Application of the unified protocol for the transdiagnostic treatment of comorbid emotional disorders in patients with ultra-high risk of developing psychosis: A randomized trial study protocol

Trinidad Peláez, Raquel López-Carrillero, Marta Ferrer-Quintero, Susana Ochoa, Jorge Osma, Trinidad Peláez, Raquel López-Carrillero, Marta Ferrer-Quintero, Susana Ochoa, Jorge Osma

Abstract

Background: Cognitive Behavioral Therapy is delivered in most of the early intervention services for psychosis in different countries around the world. This approach has been demonstrated to be effective in decreasing or at least delaying the onset of psychosis. However, none of them directly affect the comorbidity of these types of patients that is often the main cause of distress and dysfunctionality. The Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders (UP) is a psychological intervention that combines cognitive-behavioral and third-generation techniques that address emotional dysregulation as an underlying mechanism that these disorders have in common. The application of this intervention could improve the comorbid emotional symptoms of these patients.

Materials and methods: The study is a randomized controlled trial in which one group receives immediate UP plus standard intervention and the other is placed on a waiting list to receive UP 7 months later, in addition to standard care in one of our early psychosis programs. The sample will be 42 patients with UHR for psychosis with comorbid emotional symptoms. The assessment is performed at baseline, at the end of treatment, and at 3-months' follow-up, and includes: general psychopathology, anxiety and depression, positive and negative emotions, emotional dysregulation, personality, functionality, quality of life, cognitive distortions, insight, and satisfaction with the UP intervention.

Discussion: This will be the first study of the efficacy, acceptability, and viability of the UP in a sample of young adults with UHR. The results of this study may have clinical implications, contributing to improving the model of care for young people who consult for underlying psychotic, anxiety, and/or depressive symptoms that can lead to high distress and dysfunctionality.

Clinical trial registration: [https://ichgcp.net/clinical-trials-registry/NCT04929938" title="See in ClinicalTrials.gov">NCT04929938].

Keywords: anxiety disorders; depressive disorders; emotional focused therapy; psychotic disorders; transdiagnostic; ultra high risk for psychosis; unified protocol.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2022 Peláez, López-Carrillero, Ferrer-Quintero, Ochoa and Osma.

