Using a Mobile Application in the Treatment of Dysregulated Anger Among Veterans

MILITARY MEDICINE, 182, 11/12:e1941, 2017 Using a Mobile Application in the Treatment of Dysregulated Anger Among Veterans Margaret-Anne Mackintosh, PhD*; James Niehaus, PhD†; Casey T. Taft, PhD‡§; Brian P. Marx, PhD‡§; Kathleen Grubbs, PhD∥; Leslie A. Morland, PsyD∥¶** INTRODUCTION Anger is a symptom of post-traumatic stress disorder (PTSD) that is frequently reported by veterans with PTSD across war eras.1–3 Higher anger symptoms among those with PTSD may result in higher overall PTSD symptom chronicity and severity, and may interfere with PTSD treatment.4,5 Anger problems also increase the risk for aggression, intimate partner violence, legal problems, and interference with social relationships.6–8 Because of the diffuse clinical, interpersonal, and social consequences of *Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road, Building 334 (NC-PTSD), Room C-130, Menlo Park, CA 94025. †Charles River Analytics, 625 Mt. Auburn Street, Cambridge, MA 02138. ‡Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, U.S. Department of Veterans Affairs, 150 South Huntington Avenue, Boston, MA 02130. §Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118. ∥Pacific Islands Division, National Center for PTSD, VA Pacific Islands Health Care System, 3375 Koapaka Street, Suite I-560, Honolulu, HI 96819. ¶VA San Diego Healthcare System, U.S. Department of Veterans Affairs, 3350 La Jolla Village Drive (664BU), San Diego, CA 92161. **Department of Psychiatry, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093. The investigator(s) adhered to the policies regarding the protection of human subjects as prescribed by Code of Federal Regulations (CFR) Title 45, Volume 1, Part 46; Title 32, Chapter 1, Part 219; and Title 21, Chapter 1, Part 50 (Protection of Human Subjects). The views, opinions and/or findings contained in this report are those of the author(s) and should not be construed as an official Department of the Army position, policy, or decision so designated by other documentation. doi: 10.7205/MILMED-D-17-00063 MILITARY MEDICINE, Vol. 182, November/December 2017 e1941 ABSTRACT Objective: Anger is a symptom of post-traumatic stress disorder (PTSD) associated with a range of clinical and functional impairments, and may be especially prevalent among veterans with PTSD. Effective anger management therapies exist but may be undermined by poor engagement or lack of treatment availability. Finding ways to engage veterans in anger management therapy or to improve access can be helpful in improving clinical outcomes. This randomized controlled trial compared anger management treatment (AMT) with AMT augmented by a mobile application (app) system, Remote Exercises for Learning Anger and Excitation Management (RELAX). Methods: Participants were 58 veterans enrolled in 12 sessions of either AMT alone or AMT with the RELAX system (AMT + RELAX). The RELAX system includes the RELAX app, a wearable heart rate monitor, a remote server, and a webbased therapist interface. RELAX allows the user to practice skills, monitor symptoms, and record physiological data. The server collects data on app use. A web-based interface allows the therapist to access data on between-session practice, and skills use. Measures administered at baseline, post-treatment, and 3-and 6-month follow-up include state and trait anger, dimensions of anger, PTSD, depression, interpersonal functioning, and satisfaction. We used multilevel modeling to account for the nesting of time points within participants and participants within treatment groups. Predictors were Treatment Condition (AMT + RELAX and AMT), Linear Time (baseline, post-treatment, 3-and 6-month follow-up), and Quadratic Time and Treatment Condition × Linear Time interaction. All analyses were conducted using SPSS 21 (Armonk, New York). Approval was obtained from the institutional review board. Results: Across groups, the treatment dropout rate was 13.8%; of those who remained in treatment, 90% received an adequate dose of treatment (10 or more sessions). There were no significant differences between groups on attendance or treatment completion. Participants in both treatments demonstrated statistically significant and clinically meaningful reductions in anger severity and significant post-treatment reductions in PTSD. Veterans did not report significant changes in depression or interpersonal functioning. Veterans in the AMT + RELAX group reported spending significantly less time on homework assignments, and they rated the AMT + RELAX app as helpful and easy to use, with these ratings improving over time. Conclusion: Findings suggest that AMT + RELAX was beneficial in reducing anger symptoms and promoting efficient use of the between-session practice; however, AMT + RELAX did not outperform AMT. This study is an important contribution as it is one of the first randomized controlled trials to study the efficacy of a technologyenhanced, evidence-based psychotherapy for anger management. Findings are limited because of small sample size and modifications to the technology during the trial. However, the results highlight the possible benefits of mobile app–supported treatment, including increasing the accessibility of treatment, lowering therapist workload, reducing costs of treatment, reducing practice time, and enabling new activities and types of treatments. This study presents preliminary evidence that mobile apps can be a valuable addition to treatment for patients with anger difficulties. Future research should evaluate how much therapist involvement is needed to support anger management. Using a Mobile Application in the Treatment of Dysregulated Anger Among Veterans e1942 satisfaction between conditions. We also explored participant satisfaction with RELAX. METHOD Participants Veterans (N = 58) were recruited from the Department of Veterans Affairs (VA) in Honolulu, Hawaii. Figure 1 provides the CONSORT table for study recruitment. Eligible veterans were men, over 18 years, with a State-Trait Anger Expression Inventory (STAXI) Trait Scale score of 20 or higher. Exclusionary criteria were active suicidal or homicidal ideation, alcohol or drug abuse, and current psychiatric hospitalization. Blinded clinicians conducted all baseline and follow-up assessments. The mean age of the participants was 53.3 years (SD = 12.5, range = 24–71 years). The sample was ethnically diverse, with 70% of veterans self-identifying as ethnoracial minorities. Roughly a third of veterans served during recent conflicts Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) and one quarter were currently employed. Approval was obtained from the institutional review board. Measures State-Trait Anger Expression Inventory-2 The State-Trait Anger Expression Inventory-2 (STAXI-2)22 is a 57-item measure assessing state-anger, trait-anger, angerexpression, (...truncated)