on intent and actual use of PE. Pre-training factors and changes in beliefs during training (especially during case consultation) influence clinicians' adoption of PE. Use of PE was influenced not only by its perceived clinical advantages/disadvantages, but also by contextual factors (working in a PTSD specialty clinic, perceived control over one's schedule, and ability to promote PE to patients and colleagues).

    View details for DOI 10.1007/s10488-015-0689-y

    View details for Web of Science ID 000392383600012

    View details for PubMedID 26487392

  • A Preliminary Investigation of a Relapse Prevention Mobile Application to Maintain Smoking Abstinence Among Individuals With Posttraumatic Stress Disorder. Journal of dual diagnosis Hicks, T. A., Thomas, S. P., Wilson, S. M., Calhoun, P. S., Kuhn, E. R., Beckham, J. C. 2016; 13 (1): 15-20

    Abstract

    Smokers with posttraumatic stress disorder (PTSD) have increased difficulty achieving and maintaining abstinence. Contingency management approaches to smoking cessation interventions have demonstrated short-term efficacy but are limited by high rates of relapse. The goal of this pilot study was to evaluate the usability and feasibility of a smartphone-based smoking cessation application (Stay Quit Coach) designed to prevent relapse among individuals with PTSD.Smokers (N = 11) were randomized to (1) QUIT4EVER, an intervention combining mobile contingency management smoking cessation counseling and medications, and Stay Quit Coach or (2) a contact control condition that was identical to QUIT4EVER except Stay Quit Coach was not included. The primary outcome was prolonged smoking abstinence.Among those queried during the follow-up periods, average Stay Quit Coach helpfulness ratings were high and ranged from 7.25 to 10 on a 10-point Likert scale (with higher scores corresponding to greater helpfulness). The Stay Quit Coach was rated by participants as being most effective at helping to quit smoking, helping to remain quit, and providing support and relevant information about quitting. Among the three quitters in the QUIT4EVER group, all reported abstinence at 3 and 6 months; however, abstinence was only bioverified for one quitter at 6 months. Among the four quitters in the contact control condition group, three reported abstinence at 3 and 6 months, but abstinence was not confirmed by bioverification.Smokers with PTSD express interest in and helpfulness of Stay Quit Coach for remaining abstinent after a quit attempt. Combined use of mobile contingency management and Stay Quit Coach is a feasible and acceptable adjunctive smoking cessation treatment for reducing smoking among smokers with PTSD. Adequately powered clinical trials are needed to demonstrate the long-term efficacy of this combined approach to smoking cessation. This study [Use of Technological Advances to Prevent Smoking Relapse among Smokers with PTSD (QUIT4EVER)] was registered on www.clinicaltrials.gov . clinicaltrials.gov identifier: NCT01990079.

    View details for DOI 10.1080/15504263.2016.1267828

    View details for PubMedID 27918881

    View details for PubMedCentralID PMC5360513

  • Mobile mental health interventions following war and disaster. mHealth Ruzek, J. I., Kuhn, E., Jaworski, B. K., Owen, J. E., Ramsey, K. M. 2016; 2: 37

    Abstract

    Mobile technologies offer potentially critical ways of delivering mental health support to those experiencing war, ethnic conflict, and human-caused and natural disasters. Research on Internet interventions suggests that effective mobile mental health technologies can be developed, and there are early indications that they will be acceptable to war and disaster survivors, and prove capable of greatly increasing the reach of mental health services. Promising mhealth interventions include video teleconferencing, text messaging, and smartphone-based applications. In addition, a variety of social media platforms has been used during and immediately after disasters to increase agility in responding, and strengthen community and individual resilience. Globally, PTSD Coach has been downloaded over 243,000 times in 96 countries, and together with large-scale use of social media for communication during disasters, suggests the potential for reach of app technology. In addition to enabling improved self-management of post-trauma problems, mobile phone interventions can also enhance delivery of face-to-face care by mental health providers and increase the effectiveness of peer helpers and mutual aid organizations. More research is needed to establish the efficacy of mhealth interventions for those affected by war and disaster. Research should also focus on the identification of active elements and core processes of change, determination of effective ways of increasing adoption and engagement, and explore ways of combining the various capabilities of mobile technologies to maximize their impact.

    View details for DOI 10.21037/mhealth.2016.08.06

    View details for PubMedID 28293610

    View details for PubMedCentralID PMC5344166

  • Feasibility, Acceptability, and Potential Efficacy of the PTSD Coach App: A Pilot Randomized Controlled Trial With Community Trauma Survivors PSYCHOLOGICAL TRAUMA-THEORY RESEARCH PRACTICE AND POLICY Miner, A., Kuhn, E., Hoffman, J. E., Owen, J. E., Ruzek, J. I., Taylor, C. B. 2016; 8 (3): 384-392

    Abstract

    Posttraumatic stress disorder (PTSD) is a major public health concern. Although effective treatments exist, affected individuals face many barriers to receiving traditional care. Smartphones are carried by nearly 2 thirds of the U.S. population, offering a promising new option to overcome many of these barriers by delivering self-help interventions through applications (apps). As there is limited research on apps for trauma survivors with PTSD symptoms, we conducted a pilot feasibility, acceptability, and potential efficacy trial of PTSD Coach, a self-management smartphone app for PTSD.A community sample of trauma survivors with PTSD symptoms (N = 49) were randomized to 1 month using PTSD Coach or a waitlist condition. Self-report assessments were completed at baseline, postcondition, and 1-month follow-up. Following the postcondition assessment, waitlist participants were crossed-over to receive PTSD Coach.Participants reported using the app several times per week, throughout the day across multiple contexts, and endorsed few barriers to use. Participants also reported that PTSD Coach components were moderately helpful and that they had learned tools and skills from the app to manage their symptoms. Between conditions effect size estimates were modest (d = -0.25 to -0.33) for PTSD symptom improvement, but not statistically significant.Findings suggest that PTSD Coach is a feasible and acceptable intervention. Findings regarding efficacy are less clear as the study suffered from low statistical power; however, effect size estimates, patterns of within group findings, and secondary analyses suggest that further development and research on PTSD Coach is warranted. (PsycINFO Database Record

