CRITICALLY APPRAISED PAPER (CAP) Acarturk, C., Konuk, E., Cetinkaya, M., Senay, I., Sijbrandij, M., Cuijpers, P., & Aker, T. (2015). EMDR for Syrian refugees with posttraumatic stress disorder symptoms: Results of a pilot randomized controlled trial. European Journal of Psychotraumatology, 6(1), 27414. https://doi.org/10.3402/ejpt.v6.27414 Acarturk_EDMR_2015 CLINICAL BOTTOM LINE Eye-movement desensitization and reprocessing (EMDR) is a therapeutic treatment for clients with posttraumatic stress disorder (PTSD). According to EMDR Extra, a U.K.-based training program for EMDR, occupational therapists working in mental health with clients who have experienced trauma are listed as eligible professionals to receive EMDR training. With this training and certification, occupational therapists can use another tool to help clients who have undergone trauma. This is an emerging area of practice, because roughly 65.6 million people have been forced to leave their home as refugees. There are currently 22.5 million refugees (UNHCR, 2016) in the world, which increases the likelihood that occupational therapy practitioners will treat clients who have undergone trauma or displacement. Again, occupational therapists can use this training and certification in their treatment of clients to assist them in overcoming traumatic experiences. This study demonstrates the statistically significant use of EMDR in reducing PTSD symptoms. RESEARCH OBJECTIVE(S) To examine the effect of using EMDR to reduce PTSD and depression symptoms among Syrian refugees, compared with the control wait-list group of Syrian refugees DESIGN TYPE AND LEVEL OF EVIDENCE Level Ib; individual randomized controlled trial, pilot study PARTICIPANT SELECTION How were participants recruited and selected to participate? 1
The researchers conducted a randomized controlled trial between April and July 2013 at the Kilis Refugee Camp on the border of Turkey and Syria. A total of 820 refugees ages 18 or older were randomly selected through a computer-generated random-number list, out of 14,000 refugees living at the camp. In all, 688 of the selected refugees scored above the predetermined cutoff point of 33 on the Impact of Event Scale Revised (IES R) assessment for probable PTSD. Of the 688 individuals, the authors randomly selected 45 from a computer-generated list. They did this by selecting 30 sets of 4 people randomly from the 688 people with PTSD symptoms. Next, the authors randomly chose and randomly ordered 4 people in each set. The randomly ordered person who came in first was approached by the research team. If they refused to participate, then the second randomly ordered person was contacted, and so forth. The researchers approached 45 individuals to participate in the study, and 16 refused. Nine individuals refused because their husband did not allow them, 6 individuals refused because of the stigma of pursuing mental health treatment, and 1 decided to return to Syria. Inclusion criteria: Participants needed to Be 18 or older Have PTSD symptoms Have an IES R score of 33 or higher. Exclusion criteria: Participants were excluded if they Had a developmental delay, Were pregnant, or Were currently taking psychiatric medication. PARTICIPANT CHARACTERISTICS N= 29 Experimental group: 15 Control group: 14 #/ % Male: 7/(24.14%) #/ % Female: 22/(75.86%) Ethnicity: Syrian Disease/disability diagnosis: PTSD as a Syrian refugee INTERVENTION AND CONTROL GROUPS Group 1: EMDR intervention 2
Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? This group of individuals was assigned to the EMDR intervention group, which consisted of a maximum of seven 90-minute sessions of EMDR. Each treatment session consisted of eight phases. Phase 1 included taking a history, formulating the case, and planning the treatment. Phase 2 consisted of preparing the client for EMDR by explaining the therapy. Individuals also learned self-calming techniques. Phase 3 consisted of targeting a trauma memory to work on. Traumatic memories were targeted from the beginning of the war until the present time. Phase 4 was the desensitization phase, when the individual was asked to hold the trauma memory in mind for 30 seconds. During this time, the individual followed the therapist s finger left to right across their visual field, or the therapist used tapping techniques. The individual then reported sensations, thoughts, and emotions. In Phase 5, sets were repeated until the individual reported minimal distress associated with the memory. Phase 6 included installation of positive cognition with bilateral stimulation. Phase 7 was a body scan, and the Phase 8 was a closure phase in which the participant used religion and a holy light image to relax. 15 participants In a clinic located in the kindergarten center at the Kilis Refugee Camp on the border of Turkey and Syria Intervention was delivered by five Turkish psychologists who had Level I training in EMDR by one of the authors, who is an EMDR Institute accredited trainer. This trainer provided weekly face-toface and online (Skype) supervision. Seven EMDR sessions over 7 weeks (weekly, but the authors were not explicit in their explanation) For how long? The intervention consisted of seven 90-minute sessions over 7 weeks. There was a 4-week follow-up assessment after the posttest. From pretest to follow-up, the study lasted 11 weeks total. Group 2: Wait-list control group Brief description of the intervention How many participants in the group? The wait-list group was the control group and did not receive any psychological or pharmacological treatment inside or outside the refugee camp. Wait-list groups receive the treatment after the study is finished. This type of control is chosen when the researchers feel it would be unethical not to offer the treatment to the individuals. 14 participants 3
