Accelerated Unified Protocol for Transdiagnostic Treatment of Anxiety Disorders in a VHA System

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Accelerated Unified Protocol for Transdiagnostic Treatment of Anxiety Disorders in a VHA System

Author(s)
Allison C. Aosved, PhD, ABPP
Marissa Sia, PsyD, MA
Jodi C. Bell, PsyD
Theresa B. Brown, PsyD
Hsin-Tine "Tina" Liu-Tom, PhD, CSAC

Cognitive behavioral therapy (CBT) is supported as an effective treatment for depression by clinical practice guidelines from the US Department of Veterans Affairs (VA) and US Department of Defense.1-3 Despite research supporting the use of evidence-based CBT for anxiety, mood, and emotional disorders, patient access to these interventions is limited.4 One barrier to CBT for anxiety, mood, and emotional disorders is the traditional use of single-disorder protocols (SDPs) to separately treat each disorder (eg, major depression, generalized anxiety disorder, panic disorder).

Use of SDPs places a high burden on clinicians, requiring them to learn and competently implement multiple different manualized interventions for each anxiety, mood, or emotional disorder encountered in practice.4 It is common for individuals who present with an anxiety, mood, or emotional disorder to experience co-occurring disorders.5 Traditional SDP-based CBT may require multiple SDPs to address co-occurring disorders, extending time in treatment and increasing training burden. There is evidence that even when an SDP is used, co-occurring difficulties may decrease in intensity.6 Thus, evidence-based CBT for 1 presenting concern may positively affect co-occurring difficulties that are not the primary treatment target.6

Unified Protocol (UP) is a transdiagnostic CBT intervention for anxiety and mood disorders. UP targets emotional experiences (eg, negative affect and emotional distress) that are present in multiple anxiety, depression, and emotional disorders. UP is organized into 8 modules and uses interventions present in other CBT SDPs, such as teaching objective assessment methods to clients, motivational enhancement and goal setting, emotion psychoeducation, mindful awareness, cognitive reframing, and exposure principles as mechanisms of change (Table 1).4 UP is an ideal intervention for addressing a number of anxiety, mood, and emotional disorders as well as addressing cooccurring disorders within the same course of treatment.

0426FED-MH-Anxiety-T1

UP has been compared to SDPs; studies illustrate that UP is equivalent to SDPs at the end of treatment and at 6 months posttreatment.4,7 Additionally, patients who received UP experienced symptom reduction for multiple co-occurring disorders.7 Furthermore, patients were less likely to drop out of UP when compared with SDPs.4

Studies have reported positive impacts on affective disorders with UP. A 2019 metaanalysis found significant reductions in depression and anxiety-related disorders.8 Additionally, UP has been shown to be effective when delivered in person and via telehealth.9,10 UP has also been successfully used in veterans.11 While traditional models of UP (1-2 sessions weekly) have a lower dropout rate than SDPs, UP and CBT dropout rates still leave room for improvement.12-14 Specifically, rates of attrition from SDP CBT and transdiagnostic CBT protocols range from 9% to 35%, and dropout reduces the likelihood of attaining a full therapeutic dose of any course of CBT. Notably, accelerated delivery of CBT (ie, ≥3 sessions/wk) has been shown to reduce risk of dropout.14,15

Veterans are at increased risk for suicide, and anxiety and mood disorders are associated with increased risk of suicide attempt and death.16,17 Very few veterans who could benefit from high-quality CBT interventions, whether SDP or UP, are able to access them. Only 6.3% of veterans received ≥1 session of an evidence-based CBT SDP for posttraumatic stress disorder (PTSD) at 6 clinics evaluated in 2010.18

We identified 2 strategies to increase access to and completion of an evidence-based CBT course. First, the use of transdiagnostic UP instead of SDPs reduced burden on therapists and allowed them to address presenting and co-occurring disorders within the same course of care. Second, the use of an accelerated model of service delivery reduced dropout risk. Training clinicians to deliver UP is efficient and cost-effective, considering clinicians use core strategies that can be tailored and flexibly applied to a range of emotional difficulties. Thus, implementing UP may decrease barriers to receiving an optimal dose of an evidence-based CBT delivered with fidelity in a time- and cost-efficient manner.4 Two studies have found no evidence of differences in outcomes between UP and SDPs, suggesting that training and supervising clinicians in a single transdiagnostic UP intervention may prepare them to treat heterogeneous and co-occurring anxiety, mood, and emotional disorders with less burden than learning multiple SDPs.7,19

Delivering UP in an accelerated or massed format (≥4 sessions/wk) instead of the traditional spaced model (1 session/wk) has empirical support but has not been widely implemented. This approach, sometimes referred to as a UP-intensive outpatient program (UP-IOP) or UP-intensive outpatient track (UP-IOT), has been shown to be feasible, acceptable, and effective, with increased completion rates compared with traditional UP delivery (1-2 sessions/wk).20-22

Ragsdale et al describe a 2-week IOP with multiple treatment tracks, including a general track.20 The general track includes massed UP and additional standard services, including case management, wellness services, family services, and a single session effective behaviors group. Additional augmentation services are available when clinically indicated (eg, repetitive transcranial magnetic stimulation, transcranial direct current stimulation, psychoeducation, motivational interviewing, relapse prevention). In other words, this was an UP-IOP.20

Thompson-Brenner et al described a successful implementation of massed UP applied in intensive treatment settings, such as residential and day-hospital programs, for eating disorders. Patients reported improvements in 3 UP targets: experiential avoidance, mindfulness, and anxiety.21 Watkins et al evaluated a 2-week IOP using CBT for comorbid substance use and mental health disorders, including prolonged exposure, UP, and relapse prevention for substance use disorders. Participants were post-9/11 veterans and activeduty personnel. Results indicated that UP reduced PTSD and depressive symptoms following treatment. Furthermore, the retention rate (91%) was higher than retention in outpatient treatment (39%-65%), supporting the IOP model as a strategy to reduce dropout.22

Massed psychotherapy has been extended to IOP programs for PTSD treatment within the Veterans Health Administration (VHA). Yamokoski et al found that patients who completed an IOP that included massed CBT for PTSD had high retention, high satisfaction, and significant reduction in self-reported co-occurring depression symptoms. The authors also found that this model of care could be implemented and sustained within a VHA facility using minimal staffing resources.23

The UP-IOP models described by Ragsdale et al and Watkins et al included massed UP as the primary evidence-based practice (EBP) with adjunctive groups (eg, wellness and educational groups and access to complementary interventions such as mindfulness and yoga); they found that adding these groups increased retention and patient- reported satisfaction (ie, UP-IOP).20,22 The addition of wellness education alongside a primary EBP aligns with the VHA focus on whole health well-being and wellness. This includes understanding factors that motivate a patient toward health and well-being, providing health education, and offering access to complementary interventions such as mindfulness.24

Dryden et al described the whole health transformation within VHA as a proactive approach to addressing both employee and patient wellness. Their research found that the whole health model promoted wellbeing in patients and staff and these improvements were sustained during the COVID-19 pandemic. Dryden et al also noted that virtual technologies facilitated continued whole health implementation.25

The literature illustrates that (1) massed UP can be delivered with complementary education and wellness offerings that may increase retention and satisfaction by enriching treatment (eg, delivering UP-IOP); (2) whole health, including wellness education and complementary interventions (eg, mindfulness, motivational enhancement), promotes well-being in patients and clinicians; and (3) whole health education and complementary interventions can be delivered virtually.

IVET

Health Care Need

Veterans Affairs Pacific Islands Health Care System (VAPIHCS) provides medical services to veterans in the Hawaiian Islands, American Samoa, Guam, and Saipan spanning nearly 4000 miles across the Pacific Ocean. Prior to implementation of this program, veterans who received care at VAPIHCS had little to no access to UP in outpatient settings and no access to UP in residential settings. Access to UP depended on the presence of a therapist trained in UP within a given clinic and was geographically limited to the location of the UPtrained therapist. The limited outpatient access to UP was restricted to the traditional UP delivery model (eg, about 1 session/wk); thus, there was no access to accelerated UP for veterans served at VAPIHCS. In the fiscal year prior to implementation of the massed UP program, > 1000 VAPIHCS veterans had been diagnosed with obsessive-compulsive related disorder or anxiety. A massed-UP program with weekly rolling admissions would support access to UP for more veterans over 12 months, and the virtual treatment modality would reduce barriers for diverse and underserved veterans, making care more equitable and inclusive.

Successful implementation and sustainment of an EBP prompted the establishment of this UP program. In 2022, VAPIHCS launched the Intensive Virtual Evidence- Based Psychotherapy Team (iVET) for treatment of PTSD. This clinic and associated EBP project demonstrated that massed (≥3 individual sessions/wk) of prolonged exposure (PE) therapy, delivered virtually to a geographically diverse veteran population with PTSD, resulted in significant reductions in PTSD, depression, and anxiety symptoms and substance use risk factors, with very high retention rates. The iVET for PTSD program was feasible, acceptable, and effective, with veterans reporting significant improvement in quality of life and high satisfaction with their mental health services.15 Given the known benefits of transdiagnostic UP treatment (vs SDPs), the need for accelerated UP, and success with accelerated PE, our goal was to spread the EBP of massed (≥3 sessions/ wk) virtual psychotherapy to other presenting problems (eg, anxiety disorders with or without co-occurring unipolar depression) using transdiagnostic UP.

