Web-Based Eye Movement Desensitization and Reprocessing for Adults With Suicidal Ideation: Protocol for a Randomized Controlled Trial

Olga Winkler, Raman Dhaliwal, Andrew Greenshaw, Katie O'Shea, Adam Abba-Aji, Chidi Chima, Scot E Purdon, Lisa Burback, Olga Winkler, Raman Dhaliwal, Andrew Greenshaw, Katie O'Shea, Adam Abba-Aji, Chidi Chima, Scot E Purdon, Lisa Burback

Abstract

Background: Adversity and traumatic experiences increase the likelihood of suicidal thoughts and behaviors. Eye Movement Desensitization and Reprocessing (EMDR) is an evidence-based, trauma-focused psychotherapy that desensitizes painful memories, so that reminders in the present no longer provoke overwhelming emotional responses. Preliminary evidence suggests that EMDR can be used as an acute intervention in suicidal patients, including those with major depressive disorder. In addition, because of social distancing restrictions during the COVID-19 pandemic, clinicians have been using EMDR on the web and, in the absence of formal evaluations of web-based EMDR, informal reports indicate good results.

Objective: The primary aim of this randomized controlled trial is to investigate whether remotely delivered EMDR (targeting experiences associated with suicidal thinking) reduces suicidal thoughts. Secondary aims include examining the impact of remotely delivered EMDR on symptoms of depression, anxiety, posttraumatic stress, emotional dysregulation, and dissociation. We will also report on adverse events in the EMDR group to explore whether targeting suicidal ideation with EMDR is safe. Finally, we will compare dropout rates between the treatment groups.

Methods: In this randomized controlled trial, 80 adults who express suicidal ideation and meet the study criteria will receive either 12 sessions of twice weekly EMDR plus treatment as usual or treatment as usual alone. EMDR sessions will focus on the most distressing and intrusive memories associated with suicidal ideation. Data for primary and secondary objectives will be collected at baseline, 2 months, and 4 months after enrollment. A subsequent longer-term analysis, beyond the scope of this protocol, will examine differences between the groups with respect to the number of posttreatment emergency room visits, hospitalizations, and overall health care use in the year before and after therapy.

Results: The protocol was approved by the University of Alberta Research Health Ethics Board (protocol ID Pro00090989). Funding for this study was provided by the Mental Health Foundation (grant RES0048906). Recruitment started in May 2021, with a projected completion date of March 2023.

Conclusions: The results of this trial will contribute to knowledge on whether web-based delivery of EMDR is a safe and effective treatment for reducing suicidal ideation and potentially reducing the incidence of suicide attempts in this patient population.

Trial registration: ClinicalTrials.gov NCT04181047; https://ichgcp.net/clinical-trials-registry/NCT04181047.

International registered report identifier (irrid): DERR1-10.2196/30711.

Keywords: digital health; eHealth; eye movement desensitization and reprocessing (EMDR); psychotherapy; remote delivery; suicide; telemedicine; trauma; virtual care.

Conflict of interest statement

Conflicts of Interest: None declared.

©Olga Winkler, Raman Dhaliwal, Andrew Greenshaw, Katie O'Shea, Adam Abba-Aji, Chidi Chima, Scot E Purdon, Lisa Burback. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 04.11.2021.

Figures

Figure 1
Figure 1
Flow diagram. DES-II: Dissociative Experiences Scale-II; EMDR: Eye Movement Desensitization and Reprocessing; TAU: treatment as usual.