Where did the intervention take place? Who delivered? How often? The intervention took place in a clinic located in the kindergarten center at the Kilis Refugee Camp on the border of Turkey and Syria. The wait-list participants lived in the Kilis Refugee Camp. NA NA For how long? The control group lasted 7 weeks, because they did not have a 4- week follow-up to the posttest, as a result of logistical problems and high participant mobility rates. INTERVENTION BIASES Contamination: The authors did not discuss specific contamination biases that occurred in the study, but one can infer contamination bias in that the participants were all from the same refugee camp and might have discussed the study with others. The individuals in the control group might have picked up knowledge from the experimental group through exposure to those participants at the refugee camp, which would thus affect the posttest results. Co-intervention: YES NO Inclusion criteria required that individuals involved in the study could not be using other therapy or mental health services. Timing of intervention: YES NO The timing of interventions was scheduled to eliminate bias and support the participants. Interviews were scheduled in the late afternoon because of participants preference to stay up later and wake up later to avoid the heat of the day. EMDR sessions were implemented over 7 weeks, as opposed to the recommended 11 weeks, because of the high percentage of participants moving camps, which is a common refugee experience. Site of intervention: YES NO The site of the intervention was in a kindergarten center to help protect the identity of the participants and to reduce the stigma that the individuals felt they would encounter on walking into a mental health clinic. Use of different therapists to provide intervention: Five Turkish psychologists administered the EMDR; they were overseen by an EMDR Institute accredited trainer. The research team also tried to match the gender of the therapist with the gender of the client to remain culturally sensitive, but the variety of therapists might have proven to be biased. 4
Baseline equality: Participants were randomly assigned to the EMDR group or the wait-list group, and sociodemographic data did not differ significantly between the two groups. IES R scores were higher in the EMDR group than in the control group before treatment, which indicates that baseline trauma scores were higher in the treatment group. The authors conducted an analysis of covariance to correct for the difference between groups at baseline. MEASURES AND OUTCOMES (Only on measures relevant to occupational therapy practice) Measure 1: IES R Name/type of IES R measure used: What outcome is measured? Is the measure reliable (as reported in the article)? Is the measure valid (as reported in the article)? When is the measure used? The authors assessed the efficacy of the EMDR treatment by comparing the IES R total scores from the EMDR group and the control group. This tool is a self-report measure that rates the severity of PTSD symptoms. The higher the score is, the greater is the severity of PTSD. The three subscales of the assessment are Re-Experiencing/Intrusion, Avoiding/Numbing, and Hyperarousal. Not Reported Not Reported This measure was used in the pretest, posttest, and 4-week follow-up after the posttest for the EMDR group, but only in the pretest and posttest for the control group. Measure 2: Beck Depression Inventory II (BDI-II) Name/type of measure used: The Arabic version of the BDI-II, which was developed with Syrians and participants from 17 other Arabic groups, was used in this study. What outcome is measured? The BDI-II is a self-report tool that measures depression symptoms. The higher the score is, the greater is the severity of depression. Is the measure Not Reported reliable as reported in the article? Is the measure valid as reported in the article? Not Reported When is the measure used? This measure was used in the pretest and posttest for the EMDR group and control group. (It is unclear why it was not used for the EMDR group at the 4-week follow-up.) MEASUREMENT BIASES 5
Were the evaluators blind to treatment status? Explanation: The participants and the therapists were aware of which group the participants were allocated to, but the outcome assessors were blind to the participants allocation. Was there recall or memory bias? Explanation: There might have been recall bias, because no participant gave permission for audio or video recording of the sessions. The supervising therapist observed a minimum of one session per therapist (five therapists) to ensure that the therapists were complying with the eight-phase EMDR standard protocol. The treatment fidelity was supported by the supervising therapist, but recall bias might have occurred. Also, participants were assessed through the IES R and the BDI-II, both self-reports that may be susceptible to recall bias. Other measurement biases: The researchers were unable to obtain a follow-up assessment for the IES R and the BDI-II for the control group 4 weeks after the posttest but were able to obtain these data for the EMDR group. Lack of formal PTSD diagnosis was a bias, because PTSD symptoms were assessed with a selfreport tool. The five therapists providing the EMDR treatment only received Level I training, although the supervising, trained therapist observed at least one session for each therapist by Skype and provided feedback. RESULTS 6
