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Most people who experience a potentially traumatic event (PTE) recover on their own. A small group of individuals develops psychological complaints, but this is often not detected in time or guidance to care is suboptimal. To identify these individuals and encourage them to seek help, a web-based self-help test called Mobile Insight in Risk, Resilience, and Online Referral (MIRROR) was developed. MIRROR takes an innovative approach since it integrates both negative and positive outcomes of PTEs and time since the event and provides direct feedback to the user.
The goal of this study was to assess MIRROR’s use, examine its psychometric properties (factor structure, internal consistency, and convergent and divergent validity), and evaluate how well it classifies respondents into different outcome categories compared with reference measures.
MIRROR was embedded in the website of Victim Support Netherlands so visitors could use it. We compared MIRROR’s outcomes to reference measures of PTSD symptoms (PTSD Checklist for DSM-5), depression, anxiety, stress (Depression Anxiety Stress Scale–21), psychological resilience (Resilience Evaluation Scale), and positive mental health (Mental Health Continuum Short Form).
In 6 months, 1112 respondents completed MIRROR, of whom 663 also completed the reference measures. Results showed good internal consistency (interitem correlations range .24 to .55, corrected item-total correlations range .30 to .54, and Cronbach alpha coefficient range .62 to .68), and convergent and divergent validity (Pearson correlations range –.259 to .665). Exploratory and confirmatory factor analyses (EFA+CFA) yielded a 2-factor model with good model fit (CFA model fit indices: χ219=107.8,
MIRROR is a valid and reliable self-help test to identify negative (PTSD complaints) and positive outcomes (psychosocial functioning and resilience) of PTEs. MIRROR is an easily accessible online tool that can help people who have experienced a PTE to timely identify psychological complaints and find appropriate support, a tool that might be highly needed in times like the coronavirus pandemic.
Most people will experience at least one potentially traumatic event (PTE) in their lives [
Experiencing psychological complaints a few days to weeks after a PTE is often considered normal [
Unfortunately, the small but significant group that develops persisting psychological complaints is often not detected in time or guidance to care is suboptimal [
In order to prevent the development and persistence of trauma-related complaints, timely and accurate identification is needed [
Multiple studies show that when one chooses to assist people who have experienced a PTE, it is important to support self-reliance and resilience [
To incorporate above guideline advice and address the aforementioned concerns in the early support of people who have experienced a PTE, Mobile Insight in Risk, Resilience, and Online Referral (MIRROR) was developed. MIRROR is a web-based self-help test with the potential to reach large groups of people who are seeking reassurance on how they are coping. MIRROR takes an innovative approach since it integrates both negative and positive outcomes of PTEs and time since the event. This was realized by creating a new questionnaire based on existing measures on resilience, functioning, and PTSD, and by developing a new algorithm that takes into account multiple factors. In compliance with NICE, TENTS, and DSM-5 guidelines [
While it is recognized that mobile apps have the potential to improve timely identification of complaints and delivery of mental health support after PTEs, there is very little research on their validity, reliability, and effectiveness [
A multidisciplinary team of professionals in the fields of psychotrauma (clinicians, researchers, and policy officers) and victim and crisis support developed MIRROR. The items and algorithm were based on existing protocols—DSM-5 and the
MIRROR consists of 2 parts. Part 1 includes items regarding event-related characteristics: type of event, measured with all events of the Dutch version of the Life Events Checklist for the DSM-5 (LEC-5) [
MIRROR’s algorithm aims to identify PTSD symptoms, psychosocial functioning, and resilience; normalize complaints (ie, reassuring users that it is normal to experience distress shortly after a PTE); and stimulate seeking support in users with persisting complaints. See
MIRROR summarizes the outcome of its algorithm to respondents as either green, orange, or red. Together with this color outcome, respondents receive personal advice. The color outcome is based on the level of complaints, functioning, and time passed since the event. MIRROR’s resilience scale is not included in the color outcome because based on current research it is unclear precisely how resilience interacts with the development of PTSD complaints and functioning after PTEs. Nonetheless, resilience is integrated in the personal advice to stimulate the use of social support. If respondents score low on resilience they are encouraged to seek support from those close to them and individuals who have experienced similar events.
