title: Prolonged exposure vs eye movement desensitization and reprocessing vs waiting list for posttraumatic stress disorder in patients with a psychotic disorder: a randomized clinical trial.
abstract: OBJECTIVE
  The efficacy of posttraumatic stress disorder (PTSD) treatments in psychosis has not been examined in a randomized clinical trial to our knowledge. Psychosis is an exclusion criterion in most PTSD trials.
  
  
  OBJECTIVE
  To examine the efficacy and safety of prolonged exposure (PE) therapy and eye movement desensitization and reprocessing (EMDR) therapy in patients with psychotic disorders and comorbid PTSD.
  
  
  METHODS
  A single-blind randomized clinical trial with 3 arms (N = 155), including PE therapy, EMDR therapy, and waiting list (WL) of 13 outpatient mental health services among patients with a lifetime psychotic disorder and current chronic PTSD. Baseline, posttreatment, and 6-month follow-up assessments were made.
  
  
  METHODS
  Participants were randomized to receive 8 weekly 90-minute sessions of PE (n = 53), EMDR (n = 55), or WL (n = 47). Standard protocols were used, and treatment was not preceded by stabilizing psychotherapeutic interventions.
  
  
  METHODS
  Clinician-rated severity of PTSD symptoms, PTSD diagnosis, and full remission (on the Clinician-Administered PTSD Scale) were primary outcomes. Self-reported PTSD symptoms and posttraumatic cognitions were secondary outcomes.
  
  
  RESULTS
  Data were analyzed as intent to treat with linear mixed models and generalized estimating equations. Participants in the PE and EMDR conditions showed a greater reduction of PTSD symptoms than those in the WL condition. Between-group effect sizes were 0.78 (P < .001) in PE and 0.65 (P = .001) in EMDR. Participants in the PE condition (56.6%; odds ratio [OR], 3.41; P = .006) or the EMDR condition (60.0%; OR, 3.92; P < .001) were significantly more likely to achieve loss of diagnosis during treatment than those in the WL condition (27.7%). Participants in the PE condition (28.3%; OR, 5.79; P = .01), but not those in the EMDR condition (16.4%; OR, 2.87; P = .10), were more likely to gain full remission than those in the WL condition (6.4%). Treatment effects were maintained at the 6-month follow-up in PE and EMDR. Similar results were obtained regarding secondary outcomes. There were no differences in severe adverse events between conditions (2 in PE, 1 in EMDR, and 4 in WL). The PE therapy and EMDR therapy showed no difference in any of the outcomes and no difference in participant dropout (24.5% in PE and 20.0% in EMDR, P = .57).
  
  
  CONCLUSIONS
  Standard PE and EMDR protocols are effective, safe, and feasible in patients with PTSD and severe psychotic disorders, including current symptoms. A priori exclusion of individuals with psychosis from evidence-based PTSD treatments may not be justifiable.
  
  
  BACKGROUND
  isrctn.com Identifier: ISRCTN79584912.
authors.affiliation: Parnassia Psychiatric Institute, Den Haag, the Netherlands.
authors.forename: David P G
authors.initials: DP
authors.lastname: van den Berg
authors.affiliation: Mental Health Organization Oost Brabant Land van Cuijk en Noord Limburg, Boxmeer, the Netherlands.
authors.forename: Paul A J M
authors.initials: PA
authors.lastname: de Bont
authors.affiliation: Mental Health Organization Noord-Holland Noord, Alkmaar, the Netherlands.
authors.forename: Berber M
authors.initials: BM
authors.lastname: van der Vleugel
authors.affiliation: Mental Health Organization Rivierduinen, Leiden, the Netherlands.
authors.forename: Carlijn
authors.initials: C
authors.lastname: de Roos
authors.affiliation: Department of Behavioral Sciences, Academic Center for Dentistry Amsterdam, University of Amsterdam and VU University Amsterdam, Amsterdam, the Netherlands6School of Health Sciences, Salford University, Manchester, England.
authors.forename: Ad
authors.initials: A
authors.lastname: de Jongh
authors.affiliation: Radboud University Nijmegen, Behavioral Science Institute, NijCare, the Netherlands, Nijmegen8Mental Health Organization "Pro Persona," Center for Anxiety Disorders Overwaal, Nijmegen, the Netherlands.
authors.forename: Agnes
authors.initials: A
authors.lastname: Van Minnen
authors.affiliation: Parnassia Psychiatric Institute, Den Haag, the Netherlands9Department of Clinical Psychology, VU University Amsterdam and EMGO+ Institute for Health and Care Research, Amsterdam, the Netherlands.
authors.forename: Mark
authors.initials: M
authors.lastname: van der Gaag
mesh_terms: D000328:Adult; D015897:Comorbidity; D003887:Desensitization, Psychologic / Q000379:methods*; D005133:Eye Movements / Q000502:physiology; D005260:Female; D006801:Humans; D007171:Implosive Therapy / Q000379:methods; D008297:Male; D011618:Psychotic Disorders / Q000453:epidemiology; D012720:Severity of Illness Index; D016037:Single-Blind Method; D013313:Stress Disorders, Post-Traumatic / Q000453:epidemiology / Q000628:therapy*; D016896:Treatment Outcome; D014850:Waiting Lists; D055815:Young Adult