The mean number of EMDR sessions was 4.13. A Kolmogorov Smirnov test for normality indicated that the number of sessions did not deviate from a normal distribution, which indicates that the number of sessions was not biased in a particular direction but was a result of a randomized process. Pretest IES R scores (PTSD symptoms) were significantly higher in the EMDR group (M = 64.80, SD = 12.08) than in the wait-list group (M = 56.93, SD = 7.15; p =.044). Trauma scores of the EMDR group significantly decreased between baseline (M = 64.80, SD = 12.08) and immediate posttest (M = 22.87, SD = 20.27; p <.001). Depression scores were lower after treatment in the EMDR group (M = 10.15, SD = 9.60) than in the wait-list group (M = 20.79, SD = 7.92). The analysis of covariance found that at the posttest, the EMDR group had significantly lower trauma scores than the wait-list group (M = 22.87, SD = 20.27 vs. M = 54.21, SD = 16.26; p <.001). The analysis of variance results indicate a significant effect of time, F(2, 28) = 62.78, p <.001 (d = 1.93, 95% confidence interval: 1.07, 2.8). The EMDR group's trauma scores did not change between immediate posttest and follow-up (M = 18.93, SD = 20.31 vs. M = 22.87, SD = 20.27), t(14) = 1.330, p >.1. The wait-list group's trauma scores did not change between pretest and immediate posttest, t(13) = 0.611, p >.1. Was this study adequately powered (large enough to show a difference)? Explanation: The sample size in the study was small, with fewer than 20 participants per condition. Generalizability is difficult to determine with the sample size. However, all analyses were carried out with p <.05 to indicate statistical significance. Pretest EMDR trauma scores were significantly lower than in the wait-list group (p =.044), and EMDR trauma scores significantly decreased between baseline and immediate posttest (p <.001). The depression score difference between the two groups after treatment was also statistically significant (p =.004). The statistical difference between groups and between the EMDR group and time offset the small sample size, indicating adequate power of the study. Were the analysis methods appropriate? The authors addressed statistical significance of EMDR in the reduction of PTSD and depression symptoms using the SPSS 19.0 t tests. Long-term treatment was analyzed with analyses of variance and t tests as contrasts. Were statistics appropriately reported (in written or table format)? 7
The statistics were reported both in written format and with more detail in table format. Table 1 included sociodemographic and migration characteristics, Table 2 presented the means and standard deviations for IES R and the BDI-II scores, and Table 3 presented statistical comparisons across time and groups. Was participant dropout less than 20% in total sample and balanced between groups? YES NO There were no participant dropouts during this study. What are the overall study limitations? There was an absence of the 11-week follow-up assessment in the wait-list control group. Fidelity was not formally assessed by the researchers. The five therapists providing the EMDR treatment only received Level I training, although the supervising, trained therapist observed at least one session for each therapist by Skype and provided feedback. The manner in which the follow-up assessment for the EMDR group was written in the study proved to be confusing to the reader. The authors described a 4-week follow-up and 7-week and 11-week reassessments, but only two reassessment scores were shown. On rereading, it became clear that the pretest was conducted at baseline, the posttest was conducted at 7 weeks, and the follow-up was conducted 4 weeks after the posttest (11 weeks after the pretest). It would have been beneficial to stay consistent in referring to these tests to decrease confusion. CONCLUSIONS The authors concluded that the results of their study indicate that EMDR was successful in reducing symptoms of PTSD and depression for the Syrian refugee population residing in a refugee camp. The study also suggests that improvements in PTSD symptoms were maintained 11 weeks after the pretest, at the follow-up assessment for the EMDR group. The authors concluded that EMDR therapy may be beneficial for non-western populations undergoing high levels of stress, such as refugees. This work is based on the evidence-based literature review completed by Emily Adams, MOTS, Megan Peterson, MOTS, and Breann Lamborn, MPA, University of North Dakota. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998 by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, and M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com 8