A green outcome indicates few complaints and/or sufficient functioning, and the accompanying advice states no further action is needed. An orange outcome indicates complaints and moderate functioning in combination with a PTE that happened only recently (ie, less than 1 month). The accompanying advice is directed at normalizing complaints combined with promoting watchful waiting and encouraging setting a reminder to use MIRROR again in 2 weeks to assess if complaints have diminished. The red outcome indicates significant complaints (ie, low functioning or complaints with moderate to low functioning for a longer period or due to a reoccurring event) which have persisted for more than 1 month. Therefore, the advice aims to encourage the user to seek consultation with a general practitioner or to contact Victim Support Netherlands. MIRROR provides follow-up support options with its advice, such as the opportunity to get in touch with people who have had similar experiences, reading information about dealing with stress reactions, or setting a reminder to use MIRROR again in 2 weeks.
MIRROR was available in the Dutch language and open for each visitor on the website of Victim Support Netherlands (Slachtofferhulp Nederland). The specifically targeted sample consisted of website visitors who were automatically led to MIRROR when searching for information regarding stress reactions following a PTE. MIRROR is a responsive website; respondents did not have to download it. MIRROR can be used on mobile and nonmobile devices. To evaluate the psychometric properties of MIRROR, we added a research survey with reference measures (see details in Measures) after the MIRROR questions. Data collection took place during a period of 6 months. We tested the usability and technical functionality of MIRROR and the research survey before making it available. Each item was presented on a new webpage.
Before starting MIRROR, respondents were invited to participate in the research survey. Participants were informed regarding the purpose of the study, duration time of the survey, and data storage. Participation was voluntary and completely anonymous. Respondents received no incentive for completing MIRROR or the research survey. They were asked for informed consent to use their data for research purposes, in accordance with the European General Data Protection Regulation. The Medical Ethical Committee of Amsterdam University Medical Center exempted this study from formal review (W18_364 #18.435).
Data collection took place between February and August 2019. Only original answers were saved in the database. That is, if respondents went back to change their answers once they already received their advice, changes were not saved. We followed data cleaning recommendations by Birnbaum [
To measure PTSD symptoms, we used the Dutch version of the PCL-5 [
To assess other common psychological complaints after PTEs, we used the Dutch short version of the Depression Anxiety Stress Scale (DASS-21) measuring depression (7 items), anxiety (7 items), and stress (7 items) [
We used the Resilience Evaluation Scale (RES) to assess psychological resilience [
We assessed positive mental health with the Dutch version of the Mental Health Continuum Short Form (MHC-SF) [
Google Analytics data were collected between March and August 2019 to examine MIRROR’s use. Due to technical problems, data from February 2019 were missing. The data provide information on the number of unique visits per page, type of device used, and number of visitors who have started MIRROR (defined as a unique page visit on MIRROR’s start page) and who have finished MIRROR (defined as unique page visit on MIRROR’s outcome and advice page). Google Analytics cannot determine to what extent the follow-up options were used, but it can detect how many respondents have visited the follow-up support option pages.
Since participation in the research survey was optional, this resulted in two 2 samples. The MIRROR-only sample consists of respondents who only completed MIRROR. The validation sample includes respondents who completed MIRROR and the accompanying survey with reference measures before receiving their advice. The total sample combines these two samples, consisting of all respondents. To examine if the validation sample was representative of the MIRROR user, we used independent-samples
We used the total sample to evaluate MIRROR’s use and examine MIRROR’s factor structure and internal consistency because for these analyses only data from MIRROR were needed. We used the validation sample to examine MIRROR’s convergent and divergent validity and evaluate how well MIRROR classifies respondents into different outcome categories because for these analyses data from MIRROR as well as reference measures from the accompanied survey were needed.