    View details for DOI 10.1037/tra0000092

    View details for Web of Science ID 000376205900016

    View details for PubMedID 27046668

  • Effects of a Comprehensive Training Program on Clinician Beliefs About and Intention to Use Prolonged Exposure Therapy for PTSD PSYCHOLOGICAL TRAUMA-THEORY RESEARCH PRACTICE AND POLICY Ruzek, J. I., Eftekhari, A., Rosen, C. S., Crowley, J. J., Kuhn, E., Foa, E. B., Hembree, E. A., Karlin, B. E. 2016; 8 (3): 348-355

    Abstract

    Evidence for treatment efficacy does not guarantee adoption in clinical practice. Attitudinal "buy-in" from clinicians is also important. This study examines evaluation data from a national training program in an evidence-based treatment for PTSD, Prolonged Exposure (PE) therapy, to assess changes in clinician beliefs related to the importance of specific treatment goals, PE outcome expectations, self-efficacy to deliver PE, perceived time and emotional burdens associated with delivering PE, and intentions to use PE.Training included both an interactive workshop and posttraining telephone consultation. Participants were 943 licensed mental health clinicians who treated veterans with PTSD. They completed questionnaires before and after the workshop, and after consultation.Results indicated that workshop participation was associated with significant increases in perceptions of the importance of helping patients improve by employing PE, expectations that patients would benefit from PE, and self-efficacy to deliver PE, and with reduced expectations of negative patient outcomes and concerns about distressing patients. The workshop alone had little impact on expected clinician emotional burden and no impact on anticipated time burden. Participation in ongoing case consultation was associated with additional increases in expected positive patient outcomes and clinician self-efficacy and further reductions in concerns about distressing patients and negative patient outcomes. Unlike the workshop, consultation was associated with decreased expectancies that PE would take too much time and would be emotionally burdensome to provide.Overall, the results suggest that the combination of workshop and ongoing consultation can significantly improve beliefs likely to affect treatment adoption. (PsycINFO Database Record

    View details for DOI 10.1037/tra0000004

    View details for Web of Science ID 000376205900012

    View details for PubMedID 26524541

  • CBT-I Coach: A Description and Clinician Perceptions of a Mobile App for Cognitive Behavioral Therapy for Insomnia JOURNAL OF CLINICAL SLEEP MEDICINE Kuhn, E., Weiss, B. J., Taylor, K. L., Hoffman, J. E., Ramsey, K. M., Manber, R., Gehrman, P., Crowley, J. J., Ruzek, J. I., Trockel, M. 2016; 12 (4): 597-606

    Abstract

    This paper describes CBT-I Coach, a patient-facing smartphone app designed to enhance cognitive behavioral therapy for insomnia (CBT-I). It presents findings of two surveys of U.S. Department of Veterans Affairs (VA) CBT-I trained clinicians regarding their perceptions of CBT-I Coach before it was released (n = 138) and use of it two years after it was released (n = 176).VA-trained CBT-I clinicians completed web-based surveys before and two years after CBT-I Coach was publicly released.Prior to CBT-I Coach release, clinicians reported that it was moderately to very likely that the app could improve care and a majority (87.0%) intended to use it if it were available. Intention to use the app was predicted by smartphone ownership (β = 0.116, p < 0.05) and perceptions of relative advantage to existing CBT-I practices (β = 0.286, p < 0.01), compatibility with their own needs and values (β = 0.307, p < 0.01), and expectations about the complexity of the app (β = 0.245, p < 0.05). Two years after CBT-I Coach became available, 59.9% of participants reported using it with patients and had favorable impressions of its impact on homework adherence and outcomes.Findings suggest that before release, CBT-I Coach was perceived to have potential to enhance CBT-I and address common adherence issues and clinicians would use it. These results are reinforced by findings two years after it was released suggesting robust uptake and favorable perceptions of its value.

    View details for DOI 10.5664/jcsm.5700

    View details for Web of Science ID 000374140000019

    View details for PubMedID 26888586

    View details for PubMedCentralID PMC4795288

  • Using PTSD Coach in primary care with and without clinician support: a pilot randomized controlled trial GENERAL HOSPITAL PSYCHIATRY Possemato, K., Kuhn, E., Johnson, E., Hoffman, J. E., Owen, J. E., Kanuri, N., De Stefano, L., Brooks, E. 2016; 38 (1): 94-98

    Abstract

    This study aims to evaluate the feasibility and potential effectiveness of two approaches to using the PTSD Coach mobile application in primary care: Self-Managed PTSD Coach and Clinician-Supported PTSD Coach. This study also aims to gather preliminary data to investigate if clinician support improves the benefits of using PTSD Coach on posttraumatic stress disorder (PTSD) severity and specialty mental healthcare utilization.Twenty primary care veterans with PTSD symptoms were randomized to either Self-Managed PTSD Coach consisting of one 10-min session providing instructions for application use or Clinician-Supported PTSD Coach consisting of four 20-min sessions focused on setting symptom reduction goals and helping veterans fully engage with application content.Research procedures and intervention conditions appear feasible as indicated by high rates of assessment and intervention retention and high clinician fidelity and satisfaction. Both treatments resulted in reductions in PTSD symptoms, with 7 Clinician-Supported PTSD Coach and 3 Self-Managed PTSD Coach participants reporting clinically significant improvements. Clinician-Supported PTSD Coach resulted in more specialty PTSD care use postintervention and possibly greater reductions in PTSD symptoms.Both PTSD Coach interventions are feasible and potentially helpful. The addition of clinician support appears to increase the effectiveness of self-management alone. A larger-scale randomized controlled trial is warranted to confirm these encouraging preliminary findings.

