Transdiagnostic and Transcultural: Pilot Study of Unified Protocol for Depressive and Anxiety Disorders in Japan

Targeting emotional regulation using an Internet-delivered psychological intervention for cancer survivors: A randomized controlled trial

OBJECTIVES

This trial assessed the efficacy of an emotion-focused, modular, Internet-delivered adaptation of the Unified Protocol (UP) in improving cancer survivors' emotion regulation strategies.

DESIGN

A two-arm randomized controlled trial (1:1) was used to compare the efficacy of two Internet-based interventions: UP-adapted CanCope Mind (CM) and lifestyle-focused active control CanCope Lifestyle (CL).

METHODS

N = 224 cancer survivors randomized to CM or CL were assessed at baseline, between-modules, at post-intervention and 3-month follow-up on emotion regulation outcomes targeted by each CM module (Module 1: beliefs about emotions; Module 2: mindfulness; Module 3: cognitive reappraisal skills, catastrophizing, refocus on planning; Module 4: experiential avoidance). Primary analyses were intention-to-treat linear regressions using Fisher randomization tests for p-values and intervals were used to compare groups with standardized mean difference (SMD) effect sizes.

RESULTS

CanCope Mind participants (n = 61 completers) experienced moderate-to-large improvements (SMDs from .44-.88) across all outcomes at post-intervention. CM's effects were larger than CL's (n = 75 completers) immediately post-intervention and at 3-month follow-up for beliefs about emotions, mindfulness, cognitive reappraisals and experiential avoidance (all p's < .05). CM experienced greater improvements in catastrophizing immediately post-intervention, with a trending effect at follow-up. However, we could not reject the null hypothesis of identical between-group effects for refocusing on planning both immediately post-intervention and at follow-up. Exploratory analyses revealed inconsistent between-module effects.

CONCLUSIONS

In its entirety, CM is a promising intervention for improving and maintaining cancer survivors' adaptive emotion regulation, especially for mindfulness and experiential avoidance. This may have important clinical implications for promoting cancer survivors' emotional functioning and general well-being.

Transdiagnostic Cognitive Behavioral Psychotherapy: Unified Protocol as an Example

The fact that there are many limitations of the current classification systems led to the emergence of transdiagnostic approaches (TA) that focus on the common psychopathological processes underlying disorders rather than categorical diagnoses. TA focuses on the underlying common psychopathological processes in the emergence and persistence of mental disorders. Thus, even if the disorders are categorically diagnosed differently, it can be determined how they overlap or separate with each other. TA aims to treat mental disorders using these aspects. TA has a flexible and modular structure that can be easily integrated into cognitive behavioral therapies. The rest of this review will focus on the Unified Protocol (UP), one of the most popular TA examples. The main purpose of the UP is to enable patients to recognize their feelings and give more adaptive reactions to their negative emotions. Accordingly, UP consists of eight modules. The modules can usually be completed in a total of 11 - 17 weeks. Each 50 to 60-minute individual session is held once a week. If necessary, changes can be made to the number or the frequency of sessions allocated to modules. The goals of each module of the UP and the treatment approaches towards these goals allow a very clearly defined approach. For this reason, there is a need for a detailed evaluation, conceptualization and treatment plan before the UP is put into practice. We hope that mental health professionals from Turkey will contribute to the developments in the UP.

Enhancing emotion regulation

BACKGROUND

Emotion regulation (ER) refers to the process of modulating an affective experience or response. Objectives: This is a systematic review of the research on therapist methods to facilitate patient ER, including affect-focused, experiential methods that aim to enhance immediate patient emotion regulation, and structured psychoeducation, skills training in ER.

METHOD

A total of 10 studies of immediate and intermediate outcomes of emotion regulation methods were examined. A total of 38 studies were included in the meta-analysis of distal treatment effects on emotion regulation.

RESULTS

In eight studies with 84 clients and 33 therapists, we found evidence of positive intermediate outcomes for affect-focused therapist methods and interpretations. A meta-analysis of 26 studies showed that the average effect size of ER methods from pre- to post-treatment was large (g = 0.82).

