A systematic review and meta-analysis of the Unified Protocol as a transdiagnostic emotion regulation based intervention

The Unified Protocol or Dialectical Behaviour Therapy? Considerations for Choosing Between Two Evidence-Based Transdiagnostic Psychotherapies for Complex Patients

The advent of multiple transdiagnostic treatments in recent decades has advanced the field of clinical psychology while also raising questions for clinicians and patients about how to decide between treatments and how to best deliver a chosen treatment. The purpose of this paper is to review two prominent transdiagnostic treatments that target emotion dysregulation: dialectical behaviour therapy and the unified protocol for transdiagnostic treatment for emotional disorders. First, we review the theoretical underpinnings, research support and proposed mechanisms of action for these treatments. Next, we discuss patient and therapist variables that might indicate which treatment is more appropriate for a given patient and discuss decision-making guidelines to help make this determination with an emphasis on complex patients who may present with risk and/or clinical comorbidities. Finally, we discuss areas for future research that can help further ensure we work to match patients to the treatment that is most likely to benefit them.

Acceptability and Feasibility of an Ecological Momentary Intervention for Managing Emotional Distress Among Psychiatric Inpatients at Risk for Suicide

The weeks following an inpatient psychiatric hospitalization are known to be the highest-risk time for suicide. Interventions are needed that are well-matched to the dynamic nature of suicidal thoughts and easily implementable during this high-risk time. We sought to determine the feasibility and acceptability of a novel registered clinical trial that combined three brief in-person sessions to teach core cognitive-behavioral therapy (CBT) skills during hospitalization followed by smartphone-based ecological momentary intervention (EMI) to facilitate real-time practice of the emotion management skills during the 28 days after hospital discharge. Results from this pilot study (N = 26) supported some aspects of feasibility and acceptability. Regarding feasibility, 14.7% of all screened inpatients met study eligibility criteria. Half (50.3%) of those who were ineligible were ineligible because they were not part of the population for whom this treatment was designed (e.g., symptoms such as psychosis rendered them ineligible for the current study). Those who were otherwise eligible based on symptoms were primarily ineligible due to inpatient stays that were too short. Nearly half (48%) of study participants did not receive all three in-person sessions during their hospitalization. Among enrolled participants, rates of engagement with the smartphone-based assessment and EMI prompts were 51.47%. Regarding acceptability, quantitative and qualitative data supported the perceived acceptability of the intervention, and provided recommendations for future iterations. Well-powered effectiveness (and effectiveness-implementation) studies are needed to determine the effects of this promising and highly scalable intervention approach.

Efficacy of a transdiagnostic internet-based program for adolescents with emotional disorders: A randomized controlled trial

OBJECTIVE

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A) is a well-established transdiagnostic cognitive-behavioral therapy (T-CBT) intervention. The aim of the present study was to examine the efficacy of the program Learn to Manage your Emotions [Aprende a Manejar tus Emociones] (AMtE), a self-applied transdiagnostic internet-delivered program based on the Spanish version of the UP-A. This is the first transdiagnostic internet-based program designed for the treatment of emotional disorders in adolescents.

METHOD

A sample of Spanish adolescents with a primary diagnosis of an anxiety and/or depressive disorder (n = 58; age range = 12-18 years; 78.3% girls; 90% Caucasian) were randomly allocated to receive AMtE (n = 28) or the UP-A via videocall (n = 30). Pre-treatment, post-treatment and 3-month follow-up data were collected using self-reports and clinician-rated measures of anxiety, depression, positive and negative affect, anxiety sensitivity and emotional avoidance.

RESULTS

Based on generalized estimating equations (GEE) models, both intervention programs were effective in significantly reducing self-reported anxiety and depressive disorder symptoms and clinician-rated severity of anxiety and depression, as well as self-reported transdiagnostic outcome variables.

CONCLUSIONS

Data provide empirical support for the efficacy of AMtE as a transdiagnostic online CBT treatment for anxiety and depressive disorders in adolescents. No marked nor consistent differences were observed between the UP-A and AMtE, highlighting the potential usefulness of the online self-administered AMtE program.

The assessment of transdiagnostic dimensions of emotional disorders: Validation of the Multidimensional Emotional Disorders Inventory (MEDI) in adolescents with subthreshold anxiety and depression

BACKGROUND

The transdiagnostic approach to psychopathology has emerged as an alternative to traditional taxonomic approaches. The Multidimensional Emotional Disorders Inventory (MEDI) is a specifically designed self-report to measure the transdiagnostic dimensions proposed by Brown and Barlow (2009). This study aims to analyse the psychometric properties of the MEDI scores in adolescents with subthreshold anxiety and depression.

METHOD

The sample consisted of a total of 476 students. The mean age was 13.77 years (SD = 1.43) (range 10 to 18 years), 73.9 % were females. Several questionnaires assessing positive affect, negative affect, mental health difficulties, and quality of life were used.

RESULTS

The original 9-factor structure of the MEDI was confirmed with good fit indices. Satisfactory levels of internal consistency were observed in most of the MEDI scores using McDonald's Omega, ranging from 0.58 to 0.87. The MEDI dimensions were associated with psychopathology, positive affect, negative affect, and quality of life.

LIMITATIONS

Reliance on self-reported data, a cross-sectional design limiting temporal assessment, and a 73.9 % female gender imbalance.

CONCLUSION

The MEDI scores showed adequate psychometric properties among adolescents with subclinical emotional symptoms. The results found might have potential clinical implications for conceptualization, assessment, intervention, and prevention of emotional disorders at both clinical and research levels.

STAT: schema therapy for addiction treatment, a proposal for the integrative treatment of addictive disorders

The nature and origins of addictions and of their adjunctive behaviors, as well as their chronicity, call for treatments that conceptualize and treat them as the long-term and complex processes that they are. Addictions are often comorbid with personality problems and with trauma histories. Patients suffering from these disorders often show poor engagement with treatment and high rates of relapse, possibly because available treatments have yet to address the patient suffering from addiction in a more integrated or holistic manner. In particular, comprehensive treatment models for addictive disorders - like treatments for personality disorders or trauma - are likely to require the integration of behavioral, cognitive, and emotion-focused interventions within a facilitative therapeutic relationship. However, most current treatment models, including ones which are highly effective in stabilization or behavioral change, lack one or more components of treatment that could sustain longer term recovery, wellness, and health for a higher percentage of patients. In this article, I propose approaching addictions and their treatment from the perspective of schema therapy, an integrative, developmental model with a strong track record of positive outcomes in addressing personality disorder symptoms and long-standing trauma histories, commonly comorbid with addictive disorders. In advancing this proposal, I begin by providing some background tying together addictions, attachment, and personality, suggesting they be treated simultaneously to achieve improved outcomes. Then, after briefly reviewing the leading approaches to the treatment of addictions, I introduce the idea that schema therapy is well-situated - both theoretically and practically - to address many of the shortcomings of existing treatment options. In particular, I note how addictive and co-occurring colluding behaviors are deeply intertwined with both early and continued frustration of core developmental needs. I illustrate how the addictive cycle is perpetuated through the process of schema reinforcement and through the operation of schema modes. I then demonstrate how these key terms (i.e., needs, schemas, and modes) inform the patient's assessment and case formulation, guiding treatment interventions from a strong therapeutic relationship that focuses on integrating recovery behavior change, healing dysfunctional schemas and modes, and preventing relapse.

Improving Access and Quality of Behavioral Health Services for Health Care Employees

OBJECTIVE

To describe key features and the initial implementation of an employer-sponsored program designed to increase access to quality mental health treatment for employees of a large health care system. Methods: Retrospective data were collected on employer's efforts to develop a programmatic solution to address barriers to accessing quality mental health treatment among its employees and on initial program implementation. Results: Data from the initial cohort ( N = 1049) of program participants support the use of low threshold digital tools to enhance access to care, the importance of care navigation and a robust curated provider network in matching employees to appropriate care options, and the value of providing online, evidence-based psychotherapy to facilitate high rates of treatment engagement. Conclusions: Findings can help inform employers about approaches to improve access to quality mental health treatment for their employees.

The Mediating Effect of Coping Strategies and Emotion Regulation in the Relationship between Impulsivity, Metacognition, and Eating Disorders

BACKGROUND

Risk factors for eating disorders are multifaceted and complex, so it is crucial to elucidate the role of executive functions, including impulsivity and metacognition, and coping strategies in the severity of eating behaviors. The study aims were threefold: (1) to analyze gender differences in impulsivity, metacognition, coping strategies, emotion regulation, and eating disorders; (2) to examine the correlation between the study variables; and (3) to test the mediating role of coping and emotion-regulation strategies in the relationship between metacognition, impulsivity, and eating disorders.

