Journal of Psychiatric Research 104 (2018) 211–216

Contents lists available at ScienceDirect

Journal of Psychiatric Research

journal homepage: www.elsevier.com/locate/jpsychires

Efficacy of the Unified Protocol for transdiagnostic treatment of comorbid T

psychopathology accompanying emotional disorders compared to
treatments targeting single disorders
Stephanie Jarvi Steele∗, Todd J. Farchione, Clair Cassiello-Robbins, Amantia Ametaj, Sophia Sbi,
Shannon Sauer-Zavala, David H. Barlow
Boston University, Center for Anxiety and Related Disorders, 648 Beacon Street, 6th Floor, Boston, MA, 02215, USA

A R T I C LE I N FO A B S T R A C T

Keywords: Objective: This study aimed to examine whether the Unified Protocol (UP), a transdiagnostic cognitive-beha-
Unified protocol vioral therapy for emotional disorders (i.e., anxiety, mood, and related disorders), is efficacious in the treatment
Cognitive-behavioral therapy of co-occurring emotional disorders compared to established single disorder protocols (SDPs) that target specific
Transdiagnostic treatment disorders (e.g., panic disorder).
Comorbidity
Method: Participants included 179 adults seeking outpatient psychotherapy. Participant age ranged from 18 to
Emotional disorders
66 years, with an average of 30.66 years (SD = 10.77). The sample was 55% female and mostly Caucasian
(83%). Diagnostic assessments were completed with the Anxiety Disorder Interview Schedule (ADIS), and dis-
order-specific, clinician-rated measures for the comorbid diagnoses of interest.
Results: In both treatment conditions, participants' mean number of diagnoses dropped significantly from
baseline to posttreatment, and baseline to 12-month follow-up. Additionally, large effects were observed for
changes in comorbid generalized anxiety (ESSG: UP = −1.72; SDP = −1.98), social anxiety (ESSG: UP = −1.33,
−0.86; SDP = −1.60, −1.54), and depression (ESSG: UP = −0.83; SDP = −0.84). Significant differences were
not observed in between-group comparisons.
Conclusions: Results suggest that both the UP and SDPs are efficacious in reducing symptoms of comorbid
emotional disorders. The clinical, practical, and cost-effective advantages of transdiagnostic CBT are discussed.

Emotional disorders (i.e., anxiety, mood, and related disorders; conditions (Barlow et al., 2014), and higher levels of this trait are as-
Barlow, 2000) are characterized by high rates of comorbidity (Barlow sociated with increased rates of comorbidity (Griffith et al., 2010).
et al., 2016); for example, estimates of lifetime comorbidity rates for Beyond the neurotic temperament, individuals with emotional dis-
anxiety and depressive disorders are as high as 75% (Brown and orders also display shared functional processes that maintain their
Barlow, 2009). Research suggests that patients with comorbid emo- symptoms; specifically, frequently occurring negative emotions are
tional disorders demonstrate poorer treatment outcomes than patients perceived as aversive, prompting avoidant coping that ultimately in-
with a single diagnosis (Rosellini et al., 2015). Specifically, comorbidity creases the frequency and intensity of these experiences (see Sauer-
has been linked to chronicity and severity of psychopathology, relapse Zavala and Barlow, 2014).
rates, treatment seeking, suicide potential, and overall psychosocial Transdiagnostic interventions that target shared mechanisms may
functioning (Brown et al., 2001). confer both clinical and practical advantages over more traditional
Recent conceptualizations of the prevalent comorbidity amongst protocols focused on a single Diagnostic and Statistical Manual (DSM;
emotional disorders have emphasized the presence of shared under- e.g., American Psychiatric Association, 2013) disorder (Sauer-Zavala
lying mechanisms that contribute to their onset (e.g., Wilamowska et al., 2017). First, by directly targeting common processes, transdiag-
et al., 2010). Specifically, neuroticism, defined as the tendency for nostic treatments can simultaneously address symptoms of co-occurring
frequent and intense negative emotions accompanied by perceived lack conditions. Additionally, transdiagnostic approaches may address the
of control over these experiences, has been implicated across a range of time and training burden that has limited successful dissemination of

∗
Corresponding author.
E-mail addresses: [email protected] (S.J. Steele), [email protected] (T.J. Farchione), [email protected] (C. Cassiello-Robbins), [email protected] (A. Ametaj),
[email protected] (S. Sbi), [email protected] (S. Sauer-Zavala), [email protected] (D.H. Barlow).

https://doi.org/10.1016/j.jpsychires.2018.08.005
Received 13 April 2018; Received in revised form 25 June 2018; Accepted 2 August 2018
0022-3956/ © 2018 Elsevier Ltd. All rights reserved.
S.J. Steele et al. Journal of Psychiatric Research 104 (2018) 211–216

