JMIR FORMATIVE RESEARCH

van Stolk-Cooke et al

Original Paper

The PTSD Family Coach App in Veteran Family Members: Pilot
Randomized Controlled Trial
Katherine van Stolk-Cooke1, PhD; Joseph Wielgosz1,2, PhD; Haijing Wu Hallenbeck1,2, PhD; Andrew Chang2, MA;
Craig Rosen1,2, PhD; Jason Owen2, PhD; Eric Kuhn1,2, PhD
1

Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, United States

2

National Center for PTSD, Veteran Affairs Palo Alto Healthcare System, Palo Alto, CA, United States

Corresponding Author:
Katherine van Stolk-Cooke, PhD
Department of Psychiatry & Behavioral Sciences
Stanford University School of Medicine
401 Quarry Rd.
Palo Alto, CA, 94304
United States
Phone: 1 860 335 2021
Email: cvscooke@stanford.edu

Abstract
Background: Posttraumatic stress disorder (PTSD) among US military veterans can adversely impact their concerned significant
others (CSOs; eg, family members and romantic partners). Mobile apps can be tailored to support CSO mental health throughpsychoeducation, coping skills, and stress monitoring.
Objective: This study assessed the feasibility, acceptability, and potential efficacy of PTSD Family Coach 1.0, a free, publicly
available app that includes psychoeducation, stress management tools, self-assessments, and features for connecting to alternative
supports, compared with a psychoeducation-only version of the app for cohabitating CSOs of veterans with PTSD.
Methods: A total of 200 participants with an average age of 39 (SD 8.44) years, primarily female (193/200, 97%), and White(160/200, 80%) were randomized to self-guided use of either PTSD Family Coach 1.0 (n=104) or a psychoeducation-only app(n=96) for 4 weeks. Caregiver burden, stress, depression, anxiety, beliefs about treatment, CSO self-efficacy, and relationshipfunctioning assessed using measures of dyadic adjustment, social constraints, and communication danger signs were administered
via a web survey at baseline and after treatment. User satisfaction and app helpfulness were assessed after treatment. Data wereanalyzed using linear mixed methods.
Results: Overall, 50.5% (101/200) of randomized participants used their allocated app. Participants found PTSD Family Coach
1.0 somewhat satisfying (mean 4.88, SD 1.11) and moderately helpful (mean 2.99, SD 0.97) to use. Linear mixed effects models
revealed no significant differences in outcomes by condition for caregiver burden (P=.45; Cohen d=0.1, 95% CI −0.2 to 0.4),
stress (P=.64; Cohen d=0.1, 95% CI −0.4 to 0.6), depression (P=.93; Cohen d= 0.0, 95% CI −0.3 to 0.3), anxiety (P=.55; Cohen
d=−0.1, 95% CI −0.4 to 0.2), beliefs about treatment (P=.71; Cohen d=0.1, 95% CI −0.2 to 0.3), partner self-efficacy (P=.59;
Cohen d=−0.1, 95% CI −0.4 to 0.2), dyadic adjustment (P=.08; Cohen d=−0.2, 95% CI −0.5 to 0.0), social constraints (P=.05;
Cohen d=0.3, 95% CI 0.0-0.6), or communication danger signs (P=.90; Cohen d=−0.0, 95% CI −0.3 to 0.3). Post hoc analyses
collapsing across conditions revealed a significant between-group effect on stress for app users versus nonusers (β=−3.62;
t281=−2.27; P=.02).
Conclusions: Approximately half of the randomized participants never used their allocated app, and participants in the PTSD
Family Coach 1.0 condition only opened the app approximately 4 times over 4 weeks, suggesting limitations to this app version’s
feasibility. PTSD Family Coach 1.0 users reported moderately favorable impressions of the app, suggesting preliminary
acceptability. Regarding efficacy, no significant difference was found between PTSD Family Coach 1.0 users and psychoeducation
app users across any outcome of interest. Post hoc analyses suggested that app use regardless of treatment condition was associatedwith reduced stress. Further research that improves app feasibility and establishes efficacy in targeting the domains most relevant
to CSOs is warranted.
Trial Registration: ClinicalTrials.gov NCT02486705; https://clinicaltrials.gov/ct2/show/NCT02486705

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van Stolk-Cooke et al(JMIR Form Res 2023;7:e42053) doi: 10.2196/42053
KEYWORDS
posttraumatic stress disorder; PTSD; veterans; family; mobile apps

Introduction

improve stress-related outcomes for CSOs living with
PTSD-affected veterans.

BackgroundToward Interventions for CSOs

Posttraumatic stress disorder (PTSD) related to military service
has negative impacts not only on service members and veterans
but also on their families [1-4]. This is unsurprising given that
PTSD is often associated with impairment in relational
functioning [5-7]. Increasingly, the field of traumatic stress isshifting from a narrow focus on PTSD-affected individuals totheir sociointerpersonal contexts [8]. This context includes
concerned significant others (CSOs), such as close friends,
family members, and romantic partners of trauma survivors[9-11].

Although the impact of PTSD can be far-reaching, efforts toaddress these consequences have typically targeted only
individuals with a PTSD diagnosis. There is evidence thatinvolving CSOs in efforts to support treatment engagement orintervention can improve the outcomes for individuals with
PTSD [10,12,17]. There are also a growing number of
informational resources (ie, psychoeducation) on the internet
to help CSOs support trauma survivors (eg, articles and blogs
for CSOs posted on mental health specialty websites) [18-20].
However, few interventions exist to support CSOs in their own
right, particularly with mental health needs that stem directlyfrom being in a support provision role for a person with PTSD.
In a meta-analysis of interventions to support caregivers ofpatients with traumatic brain injury, PTSD or polytrauma, only
4 studies were identified that incorporated family caregivers
into PTSD treatment, and only 2 of these examined CSO mental
health outcomes (eg, anxiety, depression, global distress) [21].
To our knowledge, no evidence-based stand-alone resources
exist that directly reduce the stress experienced by CSOs ofpeople with PTSD.

