Laren R. Conklin

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders Compared With Diagnosis-Specific Protocols for Anxiety Disorders: A Randomized Clinical Trial

Importance Transdiagnostic interventions have been developed to address barriers to the dissemination of evidence-based psychological treatments, but only a few preliminary studies have compared these approaches with existing evidence-based psychological treatments. Objective To determine whether the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is at least as efficacious as single-disorder protocols (SDPs) in the treatment of anxiety disorders. Design, Setting, and Participants From June 23, 2011, to March 5, 2015, a total of 223 patients at an outpatient treatment center with a principal diagnosis of panic disorder with or without agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, or social anxiety disorder were randomly assigned by principal diagnosis to the UP, an SDP, or a waitlist control condition. Patients received up to 16 sessions of the UP or an SDP for 16 to 21 weeks. Outcomes were assessed at baseline, after treatment, and at 6-month follow-up. Analysis in this equivalence trial was based on intention to treat. Interventions The UP or SDPs. Main Outcomes and Measures Blinded evaluations of principal diagnosis clinical severity rating were used to evaluate an a priori hypothesis of equivalence between the UP and SDPs. Results Among the 223 patients (124 women and 99 men; mean [SD] age, 31.1 [11.0] years), 88 were randomized to receive the UP, 91 to receive an SDP, and 44 to the waitlist control condition. Patients were more likely to complete treatment with the UP than with SDPs (odds ratio, 3.11; 95% CI, 1.44-6.74). Both the UP (Cohen d, −0.93; 95% CI, −1.29 to −0.57) and SDPs (Cohen d, −1.08; 95% CI, −1.43 to −0.73) were superior to the waitlist control condition at acute outcome. Reductions in clinical severity rating from baseline to the end of treatment (&bgr;, 0.25; 95% CI, −0.26 to 0.75) and from baseline to the 6-month follow-up (&bgr;, 0.16; 95% CI, −0.39 to 0.70) indicated statistical equivalence between the UP and SDPs. Conclusions and Relevance The UP produces symptom reduction equivalent to criterion standard evidence-based psychological treatments for anxiety disorders with less attrition. Thus, it may be possible to use 1 protocol instead of multiple SDPs to more efficiently treat the most commonly occurring anxiety and depressive disorders. Trial Registration clinicaltrials.gov Identifier: NCT01243606

Dropout from individual psychotherapy for major depression: A meta-analysis of randomized clinical trials.

Dropout from mental health treatment poses a substantial problem, but rates vary substantially across studies and diagnoses. Focused reviews are needed to provide more detailed estimates for specific areas of research. Randomized clinical trials involving individual psychotherapy for unipolar depression are ubiquitous and important, but empirical data on average dropout rates from these studies is lacking. We conducted a random-effects meta-analysis of 54 such studies (N=5852) including 80 psychotherapy conditions, and evaluated a number of predictors of treatment- and study-level dropout rates. Our overall weighted dropout estimates were 19.9% at the study level, and 17.5% for psychotherapy conditions specifically. Therapy orientation did not significantly account for variance in dropout estimates, but estimates were significantly higher in psychotherapy conditions with more patients of minority racial status or with comorbid personality disorders. Treatment duration was also positively associated with dropout rates at trend level. Studies with an inactive control comparison had higher dropout rates than those without such a condition. Limitations include the inability to test certain potential predictors (e.g., socioeconomic status) due to infrequent reporting. Overall, our findings suggest the need to consider how specific patient and study characteristics may influence dropout rates in clinical research on individual therapy for depression.

Relationships among adaptive and maladaptive emotion regulation strategies and psychopathology during the treatment of comorbid anxiety and alcohol use disorders

Both maladaptive and adaptive emotion regulation strategies have been linked with psychopathology. However, previous studies have largely examined them separately, and little research has examined the interplay of these strategies cross-sectionally or longitudinally in patients undergoing psychological treatment. This study examined the use and interplay of adaptive and maladaptive emotion regulation strategies in 81 patients receiving cognitive-behavioral interventions for comorbid alcohol use and anxiety disorders. Patients completed measures of emotion regulation strategy use and symptoms of psychopathology pre- and post-treatment. Cross-sectionally, higher use of maladaptive strategies (e.g., denial) was significantly related to higher psychopathology pre- and post-treatment, whereas higher use of adaptive strategies (e.g., acceptance) only significantly related to lower psychopathology post-treatment. Prospectively, changes in maladaptive strategies, but not changes in adaptive strategies, were significantly associated with post-treatment psychopathology. However, for patients with higher pre-treatment maladaptive strategy use, gains in adaptive strategies were significantly associated with lower post-treatment psychopathology. These findings suggest that psychological treatments may maximize efficacy by considering patient skill use at treatment outset. By better understanding a patients initial emotion regulation skills, clinicians may be better able to optimize treatment outcomes by emphasizing maladaptive strategy use reduction predominately, or in conjunction with increasing adaptive skill use.