evidence-based psychological treatments as clinicians need only learn corresponding to their principal diagnosis (1:2:2 allocation ratio, re-
the basics of one treatment approach to provide research supported spectively). All participants were assigned one principal diagnosis after
care to a range of common presentations. Several studies have found administration of a diagnostic interview (see Measures below); if ran-
transdiagnostic treatments to be efficacious in the treatment of emo- domized to the SDP condition, the principal diagnosis determined
tional conditions (Akbari et al., 2015; Milosevic et al., 2017; Palermo which SDP the participant received. SDPs included: 1) SAD: Managing
et al., 2016), as well as in the treatment of comorbid emotional dis- Social Anxiety: A Cognitive-Behavioral Therapy Approach – 2nd edition
orders compared to other specific interventions or treatment as usual (MSA-II; Hope et al., 2006; Hope et al., 2000); 2) PD/A: Mastery of Your
more broadly (Stice et al., 2015; Titov et al., 2015). Anxiety and Panic – 4th edition (MAP-IV; Barlow and Craske, 2007;
The Unified Protocol for Transdiagnostic Treatment of Emotional Craske and Barlow, 2007); 3) GAD: Mastery of Your Anxiety and Worry
Disorders (UP; Barlow et al., 2011a; Barlow et al., 2011b; Barlow et al., – 2nd edition (MAW-II; Craske and Barlow, 2006; Zinbarg et al., 2006);
2018a; Barlow et al., 2018b) is a transdiagnostic, cognitive-behavioral and 4) OCD: Treating Your OCD with Exposure and Response (Ritual)
intervention consisting of 5 core modules that target the above- Prevention Therapy – 2nd edition (Foa et al., 2012; Yadin et al., 2012).
mentioned temperamental characteristics underlying all anxiety, de- The number and duration of sessions was determined via published
pressive, and related disorders. The UP has demonstrated efficacy in guidelines associated with each SDP protocol; UP treatment (session
reducing general symptoms of anxiety and depression (Ellard et al., number/duration) was provided in accordance with recommendations
2010; Farchione et al., 2012) and these improvements were maintained for the SDP corresponding to the patient's principal diagnosis.
18 months after treatment (Bullis et al., 2014). Further, in a recently Specifically, patients with GAD, SAD, and OCD received 16 sessions
conducted larger clinical trial comparing the UP to gold-standard, (within a 21-week treatment window) and patients with PD/A received
single-disorder protocols (SDPs) for generalized anxiety disorder 12 sessions (within a 16-week treatment window). Further, sessions
(GAD), social anxiety disorder (SAD), Panic Disorder (PD), and ob- were 50-minutes in duration, with the exception of treatment for par-
sessive-compulsive disorder (OCD), the transdiagnostic UP approach ticipants with a principal diagnosis of OCD, for whom sessions lasted
led to equivalent symptom reduction on patients' principal diagnosis 90 min. To ensure treatment fidelity, expert raters associated with the
compared to the SDP associated with that disorder. Notably, the UP development of each protocol assessed 20% of randomly selected
condition evidenced lower rates of attrition than the SDP condition treatment sessions for adherence and competence. Overall scores for
(Barlow et al., 2017). treatment fidelity fell in the good to excellent range (M: UP = 4.44/5;
The current study aimed to explore the efficacy of the UP in treating SDPs = 4.09/5).
comorbid emotional conditions in a diagnostically heterogeneous Patients were also required to attend assessment visits while en-
sample from this larger clinical trial (Barlow et al., 2017). Specially, rolled in the trial. Data were collected at baseline, posttreatment, and
this study had three aims: 1) Characterize comorbidity in the current 12-month follow-up. All assessments were conducted by independent
sample, 2) Evaluate whether the UP indeed leads to reductions in study evaluators who were blinded to participants' study condition.
symptoms of comorbid disorders, and 3) Compare the UP to established
SDPs in the reduction of comorbid psychopathology. 1.3. Measures

1. Methods Anxiety Disorders Interview Schedule (ADIS; Di Nardo et al.,

1994; Brown and Barlow, 2014). The ADIS is a semi-structured clinical
1.1. Participants interview based on diagnostic criteria from the Diagnostic and Statistical
Manual (DSM; APA, 2013). Study evaluators assessed patients using the
Individuals in the present study were a subset of participants from a ADIS for anxiety, mood, somatic symptom disorders, and substance use
clinical trial comparing two active treatment conditions (UP and SDPS disorders, and screened them for other disorders (e.g., ADHD, eating
targeting four principal anxiety disorders) and a waitlist control con- disorders). Due to the publication of DSM-5 (APA, 2013) partway
dition (n = 223; see Barlow et al., 2017). The current study included through the clinical trial, 137 patients (76.5%) were assigned diagnoses
those participants who received psychological treatment during the based on DSM-IV criteria and 42 patients (23.5%) were assigned di-
trial (n = 179), and excluded individuals that were randomized to the agnoses based on DSM-5 criteria. Since panic disorder and agoraphobia
waitlist condition. Additional information regarding inclusion and ex- are separated in DSM-5, study evaluators rated these diagnoses together
clusion criteria can be found in Barlow et al. (2017). as overall PD/A symptoms for those patients diagnosed according to the
Participants in the current subsample ranged in age from 18 to 66 new diagnostic criteria in DSM-5 (APA, 2013).
years old, with an average age of 30.60 years (SD = 10.70). The ma- Panic Disorder Severity Scale (PDSS; Shear et al., 1997). The PDSS
jority of the sample identified as female (55.30%), non-Hispanic White is a brief, 7-item, clinician-rated measure that was designed to assess
(76.0%), and college educated or higher (65.40%). All participants met panic disorder symptoms and their impact on an individual's func-
diagnostic criteria for at least one principal (most interfering and se- tioning. Each item on the PDSS falls on a 5-point Likert-scale, with
vere) anxiety disorder restricted to the following four categories: panic higher scores indicating higher symptom severity and impairment. The
disorder, with or without agoraphobia (PD/A; n = 47 [26.30%]); gen- PDSS displays good concurrent validity and inter-rater reliability, in-
eralized anxiety disorder (GAD; n = 49 [27.40%]), obsessive-compul- cluding in treatment outcome research for patients with panic disorder
sive disorder (OCD; n = 35 [19.60%]), or social anxiety disorder (SAD; with or without agoraphobia (Shear et al., 1997, 2001a; Wuyek et al.,
n = 48 [26.80%]). Clinical diagnoses were made with the Anxiety 2011). Study evaluators administered the PDSS to all participants with
Disorder Interview Schedule (ADIS; Di Nardo et al., 1994; Brown and a clinical PD/A diagnosis at all assessment visits.
Barlow, 2014). Liebowitz Social Anxiety Scale (LSAS; Liebowitz, 1987). The LSAS
is a 24-item, clinician-rated scale that measures both fear and avoid-
1.2. Procedures ance of social interactions and performances. A total score was obtained
by adding the separate fear and avoidance scores for each item, with
The clinical trial was approved by the study site's Institutional higher scores indicating higher severity. The LSAS has demonstrated
Review Board, and all participants provided written informed consent strong internal consistency and convergent validity with other mea-
prior to enrolling. The current study was carried out in accordance with sures of SAD (Fresco et al., 2001; Heimberg et al., 1999). Study eva-
the latest version of the Declaration of Helsinki. Fig. 1 illustrates the luators administered the LSAS to all patients in the trial with a clinical
study design and patient flow. As noted above, participants were ran- SAD diagnosis at all assessment time-points.
domized to either a waitlist condition or treatment with the UP or SDPs Generalized Anxiety Disorder Severity Scale (GADSS; Shear

