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APP REVIEWS

Post-Traumatic Stress Disorder (PTSD)

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Dr. Rajesh Girdhari
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In 1980, the American Psychiatric Association (APA) added Post-Traumatic Stress Disorder (PTSD) to the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-III). PTSD is a type of anxiety disorder characterized by recurrent re-experiencing of symptoms an individual suffered during a traumatic event. Recurrences (“flashbacks”) can be triggered by any stimulus that causes the patient’s brain to feel, even if temporarily, as it did during the traumatic event. During flashbacks, patients may exhibit a wide range of signs and symptoms, from withdrawal to aggression; generally, these signs and symptoms are the same as those the patient experienced during the initial traumatic event. Additionally, as a result of these flashbacks, people often develop behaviours to avoid these triggers or other coping strategies (e.g. substance use) to deal with the symptoms triggered during flashbacks.

The lifetime prevalence of PTSD in Canada was recently estimated at 9.2%, which means that PTSD is likely something that every family physician will encounter in their practice. Prevalence of PTSD is generally higher in certain populations, including women, people who have been in the military, and people with substance use disorders. Not surprisingly, military health systems have, at least as of late, become leaders in the development of treatments for PTSD, including several of the apps reviewed in this article.

A recent study identified six different types of PTSD apps, including (1) apps that focused on facilitating evidence-based therapies (EBT) for PTSD (e.g. Exposure Therapy); (2) PTSD-specific apps that provide educational materials and symptom tracking for PTSD, but are not directly tied to a form of EBT; (3) general mental health apps that address symptoms of PTSD (e.g. anxiety and depression-oriented apps); (4) mindfulness and relaxation-oriented apps; (5) anger management apps; (6) apps for sleep disturbances/insomnia. This review focuses on the second type from this categorization: PTSD-specific apps that provide patient-oriented educational materials, symptom trackers, and coping strategies for symptoms associated with PTSD.

Apps Reviewed

PTSD Coach Canada
3.5 stars3.5 stars3.5 stars3.5 stars3.5 stars
PTSD Family Coach
3.5 stars3.5 stars3.5 stars3.5 stars3.5 stars
PTSD Hub
2.5 stars2.5 stars2.5 stars2.5 stars2.5 stars
PTSD Support on the Go
1.5 stars1.5 stars1.5 stars1.5 stars1.5 stars

PTSD Support on the Go

1.5 stars1.5 stars1.5 stars1.5 stars1.5 stars

While touted as an app that “allows you to put all your inspiring moments in one easy to find location” and share with a community, PTSD Support on the Go is in practice very confusing, opaque, and difficult to use. The user interface is not intuitive and the “instant message” feature often caused the app to crash. Aside from linking to a third-party deep breathing website (xhalr.com) and podcast (PTSD Bunker Gear For Your Brain), this app provides little in the way of psychoeducation to users. The background and credentials of the app developer are unclear, though the app has been updated several times. Given the strength of other PTSD apps on the market, I would not recommend this app.

Detailed Review View All

Features

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It is unclear to whom this app is targeted, though presumably it is individuals with PTSD. PTSD Support on the Go app encourages users to create a profile page, upload media to a favourite social media, learn breathing techniques, and instant message (though this didn’t seem to be functional). There are also features to “view all media on the app”, access favourite media — apparently posted by other app users (though who posts these is not clear). Direct links also take the user to the PTSD Bunker Gear For Your Brain podcast and an external guided breathing website (xhalr.com).

Effectiveness

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Some people may find the various features of the app helpful for controlling/coping with symptoms of PTSD. The app itself provides very little information or guidance to users. It is unclear who the app developers are or if they have any professional designation or expertise in the area of PTSD.

Usability

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A non-intuitive user interface consists of five tabs: Profile, Message, Home, Favourite Media, and Settings. The app tends to crash when trying to send a message. “Home” consists of a stream of media/photos – it is unclear who or how this media is added, and also what the purpose of this media is (upon browsing, some of the media contained advertisements for cannabis). Generally, this app is confusing to use.

Privacy & Security

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The app contains a generic privacy policy, no security policy, and another very generic Terms of Use. It is unclear if the app is collecting data or sharing data with any third parties. The app does require the user to create a password to log in, though it was unclear how to log out of the app. The app appears to request appropriate permissions to access media (e.g. photo files, camera).

