Effectiveness of the Unified Protocol for transdiagnostic treatment of emotional disorders in group format in Spain: Results from a randomized controlled trial with 6-months follow-up

Psychotherapy Research · 2021 · 37 citations

• Psychology
• Clinical psychology
• Psychiatry

BACKGROUND: The present study aims to investigate the effectiveness of the Unified Protocol (UP), a transdiagnostic treatment of emotional disorders (EDs), when applied in a group format in the public mental health system in Spain. METHODS: 488 participants with a primary diagnosis of ED were randomized to the UP group or to the treatment as usual (TAU; individual, disorder-specific cognitive behavioral therapy). Personality, depression and anxiety symptoms, affect, and quality of life were assessed at pre-treatment, 3 months after treatment onset (coinciding with the end of the UP treatment), and 6 and 9 months after treatment onset (follow-ups). The moderating effect of the treatment condition and the number of sessions received in the evolution of study outcomes was investigated with a linear mixed model analysis. RESULTS: A significant improvement in outcomes occurred in both conditions, except for extraversion in the TAU. Improvements in depression, anxiety and quality of life were larger in the UP condition. After the treatment, improvements were maintained at follow-ups in all study outcomes. An interaction between Time*Condition*Sessions was found for depression. CONCLUSION: The results add to the existing evidence on the effectiveness of the UP and may be important for implementation purposes in the Spanish or other similar public mental health systems. Trial registration number NCT03064477 (March 10, 2017).

The unified protocol for transdiagnostic treatment of emotional disorders

World Psychiatry · 2020 · 226 citations

• Medicine
• Psychiatry
• Psychotherapist

Broadly defined, the fields of psychotherapy and psychopathology have been with us for well over 100 years, but in recent decades substantial paradigm shifts have occurred. In particular, classification of mental disorders shifted from a global set of descriptors based almost entirely on theoretical conceptions to a more atheoretical empirically derived and more narrowly construed set of criteria, resulting in a substantial increase in the total number of disorders. Paradigm shifts such as this often produce a substantial surge in research, which was indeed soon evident. In addition to ramping up research on neurobiological and cognitive bases of various disorders, these new more precise descriptions of psychopathology led to operational definitions of disorders as dependent variables. This development resulted in well-defined clinical trials typically evaluating either drugs or very specific psychological treatments targeted to the main features of each disorder1. These outcomes were seen as positive by most clinical scientists and, in the years following, enabled a closer look at commonalities among disorders, differences that define the disorders, and response to treatment. This was particularly true for a class of disorders we have come to refer to as “emotional disorders”2, comprising anxiety, depressive, and related disorders that constitute what used to be called the “neurotic spectrum” . Clinical scientists came to discover common neurobiological mechanisms underlying emotional disorders, and a hierarchical structure with dimensions of temperament at the top of the hierarchy, specifically neuroticism or negative affect and extraversion or positive affect3. Based on this research, we developed a single “transdiagnostic” treatment that no longer focuses directly on what we now regard as trivial symptomatic differences among disorders such as panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, and depression, but rather targets their shared temperamental core4. Thus, the term “transdiagnostic” does not, in our view, simply refer to a treatment thought to be applicable across a wide range of psychopathology, as was true for old “schools” of psychotherapy, but rather to an intervention that targets specific psychopathological mechanisms (e.g., neuroticism) shared across a defined class of disorders2. The unified protocol for transdiagnostic treatment of emotional disorders (UP) is an emotion focused cognitive-behavioral intervention consisting of five “core” modules or components based on cognitive behavior therapy (CBT) elements of proven effectiveness that target negative emotionality and aversive reactions to emotions when they occur. These modules are preceded by an introductory session that reviews the patient's presenting symptoms and provides a therapeutic rationale, a module on motivational enhancement, and a module focusing on psycho­education about emotions. A final module consists of relapse prevention5. As the treatment proceeds, the domains of thoughts, physical sensations, and behaviors are each explored in detail, focusing specifically on elucidating dysfunctional emotion regulation strategies that the patient has developed over time within each of these domains, and teaching patients more adaptive emotion regulation skills. The UP has accrued substantial support for its efficacy in the treatment of anxiety and depression. In fact, a recent systematic review and meta-analysis examined 15 studies with a total of 1,244 participants and found large effect sizes across studies for symptoms of anxiety and depression when UP was delivered in both individual and group format6. Following two small open trials and an initial randomized controlled trial comparing the UP to a waitlist control condition, our group conducted a large randomized controlled equivalence trial (N=223) comparing the efficacy of the UP to established single-disorder protocols (SDPs) and a waitlist control condition. The UP was equally effective as SDPs in reducing symptom severity ratings across disorders, as well as decreasing symptoms of anxiety and depression, both at the end of treatment and at 6-month follow-up7. In addition, the UP condition exhibited lower rates of attrition over the course of the study. Meanwhile, other researchers have examined the efficacy of the UP in both individual and group contexts globally, including countries in South America, Asia and Europe. In general, these studies have also found the UP to be efficacious in the treatment of emotional disorders. While all humans experience emotions, culture can impact the messages one receives about the experience and expression of emotions, and the relevance of emotion regulation. Given that the majority of research has been conducted in Europe and the US to date, further research in other global contexts is warranted. As with any CBT, cultural competence is critical when using the UP. A promising recent pilot study conducted in Japan with the UP found significant reductions in symptoms of anxiety and depression that were large in magnitude8. The authors did not find any difference in emotion suppression from pre- to post-treatment, which they state is consistent with existing literature showing a lack of association between suppression and psychopathology in Japan, and may represent an important cultural difference to consider when delivering the UP. In another example, the UP has been adapted to fit the uniquely broad spectrum of cultures, education levels and backgrounds of victims of Colombia's armed conflict9. The UP has been translated into numerous languages, including Chinese, Dutch, German, Japanese, Korean and Spanish. An Internet-delivered version of the protocol has recently been developed. In summary, the UP provides a transdiagnostic psychological treatment that targets shared underlying mechanisms of all emotional disorders, thereby offering a single treatment that can be used across the most common clinical presentations. This treatment is equally effective as gold-standard SDPs, but may confer additional benefits with regard to efficiency, dropout, and training therapists. Given the unmet global demand for mental health care, combined with the lack of clinicians trained in evidence-based treatments, we believe that transdiagnostic treatments are the future of mental health care, and represent one approach to increasing access to evidence-based care and impacting global mental health.

