Adolescence is one of the most important stages of life when, along with physical changes, a series of changes occur in a person's emotions, feelings, desires and imaginations. In this regard, emotional disorders such as anxiety, depression, and stress are common in adolescents. Emotional disorders are so highly correlated with each other. Adolescents who experience anxiety symptoms are more likely to be at risk for an anxiety disorder or depression (Sherman et al. 2018). Co-occurrence of anxiety and depression has been reported in more than 50% of patients (Amiri et al.2015). High anxiety-depression comorbidity is associated with exacerbation of psychological symptoms. Unfortunately, most of adolescents who suffer an emotional disorder do not receive treatment of any kind. Symptoms of emotional disorders in adolescents and factors that play a mediating role in the formation or persistence of these disorders should be given more attention. Another issue that plays an important role in adolescents' mental health is psychological flexibility. It is defined as being in contact with the present moment, fully aware of emotions, sensations, and thoughts, welcoming them, including the undesired ones, and moving in a pattern of behavior in the service of chosen values (Ramaci et al., 2019). In other words, it means accepting our own thoughts and emotions and acting on long-term values rather than short-term impulses, thoughts, and feelings that are often linked to experiential avoidance and a way to control unwanted inner events (Hülsheger et al., 2013). Psychological flexibility can significantly predict quality of life and peer support for learning (school engagement) of adolescents with emotional problems (Zaheer, 2015). Studies on healthy adolescents have shown that psychological inflexibility is correlated with greater anxiety and depression, as well as lower self-esteem (Masuda and Tully, 2012; Bluett et al., 2014; Tan and Martin, 2016), lower quality of life, social skills, and academic competence (Greco et al., 2008). Because of the negative implications for psychological flexibility in adolescents, it is important to target psychological flexibility in treatments for adolescence.
Over the last few decades, diagnosis-specific cognitive-behavioral approaches have been recognized as evidence-based approaches for treatment of emotional disorders. However, these approaches have limitations, such as low attention to comorbidities, multiple underlying theories for each specific diagnosis, multiple treatment protocols, patients’ limited access to the most effective treatment, and the difficulty of specialist training (Pearl and Norton,2016; Khakpoor and Saed, 2018). In this regard, a new generation of cognitive-behavioral approaches has been introduced based on the concept of transdiagnosis in the last two decades (Barlow et al., 2016) Ttransdiagnostic approaches emphasize the commonalities between emotional disorders rather than their differences. They seek to treat comorbid disorders through the development of new and unified therapeutic protocols. In a systematic review and meta-analysis, Newby et al. (2015) reported that transdiagnostic treatments are effective for reducing anxiety, and may be superior for reducing depression. One of the transdiagnostic approaches is the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP). It is an emotion-focused, cognitive-behavioral therapy consisting of 5 core modules or components that target temperamental characteristics, particularly neuroticism and resulting emotion dysregulation, underlying all anxiety, depressive, and related disorders. These modules are preceded by a module focused on enhancing motivation as well as an introductory module on the adaptive nature of emotions that provides a framework for understanding emotional experiences. The UP contains cognitive reappraisal and exposure strategies, but the focus is on the reactions to the experience of emotion itself (Barlow et al., 2017). The results of studies support the efficacy of UP in the treatment of emotional disorders in Iran and other countries (Ellard et al., 2010; Farchione et al., 2012; Mohammadi et al., 2013; Akbari et al., 2015; Doos Ali Vand et al., 2018; Sakiris and Berle, 2019). The UP for Adolescents (UP-A) is a recent manualized treatment developed by Ehrenreich-May et al. (2018) to address different emotional disorders in adolescents. Its goal is to improve emotion reactivity and emotion regulation and to reduce anxiety and depressive symptoms by means of evidence-based treatment techniques (e.g., psychoeducation) that are applied to different emotions including fear, anxiety, sadness, and anger (Sandín et al., 2020). Studies have shown the efficacy of UP-A in treating anxiety and depressive disorders and symptoms in adolescents (Ehrenreich et al., 2009; Trosper et al., 2009; Ehrenreich-May et al., 2017).
An emerging model of service delivery via Internet have the potential to improve access to evidence-based treatments for anxiety and depressive disorder (Titov et al., 2012). Internet-based treatments have many advantages including improved access to evidence-based treatments and cost-effectiveness compared to traditional face-to-face interventions (Andersson and Titov, 2012). Patients in internet-based interventions may receive the support of therapist faster than in traditional face-to-face treatments. Several meta-analyses have shown that internet-based cognitive-behavioral protocols can be effective in the reduction of anxious and depressive symptoms (García-Escalera et al., 2016). An internet-based version of UP-A with high feasibility and acceptability was recently developed by Sandín et al. (2020) that provides a new approach to improve access to treatment for anxious and depressive adolescents. There is no other study that have delivered the UP-A online for treatment of anxious and depressed adolescents. Furthermore, we found no study on the effectiveness of UP-A (online or face-to-face) in improving psychological flexibility of anxious and depressed adolescents. In this regard and considering the importance of paying attention to the adolescents' emotional disorders and the negative impact of current COVID-19 pandemic on their mental health, this study aims to investigate the effect of internet-based UP-A intervention on anxiety, depression, stress, and psychological flexibility of adolescents with subclinical features of emotional disorder during the COVID-19 pandemic.