Program Description

The program implemented within outpatient mental health services at VAPIHCS was iVET for the treatment of anxiety with or without co-occurring depression. The program model consists of an accelerated course of UP and whole health education provided via VA Video Connect (VVC), the VA video telehealth platform. iVET is a 2- to 4-week program and consists of 3 parts: (1) massed individual UP for transdiagnostic treatment of anxiety and co-occurring depression, (2) group whole health and wellness classes, and (3) individual health coaching to address personal wellness goals. Programming is offered over 10-hour days to increase access across multiple time zones, especially to allow participation from Guam and Saipan.

When a patient is referred to iVET, the first contact is a video (or telephone) appointment with a registered nurse (RN) for a screening session. The screening session is designed to provide education about the program (including interventions, time commitment, and resources required for participation). Following education, the RN completes a safety screening, including screening for suicidal ideation and risk, as well as intimate partner violence risk. If urgent safety concerns are present, a licensed social worker or psychologist joins the screening to complete further risk assessment and address any safety concerns.

Following screening, patients are scheduled for a VVC telehealth intake with a licensed therapist (social worker or psychologist) to complete a diagnostic interview. Patients are sent a secure link to complete a measurement-based care (MBC) battery of self-report measures, including assessments of demographics, anxiety symptoms, depression symptoms, substance use, psychological flexibility, quality of life, and satisfaction with mental health care. The results of the diagnostic interview and self-report measures are discussed with the patient during the intake session to plan next steps and support shared decision-making. This initial VVC intake not only allows for fit assessment but also serves to troubleshoot technical difficulties with the virtual platforms.

Notably, there are minimal exclusion criteria for participation in iVET. These include active unmanaged psychosis or manic symptoms, recent suicidal crises (attempt within 8 weeks), active nonsuicidal self-injury (within 8 weeks), and moderate to severe cognitive impairment. Following intake, patients are scheduled to begin their course of care with iVET. Upon completion of intake, patients receive program materials for individual and group classes and are told they will receive email links for all VVC telehealth appointments. Patients are admitted to the iVET on a rolling basis, thereby increasing access compared with closed group and/or cohort models of care.

Patients receiving iVET attend 2 to 4 telehealth appointments daily and complete exercises between sessions. The primary iVET for Anxiety program EBP intervention is a massed or accelerated individual course of UP, which includes 8 primary components: assessment, goals and motivation, understanding emotions, mindful emotion awareness, cognitive flexibility, countering emotional behaviors, understanding and confronting physical sensations, and emotional exposures. UP is delivered in 4 to 8 individual sessions weekly (60-90 minutes each), allowing completion of the full UP protocol with fidelity in 2 to 4 weeks. In addition to primary EBP intervention, patients participate in 4 group sessions weekly (50 minutes each) of a whole health and wellness education class and have access to 1 individual health coaching session weekly (30- 60 minutes) to set wellness goals and receive coaching. During iVET, patients are invited to complete MBC batteries of self-report measures assessing anxiety symptoms, depression symptoms, substance use, psychological flexibility, quality of life, and satisfaction with mental health care at sessions 1, 5, 9, 13, and the final UP session. Following discharge from the iVET, patients are offered 1-, 3-, and 6-month individual postdischarge check-up sessions with a therapist, during which they are invited to complete MBC measures and review relapse prevention and maintenance of treatment gains. Likewise, patients are offered 1-, 3-, and 6-month individual postdischarge check-up sessions with an RN focused on maintaining wellness gains.

The iVET for Anxiety staff has 3 therapists (psychologists or social workers) and 1 RN. Additionally, the iVET for Anxiety is supported by a program manager and a program support assistant who support 2 programs total (the iVET for Anxiety plus another mental health program). The primary cost of the program is staff salary. Additional resources included computer equipment for staff and supplies (eg, printed materials for patients and office supplies). Due to the virtual environment of care, iVET staff telework and do not require physical space within VAPIHCS.

Outcomes

Veterans receiving iVET for Anxiety are invited to complete MBC multiple times, including pretreatment, during UP treatment (sessions 1, 5, 9, 13, and the final session), and posttreatment (1, 3, and 6 months). MBC measures include self-reported demographics; a 2-item measure of satisfaction with mental health services; the Acceptance and Action Questionnaire II,26 the Brief Addiction Monitor-Intensive Outpatient Program, 27 the Generalized Anxiety Disorder-7,28 the Patient Health Questionnaire (PHQ-9),29 and the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form.30

Forty-two veterans completed the iVET for Anxiety program, with a retention rate of 87.5% completing . 16 sessions of massed UP (Table 2). Veterans reported reduced anxiety (P < .001), depression (P < .001), and substance use risk (P < .001). Veterans experienced improved acceptance of emotional experiences (P < .001) and quality of life (P < .001), based on paired sample t tests comparing session 1 vs final session scores on the self-reported measures. Veterans also reported high satisfaction with mental health care in iVET for Anxiety.

0426FED-MH-Anxiety-T2

Veterans experienced reduced thoughts of death or suicidal ideation (SI) based on responses to item 9 of PHQ-9. When SI was categorically analyzed (presence vs absence) using PHQ-9 item 9, there was an association observed between absence of SI and completion of a course of massed UP that does not appear to be due to chance, (X2 [1, N = 42) = 3.94; P = .047). In addition, veterans who completed the program showed a significant decrease in SI severity measured continuously (range, 0-3) on PHQ-9 item 9 (P < .05) (Table 3).

0426FED-MH-Anxiety-T3

Future Directions

The aim of this program is to see sustained patient outcomes as iVET continues to serve more veterans. Another line of inquiry is longer- term follow-up, given that long-term follow- up was not addressed in this project. We also hope that the accelerated model of care can be applied to treatment of other presenting concerns (eg, relationship difficulties, insomnia). Expansion of accelerated mental health treatment into other federal and nonfederal health care settings is another area worthy of future inquiry. Exploration of staff satisfaction and burnout related to providing accelerated UP is another important future direction. Relatedly, assessment of the staff burden to learn 1 transdiagnostic EBP vs learning multiple SDPs is another future direction. Likewise, exploration of institutional benefits of investment in transdiagnostic training, supervision, and consultation for UP vs multiple SDPs may be important. These areas could also result in insightful, beneficial evidence of the effectiveness of massed UP to add to the existing literature.

Conclusions

UP for transdiagnostic treatment of anxiety, depressive, and emotional disorders has demonstrated reduced suffering and improved functioning and is supported by multiple clinical practice guidelines.1-4 Federal practitioners are positioned to improve access to this intervention, thereby reducing pain and improving lives. Indeed, it is crucial to envision a future state in which access to UP for a range of anxiety and depressive disorders is improved and broad, retention rates are dramatically improved, and clinicians providing UP do not experience the high burden and burnout associated with needing to learn and implement a variety of SDPs. Development of these programs, or similar tracks within existing programs, that provide massed or accelerated UP for transdiagnostic treatment of a range of anxiety and depressive disorders with virtual delivery options, is imperative to advance improved care for patients and clinicians.

Federal health care settings treating patients with anxiety and depression, such as those within the US Department of Defense, Indian Health Services, Bureau of Prisons, and VHA, are positioned to implement programs like iVET. Moreover, at the institutional level, investment in training and supervision in the transdiagnostic UP as opposed to multiple SDPs warrants consideration. We believe this model of care has great merit and foresee a future where all patients seeking treatment for anxiety and depression have the option to complete an accelerated or massed course of transdiagnostic care with UP if they so desire. Our experiences with iVET illustrate the feasibility, acceptability, and sustainability of such programs without requiring substantial staffing and financial resources.