METHODS

A total of 1076 participants (Mage = 21.78, SD = 5.10; 77.7% women) completed a set of questionnaires. Two mediation analyses were conducted to test the mediating role of coping strategies, including emotion regulation, in the relationship between executive functions (i.e., impulsivity and metacognition) and eating disorders.

RESULTS

Women displayed higher coping strategies, specifically emotional expression, wishful thinking, and social support, whereas men presented greater social withdrawal. Mediational analyses showed a significant association between impulsivity, metacognition, and eating disorders, whose relationship was partially mediated by coping strategies and mainly by emotion regulation.

CONCLUSION

Interventions based on coping strategies and emotion regulation could be a feasible and effective option to deal with eating disorders among the young population.

Interventions targeting emotion regulation: A systematic umbrella review

BACKGROUND

Emotion dysregulation (ED), the difficulty in modulating which emotions are felt, and when and how they are expressed or experienced, has been implicated in an array of psychological disorders. Despite potentially different manifestations depending on the disorder, this symptom is emerging as a transdiagnostic construct that can and should be targeted early, given the associations with various maladaptive behaviors as early as childhood and adolescence. As such, our goal was to investigate the psychotherapeutic interventions used to address ED and gauge their effectiveness, safety, and potential mechanisms across various populations.

METHODS

This umbrella systematic review, pre-registered under PROSPERO (registration: CRD42023411452), consolidates evidence from systematic reviews and meta-analyses on psychotherapeutic interventions targeting ED, in accordance with PRISMA guidelines.

RESULTS

Our synthesis of quantitative and qualitative evidence from 21 systematic reviews (including 11 meta-analyses) points-with moderate overall risk of bias-to the effectiveness of Dialectical Behavior Therapy and Cognitive Behavioral Therapy in reducing ED in a wide range of adult transdiagnostic psychiatric patients and healthy participants. Similar results have emerged in other less extensively researched methods as well. However, results on adolescents and children are sparse, highlighting the need for additional research to tailor these interventions to the unique challenges of ED in younger populations with diverse externalizing and internalizing disorders.

CONCLUSIONS

These demonstrated transdiagnostic advantages of psychotherapy for ED underscore the potential for specifically designed interventions that address this issue directly, particularly for high-risk individuals. In these individuals, early interventions targeting transdiagnostic core dimensions may mitigate the emergence of full-blown disorders. Future research on the mediating factors, the durability of intervention effects, and the exploration of understudied interventions and populations may enhance prevention and treatment efficiency, enhancing the quality of life for those affected by varied manifestations of ED.

Emotional Regulation as a Transdiagnostic Process of Emotional Disorders in Therapy: A Systematic Review and Meta-Analysis

CONTEXT

Several studies have shown that emotional regulation (ER) is a transdiagnostic construct of emotional disorders. Therefore, if therapy improves ER, it would improve psychological distress.

OBJECTIVE

This review assesses and compares the changes in ER due to psychological treatment in different therapies.

METHODS

A systematic review and meta-analysis of RCTs published in the databases PubMed, PsycINFO and Web of Science was performed. It was registered in PROSPERO under the number CRD42023387317. Two independent experts in the field reviewed the articles.

RESULTS

A total of 18 articles met the criteria for inclusion in the review. Analysis of these studies suggests that in unified protocol (UP), cognitive behaviour therapy, dialectical behaviour therapy (DBT) and mindfulness, there is evidence to support that a moderate effect occurs during treatment. Furthermore, in mindfulness and DBT, the effect was moderate in the follow-up period, while in UP, it was high.

LIMITATIONS

Given the heterogeneity of the applied interventions and the methodological limitations found in the reviewed trials, the results should be interpreted with caution.

CONCLUSIONS

UP, cognitive behaviour therapy, DBT and mindfulness can improve ER after therapy, while UP, DBT and mindfulness in the follow-up period. Other therapies, such as SKY or Flotation REST, require more research.

Universal, school-based transdiagnostic interventions to promote mental health and emotional wellbeing: a systematic review

OBJECTIVE

This systematic review aims to evaluate the effectiveness of universal school-based transdiagnostic interventions in promoting the mental health of children and adolescents. It compares and discusses interventions targeting the prevention of mental disorders versus the promotion of mental health. Additionally, the roles of teachers and psychologists as intervention conductors are examined.

METHODS

A comprehensive search of the Psycinfo, Pubmed, and Web of Science databases was conducted without any time restrictions to identify relevant literature on universal school-based transdiagnostic interventions promoting children and adolescents' mental health.

RESULTS AND DISCUSSION

The findings reveal that universal school-based transdiagnostic promotion/prevention programs have a small to medium overall effect size. These interventions demonstrate a broad coverage of different aspects of children and adolescents' mental health. However, the relative effectiveness of teacher-led versus psychologist-led interventions remains unclear. Interventions focused on preventing mental disorders exhibit a higher effect size, albeit on a narrower range of mental health aspects for children and adolescents.

SIGNIFICANCE

This study enhances our understanding of universal school-based transdiagnostic interventions and their impact on children and adolescents' mental health. Further research is needed to elucidate the comparative efficacy of teacher-led and psychologist-led interventions and to explore the specific dimensions of mental health targeted by these interventions.

Initial Effects of a Brief Transdiagnostic Intervention on Parent Emotion Management During COVID-19

Parents are a vulnerable group to increased distress resulting from the COVID-19 pandemic. In this study, 80 parents with at least mildly elevated internalizing symptoms were randomized to receive a four session, transdiagnostic intervention via telehealth during the height of the COVID-19 pandemic based on the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders (UP-Caregiver), immediately or 6-weeks after receipt of psychoeducational materials. Results showed no between-condition differences in slopes of primary outcome measures; however, significant group differences in intercepts indicated that those receiving UP-Caregiver immediately had greater improvements in distress tolerance and intolerance of uncertainty than those in the delayed condition. Analyses also suggested within-condition improvements in emotional functioning and high satisfaction with UP-Caregiver. Results suggest that psychoeducation and symptom monitoring may be helpful to some distressed parents. Future investigations should utilize a larger sample to identify which parents might benefit the most from interventions like UP-Caregiver during crises.

Adaptive-to-maladaptive gradient of emotion regulation tendencies are embedded in the functional-structural hybrid connectome

BACKGROUND

Emotion regulation tendencies are well-known transdiagnostic markers of psychopathology, but their neurobiological foundations have mostly been examined within the theoretical framework of cortical-subcortical interactions.

METHODS

We explored the connectome-wide neural correlates of emotion regulation tendencies using functional and diffusion magnetic resonance images of healthy young adults (N = 99; age 20-30; 28 females). We first tested the importance of considering both the functional and structural connectome through intersubject representational similarity analyses. Then, we employed a canonical correlation analysis between the functional-structural hybrid connectome and 23 emotion regulation strategies. Lastly, we sought to externally validate the results on a transdiagnostic adolescent sample (N = 93; age 11-19; 34 females).

RESULTS

First, interindividual similarity of emotion regulation profiles was significantly correlated with interindividual similarity of the functional-structural hybrid connectome, more so than either the functional or structural connectome. Canonical correlation analysis revealed that an adaptive-to-maladaptive gradient of emotion regulation tendencies mapped onto a specific configuration of covariance within the functional-structural hybrid connectome, which primarily involved functional connections in the motor network and the visual networks as well as structural connections in the default mode network and the subcortical-cerebellar network. In the transdiagnostic adolescent dataset, stronger functional signatures of the found network were associated with higher general positive affect through more frequent use of adaptive coping strategies.

CONCLUSIONS

Taken together, our study illustrates a gradient of emotion regulation tendencies that is best captured when simultaneously considering the functional and structural connections across the whole brain.

Psychological interventions for depression in children and adolescents: A bibliometric analysis

BACKGROUND

Depression has gradually become a common psychological disorder among children and adolescents. Depression in children and adolescents affects their physical and mental development. Psychotherapy is considered to be one of the main treatment options for depressed children and adolescents. However, our understanding of the global performance and progress of psychological interventions for depression in children and adolescents (PIDCA) research is limited.

AIM

To identify collaborative research networks in this field and explore the current research status and hotspots through bibliometrics.

METHODS

Articles and reviews related to PIDCA from January 2010 to April 2023 were identified from the Web of Science Core Collection database. The Charticulator website, CiteSpace and VOSviewer software were used to visualize the trends in publications and citations, the collaborative research networks (countries, institutions, and authors), and the current research status and hotspots.

RESULTS

Until April 16, 2023, 1482 publications were identified. The number of documents published each year and citations had increased rapidly in this field. The United States had the highest productivity in this field. The most prolific institution was the University of London. Pim Cuijpers was the most prolific author. In the context of research related to PIDCA, both reference co-citation analysis and keywords co-occurrence analysis identified 10 research hotspots, including third-wave cognitive behavior therapy, short-term psychoanalytic psychotherapy, cognitive behavioral analysis system of psychotherapy, family element in psychotherapy, modular treatment, mobile-health, emotion-regulation-based transdiagnostic intervention program, dementia risk in later life, predictors of the efficacy of psychological intervention, and risks of psychological intervention.

