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Listening to users: How VA developed its PTSD Coach mobile app

When Dr. Julia Hoffman wanted to build a mobile app to help veterans suffering from post-traumatic stress disorder, she went to the source: 80 residential PTSD patients at the Veterans Affairs Department Trauma Recovery Program in Palo Alto, Calif.

The vets' top priority, they told her, was finding something to help them relax and focus when they were in the grip of a PTSD attack, suffering from related symptoms such as anger or sleeplessness or generally stressed out.

The vets wanted an app to guide them through many of the same techniques they followed with therapists, such as rating their stress level, practicing deep breathing and progressively relaxing their muscles, she said.

So Hoffman and other clinicians at the Veterans Affairs Department's National Center for PTSD and the Defense Department's National Center for Telehealth and Technology built tutorials for those practices into the "manage symptoms" tab on the PTSD Coach app, one of the most praised and downloaded apps created by a government agency.

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The veterans also wanted to be reminded of family members and other people who make them want to live a healthy life, Hoffman said. That's a tactic that's been used successfully by PTSD sufferers who are prone to behavior like aggressive driving and report that a picture of a loved one on the dashboard helps them slow down.

So the designers allowed vets to personalize the app with pictures from their smartphone's photo gallery and music from iTunes or an Android-complaint audio player and to load in a list of people to call or text for help out of their contacts list.

The government has moved aggressively into the mobile app market, launching more than 80 in the past 18 months with almost every agency providing at least one app. PTSD Coach, which has been downloaded more than 27,000 times and from 53 countries, often is held up by leaders of the General Services Administration's Mobile Government advisory board and others as a model of a successful app that is task-oriented and understands its audience.

Hoffman, who is mobile apps lead at the National Center for Telehealth and Technology, credits PTSD Coach's success in part to developers working closely with veterans to figure out exactly what they wanted in the app, but also to a partnership between PTSD clinicians, app developers and user interface experts who spent hours sifting through what could be a part of the app, what couldn't and how to best present it.

About 40 percent of veterans suffering from PTSD don't seek treatment, either because they're embarrassed by the condition, worried it will hurt their career prospects or social standing, or live in rural areas distant from trained PTSD therapists, Hoffman said.

Hoffman and her team wanted to provide something to help those vets assess the severity of their symptoms but didn't want to present the app as a replacement for a formal PTSD diagnosis or for therapy, she said. They settled on including a 17-question self-assessment tool, but stated clearly that it should not replace a formal diagnosis. They also provided phone numbers that veterans can call to get professional help, including the VA's crisis hot line.

"We've had a number of anecdotal reports, some of them quite moving, of active-duty service personnel or vets who were within minutes of taking their own lives and the app instructed them to call the veterans' crisis line," said Dr. Josef Ruzek, director of dissemination and training at the National Center for PTSD, who worked with Hoffman on developing the app.

The veterans also told Hoffman some things they didn't want on the app. She initially thought it would be helpful to use the smartphones' GPS system to give directions to nearby PTSD resources. But the veterans told her military training had made them hesitant to share personal information, including location information, over their phones.

It's difficult to tell how many active-duty soldiers overseas have downloaded the app because the military routinely instructs soldiers to disable location features on their phones.

Veterans suggested linking to information about Alcoholics Anonymous and Narcotics Anonymous meetings, Hoffman said, but the designers weren't able to do that because AA and NA don't have a central database for information about meetings. Alcohol and substance abuse are common symptoms of PTSD.

Vets also told Hoffman they often don't feel like reading when under stress, so the app includes an audio option for all text.

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