The Effectiveness of Using Eye Movement Desensitization and Reprocessing Therapy on Reducing the Severity of Symptoms among Individuals Diagnosed with Post-Traumatic Stress Disorder: A Systematic Review

doi:10.21203/rs.3.rs-3902418/v2

Background: Post Traumatic Stress Disorder (PTSD) is a global-concern mental illness that occurs due to exposure to a traumatic life experience such as a natural disaster, a severe accident, or a physical or sexual assault in adulthood or childhood. The consequence of PTSD warrants mental health professionals to find effective interventions to maintain and restore mental-well-being. Therefore, selection of intervention is a cornerstone element in deciding successful interventions.

Objectives: The aim of this systematic review was to evaluate and summarize the effectiveness of using eye movement desensitization and reprocessing (EMDR) intervention among individuals diagnosed with PTSD. As well as to highlight the standardized EMDR-based-interventional protocol.

Data source: The relevant literature was extracted and conducted using the following online bibliographic databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), ProQuest, MEDLINE, Google Scholar, SAGE Journals, and Science Direct and by hand checking reference lists of past similar reviews.

Methods: This Systematic review is guided according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. Several online databases were used in searching for eligible studies in peer-reviewed journals relevant to the study keywords. The included studies were Systematic reviews and clinical trials which used EMDR intervention among patients experiencing PTSD symptoms, older than 18 years and were published in the English language from 2017 to 2022. Three researchers independently contributed to study selections, data extraction and study evaluations from different aspects: including quality assessment, risk of bias, and study synthesis.

Results: A total of eight published studies met the inclusion criteria and were included in this systematic review; four articles were randomized controlled trials and four were systematic review and meta-analysis studies. In all included studies, the EMDR was utilized as a primary psychotherapy intervention for PTSD symptoms. The results of this extensive and comprehensive review showed that EMDR is an effective psychotherapeutic intervention to reduce and control the severity of symptoms among individuals with PTSD.

Conclusions: This Systematic review gives an overview and explains strong supportive evidence for effectiveness of the EMDR interventions among individuals with PTSD. Therefore, EMDR therapy could be assumed as one standard treatment option for PTSD aiming at reducing treatment duration, and cost of treatment, and restoring the mental well-being and functionality of those suffering from PTSD.

Psychiatry

Psychology

Nursing

PTSD

Post-Traumatic Stress Disorder

EMDR

Eye Movement Desensitization and Reprocessing

AIP

Model Adaptive Information Processing Model

By the early 19th century, associated symptoms of PTSD were named hysterical symptoms, and believed to be controlled by evil spirits; an interpretation that addressed the problem as a result of guilt feeling (McFarlane and Kilpatrick, 2023). It is not until the 20th century that an understanding and recognizing that hysterical symptoms are not solely related to evil power; rather, environmental, and personal factors might have a role, as well Nissen, (2023). PTSD is also known by several terms in the past such as “shell shock” during the years of World War I and “combat fatigue” after World War II although PTSD is not just associated with and occurred among battle veterans (American Psychiatric Association [APA], 2023).

PTSD is a global-concern mental illness that occurs due to exposure to a traumatic life experience such as a natural disaster, a radical attack, a severe accident, or a physical or sexual assault in adult or childhood (World Health Organization, [WHO], 2022). Prevalence of PTSD is estimated to be 3.9% globally, and it is approximately twice as common in women as men (Koenen et al, 2017). Individuals with PTSD re-experience the traumatic incident over nightmares or flashbacks, attempting to avoid situations, persons and places that are reminders of the traumatic incident. They may suffer from isolation, irritability, guilt, and have profoundness in concentration and sleep complications (APA, [DSM 5TR], 2022). Most people do not experience any PTSD symptoms or experience initial symptoms in the first few days or weeks as part of grieving process that is reduce naturally during weeks depending upon individuals’ psychological preparedness and the nature of the event (Deng et al, 2019). However, some people will continue to experience symptoms such as avoidance, negative alteration in cognition and mood, and changes in arousal and reactivity that later can be referred to as PTSD (American Psychiatric Association [APA], 2018). Moreover, PTSD symptoms may extensively impair the individuals’ ability to function appropriately inter terms of social and family relationships, and negatively affect their quality of life (Dauphin, 2020; McCabe et al., 2020).

PTSD prevalence rates vary widely, depending on various risk factors including individuals’ socio-demographic ones, type of trauma, sources and availability of social support, and the intensity of the acute response to the traumatic event (Farooqui et al., 2017; Marthoenis et al., 2019). the prevalence of PTSD in the first year after exposure among survivors of a natural disaster ranges between 30% and 40%; the prevalence range of PTSD among rescue workers was 10 and 20%, as compared to a PTSD prevalence in the general population ranging between 5 and 10% (Neria and Galea, 2008). The overall PTSD rate in 3–6 years after major natural disasters was 20.9% (Downs et al., 2017). Traumatic events are experienced by a considerable number of individuals, with approximately 60% of men and 50% of women encountering at least one trauma during their lifetimes, as reported by the National Center for PTSD statistics in 2022.

Jordan, as a low- to middle-income country, has overwhelmed with large number of refugees and the complexities arising from national conflicts and the influx of refugees. (The UN Refugee Agency [UNHCR], 2022). For several decades, Jordan has been a host country for millions of refugees escaping from near countries such a Palestinian, Iraq, and Syrian (Dardas et al., 2019). Refugees arriving in the host country are at high risk of PTSD hastened by the refugee experience and an increased vulnerability to chronic diseases and mental illness (Al-Smadi et al.,2016). PTSD might be highly prevalent in Jordanian residents. One local study showed that PTSD rate is about 24% among youths aged 7–18 years (Gearing et al., 2015). Another study showed that, the majority of the Syrian refugees in Jordan suffer from PTSD and other Stress-related Trauma symptoms and numerus of these refugees have low satisfaction with the healthcare and psychological counselling services provided. (Gammoh et al., 2023). However, mental health issues persist as a major concern in low- and middle-income countries like Jordan. Barriers to access mental health services, such as limited human and financial resources, rural poverty, and societal stigma, further exacerbate the challenges faced in addressing mental health concerns (Alloh et al., 2018).

Currently, there are several available psychological counseling services and various therapeutic modalities and treatment approaches for individuals suffering from PTSD. In a study conducted by Doran (2023), it was found that a trauma-focused cognitive behavioral therapy (TF-CBT) intervention was beneficial for individuals experiencing PTSD symptoms. Additionally, Cognitive Behavioral Therapy (CBT) has proven to be an effective approach in reducing the severity of PTSD symptoms, as supported by the research of Öst et al. 2023; Hudays et al., 2022; Mavranezouli et al., 2020; Yunitri et al. 2023; Fynn et al. 2023; and Meijer 2023. Trauma-focused Cognitive Behavioral Therapy is also considered effective in reducing associated symptoms of PTSD. The majority of the researchers comparing CBT and EMDR have reported equivalence or non-significant differences between the two approaches on reducing the severity of PTSD symptoms. One promising and posed intervention to manage PTSD could be EMDR.