Consequences of PTSD for CSOs
Given that several PTSD symptoms involve social impairment,
there has been a growing interest in understanding the ways inwhich PTSD may adversely impact trauma survivors’ CSOs
[2,4]. The negative consequences of PTSD for CSOs are
far-reaching and can range in severity from reduced relationshipsatisfaction to an increased risk of emotional and physical abuse[12]. The literature on CSO outcomes has focused primarily oninterpersonal variables, such as relationship functioning andcommunication problems. Female spouses of male National
Guard members with PTSD have reported high rates of marital
distress [13]. In their examination of the experiences of spousesof ex-prisoners of war, Lahav et al [13] found that the spousesof ex-prisoners of war struggled with PTSD symptoms andreported lower sexual satisfaction in their relationships. Calhoun
et al [14] found that romantic partners of Vietnam War veteranswith PTSD experienced difficulties with psychologicaladjustment, encompassing mood-related concerns (eg, stress,
depression, and anxiety) and caregiver burden, compared withpartners of veterans without the diagnosis. Taken together, thesefindings suggest that military and veteran PTSD can create newsources of stress and impairment for CSOs who surround these
individuals and highlight communication problems as a potential
interpersonal intervention target.
CSOs of PTSD-affected individuals also report high rates ofcaregiver burden [12]. Caregiver burden is definitionallymultifaceted, including inter- and intrapersonal strain, and bothobjective (eg, constraints on CSOs’ tangible and social
resources) and subjective consequences of caring for someone
with heightened physical or mental health needs [15]. Somefacets of caregiver burden have been explored in the literature
on CSOs of PTSD-affected individuals [14], with the aim ofidentifying the potential mechanisms of CSO stress. For
example, in a study of female partners of combat veterans with
PTSD, partner self-efficacy significantly predicted partner
burden [16], suggesting that some CSOs may experience low
self-efficacy in a caregiving role. Consequently, CSO burden
and self-efficacy present potential targets for interventions tohttps://formative.jmir.org/2023/1/e42053

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Resources that are tailored to meet the needs of CSOs holdpromise to address this gap; however, scalability and availability
continue to be barriers to reaching CSOs in need of support[22]. Mobile phone–based interventions, such as text messaging
and mobile app interventions, have been increasingly used toreach individuals who might not otherwise access mental healthtreatment [23]. Mobile apps may be particularly beneficial for
members of the armed forces because they are housed on users’
mobile phones and can be used without web connectivity andare therefore always accessible and more secure thaninternet-based interventions [24]. Within the US military andveteran communities, several scalable, easily accessible mobile
apps have been developed and have demonstrated efficacy inimproving user well-being and reducing stress [25,26]. For
example, PTSD Coach [27] was developed to provide
PTSD-affected users with a suite of supportive, evidence-based
tools, including psychoeducation about PTSD and treatment,
self-assessments, links to external sources of support, and skills
for stress management (eg, relaxation strategies, positive
self-talk, and distress tolerance). One benefit of mobile apps istheir capacity to deliver a broad range of audio and visual tools[28]. Compared with informational brochures or websites thatprovide only psychoeducation, mobile apps may provide a richer
and more engaging experience for those seeking support. An
added benefit of mobile app interventions relative to traditional
provider-based interventions (eg, face-to-face psychotherapies)
is that once deployed, mobile apps are less resource-intensive[29]. These findings suggest that mobile apps may offer anengaging, scalable means for reaching CSOs withpsychoeducation, cognitive-behavioral coping strategies,
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opportunities to track symptoms, monitor wellness, or progress
toward behavioral goals to support social and emotional health.
Little work has been done to elucidate CSO experiences associal support providers for loved ones with PTSD [30], limiting
the evidence base on what type of therapeutic content might bebeneficial to CSOs versus a person directly experiencing PTSD.
Therefore, an examination was conducted to understand theneeds of family members cohabitating with a PTSD-affectedveteran before the development of PTSD Family Coach 1.0[31]. The CSO participants in this study supported that theywould like to see built into a mobile app, including support for
managing veteran PTSD symptoms, interacting with health caresystems, interactions within the relationship, experiences of
CSO burden and stress, and promoting CSO safety from abuseor violence. These themes informed the development of 4
modules in PTSD Family Coach 1.0. Notably, there was someoverlap between the tools requested by CSOs and the tools thatthe study team had developed for the PTSD Coach app, a tool
directed at PTSD-affected veterans (eg, psychoeducation on
PTSD and stress management). Given this, some tools that havebeen shown to promote positive outcomes in PTSD-affectedveterans [32,33] were likewise included in PTSD Family Coach
1.0, along with CSO-specific features. To address CSOs’ statedneed for informational support for PTSD, the Learn section
aims to provide psychoeducation on the nature of PTSD, theimportance of CSO self-care and safety, and treatment options.
To address CSOs’ stated need for support around burden andstress, the Manage Stress section was designed to offer
cognitive-behavioral coping strategies that CSOs could practiceto promote stress reduction, and the Self-Assessment section
was designed to offer CSOs an opportunity to assess their stresslevels related to veteran PTSD and track progress. To address
CSOs’ stated need for support navigating health care systems,
the Get Support section was designed to offer networking
support to link CSOs to other sources of assistance to promoteveteran recovery and CSO and family safety.

This Study
This study was designed to gather preliminary evidence for thefeasibility, acceptability, and efficacy of PTSD Family Coach
1.0, the first iteration of a mobile app-based health support tool
for family member CSOs of veterans with PTSD. The PTSD
Family Coach 1.0 was developed by clinical experts in PTSD
to address the specific needs of CSOs and to serve as acompanion tool to the PTSD Coach app for PTSD-affectedveterans, which has been shown to improve user outcomes,
including satisfaction, perceived helpfulness, and PTSD
symptom severity [32,33]. Although both apps included
mindfulness and breathing-based stress management tools,
PTSD Family Coach 1.0 included CSO-specific tools, such as
guidance for setting appropriate boundaries with veterans to
reduce CSO burden, and skills for promoting positive
communication to improve relationship functioning. Given thatthe app was developed based on CSOs’ articulated needs, it was
hypothesized that participants would use PTSD Family Coach
1.0 and find it satisfying and helpful. Given that a needs
assessment highlighted several CSO concerns above and beyond
traditional psychoeducation [31], in which CSOs can access via
the internet even if they do not use a mobile app [19-21],https://formative.jmir.org/2023/1/e42053

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preliminary efficacy was assessed by testing the hypothesis thatthe full version of PTSD Family Coach 1.0, including stressmanagement and self-assessment features, would outperform a
psychoeducation-only version of the app in reducing caregiverburden, stress, depression and anxiety, and improving beliefs
about accessing psychiatric or psychological treatment andsocial constraints as a function of coexisting with PTSD,
self-efficacy, relationship functioning, and communication
danger signs.

