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. Author manuscript; available in PMC: 2025 Oct 31.
Published in final edited form as: Psychol Trauma. 2024 Oct 31;17(6):1183–1191. doi: 10.1037/tra0001811

Evaluating the mobile Mantram Repetition Program for Veterans with PTSD: A multi-method randomized feasibility trial of self-directed versus text-support delivery

Caitlin L McLean 1,2,*, Ashley Faytol 1,2,3, Gage M Chu 1, Andrea Henneken 1, Borsika A Rabin 3,4, James O E Pittman 3,2,1, Laurie Lindamer 2,3, Ariel J Lang 3,2,4
PMCID: PMC12041292  NIHMSID: NIHMS2056872  PMID: 39480321

Abstract

Objective:

While mobile-delivery can help increase access to evidence-based treatment for Veterans with PTSD, feasibility and acceptability are of concern with potential for high attrition rates and limited participation. The Mantram Repetition Program (MRP), a meditation-focused approach with documented efficacy for reducing symptoms of PTSD and insomnia, was adapted as a brief, mobile-delivered training (mMRP). This study assessed implementation indicators of mMRP and compared self-directed users of mMRP versus users who received additional text message support.

Method:

Thirty-six Veterans with clinically significant PTSD symptoms (Mage=50.50 years; 83.3% male; 72.2% white; 88.9% heterosexual) completed four weekly training video modules. Participants completed questions related to program satisfaction, mantram repetition use, clinical measures, and a 30-minute individual interview.

Results:

Participants reported using their mantram between 4–5 days per week. Participants indicated that mMRP was generally acceptable, appropriate, and feasible across quantitative and qualitative data. On clinical measures, change from pre- to post-intervention was significant for the brief symptom screen, PTSD symptoms, and personal health inventory but not for depression nor insomnia symptoms. No significant differences were found between the self-directed and supported groups; however, data suggest that participants primarily engaged with the support for administrative needs. Qualitative data highlighted suggestions for mMRP improvement, including alternative methods for receiving support and more content on how to use the skills taught.

Conclusions:

Findings suggest that mMRP can be delivered in a brief format, with Veterans learning and using mantram repetition. Developing additional ways of individualizing the mMRP and further testing are warranted.

Keywords: Veterans, posttraumatic stress disorder, mobile-delivery implementation, mantram repetition, complementary and integrative healthcare

Posttraumatic stress disorder (PTSD) is common among United States Veterans, with Veterans Health Administration (VHA) users having a lifetime prevalence estimate of 23% and current prevalence of 13% (Wisco et al., 2022). While gold-standard trauma-focused therapies can be highly effective for PTSD (e.g., Haagen et al. 2015), many Veterans remain symptomatic after treatment completion or drop out of treatment prematurely (Steenkamp et al., 2020). As many Veterans express a preference for alternative approaches (Whitehead & Kligler, 2020), it is important to leverage empirically-supported complementary interventions and evaluate modes of delivery to decrease barriers and increase uptake.

Attitudinal and structural barriers exacerbate problems with accessing treatment for PTSD. In one sample of Veterans with PTSD who declined trauma-focused treatment, two-thirds of participants identified VHA-system-level barriers to care, such as delays in receiving treatment, negative experiences with staff and providers, discomfort with the environment, and difficulty navigating the system (Hundt et al., 2018). Rural populations or those who have scheduling challenges to attending face-to-face treatment may be additionally impacted by logistical barriers to attending weekly therapy (Morland et al., 2019), although accessibility of telehealth has greatly increased in recent years. In a sample of Veterans with PTSD symptoms, 35% reported beliefs that they were not emotionally ready for therapy (Stecker et al., 2013). Emotional readiness additionally appears to impact dropout, as treatment being “too stressful” was a common reason for dropout from trauma-focused therapy (Hundt et al., 2020). Non-trauma-focused interventions built for access and ease of understanding, such as meditation-based Internet-and mobile-based interventions (IMIs), may be especially beneficial to Veterans struggling with such barriers.

