TYPE Original Research

PUBLISHED 10 August 2022

DOI 10.3389/fpsyg.2022.937204

Effectiveness of treating
OPEN ACCESS depression with eye movement
EDITED BY
Antonio Onofri,
Azienda Sanitaria Locale Roma 1, Italy
desensitization and
REVIEWED BY
Mo MirMotahari,
reprocessing among
King’s College London,
United Kingdom
Enayatollah Shahidi,
inpatients–A follow-up study
Iranian Institute of Psychology and
Mental Training, Tehran, Iran over 12 months
*CORRESPONDENCE
Susanne Altmeyer
[email protected] Susanne Altmeyer1*† , Leonie Wollersheim1*† ,
Leonie Wollersheim
[email protected]
Niclas Kilian-Hütten1*, Alexander Behnke2*, Arne Hofmann3*
Niclas Kilian-Hütten and Visal Tumani4*
[email protected]
Alexander Behnke 1
Gezeitenhaus Traumahospital Schloss Eichholz, Wesseling, Germany, 2 Clinical and Biological
[email protected] Psychology, Institute of Psychology and Education, Ulm University, Ulm, Germany, 3 EMDR-Institute
Arne Hofmann Germany, Gezeitenhaus Traumahospital Schloss Eichholz, Wesseling, Germany, 4 Department
[email protected] of Psychiatry and Psychotherapy III, Ulm University, Ulm, Germany
Visal Tumani
[email protected]
† These authors have contributed
equally to this work and share first Increasing prevalence of depression poses a huge challenge to the
authorship healthcare systems, and the success rates of current standard therapies
SPECIALTY SECTION are limited. While 30% of treated patients do not experience a full
This article was submitted to remission after treatment, more than 75% of patients suffer from recurrent
Psychology for Clinical Settings,
a section of the journal depressive episodes. Eye Movement Desensitization and Reprocessing
Frontiers in Psychology (EMDR) therapy represents an emerging treatment option of depression,
RECEIVED 05 May 2022 and preliminary studies show promising effects with a probably higher
ACCEPTED 27 June 2022
PUBLISHED 10 August 2022
remission rate when compared to control-therapies such as cognitive
CITATION
behavioral therapy. In the present study, 49 patients with severe depression
Altmeyer S, Wollersheim L, were treated with an integrated systemic treatment approach including
Kilian-Hütten N, Behnke A, Hofmann A
and Tumani V (2022) Effectiveness
EMDR therapy that followed a specific protocol with a treatment
of treating depression with eye algorithm for depression in a naturalistic hospital setting. Following
movement desensitization
their discharge from the hospital, the patients were followed up by a
and reprocessing among inpatients–A
follow-up study over 12 months. structured telephone interview after 3 and 12 months. 27 of the 49
Front. Psychol. 13:937204. (55%) patients fulfilled the Beck’s depression criteria of a full remission
doi: 10.3389/fpsyg.2022.937204
when they were discharged. At the follow-up interview, 12 months
COPYRIGHT
© 2022 Altmeyer, Wollersheim, after discharge, 7 of the 27 patients (26%) reported a relapse, while
Kilian-Hütten, Behnke, Hofmann and the remaining 20 patients (74%) had stayed relapse-free. The findings
Tumani. This is an open-access article
distributed under the terms of the
of our observational study confirm reports of earlier studies in patients
Creative Commons Attribution License with depression, showing that EMDR therapy leads to a high rate
(CC BY). The use, distribution or
of remission, and is associated with a decreased number of relapses.
reproduction in other forums is
permitted, provided the original Patients with depression receiving EMDR treatment may be more resilient
author(s) and the copyright owner(s) to stressors.
are credited and that the original
publication in this journal is cited, in
accordance with accepted academic
KEYWORDS
practice. No use, distribution or
reproduction is permitted which does depression, EMDR, EMDR DeprEnd protocol, psychotherapy, follow up
not comply with these terms.

