Effect of internet-based UP-A intervention on stress, anxiety, depression, and psychological flexibility during the COVID-19 pandemic: A clinical trial

doi:10.21203/rs.3.rs-1525711/v1

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Effect of internet-based UP-A intervention on stress, anxiety, depression, and psychological flexibility during the COVID-19 pandemic: A clinical trial

https://doi.org/10.21203/rs.3.rs-1525711/v1

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Objective: The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A) has been shown to be effective for reducing symptoms of anxiety and depression in adolescents with emotional disorders. The present study aims to assess the effectiveness of internet-based UP-A in reducing stress, anxiety, and depression, and psychological flexibility of adolescents with subclinical features of emotional disorder during the COVID-19 pandemic.

Methods: This is a longitudinal randomized clinical trial conducted on 40 adolescents aged 12-17 years with subclinical features of emotional disorder. They were assigned randomly into two groups of intervention (n=20) and control (n=20). They first completed the Depression Anxiety Stress Scale- 21 item (DASS-21) and the Acceptance and Action Questionnaire (AAQ-2) online. Then, the intervention group received 12 sessions of UP-A through video call on WhatsApp, two days per week each for 45 minutes. The control group received no treatment. Immediately and 3 months after the intervention, the questionnaires were completed again. Collected data were analyzed using longitudinal marginal modeling.

Results: The stress, anxiety, and depression levels of adolescents decreased and their psychological flexibility increased immediately and 3 months after the intervention. The marginal modeling showed the interaction effect of time and group (p<0.05), indicating that the difference between groups was significant at all three time points.

Conclusion: Online transdiagnostic therapy based on the UP-A is effective in reducing the symptoms of anxiety, depression, stress, and improving psychological flexibility of adolescents during the COVID-19 pandemic.

Transdiagnostic therapy

anxiety

depression

psychological flexibility

adolescents

telemental health

COVID-19.

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.

Study Design and Participants

This is a longitudinal randomized clinical trial conducted in 2020 (during the COVID-19 pandemic). Participants were 40 adolescents (girls and boys) with subclinical features of emotional disorder. They were selected purposively from among individuals seeking treatment at Sohravardi and Shafieie General Outpatient Clinics in Zanjan, Iran (n = 93) based on the following inclusion criteria: Having subclinical features of emotional disorders according to the results of Kiddie- Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime (K-SADS-PL) interview and the Depression Anxiety Stress Scale- 21 item (DASS-21) score (14–20 for depression and 10–14 for anxiety), age 12–17 years, no severe psychiatric disorders (e.g. psychosis and bipolar disorder), no cognitive-behavioral interventions in the past five years, no medication therapy in the past one month, The exclusion criteria were: Absence from more than two sessions, receiving another similar psychological intervention or medication therapy simultaneously, having complete clinical features of emotional disorders, drug or alcohol use in the past three months, any chronic disease, unwillingness to participate, and recurrence of emotional problems during the intervention that may require another intervention. Sample size was determined 20 for each group using the following formula: \(\mathop n\nolimits_{1} =\mathop n\nolimits_{2} =\frac{{4\left( {1 - \mathop \rho \nolimits^{2} } \right){{\left( {{Z_{1 - \alpha /2}}+{Z_{1 - \beta }}} \right)}^2}}}{{\mathop \delta \nolimits^{2} }}\), considering an effect size (δ) of 0.73, α = 0.05, β = 0.20, and ρ = 0.1. In case of excluding samples, they would been replaced with eligible ones. Samples were assigned into two groups of intervention (n = 20) and control (n = 20) randomly using the function RAND () in Excel software.