212
S.J. Steele et al. Journal of Psychiatric Research 104 (2018) 211–216

Fig. 1. Recruitment flow diagram.

Table 1 high internal consistency, good convergent validity with other mea-
Presence of Comorbid Diagnoses by Principal Diagnosis and Treatment sures, and captures changes in symptoms and impairment over the
Condition (N = 179; UP n = 88; SDP n = 91). course of treatment (Shear et al., 2006). Study evaluators administered
CO-SAD CO-PD CO-AG CO-GAD CO-OCD CO-DEP the GADSS to all patients in the trial with a clinical GAD diagnosis at all
assessments.
SAD Yale-Brown Obsessive Compulsive Scale Interview-2nd edition
UP n = 23 – 2 (9%) 1 (4%) 0 1 (4%) 5 (22%)
(Y-BOCS-II; Goodman et al., 1989; Storch et al., 2010). The Y-BOCS-II is
(26%)
SDP n = 25 – 0 0 7 (28%) 3 (12%) 2 (8%)
a 10-item, clinician-rated interview designed to assess severity of OCD
(28%) symptoms and resulting impairment. Items on the scale are scored on a
PD/A 0 (none) to 5 (extreme) Likert-scale. The Y-BOCS has demonstrated high
UP n = 25 6 (24%) – 22 (88%) 7 (28%) 1 (4%) 2 (8%) internal consistency, one-week test–retest reliability, and interrater
(28%)
reliability as well as good construct validity (Goodman et al., 1989;
SDP n = 22 6 (27%) 2 (10%) 20 (91%) 8 (36%) 0 1 (5%)
(24%) Storch et al., 2010; Wu et al., 2016). Patients with an OCD diagnosis
GAD were given a 64-item checklist at baseline, listing possible obsessions
UP n = 22 10 (45%) 1 (5%) 1 (5%) – 1 (5%) 4 (18%) and compulsions. In addition, these patients were administered the Y-
(25%)
BOCS-II at all assessment visits.
SDP n = 27 10 (37%) 4 (15%) 4 (15%) – 7 (26%) 5 (19%)
(30%)
Structured Interview Guide for the Hamilton Depression Rating
OCD Scale (SIGH-D; Williams, 1988). The SIGH-D is a 17-item, clinician-
UP n = 18 7 (39%) 0 0 4 (22%) – 1 (6%) rated interview guide that was developed to provide specific instruc-
(21%) tions for administration and scoring of the Hamilton Rating Scale for
SDP n = 17 4 (24%) 1 (6%) 0 5 (29%) – 1 (6%)
Depression (HRSD; Hamilton, 1960; Shear et al., 2001b). The SIGH-D
(19%)
has demonstrated good inter-rater and test-retest reliability (Shear
Note. Patients were included in the PRIN PD/A category if they met diagnostic et al., 1997). This interview was completed with all participants at each
criteria for DSM-IV PD/A or DSM-5 diagnostic criteria for PD. As represented assessment point.
above, all patients in the UP condition had principal PD and 22 had co-occur-
ring AG. In the SDP condition, 20 patients had principal PD with co-occurring
2. Results
AG, and 2 patients had principal AG.

Aim 1. A summary of the diagnostic composition of the sample can

et al., 2006). The GADSS is a 6-item, clinician-rated measure that
be viewed in Table 1. Comorbidity was highly prevalent; 150 (83.80%)
evaluates core symptoms of GAD and their impact on an individual's
participants met diagnostic criteria for at least one co-occurring dis-
functioning. Items are rated on a 5-point scale, ranging from 0 (none) to
order at baseline assessment, with a range of one to seven diagnoses
4 (very severe). Psychometric studies have shown that the GADSS has
(M = 2.49, SD = 1.44). Chi square analyses indicated no significant

