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Cited by 15Maternal Mental Health During Pregnancy and PostpartumAnxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesPersonality Disorders and Psychopathology

The Unified Protocol for Transdiagnostic Treatment of Perinatal Depression: A Case Study

Open access
Crespo-Delgado, Elena, Martínez-Borba, Verónica, Osma, Jorge·2020·Clinical Case Studies
DOI 10.1177/1534650120951266
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Abstract

This case study aims to present the application of the Unified Protocol (UP) for the Transdiagnostic Treatment of Emotional Disorders in the case of a 38-year-old pregnant woman with a peripartum onset of major depressive disorder and anxiety symptoms. The UP is a cognitive-behavioral intervention based on the shared etiological and maintenance mechanisms of emotional disorders (i.e., mood, anxiety, and related disorders). The UP helps to modify maladaptive emotion-regulation strategies and enhance tolerance of unpleasant and intense emotions (sadness, anxiety, anger, etc.). Whereas previous studies demonstrate the efficacy of the UP in different emotional disorders, to our knowledge, none of them have used the UP to treat perinatal emotional disorders. After the eight UP modules of individual treatment, a significant decrease in anxiety, depression, negative affect, and anxiety sensitivity, and also an increase in positive affect were observed. These results were maintained at the 12-month follow-up. In addition to its clinical utility and acceptance, these results indicate that the UP can be adapted and personalized for the treatment of perinatal emotional disorders. Future studies with larger samples and controlled experimental designs should be developed to demonstrate its efficacy. Furthermore, as the UP seems to be useful in a group format, future efforts should be focused on the UP with perinatal women in a group format. © The Author(s) 2020.

Integrity signals

Registry

Crossref · 10.1177/1534650120951266

Cites

50 of 52 references verified0 citation errors · 2 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

2 of 39 cited sources checked · 1 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    High comorbidity between different emotional disturbances leads clinicians either to treat the main pathology and expect effects on comorbid pathology, or to apply two treatments simultaneously.

    “Second, because high comorbidity between different emotional disturbances (Barlow et al., 2013) leads clinicians either to treat the main pathology and expect the effects of treatment to affect the comorbid pathology, or to apply two treatments simultaneously (McManus et al., 2010).”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites Barlow et al., 2013

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites McManus et al., 2010 source
  • Findingown data

    After the eight UP modules, there was a significant decrease in anxiety sensitivity.

    “After the eight UP modules of individual treatment, a significant decrease in anxiety, depression, negative affect, and anxiety sensitivity, and also an increase in positive affect were observed.”
    Quote in the paperSubstantial claim
  • Findingown data

    At the end of the intervention, Patricia did not meet criteria for any psychological disturbance on the MINI.

    “The MINI interview was also administered at the end of the intervention, without Patricia meeting the criteria for any of the psychological disturbances.”
    Quote in the paperSubstantial claim
  • Findingown data

    Patricia experienced intense unpleasant emotions and aversive reactions when facing challenging situations.

    “When facing challenging situations, she experienced intense emotions and aversive reactions (thoughts and physical sensations).”
    Quote in the paperSubstantial claim
  • Findingown data

    After the eight UP modules, there was a significant decrease in depression.

    “After the eight UP modules of individual treatment, a significant decrease in anxiety, depression, negative affect, and anxiety sensitivity, and also an increase in positive affect were observed.”
    Quote in the paperSubstantial claim
  • May combine two claims. 26
  • The quote only partly states this claim. 2
  • Classified as probably not a substantial claim. 13

  • May combine two claims.

    Premisecitation

    Perinatal women and the general population both accept ICTs for mental health intervention programs.

    “there is evidence indicating that perinatal women and the general population both accept ICTs for mental health intervention programs (Miralles et al., 2020;Osma et al., 2020).”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites Miralles et al., 2020 source

      Theoretical and Research Basis for Treatment (p. 3) reports high satisfaction with technology-mediated psychological treatment and says ICTs have been well supported on acceptability. Miralles et al. do not provide evidence about perinatal women or the general population as such; their own acceptability assessment concerns one patient with panic disorder and agoraphobia. (LLM, conf=0.82)

      Experimental — accuracy not yet measured
    • cites Osma et al., 2020

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Findingown data

    Patricia reported symptoms of sadness, anhedonia, daily crying, fatigue, abulia, insomnia, feelings of guilt and worthlessness, and concentration problems.