Methods
Ethics Approval
The VA Medical Center and Stanford University's Institutional
Review Board approved all study procedures (eProtocol#28147), and all participants provided electronic consent.
Participants received US $20 in major retail store gift cards (ie,Target and Walmart) for completing each assessment, for totalcompensation of up to US $40 in gift cards.

Consent to Participate
Informed consent was obtained from all participants includedin the study.

Consent for Publication
The authors affirm that human research participants provided
informed consent for the publication of deidentified data
included in all tables and figures.

Participants
Adult family members of veterans with PTSD were recruited
through Facebook advertising. The study inclusion criteria wereas follows: (1) age ≥18 years, (2) iPhone ownership, (3)cohabitation with a veteran with a diagnosis of PTSD, and (4)a Perceived Stress Scale (PSS) score >14, indicating moderateor higher stress [34].

Procedure
Prospective participants were recruited via Facebook and Google
advertisements targeting those who were interested inveteran-related issues that directed them to the baseline Qualtrics
survey where they accessed an electronic consent form. Those
who consented were directed to a brief screener questionnaire,
which included an assessment of age, PSS, and three yes or noquestions as follows: (1) Do you own an iPhone or iPad? (2)Are you currently living with a Veteran? and (3) Has the Veteranthat you are living with been diagnosed with PTSD? Those who
were screened completed the baseline survey and provided anemail address to receive randomization information andinstructions for downloading their allocated app.
The participants were enrolled in 2014. At that time,
downloading a prototype app for research on an iPhone involveda specialized multistep process. Once participants had identified
the app in the app store, they were required to open Settings ontheir device, select Device Management, and “Trust” anonverified developer (ie, the research app platform) to install
the app on their device. Upon first opening the app, participants
were required to enter a unique 6-character study invite code.
Thereafter, participants were able to access the app freely at
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any time. About half of the participants in both the full version
of PTSD Family Coach 1.0 (54/104, 51.9%) andpsychoeducation-only app conditions (47/96, 49%) completed
this process and opened their allocated app at least once.
Hereafter, these participants are referred to as app users. Those
who failed to download or for other reasons never opened their
app are referred to as appnonusers. Limited data, such as thenumber of times each participant opened their app, werecollected; however, whether, how long, and how individuals
used various tools within their allocated app were not available.
After 4 weeks, participants were e-mailed a link to theposttreatment survey. The 4-week treatment period was chosenbecause of the pilot nature of the study, the novelty of theintervention, and the feasibility and acceptability aims. Prior
mobile app development work in related domains (ie, PTSD
Coach) used a 4-week study timeline, which was adequate to
demonstrate feasibility, acceptability, and potential improvementin participant outcomes [35].

Measures
Feasibility or Acceptability Measures
Study Metrics
Information on the number of prospective participants,
individuals who were eligible after screening, and individuals
who completed the baseline and posttreatment surveys werecollected within Qualtrics. Intervention feasibility metrics
included the number of times PTSD Family Coach 1.0
participants opened the app each week.
User Satisfaction
Participants’ satisfaction with their allocated app was assessed
through the 7-item satisfaction subscale of the Usefulness,
Satisfaction, and Ease of Use (USE) Questionnaire [36]. Each
item was scored on a seven-point Likert scale ranging from 1(strongly disagree) to 7 (strongly agree), and a mean score was
generated for the 7 items overall. Scores range from 1 to 7, witha score of 4 reflecting neutral feelings toward the app and higherscores reflecting greater user satisfaction. The USE
Questionnaire has been found to be a valid and reliable
instrument with excellent internal consistency (α=.98) [37].
Perceived Helpfulness
Participants’ perceptions of the helpfulness of their allocatedmobile app were assessed through an 18-item measure basedon a measure used in a prior study of the PTSD Coach app [32].
Items assessed the degree to which participants believed theirapp helped them learn about PTSD, resources fortrauma-exposed individuals, and self-care practices. Items arescored on a 5-point Likert scale ranging from 1 (not at all
helpful) to 5 (extremely helpful), and the mean score of all items
is generated for an overall rating of perceived helpfulness.
Scores range from 1 to 5, with a score of 3 reflecting moderate
helpfulness of the app and higher scores reflecting more
helpfulness. The perceived helpfulness items used in this study
demonstrated excellent internal consistency in prior work
(α=.96) [38].

