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

Abstract

Background

Access to evidence-based psychological treatments for common mental health disorders remains limited in low-resource settings. This pilot randomized controlled trial evaluated the feasibility and acceptability of the Urdu Adapted Unified Protocol (UA-UP), a transdiagnostic cognitive-behavioral intervention for anxiety and depression, in Pakistan, and explored preliminary clinical outcomes.

Methods

51 adults meeting diagnostic criteria for anxiety and/or depressive disorders were randomized to a 14-week UA-UP intervention (n=25) or a waitlist control (n=26). Feasibility was assessed through recruitment, retention, and adherence rates. Acceptability was evaluated via session attendance, homework completion, participant satisfaction (CSQ-8), and qualitative feedback. Clinical outcomes (anxiety, depression, emotion regulation, and functional impairment) were assessed using validated measures. Between-group differences were analyzed using repeated-measures general linear models, and 95% confidence intervals were reported.

Results

Feasibility indicators were high, with recruitment (85.7%), retention (82.4%), and strong session adherence. Acceptability was supported by 79% homework completion and high satisfaction (mean CSQ-8=29.65, SD=2.60). Participants in the UA-UP group demonstrated greater improvements in anxiety, depression, and functional impairment compared to the control group, with large effect size estimates (e.g., anxiety g=1.18; depression g=1.15). Qualitative findings indicated enhanced emotional awareness, improved coping, and strong engagement with culturally adapted content.

Conclusions

The UA-UP demonstrated high feasibility and acceptability as a culturally adapted transdiagnostic CBT intervention in Pakistan. These findings support the conduct of a fully powered randomized controlled trial to evaluate clinical effectiveness and inform scalable implementation in low-resource settings.

Trial registration

ClinicalTrials.gov, NCT06002087. Registered 03 August 2023 (retrospectively registered). https://clinicaltrials.gov/study/NCT06002087?term=Asma%20Nisa&rank=1.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12888-026-08345-x.

Introduction

Anxiety and depressive disorders rank among the top contributors to global disability and health-care expenditure, imposing heavy personal and societal costs [1, 2]. These challenges are magnified in low- and middle-income countries (LMICs) such as Pakistan, where structural barriers including chronic under-investment, limited mental-health literacy, and a severe shortage of trained clinicians, curtail access to evidence-based care [3]. National surveys estimate that 22%–60% of Pakistanis meet criteria for anxiety or depression, and comorbid presentations in primary care approach 63% [4, 5]. Such comorbidity predicts more severe symptoms, elevated suicide risk, and complex treatment trajectories, underscoring the need for integrative models that target shared psychopathological mechanisms [6].

Cognitive-behavioral therapy (CBT) is a first-line treatment for both disorders [7]. Yet disorder-specific CBT manuals demand extensive clinician training and are ill-equipped for the high rates of comorbidity typical in routine practice, particularly in resource-constrained settings [8]. Transdiagnostic CBT (T-CBT), most notably the Unified Protocol (UP) treatment, addresses this gap by focusing on common emotional and cognitive processes underlying anxiety and mood disorders. Meta-analyses show the UP matches disorder-specific protocols in efficacy while reducing training burden and facilitating scalability [9–11].

Given Pakistan’s exceptionally high rates of anxiety–depression comorbidity and its severe shortage of mental-health specialists [3], a flexible, easily scalable treatment like the UP is urgently needed. The UP is well positioned for use in Pakistan because it has already been adapted successfully in culturally distinct settings like Japan, Spain, Brazil, and Iran, demonstrating its flexibility across languages and health-care systems [12–15]. Its core focus on emotion regulation resonates with Pakistani social values that encourage emotional composure and social harmony within familial and community settings [16]. Tailoring the treatment with Islamic reflective practices, culturally familiar metaphors, and traditional storytelling may further enhance engagement and reduce stigma [17, 18].

Despite this clear rationale, empirical research on transdiagnostic treatments in Pakistan remains sparse; most published trials still evaluate diagnosis-specific CBT protocols [17, 19]. The updated Medical Research Council (MRC) framework for complex treatments outlines four sequential phases: development, feasibility, evaluation, and implementation [20]. In strict adherence to this roadmap, we have completed the following steps:

1. Development phase – We undertook a systematic cultural and linguistic adaptation of the UP for Urdu speakers, and the full cultural adaptation process has been reported elsewhere [21]. Briefly, the UA-UP retained the core UP modules while incorporating linguistic and cultural modifications to improve clarity, accessibility, and relevance for Pakistani participants. Key adaptations included simplifying psychological terminology in Urdu, replacing culturally less relevant examples with locally meaningful scenarios, adding visual aids to support understanding of key concepts and exercises, and broadening emotional-awareness activities to include culturally acceptable audio and video materials according to participant preference.

2. Feasibility phase – We conducted the present pilot randomized controlled trial (RCT) to establish whether the UA-UP can be delivered with fidelity and sustained engagement within Pakistan’s overstretched mental-health system.

Barriers such as stigma, clinician shortages, and access difficulties continue to impede service delivery [3, 22]. In this context, the MRC’s emphasis on contextual adaptation and process evaluation is especially relevant [23]. This study therefore examines the feasibility, acceptability, and preliminary outcome trends of the UA-UP, establishing critical groundwork for subsequent evaluation and implementation phases. The findings aim to inform scalable and culturally responsive models for delivering mental-health care in LMICs.

Method

Objectives

This study was conducted in accordance with the CONSORT 2010 extension for randomized pilot and feasibility trials [24], the study objectives are categorized into four key areas:

1. To assess the feasibility of trial procedures:

• Evaluate the relative effectiveness of three recruitment methods in generating registrations.

• Determine overall recruitment and retention rates.

• Assess the feasibility of delivering the UA-UP treatment in a face-to-face format.

• Evaluate the appropriateness of the eligibility criteria for the target population.

• Assess the feasibility of the randomization procedures.

• Evaluate feasibility of outcome measures by examining completion rates.

• 2.To assess the acceptability of the trial design:

• Assess participant acceptability of randomization to treatment or control.

• Determine trial attrition rates.

• 3.To evaluate the acceptability of the treatment itself:

• Measure participant engagement with treatment.

• Assess completion rates of home practice assignments.

• Explore participants’ perceptions of the treatment, including satisfaction, comprehension of treatment content, perceived usefulness of techniques, discomfort experienced, and suggestions for improvement.

• 4.To explore preliminary trends in clinical outcomes:

• Examine trends in depression, anxiety, emotion regulation, and functional impairment between the treatment and control arms over time.

