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

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.