Research Questions 1. What is the evidence regarding the effectiveness of EMDR for PTSD?

Transcription

1 No. 35 May 2004 Before CCOHTA decides to undertake a health technology assessment, a pre-assessment of the literature is performed. Pre-assessments are based on a limited literature search; they are not extensive, systematic reviews of the literature. They are provided here as a quick guide to important, current assessment information on this topic. Readers are cautioned that the pre-assessments have not been externally peer reviewed. Introduction Eye Movement Desensitization and Reprocessing (EMDR) is a form of psychotherapy used for the treatment of post-traumatic stress disorder (PTSD). 1,2 It was introduced as Eye Movement Desensitization (EMD) by Frances Shapiro in ,3 After undergoing some procedural refinements, EMD subsequently became known as EMDR. 4 In this report, EMD is used for studies that involve the procedure described in the original publication 1,3 and EMDR is used for studies involving the more comprehensive approach. 3 PTSD is a psychiatric disorder that affects individuals who have experienced a traumatic event. PTSD is characterized by symptoms such as anxiety attacks, sleep disturbances, flashbacks and intrusive thoughts. 5 PTSD is relatively common, with a lifetime prevalence of approximately 8% in the general population. 5 The most common precipitating events for PTSD are combat trauma, physical and sexual assault, natural disasters and motor vehicle accidents. 6,7 PTSD is often a chronic condition that persists for at least one year in 50% of cases; 6 and in some cases, symptoms persist much longer. 8 Treatment approaches to PTSD include individual therapy (cognitive, psychodynamic or behavioural), medication (antidepressants, antianxiety medications) and group therapy. The therapeutic goal of EMDR is to ameliorate the emotional consequences associated with traumatic memories. 1,2,4 The patient recalls the traumatic experience while the therapist guides the patient in a series of rapid and rhythmic eye movements. At strategic points in the therapy, the therapist assists the patient to associate a positive cognition with the traumatic event. The eye movements are thought to activate neurochemical responses that facilitate relearning. 1,2 The process generally involves eight phases, which can be completed in one treatment session, although the number of sessions required varies among patients. 4 Research Questions 1. What is the evidence regarding the effectiveness of EMDR for PTSD? 2. How does EMDR compare with other treatment options (e.g., exposure therapy) for PTSD?

2 Assessment Process A preliminary literature search of PubMed, the Cochrane Library, PsycInfo and the Centre for Reviews and Dissemination (NHS EED, DARE and HTA) was performed in November The web sites of health technology assessment (HTA) agencies were also searched. Summary of Findings Primary studies Since 1989, 20 randomized controlled trials (RCTs) have been performed to assess the efficacy of EMDR and EMD in patients with PTSD (Table 1). Table 1: Summary of findings from identified RCTs Author, Year Comparison Therapy Patients Results Van Der Kolk et al., not published yet, available at altrials.gov/show /NCT Fluoxetine (an antidepressant) or placebo Taylor et al., Exposure therapy or relaxation training Chemtob et al., Delayed treatment (delayed for ~1 month in waiting list group) Not reported Estimated completion date: December adults EMDR and relaxation training did not differ in their effects on PTSD symptoms at post-treatment and ; exposure therapy resulted in significantly larger improvements on two subscales at post-treatment and at 32 elementary school children with disasterrelated PTSD who failed to respond to prior treatment Ironson et al., Prolonged exposure 22 (2 teens and 20 adults) Lee et al., Stress inoculation training with prolonged exposure Three sessions of EMDR resulted in substantial reductions in PTSD symptoms; positive results maintained at six-month follow-up Both treatment approaches significantly reduced symptoms, although EMDR produced faster results and was associated with fewer dropouts; results with both treatments maintained at threemonth follow-up 24 adults Both treatment groups experienced significant improvement; EMDR patients experienced greater improvement in PTSD-intrusive symptoms and greater gains at

