Original Article

Alpha Psychiatry 2022;23(3):121-127

DOI: 10.5152/alphapsychiatry.2022.21763

Recent Traumatic Episode Protocol EMDR Applied Online for COVID-19-Related Symptoms of Turkish Health Care Workers Diagnosed with COVID-19-Related PTSD: A Pilot Study

Eser Sağaltıcı¹

Mustafa Çetinkaya²

Şengül Kocamer Şahin³

Birgül Gülen⁴

Şenel Karaman⁴

¹ Department of Psychiatry, Bagcilar Research and Training Hospital, University of Health Sciences, İstanbul, Turkey

² Department of Psychiatry, İstanbul University Faculty of Medicine, İstanbul, Turkey

³ Department of Psychiatry, Gaziantep University Faculty of Medicine, Gaziantep, Turkey

⁴ Liman Psychology, İstanbul, Turkey

Corresponding author: Şengül Kocamer Şahin ✉ snglkcmr@hotmail.com

Cite this article as: Sağaltıcı E, Çetinkaya M, Kocamer Şahin Ş, Gülen B, Karaman Ş. Recent traumatic episode protocol EMDR applied online for COVID-19-related symptoms of turkish health care workers diagnosed with COVID-19-related PTSD: A pilot study. Alpha Psychiatry. 2022;23(3):121-127.

ABSTRACT:

Background: This study investigates the effect of the online Eye Movement Desensitization and Reprocessing Recent Traumatic Episode Protocol on posttraumatic stress disorder, anxiety, depression, and burnout symptoms in healthcare workers diagnosed with pandemic-related post-traumatic stress disorder.

Methods: The study included healthcare workers who applied to psychiatry outpatient clinics due to the psychiatric symptoms that developed related to the pandemic and who were diagnosed with post-traumatic stress disorder. The Beck Anxiety Inventory, Impact of Event Scale-Revised to evaluate the symptoms of post-traumatic stress disorder (avoidance, intrusion, and hyperarousal), Maslach Burnout Inventory, and Beck Depression Inventory were used for the assessment. The tests were administered 3 times (pre-treatment, post-treatment, and at 1-month follow-up).

Results: This study included 14 healthcare workers diagnosed with post-traumatic stress disorder; 2 (14.3%) physicians, 2 (14.3%) nurses, 4 (28.6%) other-healthcare workers/medical staff, and 6 (42.8%) other healthcare workers/non-medical staff. There was a significant decrease in Impact of Event Scale-Revised total score, the intrusion and hyper-arousal sub-scores between T1 and T2 (P = .018; P = .005; P = .0005, respectively) and between T1 and T3 (P < .001; P < .001; P < .001, respectively), but there was no difference between T2 and T3 (P = .89). A significant difference was found in repeated measurements of both Beck Depression Inventory [P < .001] and Beck Anxiety Inventory [P < .001] scores. There was a significant difference in emotional exhaustion, one of the subscales of Maslach Burnout Inventory (P = .09). However, there was no significant difference in depersonalization (P = .48) and personal accomplishment (P = .66).

Conclusion: Recent Traumatic Episode Protocol appears to be capable of reducing symptoms of anxiety, depression, intrusion, and hyperarousal symptoms of post-traumatic stress disorder and emotional exhaustion when symptoms that developed are related to the pandemic in healthcare workers.

Keywords: Eye Movement Desensitization Reprocessing, COVID-19, pandemics, healthcare workers;

Introduction

Since the end of December 2019, coronavirus disease 2019 (COVID-19) spread across the world with almost 180 million confirmed cases and about 3 million deaths by July 25, 2021.¹ In this process, healthcare workers (HCWs) have undertaken the greatest burden. In addition to the existing complexity and difficulty of working as an HCW, considering the circumstances such as the risk of infecting relatives, inability to take care of their children, being set aside from their family, witnessing or hearing their colleague' deaths, it is evident that the HCWs are exposed to critical psychological stress during the COVID 19 outbreak.²-4 Thus, in addition to the difficulties mentioned above, inadequate psychological precaution and overwhelming workload caused the development of diverse mental problems such as anxiety, insomnia, burnout, and post-traumatic stress disorder (PTSD) among HCWs during the outbreak.⁵-7

Post-traumatic stress disorder is a mental disorder marked by avoidance distressing trauma reminders, intrusion symptoms (such as recurring images and dreams), hyper-arousal symptoms (such as sleep problems and concentration problems) and resulting in a significant loss of functionality.⁸ The prevalence of PTSD among healthcare workers ranges from 3.4% to 71.5%, depending on the target population in studies, course of the pandemic, and procedure used to assess the mental problems.⁹ Since this work involves intervention during ongoing trauma, it should be differentiated from PTSD after trauma has ended. The major difference between the 2 is that the former is characterized by a constant and possibly inevitable, stressful, and traumatic environment that fuels PTSD. It is supported by some studies that ongoing threatened PTSD may be associated with higher cortisol levels.¹⁰

Burnout is a phenomenon characterized by reduced personal accomplishment, emotional exhaustion (running out of personal resources), and depersonalization (perception of excessive disconnection that reduces harmony in relationships unlike in the context of traumatic dissociation).¹¹ During outbreaks, risk factors for adverse psychological reactions may be related to burnout. Indeed, coexisting acute stress has been shown to contribute to PTSD symptoms in frontline HCWs in COVID-19 patient care.¹²

Eye Movement Desensitization and Reprocessing (EMDR) is an 8-stage psychotherapy technique based on the adaptive information processing (AIP) model to alleviate distress caused by traumatic memories.¹³ Francine Shapiro first proposed this strategy, claiming that rhythmic bilateral eye movements during periods of strategic exposure to stress stimuli can lessen the trauma reaction. Based on clinical observations, Shapiro created the AIP model, which explains how poorly processed psychological stressors from prior developmental experiences influence current emotional, behavioral, and cognitive phenomena that define our identity.¹³ As the clinical use of EMDR has expanded, numerous controlled, randomized studies have shown that EMDR is clinically effective for PTSD. In international guidelines, EMDR is currently recognized and recommended as first-line therapy for trauma.¹⁴ The EMDR R-TEP is a comprehensive, structured, and integrative recent trauma-focused protocol for early EMDR intervention (EEI). This was an 8-phase protocol including history-taking, preparation, assessment, desensitization, installation, search for body sensations, closing the session, and re-evaluation.¹⁵ It provides a mental health screening, which is useful for treating traumatic distress and preventing post-traumatic problems and trauma memory build-up.