    View details for DOI 10.1016/j.genhosppsych.2015.09.005

    View details for Web of Science ID 000367358000018

    View details for PubMedID 26589765

  • Clinician Characteristics and Perceptions Related to Use of the PE (Prolonged Exposure) Coach Mobile App PROFESSIONAL PSYCHOLOGY-RESEARCH AND PRACTICE Kuhn, E., Crowley, J. J., Hoffman, J. E., Eftekhari, A., Ramsey, K. M., Owen, J. E., Reger, G. M., Ruzek, J. I. 2015; 46 (6): 437-443

    View details for DOI 10.1037/pro0000051

    View details for Web of Science ID 000366314300008

  • Comparison of the PTSD Checklist (PCL) Administered via a Mobile Device Relative to a Paper Form JOURNAL OF TRAUMATIC STRESS Price, M., Kuhn, E., Hoffman, J. E., Ruzek, J., Acierno, R. 2015; 28 (5): 480-483

    Abstract

    Mobile devices are increasingly used to administer self-report measures of mental health symptoms. There are significant differences, however, in the way that information is presented on mobile devices compared to the traditional paper forms that were used to administer such measures. Such differences may systematically alter responses. The present study evaluated if and how responses differed for a self-report measure, the PTSD Checklist (PCL), administered via mobile device relative to paper and pencil. Participants were 153 trauma-exposed individuals who completed counterbalanced administrations of the PCL on a mobile device and on paper. PCL total scores (d = 0.07) and item responses did not meaningfully or significantly differ across administrations. Power was sufficient to detect a difference in total score between administrations determined by prior work of 3.46 with a d = 0.23. The magnitude of differences between administration formats was unrelated to prior use of mobile devices or participant age. These findings suggest that responses to self-report measures administered via mobile device are equivalent to those obtained via paper and they can be used with experienced as well as naïve users of mobile devices.

    View details for DOI 10.1002/jts.22037

    View details for Web of Science ID 000365385200015

    View details for PubMedID 26375277

  • A Preliminary Study of an Internet-Based Intervention for OEF/OIF Veterans Presenting for VA Specialty PTSD Care JOURNAL OF TRAUMATIC STRESS Belsher, B. E., Kuhn, E., Maron, D., Prins, A., Cueva, D., Fast, E., France, D. 2015; 28 (2): 153-156

    Abstract

    This preliminary study sought to evaluate the feasibility and potential effectiveness of a cognitive-behavioral, web-based intervention for posttraumatic stress in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans who are not able to participate, or not eligible to participate, in evidence-based posttraumatic stress disorder (PTSD) treatments. The study used an uncontrolled pre-posttest design with a sample of 24 OEF/OIF veterans presenting to a VA PTSD specialty clinic. Participants used the afterdeployment.org, Post-Traumatic Stress (PTS) Workshop, which was supplemented with brief weekly telephone calls. Half of the participants (n = 12) completed at least 5 of the 8 workshop sessions. At posttreatment, 40.0% of completers demonstrated reliable reductions on PTSD symptoms and overall d = 1.04. Treatment satisfaction and acceptability was generally positive based on Likert ratings. This web-based intervention for PTS appears to be a feasible and potentially helpful intervention for veterans who may not otherwise receive psychosocial interventions. Given the minimal resources required and the potential reach, this web-based intervention could be a viable addition to services provided to OEF/OIF veterans seeking PTSD specialty care. Efforts to further develop and more rigorously evaluate this approach are warranted.

    View details for DOI 10.1002/jts.21994

    View details for Web of Science ID 000352818300010

    View details for PubMedID 25864506

  • The Feasibility, Acceptability, and Efficacy of Delivering Internet-Based Self-Help and Guided Self-Help Interventions for Generalized Anxiety Disorder to Indian University Students: Design of a Randomized Controlled Trial. JMIR research protocols Kanuri, N., Newman, M. G., Ruzek, J. I., Kuhn, E., Manjula, M., Jones, M., Thomas, N., Abbott, J. M., Sharma, S., Taylor, C. B. 2015; 4 (4)

    Abstract

    Generalized anxiety disorder (GAD) is one of the most common mental disorders among university students; however, many students go untreated due to treatment costs, stigma concerns, and limited access to trained mental health professionals. These barriers are heightened in universities in India, where there are scant mental health care services and severe stigma surrounding help seeking.To evaluate the feasibility, acceptability, and efficacy of Internet-based, or "online," cognitive behavioral therapy (CBT)-based unguided and guided self-help interventions (using the programs GAD Online and Lantern, respectively) to reduce GAD symptoms in students with clinical and subthreshold GAD and, ultimately, reduce the prevalence and incidence of GAD among the student population.Students will be recruited via 3 colleges in Hyderabad, India, and referred for a campus-wide online screening. Self-report data will be collected entirely online. A total of 300 qualifying students will be randomized in a 1:1:1 ratio to receive GAD Online, Lantern, or to be in a wait-list control condition, stratified by clinical and subthreshold GAD symptomatology. Students will complete a postintervention assessment after 3 months and a follow-up assessment 6 months later, at which point students in the wait-list control condition will receive one of the programs. The primary outcome is GAD symptom severity at 3 months postintervention. Secondary outcomes include GAD caseness at 9 months, other anxiety and depression symptoms, self-efficacy, and functional measures (eg, sleep, social functioning) at 3 and 9 months, respectively. Primary analyses will be differences between each of the intervention groups and the wait-list control group, analyzed on an intention-to-treat (ITT) basis using mixed-design ANOVA.The study commenced in February 2015. The sample was recruited over a 3-week period at each college. The trial is expected to end in December 2015.This trial will be the first to evaluate the use of Internet-based CBT programs compared with a wait-list control group for the treatment of GAD among students in Indian universities. If effective, these programs have the potential to reduce the mental health care treatment gap by providing readily accessible, private, and cost-effective evidence-based care to students with GAD who do not currently receive the treatment they need.ClinicalTrials.gov NCT02410265 http://clinicaltrials.gov/ct2/show/NCT02410265 (Archived by WebCite at http://www.webcitation.org/6ddqH6Rbt).