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Altmeyer et al. 10.3389/fpsyg.2022.937204

Introduction Teicher et al., 2006; Hase et al., 2018). Besides increasing

the risk to develop depression, it also plays a crucial role
Eye Movement Desensitization and Reprocessing (EMDR) concerning symptom severity and the course of depression
therapy was introduced in 1987 by Francine Shapiro as a (Karabatsiakis and Schönfeldt-Lecuona, 2020).
treatment for post-traumatic stress disorder (PTSD). EMDR Eye Movement Desensitization and Reprocessing is an
therapy has the goal to integrate maladaptive information into effective trauma focused approach to treat depression, and in
a functional memory network by focusing on stressful memory clinical practice, since many years therapists use EMDR therapy
content and simultaneous bilateral stimulation (Shapiro, 2018). to work with stressful and traumatic memories in depressed
EMDR Therapy consists of a structured set of protocols and patients (Hofmann, 2020). Moreover, a recent systematic review
procedures based on the Adaptive Information Processing (AIP) and metanalysis by Carletto et al. (2021) and Yan et al.
Model. The AIP model postulates that traumatic experiences (2021) reported efficacy of EMDR therapy in the treatment of
are stored in a dysfunctional and frozen state which enhances depression in 9 controlled studies. Most of these 9 studies show
the possibility of suffering a mental disorder (Shapiro, 2018). a higher rate of remission at the end of therapy compared to
A recent study of Baek et al. (2019) could demonstrate the the control therapies (including cognitive behavioral therapy;
plausible biological main mechanism of EMDR treatment Yan et al., 2021). Usually patients with full remissions of their
by showing that a fear response learned through classical depression have a significantly lower risk to relapse again (Paykel
conditioning is unlearned more quickly if the mouse’s gaze or et al., 1995; Nierenberg et al., 2003). So far, no study has
attention is directed back and forth with the aid of a moving investigated long-term stability of EMDR therapy in treating
LED light. Meanwhile, a large number of scientific studies are depressive symptoms (Carletto et al., 2021). To advance the
available that not only demonstrate the effect of EMDR in PTSD existing evidences, in our present study, the aim was to
(Chen et al., 2014), but also that EMDR leads to symptom evaluate the efficiency and stability of treatment results with
reductions in depressive disorders, anxiety disorders, and other "EMDR therapy," for depressive inpatients in the Gezeiten Haus,
medical conditions (Shapiro, 2018; Wilson et al., 2018). Hospital Schloss Eichholz.
Depression is one of the most common mental illnesses
that pose major challenges to the healthcare system worldwide
(suicides, work disability, inpatient treatment, and early
retirement). With a lifetime prevalence of up to 20% (Ebmeier Materials and methods
et al., 2006; Kessler and Bromet, 2013), depression is considered
one of the most common mental disorders, affecting more The study aimed to show whether the intervention with
than 350 million people worldwide (Depression, 2017). Current EMDR leads to an improvement of symptoms in depressive
statistics also show that depression has become more prevalent patients and if the stability of the remission rates in patients
due to the COVID-19 pandemic (Hawes et al., 2021). treated with EMDR therapy are different from those mentioned
Depressive illness has been treated to date with behavioral in the previously reported literature. The protocol and
therapy, psychodynamic psychotherapy and, in severe cases, implementation of the study was carried out according to the
additional medication (DGPPN, 2015). In severe forms of ethics committee Ärztekammer Nordrhein. The patients were
depression, patients must also be provided with inpatient selected according to their date of admission if they met the
treatment. However, the major problem is that many patients inclusion criteria.
get readmitted as inpatients due to the high recurrence rate, Our study consisted of 49 inpatients who were treated in
i.e., after treatment, 30% of treated patients do not achieve the Gezeiten Haus, hospital Schloss Eichholz (see Table 1 and
a complete remission (cure) and more than 75% of patients Figure 1). The Gezeiten Haus hospital, Schloss Eichholz
suffer from recurrent depressive episodes (Maj et al., 1992; is a private hospital for psychotraumatology, EMDR,
de Jong-Meyer et al., 2007; Fostick et al., 2010). Although psychosomatics and traditional Chinese medicine. The focus
psychotherapy and medication can improve remission rates, the of the specialist hospital is on integrative acute treatment of
success rates of currently available treatments are limited. Even psychological and psychosomatic disorders, especially trauma
after a successful treatment with full remission of symptoms, related disorders and depression. The patients are usually
40–50% of patients experience a relapse within the first year referred to the hospital by psychiatrists and psychotherapists
after completing treatment (Hollon et al., 1992; Hautzinger et al., as well as other psychiatric units who recommend the clinic
1996; de Jong-Meyer et al., 2007). for a specialized intensive EMDR treatment because they
Stressful traumatic life events and stressful experiences (e.g., don’t respond to guideline oriented treatment any more. The
separation, loss, humiliation, embarrassment, serious illness, EMDR therapy followed the EMDR DeprEnd protocol and the
excessive demands, childhood abuse and maltreatment, neglect eight-phase approach by Shapiro, 2018). The EMDR DeprEnd
and other negative childhood stresses etc.) play a crucial protocol is an EMDR treatment algorithm for depression that
role in the development of depression (Kendler et al., 2003; focuses on stressful or traumatic episode triggers of depressive