CONCLUSION

This bibliometric study provides a comprehensive overview of PIDCA from 2010 to present. Psychological intervention characterized as psychological-process-focused, short, family-involved, modular, internet-based, emotion-regulation-based, and personalized may benefit more young people.

Psychological interventions for pre-event and post-event rumination in social anxiety: A systematic review and meta-analysis

Pre-event and post-event rumination have been consistently identified by cognitive models as important maintaining factors in Social Anxiety Disorder (SAD). This systematic review and meta-analysis aimed to investigate the effectiveness of psychological treatment in reducing pre-event and post-event rumination in adults with social anxiety. A comprehensive literature search identified 26 eligible studies, with 1524 total participants. Psychological treatments demonstrated large significant within-group effect sizes (from pre- to post-treatment) in reducing pre-event rumination (g = 0.86) and post-event rumination (g = 0.83). Subgroups analysed showed CBT to have large significant effect sizes in reducing pre-event rumination (g = 0.97) and post-event rumination (g = 0.85). Interventions that specifically addressed rumination were found to be significantly more effective in reducing pre-event rumination than those that did not (p = .006). Both individual and group treatment formats were equally effective in reducing pre-event rumination and post-event rumination. Meta-regressions revealed that pre-event rumination treatment effects were significantly larger in individuals with higher baseline social anxiety, meanwhile post-event rumination treatment effects were larger for those with higher baseline depression. Overall findings show that pre-event and post-event rumination are effectively reduced through psychological treatment, and clinical implications for the enhancement of evidence-based treatment protocols are discussed.

Skill Use Mediates the Within-Person Effect of the Alliance on Session-to-Session Changes in Anxiety and Depression in the Unified Protocol

Objective

Both the therapeutic alliance and the specific skills taught in treatment are thought to contribute to change in cognitive-behavior therapy (CBT), but it is unclear if or how these processes influence each other and outcomes in treatment. We tested the hypothesis that the degree to which patients used CBT skills would mediate the relation between the alliance and session-to-session changes in anxiety and depression.

Method

Adult participants (N = 70; Mage = 33.74, 67% female, 70% White) with emotional disorders were randomized to receive 6 or 12 sessions of the Unified Protocol. Before each session, participants reported anxiety and depression severity and past-week skillfulness. After each session, participants rated the strength of the alliance. We tested whether greater within-person skillfulness mediated the relation between within-person alliance strength and session-to-session changes in anxiety and depression.

Results

Skillfulness significantly mediated the effect of the alliance on session-to-session changes in anxiety, ab = -.02, p = .04, and depression, ab = -.02, p = .02, such that a stronger alliance predicted greater next-session skillfulness, which predicted session-to-session decreases in anxiety and depression. When alliance subscales were examined separately, the strongest effect was observed for agreement on therapy tasks.

Conclusions

Improvements in the alliance may facilitate skill use and indirectly predict reductions in anxiety and depression through skill use in CBT. We encourage research on how to enhance both the alliance and skillfulness in CBT.

The utility of completing adjuvant video lessons based on the unified protocol during psychotherapy: A retrospective study using a telehealth platform in routine clinical care

Digital supplements to tele-psychotherapy are increasingly needed. The purpose of this retrospective study was to investigate the association between outcomes and the use of supplemental video lessons based on the Unified Protocol (UP), an empirically supported transdiagnostic treatment.

Participants included 7,326 adults in psychotherapy for depression and/or anxiety. Partial correlations were calculated between number of UP video lessons completed and change in outcomes after 10 weeks, controlling for number of therapy sessions and baseline scores. Then, participants were divided into those who did not complete any UP video lessons (n = 2355) and those who completed at least 7/10 video lessons (n = 549), and propensity-matched on 14 covariates. Repeated measures analysis of variance compared these groups (n = 401 in each group) on outcomes.

Among the entire sample, symptom severity decreased as the number of UP video lessons completed increased, with the exception of lessons on avoidance and exposure. Those watching at least 7 lessons showed significantly greater reduction in both depression and anxiety symptoms than those who did not watch any.

Viewing supplemental UP video lessons in addition to tele-psychotherapy had a positive and significant association with symptom improvement and may provide an additional tool for clinicians to implement UP components virtually.

Psychometric properties of the Persian version of the cognitive emotion regulation questionnaire-short (CERQ-P-short): Reliability, validity, factor structure, treatment sensitivity, and measurement invariance

AIMS

This study aimed to examine the psychometric properties of a widely-used measure of emotion regulation, the short version of the Cognitive Emotion Regulation Questionnaire (CERQ-short), in the Persian language (CERQ-P-short) among Iranian populations.

METHODS

The CERQ-P-short was administered to 1825 participants (female = 974) including 436 adolescents, 834 adults from the general population, 45 patients each with generalized anxiety and obsessive-compulsive disorders, an additional 30 patients each with generalized anxiety and obsessive-compulsive disorders receiving treatment, 45 patients with substance use disorders (SUDs) and an additional 360 adult psychiatric patients. We tested reliability, factor structure, measurement invariance, convergent and discriminant validity, and treatment sensitivity (i.e., intervention response) by age, sex, and diagnostic group. The Depression Anxiety Stress Scale-21 was also administered.

RESULTS

Cronbach's alpha coefficient and test-retest coefficients suggested good reliability. Fit indices suggested that the 9-factor CERQ-P-Short model was good across groups. The CERQ-P-Short showed good measurement invariance in all four models (configural, metric, scalar, and strict) in all groups. Both adaptive and maladaptive cognitive emotion-regulation strategies demonstrated convergent and discriminant validity. Finally, treatment sensitivity of the CERQ-P-Short scale before and after the completion of treatment sessions was suggested for patients with generalized anxiety and obsessive-compulsive disorders.

CONCLUSIONS

While the present study has some limitations, it represents a significant contribution because it supports CERQ-P-Short scales usefulness, validity, and reliability in the general population and among psychiatric patients. The results of the current study can be beneficial to the both clinicians and researchers.

A roadmap to address stress in graduate students: How to develop and disseminate a student-led single-session evidence based intervention

Objective: This manuscript describes an evidence-based, student-led, single-session group intervention to support emotional wellbeing among graduate students. The present objective is to provide a roadmap for other universities. Participants: Key participants include clinical psychology graduate students (leader and workshop facilitators), faculty supervisor, representatives from receiving departments or schools, and institutional advocates. Methods: The two-hour workshop was based on four core transdiagnostic cognitive behavioral skills, including psychoeducation about emotions, mindful emotional awareness, cognitive flexibility, and behavior change. The workshop was designed and continues to be led by trained graduate students. Results: Key steps and lessons learned are presented for the exploration, preparation, implementation, and sustainment phases. Conclusions: This program has the potential to be flexibly replicated at other universities to assist with graduate student mental health. It provides unique supports for recipients and unique training opportunities for student facilitators.

Effectiveness of online integrative trans-diagnostic treatment on internet addiction and high-risk behaviors in female adolescents with borderline personality disorder with comorbid depressive disorder

Background

Based on research, borderline personality disorder is associated with many behavioral and emotional problems, including Internet addiction and high-risk behaviors. On the other hand, integrative trans-diagnostic treatment, by targeting trans-diagnostic factors in emotional pathology, is considered a suitable treatment for comorbid psychological pathologies. Also, since in adolescence, the opinion of others about oneself is more important, online therapy has the advantage of protecting them from the fear of stigma and shame in the face of others' judgments. Therefore, the aim of the current research was to investigate the effectiveness of online integrative trans-diagnostic treatment on the internet addiction and high-risk behaviors in adolescents with borderline personality disorder.

Methods

The current research was applied and quasi-experimental in a pre-test-post-test manner with a control group. The research sample included 40 female adolescents with borderline personality disorder who were randomly divided into two groups of 20 people, experimental and control groups. The criteria for entering the research included the age range of 12 to 18 years, female, confirmation of the disease by a psychologist, not receiving other psychological treatments in the last 3 months, and having a smartphone to participate in the online group. Substance abuse, any serious mental and physical illness/disorder that interferes with treatment, and failure to attend more than two sessions in therapy sessions were some of the exclusion criteria.The participants were tested on the scales of internet addiction and high-risk behaviors. Then, the treatment plan based on online integrative trans-diagnostic group therapy was presented to the participants of the experimental group online in 9 two-hour sessions. The control group was placed on the waiting list until the completion of the treatment sessions and the post-test implementation, and after the post-test implementation, they received the treatment. Then, their scores were measured, after completing the treatment, and a three-month follow-up period. Descriptive statistics and covariance test were used to analyze the data.