Study design

This pilot used a convergent-parallel mixed-methods randomized controlled trial design. Adults meeting the inclusion criteria were randomized (1:1 allocation ratio) to either the UA-UP treatment or a waitlist control condition. Quantitative and qualitative data were collected concurrently, analyzed independently, and integrated at the interpretation stage. The trial was conducted according to the protocol approved prior to the start of the study. No modifications were made to the protocol during the trial. A CONSORT flow diagram is provided in Fig. 1, and the complete CONSORT checklist is available on the Equator Network reporting checklist.

Fig. 1.

CONSORT diagram showing the flow of participants through each stage of a randomized trial

Participants

Eligibility criteria

Eligible participants were: (a) adults aged 18 years or older, (b) scoring in the moderate-to-severe range on both the Beck Depression Inventory–II (BDI-II ≥ 20) [25] and the Beck Anxiety Inventory (BAI ≥ 16) [26], and (c) meeting DSM-5 diagnostic criteria for a depressive and/or anxiety disorder, confirmed using the Structured Clinical Interview for DSM-5 – Research Version (SCID-5-RV) [27]. Exclusion criteria included: (a) acute suicide risk, (b) comorbid psychotic or pervasive developmental disorders, (c) substance use disorder, (d) severe concurrent medical condition, or (e) current engagement in psychotherapy or psychotropic medication.

Recruitment methods

Three master’s-level research assistants (RAs), independent of all other study procedures, conducted recruitment over a six-week period. A recruitment flyer described the study objectives, inclusion criteria, online registration link, institutional email, and a contact telephone number.

Recruitment strategies included:

• Online dissemination: Flyers were distributed via WhatsApp groups and posted on Facebook, Instagram, X (formerly Twitter), and LinkedIn community pages targeting students, professionals, and general audiences.

• Community outreach: Physical flyers were placed in career academies, rural vocational centers, libraries, and local markets in Islamabad and Rawalpindi.

• Professional referrals: Local therapists were invited to refer potentially eligible clients. No incentives were provided for referrals.

Sample size

This pilot enrolled 25 participants per arm (N = 50) to address feasibility rather than statistical power. Feasibility trials commonly recruit 12–30 participants per group to test recruitment, retention, and delivery procedures [25, 26]. Resource limitations typical of LMICs including restricted funding, infrastructure, and personnel also informed the decision [27]. As a single therapist delivered all sessions, increasing the sample could have compromised treatment fidelity. These considerations align with guidance to match pilot designs to available resources while maintaining rigor [24]. Assuming a 15% attrition rate, based on prior UP and CBT trials [12, 28], enrolling 25 participants per group was expected to yield approximately 20 completers per arm.

To guide this, the expected precision of key feasibility metrics was also considered. For example, assuming an expected retention rate of 80%, a sample of 50 participants provides a 95% confidence interval of approximately ± 11%, which is considered acceptable for feasibility planning [29]. This level of precision allows for reliable estimation of trial processes such as participant retention and adherence, which are critical to the design and justification of a future definitive trial. While the small sample limits generalizability, it provides critical data to inform the design of a future full-scale RCT.

Participant selection

Purposive sampling was used to recruit adults living in Islamabad or Rawalpindi who met a priori inclusion criteria for elevated depression and/or anxiety, consistent with the study’s in-person delivery at the university counselling center in Islamabad. Research assistants posted flyers containing an active registration link that directed interested individuals to a Google form. The form (a) described the study, (b) obtained electronic informed consent, and (c) administered the BDI-II [30] and BAI [31]. Respondents scoring in the moderate-to-severe range (BDI-II ≥ 20; BAI ≥ 16) were invited to a follow-up assessment, during which the primary researcher conducted the SCID-5-RV [32] to confirm eligibility and assess comorbid conditions.

Participant enrolment and allocation

A total of 63 individuals completed the online screening using the BDI-II and BAI. Of these, 61 (47 women, 14 men) met symptom thresholds. Seven could not be re-contacted, and 54 participants completed the SCID-5-RV. One participant was excluded due to acute suicide risk and referred to urgent care; two withdrew prior to randomization. The final sample included 51 participants (39 women, 12 men), who were randomized in a 1:1 ratio to either the UA-UP treatment arm (n = 25) or a wait-list control (n = 26). Randomization was performed using a computer-generated sequence by an independent researcher, and allocation concealment was maintained via sequentially numbered, sealed, opaque envelopes, opened only after eligibility was confirmed.

Baseline characteristics

Baseline demographic and clinical characteristics of the randomized participants (N = 51) are presented in Table 1.

Table 1.

Baseline information of the randomized participants (N = 51)

Parameter	Total (N = 51)	Experimental (n = 25)	Control (n = 26)
Gender
Male	13 (23.5%)	5	8
Female	38 (76.5%)	20	18
Age (M, SD)	31.38 (9.54)	26.88 (8.28)	30.88 (9.81)
Marital Status
Unmarried	35 (62.8%)	16	19
Married	15 (29.4%)	8	7
Divorced	1 (2.0%)	1	0
Education Level
Matric	3 (5.9%)	1	2
Intermediate	11 (21.6%)	6	5
Bachelors	28 (54.9%)	15	13
Masters or above	9 (17.6%)	3	6
Employment Status
Employed	19 (37.3%)	8	11
Unemployed	32 (62.7%)	17	15
Principal Diagnosis
MDD	11 (21.6%)	5	7
Dysthymia	8 (15.7%)	5	3
GAD	13 (25.5%)	6	7
Panic/Agoraphobia	7 (13.7%)	4	3
Social Anxiety	6 (11.8%)	2	4
Illness Anxiety	2 (3.9%)	0	1
Adjustment Disorder	4 (7.8%)	3	1
No. of Diagnoses
1	14 (27.5%)	6	8
2	18 (35.3%)	10	8
3	13 (25.5%)	7	6
> 3	6 (11.8%)	2	4
Mental Health Measures (M, SD)
BAI	—	31.60 (14.80)	33.05 (25.51)
BDI	—	37.26 (15.44)	38.73 (17.72)
WSAS	—	17.30 (3.06)	16.78 (4.38)
OASIS	—	15.82 (3.09)	13.47 (3.40)
ODSIS	—	13.52 (4.90)	12.36 (5.08)
DERS	—	126.3 (26.77)	125.0 (25.37)
PANAS (P)	—	16.21 (1.85)	16.47 (1.46)
PANAS (N)	—	40.91 (3.44)	41.05 (3.44)

Note. MDD = major depressive disorder; GAD = generalized anxiety disorder; BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory–II; WSAS = Work and Social Adjustment Scale; OASIS = Overall Anxiety Severity and Impairment Scale; ODSIS = Overall Depression Severity and Impairment Scale; DERS = Difficulties in Emotion Regulation Scale; PANAS (P/N) = Positive/Negative Affect Schedule. Group comparisons used two-tailed tests

