Clinical Utility of an Internet-Delivered Version of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (iUP-A): A Pilot Open Trial

Bonifacio Sandín, Julia García-Escalera, Rosa M Valiente, Victoria Espinosa, Paloma Chorot, Bonifacio Sandín, Julia García-Escalera, Rosa M Valiente, Victoria Espinosa, Paloma Chorot

Abstract

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A; Ehrenreich-May et al., 2018) has been shown to be effective for reducing symptoms of anxiety and depression in adolescents with emotional disorders. Internet-delivered psychological treatments have great potential to improve access to evidence-based psychological therapy since they are associated with reduced human and economic costs and less social stigma. Recently, our group developed an online version of the UP-A (the iUP-A) for the treatment of emotional disorders in adolescents. The aim of this pilot trial was to test the clinical utility of the iUP-A in a small sample (n = 12) of adolescents with elevated anxiety and/or depressive symptoms. Intention-to-treat and completer analyses revealed pre- to post-intervention self-reported decreases of anxiety and depressive symptoms, anxiety sensitivity, emotional avoidance, panic disorder symptoms, panic disorder severity, generalized anxiety disorder symptoms, pathological worry, and major depressive disorder symptoms. We found high feasibility and acceptability of the program with all participants and responsible parents reporting an improvement in the adolescents' ability to cope with emotions. Results suggest that the iUP-A may provide a new approach to improve access to treatment for anxious and depressive adolescents in Spain; however, further research must be conducted before firm conclusions can be drawn.

Keywords: AMTE; adolescents; anxiety; depression; i-CBT; iUP-A; online therapy; transdiagnostic.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Participant flow through the study.
Figure 2
Figure 2
Screenshot of the AMTE homepage.

References

    1. Kessler R.C., Petukhova M., Sampson N.A., Zaslavsky A.M., Wittchen H. Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. Int. J. Methods Psychiatry. Res. 2012;21:169–184. doi: 10.1002/mpr.1359.
    1. Ahlen J., Lenhard F., Ghaderi A. Universal prevention for anxiety and depressive symptoms in children: A meta-analysis of randomized and cluster-randomized trials. J. Prim. Prev. 2015;36:387–403. doi: 10.1007/s10935-015-0405-4.
    1. Balázs J., Miklósi M., Keresztény Á., Hoven C.W., Carli V., Wasserman C., Apter A., Bobes J., Brunner R., Cosman D. Adolescent subthreshold-depression and anxiety: Psychopathology, functional impairment and increased suicide risk. J. Child. Psychol. Psychiatry. 2013;54:670–677. doi: 10.1111/jcpp.12016.
    1. Weersing V.R., Gonzalez A., Campo J.V., Lucas A.N. Brief behavioral therapy for pediatric anxiety and depression: Piloting an integrated treatment approach. Cogn. Behav. Pract. 2008;15:126–139. doi: 10.1016/j.cbpra.2007.10.001.
    1. Ehrenreich-May J., Bilek E.L., Queen A.H., Hernandez Rodriguez J. A unified protocol for the group treatment of childhood anxiety and depression. Rev. Psicopatol. Psicol. Clin. 2012;17:219–236. doi: 10.5944/rppc.vol.17.num.3.2012.
    1. Sandín B., Chorot P., Valiente R.M. Psicopatología de la ansiedad y trastornos de ansiedad: Hacia un enfoque transdiagnóstico [Psychopathology of anxiety and the anxiety disorders: Towards a transdignostic perspective] In: Belloch A., Sandín B., Ramos F., editors. Manual de Psicopatología. 3rd ed. Volume 2. McGraw-Hill; Madrid, Spain: 2020. pp. 3–34.
    1. Sandín B., Chorot P., Valiente R.M. Transdiagnóstico: Nueva frontera en psicología clínica [Transdiagnostic: A new frontier in clinical psychology] Rev. Psicopatol. Psicol. Clin. 2012;17:185–203. doi: 10.5944/rppc.vol.17.num.3.2012.11839.