    View details for DOI 10.2196/resprot.4783

    View details for PubMedID 26679295

  • mHealth in the Wild: Using Novel Data to Examine the Reach, Use, and Impact of PTSD Coach JMIR MENTAL HEALTH Owen, J. E., Jaworski, B. K., Kuhn, E., Makin-Byrd, K. N., Ramsey, K. M., Hoffman, J. E. 2015; 2 (1): e7

    Abstract

    A majority of Americans (58%) now use smartphones, making it possible for mobile mental health apps to reach large numbers of those who are living with untreated, or under-treated, mental health symptoms. Although early trials suggest positive effects for mobile health (mHealth) interventions, little is known about the potential public health impact of mobile mental health apps.The purpose of this study was to characterize reach, use, and impact of "PTSD Coach", a free, broadly disseminated mental health app for managing posttraumatic stress disorder (PTSD) symptoms.Using a mixed-methods approach, aggregate mobile analytics data from 153,834 downloads of PTSD Coach were analyzed in conjunction with 156 user reviews.Over 60% of users engaged with PTSD Coach on multiple occasions (mean=6.3 sessions). User reviews reflected gratitude for the availability of the app and being able to use the app specifically during moments of need. PTSD Coach users reported relatively high levels of trauma symptoms (mean PTSD Checklist Score=57.2, SD=15.7). For users who chose to use a symptom management tool, distress declined significantly for both first-time users (mean=1.6 points, SD=2.6 on the 10-point distress thermometer) and return-visit users (mean=2.0, SD=2.3). Analysis of app session data identified common points of attrition, with only 80% of first-time users reaching the app's home screen and 37% accessing one of the app's primary content areas.These findings suggest that PTSD Coach has achieved substantial and sustained reach in the population, is being used as intended, and has been favorably received. PTSD Coach is a unique platform for the delivery of mobile mental health education and treatment, and continuing evaluation and improvement of the app could further strengthen its public health impact.

    View details for DOI 10.2196/mental.3935

    View details for Web of Science ID 000414977800010

    View details for PubMedID 26543913

    View details for PubMedCentralID PMC4607374

  • Applying Behavior Change Theory to Technology Promoting Veteran Mental Health Care Seeking PSYCHOLOGICAL SERVICES Whealin, J. M., Kuhn, E., Pietrzak, R. H. 2014; 11 (4): 486-494

    Abstract

    Despite the availability of effective mental health interventions, the vast majority of veterans with a mental disorder underutilize psychological services. Contemporary research has revealed that several factors such as low education, stigma, stoicism, lack of knowledge, and negative beliefs about mental health services are associated with veterans' underutilization of services. In this article, the authors provide an overview of factors that affect symptomatic veterans' decisions about whether to seek mental health services. Second, they describe the theory of planned behavior (Ajzen & Fishbein, 1980), a useful model for understanding mental health care seeking that can inform the development of technology-based interventions designed to increase veterans' willingness to seek psychological services. Third, the authors describe the development of Considering Professional Help, a personalized web-based tool developed by the Department of Veterans Affairs, which has been designed to promote mental health care seeking in veterans with mental health problems.

    View details for DOI 10.1037/a0037232

    View details for Web of Science ID 000345159300013

    View details for PubMedID 25384001

  • Clinician Perceptions of Using a Smartphone App with Prolonged Exposure Therapy ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH Kuhn, E., Eftekhari, A., Hoffman, J. E., Crowley, J. J., Ramsey, K. M., Reger, G. M., Ruzek, J. I. 2014; 41 (6): 800-807

    Abstract

    Clinician perceptions of clinical innovations affect their adoption and spread. This study investigated mental health clinicians' (n = 163) perceptions of a patient-facing smartphone application (app) for prolonged exposure (PE) therapy for posttraumatic stress disorder, before its public release. After reading a description of the app, participants rated perceptions of it based on diffusion of innovations theory constructs. Perceptions were generally favorable regarding the app's relative advantage over existing PE practices, compatibility with their values and needs, and complexity. Age (<40 years), smartphone ownership, and having used apps in care related to more favorable perceptions. Smartphone ownership, relative advantage, and complexity significantly predicted intention to use the app if it were available. These findings suggest that clinicians are receptive to using a PE app and that dissemination efforts should target sub-groups of PE clinicians to maximize adoption.

