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Eye movement desensitisation and reprocessing therapy v. stabilisation as usual for refugees: randomised controlled trial

  • F. Jackie June ter Heide (a1), Trudy M. Mooren (a1), Rens van de Schoot (a2), Ad de Jongh (a3) and Rolf J. Kleber (a4)...
Abstract
Background

Eye movement desensitisation and reprocessing (EMDR) therapy is a first-line treatment for adults with post-traumatic stress disorder (PTSD). Some clinicians argue that with refugees, directly targeting traumatic memories through EMDR may be harmful or ineffective.

Aims

To determine the safety and efficacy of EMDR in adult refugees with PTSD (trial registration: ISRCTN20310201).

Method

In total, 72 refugees referred for specialised treatment were randomly assigned to 12 h of EMDR (3×60 min planning/preparation followed by 6×90 min desensitisation/reprocessing) or 12 h (12×60 min) of stabilisation. The Clinician-Administered PTSD Scale (CAPS) and Harvard Trauma Questionnaire (HTQ) were primary outcome measures.

Results

Intention-to-treat analyses found no differences in safety (one severe adverse event in the stabilisation condition only) or efficacy (effect sizes: CAPS –0.04 and HTQ 0.20) between the two conditions.

Conclusions

Directly targeting traumatic memories through 12 h of EMDR in refugee patients needing specialised treatment is safe, but is only of limited efficacy.

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Copyright
Corresponding author
F. J. J. ter Heide, PhD, MPhil (Cantab), Foundation Centrum’45 – partner in Arq Psychotrauma Expert Group, Nienoord 5, 1112 XE Diemen, The Netherlands. Email: j.ter.heide@centrum45.nl
Footnotes
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This study was jointly funded by ZonMW, The Netherlands organisation for health research and development, and Foundation Centrum ‘45, partner in Arq Psychotrauma Expert Group. R.v.d.S. was supported by a grant from The Netherlands organization for scientific research: NWO-VENI-451-11-008.

Declaration of interest

A.d.J. reports receiving personal fees from teaching activities and from books about trauma and its treatment (including EMDR). He is a board member of the Dutch EMDR Association and the EMDR Europe Association.

Footnotes
References
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Eye movement desensitisation and reprocessing therapy v. stabilisation as usual for refugees: randomised controlled trial

  • F. Jackie June ter Heide (a1), Trudy M. Mooren (a1), Rens van de Schoot (a2), Ad de Jongh (a3) and Rolf J. Kleber (a4)...
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eLetters

Defining clinically significant change

Joar Øveraas Halvorsen, Authorised clinical psychologist, Ph.D., St. Olavs Hospital, Trondheim University Hospital
04 March 2016

First of all I want to congratulate the authors on conducting an extremely timely and important clinical trial. As stated by the authors there’s a conspicuous lack of clinical trials investigating the effect of EMDR in treating traumatized refugees.

However, in order to be able to appraise/interpret the results more fully, it would be of great value if the authors could analyze their data with different cut-off points for defining clinically significant change. In their article the authors define clinically significant change as a decrease of 10 points or more on the Clinician-administered PTSD scale (1). The authors report that approximately 40% of patients in both conditions achieved clinically significant improvement (Table 2).

However, there is currently no widely agreed upon threshold for defining clinically significant change on the CAPS and different clinical trials has utilized a wide range of different cut-off scores. For example, in two major publications Schnurr and colleagues (2, 3) defined clinically significant change as a decrease of at least 10 points in total CAPS scores. Hinton et al. (4) used the rationally derived 15-point change (1) as a marker of clinically significant change. In line with the method set forth by Jacobson and Truax (5), Taylor et al. (6) defined clinically significant change as a reduction in total CAPS scores of at least two standard deviations. Hien et al. (7) used a 30-point or greater improvement on the CAPS to determine clinically significant improvement of PTSD symptoms, whereas Bryant et al. (8) defined clinically significant change as a cutoff of <45 on the CAPS at follow-up.

It is also important to take into consideration the measurement variability of the instrument (5). A change of 10 points on the CAPS is not necessarily even reliable. Monson et al. (9) calculated an reliable change score of 12.22 points on the CAPS, whereas we (10) previously have calculated a conservative reliable change score of 14.3 points. As such a change of 10 points might simply be within the measurement variability of the CAPS.

These issues taken together it would be very informative if the authors made use of different cut-off scores for defining clinically significant change. The Institute of Medicine (11) note that common methods to define clinically significant change on the CAPS in the treatment literature is to either define it as a ≥10 point decrease, ≥30 percent decrease, or as two standard deviations below pre-treatment level. Using a 30 percent decrease in total CAPS-scores for the present sample entails a cut-off score for clinically significant change of approximately 23 points. Using two standard deviations below pre-treatment level (5) as a marker for clinically significant change entails a cut-off score of approximately 36 points. It would be very informative if the authors re-analyzed their data with at least these two thresholds for defining clinically significant change in addition to the 10-points cut-off score reported in their paper.

References

1.Weathers FW, Keane TM, Davidson JR. Clinician-administered PTSD scale: a review of the first ten years of research. Depression and Anxiety. 2001;13(3):132-56.

2.Schnurr PP, Friedman MJ, Engel CC, Foa EB, Shea MT, Chow BK, et al. Cognitive behavioral therapy for posttraumatic stress disorder in women: A randomized controlled trial. JAMA: Journal of the American Medical Association. 2007;297(8):820-30.

3.Schnurr PP, Friedman MJ, Foy DW, Shea MT, Hsieh FY, Lavori PW, et al. Randomized trial of trauma-focused group therapy for posttraumatic stress disorder: Results from a Department of Veterans Affairs Cooperative Study. Archives of General Psychiatry. 2003;60(5):481-9.

4.Hinton DE, Chhean D, Pich V, Safren SA, Hofmann SG, Pollack MH. A Randomized Controlled Trial of Cognitive-Behavior Therapy for Cambodian Refugees With Treatment-Resistant PTSD and Panic Attacks: A Cross-Over Design. Journal of Traumatic Stress. 2005;18(6):617-29.

5.Jacobson NS, Truax P. Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology. 1991;59(1):12-9.

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. Journal of Consulting and Clinical Psychology. 2003;71(2):330-8.

7.Hien DA, Wells EA, Jiang H, Suarez-Morales L, Campbell ANC, Cohen LR, et al. Multisite randomized trial of behavioral interventions for women with co-occurring PTSD and substance use disorders. Journal of Consulting and Clinical Psychology. 2009;77(4):607-19.

8.Bryant RA, Moulds ML, Guthrie RM, Dang ST, Mastrodomenico J, Nixon RDV, et al. A randomized controlled trial of exposure therapy and cognitive restructuring for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology. 2008;76(4):695-703.

9.Monson CM, Schnurr PP, Resick PA, Friedman MJ, Young-Xu Y, Stevens SP. Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology. 2006;74(5):898-907.

10.Halvorsen JØ, Stenmark H. Narrative exposure therapy for posttraumatic stress disorder in tortured refugees: A preliminary uncontrolled trial. Scandinavian Journal of Psychology. 2010;51(6):495-502.

11.Institute of Medicine. Treatment of posttraumatic stress disorder: An assessment of the evidence. Washington, D.C.: The National Academies Press; 2008. 224 p.
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