Psychology and Psychotherapy: Theory, Research and Practice (2017) [612059]

Psychology and Psychotherapy: Theory, Research and Practice (2017)
©2017 The Authors. Psychology and Psychotherapy: Theory, Research and Practice published by
John Wiley &Sons Ltd on behalf of British Psychological Society
www.wileyonlinelibrary.com
EMDR as a treatment for long-term depression:
A feasibility study
Emily Wood1*, Thomas Ricketts1,2and Glenys Parry1
1School of Health and Related Research, The University of Sheffield, UK
2Sheffield Health and Social Care NHS FT, UK
Objective. Current treatments for long-term depression –medication and psy-
chotherapy –are effective for some but not all clients. New approaches need to be
developed to complement the ones already available. This study was designed to test thefeasibility of using an effective post-traumatic stress disorder treatment for people with
long-term depression.
Design. A single-case experimental design with replications was undertaken as a
feasibility study of eye movement desensitization and reprocessing (EMDR) in treatinglong-term depression.
Methods. Thirteen people with recurrent and/or long-term depression were recruited
from primary care mental health services and given standard protocol EMDR for a
maximum of 20 sessions. Levels of depression were measured before and after treatmentand at follow-up, clients also rated their mood each day.
Results. Eight people engaged with the treatment; seven of these had clinically significant
and statistically reliable improvement on the Hamilton Rating Scale for Depression. Daily
mood ratings were highly variable both during baseline and intervention.
Conclusions. EMDR is a feasible treatment for recurrent and/or long-term depression.
Research on treatment efficacy and effectiveness is now required.
Practitioner points
/C15EMDR may be an effective treatment for depression.
/C15EMDR could be considered if first-line approaches (CBT and counselling) have been tried and failed.
/C15EMDR may be particularly helpful for service users with a history of trauma.
Long-term depression comprises of recurrent major depressive disorder (MDD; two or
more episodes) and persistent depressive disorder (a chronic episode of depression that
lasts for more than 2 years; APA, 2013). Although some consider recurrent and chronicdepression to be different illnesses (Klein & Santiago, 2003), identifying the correctdiagnosis in a particular client is hampered by incomplete remission and memory bias.Current recommended treatments for depression include antidepressant medication,
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which
permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and nomodifications or adaptations are made.
*Correspondence should be addressed to Emily Wood, School of Health and Related Research, The University of Sheffield,
Regent Court, 30 Regent Street, Sheffield S1 4DA, UK (email: e.f.wood@sheffield.ac.uk).
DOI:10.1111/papt.121451

cognitive behavioural therapy (CBT), counselling, and interpersonal therapy (NCCMH,
2010). However, despite the efficacy of these interventions (Butler, Chapman, Forman, &Beck, 2006; Olfson, Marcus, Tedeschi, & Wan, 2006), they do have limitations. In long-term depression, typical response rates to both medication and psychotherapy may be
<50% (Torpey & Klein, 2008). Psychotherapy for long-term depression may be less
effective than for acute-phase depression (Cuijpers et al. , 2010).
Eye movement desensitization and reprocessing (EMDR; Shapiro, 1995) is a
psychotherapy that was initially developed for the treatment of post-traumatic stressdisorder (PTSD). A Cochrane Collaboration review of treatments for chronic PTSDrecommended EMDR, trauma-focussed CBT (group and individual) and non-trauma-focussed CBT (Bisson, Roberts, Andrew, Cooper, & Lewis, 2013). There is interestamongst EMDR clinicians in using EMDR with other diagnoses. The theoretical model
behind EMDR, the adaptive information processing model (AIP), suggests that problem-
atic memories of trauma events are the cause of pathology and these are not limited toPTSD (Solomon & Shapiro, 2008). Four randomized controlled trials into EMDR for PTSDhave also reported significant improvements in comorbid depression (Arabia, Manca, &Solomon, 2011; Ironson et al. , 2002; Lee, Gavriel, Drummond, Richards, & Greenwald,
2002; van der Kolk et al. , 2007). However, there is little research into EMDR for clients
who have a primary diagnosis of depression without PTSD; this is limited to case studiesand clinical reports (Wood & Ricketts, 2013).