Reliability

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The app crashed when trying to send messages using the app’s messaging feature. An email link for technical support appears to be available in the app. The app was updated in April 2018, though it is unclear what was updated — it says ‘Improvement’ in the App Store. The background and credentials of the app developer are unclear; it also appears to be the first and only app created by this developer. No emergency instructions/notifications appear in the app.

Accessibility

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The app is available for free on both iOS and Android. It is available in English only. It appears to be generally inclusive of multiple demographic groups. Very little text appears in the app, which could theoretically make it accessible for those with low literacy and/or health literacy. No accommodations for disabilities appear in the app.

PTSD Hub

2.5 stars2.5 stars2.5 stars2.5 stars2.5 stars

This app was developed by someone who suffers from PTSD as a way to help others with PTSD. Similar to PTSD Family Coach and PTSD Coach Canada, PTSD Hub is divided into four sections: “Information,” which provides short text-based summaries of different aspects of PTSD, including symptom management and treatment; “Coping Strategies,” which lists common PTSD symptoms and offers a space for users to share/post their own coping strategies for each symptom (posts are reviewed by the app creator prior to being posted); “Resources,” which links out to other online PTSD-related resources, including the PTSD Hub, Twitter and Facebook accounts; and “Get Help,” which contains phone numbers (“helplines”) from many countries, including Canada. The crowdsourcing aspect of the “Coping Strategies” section of the app (see above) is a unique feature that sets this app apart from others in the field. This app is primarily text-based and not as visually appealing as some of the other PTSD apps on the market.

Detailed Review View All

Features

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The app largely contains short text-based information pages about various aspects of PTSD as outlined in the four subsections detailed above, but little in the way of video or other media. There is no clinical integration or data export.

Effectiveness

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The app contains information about PTSD symptoms, co-morbid diseases (such as depression), coping skills, and various evidence-based treatments for PTSD including CBT, Exposure Therapy, and Eye Movement Desensitization and Reprocessing. These information sections are generally brief and at a high level; they are meant for basic psychoeducation. The app was developed by someone who suffers from PTSD as a way to help others with PTSD; it is unclear if this individual is a health professional.

Usability

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Once it becomes clear that all words in the app are “clickable”, the app function is straightforward and intuitive. Wording is concise and economical. The major drawback of this app is that it is not particularly graphically appealing and has little in the way of features beyond text. The display is quite busy, which can be overwhelming for the user.

Privacy & Security

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The app does not seem to have a privacy policy or terms of use. It is unclear if the app is collecting any data from users and, if data is collected, how and with which parties this data is shared.

Reliability

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This seems to be a low-energy, efficient app; mostly lots of text that loads quickly. This appears to be the first and only app to date created by the developer. The “Resources” section of the app appears to require an active internet connection to function; the rest of the app functions without connectivity. Some sort of technical support appears to possibly be available via the app’s Twitter feed. There are some limited resources available for users who may self-identify as having a potential emergency, such as patients who are feeling suicidal.

Accessibility

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There is a free version of the app; users can pay a small fee to have an ad-free version of the app. The app is only available in English. The app is available on both iOS and Android platforms. There are no obvious accommodations for people with disabilities in the current version of the app.

PTSD Coach Canada

3.5 stars3.5 stars3.5 stars3.5 stars3.5 stars

PTSD Coach Canada is an adaptation of PTSD Coach, developed by the U.S. Veterans Administration National Center for PTSD and the Department of Defense’s National Centre for Telehealth and Technology. Veterans affairs departments in other countries, including Canada and Australia, have developed their own versions of the app, with features more specific to local context. Within the app, users can take a validated assessment of their symptoms to see if they may have PTSD. They also are provided with several tools for helping their symptoms, including tools that access calming photos and songs from the patient’s phone. A lot of information is also provided about how patients can access care, whether emergency care or through local resources. What really separates this app from the rest of the pack is that the US version has been subject of rigorous evaluation, including at least one moderate-sized RCT that showed modest benefits to patients who used the app.

Detailed Review View All

Features

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There is a clear target condition and a clear audience. Patients can take a validated assessment of their symptoms to see if they may have PTSD. They also are provided with several tools for helping their symptoms, including tools that access calming photos and songs from the patient’s phone. A lot of information is also provided about how patients can access care, whether emergency care or through local resources.