MAIN POINTS

The online EMDR R-TEP protocol has been found to be effective on pandemic-related Post Traumatic Stress Disorder (PTSD) in healthcare workers.

The online EDMR R-TEP has been shown to reduce the symptoms of emotional exhaustion when symptoms related to the pandemic develop in healthcare workers diagnosed with PTSD.

EDMR R-TEP appears to have the ability to reduce symptoms of anxiety, depression, intrusion, and hyper-arousal in healthcare workers with PTSD.

Mental disorders such as anxiety, depression, insomnia, and burnout that may develop due to the stress caused by the pandemic may induce a substantial slowdown in motivation and productivity, even neglect of self-protection in HCWs.⁷,¹⁶ For this reason, the importance of mental support to HCWs for the sustainability of health systems has been emphasized since the beginning of the pandemic.¹⁶,¹⁷ Social distancing measures implemented in a number of countries to reduce the diffusion of COVID-19 are forcing clinicians to offer online treatments. For this reason, some online therapies have been shown to be effective. A meta-analysis stated that online cognitive behavioral therapy (CBT) practice for PTSD is promising.¹⁸ The online short group therapy intervention according to the EMDR protocol was found to be effective in a clinical population of adolescents and young adults in improving anxiety levels, particularly intrusiveness and hyperarousal symptoms of post-traumatic stress.¹⁹ It has been reported that the URG-EMDR protocol in the telemental health setting provides an improvement in anxiety, depression, and reduction in perceived disturbance assessed with Subjective Units of Disturbance scale even in a single session.²⁰ The URG-EMDR used in that study was a single session early psychological intervention that included standard EMDR phases lasting an average of 2 hours and 14 minutes with no questions about positive cognition and somatic. The quantity of studies indicating the effectiveness of online EMDR therapy is still limited in the literature.¹⁸ There are many application protocols of EMDR therapy in the literature. Some of these were created for early EEI, and a favorite is the EMDR Recent Traumatic Episode Protocol (EDMR R-TEP).¹⁵ Recent Traumatic Episode Protocol is a protocol that combines the “Recent Event” and “eye movement desensitization” protocols, making the entire episode’s (from the event to the present) strategic focus within its expand.¹⁵ In this study, we used the online EMDR R-TEP protocol in HCWs diagnosed with PTSD associated with the pandemic to evaluate its effect on PTSD, anxiety, depression, and burnout symptoms.

Methods

Participants

The study was conducted at the Bağcılar Training And Research Hospital between September 1, 2020, and December 1, 2020. The study population was the HCWs who applied to psychiatry outpatient clinic due to the psychiatric symptoms that developed related to the pandemic (e.g., working in the COVID-19 intensive care or clinics where COVID-19-positive patients are followed, being quarantined, having a COVID-19 infection in self or his/her family including having symptoms of the disease along with a positive COVID-19 test). In this study aiming to investigate the effect of the online EMDR R-TEP protocol on PTSD, anxiety, depression, and burnout symptoms in HCWs diagnosed with pandemic-related PTSD, the effect size (i = 0.35) was chosen as statistically significant and the minimum number of participants was determined as 5 (α = 0.05, 1 − β = 0.80) based on another EMDR study in Turkey.²¹ Analysis was performed in G power versions 3.9.1. Considering dropouts, this study started with 16 participants who applied for treatment, met the study criteria, and voluntarily agreed to participate.

Inclusion criteria for the study were (1) being diagnosed with PTSD according to The Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 criteria by the psychiatrists, (2) Being between the ages of 18 and 65 years old, (3) not taking any psychotropic drugs and/or psychotherapy, and (4) accepting to participate in the study voluntarily. Healthcare workers who had serious mental or physical illness, comorbid schizophrenia, other psychotic disorders, severe depression with suicidal ideation or with psychotic features, bipolar spectrum disorders, organic brain syndrome, pronounced personality disorder, and substance and/or alcohol dependence/abuse were excluded from the study. The informed consent forms were taken from the participants. The research was approved by the Bagcilar Research and Training Hospital’s Ethical Committee (2020.1.01.099.r1.147). We have obtained permission from the Ministry of Health in this study related to COVID-19. This study complied with the Declaration of Helsinki. After informed consent forms were signed, 1 participant dropped out of the study before therapy began and 1 participant after the first interview. The study was completed with 14 participants.

