Eric Kuhn

Posttraumatic stress disorder and depression adversely affect psychosocial functioning, both separately and especially when they co-occur. Despite the high prevalence of these conditions in veterans, it is unclear which specific posttraumatic stress disorder and depression symptoms contribute most to psychosocial functioning impairment. Network analysis can help elucidate these associations by examining symptoms and functioning difficulties as components of a dynamic system. Using cross-sectional data from 3,847 trauma-exposed U.S. veterans in the National Health and Resilience in Veterans Study, we constructed a Gaussian graphical model of individual posttraumatic stress disorder and depression symptoms and psychosocial functioning impairment. The cardinal symptoms of depression-anhedonia and depressed mood-showed the strongest associations with functioning impairment, followed by restricted affect, suicidal ideation, and irritability/anger. These five symptoms may serve as potential targets of interventions to bolster psychosocial functioning among trauma-exposed veterans. Future research should include the application of network models to intensive longitudinal data to gain insights into whether these symptoms may have a causal role in impairing psychosocial functioning. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

BACKGROUND American military veterans who served since September 11, 2001 (post-9/11 veterans) are at particularly high risk of alcohol misuse and alcohol use disorder (AUD), which often co-occurs with insomnia. Cognitive behavioral therapy for insomnia (CBT-I) is the gold-standard treatment for veterans with insomnia, and Insomnia Coach, a VA mobile app based on CBT-I, has shown feasibility, acceptability, and efficacy for improving sleep. However, Insomnia Coach has only been tested with veterans without AUD, leaving its efficacy for veterans with co-occurring AUD unclear. OBJECTIVE We report findings from Phase 1 (development) and Phase 2 (beta test) of our study, in which we added brief alcohol intervention content to Insomnia Coach and evaluated its usability, feasibility, and acceptability among veterans with both insomnia and AUD symptoms. We then outline the study protocol for Phase 3, our upcoming pilot randomized controlled trial (RCT). METHODS In Phase 1, we developed brief alcohol intervention content informed by the literature and expert consultation. In Phase 2, beta-test participants (N = 20) used the original Insomnia Coach app for two weeks, then gave feedback on the new, to-be-added, brief alcohol intervention content via semi-structured interview. Insomnia and alcohol outcomes were assessed pre- and post-intervention (1 month after baseline). In Phase 3, we will conduct a pilot RCT with 130 post-9/11 veterans with insomnia and AUD symptoms, randomized to Enhanced Insomnia Coach or a sleep hygiene mobile-enabled website control. RESULTS Beta-test participants showed significant reductions in insomnia symptoms and use of alcohol as a sleep aid, with small-to-moderate improvements in drinking frequency, sleep quality, and alcohol consequences. Usability and app quality ratings were favorable, and qualitative feedback on visual appeal, app features, information quality, and confidentiality informed app refinements. The RCT will evaluate whether Enhanced Insomnia Coach improves insomnia and AUD symptoms among veterans not currently accessing insomnia care. We will assess insomnia symptoms and alcohol quantity and frequency at baseline, 4-, 8-, 12-, and 16-weeks. Secondary outcomes include sleep quality, alcohol-related consequences, and receipt of more formal treatment for insomnia or other mental health concerns. We will test moderation by sex, race/ethnicity, PTSD, depression, and cannabis use disorder. CONCLUSIONS These beta-test findings support the feasibility and acceptability of Enhanced Insomnia Coach and justify testing its efficacy in the planned pilot RCT. If effective, Enhanced Insomnia Coach could offer a scalable, low-burden option for addressing co-occurring insomnia and alcohol misuse among veterans outside traditional VA care settings. CLINICALTRIAL NCT06487793 on 6/27/24

