Pilot randomized trial of MOMENT, a motivational counseling-plus-ecological momentary intervention to reduce marijuana use in youth

Telehealth counseling plus mHealth intervention for cannabis use in emerging adults: Development and a remote open pilot trial

INTRODUCTION

To improve treatment access for emerging adults with cannabis use disorder (CUD), we developed a telehealth counseling-plus-mHealth intervention and remotely conducted a single-arm open pilot study to preliminarily evaluate its feasibility in primary care.

METHODS

A multidisciplinary team including youth developed the intervention using the structure of the MOMENT intervention: two weekly counselor-delivered Motivational Enhancement Therapy (MET) sessions, then two weeks of smartphone surveys (4 prompted/day) querying socioemotional contexts and cannabis use, with pre-programmed messages on report of personal triggers for use (Ecological Momentary Intervention; EMI). The team adapted the MET for virtual delivery; created material to enhance self-reflection, plan behavior change, and anticipate withdrawal; shortened the sessions; and tested them with five youth actors. EMI messages were created to align with the MET and programmed to minimize repetition. Patients aged 18-25 using recreational cannabis ≥3 days/week were recruited from an urban medical practice. Participants received the intervention and responded to surveys on satisfaction and burden. At baseline, post-intervention, and two months, participants reported behavior change readiness/importance/confidence and cannabis use. EMI engagement was calculated as % days with ≥1 phone survey completed.

RESULTS

Fourteen eligible patients enrolled; 79 % used cannabis daily/near-daily and 100 % reported use problems. All completed both MET sessions and responded to EMI surveys. All agreed/strongly agreed that they felt respected by, comfortable with, and trust for the counselor and that the activities and discussion were helpful; all rated the MET sessions as very good/excellent. Technical issues were infrequent and minor. Median EMI engagement was 100 % (≥1 report/day) in each week. Behavior change confidence was higher post-intervention and importance and confidence were higher at two months vs. baseline. By two months, 11 participants had started to change cannabis use; median percent days of use in the past 30 days declined by 27 % and average times of use per use day declined by 28 %. All rated intervention quality as good, very good, or excellent.

CONCLUSIONS

Emerging adults were highly satisfied and engaged with a telehealth MET counseling-plus-mHealth EMI intervention for cannabis use and reported higher motivation to change cannabis use and less use post-intervention and at 2-month follow-up.

A mobile health intervention for emerging adults with regular cannabis use: A micro-randomized pilot trial design protocol

BACKGROUND

Emerging adult (EA) cannabis use is associated with increased risk for health consequences. Just-in-time adaptive interventions (JITAIs) provide potential for preventing the escalation and consequences of cannabis use. Powered by mobile devices, JITAIs use decision rules that take the person's state and context as input, and output a recommended intervention (e.g., alternative activities, coping strategies). The mHealth literature on JITAIs is nascent, with additional research needed to identify what intervention content to deliver when and to whom.

METHODS

Herein we describe the protocol for a pilot study testing the feasibility and acceptability of a micro-randomized trial for optimizing MiWaves mobile intervention app for EAs (ages 18-25; target N = 120) with regular cannabis use (≥3 times per week). Micro-randomizations will be determined by a reinforcement learning algorithm that continually learns and improves the decision rules as participants experience the intervention. MiWaves will prompt participants to complete an in-app twice-daily survey over 30 days and participants will be micro-randomized twice daily to either: no message or a message [1 of 6 types varying in length (short, long) and interaction type (acknowledge message, acknowledge message + click additional resources, acknowledge message + fill in the blank/select an option)]. Participants recruited via social media will download the MiWaves app, and complete screening, baseline, weekly, post-intervention, and 2-month follow-up assessments. Primary outcomes include feasibility and acceptability, with additional exploratory behavioral outcomes.

CONCLUSION

This study represents a critical first step in developing an effective mHealth intervention for reducing cannabis use and associated harms in EAs.

Systematic review of treatment completion rates and correlates among young people accessing alcohol and other drug treatment

BACKGROUND AND AIMS

Treatment completion is associated with improved alcohol and other drug (AOD) treatment outcomes. Unfortunately, treatment disengagement is common, particularly among young people. We reviewed and synthesised research on AOD treatment completion and/or early disengagement among young people.

METHODS

We conducted a systematic review and meta-analysis of studies reporting on completion rates and/or early disengagement from psychosocial AOD treatment among adolescents and young adults. An overall estimated treatment completion rate was calculated using inverse-variance random effects meta-analysis, and random-effects meta-regression was used to identify between-study level moderators of completion rate. We completed a narrative review summarising literature on early treatment disengagement and within-study level correlates of treatment completion. Study quality was assessed using the EPHPP.

RESULTS

Of the 6158 studies screened, we retained 410 for full text review and included 98 studies in the review. Treatment completion rates were reported in 88 studies, and early disengagement rates were reported in 13. The estimated overall treatment completion rate was 59 % (95 % CI=57-61 %), with experimental studies reporting higher rates of completion than observational studies. There was limited evidence for demographic or substance-related correlates of treatment completion. Contingency management was associated with increased completion rates, as was family-based intervention.

CONCLUSIONS

Disengagement from AOD treatment among youth populations is common and contributes to poor treatment outcomes. Existing research has yielded little consensus on the factors associated with treatment completion. The use of contingency management strategies and involving family/social supports in treatment were identified as potential avenues for promoting ongoing treatment engagement.

Mobile Health Interventions for Substance Use Disorders

Substance use disorders (SUDs) have an enormous negative impact on individuals, families, and society as a whole. Most individuals with SUDs do not receive treatment because of the limited availability of treatment providers, costs, inflexible work schedules, required treatment-related time commitments, and other hurdles. A paradigm shift in the provision of SUD treatments is currently underway. Indeed, with rapid technological advances, novel mobile health (mHealth) interventions can now be downloaded and accessed by those that need them anytime and anywhere. Nevertheless, the development and evaluation process for mHealth interventions for SUDs is still in its infancy. This review provides a critical appraisal of the significant literature in the field of mHealth interventions for SUDs with a particular emphasis on interventions for understudied and underserved populations. We also discuss the mHealth intervention development process, intervention optimization, and important remaining questions.

Working mechanisms of the use and acceptability of ecological momentary interventions: a realist evaluation of a guided self-help ecological momentary intervention targeting self-esteem

BACKGROUND

Technology improves accessibility of psychological interventions for youth. An ecological momentary intervention (EMI) is a digital intervention geared toward intervening in daily life to enhance the generalizability and ecological validity, and to be able to intervene in moments most needed. Identifying working mechanisms of the use of ecological momentary interventions might generate insights to improve interventions.

METHODS

The present study investigates the working mechanisms of the use and acceptability of an ecological momentary intervention, named SELFIE, targeting self-esteem in youth exposed to childhood trauma, and evaluates under what circumstances these mechanisms of use and acceptability do or do not come into play. A realist evaluation approach was used for developing initial program theories (data: expert interviews and a stakeholders focus group), and subsequently testing (data: 15 interviews with participants, a focus group with therapists, debriefing questionnaire), and refining them.

RESULTS

The SELFIE intervention is offered through a smartphone application enabling constant availability of the intervention and thereby increasing accessibility and feasibility. When the intervention was offered on their personal smartphone, this enhanced a sense of privacy and less hesitance in engaging with the app, leading to increased disclosure and active participation. Further, the smartphone application facilitates the practice of skills in daily life, supporting the repeated practice of exercises in different situations leading to the generalizability of the effect. Buffering against technical malfunction seemed important to decrease its possible negative effects.