Treatment conditions

UA-UP treatment

The UP is a T- CBT based treatment targeting heightened emotional reactivity and maladaptive emotion-regulation strategies [33]. The Urdu Adaptation (UA-UP) retains all eight UP modules including motivation enhancement, psychoeducation, mindful emotion awareness, cognitive flexibility, countering emotional behaviors, interoceptive exposure, situational exposure, and relapse prevention, while incorporating culturally relevant idioms, metaphors, examples, and Urdu terminology [21]. Participants received 14 weekly sessions, each 50–60 min long. Each session followed a 10-min homework review, 30 min of new skill practice, and 10 min of homework planning. During these sessions, the therapist used a participatory inductive approach to simplify concepts, encouraged participants to relate their experiences to treatment concepts, and emphasized empathy and validation. The therapy process focused on understanding and exploring the clients’ experiences throughout the sessions, helping them to actively engage in their personal growth and emotional processing. Treatment was delivered by a clinical psychologist (A.N., the primary researcher) who completed an 18-week online UP training course and received weekly clinical supervision via videoconference prior to trial delivery. As part of this pre-trial training process, the therapist delivered a full course of treatment to a separate training client; with this client’s written consent and verbal reconfirmation, 20 training sessions were audio-recorded, transcribed, translated into English, and reviewed by a certified-UP trainer (A.A.A.) to support treatment adherence and clinical feedback. The UA-UP treatment was subsequently delivered to participants in the present pilot trial.

Wait-list control

Participants in the wait-list control group did not receive active treatment during the 14-week study period but completed the same assessments as the treatment group at three time points: baseline (T1), mid-treatment (week 7) (T2), and post-treatment (T3). The wait-list condition was selected because the present study was an early-stage pilot feasibility trial focused primarily on assessing feasibility and acceptability outcomes rather than establishing definitive comparative effectiveness. Treatment as usual (TAU) was not selected as the comparator because TAU conditions can be highly heterogeneous, ranging from minimal or unknown mental health care to structured psychotherapeutic input, which can complicate interpretation in small trials [34]. In addition, routine care for common mental disorders in Pakistan is often constrained by limited-service availability and may vary considerably across settings [35]. Including TAU in this small pilot trial would therefore have introduced heterogeneity that was beyond the scope of the study objectives. Upon study completion, control participants were provided referral information for accessing psychological care, in accordance with ethical guidelines.

Procedure

Participants in the UA-UP arm attended 14 weekly, individual face-to-face sessions (50–60 min each) at the university counselling center, while wait-list controls received no treatment during the study period. Both groups completed the full set of demographic and mental health questionnaires at three time points: T1, T2, and T3. The UA-UP group also completed two brief post-treatment measures assessing treatment engagement and satisfaction. Participants in the treatment group received weekly reminders via SMS and email to attend sessions and complete their homework, while both the treatment and control groups were reminded to complete their assessments. All compliance data were logged for feasibility analyses. Following completion of treatment, participants in the UA-UP group were invited to a 20–25-minute semi-structured interview exploring perceptions of treatment acceptability. Interviews were conducted in a private consultation room by an independent clinical psychologist unaffiliated with treatment delivery. Written informed consent was obtained at enrollment, and verbal consent was reconfirmed immediately before interview recording. All interviews were audio-recorded, transcribed verbatim, and analyzed thematically using Braun and Clarke’s framework [36].

Outcome measures

The primary outcomes of this study were feasibility and acceptability indicators, while clinical measures were assessed as exploratory secondary outcomes. Feasibility was assessed across six trial domains.

Recruitment methods were evaluated by calculating the number of participants enrolled through each strategy including online dissemination, community outreach, and professional referral, as well as each method’s proportional contribution to the total sample.

Recruitment and retention were assessed through several indicators: the volunteer rate (proportion of individuals approached who consented to participate), screening success rate (proportion who met inclusion criteria after initial screening), retention rate (proportion of enrolled participants who completed the study), drop-out rate (participants who discontinued prematurely), and final-assessment completion rate for both groups.

Eligibility criteria feasibility was examined by determining the percentage of participants who met inclusion criteria at both screening and diagnostic stages. Reasons for ineligibility such as high suicide risk, medical conditions, age restrictions, or concurrent treatment were also recorded to inform future adaptations.

Attendance at face-to-face sessions was used to evaluate the practicality of delivering the UA-UP. This included session attendance rates, frequency of scheduling adjustments, and documented barriers to participation (e.g., work obligations, childcare, or transportation issues).

Outcome measure feasibility was assessed by calculating completion rates at baseline, mid-treatment, and post-treatment. These were defined as the percentage of participants who fully completed all questionnaires. High completion rates were taken as evidence of procedural feasibility; low rates suggested issues with burden or relevance.

Randomization procedures were reviewed to confirm adherence to the computer-generated allocation schedule. The proportion of participants randomized exactly as assigned was calculated, with any deviations classified as misallocations.

Acceptability of trial

The acceptability of the randomization process was assessed by calculating the proportion of eligible participants who consented to random allocation. Reasons for declining such as strong treatment preference, concerns about being assigned to the control group, or logistical constraints were recorded. A high consent rate was interpreted as evidence of procedural acceptability.

Attrition was assessed at T1, T2, and T3 by calculating the proportion of participants lost to follow-up at each time point. Dropout rates were calculated by dividing the number of withdrawals at each stage by the number of participants retained from the prior time point.

Acceptability of the treatment

Treatment engagement was assessed through homework completion and responses to the Urdu-adapted Homework Rating Scale–Revised (HRS-II) [37]. At each session, participants rated their homework completion on a three-point scale: completed, partially completed, or not completed. The HRS-II assessed participants’ perceptions of homework relevance, perceived consequences of non-completion, invested effort, and follow-through. The Urdu version of the HRS-II demonstrated strong internal consistency (α = 0.91) in this sample.

Treatment satisfaction was evaluated using both quantitative and qualitative methods. The Urdu version of the Client Satisfaction Questionnaire (CSQ-8) [38, 39] measured global satisfaction across eight items, with scores ranging from 8 to 32; higher scores indicate greater satisfaction. CSQ-8 demonstrated high internal reliability (α = 0.94) in the current sample.

In addition, semi-structured interviews were conducted to explore participants’ subjective experiences of treatment. Questions probed the usefulness of techniques, clarity of the session content, any discomfort or challenges, likelihood of choosing the treatment again, willingness to recommend it to others, and suggestions for improvement. (See Supplementary File 1 for the full interview guide)

Mental health outcome measures

Beck anxiety inventory

The BAI is a self-report tool that assesses anxiety symptom severity through a 21-item questionnaire, with higher scores indicating higher anxiety levels [30]. The current study used the Urdu version [40], which showed excellent internal consistency (α = 0.90).