    1. Andersen P., Toner P., Bland M., McMillan D. Effectiveness of transdiagnostic cognitive behaviour therapy for anxiety and depression in adults: A systematic review and meta-analysis. Behav. Cogn. Psychother. 2016;44:673–690. doi: 10.1017/S1352465816000229.
    1. García-Escalera J., Chorot P., Valiente R.M., Reales J.M., Sandín B. Efficacy of transdiagnostic cognitive-behavioral therapy for anxiety and depression in adults, children and adolescents: A meta-analysis. Rev. Psicopatol. Psicol. Clin. 2016;21:147–175. doi: 10.5944/rppc.vol.21.num.3.2016.17811.
    1. Sakiris N., Berle D. A systematic review and meta-analysis of the unified protocol as a transdiagnostic emotion regulation based intervention. Clin. Psychol. Rev. 2019;72:1–13. doi: 10.1016/j.cpr.2019.101751.
    1. Ehrenreich-May J., Kennedy S.M., Sherman J.A., Bilek L.B., Buzzella B.A., Bennett S.M., Barlow D.H. Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents. Oxford University Press; New York, NY, USA: 2018.
    1. Ehrenreich J.T., Goldstein C.R., Wright L.R., Barlow D.H. Development of a unified protocol for the treatment of emotional disorders in youth. Child. Fam. Behav. Ther. 2009;31:20–37. doi: 10.1080/07317100802701228.
    1. Ehrenreich-May J., Rosenfield D., Queen A.H., Kennedy S.M., Remmes C.S., Barlow D.H. An initial waitlist-controlled trial of the unified protocol for the treatment of emotional disorders in adolescents. J. Anxiety Disord. 2017;46:46–55. doi: 10.1016/j.janxdis.2016.10.006.
    1. Osma J. Aplicaciones del Protocolo Unificado Para el Tratamiento Transdiagnóstico de la Disregulación Emocional. Alianza Editorial; Madrid, Spain: 2019.
    1. Trosper S.E., Buzzella B.A., Bennett S.M., Ehrenreich J.T. Emotion regulation in youth with emotional disorders: Implications for a unified treatment approach. Clin. Child. Fam. Psychol. Rev. 2009;12:234–254. doi: 10.1007/s10567-009-0043-6.
    1. García-Escalera J., Valiente R.M., Sandín B., Ehrenreich-May J., Prieto A., Chorot P. The unified protocol for transdiagnostic treatment of emotional disorders in adolescents (UP-A) adapted as a school-based anxiety and depression prevention program: An initial cluster randomized wait-list-controlled trial. Behav. Ther. 2020;51:461–473. doi: 10.1016/j.beth.2019.08.003.
    1. García-Escalera J., Chorot P., Sandín B., Ehrenreich-May J., Prieto A., Valiente R.M. An open trial applying the unified protocol for transdiagnostic treatment of emotional disorders in adolescents (UP-A) adapted as a school-based prevention program. Child. Youth Care Forum. 2019;48:29–53. doi: 10.1007/s10566-018-9471-0.
    1. Titov N., Dear B.F., Johnston L., Terides M. Transdiagnostic internet treatment for anxiety and depression. Rev. Psicopatol. Psicol. Clin. 2012;17:237–260. doi: 10.5944/rppc.vol.17.num.3.2012.
    1. Andersson G., Titov N. Advantages and limitations of internet-based interventions for common mental disorders. World Psychiatry. 2014;13:4–11. doi: 10.1002/wps.20083.
    1. Carlbring P., Andersson G., Cuijpers P., Riper H., Hedman-Lagerlöf E. Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: An updated systematic review and meta-analysis. Cogn. Behav. Ther. 2018;47:1–18. doi: 10.1080/16506073.2017.1401115.
    1. Etzelmueller A., Vis C., Karyotaki E., Baumeister H., Titov N., Berking M., Cuijpers P., Riper H., Ebert D.D. Effects of internet-based cognitive behavioral therapy in routine care for adults in treatment for depression and anxiety: Systematic review and meta-analysis. JMIR. 2020;22:1–27. doi: 10.2196/18100.