UNSTRUCTURED This article describes the development, implementation, evaluation, and optimization of the COVID Coach app, a mobile application created by the National Center for PTSD (NC-PTSD) to help people cope with trauma and stressor-related symptoms associated with the COVID-19 pandemic. Using the PTSD Coach as a foundation, NC-PTSD rapidly developed COVID Coach in the spring of 2020 as a key aspect of both the VA and the nation’s pandemic response. It was disseminated widely through both public and VA channels. Based on our research and evaluation of the app, we have concluded that COVID Coach was well-received and popular during the pandemic. Reductions in anxiety, depression and burnout were mixed; however, as late as 2025 COVID Coach retained a loyal long-term user base with high engagement and a user retention rate comparable to that of NC-PTSD’s most popular apps. Research and evaluation data suggests that there is a case for continued sustainment and improvement of COVID Coach, thus this article describes the optimization and transition of COVID Coach into Coping Coach, a coping and stress management tool designed to prevent and target trauma and stressor-related symptoms in those who may not identify with a formal diagnosis like PTSD.

Background: World Trade Center (WTC) general responders (GRs) continue to experience long-term mental health conditions, including posttraumatic stress disorder (PTSD), depression, anxiety, and sleep disturbance. A growing number of GRs reside in Florida, where barriers such as stigma, limited access to specialty care, and age-related limitations contribute to persistent unmet mental health needs. PTSD Coach, a mobile app originally developed for trauma-exposed veterans, has shown promise but has not been evaluated with WTC GRs or adapted for Spanish-speaking responders. Objective: This study aims to evaluate the feasibility, acceptability, and efficacy of Clinician-Supported (CS) PTSD Coach for reducing PTSD symptoms among English-speaking and Spanish-speaking WTC GRs living in Florida. Secondary objectives include evaluating effects on depression, anxiety, and sleep disturbance; comparing CS PTSD Coach with Self-Managed (SM) PTSD Coach and a waitlist control; and adapting and delivering a Spanish-language version of the intervention. Methods: This study is a 3-arm randomized controlled trial comparing CS PTSD Coach, SM PTSD Coach, and a waitlist control for reducing PTSD, depression, anxiety, and sleep disturbance among English-speaking and Spanish-speaking WTC GRs living in Florida. A total of 120 participants are randomized and assessed at baseline, 8 weeks, and a 12-week follow-up. CS PTSD Coach includes 4 clinician-guided sessions integrated with app-based activities, whereas SM PTSD Coach includes a single orientation session. Outcomes include PTSD symptoms (PTSD Checklist for DSM-5), depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), and sleep disturbance (Insomnia Severity Index). Feasibility and acceptability are assessed using app use data, satisfaction ratings, and usability measures. Primary analyses focus on between-group differences after the intervention (8 weeks), with secondary longitudinal analyses incorporating all assessment time points. Results: The notice of award was received in September 2024, and institutional review board approval, including amendments, was granted in January 2025. Recruitment began in February 2025, with data collection initiated in March 2025. As of April 2026, 63 participants have been enrolled, and outcome data collection is ongoing. Data analysis will commence following completion of follow-up assessments, with dissemination of results anticipated in 2027. Conclusions: This trial will provide the first randomized controlled evaluation of a clinician-supported mobile PTSD intervention for WTC responders, including Spanish-speaking GRs. Findings will inform the feasibility, acceptability, and potential scalability of supported digital mental health interventions for aging, geographically dispersed disaster-exposed populations.