A number of interventions appear to be cost-effective for the management of PTSD in adults. EMDR seems to be the most cost-effective amongst them. TF-CBT has the largest evidence base. There remains a need for well-conducted studies that examine the long-term clinical and cost-effectiveness of a range of treatments for adults with PTSD (Al-Murad, 2023; Mavranezouli et al., 2020; Schumm et al., 2023). Although EMDR is only one of the options available for people suffering from PTSD, the literature supports its efficiency in appropriately intervening with individuals diagnosed with PTSD. However, Eye Movement Desensitization and Reprocessing (EMDR) intervention offers significant alternative treatment opportunities for individuals suffering from PTSD, Depression, Anxiety, and Stress (Hase, M. 2021). In addition, the implementation of Eye Movement Desensitization and Reprocessing for Depression, Anxiety, and Post-Traumatic Stress Disorder improves patient outcomes as compared to standard therapeutic modalities in PTSD (Banerjee & Argaez, 2018).

Eye Movement Desensitization and Reprocessing (EMDR) is a psychotherapy intervention developed in 1987 by Dr. Francine Shapiro (Shapiro, 1989). is directed by the Adaptive Information Processing model. that aims to treat traumatic memories and their associated stress symptoms. This therapy consists of a standard protocol which includes eight phases and bilateral stimulation (usually horizontal saccadic eye movements) to desensitize the discomfort caused by traumatic memories and the aim of the intervention is to attain their reprocessing and integration within the patient’s standard biographical memories (Shapiro,2005). Hence, EMDR therapeutic approach follows standard protocols for processing memories of traumatic experience or stressful life incidents (Shapiro, 2001).

EMDR is an individual therapy distributed one to two times per week for a total of 3 -12 sessions, although some patients enhanced from fewer sessions. Hence, Depressive symptoms and Anxiety Disorder Without management and treatment, symptoms can last for weeks, months, or years, then many complicated issues that happen such as suicidal thoughts and actual attempts. Appropriate treatment, however, can help most people with depressive symptoms (Jiang et al, 2022) & (Young et al, 2022). Furthermore, the effectiveness of EMDR therapy in treating Post-Traumatic Stress Disorder (PTSD) has undergone the scrutiny of several meta-analyses (2013; Chen et al., 2014, 2015); this led to the final recognition by the World Health Organization (2013) as a Valiente-Gómez et al. EMDR beyond PTSD: A Systematic Literature Review psychotherapy of choice in the treatment of PTSD in children, teenagers, and adults.

Several studies conducted worldwide showed that the combination with psychotherapy and pharmacotherapy is effective for management of anxiety and depressive symptoms associated with PTSD, moreover, Eye Movement Desensitization and Reprocessing (EMDR) as a psychotherapy is effective in management of depression and Anxiety and several studies focused in EMDR and showed improvement in patient’s outcomes and status. Consequently, the current author aims to conduct a randomized control trial to examine the effectiveness of Eye Movement Desensitization and Reprocessing (EMDR) in management of depressive and anxiety symptoms in Jordanian hospitals. Moreover, Carletto and her colleagues in (2021) mention in their study, The Adaptive Processing model reflects symptoms of PTSD and other disorders to result from past distressing experiences that remain to cause distress because the memory was not sufficiently processed. These untreated memories are unstated to hold the emotions, thoughts, beliefs and physical sensations that happened at the time of the event. When the memories are triggered, these stored worrying components are experienced and source the symptoms of PTSD, Depression and Anxiety disorders.

The current systematic review attempted to accumulate the available research evidence on EMDR interventions that have targeted reducing the severity of symptoms among individuals experiencing moderate to severe symptoms of PTSD.

Purpose

The purposes of this review were to scan and summarize the effectiveness of using eye movement desensitization and reprocessing (EMDR) intervention among patients diagnosed with PTSD and assess the role of EMDR in reducing the severity of symptoms of patients with PTSD.

Table (1) DSM-5 Criteria for Post-Traumatic Stress Disorder

Content
Criterion A	Stressor (one required) The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s): Direct exposure Witnessing the trauma Learning that a relative or close friend was exposed to a trauma Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics)
Criterion B	Intrusion symptoms (one required) The traumatic event is persistently re-experienced in the following way(s): Unwanted upsetting memories Nightmares Flashbacks Emotional distress after exposure to traumatic reminders Physical reactivity after exposure to traumatic reminders
Criterion C	Avoidance (one required) Avoidance of trauma-related stimuli after the trauma, in the following way(s): Trauma-related thoughts or feelings Trauma-related external reminders
Criterion D	Negative alterations in cognitions and mood (two required) Negative thoughts or feelings that began or worsened after the trauma, in the following way(s): Inability to recall key features of the trauma Overly negative thoughts and assumptions about oneself or the world Exaggerated blame of self or others for causing the trauma Negative affect Decreased interest in activities Feeling isolated Difficulty experiencing positive affect
Criterion E	Alterations in arousal and reactivity Trauma-related arousal and reactivity that began or worsened after the trauma, in the following way(s): Irritability or aggression Risky or destructive behavior Hypervigilance Heightened startle reaction Difficulty concentrating Difficulty sleeping
Criterion F	Duration (required) Symptoms last for more than 1 month.
Criterion G	Functional significance (required) Symptoms create distress or functional impairment (e.g., social, occupational).
Criterion H	Exclusion (required) Symptoms are not due to medication, substance use, or other illness.

* First, M. B., Clarke, D. E., Yousif, L., Eng, A. M., Gogtay, N., & Appelbaum, P. S. (2023). DSM-5-TR: rationale, process, and overview of changes. Psychiatric Services, 74(8), 869-875.

2.1. Protocol

This review was written following the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) protocol for systematic reviews (Liberati et al., 2009).