CONCLUSIONS

This study enhanced our understanding of possible working mechanisms in EMIs, such as the constant availability supporting increased accessibility and feasibility, for which the use of the personal smartphone was experienced as a facilitating context. Hereby, the current study contributes to relatively limited research in this field. For the field to move forward, mechanisms of use, and acceptability of EMIs need to be understood. It is strongly recommended that alongside efficacy trials of an EMI on specific target mechanisms, a process evaluation is conducted investigating the working mechanisms of use.

TRIAL REGISTRATION

The current paper reports on a realist evaluation within the SELFIE trial (Netherlands Trial Register NL7129 (NTR7475)).

Combined Motivational Interviewing and Ecological Momentary Intervention to Reduce Hazardous Alcohol Use Among Sexual Minority Cisgender Men and Transgender Individuals: Protocol for a Randomized Controlled Trial

BACKGROUND

Sexual minority cisgender men and transgender (SMMT) individuals, particularly emerging adults (aged 18-34 years), often report hazardous drinking. Given that alcohol use increases the likelihood of HIV risk behaviors, and HIV disproportionately affects SMMT individuals, there is a need to test interventions that reduce hazardous alcohol use and subsequent HIV risk behaviors among this population. Ecological momentary interventions (EMIs), which use mobile phones to deliver risk reduction messages based on current location and behaviors, can help to address triggers that lead to drinking in real time.

OBJECTIVE

This study will test an EMI that uses motivational interviewing (MI), smartphone surveys, mobile breathalyzers, and location tracking to provide real-time messaging that addresses triggers for drinking when SMMT individuals visit locations associated with hazardous alcohol use. In addition, the intervention will deliver harm reduction messaging if individuals report engaging in alcohol use.

METHODS

We will conduct a 3-arm randomized controlled trial (N=405 HIV-negative SMMT individuals; n=135, 33% per arm) comparing the following conditions: (1) Tracking and Reducing Alcohol Consumption (a smartphone-delivered 4-session MI intervention), (2) Tracking and Reducing Alcohol Consumption and Environmental Risk (an EMI combining MI with real-time messaging based on geographic locations that are triggers to drinking), and (3) a smartphone-based alcohol monitoring-only control group. Breathalyzer results and daily self-reports will be used to assess the primary and secondary outcomes of drinking days, drinks per drinking day, binge drinking episodes, and HIV risk behaviors. Additional assessments at baseline, 3 months, 6 months, and 9 months will evaluate exploratory long-term outcomes.

RESULTS

The study is part of a 5-year research project funded in August 2022 by the National Institute on Alcohol Abuse and Alcoholism. The first 1.5 years of the study will be dedicated to planning and development activities, including formative research, app design and testing, and message design and testing. The subsequent 3.5 years will see the study complete participant recruitment, data collection, analyses, report writing, and dissemination. We expect to complete all study data collection in or before January 2027.

CONCLUSIONS

This study will provide novel evidence about the relative efficacy of using a smartphone-delivered MI intervention and real-time messaging to address triggers for hazardous alcohol use and sexual risk behaviors. The EMI approach, which incorporates location-based preventive messaging and behavior surveys, may help to better understand the complexity of daily stressors among SMMT individuals and their impact on hazardous alcohol use and HIV risk behaviors. The tailoring of this intervention toward SMMT individuals helps to address their underrepresentation in existing alcohol use research and will be promising for informing where structural alcohol use prevention and treatment interventions are needed to support SMMT individuals.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05576350; https://www.clinicaltrials.gov/study/NCT05576350.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/55166.

Brief observable anxiety sensitivity treatment: intervention development and a pilot randomized-controlled acceptability and feasibility trial to evaluate a brief intervention for anxiety sensitivity social concerns

Social anxiety disorder is one of the most prevalent anxiety disorders. There is a need to develop brief, virtual, single-session interventions targeting constructs associated with social anxiety, such as anxiety sensitivity social concerns (ASSC). ASSC is the maladaptive belief about consequences arising from observable symptoms of anxious arousal. This study was designed to evaluate the initial acceptability and feasibility of a brief ASSC reduction program (Brief Observable Anxiety Sensitivity Treatment [BOAST]) which included a single clinician-led intervention session followed by a two-week ecological momentary intervention (EMI), delivered via mobile app. Participants (N = 36) were adults with elevated ASSC who were randomly assigned to receive BOAST (n = 19) or a waitlist control (n = 17). The trial was prospectively registered at clinicaltrials.gov (NCT04859790). Results supported the acceptability of BOAST with mixed findings for feasibility. Feasibility metrics for the EMI component were below pre-defined thresholds; however, there was evidence that homework completion was associated with symptom reduction. Preliminary efficacy metrics indicated that participants in the BOAST condition had large reductions in ASSC and one measure of social anxiety at 1-month follow-up. This study provides preliminary support for the acceptability of BOAST and elucidates avenues for future clinical and research efforts.

Substance Use Screening, Brief Intervention, and Referral to Treatment in Pediatric Primary Care, School-Based Health Clinics, and Mental Health Clinics

Adolescent cannabis use is a modifiable health behavior with potential adverse developmental, cognitive, psychological, and health effects. Over the last 2 decades, work to promote implementation of screening, brief intervention, and referral to treatment has improved screening, use of validated screening tools, and preventive messaging. Current intervention strategies for cannabis use are associated with modest, short-term effects, and referral to treatment is limited by availability of resources for adolescent substance use. This article provides an update on the evidence base for screening, brief intervention, referral to treatment, and the current state of implementation focused on management of cannabis use disorder.

The effectiveness of mobile-based ecological momentary motivational enhancement therapy in reducing craving and severity of cannabis use disorder: Study protocol for a randomized controlled trial

Objective

This study aims to investigate the effectiveness of Ecological Momentary Motivational Enhancement Therapy (EM-MET) in reducing craving and severity of Cannabis Use Disorder (CUD) among young adults.

Methods

This multicenter, single-blinded randomized controlled trial (RCT) will be conducted over a period of 11 weeks. Eighty patients with CUD will be randomly assigned to two equal-sized parallel groups, either the Motivational Enhancement Therapy (MET) group or the EM-MET group. All participants will receive four individual face-to-face sessions of MET (twice a week). The MET group will not receive any other treatments after these sessions; however, in the EM-MET group, the top triggers of patients will be assessed using mobile-based Ecological Momentary Assessment (EMA) five times a day within three weeks (after face-to-face sessions) and they will receive a call from the therapist who provides them with EM-MET (in the form of an emergency telephone helpline) as soon as they report experiencing triggers of cannabis use that are assessed using EMA in their everyday lives. Primary outcomes including CUD severity and the severity of craving will be evaluated using the Leeds Dependence Questionnaire and the Self-efficacy and Temptation Scale, respectively. These assessments will be conducted at pre-treatment, post-treatment, and a six-week follow-up.

Discussion

If proven feasible and effective, the results of this study will offer clinicians an evidence-based treatment approach to address craving and dependency in patients with CUD. Moreover, these patients will receive effective treatment in real time and in real life, when and where it is most needed. However, it is important to consider the limitations of this study, such as the specific population studied in Tehran, Iran, which may affect the generalizability of the results. Nevertheless, the implementation of Ecological Momentary Interventions (EMIs) in real-life settings holds promise for timely and effective treatment.Trial registration: This trial was registered in the Iranian Registry of Clinical Trials on 21 February 2023. Registry No. IRCT20221224056908N1.