References

    1. The Federal Framework for Suicide Prevention – Progress Report 2018. Public Health Agency of Canada, Government of Canada. [2021-03-13]. .
    1. Klonsky ED, May AM, Saffer BY. Suicide, suicide attempts, and suicidal ideation. Annu Rev Clin Psychol. 2016;12:307–30. doi: 10.1146/annurev-clinpsy-021815-093204.
    1. Afifi TO, Enns MW, Cox BJ, Asmundson GJ, Stein MB, Sareen J. Population attributable fractions of psychiatric disorders and suicide ideation and attempts associated with adverse childhood experiences. Am J Public Health. 2008 May;98(5):946–52. doi: 10.2105/AJPH.2007.120253.AJPH.2007.120253
    1. Afifi TO, Boman J, Fleisher W, Sareen J. The relationship between child abuse, parental divorce, and lifetime mental disorders and suicidality in a nationally representative adult sample. Child Abuse Negl. 2009 Mar;33(3):139–47. doi: 10.1016/j.chiabu.2008.12.009.S0145-2134(09)00030-1
    1. Afifi TO, Taillieu T, Zamorski MA, Turner S, Cheung K, Sareen J. Association of child abuse exposure with suicidal ideation, suicide plans, and suicide attempts in military personnel and the general population in Canada. JAMA Psychiatry. 2016 Mar;73(3):229–38. doi: 10.1001/jamapsychiatry.2015.2732.2484486
    1. Ásgeirsdóttir HG, Valdimarsdóttir UA, Þorsteinsdóttir ÞK, Lund SH, Tomasson G, Nyberg U, Ásgeirsdóttir TL, Hauksdóttir A. The association between different traumatic life events and suicidality. Eur J Psychotraumatol. 2018;9(1):1510279. doi: 10.1080/20008198.2018.1510279. 1510279
    1. de Araújo RM, Lara DR. More than words: the association of childhood emotional abuse and suicidal behavior. Eur Psychiatry. 2016 Sep;37:14–21. doi: 10.1016/j.eurpsy.2016.04.002.S0924-9338(16)30006-2
    1. Dube SR, Anda RF, Felitti VJ, Chapman DP, Williamson DF, Giles WH. Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the adverse childhood experiences study. J Am Med Assoc. 2001 Dec 26;286(24):3089–96. doi: 10.1001/jama.286.24.3089.joc11276
    1. Kisely S, Abajobir AA, Mills R, Strathearn L, Clavarino A, Najman JM. Child maltreatment and mental health problems in adulthood: birth cohort study. Br J Psychiatry. 2018 Dec;213(6):698–703. doi: 10.1192/bjp.2018.207.S0007125018002076
    1. Shapero BG, Farabaugh A, Terechina O, DeCross S, Cheung JC, Fava M, Holt DJ. Understanding the effects of emotional reactivity on depression and suicidal thoughts and behaviors: moderating effects of childhood adversity and resilience. J Affect Disord. 2019 Feb 15;245:419–27. doi: 10.1016/j.jad.2018.11.033.S0165-0327(18)31648-3
    1. van Heeringen K, Mann JJ. The neurobiology of suicide. Lancet Psychiatry. 2014 Jun;1(1):63–72. doi: 10.1016/S2215-0366(14)70220-2.S2215-0366(14)70220-2
    1. O'Connor RC, Nock MK. The psychology of suicidal behaviour. Lancet Psychiatry. 2014 Jun;1(1):73–85. doi: 10.1016/S2215-0366(14)70222-6.S2215-0366(14)70222-6
    1. Petruccelli K, Davis J, Berman T. Adverse childhood experiences and associated health outcomes: a systematic review and meta-analysis. Child Abuse Negl. 2019 Nov;97:104127. doi: 10.1016/j.chiabu.2019.104127.S0145-2134(19)30304-7
    1. Herzog JI, Schmahl C. Adverse childhood experiences and the consequences on neurobiological, psychosocial, and somatic conditions across the lifespan. Front Psychiatry. 2018;9:420. doi: 10.3389/fpsyt.2018.00420. doi: 10.3389/fpsyt.2018.00420.