Life events describe any stressful occurrence in a person’s life, these can be positive
such as moving house or getting married, or negative such as getting ill or being assaulted.In the EMDR literature, life events are sometimes referred to as ‘small t traumas’ (asopposed to ‘big T traumas’ which are the life-threatening events associated with PTSDonset). Depression is often associated with negative life events (Lenze, Cyranowski,Thompson, Anderson, & Frank, 2008), and people with chronic depression tend to reportgreater levels of early life adversity (Riso & Newman, 2003). Childhood trauma is a directand strong risk factor for developing depression later in life (Heim, Newport, Mletzko,
Miller, & Nemeroff, 2008). There is a strong dose –response relationship between adverse
childhood experiences and lifetime depressive illness (Chapman et al. , 2004), and it can
be considered a determinate for chronicity (Wiersma et al. , 2009), earlier onset (Bernet &
Stein, 1999), more lifetime episodes (Bernet & Stein, 1999), and treatment resistance(Kaplan & Klinetob, 2000). In theory, if EMDR is designed to treat the effect of beingtraumatized and depression is associated with a high incidence of trauma, then EMDRshould be able to treat depression. Therefore, the aim of this research was to investigatewhether EMDR has the potential to be a treatment for long-term depression without PTSD
by testing whether it is (1) feasible to deliver, (2) acceptable to patients, and (3) associated
with reductions in symptoms of depression.
Method
As there is little research on EMDR and depression (Wood & Ricketts, 2013), this studyfollowed the Medical Research Council guidelines (Craig et al. , 2008) and began with a
feasibility study.
Design
A single-case experimental design (SCED) with replications (Barlow & Hersen, 1984) wasused. Before and after, measures were used to see whether change occurred, with the2Emily Wood et al.

primary outcome being change on the Hamilton Rating Scale for Depression (HRSD;
Hamilton, 1960). A daily measure of low mood was also completed to investigate whetherchange in mood was associated with delivery of EMDR. An AB design was used, withbaseline periods during which the participant rated their mood on the daily measure before
receiving treatment. The baselines were between 9 and 48 days long and were used to
predict natural fluctuations in mood. Once treatment started, the daily measure ratingscontinued and were used to show how and when change occurred, if it occurred at all.
Participants
Thirteen patients were recruited with a primary diagnosis of long-term depression (definedas at least 2 years in duration or two or more episodes over the lifetime; APA, 2003).
Although they did not need to be native English speakers, they did need sufficient English to
be able to understand the testing and fully describe their memories. They had all receivedtreatment from the United Kingdom improving access to psychological therapy (IAPT)primary care mental health service. Their therapist then introduced them to the research,and if interested, their details were passed to the researcher. They were screened using theMini-international neuropsychiatric interview (MINI; Sheehan et al. , 1998).
Inclusion criteria –People aged 18 and over, with long-term depression, confirmed
through structured interview (MINI) to ensure they met the DSM-IV-R criteria.
Participants must meet the criteria for a current major depressive episode AND have
had at least two episodes (i.e., it is recurrent depression) OR the current episode lasted2 years or more (long-term MDD or dysthymia were accepted). Participants had to be ableto give informed consent. Participants must have tried at least one-first-line treatment andnot responded.
Exclusion criteria –those under 18, those unable to give informed consent, those with
current suicidal intent or behaviour, psychosis, bipolar disorder, PTSD, dementia, braininjury, current drug/alcohol dependence, epilepsy, pregnancy, current opiate analgesic
use, ECT in the last 6 months, primary mental health diagnosis was not long-term
depression.