CONCLUSIONS

Both affect-focused and structured skill training are associated with distal improvements in emotion regulation. When working with ER in psychotherapy, therapists must consider how patients' cultural backgrounds inform display rules, as well as what might be considered adaptive or maladaptive. The article concludes with training implications and therapeutic practices based on the research evidence.

The unified protocol as an internet-based intervention for emotional disorders: Randomized controlled trial

The Unified Protocol (UP) as a transdiagnostic intervention has primarily been applied in the treatment of anxiety disorders and in face-to-face-settings. The current study investigated the efficacy of a 10-week Internet-based adaptation of the UP for anxiety, depressive, and somatic symptom disorders. The trial was registered under DRKS00014820 at the German Clinical Trial Registry, DRKS. Participants (n = 129) were randomized to treatment or waitlist control. Significant treatment effects were found for symptom distress, satisfaction with life, positive/negative affect and markers of anxiety, depression, and somatic symptom burden (within-group Hedges’ g = 0.32–1.38 and between-group g = 0.20–1.11). Treatment gains were maintained at 1- and 6-month-follow-up. Subgroup analyses showed comparable effects in participants with anxiety and depressive disorders. 26.6% dropped out of treatment and 35.38% did not provide post-treatment assessments. The results strengthen the application of the UP as an Internet-based treatment for alleviating symptom distress across emotional disorders. More research on the applicability for single disorders is needed and avenues to improve adherence and attrition rates should be explored.

Application of the Unified Protocol for a Japanese Patient with Post-Traumatic Stress Disorder and Multiple Comorbidities: A Single-Case Study

(1) Background: The efficacy of the Unified Protocol (UP), a transdiagnostic cognitive-behavioral therapy, with trauma-focused exposure has not been sufficiently demonstrated for post-traumatic stress disorder (PTSD) with multiple comorbidities. This study examined the effects of UP treatment with trauma-focused exposure on symptoms of PTSD and comorbidities in a client who was hesitant about exposure. (2) Methods: The client, who had comorbid dysthymia, social anxiety disorder, agoraphobia, and bulimia nervosa, participated in the UP for 20 sessions over 6 months. The principal diagnosis and symptoms of the comorbid disorders were assessed at baseline, post-intervention, and at the 3-month follow-up. This treatment was conducted as part of a clinical study (UMIN000008322). (3) Results: The client showed improvement in the principal diagnosis and symptoms of the comorbid disorders post-intervention compared with baseline and no longer met the diagnostic criteria for any of the disorders. Considerable symptom improvement was observed with imaginal exposure to trauma memories. (4) Conclusions: The UP was an effective alternative treatment for PTSD and symptoms of comorbidities in this client who was hesitant about exposure to traumatic memories, and that the inclusion of trauma-focused exposure provided sufficient therapeutic effects. Further research is needed to examine the generalizability of our findings.

Negative and Positive Affect Regulation in a Transdiagnostic Internet-Based Protocol for Emotional Disorders: Randomized Controlled Trial

BACKGROUND

Emotional disorders (EDs) are among the most prevalent mental disorders. Existing evidence-based psychological treatments are not sufficient to reduce the disease burden of mental disorders. It is therefore essential to implement innovative solutions to achieve a successful dissemination of psychological treatment protocols, and in this regard, the use of information and communication technologies such as the internet can be very useful. Furthermore, the literature suggests that not everyone with an ED receives the appropriate treatment. This situation has led to the development of new intervention proposals based on the transdiagnostic perspective, which attempts to address the underlying processes common to EDs. Most of these transdiagnostic interventions focus primarily on downregulating negative affectivity (NA), and less attention has been paid to strengths and the upregulation of positive affectivity, despite its importance for well-being and mental health.

OBJECTIVE

This study aims to evaluate the efficacy of a transdiagnostic internet-based treatment for EDs in a community sample.

METHODS

A 3-armed randomized controlled trial was conducted. A total of 216 participants were randomly assigned to a transdiagnostic internet-based protocol (TIBP), a TIBP+ positive affect (PA) component, or a waiting list (WL) control group. The treatment protocol contained core components mainly addressed to downregulate NA (ie, present-focused emotional awareness and acceptance, cognitive flexibility, behavioral and emotional avoidance patterns, and interoceptive and situational exposure) as well as a PA regulation component to promote psychological strengths and enhance well-being. Data on depression, anxiety, quality of life, neuroticism and extraversion, and PA/NA before and after treatment were analyzed. Expectations and opinions of treatment were also analyzed.