Beck depression inventory-II

The BDI-II is a 21-item self-report questionnaire to evaluate depressive symptoms, with higher scores indicating severe symptoms [31]. The Urdu version used in this study demonstrated excellent reliability (α = 0.92) [41].

Structured clinical interview for diagnostic and statistical manual of mental disorders-5, the research version (SCID-5-RV)

The SCID-5-RV is a semi-structured diagnostic interview for assessing DSM-5 disorders [32]. It was used to confirm eligibility and rule out exclusions such as bipolar disorder, substance use, or psychosis. The items are scored on a scale of 1 to 3. A higher score on this scale suggests the presence of a mental condition.

Work and social adjustment scale (WSAS)

It is a recognized measure of functional impairment, having 5 eight-point severity items, scoring up to 40 points in total severity [42]. The WSAS showed high internal consistency in this sample (α = 0.89).

Difficulties in emotion regulation scale (DERS)

The DERS is a 36-item tool that contains 6 subscales. It measures a person’s competency in managing emotions and their emotional responses [43]. The subscales evaluate acceptance of emotional responses, purposeful behavior performance, impulse control, emotional awareness, emotion regulation strategies availability, and emotional clarity. The items range from 1 to 5, with higher values reflecting more severe emotion regulation issues. The scale demonstrated strong reliability (α = 0.87).

Positive and negative affect schedule (PANAS)

This is a self-report measure that assesses the two broad dimensions of affect: positive affect and negative affect [44]. The items are rated on a 5-point scale, with higher scores indicating greater experience of the evaluated emotions. The Urdu version used in this study demonstrated good reliability for both subscales (α = 0.86 for Positive Affect, α = 0.84 for Negative Affect) [45].

Overall depression severity and impairment scale (ODSIS)

It uses a 5-point Likert scale to evaluate the frequency, severity, and impacts of depression symptoms on pleasurable activities, work or school performance, and interpersonal relationships [46]. Scores range from 0 to 20, with higher scores indicating more severe depression and impairment. Internal consistency in this study was excellent (α = 0.90).

Overall anxiety severity and impairment scale (OASIS)

It is a 5-item scale, scored on a scale of 0–4 to assess the frequency and severity of symptoms, along with the impairments in enjoyable activities, work, school, and interpersonal relations [47]. The scale demonstrated strong reliability (α = 0.88).

Data analysis

This study used a convergent-parallel mixed-methods design, analyzing quantitative and qualitative data independently prior to integration to assess the feasibility, acceptability, and preliminary effectiveness of the UA-UP treatment.

Quantitative data were analyzed in SPSS Statistics (Version 26). Descriptive statistics (means, standard deviations, frequencies, and percentages) were used to summarize key feasibility indicators. A general linear model (GLM) with repeated measures was used to assess within-subject effects (across three time points) and between-subject effects (UA-UP vs. control group). Prior to analysis, the dataset was screened for missing values, outliers, and data entry inconsistencies. Missing data were minimal and handled using pairwise deletion.

Qualitative data from semi-structured interviews were analyzed using reflexive thematic analysis, following Braun and Clarke’s framework [36]. A combined inductive–deductive coding approach was employed to explore participants’ experiences, perceived changes, barriers to engagement, and suggestions for improvement. Coding and theme development were conducted by the primary researcher, with ongoing reflexive journaling used to monitor positionality and reduce bias. Emerging themes were reviewed iteratively to ensure they captured both anticipated and unexpected perspectives.

Quantitative and qualitative findings were compared during the interpretation phase to identify convergent, divergent, and complementary insights, thereby strengthening the study’s conclusions about the treatment’s feasibility, acceptability, and preliminary outcomes. All analyses of clinical outcomes were exploratory in nature.

Ethical considerations

The study received ethical clearance from the School of Social Sciences and Humanities Ethics Committee at the National University of Sciences and Technology (Reference 0098/Ethic/01/S3H/083/DBS). The trial protocol and statistical analysis plan can be accessed at ClinicalTrials.gov using the trial identifier NCT06002087. All volunteers were given a written information sheet and a verbal briefing describing aims, procedures, potential risks, and benefits. Written informed consent was obtained before enrolment; verbal confirmation was documented again at the baseline interview. Confidentiality was ensured through de-identified data storage and password-protected files. Participants identified as having high suicide risk during screening were withdrawn and referred to appropriate clinical services.

Participant data and statistical code may be made available from the corresponding author upon reasonable request and in accordance with ethical guidelines and the journal’s data-sharing policy.

Results

Trial feasibility

Participant flow

Figure 1 presents the CONSORT diagram summarizing participant recruitment, eligibility screening, randomization, and follow-up across the two study arms.

Recruitment strategies

A total of 63 participants were recruited: online dissemination (52.4%), community outreach (28.6%), and referrals (19.0%) (see Table 2).

Table 2.

Recruitment methods used in the study

Recruitment strategy	n (%)
Online dissemination	33 (52.4)
Community outreach	18 (28.6)
Referrals	12 (19.0)

Recruitment and retention rates

Feasibility of recruitment and retention was demonstrated through high success rates (see Table 3).

Table 3.

Recruitment and retention outcomes

Indicator	Total (n)
Initial Approached Participants	63
Screening Success Rate	61/63 (96.8%)
Participants Eligible for Study	54
Participants Retained (Until Allocation)	51/54 (94.4%)
Completion Rate	42/51 (82.4%)
Experimental Group	23/25 (92.0%)
Control Group	19/26 (73.1%)

Attendance at face-to-face sessions

Session attendance was high: with 23 of 25 participants in the treatment group (92.0%) completing the 14-week UA-UP treatment. Twenty-one participants attended all sessions without reported difficulty, while two participants required minor scheduling adjustments due to work or childcare responsibilities; these sessions were rescheduled within the same week. Two participants withdrew from the treatment group due to transportation difficulties, with one also reporting educational commitments that interfered with continued attendance. Participants did not receive travel reimbursement or other forms of support to facilitate attendance at face-to-face sessions.

Eligibility criteria

The eligibility criteria were found to be appropriate and practical, with minimal exclusions across screening stages (see Table 4).

Table 4.

Feasibility of eligibility criteria

Stage	Participants Screened (n)	Excluded (n)	Success Rate (%)
Initial Screening	63	2	96.8%
Diagnostic Interview	54	1	98.1%

Completion of outcome measures

Completion rates were consistently higher in the treatment group, indicating strong engagement with assessment protocols (see Table 5).

Table 5.