Measures

After obtaining a written informed consent from the participants, they were first underwent screening by the K-SADS-PL interview via video call in WhatsApp and completed the DASS-21 online for diagnosing their emotional disorders. Their parents were also invited to an assessment session that was conducted through video call. The K-SADS-PL a semi-structured interview designed for children 6–18 years by Kaufman et al. (1997) based on the Diagnostic and Statistical Manual of Mental Disorders-5th edition (DSM-5). We used the Persian version of K-SADS-PL prepared by Shahrivar et al. (2010). They reported its good-to-excellent concurrent validity in diagnosing current major disorders, and good-to-excellent test-retest reliabilities for most of the current diagnoses. The DASS-21 is a valid and reliable self-report questionnaire that measures the emotional states of depression, anxiety and stress. It has 21 items, 7 for each three subscales. The items are rated on a 4-point Likert scale from 0 (did not apply to me at all) to 3 (applied to me very much). We used the Persian version of DASS-21 prepared by Sahebi et al. (2005) who reported its good validity and reliability for Iranian population. After assigning patients into two groups, they were asked to complete the Acceptance and Action Questionnaire (AAQ-2) online to measure their psychological flexibility. It was developed by Bond et al. (2011) and has 7 items rated on a 7-point Likert scale from 1 (never true) to 7 (always true). Higher total scores mean less flexibility, while lower total scores mean more flexibility. We used the Persian version of AAQ prepared by Abasi et al. (2013) who reported its good validity and reliability (0.71–0.89). The two questionnaires were completed before, immediately after, and 3 months after the intervention. It should be mentioned that assessments before and after intervention were performed by an expert in Clinical Psychology.

Intervention

The UP-A has 8 treatment modules for adolescents and one additional module called the “parenting module”. In our study, the intervention group received the UP-A online via video call on WhatsApp application according to Table 1 for 2 months at 12 session of 45 minutes (one session for modules 1,3,4,6,8, two sessions for modules 2 and 7, and three sessions for module 5), 2 days per week. Moreover, the parents of 8 adolescents who needed this intervention based on the interview results received the parenting module at 1–3 sessions of 45 minutes for 2–3 weeks, once per week. The control group received no treatment.

Table 1

Descriptions of the modules in the UP-A
Module title	Main contents
Module 1: Building motivation and maintaining it	Establishing a friendly relationship, talking about important problems and targeting them, using strategies and increasing motivation in the adolescent
Module 2: Getting to know emotions and behaviors	Psychoeducation about different emotions and their function, talking about the purpose of emotions, understanding the three parts of emotional experiences, learning about the cycle of avoidance and emotional behaviors
Module 3: Introducing emotion-focused behavioral experiments	Psychoeducation about contrasting behavior and emotion-focused behavioral experiments, learning how to test the level of emotions and activities, perform behavioral experiments focused on different emotions
Module 4: Awareness of body sensations	Psychoeducation about body sensations and their relationship with intense emotions, conducting exposures to body sensations to learn to tolerate uncomfortable physical feelings.
Module 5: Cognitive flexibility	Learning about the concept of “thinking traps”, learning to be flexible in thinking, learning detective thinking and problem-solving skills.
Module 6: Awareness of emotional experiences	Introducing the rationale for present-moment awareness and non-judgmental awareness,
Module 7: Coping with situational emotion exposures	Reviewing the skills that the adolescent learned during treatment, discussing the logic of coping with situational emotion exposures as a type of behavioral experiment for the adolescent, conducting exposures and assigning them for home learning.
Module 8: Maintaining the gains	Reviewing skills and making an individualized relapse prevention plan
Parenting Module	Informing parents about how to respond to the adolescent’s emotional disorders, introducing four common emotional behaviors and their contrasting behaviors

Data analysis

Collected data were analyzed in SPSS v.20 software using descriptive statistics (frequency, percentage, mean, standard deviation) and statistical tests including chi-squared test to compare the study groups in terms of gender, independent t-test to compare the groups in terms of age, and Mann-Whitney U test to compare the groups in terms of pretest DASS-21 and pretest AAQ-2 scores. Furthermore, Generalized Estimating Equation (GEE), as a marginal model for analysis of longitudinal data, was used to compare the groups in terms of DASS-21 and AAQ-2 scores at three evaluation times. Before selecting GEE, results of Shapiro-Wilk test showed that the data distribution was not normal (p < 0.05).