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Altmeyer et al. 10.3389/fpsyg.2022.937204

episodes, negative belief systems, depressive or suicidal states examine the further course, especially after leaving the hospital,
(Hofmann et al., 2018). as follow-up, two telephone interviews were conducted both
The current study included all patients between 18 and after 3 and 12 months. In the short telephone interview,
70 years of age with the diagnoses of depression (ICD 10 experienced psychological staff asked the patients about their
F32.XX, F33.XX) potentially with a combination of PTBS (ICD further therapeutic treatment after discharge, their current work
10 F43.1). Exclusion criteria were acute suicidal tendencies, situation, and whether they have had a relapse in the last 3 or
acute psychoses, manic episodes, severe dissociation, severe self- 12 months. At the end of the telephone interviews, the former
harm or addiction due to the additional complexity that these patients were asked to answer the three questionnaires. If they
disorders add to the treatment time. Most patients (75.5%) were agreed, they were sent an e-mail with information and link for
admitted with a prescribed medication. During hospitalization, completion and submission of the questionnaires.
the main focus is not on medication change, so patients are
usually discharged with similar medications. If medications
were administered, they had to be stable for 2–4 weeks for the Statistical analysis
patient to be enrolled in the study.
All data were saved and analyzed in anonymized form using
IBM SPSS Statistics (version 26.0.0) and R (version 4.1.3). Four-
Study design and procedure field tables on remission and relapse after therapy provided
a descriptive overview of the success of treatment. Further
As part of quality assurance, a series of diagnostic tests is analyses on the success of the treatment were performed using
routinely administered to all inpatients admitted to the Hospital two-tailed paired t-tests for pre-post comparisons of symptom
Gezeiten Haus with written informed consent. This test package severity measures. Repeated measures ANOVAs with BDI-II
is given both at the beginning of the hospital stay and shortly and IES-R scores and overall symptom burden as dependent
before discharge. variable, measurement time (pre, post) as independent variable
The questionnaires cover the following topics: Symptomatic and the CTQ score as a potential covariate, as well as
Distress in various domains [Symptom-Checklist (SCL-90-R)]; the interaction of time × CTQ score were conducted to
depressive symptoms [Beck Depression Inventory (BDI-II)]; determine a possible influence of childhood maltreatment on
Self-esteem [Rosenberg Self-esteem Scale (RSE)]; Dissociative symptom reduction.
phenomena [Dissociative Experiences Scale (DES)]; Trauma
related disorder, intrusion, avoidance and hyperarousal [Impact
of Events Scale (IES-R)]; childhood traumatic experiences Results
[Childhood Trauma Questionnaire (CTQ)]; complex PTSD
[Screening of complex post-traumatic stress disorder (Sk- Evaluation of treatment changes
PTBS)].
After the diagnostic phase, psychotherapeutic treatment A total of 49 of the patients who met the search criteria were
is provided in an overall treatment plan, which includes analyzed. The average follow-up time at the end of the inpatient
psycho- and sociotherapeutic as well as psychoeducational treatment was 13 and a half months (MDN = 11.5 months).
and supportive measures in addition to medication. After a Table 2 and Figure 2 display an overview of the distribution
potential remission, BDI-II score under 12 (as per the BDI- of remission and relapse from depressive symptoms in our
II recommendation), of depressive symptoms and individual study cohort. 27 (55.0%) of patients achieved a remission after
discharge preparations, patients were discharged. In order to therapy, 22 (44.9%) did not. If remission was achieved during
therapy, 74.07% (20 out of 27) of cases remained stable during
follow-up phase; 25.93% (7 out of 27) relapsed. If no remission
TABLE 1 Sociodemographic characteristics of the study cohort
(n = 49). was achieved during therapy, 59.09% (13 out of 22) relapsed
and 40.91% (9 out of 22) achieved a remission during follow-
Gender (f/m) 32 (65.31%)/17 (34.69%) up phase.
Age (M (SD) (years) 46 (11.1)
Marital status TABLE 2 Therapy-related characteristics of the study cohort (n = 49).

In a relationship 9 (18.37%)
Number of EMDR sessions M (SD) 12.88 (6.02)
Married 24 (48.98%)
Divorced/separated 10 (20.41%) Remission (yes/no) 27 (55, 1%)/22 (44, 9%)
Single 3 (6.12%) Relapse (yes/no) 20 (40, 82%)/29 (59, 18%)
No information 3 (6.12%) Working (yes/no) 30 (63, 83%)/17 (36, 17%)

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FIGURE 1
Overview of the data collection process.