    “The symptoms reported by Patricia were sadness, anhedonia, daily crying, fatigue, abulia (i.e., lack of motivation and energy in daily activities), insomnia, feelings of guilt and worthlessness, and concentration problems.”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    Patricia's ODSIS score progressively decreased to 4 by Module 8.

    “the depressive symptoms progressively decreased until reaching a total of 4 points in Module 8 of the intervention.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Patricia's anxiety symptoms decreased throughout the modules, with OASIS score decreasing from 17 at first module to 13 at Module 4 to 4 after Module 8.

    “The initial OASIS score was very high in the first module (17 out of a maximum of 20), and this score decreased to 13 toward the middle of the intervention protocol (Module 4) until reaching a score of 4 after finishing Module 8.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    Patricia presented major depressive disorder with peripartum specifier and obsessive personality traits according to DSM-5.

    “At the time of her consultation, Patricia presented a Major Depressive Disorder (MDD) with peripartum specifier and obsessive personality traits according to the Diagnostic and Statistical Manual of Mental Disorders-text revision (5th ed.) (American Psychiatric Association [APA], 2013).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites American Psychiatric Association [APA], 2013

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Findingown data

    Patricia is a 38-year-old pregnant woman in the 34th week of her second pregnancy with a peripartum onset of major depressive disorder and anxiety symptoms.

    “Patricia (pseudonym) is a 38-year-old woman, married for 18 years, with a 6-year-old son.She was in the 34th week of her second pregnancy when she came to our clinic for treatment.”
    • Also stated in: § Abstract · plain
      “This case study aims to present the application of the Unified Protocol (UP) for the Transdiagnostic Treatment of Emotional Disorders in the case of a 38-year-old pregnant woman with a peripartum onset of major depressive disorder and anxiety symptoms.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    ASI-3 decreased from 36 at pretest to 15 at posttest, a statistically significant change (RCI = -5.00, p < .050).

    “The initial ASI-3 score of 36 revealed high sensitivity to anxiety, whereas, at posttest, the score was 15.This change between pretest and posttest in sensitivity to anxiety was statistically significant (RCI = -5.00,p < .050).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    PANAS-NA decreased from 29 at pretest to 12 at posttest, a statistically significant change (RCI = -5.31, p < .050).

    “Conversely, PANAS-NA decreased significantly from a score of 29 at pretest to 12 at posttest (RCI = -5.31,p < .050).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Both anxiety and depression scores at posttest were below the Spanish clinical cut-off of 10 points.

    “Both anxiety and depression scores at the posttest were below the cut-off point established for the Spanish clinical population, which was 10 points”
    Quote in the paperSubstantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    Patricia's ODSIS score increased slightly in Module 6, coinciding with a couple argument.

    “Again, in Module 6, we found a slight increase in depressive symptomatology coinciding with a couple argument.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Patricia's ODSIS score increased to 15 in Module 2, coinciding with a family problem.

    “An increase in scores was observed in Module 2, coinciding with a family problem, with a total score of 15.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    PANAS-PA increased from 15 at pretest to 32 at posttest, a clinically significant change (RCI = 5.48, p < .050).

    “PANAS-PA increased significantly from pretest (15 out of 50 points) to posttest (32 out of 50 points).This change was clinically significant (Reliable Change Index [RCI] = 5.48, p < .050).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In Patricia's case, depressive symptoms emerged in the 20th week of pregnancy and worsened as anxiety symptoms appeared.

    “In Patricia's case, depressive symptoms emerged in the 20th week of pregnancy and, far from receding during the following weeks of pregnancy, worsened as anxiety symptoms appeared.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    The posttest EPDS score was less than 11, the cut-off for clinical symptoms.