    1. Vigerland S., Lenhard F., Bonnert M., Lalouni M., Hedman E., Ahlen J., Olén O., Serlachius E., Ljótsson B. Internet-delivered cognitive behavior therapy for children and adolescents: A systematic review and meta-analysis. Clin. Psychol. Rev. 2016;50:1–10. doi: 10.1016/j.cpr.2016.09.005.
    1. Barlow D.H., Farchione T.J., Sauer-Zavala S., Latin H.M., Ellard K.K., Bullis J.R., Bentley K.H., Boettcher H.T., Cassiello-Robbins C. Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: Therapist Guide. Oxford University Press; New York, NY, USA: 2018.
    1. Gonzalez-Robles A., Garcia-Palacios A., Baños R., Riera A., Llorca G., Traver F., Haro G., Palop V., Lera G., Romeu J.E., et al. Effectiveness of a transdiagnostic internet-based protocol for the treatment of emotional disorders versus treatment as usual in specialized care: Study protocol for a randomized controlled trial. Trials. 2015;16:488–493. doi: 10.1186/s13063-015-1024-3.
    1. Păsărelu C.R., Andersson G., Bergman Nordgren L., Dobrean A. Internet-delivered transdiagnostic and tailored cognitive behavioral therapy for anxiety and depression: A systematic review and meta-analysis of randomized controlled trials. Cogn. Behav. Ther. 2017;46:1–28. doi: 10.1080/16506073.2016.1231219.
    1. Sandín B., Valiente R.M., García-Escalera J., Pineda D., Espinosa V., Magaz A.M., Chorot P. Protocolo unificado para el tratamiento transdiagnóstico de los trastornos emocionales en adolescentes a través de internet (iUP-A): Aplicación web y protocolo de un ensayo controlado aleatorizado [Internet-delivered unified protocol for transdiagnostic treatment of emotional disorders in adolescents (iUP-A): Web application and study protocol for a randomized controlled trial] Rev. Psicopatol. Psicol. Clin. 2019;24:197–215. doi: 10.5944/rppc.26460.
    1. Sheehan D.V., Lecrubier Y., Sheehan K.H., Amorim P., Janavs J., Weiller E., Hergueta T., Baker R., Dunbar G.C. The Mini-International Neuropsychiatric Interview (MINI): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J. Clin. Psychiatry. 1998;59:22–33. doi: 10.1016/S0924-9338(97)83296-8.
    1. Colón-Soto M., Díaz V., Soto O., Santana C. Mini International Neuropsychiatric Interview Para Niños y Adolescentes (MINI-KID) Versión en Español. Medical Outcome Symptoms; Tampa, FL, USA: 2005.
    1. Des Jarlais D.C., Lyles C., Crepaz N. TREND Group Improving the reporting quality of nonrandomized evaluations of behavioral and public health interventions: The TREND statement. Am. J. Public Health. 2004;94:361–366. doi: 10.2105/AJPH.94.3.361.
    1. Ehrenreich-May J., Queen A.H., Bilek E.L., Remmes C.S., Kristen K.M. The Unified Protocols for the Treatment of Emotional Disorders in Children and Adolescents. In: Ehrenreich-May J., Chu B.C., editors. Transdiagnostic Treatments for Children and Adolescents: Principles and Practice. Guilford Press; New York, NY, USA: 2014. pp. 267–292.
    1. Sandín B., Chorot P., Valiente R.M. TCC de los Trastornos de Ansiedad: Innovaciones en Niños y Adolescentes [CBT for Anxiety Disorders: Innovations for Children and Adolescents] Klinik; Madrid, Spain: 2016.
    1. Sandín B., Chorot P., Valiente R.M., Chorpita B.F. Development of a 30-item version of the Revised Child Anxiety and Depression Scale. Rev. Psicopatol. Psicol. Clin. 2010;15:165–178. doi: 10.5944/rppc.vol.15.num.3.2010.4095.
    1. Sandín B. Escalas PANAS de afecto positivo y negativo para niños y adolescentes (PANASN) [The PANAS scales of positive and negative affect for children and adolescents (PANASN)] Rev. Psicopatol. Psicol. Clin. 2003;8:173–182. doi: 10.5944/rppc.vol.8.num.2.2003.3953.
