Difficulty controlling anger is the most commonly reported reintegration concern among combat Veterans, especially those with a diagnosis of posttraumatic stress disorder (PTSD). In Veterans, problematic anger is associated with numerous negative psychosocial outcomes, including poor functional outcomes (both social and occupational), family discord, aggression, road rage, and suicide risk. Anger can also impede successful outcomes from PTSD treatment. Given the high prevalence of anger problems among Veterans with PTSD and the associated functional impairments, there is a clear need to develop innovative and effective anger interventions to improve functional outcomes of Veterans. The use of mobile health (mHealth) technology could provide a low-cost method to increase the reach of anger management treatments to this high-need group of Veterans. One of the mechanisms associated with problematic anger and aggression is hostile interpretation bias, i.e., a tendency to interpret ambiguous interpersonal situations as hostile. By reducing hostile interpretation bias, it may be possible to significantly reduce problematic anger and aggression and improve functional outcomes. The applicant has developed and piloted a computer-based interpretation bias modification intervention that successfully reduces hostile interpretation bias and anger outcomes. The goal of this project is to further develop this intervention for Veterans with PTSD, using mHealth technology to increase the portability of this promising approach to reduce anger and enhance occupational and psychosocial functioning. The Research Plan proposes to develop, refine, and pilot-test a mobile application version of the existing computer-based interpretation bias modification intervention for individuals with PTSD and problematic anger. The central hypothesis is that patients with PTSD and problematic anger will find this mobile intervention acceptable and will be willing to use it to reduce their anger difficulties and improve psychosocial and occupational functioning. The proposed research project will address the following Specific Aims: Aim 1(a): To develop a mobile interpretation bias modification intervention entitled Mobile Intervention for Reducing Anger (MIRA) for Veterans with PTSD and problematic anger; Aim 1(b): To use a successive cohort design to refine the MIRA intervention for Veterans with PTSD and problematic anger; and Aim 2: To: a) evaluate the feasibility of recruitment, randomization, and retention procedures in a pilot study comparing MIRA to a contact control condition, focusing on community reintegration and functional outcomes, and b) conduct an exploratory aim utilizing psychophysiological and electronic diary monitoring to determine whether this assessment could be utilized as an outcome or mechanistic variable in a subsequent randomized clinical trial application focused on evaluating the efficacy of the MIRA intervention. The results generated will guide the design of a sufficiently-powered RCT to test the effectiveness of the MIRA intervention to be funded by the end of the CDA-2 funding period. The Training and Mentoring Plans outline coursework, training, and experiences that will provide the applicant with the foundation to establish a career focused on developing innovative and effective treatments that improve functional outcomes and community reintegration in Veterans with PTSD. The following Training Goals have been formulated: 1) To acquire additional knowledge of mHealth methodologies; 2) To acquire expertise conducting and analyzing qualitative research; 3) To acquire additional expertise in the design and management of clinical trials; 4) To expand knowledge and skills in analyzing clinical trials data; 5) To extend understanding of rehabilitation theory and methods; and 6) To acquire additional skills in grant-writing and general professional development. The research, training, and mentoring plans outlined in this application will provide the foundation for the PI’s transition to an independent VA research career.

In a national survey of Iraq and Afghanistan combat Veterans receiving VA medical care, anger difficulties were the most commonly reported reintegration concern, particularly among Veterans with PTSD. Problematic anger is associated with numerous negative psychosocial outcomes for Veterans, including discord in family relationships, aggression, road rage, unemployment, and suicide risk. Anger also interferes with progress in PTSD treatment, further highlighting the need for improving anger treatments for Veterans with PTSD. Despite many Veterans reporting a desire for anger management treatments, current available treatments are limited by low rates of engagement and high rates of dropout. Developing an effective and convenient mobile intervention may help to overcome some of the barriers that have kept Veterans from engaging in, or benefitting from, anger management therapy services and improve functional outcomes and community reintegration for these Veterans.