    1. Lund JI, Toombs E, Radford A, Boles K, Mushquash C. Adverse childhood experiences and executive function difficulties in children: a systematic review. Child Abuse Negl. 2020 Aug;106:104485. doi: 10.1016/j.chiabu.2020.104485.S0145-2134(20)30140-X
    1. Dvir Y, Ford JD, Hill M, Frazier JA. Childhood maltreatment, emotional dysregulation, and psychiatric comorbidities. Harv Rev Psychiatry. 2014;22(3):149–61. doi: 10.1097/HRP.0000000000000014.
    1. Navarro PN, Landin-Romero R, Guardiola-Wanden-Berghe R, Moreno-Alcázar A, Valiente-Gómez A, Lupo W, García F, Fernández I, Pérez V, Amann BL. 25 years of eye movement desensitization and reprocessing (EMDR): the EMDR therapy protocol, hypotheses of its mechanism of action and a systematic review of its efficacy in the treatment of post-traumatic stress disorder. Rev Psiquiatr Salud Ment (Engl Ed) 2018;11(2):101–14. doi: 10.1016/j.rpsm.2015.12.002.S1888-9891(16)00019-7
    1. Wilson G, Farrell D, Barron I, Hutchins J, Whybrow D, Kiernan MD. The use of eye-movement desensitization reprocessing (EMDR) therapy in treating post-traumatic stress disorder-a systematic narrative review. Front Psychol. 2018;9:923. doi: 10.3389/fpsyg.2018.00923. doi: 10.3389/fpsyg.2018.00923.
    1. Carletto S, Malandrone F, Berchialla P, Oliva F, Colombi N, Hase M, Hofmann A, Ostacoli L. Eye movement desensitization and reprocessing for depression: a systematic review and meta-analysis. Eur J Psychotraumatol. 2021 Apr 09;12(1):1894736. doi: 10.1080/20008198.2021.1894736. 1894736
    1. Valiente-Gómez A, Moreno-Alcázar A, Treen D, Cedrón C, Colom F, Pérez V, Amann BL. EMDR beyond PTSD: a systematic literature review. Front Psychol. 2017;8:1668. doi: 10.3389/fpsyg.2017.01668. doi: 10.3389/fpsyg.2017.01668.
    1. Shapiro F. Eye Movement Desensitization and Reprocessing (EMDR) Therapy: Basic Principles, Protocols, and Procedures. New York, NY: Guildford Press; 2018. Jan 19, pp. 87–8.
    1. Baumeister RF. Suicide as escape from self. Psychol Rev. 1990 Jan;97(1):90–113. doi: 10.1037/0033-295x.97.1.90.
    1. Rudd MD. Fluid vulnerability theory: a cognitive approach to understanding the process of acute and chronic suicide risk. In: Ellis TE, editor. Cognition and Suicide: Theory, Research, and Therapy. Washington D.C: American Psychological Association; 2006. pp. 355–68.
    1. Beck AT. Beyond belief: a theory of modes, personality, and psychopathology. In: Salkovskis P, editor. Frontiers of Cognitive Therapy. New York, United States: Guilford Press; 1996. pp. 1–25.
    1. Andrade J, Kavanagh D, Baddeley A. Eye-movements and visual imagery: a working memory approach to the treatment of post-traumatic stress disorder. Br J Clin Psychol. 1997 May;36(2):209–23. doi: 10.1111/j.2044-8260.1997.tb01408.x.
    1. de Voogd LD, Kanen JW, Neville DA, Roelofs K, Fernández G, Hermans EJ. Eye-movement intervention enhances extinction via amygdala deactivation. J Neurosci. 2018 Oct 03;38(40):8694–706. doi: 10.1523/JNEUROSCI.0703-18.2018. JNEUROSCI.0703-18.2018
    1. Proudlock S, Hutchins J. EMDR within crisis resolution and home treatment teams. J EMDR Prac Res. 2016 Jan 01;10(1):47–56. doi: 10.1891/1933-3196.10.1.47.
    1. Fereidouni Z, Behnammoghadam M, Jahanfar A, Dehghan A. The effect of eye movement desensitization and reprocessing (EMDR) on the severity of suicidal thoughts in patients with major depressive disorder: a randomized controlled trial. Neuropsychiatr Dis Treat. 2019;15:2459–66. doi: 10.2147/NDT.S210757. doi: 10.2147/NDT.S210757.210757