3 Table 1 continued Lytle et al., 2002(EMD) 13 Power, Identical procedure but with eyes fixed on a stationary target or nondirective therapy Exposure plus cognitive restructuring (E+CR) or waiting-list control Edmond et al., Eclectic treatment techniques or delayed treatment (delayed for ~6 weeks in waiting list group) 48 undergraduate students After one treatment session, treatment results for all three approaches were comparable at one-week follow-up 105 adults EMDR and E+CR produced significant improvement over 10 weeks (~1 treatment session/week); at 15-month followup, treatment gains were generally well maintained, but EMDR was found to be more beneficial for depression and required fewer treatment sessions 59 adult female survivors of sexual abuse Rogers et al., Exposure therapy 12 Vietnam combat Carlson et al., Biofeedback-assisted relaxation or routine clinical care 35 combat EMDR resulted in fewer clinical symptoms at compared with group receiving other treatment techniques After one session, patients in EMDR group experienced greater withinsession improvement Group that received 12 sessions of EMDR demonstrated significant improvement compared with other treatment groups; EMDR treatment effects were generally maintained at Scheck et al., Active listening 60 women Two sessions of EMDR resulted in significant improvements in posttreatment psychological distress scores, reducing scores to within range observed for comparable normative group; effect of EMDR maintained at (although data were collected for two of five outcome measures and in a non-standardized fashion) Devilly et al., Equivalent procedure without eye movements or standard psychiatric support Devilly and Spence, Trauma treatment protocol (TTP), a variant of cognitive behaviour therapy 51 combat Three treatment groups reported reduction in PTSD symptoms, but no significant differences in magnitude among groups; at sixmonth follow-up, treatment effects generally diminished 23 adults TTP was statistically and clinically more effective than EMDR: superiority even more evident at

4 Table 1 continued Marcus et al., Standard care (SC, i.e., individual psychotherapy, medication, group therapy) Rothbaum et al., Waiting list control 21 adult female sexual assault victims Pitman et al., Similar treatment without eye movement component (crossover study design) Wilson et al., 1995, ,25 Delayed treatment (delayed by ~1 month) Jensen, Control condition (i.e., identical procedure without EMDR component; control subjects were not deterred from pursuing other mental health treatment during study) Vaughan et al., Image habituation training, 1994 (EMD) 27 applied muscle relaxation or waiting list 67 adults EMDR group showed significantly greater and more rapid improvement. After three treatment sessions, 50% of EMDR group no longer met criteria for PTSD, compared with 20% of SC group; at ~6 months to one-year posttreatment, 77% of EMDR group no longer met criteria for PTSD, compared with 50% of SC group 17 Vietnam combat 37 adults (32 participated in the 15-month follow-up study) 25 Vietnam combat Shapiro, 1989b Placebo treatment 22 children (EMD) 2 and adults Three 90-minute sessions of EMDR eliminated PTSD symptoms in 90% of participants; results maintained at After mean of 9.7 therapy sessions, both procedures produced moderate to modest overall improvement; follow-up was ~7 weeks after completion of therapy In EMDR group, three treatment sessions resulted in significant decreases in PTSD symptoms; in delayed treatment group, significant improvements noted once treatment initiated; for all EMDR participants, treatment effects maintained at 90-day follow-up; at 15-month follow-up, 84% reduction in number of participants who met PTSD criteria and 68% reduction in number of PTSD symptoms At 17-day follow-up, three sessions of EMD showed little effectiveness, although it was effective at reducing in-session subjective anxiety 36 adults All treatments resulted in significant improvement in PTSD symptoms compared with waiting list group; EMD appeared to be superior at reducing intrusive memories immediately after treatment; treatment benefits maintained at Single session of EMD resulted in significant improvement in PTDS symptoms; benefits maintained at

5 Systematic reviews, meta-analyses and HTAs One HTA and five meta-analyses regarding the efficacy of EMDR were identified. Table 2: Summary of findings from HTA and meta-analyses* Author, Year Study Type, Assessment Findings Shepherd et al., 1998 (United Kingdom) 28 Maxfield and Hyer, Davidson and Parker, Sack et al., 2001 (full report available in German only) 31 Van Etten and Taylor, HTA: examined efficacy of EMDR for PTSD, but did not compare EMDR with other interventions sought to determine if differences in outcome related to methodological differences in studies evaluating EMDR for PTSD compared treatment approaches for PTSD examined whether EMDR studies with higher quality standards achieved better results than EMDR studies with low methodological standards examined psychotherapeutic (including EMDR) and pharmacological treatments of PTSD 12 RCTs were identified that evaluated efficacy of EMDR for PTSD evidence in support of EMDR of limited quality economic evaluation based on one study (Wilson et al., 1995; 1999); at three-month post-treatment, cost per quality adjusted life-years (QALYs) for EMDR may be as high as 20,568 or as low as 3,935, depending on who provides treatment further research, using larger samples and with longer periods of follow-up, is warranted 12 controlled studies investigating efficacy of EMDR for treatment of PTSD evaluated in EMDR studies, methodological rigour is necessary for more accurate detection of true treatment effects 21 EMDR controlled trials for treatment of PTSD identified EMDR superior to no treatment and nonspecific treatment controls; and equivalent in outcome to exposure and cognitive behavioural therapies Treatment by trained therapists and sufficient number of treatment sessions produced better results than studies that used low methodological treatment standards 61 treatment-outcome trials identified; 11 trials of EMDR included EMDR and exposure therapies had similar outcomes, but EMDR required fewer sessions to achieve same results both therapies superior to other psychotherapeutic treatments and pharmacological treatments