References
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  12. Oliveira JT, Sousa I, Ribeiro AP, et al. Premature termination of the unified protocol for the transdiagnostic treatment of emotional disorders: The role of ambivalence towards change. Clin Psychol Psychother. 2022;29:1089-1100. doi:10.1002/cpp.2694
  13. Schaeuffele C, Homeyer S, Perea L, et al. The unified protocol as an internet-based intervention for emotional disorders: Randomized controlled trial. PLoS One. 2022;17:e0270178. doi:10.1371/journal.pone.0270178
  14. Bentley KH, Cohen ZD, Kim T, et al. The nature, timing, and symptom trajectories of dropout from transdiagnostic and single-diagnosis cognitive-behavioral therapy for anxiety disorders. Behav Ther. 2021;52:1364-1376. doi:10.1016/j.beth.2021.03.007
  15. Aosved AC, Brown TB, Bell JC, et al. Accelerated prolonged exposure therapy for posttraumatic stress disorder in a Veterans Health Administration system. Fed Pract. 2025;42:S6-S11. doi:10.12788/fp.0568
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  18. Nichter B, Stein MB, Monteith LL, et al. Risk factors for suicide attempts among U.S. military veterans: A 7-year population-based, longitudinal cohort study. Suicide Life Threat Behav. 2022;52:303-316. doi:10.1111/sltb.12822
  19. McHugh RK, Barlow DH. The dissemination and implementation of evidence-based psychological treatments. A review of current efforts. Am Psychol. 2010;65:73-84. doi:10.1037/a0018121
  20. Ragsdale KA, Nichols AA, Mehta M, et al. Comorbid treatment of traumatic brain injury and mental health disorders. NeuroRehabilitation. 2024;55:375-384. doi:10.3233/NRE-230235
  21. Thompson-Brenner H, Brooks GE, Boswell JF, et al. Evidence-based implementation practices applied to the intensive treatment of eating disorders: summary of research and illustration of principles using a case example. Clin Psychol Sci Pract. 2018;25:e12221. doi:10.1111/cpsp.12221
  22. Watkins LE, Patton SC, Drexler K, et al. Clinical effectiveness of an intensive outpatient program for integrated treatment of comorbid substance abuse and mental health disorders. Cog Behav Pract. 2023;30:354-366.
  23. Yamokoski C, Flores H, Facemire V, et al. Feasibility of an intensive outpatient treatment program for post-traumatic stress disorder within the veterans health care administration. Psychol Serv. 2023;20:506-515. doi:10.1037/ser0000628
  24. Gaudet T, Kligler B. Whole health in the whole system of the Veterans Administration: how will we know we have reached this future state?. J Altern Complement Med. 2019;25:S7-S11. doi:10.1089/acm.2018.29061.gau
  25. Dryden EM, Bolton RE, Bokhour BG, et al. Leaning into whole health: sustaining system transformation while supporting patients and employees during COVID-19. Glob Adv Health Med. 2021;10:21649561211021047. doi:10.1177/21649561211021047
  26. Bond FW, Hayes SC, Baer RA, et al. Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: a revised measure of psychological inflexibility and experiential avoidance. Behav Ther. 2011;42:676-688. doi:10.1016/j.beth.2011.03.007
  27. Cacciola JS, Alterman AI, Dephilippis D, et al. Development and initial evaluation of the Brief Addiction Monitor (BAM). J Subst Abuse Treat. 2013;44:256-263. doi:10.1016/j.jsat.2012.07.013
  28. Spitzer RL, Kroenke K, Williams JB, et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166:1092-1097. doi:10.1001/archinte.166.10.1092
  29. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606-613. doi:10.1046/j.1525-1497.2001.016009606.x
  30. Stevanovic D. Quality of life enjoyment and satisfaction questionnaire-short form for quality of life assessments in clinical practice: a psychometric study. J Psychiatr Ment Health Nurs. 2011;18:744-750. doi:10.1111/j.1365-2850.2011.01735.x
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0426FED MH ANXIETY.pdf
Author and Disclosure Information

Allison C. Aosved, PhD, ABPPa,b; Marissa Sia, PsyD, MAa; Jodi C. Bell, PsyDa; Theresa B. Brown, PsyDa; Hsin-Tine "Tina" Liu-Tom, PhD, CSACa

Author affiliations
aVeterans Affairs Pacific Islands Health Care System, Honolulu, Hawaii
bThrive Psychology LLC, Honolulu, Hawaii

Author disclosures
The authors report no actual or potential conflicts of interest regarding this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.

Ethics and consent
Veteran participation in iVET was voluntary and optional. Participants engaged in routine informed consent practices utilized for all veterans receiving mental health care at VAPIHCS. The development of iVET was an Evidence Based Practice (EBP) Council approved project at VAPIHCS and, as such, it is not considered research and is exempt from Institutional Review Board review. The project was approved by the council on December 26, 2023, and Chief of Staff on December 29, 2023. The project final report was submitted to the EBP Council on February 28, 2025, and the project remains in the sustainment phase.

Acknowledgments
The authors thank iVET colleagues Chelsea Briggs, Maria Cabrera, Janver Fudolig, Bernadette Furtado, Christine Kindler, Mukul Khandelwal, Gaudencia Palomo-Burns, Kanani Racimo. Collaborators outside of iVET, including David Bernstein, Judy Carlson, Shiloh Jordan, Scott Masters, Dennis Perez, Sheila Rauch, Andrew Sherrill, and Cynthia Yamokoski provided valuable contributions including, but not limited to, administrative support, service delivery, mentorship, consultation, and sponsorship that was instrumental for the development of the iVET.

Correspondence: Allison Aosved (dr.a@thrivepsychologyllc.com)

Fed Pract. 2026;43(suppl 1). Published online April 15. doi:10.12788/fp.0687

Issue
Federal Practitioner 43(suppl 1)
Publications
Federal Practitioner
Topics
Mental Health
Anxiety Disorders
Page Number
S1-S7
Sections
Program Profile
Author(s)
Allison C. Aosved, PhD, ABPP
Marissa Sia, PsyD, MA
Jodi C. Bell, PsyD
Theresa B. Brown, PsyD
Hsin-Tine "Tina" Liu-Tom, PhD, CSAC
Author(s)
Allison C. Aosved, PhD, ABPP
Marissa Sia, PsyD, MA
Jodi C. Bell, PsyD
Theresa B. Brown, PsyD
Hsin-Tine "Tina" Liu-Tom, PhD, CSAC
Author and Disclosure Information

Allison C. Aosved, PhD, ABPPa,b; Marissa Sia, PsyD, MAa; Jodi C. Bell, PsyDa; Theresa B. Brown, PsyDa; Hsin-Tine "Tina" Liu-Tom, PhD, CSACa

Author affiliations
aVeterans Affairs Pacific Islands Health Care System, Honolulu, Hawaii
bThrive Psychology LLC, Honolulu, Hawaii

Author disclosures
The authors report no actual or potential conflicts of interest regarding this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.

Ethics and consent
Veteran participation in iVET was voluntary and optional. Participants engaged in routine informed consent practices utilized for all veterans receiving mental health care at VAPIHCS. The development of iVET was an Evidence Based Practice (EBP) Council approved project at VAPIHCS and, as such, it is not considered research and is exempt from Institutional Review Board review. The project was approved by the council on December 26, 2023, and Chief of Staff on December 29, 2023. The project final report was submitted to the EBP Council on February 28, 2025, and the project remains in the sustainment phase.

Acknowledgments
The authors thank iVET colleagues Chelsea Briggs, Maria Cabrera, Janver Fudolig, Bernadette Furtado, Christine Kindler, Mukul Khandelwal, Gaudencia Palomo-Burns, Kanani Racimo. Collaborators outside of iVET, including David Bernstein, Judy Carlson, Shiloh Jordan, Scott Masters, Dennis Perez, Sheila Rauch, Andrew Sherrill, and Cynthia Yamokoski provided valuable contributions including, but not limited to, administrative support, service delivery, mentorship, consultation, and sponsorship that was instrumental for the development of the iVET.

Correspondence: Allison Aosved (dr.a@thrivepsychologyllc.com)

Fed Pract. 2026;43(suppl 1). Published online April 15. doi:10.12788/fp.0687

Author and Disclosure Information

Allison C. Aosved, PhD, ABPPa,b; Marissa Sia, PsyD, MAa; Jodi C. Bell, PsyDa; Theresa B. Brown, PsyDa; Hsin-Tine "Tina" Liu-Tom, PhD, CSACa

Author affiliations
aVeterans Affairs Pacific Islands Health Care System, Honolulu, Hawaii
bThrive Psychology LLC, Honolulu, Hawaii

Author disclosures
The authors report no actual or potential conflicts of interest regarding this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.

Ethics and consent
Veteran participation in iVET was voluntary and optional. Participants engaged in routine informed consent practices utilized for all veterans receiving mental health care at VAPIHCS. The development of iVET was an Evidence Based Practice (EBP) Council approved project at VAPIHCS and, as such, it is not considered research and is exempt from Institutional Review Board review. The project was approved by the council on December 26, 2023, and Chief of Staff on December 29, 2023. The project final report was submitted to the EBP Council on February 28, 2025, and the project remains in the sustainment phase.

Acknowledgments
The authors thank iVET colleagues Chelsea Briggs, Maria Cabrera, Janver Fudolig, Bernadette Furtado, Christine Kindler, Mukul Khandelwal, Gaudencia Palomo-Burns, Kanani Racimo. Collaborators outside of iVET, including David Bernstein, Judy Carlson, Shiloh Jordan, Scott Masters, Dennis Perez, Sheila Rauch, Andrew Sherrill, and Cynthia Yamokoski provided valuable contributions including, but not limited to, administrative support, service delivery, mentorship, consultation, and sponsorship that was instrumental for the development of the iVET.

Correspondence: Allison Aosved (dr.a@thrivepsychologyllc.com)

Fed Pract. 2026;43(suppl 1). Published online April 15. doi:10.12788/fp.0687

Article PDF
0426FED MH ANXIETY.pdf
Article PDF
0426FED MH ANXIETY.pdf

Cognitive behavioral therapy (CBT) is supported as an effective treatment for depression by clinical practice guidelines from the US Department of Veterans Affairs (VA) and US Department of Defense.1-3 Despite research supporting the use of evidence-based CBT for anxiety, mood, and emotional disorders, patient access to these interventions is limited.4 One barrier to CBT for anxiety, mood, and emotional disorders is the traditional use of single-disorder protocols (SDPs) to separately treat each disorder (eg, major depression, generalized anxiety disorder, panic disorder).