    1. Silverman W.K., Fleisig W., Rabian B., Peterson R.A. Childhood anxiety sensitivity index. J. Clin. Child. Adolesc. Psychol. 1991;20:162–168. doi: 10.1207/s15374424jccp2002_7.
    1. Sandín B., Chorot P., Santed M.A., Valiente R.M. Análisis factorial confirmatorio del Índice de Sensibilidad a la Ansiedad para Niños [A confirmatory factor analysis of the Childhood Anxiety Sensitivity Index] Psicothema. 2002;14:333–339.
    1. Kennedy S.M., Ehrenreich-May J. Assessment of emotional avoidance in adolescents: Psychometric properties of a new multidimensional measure. J. Psychopathol. Behav. Assess. 2016;39:279–290. doi: 10.1007/s10862-016-9581-7.
    1. García-Escalera J., Chorot P., Valiente R., Sandín B., Tonarely N., Ehrenreich-May J. Spanish Version of the Emotional Avoidance Strategy Inventory for Adolescents (EASI-A) Universidad Nacional de Educación a Distancia; Madrid, Spain: 2016. Unpublished.
    1. Sandín B., Chorot P., Valiente R.M. Cuestionario PSWQ para Niños y Adolescentes (PSWQN-11) [Questionnaire PSWQ for Children and Adolescents (PSWQ-11)] Universidad Nacional de Educación a Distancia; Madrid, Spain: 2010. Unpublished.
    1. La Greca A.M., Stone W.L. Social anxiety scale for children-revised: Factor structure and concurrent validity. J. Clin. Child. Psychol. 1993;22:17–27. doi: 10.1207/s15374424jccp2201_2.
    1. Sandín B. Ansiedad, Miedos y Fobias en Niños y Adolescentes [Anxiety, Fears and Phobias in Children and Adolescents] Dykinson; Madrid, Spain: 1997.
    1. Houck P.R., Spiegel D.A., Shear M.K., Rucci P. Reliability of the self-report version of the panic disorder severity scale. Depress. Anxiety. 2002;15:183–185. doi: 10.1002/da.10049.
    1. Sandín B. Panic Disorder Severity Scale–Self Report (PDSS-SR) (Spanish version) In: Sandín B., editor. Trastorno de Pánico. UNED; Madrid, Spain: 2010.
    1. Sheehan D.V., Sheehan K.H., Shytle R.D., Janavs J., Bannon Y., Rogers J.E., Milo K.M., Stock S.L., Wilkinson B. Reliability and validity of the mini international neuropsychiatric interview for children and adolescents (MINI-KID) J. Clin. Psychiatry. 2010;71:313–326. doi: 10.4088/JCP.09m05305whi.
    1. Valiente R.M., Sandín B., Chorot P. Miedos comunes en niños y adolescentes: Relación con la sensibilidad a la ansiedad, el rasgo de ansiedad, la afectividad negativa y la depresión [Common fears in children and adolescents: Their relationship to anxiety sensitivity, trait anxiety, negative affectivity, and depression] Rev. Psicopatol. Psicol. Clin. 2002;7:61–70. doi: 10.5944/rppc.vol.7.num.1.2002.3922.
    1. Sandín B., Chorot P., Valiente R.M., Lostao L. Validación española del cuestionario de preocupación PSWQ: Estructura factorial y propiedades psicométricas [Spanish validation of the PSWQ: Factor structure and psychometric properties] Rev. Psicopatol. Psicol. Clin. 2009;14:107–122. doi: 10.5944/rppc.vol.14.num.2.2009.4070.
    1. Sánchez-Arribas C., Chorot P., Valiente R.M., Sandín B. Evaluación de factores cognitivos positivos y negativos relacionadas con el trastorno de pánico: Validación del CATP [Assessment of positive and negative cognitive factors related to panic disorder: Validation of the CATP] Rev. Psicopatol. Psicol. Clin. 2015;20:85–100. doi: 10.5944/rppc.vol.20.num.2.2015.15164.
    1. Sandín B., Valiente R.M., García-Escalera J., Chorot P. Feasibility and Acceptability Questionnaire (FAQ) Universidad Nacional de Educación a Distancia; Madrid, Spain: 2020. Unpublished.