Of 40 participants, 28 (70%) were boys and 12 (30%) were girls; 15 boys and 5 girls in the intervention group (Mean age = 14.2 ± 1.79 years) and 13 boys and 7 girls in the control group (14.6 ± 1.93 years). The results of chi-squared test for gender (p = 0.490), independent t-test for age (p = 0.501), and Mann-Whitney U test for pretest DASS-21 and AAQ-2 (p > 0.05) showed no significant difference between the two groups at baseline. The mean scores of DASS-21 subscales (depression, anxiety and stress) and AAQ-2 (psychological flexibility) are presented in Table 2. As can be seen, after intervention, the anxiety of patients in the intervention group was reduced from 14.40 ± 4.33 to 11.05 ± 3.50; their depression was reduced from 15.80 ± 5.42 to 12.85 ± 3.85; their stress was reduced from 19.05 ± 4.22 to 15.15 ± 3.15; and their psychological flexibility was reduced (improved) from 24.8 ± 10.68 to 18 ± 7.96. In the control group, anxiety and stress of participants were increased after intervention and their depression and psychological flexibility remained almost unchanged. After three months, the anxiety and depression of patients in the intervention group remained almost unchanged, while their stress continued to decrease from 15.15 ± 3.15 to 13.30 ± 3.85, and their psychological flexibility increased (worsened) from 18 ± 7.96 to 20.35 ± 7.26. In the control group, the depression and psychological flexibility of patients were increased, their anxiety remained almost unchanged, but their stress decreased after three months.

The results of marginal GEE-type modeling to compare the two study groups at three time points (before, immediately after, and three months after) for each of the four study variables are reported in Table 3. The interaction effect of time and group was significant in all study variables (p < 0.05), indicating that the difference between groups was significant at all three time points.

Table 2

Mean scores of the study variables in the two study groups
Variables	Time	Groups
Variables	Time	Intervention, Mean ± SD	Control, Mean ± SD
Anxiety	Pretest	14.40 ± 4.33	13.85 ± 4.08
	Posttest	11.05 ± 3.50	16.35 ± 4.42
	Follow-up	11.70 ± 3.23	16.25 ± 5.24
Depression	Pretest	15.80 ± 5.42	18.30 ± 6.40
	Posttest	12.85 ± 3.85	18.55 ± 5.33
	Follow-up	12.60 ± 3.76	19.30 ± 5.72
Stress	Pretest	19.05 ± 4.22	18.55 ± 4.95
	Posttest	15.15 ± 3.15	19.60 ± 3.36
	Follow-up	13.30 ± 3.85	18.55 ± 5.35
Psychological flexibility	Pretest	24.80 ± 10.68	28.10 ± 10.62
	Posttest	18 ± 7.96	28.40 ± 10.03
	Follow-up	20.35 ± 7.26	29.40 ± 9.88
SD = Standard deviation

