Dominguez, Matthijssen, & Lee (2021)
What the research suggests
The researchers identified 11 randomized controlled trials involving 567 adults whose primary concern was depression. Ten studies used EMDR and one used imagery rescripting. Unlike studies examining depression as a secondary outcome of PTSD treatment, the review specifically excluded trials in which PTSD or another mental health condition was the primary focus.
Across the studies, trauma-focused treatments produced a large reduction in depressive symptoms compared with control conditions. The effect remained large after removing an outlier, and the smaller group of studies with follow-up data suggested that improvement persisted after treatment. In three trials directly comparing EMDR with non-trauma-focused CBT, EMDR also showed an advantage in reducing depressive symptoms.
The findings are particularly interesting because the targeted memories did not necessarily meet conventional definitions of trauma. The authors were examining whether distressing experiences and negative autobiographical memories could function as treatment targets within depression itself.
Why I care
This gets closer to the question I’m interested in than research simply showing that trauma and depression are associated.
If depressive symptoms change when treatment intervenes directly on distressing past experiences, it raises the possibility that those experiences may be functionally important to the depression for some people. The diagnosis describes what someone is experiencing; it does not necessarily tell us what is maintaining it.
I find that distinction clinically useful because it keeps formulation open. Similar depressive symptoms may emerge from very different processes and therefore may not always call for the same therapeutic emphasis.
How it connects to my clinical thinking
This supports my interest in working upstream when the formulation points there. I can treat low mood, withdrawal, rumination, or negative beliefs directly while still asking whether something else is helping organize or maintain them.
It also fits with thinking of treatment as hypothesis testing. If we believe distressing experiences are meaningfully connected to someone’s depression and addressing those experiences changes the depression, that gives us information about the formulation. If the symptoms do not move together, that gives us information too.
The point is not to assume trauma underneath depression. It is to remain curious about what is actually maintaining the problem.
What it doesn’t establish
This is much stronger evidence for EMDR than for trauma-focused treatment broadly: ten of the eleven studies used EMDR. Six studies were rated at high risk of bias, several had small samples, and ten relied on self-report rather than clinician-rated depression outcomes.
The studies also did not formally assess and exclude comorbid PTSD, so the review cannot establish with certainty that the effects occurred entirely outside PTSD. And improvement in depression after targeting distressing memories does not establish that trauma caused the depression. It shows that those memories may be therapeutically relevant for some people with depressive symptoms.