Completion rates for outcome measures

Assessment Point	Experimental Group (n, %)	Control Group (n, %)	Total (n, %)
Baseline Assessment	25 (100%)	26 (100%)	51 (100%)
Mid-Assessment	23 (92.0%)	21 (80.8%)	44 (86.3%)
Post-Treatment Assessment	23 (92.0%)	19 (73.1%)	42 (82.4%)

Randomization procedures

Randomization was executed without error, adhering fully to the pre-specified, computer-generated allocation sequence. There were no deviations or misallocations. Baseline comparability between the treatment and control groups was confirmed across demographic and clinical variables (see Table 1).

Trial acceptability

Trial acceptability was high, with all 51 eligible participants consenting to randomization, reflecting a 100% acceptance rate. However, participant attrition occurred over the course of the study, with 9 individuals (17.6%) discontinuing prior to post-treatment assessment. The final trial completion rate was 82.4% (42/51), indicating generally strong adherence to study procedures and support for the acceptability of the trial design.

Treatment acceptability

Treatment engagement

Engagement with the UA-UP was assessed through homework completion rates and participant responses on the Homework Rating Scale–Revised (HRS-II) [33]. On average, participants completed 81.8% of assigned homework tasks across the treatment modules, reflecting a high level of adherence (see Fig. 2).

Fig. 2.

Homework completion rates by module (N = 23). ARC = Antecedents, Responses, and Consequences

Responses on the HRS-II indicated strong overall engagement (see Table 6). Participants rated their understanding, perceived relevance, and collaboration in homework planning highly. Key indicators such as comprehension, rationale for tasks, alignment with therapy goals, and perceived mastery, all received mean scores above 3.7 on a 4-point scale. Ratings for difficulty and perceived obstacles were noticeably lower, suggesting that participants generally found the tasks manageable and motivating.

Table 6.

Descriptive statistics for HRS-II indicators (N = 23)

HRS-II Indicator	M	SD
HRS (total score)	41.73	3.70
Quantity	3.22	0.42
Quality	3.48	0.51
Difficulty	1.74	1.45
Obstacles	1.78	0.42
Comprehension	3.74	0.45
Rationale for doing Homework	3.83	0.39
Collaboration	3.83	0.39
Specificity with Treatment Instructions	3.87	0.34
Match with Therapy Goals	3.78	0.42
Pleasure	3.74	0.45
Mastery with Therapy Skills	3.74	0.45
Progress	3.74	0.45

Treatment satisfaction

Participants in the UA-UP group reported high overall satisfaction, with mean total scores reflecting strong approval across all eight items. These findings suggest that participants found the treatment to be both valuable and acceptable (see Fig. 3).

Fig. 3.

Descriptive statistics for CSQ-8 item scores (N = 23)

Perceived effectiveness of UA-UP

Findings from post-treatment qualitative interviews revealed three overarching themes capturing participants’ perceptions of the UA-UP’s effectiveness. Each theme includes multiple subthemes, reflecting the progression from initial engagement with the treatment to overcoming barriers and achieving meaningful therapeutic gains. A summary of themes, subthemes, and illustrative participant quotes is presented in Supplementary File 2.

Theme 1: Therapeutic processes

Participants described the UA-UP as providing structured tools for understanding, regulating, and responding to difficult emotions. The treatment was experienced as a gradual process, beginning with increased awareness, followed by the development of regulation and cognitive skills, and progressing toward behavioral engagement and emotional acceptance.

Self-awareness. Participants consistently described increased awareness of their emotional experiences as a central aspect of the intervention. They reported greater recognition of emotional triggers and connections between thoughts, feelings, and behaviors. Structured activities such as journaling and guided reflection were frequently mentioned as facilitating this awareness. For example, one participant stated: “I didn’t even realize how much I was holding back. Writing about my emotions helped me see patterns I wasn’t aware of, and it motivated me to start changing those behaviors.” Participants described these experiences as helping them better understand their emotional patterns.

Emotion regulation. Participants described acquiring practical skills, including mindfulness, breathing techniques, and cognitive flexibility strategies, which they reported using in daily situations. These techniques were described as helping them pause and respond more deliberately to emotional experiences. One participant noted: “I used to feel like my emotions controlled me. But when I practiced mindfulness, it was like I finally had the power to stop and breathe, to be present and not spiral into panic.” Some participants also described changes in how they managed interpersonal situations, particularly within family contexts.

Cognitive restructuring. Participants described using structured techniques to identify and re-evaluate unhelpful thoughts, including the “Three Component Model.” These strategies were reported as helping them examine self-critical beliefs and consider alternative perspectives. One participant explained: “I used to think I wasn’t good enough, and it held me back from doing so many things. The exercises showed me how to challenge those thoughts and see myself differently. It gave me the confidence to try again.” Participants described these techniques as useful in reconsidering previously held beliefs.

Reduced avoidance. Participants described engaging in gradual exposure tasks that involved confronting situations they had previously avoided. These activities were often described as challenging initially but manageable when introduced step-by-step. One participant shared: “I avoided meeting new people for years because I was scared of being judged. The exposure tasks started small, like just saying hello, and then built up. Now I can go to social events without feeling that fear anymore.” Participants reported increased willingness to engage in situations they had previously avoided.

Emotional acceptance. Participants described changes in how they related to their emotions, particularly a shift from suppression or judgment toward acknowledgment. Emotional experiences were increasingly described as manageable rather than overwhelming. One participant reflected: “I always thought feeling sad or scared meant I was weak. But the therapist helped me see that emotions are normal. When I started accepting them, I felt lighter and more in control.” Participants described this shift as influencing how they responded to emotional experiences in daily life.

Theme 2: Overcoming initial discomfort

Participants described experiencing an initial period of emotional or psychological discomfort during the early stages of the UA-UP. This discomfort was often reported in relation to engaging with challenging material and unfamiliar therapeutic tasks. Over time, participants described becoming more accustomed to these experiences and continuing their engagement with the intervention.

Perseverance. Participants described the need to persist through early discomfort, particularly during tasks involving exposure or confronting previously avoided situations. Initial sessions were sometimes described as difficult or emotionally demanding. One participant shared: “At first, I didn’t want to do the tasks because they felt too hard. But when I kept trying, little by little, I started to feel stronger, and things got easier.”

Some participants described maintaining engagement by focusing on their reasons for participating in the intervention. As one participant explained: “Keeping my focus during the exercises was tough in the beginning, but I kept reminding myself why I was doing this. With time, I got the hang of it, and it became part of my routine.” Participants described continuing with the tasks despite initial hesitation or discomfort.

Visible change. Participants described noticing changes in their emotional responses, thoughts, and behaviors over time. These changes were often identified through specific examples from daily life. One participant reflected: “At the start, I wasn’t sure if this would work, but then I saw myself reacting differently in situations that used to make me anxious. That gave me hope and made me want to keep going.”