The Mantram Repetition Program (MRP) teaches the silent repetition of a self-selected word or phrase (i.e., mantram repetition) that has been sanctified within a spiritual tradition (Oman, 2024) coupled with one-pointed attention and slowing down. MRP is theorized to improve psychological outcomes through fostering mindful awareness, shifting attention away from unhelpful thoughts, and activating coping frameworks (Oman et al., 2022). Two large randomized controlled trials of MRP delivered by clinicians demonstrated efficacy for reduction of PTSD symptoms and insomnia among Veterans with PTSD (Bormann et al., 2013; Bormann et al., 2018).

Distilled into the three main treatment components, MRP is easily learnable, thus well-positioned for mobile-delivery. Accordingly, a recent pilot found that MRP was feasible and acceptable to deliver in an IMI video format with college students (Vannini et al., 2022). Mobile delivery has been found to improve mental health care through providing timely support, reducing costs, reducing help-seeking stigma, and enhancing therapeutic outcomes (Koh et al., 2022). Mobile-delivery of MRP (mMRP) allows for increased accessibility, as this program can be accessed at one’s convenience and in an easily scalable format. mMRP could ultimately be applied in various ways to increase access to and enhance care, such as a low-intensity, non-trauma-focused coping tool, a precursor to therapy, or a post-therapy tool to help maintain gains and/or resolve remaining symptoms.

While IMI can help increase access to MRP, the impact of online programs can be significantly reduced due to low rates of adherence with potential for high attrition rates and limited participation (Baumel et al., 2019; Koh et al., 2022). Attrition for online mental health programs in randomized controlled trials (RCTs) commonly exceeds 50%, as users are more likely to lose interest or forget about the program than face-to-face treatment (Wangberg et al., 2008). A systematic review of attrition from IMI RCTs found that 36% of Veterans and service members were lost at the first posttreatment assessment (Pearson et al., 2022). Across these RCTs, completion of all study sessions ranged from 25% to 100% (Pearson et al., 2022), with adherence being inferior in real-world settings. A systematic comparison found adherence in natural use to be four times worse than when the same program was evaluated in an RCT (Baumel et al., 2019). The very nature of PTSD may also impact adherence: trauma-avoidance or difficulty concentrating and remembering may reduce likelihood of engagement in online programs (Parish et al., 2014). Improving adherence is especially valuable to MRP, as increased practice was associated with improved outcomes in Veterans with PTSD (Malaktaris et al., 2022).

One approach to improving engagement with IMIs is through support, which reminds individuals to use the program, reinforces program practice, and provides information or help on program use (Shim et al., 2017). Support may be delivered via text messages or phone calls and be administrative or therapeutic in nature. However, RCTs comparing support to no-support demonstrate mixed findings, with some studies failing to demonstrate that support improves adherence rates or mental health outcomes (Shim et al., 2017). In a review of RCTs with Veterans and service members, attrition from IMIs was impacted by the type of support received: 51.78% attritted when not receiving support, 17.29% attritted when receiving administrative support, and 21.50% attritted when receiving therapeutic support (Pearson et al., 2022). Additionally, IMIs with support demonstrate better adherence rates than those without when implemented in real-world settings (Baumel et al., 2019; Titov et al., 2017).

This pilot study used a systematic approach to evaluate mMRP in two conditions—self-directed and with support. The first aim was to assess the reach and implementation of mMRP using a multi-method approach focusing on acceptability, appropriateness, feasibility, and facilitators of and barriers to program implementation. The second aim was to compare Veterans who were self-directed users of mMRP to Veterans who received text and phone support in terms of engagement with the intervention and change in PTSD and associated symptoms.

Methods

Participants

Participants were recruited from the Veterans Administration San Diego Healthcare System (VASDHS) through clinician referrals and a research re-contact list. Eligibility requirements were broad to approximate potential real-world users of mMRP and included: Veteran, 18 years of age or older, primary clinical complaint of PTSD, and access to an Internet-enabled smart phone, tablet, or computer. Exclusion criteria were: cognitive impairment or mental health concerns that necessitated a higher level of care or interfered with the ability to engage in study activities (e.g., traumatic brain injury, serious mental illness, untreated alcohol or substance use disorder).

