Comparing the effectiveness of the unified protocol in combination with an additional mindfulness treatment to the unified protocol alone as treatment for adolescents diagnosed with emotional disorders

Abstract Objective Many adolescents suffer from depressive and anxiety disorders simultaneously and current treatment methods do not put enough emphasis on comorbidity of these disorders. The unified protocol for treating emotional disorders in adolescents is a transdiagnostic therapy which targets mutual fundamental factors. Therefore, the current study aims to compare the effectiveness of the unified protocol alone with the unified protocol combined with mindfulness as an additional treatment in adolescents suffering from emotional disorders. Method A quasi-experimental study was conducted with adolescents. The participants had been diagnosed with emotional disorders and were divided into a control group (15 participants) and an experimental group (16 participants). Both groups were offered 14 sessions of therapy. They were assessed at pre-test, post-test, and two-month follow-up. Scales used in the study included the Child Behavior Checklist (CBCL), the Children’s Depression Inventory (CDI), and the Youth Anxiety Measure for DSM-5 (YAM-5). Results The results showed that both of the treatment methods effectively reduced adolescents’ emotional problems, but improvements were more significant in the group administered the additional mindfulness program. Among the variables assessed, non-phobic anxiety disorders and depression improved more than specific phobia and behavioral problems. Between-subjects (Group) partial etas for non-phobic anxiety, depression, specific phobia, and behavioral problems were 0.67, 0.50, 0.23, and 0.16, respectively. Conclusion According to the findings of this study, additional treatment methods such as mindfulness could increase the effectiveness of the unified transdiagnostic protocol for adolescents (UP-A). The therapeutic implications are discussed.


Introduction
According to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), anxiety and depressive disorders encompass a large range of emotional disorders and are among the most prevalent types of psychiatric illnesses during childhood and adolescence. 1,2 In Iran, anxiety disorders are the most prevalent disorders among children and adolescents. 3,4 Studies show there is a high rate of comorbidity between anxiety and depressive disorders; such that 16 to 62 percent of children and adolescents are simultaneously diagnosed with criteria for anxiety and depressive disorders. 5 If these problems are left untreated at these ages, they might lead to emotional disorders during adulthood and could even become lifelong. 6 Experiencing these symptoms, and also behavioral problems or issues of emotion regulation, could significantly affect the quality of adolescents' functional performance in education and social communication. 7 Evidence-based studies demonstrate the effectiveness and advantages of cognitive-behavioral therapies for treating depression and anxiety symptoms among adolescents, 8 but cognitive behavioral therapies (CBTs) have faced serious financial and clinical problems due to high comorbidity of emotional disorders and these illnesses' mutual symptoms. 9 Studying the follow-up results of investigations show that about half of adolescents treated with CBT, experience symptom recurrence. Furthermore, anxious adolescents who suffer from comorbid depression have a slower response to anxiety-specific CBT. 10 Actually, evidence suggests that most of these therapeutic approaches focus exclusively on symptoms and on reducing them and do not target the mutual fundamental factors (transdiagnostic factors) that play a role in formation and continuity of a wide range of emotional disorders. 11 Therefore, there is an emphasis on utilizing treatment methods which not only concentrate on how different disorders are, but also simultaneously focus on multiple disorders and the factors they have in common; methods which are easy to teach, and financially reasonable to apply. 12 With an emphasis on regulation of emotion, the unified protocol for transdiagnostic treatment in adolescents (UP-A) utilizes similar CBTs for a spectrum of emotional experiences and their mutual fundamental factors. The therapeutic methods used in this protocol allow clinicians to make diagnoses and recognize subthreshold symptoms in the unified program. 1 Another treatment used for children's emotional disorders during recent years is mindfulness. Mindfulness is known as a non-judgmental present-moment awareness which validates any thought, sensation or feeling that enters awareness and accepts it the way it really is. 13 Mindfulness-based interventions have been mostly examined in adults, but recently they have been increasingly used and studied at younger ages too. 14,15 Therefore, considering the problems caused by emotional disorders in adolescents and in response to a lack of sufficient investigations of the effectiveness of the unified protocol in this population, the aim of the current study is to compare the effectiveness of the unified protocol combined with additional mindfulness treatment and the unified protocol applied independently.

Materials and method Participants
The participants were allocated to an experimental group (16 participants) or a control group (15 participants) after screening ( Figure 1). Sample size was obtained either from previous studies or calculated using the following formula. 7     were observed by the supervisor from behind a oneway mirror.

Intervention
The transdiagnostic treatment administered was based on the Ehrenreich protocol for adolescents. 1 This book contains nine chapters covering the

Results
The total number of participants in this study was 31.
Their demographic characteristics are shown in Table 2.
According to the analysis, there were no significant differences between the two groups of patients in terms of demographic characteristics.
The patients were diagnosed with emotional disorders and their frequencies of diagnoses at pretreatment baseline are presented in Table 3.  shows that the error variance of the dependent variables is equal in all the groups. Table 4 shows the means and standard deviations of dependent variables in the pretest, post-test, and follow-up stages. Table 5 indicates that UP-A+ mindfulness significantly   changed depression, CBCL, YAM-I, and YAM-II variables. These meaningful changes were significant and persistent over time.
Moreover, the results of analysis of variables using Bonferroni pairwise comparisons showed that meaningful changes were observed in the experimental group when pre-test was compared to post-test and to follow-up (p < 0.01).

Discussion
The aim of this study was to assess the effectiveness it keeps the person in an observational situation. 13,29,30 Therefore, mindfulness helps to regulate emotions and to decrease emotional problems by keeping the person at a psychological distance from the emotions they are experiencing. 31 Moreover, the results of this study show that this therapeutic method was able to reduce non-phobic anxiety symptoms in adolescents, which may have stemmed from the principle of identifying emotions and preventing emotional avoidance. 1  despite all the possible changes. 33 The low effect size for behavioral problems and specific phobia compared to non-phobic anxiety disorders and depression might therefore be because of a lack of commitment to, or interest in, employing these techniques on the part of adolescents or their parents. Moreover, it could be stated that using behavioral techniques might be beneficial for treating phobia; because coping with phobia requires real exposure, desensitization, and relaxation and these techniques form the foundation of behavioral therapy.
Despite the findings mentioned above, the current research has some limitations which might have restricted generalizability of the findings. Firstly, due to the limited number of participants in our study, the findings should be generalized to other adolescents with caution. Future studies should enroll larger groups of people. Secondly, only self-report scales were used to assess the effectiveness of the treatment and, therefore, it is suggested that future researchers utilize therapist-rated scales. Information generated by techniques like MRI and fMRI might also be beneficial.

Conclusion
On the whole, it can be concluded that additional treatment methods like mindfulness, could enrich the therapy outcomes of the unified protocol for adolescents.