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

COVID-19大流行加剧了创伤暴露者的心理健康挑战， 孤独感增加，心理健康工作人员能力不足，以及预计的第四波心理健康危机。 大流行本身的健康影响[1，2]。迫切需要增加治疗能力， 与大流行直接相关或因大流行而加剧的创伤相关心理健康问题的个人[6]。 创伤后应激障碍（PTSD）的数字心理健康（DMH）干预解决了有据可查的 传统的面对面心理治疗或远程医疗提供循证治疗的障碍 PTSD，但许多消费者并没有保持参与[7]。因此，可接受的，有效的，和参与的形式， EBT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那些 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文本），我们发现CPT文本是可行的，客户 与文本治疗相比，在较短的时间内显示出更大的PTSD症状改善， 通常（TAU）[5，6]。需要更大规模、更严格的测试。还需要进一步的改进， 解决在试点项目和更广泛的其他项目中确定的持续参与的挑战 DMH干预措施。我们提出了一个随机的，混合1型，实施效果试验， 析因设计比较使用符合HIPAA的安全短信的基于文本的PTSD治疗 我们的DMH合作伙伴Talkspace的平台。我们将随机选择患有PTSD的参与者（N= 400）， 与COVID-19大流行相关或因COVID-19大流行而恶化为CPT-Text或基于文本的TAU。参与者 也将被随机分为两种参与策略之一：治疗师照常提醒（RAU）或RAU + 激励（RI）。我们将研究一种创新的激励结构，在这种结构中， 干预机构可以选择保留其介绍性折扣或将其捐赠给有需要的个人 财政支持。我们将比较参与策略对治疗反应的影响， 参与，我们将研究动机作为一种潜在的机制。我们还将评估一本小说自然 语言处理（NLP）方法来评估CPT文本保真度。这项研究将由一个小组进行， 在创伤后应激障碍治疗，DMH，生物统计学，市场营销和实施方面具有专业知识。它符合PAR-20- 243通过专注于基于文本的干预措施与COVID大流行相关或加剧的PTSD。它 还拥有一个成熟的DMH合作伙伴，以增加EBT的覆盖面和访问，以应对日益增长的 大流行造成的需求。这项研究将（1）提供关于如何促进持续发展的关键信息 DMH参与使用独特的激励策略和主持人的参与和成果和（2） 为使用NLP支持基于消息传递的EBT的质量和保真度提供了第一个指导。

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.