Results

Patients showed a clear improvement in the severity of internet addiction and high-risk behavior symptoms. So that the scores of internet addiction and high-risk behaviors in the experimental group after receiving the treatment, as well as after a three-month follow-up period, were significantly reduced (p < 0.001).

Conclusion

These results show that online integrative trans-diagnostic therapy can be an effective treatment option for reducing some symptoms of risky behaviors and internet addiction in adolescents with borderline personality disorder and should be studied further. It is noteworthy that the limitations of this study were the available sampling method, the use of a unisex sample of female patients, and the short-term follow-up period, which makes it difficult to generalize the results.

Mechanism engagement as a potential evidence-based approach to personalized treatment termination

Objective: This study explores whether early change on a putative mechanism maintaining symptoms can serve as a proximal indicator of response to prompt discontinuation. Method: Patients (N = 70; Mage = 33.74, 67% female, 74% white) with heterogeneous anxiety and depressive disorders completed a sequential multiple assignment randomized trial (SMART). Patients received 6 sessions of skill modules from the Unified Protocol and then underwent a second-stage randomization to either receive the remaining 6 sessions (Full duration) or discontinue treatment (Brief duration). All participants completed weekly self-report measures of anxiety and depressive symptoms and distress aversion for the full 12-week treatment window. We used structural equation modeling to test (1) if distress aversion demonstrated significant variability during the first-stage randomization and (2) if distress aversion during the first-stage randomization predicted second-stage changes in anxiety and depression. Results: Participants demonstrated significant variability in first-stage distress aversion. Latent distress aversion slopes significantly predicted latent second-stage anxiety slopes, whereas latent distress aversion intercepts significantly predicted latent second-stage depression slopes. Conclusions: These results suggest that early mechanism engagement may have potential as a trigger to prompt personalized termination. Shorter courses of care may reduce patient costs and increase the mental health service system's capacity.

Assessing Theories of State and Trait Change in Neuroticism and Symptom Improvement in the Unified Protocol

Researchers have shown neuroticism decreases with treatment (Roberts et al., 2017), although it is unclear if this reflects fleeting state-level changes (state-artifact position) or trait-level change (cause-correction hypothesis). These theories further propose that changes in neuroticism predict symptom change (cause-correction hypothesis) or are predicted by symptom change (state-artifact position). We compared these theories in a clinical trial of the Unified Protocol (UP). Participants (N = 38; Mage = 34.55, 71.1% female, 78.9% Caucasian) meeting DSM-5 criteria for a primary emotional disorder completed up to 12 weekly sessions of the UP. Neuroticism exhibited state-level changes by Session 6 but trait-level changes by Session 12. Within-person reductions in neuroticism exhibited bidirectional relations with anxiety symptom change but predicted unidirectional session-to-session reductions in depression. These findings provide relatively more nuanced support for the cause-correction hypothesis that the UP leads to trait changes in neuroticism that tend to precede symptom change.

A qualitative study on the implementation of a transdiagnostic cognitive behavioral therapy for children in a child welfare residential treatment program

BACKGROUND

Youth with severe emotional or behavioral issues who are involved with child welfare authorities are sometimes placed in intensive care services in a residential treatment program. Evidence-based psychotherapies are often used in residential treatments, but there is very little research on how to adapt psychotherapy for residential treatment.

OBJECTIVE

To describe the implementation of a transdiagnostic cognitive behavioral therapy (the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children) in a residential treatment program for children.

PARTICIPANTS AND SETTING

Staff (n = 20) at a residential facility in Calgary, Canada.

METHODS

A combination of qualitative interviews and focus groups were conducted before and after therapy to identify barriers and facilitators to implementation. Data were analyzed and reported using the Consolidated Framework for Implementation Research and the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies.

RESULTS

Modifications were made to the program including creating inclusive language, integrating relevant content targeting pediatric irritability, delivering sessions online for caregivers, and using additional staff to support youth to learn and practice the application of the content and behavioral interventions. Key barriers to implementation of the Unified Protocol included staff turnover and the difficulty of sustaining a critical mass of knowledge surrounding the Unified Protocol. The major facilitators to implementation were the perceived quality of the program and advantages of the program to children and their caregivers.

CONCLUSIONS

This study supports the feasibility and acceptability of providing transdiagnostic cognitive behavioral therapies for children in residential treatment and provides a template for how to implement evidence-based practice in residential treatment.

Effectiveness and mediators of change of an online CBT intervention for students with adjustment disorder-study protocol for a randomized controlled trial

BACKGROUND

Adjustment problems and disorders are highly prevalent among university students worldwide. These problems can cause significant interference in academic and social functioning and increase vulnerability to other mental health disorders. Unfortunately, only half of students in need receive psychological help. Furthermore, few studies have evaluated psychological interventions for adjustment disorders in students. New, more scalable forms of treatment for students with an adjustment disorder need to be developed, evaluated, and implemented. The study aims to determine the effectiveness of an online transdiagnostic cognitive behavioural intervention for students experiencing adjustment disorder and to assess mediators of change.

METHOD/DESIGN

In this three-arm randomized controlled trial, we plan to recruit 214 Polish students diagnosed with an adjustment disorder. Participants who meet initial eligibility criteria will be randomly assigned to one of three 6-week conditions: (1) online cognitive behavioural therapy intervention based on an existing, empirically supported transdiagnostic protocol, the unified protocol; (2) online progressive muscle relaxation training as an active control group; or (3) waiting-list control group. Both interventions are asynchronous, interactive, and include minimal amount of therapist support. Assessments will consist of self-report questionnaires, daily diary measures, and neurocognitive tasks for evaluating cognitive functioning. These will be conducted at baseline, post-treatment, and 1-month follow-up. Daily diary measures will be taken during the first and last week of treatment (or waitlist period). Primary outcome measures will include adjustment disorder severity; secondary outcome measures will consist of other negative (psychopathology: depression, anxiety, and stress) and positive (life satisfaction) indexes of mental health as well as process measures (e.g. mindfulness, experiential avoidance, cognitive fusion).

DISCUSSION

To our knowledge, the current study is the first to evaluate the effectiveness of a psychological intervention for students with adjustment disorder. Therefore, it may have important practical implications for students with this disorder. It can potentially guide the development of a scalable, validated treatment option.

TRIAL REGISTRATION

Clinical Trials, NCT05768308, registered 14 March 2023, https://www.

CLINICALTRIALS

gov/ct2/show/NCT05768308.

Feasibility and Efficacy of Intensive Dialectical Behavior Therapy Skills Training in An Outpatient Setting for A Group of Patients with Extensive Care Needs - A Transdiagnostic Approach

PURPOSE

Dialectical behavior therapy (DBT) is a treatment originally developed för chronically suicidal adults. It is common to adapt it by using one specific component, the DBT skills training (DBT-ST) and apply it in a group therapy setting for a variety of mental disorders. The primary aim of the study was to explore whether patients with extended care needs would report improved mental health after participating in an intensive form of DBT-ST. The secondary aim was to explore whether the use of psychiatric inpatient care for the group would decrease.

METHODS

Thirty-seven participants completed the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM), and visual analogue scale (VAS) at three time points: pre-intervention, post-intervention and at 6-month follow-up after intensive DBT-ST.

RESULTS

One-way ANOVA showed a significant effect for time on the CORE-OM: F (2,35) = 7.93, p = .001, η2 = 0.312 (large effect size). Post hoc tests indicated a significant difference between pre-intervention and post-intervention (p = .001) and between pre-intervention and follow-up (p = .01). A Friedman test indicated a statistically significant difference in the VAS scale scores across the three time points, with p-values between 0.00 and 0.05. There was no difference in psychiatric healthcare consumption.

CONCLUSION

These study results confirm to some extent the feasibility and effectiveness of the intensive DBT-ST in a transdiagnostic clinical setting. The participants had a positive outcome from the skills training program, but psychiatric healthcare consumption did not decrease.

A Scoping Review of Factors Associated With Emotional Dysregulation in Adults With ADHD

OBJECTIVE

Emotion dysregulation is frequently seen in adults with ADHD and is associated with many adverse outcomes. We conducted a scoping review of factors associated with emotion dysregulation in adults with ADHD.

METHOD

PubMed and PsycInfo (EBSCO) were searched. Articles were included if they measured ADHD, emotional dysregulation or some aspect of emotional dysregulation, and at least one other construct. Studies examining physiological underpinnings as well as clinical trials examining the effect of ADHD medications on emotional dysregulation were excluded because recent reviews have already examined these topics.

RESULTS

Thirty-five studies were included in the review. Factors such as biological sex, comorbidities, attachment style, using certain emotional regulation strategies, and ADHD subtype tend to be related to emotion dysregulation.