6 Table 2 continued Sherman, examined efficacy of psychotherapeutic treatments (including EMDR) for PTSD Psychotherapeutic treatment, including EMDR, reduced PTSD and general psychiatric symptoms; effects maintained after treatment *All reports included only those studies that evaluated subjects who met DSM III, DSM III-R, or DSM IV criteria for PTSD Guidelines Table 3: Guidelines for use of EMDR for PTSD Reference Management of post-traumatic stress disorder in adults in primary, secondary and community care (clinical guideline) (in progress) The National Collaborating Centre for Mental Health commissioned by the National Institute for Clinical Excellence (NICE) Management of post-traumatic stress. Clinical Practice Guideline Working Group, Veterans Health Administration, Department of Veterans Affairs and Health Affairs, Department of Defense, December t.htm Ontario Guidelines for the Management of Anxiety s in Primary Care Ontario Program for Optimal Theraupeutics Anxiety Review Panel September 2000 Available at Findings and Recommendations Guideline will include advice on appropriate use of psychological interventions including type, modality, frequency and duration Expected date of issue: February 2005 Stress inoculation training (SIT), cognitive therapy, exposure therapy and EMDR all demonstrate significant benefit for treatment of PTSD; EMDR is as effective as other treatments in some studies; and less effective than other treatments in other studies EMDR has been shown to be useful, but effective element is probably imaginal exposure and not eye movements; EMDR recommended as second-line therapy Conclusion EMDR is one of the first treatments for PTSD to have been evaluated by controlled studies. 3 EMDR seems to be more effective than no treatment. 2,10,14,15,22,24,25,27 Its role relative to other similar therapies is less clear. Although the technique appears to show promising results, the quality of the RCTs is, however, questionable, with many of the studies having small sample sizes. Moreover, there seems to be considerable variability in methodology and in the patient population. With the exception of the study by Wilson et al., (1997) there are no longterm follow-up studies.

7 As EMDR is considered to be a more rapid treatment than other psychotherapeutic treatments, savings could be gained from replacing existing therapy with EMDR. EMDR is often a complement to other forms of psychotherapy, however, so potential savings are questionable. One economic assessment of EMDR for PTSD has been performed in the UK. 28 This cost-utility analysis showed that at three-month post-treatment, the cost per quality adjusted life-years (QALYs) may be as high as 20,568 or as low as 3,935, depending on who provides the treatment (i.e., state psychiatrist or community psychiatric nurse). An economic evaluation in Canada may be warranted. Although initial studies supported the notion that eye movements are a vital component of EMDR, results of recent studies indicate that eye movements may be unnecessary. Shapiro reports that alternative techniques, such as alternating taps and auditory tones, also seem to be effective. 3 In conclusion, EMDR may be a promising treatment for PTSD, but an evaluation of its clinical effectiveness must await the completion of further studies with large sample sizes, consistent methodology and longer follow-up. References 1. Shapiro F. Eye movement desensitization: a new treatment for post-traumatic stress disorder. J Behav Ther Exp Psychiatry 1989;20(3): Shapiro F. Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. J Trauma Stress 1989;2: Shapiro F. EMDR 12 years after its introduction: past and future research. J Clin Psychol 2002;58(1): Shapiro F. Eye movement desensitization and reprocessing: basic principles, protocols and procedures. New York: Guilford; American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV-TR. 4th ed, text revision. Washington: The Association; Davidson JR, Hughes D, Blazer DG, George LK. Post-traumatic stress disorder in the community: an epidemiological study. Psychol Med 1991;21(3): Norris FH. Epidemiology of trauma: frequency and impact of different potentially traumatic events on different demographic groups. J Consult Clin Psychol 1992;60(3): D'Souza D. Post-traumatic stress disorder--a scar for life. Br J Clin Pract 1995;49(6): Taylor S, Thordarson DS, Maxfield L, Fedoroff IC, Lovell K, Ogrodniczuk J. Comparative efficacy, speed, and adverse effects of three PTSD treatments: exposure therapy, EMDR, and relaxation training. J Consult Clin Psychol 2003;71(2):330-8.