    1. Proudlock S, Peris J. Using EMDR therapy with patients in an acute mental health crisis. BMC Psychiatry. 2020 Jan 09;20(1):14. doi: 10.1186/s12888-019-2426-7. 10.1186/s12888-019-2426-7
    1. Jamshidi F, Rajabi S, Dehghani Y. How to heal their psychological wounds? Effectiveness of EMDR therapy on post-traumatic stress symptoms, mind-wandering and suicidal ideation in Iranian child abuse victims. Couns Psychother Res. 2020 Jul 22;21(2):412–21. doi: 10.1002/capr.12339.
    1. van den Berg DP, de Bont PA, van der Vleugel BM, de Roos C, de Jongh A, Van Minnen A, van der Gaag M. Prolonged exposure vs eye movement desensitization and reprocessing vs waiting list for posttraumatic stress disorder in patients with a psychotic disorder: a randomized clinical trial. JAMA Psychiatry. 2015 Mar;72(3):259–67. doi: 10.1001/jamapsychiatry.2014.2637.2091663
    1. May JM, Richardi TM, Barth KS. Dialectical behavior therapy as treatment for borderline personality disorder. Ment Health Clin. 2016 Mar;6(2):62–7. doi: 10.9740/mhc.2016.03.62.
    1. Jones C, Miguel-Cruz A, Smith-MacDonald L, Cruikshank E, Baghoori D, Chohan AK, Laidlaw A, White A, Cao B, Agyapong V, Burback L, Winkler O, Sevigny PR, Dennett L, Ferguson-Pell M, Greenshaw A, Brémault-Phillips S. Virtual trauma-focused therapy for military members, veterans, and public safety personnel with posttraumatic stress injury: systematic scoping review. JMIR Mhealth Uhealth. 2020 Sep 21;8(9):e22079. doi: 10.2196/22079. v8i9e22079
    1. Lenferink LI, Meyerbröker K, Boelen PA. PTSD treatment in times of COVID-19: a systematic review of the effects of online EMDR. Psychiatry Res. 2020 Nov;293:113438. doi: 10.1016/j.psychres.2020.113438. S0165-1781(20)31459-1
    1. Korzekwa MI, Dell PF, Links PS, Thabane L, Fougere P. Dissociation in borderline personality disorder: a detailed look. J Trauma Dissociation. 2009;10(3):346–67. doi: 10.1080/15299730902956838.912961728
    1. Carlson EB, Dalenberg C, McDade-Montez E. "Dissociation in posttraumatic stress disorder Part I: Definitions and review of research": correction to Carlson, Dalenberg, and McDade-Montez (2012) Psychol Trauma. 2012;4(5):489. doi: 10.1037/a0030230.
    1. Choi H, Kim S, Yun KW, Kim YC, Lim W, Kim E, Ryoo J. A study on correlation between anxiety symptoms and suicidal ideation. Psychiatry Investig. 2011 Dec;8(4):320–6. doi: 10.4306/pi.2011.8.4.320.
    1. Brown LA, Zang Y, Benhamou K, Taylor DJ, Bryan CJ, Yarvis JS, Dondanville KA, Litz BT, Mintz J, Roache JD, Pruiksma KE, Fina BA, Young-McCaughan S, Peterson AL, Foa EB, STRONG STAR Consortium Mediation of suicide ideation in prolonged exposure therapy for posttraumatic stress disorder. Behav Res Ther. 2019 Aug;119:103409. doi: 10.1016/j.brat.2019.103409.S0005-7967(19)30095-6
    1. Rafiq S, Campodonico C, Varese F. The relationship between childhood adversities and dissociation in severe mental illness: a meta-analytic review. Acta Psychiatr Scand. 2018 Dec;138(6):509–25. doi: 10.1111/acps.12969.
    1. Lyssenko L, Schmahl C, Bockhacker L, Vonderlin R, Bohus M, Kleindienst N. Dissociation in psychiatric disorders: a meta-analysis of studies using the dissociative experiences scale. Am J Psychiatry. 2018 Jan 01;175(1):37–46. doi: 10.1176/appi.ajp.2017.17010025.