213
S.J. Steele et al. Journal of Psychiatric Research 104 (2018) 211–216

differences in the presence of comorbid diagnoses as a function of Aim 3. As described above, Aim 3 of the present study was to ex-
treatment condition at baseline, χ2 (1, n = 179) = 0.25, p = .61, plore whether the transdiagnostic UP approach was associated with
phi = .05. Notably, almost half of the GAD sample met diagnostic cri- greater decreases in comorbid conditions than single disorder ap-
teria for co-occurring SAD. Co-occurring PD and GAD were diagnosed proaches designed to address one primary condition. Consistent with
most frequently among participants with principal OCD. analytic procedures used in our primary outcomes paper (Barlow et al.,
Aim 2. The second aim of this study was to explore the extent to 2017), we combined the individual SDPs into one variable to represent
which the UP addresses comorbid disorders in a diagnostically het- all of the SDPs used in the trial. Similar to Aim 2, we compared the UP
erogeneous sample with a high degree of co-occurring conditions. To to SDP on: 1) number of clinically significant diagnoses on the ADIS at
address this aim, we first examined the UP's efficacy in significantly baseline, posttreatment, and 12-month follow-up, and 2) scores on
reducing: 1) the number of clinically significant diagnoses on the ADIS disorder-specific measures from baseline to post-treatment, and base-
from baseline to posttreatment and baseline to 12-month follow-up, and line to 12-month follow-up. First, independent samples t-tests revealed
2) scores on disorder-specific, clinician-rated measures from baseline to no significant differences for mean number of diagnoses between the
posttreatment and baseline to 12-month follow-up. First, paired-sam- UP and SDPs at baseline (UP M = 2.48, SD = 1.44; SDP M = 2.51,
ples t-tests were conducted to evaluate the impact of the UP on parti- SD = 1.46; t (177) = −0.13, p = .90), posttreatment (UP M = .84,
cipants' mean number of clinically significant diagnoses. There was a SD = 1.30; SDP M = 1.05, SD = 1.27; t (118) = −0.90, p = .37), or
statistically significant decrease in number of diagnoses from baseline 12- month follow-up (UP M = .82, SD = 1.20; SDP M = .83, SD = 1.21;
(M = 2.56, SD = 1.47) to posttreatment (M = 0.84, SD = 1.30), t t (132) = −0.02, p = .98).
(62) = 8.96, p < .0005, and baseline (M = 2.42, SD = 1.40) to 12- To evaluate changes on the disorder-specific measures by treatment
month follow-up (M = 0.83, SD = 1.20), t (68) = 9.41, p < .0005. condition at each time point, within group and between group effect
Next, to ensure that our estimates were limited to the UP's effects on sizes were examined. Again, individuals with the principal diagnosis
comorbid conditions, we restricted our sample to include individuals associated with each disorder-specific measure were removed, allowing
with co-occurring PD/A (or PD or AG), SAD, GAD, OCD, major de- for examination of specific change in comorbid diagnoses. And again,
pressive disorder (MDD), and persistent depressive disorder (PDD), due to small sample sizes, analyses were not completed for the PDSS or
which were evaluated at each time point by clinician-rated, disorder- the YBOCS. Effect sizes (ESSG) were calculated to determine the mag-
specific measures (see Method). For example, individuals with a prin- nitude of change from pre-to post-treatment and from pre-treatment to
cipal diagnosis of SAD were removed from our evaluations of change on follow-up for the SDP condition (see Table 2). Similar to the UP con-
the LSAS, our measure of SAD severity. Standardized Mean Gain Effect dition, large effects were seen for change on the GADSS, LSAS, and
sizes (ESSG) were calculated to determine the magnitude of change from HAM-D. Next, between group effect sizes (Hedge's g, with correction for
baseline to posttreatment, and baseline to 12-month follow-up. small sample size) were calculated to determine the magnitude of the
Standardized mean gain was chosen for these analyses due its inclusion difference between conditions at each time point on disorder-specific
of a correction for repeated measures assessments (King et al., 2006). symptom measures (see Table 3). Very small, nonsignificant effects
Large effects were seen for change on the GADSS, LSAS, and HAM-D were observed on the HAM-D (−0.04 to 0.10) at all time points be-
(see Table 2). Due to small number of individuals with comorbid PD/A tween the UP and SDP, and small to moderate (though still non-
and OCD, analyses were not completed for the PDSS baseline to post- significant) effects were observed on the GADSS (−0.4 to 0.6) and LSAS
treatment (n = 2), or the YBOCS for posttreatment (n = 2) or 12-month (−0.5 to 0.6). In sum, results suggested that there were no significant
follow-up (n = 2). differences between UP and SDP in decreasing comorbid symptoms at
posttreatment and 12-month follow-up for GAD, SAD, or DEP.
Table 2
Effect sizes for change on comorbid disorder-specific measures by treatment
3. Discussion
condition.
Unified Protocol Single Disorder Protocols The ability to elegantly address symptoms of comorbid conditions is
often cited as a potential advantage of transdiagnostic interventions.
ES SE 95% CI ES SE 95% CI
The primary purpose of the present study was to explore whether a
Baseline to Posttreatment:
GAD (GADSS) −1.72 0.52 −2.73: −1.98 0.44 −1.69: Table 3
−0.76 −0.03 Effect sizes for between group differences on comorbid disorder-specific mea-
PD/A (PDSS) – – – – – –
sures.
SAD
(LSAS fear) −1.33 0.33 −1.98: 0.67 −1.60 0.47 −2.53: Pooled SD Hedge's g SE 95% CI
−0.67
(LSAS −0.86 0.30 −1.45: −1.54 0.49 −2.50: Baseline:
avoidance) −0.27 −0.59 GAD (GADSS) 3.38 −0.39 0.33 −1.04: 0.27
OCD (YBOCS) – – – −0.72 0.36 −1.42: SAD
−0.01 (LSAS fear) 12.39 −0.46 0.30 −1.06: 0.13
DEP (HAM-D) −0.83 0.15 −1.12: −0.84 0.18 −1.19: (LSAS avoidance) 14.10 −0.51 0.30 −1.11: 0.09
−0.54 −0.48 DEP (HAM-D) 6.80 −0.04 0.16 −0.35: 0.27
Baseline to 12 mo f/u: Posttreatment:
GAD (GADSS) −0.81 0.40 −1.59: −1.76 0.48 −2.70: GAD (GADSS) 3.31 −0.29 0.42 −1.12: 0.54
−0.03 −0.82 SAD
PD/A (PDSS) −2.85 1.48 −5.76: 0.05 – – – (LSAS fear) 10.59 0.58 0.38 −0.17: 1.32
SAD (LSAS avoidance) 11.06 0.17 0.37 −0.57: 0.90
(LSAS fear) −1.63 0.39 −2.39: −1.42 0.43 −2.27: DEP (HAM-D) 4.98 −0.01 0.19 −0.38: 0.37
−0.88 −0.57 12-month follow-up:
(LSAS −1.06 0.32 −1.70: −1.59 0.47 −2.51: GAD (GADSS) 4.80 0.58 0.41 −0.21: 1.38
avoidance) −0.43 −0.66 SAD
OCD (YBOCS) – – – −0.69 0.39 −1.45: 0.08 (LSAS fear) 12.37 0.39 0.36 −0.31: 1.10
DEP (HAM-D) −0.80 0.16 −1.12: −0.95 0.19 −1.32: (LSAS avoidance) 12.27 0.23 0.36 −0.47: 0.93
−0.48 −0.58 DEP (HAM-D) 5.58 0.10 0.18 −0.26: 0.45