    View details for DOI 10.1007/s10488-013-0532-2

    View details for Web of Science ID 000343994900010

    View details for PubMedID 24398700

  • Access, Utilization, and Interest in mHealth Applications Among Veterans Receiving Outpatient Care for PTSD MILITARY MEDICINE Erbes, C. R., Stinson, R., Kuhn, E., Polusny, M., Urban, J., Hoffman, J., Ruzek, J. I., Stepnowsky, C., Thorp, S. R. 2014; 179 (11): 1218-1222

    Abstract

    Mobile health (mHealth) refers to the use of mobile technology (e.g., smartphones) and software (i.e., applications) to facilitate or enhance health care. Several mHealth programs act as either stand-alone aids for Veterans with post-traumatic stress disorder (PTSD) or adjuncts to conventional psychotherapy approaches. Veterans enrolled in a Veterans Affairs outpatient treatment program for PTSD (N = 188) completed anonymous questionnaires that assessed Veterans' access to mHealth-capable devices and their utilization of and interest in mHealth programs for PTSD. The majority of respondents (n = 142, 76%) reported having access to a cell phone or tablet capable of running applications, but only a small group (n = 18) reported use of existing mHealth programs for PTSD. Age significantly predicted ownership of mHealth devices, but not utilization or interest in mHealth applications among device owners. Around 56% to 76% of respondents with access indicated that they were interested in trying mHealth programs for such issues as anger management, sleep hygiene, and management of anxiety symptoms. Findings from this sample suggest that Veterans have adequate access to, and interest in, using mHealth applications to warrant continued development and evaluation of mobile applications for the treatment of PTSD and other mental health conditions.

    View details for DOI 10.7205/MILMED-D-14-00014

    View details for Web of Science ID 000349098600013

    View details for PubMedID 25373044

  • Factors Related to Clinician Attitudes Toward Prolonged Exposure Therapy for PTSD JOURNAL OF TRAUMATIC STRESS Ruzek, J. I., Eftekhari, A., Rosen, C. S., Crowley, J. J., Kuhn, E., Foa, E. B., Hembree, E. A., Karlin, B. E. 2014; 27 (4): 423-429

    Abstract

    This study examines pretraining attitudes toward prolonged exposure (PE) therapy in a sample of 1,275 mental health clinicians enrolled in a national PE training program sponsored by the U.S. Department of Veterans Affairs. Attitudes assessed via survey included values placed on outcomes targeted by PE, outcome expectancies (positive expectancies for patient improvement and negative expectancies related to patient deterioration, clinician time burden, and clinician emotional burden), and self-efficacy for delivering PE. Results indicated that clinicians were receptive to learning PE and had positive expectations about the treatment, but expressed concerns that PE might increase patient distress. Responses varied by clinician characteristics with psychologists, clinicians working in specialty PTSD treatment settings (as opposed to those in mental health clinics and other clinic types), and those with a primarily cognitive-behavioral orientation expressing attitudes that were most supportive of learning and implementing PE across various indicators. Implications for addressing attitudinal barriers to implementation of PE therapy are discussed.

    View details for DOI 10.1002/jts.21945

    View details for Web of Science ID 000341198000006

    View details for PubMedID 25158635

  • Preliminary Evaluation of PTSD Coach, a Smartphone App for Post-Traumatic Stress Symptoms MILITARY MEDICINE Kuhn, E., Greene, C., Hoffman, J., Nguyen, T., Wald, L., Schmidt, J., Ramsey, K. M., Ruzek, J. 2014; 179 (1): 12-18

    Abstract

    PTSD Coach is a mobile application (app) designed to help individuals who have post-traumatic stress disorder (PTSD) symptoms better understand and self-manage their symptoms. It has wide-scale use (over 130,000 downloads in 78 countries) and very favorable reviews but has yet to be evaluated. Therefore, this study examines user satisfaction, perceived helpfulness, and usage patterns of PTSD Coach in a sample of 45 veterans receiving PTSD treatment. After using PTSD Coach for several days, participants completed a survey of satisfaction and perceived helpfulness and focus groups exploring app use and benefit from use. Data indicate that participants were very satisfied with PTSD Coach and perceived it as being moderately to very helpful with their PTSD symptoms. Analysis of focus group data resulted in several categories of app use: to manage acute distress and PTSD symptoms, at scheduled times, and to help with sleep. These findings offer preliminary support for the acceptability and perceived helpfulness of PTSD Coach and suggest that it has potential to be an effective self-management tool for PTSD. Although promising, future research is required to validate this, given study limitations.

    View details for DOI 10.7205/MILMED-D-13-00271

    View details for Web of Science ID 000340806000003

    View details for PubMedID 24402979

  • The "PE Coach" Smartphone Application: An Innovative Approach to Improving Implementation, Fidelity, and Homework Adherence During Prolonged Exposure PSYCHOLOGICAL SERVICES Reger, G. M., Hoffman, J., Riggs, D., Rothbaum, B. O., Ruzek, J., Holloway, K. M., Kuhn, E. 2013; 10 (3): 342-349

    Abstract

    Prolonged exposure (PE) is an empirically supported treatment that is being disseminated broadly to providers in the Department of Veterans Affairs and Department of Defense. Innovative methods are needed to support the implementation, dissemination, and patient and provider adherence to PE. The PE Coach is a smartphone application (app) designed to mitigate barriers to PE implementation. PE Coach is installed on the patient's phone and includes a range of capabilities for use during the PE session and after each session to support the treatment. Functions include the ability to audio record treatment sessions onto the patient's device, to construct the in vivo hierarchy on the device, to record completed homework exercises, to review homework adherence, and to track symptom severity over time. The app also allows sessions and homework to be scheduled directly in the app, populating the device calendar with patient reminder notifications. In the final session, a visual display of symptom improvement and habituation to items on the in vivo hierarchy is presented. These capabilities may significantly improve convenience, provider implementation and adherence, and patient compliance with treatment. Future research is needed to test whether PE Coach is useful and effective.