Use of SDPs places a high burden on clinicians, requiring them to learn and competently implement multiple different manualized interventions for each anxiety, mood, or emotional disorder encountered in practice.4 It is common for individuals who present with an anxiety, mood, or emotional disorder to experience co-occurring disorders.5 Traditional SDP-based CBT may require multiple SDPs to address co-occurring disorders, extending time in treatment and increasing training burden. There is evidence that even when an SDP is used, co-occurring difficulties may decrease in intensity.6 Thus, evidence-based CBT for 1 presenting concern may positively affect co-occurring difficulties that are not the primary treatment target.6

Unified Protocol (UP) is a transdiagnostic CBT intervention for anxiety and mood disorders. UP targets emotional experiences (eg, negative affect and emotional distress) that are present in multiple anxiety, depression, and emotional disorders. UP is organized into 8 modules and uses interventions present in other CBT SDPs, such as teaching objective assessment methods to clients, motivational enhancement and goal setting, emotion psychoeducation, mindful awareness, cognitive reframing, and exposure principles as mechanisms of change (Table 1).4 UP is an ideal intervention for addressing a number of anxiety, mood, and emotional disorders as well as addressing cooccurring disorders within the same course of treatment.

0426FED-MH-Anxiety-T1

UP has been compared to SDPs; studies illustrate that UP is equivalent to SDPs at the end of treatment and at 6 months posttreatment.4,7 Additionally, patients who received UP experienced symptom reduction for multiple co-occurring disorders.7 Furthermore, patients were less likely to drop out of UP when compared with SDPs.4

Studies have reported positive impacts on affective disorders with UP. A 2019 metaanalysis found significant reductions in depression and anxiety-related disorders.8 Additionally, UP has been shown to be effective when delivered in person and via telehealth.9,10 UP has also been successfully used in veterans.11 While traditional models of UP (1-2 sessions weekly) have a lower dropout rate than SDPs, UP and CBT dropout rates still leave room for improvement.12-14 Specifically, rates of attrition from SDP CBT and transdiagnostic CBT protocols range from 9% to 35%, and dropout reduces the likelihood of attaining a full therapeutic dose of any course of CBT. Notably, accelerated delivery of CBT (ie, ≥3 sessions/wk) has been shown to reduce risk of dropout.14,15

Veterans are at increased risk for suicide, and anxiety and mood disorders are associated with increased risk of suicide attempt and death.16,17 Very few veterans who could benefit from high-quality CBT interventions, whether SDP or UP, are able to access them. Only 6.3% of veterans received ≥1 session of an evidence-based CBT SDP for posttraumatic stress disorder (PTSD) at 6 clinics evaluated in 2010.18

We identified 2 strategies to increase access to and completion of an evidence-based CBT course. First, the use of transdiagnostic UP instead of SDPs reduced burden on therapists and allowed them to address presenting and co-occurring disorders within the same course of care. Second, the use of an accelerated model of service delivery reduced dropout risk. Training clinicians to deliver UP is efficient and cost-effective, considering clinicians use core strategies that can be tailored and flexibly applied to a range of emotional difficulties. Thus, implementing UP may decrease barriers to receiving an optimal dose of an evidence-based CBT delivered with fidelity in a time- and cost-efficient manner.4 Two studies have found no evidence of differences in outcomes between UP and SDPs, suggesting that training and supervising clinicians in a single transdiagnostic UP intervention may prepare them to treat heterogeneous and co-occurring anxiety, mood, and emotional disorders with less burden than learning multiple SDPs.7,19

Delivering UP in an accelerated or massed format (≥4 sessions/wk) instead of the traditional spaced model (1 session/wk) has empirical support but has not been widely implemented. This approach, sometimes referred to as a UP-intensive outpatient program (UP-IOP) or UP-intensive outpatient track (UP-IOT), has been shown to be feasible, acceptable, and effective, with increased completion rates compared with traditional UP delivery (1-2 sessions/wk).20-22

Ragsdale et al describe a 2-week IOP with multiple treatment tracks, including a general track.20 The general track includes massed UP and additional standard services, including case management, wellness services, family services, and a single session effective behaviors group. Additional augmentation services are available when clinically indicated (eg, repetitive transcranial magnetic stimulation, transcranial direct current stimulation, psychoeducation, motivational interviewing, relapse prevention). In other words, this was an UP-IOP.20

Thompson-Brenner et al described a successful implementation of massed UP applied in intensive treatment settings, such as residential and day-hospital programs, for eating disorders. Patients reported improvements in 3 UP targets: experiential avoidance, mindfulness, and anxiety.21 Watkins et al evaluated a 2-week IOP using CBT for comorbid substance use and mental health disorders, including prolonged exposure, UP, and relapse prevention for substance use disorders. Participants were post-9/11 veterans and activeduty personnel. Results indicated that UP reduced PTSD and depressive symptoms following treatment. Furthermore, the retention rate (91%) was higher than retention in outpatient treatment (39%-65%), supporting the IOP model as a strategy to reduce dropout.22

Massed psychotherapy has been extended to IOP programs for PTSD treatment within the Veterans Health Administration (VHA). Yamokoski et al found that patients who completed an IOP that included massed CBT for PTSD had high retention, high satisfaction, and significant reduction in self-reported co-occurring depression symptoms. The authors also found that this model of care could be implemented and sustained within a VHA facility using minimal staffing resources.23

The UP-IOP models described by Ragsdale et al and Watkins et al included massed UP as the primary evidence-based practice (EBP) with adjunctive groups (eg, wellness and educational groups and access to complementary interventions such as mindfulness and yoga); they found that adding these groups increased retention and patient- reported satisfaction (ie, UP-IOP).20,22 The addition of wellness education alongside a primary EBP aligns with the VHA focus on whole health well-being and wellness. This includes understanding factors that motivate a patient toward health and well-being, providing health education, and offering access to complementary interventions such as mindfulness.24

Dryden et al described the whole health transformation within VHA as a proactive approach to addressing both employee and patient wellness. Their research found that the whole health model promoted wellbeing in patients and staff and these improvements were sustained during the COVID-19 pandemic. Dryden et al also noted that virtual technologies facilitated continued whole health implementation.25

The literature illustrates that (1) massed UP can be delivered with complementary education and wellness offerings that may increase retention and satisfaction by enriching treatment (eg, delivering UP-IOP); (2) whole health, including wellness education and complementary interventions (eg, mindfulness, motivational enhancement), promotes well-being in patients and clinicians; and (3) whole health education and complementary interventions can be delivered virtually.

IVET

Health Care Need

Veterans Affairs Pacific Islands Health Care System (VAPIHCS) provides medical services to veterans in the Hawaiian Islands, American Samoa, Guam, and Saipan spanning nearly 4000 miles across the Pacific Ocean. Prior to implementation of this program, veterans who received care at VAPIHCS had little to no access to UP in outpatient settings and no access to UP in residential settings. Access to UP depended on the presence of a therapist trained in UP within a given clinic and was geographically limited to the location of the UPtrained therapist. The limited outpatient access to UP was restricted to the traditional UP delivery model (eg, about 1 session/wk); thus, there was no access to accelerated UP for veterans served at VAPIHCS. In the fiscal year prior to implementation of the massed UP program, > 1000 VAPIHCS veterans had been diagnosed with obsessive-compulsive related disorder or anxiety. A massed-UP program with weekly rolling admissions would support access to UP for more veterans over 12 months, and the virtual treatment modality would reduce barriers for diverse and underserved veterans, making care more equitable and inclusive.

Successful implementation and sustainment of an EBP prompted the establishment of this UP program. In 2022, VAPIHCS launched the Intensive Virtual Evidence- Based Psychotherapy Team (iVET) for treatment of PTSD. This clinic and associated EBP project demonstrated that massed (≥3 individual sessions/wk) of prolonged exposure (PE) therapy, delivered virtually to a geographically diverse veteran population with PTSD, resulted in significant reductions in PTSD, depression, and anxiety symptoms and substance use risk factors, with very high retention rates. The iVET for PTSD program was feasible, acceptable, and effective, with veterans reporting significant improvement in quality of life and high satisfaction with their mental health services.15 Given the known benefits of transdiagnostic UP treatment (vs SDPs), the need for accelerated UP, and success with accelerated PE, our goal was to spread the EBP of massed (≥3 sessions/ wk) virtual psychotherapy to other presenting problems (eg, anxiety disorders with or without co-occurring unipolar depression) using transdiagnostic UP.

Program Description

The program implemented within outpatient mental health services at VAPIHCS was iVET for the treatment of anxiety with or without co-occurring depression. The program model consists of an accelerated course of UP and whole health education provided via VA Video Connect (VVC), the VA video telehealth platform. iVET is a 2- to 4-week program and consists of 3 parts: (1) massed individual UP for transdiagnostic treatment of anxiety and co-occurring depression, (2) group whole health and wellness classes, and (3) individual health coaching to address personal wellness goals. Programming is offered over 10-hour days to increase access across multiple time zones, especially to allow participation from Guam and Saipan.

When a patient is referred to iVET, the first contact is a video (or telephone) appointment with a registered nurse (RN) for a screening session. The screening session is designed to provide education about the program (including interventions, time commitment, and resources required for participation). Following education, the RN completes a safety screening, including screening for suicidal ideation and risk, as well as intimate partner violence risk. If urgent safety concerns are present, a licensed social worker or psychologist joins the screening to complete further risk assessment and address any safety concerns.