    1. Rapee R.M., Wignall A., Sheffield J., Kowalenko N., Davis A., McLoone J., Spence S.H. Adolescents’ reactions to universal and indicated prevention programs for depression: Perceived stigma and consumer satisfaction. Prevent. Sci. 2006;7:167–177. doi: 10.1007/s11121-006-0035-4.
    1. Cohen J. A power primer. Psychol. Bull. 1992;112:155. doi: 10.1037/0033-2909.112.1.155.
    1. Faul F., Erdfelder E., Lang A.-G., Buchner A. G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav. Res. Methods. 2007;39:175–191. doi: 10.3758/BF03193146.
    1. De la Torre-Luque A., Fiol-Veny A., Essau C.A., Balle M., Bornas X. Effects of a transdiagnostic cognitive behaviour therapy-based programme on the natural course of anxiety symptoms in adolescence. J. Affect. Disord. 2020;264:474–482. doi: 10.1016/j.jad.2019.11.078.
    1. Fernández-Martínez I., Orgilés M., Morales A., Espada J.P., Essau C.A. One-Year follow-up effects of a cognitive behavior therapy-based transdiagnostic program for emotional problems in young children: A school-based cluster-randomized controlled trial. J. Affect. Disord. 2020;262:258–266. doi: 10.1016/j.jad.2019.11.002.
    1. Calear A.L., Batterham P.J., Poyser C.T., Mackinnon A.J., Griffiths K.M., Christensen H. Cluster randomised controlled trial of the e-couch Anxiety and Worry program in schools. J. Affect. Disord. 2016;196:210–217. doi: 10.1016/j.jad.2016.02.049.
    1. González-Robles A., Díaz-García A., García-Palacios A., Roca P., Ramos-Quiroga J.A., Botella C. Effectiveness of a Transdiagnostic Guided Internet-Delivered Protocol for Emotional Disorders Versus Treatment as Usual in Specialized Care: Randomized Controlled Trial. J. Med. Internet Res. 2020;22:1–23. doi: 10.2196/18220.
    1. Ellard K.K., Bernstein E.E., Hearing C., Baek J.H., Sylvia L.G., Nierenberg A.A., Barlow D.H., Deckersbach T. Transdiagnostic treatment of bipolar disorder and comorbid anxiety using the Unified Protocol for Emotional Disorders: A pilot feasibility and acceptability trial. J. Affect. Disord. 2017;219:209–221. doi: 10.1016/j.jad.2017.05.011.
    1. Bilek E.L., Ehrenreich-May J. An open trial investigation of a transdiagnostic group treatment for children with anxiety and depressive symptoms. Behav. Ther. 2012;43:887–897. doi: 10.1016/j.beth.2012.04.007.
    1. Stallard P., Richardson T., Velleman S., Attwood M. Computerized CBT (Think, Feel, Do) for depression and anxiety in children and adolescents: Outcomes and feedback from a pilot randomized controlled trial. Behav. Cogn. Psychother. 2011;39:273. doi: 10.1017/S135246581000086X.
    1. Tillfors M., Andersson G., Ekselius L., Furmark T., Lewenhaupt S., Karlsson A., Carlbring P. A randomized trial of internet-delivered treatment for social anxiety disorder in high school students. Cogn. Behav. Ther. 2011;40:147–157. doi: 10.1080/16506073.2011.555486.
    1. Carlbring P., Gunnarsdóttir M., Hedensjö L., Andersson G., Ekselius L., Furmark T. Treatment of social phobia: Randomised trial of internet-delivered cognitive-behavioural therapy with telephone support. Br. J. Psychiatry. 2007;190:123–128. doi: 10.1192/bjp.bp.105.020107.
    1. Andersson G., Paxling B., Wiwe M., Vernmark K., Felix C.B., Lundborg L., Furmark T., Cuijpers P., Carlbring P. Therapeutic alliance in guided internet-delivered cognitive behavioural treatment of depression, generalized anxiety disorder and social anxiety disorder. Behav. Res. Ther. 2012;50:544–550. doi: 10.1016/j.brat.2012.05.003.

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