A SMART approach to personalized care: preliminary data on how to select and sequence skills in transdiagnostic CBT

Abstract

Given that over 20 million adults each year do not receive care for their mental health difficulties, it is imperative to improve system-level capacity issues by increasing treatment efficiency. The present study aimed to collect feasibility/acceptability data on two strategies for increasing the efficiency of cognitive behavioral therapy: (1) personalized skill sequences and (2) personalized skill selections. Participants (N = 70) with anxiety and depressive disorders were enrolled in a pilot sequential multiple assignment randomized trial (SMART). Patients were randomly assigned to receive skill modules from the Unified Protocol in one of three sequencing conditions: standard, sequences that prioritized patients' relative strengths, and sequences that prioritized relative deficits. Participants also underwent a second-stage randomization to either receive 6 sessions or 12 sessions of treatment. Participants were generally satisfied with the treatment they received, though significant differences favored the Capitalization and Full duration conditions. There were no differences in trajectories of improvement as a function of sequencing condition. There were also no differences in end-of-study outcomes between brief personalized treatment and full standard treatment. Thus, it may be feasible to deliver CBT for personalized durations, though this may not substantially impact trajectories of change in anxiety or depressive symptoms.

The effects of the Unified Protocol and Unified Protocol skills on loneliness in the COVID‐19 pandemic

“…Potential participants were eligible for the study if they met criteria for at least one of the following disorders 1 : generalized anxiety disorder (GAD; n = 33; 47.1%), major depressive disorder (MDD; n = 19; 27.1%), social anxiety disorder (SAD; n = 16; 22.9%), persistent depressive disorder (PDD; n = 12; 17.1%), obsessive‐compulsive disorder (OCD; n = 5; 7.1%), panic disorder (PD; n = 4; 5.7%), posttraumatic stress disorder (PTSD; n = 3; 4.3%), acute stress disorder (ASD; n = 1; 1.4%), or agoraphobia (AG; n = 1; 1.4%). Complete diagnostic information is available in Sauer‐Zavala et al ( 2022 ). Potential participants were excluded for exhibiting symptoms requiring more intensive treatment (i.e., mania in the past year; acute suicidality; substance use disorder in the past 3 months; psychotic features); receiving ≥5 sessions of CBT in the past 5 years; being unwilling to stop concurrent treatment for an emotional disorder; or being unwilling to maintain a stable dosage of medication during participation.…”

“…The treatment consisted of the five core modules of the UP, with all but one (i.e., Countering Emotional Behaviors) delivered over two weekly, 50–60‐min individual sessions in a randomized order (see Study Design below). Four therapists (a licensed clinical psychologist, a post‐doctoral fellow, and two advanced clinical psychology graduate students; two men, two women) provided the treatment and demonstrated good adherence (Sauer‐Zavala et al, 2022 ). In previous research (Sakiris & Berle, 2019 ) and the current sample (Sauer‐Zavala et al, 2022 ), the UP demonstrated efficacy in reducing anxiety and depression.…”

“…Four therapists (a licensed clinical psychologist, a post‐doctoral fellow, and two advanced clinical psychology graduate students; two men, two women) provided the treatment and demonstrated good adherence (Sauer‐Zavala et al, 2022 ). In previous research (Sakiris & Berle, 2019 ) and the current sample (Sauer‐Zavala et al, 2022 ), the UP demonstrated efficacy in reducing anxiety and depression.…”

“…Examining loneliness more frequently and disaggregating between-from within-person effects of skills allows for stronger tests of the relative efficacy of skill use on loneliness . Thus, we conducted a secondary data analysis from a sequential multiple assignment randomized trial of the UP (Sauer-Zavala et al, 2022;NCT04584879). We hypothesized that the UP would lead to significant reductions in loneliness (Aim 1).…”

“…Thus, we conducted a secondary data analysis from a sequential multiple assignment randomized trial of the UP (Sauer‐Zavala et al, 2022 ; NCT04584879). We hypothesized that the UP would lead to significant reductions in loneliness (Aim 1).…”