Following screening, patients are scheduled for a VVC telehealth intake with a licensed therapist (social worker or psychologist) to complete a diagnostic interview. Patients are sent a secure link to complete a measurement-based care (MBC) battery of self-report measures, including assessments of demographics, anxiety symptoms, depression symptoms, substance use, psychological flexibility, quality of life, and satisfaction with mental health care. The results of the diagnostic interview and self-report measures are discussed with the patient during the intake session to plan next steps and support shared decision-making. This initial VVC intake not only allows for fit assessment but also serves to troubleshoot technical difficulties with the virtual platforms.

Notably, there are minimal exclusion criteria for participation in iVET. These include active unmanaged psychosis or manic symptoms, recent suicidal crises (attempt within 8 weeks), active nonsuicidal self-injury (within 8 weeks), and moderate to severe cognitive impairment. Following intake, patients are scheduled to begin their course of care with iVET. Upon completion of intake, patients receive program materials for individual and group classes and are told they will receive email links for all VVC telehealth appointments. Patients are admitted to the iVET on a rolling basis, thereby increasing access compared with closed group and/or cohort models of care.

Patients receiving iVET attend 2 to 4 telehealth appointments daily and complete exercises between sessions. The primary iVET for Anxiety program EBP intervention is a massed or accelerated individual course of UP, which includes 8 primary components: assessment, goals and motivation, understanding emotions, mindful emotion awareness, cognitive flexibility, countering emotional behaviors, understanding and confronting physical sensations, and emotional exposures. UP is delivered in 4 to 8 individual sessions weekly (60-90 minutes each), allowing completion of the full UP protocol with fidelity in 2 to 4 weeks. In addition to primary EBP intervention, patients participate in 4 group sessions weekly (50 minutes each) of a whole health and wellness education class and have access to 1 individual health coaching session weekly (30- 60 minutes) to set wellness goals and receive coaching. During iVET, patients are invited to complete MBC batteries of self-report measures assessing anxiety symptoms, depression symptoms, substance use, psychological flexibility, quality of life, and satisfaction with mental health care at sessions 1, 5, 9, 13, and the final UP session. Following discharge from the iVET, patients are offered 1-, 3-, and 6-month individual postdischarge check-up sessions with a therapist, during which they are invited to complete MBC measures and review relapse prevention and maintenance of treatment gains. Likewise, patients are offered 1-, 3-, and 6-month individual postdischarge check-up sessions with an RN focused on maintaining wellness gains.

The iVET for Anxiety staff has 3 therapists (psychologists or social workers) and 1 RN. Additionally, the iVET for Anxiety is supported by a program manager and a program support assistant who support 2 programs total (the iVET for Anxiety plus another mental health program). The primary cost of the program is staff salary. Additional resources included computer equipment for staff and supplies (eg, printed materials for patients and office supplies). Due to the virtual environment of care, iVET staff telework and do not require physical space within VAPIHCS.

Outcomes

Veterans receiving iVET for Anxiety are invited to complete MBC multiple times, including pretreatment, during UP treatment (sessions 1, 5, 9, 13, and the final session), and posttreatment (1, 3, and 6 months). MBC measures include self-reported demographics; a 2-item measure of satisfaction with mental health services; the Acceptance and Action Questionnaire II,26 the Brief Addiction Monitor-Intensive Outpatient Program, 27 the Generalized Anxiety Disorder-7,28 the Patient Health Questionnaire (PHQ-9),29 and the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form.30

Forty-two veterans completed the iVET for Anxiety program, with a retention rate of 87.5% completing . 16 sessions of massed UP (Table 2). Veterans reported reduced anxiety (P < .001), depression (P < .001), and substance use risk (P < .001). Veterans experienced improved acceptance of emotional experiences (P < .001) and quality of life (P < .001), based on paired sample t tests comparing session 1 vs final session scores on the self-reported measures. Veterans also reported high satisfaction with mental health care in iVET for Anxiety.

0426FED-MH-Anxiety-T2

Veterans experienced reduced thoughts of death or suicidal ideation (SI) based on responses to item 9 of PHQ-9. When SI was categorically analyzed (presence vs absence) using PHQ-9 item 9, there was an association observed between absence of SI and completion of a course of massed UP that does not appear to be due to chance, (X2 [1, N = 42) = 3.94; P = .047). In addition, veterans who completed the program showed a significant decrease in SI severity measured continuously (range, 0-3) on PHQ-9 item 9 (P < .05) (Table 3).

0426FED-MH-Anxiety-T3

Future Directions

The aim of this program is to see sustained patient outcomes as iVET continues to serve more veterans. Another line of inquiry is longer- term follow-up, given that long-term follow- up was not addressed in this project. We also hope that the accelerated model of care can be applied to treatment of other presenting concerns (eg, relationship difficulties, insomnia). Expansion of accelerated mental health treatment into other federal and nonfederal health care settings is another area worthy of future inquiry. Exploration of staff satisfaction and burnout related to providing accelerated UP is another important future direction. Relatedly, assessment of the staff burden to learn 1 transdiagnostic EBP vs learning multiple SDPs is another future direction. Likewise, exploration of institutional benefits of investment in transdiagnostic training, supervision, and consultation for UP vs multiple SDPs may be important. These areas could also result in insightful, beneficial evidence of the effectiveness of massed UP to add to the existing literature.

Conclusions

UP for transdiagnostic treatment of anxiety, depressive, and emotional disorders has demonstrated reduced suffering and improved functioning and is supported by multiple clinical practice guidelines.1-4 Federal practitioners are positioned to improve access to this intervention, thereby reducing pain and improving lives. Indeed, it is crucial to envision a future state in which access to UP for a range of anxiety and depressive disorders is improved and broad, retention rates are dramatically improved, and clinicians providing UP do not experience the high burden and burnout associated with needing to learn and implement a variety of SDPs. Development of these programs, or similar tracks within existing programs, that provide massed or accelerated UP for transdiagnostic treatment of a range of anxiety and depressive disorders with virtual delivery options, is imperative to advance improved care for patients and clinicians.

Federal health care settings treating patients with anxiety and depression, such as those within the US Department of Defense, Indian Health Services, Bureau of Prisons, and VHA, are positioned to implement programs like iVET. Moreover, at the institutional level, investment in training and supervision in the transdiagnostic UP as opposed to multiple SDPs warrants consideration. We believe this model of care has great merit and foresee a future where all patients seeking treatment for anxiety and depression have the option to complete an accelerated or massed course of transdiagnostic care with UP if they so desire. Our experiences with iVET illustrate the feasibility, acceptability, and sustainability of such programs without requiring substantial staffing and financial resources.

Cognitive behavioral therapy (CBT) is supported as an effective treatment for depression by clinical practice guidelines from the US Department of Veterans Affairs (VA) and US Department of Defense.1-3 Despite research supporting the use of evidence-based CBT for anxiety, mood, and emotional disorders, patient access to these interventions is limited.4 One barrier to CBT for anxiety, mood, and emotional disorders is the traditional use of single-disorder protocols (SDPs) to separately treat each disorder (eg, major depression, generalized anxiety disorder, panic disorder).

Use of SDPs places a high burden on clinicians, requiring them to learn and competently implement multiple different manualized interventions for each anxiety, mood, or emotional disorder encountered in practice.4 It is common for individuals who present with an anxiety, mood, or emotional disorder to experience co-occurring disorders.5 Traditional SDP-based CBT may require multiple SDPs to address co-occurring disorders, extending time in treatment and increasing training burden. There is evidence that even when an SDP is used, co-occurring difficulties may decrease in intensity.6 Thus, evidence-based CBT for 1 presenting concern may positively affect co-occurring difficulties that are not the primary treatment target.6

Unified Protocol (UP) is a transdiagnostic CBT intervention for anxiety and mood disorders. UP targets emotional experiences (eg, negative affect and emotional distress) that are present in multiple anxiety, depression, and emotional disorders. UP is organized into 8 modules and uses interventions present in other CBT SDPs, such as teaching objective assessment methods to clients, motivational enhancement and goal setting, emotion psychoeducation, mindful awareness, cognitive reframing, and exposure principles as mechanisms of change (Table 1).4 UP is an ideal intervention for addressing a number of anxiety, mood, and emotional disorders as well as addressing cooccurring disorders within the same course of treatment.