    “the posttest score of EPDS was less than 11, a cut-off point established to consider clinical symptoms (Garcia-Esteve et al., 2003).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Garcia-Esteve et al., 2003 source

  • Classified as probably not a substantial claim.

    Premisecitation

    There is a need to transfer transdiagnostic treatments to the approach of perinatal anxiety and depression.

    “recently considering the need to transfer these transdiagnostic treatments to the approach of perinatal anxiety and depression (Pilkington et al., 2015).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Pilkington et al., 2015 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Different transdiagnostic treatments have recently been designed to address Emotional Disorders.

    “As a solution to these limitations, different transdiagnostic treatments have recently been designed to address Emotional Disorders (ED; mood, anxiety, and related disorders; Bullis et al., 2019).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Bullis et al., 2019 source

  • May combine two claims.

    Premisecitation

    Perinatal depression is an under-diagnosed and under-treated problem.

    “Perinatal depression is an under-diagnosed and under-treated problem (Cox et al., 2016).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Cox et al., 2016 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Perinatal depression produces negative consequences for the mother, the fetus/baby, and society, including risk of suicide or infanticide, preeclampsia, increased maternal use of substances, birth complications, premature delivery, low birth weight, and difficulties in the child's socio-emotional, behavioral, and cognitive development.

    “Perinatal depression produces negative consequences for the mother and the fetus/baby and society, including the risk of suicide or infanticide, preeclampsia, increased maternal use of substances, birth complications, premature delivery, low birth weight, and difficulties in the child's socio-emotional, behavioral, and cognitive development (Lobel & Dunkel-Schetter, 2016).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Lobel & Dunkel-Schetter, 2016 source

  • May combine two claims.

    Premisecitation

    People with emotional disorders experience frequent and intense emotions that cause discomfort, leading to aversive reaction and emotional avoidance behaviors that bring short-term relief but maintain emotional distress long-term.

    “People with ED experience frequent and intense emotions that cause them discomfort, leading to an aversive reaction to emotions and the initiation of emotional avoidance behaviors that, in the short term, will bring relief but, in the long term, will maintain the emotional distress (Bullis et al., 2019).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Bullis et al., 2019 source

  • Classified as probably not a substantial claim.

    Premisecitation

    The UP is a flexible modular treatment which can be adapted as required.

    “The UP is a flexible modular treatment which can be adapted as required to help patients to learn new adaptive emotion-regulation strategies to tolerate intense emotions.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Barlow et al., 2018a

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Classified as probably not a substantial claim.

    Premisecitation

    The Unified Protocol (UP) is a cognitive-behavioral intervention based on the shared etiological and maintenance mechanisms of emotional disorders.

    “The UP is a cognitive-behavioral intervention based on the shared etiological and maintenance mechanisms of emotional disorders (i.e., mood, anxiety, and related disorders).”
    • Also stated in: § Abstract · plain
      “One of them is the Unified Protocol (hereinafter UP; Barlow et al., 2004), which postulates the existence of shared etiological and maintenance mechanisms among the different ED.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Barlow et al., 2004 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Perinatal depression is a highly under-diagnosed and under-treated disorder.

    “Perinatal depression is a highly under-diagnosed and under-treated disorder (Cox et al., 2016), hindering accurate estimates in terms of prevalence.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Cox et al., 2016 source

  • May combine two claims.

    Premisecitation

    The UP helps to modify maladaptive emotion-regulation strategies and enhance tolerance of unpleasant and intense emotions.

    “The UP helps to modify maladaptive emotion-regulation strategies and enhance tolerance of unpleasant and intense emotions (sadness, anxiety, anger, etc.).”
    • Also stated in: § Abstract · plain
      “The UP aims to address these shared etiological and maintenance mechanisms, that is, to train in new adaptive emotion regulation strategies to tolerate intense emotions and improve patients' quality of life (Barlow et al., 2018a).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Barlow et al., 2018a

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Interpretationown data

    The UP was effective in treating Patricia's anxious and depressive symptoms, including in a case of MDD with peripartum onset, obsessive traits, and unspecified anxiety symptoms, and regardless of format.