Table 3

Results of marginal modeling for the study variables
Variable		B	Std. Error	95% Wald Confidence Interval		Hypothesis Test
Variable		B	Std. Error	Lower	Upper	Wald Chi-Square	df	Sig.
Anxiety	(Intercept)	13.85	0.8896	12.106	15.594	242.391	1	0.000
	Time (Follow-up)	2.400	1.1278	0.189	4.611	4.528	1	0.033
	Time (Posttest)	2.500	0.7632	1.004	3.996	10.730	1	0.001
	Group (Intervention)	0.550	1.2974	-1.993	3.093	0.180	1	0.672
	TimeGroup (Follow-upintervention)	-5.10	1.6934	-8.419	-1.781	9.071	1	0.003
	TimeGroup (Posttestintervention)	-5.85	1.1309	-8.066	-3.634	26.760	1	0.000
Depression	(Intercept)	18.30	1.3966	15.563	21.037	171.694	1	0.000
	Time (Follow-up)	1	1.2470	-1.444	3.444	0.643	1	0.423
	Time (Posttest)	0.25	0.8027	-1.323	1.823	0.097	1	0.755
	Group (Intervention)	-2.50	1.8299	-6.087	1.087	1.867	1	0.172
	TimeGroup (Follow-upintervention)	-4.20	1.7184	-7.568	-0.832	5.974	1	0.015
	TimeGroup (Posttestintervention)	-3.20	1.2152	-5.582	-0.818	6.934	1	0.008
Stress	(Intercept)	18.55	1.0805	16.432	20.668	294.766	1	0.000
	Time (Follow-up)	???	1.1705	-2.294	2.294	0.000	1	1
	Time (Posttest)	1.05	0.9526	-0.817	2.917	1.215	1	0.270
	Group (Intervention)	0.50	1.4194	-2.282	3.282	0.124	1	0.725
	TimeGroup (Follow-upintervention)	-5.75	1.5441	-8.776	-2.724	13.866	1	0.000
	TimeGroup (Posttestintervention)	-4.95	1.2457	-7.392	-2.508	15.789	1	0.000
Psychological flexibility	(Intercept)	28.10	2.3151	23.563	32.637	147.329	1	0.000
	Time (Follow-up)	1.30	1.7206	-2.072	4.672	0.571	1	0.450
	Time (Posttest)	0.30	1.3306	-2.308	2.908	0.051	1	0.822
	Group (Intervention)	-3.30	3.2837	-9.736	3.136	1.010	1	0.315
	TimeGroup (Follow-upintervention)	-5.75	2.3201	-10.297	-1.203	6.142	1	0.013
	TimeGroup (Posttestintervention)	-7.10	2.1292	-11.273	-2.927	11.119	1	0.001

The purpose of this clinical trial was to evaluate the effectiveness of Internet-based UP-A on stress, anxiety, depression, and psychological flexibility in adolescents with preclinical symptoms of emotional disorders. To our knowledge, this is the first study in Iran and the second study in the world that presented the UP-A online to anxious and depressed adolescents. It was conducted during the COVID-19 pandemic. Based on the results, the intervention could significantly reduce the preclinical symptoms of anxiety and depression in adolescents. This is consistent with the results of Sherman et al. (2018) and Sandín et al. (2020). Sherman et al. (2018) used the UP-A at 16 sessions on a 15-year-old boy with severe social and generalized anxiety and mild levels of depression. Their results demonstrated significant reductions in anxiety and depressive symptoms, as well as an ability to respond more adaptively to a range of emotional experiences. Sandín et al. (2020) used online version of the UP-A in a pilot study for the treatment of emotional disorders in 12 adolescents in Spain. Their 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. Our results are also consistent with the findings of Ehrenreich et al. (2009), Trosper et al. (2009), Ehrenreich-May et al. (2017), Sharma et al. (2017), and O'Donnell et al. (2021). To explain the result, it can be said that the UP-A is probably correct two major transdiagnostic factors of anxiety sensitivity and emotional avoidance and, thereby, affects the symptoms of emotional disorders. This unified protocol uses various modules (especially modules 3 to 7) to target the common features between anxiety and mood disorders and correct inefficient and pathological strategies of individuals. By emphasizing how individuals experience and deal with their emotions, it teaches them to respond to their emotions in a more adaptive way. During treatment, efforts are made to improve individuals’ relationship with their emotions by using present-moment and non-judgmental awareness and performing behaviors that are contrary to emotion-focused behaviors, and to modify their behavioral experiments. They practice emotion regulation skills along with situational emotion exposures. These exposures help them tolerate negative feelings.

The internet-based UP-A in our study improved psychological flexibility of anxious and depressed adolescents, as well. This is somehow consistent with the results of Sauer-Zavala et al. (2021). In a controlled trial, they assessed the effect of UP on the cognitive flexibility of 88 patients with principal anxiety disorders. After 12–16 treatment sessions, the cognitive flexibility of patients was improved as well as their understanding of emotions, mindful-based emotion awareness, countering emotional behaviors, and interoceptive awareness and tolerance. Nasri et al. (2017) assessed the effectiveness of UP on cognitive flexibility and emotion regulation of 32 patients with type 2 diabetes, and reported that 12 one-hour sessions of UP could improve their cognitive flexibility and emotion reappraisal. For justifying the results, it can be said that, under the UP treatment, psychological flexibility of patients increases following the evaluation of negative automatic thoughts and thinking traps, and solving them. The cognitive flexibility module of this protocol targets these problems. Finally, our result showed that the internet-based UP-A could reduce the stress of adolescents with emotional disorders. O'Donnell et al. (2021) and Varkovitzky et al. (2018) in pilot studies showed that 10–14 week and 16 week UP treatment significantly reduced posttraumatic stress disorder in patients with posttraumatic psychopathology and veterans, respectively. Mohsenabadi et al. (2018) in a randomized clinical trial reported the efficacy of 12 weekly UP treatment in reducing stress of patients with irritable bowel syndrome. These are consistent with our results.