Measures
The primary outcome measure for the study was the HRSD (Hamilton, 1960). This wascollected at entry to the study and after the intervention and at 3-month follow-up by thefirst author who was trained to use all measures. Also collected at the start, end, and
follow-up were the Impact of Event Scale –revised (IES-r; Creamer, Bell, & Failla, 2003),
the Patient Health Questionnaire –9 items (PHQ-9; Kroenke, Spitzer, & Williams, 2001)
and the Beck Depression Inventory (v.2) (BDI-II; Beck, Steer, & Brown, 1996). At the startof every session, the clients completed the PHQ-9.
Hamilton Rating Scale for Depression
The HRSD is a 24-item clinician-rated scale for depression symptoms. It has been shown to
have good reliability between raters (Hamilton, 1960) and is sensitive to change over time
and treatment (Miller, Bishop, Norman, & Maddever, 1985). This is the primary outcomefor the indicators of symptoms change. Scores range from 0 to 75 and 8 or less =no
symptoms, 9 to 18 =mild, 19 to 26 =moderate, 27 to 34 =severe, 35 +(max score
75)=very severe.EMDR and depression 3

Hamilton Rating Scale for Depression was the primary outcome measure as this is a
validated and recognized scale worldwide. It has been the gold standard in depressionrating scales for 40 years (Bagby, Ryder, Schuller, & Marshall, 2004). It enables theresearch to be compared to other research. The HRSD is heavily biological in its design
whereas the BDI is more responsive to the cognitive aspects of depression. It is advisable
to have more than one scale covering differing perspectives and symptom domains (Roth& Fonagy, 2005). The HRSD and the BDI-II are considered two of the best tested andreliable rating scales available for depression (Cusin, Yang, Yeung, & Fava, 2009) but arenot commonly used in clinical practice in the United Kingdom. The BDI-II is regularly usedin American studies but less so in the United Kingdom. The PHQ-9 is a standard measureused in IAPT in the United Kingdom so allows the results to be comparable to the IAPTdata set should that be appropriate.
The Patient Health Questionnaire –9 items
The PHQ-9 (Kroenke & Spitzer, 2002) is a self-rated depression measure routinely used inIAPT services that takes about two minutes to complete, and it is validated in a UKpopulation (Gilbody, Richards, & Barkham, 2007). The IAPT handbook recommends thefollowing interpretation of PHQ-9 scores, 1 –4 minimal depression, 5 –9 mild depression,
10–14 moderate depression, 15 –19 moderately severe depression, and 20 –27 severe
depression (Department of Health, 2011).
Beck Depression Inventory (v.2)
The BDI-II is a 21-item self-report rating scale for depression (Beck et al. , 1996), it covers
all nine of the DSM diagnostic criteria rather than the six of the BDI, and it includesincreases as well as decreases in somatic symptoms (Dozois, Dobson, & Ahnberg, 1998). Itis used in many research studies into depression and is the primary depression tool in the
United States (Sharp & Lipsky, 2002). It has good validity when compared with other self-
rate scales and clinician-rated measures for depression (Steer, Ball, Raneeri, & Beck, 1997).The interpretation of the score should 1 –10 no depression, 11 –16 mild mood disturbance,
17–20 borderline clinical depression, 21 –30 moderate depression, 31 –40 severe
depression, and over 40 extreme depression (Beck et al. , 1996).
Impact of Event Scale –revised
The IES-r is a self-report scale measuring traumatic stress; it was developed to improve the
IES scale, which did not include persistent hyper-arousal (Creamer et al. , 2003). It is a
useful instrument for measuring traumatic stress, and a score of 33 or more gives optimaldiagnostic accuracy for PTSD (Creamer et al. , 2003).
To assess whether participants had made clinically significant and statistically
significant changes, the reliable change index (RCI) was used. Reliable change is a wayof determining whether the change you see is likely to be real or simply an artefact due tothe unreliability of the instrument (Jacobson & Truax, 1991). A RCI can be determined for
each measure. If the client’s score on the measure changes between the initial and end of
therapy reading by more than the RCI, then we can be confident that in 95% of cases thischange will be real and not due to error in the measure (i.e., it is statistically reliable). TheRCI was calculated for all of the scales. Due to the small sample size in this study,previously published means, standard deviations, and internal consistency scores derived4Emily Wood et al.

