Unified Protocol for Treatment of Depression

Abstract

Numerous cognitive-behavioral treatment manuals have been developed to treat specific psychiatric disorders. Although these treatments are generally effective for those specific conditions, there remains a great need for interventions that can be flexibly applied across many disorders and symptoms due to high comorbidity rates and significant barriers to clinician training in distinct evidence-based psychological treatments. The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is a cognitive-behavioral treatment designed to treat neuroticism, a core temperamental factor that underlies the development and maintenance of emotional disorders (i.e., anxiety, depressive, and related disorders). In this chapter, we discuss the rationale for and conceptualization of the UP and its eight treatment modules. Since its development, the UP has garnered significant research support. As such, we detail findings from relevant research focused on treating depressive disorders and other related conditions. Finally, we describe each UP treatment module in depth and how providers can utilize the UP in their practice with patients with depression. Overall, the UP is a promising intervention that can be utilized across emotional disorders, including depression, and may be an intervention that is advantageous for widespread dissemination.

FAQs: Common Questions and Answers

• Q1. Multiple evidence-based treatments have been designed to treat depression (e.g., interpersonal therapy, cognitive therapy, behavioral activation, problem-solving therapy, acceptance and commitment therapy). If a clinician is trained in other treatments, in what circumstances would the UP be recommended?

• A1. Multiple factors can be weighed in determining whether the UP would be a recommended treatment for a patient presenting with depression. If a patient has a comorbid anxiety disorder or other emotional disorder that the patient would also like to target, the UP is particularly well suited to these individuals due to its transdiagnostic approach. Similarly, if a patient presents with a desire to learn how to more adaptively respond to negative emotions and wants a treatment that focuses on emotions (rather than, say, interpersonal relationships or problems in life), the UP would be an appropriate selection. If a patient would like a structured treatment and to incorporate reading materials to better learn the skills, the UP would have an advantage over treatments for which there is not a standard patient workbook.

• Q2. When would the UP not be recommended for a patient with depression ?

• A2. The UP may not be recommended when a patient presents with a primary disorder that does not fit within the therapeutic framework of an “emotional disorder.” In the UP, an “emotional disorder” is conceptualized as any condition in which the functional process of experience of intense negative affect, aversive reactivity to emotion, and avoidant, maladaptive responding serves to maintain symptoms. Per this framework, prototypical emotional disorders include anxiety, depression, PTSD, OCD, and somatic symptom disorders and thus are usually appropriate to target with the UP. The UP’s emphasis on promoting more adaptive emotion management is also well suited to targeting the deficits in emotion processing and emotion dysregulation that are prominent in patients with bipolar disorder [61, 71]. Although the UP framework applies directly to the recurrent depressive episodes that are often present in bipolar disorder—as discussed throughout this chapter—additional treatment or crisis management strategies geared toward immediate mood stabilization may be indicated to directly address the (hypo) manic episodes that characterize this condition. Some eating and substance use disorders may also fit within this framework, depending on whether the functional process described above applies to the presenting individual (e.g., does the patient engage in eating disordered behavior or use alcohol/drugs primarily to relieve, suppress, or avoid unwanted emotion?). This highlights the importance of conducting a functional analysis at the start of treatment to determine whether the UP is an appropriate approach for patients presenting with a primary disorder that may or may not clearly fit within this framework. Psychotic disorders, impulsive behavioral disorders (e.g., Tourette’s), and attention-deficit hyperactivity disorder (ADHD) would generally not be appropriate to target with the UP, as these do not share the emotion-focused, mechanistic process noted above.

  A patient’s motivation for treatment is also important, and as such, if a patient prefers another evidence-based treatment modality, then that preference would generally take precedence. Patients who do not want to engage in between-session homework may prefer a treatment with less of an emphasis on homework (e.g., interpersonal therapy). Lastly, if a patient has depression that is comorbid with more extreme difficulties with emotion regulation, acute suicidality, or chronic self-harm, a more intensive and multi-modal treatment, such as dialectical behavior therapy, may be indicated; however, as previously noted, the UP has demonstrated promising results for lower-risk presentations of BPD [64].

• Q3. A common symptom of MDD is suicidal ideation . Can that be directly addressed in the UP?

• A3. A suicide risk assessment is an important part of diagnostic evaluation for individuals presenting with depressive symptoms. This assessment, and, if appropriate, the creation of a safety plan, typically precedes selection of treatment and, thus, the beginning of the UP. within the context of the UP, suicidal ideation can often be conceptualized as a form of emotion avoidance. Individuals who passively wish they would die (“I wish I just would not wake up”) or think about ways they could end their life may, in the short term, feel temporarily relieved by thinking about this form of escape. In the long term, however, suicidal ideation may maintain low mood and impede more healthy responses to emotional distress or generation of more adaptive solutions to problems in life. Normalization of how common suicidal ideation is in individuals with depression and that it makes sense that when someone is feeling overwhelmed or hopeless that they would consider life-ending solutions is part of starting a nonjudgmental dialogue about the role that suicidal ideation is playing in their overall experience with depression. See Bentley et al. [67] for further discussion of the UP’s approach to suicidal thoughts and behaviors.

• Q4. How is the UP different than CBT?

• A4. The UP is a cognitive-behavioral treatment that utilizes skills taught in other CBT manuals, and in some ways, looks functionally like other CBT interventions. Similar to other forms of CBT, clinically, the UP can also be used as a broader therapeutic “framework” rather than a structured, manualized intervention. The UP differs from most other structured CBT interventions in its transdiagnostic nature (as opposed to single-diagnosis approaches; CBT for MDD, CBT for social anxiety, CBT for OCD) and emphasis on emotion, rather than, for example, specific symptoms or situations. The UP aims to foster adaptive responses to the full range of emotions—including positive emotions, which for many patients with emotional disorders, and especially depression, may be uncomfortable to experience. Along these lines, the UP is unique from other CBT protocols in that it was designed to directly target neuroticism, a temperamental or trait-like characteristic thought to underlie a broad range of anxiety, depressive, and related disorders, rather than the surface-level symptoms of individual disorders. The UP’s modular approach, in which each module can be delivered independently, repeated, and (in some cases) reordered, is also a structural difference from many other CBT protocols.

• Q5. How long does this treatment take to administer?

• A5. The UP was designed to be a time-limited treatment ; however, the treatment framework and strategies can be utilized during a therapy course of any length. Most studies of the UP to date have tested the treatment when delivered in 12–20 weekly individual or group outpatient sessions; however, we have also used the UP clinically over longer courses of therapy. Our group has a variety of projects underway in which the UP is being adapted and implemented in nontraditional outpatient settings, such as partial hospital, crisis stabilization, and inpatient units, each of which requires different lengths and structures of administration (e.g., multiple daily groups, rolling admission formats). In this regard, the UP’s flexible, modular structure is advantageous as it lends itself well to a broad range of delivery formats.

• Q6. I am interested in using the UP in my practice. How do I get started?

• A6. The published UP, UP-A, and UP-C therapist guides and patient workbooks are available for online purchase. We have found that clinicians who are already well-versed in CBT tend to pick up the protocol easily. However, learning the nuances of the UP’s transdiagnostic, emotion-focused emphasis can be facilitated by attending UP workshops and/or receiving consultation, supervision, or program implementation services through the Unified Protocol Institute.