RESULTS

Within-group comparisons indicated significant pre-post reductions in the two experimental conditions. In the TIBP+PA condition, the effect sizes were large for all primary outcomes (d=1.42, Beck Depression Inventory [BDI-II]; d=0.91, Beck Anxiety Inventory [BAI]; d=1.27, Positive and Negative Affect Schedule-Positive [PANAS-P]; d=1.26, Positive and Negative Affect Schedule-Negative [PANAS-N]), whereas the TIBP condition yielded large effect sizes for BDI-II (d=1.19) and PANAS-N (d=1.28) and medium effect sizes for BAI (d=0.63) and PANAS-P (d=0.69). Between-group comparisons revealed that participants who received one of the two active treatments scored better at posttreatment than WL participants. Although there were no statistically significant differences between the two intervention groups on the PA measure, effect sizes were consistently larger in the TIBP+PA condition than in the standard transdiagnostic protocol.

CONCLUSIONS

Overall, the findings indicate that EDs can be effectively treated with a transdiagnostic intervention via the internet, as significant improvements in depression, anxiety, and quality of life measures were observed. Regarding PA measures, promising effects were found, but more research is needed to study the role of PA as a therapeutic component.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02578758; https://clinicaltrials.gov/ct2/show/NCT02578758.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12888-017-1297-z.

Initial Effectiveness Evaluation of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders for Homeless Women

The purpose of this study is to evaluate the effectiveness of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders adapted for homeless women (UPHW). Eighty-one homeless women participated in this single-blinded quasi-experimental clinical trial, involving up to 12 sessions of group treatment, and 3-and 6-month follow-ups. The participants received either immediate treatment with the UPHW (n = 46) or delayed treatment, following a 12-week wait-list control period (WLC; n = 35). Primary outcomes included depression and anxiety. Secondary measures comprised positive and negative affect, psychological well-being, health perception, and social support. The UPHW resulted in significant improvement on measures of anxiety, depression and negative affect. Improvements in anxiety and depression were maintained over a 3-month follow-up period, but not at 6-month. The reliability of the clinical changes showed significant differences between UPHW and WLC for depression. Moreover, the inter-session assessment in the UPHW group showed a linear trend reduction for depression and anxiety scores along the 12 sessions. The clinical implications on the UPHW in social settings are also discussed.

Expressive suppression of emotion is a moderator of anxiety in a unified protocol for transdiagnostic treatment of anxiety and depressive disorders: A secondary analysis

BACKGROUND

Expressive suppression (ES) of emotion is considered a moderator that reduces the efficacy of cognitive behavioural therapy (CBT); however, whether and how ES moderates the efficacy of the unified protocol for transdiagnostic treatment of emotional disorders (UP), a version of CBT targeting aversive/avoidant responses to emotions, including ES, remain unclear. We investigated whether and how emotion regulation, especially ES, moderates UP efficacy for anxiety symptoms in patients with anxiety and depressive disorders.

METHODS

We conducted a secondary analysis of data from a previous trial. Seventeen patients with anxiety and/or depressive disorders were included. Changes (slope estimates) in the Structured Interview Guide for the Hamilton Anxiety Rating Scale from pre-treatment to post-treatment were measured using a latent growth curve model with empirical Bayesian estimation. Pre-treatment ES, cognitive reappraisal, and depressive symptoms were used as slope factor predictors.

RESULTS

Only pre-treatment ES significantly predicted the slope in the latent growth curve model (estimate value = 0.45; standard deviation = 0.21; 95% credible interval = 0.03-0.87, one-tailed p-value = 0.004), and an inverse correlation between pre-treatment ES levels and improvement magnitude of anxiety symptoms was demonstrated.

LIMITATIONS

Because the data were obtained from a single-arm trial, this study did not have controls, and most participants received pharmacotherapy in addition to UP. Therefore, generalisability of the present findings might be compromised.