2.2. Data Sources and Search Strategies

A search strategy was implemented to include all relevant articles regarding the effectiveness of EMDR in reducing the severity of symptoms among patients experiencing PTSD symptoms. Search process targeted primary resources with no geographical limits and targeted disciplines other than nursing such as psychology, psychiatry. Articles excluded from search those that focus on populations not similar to PTSD, also articles published in languages other than English. Search was completed on 7th December 2022 and updated on 6th December 2023. Search was conducted using the following online bibliographic data bases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), ProQuest, MEDLINE, Google Scholar, SAGE Journals, Wiley on Line Library, and Science Direct. These databases were consulted to include nursing, psychology, medical, and psychotherapy areas. Database searches were conducted using following terms: “PTSD”, “post-traumatic stress disorder”, “stress related trauma”, “EMDR”, “traumatic stress”, “eye movement desensitization and reprocessing”. Boolean operators (AND, OR) have been applied separately and in combination with the keywords to expand, combine, or exclude keywords in a search to narrow down the results and reach a more focused and productive results. Search process has also targeted resources other than online data bases such as: websites of relevant research institutes and other older resources such as published books and theoretical literature about the topic. Manual search of the reference lists from selected citations was conducted to locate relevant and significant resources that were not identified in the online databases. Critical Appraisal of the relevant articles was conducted based on the guidelines suggested by Critical Appraisal Skills Program (CASP). Each study was appraised against the following questions: was the study valid? What were the results? And are the results useful? All searched articles were evaluated in terms of their weaknesses and strengths to minimize the validity threats (CASP checklist, 2014).

2.3. Inclusion and Exclusion Criteria

The final selection of the articles for this systematic review was carried out using the following criteria: (i) all articles published in peer-reviewed journals (ii) published in the English language (iii) in adult populations (over 18 years) that (iv) examined the effectiveness of using EMDR among patients diagnosed with PTSD. (v) Studies published from 2017 to 2023. So, the criteria for exclusion were: (i)studies that examined EMDR for other Psychiatric disorders were not included. and (ii) quasi-experimental designs (single case and/or no control group).

2.3. Quality assessment

2.3.1. Quality assessment for included clinical trial studies.

The quality of all included quantitative studies was evaluated by using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool, and each study was evaluated in six

domains (Study bias, study design, control of confounders, blinding, data collection method, and

withdrawals and dropouts of participants from the study), According to the EPHPP- dictionary,

each article's quality was classified as strong, moderate, or weak based on the individual scores

given to each dimension. The results from each domain were then summed to provide an overall

score. The studies were graded as poor quality (two or more elements were rated as weak), moderate quality (one element was rated as weak), or high quality (no element was rated as weak). Two authors independently assessed the study's quality. Disagreements and questions

that emerged throughout the review process were resolved through discussions between authors.

2.3.2. Quality assessment for included review studies.

The quality assessment of the review studied was conducted by two authors, using AMSTAR 2. A Measuring Tool to Assess Systematic Reviews-2 is suitable for evaluating systematic reviews of healthcare interventions and has good psychometric properties. To determine the overall confidence level in a systematic review's findings, the instrument has 16 elements that have to be rated (critically low, low, moderate, or high). The overall confidence rating was derived for each systematic review based on a combination of scores on 7 critical and 9 noncritical items following AMSTAR 2 guidelines. Furthermore, only items with option 1 ("yes") generated scores. Therefore, each article could obtain a score between 0 (no criteria) and 16 (all criteria). A form for appraising systematic reviews with AMSTAR 2 was self-developed in Microsoft Word. AMSTAR 2 appraisals were performed in 2 phases independently by 2 authors. Moreover, differences between evaluators in rating each domain item were identified. The evaluators then discussed the rationales for their respective scores, and the differences were resolved when both evaluators agreed on a common assessment.

2.4. Risk of bias

2.4.1. Risk of Bias Assessment of the Included Clinical Trials

The risk of bias in the included quantitative studies was evaluated using the Cochrane risk

of bias tool/version 2 (ROB 2) (Higgins et al., 2019). Accordingly, each study was evaluated

through the different domains included in ROB 2, which reflect the several aspects of the result of each included clinical trial. These domains include: random sequence generation, allocation

concealment, degree of blinding, sample drop, and non-selective reporting (Sterne et al., 2019).

Each domain of ROB 2 is evaluated in relation to the risk of bias found in one of the three major

assessments: Low risk of bias, some concerns of bias, or high risk of bias (Higgins et al., 2019;

Sterne et al., 2019). The overall risk of bias judgment is evaluated by assessing the different domains of ROB 2 for each study and deciding based on those domains' evaluations of the risk of

bias.

2.4.2 Assessment of Risk Bias for systematic review

Assessment of bias was conducted using the ROBIS tool, which was designed specifically, to assess the risk of bias in systematic reviews (Whiting et al., 2016). Accordingly, the bias tool evaluated each systematic review as a 'high,' 'low,' or 'unclear' risk. The tool is completed in three phases: relevancy assessment (optional), identification with the review process, and risk judgment of bias in the review study. The risk of bias assessment includes signaling questions to assist in analyzing specific concerns regarding potential biases. The evaluations from these signaling questions assist assessors in determining the overall risk of bias.

2.5 Study Synthesis

Three reviewers synthesized and evaluated the data; any disagreement was resolved through consensus, and data were included if all three reviewers agreed. A narrative-descriptive synthesis of the evidence was created, including the main findings and consistency of findings across studies, as well as tables were structured.

3.1 Study synthesis and Data Extraction

The synthesis process of the extracted data involves the collection and summarization of the findings from the primary studies that were included. In the initial round of the search, all studies that focused on EMDR therapy for PTSD were gathered, resulting in a total of 4400 studies. After eliminating duplicate studies, the number was reduced. The second round involved examining the effectiveness of EMDR among patients with PTSD in general. Out of the initial 519 studies, only 97 met the inclusion criteria. Further assessment was conducted on the full text articles, and 65 out of the 97 studies met the criteria for this stage. Finally, after careful evaluation, a total of 8 articles were found to meet all the criteria, as depicted in Figure 1.

A comprehensive systematic review was conducted, including a thorough evaluation of eight published studies that met the specific criteria for inclusion. Among these selected studies, four were classified as randomized controlled studies, while the remaining four were categorized as systematic review and met-analysis studies. Within the scope of all these included studies, it was observed that the primary method of psychotherapy intervention for addressing symptoms of post-traumatic stress disorder (PTSD) was the utilization of Eye Movement Desensitization and Reprocessing (EMDR) therapy.

3.2. Selected Studies characteristics:

Table 1 provides a comprehensive overview of the primary features of the studies that were considered in our analysis. In total, we identified and included 8 studies in our research. Upon further examination, we determined that out of these 8 studies, 4 of them, constituting 50% of the total, were randomized controlled trials, while the remaining 4 studies, accounting for 50%, were review articles. These studies were published within the time frame of 2017 to 2022 and were sourced from various reputable Scopus journals across several countries.