Procedure and Treatments

The EMDR R-TEP was applied online to the HCWs included in the study. No other psychotherapeutic agent was initiated for the patients who were included in the study. The EMDR R-TEP includes an adaptation of the eye movement desensitization and recent event protocols, with additional precautions for containment and security. It provides guidelines for a first therapy contract that uses the bare minimum of contemporary trauma-focused intervention modalities. The protocol has the ability to provide quick treatment results, usually in 2-4 sessions. Because the follow-up is considered crucial, a minimum of 2 sessions is required. The intervention can take place on consecutive days, which is beneficial for high-distress individuals and field teams. Because the experiences have not yet been integrated or adaptively processed, the initial crucial occurrence and its painful aftermath are regarded as a continuous traumatic episode continuum. The episode includes a number of traumatic incidents, ranging from the original occurrence to the present day, as well as multiple targets of disturbance. Points of disturbance are the name given to these target components (PoDs). The client is taught scanning and self-stabilization exercises. The client is invited to speak out loud the traumatic tale of the occurrence while getting bilateral stimulation, preferentially involving eye movements for preserving dual consciousness and anchoring in the present safety.²² This is the first stage of processing that allows certain gaps in the traumatic story to be filled in. Then comes the "Google search," which entails a non-consecutive inner scanning of the section in order to find a PoD. As with the conventional EMDR technique, this target fragment is appraised and subsequently processed using strategies that keep associations within the traumatic episode's bounds. Any connections made during the episode are acknowledged, but the client is instructed to return to goal to refocus and check the Subjective Units of Disturbance Scale (SUD). If the client does not achieve an adaptable resolution, client can be invited to work with the conventional EMDR protocol for more extended processing, with the client's consent. The EMD technique, which incorporates a restricted associative focus just on the target/fragment, is the best way to process intrusive fragments. This is usually a quick treatment that can help reduce the disruption caused by invasive pieces quickly.²³ The therapist will install a PC if the SUD of the PoD target is decreased to a practical level. The therapist moves to the episode level for completion once no more fragments are found in the Google search. The entire episode's SUD is verified, and if ecological, the episode's PC is determined and installed. After that, the first body scan is performed, and the treatment is completed with stabilizing operations. Each treatment session is ended with a vigorous closure of resources to ensure that containment is maintained. The EMDR R-TEP protocol is based on a theoretical understanding of the nature of the AIP system’s memory consolidation process following recent trauma.¹⁵,²⁴,²⁵ From fragment to identity, a shift in processing focus is suggested. The EMD technique with a restricted and concentrated border on connections connected solely to the intrusive target/fragment (PoD) promotes contained, concise processing, which matches this stage. The EMDr method with a broader border of associations connected to the present traumatic incident is appropriate, since it keeps the processing restricted and episode-focused. With unlimited free associations and increased cognitive organization, this could serve as a transition to the wide focus of the EMDR classical protocol. Retrospective and future adaptive connections to past traumatic memory networks are supported by episode adaptive analysis. This results in coping, self-affirmation, and resilience.

Therapists were selected from EMDR Turkey Trauma Recovery Group (EMDR Turkey Humanitarian Assistance Program) as volunteer therapists for this study. The therapists were selected according to the criteria of having completed at least EMDR basic training part II, received training in the application of the R-TEP protocol, and had experience in the application of the protocol in previous volunteer studies. In addition, therapists were given 2 hours of online training on the online EMDR R-TEP application before the application. The therapists received regular and daily 1 hour group supervision by EMDR EUROPE Accredited Consultants and worked in the presence of a supervisor. Thus, it was ensured that every client was treated in the same way. Based on the average of previous humanitarian-aid sessions, the number of therapy sessions to be given within the scope of the study by the EMDR Turkey Trauma Recovery Group Supervision and Training Commission was planned as 90 minutes and 5 consecutive sessions. All participants completed the 5 consecutive therapy sessions twice weekly.

Measures

The assessment tools were applied to the HCWs 3 times (pre-treatment, post-treatment, and 1-month follow-up) by the same accredited consultant.

Sociodemographic and Characteristics Form

The sociodemographic information form consisted of 9 questions aiming to collect information in line with the purpose of the study, such as age, gender, marital status, weekly working hours during the pandemic, and job [physician, nurse, and other HCWs (other HCWs include medical staff such as surgery technician, anesthesia technician, laboratory technician, etc. and non-medical staff such as secretary, security staff, cleaning staff)] of participants were determined. Information on stressful events (family members who have been diagnosed with COVID-19 and being quarantined and diagnosed with COVID-19) that were experienced during the pandemic was obtained.

The Assessment Tools Were Administered Per 3Times (Pre-treatment, Posttreatment, and at 1-Month Follow-Up)

The Impact of Event Scale-Revised):

This scale measures psychological distress. It is a 22-item and 5-point scale ranging from 0 to 4; higher total scores indicate severe distress. The Impact of Event Scale-Revised (IES-R) measures the 3 major symptoms of distress: avoidance (8 items), intrusion (7 items), and hyperarousal (7 items).²⁶ The validity and reliability studies of the Turkish version of the IES-R were performed by Corapcioglu et al.²⁷

Beck Anxiety Inventory:

Beck Anxiety Inventory (BAI) is a self-report scale that aims to measure the density of anxiety symptoms.²⁸ The scores range from 0 to 63. Higher scores show severe anxiety. The Turkish validation study of this scale was conducted by Ulusoy et al.²⁹

The Beck Depression Inventory:

Beck Depression Inventory (BDI) is a clinical scale developed by Beck et al³⁰ (1961) to evaluate depressive symptoms. The scores range from 0 to 63. Higher scores show severe depression. The Turkish version of this scale was adapted by Hisli.³¹

Maslach Burnout Inventory:

This scale was developed by Maslach and Jackson (1981).³² The sub-dimensions of the burnout scale were divided into 3 groups emotional exhaustion, depersonalization, and personal accomplishment. The high score obtained from the emotional exhaustion and depersonalization and the low score obtained from the personal accomplishment indicated high burnout. The Turkish adaptation of the scale was performed on health professionals by Ergin (1995)³³ and the original scale was changed to a 5-point Likert scale. On the scale, (0) never, (1) very rare, (2) sometimes, (3) most of the time, (4) always was used as a 5-point rating.