0426FED-MH-Anxiety-T1

UP has been compared to SDPs; studies illustrate that UP is equivalent to SDPs at the end of treatment and at 6 months posttreatment.4,7 Additionally, patients who received UP experienced symptom reduction for multiple co-occurring disorders.7 Furthermore, patients were less likely to drop out of UP when compared with SDPs.4

Studies have reported positive impacts on affective disorders with UP. A 2019 metaanalysis found significant reductions in depression and anxiety-related disorders.8 Additionally, UP has been shown to be effective when delivered in person and via telehealth.9,10 UP has also been successfully used in veterans.11 While traditional models of UP (1-2 sessions weekly) have a lower dropout rate than SDPs, UP and CBT dropout rates still leave room for improvement.12-14 Specifically, rates of attrition from SDP CBT and transdiagnostic CBT protocols range from 9% to 35%, and dropout reduces the likelihood of attaining a full therapeutic dose of any course of CBT. Notably, accelerated delivery of CBT (ie, ≥3 sessions/wk) has been shown to reduce risk of dropout.14,15

Veterans are at increased risk for suicide, and anxiety and mood disorders are associated with increased risk of suicide attempt and death.16,17 Very few veterans who could benefit from high-quality CBT interventions, whether SDP or UP, are able to access them. Only 6.3% of veterans received ≥1 session of an evidence-based CBT SDP for posttraumatic stress disorder (PTSD) at 6 clinics evaluated in 2010.18

We identified 2 strategies to increase access to and completion of an evidence-based CBT course. First, the use of transdiagnostic UP instead of SDPs reduced burden on therapists and allowed them to address presenting and co-occurring disorders within the same course of care. Second, the use of an accelerated model of service delivery reduced dropout risk. Training clinicians to deliver UP is efficient and cost-effective, considering clinicians use core strategies that can be tailored and flexibly applied to a range of emotional difficulties. Thus, implementing UP may decrease barriers to receiving an optimal dose of an evidence-based CBT delivered with fidelity in a time- and cost-efficient manner.4 Two studies have found no evidence of differences in outcomes between UP and SDPs, suggesting that training and supervising clinicians in a single transdiagnostic UP intervention may prepare them to treat heterogeneous and co-occurring anxiety, mood, and emotional disorders with less burden than learning multiple SDPs.7,19

Delivering UP in an accelerated or massed format (≥4 sessions/wk) instead of the traditional spaced model (1 session/wk) has empirical support but has not been widely implemented. This approach, sometimes referred to as a UP-intensive outpatient program (UP-IOP) or UP-intensive outpatient track (UP-IOT), has been shown to be feasible, acceptable, and effective, with increased completion rates compared with traditional UP delivery (1-2 sessions/wk).20-22

Ragsdale et al describe a 2-week IOP with multiple treatment tracks, including a general track.20 The general track includes massed UP and additional standard services, including case management, wellness services, family services, and a single session effective behaviors group. Additional augmentation services are available when clinically indicated (eg, repetitive transcranial magnetic stimulation, transcranial direct current stimulation, psychoeducation, motivational interviewing, relapse prevention). In other words, this was an UP-IOP.20

Thompson-Brenner et al described a successful implementation of massed UP applied in intensive treatment settings, such as residential and day-hospital programs, for eating disorders. Patients reported improvements in 3 UP targets: experiential avoidance, mindfulness, and anxiety.21 Watkins et al evaluated a 2-week IOP using CBT for comorbid substance use and mental health disorders, including prolonged exposure, UP, and relapse prevention for substance use disorders. Participants were post-9/11 veterans and activeduty personnel. Results indicated that UP reduced PTSD and depressive symptoms following treatment. Furthermore, the retention rate (91%) was higher than retention in outpatient treatment (39%-65%), supporting the IOP model as a strategy to reduce dropout.22

Massed psychotherapy has been extended to IOP programs for PTSD treatment within the Veterans Health Administration (VHA). Yamokoski et al found that patients who completed an IOP that included massed CBT for PTSD had high retention, high satisfaction, and significant reduction in self-reported co-occurring depression symptoms. The authors also found that this model of care could be implemented and sustained within a VHA facility using minimal staffing resources.23

The UP-IOP models described by Ragsdale et al and Watkins et al included massed UP as the primary evidence-based practice (EBP) with adjunctive groups (eg, wellness and educational groups and access to complementary interventions such as mindfulness and yoga); they found that adding these groups increased retention and patient- reported satisfaction (ie, UP-IOP).20,22 The addition of wellness education alongside a primary EBP aligns with the VHA focus on whole health well-being and wellness. This includes understanding factors that motivate a patient toward health and well-being, providing health education, and offering access to complementary interventions such as mindfulness.24

Dryden et al described the whole health transformation within VHA as a proactive approach to addressing both employee and patient wellness. Their research found that the whole health model promoted wellbeing in patients and staff and these improvements were sustained during the COVID-19 pandemic. Dryden et al also noted that virtual technologies facilitated continued whole health implementation.25

The literature illustrates that (1) massed UP can be delivered with complementary education and wellness offerings that may increase retention and satisfaction by enriching treatment (eg, delivering UP-IOP); (2) whole health, including wellness education and complementary interventions (eg, mindfulness, motivational enhancement), promotes well-being in patients and clinicians; and (3) whole health education and complementary interventions can be delivered virtually.

IVET

Health Care Need

Veterans Affairs Pacific Islands Health Care System (VAPIHCS) provides medical services to veterans in the Hawaiian Islands, American Samoa, Guam, and Saipan spanning nearly 4000 miles across the Pacific Ocean. Prior to implementation of this program, veterans who received care at VAPIHCS had little to no access to UP in outpatient settings and no access to UP in residential settings. Access to UP depended on the presence of a therapist trained in UP within a given clinic and was geographically limited to the location of the UPtrained therapist. The limited outpatient access to UP was restricted to the traditional UP delivery model (eg, about 1 session/wk); thus, there was no access to accelerated UP for veterans served at VAPIHCS. In the fiscal year prior to implementation of the massed UP program, > 1000 VAPIHCS veterans had been diagnosed with obsessive-compulsive related disorder or anxiety. A massed-UP program with weekly rolling admissions would support access to UP for more veterans over 12 months, and the virtual treatment modality would reduce barriers for diverse and underserved veterans, making care more equitable and inclusive.

Successful implementation and sustainment of an EBP prompted the establishment of this UP program. In 2022, VAPIHCS launched the Intensive Virtual Evidence- Based Psychotherapy Team (iVET) for treatment of PTSD. This clinic and associated EBP project demonstrated that massed (≥3 individual sessions/wk) of prolonged exposure (PE) therapy, delivered virtually to a geographically diverse veteran population with PTSD, resulted in significant reductions in PTSD, depression, and anxiety symptoms and substance use risk factors, with very high retention rates. The iVET for PTSD program was feasible, acceptable, and effective, with veterans reporting significant improvement in quality of life and high satisfaction with their mental health services.15 Given the known benefits of transdiagnostic UP treatment (vs SDPs), the need for accelerated UP, and success with accelerated PE, our goal was to spread the EBP of massed (≥3 sessions/ wk) virtual psychotherapy to other presenting problems (eg, anxiety disorders with or without co-occurring unipolar depression) using transdiagnostic UP.

Program Description

The program implemented within outpatient mental health services at VAPIHCS was iVET for the treatment of anxiety with or without co-occurring depression. The program model consists of an accelerated course of UP and whole health education provided via VA Video Connect (VVC), the VA video telehealth platform. iVET is a 2- to 4-week program and consists of 3 parts: (1) massed individual UP for transdiagnostic treatment of anxiety and co-occurring depression, (2) group whole health and wellness classes, and (3) individual health coaching to address personal wellness goals. Programming is offered over 10-hour days to increase access across multiple time zones, especially to allow participation from Guam and Saipan.

When a patient is referred to iVET, the first contact is a video (or telephone) appointment with a registered nurse (RN) for a screening session. The screening session is designed to provide education about the program (including interventions, time commitment, and resources required for participation). Following education, the RN completes a safety screening, including screening for suicidal ideation and risk, as well as intimate partner violence risk. If urgent safety concerns are present, a licensed social worker or psychologist joins the screening to complete further risk assessment and address any safety concerns.

Following screening, patients are scheduled for a VVC telehealth intake with a licensed therapist (social worker or psychologist) to complete a diagnostic interview. Patients are sent a secure link to complete a measurement-based care (MBC) battery of self-report measures, including assessments of demographics, anxiety symptoms, depression symptoms, substance use, psychological flexibility, quality of life, and satisfaction with mental health care. The results of the diagnostic interview and self-report measures are discussed with the patient during the intake session to plan next steps and support shared decision-making. This initial VVC intake not only allows for fit assessment but also serves to troubleshoot technical difficulties with the virtual platforms.

Notably, there are minimal exclusion criteria for participation in iVET. These include active unmanaged psychosis or manic symptoms, recent suicidal crises (attempt within 8 weeks), active nonsuicidal self-injury (within 8 weeks), and moderate to severe cognitive impairment. Following intake, patients are scheduled to begin their course of care with iVET. Upon completion of intake, patients receive program materials for individual and group classes and are told they will receive email links for all VVC telehealth appointments. Patients are admitted to the iVET on a rolling basis, thereby increasing access compared with closed group and/or cohort models of care.

Patients receiving iVET attend 2 to 4 telehealth appointments daily and complete exercises between sessions. The primary iVET for Anxiety program EBP intervention is a massed or accelerated individual course of UP, which includes 8 primary components: assessment, goals and motivation, understanding emotions, mindful emotion awareness, cognitive flexibility, countering emotional behaviors, understanding and confronting physical sensations, and emotional exposures. UP is delivered in 4 to 8 individual sessions weekly (60-90 minutes each), allowing completion of the full UP protocol with fidelity in 2 to 4 weeks. In addition to primary EBP intervention, patients participate in 4 group sessions weekly (50 minutes each) of a whole health and wellness education class and have access to 1 individual health coaching session weekly (30- 60 minutes) to set wellness goals and receive coaching. During iVET, patients are invited to complete MBC batteries of self-report measures assessing anxiety symptoms, depression symptoms, substance use, psychological flexibility, quality of life, and satisfaction with mental health care at sessions 1, 5, 9, 13, and the final UP session. Following discharge from the iVET, patients are offered 1-, 3-, and 6-month individual postdischarge check-up sessions with a therapist, during which they are invited to complete MBC measures and review relapse prevention and maintenance of treatment gains. Likewise, patients are offered 1-, 3-, and 6-month individual postdischarge check-up sessions with an RN focused on maintaining wellness gains.