Procedures

Procedures were approved by the VASDHS Institutional Review Board. Study activities occurred over a four-week period as depicted in Figure 1. Potential participants were contacted and pre-screened for inclusion/exclusion criteria and their willingness to receive text messages from study staff. After participants provided consent, PTSD status and other mental health conditions were determined by doctoral-level clinician administered Mini-International Neuropsychiatric Interview (Sheehan et al., 1997). Cognitive impairment was assessed using the Montreal Cognitive Assessment Telephone version (Dawes et al., 2019). Participants completed a pre-intervention assessment (day 0) consisting of demographics and mental health measures, then were contacted via a weekly email (days 1, 8, 15, and 22) with a prompt to complete a brief symptom screener and questions about mantram repetition practice, watch the week’s MRP training video, and answer video comprehension questions. Participants then completed a final post-intervention assessment battery (day 28) consisting of mental health measures, and all were invited to take part in a 30-minute phone interview. Participants accessed assessments and training videos using eScreening (Pittman et al., 2017).

Figure 1.

Figure 1.

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Participant Flow.

Intervention

The mMRP intervention consisted of four internet-delivered training video modules, which ranged from 5 to 9 minutes in length. The modules presented the material as follows: 1) introducing MRP, choosing a mantram, and practicing the silent repetition; 2) explaining the concept of one-pointed attention and how to practice; 3) describing monotasking and the value of focusing on one thing at a time; and, 4) reviewing the skills with an emphasis on habit formation and how to maintain practice.

Conditions

Participants were randomized to either a self-directed condition or to a support condition. All other intervention materials were the same (see Intervention section). In the self-directed condition, participants independently completed mMRP modules and only interacted with research staff if they initiated contact. In the supported condition, participants received a standardized weekly text (e.g., “Congratulations on completing this week’s module! Do you have any questions about one-pointed attention?”) and prompt to practice after completing each video module. Those who indicated they had used their mantram received support (e.g., “Great job! A regular practice happens one day at a time!”). Those who had not received encouragement and an offer of assistance (e.g., “You can repeat your mantram at any spare moment. Do you have any questions about working it into your day?”). A request for support was followed by a personalized text by study staff and the offer of telephone support. In both groups, participants who had fallen behind in their training by two or more days received reminders to complete their current week’s lesson (e.g., “You’re 94% done with the eScreening module for the week. Only a few more questions left! Please respond “?” if you are having any trouble accessing or completing the module.”).

Measures

Future implementation success can be evaluated by assessing key implementation outcomes in addition to traditional clinical endpoints. Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM; Glasgow et al., 2019) framework, we focused on Reach (characteristics of participants engaged from the target population), Effectiveness (impact of the program on important outcomes), and Implementation (fidelity and time required, clients’ use of the intervention and implementation strategies) as most relevant outcomes for this study.

Reach

Reach was determined by rates of screening, eligibility, refusal, and demographics.

Implementation

Credibility of the intervention was assessed after Session 1 using four items adapted from Borkovec & Nau (1972). Items assessed perceptions of the treatment, including logic, utility, and expected benefit of the intervention, and were rated from 0 (not at all) to 8 (very).

Satisfaction with the intervention was assessed post-treatment using a set of four items. Participants rated the module content, narrator, learning outcomes, and the overall course from 1 (very dissatisfied) to 5 (very satisfied).

Program comprehension was assessed using module-specific questions that tested the participants’ knowledge and understanding of each module. The questions were developed for Vannini et al. (2022), with each module having two comprehension questions. Using a conservative approach, a module was only considered completed if both comprehension questions were answered successfully.

Mantram practice was ascertained using the Mantram Repetition Use (MRU) questions, which has been used in several MRP efficacy studies (e.g., Bormann et al., 2018; Vannini et al., 2022). The 7-items query aspects of mantram repetition use: frequency of use over the past week and per day, practice when distressed (i.e., use for coping), practice when not distressed (i.e., skill building), cultivating one-pointed attention, and actively slowing down.