Statistical Analysis

Median values, 25%-75% interquartile ranges, and mean (Standard Deviation) for quantitative variables are presented. For categorical variables, frequencies and percentages were presented. A non-parametric Friedman's test was conducted to test the efficacy of the treatment for decreasing IES-R, BDI, BAI, and MBI scores. All the analyses were 2-sided with α of 0.05 and with Bonferroni correction test. Statistical Package for the Social Sciences (SPSS) version 26.0 (IBM SPSS Corp.; Armonk, NY, USA) was used for the analysis.

Results

This study included totally 14 HCWs diagnosed with PTSD as 2 (14.3%) physician, 2 (14.3%) nurse, 4 (28.6%) other HCWs/medical staff, and 6 (42.8%) other HCWs/non-medical staff. Eleven (78.6%) of them were women, 9 (64.3%) of them were married, and their mean age was 34.14 (SD = 8.06). During the pandemic, 5 (28.6%) of the participants and 1 of the family members of 2 participants (14.3%) were diagnosed with COVID-19 and 7 HCWs (5 .0%) were quarantined. Average work experience (years) was 9.13 (SD = 7.38) and average weekly working hours during the pandemic was 45.42 (SD = 5.04) (Table 1).

Evaluation of the differences between repeated measurements (T1, pre-test; T2, post-test; T3, 1-month follow-up) was made with the Friedman test. While there was a significant difference between the measurements in terms of IES-R total score [P < .001], intrusion [P < .001], and hyperarousal [P < .001] subscores. Avoidance [P = 0.211] sub scores were not significantly different (P = .21) (Table 2).

There was a significant decrease in IES-R total score and the intrusion and hyperarousal subscore between T1 and T2 (P = .018; P = .005; P= .005, respectively) and between T1 and T3 (the median difference, P < .001; P < .001; P < .001, respectively), but there was no difference between T2 and T3 (Table 2).

A significant difference was found in repeated measurements of both BDI [P < .001] and BAI [P < .001] scores. There was a significant decrease in BDI and BAI scores between T1 and T2 (the median difference, P = .002; P = .024, respectively) and between T1 and T3 (the median difference, P < .001; P < .001, respectively), but there was no significant difference between T2 and T3 (P = 1.00 for both BDI and BAI) (Table 2)

While there was a significant difference in EE, one of the subscales of MBI, in repeated measurements, there was no significant difference in depersonalization and personal accomplishment. A significant decrease was observed in the emotional exhaustion score between T1 and T2 (the median difference, P = .032) and between T1 and T3 (the median difference, P < .032), but there was no significant difference between T2 and T3 (P =1.00) (Table 2).

Discussion

In this study, in which the online application of the R-TEP protocol on HCWs diagnosed with PTSD associated with the pandemic was evaluated, PTSD symptom severity and PTSD symptom clusters, intrusion, and hyperarousal symptom severity, it was determined that the severity of anxiety, depression, and emotional exhaustion symptoms decreased significantly both in the first week after the application and in the first month of follow-up compared to the pre-treatment. It was observed that there was no significant change in depersonalization and personal accomplishment scores of avoidance symptom cluster and burnout in these measurements.

Table 1. Sociodemographic and Work-Related Characteristics of Participants

Variables | n (%)
Sex |
Female | 11 (78.6)
Male | 3 (21.4)
Marital status |
Unmarried | 5 (35.7)
Married | 9 (64.3)
Professions |
Physician | 2 (14.3)
Nurse | 2 (14.3)
Other HCWs/medical staff | 4 (28.6)
Other HCWs/non-medical staff | 6 (42.8)
Family members who have been diagnosed with COVID-19 | 2 (14.3)
Being quarantined | 7 (5 .0)
Diagnosed with COVID-19 | 5 (28.6)
| Mean (SD)/(min-max)
Age (years) | 34.14 (8.06)/(22-49)
Work experience (years) | 9.13 (7.38)/ (2-19)
Weekly working hours during the COVID-19 outbreak | 45.42 (5.04)/(40-56)
HCWS, healthcare workers; COVID-19, coronavirus disease 2019; SD, standard deviation.

Table 2. Scores of the Measures at Pre-test, Post-test, and1-Month Follow-Up for the EMDR

| Time Line | P | Effect Size | Differences Between Repeated Measures (95% CI)
| T₁ | T₂ | T₃ |  | Kendall’s W | T₁–T₂ | T₁–T₃ | T₂–T₃
IES-R total | 48.5 (32-61.5) | 19.5 (12.25-29.5) | 19 (11-25.75) | <.001 | 0.555 | 29 (9 to 48) P = .018 | 29.5 (13 to 49) P < .001 | 0.5 (−11 to 15)P = .896
Intrusion | 19.5 (10.75-25.75) | 6 (1.75-7.25) | 5 (1.75-9) | <.001 | 0.699 | 13.5 (7 to 23) P = .005 | 14.5 (5 to 23) P <.001 | 1 (−7 to 5)P = 1.00
Avoidance | 12.5 (8.5-17) | 10 (7-16) | 9 (8-13) | .211 | 0.111 | 2.5 (−5 to 8) | 3.5 (−4 to 7) | 1 (−5 to 5)
Hyper arousal | 15.5 (9-20.5) | 4 (3-7.75) | 5 (2.25-6) | <.001 | 0.618 | 11.5 (2.5 to 17) P = .005 | 10.5 (3.5 to 17) P = 0.001 | −1 (−3 to 4)P =1.00
BDI | 20 (15-25.75) | 7.5 (3.75-10.25) | 6 (1.75-13) | <.001 | 0.764 | 12.5 (6 to 21) P = .002 | 14 (3 to 23) P < .001 | 1.5 (−9 to 8)P = 1.00
BAI | 24 (19.75-32.25) | 11.5 (8-20.25) | 13 (5.25-22) | <.001 | 0.554 | 12.5 (0 to 23.5) P = .024 | 11 (−1 to 23.5)P = .001 | −1.5 (−12.5 to 13)P = 1.00
EE | 32 (24.5-38.25) | 23 (17-28.25) | 24 (16.75-28) | .009 | 0.340 | 9 (−2 to19)P = .032 | 8 (−2 to 18)P = .032 | −1 (−9 to 8)P = 1.00
DP | 8.5 (6-11.25) | 8.5 (5.75-12) | 7.5 (5.75-12.25) | 0.484 | 0 .052 | 0 (−5 to 4.5) | 1 (−5 to 4.5) | 1 (0 to 0)
PA | 31.5 (27-34.5) | 32.5 (30.75-36) | 33 (29.5-36) | .662 | 0 .029 | −1 (−7.5 to 3) | −1.5 (−7.5 to 3.5) | −0.5 (−4.5 to 5)
T₁ , pre-test; T₂, post-test; T₃ , 1-month follow-up; IES-R, Impact of Event Scale-Revised; BDI, Beck Depression Inventory; BAI, Beck Anxiety Inventory; EE, emotional exhaustion; DP, depersonalization; PA, personal accomplishment.

In a recent metanalysis about the effectiveness of psychological therapies for PTSD, trauma-focused CBT, and EMDR are recommended as safety as first-line treatments among trauma-focused CBT, EMDR, brief eclectic psychotherapy, cognitive processing therapy, narrative exposure therapy, prolonged exposure, single-session CBT, reconsolidation of traumatic memories, non-trauma-focused CBT, supportive counseling, present-centered therapy, psychodynamic therapy, written exposure therapy, virtual reality therapy, observed and experimental integration, relaxation training, group CBT, group interpersonal therapy, and guided internet-based trauma-focused CBT. Among the trauma-focused CBTs evaluated in a review by Lewis et al. cognitive processing therapy and prolonged exposure and cognitive therapy were recommended as treatments of choice.³⁴ Studies on the effectiveness of various treatment protocols in the protection and/or treatment of HCWs during the current pandemic process have begun to be reported. Moench et al³⁵ evaluated the effectiveness of Self-Care Traumatic Episode Protocol (STEP) for mental health clinicians in the context of COVID-19 in their randomized clinical trial.³⁵ They showed that STEP was effective in increasing self-efficacy and improving symptoms of anxiety, depression, and stress according to “Self-Efficacy Scale” and “Depression and Anxiety Stress Scale” to facilitate the processing of a recent, ongoing traumatic episode. Tarquinio et al²⁰ evaluated the effectiveness of URG-EMDR in HCWs suffering from conditions imposed by the COVID-19 pandemic. However, the participants in this study were not directly diagnosed with PTSD but had been exposed to one or several recent occupational events related to the COVID-19 pandemic and had associated clinical symptoms of an anxiety or depressive nature. In this study, URG-EMDR was found to be effective in decreasing anxiety and depression scores. Perri et al³⁶ evaluated the effectiveness of 2 short treatments in HCWs and individuals diagnosed with acute stress disorder and suffering from conditions imposed by the COVID-19 pandemic. In this study, EMDR and trauma-focused CBT were found to be equally effective to reduce anxiety, depressive, and traumatic symptoms. It also stressed the importance of assessment and follow-up at the earliest stage of distress to manage ongoing trauma associated with quarantine or illness.

In our literature review, we could not find any new study results that directly evaluated the efficacy of R-TEP during the COVID-19 pandemic. The results of the CovEMERALD study, in which the study protocol was reported and in which COVID-19-related critical illness, and also PTSD, anxiety, and depression were investigated, have not been published.³⁷ However, successful results of the R-TEP protocol have been reported in different trauma patients. The URGent EMDR protocol that based on the combination of R-TEP, modified abridged EMDR, and emergency response procedure of Quinn was effectively used in 17 female rape victims within 24-78 hours after their aggression.³⁸ Irish reported the usefulness and effectiveness of the R-TEP protocol in 1 case who was experienced mental distress following the mass casualty shooting.³⁹ Tofani et al²⁵ assessed the use of the R-TEP with 3 different clients: a kid with a chronic disease, a woman who has experienced a profound loss, and a teenager who has self-harmed. They concluded that the value of identifying and treating intrusive fragments as well as the procedure's incisiveness in reducing intrusive sensorimotor disturbance using an initial EMD strategy is demonstrated. Saltini et al⁴⁰ examined the effects of R-TEP administered within 3 months of a traumatic incident to a large group of people who were affected by the earthquake that struck Emilia Romagna in 2012. They found that in both the early (treated within 1 month after the earthquake) and late treatment samples (treated after the first month from the earthquake), post-treatment IES-R average scores were considerably lower than baseline.

When we examine early psychological interventions for ongoing traumas, a study reported that prolonged exposure and cognitive therapy resulted in significant reductions in PTSD symptoms, including intrusion, hyperarousal, and avoidance in recent survivors from the Jerusalem Trauma.⁴¹ In our study, R-TEP resulted in reductions in anxiety, depression, and imaginal exposure (IE) symptoms. Rothbaum et al⁴² found that modified prolonged exposure (trauma memory imaginal exposure, traumatic material processing, and exposure homework) was successful at reducing post-traumatic stress reactions including numbing, depersonalization, re-experiencing, and dissociation after trauma exposure in patients in an average time of 11.79 hours since trauma. Shalev et al⁴³ reported that prolonged exposure and cognitive therapy enhanced recovery from acute PTSD. A study did not support the efficacy of self-guided internet-based intervention (called Trauma TIPS) based on techniques from CBT for early intervention in preventing PTSD symptoms for an unselected injury patient population.⁴⁴