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Outcomes of Interest
Caregiver Burden
Participants’ perceptions of caregiver burden were measured
using the Montgomery Borgatta Caregiver Burden Scale [39],a 16-item self-report measure. Items are scored on a 5-point
Likert scale ranging from 1 (not at all) to 5 (a great deal).
Scores range from 16 to 80, with higher scores reflecting agreater caregiver burden. The Montgomery Borgatta Caregiver
Burden Scale has been shown to have good internal consistency(α=.86).
Perceptions of StressParticipants’ perceptions of stress were measured using the PSS[40]. The PSS is a 10-item self-report measure of respondents’
perception of stress in their lives. Items are scored on a 5-point
Likert scale for frequency, ranging from 0 (never) to 4 (very
often). Scores ranged from 0 to 40, with higher scores reflecting
greater perceived stress. The PSS has been shown to haveacceptable internal consistency (α=.78) [40].
Depression Symptoms
Participants’ depression symptoms were measured using the8-item version of the Patient Health Questionnaire (PHQ)-8.
This version is identical to the PHQ-9 [41] but does not include
the item on suicidal ideation and was developed for instancesin which study staff were not able to provide immediate crisis
intervention if participants endorsed suicidal thoughts or feelings[42], as was the case in this study. Items are rated on a 4-point
Likert scale for frequency, ranging from 0 (not at all) to 3
(nearly every day). Scores ranged from 0 to 24, with higherscores reflecting more severe depressive symptoms. The PHQ-8
has been shown to have good internal consistency (α=.89) [43].
Anxiety Symptoms
Participants’ anxiety symptoms were measured using theGeneralized Anxiety Disorder-7 (GAD-7) [43]. The GAD-7 is
a 7-item self-report measure of physiological and psychologicalindicators of generalized anxiety. Items are rated on a 4-point
Likert scale ranging from 0 (not at all) to 3 (nearly every day).
Scores ranged from 0 to 21, with higher scores reflecting more
severe anxiety symptoms. The GAD-7 has been shown to haveexcellent internal consistency (α=.92) [43].
Beliefs About Treatment
Participants’ views on psychological and psychiatric treatment
for mental health problems were assessed using the Beliefs
about Psychotherapy and Medications Scale [44]. This is a
14-item self-report measure, with items rated on a 5-point Likert
scale ranging from 1 (strongly disagree) to 5 (strongly agree).
Scores range from 14 to 70, with higher scores reflecting morefavorable views of mental health treatment. The medication
subscale demonstrated acceptable internal consistency (α=.71),
and the psychotherapy subscale has demonstrated good internalconsistency (α=.82) [44].
Social Constraints
Participants’ perceptions of constraints on their relationshipwere assessed using the Social Constraints Scale (SCS) [45].
The SCS is a 5-item self-report measure, with items rated on a
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5-point Likert scale for frequency ranging from 1 (almost never)to 5 (almost always). Scores ranged from 5 to 25, with higherscores reflecting greater perceived constraints on social
functioning. The SCS has been shown to have good internalconsistency (α=.81).
Self-efficacy
Participants’ perceptions of self-efficacy were assessed using
3 items from the Partner Self-Efficacy scale (PSE) [16]. The
items assessed the degree to which control CSOs felt that they
had over their loved ones’ emotional difficulties and were rated
on a 5-point Likert scale of control, ranging from 0 (nocontrol/ability) to 4 (total control/ability). PSE scores ranged
from 0 to 12, with higher scores reflecting greater perceived
self-efficacy. The PSE has been shown to have questionableinternal consistency (α=.54) [16].
Relationship Functioning
Participants’ perceptions of overall relationship functioning
with veterans were assessed using the Dyadic Adjustment Scale(DAS) [46]. DAS is a 47-item self-report measure with subscales
for consensus, cohesion, and satisfaction. Items 1 to 3 werescored on a 6-point Likert scale ranging from 1 (always agree)
to 6 (always disagree). Items 4 to 6 were scored on a 6-point
Likert scale ranging from 1 (never) to 6 (more often than once
per day). Item 7 was scored on a 7-point Likert scale ranging
from 1 (extremely unhappy) to 7 (perfect). Scores ranged from
7 to 43, with higher scores reflecting more effective relationshipfunctioning. The DAS has demonstrated excellent internalconsistency (α=.96) [46].

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Communication Danger Signs
Perceived communication problems between participants andveterans were assessed using the Communication Danger Signs
scale (CDS) [47]. The CDS is an 8-item self-report measurewith items rated on a 3-point Likert scale ranging from 1 (almost
never) to 3 (frequently). Scores ranged from 8 to 24, with higherscores reflecting more problematic communication patterns.
The CDS has demonstrated acceptable internal consistency(α=.73) [47].

Interventions
PTSD Family Coach 1.0
Participants randomized to the full version of PTSD Family
Coach 1.0 had access to all features of the app for 4 weeks andcould use it as much or as little as they wished. Features of
PTSD Family Coach 1.0 included the following: (1)psychoeducation on PTSD, self-care, relationship functioning,and military and veteran-specific issues (Learn); (2) 24 uniquestress management tools, including mindfulness exercises, social
skills resources, and cognitive-behavioral strategies (Manage
Stress); (3) a self-assessment tool (ie, the PSS) so that users
could track their stress levels over time (Self-Assessment); and(4) resources for connecting to other military families andcaregivers, finding professional help, contacting crisis services,and reaching out to existing social support (Get Support).
Screenshots of PTSD Family Coach 1.0 can be found in Figure
1.

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Figure 1. PTSD Family Coach screenshots. PTSD: posttraumatic stress disorder.

Psychoeducation Comparison
Participants randomized to the psychoeducation app had accessonly to the psychoeducation and support resources (ie, Learn
and Get Support) from PTSD Family Coach 1.0 (Figure 1) andcould use these resources as much or as little as they wished.

Data Analyses
All data analyses were conducted in R using the lme4 package[48]. Data inspection and visualization revealed that all variables
met the assumptions of normality. Observed scores for all
variables of interest were plotted for individuals by time point,
and observed variance-covariance and correlation matrices weregenerated. Ordinary least squares residuals were plotted todetermine whether they appeared to have any remaining timetrend that would need to be addressed before analyses [49]. Nochanges were needed.
Descriptive and summary statistics were used to assess
feasibility, and 2-tailed t tests were used to assess differencesin acceptability metrics by condition. For all efficacy analyses,

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maximum likelihood estimation methods were used to makeuse of all available data for each participant [50]. Intent-to-treat
analyses were performed using linear mixed effects models[51]. As this was a pilot project, additional exploratory post hoc
analyses were conducted to better understand how mobile app
uptake might impact the outcomes of interest. These analyses
explored outcomes by app use versus nonuse as well as by grouprandomization.

Results
Baseline Characteristics
Demographic characteristics of the participants are presented
in Table 1. The flow of the study is presented in Figure 2. Of
the 665 individuals assessed for eligibility, 465 (69.9%) did notconsent, completed the initial assessment, or met the study
inclusion criteria. Of those remaining, 200 individuals wererandomized (1:1) into the PTSD Family Coach (n=104) andpsychoeducation app conditions (n=96).

