Title: Psychological recovery following critical illness: a feasibility study to investigate whether online eye movement desensitisation and reprocessing (EMDR) improves the psychological health of adult survivors of an intensive care admission
Funder: Health Education England

Abstract: Background:Each year in the UK, over 200,000 patients are discharged from intensive care units. Patients frequently experience profound and persistent impairments in physical, cognitive, and psychological health. Families carry a burden of psychological stress and economic disadvantage. Society bears the cost of increased healthcare and social support costs.Clinically significant symptoms of anxiety, post-traumatic stress and depression are common and frequently co-exist. Meta-analyses report incidence of 40%, 20% and 34% respectively. These symptoms are associated with increased risk of suicide, non-fatal self-harm, reduced quality of life, delayed return to work, increased healthcare utilisation and premature death.Despite this well-characterised problem, patients must navigate a complex convalescence, without established follow-up care pathways. Guidance exists, but implementation is inconsistent. There has been limited high-quality research in this area. The James Lind Priority Setting workshop and the Faculty of Intensive Care Medicine acknowledge that improving psychological recovery of patients is a high-priority feature of intensive care.Eye Movement Desensitisation and Reprocessing (EMDR) is an effective and cost-effective trauma-focussed psychotherapy. It is recommended by the National Institute for Health and Care Excellence and the World Health Organisation for treating post-traumatic stress disorder. EMDR outperforms alternative psychotherapies in reducing anxiety and depression. EMDR has been shown to reduce psychological symptoms following life-threatening Emergency department admission, cardiac and cancer diagnoses. However, it has never been tested in a cohort of patients experiencing the traumatic after-effects of an intensive care admission. Research question: Is it feasible and acceptable to investigate whether online EMDR improves the psychological health of adult intensive care survivors? Aim: to create knowledge that informs the design and delivery of a subsequent, effectiveness evaluation of EMDR for intensive care survivors. Method: Mixed-methods feasibility trial comprising 4 work packages, consistent with Medical Research Council guidance on evaluating complex interventions.Work package 1: A systematic review to identify, critically appraise and synthesise the evidence for using EMDR, to improve psychological health of adult survivors of life-threatening medical event.Work package 2: A quantitative feasibility evaluation of delivering an online EMDR intervention. Intensive care survivors who exhibit psychological symptoms at their 3-month, post-discharge follow-up, will be offered online EMDR with their primary care mental health team. Work package 3: Parallel observational study of participants not exhibiting psychological symptoms at their 3-month post-hospital discharge follow-up. I will also follow up symptomatic participants, who are physically unable or unwilling to undertake EMDR. I will map the trajectory of post-intensive care psychological health and potential need for an additional entry point to the intervention. Work package 4: Process evaluation using semi-structured interviews with participants, research staff and therapists, using the rapid assessment procedure informed clinical ethnography technique to capture intervention fidelity, acceptability, participant experience, unintended consequences, and perceived effectiveness.Dissemination and impact: To refine design parameters of a subsequent full trial. To inform patient groups, care providers and policy makers about the potential for delivering an effective and cost-effective, post-discharge psychological care pathway for ICU survivors. To encourage and recruit further centres to take part in the full trial.

Lay abstract: Aims:This research will evaluate whether it is feasible to investigate the use of online eye movement desensitisation and reprocessing (EMDR) for intensive care survivors in a clinical trial. The findings will help me to design a larger clinical trial, which will test whether EMDR improves the psychological health of these patients. Background:Each year, over 250,000 patients are admitted to UK intensive care units for lifesaving medical treatment. However, experiencing a life-threatening event, infusion of powerful drugs, near constant light and noise, and undergoing and witnessing medical emergencies, can be frightening and traumatic. While most patients do survive and go home, research shows that approximately half of intensive care survivors suffer from serious psychological symptoms such as post-traumatic stress disorder (PTSD), anxiety and/or depression. These symptoms reduce quality of life, worsen physical health, delay return to work and are highly distressing for patients and their relatives. Unfortunately, due to limitations in the available research, we don't know how best to care for these patients.EMDR is a psychological talking therapy that helps patients to process traumatic memories, in a calm, controlled manner, while watching a skilled therapist perform side-to-side finger movements. EMDR has been shown to improve psychological health following a range of life-threatening events including armed combat, natural disasters and assault. Because of this, the NHS and the World Health Organisation recommend EMDR for patients with PTSD, but it has never been evaluated for the benefit of intensive care survivors.Methods:My project will consist of 4 linked work packages: Systematic review: I will evaluate all research that has tested EMDR following life threatening medical events, such as heart attacks and cancer. Identifying which elements of the trials worked well and which did not, will inform my study design. Feasibility study: I will recruit a group of intensive care patients, who will undergo psychological assessment 3-months after hospital discharge. Patients suffering distress will be offered online EMDR to determine whether they are willing and able to take part, attend the sessions and complete the follow up assessments that map their recovery. Observational study: I will also map the recovery of patients who are not suffering from psychological symptoms. This will reveal how their psychological health changes over time and whether EMDR should be offered later. Process evaluation: Semi-structured interviews with a sample group of patients and therapists will enrich my understanding of why people completed the trial, why they dropped out, what were the benefits and harms, were there any unintended consequences and whether anything needs to be changed before the subsequent clinical trial.Patient and public involvement: Intensive care survivors and patient support groups have helped me to develop this project. I have already tested EMDR on a small group of intensive care patients with COVID-19. Their feedback has been highly encouraging. They also helped me to understand when to offer EMDR and how to best identify patients needing help. A group of patients have agreed to be part of my study team, to review study design, findings and future plans.Dissemination:First, I will share my results with patients and patient support groups. Then, by reporting my findings in scientific journals, at national conferences, on social media, and to policy makers I will broaden understanding of this complex issue and hope to increase the number of hospitals interested in the full trial.Anticipated impact:This project will provide the information needed to design the full trial. This would show whether EMDR is effective in improving the recovery of intensive care survivors. Ultimately, EMDR could become an integral part of the intensive care psychological recovery pathway.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH