J Korean Med Sci.
2018 Nov 26;33(48):e306
https://doi.org/10.3346/jkms.2018.33.e306
eISSN 1598-6357·pISSN 1011-8934
Brief Communication
Psychiatry & Psychology
Add-on Eye Movement Desensitization
and Reprocessing (EMDR) Therapy
for Adults with Post-traumatic
Stress Disorder Who Failed to
Respond to Initial Antidepressant
Pharmacotherapy
Hwallip Bae ,1 Daeho Kim ,2,3 Yubin Cho ,2 Dongjoo Kim ,2 and
Received: Apr 26, 2018 Seok Hyeon Kim 2
Accepted: Aug 27, 2018 1
Workplace Mental Health Institute, Gangbuk Samsung Medical Center, Seoul, Korea
Address for Correspondence:
2
Department of Psychiatry, College of Medicine, Hanyang University, Seoul, Korea
Daeho Kim, MD
3
Trauma and Stress Program, Hanyang University Guri Hospital, Guri, Korea
Department of Psychiatry, College of Medicine,
Hanyang University, 222 Wangsimni-ro,
Seongdon-gu, Seoul 04763, Korea. ABSTRACT
E-mail: [email protected]
© 2018 The Korean Academy of Medical This study examined the add-on efficacy of eye movement desensitization and reprocessing
Sciences. (EMDR) therapy among adult civilians with post-traumatic stress disorder (PTSD) who
This is an Open Access article distributed continued to be symptomatic after more than 12 weeks of initial antidepressant treatment.
under the terms of the Creative Commons
Scores for the Clinician Administered PTSD Scale (CAPS) were rated pre- and post-EMDR
Attribution Non-Commercial License (https://
creativecommons.org/licenses/by-nc/4.0/)
and at a 6-month follow-up. After an average of six sessions of EMDR treatment, seven of 14
which permits unrestricted non-commercial patients (50%) showed more than a 30% decrease in CAPS score and eight (57%) no longer
use, distribution, and reproduction in any met the criteria for PTSD. Our results indicate that EMDR could be successfully added after
medium, provided the original work is properly failure of initial pharmacotherapy for PTSD.
cited.
Keywords: PTSD; Drug Therapy; Antidepressants; EMDR
ORCID iDs
Hwallip Bae
https://orcid.org/0000-0002-9768-7368
Daeho Kim Although pharmacotherapy is considered the second line treatment for post-traumatic stress
https://orcid.org/0000-0002-6834-6775
disorder (PTSD),1,2 medication is still the most commonly referred treatment option for this
Yubin Cho
https://orcid.org/0000-0002-3981-8649 chronic and debilitating illness. For example, among 186,460 Iraq and Afghanistan veterans
Dongjoo Kim with PTSD enrolled in Veterans Affairs care, 80.1% received psychotropic medication.3 The
https://orcid.org/0000-0003-0557-1366 referral rate for medication from the US general hospital settings is also substantial; of
Seok Hyeon Kim 1,848 individuals with a diagnosis of PTSD, 74.6% and 63.0% received psychotherapy and
https://orcid.org/0000-0002-0530-8026
medication respectively, and 37.6% were treated with both treatment modalities.4
Funding
This research was supported by a grant of the Despite the popularity of pharmacotherapy as the most frequently offered treatment for
Korea Healthcare Technology R&D Project, PTSD, the overall response rates from clinical trials with selective serotonin reuptake
Ministry of Health and Welfare, Republic of inhibitors (SSRIs), the mostly recommended pharmacological agents for PTSD, range from
Korea (grant number, HM15C1058).
50%–60% and only 20%–30% of patients achieve complete remission of symptoms.5,6
Disclosure Moreover, next-step treatment strategies for these individuals who failed to respond, such
The authors have no potential conflicts of as combination therapy or a switch to other medications or psychotherapy, are poorly
interest to disclose. understood. In this context, trauma-focused psychotherapies were examined for the possible
https://jkms.org 1/6
EMDR for Non-Responder to Antidepressant Therapy
Author Contributions next-step candidates of poor medication responders including cognitive behavior therapy
Conceptualization: Bae H, Kim D,1 Kim SH. (CBT), interpersonal psychotherapy, and prolonged exposure.7-11
Data curation: Bae H, Kim D, Cho Y, Kim D.2
Formal analysis: Kim D. Methodology: Kim D.
Validation: Kim SH. Investigation: Bae H, Kim
As an alternative to these treatments usually delivered for 10–16 sessions, eye movement
D, Cho Y, Kim D.2 Visualization: Bae H, Kim desensitization and reprocessing (EMDR) therapy is the other option from evidence-
D, Kim D.2 Resources: Bae H, Kim D, Kim SH, based psychotherapeutic strategies.2,12 EMDR therapy is a trans-diagnostic, integrative
Cho Y. Supervision: Kim D, Kim SH. Project psychotherapy approach, which is intrinsically client-centered at its core.13 It has been
administration: Kim D. Funding acquisition: extensively researched and proven effective for the treatment of adverse life experiences.12
Kim D. Writing - original draft: Bae H, Kim D.
