Virtual Trauma-Focused Therapy for Military Members, Veterans, and Public Safety Personnel With Posttraumatic Stress Injury: Systematic Scoping Review

Abstract

Background A necessary shift from in-person to remote delivery of psychotherapy (eg, teletherapy, eHealth, videoconferencing) has occurred because of the COVID-19 pandemic. A corollary benefit is a potential fit in terms of the need for equitable and timely access to mental health services in remote and rural locations. Owing to COVID-19, there may be an increase in the demand for timely, virtual delivery of services among trauma-affected populations, including public safety personnel (PSP; eg, paramedics, police, fire, correctional officers), military members, and veterans. There is a lack of evidence on the question of whether digital delivery of trauma-therapies for military members, veterans, and PSP leads to similar outcomes to in-person delivery. Information on barriers and facilitators and recommendations regarding digital-delivery is also scarce. Objective This study aims to evaluate the scope and quality of peer-reviewed literature on psychotherapeutic digital health interventions delivered remotely to military members, veterans, and PSP and synthesize the knowledge of needs, gaps, barriers to, and facilitators for virtual assessment of and virtual interventions for posttraumatic stress injury. Methods Relevant studies were identified using MEDLINE (Medical Literature Analysis and Retrieval System Online), EMBASE (Excerpta Medica dataBASE), APA (American Psychological Association) PsycINFO, CINAHL (Cumulative Index of Nursing and Allied Health Literature) Plus with Full Text, and Military & Government Collection. For collation, analysis, summarizing, and reporting of results, we used the CASP (Critical Skills Appraisal Program) qualitative checklist, PEDro (Physiotherapy Evidence Database) scale, level of evidence hierarchy, PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews), and narrative synthesis. Results A total of 38 studies were included in this review. Evidence for the effectiveness of digital delivery of prolonged exposure therapy, cognitive processing therapy, behavioral activation treatment with therapeutic exposure to military members, veterans, and PSP was rated level 1a, whereas evidence for cognitive behavioral therapy was conflicting. The narrative synthesis indicated that virtual delivery of these therapies can be as effective as in-person delivery but may reduce stigma and cost while increasing access to therapy. Issues of risk, safety, potential harm (ie, suicidality, enabling avoidance), privacy, security, and the match among the therapist, modality, and patient warrant further consideration. There is a lack of studies on the influences of gender, racial, and cultural factors that may result in differential outcomes, preferences, and/or needs. An investigation into other therapies that may be suitable for digital delivery is needed. Conclusions Digital delivery of trauma therapies for military members, veterans, and PSP is a critical area for further research. Although promising evidence exists regarding the effectiveness of digital health within these populations, many questions remain, and a cautious approach to more widespread implementation is warranted.

The Experience of Key Stakeholders During the Implementation and Use of Trauma Therapy via Digital Health for Military, Veteran, and Public Safety Personnel: Qualitative Thematic Analysis

“…In particular, issues relating to privacy are especially salient given not only the widespread stigma associated with mental health concerns in the military or PSP organizations but also the sensitivity of disclosures that may occur when working with MMs or PSP who have high security clearance. Despite these barriers, encouraging evidence supporting the use of digital health was identified through a systematic scoping review conducted by members of this research team in advance of this study regarding digital health delivery of trauma therapies for MMs, veterans, and PSP [19]. This review illustrated that the delivery of cognitive processing therapy (CPT), prolonged exposure therapy, and behavioral activation therapy using videoconferencing demonstrated comparable effectiveness to in-person treatment in reducing posttraumatic stress disorder symptoms in MMs and veterans [19].…”

“…Despite these barriers, encouraging evidence supporting the use of digital health was identified through a systematic scoping review conducted by members of this research team in advance of this study regarding digital health delivery of trauma therapies for MMs, veterans, and PSP [19]. This review illustrated that the delivery of cognitive processing therapy (CPT), prolonged exposure therapy, and behavioral activation therapy using videoconferencing demonstrated comparable effectiveness to in-person treatment in reducing posttraumatic stress disorder symptoms in MMs and veterans [19]. This scoping review identified significant knowledge gaps.…”

“…Given that cognitive impairment (including memory, attention, concentration, and executive processes) is fairly common in trauma-induced mental health disorders, it is unclear whether some elements of digital health could be specifically problematic or challenging to certain MMs, veterans, and PSP [38,39]. Jones et al [19] determined that the use of digital health for trauma therapy in these populations showed comparable results to that of in-person therapy. Similar results have been found regarding the feasibility of telehealth for serious mental illnesses (ie, schizophrenia, schizoaffective disorder, and bipolar disorder) [37,38].…”

Technology Acceptance and Usability of the BrainFx SCREEN in Canadian Military Members and Veterans With Posttraumatic Stress Disorder and Mild Traumatic Brain Injury: Mixed Methods UTAUT Study

“…This has been amplified by the recent COVID-19 pandemic when virtual health solutions have become increasingly common in all health care practices, including those in military environments. Although most studies addressing technology attitudes, beliefs, acceptance, and usability within military and veteran populations are US based, current evidence suggests that the military population is willing to use digital health and mHealth technologies [25][26][27]. Regardless of the context for technological innovation, adequate technology acceptance and usability is key to its uptake within that environment and culture.…”

The Impact of COVID-19 Pandemic on Suicidal Behavior

“…For example, it may not be possible to provide personal hygiene and maintain physical distance in convicts and detainees who cannot see their relatives due to visiting ban. All these stressful life events require caution in these special groups who are at risk in terms of suicidal behavior during and after the pandemic [59]. In addition, it should be kept in mind that people who work in funeral burials, for whom no risk for suicidal behavior has been identified, may be in a risk group for suicidal behavior.…”