Effectiveness

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The app was initially developed by the U.S. Department of Veterans Affairs and veterans’ affairs departments in other countries, including Canada and Australia, have developed their own local versions of the app. The U.S. version has been the subject of at least one moderate-sized RCT that showed modest benefits to patients who used the app.

Usability

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The app has a simple user interface that is easy to navigate. It could benefit from more variety in media types, including videos. It also appears a bit dated, which is consistent with the fact that the app has not been substantially updated in four years.

Privacy & Security

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The app has an easy to access, short privacy statement that lets users know that no individual-level data is transmitted or analyzed centrally. It is not clear whether anonymized or aggregate data is transmitted or analyzed by the app developers or a third party. It is unclear where data collected by the app is stored.

Reliability

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The app provides clear direction to users about what to do in case of an emergency, including recommending patients call 911 if symptoms are severe. No technical support number is provided, however, and the app has not been extensively updated since its release.

Accessibility

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The app is free and has both iPhone and Android versions. It does not appear to be available in French or other languages, which is significant given that it is an app designed for Canadian Forces veterans. The app uses plain language and there is an option to hear an audio recording of the text to help visually impaired individuals.

PTSD Family Coach

3.5 stars3.5 stars3.5 stars3.5 stars3.5 stars

Like PTSD Coach, PTSD Family Coach was developed in the U.S. by the Veterans Administration National Center for PTSD and the Department of Defense’s National Center for Telehealth and Technology, two credible organizations that have developed other highly rated apps for PTSD. Unlike PTSD Coach, this app is designed for the family members and friends of people who are struggling with PTSD. It features a similar user experience to PTSD Coach, including being divided into the same four sub-sections (“Learn”, “Self Assessment”, “Manage Symptoms”, and “Find Support”). It appears a bit dated, but is generally visually appealing. It uses validated tools (e.g. 10-Item Perceived Stress Scale) and provides up-to-date educational resources to users. No clinical integration or data export appears possible. The app does a good job of identifying “high risk” scores on self-assessments and directing people to emergency/crisis resources.

Detailed Review View All

Features

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The app features primarily text-based educational vignettes, self-assessment tools, and activities designed to help users cope with or reduce symptoms. The app also helps users create safety plans and provides contacts and resources (some customizable) that users can reach out to if they require additional assistance. No data export is possible.

Effectiveness

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This app was developed by two credible organizations that have developed other highly rated PTSD-oriented apps. It uses validated tools (10-Item Perceived Stress Scale) and provides up-to-date educational resources to users. It is comprehensive in its approach to PTSD.

Usability

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This app features a user experience that is very similar to other PTSD apps from the same developers (e.g. PTSD Coach). Users who have experience with these other apps will have no problem navigating this one. Even for first-time users, the interface is very simple and straightforward. The developers have made good use of simple pictures and icons; however, the app does feel a bit dated and “low tech”.

Privacy & Security

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It is not clear if any data is being shared with the developers, either at the individual or aggregate level. Furthermore, it is also unclear if user data is stored only on the user’s phone or elsewhere (possibly in the U.S.). There is no password to log in, and previous self-assessment scores are retained by the app and could be accessed by someone else who gains access to the user’s phone. Furthermore, there is no security policy and only a brief privacy statement; the developer’s website states the “data are only secure as the phone itself.” The app does appropriately ask for permission when accessing a user’s photos or contacts.

Reliability

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The app seems to be very low resource intensive. I noted no performance or reliability issues during testing. It is unclear if any technical support exists for the app; presumably the developer could be contacted if assistance were required. The app does a good job of identifying “high risk” scores on self-assessments and directing people to emergency/crisis resources. It appears to function well even without an active internet connection.

Accessibility

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PTSD Family Coach is free to download and is available on both iOS and Android platforms. The language is generally inclusive and written to accommodate individuals with varying education levels. This app also offers closed captioning for certain segments of the app and audio recordings of some of the app text for those who are visually impaired. The app appears to be available only in English, which is an issue given the wide variety of languages spoken in both Canada and the U.S.

References

  1. https://www.ncbi.nlm.nih.gov/pubmed/24402979
  2. https://www.ptsd.va.gov/professional/ptsd-overview/ptsd-overview.asp
  3. https://www.ncbi.nlm.nih.gov/pubmed/18801110
  4. https://www.ncbi.nlm.nih.gov/pubmed/29074470
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