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Technical Commentary TECHNICAL COMMENTARY Eye movement desensitisation and reprocessing Introduction stringent reporting checklists than the PRISMA, and that some reviews may have been limited Eye movement desensitisation and by journal guidelines. reprocessing (EMDR) is based on the observation that the intensity of traumatic Evidence was graded using the Grading of memories can be reduced through eye Recommendations Assessment, Development movements. While the patient focusses on the and Evaluation (GRADE) Working Group traumatic memory or thought, he or she approach where high quality evidence such as simultaneously moves his or her eyes back and that gained from randomised controlled trials forth, following the movement of the therapist’s (RCTs) may be downgraded to moderate or low finger. The exact mechanisms through which if review and study quality is limited, if there is EMDR works are not clear, although it is inconsistency in results, indirect comparisons, proposed that when a traumatic memory is imprecise or sparse data and high probability of activated in working memory, and at the same reporting bias. It may also be downgraded if time the patient focusses on the movement of risks associated with the intervention or other the fingers, the vividness and intensity of the matter under review are high. Conversely, low memory are reduced. This blurred memory is quality evidence such as that gained from restored in the long-term memory, leading to a observational studies may be upgraded if effect less emotional reaction at future activation. An sizes are large or if there is a dose dependent alternative theory suggests EMDR elicits an response. We have also taken into account investigatory reflex which first results in an alert sample size and whether results are consistent, response, and then, when it appears there is no precise and direct with low associated risks threat, produces a sense of relaxation which (see end of table for an explanation of these inhibits negative affect associated with the terms)2. The resulting table represents an traumatic memory. objective summary of the available evidence, although the conclusions are solely the opinion Method of staff of NeuRA (Neuroscience Research We have included only systematic reviews Australia). (systematic literature search, detailed methodology with inclusion/exclusion criteria) published in full text, in English, from the year 2010 that report results separately for people Results with PTSD. Reviews were identified by We found three systematic reviews that met our searching the databases MEDLINE, EMBASE, inclusion criteria3-5. and PsycINFO. When multiple copies of review topics were found, only the most recent and • Moderate quality evidence found a large comprehensive version was included. We effect of improved PTSD and depression prioritised reviews with pooled data for symptoms with EMDR compared to inactive inclusion. controls, particularly when compared to waitlist/no treatment than to usual care. The Review reporting assessment was guided by effect for PTSD symptoms was medium- the Preferred Reporting Items for Systematic sized at the 3-month follow-up. There was Reviews and Meta-Analyses (PRISMA) also a small effect of improved PTSD, but checklist that describes a preferred way to not depression, symptoms with EMDR present a meta-analysis1. Reviews with less compared to active controls (e.g., CBT, than 50% of items checked have been exposure therapy). The effect for PTSD excluded from the library. Note that early symptoms was large at 3-month follow-up, reviews may have been guided by less but small at 6-month follow-up. However, there were larger effect sizes in studies with NeuRA EMDR August 2021 Margarete Ainsworth Building, Barker Street, Randwick NSW 2031. Phone: 02 9399 1000. Email: [email protected] Page 1 To donate, phone 1800 888 019 or visit www.neura.edu.au TECHNICAL COMMENTARY Eye movement desensitisation and reprocessing researcher allegiance to EMDR (hypothesis that EMDR was more effective than the active comparator) compared to no/unclear allegiance, and in studies with a high risk of bias compared to studies with a low risk of bias. • Moderate to low quality evidence found EMDR improved PTSD symptoms when compared to standard care/waitlist (large effect) and when compared to non-specific therapies (small to medium-sized effect) in people with complex PTSD. EMDR may also improve the complex symptoms of negative self-concept and disturbances in relationships. The sample was too small to assess EMDRs effect on affect dysregulation. • Moderate to low quality evidence found a large effect of reduced PTSD symptom severity compared to waitlist/no treatment following EMDR in children and adolescents. At 1-4 months follow-up, the effect was not