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Table 1. Baseline characteristics by group.
Characteristics

Family coach (n=104)

Psychoeducation (n=96)

Female, n (%)

99 (95.19)

94 (97.92)

Age (years), mean (SD)39.23 (8.88)

38.97 (8.00)

White

89 (85.58)

71 (73.96)

African American or Black

4 (3.85)

3 (3.13)

Asian

0 (0)

2 (2.08)

Latino4 (3.38)

15 (15.63)

Native American or Pacific Islander

6 (5.77)

3 (3.13)Other

1 (0.96)

2 (2.08)

Less than high school

6 (5.77)

5 (5.21)High school or equivalent degree

6 (5.77)

11 (11.46)

Some college

47 (45.19)

33 (34.38)

Associate degree

13 (12.5)

16 (16.67)

Bachelor’s degree

18 (17.31)

19 (19.79)

Advanced degree

14 (13.46)

12 (12.5)

Full-time45 (43.27)

37 (38.54)

Part-time

14 (13.46)

14 (14.58)

Student

7 (6.67)

9 (9.38)

Retired1 (0.96)

1 (1.04)

Disabled

13 (12.5)

9 (9.38)

Unemployed24 (23.08)

25 (26.04)

Air Force

5 (4.81)

4 (4.17)Army

66 (63.46)

55 (57.29)

Marine Corps

14 (13.46)

15 (15.63)

Navy

11 (10.58)

10 (10.42)

National Guard

8 (7.69)

12 (12.5)

90 (86.54)

84 (87.5)

Spouse94 (90.38)

86 (89.58)

Other

10 (9.62)

10 (10.42)<25,000

15 (14.42)

15 (15.63)

25,000-50,000

35 (33.65)

27 (28.13)

50,000-75,000

23 (22.12)

27 (28.13)

75,000-100,000

14 (13.46)

9 (9.38)>100,000

5 (4.81)

5 (5.2)

Do not know or refused to disclose

12 (11.54)

13 (13.54)

Race or ethnicity, n (%)

Education, n (%)

Employment, n (%)

Branch of veteran’s service, n (%)

Veteran combat exposure, n (%)
Relation to veteran, n (%)

Annual household income (US $), n (%)

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Figure 2. CONSORT (Consolidated Standards of Reporting Trials) flow diagram of recruitment, reasons for exclusion, and experimental compliance.

PTSD Family Coach Feasibility and Acceptability
Of the 200 randomized individuals, 101 (50.5%) used their
allocated app at least once over 4 weeks of the study. There
were no significant differences between the proportion of app
users in each condition (PTSD Family Coach, n=54, 51.9%;
psychoeducation, n=47, 49%; N=200; χ21=0.2; P=.62) or the
average number of times the app was opened overall(t163.94=−1.03; P=.31): PTSD Family Coach, mean 3.77 (SD4.22), psychoeducation, mean 3.10 (SD 4.21). Similarly, there
was no significant difference in app use each week by condition(Figure 3). PTSD Family Coach 1.0 users opened their apps an

average of 2.38 times in the first week (SD 2.86), with areduction in use for weeks 2 (mean 0.45, SD 1.13), 3 (mean0.14, SD 0.46) and 4 (mean 0.22, SD 0.92).
PTSD Family Coach 1.0 users reported scores of approximately
5 out of 7 on the USE Questionnaire measuring satisfaction(mean 4.88, SD 1.11), corresponding to “somewhat agree[ing]”that the app was satisfying to use. Regarding perceived
helpfulness, PTSD Family Coach 1.0 users reported scores ofaround 3 out of 5 (mean 2.99, SD 0.97), suggesting that they
considered the app to be moderately helpful. There were no
significant differences in user satisfaction or helpfulness bycondition.

Figure 3. App users by condition over time.

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Treatment Effects
Analyses were performed to examine the outcomes of interest
on an intent-to-treat basis. No significant treatment by timeinteraction effects were identified between users in the PTSD
Family Coach 1.0 and psychoeducation app conditions (Table2). There were no significant correlations between the numberof times the app was opened and changes in outcomes of interestfor either PTSD Family Coach 1.0 users or psychoeducation
app users (all values of P>.05).
Given that approximately half of the participants accessed their
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found, post hoc analyses were run collapsing across app versions(Table 3) to compare app users (n=101) with app nonusers(n=99). There were no significant differences between app users
and nonusers in any demographic variables or outcome variablesof interest at baseline. A significant treatment-by-time
interaction effect was identified for changes in perceived stress,
such that app users experienced reductions in perceived stress,
while app nonusers did not (β=−3.21; t281=−2.34; P=.02). No
other significant treatment × time interaction effects wereidentified.

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Table 2. Treatment effects for family coach condition relative to psychoeducation condition on study outcomes.
Family coach (n=105)
Measure and time

Psychoeducation (n=100)

Treatment effectMean (SE)Cohen dw (95% CI)

P value

Mean (SE)Cohen dw (95% CI)

P value

Cohen d (95% CI)

P valueBLb

48.6 (1.5)

N/Ac

N/A

49.2 (1.6)

N/A

N/A

N/A

N/A

PTd

46.3, (1.7)−0.2 (−0.3 to 0.0).1244.9 (1.9)−0.3 (−0.5 to −0.1).01e0.1 (−0.2 to 0.4)

.45

BL

24.7 (0.6)

N/A

N/A

24.4 (0.6)

N/A

N/A

N/A

N/A

PT

23.9 (0.8)−0.2 (−0.5 to 0.2)

.39

23.0 (0.9)−0.3 (−0.7 to 0.1)

.17

0.1 (−0.4 to 0.6)

.64

11.1 (0.6)

N/A

N/A

11.8 (0.6)

N/A

N/A

N/A

N/A

MBBSa

PSSf

PHQg
BL
PT

g

e

9.4 (0.7)−0.3 (−0.5 to −0.1).01

10.2 (0.8)−0.3 (−0.5 to −0.0).03−0.0 (−0.3 to 0.3)

.93

BL

10.0 (0.6)

N/A

N/A

10.4 (0.6)

N/A

N/A

N/A

N/A

PT

8.4 (0.7)−0.3 (−0.5 to −0.1).009g

9.4 (0.7)−0.2 (−0.4 to 0.0)

.11

−0.1 (−0.4 to 0.2)

.55

BL

53.1 (0.6)

N/A

N/A

53.9 (0.7)

N/A

N/A

N/A

N/A

PT

54.8 (0.7)

0.2 (0.1 to 0.5).01g

55.2 (0.8)

0.2 (−0.0 to 0.4).06

0.1 (−0.2 to 0.3)

.71

BL

17.1 (0.4)

N/A

N/A

18.0 (0.4)