Psychological Interventions for Cannabis Use among Adolescents and Young Adults: A Systematic Review

Regular cannabis use during adolescence can lead to cognitive, psychological, and social consequences, causing significant distress. Although psychological interventions are the mainstay type of treatment for cannabis use disorder, the results remain mixed among youths. The objective of this review is twofold: to identify the existing psychological interventions for cannabis use among youths, and to assess the evidence regarding the effectiveness of those interventions. Randomized controlled trials focused exclusively on cannabis use among adolescents and young adults were included. Three databases-Embase, PsycInfo, and PubMed-were searched to identify relevant peer-reviewed manuscripts published before February 2022 in English and French. The risk of bias was assessed using the Cochrane Collaboration's tool. Twenty-five randomized controlled trials were included. Fourteen studies reported a significant outcome related to cannabis use. These were mainly non-intensive, online interventions that aimed to improve the patients' relationships and emotion regulation. This review highlights the need to conduct additional randomized control trials that target cannabis use disorder specifically among adolescents. These randomized control trials should also aim to reduce the risk of bias related to psychiatric comorbidities as well as detection and attrition problems.

The Craving-Manager smartphone app designed to diagnose substance use/addictive disorders, and manage craving and individual predictors of relapse: a study protocol for a multicenter randomized controlled trial

Background

The rate of individuals with addiction who are currently treated are low, and this can be explained by barriers such as stigma, desire to cope alone, and difficulty to access treatment. These barriers could be overcome by mobile technologies. EMI (Ecological Momentary Intervention) is a treatment procedure characterized by the delivery of interventions (messages on smartphones) to people in their daily lives. EMI presents opportunities for treatments to be available to people during times and in situations when they are most needed. Craving is a strong predictor of relapse and a key target for addiction treatment. Studies using Ecological Momentary Assessment (EMA) method have revealed that, in daily life, person-specific cues could precipitate craving, that in turn, is associated with a higher probability to report substance use and relapse in the following hours. Assessment and management of these specific situations in daily life could help to decrease addictive use and avoid relapse. The Craving-Manager smartphone app has been designed to diagnose addictive disorders, and assess and manage craving as well as individual predictors of use/relapse. It delivers specific and individualized interventions (counseling messages) composed of evidence-based addiction treatments approaches (cognitive behavioral therapy and mindfulness). The Craving-Manager app can be used for any addiction (substance or behavior). The objective of this protocol is to evaluate the efficacy of the Craving-Manager app in decreasing use (of primary substance(s)/addictive behavior(s)) over 4 weeks, among individuals on a waiting list for outpatient addiction treatment.

Methods/design

This multicenter double-blind randomized controlled trial (RCT) will compare two parallel groups: experimental group (full interventional version of the app, 4 weeks, EMA + EMI), versus control group (restricted version of the app, 4 weeks, only EMA). Two hundred and seventy-four participants will be recruited in 6 addiction treatment centers in France.

Discussion

This RCT will provide indication on how the Craving-Manager app will reduce addictive use (e.g., better craving management, better stimulus control) in both substance and behavioral addictions. If its efficacy is confirmed, the app could offer the possibility of an easy to use and personalized intervention accessible to the greatest number of individuals with addiction.

Clinical Trial Registration

ClinicalTrials.gov: NCT04732676.

Associations of Momentary Mindfulness With Affect and Cannabis Desire in a Trial of Cannabis Use Interventions With and Without Momentary Assessment

PURPOSE

Mindfulness, awareness resulting from attending to the present without judgment, has been associated with improved health. When considered as a time-varying momentary state, mindfulness is associated with other momentary states such as affect. We examined whether momentary mindfulness, specifically mindful attention and awareness (MAA), changed after counseling interventions to reduce cannabis use that included ecological momentary assessment (EMA) and explored associations with negative affect, positive affect, and cannabis desire.

METHODS

Outpatients 15-24 years using cannabis ≥3x/week were randomized to one of the three interventions, each including two motivational enhancement therapy (MET) sessions. For two interventions, MET was followed by 2 weeks of EMA (with/without messaging). Momentary MAA, negative affect, positive affect, and cannabis desire were assessed over 1 week of EMA at baseline and 3-month follow-up (N = 1,971 reports, 68 participants). We examined changes in momentary MAA from baseline to follow-up overall and by group (MET + EMA, MET-only) using generalized linear mixed effects models. We tested associations of momentary MAA with momentary affect and cannabis desire using generalized estimating equations.

RESULTS

Momentary MAA increased from baseline to follow-up after MET counseling plus EMA (β = 0.237), but did not change with MET counseling alone. Higher momentary MAA was associated with lower negative affect (β = -0.526) and cannabis desire (β = -0.521), but not with positive affect.

DISCUSSION

Among youth using cannabis frequently, momentary MAA was increased 3 months after interventions with EMA after counseling and was inversely associated with momentary negative affect and momentary cannabis desire. Mindfulness may be a useful target for momentary intervention.

Substance Use Screening, Brief Intervention, and Referral to Treatment in Pediatric Primary Care, School-Based Health Clinics, and Mental Health Clinics

Adolescent cannabis use is a modifiable health behavior with potential adverse developmental, cognitive, psychological, and health effects. Over the last 2 decades, work to promote implementation of screening, brief intervention, and referral to treatment has improved screening, use of validated screening tools, and preventive messaging. Current intervention strategies for cannabis use are associated with modest, short-term effects, and referral to treatment is limited by availability of resources for adolescent substance use. This article provides an update on the evidence base for screening, brief intervention, referral to treatment, and the current state of implementation focused on management of cannabis use disorder.

Online interventions for cannabis use among adolescents and young adults: Systematic review and meta-analysis

BACKGROUND

Young people present high rates of cannabis use, abuse, and dependence. The United Nations estimates that roughly 3.8% of the global population aged 15-64 years used cannabis at least once in 2017. Cannabis use in young people may impair cognitive skills, interfere with learning, impact relationships, and lead to long term behavioural and psychological consequences. Online cannabis interventions (OCI) are increasingly popular, but their dissemination is not often supported by empirical evidence.

AIM

To systematically compile and analyse the effectiveness of OCI for the reduction of cannabis use among adolescents and young adults (AYA).

METHODS

Pooled effect sizes of cannabis use between treatment and control groups were estimated. For each comparison, Hedge's g was calculated using a random effects model.

RESULTS

The search strategy yielded 4531 articles. Of those, a total of 411 articles were retrieved for detailed evaluation resulting in 17 eligible studies (n = 3525). Analyses revealed that online interventions did not significantly reduce cannabis consumption (Hedge's g = -0.061, 95% CI [-0.363] to [-0.242], p = .695) and high heterogeneity was noted (Q = 191.290). More recent studies using structured interventions, daily feedback, AYA centred designs, and peer support, specifically targeting CU seemed to have positive effects to address CU in this population.

CONCLUSIONS

The lack of positive outcomes suggests that more specific and targeted interventions may be necessary to promote cannabis-related behavioural change among young people. These targeted interventions may include structured CU modules, daily feedback, peer support for increased adherence, user-centred design procedures, and input from key stakeholders such as families and service providers.

