Telehealth 2.0: Evaluating effectiveness and engagement strategies for asynchronous texting based trauma focused therapy for PTSD

新冠肺炎大流行加剧了创伤暴露者的心理健康挑战，原因是 与世隔绝的加剧，精神卫生工作者的能力不足，以及预计将出现第四波精神疾病 大流行本身对健康的影响[1，2]。迫切需要增加治疗能力，以减少 与创伤有关的精神健康问题与大流行直接相关或因大流行而加剧的个人[6]。 数字心理健康(DMH)对创伤后应激障碍(PTSD)的干预解决了有据可查的问题 传统面对面心理治疗或远程医疗提供循证治疗(EBTS)的障碍 创伤后应激障碍，但许多消费者没有保持参与[7]。因此，可接受的、高效的和引人入胜的形式 EBTS是迫切需要的，特别是对于那些不太可能获得传统心理治疗或使用 在线节目。异步短信治疗平台可以促进这些人之间的治疗参与度 他们寻求离散的、方便的和负担得起的支持[9]。在我们的基于文本的EBT格式的试点中 PTSD，认知加工疗法(CPT-TEXT)，我们发现CPT-TEXT是可行的，客户 与文本治疗相比，在更短的时间内显示出显著更大的PTSD症状改善，如 通常(TAU)[5，6]。有必要进行更大规模、更严格的测试。还需要进一步的改进，以 应对在试点和其他更广泛的项目中发现的持续参与面临的挑战 DMH干预。我们提出了一项随机、混合类型1的实施-有效性试验， 使用符合HIPAA的安全短信比较基于文本的PTSD治疗的析因设计 我们的DMH合作伙伴Talkspace的平台。我们将对患有创伤后应激障碍的参与者(N=400)进行随机分组 与新冠肺炎大流行有关或已因此而加剧--文本或基于文本的TAU。参与者 还将随机分为两种参与策略之一：照常提醒治疗师(RAU)或RAU+ 激励(RI)。我们将研究一种创新的激励结构，让继续参与的参与者 干预将可以选择保留他们的介绍性折扣或将其捐赠给有需要的个人 财政支持的问题。我们将比较接触策略对治疗反应和 参与，我们将考察激励作为一种潜在的机制。我们还将评估一部小说《自然》 评估CPT-文本保真度的语言处理(NLP)方法。这项研究将由一个团队进行 拥有创伤后应激障碍治疗、DMH、生物统计学、市场营销和实施方面的专业知识。它与标准杆-20一致- 243侧重于针对与COVID大流行有关或因COVID大流行而加剧的创伤后应激障碍的基于文本的干预措施。它 还拥有久负盛名的DMH合作伙伴，以扩大EBTS的覆盖范围和获取途径，以应对不断增长的 大流行带来的需求。这项研究将(1)提供有关如何促进可持续发展的关键信息 DMH使用独特的激励策略和参与度和结果的协调者参与，以及(2) 提供有关使用NLP支持基于报文传送的EBTS的质量和保真度的首个指导。

The COVID-19 pandemic has exacerbated mental health challenges for trauma-exposed individuals due to increased isolation, insufficient capacity in the mental health workforce, and a predicted fourth wave of mental health impacts of the pandemic itself [1,2]. There is a pressing need to increase treatment capacity for individuals with trauma-related mental health problems directly related to or exacerbated by the pandemic [6]. Digital mental health (DMH) interventions for posttraumatic stress disorder (PTSD) address well-documented barriers to traditional in-person psychotherapy or telehealth delivery of evidence-based treatments (EBTs) for PTSD, but many consumers do not remain engaged [7]. Thus, acceptable, efficient, and engaging forms of EBTs are sorely needed, particularly for those who are less likely to access traditional psychotherapy or use online programs. Asynchronous texting therapy platforms may facilitate treatment engagement among those who seek discrete, convenient, and affordable support [9]. In our pilot of a texting-based format of an EBT for PTSD, Cognitive Processing Therapy (CPT-Text), we found CPT-Text was feasible to deliver, and clients showed substantially greater PTSD symptom improvement over a shorter time compared to text therapy as usual (TAU) [5,6]. A larger scale, more rigorous test is necessary. Additional refinement also is needed to address challenges to sustained engagement that were identified both in the pilot and more broadly in other DMH interventions. We propose a randomized, Hybrid Type 1, implementation-effectiveness trial with a factorial design to compare text-based therapies for PTSD utilizing the HIPAA-compliant secure texting platform of our DMH partner, Talkspace. We will randomize participants (N= 400) who have PTSD that is related to or has been exacerbated by the COVID-19 pandemic into CPT-Text or text-based TAU. Participants will also be randomized into one of two engagement strategies: therapist reminder as usual (RAU) or RAU + incentive (RI). We will examine an innovative incentive structure in which participants who remain engaged in the intervention will have the option of retaining their introductory discount or donating it to individuals in need of financial support. We will compare the impact of engagement strategy on treatment response and engagement, and we will examine motivation as a potential mechanism. We also will evaluate a novel Natural Language Processing (NLP) approach to assessing CPT-Text fidelity. This study will be conducted by a team with expertise in PTSD treatment, DMH, biostatistics, marketing, and implementation. It aligns with PAR-20- 243 by focusing on text-based interventions for PTSD related to or exacerbated by the COVID pandemic. It also has a well-established DMH partner to increase reach of and access to EBTs in response to the growing needs created by the pandemic. This study will (1) provide critical information about how to promote sustained DMH engagement using unique incentive strategies and moderators of engagement and outcomes and (2) offer first guidance on supporting quality and fidelity of messaging-based EBTs using NLP.