The Development of a Personalized, Real-time Intervention for Substance-using Emerging Adults Leaving Psychiatric Partial Hospitalization
Phase: NA
Conditions: Drinking, Alcohol
Sponsor: Butler Hospital

Development of a Personalized, Real-time Intervention (PFIcope+EMI) 
 
NCT03518619 
 
January 15, 2021 
 
 

STUDY PROTOCOL 
 
Emerging adulthood (18-25 years) represents a risky time for mental health and 
substance use. Emerging adults (EA) are particularly susceptible to problematic patterns of 
substance use, especially if they experience anxiety and/or depression and use substances as 
a way to cope with such issues. However, many mental health treatments do not address 
substance use. We developed an ecological momentary assessment and intervention 
(EMA/EMI) to specifically target the motive of drinking to cope with anxiety/depression. Project 
CHOICE was a 6-week intervention that paired in-person normative feedback with daily EMA 
and, if an individual reported negative affect and intent to drink, an EMI was immediately sent to 
their phone (a personally-chosen coping skill). 
 
Methods and Materials 
Participants and Procedures  
Participants (n=20) were recruited from a Young Adult Partial Hospitalization program at 
a private psychiatric institution. The program runs from 9:00am to 3:30pm, Monday through 
Friday, for approximately 7 days, serving EA for a variety of psychiatric problems, most 
commonly depression and anxiety. Many EAs in the program also have co-occurring substance 
use problems which, although they are assessed at time of entry into the program, specific 
substance use programming is not offered. Program components include group therapy with 3-4 
topics covered daily, individual counseling, and evaluation by an attending psychiatrist (who 
may prescribe psychiatric medication). Recruitment occurred between September 2018 and 
February 2019. Patients’ medical records were reviewed by study staff in accordance with 
Institutional Review Board guidelines to assess the inclusion and exclusion criteria. Additionally, 
participants were screened in-person to verify eligibility.  
Inclusion criteria included: being between ages of 18-25, past month alcohol use greater 
or equal to 2-3 times weekly, a score of 2+ average on the coping scales of the motives 
measure (see below), current anxiety and depression symptomatology (as measured by scores 
of 6+ Generalized Anxiety Disorder-7(Spitzer et al., 2006) corresponding to moderate to severe 
anxiety, and a score of 16+ on the Center for Epidemiology Studies-Depression scale(Radloff, 
1977), corresponding to high risk for clinical depression), and smartphone ownership.  
Exclusion criteria included current diagnosis of other moderate/severe substance use 
disorder (other than alcohol), history of or current psychotic disorder, and current 
suicidal/homicidal ideation.  
 
Intervention components 
This 6-week open pilot was comprised of the following components: 
1. Orientation Session. This in-person session with a PhD-level clinical psychologist 
included: a) normative feedback on their alcohol use compared to other EAs, b) education on 
the coping motive and negative outcomes associated with use, c) normative feedback regarding 
the individual’s use of alcohol to cope (based on responses to the motives measure as 
compared with normative samples), d) generation of alternate coping strategies to inform EMI 
text relapse prevention messages (e.g., try taking a walk if you feel like drinking, calling a friend 
has helped you in the past when you feel down or want to drink), e) installation of the 
smartphone app (mEMA, designed by ilumivu)  on the individual’s smartphone, and f) 
orientation to components and timeline of the intervention, including a discussion of methods of 
increase EMA adherence/compliance. Components a-c were used in the previous PFIcope 
study(Blevins & Stephens, 2016). 
2. EMA Prompts. Following discharge from YAPH, participants received EMA prompts 
4x/daily (sent at random times between the hours of 9am-12pm, 12pm-3pm, 3pm-6pm, and 
6pm-9pm) through the mEMA app, a HIPAA-compliant web-based platform specifically 