Some participants described engaging in previously avoided situations or managing emotional reactions differently. For example, one participant shared: “I used to avoid social gatherings completely, but after practicing the techniques, I went to a family event and didn’t feel the need to leave. That was a big step for me.” Participants described these changes as noticeable within their everyday experiences.

Therapist’s empathic presence. Participants described the therapist’s interpersonal style as supportive, nonjudgmental, and patient. This was frequently mentioned in relation to their willingness to engage with the intervention. One participant explained: “I was so nervous about being judged, but the therapist was so kind and patient. Even when I struggled, they never made me feel bad about it.”

Participants also described the therapist as adjusting the pace of the sessions and providing encouragement. As one participant noted: “The therapist didn’t push me too hard; they made sure I was ready for each step. That made all the difference because I felt supported rather than overwhelmed.” Participants described these interactions as contributing to their continued participation in the sessions.

Theme 3: Outcome/Therapeutic change

Participants described a range of changes across emotional, cognitive, behavioral, and interpersonal domains following the intervention. These experiences were reflected in five interrelated subthemes: personal growth, self-image, relationships, emotional well-being, and problem-solving.

Personal growth and self-understanding. Participants described increased reflection on their thoughts, emotions, and personal goals. Structured exercises were reported as facilitating awareness of previously unexamined aspects of their experiences. One participant noted: “I explored sides of myself that I didn’t know existed. I learned a lot about who I am and what I want. For a long time, I was underestimating myself, but now I see my potential.”

Some participants also described changes in their ability to manage daily challenges. As another participant shared: “I feel like I have certain tools now to deal with things. My mind is calmer, and I’m improving my focus every day.”

Improved self-image. Participants described changes in how they viewed themselves, including reduced self-criticism and increased confidence. These changes were often linked to engagement with cognitive and behavioral techniques. One participant stated: “I used to think I wasn’t good enough for anything. But through this program, I’ve learned to see my strengths and value myself more. I feel more confident now.” Participants also described approaching challenges with greater confidence and persistence.

Enhanced relationships and social interactions. Participants described changes in their interpersonal interactions, particularly within family contexts. These included increased communication and reduced avoidance of conflict. One participant explained: “I used to stop talking to my in-laws whenever things got tense, but I realized that it didn’t bring me peace. Now, I let them visit me, and I go to see them too. It’s gradual, but it feels nice, and my relationship with my spouse has also improved.” Another participant noted: “We talked about how to communicate better with my husband. That made me feel seen because family is such an important part of my life.”

Emotional well-being. Participants described changes in their emotional experiences, including feeling calmer and less reactive. They reported using strategies learned during the intervention to manage emotional responses. One participant shared: “I can be calmer and manage my anger now. I used to get so overwhelmed that I couldn’t focus on anything, but now I know how to handle those moments.” Participants described these changes as part of their everyday emotional experiences.

Problem-solving and decision-making. Participants described changes in how they approached challenges and decision-making. They reported being more deliberate and less avoidant in their responses to difficult situations. One participant explained: “I used to choose the easiest option in the moment, even if it caused problems later. Now, I think ahead and tackle things that are hard but necessary. It’s helped me in so many ways.”

Another participant added: “I feel like I can solve problems better now because I’m not reacting emotionally all the time. I can step back, think, and figure out what to do.” Participants described approaching problems in a more structured and considered manner.

Following the qualitative findings, quantitative results on mental health outcomes are presented below.

Quantitative outcomes

Table 7 presents descriptive statistics for outcome measures across three time points, along with exploratory effect size estimates.

Table 7.

Descriptive statistics and exploratory effect size estimates for outcome measures across time (N = 42)

Outcome Measure	Group	T1 M(SD)	T2 M(SD)	T3 M(SD)	Partial η²	95% CI (LL–UL)
BAI	Experimental	31.60 (14.80)	32.17 (10.23)	16.91 (11.07)	0.136	0.056–0.216
	Control	33.05 (15.51)	32.15 (14.75)	31.00 (15.11)
BDI	Experimental	37.26 (15.44)	27.60 (7.42)	15.30 (11.22)	0.295	0.209–0.381
	Control	38.73 (15.72)	36.15 (13.09)	35.89 (13.88)
WSAS	Experimental	17.30 (3.06)	15.43 (4.33)	4.52 (3.31)	0.538	0.448–0.628
	Control	14.78 (4.38)	13.00 (5.88)	11.10 (6.15)
OASIS	Experimental	15.82 (3.09)	10.91 (3.11)	4.82 (2.38)	0.598	0.509–0.687
	Control	11.47 (5.40)	13.31 (5.24)	13.47 (4.20)
ODSIS	Experimental	13.52 (4.90)	8.39 (1.92)	5.04 (2.99)	0.347	0.192–0.496
	Control	9.36 (7.08)	11.73 (7.08)	8.78 (6.19)
DERS	Experimental	126.30 (26.77)	116.47 (20.54)	89.17 (26.92)	0.165	0.075–0.255
	Control	118.00 (24.37)	126.20 (22.72)	118.30 (25.29)
PANAS – Positive	Experimental	16.21 (1.85)	28.73 (2.47)	38.30 (2.73)	0.571	0.481–0.661
	Control	16.47 (1.46)	16.42 (1.57)	19.78 (4.91)
PANAS – Negative	Experimental	40.91 (3.44)	24.13 (2.37)	13.78 (2.06)	0.565	0.474–0.656
	Control	41.05 (3.44)	36.63 (15.48)	35.00 (9.74)

M = Mean; SD = Standard Deviation; BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; WSAS = Work and Social Adjustment Scale; OASIS = Overall Anxiety Severity and Impairment Scale; ODSIS = Overall Depression Severity and Impairment Scale; DERS = Difficulties in Emotion Regulation Scale; PANAS-P = Positive Affect Schedule; PANAS-N = Negative Affect Schedule; η² = partial eta squared; CI = confidence interval

Across the study period, participants in the experimental group demonstrated greater reductions in anxiety, depression, and functional impairment compared to the waitlist control group. Improvements were also observed in emotion regulation and positive affect, alongside reductions in negative affect. In contrast, changes in the control group were smaller and less consistent across time points.

Descriptive statistics are presented to illustrate observed trends over time. Effect size estimates (partial eta squared and 95% confidence intervals) are reported for estimation purposes only and should be interpreted with caution given the pilot nature of the study. These estimates are exploratory and not intended for hypothesis testing.

A joint display table integrating quantitative and qualitative findings across feasibility, treatment engagement, satisfaction, and clinical outcomes is provided in Supplementary File 3. This table presents areas of convergence, divergence, and complementarity across data sources.