    1. Bae H, Kim D, Park YC. Dissociation predicts treatment response in eye-movement desensitization and reprocessing for posttraumatic stress disorder. J Trauma Dissociation. 2016;17(1):112–30. doi: 10.1080/15299732.2015.1037039.
    1. Lanius RA, Vermetten E, Loewenstein RJ, Brand B, Schmahl C, Bremner JD, Spiegel D. Emotion modulation in PTSD: clinical and neurobiological evidence for a dissociative subtype. Am J Psychiatry. 2010 Jun;167(6):640–7. doi: 10.1176/appi.ajp.2009.09081168. appi.ajp.2009.09081168
    1. Lynch SM, Forman E, Mendelsohn M, Herman J. Attending to dissociation: assessing change in dissociation and predicting treatment outcome. J Trauma Dissociation. 2008;9(3):301–19. doi: 10.1080/15299730802139063.
    1. Herman J. Recovery from psychological trauma. Psychiatry Clin Neurosci. 1998;52:98–103. doi: 10.1046/j.1440-1819.1998.0520s5S1x. doi: 10.1046/j.1440-1819.1998.0520s5s145.x.
    1. Cloitre M, Courtois CA, Charuvastra A, Carapezza R, Stolbach BC, Green BL. Treatment of complex PTSD: results of the ISTSS expert clinician survey on best practices. J Trauma Stress. 2011 Dec;24(6):615–27. doi: 10.1002/jts.20697.
    1. van der Kolk B. Posttraumatic stress disorder and the nature of trauma. Dialogues Clin Neurosci. 2000 Mar;2(1):7–22.
    1. De Jongh A, Resick PA, Zoellner LA, van Minnen A, Lee CW, Monson CM, Foa EB, Wheeler K, Broeke ET, Feeny N, Rauch SA, Chard KM, Mueser KT, Sloan DM, van der Gaag M, Rothbaum BO, Neuner F, de Roos C, Hehenkamp LM, Rosner R, Bicanic IA. Critical analysis of the current treatment guidelines for complex PTSD in adults. Depress Anxiety. 2016 May;33(5):359–69. doi: 10.1002/da.22469.
    1. Méndez MZ, Nijdam MJ, Heide FJ, van der Aa N, Olff M. A five-day inpatient emdr treatment programme for PTSD: pilot study. Eur J Psychotraumatol. 2018;9(1):1425575. doi: 10.1080/20008198.2018.1425575. 1425575
    1. Van Woudenberg C, Voorendonk EM, Bongaerts H, Zoet HA, Verhagen M, Lee CW, van Minnen A, De Jongh A. Effectiveness of an intensive treatment programme combining prolonged exposure and eye movement desensitization and reprocessing for severe post-traumatic stress disorder. Eur J Psychotraumatol. 2018;9(1):1487225. doi: 10.1080/20008198.2018.1487225. 1487225
    1. Jacobs DG, Baldessarini RJ, Conwell Y, Fawcett JA, Horton L, Meltzer H, Pfeffer CR, Simon RI. Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry. 2003 Nov;160(11 Suppl):1–60.
    1. Lewis C, Roberts NP, Gibson S, Bisson JI. Dropout from psychological therapies for post-traumatic stress disorder (PTSD) in adults: systematic review and meta-analysis. Eur J Psychotraumatol. 2020;11(1):1709709. doi: 10.1080/20008198.2019.1709709. 1709709
    1. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009 Apr;42(2):377–81. doi: 10.1016/j.jbi.2008.08.010. S1532-0464(08)00122-6
    1. O’Shea K. EMDR friendly preparation methods for adults and children. In: Shapiro R, editor. EMDR Solutions II: For Depression, Eating Disorders, Performance, and More. New York, United States: W. W. Norton & Company; 2009. pp. 289–312.
    1. Logie RD, Jongh AD. The “flashforward procedure”: confronting the catastrophe. J EMDR Prac Res. 2014 Jan 01;8(1):25–32. doi: 10.1891/1933-3196.8.1.25.