from larger samples were used to calculate the RCIs as they may be considered more
reliable.
Although it is important to know that change is reliable, it must be meaningful to the
clinicians as well and therefore needs to be related to caseness and severity of illness. The
RCI tells us whether the change is statistically reliable, and it does not necessarily tell us
whether it is clinically meaningful (Barkham & Mellor-Clark, 2003). Many articlesreporting a clinical measure will assign a cut-off level (Table 1) to determine what levels ofsymptoms are clinically significant enough to be considered a ‘case’. Sometimes they alsosuggest levels of change that can be considered clinically significant or an adequateresponse to treatment. This acknowledges that although a client’s symptoms may notdisappear entirely this does not mean that a treatment has not made a major improvementto their life.
The repeated measure
Using this repeated measure, it was possible to track fluctuations in mood in between thesessions; this aims to add insight into the before and after measures and enabled theresearch to be placed in context of the natural changes in depressive symptoms over time(Turpin, 2001). As has been used in other time series evaluations, the repeated measurewas based on the DSM-IV-R criteria for the disorder of interest (Kellett, 2007), in this case
MDD. The questions were derived from the wording of the PHQ-9 (Kroenke et al. , 2001),
and reflected the essential criteria from both the DSM-IV-R criteria for MDD (APA, 2003)and the essential criteria for MDD from the ICD-10 (WHO, 1993; question 3). It was pilotedand the wording was borrowed from the PHQ-9 which has been validated for British adultswith depression (Gilbody et al. , 2007). The participants were given a paper copy of the
scale to complete every day. Three questions addressed low mood/depression, loss ofinterest or pleasure in activities, and energy levels. The questions were set out in thestandard visual analogue form, and the participant had to make a mark on the line
representing their mood at that time. The scales had anchored endpoints, for instance ‘I
Table 1. Reliable change and clinically significant response
Measure Caseness cut-offClinically significant
responseReliable
change
Hamilton Rating Scale for
Depression (Hamilton,1960; Schramm et al. , 2011)<8 is non-clinical At least 50% reduction
in score and score isnow<155.95
Patient Health Questionnaire
–9 items (Kroenke et al. ,
2001; Smarr and Keefer,
2011)<10 is non-clinical At least a 5-point
reduction6.33
BDI-II =Beck Depression
Inventory (v.2) (Smarr and
Keefer, 2011)No official level of caseness
but some have suggested
at least 16 points is
required for diagnosis5-point
decrease =minimal
improvement
10–19=moderate
20+= large8.94
Impact of Event Scale –
revised (Creamer et al. ,
2003)33 or more indicates PTSD 17.84EMDR and depression 5

am extremely low or depressed’ to ‘I don’t have low mood’ (see Appendix). Completed
forms were returned to the therapy session where participants collected the next week’sdiary. Afterwards, the mark was measured from the right-hand side to give a decreasingnumber as the symptoms improved.
At the end of the treatment, all participants were asked the NHS ‘Friends and Family’
question, would you recommend this treatment to friends or family in the same situation?
The intervention
The EMDR adhered to the manualized eight-phase standard protocol design byFrancine Shapiro and approved by the EMDRIA institute (Shapiro, 2001). There arenumerous different protocols for EMDR for a range of illnesses, conditions, and
situations, but only the original standard protocol has been used in clinical trials. For
this reason, the standard protocol was chosen for this study. To ensure the therapistsadhered to the standard protocol, they were asked to complete a therapy processrecord each session. Therapy was twice a week in 60-min sessions in a NationalHealth Service building that provided psychological therapies. Participants couldreceive up to 20 sessions, but the final number was a clinical decision. Threetherapists provided EMDR; they were all fully qualified to do so and had been trainedby EMDRIA institute approved trainers to at least level three.