Note. ES = Standardized Mean Gain effect size. Note. Hedge's g includes correction for small sample size, n < 20.

214
S.J. Steele et al. Journal of Psychiatric Research 104 (2018) 211–216

leading transdiagnostic treatment, the UP, leads to improvements in co- comparisons on diagnosis-specific measures after principal diagnoses
occurring disorders. Indeed, results suggest that the UP is efficacious in were removed. A power analysis in G*Power (Faul et al., 2007) in-
reducing symptoms of comorbid psychopathology; specifically, parti- dicated that a minimum of 52 patients (26 per group) would be ne-
cipants in the UP condition evidenced significant decreases in mean cessary to explore changes on diagnosis-specific measures (e.g., using t-
number of clinically significant diagnoses from baseline to posttreat- tests) to be adequately powered to find a large effect. Of note, the
ment, and baseline to 12-month follow-up. Similarly, significant current study was adequately powered for the between-group analyses
changes on clinician-rated, disorder-specific measures were also ob- examining changes in number of diagnoses between conditions.
served at each time point. A secondary aim of the present study was to In sum, both treatments were effective in reducing comorbid
compare this change in comorbid disorder symptoms following treat- symptoms. This study offers preliminary evidence for the UP's efficacy
ment with the UP to treatment with leading and well established SDPs. in treating co-occurring emotional disorders. Current results require
Contrary to expectations, significant differences were not found when further study through replication and in different clinical settings.
comparing the UP and SDP in the reduction of comorbid psycho- Future work is needed to more specifically understand how these out-
pathology; that is, both treatments led to decreases in mean number of comes are achieved (i.e., which underlying mechanisms might be in-
diagnoses, and decline in symptoms of co-occurring conditions on dis- volved) and whether there are differences in mechanisms across treat-
order-specific measures. ments.
Few studies have investigated the effect of treatment on comorbid
disorders. However, in several studies, treatment for a principal anxiety Conflicts of interest
disorder resulted in significant decreases in the frequency of comorbid
disorders from pretreatment to posttreatment (e.g., Allen et al., 2010; Please note the following financial disclosures/conflicts of interest:
Craske et al., 2007). Davis et al. (2010) reported similar findings in a Dr. Barlow reported receiving royalties from Oxford University Press,
naturalistic sample taken from our clinical center; specifically, treat- United Kingdom (which includes royalties for the treatment manuals
ment for principal anxiety and depressive disorders led to decreases in included in this study); Guilford Publications Inc., United States;
the number of patients with comorbid disorders. Cengage Learning, United States; Pearson Publishing, United Kingdom.
Consistent with these findings, the lack of significant differences He reported receiving grants from the National Institute of Mental
observed by treatment condition in this study suggests that both the UP Health, United States (R01 MH090053) and the National Institute of
and SDPs are efficacious treatments for co-occurring emotional dis- Alcohol and Alcohol Abuse, United States (R01 AA023676). He re-
orders. The lingering question is, why? One potential explanation for ported serving as a consultant for and receiving honoraria from the
these findings lies in the similarities of the treatments; skills presented Agency for Healthcare Research and Quality, United States; the
in both the UP and SDPs were similar and often overlapped (e.g., Foundation for Informed Medical Decision Making, United States; the
cognitive interventions, exposures), although these skills, and other Department of Defense, United States; the Renfrew Center, United
aspects of treatment, are very specifically targeted in SDPs and require States; the Chinese University of Hong Kong, Hong Kong;Universidad
somewhat different application procedures. Nevertheless, the fact that Catolica de Santa Maria, Peru); New Zealand Psychological Association,
participants were able to generalize these skills is quite encouraging New Zealand; Hebrew University of Jerusalem, Israel; Mayo Clinic,