References

    1. Allswede D. M., Addington J., Bearden C. E., Cadenhead K. S., Cornblatt B. A., Mathalon D. H., et al. (2020). Characterizing covariant trajectories of individuals at clinical high risk for psychosis across symptomatic and functional domains. Am. J. Psychiatry 177 164–171. 10.1176/appi.ajp.2019.18111290
    1. Andersson G., Cuijpers P., Carlbring P., Riper H., Hedman E. (2014). Guided Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: A systematic review and meta-analysis. World Psychiatry 13 288–295. 10.1002/wps.20151
    1. Barajas A., Pelaez T., González O., Usall J., Iniesta R., Arteaga M., et al. (2019). Predictive capacity of prodromal symptoms in first-episode psychosis of recent onset. Early Interv. Psychiatry 13 414–424. 10.1111/eip.12498
    1. Barlow D. H., Farchione T. J., Bullis J. R., Gallagher M. W., Murray-Latin H., Sauer-Zavala S., et al. (2017). The unified protocol for transdiagnostic treatment of emotional disorders compared with diagnosis-specific protocols for anxiety disorders: A randomized clinical trial. JAMA Psychiatry 74:875. 10.1001/jamapsychiatry.2017.2164
    1. Barlow D. H., Farchione T. J., Sauer-Zavala S., Murray H., Ellard K. K., Bullis J. R., et al. (2019). Protocolo Unificado Para el Tratamiento Transdiagnóstico de los Trastornos Emocionales. Madrid: Alianza Editorial.
    1. Beck A. T., Baruch E., Balter J. M., Steer R. A., Warman D. M. (2004). A new instrument for measuring insight: The Beck Cognitive Insight Scale (BCIS). Schizophre. Res. 68 319–329. 10.1016/S0920-9964(03)00189-0
    1. Beck A. T., Steer R. A. (1993). Beck Anxiety Inventory Manual. San Antonio, TX: Psychological Corporation.
    1. Beck A. T., Steer R. A., Brown G. K. (1996). BDI-II. Beck Depression Inventory-Second Edition Manual. San Antonio, TX: Psychological Corporation.
    1. Ben-David S., Cole A. R., Brucato G., Girgis R., Munson M. R. A. (2019). conceptual model of mental health service utilization among young adults at clinical high-risk for developing psychosis. Psychiatr. Rehabil. J. 42 17–25. 10.1037/prj0000336
    1. Bentley K. H., Gallagher M. W., Carl J. R., Barlow D. H. (2014). Development and validation of the Overall Depression Severity and Impairment Scale. Psychol. Assess. 26 815–830. 10.1037/a0036216
    1. Bullis J. R., Fortune M. R., Farchione T. J., Barlow D. H. A. (2014). preliminary investigation of the long-term outcome of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders. Compr. Psychiatry 55 1920–1927. 10.1016/j.comppsych.2014.07.016
    1. Carl J. R., Gallagher M. W., Sauer-Zavala S. E., Bentley K. H., Barlow D. H. A. (2014). preliminary investigation of the effects of the unified protocol on temperament. Compr. Psychiatry 55 1426–1434. 10.1016/j.comppsych.2014.04.015)
    1. Carlucci L., Saggino A., Balsamo M. (2021). On the efficacy of the unified protocol for transdiagnostic treatment of emotional disorders: A systematic review and meta-analysis. Clin. Psychol. Rev. 87:101999. 10.1016/j.cpr.2021.101999
    1. Cassiello-Robbins C., Southward M. W., Tirpak J. W., Sauer-Zavala S. A. (2020). systematic review of Unified Protocol applications with adult populations: Facilitating widespread dissemination via adaptability. Clin. Psychol. Rev. 78:101852. 10.1016/j.cpr.2020.101852
    1. Colizzi M., Ruggeri M., Lasalvia A. (2020). Should we be concerned about stigma and discrimination in people at risk for psychosis? A systematic review. Psychol. Med. 50 705–726. 10.1017/S0033291720000148
    1. Corral L., Labad J., Ochoa S., Cabezas A., Muntané G., Valero J., et al. (2018). Cognitive Biases Questionnaire for Psychosis (CBQ-sp): Spanish validation and relationship with cognitive insight in psychotic patients. Front. Psychiatry 11:596625. 10.3389/fpsyt.2020.596625
    1. Costa P. T., Mccrae R. R. (1992). Manual For the Revised NEO Personality Inventory (NEO-PIR) and NEO Five-Factor Inventory (NEO-FFI)Professional Manual. Odessa, FL: Psychological Assessment Resources.
    1. Echeburúa E., Corral P. D., Fernández-Montalvo J. (2000). Escala de inadaptación (EI): Propiedades psicométricas en contextos clínicos. Análisis yModificación de Conducta 26 325–340.