We used Mplus version 8 (Muthen & Muthen) to conduct exploratory factor analysis (EFA) using geomin rotation and confirmatory analysis (CFA). EFA assumes that any item may be associated with any factor. CFA specifies expected relationships between items and their underlying latent factors. Because items of MIRROR’s PTSD and resilience section were categorical, they were treated as ordinal and therefore the means and variance adjusted weighted least square (WLSMV) estimator was used. An underlying normal distribution was assumed for each ordinal item, where the 5 response categories were divided by 4 thresholds estimated from the data. MIRROR’s functioning item has 10 response categories and was treated as continuous. Because MIRROR’s factor structure was not tested before, several models with different numbers of latent factors were examined using EFA. To assess the model with the optimal number of latent factors needed to adequately account for the correlations among item scores, we used Kaiser criterion (ie, eigenvalues of the latent factors >1) and model fit statistics. The model with the best balance between model fit, parsimony, and conceptual interpretability was selected as the most optimal model. Subsequently, CFA was used to test the optimal model based on EFA. The difference in goodness-of-fit between nested models was evaluated with the difftest option in Mplus for appropriate chi-square difference testing with the WLSMV estimator [
We evaluated internal consistency of MIRROR’s PTSD and resilience section with interitem correlations, corrected item-total correlations, and Cronbach alpha in SPSS Statistics version 23. Internal consistency of MIRROR’s functioning section could not be evaluated since it is represented by only one item. When most interitem correlations are in the recommended range of .15 to .50 (moderate magnitude) and Cronbach alpha for the scale is >.80, internal consistency can be considered good [
To evaluate MIRROR’s convergent and divergent validity, we calculated Pearson correlations between the MIRROR scales and reference measures. Convergent and divergent validity can be considered good when the correlations between a scale and equivalent measure (eg, MIRROR’s PTSD scale and the PTSD scale of the PCL-5) are significant and high while correlations between this scale and other related measures (eg, MIRROR’s PTSD scale and depression scale of the DASS-21) are lower and moderate or modest in magnitude.
To evaluate how well MIRROR classifies respondents into a red, orange, or green outcome, we tested whether respondents in these three outcome categories differed on related reference measures by using cross-tabs and analysis of variance (ANOVA). If the assumption of equal variances was violated, we used the Welch
MIRROR was completed 1314 times in the study period of 6 months. In total, 51.90% (682/1314) of respondents started the research survey. We deleted 51 respondents who indicated they used MIRROR on behalf of a family member, partner, friend, or colleague who experienced a PTE. We deleted 37 repeated measurements, completed by respondents who set a reminder. We excluded 95 respondents because they did not complete all research survey items. After thorough investigation of the answering patterns, we deleted 19 respondents because of unusual answering patterns. A total of 84.63% (1112/1314) of respondents were retained in the total sample, of whom 59.62% (validation sample, 663/1112) also completed all questionnaires of the accompanying research survey.
Mobile Insight in Risk, Resilience and Online Referral (MIRROR) scores, outcomes, and event-related characteristics for the validation sample and MIRROR-only sample.