FIGURE 2
Distribution of relapse and remission in the study cohort.

A total of 15 of the patients suffered from primary Figure 3B) and subjective distress caused by traumatic events
depression without PTSD comorbidity. Eleven of them suffered (p < 0.001; Figure 3C) after treatment with EMDR. Similarly,
from recurrent depression, four suffered from a first episode of overall symptom burden, as assessed by sum of depressive and
depression. In the follow-up (MDN = 12 months after discharge; distress symptoms, significantly decreased over time (p < 0.001;
M = 15 months after discharge) nine (60%) of these patients Figure 3A). All changes were considered very robust in effect
reported a remission from their depressive symptoms at the (g > 1.0). Details of all pre-post comparisons can be seen in
end of their inpatient therapy. After the 3-month follow-up one Figure 3.
patient reported a relapse that occurred 3 months after being A repeated measures ANOVA, F (3,60.4) = 24.6, p < 0.001,
discharged from hospital. The others reported that they had R2 = 0.289 (0.652), indicated that the reduction of overall
not had a relapse at follow up (on average M = 12 months symptom burden during therapy differed depending on the
after discharge). patients’ experience of child maltreatment (CM), Time × CM:
In comparison, in the group of patients with depression and F (1,45) = 3.14, p = 0.08, η2 p = 0.07. Explorative post-hoc tests
comorbid PTSD, 18 (52.9%) patients had remissions at the end showed that before therapy, the patients’ symptom burden did
of treatment in the hospital and 12 of these patients also did not not correlate with their CM experiences, d = −0.03, p = 0.9.
report relapse in the follow-up interview (MDN = 11 months Through therapy, symptoms were reduced more in patients
after discharge; M = 13 months after discharge). with more CM experiences (e.g., at CTQ score = 58: Cohen’s
Paired t-tests were used to examine all pre- and d = −1.94, p < 0.001) whereas symptom reduction was lower
post-treatment changes. Results revealed a statistically in patients with less CM experiences (e.g., at CTQ score = 32:
significant decline in depressive symptoms (p < 0.001; Cohen’s d = −1.4, p < 0.001). Consequently, patients reporting

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FIGURE 3
Symptom change from pre- to post Eye Movement Desensitization and Reprocessing (EMDR) treatment. (A) Overall symptom burden, (B)
depressive symptoms BDI-II, (C) posttraumatic symptoms IES.

FIGURE 4
Influence of childhood maltreatment on therapy outcome. (A) Overall symptom burden, (B) depressive symptoms BDI-II, (C) posttraumatic
symptoms IES.

more CM showed less symptom burden at post therapy, Ostacoli et al. (2018) reported a 71% remission rate in the
d = −0.46, p = 0.06. Results are visualized in Figure 4A (for EMDR group right after treatment and 54.8% stable remissions
statistical details, see Supplementary Tables 1a–c). Similar effect after 6 months follow-up. Hase et al. (2018) reported a 50%
patterns could also be shown for the independent consideration remission rate in patients with depression after being treated
of depressive symptoms (Figure 4B and Supplementary with EMDR therapy in an inpatient setting. Accordingly, in
Tables 2a–c) and subjective distress caused by traumatic events our study, we showed a comparable overall remission rate,
(Figure 4C and Supplementary Tables 3a–c). although there was a difference in the remission rate between
In this context, it was also investigated whether patients patients with depression as primary diagnosis and patients with
with depression as primary diagnoses differed from patients a comorbid PTSD. Patients without PTSD had better remission
with depression and comorbid PTSD regarding their CM rates after completion of EMDR therapy, which remained stable
experiences. An independent t-test showed no significant after an average of 1 year of follow-up in almost all cases. Here,
difference, t(45) = 0.411, p = 0.683. it should be mentioned that in some previously listed studies,
remission was considered to be a BDI-II value below 9. In our
study, we defined remission as a BDI-II value below 12.
Discussion The results in our study population show fewer
relapses (26% Figure 2) in depressed patients after
In a naturalistic setting, the present study investigated, successful treatment compared to relapse rates reported
whether EMDR intervention leads to a symptomatic in previous literature (Hollon et al., 1992; Hautzinger
improvement in depressed patients, and whether remission et al., 1996; de Jong-Meyer et al., 2007). This finding is
rates in EMDR-treated patients are stable at the follow-up (Hase comparable to the follow-up results reported by Ostacoli
et al., 2018; Ostacoli et al., 2018). et al. (2018), who reported 54.8% relapse free patients at
Randomized clinical trials have already shown that EMDR 6 months follow-up in the group of depressed patients
is an effective method for treating patients with depressive treated with EMDR.
symptoms (Yan et al., 2021). In the present study comparable Therefore, these results are consistent with recent EMDR
results could be obtained under naturalistic conditions. studies reporting that EMDR therapy possibly leads not only to