BACKGROUND World Trade Center (WTC) General Responders (GRs) continue to experience long‑term mental health conditions, including posttraumatic stress disorder (PTSD), depression, anxiety, and sleep disturbance. A growing number of GRs reside in Florida, where barriers such as stigma, limited access to specialty care, and age‑related limitations contribute to persistent unmet mental health needs. PTSD Coach, a mobile application originally developed for trauma‑exposed veterans, has shown promise but has not been evaluated with WTC GRs or adapted for Spanish‑speaking responders. OBJECTIVE This study is a three‑arm randomized controlled trial comparing Clinician‑Supported (CS) PTSD Coach, Self‑Managed (SM) PTSD Coach, and a wait‑list control for reducing PTSD, depression, anxiety, and sleep disturbance among English‑ and Spanish‑speaking WTC GRs living in Florida. METHODS A total of 120 participants are randomized and assessed at baseline, 8 weeks, and 12‑week follow‑up. CS PTSD Coach includes four clinician‑guided sessions integrated with app‑based activities, whereas SM PTSD Coach includes a single orientation session. Outcomes include PTSD symptoms (PTSD Checklist for DSM‑5), depression (Patient Health Questionnaire‑9), anxiety (Generalized Anxiety Disorder‑7), and sleep disturbance (Insomnia Severity Index). Feasibility and acceptability are assessed using app usage data, satisfaction ratings, and usability measures. RESULTS The notice of award was received in September 2024, and Institutional Review Board approval, including amendments, was granted in January 2025. Recruitment began in February 2025, with data collection initiated in March 2025. As of March 2026, 55 participants have been enrolled, and outcome data collection is ongoing. Data analysis will commence following completion of follow‑up assessments, with results expected to be disseminated in Spring 2027. CONCLUSIONS This trial will provide the first randomized controlled evaluation of a clinician‑supported mobile PTSD intervention for WTC responders, including Spanish‑speaking GRs. Findings will inform the feasibility, acceptability, and potential scalability of supported digital mental health interventions for aging, geographically dispersed disaster‑exposed populations. CLINICALTRIAL

Objective: This study delineated the unmet mental health needs of peripartum mothers with symptoms of depression, ascertained their willingness to engage in psychotherapy via text message, and identified potential determinants of that willingness (e.g., demographics, preferred communication methods) to inform improvement to service delivery. Method: This was a cross-sectional national survey of 897 adults who had given birth in the previous 24 months, had at least one lifetime symptom of depression, had internet access, and could read English. Univariate analysis was followed by multivariable Firth’s logistic regression. Results: Peripartum participants with at least one symptom of depression wanted mental health care the most within 2 years of giving birth (64.4%) and had less access to mental health care during pregnancy and postpartum (35.1% and 38.1%, compared with 23.9%). Fifty-three percent of participants were willing to engage in psychotherapy via text message. Determinants of willingness to engage in text message therapy for all periods (pregnancy, postpartum, and not peripartum) included wanting mental health treatment but not having access and previous experience with psychotherapy via text message. During pregnancy and not peripartum, more depressive symptoms were associated with willingness to engage in psychotherapy via text message. Conclusion: The peripartum period is an especially high-risk time for mothers to experience depressive symptoms. In general, most wanted therapy but were unable to access it. Most participants were willing to engage in text message therapy.

CBT-i Coach is a free, publicly available mobile health application (app) that provides users with the core intervention components of cognitive behavioral therapy for insomnia (CBT-i). By making these components directly accessible to users, CBT-i Coach potentially circumvents barriers to accessing CBT-i, such as a scarcity of and lack of referral to trained providers. It may also serve a preventative function by helping address sleep disruption before it reaches clinical levels. However, no study to date has investigated the potential effectiveness of CBT-i Coach for either of these two purposes in public, naturalistic use. This study observed public CBT-i Coach use over an 18-month period to investigate whether users reporting either clinical or subclinical insomnia symptoms (N = 1618) showed improvement in insomnia symptoms, sleep efficiency, and sleep quality while using the app and whether clinically meaningful engagement with the app was associated with improvements. Users’ insomnia symptoms, sleep efficiency, and sleep quality improved while using CBT-i Coach (d = 0.57, 0.41, and 0.24, respectively). Regarding clinically meaningful engagement, greater engagement with the My Sleep (b = − 0.004) and Tools (b = − 0.050) sections were associated with lower final insomnia symptoms, and greater engagement with the My Sleep section (b = 0.012) was associated with higher final sleep quality. CBT-i Coach therefore appears to be a valuable public health tool to improve sleep. It may also provide a preventative service by addressing sleep disruption among those with subclinical symptom levels who otherwise might not have access to CBT-i.