The iVET for Anxiety staff has 3 therapists (psychologists or social workers) and 1 RN. Additionally, the iVET for Anxiety is supported by a program manager and a program support assistant who support 2 programs total (the iVET for Anxiety plus another mental health program). The primary cost of the program is staff salary. Additional resources included computer equipment for staff and supplies (eg, printed materials for patients and office supplies). Due to the virtual environment of care, iVET staff telework and do not require physical space within VAPIHCS.

Outcomes

Veterans receiving iVET for Anxiety are invited to complete MBC multiple times, including pretreatment, during UP treatment (sessions 1, 5, 9, 13, and the final session), and posttreatment (1, 3, and 6 months). MBC measures include self-reported demographics; a 2-item measure of satisfaction with mental health services; the Acceptance and Action Questionnaire II,26 the Brief Addiction Monitor-Intensive Outpatient Program, 27 the Generalized Anxiety Disorder-7,28 the Patient Health Questionnaire (PHQ-9),29 and the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form.30

Forty-two veterans completed the iVET for Anxiety program, with a retention rate of 87.5% completing . 16 sessions of massed UP (Table 2). Veterans reported reduced anxiety (P < .001), depression (P < .001), and substance use risk (P < .001). Veterans experienced improved acceptance of emotional experiences (P < .001) and quality of life (P < .001), based on paired sample t tests comparing session 1 vs final session scores on the self-reported measures. Veterans also reported high satisfaction with mental health care in iVET for Anxiety.

0426FED-MH-Anxiety-T2

Veterans experienced reduced thoughts of death or suicidal ideation (SI) based on responses to item 9 of PHQ-9. When SI was categorically analyzed (presence vs absence) using PHQ-9 item 9, there was an association observed between absence of SI and completion of a course of massed UP that does not appear to be due to chance, (X2 [1, N = 42) = 3.94; P = .047). In addition, veterans who completed the program showed a significant decrease in SI severity measured continuously (range, 0-3) on PHQ-9 item 9 (P < .05) (Table 3).

0426FED-MH-Anxiety-T3

Future Directions

The aim of this program is to see sustained patient outcomes as iVET continues to serve more veterans. Another line of inquiry is longer- term follow-up, given that long-term follow- up was not addressed in this project. We also hope that the accelerated model of care can be applied to treatment of other presenting concerns (eg, relationship difficulties, insomnia). Expansion of accelerated mental health treatment into other federal and nonfederal health care settings is another area worthy of future inquiry. Exploration of staff satisfaction and burnout related to providing accelerated UP is another important future direction. Relatedly, assessment of the staff burden to learn 1 transdiagnostic EBP vs learning multiple SDPs is another future direction. Likewise, exploration of institutional benefits of investment in transdiagnostic training, supervision, and consultation for UP vs multiple SDPs may be important. These areas could also result in insightful, beneficial evidence of the effectiveness of massed UP to add to the existing literature.

Conclusions

UP for transdiagnostic treatment of anxiety, depressive, and emotional disorders has demonstrated reduced suffering and improved functioning and is supported by multiple clinical practice guidelines.1-4 Federal practitioners are positioned to improve access to this intervention, thereby reducing pain and improving lives. Indeed, it is crucial to envision a future state in which access to UP for a range of anxiety and depressive disorders is improved and broad, retention rates are dramatically improved, and clinicians providing UP do not experience the high burden and burnout associated with needing to learn and implement a variety of SDPs. Development of these programs, or similar tracks within existing programs, that provide massed or accelerated UP for transdiagnostic treatment of a range of anxiety and depressive disorders with virtual delivery options, is imperative to advance improved care for patients and clinicians.

Federal health care settings treating patients with anxiety and depression, such as those within the US Department of Defense, Indian Health Services, Bureau of Prisons, and VHA, are positioned to implement programs like iVET. Moreover, at the institutional level, investment in training and supervision in the transdiagnostic UP as opposed to multiple SDPs warrants consideration. We believe this model of care has great merit and foresee a future where all patients seeking treatment for anxiety and depression have the option to complete an accelerated or massed course of transdiagnostic care with UP if they so desire. Our experiences with iVET illustrate the feasibility, acceptability, and sustainability of such programs without requiring substantial staffing and financial resources.