N/A

N/A

N/A

N/A

PT

16.7 (0.4)−0.1 (−0.3 to 0.1)

.24

16.5 (0.5)−0.4 (−0.6 to −0.2).001k0.3 (0.0 to 0.6)

.05

BL

7.5 (0.3)

N/A

N/A

7.2 (0.3)

N/A

N/A

N/A

N/A

PT

7.4 (0.3)−0.0 (−0.2 to 0.2).74

7.4 (0.4)

0.0 (−0.2 to 0.3)

.68

−0.1 (−0.4 to 0.2)

.59

BL

25.5 (0.7)

N/A

N/A

24.4 (0.7)

N/A

N/A

N/A

N/A

PT

26.0 (0.7)

0.1 (−0.1 to 0.2)

.37

26.4 (0.8)

0.3 (0.1 to 0.5).002k

−0.2 (−0.5 to 0.0)

.08

BL

16.5 (0.4)

N/A

N/A

16.8 (0.4)

N/A

N/A

N/A

N/A

PT

16.0 (0.4)−0.1 (−0.3 to 0.0)

.15

16.3 (0.4)−0.1 (−0.3 to 0.1)

.26

−0.0 (−0.3 to 0.3)

.90GAD-7h

BATi

SCSj

PSEl

DASm

CDSn

a

MBBS: Montgomery Borgatta Caregiver Burden Scale.

b

BL: baseline.

c

N/A: not applicable.

d

PT: posttreatment.

eP<.05.

f

PSS: Perceived Stress Scale.

g

PHQ: Patient Health Questionnaire.

h

GAD: Generalized Anxiety Disorder-7.

i

BAT: Beliefs About Treatment.

j

SCS: Social Constraints Scale.

kP<.01.

l

PSE: Partner Self-Efficacy.

m

DAS: Dyadic Adjustment Scale.

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CDS: Communication Danger Signs.

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Table 3. Treatment effects for app users versus app nonusers on study outcomes.
App users (n=101)
Measure and time Mean (SE)App nonusers (n=99)

Treatment effectCohen dw (95% CI)

P value

Mean (SE)Cohen dw (95% CI)

P value

Cohen d (95% CI)

P value

MBBSa
BLb

48.2 (1.5)

N/Ac

N/A

49.5 (1.5)

N/A

N/A

N/A

N/A

PTd

44.4 (1.6)−0.3 (−0.4 to −0.1).005e48.2 (2.2)−0.1 (−0.3 to 0.2)

.52

−0.2 (−0.5 to 0.1)

.30

24.3 (0.6)

N/A

N/A

24.8 (0.5)

N/A

N/A

N/A

N/A

g

PSSf
BL

22.1 (0.8)−0.5 (−0.8 to −0.1).0125.8 (1.0)

0.2 (−0.2 to 0.6)

.33

−0.6 (−1.2 to −0.1) .02eBL

10.6 (0.8)

N/A

N/A

12.3 (0.6)

N/A

N/A

N/A

N/A

PT

8.9 (0.6)−0.3 (−0.5 to −0.1).004e11.2 (0.9)−0.2 (−0.4 to 0.1)

.21

−0.1 (−0.4 to 0.2)

.54

BL

9.6 (0.6)

N/A

N/A

10.8 (0.6)

N/A

N/A

N/A

N/A

PT

8.1 (0.6)−0.3 (−0.4 to −0.1).005g

10.2 (0.8)−0.1 (−0.4 to 0.2)

.49

−0.2 (−0.5 to 0.2)

.31

BL

53.6 (0.6)

N/A

N/A

53.4 (0.6)

N/A

N/A

N/A

N/A

PT

55.1 (0.7)

0.2 (0.1 to 0.4).006d

54.6 (0.9)

0.2 (−0.1 to 0.5).15

0.1 (−0.3 to 0.4)

.74

BL

17.4 (0.4)

N/A

N/A

17.7 (0.4)

N/A

N/A

N/A

N/A

PT

16.3 (0.4)−0.3 (−0.5 to −0.1).003e17.1 (0.5)

0.2 (−0.4 to 0.1)

.22

−0.1 (−0.4 to 0.2)

.50

BL

7.6 (0.3)

N/A

N/A

7.1 (0.3)

N/A

N/A

N/A

N/A

PT

7.6 (0.3)

0.0 (−0.2 to 0.2).87

6.9 (0.4)−0.1 (−0.3 to 0.2).58

0.1 (−0.2 to 0.4)

.60

BL

25.2 (0.7)

N/A

N/A

24.8 (0.7)

N/A

N/A

N/A

N/A

PT

26.6 (0.7)

0.2 (0.1 to 0.4)

.006e

25.4 (0.9)

0.1 (−0.1 to 0.3).50

0.1 (−0.1 to 0.4)

.33

BL

16.1 (0.4)

N/A

N/A

17.1 (0.4)

N/A

N/A

N/A

N/A

PT

15.8 (0.5)−0.1 (−0.2 to 0.1)

.34

16.5 (0.5)−0.2 (−0.4 to 0.1)

.14

0.1 (−0.2 to 0.4)

.48

PT
PHQh

GAD-7i

BATj

SCSk

PSEl

DAS

m

CDSn

a

MBBS: Montgomery Borgatta Caregiver Burden Scale.

b

BL: baseline.

c

N/A: not applicable.

d

PT: posttreatment.

eP<.01.

f

PSS: Perceived Stress Scale.

gP<.05.

h

PHQ: Patient Health Questionnaire.

i

GAD: Generalized Anxiety Disorder-7.

j

BAT: Beliefs About Treatment.

k

SCS: Social Constraints Scale.

l

PSE: Partner Self-Efficacy.

m

DAS: Dyadic Adjustment Scale.

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CDS: Communication Danger Signs.