Table (1) Characteristics of the studies included in the Literature

Authors	Title		Design	Major findings
Covers et al., 2021		Early intervention with eye movement desensitization and reprocessing (EMDR) therapy to reduce the severity of post-traumatic stress symptoms in recent rape victims: a randomized controlled trial	RCT	EMDR therapy was found to be more effective than watchful waiting in reducing anxiety and dissociative symptoms in the post-treatment assessment
Stanbury et al., 2020		Comparative Efficiency of EMDR and Prolonged Exposure in Treating Posttraumatic Stress Disorder: A Randomized Trial	RCT		Results demonstrated a significant decrease in symptoms post treatment for PTSD, depression, anxiety, and stress for both groups, which was maintained at 3 months. At 6 months there was a small increase in symptoms compared to the 3-month time point on the Clinician-Administered PTSD Scale (CAPS) but no significant change in any self-report symptoms EMDR was significantly more efficient than PE. EMDR participants had less total exposure time to traumatic memories when homework hours were included, reported lower SUD scores after the first session, required fewer sessions for the target memory to decrease to near zero distress levels, and processed more traumatic memories.
Acarturk et al., 2015		EMDR for Syrian refugees with posttraumatic stress disorder symptoms: results of a pilot randomized controlled trial	RCT	showed that the EMDR group had significantly lower trauma scores at post treatment as compared with the wait-list group. The EMDR group also had a lower depression score after treatment as compared with the wait-list group.
Yurtsever et al., 2018		An Eye Movement Desensitization and Reprocessing (EMDR) Group Intervention for Syrian Refugees With Post-traumatic Stress Symptoms: Results of a Randomized Controlled Trial	RCT	The results showed that the EMDR G-TEP group had significantly lower PTSD and depression symptoms after intervention. The percentage of PTSD diagnosis decreased from 100 to 38.9% in the EMDR G-TEP group and was unchanged in the control group. Following the EMDR G-TEP intervention 61.1% of the experimental group no longer had a PTSD diagnosis; this decrease was maintained at 4 weeks follow-up. In the control group the percentage of people who no longer met the diagnostic criteria for PTSD was 10.3% post-test and 6.9% at 4 weeks follow-up. A significant decrease in depression symptoms from pre-test levels was found in EMDR group but not in the control group follow up-test.
Valiente-Gómez et al., 2017		EMDR beyond PTSD: A Systematic Literature Review	SR	EMDR therapy could be a useful psychotherapy to treat trauma-associated symptoms in patients with comorbid psychiatric disorders. Preliminary evidence also suggests that EMDR therapy might be useful to improve psychotic or affective symptoms and could be an add-on treatment
Khan et al., 2018		Cognitive Behavioral Therapy versus Eye Movement Desensitization and Reprocessing in Patients with Post-traumatic Stress Disorder: Systematic Review and Meta-analysis of Randomized Clinical Trials	SR	EMDR is better than CBT in reducing post-traumatic symptoms and anxiety
Wilson et al., 2018		The Use of Eye-Movement Desensitization Reprocessing (EMDR) Therapy in Treating Post-traumatic stress disorder A Systematic Narrative Review	SR	EMDR therapy improved PTSD diagnosis, reduced PTSD symptoms, and reduced other trauma-related symptoms. EMDR therapy was evidenced as being more effective than other trauma treatments, and was shown to be an effective therapy when delivered with different cultures.
Wadji et al., 2022		Can working memory account for EMDR efficacy in PTSD?	SR	EMDR has been shown to be effective in the treatment of PTSD for years, also associated with the reduction of symptoms.

3.1.2 Characteristics of all included RCTs based on country and number of participants:

In this review, a comprehensive analysis was conducted on a total of 153 participants, who were selected from four randomized controlled studies. Specifically, the EMDR based intervention group comprised 72 participants, while the control group consisted of 81 participants. It is worth noting that the distribution of these trials was geographically diverse, with 50% being conducted in Turkey (Stanbury et al., 2020 & Acarturk et al., 2015), 25% in the Netherlands (Covers et al., 2021), and the remaining 25% in Australia (Stanbury et al., 2020), therefore, this wide range of locations adds to the robustness and generalizability of the findings.

Table (2): Characteristics of all included RCTs based on country and number of participants

Author/Year	Country	Number of participants in the EMDR group	Number of participants in the control group
Covers et al., 2021	Netherland	29	28
Stanbury et al., 2020	Australia	10	10
Acarturk et al., 2015	Turkey	15	14
Yurtsever et al., 2018	Turkey	18	29
Total	-	72	81

3.1.2 Characteristics of all included review studies based on the number of participants and the number of included studies:

After a thorough synthesis and review of all systematic reviews and meta-analyses included in this study, a total of 2759 participants from four review studies were identified. These participants were drawn from a pool of 48 articles. It is worth noting that the number of included studies varied across the reviews, with a minimum of 6 articles (Wilson et al., 2018) and a maximum of 17 articles (Valiente-Gómez et al., 2017). However, it is important to mention that not all authors reported the exact number of participants included in their studies. As a result, the researchers in this study carefully examined each original article included in the reviews to determine the accurate number of participants included.

Table (3): EMDR Systematic Reviews characteristics based on the number of included studies and total Number of participants:

Author/Year	Number of included studies	Total Number of participants
Valiente-Gómez et al., 2017	17	976
Khan et al., 2018	14	836
Wilson et al., 2018	6	384
Wadji et al., 2022	11	563
Total	48	2759

3.3 Quality of included studies.

3.3.1 Quality of included clinical trial studies:

The quality of 4 included clinical trial studies were assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies table (2). Each study was evaluated in six domains including Study bias, study design, control of confounders, blinding, data collection method, and withdrawals and dropouts of participants from the study). Based on selection bias domain; all participants in all included studies were agreed to participant in the study prior any intervention and the authors stated that the consents were signed by all participants, furthermore, according to the blinding domain; one randomized control trial (16%) followed a double-blind study design (Stanbury et al., 2020). However, the majority of the included clinical trials applied partial blinding study design (84%). Furthermore, the data in all included studies were collected using tools shown to be reliable and valid, all authors of included studies (100%) reported the number of withdrawals and dropouts participants in their study, however the percentage of participants completed the study in all articles were above 75%. Thus, the overall result after both reviewer discussions showed the 50% of study rated with moderate quality, no study was rated with low quality, and (50%) studies rated as high-quality study.