    View details for DOI 10.1037/a0032774

    View details for Web of Science ID 000322914400011

    View details for PubMedID 23937084

  • The Relationship between Religiosity, PTSD, and Depressive Symptoms in Veterans in PTSD Residential Treatment JOURNAL OF PSYCHOLOGY AND THEOLOGY Tran, C. T., Kuhn, E., Walser, R. D., Drescher, K. D. 2012; 40 (4): 313-322
  • Bringing Internet-based education and intervention into mental health practice: afterdeployment.org EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY Ruzek, J. I., Hoffman, J., Ciulla, R., Prins, A., Kuhn, E., Gahm, G. 2011; 2

    Abstract

    Internet-facilitated interventions may offer numerous advantages in reaching the large numbers of military service men and women exposed to traumatic events. The Internet is now a primary source of health-related information for consumers and research has shown the effectiveness of web-based interventions in addressing a range of mental health problems.Clinicians can learn how to bring Internet education and intervention into routine care, to help clients better understand mental health issues and learn skills for self-management of problems.The Afterdeployment.org (AD) Internet site can be used by health care professionals serving U.S. military personnel returning from Iraq and Afghanistan, and their families. The site currently addresses 18 key domains of functioning, including post-traumatic stress, sleep, anger, alcohol and drugs, and military sexual trauma. It provides an extensive amount of client and family education that is suitable for immediate use by clients and providers, as well as the kinds of interactive workshop content and self-assessment tools that have been shown to be helpful in other treatment contexts.AD CAN BE UTILIZED IN CLINICAL PRACTICE IN A VARIETY OF WAYS: as an adjunct to treatment for PTSD, to supplement existing treatments for a range of post-deployment problems, or as the primary focus of treatment for a client.AD represents a kind of service that is likely to become increasingly available in coming years and that is important for mental health providers to actively explore as a tool for extending their reach, improving their efficiency, and improving quality of care.

    View details for DOI 10.3402/ejpt.v2i0.7278

    View details for Web of Science ID 000208868000015

    View details for PubMedID 22893824

    View details for PubMedCentralID PMC3402153

  • Aggressive and Unsafe Driving in Male Veterans Receiving Residential Treatment for PTSD JOURNAL OF TRAUMATIC STRESS Kuhn, E., Drescher, K., Ruzek, J., Rosen, C. 2010; 23 (3): 399-402

    Abstract

    Aggressive and unsafe driving was examined in 474 male veterans receiving Veterans Affairs residential treatment for posttraumatic stress disorder (PTSD). Specifically, the authors evaluated if PTSD was associated with aggressive and unsafe driving and if Iraq and Afghanistan War veterans were at higher risk than other war veterans. Approximately two thirds of the sample reported lifetime aggressive driving and one third reported current aggressive driving. Posttraumatic stress disorder severity was associated with aggressive driving, but not other forms of unsafe driving. Iraq and Afghanistan veterans endorsed higher rates of and more frequent aggressive driving than did other veterans. After accounting for PTSD severity, age, income, and marital status being an Iraq and Afghanistan War veteran predicted aggressive driving frequency and infrequent seatbelt use.

    View details for DOI 10.1002/jts.20536

    View details for Web of Science ID 000279419300012

    View details for PubMedID 20564373

  • Substance abuse-related mortality among middle-aged male VA psychiatric patients PSYCHIATRIC SERVICES Rosen, C. S., Kuhn, E., Greenbaum, M. A., Drescher, K. D. 2008; 59 (3): 290-296

    Abstract

    This study evaluated mortality and causes of death over a seven-year period among middle-aged male psychiatric patients with and without co-occurring substance use disorder.This cohort study examined mortality among 169,051 male Vietnam-era veterans ages 40 to 59 treated for psychiatric disorders by the U.S. Department of Veterans Affairs (VA) between April and September 1998. Demographic variables, diagnoses, and prior hospitalizations were obtained from VA electronic medical records. Mortality status was obtained from VA benefits records. Cause-of-death data were purchased from the National Death Index for a random sample of 3,383 decedents. Mortality among psychiatric patients with and without diagnosed co-occurring substance use disorders was compared by logistic regression, with controls for demographic factors, psychiatric and medical diagnoses, and prior hospitalizations. Causes of death for psychiatric patients with and without co-occurring disorders were compared by chi square analyses. Results were compared to age- and race-matched norms for the U.S. population.The risk-adjusted probability of dying was 55% higher among psychiatric patients with co-occurring substance use disorders than among those without substance use disorders (OR=1.58-1.69). Overdoses and substance abuse-linked illnesses accounted for 27.6% of deaths among psychiatric patients with co-occurring substance use disorders, compared with only 8.8% of deaths among other psychiatric patients.Substance use disorders strongly contributed to premature death among male psychiatric patients. Secondary prevention is needed to reduce substance misuse and improve medical care for substance-related illnesses among psychiatric patients with co-occurring substance use disorders.

    View details for Web of Science ID 000253788400012

    View details for PubMedID 18308910

  • The role of stress in symptom exacerbation among IBS patients JOURNAL OF PSYCHOSOMATIC RESEARCH Blanchard, E. B., Lackner, J. M., Jaccard, J., Rowell, D., Carosella, A., Powell, C., Sanders, K., Krasner, S., Kuhn, E. 2008; 64 (2): 119-128

    Abstract

    Over 200 treatment-seeking irritable bowel syndrome (IBS) patients completed 4 weeks of daily prospective measures of stress and gastrointestinal symptoms as well as retrospective measures of stress (life events over 12 months, hassles over 1 month). We also obtained the stress measures on 66 nonill controls. Irritable bowel syndrome patients report more frequent hassles than controls and a greater stress impact than controls. Using structural equation modeling, we found that the data were consistent with a model of robust autocorrelation effects of both week-to-week gastrointestinal (GI) symptom indices (r=.84) and stress indices (r=.73), as well as strong concurrent effects of stress on IBS symptoms (r=.90) and vice versa (r=.41). The data also were consistent with a model where there were effects of stress in Week t upon GI symptoms in Week t+1 and t+2, but they were mediated through the concurrent week effects and/or autocorrelation effects. There were no statistically significant independent pathways from stress in Week t to GI symptoms in Week t+1 or t+2. Thus, there is more support for a reciprocal relation between stress and symptoms than there is for a causal relation.