Acceptability, appropriateness, and feasibility were assessed quantitatively and qualitatively. All participants were contacted by trained research staff to complete a 30-minute semi-structured interview in which the Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM; Weiner et al, 2017) was administered to assess participants’ perception of corresponding constructs. Participants responded to items from 1 (completely disagree) to 5 (completely agree) and discussed their scoring decisions for each question. The interview guide was modeled on previous work (e.g., McCreight et al., 2019). Additionally, the individual interview explored implementation barriers and facilitators of mMRP.

Effectiveness

A brief symptom screen (items 9–11 of the SF-12, Ware et al., 1996) contains 3 items that assessed feeling calm/peaceful, energetic, and downhearted/blue. Items were rated from 1 (all of the time) to 6 (none of the time) and scored so that higher scores indicated more distress (range: 3 – 18). Cronbach’s alpha was .814 in the sample.

The PTSD Checklist for DSM-5 version (PCL-5, Bovin et al., 2016) consists of 20 items that assessed PTSD symptoms over the past month. Participants rated items from 0 (not at all) to 4 (extremely) with higher scores indicating more severe symptomology (range: 0 – 80). Cronbach’s alpha was .949 in the sample.

The Patient Health Questionnaire (PHQ-9; Kroenke et al., 2001) is a 9-item measure of depression symptoms over the past two weeks. Item responses ranged from 0 (not at all) to 3 (nearly every day) with higher scores indicating more severe symptomology (range: 0 – 27). Cronbach’s alpha was .869 in the sample.

The Insomnia Severity Index (ISI; Bastien et al., 2001) consists of 7-items that assess the consequences of and distress related to insomnia over the prior month. Participants rated items from 1 (none or not at all) to 4 (very much) with higher sores indicating worse insomnia severity (range: 0 – 28). Cronbach’s alpha was .914 in the sample.

The Brief Personal Health Inventory (Brief PHI; Department of Veterans Affairs, 2019) is a 21-item self-reflection tool that assesses all aspects of Whole Health corresponding to the Circle of Health (Department of Veterans Affairs, 2019). The inventory asks participants to rate their current and ideal functioning with respect to eight areas of self-care. The current and ideal state functioning ratings were used to determine improvement potential across all domains, with higher values indicating more discrepancy between current and ideal health. Cronbach’s alpha was .867 in the sample for domains of current functioning.

Data Analysis

Quantitative analysis included descriptive statistics of reach, implementation, and effectiveness outcomes. Change from pre- to post-intervention on effectiveness measures were calculated overall and by group (self-directed vs. supported). Wilcoxon signed rank tests and Mann Whitney U tests were used to examine pre- to post-intervention change and compare the change between two groups.

To analyze interviews, we used an adapted rapid qualitative analysis approach (Hamilton, 2013). Following transcription, we created a set of codes that reflected the content of the interview questions, then pilot tested to refine the codes and to develop agreement on application. Transcripts were then coded and data were summarized with themes emerging through supporting quotes (Gale et al., 2019). Through an initial and secondary review process, the research team collaboratively and iteratively reviewed, discussed, and sorted the data, refining the initial list of codes and highlighting the most salient quotes. Rigor and validity were established through research team prolonged engagement with the data, member checking, triangulation, and rich descriptions of the data (Hamilton & Finley, 2019).

Results

Reach

A total of 129 Veterans were contacted for potential participation. Participant flow is outlined in Figure 1. The ineligibility rate was 12.1% (7 ineligible/58 screened), eligibility rate was 87.9% (51 eligible/58 screened), and refusal/lost to contact rate was 22.4% (13 lost to contact/58 screened).

A final sample of 36 Veterans was on average 50.50 years of age (SD = 15.49), and the majority identified as men (83.3%) and heterosexual (88.9%). For ethnicity and race, participants could endorse more than one and identified as Latinx/Hispanic (25.0%), white (72.2%), Black (16.7%), Asian (8.3%), Indigenous American (5.6%), and Pacific Islander (2.8%).