Discussion

This pilot trial demonstrates the feasibility, acceptability, and preliminary signals of clinical improvement of the culturally adapted UA-UP in treating depression and anxiety in Pakistani adults. Outcomes align with previous UP studies across diverse populations, supporting its adaptability for low-resource, high-need settings.

Recruitment through digital platforms proved the most effective, supported by existing literature on the reach and efficiency of online strategies [48]. However, community outreach and referrals also contributed meaningfully, suggesting that a combined strategy enhances accessibility across varying trust levels and digital access [49]. Furthermore, retention and session adherence were strong, suggesting that participant-centered delivery and cultural relevance supported sustained engagement. These patterns are consistent with culturally adapted UP studies, where attrition has been notably lower than standard protocols [50, 51]. At the same time, the retention findings should be interpreted in light of the practical demands of attending university-based face-to-face sessions. Although most participants were retained, two treatment-group participants withdrew because of transportation difficulties, with one also reporting educational commitments. This suggests that treatment acceptability alone may not fully overcome access-related barriers in low-resource settings, particularly for participants with limited financial flexibility or competing educational, work, or family responsibilities [52]. The screening protocol was efficient and inclusive, maintaining diagnostic rigor while minimizing exclusions, supporting its appropriateness for future scaled trials. Outcome measures completion remained high across assessment points, reflecting both the clarity of procedures and strong participant engagement, despite minor expected declines due to fatigue and other related factors.

Therapeutic engagement was further evident in participants’ sustained involvement with core treatment practices like mindfulness, exposure, and interoceptive techniques. The treatment’s structured and experiential design especially modules like the “Three Component Model” appears to have promoted a sense of mastery, reinforcing findings that concrete behavioral tasks improve engagement [52]. Consistently high ratings on the HRS-II, particularly in collaboration and relevance, suggest that the treatment struck an effective balance between structure and personalization [53].

Cultural adaptation likely contributed to this engagement by aligning therapeutic content with participants’ lived realities such as familial interdependence, emotional restraint, and gradual change, an approach previously shown to increase trust and relevance [54]. The minimal burden reported by participants further supports the program’s appropriateness for low-resource settings. These findings extend the growing literature on the UP’s transdiagnostic applicability [55, 56] and offer encouraging evidence that culturally tailored treatments can be feasible, acceptable, and clinically meaningful in LMICs as well.

The present findings are also consistent with Pakistan-based evidence showing that culturally adapted psychological interventions can be feasible and acceptable when they respond to local language, explanatory models, family structures, and service constraints. Naeem and colleagues’ work on culturally adapted CBT, including the Southampton Adaptation Framework, emphasizes that adaptation should extend beyond translation to include culturally meaningful examples, idioms of distress, therapist–client communication, family and social context, and barriers to engagement [57–59]. Similarly, Husain and colleagues have demonstrated the feasibility of culturally adapted psychosocial interventions in Pakistan, including group psychosocial treatment for depression in primary care and manual-assisted problem-solving approaches for self-harm [60]. Evidence from the Thinking Healthy Program and Problem Management Plus further shows that structured psychological interventions can be delivered through community, primary-care, and routine-care pathways, while highlighting challenges such as limited specialist workforce, access barriers, and the need for training and supervision [35, 61]. The present study extends this local evidence base by evaluating the UA-UP for adults with anxiety and depression, using a transdiagnostic approach that targets shared emotional processes across comorbid presentations in a setting where specialist psychological care remains limited [62, 63].

Integration of quantitative and qualitative data provided a nuanced understanding of the UA-UP’s acceptability and perceived effectiveness. High scores on the CSQ-8 align with findings from similar CBT trials in LMICs [64], and the unanimous recommendation by participants suggests strong endorsement of the treatment. While slightly lower ratings on service quality reflect the expected logistical limitations in low-resource settings, overall satisfaction appears driven more by the treatment’s perceived relevance than by infrastructure quality.

Qualitative findings complemented these results by illuminating the processes underpinning satisfaction. Participants emphasized the value of culturally attuned strategies such as mindfulness, exposure, and cognitive restructuring that directly addressed their emotional and interpersonal challenges. These techniques were described not only as helpful for symptom relief but as tools that resonated with broader sociocultural priorities, particularly around family harmony, self-restraint, and social responsibility. This alignment likely contributed to participants’ willingness to remain engaged, echoing broader evidence that culturally congruent treatments enhance both adherence and outcomes [65].

Such congruence is consistent with literature on culturally adapted transdiagnostic protocols, where flexibility and values-based content are key drivers of engagement [66]. In this context, participant reflections suggest that acceptability was not merely a function of clinical outcomes but was deeply rooted in the treatment’s fit with participants’ lived experiences. As reported in prior UP studies [67], satisfaction increased when therapeutic tools were perceived as personally relevant and actionable, similar pattern was mirrored in the current sample’s feedback on task-specific gains and emotional insight.

Comparisons with other UP feasibility studies also support the treatment’s cultural fit. Participants in this face-to-face trial reported greater satisfaction than those in a recent internet-delivered UP study in Iran [68], particularly in ratings of overall satisfaction and willingness to recommend. While these differences may reflect advantages of in-person formats such as stronger therapeutic alliance, they also suggest that the UA-UP’s emphasis on relational and culturally grounded content played a key role in participant engagement.

In sum, the combined findings affirm the UA-UP’s high acceptability and relevance in the Pakistani context. By integrating transdiagnostic techniques with culturally aligned delivery, the treatment addressed both clinical needs and contextual realities. These outcomes support growing international evidence for the adaptability of the UP in LMIC settings [13, 14, 68], and highlight the value of mixed methods in capturing the full scope of treatment impact.

This pilot trial provides preliminary support for the UA-UP’s effectiveness in reducing symptoms of anxiety and depression while enhancing work and social functioning in Pakistani adults. These outcomes are consistent with the UP’s transdiagnostic focus on emotion regulation as a core mechanism of change and align with global findings demonstrating the UP’s capacity to improve affective functioning and daily adjustment [69, 70].

Observed improvements in both positive and negative affect mirror results from prior UP trials conducted in Western and non-Western contexts [55, 70], suggesting cross-cultural consistency in emotional outcomes. Notably, gains in positive affect parallel those reported in Japan [12], while reductions in emotional distress align with findings from other LMIC studies such as those in Iran [15, 68] and among Spanish-speaking populations [71]. These parallels point to the protocol’s cultural adaptability and therapeutic relevance in diverse settings. Improvements in functional outcomes further echo previous research demonstrating the UP’s impact on real-world adjustment [69], reinforcing its value as a scalable treatment in resource-limited contexts.