An earlier study that compared IE and in vivo exposure (IVE) revealed that IVE was more effective at reducing avoidance than IE, probably because IVE targeted phobic avoidance behaviors directly.⁴⁵ According to Devilly and Foa (2001), research that combines IVE and IE performs better than studies that only use IE, presumably because exposure to fearful stimuli facilitates higher skill of avoidance strategies.⁴⁶ Imaginal exposure/in vitro exposure with cognitive reprocessing found to have greater effect on PTSD and depressive symptoms than either alone or in combination with IE and IVE.⁴⁷

According to our findings, it was determined that the R-TEP protocol was not effective on burnout. Although emotional exhaustion improved after the application, there was no significant change after 1 month, and there was no regression in depersonalization and personal accomplishment. These results may be related to the pandemic conditions and policies in our country. While the number of cases in Turkey was 1572 daily at the start of the study, the number of patients decreased to 1407 in the 1 month later evaluation, but the number of deaths in cases increased from 47 to 67 daily.⁴⁸ In other words, it was seen that COVID-19 mortality increased. Hospital bed capacities were still full, and the daily number of COVID tests had increased from 109.443 to 113.546. Coronavirus disease 2019 infections were also increasing in HCWs. More than 4 months later from the pandemic, the Ministry of Health announced that 29 865 HCWs were diagnosed with COVID-19 on September 2, 2020, and 52 HCWs died.⁴⁹ In addition, the lack of change in terms of avoidance, intrusion, and depression between T2 and T3 may be related to re-exposure due to the reasons mentioned above and the unfolding of the increased risk in HCWs during the follow-up period.

The small sample size only allows for pilot research to examine treatment in this study. Another limitation of the current research is the absence of a waiting list, hence a control group. As for follow-up, we are aware that there is only 1 month of evaluation and the lack of follow-up may limit medium and long-term results, so multiple evaluations should also be considered in future studies. A structural interview like Structured Clinical Interview for DSM-5 (SCID) was not used to diagnose. Another limitation of the study is that anxiety disorders were not classified and defined. It would be more appropriate to use a scale related to the severity of PTSD in order to confirm the diagnosis of PTSD and to demonstrate the effectiveness of the treatment protocol more accurately. Extensive participant exclusions (personality disorder, suicidal ideation, psychiatric medications, etc) limit the generalizability and make conclusions about safety. It can be said that the online application also has some limitations. A study found that teletherapy can result in a weaker therapeutic connection. On the other hand, the online EMDR and other such online health services are found to be both effective and cost-efficient while also improving access to care 20,50

The early stages of trauma are seldom investigated. So, analyzing the information processing of trauma that impacts a large number of people, such as a pandemic, could be especially useful in understanding the symptoms and treatment of acute stress. This study shows that the R-TEP protocol is effective in reducing the symptoms of anxiety, depression, and burnout, especially emotional exhaustion, when symptoms related to the pandemic develop in HCWs. Recent Traumatic Episode Protocol can be used as an effective approach to HCWs who are considered at risk in a pandemic-related traumatic event, in order to protect them from burnout, anxiety, and depression.

Ethics Committee Approval: Ethical committee approval was received from the Ethics Committee of Bagcilar Research and Training Hospital University, (Approval No: 2020.1.01.099.r1.147).

Informed Consent: Written informed consent was obtained from all participants who participated in this study.

Peer-Review: Externally peer-reviewed.

Author Contributions: Concept – E.S., M.Ç., B.G.; Design - E.S., M.Ç., B.G.; Supervision - E.S., M.Ç., B.G.; Resource - E.S., M.Ç., B.G.; Materials - E.S., M.Ç., B.G.; Data Collection and/or Processing - E.S., Ş.K.Ş.; Analysis and/or Interpretation - E.S., Ş.K.Ş.; Literature Search - E.S., Ş.K.Ş.; Writing - E.S., Ş.K.Ş.; Critical Reviews - E.S., Ş.K.Ş.

Declaration of Interests: The authors have no conflicts of interest to declare.

Funding: The authors declared that this study has received no financial support.

References

  1. World Health Organisation. https://covid19.who.int/.

  2. Shanafelt, T, Ripp, J, & Trockel, M. (2020). Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA, 323(21), 2133-2134, (https://doi.org/10.1001/jama.2020.5893).

  3. Chen, Y, Zhou, H, Zhou, Y, & Zhou, F. (2020). Prevalence of self-reported depression and anxiety among pediatric medical staff members during the COVID-19 outbreak in Guiyang, China. Psychiatry Res, 288, 113005, (https://doi.org/10.1016/j.psychres.2020.113005).

  4. Asmundson, GJG, & Taylor, S. (2020). How health anxiety influences responses to viral outbreaks like COVID-19: what all decision-makers, health authorities, and health care professionals need to know. J Anxiety Disord, 71, 102211, (https://doi.org/10.1016/j.janxdis.2020.102211).

  5. Sahebi, A, Nejati-Zarnaqi, B, Moayedi, S, Yousefi, K, Torres, M, & Golitaleb, M. (2021). The prevalence of anxiety and depression among healthcare workers during the COVID-19 pandemic: an umbrella review of meta-analyses. Prog Neuropsychopharmacol Biol Psychiatry, 107, 110247, (https://doi.org/10.1016/j.pnpbp.2021.110247).

  6. Marvaldi, M, Mallet, J, Dubertret, C, Moro, MR, & Guessoum, SB. (2021). Anxiety, depression, trauma-related, and sleep disorders among healthcare workers duirng the COVID-19 pandemic: a systematic review and meta-analysis. Neurosci Biobehav Rev, 126, 252-264, (https://doi.org/10.1016/j.neubiorev.2021.03.024).