Implementation

Credibility of the approach indicated moderate levels of treatment credibility after module 1. Specifically, “How logical does this type of practice seem to you for helping people reduce PTSD symptoms?”, M = 5.35, SD = 1.72; “How confident are you that this practice will be successful in reducing your symptoms?”, M = 4.77, SD = 1.54; “How confident would you be in recommending this program to a friend?”, M = 4.81, SD = 1.64; “How successful do you feel this treatment would be in decreasing other problems like stress, anxiety, headaches, insomnia, etc.?”, M = 5.13, SD = 1.57.

Satisfaction with MRP suggested moderate levels of satisfaction at post-intervention. Ratings were: module content, M = 3.04, SD = 0.74, narrator, M = 3.16, SD = 0.80, learning outcomes, M = 3.08, SD = 0.86, and overall course, M = 3.08, SD = 0.91.

Module-specific comprehension questions indicated that 83.9% of participants successfully completed module 1, 89.3% module 2, 100% module 3, and 92.0% module 4.

Mantram use was assessed from module 2 onwards and results are presented in Table 1. A Mann-Whitney U test revealed no significant differences between the non-supported and supported conditions on change scores from module 2 to post-intervention for the item, “Days remembered to use mantram” (U = 80.50, p = .411). The item, “Average number of times repeated mantram per day,” was trending in the unpredicted direction (U = 46.00, p = .053), in that the unsupported condition (Mrank = 16.67) reported more daily repetitions than the supported condition (Mrank = 10.79).

Table 1.

Mantram Repetition Use and Acceptability, Appropriateness, and Feasibility Indicators

M2 M3 M4 Post-
M (SD) M (SD) M (SD) M (SD)
Mantram Repetition Use (n = 28)
 During the past week, on how many days did you remember to repeat your mantram? (Range: 0–7) 4.31 (2.02) 4.75 (1.97) 4.96 (1.93) 4.96 (2.03)
 Did you repeat your mantram when you did not need it (in other words, just for practice)? (Yes) 93% 82% 74% 81%
 Did you repeat your mantram to help yourself calm down or cope? (Yes) 72% 93% 100% 100%
 Did you use your mantram to help yourself fall asleep? (Yes) 38% 39% 67% 50%
 On days that you practiced your mantram, how often per day, on average, did you remember to repeat your mantram? (Range: 0–15) 3.45 (3.41) 3.71 (3.26) 3.26 (2.28) 4.50 (3.99)
 Did you practice one-pointed attention? (Yes) NA 71% 75% 89%
 Did you practice slowing down? (Yes) NA NA 89% 93%
Acceptability, Appropriateness, and Feasibility (n = 26)
 The Mobile Mantram Program worked for me. (Range: 0–5) 3.96 (0.87)
 Accessing the Mobile Mantram Program lessons was straight forward. (Range: 0–5) 3.92 (1.29)
 I would imagine that most Veterans would learn to use mantram repetition through this program very quickly. (Range: 0–5) 3.94 (0.88)
 I like the Mobile Mantram Program. (Range: 0–5) 4.23 (0.76)
 I would be pleased to have the VA offer the Mobile Mantram Program. (Range: 0–5) 4.46 (0.76)
 The Mobile Mantram Program seems fitting to help me manage my PTSD symptoms. (Range: 0–5) 3.67 (0.93)
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Note. M2 = module 2; M3 = module 3, M4 = module 4.

In terms of acceptability, appropriateness, and feasibility, participants agreed that the program was acceptable (AIM, M = 4.39, SD = 0.76), appropriate (IAM, M = 3.67, SD = 0.93), and feasible (FIM, M = 3.94, SD = 1.01). Table 1 includes the mean response ratings of the individual items. Mann-Whitney U tests revealed no significant differences between the non-supported and supported groups (all ps > .480).