Novel approaches for treating Internet Gaming Disorder: A review of technology-based interventions

Internet Gaming Disorder (IGD) has become a significant issue in mental healthcare over the past decades as the number of people engaging in excessive and unhealthy gaming increases with each year. Despite its inclusion in the 5th Edition of Diagnostic Statistical Manual and the development of a number of treatment methods that have been designed and tested for IGD, treatment remains a challenge. This review attempts to give an overview of the current state of IGD and its treatment with a specific focus on the potential of technology-based solutions, such as web-based programs, mobile applications, and virtual reality. The review also highlights the need for additional work in the area of treatment development for IGD and the preliminary evidence for the usefulness and importance of technology-based treatment methods which offer unique advantages, such as accessibility, scalability, and cost-effectiveness, over other existing treatment options.

Technology-mediated just-in-time adaptive interventions (JITAIs) to reduce harmful substance use: a systematic review

BACKGROUND AND AIMS

Lapse risk when trying to stop or reduce harmful substance use is idiosyncratic, dynamic and multi-factorial. Just-in-time adaptive interventions (JITAIs) aim to deliver tailored support at moments of need or opportunity. We aimed to synthesize evidence on decision points, tailoring variables, intervention options, decision rules, study designs, user engagement and effectiveness of technology-mediated JITAIs for reducing harmful substance use.

METHODS

Systematic review of empirical studies of any design with a narrative synthesis. We searched Ovid MEDLINE, Embase, PsycINFO, Web of Science, the ACM Digital Library, the IEEE Digital Library, ClinicalTrials.gov, the ISRCTN register and dblp using terms related to substance use/mHealth/JITAIs. Outcomes were user engagement and intervention effectiveness. Study quality was assessed with the mHealth Evidence Reporting and Assessment checklist.

FINDINGS

We included 17 reports of 14 unique studies, including two randomized controlled trials. JITAIs targeted alcohol (S = 7, n = 120 520), tobacco (S = 4, n = 187), cannabis (S = 2, n = 97) and a combination of alcohol and illicit substance use (S = 1, n = 63), and primarily relied on active measurement and static (i.e. time-invariant) decision rules to deliver support tailored to micro-scale changes in mood or urges. Two studies used data from prior participants and four drew upon theory to devise decision rules. Engagement with available JITAIs was moderate-to-high and evidence of effectiveness was mixed. Due to substantial heterogeneity in study designs and outcome variables assessed, no meta-analysis was performed. Many studies reported insufficient detail on JITAI infrastructure, content, development costs and data security.

CONCLUSIONS

Current implementations of just-in-time adaptive interventions (JITAIs) for reducing harmful substance use rely on active measurement and static decision rules to deliver support tailored to micro-scale changes in mood or urges. Studies on JITAI effectiveness are lacking.

Trends in cannabis-related attitudes and behaviors among cannabis-using adolescent and young adult outpatients following medical cannabis legalization in Massachusetts

Background: Among youth already using cannabis, legalization of medical cannabis may influence cannabis-related attitudes and behaviors, including increasing access through use of someone else's medical cannabis (diversion). Objective: To examine cannabis-related attitudes and behaviors (including diverted cannabis use) in cannabis-using youth in the four years following medical cannabis legalization. Additionally, we investigated characteristics of youth who used vs. did not use diverted medical cannabis. Methods: Data were collected in Boston from 2013 (when medical cannabis legislation took effect in Massachusetts) through 2016 (when recreational cannabis use became legal in Massachusetts). Cannabis-using youth (age 13-24) presenting to an outpatient adolescent substance use treatment program (ASUTP) or recruited for an adolescent medicine clinic study (AMCS) completed a confidential survey on demographic characteristics and cannabis use behaviors and attitudes. We used multiple logistic regression to analyze changes in attitudes and behaviors over three years versus the reference year (2013), controlling for demographics. We used chi-square to compare characteristics of youth reporting use of diverted medical cannabis versus those not. Results: The sample included 273 cannabis-using youth (ASUTP n = 203, AMCS n = 70; 2013 n = 67, 2014 n = 67, 2015 n = 77, 2016 n = 62). Mean ± SD age was 18.2 ± 2.5 years, 32% were female, 58% were White non-Hispanic, and 70% had college-graduate parents. In 2013, most youth reported that cannabis was easy to obtain (97.9%), and that occasional cannabis use had "no" or "slight" risk of harm (89.4%), with little change across years. In 2016, 44% of youth reported using someone else's medical cannabis, versus 15% in 2013 (aOR 4.66, 95% CI 1.81, 11.95). Youth using diverted medical cannabis had higher likelihood of reporting riding with a driver, or driving themselves, after cannabis use (both p < .01). Conclusion: Among at-risk youth in Massachusetts, use of diverted medical cannabis increased after medical cannabis legalization, and those using diverted medical cannabis reported higher risk for cannabis-related traffic injury.

Developing a Smartphone-Based Adjunct Intervention to Reduce Cannabis Use Among Juvenile Justice-Involved Adolescents: A Multiphase Study Protocol (Preprint)

Background

Adolescents involved in the juvenile justice system who use cannabis are at an increased risk of future substance use disorders and rearrest. Many court-involved, nonincarcerated (CINI) youth are referred for services in the community and often encounter multiple barriers to care, highlighting the need for minimally burdensome services that can be delivered in justice settings. Digital health interventions are accessible, easy to implement, and can provide ongoing support but have not been developed to address the unique needs of CINI youth who use cannabis.

Objective

This multiphase study will aim to develop, implement, and pilot test a novel smartphone app, Teen Empowerment through Computerized Health (TECH), to reduce cannabis and other substance use among CINI youth. TECH is conceptualized as a digital adjunct to a brief computerized intervention delivered by our family court partner.

Methods

Following the principles of user-centered design, phase I interviews with CINI youth aged 14-18 years (n=14-18), their caregivers (n=6-8), and behavioral health app developers (n=6-8) will guide the TECH design decisions. Next, in phase II, CINI youth (n=10) will beta test the TECH app prototype for 1 month; their feedback regarding feasibility and acceptability will directly inform the app refinement process. Finally, in phase III, CINI youth (n=60) will participate in a pilot randomized controlled trial for 6 months, comparing the preliminary effectiveness of the adjunctive TECH app on cannabis use outcomes.

Results

Phase I data collection began in September 2020 and was completed in December 2021; 14 CINI youth, 8 caregivers, and 11 behavioral health app developers participated in the study. Phases II and III will occur in 2022 and 2023 and 2023 and 2025, respectively.

Conclusions

This body of work will provide insight into the feasibility and acceptability of a smartphone-based adjunctive intervention designed for CINI youth. Phase III results will offer a preliminary indication of the effectiveness of the TECH app in reducing cannabis use among CINI youth.

International Registered Report Identifier (IRRID)

DERR1-10.2196/35402

Translating strategies for promoting engagement in mobile health: A proof-of-concept microrandomized trial

OBJECTIVE

Mobile technologies allow for accessible and cost-effective health monitoring and intervention delivery. Despite these advantages, mobile health (mHealth) engagement is often insufficient. While monetary incentives may increase engagement, they can backfire, dampening intrinsic motivations and undermining intervention scalability. Theories from psychology and behavioral economics suggest useful nonmonetary strategies for promoting engagement; however, examinations of the applicability of these strategies to mHealth engagement are lacking. This proof-of-concept study evaluates the translation of theoretically-grounded engagement strategies into mHealth, by testing their potential utility in promoting daily self-reporting.

METHOD

A microrandomized trial (MRT) was conducted with adolescents and emerging adults with past-month substance use. Participants were randomized multiple times daily to receive theoretically-grounded strategies, namely reciprocity (the delivery of inspirational quote prior to self-reporting window) and nonmonetary reinforcers (e.g., the delivery of meme/gif following self-reporting completion) to improve proximal engagement in daily mHealth self-reporting.