    View details for DOI 10.1016/j.jpsychores.2007.10.010

    View details for Web of Science ID 000252967500001

    View details for PubMedID 18222125

  • A controlled evaluation of group cognitive therapy in the treatment of irritable bowel syndrome BEHAVIOUR RESEARCH AND THERAPY Blanchard, E. B., Lackner, J. M., Sanders, K., Krasner, S., Keefer, L., Payne, A., Gudleski, G. D., Katz, L., Rowell, D., Sykes, M., Kuhn, E., Gusmano, R., Carosella, A., Firth, R., Dulgar-Tulloch, L. 2007; 45 (4): 633-648

    Abstract

    We randomized, at two sites, 210 patients with Rome II diagnosed irritable bowel syndrome (IBS), of at least moderate severity, to one of three conditions: group-based cognitive therapy (CT; n=120), psychoeducational support groups (n=46) as an active control, or intensive symptom and daily stress monitoring (n=44). One hundred eighty-eight participants completed the initial treatment. Those in symptom monitoring were then crossed over to CT. For an intent to treat analysis on a composite GI symptom measure derived from daily symptom diaries, both CT and the psychoeducational support groups were significantly more improved than those in the intensive symptom monitoring condition, but the CT and psychoeducational support group did not differ. Among treatment completers on the same composite measure of GI symptoms, again, both CT and psychoeducational support groups were statistically superior to symptom monitoring but did not differ on the symptom composite, or on any other measure. On individual IBS symptoms, both CT and psychoeducational support were statistically superior to symptom monitoring on reductions in abdominal pain and tenderness and for flatulence. Patient global ratings at the end of treatment showed the two active conditions statistically superior to symptom monitoring on change in Bowel Regularity, with CT superior to symptom monitoring on reduction in overall pain and in improvement in sense of well-being. Three-month follow-up data on 175 patients revealed maintenance of significant improvement or continued significant improvement on all IBS symptoms, including the McGill Pain Questionnaire. Group CT and psychoeducational support groups continued not to differ on any measure. We thus conclude that group CT is not superior to an attention placebo control condition.

    View details for DOI 10.1016/j.brat.2006.07.003

    View details for Web of Science ID 000245164500001

    View details for PubMedID 16979581

  • Treating posttraumatic stress in motor vehicle accident survivors Current Psychiatry Kuhn, E., Hickling, E. J. 2007; 6: 17-27
  • Heart rate of motor vehicle accident survivors in the emergency department, peritraumatic psychological reactions, ASD, and PTSD severity: A 6-month prospective study Kuhn, E., Blanchard, E. B., Fuse, T., Hickling, E. J., Broderick, J. JOHN WILEY & SONS INC. 2006: 735-740

    Abstract

    This small-scale study investigates the relationships between the heart rate of motor vehicle accident survivors presenting in the emergency department (ED) and acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) symptom severity. It also examines the relationships between the survivor's heart rate in the ED and peritraumatic dissociation and peritraumatic distress reported 2 weeks posttrauma. Fifty motor vehicle accident (MVA) survivors were assessed 2 weeks, 1 (N = 42), 3 (N = 37), and 6 months (N = 37) post-MVA. The heart rate in the ED predicted self-reported ASD symptom severity and clinician-rated PTSD symptom severity at 6 months but not at 1 or 3 months. Survivors' heart rate in the ED was significantly correlated with peritraumatic dissociation but not peritraumatic distress. These findings support the role of elevated ED heart rate as a predictor of both ASD and chronic PTSD symptom severity and may help to clarify the discrepant findings of previous research.

    View details for DOI 10.1002/jts.20150

    View details for Web of Science ID 000242281000015

    View details for PubMedID 17075910

  • Brief, early treatment for ASD/PTSD following motor vehicle accidents COGNITIVE AND BEHAVIORAL PRACTICE Hickling, E. J., Blanchard, E. B., Kuhn, E. 2005; 12 (4): 461-467
  • Posttraumatic stress and depressive symptoms in a college population one year after the September 11 attacks: the effect of proximity BEHAVIOUR RESEARCH AND THERAPY Blanchard, E. B., Rowell, D., Kuhn, E., Rogers, R., Wittrock, D. 2005; 43 (1): 143-150

    Abstract

    As a follow-up to our earlier report [Behav. Res. Ther., in press] on the level of posttraumatic stress symptoms (PTSS), depressive symptoms, and frequency of diagnoses of probable posttraumatic stress disorder (PTSD) among college students at three public universities (Albany, NY, Augusta, GA, and Fargo, ND) resulting from the September 11, 2001. Terrorist attacks, we surveyed comparable groups of students (total, n = 1313) from these three institutions in the weeks following the first anniversary (2002) of the attacks. We found proximity effects (Albany higher than Augusta which was higher than Fargo) for PTSS and depressive symptoms but not for frequency of diagnoses of probable PTSD. Within the Albany site data, proximity of county of residence to New York City (NYC) also showed a proximity effect on PTSS. Although depressive symptoms were significantly different in 2002 versus 2001, the arithmetic differences in PTSS or in frequency of diagnoses of probable PTSD were not significant. The September 11 attacks continued to exert a psychic toll on college students even a year later.