Our qualitative interviews provided additional insight on participants’ perceptions of acceptability, appropriateness, and feasibility. Specifically, participants discussed mMRP as acceptable and feasible due to being short, easy to use, and accessible. The ease and overall positive experience of the program led participants to largely endorse the intervention as also being appropriate to help them address their PTSD symptoms, sometimes seeing improvements within 1–2 weeks. Speaking to how the program helped them, Participant 10 stated, “...I think it’s a good tool [mantram repetition], especially to make you take a step back...if you’re getting burned up or [having a] nervous system reaction, then this can help break that.” mMRP provided the participant the skills they needed to begin to ground themselves.

Participants noted that mMRP skills helped ease rumination and physiological hyperarousal, which for some subsequently led to feelings of empowerment. “I didn’t know how to get rid of something circling around in my mind, [mantram repetition] stopped it almost immediately, and it was a nice feeling of strength to have that” (Participant 6). The experience of quieting symptoms that had previously felt uncontrollable and immutable also gave Participant 10 the opportunity to reflect on their reactions, “...you get agitated sometimes and you do your mantram and it brings you down. And then you can reflect on [the situation] later”

Some participants encountered challenges in using the skills and did not find relief from some of their PTSD symptoms. Participant 3 reported, “I never remembered it in a stressful situation. Which might come with time...but I still have pretty bad nightmares and interrupted sleep. Not once after waking up from a nightmare was I like ‘oh yeah, my mantra[m]’.” Participant 25 stated, “...it didn’t really help alleviate my thoughts about things that trigger my PTSD symptoms.” While these Veterans did not get all the results they hoped for, they were still a part of the group that spoke to their appreciation of the VHA providing alternative and holistic approaches to symptom management. As Participant 18 stated, “I think it’s good that the VA is offering more alternative solutions rather than just throwing pills at somebody.”

It is important to recognize that participants may have had differing experiences depending on whether they were randomized to the self-directed or the support condition. For those who were randomized to the support condition, 18 received text messages (one person withdrew after completing the module but before receiving a text). Of those 18 participants, 66.7% responded to the text prompt after module 1, 50.0% after module 2, 36.3% after module 3, and 41.7% after module 4. In total, 4 never responded, 11 responded with minimal substance or logistical questions only (e.g., “No questions. All is good so far,” “thumbs-up” to a text), and 2 responded with more substance (e.g., Prompt: “Do you have any questions about one-pointed attention?” Response: “None so far. I’ve been pretty successful in using my mantram in moments of irritation – have to practice using it when I’m calm. Also, will practice one-pointed attention.”) No participants requested a phone call when offered.

While no participants requested a phone call, many participants talked about incorporating a check-in process as being something that would benefit the program. For example, Participant 24 stated, “...If you’re having problems, you could come in [to] the VHA or something.” For this participant and others, adding a component that would enable them to reach out for support was a feature they believed would increase feasibility. However, participants were divided on what would be the best method of providing that support. While the above participant desired additional support in person, other participants wanted the ability to communicate by text message to discuss their individual experiences.

This personal support could help to remedy some of the challenges that participants experienced engaging with the mMRP program. For instance, participants shared difficulties accessing content through the eScreening interface, remembering to engage with the program, staying focused on their mantram, and slowing down their emotional responses to incorporate the mantram. From these challenges, participants provided feedback for how mMRP could be improved. Over half of participants endorsed incorporating mMRP materials into a mobile app to gain the features often engrained in such programs. Participant 12 detailed, “[Users] can download the app, set up a profile, ask questions...if they agree to it, allow their doctor to also see some of that information. [Users] could set up their own reminders...”

Participants shared additional content they would like to see incorporated into the program. Suggestions included making videos longer and adding more information on the historical background of mantram repetition, more tips for how and when to use the techniques, and guidance on being deliberate and reflecting, having a weekly “podcast-like” audio recording of weekly content. A couple participants recommended extending the program, “rather than having a four-week program, make it like a six- or eight-week program” (Participant 17). They felt by engaging with the program longer, they would get more benefit.