MIRRORa | Validationb (n=663) | MIRRORb only (n=449) | |
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MIRROR PTSDc scale | 14.88 (3.39) | 14.80 (3.28) |
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MIRROR functioning | 4.92 (1.96) | 5.11 (1.94) |
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MIRROR resilience scale | 10.08 (2.36) | 10.91 (2.37) |
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Red | 409 (61.7) | 224 (49.9) |
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Orange | 230 (34.7) | 214 (47.7) |
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Green | 24 (3.6) | 11 (2.4) |
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Another very stressful event or experience | 216 (32.6) | 150 (33.4) |
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Transportation accident | 115 (17.4) | 107 (23.8) |
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Physical assault | 109 (16.5) | 50 (11.1) |
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Sudden accidental death | 38 (5.7) | 20 (4.5) |
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Serious accident at work, home, or during recreation | 33 (5.0) | 28 (6.2) |
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Sexual assault | 33 (5.0) | 18 (4.0) |
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Assault with a weapon | 30 (4.5) | 25 (5.6) |
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Other unwanted or uncomfortable sexual experience | 30 (4.5) | 14 (3.1) |
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Sudden violent death | 24 (3.6) | 16(3.6) |
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Severe human suffering | 14 (2.1) | 5 (1.1) |
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Life-threatening illness or injury | 10 (1.5) | 5 (1.1) |
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Fire or explosion | 9 (1.4) | 4 (0.9) |
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Combat or exposure to a war zone | 1 (0.2) | 0 (0) |
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Captivity | 0 (0) | 4 (0.9) |
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Serious injury, harm, or death caused by you to someone else | 0 (0) | 3 (0.7) |
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Natural disaster | 0 (0) | 0 (0) |
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Event happened to me | 480 (72.5) | 311 (69.3) |
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I witnessed the event | 129 (19.5) | 94 (20.9) |
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I learned about the event | 42 (6.3) | 35 (7.8) |
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Othere | 11 (1.7) | 9 (2.0) |
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No | 586 (88.4) | 379 (84.4) |
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Yes | 77 (11.6) | 70 (15.6) |
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Less than 1 week | 241 (36.3) | 218 (48.6) |
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Over 4 weeks | 214 (32.3) | 113 (25.2) |
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Between 1 and 4 weeks | 144 (21.7) | 90 (20.0) |
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It happens repeatedly | 64 (9.7) | 28 (6.2) |
aMIRROR: Mobile Insight in Risk, Resilience, and Online Referral.
bSignificant association between sample and MIRROR outcome,
cPTSD: posttraumatic stress disorder.
dLEC-5: Life Events Checklist for DSM-5.
eIf respondents could not select one of the event relations (happened to me, witnessed it, learned about it, work-related), they are asked to specify their relation to the event.
Frequency distribution in percentages of Mobile Insight in Risk, Resilience and Online Referral (MIRROR) item response categories, items 1-4 and 6-8 (n=1112).
Scale and item number | Never | Rarely | Sometimes | Often | All the time | |
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1 | 2.7 | 5.7 | 16.6 | 38.5 | 36.5 |
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2 | 5.1 | 8.5 | 19.3 | 27.4 | 39.6 |
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3 | 9.3 | 13.8 | 26.9 | 22.9 | 27.1 |
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4 | 8.5 | 11.4 | 26.7 | 26.8 | 26.6 |
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6 | 5.3 | 8.5 | 21.7 | 35.3 | 29.3 |
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7 | 7.3 | 15.6 | 35.2 | 30.5 | 11.5 |
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8 | 5.2 | 15.1 | 45.6 | 28.1 | 5.9 |
aPTSD: posttraumatic stress disorder.
Frequency distribution in percentages of Mobile Insight in Risk, Resilience and Online Referral (MIRROR) item response categories, item 5 (n=1112).
Scale and item number | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | |
Functioning |
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5 | 4.9 | 6.9 | 10.4 | 15.8 | 19.8 | 20.9 | 12.1 | 6.3 | 1.6 | 1.3 |
A detailed overview of the scores of the validation sample on the reference measures can be found in
Google Analytics data provided insight into MIRROR’s use. The number of visitors who started MIRROR was 2555, of whom 2247 (87.95%) finished it. The original database contained 1314 entries. This discrepancy can be explained by users having the opportunity to refuse to have their data saved before starting. Of all users, 47.59% (1216/2555) chose this option. Furthermore, of the follow-up support options, the “seek contact with Victim Support Netherlands” page had most views (411 unique views), followed by “more information” (293 unique views), “send your advice to yourself or someone else” (235 unique views), “seek contact with people who have had similar experiences” (209 unique views), and “set a reminder” (161 unique views). A total of 28.7% (113/394) of respondents who received the orange outcome and were advised to complete MIRROR again in 2 weeks immediately set a reminder to complete MIRROR again in 2 weeks. A total of 22.1% (25/113) did so at the time of data analyses. The most often used device was the smartphone (1566/2555, 61.29%), followed by desktop (794/2555, 31.08%), and tablet (195/2555, 7.63%).
Geomin rotated factor loadings for the 2-factor and 3-factor solution model of Mobile Insight in Risk, Resilience and Online Referral (MIRROR) as estimated by exploratory factor analysis (n=1112).