  7. Bahadirli, S, & Sagaltici, E. (2021). Burnout, Job satisfaction, and psychological symptoms among emergency physicians during COVID-19 outbreak: a cross-sectional study. Practitioner, 83, 20.8-9.9.

  8. Pai, A, Suris, AM, & North, CS. (2017). Posttraumatic stress disorder in the DSM-5: controversy, change, and conceptual considerations. Behav Sci (Basel), 7(1), (https://doi.org/10.3390/bs7010007).

  9. Al Falasi, B, Al Mazrouei, M, & Al Ali, M. (2021). Prevalence and determinants of immediate and long-term PTSD consequences of coronavirus-related (CoV-1 and CoV-2) pandemics among healthcare professionals: a systematic review and meta-analysis. Int J Environ Res Public Health, 18(4), (https://doi.org/10.3390/ijerph18042182).

10. Fragkaki, I, Thomaes, K, & Sijbrandij, M. (2016). Posttraumatic stress disorder under ongoing threat: a review of neurobiological and neuroendocrine findings. Eur J Psychotraumatol, 7, (https://doi.org/10.3402/ejpt.v7.30915).

11. Maslach, C, & Leiter, MP. (2017). Understanding burnout: new models. The Handbook of Stress and Health: A Guide to Research and Practice, New York, Wiley Blackwell, 36-56.

12. Miguel Puga, JA, Cooper Bribiesca, D, & Avelar Garnica, FJ. (2021). Burnout, depersonalization, and anxiety contribute to post traumatic stress in frontline health workers at COVID-19 patient care, a follow-up study. Brain Behav, 11(3), (https://doi.org/10.1002/brb3.2007).

13. Shapiro, F. (2017). Eye Movement Desensitization and Reprocessing (EMDR) Therapy: Basic Principles, Protocols, and Procedures, New York, Guilford Publications.

14. Wilson, G, Farrell, D, Barron, I, Hutchins, J, Whybrow, D, & Kiernan, MD. (2018). The use of Eye-Movement Desensitization Reprocessing (EMDR) therapy in treating post-traumatic stress disorder—a systematic narrative review. Front Psychol, 9, (https://doi.org/10.3389/fpsyg.2018.00923).

15. Shapiro, E, & Laub, B. (2015). Early EMDR intervention following a community critical incident: a randomized clinical trial. J EMDR Pract Res, 9(1), 17-27, (https://doi.org/10.1891/1933-3196.9.1.17).

16. Kang, L, Li, Y, & Hu, S. (2020). The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus. Lancet Psychiatry, 7(3), e14, (https://doi.org/10.1016/S2215-0366(20)30047-X).

17. Chen, Q, Liang, M, & Li, Y. (2020). Mental health care for medical staff in China during the COVID-19 outbreak. Lancet Psychiatry, 7(4), e15-e16, (https://doi.org/10.1016/S2215-0366(20)30078-X).

18. Lenferink, LIM, Meyerbröker, K, & Boelen, PA. (2020). PTSD treatment in times of COVID-19: a systematic review of the effects of online EMDR. Psychiatry Res, 293, 113438, (https://doi.org/10.1016/j.psychres.2020.113438).

19. Lazzaroni, E, Invernizzi, R, Fogliato, E, Pagani, M, & Maslovaric, G. (2021). Coronavirus disease 2019 emergency and remote eye movement desensitization and reprocessing group therapy with adolescents and young adults: overcoming lockdown with the butterfly hug. Front Psychol, 12, 701381, (https://doi.org/10.3389/fpsyg.2021.701381).

20. Tarquinio, C, Brennstuhl, MJ, & Rydberg, JA. (2021). EMDR in telemental health counseling for healthcare workers caring for COVID-19 patients: a pilot study. Issues Ment Health Nurs, 42(1), 3-14, (https://doi.org/10.1080/01612840.2020.1818014).

21. Acarturk, C, Konuk, E, & Cetinkaya, M. (2015). EMDR for Syrian refugees with posttraumatic stress disorder symptoms: results of a pilot randomized controlled trial. Eur J Psychotraumatol, 6, 27414, (https://doi.org/10.3402/ejpt.v6.27414).

22. Shapiro, E. (2011). Suggestions for Teaching the Application of eye movements in EMDR. J EMDR Pract Res, 5(2), 73-77, (https://doi.org/10.1891/1933-3196.5.2.73).

23. Kutz, I, Resnik, V, & Dekel, R. (2008). The effect of single session modified EMDR on acute stress syndromes. J EMDR Pract Res, 2(3), 190-200, (https://doi.org/10.1891/1933-3196.2.3.190).

24. Laub, B, & Weiner, N. (2011). A developmental/ integrative perspective of the recent traumatic episode protocol. J EMDR Pract Res, 5(2), 57-72, (https://doi.org/10.1891/1933-3196.5.2.57).

25. Tofani, LR, & Wheeler, K. (2011). The recent-traumatic episode protocol: outcome evaluation and analysis of three case studies. J EMDR Pract Res, 5(3), 95-110, (https://doi.org/10.1891/1933-3196.5.3.95).

26. Weiss, DS. (2007). The impact of event scale: revised. Cross-Cultural Assessment of Psychological Trauma and PTSD, Berlin, Springer, 219-238.

27. Çorapçıoğlu, A, Yargıç, İ, Geyran, P, & Kocabaşoğlu, N. (2006). Validity and reliability of Turkish version of “impact of event scale-revised”(IES-R). Yeni Symp, 44, 14-22.

28. Beck, AT, Epstein, N, Brown, G, & Steer, RA. (1988). An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol, 56(6), 897, (https://doi.org/10.1037//0022-006x.56.6.893).

29. Ulusoy, M, Sahin, NH, & Erkmen, H. (1998). Turkish version of the Beck Anxiety Inventory: psychometric properties. J Cogn Psychother, 12.

