- Design
- pilot randomised controlled trial, waitlist-controlled, powered for feasibility
- Population
- 51 adults in Pakistan meeting criteria for anxiety and/or depressive disorders
- Primary outcome
- feasibility and acceptability — recruitment, retention, adherence, satisfaction
- Effect
- recruitment 85.7%, retention 82.4%, homework completion 79%, CSQ-8 mean 29.65 (SD 2.60); preliminary anxiety g = 1.18, depression g = 1.15
Most evidence-based psychological treatment is developed and tested in settings that look nothing like a South Asian outpatient department. This pilot randomised trial tested an Urdu-adapted version of the Unified Protocol — a transdiagnostic cognitive behavioural approach that treats anxiety and depression through shared emotion-regulation mechanisms rather than as separate protocols — in 51 adults in Pakistan meeting criteria for anxiety and/or depressive disorders, randomised to 14 weeks of treatment or a waitlist.
The trial was designed to answer whether this can be delivered, not whether it works. On that question the answers were clear: 85.7% of those approached were recruited, 82.4% were retained, homework completion ran at 79%, and satisfaction on the CSQ-8 averaged 29.65 out of a possible 32. Preliminary clinical effects were large — Hedges' g of 1.18 for anxiety and 1.15 for depression against waitlist.
The transdiagnostic structure is what makes this relevant beyond Pakistan. A service that cannot staff separate protocols for panic, generalised anxiety and depression can train clinicians in one, and the cultural adaptation work here — not merely translation — is the part that produced 79% homework completion. For Indian services facing the same mismatch between protocol libraries and workforce, this is a model worth reading rather than a result to cite.
- Transdiagnostic protocols reduce the training burden where one clinician sees the whole mixed caseload.
- Adaptation means reworking examples, metaphors and homework, not translating a manual.
- Judge a pilot on recruitment, retention and adherence — that is what it was built to measure.
- A waitlist comparison cannot separate the treatment from attention and expectation.
Why it matters
It tests the deliverability of one protocol for a mixed anxiety-and-depression caseload, which is the shape of most South Asian outpatient practice.
Don't overread it
This is a pilot against a waitlist, powered for feasibility — the effect sizes are preliminary and should not be quoted as treatment effects.
The statistics, in plain English
Hedges' g of about 1.15 is a very large effect, and large effects against a waitlist in a small pilot are routine rather than impressive: a waitlist controls for the passage of time and nothing else — not attention, not expectation, not the therapeutic relationship. With 25 and 26 patients per arm, the confidence intervals around those estimates will be wide. The feasibility numbers, which the trial was actually designed to measure, are the trustworthy part.
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