MIRRORa items | 2-factor solutionb | 3-factor solutionc | |||
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F1 | F2 | F1 | F2 | F3 |
1. Are you troubled by images of or thoughts about the event?d | 0.525* | –0.004 | 0.813* | 0.015 | 0.018 |
2. Have you become jumpy and/or vigilant since the event?e | 0.585* | –0.009 | 0.308* | 0.338* | –0.012 |
3. Do you try to avoid things that are related to the event?f | 0.789* | 0.071 | –0.000 | 1.078* | 0.245* |
4. Do you try to avoid thinking about the event?g | 0.648* | –0.016 | 0.208* | 0.459* | –0.019 |
5. How would you rate your present functioning (at work/home)?h | –0.153* | 0.354* | –0.213* | 0.004 | 0.360* |
6. Do you experience support from those close to you?i | 0.081* | 0.388* | 0.160* | –0.064 | 0.374* |
7. Are you confident in yourself?j | 0.006 | 0.827* | 0.010 | –0.021 | 0.827* |
8. Are you able to deal with any problems you encounter?k | –0.015 | 0.730* | –0.074 | 0.018 | 0.718* |
aMobile Insight in Risk, Resilience and Online Referral.
bModel fit indices for the 2-factor solution: χ213=88.7,
cModel fit indices for the 3-factor solution: χ27=12.6,
dEigenvalue 2.777,
eEigenvalue 1.466.
fEigenvalue .927.
gEigenvalue .715.
hEigenvalue .668.
iEigenvalue .640.
jEigenvalue .437.
kEigenvalue .369.
*
EFA yielded a 2-factor solution with adequate model fit. The RMSEA and TLI indicated adequate model fit and CFI indicated good model fit (
Next, we conducted CFA to further compare the 2- and 3-factor model that resulted from EFA.
Confirmatory factor analysis model fit indices (n=1112).
Model | χ2 | dfa | CFIb | TLIc | RMSEAd | |
Two-factor solution | 107.78 | <.001 | 19 | 0.965 | 0.948 | 0.065 |
Three-factor solution | 95.868 | <.001 | 17 | 0.969 | 0.949 | 0.064 |
adf: degree of freedom.
bCFI: comparative fit index.
cTLI: Tucker-Lewis index.
dRMSEA: root mean square error of approximation.
Interitem correlations of MIRROR’s PTSD complaints scale ranged between .28 and .48 with a mean of .34. All of the interitem correlations of the PTSD scale were in the recommended range of moderate magnitude of .15 to .50, indicating that this scale has high internal consistency in combination with a differentiated item set. Corrected item-total correlations for this scale ranged between .39 and .54 with a mean of .46, indicating that high scores on the PTSD items are associated with high scores on the overall PTSD scale of MIRROR. Cronbach alpha coefficient for MIRROR’s PTSD scale was .68.
Interitem correlations of MIRROR’s resilience scale ranged between .24 and .55, with a mean of .36. In addition, 1 out of 3 interitem correlations was higher than the recommended range of moderate magnitude of .15 to .50 (between “are you confident in yourself” and “are you able to deal with any problems you encounter”), indicating that this scale has high internal consistency in combination with a differentiated item set. Corrected item-total correlations ranged between .30 and .52 with a mean of .44, indicating that high scores on the resilience items are associated with high scores on the overall resilience scale of MIRROR. Cronbach alpha coefficient for MIRROR’s resilience scale was .62.
Pearson correlations between MIRROR and reference measures are presented in
Correlations between Mobile Insight in Risk, Resilience and Online Referral (MIRROR) subscales and reference measures (n=663).
MIRROR | PTSDa | Resilience | Functioning | |||
PCL-5b | .665 | <.001 | –.507 | <.001 | –.442 | <.001 |
DASS-21c | .486 | <.001 | –.539 | <.001 | –.449 | <.001 |
RESd | –.265 | <.001 | .612 | <.001 | .279 | <.001 |
MHC-SFe | –.259 | <.001 | .603 | <.001 | .319 | <.001 |
aPTSD: posttraumatic stress disorder.
bPCL-5: PTSD Checklist for DSM-5.
cDASS-21: Depression Anxiety Stress scale.
dRES: Resilience Evaluation Scale.
eMHC-SF: Mental Health Continuum Short Form.