Discussion
Principal Findings
This study tested the feasibility, acceptability, and potential
efficacy of a mobile app-based mental health resource for CSOs
living with veterans with PTSD. Approximately half of therandomized participants never opened the app, and participantsin the PTSD Family Coach 1.0 condition only opened the appapproximately 4 times over 4 weeks, suggesting limitations tothis version’s feasibility. In terms of acceptability, PTSD Family
Coach 1.0 users reported moderately favorable impressions of
the app regarding satisfaction and perceived helpfulness. For
potential efficacy, findings suggested no differences between
participants randomized to PTSD Family Coach 1.0 versus thepsychoeducation app on any outcome of interest. Post hoc
analyses of participants who did and did not download and open
their allocated app yielded a significant between-groups effectfor perceived stress, such that app users had moderately greater
reductions (ie, Cohen d=−0.6) in perceived stress scores frombaseline to posttreatment compared with nonusers.
Evidence for the feasibility of an intervention tool accrues as afunction of participant recruitment, retention, and adherence
rates, among other factors [52]. Given these metrics, the resultsfrom this study suggest that updates will be needed to improve
the feasibility of PTSD Family Coach for participants. Owing
to the nature of recruitment and retention procedures,information about why app nonusers never opened their assigned
app is not available. It is possible that discomfort with mobile
technology or the complexity of the app download procedure
constituted significant barriers to successful downloading of
the app. At the time of the study, accessing the research versionsof PTSD Family Coach 1.0 and the psychoeducation app
required a multistep procedure involving granting customized
permissions, which users may have found confusing or
anxiety-provoking from a data security or privacy standpoint.
Mobile app studies no longer require this step, which has
eliminated one potential barrier to user engagement and retention
in future studies [53]. Another hypothesis was that family
members with particularly high rates of stress or burden might
have been less likely to access an app because of the competing
demands on their time and psychological resources. However,app users and nonusers did not significantly differ in baseline
levels of stress, burden, depression symptoms, or anxiety
symptoms. Adherence rates among those who used PTSD
Family Coach 1.0 (ie, app use less than once per week) werealso lower than anticipated, given that prior research on apps
to support PTSD-related concerns has found app use rates
around 2 to 3 times weekly [27,35]. Given that psychoeducation
was one of the support CSOs desired in a mobile app [31], andpsychoeducation is a common component in PTSD treatmentsthat involve family members [54,55], it is possible that CSOs
accessed the app for psychoeducation, after which they did not
see a need to return for skills practice.
This study found preliminary support for the hypothesis that
PTSD Family Coach 1.0 would be deemed acceptable by users.
Participants reported being moderately satisfied with the app
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1.0 was conceived in response to CSO demands and high levelsof unmet mental health needs among CSOs of PTSD-affected
Veterans [31]. As such, the evidence for moderate acceptability
in this study may best be conceptualized as a starting point forengaging CSOs, with room to improve the CSO experience with
future iterations of PTSD Family Coach.
This study did not find support for the hypothesis that accessto the full version of PTSD Family Coach 1.0 would be superior
to access to a psychoeducation-only version. One possible
explanation for the absence of a significant difference between
groups is that veterans’ CSOs have a particular interest in theinformational support characteristic of psychoeducation[31,55,56]. Specifically, CSOs may benefit from informationthat provides a context for the behaviors or struggles they are
witnessing in their veterans, as this information can normalizedifficult experiences and provide a framework for how CSOs
can proceed. Furthermore, the full version of PTSD Family
Coach 1.0 involves components that require active engagement
and time (eg, interactive coping tools and assessments of stress),which may prove difficult in a CSO population with high rates
of caregiver burden [31]. CSO burden, CSOs’ greater initialadherence to the app (Figure 3), and existing literature
highlighting CSOs’ desire for and benefit from psychoeducation[54,55] may suggest that a light-touch psychoeducationintervention is more conducive to a CSO’s limited time,
availability, and prioritized needs. Most PTSD Family Coach
1.0 users opened the app between one and two times within thefirst week, and minimally thereafter. This may indicate thatusers accessed the app to gain psychoeducation, after which
they no longer felt the need to return to the tool.

Limitations
This study has several limitations. The app was built and data
were collected in 2014. Given the rapid rate of change intechnological platforms [57], this dates and limits theapplicability of the study findings to current efforts to develop
and pilot-test app-based interventions. The attrition rates in bothrandomized conditions were high. This may be attributable toa less directive methodological approach to study recruitment
and retention [58]. Approximately half of those randomized toa condition accessed their allocated app, and approximately
40% of all participants did not complete the posttreatment
survey. High rates of attrition and low levels of intervention
engagement are common problems in internet-based intervention
studies [59,60], and this problem likely extends to mobile app
interventions as well. In epidemiological-level work,
internet-based projects that use some offline enrollment
initiatives outperform those that are completely virtual [58].
For evidence-based interventions to be developed for mobile
apps such that they are widely available and scalable, however,it will be crucial to use research methods that allow participants
to find and use these tools with minimal to no face-to-face
support. Subsequent studies may benefit from using larger
incentives [61], more user-friendly training tools (eg, a training
video or an interactive step-by-step guide to download the app),or more readily available access to troubleshooting technology.
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Therefore, linear mixed modeling approaches, which are robust
to high rates of attrition, such as those observed in this project,
were therefore used to maximize data quality [62]. However,
future work should prioritize app training and retention efforts
to ensure that those who enroll are more likely to receive their
allocated interventions.
The demographic features of the sample were narrow, such that
it was composed primarily of White female spouses of maleveterans. Thus, cohabitating CSOs other than White female
spouses were not adequately represented in this study, and theextent to which these findings generalize across demographic
factors such as gender, race, ethnicity, and family role forfamilies of veterans living with PTSD. At the time the study
procedures were conducted, granular descriptive use data, suchas which tools participants accessed or returned the most, were
not available. The absence of significant differences between
PTSD Family Coach 1.0 users and psychoeducation-only users
may point to CSO reliance on psychoeducation tools in bothconditions. However, information on how users navigated theapp could potentially shed light on whether CSOs gravitated to
psychoeducation over more active tools, such as skill-building
or self-assessment, and these anonymized data were collected
for the updated version of the app, PTSD Family Coach 2.0. It
is possible that constraints on app content and design diminished
PTSD Family Coach 1.0’s usefulness for CSOs, and the lackof descriptive data on how CSOs used various tools limits theconclusions that can be drawn about these potential constraints.
For example, it is possible that the coping skills CSOs wereencouraged to practice in the Manage Stress section required
further tailoring to address CSOs’ articulated needs (eg,managing reactions to veterans’ PTSD symptoms). Across its
various features, PTSD Family Coach 1.0 was heavy in text,
which may have made the tools less accessible or more difficult
to navigate. Updates to PTSD Family Coach 2.0 included
revisions to how tools were labeled, and how much text-based
content users would need to navigate on each screen. Future
work would benefit from more granular data about which tools
are used, and it may prove beneficial to build in opportunities
for CSOs to provide immediate feedback on each accessed tool(eg, 3 yes or no questions after a tool has been accessed todetermine whether CSOs found the tool helpful, appealing, andeasy to understand). PTSD Family Coach 1.0 was available forresearch use only on iOS devices, limiting inclusion to only
those with iPhones. Some demographic and personality
differences between iOS and Android users have been identified
in prior work, suggesting that apps available only to iOS users
may limit the generalizability of the findings [63,64]. PTSD
Family Coach 2.0 is available on Android platforms and shouldbe tested by both types of smartphone users. Minimal training
on downloading the mobile app and now obsolete security
barriers appear to have resulted in more-than-typical issues withaccessing both app versions. Study procedures should be
replicated with the more user-friendly functionality of being
able to download the app directly from the app store on a user’s
phone. Finally, the study was conducted in 2014. Smartphoneownership in the United States has increased by 30% from 2014
to 2021, and mobile technologies are undergoing nearly constantchanges and updates [65]. As such, future projects examining
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PTSD Family Coach 2.0 are likely to include more generalizablesamples with more experience using smartphone technologies.