    “This indicates that the UP was effective in treating the anxious and depressive symptoms.”
    • Also stated in: § 11 Treatment Implications of the Case · plain
      “In this case study, the UP was effective in a case of MDD with peripartum onset, obsessive traits, and unspecified anxiety symptoms.”
    • Also stated in: § 11 Treatment Implications of the Case · plain
      “in our case, the UP has also proven to be effective in reducing anxious and depressive symptoms regardless of the format.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The improvements in Patricia's symptoms were caused by the UP rather than by other factors such as delivery, passage of time, or family support.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Half of the women with depression also present anxious symptoms.

    “Also, from a clinical point of view, it must be considered that half of the women with depression also present anxious symptoms (Dennis et al., 2017).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Dennis et al., 2017

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Study design and conductown data

    Adherence was maintained in the online format, with no cancelled sessions.

    “No cancellation sessions occurred, so adherence was maintained in the online format.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Email, videoconferencing, and telephone have emerged as important tools in providing online therapy.

    “Since email, videoconferencing, and telephone have emerged as important tools in providing online therapy (Roman et al., 2020)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Roman et al., 2020 source

  • Classified as probably not a substantial claim.

    Interpretationnone given

    The present study is limited as it is a case study with only one participant.

    “Although the present study is limited, as it is a case study with only one participant”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    ICTs could be helpful in programs to assess and treat depressive symptoms in the perinatal stage.

    “recent research has suggested that the use of Information and Communication Technologies (ICTs; Internet, wireless networks, phones, mobile applications), with their advantage of anonymity, could be of great help in programs to assess and treat depressive symptoms in the perinatal stage (Donker et al., 2015).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Donker et al., 2015 source

  • May combine two claims.

    Interpretationown data

    The UP has clinical utility and viability for the psychological treatment of perinatal depression.

    “Therefore, we can propose the clinical utility and viability of the UP for the psychological treatment of perinatal depression.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The improvements in Patricia's symptoms were caused by the UP rather than by other factors such as delivery, passage of time, or family support.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Premisecitation

    Working with partners or other family members is especially important in psychological work with perinatal women.

    “In psychological work with perinatal women, working with partners or other family members is especially important (Pilkington et al., 2015).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Pilkington et al., 2015 source

  • May combine two claims.

    Premisecitation

    Common barriers to accessing mental health care include stigma, travel difficulties, lack of time, physical limitations, and little knowledge about mental health issues.

    “Among the most common barriers to accessing mental health care resources are the stigma associated with mental illness, travel difficulties for patients, lack of time, physical limitations, and little knowledge about mental health issues and when to see a professional (Byatt et al., 2012;Maxfield & Segal, 2008).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Byatt et al., 2012 source
    • cites Maxfield & Segal, 2008 source

  • May combine two claims.

    Premisecitation

    The UP can be used when various intense emotions/symptoms or comorbid diagnoses are present, which is common in emotional disorders, including peripartum-onset MDD.

    “The results of this study are important because the UP can be used when various intense emotions/symptoms (anxiety, sadness, guilt, anger, shame, etc.) or comorbid diagnoses are present, which is common in EDs (Barlow et al., 2013;Dennis et al., 2017), including peripartum-onset MDD.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Barlow et al., 2013

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites Dennis et al., 2017

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Interpretationcitation

    The use of ICTs in perinatal mental health could be well accepted not only by health professionals but also by women in the perinatal stage.

    “These data show that, as has been found in previous research, the use of ICTs in the area of perinatal mental health could be well accepted not only by health professionals but also by women in the perinatal stage (Martínez-Borba et al., 2019).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Martínez-Borba et al., 2019 source

  • Classified as probably not a substantial claim.

    Premisecitation

    Therapists must be able to address personal and contextual factors when following manualized protocols.

    “As stated in previous research, therapists must be able to address personal and contextual factors when following manualized protocols (Donahue et al., 2019)”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Donahue et al., 2019 source

  • May combine two claims.