from a clinical standpoint, and speaks to the broad-based and trans- United States; and various American universities.
diagnostic utility of cognitive-behavioral treatment elements. Another Drs. Farchione and Sauer-Zavala reported receiving royalties from
possibility, consistent with a more mechanism-based perspective of Oxford University Press, United Kingdom (for one of the treatment
psychopathology, is that both treatments resulted in changes to un- manuals included in this study). No other disclosures were reported.
derlying, core processes common to the range of emotional disorders,
such as neuroticism. Although SDPs did not directly target shared me- Appendix A. Supplementary data
chanisms, at least in the way that the UP was designed to do, many of
the procedures were similar and it is possible that changes occurred at Supplementary data related to this article can be found at https://
that level. Further investigation in this area is needed. doi.org/10.1016/j.jpsychires.2018.08.005.
Current findings support the practical and cost-effective nature of
incorporating transdiagnostic treatments into both clinical training References
programs and routine clinical practice. As outpatient psychotherapy
continues to shift away from the standard 50-minute session (Olfson Akbari, M., Roshan, R., Shabani, A., Fata, L., Shairi, M.R., Zarghami, F., 2015.
and Marcus, 2010), dissemination of effective science-based treatment Transdiagnostic treatment of co-occurrence of anxiety and depressive disorders based
on repetitive negative thinking: a case series. Ir. J. Psychol. 10, 200–211.
is becoming even more critical in our field. Training clinicians to use Allen, L.B., White, K.S., Barlow, D.H., Shear, M.K., Gorman, J.M., Woods, S.W., 2010.
one set of research supported modules for patients presenting with Cognitive-behavior therapy (CBT) for panic disorder: relationship of anxiety and
heterogeneous, co-occurring psychological disorders reduces the time depression comorbidity with treatment outcome. J. Psychopathol. Behav. Assess. 32,
185–192. https://doi.org/10.1007/s10862-009-9151-3.
and effort it takes to learn multiple SDPs, the cost of training, super- American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental
vising, and implementing different manualized treatments for different Disorders (DSM-5), fifth ed. American Psychiatric Associations Publishing,
diagnoses, and provides the potential for more efficient and more Washington, D.C.
Barlow, D.H., 2000. Unraveling the mysteries of anxiety and its disorders from the per-
broad-based dissemination of effective treatment (McHugh and Barlow, spective of emotion theory. Am. Psychol. 55, 1247–1263. https://doi.org/10.1037//
2010). Thus, transdiagnostic treatments offer a promising avenue for 0003-066X.55.11.1247.
treating co-occurring emotional disorders to address the comorbid, Barlow, D.H., Allen, L.B., Choate, M.L., 2016. Toward a unified treatment for emotional
disorders–Republished article. Behav. Ther. 47, 838–853. https://doi.org/10.1016/j.
complex presentations regularly seen in routine clinical practice.
beth.2016.11.005.
Despite promising early findings, study limitations warrant men- Barlow, D.H., Craske, M.G., 2007. Mastery of Your Anxiety and Panic: Workbook. Oxford,
tion. As published previously, participants reported generally high le- New York.
vels of education and lower depression than comparable participant Barlow, D.H., Ellard, K.K., Fairholme, C.P., Farchione, T.J., Boisseau, C.L., Allen, L.B.,
Ehrenreich-May, J., 2011a. Unified Protocol for Transdiagnostic Treatment of
samples. Additionally, the UP and three of the four SDPs included were Emotional Disorders: Workbook, first ed. Oxford, New York.
developed at the data collection/treatment site, potentially limiting Barlow, D.H., Farchione, T.J., Bullis, J.R., Gallagher, M.W., Murray-Latin, H., Sauer-
generalizability (Barlow et al., 2017). Specific to the current study's Zavala, S., et al., 2017. The Unified Protocol for Transdiagnostic Treatment of
Emotional Disorders compared with diagnosis-specific protocols for anxiety dis-
focus on comorbid conditions, sample sizes were small after removing orders: a randomized clinical trial. JAMA Psychiatr. 74, 875–884. https://doi.org/10.
principal diagnoses, limiting between-group comparisons across time 1001/jamapsychiatry.2017.2164.
points in some instances. Specifically, sample sizes were small for Barlow, D.H., Fairholme, C.P., Ellard, K.K., Boisseau, C.L., Allen, L.B., Ehrenreich-May, J.,