As a pilot study, these findings must be interpreted with caution. The modest sample size limits generalizability, and effect sizes should be viewed as preliminary. However, the patterns of change observed are consistent with those reported in similarly sized trials (e.g., [28, 65]), suggesting the UA-UP may offer clinically meaningful benefits. Reported improvements in functional and affective domains such as work adjustment, daily impairment, and emotional vitality appeared particularly robust, which may reflect the UP’s emphasis on enhancing emotional flexibility rather than symptom elimination alone [66, 72].

This pattern aligns with recent conceptualizations of the UP that prioritize mechanism-driven outcomes. Rather than aiming solely to reduce symptom intensity, the treatment targets maladaptive emotional responses and avoidance patterns, fostering greater tolerance, psychological flexibility, and engagement with daily life. This was reflected in participants’ qualitative accounts, many of whom described continued emotional reactivity accompanied by improved functioning, captured in statements like “still feeling nervous but functioning better.” Such perspectives underscore the importance of broadening success criteria beyond symptom reduction to include shifts in emotional processing and behavioral capacity.

These findings also point to key considerations for future trials. In LMIC contexts, where functionality, relational obligations, and resilience often carry more weight than symptom counts alone, outcome measures should be chosen to reflect locally meaningful markers of recovery. Integrating culturally sensitive, function-focused metrics could provide a more accurate picture of treatment impact and better inform implementation strategies.

The results of this feasibility trial provide critical groundwork for advancing to a fully powered RCT to evaluate the efficacy of the UA-UP in a low-resource setting. High recruitment and retention rates, successful implementation of the treatment protocol, strong participant engagement, and acceptable completion of outcome measures collectively demonstrate that the core procedures of a definitive trial are viable. Furthermore, preliminary trends in clinical outcomes and exploratory effect sizes offer valuable guidance for estimating sample size and prioritizing outcome domains in a future trial. These findings confirm that the current study has achieved its feasibility objectives and offer a clear pathway for scaling up to a hypothesis-driven RCT with appropriate statistical power, long-term follow-up, and potential for broader implementation across LMICs.

Limitations

This study has several limitations relevant to its feasibility focus. First, the trial was conducted in a single urban university-based setting, potentially limiting generalizability to rural or under-resourced regions where access to psychological care, digital infrastructure, literacy levels, and sociocultural norms may differ. Because participants were recruited primarily through online methods and received treatment in a university-based setting, the sample may not fully represent individuals who seek care through primary healthcare services or community-based settings. Future feasibility studies should include diverse geographic sites and primary healthcare or community-based delivery settings to enhance external validity.

Second, although the sample size was appropriate for a feasibility design, it limits statistical power and limits conclusions about efficacy. Larger trials are needed to confirm treatment effects and evaluate subgroup differences in future randomized controlled trials.

Third, the demographic profile of participants, who were predominantly unemployed and more educated than the general Pakistani population, may reduce representativeness. Although employment status was collected, formal household income and broader socioeconomic status indicators were not assessed, limiting our ability to determine how economic factors influenced treatment attendance and engagement. Additionally, online recruitment may have excluded individuals with limited digital access or lower literacy. Future studies should use targeted recruitment strategies to improve inclusion of underrepresented groups, systematically assess travel distance and transport costs, and consider strategies such as travel reimbursement, community-based delivery sites, or hybrid/remote formats to improve inclusion and retention.

Fourth, the absence of a follow-up period limits conclusions regarding the sustainability of observed improvements. Assessing long-term outcomes is a critical next step in establishing the treatment’s durability. Furthermore, the use of a waitlist control group, while appropriate for an early-phase trial, limits interpretability regarding comparative effectiveness. Differences between groups may have reflected non-specific treatment factors, expectancy effects, regression to the mean, or spontaneous recovery. Future fully powered trials should consider TAU or another active comparator to better situate the UA-UP relative to standard care or other evidence-based treatments.

Finally, all UA-UP sessions were delivered by a single therapist, who was also the primary researcher. This approach was appropriate for an early-stage pilot feasibility trial and helped support consistency of delivery during the initial evaluation of the culturally adapted treatment. Treatment consistency was further supported through prior UP training, clinical supervision, and adherence to the standard UP module sequence and session structure. Nevertheless, therapist allegiance and competence effects cannot be fully ruled out, and the single-therapist design limits conclusions regarding scalability across providers and settings. Future trials should include multiple therapists, independent fidelity assessment, and procedures to examine whether the UA-UP can be delivered consistently by different providers in routine care contexts.

Conclusion

This pilot study provides promising preliminary evidence supporting the feasibility and acceptability of the UA-UP for treating common emotional disorders in a Pakistani population. High retention, strong treatment engagement, and positive participant feedback suggest the treatment is both manageable and culturally appropriate in a low-resource, collectivist setting. These findings align with the UP’s transdiagnostic focus and add to the growing literature supporting its adaptability across cultures. The treatment’s modular design, flexibility, and culturally tailored adaptations suggest it may be a viable candidate for broader implementation in LMICs. Observed improvements across emotional, behavioral, and functional domains offer early signals of clinical benefit, reinforcing the case for a fully powered RCT. Future research should formally evaluate efficacy through between-group comparisons, larger sample sizes, and long-term follow-up, guided by the feasibility parameters established in this pilot.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

A.N. conceptualized the study, conducted the analysis, and drafted the manuscript. S.S. contributed to conceptualization, supervision, and manuscript revision. A.A. contributed to conceptualization, methodology, data analysis, and manuscript revision. All authors read and approved the final manuscript.

Funding

This study did not receive any external or institutional funding.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to ethical and confidentiality restrictions related to participant data but are available from the corresponding author on request.

Declarations

Ethics approval and consent to participate

The study received ethical clearance from the School of Social Sciences and Humanities Ethics Committee at the National University of Sciences and Technology (NUST) (Reference: 0098/Ethic/01/S3H/083/DBS) and was retrospectively registered at ClinicalTrials.gov (NCT06002087). All participants were provided with a written information sheet and a verbal briefing describing the study’s aims, procedures, potential risks, and benefits. Written informed consent was obtained prior to enrollment, with verbal confirmation documented again during the baseline interview. Confidentiality was maintained through de-identified data storage and password-protected files. Participants identified as having high suicide risk during screening were withdrawn and referred to appropriate clinical services.

Consent for publication

Not applicable.

Authors’ information

Asma Nisa is an Assistant Professor in the Department of Behavioral Sciences at the National University of Sciences and Technology (NUST), Pakistan. Her research focuses on transdiagnostic interventions and global mental health. Salma Siddiqui is a Professor of Clinical Psychology, Clinical Consultant, and former Dean of the School of Social Sciences and Humanities (S3H), as well as Founding Head of the Department of Behavioral Sciences at NUST, Pakistan. Amantia A. Ametaj is affiliated with Northeastern University, USA, and her work focuses on health equity and culturally responsive interventions.

Competing interests

The authors declare no competing interests.