Toward a Unified Treatment for Emotional Disorders

Routledge eBooks · 2020 · 70 citations

• Psychology
• Psychotherapist
• Medicine

Deepening understanding of the nature of emotional disorders reveals that commonalities in etiology and latent structure among these disorders supercedes differences. In the 1960s, cognitive behavioral approaches to treating emotional disorders such as anxiety and mood disorders began to emanate from basic psychological science; specifically, theories and data pertaining to learning, emotional development and regulation and, somewhat later, cognitive science. To justify a relatively radical new and unified psychological approach to treating emotional disorders, it is important to provide some background. One argument for a unified treatment approach to emotional disorders is the facilitation of dissemination and training focused on a single set of therapeutic principles rather than diverse protocols. Antecedent cognitive reappraisal in each of the emotional disorders is easily categorized into overestimating the probability of a negative event happening and exaggerating the consequences of that negative effect if it did happen.

Does the unified protocol really change neuroticism? Results from a randomized trial

Psychological Medicine · 2020 · 125 citations

• Clinical psychology
• Psychology
• Psychiatry

BACKGROUND: Neuroticism is associated with the onset and maintenance of a number of mental health conditions, as well as a number of deleterious outcomes (e.g. physical health problems, higher divorce rates, lost productivity, and increased treatment seeking); thus, the consideration of whether this trait can be addressed in treatment is warranted. To date, outcome research has yielded mixed results regarding neuroticism's responsiveness to treatment, perhaps due to the fact that study interventions are typically designed to target disorder symptoms rather than neuroticism itself. The purpose of the current study was to explore whether a course of treatment with the unified protocol (UP), a transdiagnostic intervention that was explicitly developed to target neuroticism, results in greater reductions in neuroticism compared to gold-standard, symptom focused cognitive behavioral therapy (CBT) protocols and a waitlist (WL) control condition. METHOD: Patients with principal anxiety disorders (N = 223) were included in this study. They completed a validated self-report measure of neuroticism, as well as clinician-rated measures of psychological symptoms. RESULTS: At week 16, participants in the UP condition exhibited significantly lower levels of neuroticism than participants in the symptom-focused CBT (t(218) = -2.17, p = 0.03, d = -0.32) and WL conditions(t(207) = -2.33, p = 0.02, d = -0.43), and these group differences remained after controlling for simultaneous fluctuations in depression and anxiety symptoms. CONCLUSIONS: Treatment effects on neuroticism may be most robust when this trait is explicitly targeted.