A Summary of Errors and Omissions A response to the Institute of Medicine report commissioned by the DVA to assess the scientific evidence on treatment modalities for PTSD. Compiled by Dr Chris Lee chairperson EMDRIA research committee

The IOM committee concluded: This conclusion is erroneous as the report: 1.Failed to consider available studies in support of EMDR. 2.Considered, but excluded studies in support of EMDR for reasons unclear. 3.Misrepresented findings of cited studies. 4.Finding is not consistent with conclusions of other independent scientific committees. “The evidence is inadequate to determine the efficacy of EMDR in the treatment of PTSD.”

1.Failed to consider available studies in support of EMDR. Ironson et al. (2002)  Compared EMDR to Prolonged Exposure.  Both treatments produced significant reductions in PTSD.  EMDR attained more rapid reductions of symptoms  70% symptom reduction after 3 sessions: EMDR 70% vs PE 22% Edmond et al. (1999/2004)  On all measures EMDR significantly better than control.  EMDR produced greater subjective trauma resolution.

2. Excluded studies in support of EMDR for reasons unclear. Rogers et al. (1999) excluded  “did not include a comparison or control group”  EMDR vs comparison Exposure group. Lee et al., (2002) excluded.  “no method of handling drop out reported”  Dropout rate less than 10% - 1 from each group. Wilson et al. (1995) excluded, (1997) overlooked.  “Separate results for those with/without PTSD not provided”  Contains most complete data set and separate analyses  EMDR: 84% reduction PTSD diagnoses, 68% symptom reduction

2. Excluded studies in support of EMDR for reasons unclear. Considered to have major limitations: Rothbaum (1997)  “no breakdown of dropout rates”  Easy to assume only 1 dropout from EMDR and 2 from control  No diagnosis PTSD: EMDR 90% vs Control 12%. Marcus et al. (1997)  “no dropout or completer data reported” and “assessor blinding or independence not reported”  1 participant out of 68 dropped out (<10%).  Independence and blinding of evaluator discussed.

3.Misrepresented findings: Failed to acknowledge positive outcomes for EMDR. Carlson et al. (1998) IOM: “showed no effect posttreatment” Significant effects for EMDR posttreatment and follow up  on Mississippi Scale, BDI, STAI-T. On all measures EMDR was lower than control posttreatment  i.e. CAPS, IES. Overall PTSD remission: EMDR 77% vs comparison gp 22%.

3.Misrepresented findings van der Kolk et al. (2007) IOM: “failed to show significant improvement” Reduction PTSD symptoms:  EMDR significantly superior to placebo PT.  EMDR superior to Flouxetine at FU. Loss of diagnosis PT: EMDR 88% vs placebo 65%. Asymptomatic FU: EMDR 75% and 33% vs Flouxetine 0% Vaughn et al. (1994) IOM: no “statistically significant benefit” demonstrated. Reduction PTSD symptoms: EMDR sig. superior to control Reduction re-experiencing/intrusive symptoms: EMDR significantly superior to comparison.

4. Finding inconsistent with other independent scientific committees Finding is inconsistent with:  Australian Centre for Post Traumatic Mental Health (2007)  UK National Institute for Clinical Excellence (2005)  American Psychiatric Association (2004)  Dutch National Steering Committee for Guidelines for Mental Health Care (2003)  Israeli National Council of Mental Health (Bleich et al., 2002)  Cochrane systematic review of EMDR (Bisson & Andrew, 2007) These committees conclude: There is sufficient evidence to support the efficacy of EMDR in the treatment of PTSD. IOM finding: “the evidence is inadequate to determine the efficacy of EMDR”