CONCLUSION

Clinicians working with adults with ADHD can collect information on these factors to better understand risk for emotion dysregulation, and emotion regulation skills may be one area for intervention.

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.

Optimization of a Transdiagnostic Mobile Emotion Regulation Intervention for University Students: Protocol for a Microrandomized Trial

BACKGROUND

Many university students experience mental health problems such as anxiety and depression. To support their mental health, a transdiagnostic mobile app intervention has been developed. The intervention provides short exercises rooted in various approaches (eg, positive psychology, mindfulness, self-compassion, and acceptance and commitment therapy) that aim to facilitate adaptive emotion regulation (ER) to help students cope with the various stressors they encounter during their time at university.

OBJECTIVE

The goals of this study are to investigate whether the intervention and its components function as intended and how participants engage with them. In addition, this study aims to monitor changes in distress symptoms and ER skills and identify relevant contextual factors that may moderate the intervention's impact.

METHODS

A sequential explanatory mixed methods design combining a microrandomized trial and semistructured interviews will be used. During the microrandomized trial, students (N=200) will be prompted via the mobile app twice a day for 3 weeks to evaluate their emotional states and complete a randomly assigned intervention (ie, an exercise supporting ER) or a control intervention (ie, a health information snippet). A subsample of participants (21/200, 10.5%) will participate in interviews exploring their user experience with the app and the completed exercises. The primary outcomes will be changes in emotional states and engagement with the intervention (ie, objective and subjective engagement). Objective engagement will be evaluated through log data (eg, exercise completion time). Subjective engagement will be evaluated through exercise likability and helpfulness ratings as well as user experience interviews. The secondary outcomes will include the distal outcomes of the intervention (ie, ER skills and distress symptoms). Finally, the contextual moderators of intervention effectiveness will be explored (eg, the time of day and momentary emotional states).

RESULTS

The study commenced on February 9, 2023, and the data collection was concluded on June 13, 2023. Of the 172 eligible participants, 161 (93.6%) decided to participate. Of these 161 participants, 137 (85.1%) completed the first phase of the study. A subsample of participants (18/172, 10.5%) participated in the user experience interviews. Currently, the data processing and analyses are being conducted.

CONCLUSIONS

This study will provide insight into the functioning of the intervention and identify areas for improvement. Furthermore, the findings will shed light on potential changes in the distal outcomes of the intervention (ie, ER skills and distress symptoms), which will be considered when designing a follow-up randomized controlled trial evaluating the full-scale effectiveness of this intervention. Finally, the results and data gathered will be used to design and train a recommendation algorithm that will be integrated into the app linking students to relevant content.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05576883; https://www.clinicaltrials.gov/study/NCT05576883.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46603.

Toward a synthesis of cognitive behaviour therapy via component analysis of self-regulation

The cognitive behavioural therapies (CBTs) are the choice psychotherapies for many clinicians treating a wide range of adult psychological disorders including various anxieties, mood, substance use, eating, schizophrenia and personality-related. Empirical research in the CBTs is ever increasing, and the accumulating evidence supporting efficacious treatments is substantial and well documented. However, with prolific research comes a seemingly accelerating and worrying trend of purportedly different therapies, and numerous hybrids and combinations of therapies and techniques. For many clinicians this is increasingly confusing and not helpful in clinical practice. This article is a critique of current trends and directions in clinical research, which show signs of limited effectiveness, fragmentation, and obfuscation. An alternative strategy is proposed-examining transdiagnostic therapeutic effects, which appear related to treating pervasive dysregulated emotions, with component analyses of four principal self-regulation components (viz., self-monitoring; functional analysis; identifying values, goals and treatment-plans; and feedback). Such a strategy is likely to lead to a more coherently synthesized and effective CBT.

Unified Protocol for the transdiagnostic treatment of emotional disorders in people with post COVID-19 condition: study protocol for a multiple baseline n-of-1 trial

Background

Post COVID-19 syndrome, defined as the persistence of COVID-19 symptoms beyond 3 months, is associated with a high emotional burden. Post COVID-19 patients frequently present comorbid anxiety, depressive and related disorders (emotional disorders, EDs) which have an important impact on their quality of life. Unfortunately, psychological interventions to manage these EDs are rarely provided to post COVID-19 patients. Also importantly, most psychological interventions do not address comorbidity, namely simultaneous EDs present in COVID-19 patients. This study will explore the clinical utility and acceptability of a protocol-based cognitive-behavioral therapy called the Unified Protocol for the transdiagnostic treatment of EDs in patients suffering post COVID-19 condition.

Methods

A multiple baseline n-of-1 trial will be used, as it allows participants to be their own comparison control. Sample will be composed of 60 patients diagnosed with post COVID-19 conditions and comorbid EDs from three Spanish hospitals. After meeting the eligibility criteria, participants will answer the pre-assessment protocol and then they will be randomly assigned to three different baseline conditions (6, 8, or 10 days of assessments before the intervention). Participants and professionals will be unblinded to participants' allocation. Once the baseline assessment has been completed, participants will receive the online psychological individual intervention through video-calls. The Unified Protocol intervention will comprise 8 sessions of a 1 h duration each. After the intervention, participants will answer the post-assessment protocol. Additional follow-up assessments will be conducted at one, three, six, and twelve months after the intervention. Primary outcomes will be anxiety and depressive symptoms. Secondary outcomes include quality of life, emotion dysregulation, distress tolerance, and satisfaction with the programme. Data analyses will include between-group and within-group differences and visual analysis of patients' progress.

Discussion

Results from this study will be disseminated in scientific journals. These findings may help to provide valuable information in the implementation of psychological interventions for patients suffering post COVID-19 conditions.

Clinical trial registration

https://clinicaltrials.gov, identifier (NCT05581277).

Effects of a Contextual Adaptation of the Unified Protocol in Multiple Emotional Disorders in Individuals Exposed to Armed Conflict in Colombia: A Randomized Clinical Trial

Importance

A transdiagnostic treatment, the Unified Protocol, is as effective as single diagnostic protocols in comorbid emotional disorders in clinical populations. However, its effects on posttraumatic stress disorder and other emotional disorders in individuals living in war and armed conflict contexts have not been studied.

Objective

To evaluate the efficacy of a cultural and contextual adaptation of the Unified Protocol (CXA-UP) on posttraumatic stress disorder, anxiety, and depression compared to waitlist control in individuals exposed to armed conflict in Colombia.

Design, Setting, and Participants

From April 2017 to March 2020, 200 participants 18 years and older were randomly assigned to the CXA-UP or to a waitlist condition. CXA-UP consisted of 12 to 14 twice-a-week or weekly individual 90-minute face-to-face sessions. Outcomes were assessed at baseline, posttreatment, and 3 months following treatment. Analyses were performed and compared for all randomly allocated participants (intent-to-treat [ITT]) and for participants who completed all sessions and posttreatment measures (per protocol [PP]). The study took place at an outpatient university center and included individuals who were registered in the Colombian Victims Unit meeting DSM-5 diagnostic criteria for posttraumatic stress disorder, anxiety, or depression or were severely impaired by anxiety or depression. Individuals who were receiving psychological therapy, were dependent on alcohol or drugs, were actively suicidal or had attempted suicide in the previous 2 months, had psychosis or bipolar disorder, or were cognitively impaired were excluded.

Intervention

CXA-UP or waitlist.

Main Outcomes and Measures

Primary outcomes were changes in anxiety, depression, and somatic scores on the Patient Health Questionnaire and Posttraumatic Stress Disorder Checklist for DSM-5.

Results

Among the 200 participants (160 women [80.0%]; 40 men [20.0%]; mean [SD] age, 43.1 [11.9] years), 120 were randomized to treatment and 80 to waitlist. Results for primary outcomes in the ITT analysis showed a significant pretreatment-to-posttreatment reduction when comparing treatment and waitlist on the posttraumatic stress disorder checklist for DSM-5 scores (slope [SE], -31.12 [3.00]; P < .001; Cohen d, 0.90; 90% CI, 0.63-1.19), 9-item Patient Health Questionnaire (PHQ-9) (slope [SE],-11.94 [1.30]; P < .001; Cohen d, 0.77; 90% CI, 0.52-1.06), PHQ-anxiety (slope [SE], -6.52 [0.67]; P < .001; Cohen d, 0.82; 90% CI, 0.49-1.15), and PHQ-somatic (slope [SE], -8.31 [0.92]; P < .001; Cohen d, 0.75; 90% CI, 0.47-1.04).

Conclusions and Relevance

In this study, significant reductions and large effect sizes in all measures of different emotional disorders showed efficacy of a single transdiagnostic intervention in individuals exposed to armed conflicts.

Trial Registration

ClinicalTrials.gov Identifier: NCT03127982.

Do Unified Protocol modules exert general or unique effects on anxiety, depression, and transdiagnostic targets?