maintained in children. NeuRA EMDR August 2021 Margarete Ainsworth Building, Barker Street, Randwick NSW 2031. Phone: 02 9399 1000. Email: [email protected] Page 2 To donate, phone 1800 888 019 or visit www.neura.edu.au TECHNICAL COMMENTARY Eye movement desensitisation and reprocessing Cuijpers P, Veen SCV, Sijbrandij M, Yoder W, Cristea IA Eye movement desensitisation and reprocessing for mental health problems: a systematic review and meta-analysis Cognitive Behaviour Therapy 2020; 49: 165-80 View review abstract online Comparison Effectiveness of EMDR vs. inactive (waitlist, usual care, relaxation) or active (CBT, exposure therapies, supportive counselling, debriefing, emotional freedom, eclectic therapy, memory training, stress management) control conditions for PTSD symptoms. Summary of evidence Moderate quality evidence (unclear sample sizes, mostly inconsistent, precise, mostly indirect) found a large effect of improved PTSD and depression symptoms with EMDR compared to inactive controls, particularly when compared to waitlist/no treatment. The effect for PTSD symptoms was medium-sized at the 3-month follow-up. A small effect of improved PTSD, but not depression symptoms was found with EMDR compared to active controls. The effect for PTSD symptoms was large at 3-month follow-up, but small at 6-month follow-up. There were larger effect sizes in studies with researcher allegiance to EMDR (hypothesis that EMDR was more effective than the active comparator) compared to no/unclear allegiance, and in studies with a high risk of bias compared to studies with a low risk of bias. PTSD symptoms A large effect showed improved PTSD and depression symptoms with EMDR compared to inactive controls; PTSD: 30 studies, N not reported, g = 0.93, 95%CI 0.67 to 1.18, p < 0.05, I2 = 72% Depression: 18 studies, N not reported, g = 0.83, 95%CI 0.58 to 1.08, p < 0.05, I2 = 57% The effect for PTSD symptoms was medium-sized at 3-month follow-up (g = 0.51). Subgroup analysis found a larger effect size when EMDR was compared to waiting list than when EMDR was compared to treatment as usual or relaxation (g = 1.13 vs. 0.60, p = 0.03). Studies conducted in the USA and other Western countries found smaller effect sizes than other countries (g = 0.78, 0.67 vs. 1.72, p < 0.04). There were no moderating effects of recruitment type (clinical vs. other), sample (military, adults, children, specific trauma, other), or risk of study bias (high vs. low). NeuRA EMDR August 2021 Margarete Ainsworth Building, Barker Street, Randwick NSW 2031. Phone: 02 9399 1000. Email: [email protected] Page 3 To donate, phone 1800 888 019 or visit www.neura.edu.au TECHNICAL COMMENTARY Eye movement desensitisation and reprocessing A small effect showed improved PTSD, but not depression symptoms with EMDR compared to active controls; PTSD: 23 studies, N not reported, g = 0.33, 95%CI 0.13 to 0.54, p < 0.05, I2 = 56% Depression: 12 studies, N not reported, g = 0.24, 95%CI -0.08 to 0.55, p > 0.05, I2 = 70% The effect for PTSD symptoms was large at 3-month follow-up, but small at 6-month follow-up (g = 0.81 vs. 0.10, p = 0.06). Subgroup analyses found larger effect sizes when there was researcher allegiance to EMDR compared to no/unclear allegiance (g = 0.93 vs. 0.17, p = 0.03), and in studies with a high risk of bias compared to studies with a low risk of bias (g = 0.56 vs. 0.07, p = 0.01). A small effect showed improved PTSD symptoms with EMDR compared to CBT/prolonged exposure; PTSD: 17 studies, N not reported, g = 0.22, 95%CI 0.04 to 0.40, p < 0.05, I2 = 27% Consistency in results‡ Mostly inconsistent Precision in results§ Precise Directness of results║ Indirect, mostly mixed control conditions. Karatzias T, Murphy P, Cloitre M, Bisson J, Roberts N, Shevlin M, Hyland, Maercker P, Ben-Ezra A, Coventry M, Mason-Roberts P, Bradley S, Aoife Hutton P Psychological interventions for ICD-11 complex PTSD symptoms: Systematic review and meta-analysis Psychological Medicine 2019; 49: 1761-75 View review abstract online Comparison Effectiveness of psychological therapies vs. standard care/waitlist or non-specific controls in people with complex PTSD. Summary of evidence Moderate to low quality evidence (small-medium sample sizes, inconsistent, imprecise, indirect) found EMDR improved PTSD symptoms when compared to standard care/waitlist (large effect) and when compared to non-specific therapies (small to medium-sized effect). EMDR may also improve negative self- concept and disturbances in relationships. The sample was too small to assess affect dysregulation. PTSD symptoms NeuRA EMDR August 2021 Margarete Ainsworth Building, Barker Street, Randwick NSW 2031. Phone: 02 9399 1000. Email: [email protected] Page 4 To donate, phone 1800 888 019 or visit www.neura.edu.au TECHNICAL COMMENTARY
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