developed for EMA. We assessed: (A) current mood at that moment (“RIGHT NOW;” stress, 
sadness, happiness, excitement, and anger, rated on a scale Likert scale of 1 to 10), alcohol 
consumption since the previous assessment (yes/no, quantity), drinking intention (yes/non), 
drinking motives (if drinking was reported, utilizing one item from each subscale of the DMQ-R; 
enhancement, coping, social, and conformity), the use of coping strategies (14 strategies 
provided endorsed yes/no; e.g., distraction, active coping), any cannabis use since the previous 
assessment (yes/no), use of cannabis for substitution of alcohol (yes/no) and motives for 
cannabis use. A total of 14 questions were included in the EMA. EMA prompts were also 
available on demand if a participant intended to consume alcohol or reported negative affect 
and desired the EMI support.  
3. EMI Relapse Prevention Coping Skills Messages. The mEMA app allows for 
individualized programming. As such, messaging can be specifically designed for each 
participant. If the participant endorsed negative affect or intent to drink on any EMA prompt, an 
individualized, self-chosen coping skills-based message was immediately sent through the EMA 
app. Participants picked their individualized coping skills messages in the orientation session 
from a list of coping strategies that are consistent with cognitive behavioral therapy techniques, 
and were also encouraged to add their own strategies if they were not listed on the sheet (e.g., 
“Try reaching out to a friend or family member if you feel down or want to drink”, and the 10-12 
messages chosen were randomized to be sent in the event of negative mood and intent to 
drink. The purpose of these messages was to remind the participant of skills and strategies to 
reduce the likelihood of drinking to cope.  
      4. Follow-Up Assessment. At the end of the intervention (6 weeks), participants completed 
self-report questionnaires and a semi-structured, in-person qualitative interview at the research 
unit .  The purpose of the interview was to determine which aspects of the intervention were 
helpful and elicit other feedback in order to shed light on acceptability, usability, and utility of the 
intervention..  
 
Measures 
Motives. Alcohol use motives were measured using the Modified Drinking Motives 
Questionnaire-Revised (MDMQ-R) (Grant et al., 2007), a 28-item assessment derived from the 
Drinking Motives Questionnaire-Revised (Cooper, 1994). The MDMQ-R measures the following 
motives: coping with anxiety (“because it helps me when I am feeling nervous”), coping with 
depression (“to cheer me up when I’m in a bad mood”), conformity (“to fit in with a group I like”), 
social (“as a way to celebrate”), and enhancement (“to get a high”). Participants are asked to 
rate on a scale of 1 (almost never/never) to 5 (almost always/always) how frequently they drink 
for each reason.  
  
Alcohol and Cannabis Use. The Timeline Followback (TLFB) (Sobell & Sobell, 1992) 
was utilized to measure quantity and frequency of alcohol use. Participants are given anchor 
points and produce their own anchor points (including holidays, special occasions) to help 
facilitate memory of alcohol use, and asked to recall alcohol use (drinks per drinking day, DDD).  
We calculated binge days according to National Institute of Alcohol Abuse and Alcoholism cut-
offs (no more than 3 drinks per day for women and no more than 4 drinks per day for men. We 
also derived a drinks/week variable from the data. Additionally, on each drinking day, 
participants were asked to report (yes/no) whether their alcohol use was motivated by the 
coping motive. As such, we created a variable that was the sum number of days that an 
individual endorsed drinking to cope on the TLFB, which allowed for computation of percentage 
of drinking days that an individual drank to cope. We also assessed days of cannabis use using 
the TLFB. 
 
 

 
STATISTICAL ANALYSIS PLAN 
 
Preliminary analyses evaluated descriptive statistics of variables of interest for missingness 
and handled such instances accordingly. Variables were examined for normality and analyses 
accounted for skewness or kurtosis utilizing bootstrapping methods or transformations. We first 
present descriptive statistics and correlations between variables, as well as results from 
analysis of variance (ANOVA) testing examining differences in baseline variables by gender. 
Main effects of the intervention were analyzed using paired-sample t-tests utilizing measures at 
baseline and 6-weeks. The primary outcomes of interest were percent days drinking in the last 
month (using the TLFB) and changes in coping drinking motives (using the MDMQR(Grant et 
al., 2007)).  
 
 
 
 
 
 

References 
 
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