    Premisecitation

    Risk factors for perinatal depression include unwanted and/or unplanned pregnancy and economic hardship.

    “Literature has shown that risk factors for the development of perinatal depression include unwanted and/or unplanned pregnancy and economic hardship (Norhayati et al., 2015).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Norhayati et al., 2015 source

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationown data

    The UP has proven to be useful, flexible, and well accepted in the treatment of anxiety and depression symptoms.

    “This intervention has proven to be useful, flexible, and well accepted in the treatment of anxiety and depression symptoms.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The improvements in Patricia's symptoms were caused by the UP rather than by other factors such as delivery, passage of time, or family support.
37 of 37

  • The paper relies on this without support.

    The clinical utility and feasibility of the UP for the treatment of perinatal depression has not been studied so far.

    “The clinical utility and feasibility of the UP for the treatment of perinatal depression has not been studied so far, so the aims of the present study are: (a) to present a case of perinatal depression in which the UP was applied, (b) to describe the adaptations of the UP that were made to adjust the intervention to the particularities of perinatal depression, and (c) to present the main results”

  • The paper relies on this without support.

    The improvements in Patricia's symptoms were caused by the UP rather than by other factors such as delivery, passage of time, or family support.

    “This indicates that the UP was effective in treating the anxious and depressive symptoms.”
2 of 2

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • MINI interview is assigned to the wrong assessment time

    Minor

    The discussion places the MINI diagnostic interview at the 12-month follow-up, but the assessment schedule says it was administered after treatment and lists only three questionnaires at follow-up.

1 of 1

Cites

Flagged first, then by citations

Research works printed but not linked: 4

  1. Barlow D., 2018, Protocolo unificado para el tratamiento transdiagnóstico de los trastornos emocionales (2nd ed.): Manual del terapeuta (Jorge Osma & Elena Crespo, trad, 2019)
  2. Barlow D., 2018, Protocolo unificado para el tratamiento transdiagnóstico de los trastornos emocionales (2nd ed.): Manual del paciente (Jorge Osma & Elena Crespo, trad, 2019)
  3. Byatt N., 2018, Position statement on screening and treatment of mood and anxiety disorders during pregnancy and postpartum
  4. Sheehan D., 2015, Mini Neuropsychiatric International Interview 7.0 (MINI 7.0)

Cited by

Sorted by citations

Related

Authors
Crespo-Delgado, E., Martínez-Borba, V., & Osma, J.
Affiliations
  • Universitat Jaume I (ES)
  • Universitat Jaume I, Castellón, Spain
  • Universidad de Zaragoza (ES)
Corresponding author
Osma, Jorge
ORCID
Osma, Jorge
Venue
Clinical Case Studies
Publisher
SAGE Publications
Published
2020-08-29
Volume
19
Issue
6
Pages
491-508
ISSN
  • 1534-6501 (ISSN-L)
  • 1552-3802
DOI
10.1177/1534650120951266
OpenAlex
W3081988599
Semantic Scholar
8c4b9579e51f8da6ba846383d8f3cc815b51a56d
Cited by
14
References
49
Citations by year
2025: 4 · 2024: 1 · 2023: 6 · 2022: 2 · 2020: 1
FWCI
1.69
Type
journal article
Language
en
Open access
Licence
Locations
  • Clinical Case Studies (publishedVersion)
  • Repositori UJI (Universitat Jaume I) (submittedVersion, public-domain)
  • Zaguan (Universidad de Zaragoza) (submittedVersion)
Funders
  • Universitat Jaume I (PREDOC/2018/43)
  • European Regional Development Fund (Gobierno de Aragón and FEDER 2014-2020 “Constr)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Maternal Mental Health During Pregnancy and Postpartum
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
Keywords
Unified Protocol for Transdiagnostic Treatment of Emotional Disorders, perinatal depression, major depressive disorder, anxiety symptoms, pregnant women, cognitive-behavioral intervention, emotion regulation, anxiety sensitivity, negative affect, positive affect, transdiagnostic treatment, group therapy

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