Fidelity Analysis of the Adapted DeprEnd EMDR Therapy Protocol for Depression-related Disability in Low-resource Settings

Major depressive disorder is a leading cause of disability worldwide, with a disproportionately high burden in low- and middle-income countries. To address this disability, experts have recently acknowledged the importance of culturally adapted psychotherapies, such as eye movement desensitization and reprocessing (EMDR) therapy as a scalable intervention. In our previous study, we developed an adapted DeprEnd EMDR therapy protocol. Building upon that work, this study assesses its treatment fidelity. The present study employed an exploratory sequential mixed-methods design to evaluate treatment fidelity by assessing therapist adherence and competence. Fidelity was evaluated sequentially. Initially, a Delphi panel of three EMDR experts qualitatively assessed fidelity by reviewing recordings of 14 sessions from four randomly selected patients. Later, to collect quantitative data, separate questionnaires were provided to the three EMDR expert raters and to the four EMDR therapists—who had delivered the therapy. Findings revealed strong therapist adherence and competence to the core DeprEnd EMDR therapy protocol guidelines. Key barriers threatened fidelity, including patient-related factors, such as stigma and low mental health literacy, which complicated patient engagement, and systemic constraints, such as time limitations, which occasionally led therapists to shorten or omit certain protocol elements. This fidelity study has important implications. The findings demonstrated that the adapted DeprEnd protocol can be delivered efficiently. This study concludes that the delivery of the adapted DeprEnd EMDR protocol is feasible in Pakistan. This finding is a critical first step toward implementing an intervention that can reduce depression-related disability in a low-resource context.