The eight phases of EMDR are (1) Client history and treatment planning, (2)
Preparation, (3) Assessment (of the trauma), (4) Desensitization, (5) Installation, (6)Body Scan, (7) Closure, and (8) Re-evaluation (Shapiro, 2001). It is phase four wherethe bilateral stimulation, that is the key (and controversial) component of EMDR,begins. Some early EMDR researchers only counted the number of sessions from themoment bilateral stimulation began. This study counts the number of sessions fromthe moment of first contact with the therapist. However, there is no set time periodfor the length of time each of these phases should take. Depending on the client, it
may be necessary to spend several sessions planning and preparing, others may get
through to phase four or five in one session. This is entirely a clinical decision and isbased on the needs of the client.
Analysis
For the before and after standardized measures, reliable change indices (Jacobson &Truax, 1991) and clinically significant change (Barkham & Mellor-Clark, 2003) were
calculated. For the primary measure, the HRSD, clinically significant change can be
defined as the participant scoring below eight (for remission) or having a 50% drop inscore and now scored under 15 (for response; Hamilton, 1960). MS Excel and SPSS wereused for the analysis.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical
standards of the relevant national and institutional committees on human experimenta-
tion and with the Helsinki Declaration of 1975, as revised in 2008. The research wasapproved by the Research Ethics Committee on behalf of the UK National Research EthicsServices.6Emily Wood et al.

Results
Participants
Fifteen people were screened; two were excluded as they had PTSD. Of the 13 who signed
consent forms, three did not begin treatment. One was no longer depressed so was insteadreferred to relapse prevention work, one repeatedly turned down appointments andfinally stopped responding to contacts and one could not start EMDR as a therapist couldnot be found for him. Ten people began treatment, and two dropped out. One droppedout after two sessions reporting family issues and not being able to commit to thetreatment. One was referred to the community mental health team. This left eight peoplewho fully engaged with the treatment programme (Figure 1).
The participants ranged in age from 29 to 65 years old with a mean age of 46 (standard
deviation 13.1); eight of the 13 were women. The reported first onset of depression rangedfrom 9 to 43 years, and the self-reported length of the current episode ranged from 1 month
15 people
screened2 have PTSD and are excluded –care from IAPT
10 people start therapy13 people consented 1 recovers – no longer meets DSM-IV criteria
for depression (referred to mindfulness relapse prevention group)
1 opt out (no response to letters)1 meeting criteria but no therapist available in
the time frame (offered EMDR outside the
research clinic)
1 withdraws after 2 sessions due to home
commitments – referred back to IAPT
1 discharged after 9 sessions – unsuitable for
further treatment – referred to community
mental health team (CMHT)
8 people
fully engage1 deteriorates and has to be discharged after 8 sessions – referred to CMHT
7 people complete treatment – all
are classed as responders to
treatment
Figure 1. Flow chart of participant recruitment and retention.EMDR and depression 7

to 10 years. All had received at least one talking therapy and at least one antidepressant
medication in the past. The range of talking therapies were CBT, computerized CBT,cognitive analytic therapy, counselling, bereavement counselling, workplace well-being,psychodynamic therapy, hypnotherapy, and pain-team psychology. All had MDD confirmed
by structured clinical interview, most reported recurrent depression (11/13), just over half
had chronic depression (7/13), and some had both (5/13).
Of the 13 participants recruited, three received no treatment sessions. As this is a
feasibility study, an intention-to-treat analysis was not conducted and their pre-therapydata were excluded. Only one other participant did not provide after therapy outcomedata, participant 008. He did begin therapy but he was discharged after eight sessions, asthe therapist deemed him unsuitable for treatment at the present time. After his discharge,he did not respond to our requests to meet for end measures. This was then treated as a
dropout. As this is a failure of treatment, his scores are included in the analyses.
Participants who received treatment had between eight and twenty sessions (average
17.6SD3.8). Phases 2, 3, and 4 of the standard protocol were the most frequently recorded.