RESULTS

Daily self-reporting rates (62.3%; n = 68) were slightly lower than prior literature, albeit with much lower financial incentives. The utility of specific strategies was found to depend on contextual factors pertaining to the individual's receptivity and risk for disengagement. For example, the effect of reciprocity significantly varied depending on whether this strategy was employed (vs. not employed) during the weekend. The nonmonetary reinforcement strategy resulted in different outcomes when operationalized in various ways.

CONCLUSIONS

While the results support the translation of the reciprocity strategy into this mHealth setting, the translation of nonmonetary reinforcement requires further consideration prior to inclusion in a full scale MRT. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Smartphone-Delivered Ecological Momentary Interventions Based on Ecological Momentary Assessments to Promote Health Behaviors: Systematic Review and Adapted Checklist for Reporting Ecological Momentary Assessment and Intervention Studies

Background

Healthy behaviors are crucial for maintaining a person’s health and well-being. The effects of health behavior interventions are mediated by individual and contextual factors that vary over time. Recently emerging smartphone-based ecological momentary interventions (EMIs) can use real-time user reports (ecological momentary assessments [EMAs]) to trigger appropriate support when needed in daily life.

Objective

This systematic review aims to assess the characteristics of smartphone-delivered EMIs using self-reported EMAs in relation to their effects on health behaviors, user engagement, and user perspectives.

Methods

We searched MEDLINE, Embase, PsycINFO, and CINAHL in June 2019 and updated the search in March 2020. We included experimental studies that incorporated EMIs based on EMAs delivered through smartphone apps to promote health behaviors in any health domain. Studies were independently screened. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. We performed a narrative synthesis of intervention effects, user perspectives and engagement, and intervention design and characteristics. Quality appraisal was conducted for all included studies.

Results

We included 19 papers describing 17 unique studies and comprising 652 participants. Most studies were quasi-experimental (13/17, 76%), had small sample sizes, and great heterogeneity in intervention designs and measurements. EMIs were most popular in the mental health domain (8/17, 47%), followed by substance abuse (3/17, 18%), diet, weight loss, physical activity (4/17, 24%), and smoking (2/17, 12%). Of the 17 studies, the 4 (24%) included randomized controlled trials reported nonstatistically significant effects on health behaviors, and 4 (24%) quasi-experimental studies reported statistically significant pre-post improvements in self-reported primary outcomes, namely depressive (P<.001) and psychotic symptoms (P=.03), drinking frequency (P<.001), and eating patterns (P=.01). EMA was commonly used to capture subjective experiences as well as behaviors, whereas sensors were rarely used. Generally, users perceived EMIs to be helpful. Common suggestions for improvement included enhancing personalization, multimedia and interactive capabilities (eg, voice recording), and lowering the EMA reporting burden. EMI and EMA components were rarely reported and were not described in a standardized manner across studies, hampering progress in this field. A reporting checklist was developed to facilitate the interpretation and comparison of findings and enhance the transparency and replicability of future studies using EMAs and EMIs.

Conclusions

The use of smartphone-delivered EMIs using self-reported EMAs to promote behavior change is an emerging area of research, with few studies evaluating efficacy. Such interventions could present an opportunity to enhance health but need further assessment in larger participant cohorts and well-designed evaluations following reporting checklists. Future research should explore combining self-reported EMAs of subjective experiences with objective data passively collected via sensors to promote personalization while minimizing user burden, as well as explore different EMA data collection methods (eg, chatbots).

Trial Registration

PROSPERO CRD42019138739; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=138739

Digital Phenotyping in Child and Adolescent Psychiatry: A Perspective

Digital phenotyping (DP) provides opportunities to study child and adolescent psychiatry from a novel perspective. DP combines objective data obtained from digital sensors with participant-generated "active data," in order to understand better an individual's behavior and environmental interactions. Although this new method has led to advances in adult psychiatry, its use in child psychiatry has been more limited. This review aims to demonstrate potential benefits of DP methodology and passive data collection by reviewing studies specifically in child and adolescent psychiatry. Twenty-six studies were identified that collected passive data from four different categories: accelerometer/actigraph data, physiological data, GPS data, and step count. Study topics ranged from the associations between manic symptomology and cardiac parameters to the role of daily emotions, sleep, and social interactions in treatment for pediatric anxiety. Reviewed studies highlighted the diverse ways in which objective data can augment naturalistic self-report methods in child and adolescent psychiatry to allow for more objective, ecologically valid, and temporally resolved conclusions. Though limitations exist-including a lack of participant adherence and device failure and misuse-DP technology may represent a new and effective method for understanding pediatric cognition, behavior, disease etiology, and treatment efficacy.

Real-world simultaneous alcohol and cannabis use: An ecological study of situational motives and social and physical contexts

OBJECTIVE

Given the adverse outcomes associated with simultaneous alcohol and marijuana (SAM) use, understanding factors that give rise to occasions of simultaneous use is critical. This study examines the relationships between situational motives and contexts and three situational outcomes: simultaneous alcohol and marijuana use (SAM) use versus cannabis-only use, number of cannabis uses, and subjective effects.

METHOD

Past-month SAM users (n = 341; 52% female; 75% White; 10% Latinx/Hispanic; age 18-24) from three U.S. college campuses completed 8 weeks of surveys up to five times a day. Three-level generalized linear mixed-effects models tested the effects of situational motives and social and physical contexts on occasion type (SAM vs. cannabis-only), cannabis use, and subjective effects.

RESULTS

Situational social and enhancement motives were related to greater odds of SAM relative to cannabis-only use; expansion motives were reported more often on cannabis-only occasions. Using with others and at friends' places, being with others consuming cannabis, and being with others who are intoxicated were more likely when combining alcohol with cannabis. Increased number of cannabis uses and subjective effects in a social context were evident only on cannabis-only occasions. Using alone and using at home were greater on cannabis-only occasions and were associated with lower cannabis use and subjective effects.

CONCLUSIONS

The combination of alcohol and cannabis use occurs during social situations and when motivated by positive reinforcement but number of cannabis uses is not increased when consuming cannabis with alcohol in social situations. Characterizing the complex interplay of situational factors that contribute to risky use will inform interventions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Mobile Ecological Momentary Assessment and Intervention and Health Behavior Change Among Adults in Rakai, Uganda: Pilot Randomized Controlled Trial

BACKGROUND

An extraordinary increase in mobile phone ownership has revolutionized the opportunities to use mobile health approaches in lower- and middle-income countries (LMICs). Ecological momentary assessment and intervention (EMAI) uses mobile technology to gather data and deliver timely, personalized behavior change interventions in an individual's natural setting. To our knowledge, there have been no previous trials of EMAI in sub-Saharan Africa.

OBJECTIVE

To advance the evidence base for mobile health (mHealth) interventions in LMICs, we conduct a pilot randomized trial to assess the feasibility of EMAI and establish estimates of the potential effect of EMAI on a range of health-related behaviors in Rakai, Uganda.

METHODS

This prospective, parallel-group, randomized pilot trial compared health behaviors between adult participants submitting ecological momentary assessment (EMA) data and receiving behaviorally responsive interventional health messaging (EMAI) with those submitting EMA data alone. Using a fully automated mobile phone app, participants submitted daily reports on 5 different health behaviors (fruit consumption, vegetable consumption, alcohol intake, cigarette smoking, and condomless sex with a non-long-term partner) during a 30-day period before randomization (P1). Participants were then block randomized to the control arm, continuing EMA reporting through exit, or the intervention arm, EMA reporting and behavioral health messaging receipt. Participants exited after 90 days of follow-up, divided into study periods 2 (P2: randomization + 29 days) and 3 (P3: 30 days postrandomization to exit). We used descriptive statistics to assess the feasibility of EMAI through the completeness of data and differences in reported behaviors between periods and study arms.