Table (4): Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies (n= 4)

Study number	Study	Selection Bias	Study Design	Control of confounders	Blinding	Data Collection Methods	Withdrawals and Dropouts	Total rating score
	Covers et al., 2021	1	1	1	2	1	2	2
	Stanbury et al., 2020	2	1	2	1	1	2	2
	Acarturk et al., 2015	2	1	1	2	1	1	1
	Yurtsever et al., 2018	2	1	1	2	1	1	1

*Total rating score (1= strong, 2= moderate, 3= weak)

3.3.2 Quality of included review studies.

The quality of all review studies in this review was assessed using a Quality assessment checklist for systematic reviews (AMSTAR 2). According to this review, only one systematic review and meta-analysis study fulfilled all the AMSTAR 2 scale requirements (Khan et al., 2018). As well as the majority of included review studies (75%) did not fulfill all the AMSTAR 2 scale requirements. Indeed the majority of included systematic reviews and meta-analysis showing a low risk of bias (75%) and only one study showed a moderate level of bias (Valiente-Gómez et al., 2017), as well as all included studies showed a high to moderate power of evidence (Table 3). The score varied from 9 (Valiente-Gómez et al., 2017) to 16 (Khan et al., 2018) points, with an average of 12 out of a possible total of 16 points. Items 1, 2, 3,4,5, 6, 9, and 12 were scored as positive for all included reviews. Moreover, items 7, 11, and 16 were scored as positive for 75% of studies; however, items 8, 10, and 13 were not applicable for 50% of systematic reviews.

Table 5: Quality assessment checklist for systematic reviews (AMSTAR 2)

No	AMSTAR Questions	Valiente-Gómez et al., 2017		Khan et al., 2018	Wilson et al., 2018	Wadji et al., 2022
1	Was an “a priori” design provided?	Yes	Yes		Yes	Yes
2	Was there duplicate study selection and data extraction?	Yes	Yes		Yes	Yes
3	Was a comprehensive literature search performed?	Yes	Yes		Yes	Yes
4	Was the status of publication (i.e., grey literature) used as an inclusion criterion?	Yes	Yes		yes	Yes
5	Was a list of studies (included and excluded) provided?	Yes	Yes		Yes	Yes
6	Were the characteristics of the included studies provided?	Yes	Yes		Yes	Yes
7	Was the scientific quality of the included studies assessed and documented?	No	Yes		Yes	Yes
8	Was the scientific quality of the included studies used appropriately in formulating conclusions?	NP	Yes		Yes	No
9	Were the methods used to combine the findings of studies appropriate?	Yes	Yes		Yes	Yes
10	Was the likelihood of publication bias assessed?	No	Yes		Yes	No
11	Was the conflict of interest stated?	Yes	Yes		Yes	No
12	Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?	Yes	Yes		Yes	Yes
13	Did the review authors account for RoB in individual studies when interpreting/discussing the results of the review?	No	Yes		Yes	No
14	Authors assess the potential impact of RoB in individual studies on the results of the meta-analysis or other evidence synthesis?	NP	Yes		NP	NP
15	If meta-analysis was justified, did the review authors use appropriate methods for statistical combination of results?	NP	Yes		NP	NP
16	Did the review authors use a satisfactory technique for assessing the risk of bias in individual studies that were included in the review?	No	Yes		Yes	Yes
	Total (yes)	9	16		14	10

3.4.1 Risk of Bias Assessment of the Included Clinical Trials

The Cochrane Risk of Bias Tool (ROB) was used to assess the potential bias in the trial studies included in this research. The ROB 2 evaluates each domain in terms of the risk of bias identified, which is categorized into three main assessments: Low risk of bias, some concerns of bias, or high risk of bias (Higgins et al., 2019 & Sterne et al., 2019). Therefore, The risk of bias assessment in this study involved a comprehensive evaluation of multiple domains using the ROB 2 framework. This evaluation considered various factors, including how the random sequence was generated, how the allocation was concealed, the level of blinding implemented, the rate at which participants dropped out of the study, and the extent to which the results were selectively reported. By carefully evaluating each of these domains, a determination was made about the potential risk of bias present in the study.

Based on the outcome, after the analyzing of all included Randomized Controlled Trials (RCTs), it was determined that tow studies, accounting for 50% of the total, were found to have a low risk of bias after undergoing assessment with ROB 2. On the other hand, the remaining two studies, also comprising 50% of the total, were found to have some concerns of bias. However, Table (4) offers further details related to the evaluation of each included study, including details regarding the assessment for each domain in ROB 2.

Table (6): Cochrane Risk of Bias Tool for Quantitative Studies (n= 4)

Study number	Study	Random Sequence Generation	Allocation Concealment Method	Degree of Blinding	Sample Drop	Non-Selective Reporting of Results	Risk of Bias
	Covers et al., 2021	**	*	*	*	*	Some concerns
	Stanbury et al., 2020	*	**	**	-	**	Low
	Acarturk et al., 2015	**	**	**	*	*	Low
	Yurtsever et al., 2018	*	*	**	-	*	Some concerns

*Reported (Some concerns of bias) **Reported in full (low risk of bias). – Not reported (High risk of bias).

3.4.2 Risk Bias for Systematic Review

The risk of bias of the systematic reviews (SRs) that were included in the study was assessed using the ROBIS tool, and the results are presented in Figure (2) and Table (5). The evaluation conducted with the ROBIS tool indicated that all of the review studies included in the analysis had a low overall risk of bias. This suggests that the SRs were conducted in a manner that minimized the potential for bias in their findings. Additionally, the included SRs were found to have clearly stated their research questions in a manner that aligned well with the goals of the overall study. Based on the criteria for determining the eligibility of studies within the field of study, it was found that only 50% of the included studies provided all the necessary information regarding their eligibility criteria. Furthermore, it was discovered that one study was evaluated to have a low risk of bias, while another study (equivalent to 25% of the total) failed to provide clear and specific details about their study's eligibility criteria. Interestingly, none of the reviews reported the registration of a previous protocol, which raises concerns about the transparency and accountability of the research. Additionally, it was observed that all the studies-imposed restrictions on the inclusion of other studies based solely on the language of publication, specifically English language, without offering any justification for this exclusionary approach. This lack of justification further calls into question the validity and comprehensiveness of the research findings. In addition, when it comes to the domain of identification and selection of studies, it is worth noting that half of the reviews that were included in the analysis demonstrated a low risk in this area. However, it is important to highlight that the other half of the reviews did not fully disclose all the pertinent information pertaining to the identification and selection of studies that were ultimately included in their review.

Table (7): Risk of bias assessment with ROBIS tool for all included review studies.