215
S.J. Steele et al. Journal of Psychiatric Research 104 (2018) 211–216

2011b. Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: behavioral Therapy Approach Therapist Guide. Oxford, UK.
Therapist Guide, first ed. Oxford, New York. King, L.A., King, D.K., McArdle, J., Saxe, G., Doran-Lamarca, S., Orazem, R., 2006. Latent
Barlow, D.H., Farchione, T.J., Sauer-Zavala, S., Latin, H.M., Ellard, K.K., Bullis, J.R., difference score approach to longitudinal trauma research. J. Trauma Stress 19,
Cassiello-Robbins, C., 2018a. Unified Protocol for Transdiagnostic Treatment of 771–785. https://doi.org/10.1002/jts.20188.
Emotional Disorders: Therapist Guide, second ed. Oxford, New York. Liebowitz, M.R., 1987. Social phobia. Mod. Probl. Pharmacopsychiatr. 22, 141–173.
Barlow, D.H., Sauer-Zavala, S., Farchione, T.J., Murray-Latin, H., Ellard, K.K., Bullis, J.R., https://doi.org/10.1159/000414022.
et al., 2018b. Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: McHugh, R.K., Barlow, D.H., 2010. The dissemination and implementation of evidence-
Workbook, second ed. Oxford, New York. based psychological treatments. A review of current efforts. Am. Psychol. 65, 73–84.
Barlow, D.H., Sauer-Zavala, S., Carl, J.R., Bullis, J.R., Ellard, K.K., 2014. The nature, https://doi.org/10.1037/a0018121.
diagnosis, and treatment of neuroticism: back to the future. Clin. Psychol. Sci. 2, Milosevic, I., Chudzik, S.M., Boyd, S., McCabe, R.E., 2017. Evaluation of an integrated
344–365. https://doi.org/10.1177/2167702613505532. group cognitive-behavioral treatment for comorbid mood, anxiety, and substance use
Brown, T.A., Barlow, D.H., 2014. Anxiety and Related Disorders Interview Schedule for disorders: a pilot study. J. Anxiety Disord. 46, 85–100. https://doi.org/10.1016/j.
DSM-5 (ADIS-5L): Lifetime Version-client Interview Schedule. Oxford, New York. janxdis.2016.08.002.
Brown, T.A., Barlow, D.H., 2009. A proposal for a dimensional classification system based Olfson, M., Marcus, S.C., 2010. National trends in outpatient psychotherapy. Am. J.
on the shared features of the DSM-IV anxiety and mood disorders: implications for Psychiatr. 167, 1456–1463. https://doi.org/10.1176/appi.ajp.2010.10040570.
assessment and treatment. Psychol. Assess. 21, 256–271. https://doi.org/10.1037/ Palermo, T.M., Bromberg, M.H., Beals-Erickson, S., Law, E.F., Durkin, L., Noel, M., Chen,
a0016608. M., 2016. Development and initial feasibility testing of brief cognitive-behavioral
Brown, T.A., Campbell, L.A., Lehman, C.L., Grisham, J.R., Mancill, R.B., 2001. Current therapy for insomnia in adolescents with comorbid conditions. Clin. Pract. Pediatr.
and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical Psychol. 4, 214–226. https://doi.org/10.1037/cpp0000140.
sample. J. Abnorm. Psychol. 110, 585–599. https://doi.org/10.1037//0021-843x. Rosellini, A.J., Boettcher, H., Brown, T.A., Barlow, D.H., 2015. A transdiagnostic tem-
110.4.585. perament-phenotype profile approach to emotional disorder classification: an update.
Bullis, J.R., Fortune, M.R., Farchione, T.J., Barlow, D.H., 2014. A preliminary in- Psychopathol. Rev. 2, 110–128. https://doi.org/10.5127/pr.036014.
vestigation of the long-term outcome of the unified protocol for transdiagnostic Sauer-Zavala, S., Barlow, D.H., 2014. The case for borderline personality disorder as an
treatment of emotional disorders. Compr. Psychiatr. 55, 1920–1927. https://doi.org/ emotional disorder: implications for treatment. Clin. Psychol. Sci. Pract. 21, 118–138.
10.1016/j.comppsych.2014.07.016. https://doi.org/10.1111/cpsp.12063.
Craske, M.G., Barlow, D.H., 2006. Mastery of Your Anxiety and Worry: Workbook. Sauer-Zavala, S., Wilner, J.G., Barlow, D.H., 2017. Addressing neuroticism in psycholo-
Oxford, New York. gical treatment. Pers. Disord. 8, 191–198. https://doi.org/10.1037/per0000224.
Craske, M.G., Barlow, D.H., 2007. Mastery of Your Anxiety and Panic: Therapist Guide. Shear, K., Belnap, B.H., Mazumdar, S., Houck, P., Rollman, B.L., 2006. Generalized an-
Oxford, New York. xiety disorder severity scale (GADSS): a preliminary validation study. Depress.
Craske, M.G., Farchione, T.J., Allen, L.B., Barrios, V., Stoyanova, M., Rose, R., 2007. Anxiety 23, 77–82. https://doi.org/10.1002/da.20149.
Cognitive behavioral therapy for panic disorder and comorbidity: more of the same or Shear, M.K., Brown, T.A., Barlow, D.H., Money, R., Sholomskas, D.E., Woods, S.W., et al.,
less of more? Behav. Res. Ther. 45, 1095–1109. https://doi.org/10.1016/j.brat.2006. 1997. Multicenter collaborative panic disorder severity scale. Am. J. Psychiatr. 154,
09.006. 1571–1575. https://doi.org/10.1176/ajp.154.11.1571.
Davis, L., Barlow, D.H., Smith, L., 2010. Comorbidity and the treatment of principal Shear, M.K., Rucci, P., Williams, J., Frank, E., Grochocinski, V., Vander Bilt, J., et al.,
anxiety disorders in a naturalistic sample. Behav. Ther. 41, 296–305. https://doi.org/ 2001a. Reliability and validity of the panic disorder severity scale: replication and