    1. Ferrando L., Bobes J., Gibert M., Soto M., Soto O. (1998). M.I.N.I. Mini International Neuropsychiatric Interview. Madrid: Instituto IAP.
    1. Ferrans C. E., Powers M. J. (1985). Quality of life index: Development and psychometric properties. ANS Adv. Nurs. Sci. 8 15–24. 10.1097/00012272-198510000-00005
    1. French P., Morrison A. P. (2004). Early Detection and Cognitive Therapy for People at High Risk of Developing Psychosis: A Treatment Approach. London: John Wiley and Sons.
    1. Fusar-Poli P., Bonoldi I., Yung A. R., Borgwardt S., Kempton M. J., Valmaggia L., et al. (2012). Predicting psychosis: Meta-analysis of transition outcomes in individuals at high clinical risk: Meta-analysis of transition outcomes in individuals at high clinical risk. Arch. Gen. Psychiatry 69 220–229. 10.1001/archgenpsychiatry.2011.1472
    1. Grasa E., Corripio I. (2019). En: Aplicaciones del Protocolo Unificado para el tratamiento transdiagnóstico de la disregulación emocional. Madrid Alianza Editor. 2019 115–138.
    1. Gratz K. L., Roemer L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. J. Psychopathol. Behav. Assess. 26 41–54. 10.1023/B:JOBA.0000007455.08539.94
    1. Gutierrez-Zotes A., Valero J., Ruiz C., Labad M., Ochoa A., Ahuir S., et al. (2012). Spanish Adaptation of the Beck Cognitive Insight Scale (BCIS) for Schizophrenia. Actas Españolas De Psiquiatría. 40 2–9.
    1. Hartmann J. A., Nelson B., Spooner R., Paul Amminger G., Chanen A., Davey C. G., et al. (2019). Broad clinical high-risk mental state (CHARMS): Methodology of a cohort study validating criteria for pluripotent risk. Early Interv. Psychiatry 13 379–386. 10.1111/eip.12483
    1. Hervás G., Jódar R. (2008). The Spanish version of the Difficulties in Emotion Regulation Scale. Clínica y Salud. 2 139–156.
    1. Howes O. D., Whitehurst T., Shatalina E., Townsend L., Onwordi E. C., Mak T. L. A., et al. (2021). The clinical significance of duration of untreated psychosis: An umbrella review and random-effects meta-analysis. World Psychiatry 20 75–95. 10.1002/wps.20822
    1. Inchausti F., Mole J., Fonseca-Pedrero E., Ortuño-Sierra J. (2015). Validity of personality measurement in adults with anxiety disorders: Psychometric properties of the Spanish NEO-FFI-R using Rasch analyses. Front. Psychol. 6:465. 10.3389/fpsyg.2015.00465
    1. Ising H. K., Lokkerbol J., Rietdijk J., Dragt S., Klaassen R. M. C., Kraan T., et al. (2017). Four-year cost-effectiveness of cognitive behavior therapy for preventing first-episode psychosis: The dutch early detection intervention evaluation (EDIE-NL) trial. Schizophr. Bull. 43 365–374. 10.1093/schbul/sbw084
    1. Lin A., Wood S. J., Nelson B., Beavan A., McGorry P., Yung A. R. (2015). Outcomes of nontransitioned cases in a sample at ultra-high risk for psychosis. Am. J. Psychiatry 172 249–258. 10.1176/appi.ajp.2014.13030418
    1. Livet A., Navarri X., Potvin S., Conrod P. (2020). Cognitive biases in individuals with psychotic-like experiences: A systematic review and a meta-analysis. Schizophr. Res. 222 10–22. 10.1016/j.schres.2020.06.016
    1. López-Gómez I., Hervás G., Vázquez C. (2015). Adaptación de la “Escala de Afecto Psotivo y Negativo” (PANAS) en una muestra general española. Behav. Psychol. 3 529–548.
    1. Lupton D. (2021). Young people’s use of digital health technologies in the Global North: Narrative review. J. Med. Int. Res. 23:e18286. 10.2196/18286
    1. McGorry P. D., Hartmann J. A., Spooner R., Nelson B. (2018). Beyond the “at risk mental state” concept: Transitioning to transdiagnostic psychiatry. World Psychiatry 17 133–142. 10.1002/wps.20514
    1. McLaren T., Peter L.-J., Tomczyk S., Muehlan H., Stolzenburg S., Schomerus G., et al. (2021). How can the utilisation of help for mental disorders be improved? A quasi-experimental online study on the changeability of stigmatising attitudes and intermediate variables in the process of utilisation. BMC Public Health 21:2124. 10.1186/s12889-021-12125-5