Development of a Single-Session, Transdiagnostic Preventive Intervention for Young Adults at Risk for Emotional Disorders:

Cognitive-behavioral prevention programs have demonstrated efficacy in reducing subclinical symptoms of anxiety and depression, and there is some evidence to suggest that they can lower the risk of future disorder onset. However, existing interventions tend to be relatively lengthy and target specific disorders or problem areas, both of which limit their potential for widespread dissemination. To address these limitations, we aimed to develop a single-session, transdiagnostic preventive intervention based on the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders for young adults at risk for developing anxiety and/or depressive disorders within a college setting. Results from this proof-of-concept study indicated that the intervention was viewed as highly satisfactory and acceptable. The intervention also was successful at delivering adaptive emotion management skills in its 2-hr workshop format. Future studies evaluating the efficacy of this novel transdiagnostic, emotion-focused prevention program are warranted.

Treating Suicidal Thoughts and Behaviors Within an Emotional Disorders Framework: Acceptability and Feasibility of the Unified Protocol in an Inpatient Setting:

We provide a theoretical rationale for applying a transdiagnostic, shared mechanism treatment (the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders [UP]) to suicidal thoughts and behaviors. We also present results from a proof of concept study examining the feasibility and acceptability of adding a modified UP to treatment as usual (TAU) in an inpatient setting for individuals reporting a recent suicide attempt or active suicidal ideation. Participants (N = 12) were randomly assigned to receive UP + TAU or TAU alone. Findings indicate good feasibility and acceptability of the adjunctive intervention. Among participants who were responsive to contact attempts postdischarge (n = 6), there were no observable differences in suicidal thoughts or behaviors during a 6-month follow-up. This application represents a promising initial extension of a cognitive-behavioral, emotion-focused treatment to suicidal individuals within an inpatient setting. Future studies adequately powered to speak to efficacy of the modified UP intervention are warranted.

The effects of aggression on symptom severity and treatment response in a trial of cognitive behavioral therapy for panic disorder

BACKGROUND Previous research suggests that patients with panic disorder exhibit higher levels of aggression than patients with other anxiety disorders. This aggression is associated with more severe symptomatology and interpersonal problems. However, few studies have examined whether higher levels of aggression are associated with a worse treatment response in this population. METHODS The present study sought to examine the association of aggression with panic disorder symptom severity in a sample of 379 patients who participated in a trial examining long-term strategies for the treatment of panic disorder. RESULTS We found that aggression was significantly associated with higher baseline levels of panic disorder symptoms, anxiety, depression, and functional impairment. Further, we found that patients higher in aggression did not achieve the same level of improvement in general anxiety symptoms during treatment compared to patients lower in aggression, even when controlling for baseline anxiety symptom severity. CONCLUSION These results suggest that more research is needed concerning patients with anxiety disorders with higher aggression, as they may be a group in need of additional treatment considerations.

Unified Protocol for Treatment of Depression

Numerous cognitive-behavioral treatment manuals have been developed to treat specific psychiatric disorders. Although these treatments are generally effective for those specific conditions, there remains a great need for interventions that can be flexibly applied across many disorders and symptoms due to high comorbidity rates and significant barriers to clinician training in distinct evidence-based psychological treatments. The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is a cognitive-behavioral treatment designed to treat neuroticism, a core temperamental factor that underlies the development and maintenance of emotional disorders (i.e., anxiety, depressive, and related disorders). In this chapter, we discuss the rationale for and conceptualization of the UP and its eight treatment modules. Since its development, the UP has garnered significant research support. As such, we detail findings from relevant research focused on treating depressive disorders and other related conditions. Finally, we describe each UP treatment module in depth and how providers can utilize the UP in their practice with patients with depression. Overall, the UP is a promising intervention that can be utilized across emotional disorders, including depression, and may be an intervention that is advantageous for widespread dissemination.

Transdiagnostic Treatment for Anxiety Disorders

Anxiety disorders are a common class of disorders, and comorbidity among anxiety disorders is frequently observed. Cognitive-behavioral and behavioral psychotherapies for anxiety disorders are effective, though most evidence-based treatment protocols focus on the treatment of one principal anxiety disorder. In the last decade, treatments that aim to treat underlying vulnerabilities shared across anxiety disorders have been developed to more efficiently help patients that present with one or more anxiety and related disorders. We discuss two of these transdiagnostic treatments, the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders, developed by David Barlow and colleagues, and Transdiagnostic Group Cognitive-Behavioral Therapy, developed by Peter Norton and colleagues. Background, similarities and differences, as well as evidence for each treatment are discussed. To date, the evidence from initial trials demonstrates efficacy for unified transdiagnostic treatments that is comparable to single-diagnosis protocols, providing promise for reducing therapist burden in acquiring and using evidence-based psychotherapies.