10.1016/j.beth.2009.09.002. extension. J. Psychiatr. Res. 35, 293–296. https://doi.org/10.1016/S0022-3956(01)
Di Nardo, P.A., Brown, T.A., Barlow, D.H., 1994. Anxiety Disorders Interview Schedule 00028-0.
for DSM-IV: Lifetime Version (ADIS-IV-L). Oxford, UK. Shear, M.K., Vander Bilt, J., Rucci, P., Endicott, J., Lydiard, B., Otto, M.W., et al., 2001b.
Ellard, K.K., Fairholme, C.P., Boisseau, C.L., Farchione, T.J., Barlow, D.H., 2010. Unified Reliability and validity of a structured interview guide for the Hamilton Anxiety
protocol for the transdiagnostic treatment of emotional disorders: protocol devel- Rating Scale (SIGH‐A). Depress. Anxiety 13, 166–178. https://doi.org/10.1002/da.
opment and initial outcome data. Cognit. Behav. Pract. 17, 88–101. https://doi.org/ 1033.abs.
10.1016/j.cbpra.2009.06.002. Stice, E., Rohde, P., Butryn, M., Menke, K.S., Marti, C.N., 2015. Randomized controlled
Farchione, T.J., Fairholme, C.P., Ellard, K.K., Boisseau, C.L., Thompson-Hollands, J., Carl, pilot trial of a novel dissonance-based group treatment for eating disorders. Behav.
J.R., et al., 2012. Unified protocol for transdiagnostic treatment of emotional dis- Res. Ther. 65, 67–75. https://doi.org/10.1016/j.brat.2014.12.012.
orders: a randomized controlled trial. Behav. Ther. 43, 666–678. https://doi.org/10. Storch, E.A., Rasmussen, S.A., Price, L.H., Larson, M.J., Murphy, T.K., Goodman, W.K.,
1016/j.beth.2012.01.001. 2010. Development and psychometric evaluation of the yale–Brown obsessive-com-
Faul, F., Erdfelder, E., Lang, A.-G., Buchner, A., 2007. G*Power 3: a flexible statistical pulsive scale—second edition. Psychol. Assess. 22, 223–232. https://doi.org/10.
power analysis program for the social, behavioral, and biomedical sciences. Behav. 1037/a0018492.
Res. Meth. 39, 175–191. Titov, N., Dear, B.F., Staples, L.G., Terides, M.D., Karin, E., Sheehan, J., et al., 2015.
Foa, E.B., Yadin, E., Lichner, T.K., 2012. Exposure and Response (Ritual) Prevention for Disorder-specific versus transdiagnostic and clinician-guided versus self-guided
Obsessive-compulsive Disorder: Therapist Guide. Oxford, New York. treatment for major depressive disorder and comorbid anxiety disorders: a rando-
Fresco, D.M., Coles, M.E., Heimberg, R.G., Liebowitz, M.R., Hami, S., Stein, M.B., Goetz, mized controlled trial. J. Anxiety Disord. 35, 88–102. https://doi.org/10.1016/j.
D., 2001. The Liebowitz Social Anxiety Scale: a comparison of the psychometric janxdis.2015.08.002.
properties of self-report and clinician-administered formats. Psychol. Med. 31, Wilamowska, Z.A., Thompson-Hollands, J., Fairholme, C.P., Ellard, K.K., Farchione, T.J.,
1025–1035. https://doi.org/10.1017/S0033291701004056. Barlow, D.H., 2010. Conceptual background, development, and preliminary data
Goodman, W.K., Price, L.H., Rasmussen, S.A., Mazure, C., Delgado, P., Heninger, G.R., from the unified protocol for transdiagnostic treatment of emotional disorders.
Charney, D.S., 1989. The yale-Brown obsessive compulsive scale II. Validity. Arch. Depress. Anxiety 27, 882–890. https://doi.org/10.1002/da.20735.
Gen. Psychiatr. 46, 1012–1016. https://doi.org/10.1001/archpsyc.1989. Williams, J.B., 1988. A structured interview guide for the Hamilton Depression Rating
01810110054008. Scale. Arch. Gen. Psychiatr. 45, 742–747. https://doi.org/10.1001/archpsyc.1988.
Griffith, J.W., Zinbarg, R.E., Craske, M.G., Mineka, S., Rose, R.D., Waters, A.M., Sutton, 01800320058007.
J.M., 2010. Neuroticism as a common dimension in the internalizing disorders. Wu, M.S., McGuire, J.F., Horng, B., Storch, E.A., 2016. Further psychometric properties of
Psychol. Med. 40, 1125–1136. https://doi.org/10.1017/s0033291709991449. the yale–Brown obsessive compulsive scale—second edition. Compr. Psychiatr. 66,
Hamilton, M., 1960. A rating scale for depression. J. Neurol. Neurosurg. Psychiatry 23, 96–103. https://doi.org/10.1016/j.comppsych.2016.01.007.
56–62. Wuyek, L.A., Antony, M.M., McCabe, R.E., 2011. Psychometric properties of the panic
Heimberg, R.G., Horner, K.J., Juster, H.R., Safren, S.A., Brown, E.J., Schneier, F.R., disorder severity scale: clinician‐administered and self‐report versions. Clin. Psychol.
Liebowitz, M.R., 1999. Psychometric properties of the Liebowitz social anxiety scale. Psychother. 18, 234–243. https://doi.org/10.1002/ccp.703.
Psychol. Med. 29, 199–212. https://doi.org/10.1016/j.janxdis.2011.03.009. Yadin, E., Foa, E.B., Lichner, T.K., 2012. Treating Your OCD with Exposure and Response
Hope, D.A., Heimberg, R.G., Juster, H.R., Turk, C.L., 2000. Managing Social Anxiety: a (Ritual) Prevention: Workbook. Oxford, New York.
Cognitive-behavioral Therapy Approach. The Psychological Corporation, New York. Zinbarg, R.E., Craske, M.G., Barlow, D.H., 2006. Mastery of Your Anxiety and Worry:
Hope, D.A., Heimberg, R.G., Turk, C.L., 2006. Managing Social Anxiety: a Cognitive- Therapist Guide. Oxford, New York.

216