Several transdiagnostic cognitive-behavior therapies include multiple treatment components. However, it is unclear whether some components are more efficacious than others at reducing symptoms or whether these components uniquely influence their putative mechanism of change. Participants (N = 70; Mage = 33.7; 67.1% female, 74.3% White) with a primary anxiety or depressive disorder were randomized to one of three standard or personalized sequences of core Unified Protocol modules. Using hierarchical linear modeling, we tested (a) whether the average session-to-session change in anxiety and depression differed between modules and (b) whether the average session-to-session change in the putative mechanism of each module differed between modules. All modules led to similar changes in anxiety, but Confronting Physical Sensations led to significantly less change in depression than other modules. There were no significant differences among modules predicting putative mechanisms of change, although there was a trend for Mindful Emotion Awareness to predict greater improvements in mindfulness than Understanding Emotions. Consistent with its transdiagnostic nature, UP modules may exert similar effects on anxiety and putative mechanisms of change, although interoceptive exposures may be less impactful for changing depressive symptoms and the mindfulness module may promote relatively specific improvements in mindfulness.

Unified Protocol vs Trauma-Focused Cognitive Behavioral Therapy Among Adolescents With PTSD

Harmful consequences of COVID-19, such as prolonged quarantine, lack of social contact, and especially loss of parents or friends, can negatively impact children and adolescents' mental health in diverse ways, including engendering posttraumatic stress symptoms. Our study is the first to compare the transdiagnostic Unified Protocol for the Treatment of Emotional Disorders in Adolescents (UP-A; Ehrenreich et al., 2009; Ehrenreich-May et al., 2017) with Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) in terms of outcomes related to PTSD symptoms (COVID-19-related vs. COVID-19 unrelated PTSD) and comorbid symptoms (i.e., anxiety, depression) and other measures (i.e., emotion regulation, self-injury, anger). Individuals diagnosed with PTSD were randomly assigned to the UP-A (n = 46) or TF-CBT group (n = 47), administered the SCID-5 and a battery of measures and followed up posttreatment and then after 3, 6, and 9 months. Ninety-three adolescents with PTSD were enrolled, 45% boys and 61% COVID-19-related PTSD. We adopted an intention-to-treat approach. At the initial post-intervention assessment, except for emotion regulation and unexpressed angry feelings, in which UP-A participants reported greater reductions, no significant differences in other variables were secured between the UP-A and TF-CBT. However, at follow-up assessments, the UP-A evidenced significantly better outcomes than TF-CBT. We found support for the UP-A compared with TF-CBT in treating adolescents with PTSD, regardless of COVID-19-related PTSD status, in maintaining treatment effectiveness over time.

Fear of falling in women: A psychological training intervention improves climbing performance

The main purpose of this study was to determine the effect of a psychological training intervention based on emotional regulation on anxiety and climbing ability in women climbers with fear of falling. A secondary aim was to compare the outcomes of climbing ability, anxiety, self-confidence and interoceptive awareness (IA) between the psychological group (PG), a training (TG) and a control group. Self-reported climbing ability, anxiety and IA were assessed using Competitive State Anxiety Inventory-2 and the Multidimensional Assessment of Interoceptive Awareness questionnaire. Results indicated a significant improvement in climbing ability for both PG and TG. The PG showed a significant reduction in cognitive and somatic anxiety, while the TG only exhibited a reduction in cognitive anxiety. Moreover, the PG demonstrated a greater significant increase in self-confidence compared to the TG. IA improved in five subscales for the PG, whereas the TG changed in only two subscales. In conclusion, a psychological training intervention focusing on emotional regulation might contribute to improvements in IA, reduced anxiety levels, and enhancements in climbing ability and self-confidence among women climbers facing fear of falling.

Comparing Kundalini Yoga, cognitive behavioral therapy, and stress education for generalized anxiety disorder: Anxiety and depression symptom outcomes

Increasingly, individuals with anxiety disorders are seeking mind-body interventions (e.g., yoga), but their effectiveness is unclear. This report summarizes seven additional, secondary outcomes measuring anxiety and depression symptoms from a study of 226 adults with generalized anxiety disorder who were randomized to 12-week Kundalini Yoga, Cognitive-Behavior Therapy (CBT) or stress education (control). At post-treatment, participants receiving CBT displayed significantly lower symptom severity, compared to those in the control group, on 6 of the 7 measures. Participants who received Yoga (vs. those in the control group) displayed lower symptom severity on 3 of the 7 measures. No significant differences were detected between participants receiving CBT vs those receiving Yoga. At the 6-month follow-up, participants from the CBT continued to display lower symptoms than the control group.

Prepulse inhibition deficit as a transdiagnostic process in neuropsychiatric disorders: a systematic review

BACKGROUND

Psychopathological research is moving from a specific approach towards transdiagnosis through the analysis of processes that appear transversally to multiple pathologies. A phenomenon disrupted in several disorders is prepulse inhibition (PPI) of the startle response, in which startle to an intense sensory stimulus, or pulse, is reduced if a weak stimulus, or prepulse, is previously presented.

OBJECTIVE AND METHODS

The present systematic review analyzed the role of PPI deficit as a possible transdiagnostic process for four main groups of neuropsychiatric disorders: (1) trauma-, stress-, and anxiety-related disorders (2) mood-related disorders, (3) neurocognitive disorders, and (4) other disorders such as obsessive-compulsive, tic-related, and substance use disorders. We used Web of Science, PubMed and PsycInfo databases to search for experimental case-control articles that were analyzed both qualitatively and based on their potential risk of bias. A total of 64 studies were included in this systematic review. Protocol was submitted prospectively to PROSPERO 04/30/2022 (CRD42022322031).

RESULTS AND CONCLUSION

The results showed a general PPI deficit in the diagnostic groups mentioned, with associated deficits in the dopaminergic neurotransmission system, several areas implied such as the medial prefrontal cortex or the amygdala, and related variables such as cognitive deficits and anxiety symptoms. It can be concluded that the PPI deficit appears across most of the neuropsychiatric disorders examined, and it could be considered as a relevant measure in translational research for the early detection of such disorders.

Comparing the unified protocol for transdiagnostic treatment of emotional disorders to prolonged exposure for the treatment of PTSD: Design of a non-inferiority randomized controlled trial

Background

Prolonged Exposure (PE), a trauma-focused therapy, is one of the most efficacious treatments available for PTSD. However, many people with PTSD do not lose their diagnosis following delivery of PE. The Unified Protocol (UP) for Transdiagnostic Treatment of Emotional Disorders is a non-trauma focused treatment that may offer an alternative treatment for PTSD.

Methods

This paper describes the study protocol for IMPACT, an assessor-blinded randomized controlled trial that examines the non-inferiority of UP relative to PE for participants who meet DSM-5 criteria for current PTSD. One hundred and twenty adult participants with PTSD will be randomized to receive either 10 × 90-min sessions of UP or PE with a trained provider. The primary outcome is severity of PTSD symptoms assessed by the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) at post-treatment.

Discussion

While evidence-based treatments are available for PTSD, high levels of treatment dropout and non-response require new approaches to be tested. The UP is based on emotion regulation theory and is effective in treating anxiety and depressive disorders, however, there has been limited application to PTSD. This is the first rigorous study comparing UP to PE in a non-inferiority randomized controlled trial and may help improve clinical outcomes for those with PTSD.

Trial registration

This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry, Trial ID (ACTRN12619000543189).

Efficacy of the unified protocol for transdiagnostic cognitive-behavioral treatment for depressive and anxiety disorders: a randomized controlled trial

BACKGROUND

The efficacy of the unified protocol of the transdiagnostic treatment for emotional disorders (UP) has been poorly studied in patients with depressive disorders. This study aimed to examine the efficacy of UP for improving depressive symptoms in patients with depressive and/or anxiety-related disorders.

METHODS

This assessor-blinded, randomized, 20-week, parallel-group, superiority study compared the efficacy of the UP with treatment-as-usual (UP-TAU) v. wait-list with treatment-as-usual (WL-TAU). Patients diagnosed with depressive and/or anxiety disorders and with depressive symptoms participated. The primary outcome was depressive symptoms assessed by GRID-Hamilton depression rating scale (GRID-HAMD) at 21 weeks. The secondary outcomes included assessor-rated anxiety symptoms, severity and improvement of clinical global impression, responder and remission status, and loss of principal diagnosis.

RESULTS

In total, 104 patients participated and were subjected to intention-to-treat analysis [mean age = 37.4, s.d. = 11.5, 63 female (61%), 54 (51.9%) with a principal diagnosis of depressive disorders]. The mean GRID-HAMD scores in the UP-TAU and WL-TAU groups were 16.15 (s.d. = 4.90) and 17.06 (s.d. = 6.46) at baseline and 12.14 (s.d. = 5.47) and 17.34 (s.d. = 5.78) at 21 weeks, with a significant adjusted mean change difference of -3.99 (95% CI -6.10 to -1.87). Patients in the UP-TAU group showed significant superiority in anxiety and clinical global impressions. The improvement in the UP-TAU group was maintained in all outcomes at 43 weeks. No serious adverse events were observed in the UP-TAU group.