Review	Phase two				Phase 3
	1. Study eligibility criteria	2.Identification and selection of studies	3. Data collection and study appraisal	4. Synthesis and findings	Risk of bias in the review
Valiente-Gómez et al., 2017	low risk	*	low risk	High risk	low risk
Khan et al., 2018	low risk	*	low risk	low risk	low risk
Wilson et al., 2018	*	low risk	low risk	*	low risk
Wadji et al., 2022	High risk	low risk	*	Low risk	low risk

*= unclear risk

3.5 Standardization of EMDR-based intervention protocol based on included RCTs:

When examining the use of EMDR-based intervention protocols in four randomized controlled trials conducted by (Covers et al.,2021, Stanbury et al., 2020, Acarturk et al., 2015 & Yurtsever et al., 2018), it becomes apparent that there is significant variability in the number and duration of EMDR sessions utilized. Despite conducting a comprehensive review, no standardized protocol for implementing EMDRS has been established. Upon analyzing each study's protocol, it was found that 50% of the trials included only two EMDR sessions (Covers et al., 2021 & Yurtsever et al., 2018), one study utilized a total of six sessions (Stanbury et al., 2020), and the remaining study incorporated seven sessions of EMDR, with one session per week (Acarturk et al., 2015). Moreover, it is important to note that the duration of each session can vary significantly between different study protocols. For instance, when examining two studies (Stanbury et al., 2020 & Acarturk et al., 2015), it was found that each session lasted for 90 minutes. However, in another study conducted by (Covers et al.,2021), the sessions were extended to 210 minutes. Additionally, in a final study conducted by (Yurtsever et al., 2018), each session had a duration of 240 minutes. Interestingly, it was observed that as the number of sessions increased, the duration of each session tended to decrease. This conclusion was drawn after evaluating all the studies included in this analysis.

Table (8) Duration and protocol of employing EMDR intervention.

Author/Year	Number of sessions	Duration of intervention	Duration of each session
Covers et al., 2021	2	4 weeks	210 minutes
Stanbury et al., 2020	6	6 Weeks	90 minutes
Acarturk et al., 2015	7	7 Weeks	90 minutes
Yurtsever et al., 2018	2	3 days	240 minutes

3.6 The effectiveness of using eye movement desensitization and reprocessing therapy on reducing the severity of symptoms among individuals diagnosed with post-traumatic stress disorder:

After conducting a thorough and comprehensive evaluation of various studies included in this review, it was found that several research studies have been carried out to assess the intensity of symptoms among individuals diagnosed with post-traumatic stress disorder (PTSD) after employing the eye movement desensitization and reprocessing therapy. Taking into account all the studies that were included, a total of eight published studies were analyzed, with a balanced distribution of 50% randomized controlled trials (RCTs) and 50% systematic reviews and meta-analyses. These studies collectively involved a total of 2912 participants. The findings from these studies indicated that eye movement desensitization and reprocessing therapy (EMDR) showed significant improvements in reducing the severity of symptoms among individuals diagnosed with PTSD. To illustrate, a previous RCT conducted by (Covers et al., 2021) to assess the effectiveness of early intervention with eye movement desensitization and reprocessing (EMDR) therapy to reduce symptoms of post-traumatic stress, feelings of guilt and shame, sexual dysfunction, and other psychological dysfunction such as general psychopathology, anxiety, depression, and dissociative symptoms in victims of rape, all participants in EMDR group received a total of two sessions over 2-4 weeks and each session lasted for 210 minutes, based on the study result, EMDR therapy was found to be more effective than watchful waiting in reducing anxiety and dissociative symptoms in the post-treatment assessment.

The second randomized controlled trial (RCT) conducted by Stanbury et al. (2020) aimed to investigate the effectiveness of eye movement desensitization and reprocessing (EMDR) therapy and prolonged exposure (PE) therapy in treating individuals with posttraumatic stress disorder (PTSD). In this study, a group of 10 participants diagnosed with PTSD were recruited for the EMDR-based intervention. Over the course of six weeks, these participants received a total of six therapy sessions, each lasting 90 minutes. The findings of this study revealed a significant reduction in symptoms of PTSD, depression, anxiety, and stress among both the EMDR and PE therapy groups immediately after the treatment. These positive effects were also sustained at the three-month follow-up assessment. However, at the six-month mark, there was a slight increase in symptoms compared to the three-month assessment on the Clinician-Administered PTSD Scale (CAPS). It is worth noting that participants receiving EMDR therapy reported spending less time overall on exposure to traumatic memories when considering the completion of homework assignments.

The third randomized controlled trial (RCT) conducted by (Acarturk et al., 2015) aimed to investigate the impact of Eye Movement Desensitization and Reprocessing (EMDR) in reducing symptoms of post-traumatic stress disorder (PTSD) and depression among Syrian refugees. The study included a total of 14 participants in the EMDR intervention group, who received seven therapy sessions lasting 90 minutes each over a period of seven weeks. The findings of the study revealed that the EMDR group exhibited significantly lower trauma scores after treatment compared to the wait-list group. Additionally, the EMDR group also displayed lower depression scores following treatment in comparison to the wait-list group.

In a recent study conducted by (Yurtsever et al., 2018), researchers aimed to explore the effectiveness of EMDR G-TEP in treating symptoms of post-trauma and depression and preventing the development of chronic PTSD in a group of refugees living in a refugee camp. The study consisted of 18 participants who were assigned to the EMDR intervention group. These individuals received two therapy sessions, each lasting 240 minutes, over the course of three days. Additionally, they were followed up for a period of four weeks. The findings of the study revealed that the participants in the EMDR group experienced a significant reduction in PTSD and depression symptoms following the intervention. Specifically, the percentage of participants diagnosed with PTSD decreased from 100% to 38.9% in the EMDR group, while remaining unchanged in the control group. Furthermore, after the EMDR intervention, 61.1% of the participants in the experimental group no longer met the diagnostic criteria for PTSD, and this improvement was sustained at the four-week follow-up. On the other hand, in the control group, only 10.3% of individuals no longer met the diagnostic criteria for PTSD after the post-test, and this number decreased to 6.9% at the four-week follow-up. The study also found a significant decrease in depression symptoms in the EMDR group when compared to the control group during the follow-up period.

In four separate review studies exploring the impact of eye movement desensitization and reprocessing therapy (EMDR) on individuals diagnosed with post-traumatic stress disorders (PTSD), it was consistently demonstrated that EMDR effectively reduces the severity of PTSD symptoms. To further illustrate this point, a previous systematic review conducted by Valiente-Gómez et al. in 2017 investigated the effectiveness of EMDR therapy. This particular review analyzed a total of 17 articles involving 976 participants. The findings of the review indicated that EMDR therapy has the potential to serve as a valuable form of psychotherapy for addressing trauma-related symptoms in patients with psychiatric disorders.

In a second review study conducted by Khan et al. in 2018, the objective was to compare the effectiveness of Cognitive Behavioral Therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR) in alleviating post-traumatic symptoms, anxiety, and depression among individuals diagnosed with Post-Traumatic Stress Disorder (PTSD). This comprehensive review examined a total of 14 articles that encompassed a significant sample size of 836 participants. The results of this study revealed that EMDR exhibited superior outcomes compared to CBT, specifically in reducing post-traumatic symptoms and anxiety levels.