    View details for DOI 10.1016/j.brat.2003.12.004

    View details for Web of Science ID 000226504700011

    View details for PubMedID 15531359

  • Contributing to interdisciplinary team rounds in the rehabilitation setting: A student’s guide SCI Psychosocial Process Dunn, M., Kuhn, E. 2005; 18: 158-163
  • One- and two-year prospective follow-up of cognitive behavior therapy or supportive psychotherapy BEHAVIOUR RESEARCH AND THERAPY Blanchard, E. B., Hickling, E. J., Malta, L. S., Freidenberg, B. M., Canna, M. A., Kuhn, E., Sykes, M. A., Galovski, T. E. 2004; 42 (7): 745-759

    Abstract

    We followed up over 90% of 57 motor vehicle accident survivors, who completed a controlled comparison of cognitive behavioral therapy (CBT) to supportive psychotherapy (SUPPORT). One-year results showed a continued significant advantage on categorical diagnosis (PTSD or not) and structured interview measures (CAPS) for CBT over SUPPORT. Other measures generally showed the same results. At two years, we were able to follow-up only 75% of one-year completers. Although there continued to be arithmetic differences favoring CBT over SUPPORT, with these attenuated samples only differences on PTSD Checklist and Impact of Event Scale scores and in overall categorical diagnoses were significant. There was very modest improvement from end of treatment to the two-year follow-up.

    View details for DOI 10.1016/S0005-7967(03)00201-8

    View details for Web of Science ID 000222195300001

    View details for PubMedID 15149896

  • Two studies of psychiatric morbidity among motor vehicle accident survivors 1 year after the crash BEHAVIOUR RESEARCH AND THERAPY Blanchard, E. B., Hickling, E. J., Freidenberg, B. M., Malta, L. S., Kuhn, E., Sykes, M. A. 2004; 42 (5): 569-583

    Abstract

    We assessed the psychiatric co-morbidity associated with chronic posttraumatic stress disorder (PTSD) (1-2 years) secondary to personal injury motor vehicle accidents (MVAs) in two studies. In Study 1, we compared the results of SCID assessments for 75 treatment-seeking MVA survivors (51 with PTSD and 24 with symptoms but no PTSD). In Study 2, we compared similar results among 132 MVA survivors who had been followed prospectively for 12+ months after their accidents (19 with PTSD, 32 who had PTSD but who had remitted, and 81 who never met criteria for PTSD). We found comparable levels of current co-morbid major depression (53%), any mood disorder (62-68%), generalized anxiety disorder (26%) and any anxiety disorder (42%) for both groups of participants with chronic PTSD. These rates of co-morbidity were higher than those found in non-PTSD comparison groups with similar MVA histories.

    View details for DOI 10.1016/S0005-7967(03)00162-1

    View details for Web of Science ID 000221280200007

    View details for PubMedID 15033502

  • Studies of the vicarious traumatization of college students by the September 11th attacks: effects of proximity, exposure and connectedness BEHAVIOUR RESEARCH AND THERAPY Blanchard, E. B., Kuhn, E., Rowell, D. L., Hickling, E. J., Wittrock, D., Rogers, R. L., Johnson, M. R., Steckler, D. C. 2004; 42 (2): 191-205

    Abstract

    From mid-October 2001 through the end of November 2001, we collected fairly large sets of questionnaires from undergraduates at three public universities (Albany, NY, n = 507, Augusta, GA, n = 336, Fargo, ND, n = 526 ) to assess rate of acute stress disorder (ASD) and level of ASD symptoms following the September 11th attacks, rate of current posttraumatic stress disorder (PTSD) and level of PTSD symptoms, and current level of depressive symptoms resulting from the September 11th attacks. We also gathered information on exposure to media coverage of the attacks, connectedness to the World Trade Center (WTC) and personnel there, and degree of engagement in reparative acts such as giving blood, attending vigils. We found higher levels of ASD, ASD symptoms, PTSD and PTSD symptoms as a function of geographical proximity to New York City (and within the Albany site, proximity of students' homes) and gender. Exposure (hours of TV watched) was a predictor in some instances as was connectedness to WTC victims. ASD symptoms were the strongest predictor of subsequent PTSD symptoms. Path models accounted for over 60% of the variance in PTSD symptoms.

    View details for DOI 10.1016/S0005-7967(03)00118-9

    View details for Web of Science ID 000220276500005

    View details for PubMedID 14975780

  • Of "crashes" and "accidents," a comment on Stewart and Lord JOURNAL OF TRAUMATIC STRESS Blanchard, E. B., Hickling, E. J., Kuhn, E. 2003; 16 (5): 527-528

    Abstract

    A. E. Stewart and J. H. Lord (2002) call for abandoning the term motor vehicle accident and substituting motor vehicle crash on definitional and patient care grounds. We disagree on definitional grounds and because of the absence of empirical data from accident survivors to support their contentions.

    View details for DOI 10.1023/A:1025727031843

    View details for Web of Science ID 000185301500015

    View details for PubMedID 14584640

  • Posttraumatic stress disorder and psychosocial functioning within two samples of MVA survivors BEHAVIOUR RESEARCH AND THERAPY Kuhn, E., Blanchard, E. B., Hickling, E. J. 2003; 41 (9): 1105-1112

    Abstract

    To examine criterion F variables of PTSD, the psychosocial functioning of two samples of motor vehicle accident (MVA) survivors was investigated. Within each sample, comparisons between MVA survivors with and without PTSD were conducted on four psychosocial functioning indices at three time points. In addition, the relationships between specific PTSD symptom clusters and psychosocial functioning indices were examined. The study revealed that, in general, MVA survivors with PTSD evidenced poorer psychosocial functioning than did survivors without PTSD. The emotional numbing symptoms of PTSD emerged as the most consistent predictors of the psychosocial functioning indices. The implications of these findings to the comprehensive treatment of PTSD are discussed.

    View details for DOI 10.1016/S0005-7967(03)00071-8

    View details for Web of Science ID 000185592100009

    View details for PubMedID 12914811