Conclusions
Despite these limitations, this study has several implications
and directions for future research. The rates of stress, anxiety,and depression in the sample at baseline were high, and theimpetus for building PTSD Family Coach stemmed from the
CSO’s demand for support. Among those who accessed the app
in this study, the rates of stress diminished. This highlights thepromise of tailored, evidence-based mobile resources to address
an as yet unmet needs in this underserved population.
Since the completion of study procedures, advances in clinicalintervention research that uses mobile platforms [66] haveresulted in improvements in app intervention development bestpractices. These best practices include both user-centered design
considerations (eg, creating platforms that are easy forprospective users to find, download, and interact with,minimizing redundancies in content, and increasing
opportunities for users to customize the app interface) [67], anddata quality considerations (eg, passive collection of granularuse data) [68]. Adherence to these revised best practices holds
promise for improving the data quality and potential clinicalimpact of future app development studies aimed at assisting
CSOs. Although PTSD Family Coach 1.0 was developed basedon the articulated needs of CSOs of PTSD-affected veterans[31], researchers who wish to intervene to address CSO needs
via mobile app development would benefit from adhering to
the principles of user-centered design [69], which is an iterative,
cyclical process involving (1) needs assessments of the target
population through field studies, focus groups, and one-on-one
interviews, (2) the development of a protype, and (3) evaluationof the prototype, followed by tool deployment or a return to aneeds assessment if the prototype requires further changes.
After the completion of this project, PTSD Family Coach 2.0
was developed including substantial updates and enhancementsthat supersede the 1.0 version. Changes in the app were largely
driven by qualitative feedback collected from participants inthis study [31]. Participants articulated a need for specificsupport in domains such as connecting their veterans totreatment, connecting to professional help for themselves, andpracticing skills specifically designed to help them manage theirreactions to their veterans’ PTSD symptoms [31]. This feedback
was used to inform them of the tools included in PTSD Family
Coach 2.0. In addition, PTSD Family Coach 2.0, which isaccessible on both iPhone and Android devices, does not entail
an involved permissions process to download and use. Thus,
more research is needed to determine whether the changes madebased on participant feedback and improvements in the userinterface translate into improved engagement and outcomes.
Future research on PTSD Family Coach 2.0 should specificallyaim to improve the tool’s feasibility, optimize user acceptability,and establish efficacy in targeting domains that CSOs find most
distressing (eg, caregiver burden and depression symptoms).
Mechanisms studies to identify which resources are most helpful
to veterans’ CSOs when delivered via mobile apps are also
warranted.

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Data Availability
The data sets generated and analyzed during this study are not publicly available due to the security requirements of the Department
of Veterans Affairs. The authors will consider reasonable requests on a case-by-case basis, subject to compliance with the
Department of Veterans Affairs data sharing agreements.

Authors' Contributions
JO, EK, and CR contributed to study conception and design. Material preparation and data analysis were performed by KvSC,
with assistance from JW. The first draft of the manuscript was written by KvSC, and all authors contributed to subsequent versionsof the manuscript. All authors have read and approved the final manuscript.

Conflicts of Interest
None declared.

Multimedia Appendix 1
CONSORT-eHEALTH checklist (V 1.6.1).
[PDF File (Adobe PDF File), 1230 KB-Multimedia Appendix 1]

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Abbreviations
CDS: Communication Danger Signs scale
CSO: concerned significant other
DAS: Dyadic Adjustment Scale
GAD-7: Generalized Anxiety Disorder-7
PHQ: Patient Health Questionnaire
PSE: Partner Self-Efficacy scale
PSS: Perceived Stress Scale
PTSD: posttraumatic stress disorder
SCS: Social Constraints Scale
USE: Usefulness, Satisfaction, and Ease of Use

Edited by A Mavragani; submitted 19.08.22; peer-reviewed by C Jones, S Toh; comments to author 20.09.22; revised version received
10.10.22; accepted 03.11.22; published 05.01.23
Please cite as:van Stolk-Cooke K, Wielgosz J, Hallenbeck HW, Chang A, Rosen C, Owen J, Kuhn E
The PTSD Family Coach App in Veteran Family Members: Pilot Randomized Controlled Trial
JMIR Form Res 2023;7:e42053
URL: https://formative.jmir.org/2023/1/e42053
doi: 10.2196/42053
PMID: 36602852©Katherine van Stolk-Cooke, Joseph Wielgosz, Haijing Wu Hallenbeck, Andrew Chang, Craig Rosen, Jason Owen, Eric Kuhn.
Originally published in JMIR Formative Research (https://formative.jmir.org), 05.01.2023. This is an open-access article distributed
under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative
Research, is properly cited. The complete bibliographic information, a link to the original publication on https://formative.jmir.org,
as well as this copyright and license information must be included.

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