CONCLUSIONS

The UP is an effective approach for patients with depressive and/or anxiety disorders.

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.

Emotion dysregulation and neuroticism as moderators of group Unified Protocol effectiveness outcomes for treating emotional disorders

BACKGROUND

The personality dimension neuroticism and difficulties in emotional regulation (ER) are two variables closely related to the onset, course, and maintenance of emotional disorders (EDs). The Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders (UP) is a treatment specifically designed to address neuroticism by training in adaptive ER skills and has been shown to be effective in reducing difficulties in ER. However, the specific impact of these variables on treatment outcomes is not entirely clear. The aim of the present study was to explore the moderating role of neuroticism and difficulties in ER regarding the evolution of depressive and anxiety symptoms and quality of life.

METHODS

This secondary study included 140 participants diagnosed with EDs, who received the UP in group format as part of an RCT being conducted in different Spanish Public Mental Health Units.

RESULTS

The results of this study found that high scores in neuroticism and difficulties in ER were associated with greater severity of depression and anxiety symptomatology, and with poorer quality of life. In addition, difficulties in ER moderated the efficacy of UP regarding anxiety symptoms, and quality of life. No moderating effects were found for depression (p > 0.5).

LIMITATIONS

We only evaluated two moderators that may influence UP effectivenes; other key moderators should be analyzed in future.

CONCLUSIONS

The identification of specific moderators affecting transdiagnostic interventions outcomes will allow the development of personalized interventions and provide useful information to improve the psychopathology and well-being of people with EDs.

Cognitive processes associated with emotional disorders: implications for efficient psychological treatments

BACKGROUND

Emotional disorders (EDs) are the most prevalent worldwide. Despite psychotherapies are their treatment of choice, there are difficulties to apply them properly in mental health services. Since literature shows that cognitive processes are associated with anxiety and depressive symptoms, more information is needed in order to improve psychological treatments.

AIMS

To determine the relation between cognitive factors with specific and non-specific ED symptoms in order to promote the development of accurate psychological treatments.

METHODS

We analyzed the relation between rumination, worry, and metacognition with generalized anxiety, panic, and depression disorder symptoms from a clinical sample of 116 individuals through correlation and linear regression analyses.

RESULTS

Although each specific disorder had a closer link with a particular cognitive process, all general ED symptoms were associated with the three cognitive factors studied.

CONCLUSIONS

For "pure" disorders, targeting a concrete cognitive process might be an optimal therapeutic option. However, due to the high comorbidity among EDs, we support the dissemination of the transdiagnostic treatment approach in which all cognitive factors are taken into account.

Transdiagnostic treatment of depression and anxiety: a meta-analysis

BACKGROUND

In the past 10 years an increasing number of randomised trials have examined the effects of transdiagnostic treatments of patients with depression or anxiety. We conducted the first comprehensive meta-analysis of the outcomes of this emerging field.

METHODS

We used the searches in PubMed, PsychINFO, Embase and the Cochrane library of an existing database of randomised trials of psychological interventions for depression to identify studies comparing a transdiagnostic treatment of patients with depression or anxiety with a control group (deadline 1 January 2022). We conducted random-effects meta-analyses and examined the effects on depression and anxiety at the short and longer term.

RESULTS

We included 45 randomised controlled trials with 51 comparisons between a psychotherapy and a control group and 5530 participants. Thirty-five (78%) studies were conducted in the last 10 years. The overall effect size was g = 0.54 (95% CI 0.40-0.69; NNT = 5.87), with high heterogeneity (I2 = 78; 95% CI 71-83), and a broad PI (-0.31-1.39). The effects remained significant in a series of sensitivity analyses, including exclusion of outliers, adjustment for publication bias, for studies with low risk of bias, and in multilevel analyses. The results were comparable for depression and anxiety separately. At 6 months after randomisation the main effects were still significant, but not at 12 months, although the number of studies was small.

CONCLUSIONS

Transdiagnostic treatments of patients with depression or anxiety are increasingly examined and are probably effective at the short term.

Enhancing Internet-based psychotherapy for adults with emotional disorders using ecological momentary assessments and interventions: Study protocol of a feasibility trial with "My EMI, Emotional Well-being" app

INTRODUCTION

Emotional disorders are the most frequent mental health problems globally. To ensure the dissemination of psychological treatments for these conditions, novel forms of delivery (e.g., Internet or mobile apps) and more scalable forms of psychotherapy (e.g., transdiagnostic interventions) have become increasingly popular. Research, however, shows that a significant number of patients, around 40 % according to some studies, do not respond to the interventions as expected (i.e., not-on-track patients). Ecological momentary assessments (EMAs) and ecological momentary interventions (EMIs) could simplify tailoring treatments to the patients' progress and rapidly respond to undesired outcomes during psychotherapy. Therefore, these would facilitate measurement-based care with little therapist involvement. This study aims to explore the feasibility of an app-based system called My EMI, Emotional Well-being for people with emotional disorders. According to daily EMAs, the app will provide personalized EMIs while participants receive a self-applied online transdiagnostic treatment. The app will be used as an add-tool to the online intervention to address emotion dysregulation, foster adherence, and reinforce contents. The current study describes the study protocol for this trial.

METHOD AND ANALYSIS

A single-group, open trial design will be used. Participants will be 30 adults suffering from emotional disorders. Primary outcomes will be app usability, acceptability, and response rates. Secondary outcomes will be either evaluated in Qualtrics at pre-treatment, post-treatment, and 3-month follow-up (depression and anxiety severity, and transdiagnostic dimensions of emotional disorders) or daily throughout the study with the app (EMAs of mood and five transdiagnostic mechanisms of therapeutic change). EMIs will consist of brief, evidence-based transdiagnostic CBT digital content (images, infographics, or videos) delivered just-in-time. Only if problems persist, short phone calls or episodic videocalls will be conducted. The Ethics Committee of the Jaume I University approved the study and all its procedures (CD/111/2021) in December 2021.

DISCUSSION

Identifying personalized and scalable interventions is paramount to improve mental health care, especially its accessibility, and to reduce the psychological distress of people with mental health problems. Feasibility data of the app (EMA and EMI system) supported by a self-applied online transdiagnostic intervention will be important to explore whether this modern approach is a real option to move forward personalized psychological interventions for persons with emotional disorders.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05109780. Registered 05 November 2021, https://clinicaltrials.gov/ct2/show/NCT05109780.

Process model of emotion regulation-based digital intervention for emotional problems

Background

To address the lack of mental health practitioners in developing countries, the current study explored the feasibility of a newly developed self-guided digital intervention program TEA (training for emotional adaptation) in alleviating depressive and anxiety symptoms, as one of a few studies which adapted from theoretical models with effective intervention techniques.

Methods

The first part of this study involved 11 professional mental health practitioners giving feedback on the feasibility of the TEA; while the second part involved a mixed-method single-arm study with 32 participants recruited online, who went through the seven intervention sessions within 14 days. The questionnaires were collected before, after, 14 days after, and 30 days after intervention. Additionally, 10 participants were invited to semi-structured interviews regarding their suggestions.

Results

Practitioners thought that the TEA showed high professionalism (8.91/10) and is suitable for treating emotional symptoms (8.09/10). The generalized estimating equation model showed that the TEA significantly reduced participants' depressive and anxiety symptoms, while the effects of the intervention remained 30 days post intervention (Cohen's d > 1). Thematic analysis revealed three main themes about future improvement, including content improvement, interaction improvement, and bug-fixing.

Conclusions

To address the current needs for digital mental health intervention programs to account for the insufficient availability of mental health services in China, the current study provides preliminary evidence of the effectiveness of TEA, with the potential to address the urgent need for remote mental health services.

Trial registration

The study was registered at the Chinese Clinical Trial Register (ChiCTR), with number [ChiCTR2200065944].

Multidimensional emotional disorders inventory: Reliability and validity in a Spanish clinical sample

BACKGROUND

The categorical approach to diagnosing mental disorders has been criticized for a number of reasons (e.g., high rates of comorbidity; larger number of diagnostic categories and combination). Diverse alternatives have been proposed using a hybrid or totally dimensional perspective. Despite the evidence supporting use of the Multidimensional Emotional Disorders Inventory (MEDI) for assessing the transdiagnostic dimensions of Emotional Disorders using a dimensional-categorical hybrid approach, no data exist on Spanish clinical samples. The present study explores the validity and reliability of the 49-item MEDI in a clinical sample and provides data for its use.