CONCLUSIONS

Low ES before UP was an effective predictor of greater improvement in anxiety symptoms after UP. The findings suggest that interventions intended to improve ES may improve UP efficacy.

Clinical effectiveness of metacognitive training as a transdiagnostic program in routine clinical settings: A prospective, multicenter, single-group study

AIM

To evaluate the clinical effectiveness of metacognitive training (MCT) as a transdiagnostic program, on a diverse population with mental disorders in routine Japanese day-care settings.

METHODS

This study employed a prospective, multicenter, single-group pre-post design. Participants diagnosed with various mental disorders received 10 MCT group sessions. We set transdiagnostic outcomes to assess quality of life, global functioning, cognitive insight, and depressive symptoms. At the end of the MCT, we also evaluated participants' satisfaction with treatment. Assessments were conducted at baseline (Pre), Week 5 (Mid), Week 10 (Post), and Week 14 (follow-up: FU).

RESULTS

Thirty-four participants enrolled in the study and received MCT (schizophrenia = 22, non-schizophrenia = 12). Intent-to-treat analyses revealed significant improvements in quality of life/global functioning during the intervention period, and further improvements were observed during the follow-up (all p < .05). The Pre-FU treatment effect sizes for quality of life and global functioning were small (Hedge's g = 0.44 and 0.47, respectively). Significant improvements were also found in depressive symptoms during both the intervention and follow-up periods (all p < .05), but not in cognitive insight. Overall, participants were highly satisfied with the MCT content and format. Scores on almost all outcomes (except for depression) at each assessment point were not significantly different between the schizophrenic and non-schizophrenic sub-groups.

CONCLUSIONS

Despite several limitations, mainly due to small sample size and having no control conditions, our results suggest that MCT for a diverse population with mental disorders is a potentially effective approach in improving quality of life/global functioning and other clinical outcomes in routine day-care settings.

The relationship between emotion regulation and well-being in patients with mental disorders: A meta-analysis

BACKGROUND

The importance of both specific emotion regulation strategies and overall deficits in emotion regulation in the context of psychopathology is widely recognized. Besides alleviating psychological symptoms, improving mental well-being is increasingly considered important in treatment of people with mental disorders. However, no comprehensive meta-analysis on the relationship between emotion regulation and well-being in people with mental disorders has been conducted yet.

OBJECTIVE

The aim of the current study was to synthesize and meta-analyze evidence regarding the relationship between emotion regulation and well-being in clinical samples across studies.

METHOD

A systematic literature search was conducted in PsycINFO, PubMed and Scopus and 94 cross-sectional effect sizes from 35 studies were meta-analyzed to explore this relationship. To be eligible for the meta-analysis, studies had to include a clinical sample, assess at least one specific emotion regulation strategy or overall deficits in emotion regulation and include well-being as outcome.

RESULTS

The findings showed significant small to moderate negative relationships with well-being for the strategies avoidance (r = -0.31) and rumination (r = -0.19) and positive relationships with reappraisal (r = 0.19) and acceptance (r = 0.42). Grouping together putative adaptive and maladaptive strategies revealed similar sized relationships with well-being in the expected direction. Overall deficits in emotion regulation showed a negative moderate correlation with well-being (r = -0.47). No substantial difference in relationships was found when clustering studies into hedonic and eudaimonic well-being.

CONCLUSION

Our findings suggest that emotion regulation is not merely related with psychopathology, but also with well-being in general as well as hedonic and eudaimonic well-being. Therefore, it might also be important to improve emotion regulation when aiming to improve well-being in people with mental disorders.

Treating depressive disorders with the Unified Protocol: A preliminary randomized evaluation

OBJECTIVES

This study aims to examine the efficacy of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) for individuals diagnosed with a depressive disorder.

METHOD

Participants included 44 adults who met criteria for major depressive disorder, persistent depressive disorder, or another specified depressive disorder according to the Anxiety Disorder Interview Schedule (ADIS). These individuals represent a subset of patients from a larger clinical trial comparing the UP to single-disorder protocols (SDPs) for discrete anxiety disorders and a waitlist control (WLC) condition (Barlow et al., 2017); inclusion criteria for the parent study required participants to have a principal anxiety disorder.