References
  1. US Department of Veterans Affairs, US Department of Defense. VA/DoD clinical practice guideline for the management of major depressive disorder. Version 4. 2022. Accessed February 1, 2026. https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPGFinal508.pdf
  2. American Psychological Association. Clinical practice guideline for the treatment of depression across three age cohorts. February 2019. Accessed February 4, 2026. https://www.apa.org/depression-guideline/guideline.pdf
  3. Katzman MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive compulsive disorders. BMC Psychiatry. 2014;14:S1. doi:10.1186/1471-244X-14-S1-S1
  4. Barlow DH, Farchione TJ, Bullis JR, et al. The unified protocol for transdiagnostic treatment of emotional disorders compared with diagnosis-specific protocols for anxiety disorders: a randomized clinical trial. JAMA Psychiatry. 2017;74:875-884. doi:10.1001/jamapsychiatry.2017.2164
  5. Calkins AW, et al. Comorbidity of anxiety and depression. In: Ressler KJ, Pine DS, Rothbaum BO, eds. Anxiety Disorders, Primer On. Oxford Academic; 2015. https://doi.org/10.1093/med/9780199395125.003.0021
  6. Manber R, Edinger JD, Gress JL, et al. Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia. Sleep. 2008;31:489-495. doi:10.1093/sleep/31.4.489
  7. Steele SJ, Farchione TJ, Cassiello-Robbins C, et al. Efficacy of the Unified Protocol for transdiagnostic treatment of comorbid psychopathology accompanying emotional disorders compared to treatments targeting single disorders. J Psychiatr Res. 2018;104:211-216. doi:10.1016/j.jpsychires.2018.08.005
  8. Sakiris N, Berle D. A systematic review and meta-analysis of the Unified Protocol as a transdiagnostic emotion regulation based intervention. Clin Psychol Rev. 2019;72:101751. doi:10.1016/j.cpr.2019.101751
  9. Cassiello-Robbins C, Rosenthal MZ, Ammirati RJ. Delivering transdiagnostic treatment over telehealth during the COVID-19 pandemic: application of the unified protocol. Cogn Behav Pract. 2021;28:555-572. doi:10.1016/j.cbpra.2021.04.007
  10. Meyer EC, Coe E, Pennington ML, et al. The unified protocol for transdiagnostic treatment of emotional disorders delivered to firefighters via videoconferencing: pilot outcomes highlighting improvements in alcohol use disorder and posttraumatic stress disorder symptoms. Cogn Behav Pract. 2024;31:215-229. doi:10.1016/j.cbpra.2022.08.004
  11. Varkovitzky RL, Sherrill AM, Reger GM. Effectiveness of the unified protocol for transdiagnostic treatment of emotional disorders among veterans with posttraumatic stress disorder: a pilot study. Behav Modif. 2018;42:210-230. doi:10.1177/0145445517724539
  12. Oliveira JT, Sousa I, Ribeiro AP, et al. Premature termination of the unified protocol for the transdiagnostic treatment of emotional disorders: The role of ambivalence towards change. Clin Psychol Psychother. 2022;29:1089-1100. doi:10.1002/cpp.2694
  13. Schaeuffele C, Homeyer S, Perea L, et al. The unified protocol as an internet-based intervention for emotional disorders: Randomized controlled trial. PLoS One. 2022;17:e0270178. doi:10.1371/journal.pone.0270178
  14. Bentley KH, Cohen ZD, Kim T, et al. The nature, timing, and symptom trajectories of dropout from transdiagnostic and single-diagnosis cognitive-behavioral therapy for anxiety disorders. Behav Ther. 2021;52:1364-1376. doi:10.1016/j.beth.2021.03.007
  15. Aosved AC, Brown TB, Bell JC, et al. Accelerated prolonged exposure therapy for posttraumatic stress disorder in a Veterans Health Administration system. Fed Pract. 2025;42:S6-S11. doi:10.12788/fp.0568
  16. Nepon J, Belik SL, Bolton J, et al. The relationship between anxiety disorders and suicide attempts: findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Depress Anxiety. 2010;27:791-798. doi:10.1002/da.20674
  17. Shiner B, D’Avolio LW, Nguyen TM, et al. Measuring use of evidence based psychotherapy for posttraumatic stress disorder. Adm Policy Ment Health. 2013;40:311-318. doi:10.1007/s10488-012-0421-0
  18. Nichter B, Stein MB, Monteith LL, et al. Risk factors for suicide attempts among U.S. military veterans: A 7-year population-based, longitudinal cohort study. Suicide Life Threat Behav. 2022;52:303-316. doi:10.1111/sltb.12822
  19. McHugh RK, Barlow DH. The dissemination and implementation of evidence-based psychological treatments. A review of current efforts. Am Psychol. 2010;65:73-84. doi:10.1037/a0018121
  20. Ragsdale KA, Nichols AA, Mehta M, et al. Comorbid treatment of traumatic brain injury and mental health disorders. NeuroRehabilitation. 2024;55:375-384. doi:10.3233/NRE-230235
  21. Thompson-Brenner H, Brooks GE, Boswell JF, et al. Evidence-based implementation practices applied to the intensive treatment of eating disorders: summary of research and illustration of principles using a case example. Clin Psychol Sci Pract. 2018;25:e12221. doi:10.1111/cpsp.12221
  22. Watkins LE, Patton SC, Drexler K, et al. Clinical effectiveness of an intensive outpatient program for integrated treatment of comorbid substance abuse and mental health disorders. Cog Behav Pract. 2023;30:354-366.
  23. Yamokoski C, Flores H, Facemire V, et al. Feasibility of an intensive outpatient treatment program for post-traumatic stress disorder within the veterans health care administration. Psychol Serv. 2023;20:506-515. doi:10.1037/ser0000628
  24. Gaudet T, Kligler B. Whole health in the whole system of the Veterans Administration: how will we know we have reached this future state?. J Altern Complement Med. 2019;25:S7-S11. doi:10.1089/acm.2018.29061.gau
  25. Dryden EM, Bolton RE, Bokhour BG, et al. Leaning into whole health: sustaining system transformation while supporting patients and employees during COVID-19. Glob Adv Health Med. 2021;10:21649561211021047. doi:10.1177/21649561211021047
  26. Bond FW, Hayes SC, Baer RA, et al. Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: a revised measure of psychological inflexibility and experiential avoidance. Behav Ther. 2011;42:676-688. doi:10.1016/j.beth.2011.03.007
  27. Cacciola JS, Alterman AI, Dephilippis D, et al. Development and initial evaluation of the Brief Addiction Monitor (BAM). J Subst Abuse Treat. 2013;44:256-263. doi:10.1016/j.jsat.2012.07.013
  28. Spitzer RL, Kroenke K, Williams JB, et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166:1092-1097. doi:10.1001/archinte.166.10.1092
  29. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606-613. doi:10.1046/j.1525-1497.2001.016009606.x
  30. Stevanovic D. Quality of life enjoyment and satisfaction questionnaire-short form for quality of life assessments in clinical practice: a psychometric study. J Psychiatr Ment Health Nurs. 2011;18:744-750. doi:10.1111/j.1365-2850.2011.01735.x
References
  1. US Department of Veterans Affairs, US Department of Defense. VA/DoD clinical practice guideline for the management of major depressive disorder. Version 4. 2022. Accessed February 1, 2026. https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPGFinal508.pdf
  2. American Psychological Association. Clinical practice guideline for the treatment of depression across three age cohorts. February 2019. Accessed February 4, 2026. https://www.apa.org/depression-guideline/guideline.pdf
  3. Katzman MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive compulsive disorders. BMC Psychiatry. 2014;14:S1. doi:10.1186/1471-244X-14-S1-S1
  4. Barlow DH, Farchione TJ, Bullis JR, et al. The unified protocol for transdiagnostic treatment of emotional disorders compared with diagnosis-specific protocols for anxiety disorders: a randomized clinical trial. JAMA Psychiatry. 2017;74:875-884. doi:10.1001/jamapsychiatry.2017.2164
  5. Calkins AW, et al. Comorbidity of anxiety and depression. In: Ressler KJ, Pine DS, Rothbaum BO, eds. Anxiety Disorders, Primer On. Oxford Academic; 2015. https://doi.org/10.1093/med/9780199395125.003.0021
  6. Manber R, Edinger JD, Gress JL, et al. Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia. Sleep. 2008;31:489-495. doi:10.1093/sleep/31.4.489
  7. Steele SJ, Farchione TJ, Cassiello-Robbins C, et al. Efficacy of the Unified Protocol for transdiagnostic treatment of comorbid psychopathology accompanying emotional disorders compared to treatments targeting single disorders. J Psychiatr Res. 2018;104:211-216. doi:10.1016/j.jpsychires.2018.08.005
  8. Sakiris N, Berle D. A systematic review and meta-analysis of the Unified Protocol as a transdiagnostic emotion regulation based intervention. Clin Psychol Rev. 2019;72:101751. doi:10.1016/j.cpr.2019.101751
  9. Cassiello-Robbins C, Rosenthal MZ, Ammirati RJ. Delivering transdiagnostic treatment over telehealth during the COVID-19 pandemic: application of the unified protocol. Cogn Behav Pract. 2021;28:555-572. doi:10.1016/j.cbpra.2021.04.007
  10. Meyer EC, Coe E, Pennington ML, et al. The unified protocol for transdiagnostic treatment of emotional disorders delivered to firefighters via videoconferencing: pilot outcomes highlighting improvements in alcohol use disorder and posttraumatic stress disorder symptoms. Cogn Behav Pract. 2024;31:215-229. doi:10.1016/j.cbpra.2022.08.004
  11. Varkovitzky RL, Sherrill AM, Reger GM. Effectiveness of the unified protocol for transdiagnostic treatment of emotional disorders among veterans with posttraumatic stress disorder: a pilot study. Behav Modif. 2018;42:210-230. doi:10.1177/0145445517724539
  12. Oliveira JT, Sousa I, Ribeiro AP, et al. Premature termination of the unified protocol for the transdiagnostic treatment of emotional disorders: The role of ambivalence towards change. Clin Psychol Psychother. 2022;29:1089-1100. doi:10.1002/cpp.2694
  13. Schaeuffele C, Homeyer S, Perea L, et al. The unified protocol as an internet-based intervention for emotional disorders: Randomized controlled trial. PLoS One. 2022;17:e0270178. doi:10.1371/journal.pone.0270178
  14. Bentley KH, Cohen ZD, Kim T, et al. The nature, timing, and symptom trajectories of dropout from transdiagnostic and single-diagnosis cognitive-behavioral therapy for anxiety disorders. Behav Ther. 2021;52:1364-1376. doi:10.1016/j.beth.2021.03.007
  15. Aosved AC, Brown TB, Bell JC, et al. Accelerated prolonged exposure therapy for posttraumatic stress disorder in a Veterans Health Administration system. Fed Pract. 2025;42:S6-S11. doi:10.12788/fp.0568
  16. Nepon J, Belik SL, Bolton J, et al. The relationship between anxiety disorders and suicide attempts: findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Depress Anxiety. 2010;27:791-798. doi:10.1002/da.20674
  17. Shiner B, D’Avolio LW, Nguyen TM, et al. Measuring use of evidence based psychotherapy for posttraumatic stress disorder. Adm Policy Ment Health. 2013;40:311-318. doi:10.1007/s10488-012-0421-0
  18. Nichter B, Stein MB, Monteith LL, et al. Risk factors for suicide attempts among U.S. military veterans: A 7-year population-based, longitudinal cohort study. Suicide Life Threat Behav. 2022;52:303-316. doi:10.1111/sltb.12822
  19. McHugh RK, Barlow DH. The dissemination and implementation of evidence-based psychological treatments. A review of current efforts. Am Psychol. 2010;65:73-84. doi:10.1037/a0018121
  20. Ragsdale KA, Nichols AA, Mehta M, et al. Comorbid treatment of traumatic brain injury and mental health disorders. NeuroRehabilitation. 2024;55:375-384. doi:10.3233/NRE-230235
  21. Thompson-Brenner H, Brooks GE, Boswell JF, et al. Evidence-based implementation practices applied to the intensive treatment of eating disorders: summary of research and illustration of principles using a case example. Clin Psychol Sci Pract. 2018;25:e12221. doi:10.1111/cpsp.12221
  22. Watkins LE, Patton SC, Drexler K, et al. Clinical effectiveness of an intensive outpatient program for integrated treatment of comorbid substance abuse and mental health disorders. Cog Behav Pract. 2023;30:354-366.
  23. Yamokoski C, Flores H, Facemire V, et al. Feasibility of an intensive outpatient treatment program for post-traumatic stress disorder within the veterans health care administration. Psychol Serv. 2023;20:506-515. doi:10.1037/ser0000628
  24. Gaudet T, Kligler B. Whole health in the whole system of the Veterans Administration: how will we know we have reached this future state?. J Altern Complement Med. 2019;25:S7-S11. doi:10.1089/acm.2018.29061.gau
  25. Dryden EM, Bolton RE, Bokhour BG, et al. Leaning into whole health: sustaining system transformation while supporting patients and employees during COVID-19. Glob Adv Health Med. 2021;10:21649561211021047. doi:10.1177/21649561211021047
  26. Bond FW, Hayes SC, Baer RA, et al. Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: a revised measure of psychological inflexibility and experiential avoidance. Behav Ther. 2011;42:676-688. doi:10.1016/j.beth.2011.03.007
  27. Cacciola JS, Alterman AI, Dephilippis D, et al. Development and initial evaluation of the Brief Addiction Monitor (BAM). J Subst Abuse Treat. 2013;44:256-263. doi:10.1016/j.jsat.2012.07.013
  28. Spitzer RL, Kroenke K, Williams JB, et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166:1092-1097. doi:10.1001/archinte.166.10.1092
  29. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606-613. doi:10.1046/j.1525-1497.2001.016009606.x
  30. Stevanovic D. Quality of life enjoyment and satisfaction questionnaire-short form for quality of life assessments in clinical practice: a psychometric study. J Psychiatr Ment Health Nurs. 2011;18:744-750. doi:10.1111/j.1365-2850.2011.01735.x
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Accelerated Unified Protocol for Transdiagnostic Treatment of Anxiety Disorders in a VHA System

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Accelerated Unified Protocol for Transdiagnostic Treatment of Anxiety Disorders in a VHA System

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