There were some limitations in conducting this study. Holding treatment sessions online caused some limitations for the therapist and participants (e.g., not possible to send/receive therapy worksheets, existence of distractions). High-speed Internet access was sometimes not possible for the participants which caused interruptions between treatment sessions. Lack of cooperation of some of participants (due to having homework or a family member with COVID-19), small sample size, and use of a purposive sampling method were another limitations. Further studies can be performed by presenting the UP-A online to assess adolescents using a designed software, larger sample size, different follow-up duration, and neuropsychological instruments rather than paper-and-pencil tests.

Online transdiagnostic therapy based on the UP-A is effective in reducing the symptoms of anxiety, depression, stress, and improving psychological flexibility of adolescents during the COVID-19 pandemic.

Ethics approval and consent to participate

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975. Written informed consent was obtained from all patients for being included in the study. This study has an ethical approval from the Research Ethics Committee of Zanjan University of Medical Sciences (Code: IR.ZUMS.REC.1400.053).

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors of this paper report no conflicts of interest in connection with this manuscript.

Funding

Not applicable.

Authors’ contributions

SEM and VJ designed the study; VJ collected the data; FA analyzed the data; VJ and LSE conducted the literature searches and wrote the initial draft. All authors contributed to review, editing, and final approval of the manuscript.

Acknowledgments

The authors would like to thank all the patients participated in this study for their cooperation.