RESULTS

Significant reductions in depressive symptoms were observed within the UP condition across clinician-rated and self-report measures of depression from baseline to post-treatment, as well as to the 12-month follow-up assessment. Compared to the WLC group, individuals in the UP condition demonstrated significantly lower levels on our continuous, clinician-rated measure of depressive symptoms at post-treatment. There were no differences between the UP and SDP conditions on depressive symptoms at post-treatment or at the 12-month follow-up timepoint.

CONCLUSIONS

In this exploratory set of analyses, the UP evidenced efficacy for reduction of depressive symptoms, adding to the growing support for its utility in treating depression.

Transdiagnostic psychiatry: a systematic review

The usefulness of current psychiatric classification, which is based on ICD/DSM categorical diagnoses, remains questionable. A promising alternative has been put forward as the "transdiagnostic" approach. This is expected to cut across existing categorical diagnoses and go beyond them, to improve the way we classify and treat mental disorders. This systematic review explores whether self-defining transdiagnostic research meets such high expectations. A multi-step Web of Science literature search was performed according to an a priori protocol, to identify all studies that used the word "transdiagnostic" in their title, up to May 5, 2018. Empirical variables which indexed core characteristics were extracted, complemented by a bibliometric and conceptual analysis. A total of 111 studies were included. Most studies were investigating interventions, followed by cognition and psychological processes, and neuroscientific topics. Their samples ranged from 15 to 91,199 (median 148) participants, with a mean age from 10 to more than 60 (median 33) years. There were several methodological inconsistencies relating to the definition of the gold standard (DSM/ICD diagnoses), of the outcome measures and of the transdiagnostic approach. The quality of the studies was generally low and only a few findings were externally replicated. The majority of studies tested transdiagnostic features cutting across different diagnoses, and only a few tested new classification systems beyond the existing diagnoses. About one fifth of the studies were not transdiagnostic at all, because they investigated symptoms and not disorders, a single disorder, or because there was no diagnostic information. The bibliometric analysis revealed that transdiagnostic research largely restricted its focus to anxiety and depressive disorders. The conceptual analysis showed that transdiagnostic research is grounded more on rediscoveries than on true innovations, and that it is affected by some conceptual biases. To date, transdiagnostic approaches have not delivered a credible paradigm shift that can impact classification and clinical care. Practical "TRANSD"iagnostic recommendations are proposed here to guide future research in this field.

Evidence-Based Brief Psychological Treatment for Emotional Disorders in Primary and Specialized Care: Study Protocol of a Randomized Controlled Trial

Emotional Disorders (EDs) are very prevalent in Primary Care (PC). However, general practitioners (GPs) have difficulties to make the diagnosis and the treatment of this disorders that are usually treated with drugs. Brief psychological therapies may be a new option to treat EDs in a PC context. This article aims to present a study protocol to evaluate the effectiveness and the efficiency of an adaptation to brief format of the "Unified Protocol (UP) for the transdiagnostic treatment of EDs." This is a single-blinded RCT among 165 patients with EDs. Patients will be randomly assigned to receive brief psychological treatment based on UP, conventional psychological treatment, conventional psychological treatment plus pharmacological treatment, minimum intervention based on basic psychoeducational information, or pharmacological treatment only. Outcome measure will be the following: GAD-7, STAI, PHQ-9, BDI-II, PHQ-15, PHQ-PD, and BSI-18. Assessments will be carried out by blinded raters at baseline, after the treatment and 6-month follow-up. The findings of this RCT may encourage the implementation of brief therapies in the PC context, what would lead to the decongestion of the public health system, the treatment of a greater number of people with EDs in a shorter time, the reduction of the side effects of pharmacological treatment and a possible economic savings for public purse. Clinical Trial Registration: ClinicalTrial.gov, identifier NCT03286881. Registered September 19, 2017.

A randomized clinical trial of the Unified Protocol for Transdiagnostic treatment of emotional and gastrointestinal symptoms in patients with irritable bowel syndrome: evaluating efficacy and mechanism of change

OBJECTIVE

The aim of this randomized controlled trial was to evaluate the efficacy of Unified Protocol (UP) for transdiagnostic treatment of psychological problems, such as anxiety, depression, and stress, and treating the intensity of gastrointestinal symptoms in individuals with Irritable Bowel Syndrome (IBS). Another aim of the study was to test whether emotion regulation mediates the effect of UP.

