• Margaret-Anne Mackintosh, James Niehaus, Casey T Taft, Brian P Marx, Kathleen Grubbs, and Leslie A Morland.
• Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road, Building 334 (NC-PTSD), Room C-130, Menlo Park, CA 94025.
• Mil Med. 2017 Nov 1; 182 (11): e1941-e1949.

ObjectiveAnger is a symptom of post-traumatic stress disorder (PTSD) associated with a range of clinical and functional impairments, and may be especially prevalent among veterans with PTSD. Effective anger management therapies exist but may be undermined by poor engagement or lack of treatment availability. Finding ways to engage veterans in anger management therapy or to improve access can be helpful in improving clinical outcomes. This randomized controlled trial compared anger management treatment (AMT) with AMT augmented by a mobile application (app) system, Remote Exercises for Learning Anger and Excitation Management (RELAX).MethodsParticipants were 58 veterans enrolled in 12 sessions of either AMT alone or AMT with the RELAX system (AMT + RELAX). The RELAX system includes the RELAX app, a wearable heart rate monitor, a remote server, and a web-based therapist interface. RELAX allows the user to practice skills, monitor symptoms, and record physiological data. The server collects data on app use. A web-based interface allows the therapist to access data on between-session practice, and skills use. Measures administered at baseline, post-treatment, and 3-and 6-month follow-up include state and trait anger, dimensions of anger, PTSD, depression, interpersonal functioning, and satisfaction. We used multilevel modeling to account for the nesting of time points within participants and participants within treatment groups. Predictors were Treatment Condition (AMT + RELAX and AMT), Linear Time (baseline, post-treatment, 3-and 6-month follow-up), and Quadratic Time and Treatment Condition × Linear Time interaction. All analyses were conducted using SPSS 21 (Armonk, New York). Approval was obtained from the institutional review board.ResultsAcross groups, the treatment dropout rate was 13.8%; of those who remained in treatment, 90% received an adequate dose of treatment (10 or more sessions). There were no significant differences between groups on attendance or treatment completion. Participants in both treatments demonstrated statistically significant and clinically meaningful reductions in anger severity and significant post-treatment reductions in PTSD. Veterans did not report significant changes in depression or interpersonal functioning. Veterans in the AMT + RELAX group reported spending significantly less time on homework assignments, and they rated the AMT + RELAX app as helpful and easy to use, with these ratings improving over time.ConclusionFindings suggest that AMT + RELAX was beneficial in reducing anger symptoms and promoting efficient use of the between-session practice; however, AMT + RELAX did not outperform AMT. This study is an important contribution as it is one of the first randomized controlled trials to study the efficacy of a technology-enhanced, evidence-based psychotherapy for anger management. Findings are limited because of small sample size and modifications to the technology during the trial. However, the results highlight the possible benefits of mobile app-supported treatment, including increasing the accessibility of treatment, lowering therapist workload, reducing costs of treatment, reducing practice time, and enabling new activities and types of treatments. This study presents preliminary evidence that mobile apps can be a valuable addition to treatment for patients with anger difficulties. Future research should evaluate how much therapist involvement is needed to support anger management.Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.

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