30. Beck, AT, Ward, CH, Mendelson, M, Mock, J, & Erbaugh, J. (1961). An inventory for measuring depression. Arch Gen Psychiatry, 4, 561-571, (https://doi.org/10.1001/archpsyc.1961.01710120031004).

31. Hisli, N. (1989). Reliability and validity of Beck Depression Inventory among university students. Turk Psikhol Derg, 7, 3-13.

32. Maslach, C, Jackson, SE, & Leiter, MP. (1996). MBI., Maslach Burnout Inventory, CA, CPP, Incorporated, Sunnyvale.

33. Ergin, C. (1993). Adaptation and validity of MBI for measuring burnout among Turkish physicians and nurses. Ankara, VIIth National Psychol Congress., Turkish Psychologists Association.

34. Lewis, C, Roberts, NP, Andrew, M, Starling, E, & Bisson, JI. (2020). Psychological therapies for post-traumatic stress disorder in adults: systematic review and meta-analysis. Eur J Psychotraumatol, 11(1), 1729633, (https://doi.org/10.1080/20008198.2020.1729633).

35. Moench, J, & Billsten, O. (2021). Randomized controlled trial: self-care traumatic episode protocol (STEP), computerized EMDR treatment of COVID-19 related stress. J EMDR Pract Res, 15(2), 99-113, (https://doi.org/10.1891/EMDR-D-20-00047).

36. Perri, RL, Castelli, P, La Rosa, C, Zucchi, T, & Onofri, A. (2021). COVID-19, isolation, quarantine: on the efficacy of Internet-based eye movement desensitization and reprocessing (EMDR) and cognitive-behavioral therapy (CBT) for ongoing trauma. Brain Sci, 11(5), (https://doi.org/10.3390/brainsci11050579).

37. Bates, A, Rushbrook, S, Shapiro, E, Grocott, M, & Cusack, R. (2020). CovEMERALD: assessing the feasibility and preliminary effectiveness of remotely delivered Eye Movement Desensitisation and Reprocessing following Covid-19 related critical illness: a structured summary of a study protocol for a randomised controlled trial. Trials, 21(1), 929, (https://doi.org/10.1186/s13063-020-04805-1).

38. Tarquinio, C, Brennstuhl, MJ, Reichenbach, S, Rydberg, JA, & Tarquinio, P. (2012). Early treatment of rape victims: presentation of an emergency EMDR protocol. Sexologies, 21(3), 113-121, (https://doi.org/10.1016/j.sexol.2011.11.012).

39. Irish, AJ. (2020). Using recent traumatic episode protocol in college counseling centers. J Coll Couns, 23(2), 180-192, (https://doi.org/10.1002/jocc.12158).

40. Saltini, A, Rebecchi, D, Callerame, C, Fernandez, I, Bergonzini, E, & Starace, F. (2018). Early Eye Movement Desensitisation and Reprocessing (EMDR) intervention in a disaster mental health care context. Psychol Health Med, 23(3), 285-294, (https://doi.org/10.1080/13548506.2017.1344255).

41. Shalev, AY, Ankri, Y, Israeli-Shalev, Y, Peleg, T, Adessky, R, & Freedman, S. (2012). Prevention of posttraumatic stress disorder by early treatment: results from the Jerusalem Trauma Outreach and Prevention study. Arch Gen Psychiatry, 69(2), 166-176, (https://doi.org/10.1001/archgenpsychiatry.2011.127).

42. Rothbaum, BO, Kearns, MC, & Price, M. (2012). Early intervention may prevent the development of posttraumatic stress disorder: a randomized pilot civilian study with modified prolonged exposure. Biol Psychiatry, 72(11), 957-963, (https://doi.org/10.1016/j.biopsych.2012.06.002).

43. Shalev, AY, Ankri, Y, & Gilad, M. (2016). Long-term outcome of early interventions to prevent posttraumatic stress disorder. J Clin Psychiatry, 77(5), e580-e587, (https://doi.org/10.4088/JCP.15m09932).

44. Mouthaan, J, Sijbrandij, M, & De Vries, GJ. (2013). Internet-based early intervention to prevent posttraumatic stress disorder in injury patients: randomized controlled trial. J Med Internet Res, 15(8), (https://doi.org/10.2196/jmir.2460).

45. Richards, DA, Lovell, K, & Marks, IM. (1994). Post-traumatic stress disorder: evaluation of a behavioral treatment program. J Trauma Stress, 7(4), 669-680, (https://doi.org/10.1007/BF02103014).

46. Devilly, GJ, & Foa, EB. (2001). The investigation of exposure and cognitive therapy: comment on Tarrier et al (1999). J Consult Clin Psychol, 69(1), 114-116, (https://doi.org/10.1037//0022-006x.69.1.114).

47. Bryant, RA, Moulds, ML, & Guthrie, RM. (2008). A randomized controlled trial of exposure therapy and cognitive restructuring for posttraumatic stress disorder. J Consult Clin Psychol, 76(4), 695-703, (https://doi.org/10.1037/a0012616).

48. Republic of Turkey. Ministry of Health. COVID-19 Information Platform, https://covid19.saglik.gov.tr/TR-66935/genel-koronavirus-tablosu.html.

49. Turkish Medical Association. (2020). COVID-19 Pandemıc 6th Month Evaluation Report. https://www.ttb.org.tr/kutuphane/covid19-rapor_6.pdf.

50. Backhaus, A, Agha, Z, & Maglione, ML. (2012). Video conferencing psychotherapy: a systematic review. Psychol Serv, 9(2), 131, (https://doi.org/10.1037/a0027924).

Received: November 18, 2021
Accepted: February 10, 2022

Content of this journal is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. Content of this journal is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.