    1. Mei C., van der Gaag M., Nelson B., Smit F., Yuen H. P., Berger M., et al. (2021). Preventive interventions for individuals at ultra high risk for psychosis: An updated and extended meta-analysis. Clin. Psychol. Rev. 86:102005. 10.1016/j.cpr.2021.102005
    1. Mezzich J. E., Ruipérez M. A., Pérez C., Yoon G., Liu J., Mahmud S. (2000). The Spanish version of the Quality of Life index: Presentation and validation. J. Nerv. Ment. Dis. 188 301–305. 10.1097/00005053-200005000-00008
    1. Morrison A. P., French P., Stewart S. L. K., Birchwood M., Fowler D., Gumley A. I., et al. (2012). Early detection and intervention evaluation for people at risk of psychosis: Multisite randomised controlled trial. BMJ 344:e2233. 10.1136/bmj.e2233
    1. Morrison A. P., French P., Walford L., Lewis S. W., Kilcommons A., Green J., et al. (2004). Cognitive therapy for the prevention of psychosis in people at ultra-high risk: Randomised controlled trial. Br. J. Psychiatry 185 291–297. 10.1192/bjp.185.4.291
    1. Nelson B. Orygen Youth Health Research Centre Issuing Body. (2012). The PACE Clinic Manual: A Treatment Approach for Young People at Ultra High Risk of Psychosis. Parkville, Vic: Orygen Youth Health Research Centre.
    1. Norman S. B., Hami Cissell S., Means-Christensen A. J., Stein M. B. (2006). Development and validation of an overall anxiety severity and impairment scale (OASIS). Depress. Anxiety 23 245–249. 10.1002/da.20182
    1. Orygen The National Center of Excellence in Youth (2016). Australian Clinical Guidelines for Early Psychosis Available onlone at: (accessed June, 2016).
    1. Osma J., Martínez-García L., Peris-Baquero Ó, Navarro-Haro M. V., González-Pérez A., Suso-Ribera C. (2021). Implementation, efficacy and cost effectiveness of the unified protocol in a blended format for the transdiagnostic treatment of emotional disorders: A study protocol for a multicentre, randomised, superiority controlled trial in the Spanish National Health System. BMJ Open 11:e054286. 10.1136/bmjopen-2021-054286.2021
    1. Osma J., Peris-Baquero O., Suso-Ribera C., Farchione T. J., Barlow D. H. (2022). 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. Psychother. Res. 32 329–342. 10.1080/10503307.2021.1939190
    1. Osma J., Quilez-Orden A., Suso-Ribera C., Peris-Baquero O., Norman S. B., Bentley K. H., et al. (2019). Psychometric properties and validation of the Spanish versions of the overall anxiety and depression severity and impairment scales. J. Affect. Disord. 252 9–18. 10.1016/j.jad.2019.03.063
    1. NICE (2014). Psychosis and Schizophrenia in Adults: Prevention and Management | Guidance | NICE. Available online at: (accessed March 1, 2014).
    1. Peters E., Moritz S., Wiseman Z., Greenwood K., Kuipers E., Schwannauer M., et al. (2010). The Cognitive Biases Questionnaire for Psychosis. (CBQP). Schizophr. Res. 117 413–413. 10.1016/j.schres.2010.02.759
    1. Polari A., Lavoie S., Yuen H.-P., Amminger P., Berger G., Chen E., et al. (2018). Clinical trajectories in the ultra-high risk for psychosis population. Schizophr. Res. 197 550–556. 10.1016/j.schres.2018.01.022
    1. Polari A., Street R., Conus P., Finkelstein A., Hartmann J. A., Kim S.-W., et al. (2021a). Patients’, carers’ and clinicians’ attitudes towards alternative terms to describe the at-risk for psychosis state. Schizophr. Res. 237 69–75. 10.1016/j.schres.2021.08.031
    1. Polari A., Yuen H. P., Amminger P., Berger G., Chen E., deHaan L., et al. (2021b). Prediction of clinical outcomes beyond psychosis in the ultra-high risk for psychosis population. Early Interv. Psychiatry 15 642–651. 10.1111/eip.13002
    1. Rosellini A. J., Brown T. A. (2019). The Multidimensional Emotional Disorder Inventory (MEDI): Assessing transdiagnostic dimensions to validate a profile approach to emotional disorder classification. Psychol. Assess. 31 59–72. 10.1037/pas0000649
    1. Rutigliano G., Valmaggia L., Landi P., Frascarelli M., Cappucciati M., Sear V., et al. (2016). Persistence or recurrence of non-psychotic comorbid mental disorders associated with 6-year poor functional outcomes in patients at ultra high risk for psychosis. J. Affect. Disord. 203 101–110. 10.1016/j.jad.2016.05.053
