The report is a product of the VA/HSR Evidence Synthesis Program.

Internet and Mobile Interventions for Adults with PTSD and Their Family Members: A Systematic Review

Takeaway: Internet and mobile interventions for PTSD may offer small to negligible benefits for military Veterans and service members with PTSD. Civilians may experience moderate benefits from these treatments, but these gains do not appear to be sustained. Consequently, the available evidence does not currently support internet and mobile interventions as effective treatments for Veterans with PTSD. Based on a small evidence base, internet and mobile interventions do not appear to benefit family members of adults with PTSD.

Approximately 10% of Veterans experience PTSD during their lifetime. Effective treatments for PTSD are available, but most Veterans with PTSD do not access these treatments for various reasons. Self-guided, asynchronous PTSD treatments that use the internet or mobile phone applications offer varying levels of therapeutic support and have the potential to expand access to PTSD treatments for anyone with internet access or a smartphone. The effectiveness of these lower-intensity treatments is unclear.

HSR’s Evidence Synthesis Program (ESP) Coordinating Center at the Portland VA Health Care System conducted a systematic review to synthesize the available evidence on the effectiveness of internet and mobile interventions for individuals with PTSD and family members or caregivers of individuals with PTSD. Investigators focused on two key questions:

• Are internet and mobile interventions with asynchronous therapist-guided or self-guided content and resources designed to improve PTSD symptom severity and/or self-management effective for improving PTSD symptoms and other mental health symptoms among adults with a diagnosis of PTSD?
• Are internet and mobile interventions with asynchronous therapist-guided or self-guided content and resources designed to enhance coping and symptom management skills for family members and caregivers of adults with PTSD effective for improving stress, mental health symptoms, and coping skills?

To identify relevant articles, investigators searched Ovid MEDLINE, PsycINFO, PTSDPubs, and the Cochrane Central Register of Controlled Trials through October 2023. Additional citations were identified from clinicaltrials.gov and hand-searching reference lists of relevant systematic reviews.

Investigators identified 60 primary studies that met eligibility criteria, including 36 randomized controlled trials (RCTs), 1 non-randomized trial, 1 cohort study, and 22 pre-post studies. Most studies were conducted in individuals with PTSD, and evidence from comparative studies (k = 36) was prioritized over evidence from pre-post studies in this population. All available evidence was considered for interventions conducted among family members and caregivers.

Summary of Findings

Most comparative studies of internet and mobile interventions for adults with PTSD were conducted in the U.S., and 13 enrolled Veterans or military service members. Most studies evaluated internet-based cognitive behavioral therapy (iCBT) interventions. Five studies on internet and mobile interventions for family members or caregivers of adults with PTSD were identified.

• The available evidence does not currently support internet and mobile interventions as an effective treatment for military populations with PTSD or family members of adults with PTSD.
• Internet and mobile interventions may have small to negligible benefits on PTSD and depression outcomes for military Veterans and service members (low strength of evidence [SOE]). Findings are based mostly on RCTs of iCBT that varied in comparison condition, treatment duration, and provider involvement. Studies had notable methodological limitations and inconsistent results.
• Internet and mobile interventions may have small to moderate benefits on PTSD and depressive symptoms for civilian populations, but these benefits are not sustained (low SOE).
• Symptom improvement appeared to be largest for interventions with greater therapist involvement, compared with interventions with minimal or no provider support.
• It is unclear whether internet and mobile interventions for caregivers and family members of adults with PTSD improve stress, coping, or mental health symptoms (low SOE). Only 5 studies were identified, and effectiveness differed across studies.

Implications

Current evidence does not indicate that internet and mobile interventions for PTSD are effective treatments for military Veterans or their caregivers/family members.

Limitations

Many of the included studies were small pilot trials that tested the feasibility and acceptability of the online intervention and were likely inadequately powered to detect all but the largest treatment effects. Most studies used self-assessments to determine PTSD status and treatment outcomes rather than clinician-administered measures. Inclusion criteria in many studies did not require a full PTSD diagnosis, and although most studies included Veterans in their samples, many participants were treatment-seeking White females, which may limit the generalizability of findings.

Future Research

Gaps to address in future research include whether greater direct therapeutic involvement with trauma-focused iCBTs increases the effectiveness of treatments for military populations. Future studies might also explore whether internet and mobile resources help support Veteran engagement in established VA clinical pathways for PTSD (e.g., by improving treatment adherence or facilitating at-home activities that reinforce principles and practices introduced during in-person therapy).

Citation: Belsher BE, Beech EH, Anderson JK, Parr NJ. Internet and Mobile Interventions for Adults with PTSD and Their Family Members: A Systematic Review. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project 09-199; 2024.

To view the full report, go to vaww.hsrd.research.va.gov/publications/esp/resources-for-ptsd.cfm . (This report is available via Intranet only.)

ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management Brief is provided to inform you about recent HSR findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR Resource Center charged with disseminating important HSR findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of VA/HSR's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers; and to disseminate these reports throughout VA.

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