J Med Internet Res. 2026 May 7;28:e85098. doi: 10.2196/85098.
ABSTRACT
BACKGROUND: Military sexual trauma (MST) can have significant adverse effects on mental health and well-being, often leading to posttraumatic stress disorder (PTSD) symptoms and maladaptive beliefs. Although effective psychotherapies exist, stigma, confidentiality concerns, and systemic barriers often hinder help-seeking among service members and veterans. Mobile mental health apps offer an accessible and anonymous support alternative, potentially addressing such barriers. However, app effectiveness depends on user engagement and emerging evidence suggests that engagement may be shaped by symptom severity.
OBJECTIVE: This retrospective observational study aimed to explore the relationship between posttraumatic symptom severity and user engagement with Beyond MST (US Department of Veterans Affairs [VA] National Center for PTSD), an app for individuals who experienced MST. Specific aims included (1) characterizing trauma-related symptom levels and app engagement among users who completed in-app assessments, and (2) evaluating how PTSD symptom severity, negative posttraumatic cognitions, and mental well-being relate to objective measures of engagement.
METHODS: Anonymous usage data from 27,517 users collected between March 11, 2021 and July 29, 2024, were analyzed. Three subsamples were identified: those who completed the in-app PTSD checklist for DSM-5 (Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]; PCL-5, n=3689), the Posttraumatic Maladaptive Beliefs Scale (PMBS; n=2197), and the Warwick-Edinburgh Mental Well-Being Scale (WEMWBS; n=2160). Engagement metrics included duration of use (ie, days of use and minutes of use), frequency of feature access (ie, coping tool and psychoeducation access), and frequency of feature use (ie, total assessment completions). Regression analyses, including quadratic terms, were conducted to evaluate how symptom severity and well-being levels influenced engagement and identify possible curvilinear trends.
RESULTS: Median engagement levels ranged across subsamples as follows: 3-4 days of use (IQR 5-6), 22-30 minutes of use (IQR 33.7-42.9), 1-5 feature accesses (IQR 6-9), and 2-3 assessment completions (IQR 2). Subsamples were highly symptomatic. Analyses revealed that moderate PTSD symptom and negative posttraumatic cognition severity were associated with higher engagement relative to users with very low and very high symptom levels, particularly for days of use and frequency of coping tool access. Conversely, higher mental well-being scores were generally linked to increased app engagement with linear effects. Effect sizes were small, suggesting limited clinical impact.
CONCLUSIONS: This study highlights the possible challenges in engaging highly symptomatic individuals with digital mental health interventions. Although Beyond MST successfully reaches its targeted population, very low or high symptom levels and lower well-being may hinder sustained engagement. These findings suggest that symptom levels should be considered in app development (ie, personalization) and when integrating apps into professional care. Interpretation is limited by the anonymous nature of the data, which prevented characterization of users and their trauma histories. Further research is needed to clarify how symptom patterns influence engagement, especially in trauma contexts.
INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.31979/etd.882a-5fcx.
PMID:42096694 | DOI:10.2196/85098