It utilizes a theoretical framework known as adaptive information processing (AIP). The
Writing - review & editing: Bae H, Cho Y, Kim
D,2 Kim SH. context of AIP is that adverse life experiences cause imbalance in the nervous system thus
creating blockages or incomplete information processing, namely trauma memories. These
Kim D,1 Daeho Kim; Kim D,2 Dongjoo Kim. inappropriately stored episodic memories, which include the perceptions, sensations,
beliefs and emotions that occurred at the time of the adverse life event, can be triggered by
current internal and external stimuli, contributing to ongoing dysfunction.12,14 This model,
developed in the early 1990's, has since demonstrated the role played by disturbing life events
in the genesis of many forms of psychological and somatic symptomology, including PTSD.12
To investigate the benefit of adding EMDR therapy as a sequencing treatment strategy for
PTSD in patients who failed to initially respond, we analyzed naturalistic cohort data of
EMDR at an outpatient trauma clinic.
The original data included 51 adult patients with a current Diagnostic and Statistical Manual
for Mental Disorders – fourth edition (DSM-IV) PTSD diagnosis who received at least one
session of EMDR and psychotropic medication at a psychological trauma clinic, Hanyang
University Guri Hospital in Gyeonggi Province, Korea. Their PTSD and comorbid diagnoses
were confirmed by the Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician
Version.15 Inclusion criteria were a total score greater than 45 on the Clinician Administered
PTSD Scale (CAPS),16,17 age between 18 to 64, and ability to read and write. Exclusion criteria
were comorbid psychotic illness and neurological or cognitive disorders.18
Subjects were included in this analysis if they had received at least 12 weeks of one or more
antidepressants at maximal tolerable dose (for example, at least fluoxetine 20 mg/day,
sertraline 50 mg, and paroxetine 20 mg) before initiation of EMDR therapy. These criteria
reflect the stringent standard for minimal effective dose and duration for antidepressant
trials for adult PTSD.19 Of 51 patients, 29 (57%) were excluded because they were not given
medication at least 12 weeks prior to EMDR treatment. Among the 22 remaining patients,
two did not receive antidepressants, two did not have detailed information for dose and four
had an inadequate dose of antidepressants leaving 14 for final analysis.
Among these 14 patients, eight were women (57.1%), eight were married (57.1%), and nine had
more than high school education (64.3%). The mean age of participants was 40.5 (standard
deviation [SD], 13.2; 95% confidence interval [CI], 32.9–48.1; range, 22–61). The index traumatic
event of participants was motor vehicle accident (n = 12), industrial accident (n = 1) and family
violence (n = 1). The median duration of illness was 7 months (range = 3–150). Six patients had
two comorbid psychiatric diagnoses other than PTSD, another six had one, and two had no
comorbidity. Baseline CAPS score was 69.6 (SD, 13.6; 95% CI, 61.7–77.5; range, 46–105).
We used The CAPS for measurement, which is a gold standard interview-based instrument
for diagnosis of DSM-IV PTSD.16 It contains 17 items of DSM-IV criteria for PTSD symptoms
and each item is rated for two categories of frequency and intensity and each scored between
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EMDR for Non-Responder to Antidepressant Therapy
Table 1. PTSD symptoms at baseline, pre-EMDR and 6 month follow-up (CAPS scores)
Variables Baseline (n = 14) Pre-EMDR (n = 14) Post-EMDR (n = 14)
Mean SD Mean SD t P Cohen's d Mean SD t P Cohen's d
Total score 75.8 10.9 69.6 13.6 2.3 0.035 0.63 49.9 26.7 3.9 0.002 1.04
Re-experience 24.6 5.2 22.0 7.4 2.0 0.067 0.53 13.8 10.3 4.0 0.002 1.06
Avoidance/numbing 27.6 6.9 27.6 7.7 0.8 0.425 0.22 20.8 10.8 3.5 0.004 0.92
Hyperarousal 23.2 4.8 20.7 6.2 1.9 0.079 0.51 15.3 8.3 2.2 0.045 0.59
PTSD = post-traumatic stress disorder, CAPS = clinician-administered PTSD scale, EMDR = eye movement desensitization and reprocessing therapy,
SD = standard deviation.
0 and 4. A symptom of PTSD is considered present if the sum of frequency and intensity is
more than 4 in this study.20
EMDR therapy was delivered weekly for a mean of 5.9 sessions (SD, 2.4; 95% CI, 2.5–7.3;
range, 2–10) depending on the clinical needs and complexity of problems. The second author
administered EMDR for 10 cases (71.4%) and four psychiatric residents each treated one of
the other patients. Participants remained on the same dose of medication during the therapy.
Paired t test was used for pre- and post-treatment comparison. Spearman's correlation was
applied for the decrease in the CAPS score and demographic or clinical variables. Statistical
significance was set at P value of 0.05 bidirectionally and all the analyses were conducted with
IBM SPSS Statistics for Windows, Version 21.0 (IBM Corp., Armonk, NY, USA).