RESULTS

The study included 48 participants (24 per arm; 23/48, 48% women; median age 31 years). EMA data collection was feasible, with 85.5% (3777/4418) of the combined days reporting behavioral data. There was a decrease in the mean proportion of days when alcohol was consumed in both arms over time (control: P1, 9.6% of days to P2, 4.3% of days; intervention: P1, 7.2% of days to P3, 2.4% of days). Decreases in sex with a non-long-term partner without a condom were also reported in both arms (P1 to P3 control: 1.9% of days to 1% of days; intervention: 6.6% of days to 1.3% of days). An increase in vegetable consumption was found in the intervention (vegetable: 65.6% of days to 76.6% of days) but not in the control arm. Between arms, there was a significant difference in the change in reported vegetable consumption between P1 and P3 (control: 8% decrease in the mean proportion of days vegetables consumed; intervention: 11.1% increase; P=.01).

CONCLUSIONS

Preliminary estimates suggest that EMAI may be a promising strategy for promoting behavior change across a range of behaviors. Larger trials examining the effectiveness of EMAI in LMICs are warranted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04375423; https://www.clinicaltrials.gov/ct2/show/NCT04375423.

Experience Sampling and Programmed Intervention Method and System for Planning, Authoring, and Deploying Mobile Health Interventions: Design and Case Reports

BACKGROUND

Health professionals initiating mobile health (mHealth) interventions may choose to adapt apps designed for other activities (eg, peer-to-peer communication) or to employ purpose-built apps specialized in the required intervention, or to exploit apps based on methods such as the experience sampling method (ESM). An alternative approach for professionals would be to create their own apps. While ESM-based methods offer important guidance, current systems do not expose their design at a level that promotes replicating, specializing, or extending their contributions. Thus, a twofold solution is required: a method that directs specialists in planning intervention programs themselves, and a model that guides specialists in adopting existing solutions and advises software developers on building new ones.

OBJECTIVE

The main objectives of this study are to design the Experience Sampling and Programmed Intervention Method (ESPIM), formulated toward supporting specialists in deploying mHealth interventions, and the ESPIM model, which guides health specialists in adopting existing solutions and advises software developers on how to build new ones. Another goal is to conceive and implement a software platform allowing specialists to be users who actually plan, create, and deploy interventions (ESPIM system).

METHODS

We conducted the design and evaluation of the ESPIM method and model alongside a software system comprising integrated web and mobile apps. A participatory design approach with stakeholders included early software prototype, predesign interviews with 12 health specialists, iterative design sustained by the software as an instance of the method's conceptual model, support to 8 real case studies, and postdesign interviews.

RESULTS

The ESPIM comprises (1) a list of requirements for mHealth experience sampling and intervention-based methods and systems, (2) a 4-dimension planning framework, (3) a 7-step-based process, and (4) an ontology-based conceptual model. The ESPIM system encompasses web and mobile apps. Eight long-term case studies, involving professionals in psychology, gerontology, computer science, speech therapy, and occupational therapy, show that the method allowed specialists to be actual users who plan, create, and deploy interventions via the associated system. Specialists' target users were parents of children diagnosed with autism spectrum disorder, older persons, graduate and undergraduate students, children (age 8-12), and caregivers of older persons. The specialists reported being able to create and conduct their own studies without modifying their original design. A qualitative evaluation of the ontology-based conceptual model showed its compliance to the functional requirements elicited.

CONCLUSIONS

The ESPIM method succeeds in supporting specialists in planning, authoring, and deploying mobile-based intervention programs when employed via a software system designed and implemented according to its conceptual model. The ESPIM ontology-based conceptual model exposes the design of systems involving active or passive sampling interventions. Such exposure supports the evaluation, implementation, adaptation, or extension of new or existing systems.

Trait mindfulness and cannabis use-related factors in adolescents and young adults with frequent use

BACKGROUND

Mindfulness-based interventions (MBIs) are effective in adult substance-use treatment and may be helpful for adolescents and young adults (AYAs). One target of MBIs is to improve trait mindfulness, which has been associated with better lifestyle and health outcomes. To inform MBIs for reducing cannabis use in AYAs, we sought to identify how trait mindfulness was associated with cannabis-related problems and quit attempts, as well as with motivation to change use in youth who report frequent use. Methods: Participants aged 15-24 years using cannabis ≥ 3x/week were recruited from AYA clinics in a northeastern US city to participate in a cannabis-use intervention pilot, randomized trial. At baseline, we assessed cannabis-use history, problems associated with use, attempts to quit, and trait mindfulness. All participants were offered two sessions of motivational enhancement therapy, during which they rated motivation to quit cannabis. Regression analyses were conducted to assess associations between trait mindfulness and cannabis use-related problems, attempts to quit, and motivation to change. Results: Seventy participants, mean age 20.7 ± 1.9 years, enrolled. Sixty percent identified as female, 47% as Black non-Hispanic, and 31% as Hispanic. Participants started using cannabis at mean age 15.0 ± 2.8 years and were using ≥ 3x/week by 17.0 ± 2.3 years. Higher mindfulness scores were associated with fewer cannabis-related problems (p = 0.004) and fewer quit attempts (p = 0.035). The number of cannabis-related problems did not significantly mediate the relationship between mindfulness and quit attempts. Trait mindfulness did not predict motivation to change cannabis use. Conclusions: Among AYAs using cannabis frequently, higher trait mindfulness was associated with both fewer cannabis use--related problems and fewer quit attempts. Future research should assess whether trait mindfulness is an appropriate target for decreasing cannabis use and the utility of MBIs for reducing cannabis-use behaviors.

Ecological momentary interventions for mental health: A scoping review

BACKGROUND

The development of mobile computing technology has enabled the delivery of psychological interventions while people go about their everyday lives. The original visions of the potential of these "ecological momentary interventions" were presented over a decade ago, and the widespread adoption of smartphones in the intervening years has led to a variety of research studies exploring the feasibility of these aspirations. However, there is a dearth of research describing the different dimensions, characteristics, and features of these interventions, as constructed.

OBJECTIVE

To provide an overview of the definitions given for "ecological momentary interventions" in the treatment of common mental health disorders, and describe the set of technological and interaction possibilities which have been used in the design of these interventions.

METHODS

A systematic search identified relevant literature published between 2009 and 2020 in the PubMed, PsycInfo, and ACM Guide to the Computing Literature databases. Following screening, data were extracted from eligible articles using a standardized extraction worksheet. Selected articles were then thematically categorized.

RESULTS

The search identified 583 articles of which 64 met the inclusion criteria. The interventions target a range of mental health problems, with diverse aims, intervention designs and evaluation approaches. The studies employed a variety of features for intervention delivery, but recent research is overwhelmingly comprised of studies based on smartphone apps (30 of 42 papers that described an intervention). Twenty two studies employed sensors for the collection of data in order to provide just-in-time support or predict psychological states.

CONCLUSIONS

With the shift towards smartphone apps, the vision for EMIs has begun to be realised. Recent years have seen increased exploration of the use of sensors and machine learning, but the role of humans in the delivery of EMI is also varied. The variety of capabilities exhibited by EMIs motivates development of a more precise vocabulary for capturing both automatic and human tailoring of these interventions.