8 10. Chemtob CM, Nakashima J, Carlson JG. Brief treatment for elementary school children with disasterrelated posttraumatic stress disorder: a field study. J Clin Psychol 2002;58(1): Ironson G, Freund B, Strauss JL, Williams J. Comparison of two treatments for traumatic stress: a community-based study of EMDR and prolonged exposure. J Clin Psychol 2002;58(1): Lee C, Gavriel H, Drummond P, Richards J, Greenwald R. Treatment of PTSD: stress inoculation training with prolonged exposure compared to EMDR. J Clin Psychol 2002;58(9): Lytle RA, Hazlett-Stevens H, Borkovec TD. Efficacy of Eye Movement Desensitization in the treatment of cognitive intrusions related to a past stressful event. J Anxiety Disord 2002;16(3): Power K, McGoldrick T, Brown K, Buchanan R, Sharp D, Swanson V, et al. A controlled comparison of eye movement desensitization and reprocessing versus exposure plus cognitive restructuring versus waiting list in the treatment of post-traumatic stress disorder. Clin Psychol Psychother 2002;9: Available: (accessed 2004 Jan 5). 15. Edmond T, Rubin A, Wambach KG. The effectiveness of EMDR with adult female survivors of childhood sexual abuse. Social Work Research 1999;23: Rogers S, Silver SM, Goss J, Obenchain J, Willis A, Whitney RL. A single session, group study of exposure and Eye Movement Desensitization and Reprocessing in treating Posttraumatic Stress among Vietnam War : preliminary data. J Anxiety Disord 1999;13(1-2): Carlson JG, Chemtob CM, Rusnak K, Hedlund NL, Muraoka MY. Eye movement desensitization and reprocessing (EDMR) treatment for combat-related posttraumatic stress disorder. J Trauma Stress 1998;11(1): Scheck MM, Schaeffer JA, Gillette C. Brief psychological intervention with traumatized young women: the efficacy of eye movement desensitization and reprocessing. J Trauma Stress 1998;11(1): Devilly GJ, Spence SH, Rapee RM. Statistical and reliable change with eye movement desensitization and reprocessing: treating trauma within a veteran population. Behav Ther 1998;29: Devilly GJ, Spence SH. The relative efficacy and treatment distress of EMDR and a cognitive-behavior trauma treatment protocol in the amelioration of posttraumatic stress disorder. J Anxiety Disord 1999;13(1-2): Marcus SV, Marquis P. Controlled study of treatment of PTSD using EMDR in an HMO setting. Psychotherapy 1997;34(3): Rothbaum BO. A controlled study of eye movement desensitization and reprocessing in the treatment of posttraumatic stress disordered sexual assault victims. Bull Menninger Clin 1997;61(3): Pitman RK, Orr SP, Altman B, Longpre RE, Poire RE, Macklin ML. Emotional processing during eye movement desensitization and reprocessing therapy of Vietnam with chronic posttraumatic stress disorder. Compr Psychiatry 1996;37(6):

9 24. Wilson SA, Becker LA, Tinker RH. Eye movement desensitization and reprocessing (EMDR) treatment for psychologically traumatized individuals. J Consult Clin Psychol 1995;63(6): Wilson SA, Becker LA, Tinker RH. Fifteen-month follow-up of eye movement desensitization and reprocessing (EMDR) treatment for posttraumatic stress disorder and psychological trauma. J Consult Clin Psychol 1997;65(6): Jensen JA. An investigation of eye movement desensitization and reprocessing (EMD/R) as a treatment for posttraumatic stress disorder (PTSD) symptoms of Vietnam combat. Behav Ther 1994;25: Vaughan K, Armstrong MS, Gold R, O'Connor N, Jenneke W, Tarrier N. A trial of eye movement desensitization compared to image habituation training and applied muscle relaxation in post-traumatic stress disorder. J Behav Ther Exp Psychiatry 1994;25(4): Shepherd J, Stein K. Eye movement desensitization and reprocessing in the treatment of post traumatic stress disorder: report to the Development and Evaluation Committee [Development and Evaluation Committee report ; no. 91]. Southampton (UK): Wessex Institute for Health Research and Development; Maxfield L, Hyer L. The relationship between efficacy and methodology in studies investigating EMDR treatment of PTSD. J Clin Psychol 2002;58(1): Davidson PR, Parker KC. Eye movement desensitization and reprocessing (EMDR): a meta-analysis. J Consult Clin Psychol 2001;69(2): Sack M, Lempa W, Lamprecht F. Study quality and effect-sizes - a metaanalysis of EMDR-treatment for posttraumatic stress disorder [in German]. Psychother Psychosom Med Psychol 2001;51(9-10): Van Etten M, Taylor S. Comparative efficacy of treatments for post-traumatic stress disorder: a metaanalysis. Clin Psychol Psychother 1998;5(3): Sherman JJ. Effects of psychotherapeutic treatments for PTSD: a meta-analysis of controlled clinical trials. J Trauma Stress 1998;11(3):