In summary, the qualitative results supported the quantitative findings that participants found the program to be generally acceptable, appropriate, and feasible. Feedback highlighted areas where the training videos may be improved for clarity, and suggestions for ways mMRP can be improved to foster implementation.

Effectiveness

For all participants, change from pre- to post-intervention was significant for the brief symptom screen, PCL-5, and Brief PHI improvement potential as presented in Table 2. Changes from pre- to post-intervention on PHQ-9 and ISI were non-significant (both ps > .454). Mann-Whitney U tests revealed no significant differences between the non-supported and supported groups on change scores from pre- to post-intervention (all ps > .113).

Table 2.

Pre- to Post-intervention Change on Outcomes for Veterans using mMRP (n = 28)

Pre-M(SD) Post-M(SD) Mean Rank (negative) Z p
PCL-5 33.17(17.46) 29.36(20.06) 14.39 −2.12 .034
PHQ-9 11.00(5.87) 10.68(7.30) 13.50 −0.72 .472
ISI 14.39(7.47) 13.96(7.98) 13.54 −0.75 .455
Brief symptom screen 11.31(2.92) 10.14(3.37) 12.19 −2.26 .024
PHI ↑ potential 15.92(6.31) 13.82(6.12) 14.03 −2.21 .027
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Note. PCL-5= PTSD Checklist for DSM-5, PHQ-9 = Patient Health Questionnaire-9 item, ISI = Insomnia Severity Index, PHI = Brief Personal Health Inventory.

Discussion

The purpose of this multi-method randomized feasibility study was to examine the implementation of mMRP, comparing self-directed and text support delivery formats, among Veterans with PTSD. Results showed that implementation of mMRP was generally successful. The video modules were not professionally developed but still reasonably well received. Veterans reported using their mantram 5 days a week on average at the conclusion of the program, supporting that those individuals practiced even with a brief amount of training. Additionally, results indicated some improvements in PTSD symptoms and indicators of wellness. We did not find any significant differences in clinical outcomes between delivery formats, which is not surprising considering the lack of use of text support, and meta-analytic evidence suggesting no differential effects of levels of support and personalization in IMIs on PTSD symptom reduction (Steubl et al., 2021). While we did not see changes in insomnia symptoms, which contrasts with prior studies (e.g., Bormann et al., 2018), this may be due to generally low numbers of participants using mantram repetition for sleep and the potential lack of power for detecting change. Considering prior studies of MRP demonstrate significant reductions in insomnia symptoms for Veterans with PTSD (Beck et al., 2017; Bormann et al., 2018), it may be beneficial for modules to increase emphasis on practicing mantram repetition prior to sleep, which is frequently reiterated in the original 8-week delivery format.

Quantitative and qualitative findings on acceptability, appropriateness, and feasibility were generally positive. Participants’ ratings were in approximate “agreement” (4 out of 5) and their qualitative responses provided a more nuanced understanding of their experiences using mMRP and clinical outcomes. Specifically, Veterans from both conditions generally had a positive experience using the program due to it being brief and easily accessible, and generally appropriate for helping them manage their PTSD symptoms. Veterans found the skills helped ease rumination and psychological hyperarousal, allowing space to reflect on their reactions, which fostered empowerment. Despite not always getting the outcomes they hoped for, several still spoke to the appreciation they had for an alternative and holistic approach to mental health being offered through VHA.

Challenges with engaging with the program were illuminated. Similar to other experiences of IMIs (Wangberg et al., 2008), one of the most endorsed difficulties faced by participants in both conditions was remembering to use the skills. Participants reported either entirely forgetting to practice the skills or forgetting during times when it would have been helpful. Considering research has indicated that increased mantram repetition practice leads to more optimal outcomes (Malaktaris et al., 2022), identifying additional ways to support and increase practice compliance may be especially fruitful for this brief program. However, it remains unclear if there is a minimum dose or amount of practice that should be a goal to achieve. Relatedly, participants suggested that push notifications be sent to their phone throughout the day as reminders to practice; this seems to contrast with the apparent low utilization of supportive text messages for participants randomized into that condition. While the text support was delivered by a study staff member, it may be beneficial to discuss with Veterans possibilities for what the support may entail in practice prior to starting the program. Offering varied types of support may ultimately be the most beneficial as participants suggested phone calls, text messages, push notifications, and participant-initiated contact with support staff, as some solutions for increasing engagement. Moreover, using gamification (using game design in non-game contexts), may enhance motivation and engagement, although findings about type of gamification are mixed and highly dependent on contextual factors (e.g., Cheng et al., 2019).