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Altmeyer et al. 10.3389/fpsyg.2022.937204

a higher rate of remissions in depressive patients, but also may group to compare the efficiency of EMDR with other
decrease the number of relapses after treatment when compared depression-focused interventions. The reliability of the follow-
to treatment as usual (Hase et al., 2018). up assessments may be lower due to use of telephone-based
Childhood trauma is a major risk factor for developing self-reporting instruments.
depression (Edwards et al., 2003; Chapman et al., 2004;
Humphreys et al., 2020). Adversities during childhood are
not only associated with the severity (Rhebergen et al., Conclusion
2012) and the chronicity (Nanni et al., 2012; Klein and
Kotov, 2016) of the course of depression, but also with a In our study EMDR therapy leads to a high rate of
longer time to remission (Fuller-Thomson et al., 2014). Heim remission and is associated with a decreased number of
et al. (2008) showed in their study that adverse childhood relapses in patients with depression. The results of the present
experiences and childhood trauma are associated with altered observational study confirm data from previous research that
HPA axis potential as well as persistent sensitization of EMDR is a promising method for treating depression as well
the stress response, which are also related to depressive as depressive symptoms in patients with history of childhood
symptoms. Studies show that neurobiological differences trauma. In the light of these results, future studies could further
exist in depressed patients depending on whether trauma examine the effectiveness of EMDR treatment in patients with
occurred in childhood or adolescence (Heim et al., 2004, depressive disorders.
2008).
Heim et al. (2008) hypothesize that different therapeutic
methods are required depending on whether childhood Data availability statement
traumatization is present in depressed patients, with the aim to
integrate the components of a neural network that have been The original contributions presented in this study are
altered by trauma, with the goal of normalizing neuroendocrine included in the article/Supplementary material, further
responsiveness and behavior. Notably, the present study also inquiries can be directed to the corresponding authors.
found that patients with more childhood trauma seem to
have achieved better improvement during the hospital stay.
In the light of the AIP model and regarding the results of Ethics statement
the present study, this could mean that EMDR is particularly
effective in patients belonging to the subgroup with childhood The studies involving human participants were reviewed
traumatization with corresponding biological changes. and approved by the protocol and implementation of the study
Since a large number of studies show that emotional was carried out according to the ethics committee Ärztekammer
abuse and maltreatment are significantly more associated with Nordrhein. The patients/participants provided their written
depression compared to physical abuse (Mandelli et al., 2015; informed consent to participate in this study.
Humphreys et al., 2020), it would be relevant to investigate
in future studies the effect of EMDR treatment in depressed
patients, distinguished by the type of childhood maltreatment.
Author contributions
AH and SA developed the study concept. LW and
NK-H introduced and established the methodology. LW
Limitations conducted the study setup, coordinated the study, and collected
the psychological data. AB performed the statistical data
The present study has limitations that should be considered analyses. VT supervised and coordinated the study. SA and
when interpreting the results. This is a naturalistic observational LW drafted the manuscript under the supervision of AH
study, in which less factors could be controlled for. For and VT. All authors contributed to data interpretation,
example, medication change and additional treatments might critically revised the manuscript, and approved its final
have influenced the course of symptoms after discharge. version for submission.
Importantly in this regard, 91% of patients received an
outpatient therapy after their hospital stay, and 25% of
the patients were in the hospital during the COVID-19 Conflict of interest
pandemic which meant potential stress exposure within
the hospital setting and after discharge. Another limitation A possible conflict of interest worth mentioning could
of the present study is that the number of subjects be that the first author SA was also the chief physician of
(N = 49) was small. Further limitations include lack of the hospital where the data were collected. Furthermore, the
randomization, and, more importantly, lack of a control co-author AH was the founder of the German EMDR Institute.

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Altmeyer et al. 10.3389/fpsyg.2022.937204

The remaining authors declare that the research was reviewers. Any product that may be evaluated in this article, or
conducted in the absence of any commercial or financial claim that may be made by its manufacturer, is not guaranteed
relationships that could be construed as a potential or endorsed by the publisher.
conflict of interest.

Publisher’s note Supplementary material

All claims expressed in this article are solely those of the The Supplementary Material for this article can be
authors and do not necessarily represent those of their affiliated found online at: https://www.frontiersin.org/articles/10.3389/
organizations, or those of the publisher, the editors and the fpsyg.2022.937204/full#supplementary-material

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