METHODS

A total of 280 outpatients with emotional disorders attended in different Spanish public Mental Health Units in Spain filled out all questionnaires during the assessment phase and the MEDI again one week after. The instruments used evaluate four main constructs: personality, mood, anxiety and avoidance.

RESULTS

The nine original factors were confirmed and showed adequate reliability (α: 0.66-0.91) and stability (r = 0.76-0.87). No differences in mean scores by sex were presented in any subscale (p ≥ .07). The MEDI subscales correlated significantly with the scales of each of the selected constructs (0.45 < r < 0.76).

LIMITATIONS

The main limitations of this study were the limited sample size and not being able to count on MEDI scores post-transdiagnostic intervention.

CONCLUSIONS

The MEDI demonstrates adequate reliability and validity. It allows to assess diverse symptoms efficiently, thus being of interest for clinical studies and practice.

Anxiety Disorders: A Review

Importance

Anxiety disorders have a lifetime prevalence of approximately 34% in the US, are often chronic, and significantly impair quality of life and functioning.

Observations

Anxiety disorders are characterized by symptoms that include worry, social and performance fears, unexpected and/or triggered panic attacks, anticipatory anxiety, and avoidance behaviors. Generalized anxiety disorder (6.2% lifetime prevalence), social anxiety disorder (13% lifetime prevalence), and panic disorder (5.2% lifetime prevalence) with or without agoraphobia are common anxiety disorders seen in primary care. Anxiety disorders are associated with physical symptoms, such as palpitations, shortness of breath, and dizziness. Brief screening measures applied in primary care, such as the Generalized Anxiety Disorder-7, can aid in diagnosis of anxiety disorders (sensitivity, 57.6% to 93.9%; specificity, 61% to 97%). Providing information about symptoms, diagnosis, and evidence-based treatments is a first step in helping patients with anxiety. First-line treatments include pharmacotherapy and psychotherapy. Selective serotonin reuptake inhibitors (SSRIs, eg, sertraline) and serotonin-norepinephrine reuptake inhibitors (SNRIs, eg, venlafaxine extended release) remain first-line pharmacotherapy for generalized anxiety disorder, social anxiety disorder, and panic disorder. Meta-analyses suggest that SSRIs and SNRIs are associated with small to medium effect sizes compared with placebo (eg, generalized anxiety disorder: standardized mean difference [SMD], -0.55 [95% CI, -0.64 to -0.46]; social anxiety disorder: SMD, -0.67 [95% CI, -0.76 to -0.58]; panic disorder: SMD, -0.30 [95% CI, -0.37 to -0.23]). Cognitive behavioral therapy is the psychotherapy with the most evidence of efficacy for anxiety disorders compared with psychological or pill placebo (eg, generalized anxiety disorder: Hedges g = 1.01 [large effect size] [95% CI, 0.44 to 1.57]; social anxiety disorder: Hedges g = 0.41 [small to medium effect] [95% CI, 0.25 to 0.57]; panic disorder: Hedges g = 0.39 [small to medium effect[ [95% CI, 0.12 to 0.65]), including in primary care. When selecting treatment, clinicians should consider patient preference, current and prior treatments, medical and psychiatric comorbid illnesses, age, sex, and reproductive planning, as well as cost and access to care.

Conclusions and Relevance

Anxiety disorders affect approximately 34% of adults during their lifetime in the US and are associated with significant distress and impairment. First-line treatments for anxiety disorders include cognitive behavioral therapy, SSRIs such as sertraline, and SNRIs such as venlafaxine extended release.

Internet-based emotion-regulation training added to CBT in adolescents with depressive and anxiety disorders: A pilot randomized controlled trial to examine feasibility, acceptability, and preliminary effectiveness

BACKGROUND

Dysfunctional emotion regulation (ER) is associated with symptoms of depression and anxiety in adolescents. This pilot study aimed to examine the acceptability and feasibility of a guided internet-based emotion regulation training (ERT) added to cognitive behavioral therapy (CBT). Furthermore, we aimed to examine the feasibility of the randomized study design and to provide a first estimate of the effectiveness of CBT + ERT compared with CBT alone in adolescents with depressive or anxiety disorders.

METHODS

In a pilot randomized controlled trial (RCT) with a parallel group design, 39 patients (13-18 years) with depressive or anxiety disorder were assigned to CBT + ERT (n = 21) or CBT (n = 18). Assessments at baseline, three-months and six-months follow-up included treatment adherence, satisfaction, depressive symptoms, anxiety symptoms, and ER strategies.

RESULTS

Adherence to ERT was 66.5 %, and treatment satisfaction was adequate. 76.5 % of eligible patients participated in the study. Linear mixed-model analyses showed significantly reduced anxiety symptoms (p = .003), depressive symptoms (p = .017), and maladaptive ER (p = .014), and enhanced adaptive ER (p = .008) at six months follow-up in the CBT + ERT group compared to controls.

LIMITATIONS

The sample size was small, and results regarding effectiveness remain preliminary. Data-collection took place during COVID-19, which may have influenced the results.

CONCLUSIONS

Both the intervention and the study design were found to be feasible. In a larger RCT, however, improvement of recruitment strategy is necessary. Preliminary results indicate potential effectiveness in decreasing anxiety, depression, and emotion dysregulation in adolescents. The next step should be the development of an improved internet-based ERT and its evaluation in a larger RCT.

TRIAL REGISTRATION

Registered on January 14th, 2020 in The Netherlands Trial Register (NL8304).

Assessing the impact of the Royal Canadian Mounted Police (RCMP) protocol and Emotional Resilience Skills Training (ERST) among diverse public safety personnel

BACKGROUND

Public safety personnel (PSP; e.g., border services personnel, correctional workers, firefighters, paramedics, police, public safety communicators) are frequently exposed to potentially psychologically traumatic events. Such events contribute to substantial and growing challenges from posttraumatic stress injuries (PTSIs), including but not limited to posttraumatic stress disorder.

METHODS

The current protocol paper describes the PSP PTSI Study (i.e., design, measures, materials, hypotheses, planned analyses, expected implications, and limitations), which was originally designed to evaluate an evidence-informed, proactive system of mental health assessment and training among Royal Canadian Mounted Police for delivery among diverse PSP (i.e., firefighters, municipal police, paramedics, public safety communicators). Specifically, the PSP PTSI Study will: (1) adapt, implement, and assess the impact of a system for ongoing (i.e., annual, monthly, daily) evidence-based assessments; (2) evaluate associations between demographic variables and PTSI; (3) longitudinally assess individual differences associated with PTSI; and, (4) assess the impact of providing diverse PSP with a tailored version of the Emotional Resilience Skills Training originally developed for the Royal Canadian Mounted Police in mitigating PTSIs based on the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders. Participants are assessed pre- and post-training, and then at a follow-up 1-year after training. The assessments include clinical interviews, self-report surveys including brief daily and monthly assessments, and daily biometric data. The current protocol paper also describes participant recruitment and developments to date.

DISCUSSION

The PSP PTSI Study is an opportunity to implement, test, and improve a set of evidence-based tools and training as part of an evidence-informed solution to protect PSP mental health. The current protocol paper provides details to inform and support translation of the PSP PTSI Study results as well as informing and supporting replication efforts by other researchers.

TRIAL REGISTRATION

Hypotheses Registration: aspredicted.org, #90136. Registered 7 March 2022-Prospectively registered.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05530642. Registered 1 September 2022-Retrospectively registered. The subsequent PSP PTSI Study results are expected to benefit the mental health of all participants and, ultimately, all PSP.

The effects of the Unified Protocol and Unified Protocol skills on loneliness in the COVID-19 pandemic

BACKGROUND

Loneliness is a significant public health concern with no established first-line intervention although modular, transdiagnostic, cognitive-behavioral interventions, such as the Unified Protocol (UP), are promising candidates. The UP contains skill modules to target anxiety, depression, and related conditions, although it is unclear if the UP can reduce loneliness and if UP skill use contributes to these reductions.

METHODS

Using data from the first-stage randomization of a sequential multiple assignment randomized trial, we tested whether the UP led to reductions in loneliness and whether specific dimensions of UP skill use predicted session-to-session changes in loneliness. Participants (N = 70; M_age  = 33.74, 67% female, 74% white) completed six sessions of core UP modules, reporting how frequently they felt lonely and used UP skills before each session. Using hierarchical linear modeling, we examined the trajectory of change in loneliness and disaggregated between- from within-person variability to test session-to-session effects of skill use.

RESULTS

Loneliness significantly decreased during treatment with the UP. Using more UP skills than one's personal average, but not frequency of skill use, predicted session-to-session decreases in loneliness.

CONCLUSIONS

Therapists may be encouraged to guide patients toward using a large quantity of different skills to specifically address loneliness.