In a study conducted by (Wilson et al., 2018), the goal was to thoroughly examine the effectiveness of Eye Movement Desensitization and Reprocessing (EMDR) therapy in treating Post-Traumatic Stress Disorder (PTSD) through a systematic and narrative review of Randomized-Controlled Trials. This review included a total of six studies that utilized randomized controlled designs and involved a combined total of 384 participants. The findings of this review revealed that EMDR therapy not only improved the diagnosis of PTSD but also led to a reduction in PTSD symptoms as well as other symptoms related to trauma. Furthermore, the study also highlighted that EMDR therapy was found to be more effective compared to other treatments for trauma and was shown to be beneficial when utilized across different cultural contexts.

Finally, in a recent systematic review conducted by (Wadji et al. in 2022), the objective was to comprehensively examine the existing research on the role of dual tasking in Eye Movement Desensitization and Reprocessing (EMDR) treatment for Post-Traumatic Stress Disorder (PTSD). This review encompassed a substantial body of literature, consisting of 11 articles and involving a total of 563 participants. Through analysis and synthesis of these studies, the findings of this extensive review shed light on the long-standing efficacy of EMDR in addressing PTSD. Over the years, numerous studies have consistently demonstrated that EMDR therapy yields positive outcomes in alleviating the distressing symptoms. Moreover, the researchers discovered a promising association between EMDR treatment and a notable decrease in PTSDs symptoms.

This systematic review aimed at evaluating the effectiveness of using EMDR to manage moderate to severe PTSD symptoms among adult patients suffering. The review revealed eight articles, published between 2015 and 2022 and met the inclusion criteria of the review. Although tens of articles have been published in the same field, only 8 met the criteria. Of those 8 studies, there are four randomized controlled trails and four systematic reviews that have investigated and testing effectiveness of EMDR on individuals with PTSD symptoms. The analysis revealed to several Categories that can be considered a description of how EMDR can be effective among individuals with PTSD.

4.1. Effectiveness of EMDR Therapy

Studies that have used EMDR, eventually, aimed at testing and ensuring that EMDR is an effective approach to be used with individuals with PTSD. Mainly, the studies attempted to quantify the effective outcomes of EMDR rather than being just proposing and testing it as an option. The studies did highlight the scientific value of EMDR compared to other approaches. Therefore, the studies asserted that EMDR therapy offers promising curative therapeutic chances to patients suffering from several psychological disturbances and problems including PTSD, depression, anxiety and worry (Hase, M. 2021). For example, Banerjee & Argaez (2018), reported that using EMDR among individuals with PTSD revealed significant positive outcomes compared to usual therapeutics modalities. For example, Hendrix and colleagues (2021), reported that EMDR therapy was an effective and an early intervention among women suffering traumatic birth experience. This infers that early use of EMDR therapy among mothers experiencing a traumatic birth incident is safe and effective (Hendrix et al. 2021). Consequently, using EMDR may reveal to positive outcomes on psychological well-being and quality of life in forensics settings. Forensic mental health services deliver assessment and psychological counseling of individuals suffering of mental conditions and a history of criminal offending. The reviewed studies reported that there is a high prevalence of PTSD in forensic settings that leads to higher levels of violence. Furthermore, they have also sustained, in their review, that there is a need to conduct more studies using the EMDR among larger groups of patients and across settings and cultural backgrounds to sustain effectiveness of EMDR across various groups and settings. Furthermore, EMDR has been found to be affective among individuals with PTSD comorbid with psychiatric disorders such depression (Covers et al., 2021; Stanbury et al., 2020; Acarturk et al., 2015; Yurtsever et al., 2018; Valiente-Gómez et al., 2017; Khan et al., 2018; Wilson et al., 2018; Wadji et al., 2022; Hendrix et al. 2021; Lortye et al. 2021; Every-Palmer et al., 2019; Scelles et al., 2021). Such a positive reports would enlighten clinicians and researchers to be more positively motivated toward using EMDR among individuals with PTSD in situations where complexes mental signs and symptoms are observed. It has been also noted that ‎ongoing EMDR trauma focused treatment ‎for patients with PTSD reduced traumatic symptoms, particularly, for those who attended the majority of intervention sessions (Schäfer et al. 2017). In other words, the EMDR can be more effective when individuals attending the therapy are more committed, have more positive attitudes, and motivated toward using the intervention for the purpose of treatments. Such condition does enhance the positive outcomes of the EMDR and indicates to those intend to use the intervention to be more ware of implementation procedure and personal preparedness issues such as personal motivation and adherence to all sessions. Finally, using EMDR therapy reduces the emotional value of the episodic memory. This could provide solid evidence that EMDR, as proposed therapy, is an effective model of treatment in individuals with PTSD symptoms, and did enable them to control and lessens the severity of symptoms.

4.3. Standardization of EMDR-based intervention protocol

By examining a diverse range of studies and consolidating their findings, this systematic review reinforces the existing body of evidence supporting the effectiveness of EMDR in PTSD treatment. The substantial number of participants involved in the analyzed studies lends credibility to the reliability and generalizability of these findings. Ultimately, this review serves as a valuable resource for clinicians, researchers, and practitioners, offering a comprehensive overview of the current state of research on the role of EMDR treatment for PTSD.

In the context of standardized EMDR based intervention study protocols, there is a notable range of variability when it comes to the number and length of EMDR sessions used to address symptoms of PTSD. Through conducting a systematic review, it was discovered that the number of sessions varied greatly, with some studies using as few as two sessions (Covers et al., 2021) and others utilizing up to seven sessions (Acarturk et al., 2015). Additionally, the duration of these sessions also exhibited diversity, with some studies implementing sessions lasting 90 minutes (Stanbury et al., 2020 & Acarturk et al., 2015) while others extended to a maximum of 240 minutes (Yurtsever et al., 2018). Interestingly, upon analyzing the protocols of these studies, it was found that there appeared to be a trend where an increase in the number of sessions corresponded with a decrease in the duration of each individual session. This observation was made after considering the findings of all the studies included in this analysis.

4.4. EMDR is Strongest supportive evidence for effectiveness of the eye movement desensitization and reprocessing (EMDR) interventions for Treatment of individuals with PTSD and employing in varies psychiatric conditions

The majority of individuals face numerous of difficult situations in their everyday life which make them unable to deal with it and leave them feeling emotionally and physically overwhelmed, that thing make them under stress. Stress can be harmful if we become over-stressed and it interferes with our ability to get on with our normal life for too long. If stress continued for a long time, it can affect the quality of life and lead to serious health problems such as sleep problems, heart diseases, depression and anxiety.