Abasi, E., Fti, L., Molodi, R., & Zarabi, H. (2013). Psychometric properties of Persian version of acceptance and action questionnaire-II. Journal of Psychological Models and Methods, 3(10), 65–80. [in Persian]
Akbari, M., Roshan, R., Shabani, A., Fata, L., Shairi, M.R., & Zarghami, F. (2015). The comparison of the efficacy of transdiagnostic therapy based on repetitive negative thoughts with unified transdiagnostic therapy in treatment of patients with co-occurrence anxiety and depressive disorders: a randomized clinical trial. Iranian Journal of Psychiatry and Clinical Psychology, 21(2), 88–107.
Amiri, S., Haj-Mirzaian, A., Rahimi-Balaei, M., & et al. (2015). Co-occurrence of anxiety and depressive-like behaviors following adolescent social isolation in male mice; possible role of nitrergic system. Physiology & Behavior,145, 38–44.
Andersson, G., & Titov, N. (2014). Advantages and limitations of internet-based interventions for common mental disorders. World Psychiatry, 13(1), 4–11.
Barlow, D.H., Allen, L.B., & Choate, M.L. (2016). Toward a unified treatment for emotional disorders. Behavior Therapy, 47(6), 838–853.
Barlow, D.H., Farchione, T.J., Bullis, J.R., & 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(9), 875–884.
Bluett, E.J., Homan, K.J., Morrison, K.L., Levin, M.E., & Twohig, M.P. (2014). Acceptance and commitment therapy for anxiety and OCD spectrum disorders: An empirical review. Journal of Anxiety Disorders, 28(6), 612–624.
Bond, F.W., Hayes, S.C., Baer, R.A., & et al. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: a revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy, 42(4), 676–688.
Doos Ali Vand, H., Gharraee, B., Asgharnejad Farid, A., Ghaleh Bandi, M.F., & Habibi, M. (2018). Investigating the effects of the unified protocol on common and specific factors in a comorbid insomniac sample: a single-case experimental design. Iranian Journal of Psychiatry and Behavioral Sciences, 12(3), e14452.
Ehrenreich, J.T., Goldstein, C.R., Wright, L.R., & Barlow, D.H. (2009). Development of a unified protocol for the treatment of emotional disorders in youth. Child & Family Behavior Therapy, 31(1), 20–37.
Ehrenreich-May, J., Rosenfield, D., Queen, A.H., Kennedy, S.M., Remmes, C.S., & Barlow, D.H. (2017). An initial waitlist-controlled trial of the unified protocol for the treatment of emotional disorders in adolescents. Journal of Anxiety Disorders, 46, 46–55.
Ehrenreich-May, J., Kennedy, S.M., Sherman, J.A., Bilek, L.B., Buzzella, B.A., Bennett, S.M., Barlow, D.H. (2018). Unified protocols for transdiagnostic treatment of emotional disorders in children and adolescents. Oxford University Press, NY, USA.
Ellard, K.K., Fairholme, C.P., Boisseau, C.L., Farchione, T.J., & Barlow, D.H. (2010). Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders: Protocol Development and Initial Outcome Data. Cognitive and Behavioral Practice, 17(1), 88–101.
Farchione, T.J., Fairholme. C.P., Ellard, K.K., Boisseau, C.L., Thompson-Hollands, J., Carl, J.R., & et al. (2012). Unified protocol for transdiagnostic treatment of emotional disorders: a randomized controlled trial. Behavior Therapy, 43(3), 666–678.
García-Escalera, J., Chorot, P., Valiente, R.M., Reales, J.M., Sandín, B. (2016). Efficacy of transdiagnostic cognitive-behavioral therapy for anxiety and depression in adults, children and adolescents: A meta-analysis. Revista de Psicopatologia y Psicologia Clinica, 21,147–175.
Greco, L.A., Lambert, W., & Baer, R.A. (2008). Psychological inflexibility in childhood and adolescence: Development and evaluation of the avoidance and fusion questionnaire for youth. Psychological Assessment, 20(2), 93–102.
Hülsheger, U.R., Alberts, H.J., Feinholdt, A., & Lang, J.W. (2013). Benefits of mindfulness at work: the role of mindfulness in emotion regulation, emotional exhaustion, and job satisfaction. Journal of Applied Psychology, 98(2), 310–325.
Kaufman, J., Bismaher, B., Brent, D.A., Rao, U., Flynn, C., Moreci, P., & et al. (1997). Schedule for affective disorders and schizophrenia for school-aged children - present and lifetime version (K-SADS-PL): initial reliability and validity data. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 980–988.
Khakpoor, S., & Saed, O. (2018). Transdiagnostic cognitive behavioral therapy based on unified protocol: new approach to emotional disorders. Asia Pacific Journal of Clinical Trials: Nervous System Diseases, 3(4), 151–155.
Masuda, A., & Tully, E.C. (2012). The role of mindfulness and psychological flexibility in somatization, depression, anxiety, and general psychological distress in a nonclinical college sample. Journal of Evidence-Based Complementary and Alternative Medicine, 17(1), 66–71.
