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DOD Smartphone App has Tools for Psychological Health

  • Published
  • By Cheryl Pellerin
  • American Forces Press Service
WASHINGTON --  A DOD-funded smartphone app whose tools have been used in their physical form for a decade to treat patients with anxiety, stress, negative thinking and more is now available free to the public, and it's being studied for use in those with more serious psychological health problems, experts involved in the app's funding and use said.

The mobile application was developed at the National Center for Telehealth and Technology, known as T2, research psychologist Dr. Nigel Bush told American Forces Press Service, and it's a digital version of a well-known physical psychological health tool -- an accessory to clinical care, he said -- called a hope box.

"These days in behavioral health clinics, when common symptoms are things like negative thinking and high stress, one approach is to have the patient collect things in a box that are important and that may be therapeutic to them," Bush said.

It can be a shoebox, a manila envelope or a backpack, he added, "but it's a repository for things that the clinician and the patient together determine are beneficial, soothing, evocative of good times, and make the patient feel more worthwhile."

T2, located at Joint Base Lewis-McChord in Washington state, is DOD's main office for cutting-edge approaches to applying technology to psychological health.

"We develop a lot of health technologies of various types at T2," Bush said, "but at the moment we primarily focus on smartphone apps because that's what military service members use most. We were aware of the hope box shoebox and we naturally thought, 'Wouldn't it be so much better if they could carry it with them?'"

Experts from T2 and the Department of Veterans Affairs developed the app, an effort funded by a grant from the DOD Military Suicide Research Consortium, or MSRC, the first organization to integrate DOD and civilian multidisciplinary research on suicide prevention.

Bush said the VHB puts in one place useful tools that patients can access when they're not physically in a clinic. He said it's also useful for people who are not in treatment.

The Virtual Hope Box's suite of tools features:

-- Phone icon: Contains personal support contacts and hotline resources;

-- Remind me: Cherished memories and digital reminders of a user's worth in photos, videos, recorded messages and music;

-- Distract me: An activity planner, puzzles and games;

-- Relax me: Relaxation and stress-reducing tools like a breathing coach and progressive muscle relaxation guide;

-- Inspire me: Preloaded or personal inspirational or comforting quotes; and

-- Coping cards: Personal affirmations that offer true positive thoughts that can replace negative thinking or be used when a patient is in crisis or managing negative core beliefs.


When the VHB initial version was complete, the MSRC funded a proof-of-concept study that Bush and co-investigators completed this year at a clinic in a large regional Veterans Administration center in the Pacific Northwest.

"The clinic already was using a physical hope box in therapy with patients who were at high-risk of considering self-harm," Bush said. "So we introduced the smartphone version to 18 of the clinical patients and had them add their own content to the Virtual Hope Box app, take it away between clinic visits, and use it just as they would the physical hope box."

Bush and his co-investigators had the patients use the physical hope box and the Virtual Hope Box in randomized order and then report along with the clinicians on their preferences. The study team also measured the amount of VHB use and other factors.

Patients in the proof-of-concept study included those diagnosed with posttraumatic stress disorder or PTSD, depression, bipolar disorder, borderline personality disorder and mood disorder, Bush said. Study results were published recently in the journal Suicide and Life-Threatening Behavior.

"If I had to summarize what they told us about the Virtual Hope Box," Bush said, "I'd say they liked it, they found it easy, they found it beneficial, they said they'd use it again in the future, and they said they would recommend it to their peers and others who were in need. When we compared it to the physical hope box, patients used the Virtual Hope Box much more regularly over the period they tested it. They preferred it."

Bush said clinicians who participated in the study also liked the VHB results and reported that patients felt it helped with a range of issues.

"But the clinicians also said that in the clinic, when they were helping patients decide what to put in the hope box, it actually helped focus the general therapeutic session," Bush said.

"By focusing on the content of the smartphone," he added, "it was helping the patient tell clinicians very specific things that ordinarily the clinicians would have to probe for."

Bush said he and co-investigators from the VA, with funding from the MSRC, in the last few months began a new study of the Virtual Hope Box's effectiveness with a broader set of patients and clinics at the same VA center where the first study took place.

In the randomized controlled trial, Bush said, "we're going to study 100 patients from a series of behavioral health clinics. We'll have 50 patients try out the Virtual Hope Box and compare them to 50 patients who are treated as usual, without the VHB, to see whether the hope box actually changes symptoms -- things like self-reports of levels of stress or negative thinking."

The investigators will do pre- and -post measures to see if those using the VHB will show changes more than those who receive treatment as usual," Bush said.

In the meantime, Bush added, the app is already out on the marketplace. We're so confident from our previous experience that it's useful, and we've been inundated by e-mails from providers wanting to know when they can have it."

The free mobile Virtual Hope Box app is available for Android and iOS devices at the App Store, Google Play, and Amazon for Kindle Fire.

At the DOD MSRC, Co-Director Dr. Peter Gutierrez, a clinical research psychologist with the VA Veterans Integrated Service Network 19 Mental Illness Research Education and Clinical Center in Denver, Colorado, said MSRC funded the first study of 18 patients and now is funding the second study of 100 patients.

"One piece of information that we got [from the first study] that we found particularly hopeful was [that the co-investigators] asked patients and clinicians variations on the same question -- would you recommend this application for other people? And both groups said yes," Gutierrez told American Forces Press Service.

Those and other findings of the pilot study provided the rationale for doing the larger clinical trial, he added, and that's why the MSRC decided to fund the clinical trial.

"We are assuming that if the study hypotheses are supported, we will have good evidence that a smartphone application that is completely portable, that can be used by troops in theater as well as in garrison, in collaboration with a provider, is effective in reducing thoughts of self-harm or suicide," Gutierrez explained.

Because the Virtual Hope Box is a component of an empirically supported treatment -- meaning treatment supported by experience -- it is much more of a clinical tool and the consortium is interested in supporting research on innovative clinical interventions, he said.

"We like the technology aspect," Gutierrez added. "We think it's something that, if it's proven effective, will be very popular with our younger troops, who are much more technology savvy than older individuals are."

The consortium also is interested in portable treatments that don't necessarily have to be used in the confines of a behavioral health office, he said.

Another advantage of the Virtual Hope Box is the ability for patients to use it confidentially, Gutierrez said, adding that a physical hope box is cumbersome and using the box in public would attract attention.

"With a smartphone application, someone could be sitting in the barracks, at lunch with colleagues, riding on a bus, looking at a Virtual Hope Box and benefitting from it, but because it's on their smartphone, people around them might think they were checking the weather, looking for news or texting a friend," Gutierrez said.

The latest clinical trial is designed so that clinicians use the Virtual Hope Box with individual patients who may be at risk of suicidal thoughts and behaviors, he added. And what the MSRC is looking for from the clinical trial is data to support that the application is effective in helping clinicians reduce suicide risk in active patients.

"But even when the clinical trial is done, the [smartphone VHB app] won't necessarily only be marketed as a clinical tool to use in treating suicidal individuals," Gutierrez said.

"It will have much broader clinical utility than that because someone who's depressed, someone who has PTSD, potentially someone who is recovering from a traumatic brain injury could benefit from some of the components that are built into the application," he said.