Several psychotherapies have been proven to be effective in treating PTSD. Therefore, Trauma-focused cognitive-behavioral therapy (TF-CBT), cognitive processing therapy (CPT) and Eye Movement Desensitization and Reprocessing (EMDR) have the strongest evidence base (Cusack et al., 2016; Lancaster et al., 2016; Tran and Gregor, 2016), and are the most recommended treatments for adults with PTSD). For example, Khan and colleagues in (2017), reviewed and compared the effectiveness of using EMDR therapy and Cognitive-behavioral therapy CBT on relieving the post-traumatic symptoms, reducing anxiety level and depressive symptoms among patients experiencing associated PTSD symptoms, in their review, concluded that there an EMDR therapy is better than CBT in reducing post-traumatic symptoms and anxiety. However, there was no difference reported in reducing depressive symptoms (Khan et al. 2017). Additionally, the use of EMDR therapy as a standard treatment option for PTSD symptoms, thereby significantly reducing treatment duration and costs, evidently benefiting the individuals and society (Hofman et al. 2022). Moreover, EMDR as psychotherapy is effective to reduction the levels of anxiety and depressive symptoms after the intervention, moreover, Nurses can use the eye movement desensitization and reprocessing intervention in medical management congruent with psychotropic medications for the decreasing of depression and anxiety levels in patients (Rahimi et al, 2019). Hence, Carletto and her colleagues mention in The Adaptive Processing model reflects symptoms of PTSD and other disorders to result from past distressing experiences that remain to cause distress because the memory was not sufficiently processed. These untreated memories are unstated to hold the emotions, thoughts, beliefs and physical sensations that happened at the time of the event (Covers et al., 2021; Stanbury et al., 2020 & Acarturk et al., 2015) . When the memories are triggered these stored worrying components are experienced and source the symptoms of PTSD, Depression and Anxiety disorders (Carletto et al, 2021). However, Carter & Farrell in 2023 reported that, EMDR therapy protocols offering more helpful and curative therapeutic option to PTSD patients who experience limited success undergoing other types of psychotherapy approaches.

Scelles and colleagues in 2021 reported that using EMDR therapy it is effective not only for PTSD and stress related trauma but also reported there is A positive effect was reported for several types of Psychiatric conditions such as, substance and addictions, somatoform disorders, sexual dysfunction, eating disorders, personality disorders, mood disorders, anxiety disorders, specific phobias, Obsessive-Compulsive Disorder (OCD), pain, neurodegenerative disorders, mental disorders of childhood and adolescence, and sleep. Furthermore, EMDR allowed the extension of treatment management as usual. they have also sustained, in their review, even with a generally positive viewpoint of EMDR therapy as a substitute therapeutics approach, and suggest to lunching Additional more methodologically rigorous studies are required to validate these conclusions and also to scientifically evaluate the effectiveness of EMDR therapy for generalized anxiety disorder, social anxiety, and agoraphobia. Since cognitive behavioral therapy (CBT) is currently reflected a first-line treatment for anxiety disorders (Faretta & Dal Farra, 2019). In other hand, EMDR therapy was effective and curative therapeutics modalities among Patients with both PTSD and Substance-Use Disorder SUD. Currently, there is evidence that a simultaneous EMDR is effective to treat PTSD in patients with co-occurring SUD. Furthermore, co-occurring PTSD and SUD can be enhanced based on the results of the RCT conducted by Lortye and colleagues in 2021, which may recover positive therapeutic outcomes of patients with this popular comorbidity. Moreover, Hofman and colleagues in 2022 conducted a multicenter RCT in Netherlands, to investigating the effectiveness of using EMDR therapy among individuals with a personality disorder experiencing traumatic symptoms, recurring suicidal thoughts and flashbacks of multiple traumatic events that had occurred in her life, meeting Criterion A of the PTSD classification. This involves a series of events related to physical and sexual violence. and to evaluate the effectiveness of EMDR therapy using the Clinician-administered PTSD Scale for DSM-5 to measuring variations in severity of PTSD symptoms. The study concluded that, EMDR therapy is a standard treatment option for
PTSD, thereby significantly reducing treatment duration and costs, evidently benefiting the individual and society.

Another study showed that, EMDR is Safe and effective in managements for MDD it is available as a pharmacological and non- pharmacological, depression remains underdiagnosed and undertreated. Also, patients with severe depression had higher mortality than the general population regarding to increase the risk of suicidality (Malandrone et al, 2019). Moreover, the combination between pharmacotherapy and EMDR psychotherapy it is effective for anxiety disorder management and EMDR therapy can be a substitute treatment method in anxiety disorder. Another study that concluded of Major enhancement was exposed after (EMDR) treatment compared to before (EMDR) treatment on anxiety, depression, and worry. But the management of Anxiety by EMDR approach need to conducting further research studies (Wallis & de Vries, 2020).

Although this systematic review has a substantial influence on nursing and other healthcare practices, as well as a profound effect on patient outcomes, it is important to acknowledge several limitations inherent in this study. First and foremost, it is noteworthy to mention that only studies conducted in the English language were included in this review, potentially restricting the overall scope and diversity of the findings. Furthermore, the number of studies incorporated into this review was limited, which may have implications for the comprehensiveness and generalizability of the results. Lastly, it is worth noting that certain studies within this review had a relatively small sample size, which could potentially limit the statistical power and precision of the conclusions drawn.

This Systematic review gives an overview and explains strong supportive evidence for effectiveness of the eye movement desensitization and reprocessing (EMDR) interventions among individuals with PTSD. Therefore, EMDR therapy could be assumed as one standard treatment option for PTSD aiming at reducing treatment duration, cost of treatment, and restoring mental wellbeing and functionality of those suffering PTSD.

5.1. Psychiatric Nursing Implication and Recommendations

this systematic review provides baseline information and plays a significant role to decrease the gap in Jordanian literature regarding to using EMDR as a strongest evident psychotherapy approach for PTSD treatment to help psychiatrist, psychologist and psychiatric nurses in healthcare sectors to designing comprehensive strategies to enhance and improve the quality of healthcare and patient’s status.

Funding: This research paper received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Data Availability: No datasets were generated or analysed during the current study.

Conflict of Interest: The authors declare no competing interests.

Human and Animal Rights and Informed Consent: This article does not contain any studies with human or animal subjects performed by any of the authors.

Authors’ contributions:

Reviewing the literature (RH, BA), created the inclusion and exclusion criteria (BA, YA), designing the PRISMA chart (RH, AM), summarizing the selected studies (RH, BA), and drafting the work (RH, YA), selecting the appropriate journal and assigned to be the corresponding author (RH).

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The authors declare no competing interests.

The Effectiveness of Using Eye Movement Desensitization and Reprocessing Therapy on Reducing the Severity of Symptoms among Individuals Diagnosed with Post-Traumatic Stress Disorder: A Systematic Review

Status:

Version 2

Abstract

Figures

1. Background

2. Literature Methodology

3. Results

4. Discussion

5. Conclusions

Declarations

References

Additional Declarations

Status:

Version 2