The protocol of this study was reviewed and approved by the Institutional Review Board (IRB)
of Hanyang University Guri Hospital (approval No. 20121119). All the participants submitted
the written informed consents when they were enrolled.
The median time of prior dose-adequate antidepressant therapy was 3.5 months (range, 3–15)
and three participants had received two concomitant antidepressants. Antidepressant prescribed
were sertraline (50–100 mg, n = 2), paroxetine (40 mg, n = 2), escitalopram (20 mg, n = 2),
venlafaxine (150 mg, n = 2), duloxetine (60 mg, n = 2), tianeptine (37.5 mg, n = 2), mirtazapine
(15–30 mg, n = 2), trazodone (200 mg, n = 1), and amitriptyline (100 mg, n = 1). Comparison
between baseline and after medication indicated a statistically significant decrease in CAPS
symptoms (t = 2.3, df = 13, P = 0.035) with a mean reduction of 8.1% (SD, 12.7; range, 14–32;
95% CI, 0.9–15.4).
The participant showed a mean 32.7% decrease in CAPS scores (SD, 26.4; range, −3.9–72.0;
95% CI, 17.5–48.0); 7 (50%) responded with a more than 30% decrease in the total CAPS
score and 8 (57%) lost the PTSD diagnosis (Table 1). When these seven participants were
followed up at 6 months, four showed similar results, one further improved to the level of
complete remission (CAPS score < 20), and one had lost the benefit and met the diagnostic
criteria for PTSD again (Table 2). No statistical differences were found for response and
decrease in CAPS scores between those who were followed-up and those who were not.
Table 2. Six-month follow-up of PTSD symptoms (CAPS scores)
Variables Post-EMDR (n = 14) Six-month follow-up (n = 7)
Mean SD Mean SD t P
Total score 55.6 30.9 54.3 28.5 0.3 0.773
Re-experience 17.0 10.0 16.0 7.2 0.6 0.593
Avoidance/numbing 21.9 11.9 23.1 11.5 −0.9 0.412
Hyperarousal 16.7 10.4 15.6 12.0 0.5 0.650
PTSD = post-traumatic stress disorder, CAPS = clinician-administered PTSD scale, EMDR = eye movement
desensitization and reprocessing therapy, SD = standard deviation.
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EMDR for Non-Responder to Antidepressant Therapy
In this study, among 14 patients who failed to respond to an initial 12-week trial of
antidepressant, seven responded with a greater than 30% decrease in the total CAPS score and
eight (57%) lost the PTSD diagnosis. This is comparable to findings from a previous study in
which CBT was added to therapy for pharmacotherapy-resistant patients with PTSD and 60%
in the immediate treatment group (n = 20) and 50% in the delayed treatment group (n = 20)
lost their PTSD diagnosis.8 It is noteworthy that the number of sessions administered with
EMDR therapy was smaller (i.e., about six sessions) than the 10 to 12 sessions reported in
previous psychotherapy studies.21 This may favor EMDR as add-on psychotherapy after failure
of pharmacotherapy in terms of cost-effectiveness; in support of this view, EMDR showed a
sharper decline in the pattern of reduction in PTSD symptoms than trauma-focused CBT.22
However, participants in three CBT studies had longer duration of SSRI treatment (at
least 6 or 12 months) with the maximally tolerated dose prior to adding psychotherapy
and are therefore more likely to be labeled pharmacotherapy-resistant or refractory.8-10
One study noted that 55% of SSRI non-responders turned into responders after additional
6-month continuation of the same drug, suggesting that a more extended period of
continued medication may be needed.23 However, it is generally recommended that at least
8 to 12 weeks of SSRIs or serotonin and norepinephrine reuptake inhibitors (SNRIs) at
maximal tolerable dose should be given to judge treatment response24; one clinical trial of
pharmacotherapy with PTSD defined SSRI resistance as less than a 30% decrease of PTSD
symptoms (based on CAPS scores) after 8 weeks of sertraline at a dose of 25 mg to 200 mg.24
Therefore, our participants at least meet the criteria for failure of treatment response.
Our finding also broadly supports the current opinions of experts that either a switch
to another medication or addition of psychotherapy should be considered when initial
pharmacotherapy with SSRIs or SNRIs fails.21 Further studies are necessary to examine
whether switching to another type of medication or adding trauma-focused psychotherapy
will provide the greatest benefit.
The first limitation of this study is that this is not a prospective clinical trial without control
group. Secondly, we do not have information for patients who improved after initial
antidepressant pharmacotherapy and there may be selection bias concerning which patients
received additional trauma psychotherapy. Thirdly, the treatment dose of EMDR may be
insufficient given that clinical trials typically administered the therapy at 8–12 sessions.22,25
However, in the real-world practice, trauma-focused psychotherapies are delivered at fewer
sessions (median, 5 sessions).26 Further clinical trials are needed to determine best practice for
combined and sequential approaches with medication and trauma-focused psychotherapy.
In conclusion, EMDR therapy seems to be a good option for addition to psychotherapy when
initial pharmacotherapy fails to improve PTSD conditions with the additional benefit of cost-
effectiveness (fewer sessions and no homework assignment).
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