Leveraging digital tools to support recovery from substance use disorder during the COVID-19 pandemic response

Treatment for substance use disorder (SUD) during the COVID-19 pandemic poses unique challenges, both due to direct effects from the illness, and indirect effects from the physical measures needed to "flatten the curve." Stress, isolation, lack of structure, limited access to physical and mental health care, and changes in treatment paradigms all increase risk of return to drug use events and pose barriers to recovery for people with SUDs. The pandemic has forced treatment providers and facilities to rapidly adapt to address these threats while redesigning their structure to accommodate physical distancing regulations. Digital health interventions can function without the need for physical proximity. Clinicians can use digital health intervention, such as telehealth, wearables, mobile applications, and other remote monitoring devices, to convert in-person care to remote-based care, and they can leverage these tools to address some of the pandemic-specific challenges to treatment. The current pandemic provides the opportunity to rapidly explore the advantages and limitations of these technologies in the care of individuals with SUD.

Engagement with Manage My Pain mobile health application among patients at the Transitional Pain Service

Objective

Mobile health platforms have become an important component of pain self-management programs and hundreds of mobile applications are commercially available for patients to monitor pain. However, few of these applications have been developed in collaboration with healthcare professionals or have been critically evaluated. Manage My Pain is a user-driven mobile health platform developed by ManagingLife in collaboration with clinician researchers. Manage My Pain allows patients to keep a "pain record" and supports communication of this information with clinicians. The current report describes a user engagement study of Manage My Pain among patients at the Transitional Pain Service (TPS) at Toronto General Hospital, a multidisciplinary clinic for patients at high risk of developing postsurgical pain.

Methods

Patients at the TPS were encouraged to register on Manage My Pain as one component of a larger, non-randomized prospective study of treatment predictors and treatment enhancement. Uptake of the application and rates of registration, use, and retention were tracked for 90 days.

Results

Of the 196 patients who consented to the larger study, 132 (67%) also provided consent to the Manage My Pain component, indicating that they found this to be an acceptable treatment adjunct, and 119 (61%) completed registration. Of those who used the app, 67.9% and 43.2% continued to use Manage My Pain beyond 30 and 90 days, respectively. On average, users engaged with the app for 93.14 days (SD = 151.9 days) logged an average of 47.39 total records (SD = 136.1).

Conclusions

Manage My Pain was found acceptable by a majority of patients at an academic pain management program. Rates of user registration and retention were favorable compared to those reported by other applications. Further research is needed to develop strategies to retain users and maximize patient benefit.

Current reporting of usability and impact of mHealth interventions for substance use disorder: A systematic review

BACKGROUND

Connected interventions use data collected through mobile/wearable devices to trigger real-time interventions and have great potential to improve treatment for substance use disorder (SUD). This review aims to describe the current landscape, effectiveness and usability of connected interventions for SUD.

METHODS

A systematic review was conducted to identify articles evaluating connected health interventions for SUD in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three databases (PubMed, IEEE, and Scopus) were searched over a five-year period. Included articles described a connected health intervention targeting SUD and provided outcomes data. Data were extracted using a standardized reporting tool.

RESULTS

A total of 1676 unique articles were identified during the initial search, with 32 articles included in the final analysis. Seven articles of the 32 were derived from two large studies. The most commonly studied SUD was alcohol use disorder. Sixteen articles reported at least one statistically significant result with respect to reduced craving and/or substance use. The majority of articles used ecological momentary assessment to trigger interventions, while four used biologic/physiologic data. Two articles used a wearable device. Common intervention types included craving management, coping assistance, and tailored feedback. Twenty-three articles measured usability factors, and acceptability was generally reported as high.

CONCLUSION

Identified themes included a focus on AUD, use of smart phones, use of EMA for intervention delivery, positive effects on SUD related outcomes, and overall high acceptability. Wearables that directly monitor biologic data and predictive analytics using integrated data streams represent understudied opportunities for new research.

Technology Use for Adolescent Health and Wellness

As avid users of technology, adolescents are a key demographic to engage when designing and developing technology applications for health. There are multiple opportunities for improving adolescent health, from promoting preventive behaviors to providing guidance for adolescents with chronic illness in supporting treatment adherence and transition to adult health care systems. This article will provide a brief overview of current technologies and then highlight new technologies being used specifically for adolescent health, such as artificial intelligence, virtual and augmented reality, and machine learning. Because there is paucity of evidence in this field, we will make recommendations for future research.

Pilot Study of a Multilevel Mobile Health App for Substance Use, Sexual Risk Behaviors, and Testing for Sexually Transmitted Infections and HIV Among Youth: Randomized Controlled Trial

BACKGROUND

Preventing and reducing substance use disorders, sexually transmitted infections (STIs)/HIV, and teen pregnancy, and the associated risk behaviors (ie, substance use and sexual risk behaviors) among youth remain public health priorities in the United States. Equally important is improving the uptake of STI/HIV testing among the youth. Mobile health (mHealth) apps may be a solution to ameliorate these public health concerns; however, few mHealth preventive interventions have demonstrated efficacy in reducing substance use or sexual risk behaviors or improving the uptake of STI/HIV testing among the youth, particularly in clinic settings.

OBJECTIVE

This small-scale study aimed to examine the feasibility of conducting a pilot randomized controlled trial (RCT). We evaluated the effects of Storytelling 4 Empowerment (S4E), relative to enhanced usual practice, on the potential mechanisms by which behavior change occurs, namely clinician-youth risk communication, prevention knowledge, and substance use and sexual risk refusal self-efficacy. We also assessed the ability to measure targeted outcomes of past 30-day substance use (ie, alcohol, tobacco, and other drug use), condomless sex, and alcohol or drug use before sex, as well as the uptake of STI/HIV testing.

METHODS

Employing community-based participatory research principles, 50 youths aged 13 to 21 years were recruited from a youth-centered community health clinic in Southeast Michigan, randomized sequentially to either S4E or enhanced usual practice, and assessed at baseline, immediately postintervention, and 30 days postintervention. S4E consists of 3 modules, including alcohol and drug use, tobacco, and STI/HIV.

RESULTS

Relative to youth in the enhanced usual practice group, S4E participants demonstrated higher youth-clinician risk communication (mean 3.22, SD 1.67) and increases in prevention knowledge (∆ score mean 0.36, SD 0.51) and self-efficacy (∆ score mean 0.16, SD 0.47). In addition, youth in the S4E group showed reductions in the proportions of past 30-day overall substance use (Cohen h=0.71, 95% CI 0.15 to 1.27), as well as past 30-day alcohol (Cohen h=0.71, 95% CI 0.15 to 1.27), tobacco (Cohen h=0.17, 95% CI -0.39 to 0.73), and drug use (Cohen h=1.28, 95% CI 0.72 to 1.84). The results also suggest a reduction in the proportion of youths who reported past 30-day condomless sex (Cohen h=0.18, 95% CI -0.38 to 0.74) and alcohol use before sex (Cohen h=0.44, 95% CI -0.12 to 1.00). Finally, the findings also demonstrated an increase in the proportion of youths who reported STI/HIV testing over time (Cohen h=0.16, 95% CI -0.39 to 0.72).

CONCLUSIONS

The findings suggest the feasibility of a small-scale pilot RCT. S4E demonstrated shifts in the hypothesized direction, reducing substance use, sexual risk behaviors, and improving the uptake of STI/HIV testing among youth in a clinic setting. The findings suggest that a larger RCT may be warranted.