METHODS

Among 91 patients diagnosed with IBS (using ROME III criteria), 64 patients were eligible to participate in the study based on the inclusion/exclusion criteria. These patients were randomly assigned to either an intervention group (n = 32) that participated in 12 weekly UP treatment sessions or to a wait-list control group (n = 32). All patients completed the Depression, Anxiety, and Stress Scale (DASS-42), Emotion Regulation Questionnaire (ERQ), and Gastrointestinal Symptoms Rating Scale (GSRS) pre- and post-intervention. The data were analyzed with SPSS 20.0 software.

RESULTS

The results of intention-to-treat (ITT) analysis indicated a significant decrease in depression, anxiety, stress, and gastrointestinal symptoms, as well as significant improvements in emotion regulation scores in the intervention group post intervention. All results were significant at P < .001. Mediation analyses indicated that changes in emotion regulation mediated the effect of UP on changes in emotional and gastrointestinal symptoms.

CONCLUSION

UP was effective and influential in emotion regulation among the intervention group and caused a decline in emotional and gastrointestinal symptoms. Hence, this intervention is promising, but larger RCTs are needed to more investigate its efficacy. Future studies could also examine the efficacy of the UP in other medical conditions with co-occurring psychological conditions. The study is registered at the irct.ir database under registration number IRCT2017010431765N1.

Effects of a Brief Transdiagnostic Cognitive Behavioural Group Therapy on Disorder Specific Symptoms

Background:In recent years, cognitive behavioural group therapies (CBGT) have been increasingly deployed as a strategy to increase the efficiency and cost-effectiveness in treatment of common mental health problems. The vast majority of these therapies are disorder specific, but in the last few years there has been growing interest in transdiagnostic CBGT.Aims:The aim of this study was twofold: to evaluate the treatment effects of transdiagnostic CBGT on disorder specific symptoms and what (if any) differences would be observed in the treatment effects with regard to general as opposed to disorder specific symptoms measured pre- and post-treatment.Method:The participants were 233 adult patients diagnosed with depression and/or anxiety disorders. They underwent a 6-week transdiagnostic CBGT. To compare treatment effects on general and disorder specific symptoms, raw scores on all measures were converted to standardized scores.Results:Pre–post differences were significant and there was no evidence that treatment was differentially effective for general and disorder specific symptoms. Effect sizes ranged from medium to large.Conclusion:The 6-week transdiagnostic CBGT is feasible for a wide range of mood and anxiety disorders. The results indicate that low-intensity transdiagnostic group therapies may have similar effects on both general and disorder specific symptoms.

Japan Unified Protocol Clinical Trial for Depressive and Anxiety Disorders (JUNP study): study protocol for a randomized controlled trial

BACKGROUND

The unified protocol for the transdiagnostic treatment of emotional disorders is a promising treatment approach that could be applicable to a broad range of mental disorders, including depressive, anxiety, trauma-related, and obsessive-compulsive disorders. However, no randomized controlled trial has been conducted to verify the efficacy of the unified protocol on the heterogeneous clinical population with depressive and anxiety disorders.

METHODS/DESIGN

The trial was designed as a single-center, assessor-blinded, randomized, 20-week, parallel-group superiority study in order to compare the efficacy of the combination of unified protocol and treatment-as-usual versus waiting-list with treatment-as-usual for patients with depressive and/or anxiety disorders. The primary outcome was depression at 21 weeks, assessed by the 17-item version of the GRID-Hamilton Rating Scale for Depression. Estimated minimum sample size was 27 participants in each group. We will also examine the treatment mechanisms, treatment processes, and neuropsychological correlates.

DISCUSSION

The results of this study will clarify the efficacy of the unified protocol for depressive and anxiety disorders, and the treatment mechanism, process, and neurological correlates for the effectiveness of the unified protocol. If its efficacy can be confirmed, the unified protocol may be of high clinical value for Japan, a country in which cognitive behavioral treatment has not yet been widely adopted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02003261 (registered on December 2, 2013).