Phase two is resourcing where the psychological resources and coping strategies of theparticipant are assessed and strengthened (present in 9 –19 sessions). Phase three is the
assessment phase where the target memory is assessed (present in 5 –17 sessions). Phase
four is desensitization and is when the bilateral stimulation is used to desensitize the client tothe traumatic memory (present in 1 –16 sessions). All participants preferred tapping to eye
movements, so the majority of bilateral stimulation sessions used this method.
Clinical measures
The mean change score on the HRSD was a decrease of 14.1 ( SD4.8). Table 2 shows the
detail of the changes for each participant.
Table 2. The change in Hamilton Rating Scale for Depression (HRSD), if that change was reliable and
clinically significant and if any change in symptoms was maintained at follow-up
ParticipantHRSD
PreHRSD
Post Change Reliable?aClinically sig?aHRSD F/UAre
benefits
maintained?
11 7 3 /C014 Yes Yes –remission 4 Yes
31 3 5 /C08 Yes Yes –remission 6 Yes
42 5 9 /C016 Yes Yes –response 7 Yes
52 6 3 /C023 Yes Yes –remission 7 Yes
6 13 25 12 Yes Yes but
deteriorated5 Improved
72 1 5 /C016 Yes Yes –remission 4 Yes
82 2 – Dropout –
10 23 11 /C012 Yes Yes –response –
11 10 2 /C08 Yes Yes –remission 5 Yes
12 26 8 /C018 Yes Yes –response –
Mean
(SD)19.6
(5.9)7.9
(7.1)/C014.1
(4.8)5.4
(1.3)
Note .aA 6-point change is required for change to be considered reliable on the HRSD, for change to be
clinically significant the participants post-score must be below 8 or have dropped by at least 50% and nowbe below 15.8Emily Wood et al.

Figure 2 is a Jacobson plot (Jacobson & Truax, 1991) of the before and after scores for
the HRSD, which shows if any change is reliable, as measured on the RCI, and if it isclinically significant. Any point below the diagonal ‘no change’ line is a participant whoimproved during the course of therapy. If that point is outside the tramlines (dashed), then
the change is statistically reliable, and if it is below the horizontal line, then the participant
is now in remission. On the HRSD, change can be clinically significant but not reach thepoint of remission; that is, the participant has shown a major improvement in his or hersymptoms, but they are not yet well enough to be considered in remission; Table 2 showsthis in more detail.
The table and Jacobson plot show that of the nine people with before and after
measures, only one deteriorated and all the others meet the criteria for response. Of these,five are in remission (001, 003, 005, 007, and 011) and three responded to treatment with
at least a 50% reduction in HRSD score and are now rated as having mild depression (004,
010, and 012). The person who deteriorated (006) went from mild-to-moderatedepression with an almost 50% increase in his HRSD score. Two people dropped outand did not receive a full treatment of EMDR but did provide pre-/post-data; their scorescorrespond to the points at coordinates 13, 25 and 23, 11.
The secondary measures also showed clinically significant improvement as Table 3
summarizes. Table 3 also shows how the results seen on the clinician-rated HRSD areremarkably consistent with the client rated BDI-II and PHQ-9. On the three depression
measures, HRSD, BDI-II, and PHQ-9, there is agreement on almost all cases. Participant 10
did not improve as much on the self-report scales as she did on the clinician-rated scoreand participant 11 did not improve as much on the PHQ-9 as she did on the other twomeasures.
The IES-r clinically significant changes need to be read with care. The change is only
clinically significant if the participant moves across a specified cut-off point, but not all theparticipants started on the pathological side of the cut-off (i.e., they did not have evidenceof being traumatized or had normal social functioning). These participants cannot achieve
clinically significant change no matter how much they improve. Change in participant 6
was clinically significant and statistically reliable but he deteriorated.
