Use of a Mood Tracker Smartphone App as a Chronic Health Management Intervention for Emotional Distress in Persons With TBI

Self-management Challenges for Persons with TBI:

A coordinated approach to chronic health management has been shown to be effective for a number of conditions such as asthma, (Wolf, et al., 2002) diabetes, (Glasgow, Funnell, et al., 2002) heart failure, (Glasgow, et al., 2002) and excess alcohol use (Hospital MM, Wagner, et al., 2016) among many others. Favorable results have been obtained across a wide range of clinical populations including adults (Glasgow et al., 2002) and children. (Hospital et al., 2016) The self-management aspect of chronic health management is often referred to as enablement. The patient is empowered to take action to improve his/her own health status. (Battersby, Von Korff, et al., 2010) Steps taken to facilitate this process are called self-management support. A wide range of self-management strategies have been used to improve health outcomes. These include skill-based training, goal setting, involvement with community based programs that provide education and support, self-monitoring, and use of technologies such as web-based content, text messages, graphic computer based feedback as opposed to verbal feedback, and others. (Battersby, Von Korff, et al., 2010) As reviewed in the Importance of the Problem section, persons with TBI have increased risk for a number of physical, cognitive, behavioral, and emotional co-morbidities that can decrease health and function, community living, and participation outcomes including employment. Given the limited availability and poor accessibility of psychiatric, psychological, counseling, and other mental health services, emotional distress is a particular concern for persons with TBI and their families. A number of studies have found that clinically significant emotional distress (defined here as depression, anxiety, or co-morbid depression and anxiety) is common after TBI. Depression and anxiety are more common in persons with TBI than in persons without TBI across all age ranges and all injury severities. (Osborn, Mathias, et al., 2016; Dikmen, Bombardier, et al., 2004) While anxiety may be more common early post-injury, depression is more problematic in the later years post-injury. (Always, Gould, et al., 2016) In this study, 40.1% of persons with TBI met diagnostic criteria for a depressive disorder at one year post-injury, while 44.1% had an anxiety disorder. By 5 years post-injury, 27.7% had depression and 16.8% had anxiety. If psychological distress is operationalized as anxiety, depression, or both, at year 1, 53.3% had psychological distress and at year 5, 33.7% had psychological distress. Anxiety and depression after TBI are associated with decreased social participation, limited independence in community living, decreased participation including employment, and low life satisfaction.

The frequent occurrence and negative impact of emotional distress after TBI is compounded by limited availability of mental health care providers and limited ability to access mental health services due to inability to pay and attitudinal barriers. Persons without TBI face challenges in obtaining mental health care. Findings from the National Comorbidity Survey Replication of 9,282 persons selected to represent the general population of the U.S. indicated that 1,350 (14.5%) met diagnostic criteria for a psychiatric disorder. Of these, 783 did not seek care for their psychiatric symptoms. (Mojtabi, Olfson, et al., 2011) Of those not seeking care, 44.8% did not perceive that they needed mental health services even though they met diagnostic criteria. The remaining 55.2% perceived that they needed care, but did not seek care due to various barriers. Structural barriers included inadequate financial resources, limited availability of providers, lack of transportation, and perceived inconvenience. Attitudinal barriers were experienced by about 4 times as many persons as structural barriers. Attitudinal barriers included perceived ineffectiveness of mental health services, stigma, and others. (Mojtabi, et al., 2011) These findings are of particular concern for our Center that serves the greater Houston metropolitan area, outlying areas in Texas, and various out of state and international constituencies. As reviewed in Section A - Importance of the Problem, Texas ranks in the lower 10% of all states in access to mental health care, persons needing mental health services who have insurance, and availability of mental health providers. (Mental Health in America, 2017) Poor accessibility of mental health services due to poor availability, cost of care, and various attitudinal barriers indicates the need for alternative service delivery models. Some encouragement is provided by a recent study (Bernecker, Banschback, et al., 2017) that found that of persons who needed mental health interventions but indicated that they would not use traditional psychotherapy even if they had an available provider and ability to pay, 51% indicated that they would be open to trying a web-based utility that would provide self-help and peer-support. Persons with TBI are even more challenged in accessing mental health services than the general population due to having more limited transportation options, being less likely to have healthcare coverage, and an even greater shortage of specialized providers.

Use of Technologic Solutions to Provide Mental Health Services in the Context of Health Management and Treatment of Emotional Distress in Persons with TBI:

The chronic health management literature provides a number of examples of electronic technologies used to support patient use of self-management strategies. In an intervention to decrease underage drinking, teens received text messages providing information about negative consequences of alcohol use, prompts to enhance self-efficacy, and social support. (Hospital et al., 2016) Teens receiving these messages showed greater interest in decreasing alcohol use than those who received control messages. A web based program was used to increase patient behavioral activation in an effort to increase self-management behaviors in a cohort including persons with asthma, hypertension, or diabetes. (Solomon, Wagner, Goes, 2012) Patients receiving this intervention showed greater increases in behavioral activation as indicated by higher self-efficacy and more regular tracking of health indicators such as medication compliance, glucose levels, and blood pressure than those not receiving the intervention.