We expected respondents with the red MIRROR outcome to report more PTSD symptoms and depression, anxiety, and stress complaints; lower psychological resilience; and positive mental health compared with respondents with the green and orange MIRROR outcome.
Means and standard deviations of reference measures for each Mobile Insight in Risk, Resilience and Online Referral (MIRROR) outcome category (n=663).
MIRRORa outcome category (n) | Green (n=24), mean (SD) | Orange (n=200), mean (SD) | Red (n=439), mean (SD) |
PTSDb (PCL-5c) | 18.04 (12.49) | 36.09 (15.77) | 46.13 (14.04) |
Depression (DASS-21d) | 4.08 (8.10) | 11.73 (11.54) | 19.66 (11.54) |
Anxiety (DASS-21) | 5.25 (6.72) | 14.03 (10.27) | 18.04 (10.30) |
Stress (DASS-21) | 10.42 (7.32) | 17.60 (9.20) | 22.49 (9.37) |
Psychological resilience (RESe) | 25.58 (5.11) | 22.04 (6.02) | 18.82 (7.15) |
Positive mental health (MHC-SFf) | 50.0 (12.05) | 43.11 (14.89) | 31.42 (14.28) |
aMIRROR: Mobile Insight in Risk, Resilience and Online Referral.
bPTSD: posttraumatic stress disorder.
cPCL-5: PTSD Checklist for DSM-5.
dDASS-21: Depression Anxiety Stress Scale.
eRES: Resilience Evaluation Scale.
fMHC-SF: Mental Health Continuum Short Form.
Classification percentages on reference measures of each Mobile Insight in Risk, Resilience, and Online Referral (MIRROR) outcome category.
We conducted several 1-way between-groups ANOVAs to investigate the difference in mean scores on the reference measures between MIRROR outcome categories. As can be seen, negative outcomes were highest for the red MIRROR outcome category and positive outcomes highest for the green outcome category. The ANOVA results are shown in
One-way between-groups analyses of variance with Mobile Insight in Risk, Resilience and Online Referral (MIRROR) outcome categories and reference measures.
Analysis of variance | Cohen |
dfa between groups | df within groups | ||
PTSDb symptomsc | 73.32 | .168 | 2 | 62.90 | <.001 |
Depressionc | 65.21 | .136 | 2 | 65.81 | <.001 |
Anxietyc | 42.48 | .072 | 2 | 67.37 | <.001 |
Stress | 34.15 | .094 | 2 | 660.0 | <.001 |
Psychological resiliencec | 30.13 | .068 | 2 | 65.44 | <.001 |
Positive mental health | 57.79 | .069 | 2 | 660.00 | <.001 |
adf: degree of freedom.
bPTSD: posttraumatic stress disorder.
cThe assumption of equal variances was violated. Therefore, the Welch
The purpose of this study was to evaluate the use and psychometric and classification properties of MIRROR. MIRROR is an innovative web-based self-help test to identify individuals who develop psychological complaints after a PTE, encourage them to seek help, and support self-reliance. Our results indicated that MIRROR is a valid and reliable self-help test to identify negative outcomes (PTSD core symptoms) and positive outcomes (psychosocial functioning and resilience). MIRROR is able to correctly classify respondents according to their PTSD complaints and scores on reference measures. During the study period, 87.95% (2247/2555) of respondents who started MIRROR completed it.