References American Psychiatric Association (2004). Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder. Arlington, VA: American Psychiatric Association Practice Guidelines. Australian Centre for Posttraumatic Mental Health. (2007). Australian guidelines for the treatment of adults with acute stress disorder and post traumatic stress disorder. Melbourne, Victoria: ACPTMH. Bisson, J., and Andrew, M. (2007). Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews, Issue 4. Bleich, A. et al (2002). A position paper of the (Israeli) National Council for Mental Health: Guidelines for the assessment and professional intervention with terror victims in the hospital and in the community. Jerusalem, Israel. Carlson, J., Chemtob, C.M., Rusnak, K., Hedlund, N.L, & Muraoka, M.Y. (1998). Eye movement desensitization and reprocessing (EMDR): Treatment for combat-related post-traumatic stress disorder. Journal of Traumatic Stress, 11, Dutch National Steering Committee Guidelines Mental Health Care (2003). Multidisciplinary Guideline Anxiety Disorders. Quality Institute Health Care CBO/Trimbos Institute. Utrecht, Netherlands. Edmond, T., Rubin, A., & Wambach, K. (1999). The effectiveness of EMDR with adult female survivors of childhood sexual abuse. Social Work Research, 23, Edmond, T., Sloan, L., & McCarty, D. (2004) Sexual abuse survivors' perceptions of the effectiveness of EMDR and eclectic therapy: A mixed-methods study. Research on Social Work Practice, 14, Hogberg, G., Pagani, M., Sundin, O., Soares, J., Aberg-Wistedt, A., Tarnell, B., & Hallstrom, T. (2006). On treatment with eye movement desensitization reprocessing of chronic post-traumatic stress disorder in public transportation workers – A randomized controlled trial, Nordic Journal of Psychiatry, 61, Ironson, G.I., Freund, B., Strauss, J.L., & Williams, J. (2002). Comparison of two treatments for traumatic stress: A community-based study of EMDR and prolonged exposure. Journal of Clinical Psychology, 58, Lee, C., Gavriel, H., Drummond, P., & Greenwald, R. (2002). Treatment of PTSD: Stress inoculation training with prolonged exposure compared to EMDR. Journal of Clinical Psychology, 58, Marcus, S., Marquis, P. & Sakai, C. (1997). Controlled study of treatment of PTSD using EMDR in an HMO setting. Psychotherapy, 34, Marcus, S., P. Marquis, and C. Sakai, (2004). Three- and 6-month follow-up of EMDR treatment of PTSD in an HMO setting. International Journal of Stress Management,. 11, Power, K.G., McGoldrick, T., Brown, K., Buchanan, R., Sharp, D., Swanson, V., & Karatzias, A. (2002). A controlled comparison of eye movement desensitisation and reprocessing versus exposure plus cognitive restructuring, versus waiting list in the treatment of posttraumatic stress disorder. Journal of Clinical Psychology and Psychotherapy, 9, Rogers, S., Silver, S., Goss, J., Obenchain, J., Willis, A., & Whitney, R. (1999). A single session, controlled group study of flooding and eye movement desensitization and reprocessing in treating posttraumatic stress disorder among Vietnam war veterans: Preliminary data. Journal of Anxiety Disorders 13, Rothbaum, B. (1997). A controlled study of eye movement desensitization and reprocessing in the treatment of post-traumatic stress disordered sexual assault victims. Bulletin of the Menninger Clinic, 61, Rothbaum, B.O., Astin, M.C., & Marsteller, F. (2005). Prolonged exposure Vs eye movement desensitization and reprocessing (EMDR) for PTSD rape victims. Journal of Traumatic Stress, 18, Scheck, M., Schaeffer, J.A., & Gillette, C. (1998). Brief psychological intervention with traumatized young women: The efficacy of eye movement desensitization and reprocessing. Journal of Traumatic Stress, 11, Taylor, S., Thordarson, D.S., Maxfield, L., Fedoroff, I.C., Lovell, K., Ogrodniczuk, J. (2003). Comparative efficacy, speed, and adverse effects of three PTSD treatments: exposure therapy, EMDR, and relaxation training. Journal of Consulting and Clinical Psychology, 71, Vaughan, K., Armstrong, M.F., Gold, R., O'Connor, N., Jenneke, W., & Tarrier, N. (1994). A trial of eye movement desensitization compared to image habituation training and applied muscle relaxation in post-traumatic stress disorder. Journal of Behavior Therapy & Experimental Psychiatry, 25, van der Kolk, B.A., Spinazzola, J., Blaustein, M.E., Hopper, J.H., Hopper, E.K., Korn, D.L., & Simpson, W.B. (2007). A randomized clinical trial of eye movement desensitization and reprocessing (EMDR), fluoxetine, and pill placebo in the treatment of posttraumatic stress disorder: treatment effects and long-term maintenance. Journal of Clinical Psychiatry, 68, Wilson, S., Becker, L.A., & Tinker, R.H. (1995). Eye movement desensitization and reprocessing (EMDR): Treatment for psychologically traumatized individuals. Journal of Consulting and Clinical Psychology, 63, Wilson, S., Becker, L.A., & Tinker, R.H. (1997). Fifteen-month follow-up of eye movement desensitization and reprocessing (EMDR) treatment of post-traumatic stress disorder and psychological trauma. Journal of Consulting and Clinical Psychology, 65, United Kingdom Department of Health. National Institute of Clinical Excellence (NICE 2005). Post traumatic stress disorder (PTSD). The management of adults and children in primary and secondary care. London. NICE Guidelines.