    1. O’Shea K. The EMDR early trauma protocol. In: Shapiro R, editor. EMDR Solutions II: For Depression, Eating Disorders, Performance, and More. New York, United States: W. W. Norton & Company; 2009. pp. 313–334.
    1. Matthijssen SJ, Verhoeven LC, van den Hout MA, Heitland I. Auditory and visual memories in PTSD patients targeted with eye movements and counting: the effect of modality-specific loading of working memory. Front Psychol. 2017;8:1937. doi: 10.3389/fpsyg.2017.01937. doi: 10.3389/fpsyg.2017.01937.
    1. Knipe J. EMDR Toolbox: Theory and Treatment of Complex PTSD and Dissociation. New York, United States: Springer Publishing Co Inc; 2015.
    1. Hofmann A, Hase M, Liebermann P, Ostacoli L, Lehnung M, Ebner F, Rost C, Luber M, Tumani V. DeprEnd – EMDR Therapy Protocol for the Treatment of Depressive Disorders. New York, United States: Springer Publishing Co Inc; 2016. pp. 290–323.
    1. Popky A. DeTUR, an Urge Reduction Protocol for Addictions and Dysfunctional Behaviors. New York, United States: W. W. Norton and Company; 2005. pp. 167–88.
    1. Mosquera D. Treating personality disorders with EMDR Therapy. Clin Neuropsychiatry. 2018;15(3):151–7.
    1. Beck AT, Kovacs M, Weissman A. Assessment of suicidal intention: the scale for suicide ideation. J Consult Clin Psychol. 1979 Apr;47(2):343–52. doi: 10.1037//0022-006x.47.2.343.
    1. Posner K, Brown GK, Stanley B, Brent DA, Yershova KV, Oquendo MA, Currier GW, Melvin GA, Greenhill L, Shen S, Mann JJ. The columbia-suicide severity rating scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011 Dec;168(12):1266–77. doi: 10.1176/appi.ajp.2011.10111704.
    1. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The adverse childhood experiences (ACE) study. Am J Prev Med. 1998 May;14(4):245–58. doi: 10.1016/s0749-3797(98)00017-8.S0749379798000178
    1. Carlson E, Putnam F. An update on the dissociative experiences scale. Dissociation. 1993;6(1):16–27. doi: 10.1037/t07472-000.
    1. Beck AT, Steer RA, Carbin MG. Psychometric properties of the beck depression inventory: twenty-five years of evaluation. Clin Psychol. 1988 Jan;8(1):77–100. doi: 10.1016/0272-7358(88)90050-5.
    1. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001 Sep;16(9):606–13. doi: 10.1046/j.1525-1497.2001.016009606.x. jgi01114
    1. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006 May 22;166(10):1092–7. doi: 10.1001/archinte.166.10.1092.166/10/1092
    1. Weiss DS, Marmar CR. The impact of event scale-revised. In: Wilson JP, Keane TM, editors. Assessing Psychological Trauma and PTSD: A Practitioner's Handbook. New York: Guilford Press; 1997. pp. 399–411.
    1. Gratz KL, Roemer L. Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the difficulties in emotion regulation scale. J Psychopathol Behav Assess. 2004 Mar;26(1):41–54. doi: 10.1023/B:JOBA.0000007455.08539.94.
    1. Cox KS, Mouilso ER, Venners MR, Defever ME, Duvivier L, Rauch SA, Strom TQ, Joiner TE, Tuerk PW. Reducing suicidal ideation through evidence-based treatment for posttraumatic stress disorder. J Psychiatr Res. 2016 Sep;80:59–63. doi: 10.1016/j.jpsychires.2016.05.011.S0022-3956(16)30102-9
    1. Gradus JL, Suvak MK, Wisco BE, Marx BP, Resick PA. Treatment of posttraumatic stress disorder reduces suicidal ideation. Depress Anxiety. 2013 Oct;30(10):1046–53. doi: 10.1002/da.22117.

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