We found that MIRROR’s presupposed model of 3 factors (PTSD symptoms, psychosocial functioning, and resilience) did not fit our data best. Instead, a 2-factor solution showed good model fit, conceptual meaning, and maximum parsimony. This model separates MIRROR’s PTSD items from the functioning and resilience items (social support, self-reliance, and problem solving). In retrospect, the grouping of the functioning and resilience items is not entirely surprising. If we assume stress to be the result of an imbalance between perceived external and internal demands and perceived personal and social resources [
The convergent and divergent validity of MIRROR is supported by the correlations that were found between MIRROR and the reference measures. The results indicate good convergent and divergent validity for MIRROR’s PTSD items. As expected, MIRROR’s PTSD showed strongest correlations with PTSD (assessed with the PCL-5), followed by a lower but substantial correlation with psychological complaints (measured with the DASS-21). MIRROR’s PTSD items showed low correlations with positive reference measures (assessed with the RES and MHC-SF). The results indicate adequate convergent and divergent validity for MIRROR’s resilience items but less distinct than MIRROR’s PTSD. MIRROR’s resilience items showed strongest correlations with psychological resilience, followed by slightly lower but substantial correlations with the other reference measures. The results in this study correspond with the finding of Van der Meer et al [
We found that both MIRROR’s PTSD and resilience scales show good internal consistency. The Cronbach alpha coefficients for these scales are relatively low (.68 and .62, respectively), but this is not unusual given the (intentionally) short scales of MIRROR and given that Cronbach alpha is a function of scale length [
MIRROR was able to correctly classify respondents into green (no further action needed), orange (encourage self-monitoring), or red (encourage seeking consultation) outcome categories and advice compared with the other measures. Results showed that respondents with a red outcome reported having more severe PTSD symptoms; more severe depression, anxiety, and stress complaints; and lower psychological resilience and positive mental health compared with respondents with a green or orange outcome. The occurrence of PTSD and other stress-related complaints like depression following traumatic exposure is in line with former results [
The evaluation of MIRROR’s use with Google Analytics showed that the number of users of MIRROR was substantial (n=2555), and the completion rate was high (2247/2555, 87.95%). These results are in line with former studies on apps assessing and monitoring mental health after PTEs indicating high use [
Although guidelines on screening for PTSD complaints and postdisaster psychosocial care are widely available [
Our study has some limitations. In our validation sample, 74.2% (492/663) of respondents were female, and 45.3% (300/663) of respondents were aged between 21 and 40 years. This could lead to selection bias and limited generalizability of the results, which is common with open internet surveys [
This study shows that MIRROR is a psychometrically sound, anonymous, and easily accessible self-help test for people who have experienced a PTE. It is able to identify both negative (PTSD symptoms) and positive (psychosocial resources) outcomes of PTEs and classify respondents in accordance with reference measures. This study will hopefully contribute to enhancing adequate and timely identification of people who suffer from psychological complaints after PTEs.
Overview of outcomes in the Mobile Insight in Risk, Resilience, and Online Referral (MIRROR) instrument.
Sample characteristics on reference measures and demography (n=663).
analysis of variance
confirmatory analysis
comparative fit index
Depression Anxiety Stress scale
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
exploratory factor analysis
e-Mental health innovation and transnational implementation platform North West Europe
Global Assessment of Functioning
International Statistical Classification of Diseases and Related Health Problems, Tenth Revision
Life Events Checklist for DSM-5
Mental Health Continuum Short Form
Mobile Insight in Risk, Resilience and Online Referral
National Institute for Health and Care Excellence
PTSD Checklist for DSM-5
potentially traumatic event
posttraumatic stress disorder
Resilience Evaluation Scale
root mean square error of approximation
The European Network for Traumatic Stress
Tucker-Lewis index
means and variance adjusted weighted least square
We would like to thank Victim Support Netherlands (Slachtofferhulp Nederland) for their help in facilitating this study. This study was partially funded by the Interreg North-West Europe Programme which invested in the e-mental health innovation and transnational implementation platform North West Europe (eMEN) project, an EU-wide platform for e-mental health innovation and implementation formed by private and public partners in northwest Europe [
This study has been conducted by the independent research center ARQ Centre of Expertise for the Impact of Disasters and Crises and ARQ Centre ’45. The funders (ARQ National Psychotrauma Centre, Interreg North-West Europe, and Victim Support Netherlands) had no influence on the outcomes of this study.