The intervention at the heart of the study is the Urdu Adapted Unified Protocol, or UA-UP. The Unified Protocol is a transdiagnostic treatment originally developed to target the shared emotional and cognitive mechanisms underlying anxiety and mood disorders, rather than treating each diagnosis separately. This design matters in Pakistan, where anxiety and depression frequently co-occur and where disorder-specific therapy manuals demand extensive clinician training that the country’s overstretched mental-health system cannot provide. Meta-analyses have shown that the Unified Protocol matches disorder-specific protocols in efficacy while reducing training burden, making it an attractive candidate for scalable implementation in resource-constrained settings.

Before any participants were recruited, the research team undertook a systematic cultural and linguistic adaptation of the protocol for Urdu speakers. The UA-UP retained all eight core modules, covering motivation enhancement, psychoeducation, mindful emotion awareness, cognitive flexibility, countering emotional behaviors, interoceptive exposure, situational exposure, and relapse prevention. Adaptations included simplifying psychological terminology in Urdu, replacing culturally distant examples with locally meaningful scenarios, adding visual aids to support understanding of key concepts, and broadening emotional-awareness activities to include culturally acceptable audio and video materials. The treatment’s focus on emotion regulation also resonates with Pakistani social values that encourage emotional composure and harmony within family and community life.

The trial enrolled 51 adults who met DSM-5 diagnostic criteria for anxiety and/or depressive disorders, confirmed through the Structured Clinical Interview for DSM-5, with moderate-to-severe symptoms on the Beck Depression Inventory-II and Beck Anxiety Inventory. Participants were randomly allocated in a 1:1 ratio to either the 14-week UA-UP intervention or a waitlist control. Those in the treatment arm attended weekly 50-to-60-minute individual face-to-face sessions at a university counselling center in Islamabad, with each session structured around homework review, new skill practice, and planning for the coming week. Treatment was delivered by a clinical psychologist who completed an 18-week Unified Protocol training course and received weekly supervision, with treatment adherence reviewed by a certified trainer before the trial began.

The feasibility results were striking. Recruitment reached 85.7 percent of eligible individuals approached, retention was 82.4 percent, and 23 of the 25 participants in the treatment arm completed the full 14-week program. Randomization proceeded without error, and completion rates for outcome measures remained high at every assessment point. Digital recruitment through platforms such as WhatsApp, Facebook, Instagram, X, and LinkedIn proved the most productive channel, generating just over half of enrolled participants, while community outreach in career academies, vocational centers, libraries, and markets contributed meaningfully, as did referrals from local therapists. Two participants withdrew from treatment because of transportation difficulties, a reminder that practical access barriers persist even when a treatment is clinically acceptable.

Acceptability indicators were equally encouraging. Participants completed an average of roughly 82 percent of assigned homework tasks, and ratings on the Homework Rating Scale showed high comprehension, perceived relevance, and collaboration. The Urdu version of the Client Satisfaction Questionnaire yielded a mean score of 29.65 out of a possible 32, reflecting strong overall approval. In semi-structured interviews, participants described increased emotional awareness, practical coping skills, cognitive restructuring, reduced avoidance, and growing emotional acceptance. One participant reported that writing about emotions revealed patterns she had not previously recognized; another described finally being able to pause, breathe, and avoid spiraling into panic; a third explained how gradually building exposure to social situations allowed her to attend gatherings she had avoided for years.

The qualitative themes that emerged from these interviews traced a coherent therapeutic arc. Participants first described initial discomfort with demanding tasks such as exposure exercises, followed by perseverance supported by an empathic, nonjudgmental therapist who adjusted the pace to their readiness. Over time they noticed visible changes in daily life, from calmer responses to family tensions to improved communication with spouses and in-laws. Many reported a fundamentally improved self-image, greater confidence, and more deliberate problem-solving. Notably, several described continuing to feel nervous in challenging situations while functioning markedly better, a pattern the authors interpret as consistent with the Unified Protocol’s emphasis on emotional flexibility and behavioral capacity rather than symptom elimination alone.

The exploratory quantitative outcomes pointed in the same direction. Using repeated-measures general linear models, the researchers found that participants in the UA-UP group showed greater improvements in anxiety, depression, and functional impairment compared to the waitlist control, with large exploratory effect size estimates: Hedges’ g of 1.18 for anxiety and 1.15 for depression. Improvements were also observed in emotion regulation and positive affect, alongside reductions in negative affect. The investigators stress that these estimates, reported with 95 percent confidence intervals, are preliminary and intended for estimation rather than hypothesis testing, given the modest sample size and the absence of a long-term follow-up period.

The authors are candid about the study’s limitations. The trial took place at a single urban university-based site with participants who were predominantly unemployed and more educated than the general Pakistani population, potentially limiting generalizability to rural regions, primary-care settings, or individuals with limited digital access. All sessions were delivered by a single therapist who was also the primary researcher, a design that preserved treatment consistency but restricts conclusions about scalability across providers and leaves open the possibility of therapist allegiance effects. The waitlist control design, while appropriate for an early-phase feasibility study, cannot rule out expectancy effects, regression to the mean, or spontaneous recovery, and the lack of follow-up data leaves the durability of gains unknown.

Even so, the trial clears the critical hurdle it set for itself. Following the Medical Research Council framework for complex interventions, the study team had already completed the development phase with its systematic adaptation of the Unified Protocol, and this pilot now establishes that the feasibility and implementation phases can proceed. High recruitment and retention, strong engagement, high satisfaction, and encouraging preliminary clinical signals collectively demonstrate that the core procedures of a fully powered randomized controlled trial are viable in Pakistan. The researchers found satisfaction with the treatment to be driven more by its perceived personal and cultural relevance than by infrastructure quality, and satisfaction ratings exceeded those reported in a recent internet-delivered Unified Protocol study in Iran, suggesting that face-to-face, culturally grounded delivery may hold particular advantages. If larger trials confirm these effects, the UA-UP could offer a practical template for scaling transdiagnostic mental-health care across Pakistan and other low-resource settings, targeting the shared emotional mechanisms that drive some of the world’s most burdensome psychiatric conditions.

Subject of Research: Feasibility and acceptability of a culturally adapted transdiagnostic cognitive-behavioral therapy for anxiety and depression in Pakistan

Article Title: Feasibility and acceptability of the Unified Protocol for anxiety and depression in Pakistan: a pilot randomized controlled trial

Article References: Nisa, A., Siddiqui, S., & Ametaj, A. A. (2026). Feasibility and acceptability of the Unified Protocol for anxiety and depression in Pakistan: a pilot randomized controlled trial. BMC Psychiatry, 26(1), Article 739. https://doi.org/10.1186/s12888-026-08345-x

Image Credits: AI Generated

DOI: 10.1186/s12888-026-08345-x

Keywords: Unified Protocol, transdiagnostic CBT, anxiety, depression, Pakistan, global mental health, culturally adapted therapy, emotion regulation, pilot randomized controlled trial, low-resource settings, BMC Psychiatry, mental health treatment gap