Participants had additional suggestions included enhancing the delivery format, including video quality, length, and ability to access videos multiple times for increased learning; and more tips for when and how to use skills. Additionally, some participants requested more videos (e.g., a library of videos) that they could access when interested in additional or more nuanced information regarding each module. Similar to the findings of Hulett and colleagues (2023), participants endorsed wanting more interactive material (e.g., reflective prompts, questions following topics, audio or reading exercises) as well as the desire to create their own mantram, which might be secular rather than strictly spiritual, instead of picking from a list. In summary, the suggestions were varied and highlighted the need and desire for different types of learning formats, including personally-relevant examples of when to practice and use the skills, and hybrid-delivery formats. Allowing for increased tailoring across these domains is likely to be more reinforcing and increase skill uptake. A person-centered care approach fits VHA’s Office of Patient Centered Care & Cultural Transformation goals and a hybrid delivery of therapeutic content is one such innovative practice that supports Veterans’ priorities and advances Whole Health initiatives.

This study has several strengths and limitations. The use of quantitative and qualitative data allows for a fuller understanding of implementation successes and challenges and increases credibility of the results. These results are limited in generalizability as participants were a convenience sample from one VHA healthcare system. For example, while some participants projected that older Veterans may have challenges with mobile delivery, we had a limited number of older adults in the sample to understand if this represents their experiences. As noted above, some Veterans wished to select or create secular mantrams, and providing only spiritual options may limit buy-in and long-term use of mantram repetition; however, dropout rates from the program were quite low and reported mantram use was rather high. Lastly, the qualitative interview inquired about how Veterans used mMRP for managing symptoms of PTSD broadly to capture Veterans’ real-life use and experiences, but did not ask about specific symptom clusters, which could prove valuable when creating additional content for managing symptoms. Lastly, these results should not be misconstrued as evidence of efficacy due to potential bias and lack of a suitable comparator. Efficacy of mental health IMIs is generally a gap in the literature (Gould et al., 2019).

Findings from this study provide evidence that mMRP is a promising program for future VHA implementation and offers benefits as an easy to learn and use program for Veterans with PTSD. Moreover, the non-trauma focused nature and brief mobile-delivery format that can be entirely self-guided is especially appealing as an adjunctive intervention for PTSD that can be employed in routine care settings. The clinical implications may be particularly poignant for settings where stepped-care models may be feasible and wait times to access front line evidence-based treatments for PTSD are longer.

Clinical Impact Statement:

Mobile-delivery of mental health interventions has become popular to help Veterans with PTSD access care. However, these programs may not teach content effectively nor be engaging to Veterans. This study assessed the mobile adaptation of the meditation-based Mantram Repetition Program (mMRP). Results indicated that participants were able to learn and practice the skills taught by the mMRP trainings, although those who received additional text messages primarily used them for administrative support. Participants identified challenges and improvements that can be made to mMRP. mMRP may be especially appealing for Veterans as an adjunctive intervention for PTSD or when waiting for psychotherapy.

Funding details:

This research was supported by VA HSR&D Small aWard Initiative for impacT – Independent VA Investigators (SWIFT-IVI FY22-13-19) grant. Dr. McLean was supported by the VA Office of Academic Affiliations Advanced Fellowship Program in Women’s Health. Dr. Faytol was supported by the VA Office of Academic Affiliations Advanced Fellowship Program in Mental Illness Research and Treatment and the VA San Diego Center of Excellence for Stress and Mental Health.

Footnotes

Disclosure statement: The authors have no conflicts to disclose. The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

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