Figure 2. Jacobson plot for the Hamilton Rating Scale for Depression (HRSD).EMDR and depression 9

Table 3. Change in BDI-II, PHQ-9, and IES, if that change was statistically reliable and clinically significant and if any change was maintained at follow-up
ParticipantIES-r
preIES-r
post ChangeIES-r
F/UPHQ-9
prePHQ-9
post ChangePHQ-9
F/UBDI-II
preBDI-II
post Change BDI-II F/U
11 3 4 /C09 8 17 7 /C010a,b4c33 10 /C023a,b6c
31 1 5 /C061 2 1 0 3 /C07a,b6c21 2 /C019a,b8c
45 0 1 3 /C037a,b15c24 11 /C013a,b7c48 29 /C019a,b27c
55 4 1 2 /C042a,b0c19 4 /C015a,b5c43 9 /C034a,b2c
61 9 6 8 4 9a,b28 10 25 15a,b13 26 5 /C024a,b25
74 5 2 0 /C035a,b22c18 6 /C012a,b7c34 17 /C017a,b8c
83 3 – Drop out – 17 –– 28 ––
10 25 24 /C01 – 13 14 1 – 23 28 5 –
11 15 1 /C014 20 10 6 /C044c24 0 /C024a,b12c
12 35 13 /C022a,b– 17 5 /C012a,b– 37 17 /C020a,b–
Mean
(SD)30.0
(15.9)17.8
(20.2)/C013.0
(27.5)11.7
(10.5)15.5
(4.6)9.0
(6.9)/C06.3
(9.4)6.6
(3.1)31.7
(9.0)13.0
(10.6)/C019.4
(10.4)12.6
(9.7)
Note . IES-r =Impact of Event Scale –revised; PHQ-9 =Patient Health Questionnaire –9 items; BDI-II =Beck Depression Inventory (v.2).
aChange is statistically reliable,bchange is clinically significant, andcpre-/post-improvement in symptoms maintained for improved at 3-month follow-up (F/U).10 Emily Wood et al.

The daily measure
The daily measure showed so much variability across all participants for all three questionsthat the results are difficult to interpret. However, there was no evidence of spontaneousimprovement during the baseline across participants. An example is shown in Figure 3.
Friends and family question
Every participant who responded to the friends and family question reported that, yes,they would recommend EMDR as a treatment for depression to friends and family in thesame situation. In fact, two of them did approach the researcher to see if they could getfriends into the research clinic. The respondents included the participant whosedepression got worse, but he still said he would recommend it and would accept it again
himself if offered in the future.
Discussion
Of the nine people who fully engaged with the treatment programme, eight had a
clinically significant and statistically reliable positive response. Five people scored as
subclinical for depression at the end of treatment. All participants would recommend it to
friends and family. This indicates that (1) EMDR can be delivered to this patient group withno observed difficulties in this small sample, (2) the treatment was acceptable, and (3) thetreatment was associated with reduction in the symptoms of depression. Although due tothe lack of an active control group and the very small sample size here, the magnitude ofthe effect or its reliability in a larger sample cannot be known.
One person’s depression worsened during treatment. When asked about this, the
participant did not feel the EMDR had been a cause of the deterioration, and he reported
that he would like to try it again in the future. Treatment safety should be taken as seriously
in psychotherapy as it is in pharmacology (Parry, Crawford, & Duggan, 2016). Based onParry et al. (2016) suggested terminology, this participant saw a clinically significant
0102030405060708090100
1
6
11
162126
31
364146
51
56
61
66
7176
81
86
91
96
101
106
111
116
121126
131
136low mood ra/g415ng mm along the line. High number equals
lower mood
Days in studyLow mood repeated data for 012
Figure 3. An example of one of the daily measure graph.EMDR and depression 11

deterioration in his mental state, but with no evidence of harm. The EMDR therapists
involved suggested that there needs to be a careful assessment of the psychologicalresources and coping methods available to the client before starting bilateral stimulation.They found this part of the protocol took longer in the clients within the study than would
be expected when working with clients with PTSD.
Many EMDR proponents claim it can be used for far more than just PTSD (Shapiro,
1995, 2005). This clinical case series complements clinical reports of the success of EMDRto treat depression (Bae, Kim, & Park, 2008; Grey, 2011), but the literature still lacks a largerandomized controlled trial to provide confirmation of efficacy and effect size (Wood &Ricketts, 2013).
