JMIR Publications

ABSTRACT

Background:

Military sexual trauma (MST) can have significant adverse effects on mental health and well-being in military populations. Posttraumatic stress disorder (PTSD) symptoms and maladaptive beliefs are common among those affected. Despite various psychotherapy interventions available, unique barriers such as stigma and confidentiality concerns often hinder help-seeking in this population. Mental health applications (apps) offer an accessible, anonymous, and supportive alternative for self-managing mental health conditions, potentially addressing some of these barriers. However, user engagement is crucial for these apps to be effective. Researchers are exploring factors impacting app engagement, with emerging evidence suggesting that symptom severity may play a key role.

Objective:

This study aimed to explore the relationship between posttraumatic symptom severity and engagement with Beyond MST, a mobile app designed for veterans and service members coping with MST. Aims included 1) characterizing subsamples of users who completed in-app assessments, and 2) examining how PTSD symptom severity, negative posttraumatic cognitions (NPCs), and mental well-being relate to objective measures of app engagement.

Methods:

Anonymous usage data from the Beyond MST app, collected between March 11, 2021, and July 29, 2024, were processed for 27,518 users. Three subsamples were identified: those who completed the in-app PTSD Checklist for DSM-5 (PCL-5, n=3,690), the Posttraumatic Maladaptive Beliefs Scale (PMBS, n=2,197), and the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS, n=2,161). App engagement was measured through the duration of app use and frequency of feature access. Regression analyses, including quadratic terms, were conducted to evaluate how symptom severity and well-being levels influenced engagement and identify possible curvilinear trends.

Results:

The subsamples of users were highly symptomatic. Median days of use, minutes of use, and feature access ranged from 3-4 days, 22-29 minutes, and 1-5 times respectively. Regression analyses revealed that higher PTSD symptom severity and severe NPCs were generally associated with reduced app engagement. Specifically, a 1-point increase in PCL-5 score predicted approximately a 1% decrease in days of use and a 9% reduction in minutes of use, with significant curvilinear effects suggesting steeper declines at higher symptom levels. Conversely, higher mental well-being scores were generally linked to increased app engagement with linear effects. Effect sizes were small, potentially limiting the clinical significance of these findings.

Conclusions:

The study highlights possible challenges of engaging highly symptomatic individuals with digital mental health interventions. While Beyond MST reaches the targeted demographic, the severity of posttraumatic symptoms may negatively impact sustained app engagement, especially for those with the highest levels of symptoms. These findings suggest symptom levels should be considered in app development (i.e., personalization) and when integrating apps into professional care. Further research is needed to refine our understanding of symptom predictors of app engagement, especially in trauma contexts.