Mohammadi, A., Birashk, B., & Gharaie, B. (2013). Comparison of the effect of group transdiagnostic therapy and group cognitive therapy on anxiety and depressive symptoms. Iranian Journal of Public Health, 42(1), 48–55.
Mohsenabadi, H., Zanjani, Z., Shabani, M.J., & Arj, A. (2018). A randomized clinical trial of the Unified Protocol for Transdiagnostic treatment of emotional and gastrointestinal symptoms in patients with irritable bowel syndrome: evaluating efficacy and mechanism of change. Journal of Psychosomatic Research, 113, 8–15.
Nasri, M. (2017). The effectiveness of transdiagnostic treatment on cognitive flexibility, emotion regulation and Hb factor in patients with type 2 diabetes. Journal of Psychological Achievements, 24(2), 81–100. [in Persian]
Newby, J.M., McKinnon, A., Kuyken, W., Gilbody, S., & Dalgleish, T. (2015). Systematic review and meta-analysis of transdiagnostic psychological treatments for anxiety and depressive disorders in adulthood. Clinical Psychology Review, 40, 91–110.
O'Donnell, M.L., Lau, W., Chisholm, K., & et al. (2021). A pilot study of the efficacy of the unified protocol for transdiagnostic treatment of emotional disorders in treating posttraumatic psychopathology: A randomized controlled trial. Journal of Traumatic Stress, 34(3):563–574.
Pearl, S.B., & Norton, P.J. (2016). Transdiagnostic versus diagnosis specific therapies cognitive behavioural for anxiety: A meta-analysis. Journal of Anxiety Disorders, 7, 1–14.
Ramaci, T., Bellini, D., Presti, G., Santisi, G. (2019). Psychological Flexibility and Mindfulness as Predictors of Individual Outcomes in Hospital Health Workers. Frontiers in Psychology, 10, 1302.
Sahebi, A., Asghari, M., Salari, R. (2005). Validation of depression anxiety and stress scale (DASS-21) for an Iranian population. Journal of Developmental Psychology, 1(4), 36–54. [in Persian]
Sakiris, N., & Berle, D. (2019). A systematic review and meta-analysis of the Unified Protocol as a transdiagnostic emotion regulation based intervention. Clinical Psychology Review, 72,101751.
Sandín, B., García-Escalera, J., Valiente, R.M., Espinosa, V., Chorot, P. (2020). 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. International Journal of Environmental Research and Public Health, 17(22), 8306.
Sauer-Zavala, S., Rosellini, A.J., Bentley, K.H., Ametaj, A.A., Boswell, J.F., Cassiello-Robbins, C., & et al. (2021). Skill acquisition during transdiagnostic treatment with the unified protocol. Behavior Therapy, 52(6),1325–1338.
Shahrivar, Z., Kousha, M., Moallemi, S., Tehrani-Doost, M., & Alaghband-Rad, J. (2010). The reliability and validity of kiddie-schedule for affective disorders and schizophrenia - present and life-time version - Persian version. Child Adolesc Ment Health, 15(2), 97–102.
Sharma, P., Mehta, M., & Sagar, R. (2017). Efficacy of transdiagnostic cognitive-behavioral group therapy for anxiety disorders and headache in adolescents. Journal of Anxiety Disorders, 46,78–84.
Sherman, J.A., Tonarely, N.A., & Ehrenreich-May, J. (2018). Targeting comorbid anxiety and depression using the unified protocol for transdiagnostic treatment of emotional disorders in adolescents. Clinical Case Studies,17(2), 59–76.
Tan, L.B.G., & Martin, G. (2016). Mind full or mindful: A report on mindfulness and psychological health in healthy adolescents. International Journal of Adolescence and Youth, 21(1), 64–75.
Titov, N., Dear, B.F., Johnston, L., & Terides, M. (2012). Transdiagnostic internet treatment for anxiety and depression. Revista de Psicopatologia y Psicologia Clinica, 17, 237–260.
Trosper, S.E., Buzzella, B.A., Bennett, S.M., & Ehrenreich, J.T. (2009). Emotion regulation in youth with emotional disorders: Implications for a unified treatment approach. Clinical Child and Family Psychology Review, 12, 234–254.
Varkovitzky, R.L., Sherrill, A.M., & Reger, G.M. (2018). Effectiveness of the unified protocol for transdiagnostic treatment of emotional disorders among veterans with posttraumatic stress disorder: a pilot study. Behavior Modification, 42(2), 210–230.
Zaheer, I. (2015). The Role of Psychological Flexibility on Mental Health and School Functioning of Adolescents with Social, Emotional and Behavioral Problems. A thesis, Lehigh University, USA. Available at: https://preserve.lib.lehigh.edu/islandora/object/preserve%3Abp-10370192

No competing interests reported.

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Effect of internet-based UP-A intervention on stress, anxiety, depression, and psychological flexibility during the COVID-19 pandemic: A clinical trial

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Abstract

Introduction

Methodology

Study Design and Participants

Measures

Intervention

Data analysis

Results

Discussion

Conclusion

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References

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