Participants with PTSD, as assessed by the structured clinical interview, were
excluded from the study. Despite this, the IES-r results show that those who were
classified as traumatized before the treatment were no longer traumatized at the end and
this remained true at follow-up. Despite screening negative for PTSD, many of theparticipants (7/13) scored highly for trauma on the IES-r. This may highlight the differencebetween PTSD criterion A events (sometimes referred to as ‘big T trauma’ in the EMDRliterature) and negative life events (‘small t trauma’). Negative life events may not be life-threatening, but they can still have a profoundly damaging effect on a person’s mentalstate (Shapero et al. , 2014; Shapiro, 2001). The AIP model states that the memory of these
events can fail to be fully processed regardless of whether or not the event is life-
threatening (Solomon & Shapiro, 2008). It also predicts that it is these memories that cause
negative thinking styles and that by processing the memory, the negative thinking stylecan be altered.
This study adds to a small, but growing body of literature that indicates EMDR has
potential to treat depression (Bae et al. , 2008; Grey, 2011; Hofmann et al. , 2014) and
symptoms of depression and hypomania in bipolar patients (Novo et al. , 2014). It also
shows that EMDR does not necessarily need to be an adjunct to another therapy but can beused as the standard protocol describes (Shapiro, 2001). The Hofmann study used EMDR
sessions (between 3 and 16) as an adjunct to CBT (around 38 sessions), with the
CBT+EMDR group achieving significantly greater improvements in depression symptoms
than those receiving CBT alone. By using only standard protocol EMDR, this study appearsto have seen results equivalent to the German study but in half the number of sessions (20instead of 40 –50 sessions; Hofmann et al. , 2014).
Limitations
This is a feasibility study involving a case series without a control group and therefore does
not aim to establish efficacy. As all the participants received EMDR, the evaluators werenot blind to treatment. The use of a predictive baseline and continuous measurementsought to partially control for the passage of time. The length of the baseline period wasdetermined by how quickly a therapist became available and was not randomized. Thismeans it is not a true experimental design, but it was considered clinically moreappropriate.
Recommendations for research
This small feasibility study has shown that it is feasible to use EMDR to treat long-termdepression. There is therefore a case for further research to investigate its efficacy,compare it to CBT and mechanism of action. Work will also be needed to see whether12 Emily Wood et al.

EMDR needs to be targeted at service users with depression that clearly links to a traumatic
past or if it can be used with anyone with depression. As long-term depression is arelapsing/remitting condition, a significant follow-up period (preferably at least12 months) is required to ensure improvements are maintained.
Conclusions
This study reports clinically significant and statistically reliable improvement in eight ofnine participants who received a complete treatment of EMDR, with one clientwithdrawing from therapy. One participant dropped out. As no single talking therapyor treatment has ever proved to be all things to all people, numerous psychotherapiesshould be researched to provide a wider range of treatment options for these prevalent
and disabling disorders. EMDR has the potential to be a treatment for long-term
depression.
Funding
This research was funded by the NIHR Collaboration for Leadership in Applied Health
Research and Care for South Yorkshire (NIHR CLAHRC SY), a pilot which ended in 2013.
Further details about the new NIHR CLAHRC Yorkshire and Humber can be found atwww.clahrc-yh.nihr.ac.uk. The views and opinions expressed are those of the authors,and not necessarily those of the NHS, the NIHR, or the Department of Health.
The funding body (NIHR CLAHRC SY) had no role in the conduct of the research or
preparation of the article.
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Received 6 April 2017; revised version received 21 July 2017
Appendix: Table A1. An example of 1 day of the repeated questions
Date
Low mood/depression ‘I am extremely low or
depressed’__________________ ‘I don’t have low mood’
Interest or
pleasure in activities‘I have no interest in
doing things’__________________ ‘I get involved’
Energy levels ‘I have no energy’ __________________ ‘I have enough energy’16 Emily Wood et al.