    1. Sakiris N., Berle D. A. (2019). A.systematic review and meta-analysis of the Unified Protocol as a transdiagnostic emotion regulation based intervention. Clin. Psychol. Rev. 2019:72. 10.1016/j.cpr.2019.101751
    1. Salazar de Pablo G., Radua J., Pereira J., Bonoldi I., Arienti V., Besana F., et al. (2021). Probability of transition to psychosis in individuals at clinical high risk: An updated meta-analysis: An updated meta-analysis. JAMA Psychiatry 78 970–978. 10.1001/jamapsychiatry.2021.0830
    1. Santesteban-Echarri O., Piskulic D., Nyman R. K., Addington J. (2020). Telehealth interventions for schizophrenia-spectrum disorders and clinical high-risk for psychosis individuals: A scoping review. J Telemed. Telecare 26 14–20. 10.1177/1357633X18794100
    1. Sanz J., García-Vera M. P., Espinosa R., Fortún M., Vázquez C. (2005). Adaptación española del Inventario para la Depresión de Beck-II (BDI-II): Propiedades psicométricas en pacientescon trastornos psicológicos. Clínica y Salud 16 121–142.
    1. Sanz J., García-Vera M. P., Fortún M. (2012). El “Inventario de Ansiedad de Beck” (BAI): Propiedades psicométricas de la Versión Española en pacientes con Trastornos Psicológicos. Behav. Psychol. 20 563–583.
    1. Sauer-Zavala S., Gutner C. A., Farchione T. J., Boettcher H. T., Bullis J. R., Barlow D. H. (2017). Current definitions of “transdiagnostic” in treatment development: A search for consensus. Behav. Ther. 48 128–138. 10.1016/j.beth.2016.09.004
    1. Shah J. L., Crawford A., Mustafa S. S., Iyer S. N., Joober R., Malla A. K. (2017). Is the clinical high-risk state a valid concept? Retrospective examination in a first-episode psychosis sample. Psychiatr. Serv. 68 1046–1052. 10.1176/appi.ps.201600304
    1. Sheehan D. V., Lecrubier Y., Sheehan K. H., Amorim P., Janavs J., Weiller E., et al. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J. Clin. Psychiatry 59 34–57. 10.1037/t18597-000
    1. Singh S., Sagar R. (2022). Online Psychotherapy During the COVID-19 Pandemic: The Good, the Bad, and the Ugly. Indian J. Psychol. Med. 44 177–180. 10.1177/02537176211070427
    1. Stubbings D. R., Rees C. S., Roberts L. D., Kane R. T. (2013). Comparing in-person to videoconference-based cognitive behavioral therapy for mood and anxiety disorders: Randomized controlled trial. J. Med. Int. Res. 15:e258. 10.2196/jmir.2564
    1. Taylor E. (2016). Program Directory of Early Psychosis Intervention Programs. Portland, OR: EASA Center for Excellence.
    1. Van der Gaag M., Nieman D., van den Berg D. (2013a). CBT for Those at Risk of a First Episode Psychosis: Evidence-Based Psychotherapy for People with an At Risk Mental State. New York: Routledge.
    1. Van der Gaag M., Smit F., Bechdolf A., French P., Linszen D. H., Yung A. R., et al. (2013b). Preventing a first episode of psychosis: Meta-analysis of randomized controlled prevention trials of 12 month and longer-term follow-ups. Schizophr. Res. 149 56–62. 10.1016/j.schres.2013.07.004
    1. Van Os J., Guloksuz S. A. (2017). critique of the “ultra-high risk” and “transtion” paradigm. World Psychiatry 16 200–206. 10.1002/wps.20423
    1. Watson D., Clark L. A., Tellegen A. (1988). Development and validation of brief measures of positive and negative affect: The PANAS scales. J. Pers. Soc. Psychol. 54 1063–1070. 10.1037//0022-3514.54.6.1063
    1. WMA (2013). “Declaration of helsinki-ethical principles for medical research involving human subjects,” in 64th General Assembly, Fortaleza.
    1. Woodberry K. A., Powers K. S., Bryant C., Downing D., Verdi M. B., Elacqua K. M., et al. (2021). Emotional and stigma-related experiences relative to being told one is at risk for psychosis. Schizophr. Res. 238 44–51. 10.1016/j.schres.2021.09.017
    1. Yung A. R., Yuen H. P., Phillips L. J., Francey S., McGorry P. D. (2005). Mapping the onset of psychosis: The comprehensive assessment of at risk mental states (CAARMS). Schizophr. Res. 60 30–31. 10.1016/s0920-9964(03)80090-7

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