A unified protocol to address sexual minority women's minority stress, mental health and hazardous drinking

PROJECT SUMMARY Background. Sexual minority women (SMW) represent one of the highest-risk groups for hazardous drinking (HD) and comorbid mental health problems (e.g., depression, anxiety) because of their exposure to minority stressors (i.e., stigma-related burdens) and associated stress reactions, like drinking to cope. Research has identified cognitive (e.g., expectations of rejection), affective (e.g., shame), and behavioral (e.g., avoidant coping) pathways through which minority stress places SMW at disproportionate risk of HD and comorbid depression/anxiety. Yet no interventions address these pathways. In fact, no HD intervention has ever been tested for efficacy with SMW. Preliminary Studies. With deep stakeholder input and NIH (R01MH109413- 02S1) and foundation (Lesbian Health Fund) support, we created EQuIP (Empowering Queer Identities in Psychotherapy). EQuIP is a 10-session cognitive-behavioral intervention focused on improving SMW’s minority stress reactions by raising awareness of the harms of minority stress, building self-affirming cognitive styles, and reducing avoidant coping. In a waitlist-controlled pilot trial (n=60), EQuIP showed strong promise for reducing HD and depression/anxiety by building adaptive responses to minority stress, making it the first intervention with preliminary efficacy for improving this population’s co-occurring behavioral and mental health challenges. Methods. We now seek to test EQuIP’s efficacy and identify facilitators of scale-up of this promising intervention. Aim 1: In a 2-arm randomized controlled trial (RCT) with SMW who experience HD and comorbid depression and/or anxiety, we will test the efficacy of EQuIP (n=225) against treatment-as-usual (i.e., supportive counseling) (n=225). Our primary outcome is proportion of heavy drinking days (≥4 drinks) on 30- day timeline followback. Secondary outcomes include reduction in WHO alcohol risk level and depression and anxiety. Because remote intervention delivery has quickly become normative, both EQuIP and treatment-as- usual will be delivered via telehealth (Zoom). In fact, our second pilot of EQuIP found strong feasibility and acceptability of telehealth delivery. Aim 2: Assessments at baseline, 4, 8, and 12 months will determine if reductions in EQuIP’s intended psychosocial mechanisms (e.g., internalized stigma, rejection sensitivity, emotion dysregulation) mediate heavy drinking reductions. To advance personalized medicine, we will also examine whether EQuIP is differentially efficacious across key demographic factors and stigma moderators. Aim 3: To prepare for implementation in frontline settings, we will conduct semi-structured interviews with directors (n=20), providers (n=20), and service users (n=20) from a network of 250 US LGBTQ community clinics. Applying the i-PARIHS framework will help identify facilitators that can support EQuIP implementation at these centers. Summary. As the first trial of an intervention for SMW’s HD and co-occurring mental health, this study responds to NIAAA’s call for trials of “interventions that address AUDs and related problems and that are appropriate to the needs of sexual and gender minority populations.”