TRIAL REGISTRATION

ClinicalTrails.gov NCT03855410, https://clinicaltrials.gov/ct2/show/NCT03855410.

Development and pilot testing of a counseling-plus-mHealth intervention to reduce risk for pregnancy and sexually transmitted infection in young women with depression

BACKGROUND

Depressed young women have elevated rates of unintended pregnancy and sexually transmitted infections (STIs). The objective of this study was to develop and pilot-test a counseling-plus-mHealth intervention to reduce sexual and reproductive health (SRH) risk in young women with depressive symptoms.

METHODS

Using the Behavior-Determinants-Intervention logic model, we developed the Momentary Affect Regulation-Safer Sex Intervention (MARSSI) to address the challenges that depression imposes on SRH risk reduction efforts of high-risk young women: (I) in-person counseling using motivational interviewing (MI) to elicit motivation for safer sex and develop a behavior change plan, and teaching cognitive-behavioral skills to manage negative thoughts and affective states; (II) 4-week Ecological Momentary Intervention (EMI) on a smartphone to report momentary phenomena related to depression and SRH risk, and receive personalized, tailored messages prompting healthy behaviors and encouraging cognitive-behavioral skill use when risk-related cognitions and negative affect are reported; and (III) booster counseling to review behavior change goals and plans and teach a new cognitive-behavioral skill. We developed the counseling through iterative interviews with 11 participants and developed the EMI through a 2-week trial with three participants, then revised MARSSI to reflect participant feedback. We next conducted a pilot-test among depressed, high-risk female adolescent clinic patients age 15-24. Pilot participants completed mental health, motivation to change behavior, and SRH behavior assessments and provided feedback at baseline, post-EMI, and at 3-month follow-up. We analyzed participant retention, counseling duration, app engagement, intervention quality ratings, and participant feedback, and compared mental health and SRH risk behavior across the study.

RESULTS

Seventeen participants completed the initial counseling session, 15 participated in the EMI, 14 returned for the booster session, and 14 completed the 3-month follow-up. App engagement was high for all 4 EMI weeks (≥1 report/day for median ≥6 days/week). Post-intervention, most or all participants agreed with each positive statement about the messages, reported "Excellent" MARSSI usefulness, and attributed improvements to MARSSI. Compared to baseline, post-EMI depressive symptoms, confidence to change self-selected risk behavior, and confidence to use the cognitive restructuring skill improved. At 3 months, depressive symptom scores remained lower and confidence to use cognitive restructuring remained higher, compared to baseline. Participants also reported lower frequency of sex, lower proportion of condom-unprotected sex events, and, among those using effective contraception, more consistent condom use at 3-month follow-up vs. baseline.

CONCLUSIONS

MARSSI was feasible, acceptable, and engaging to young women with depression and SRH risk behavior, and was associated with increased confidence to reduce SRH risk, decreased SRH risk behaviors, increased confidence to use cognitive restructuring, and decreased depressive symptoms over 3 months. Future research is warranted to evaluate MARSSI's efficacy to improve motivation, skills, affect, and behaviors, as well as reproductive health outcomes in high-risk depressed young women.

Engaging Youth (Adolescents and Young Adults) to Change Frequent Marijuana Use: Motivational Enhancement Therapy (MET) in Primary Care

PURPOSE

To characterize information elicited from adolescent/young adults with frequent cannabis use in Motivational Enhancement Therapy (MET), and determine whether differences exist across stages of change (SOC) for reducing use.

DESIGN AND METHODS

Primary care patients 15-24 years old using cannabis ≥3 times/week enrolled in a pilot randomized intervention trial. All youth were offered two 1-hour MET sessions. Content analysis was used to code and categorize main reasons for use, alternative behaviors, goals, values, pros and cons of change, and compared results between youth in Pre-Contemplation vs. Contemplation SOC.

RESULTS

Fifty-six youth completed MET session 1, 46 completed session 2. Most reported their main reason for use was related to emotional coping, negative feelings were a top-3 trigger, and distraction was an alternative way to meet their needs. Youth most frequently described progress in education or career/job as 1-year goals. More than half identified family as a very important value. They most frequently reported pros of using less related to achieving goals, self-improving, and saving money, and a con related to stress/coping. Compared to youth in Pre-Contemplation SOC, those in Contemplation were more likely to identify relationships as both a pro and con of using less cannabis.

CONCLUSIONS

MET can reveal developmentally appropriate goals, healthy values, and ambivalence about cannabis use that can be used to facilitate movement along the stages of behavior change toward reduction/cessation.

PRACTICE IMPLICATIONS

Brief motivational therapy can be used in primary care to gather information important in helping youth to reduce cannabis use.

Juvenile justice systems of care: results of a national survey of community supervision agencies and behavioral health providers on services provision and cross-system interactions

BACKGROUND

Youth involved in the juvenile justice (JJ) system have high needs for behavioral health services, especially related to substance use and mental disorders. This study aimed to understand the extent to which elements in the cascade model of behavioral health services for JJ-involved youth are provided to youth by Community Supervision (CS) and/or Behavioral Health (BH) providers. In order to understand interactions across CS and BH systems, this study used a multistage probabilistic survey design to sample CS agencies and their primary BH service providers of substance use and mental health treatment in the United States. Parallel surveys were administered to both CS and BH providers regarding: characteristics of youth served, BH services available, whether services were provided directly and/or by referral, use of evidence-based practices (EBPs), and methods of collaboration, referral, and information exchange across CS and BH providers.

RESULTS

The findings from weighted national estimates demonstrate that youth referred from CS to the BH programs represent a more severe sub-group of youth under CS supervision. There are established cross-system relationships for assessment and referral for substance use and mental health treatment, but less so for prevention services. Most CS programs refer youth to BH providers for these services, which typically utilize more highly trained staff to provide EBPs to a majority of the youth served. More intensive substance use and mental health treatment, aftercare, and recovery support services were limited in availability.

CONCLUSIONS

The findings suggest that although many elements in a cascade model of BH services for JJ-involved youth have been implemented within local systems of care through collaboration between CS and BH providers, there are several underdeveloped areas and potential for attrition across the service cascade. Greater attention to providing services to youth with higher levels of severity, aftercare services, and recovery support is warranted within a multi-systemic framework.

Mobile Intervention for Individuals With Psychosis, Dual Disorders, and Their Common Comorbidities: A Literature Review

Over 50% of people diagnosed with a severe mental illness, such as schizophrenia or bipolar disorder, will meet criteria for a substance use disorder in their lifetime. This dual disorder often starts during youth and leads to significant societal costs, including lower employability rates, more hospitalizations, and higher risk of homelessness and of suicide attempts when compared to those with a serious mental illness without substance misuse. Moreover, many individuals presenting with comorbid disorders also present with other psychological difficulties as well, such as personality disorders or anxiety and depression, also known as complex comorbid disorders. Transdiagnostic treatments that focus on core difficulties found in people with complex dual disorders, such as emotional regulation, are direly needed. Emotional regulation skills can help reduce distress related to psychotic symptoms and maintain abstinence in substance use disorders. New technologies in the field of communications have developed considerably over the past decade and have the potential to improve access to such treatments, a major problem in many health care settings. As such, this paper aims at: presenting core difficulties present in many individuals with dual disorders, reviewing the scientific literature pertaining to the use of mobile applications in mental health and addictions, and presenting the development and potential of a new application for emotional regulation for people with dual disorders.