Pharmacological secondary prevention of PTSD in youth: challenges and opportunities for advancement

Expanding Neuroprotective Care: A Trauma-Informed Approach to Delivery of Services within Pediatric Inpatient Units

Children with a history of trauma or adverse childhood experiences may be at higher risk for poor psychological and physical responses to medical experiences aimed at enhancing their well-being. Health care institutions are aware of the need for integration of trauma-informed care (TIC) practices yet struggle to find frameworks that promote resiliency to medical stress. An approach called neuroprotective care buffers the effects of toxic stress negatively affecting child health and well-being. Although often used in neonatal and cardiac intensive care units, the development and broad implementation of universal neuroprotective care measures across age groups and hospital settings has not been previously explored. An expanded neuroprotective care protocol takes a prevention approach to TIC. It fits a TIC framework, accounts for children's ecological, biological, and developmental needs, protects them against medical traumatic stress and retraumatization, and provides a tailored, measurable approach that systematically preserves child well-being within hospital settings.

Trauma Functioning and Well-Being in Children Who Receive Mental Health Aid after Natural Disaster or War

Background: There is worldwide consensus that providing secondary prevention to promote resilience and prevent mental health concerns after a disaster is important. However, data supporting this kind of intervention is largely lacking. The current study evaluates the effectiveness of OperationSAFE, an early intervention for children after community-wide trauma. Methods: Secondary data analyses of data collected during 158 OperationSAFE camps (a five day camp with a curriculum focused on coping with stressors) in five countries and ten disasters between 2015 and 2020 were performed. Data on child trauma-related functioning/well-being were collected by an OperationSAFE in-house developed symptom checklist and completed by counselors about children on the first and last day of the 5-day camp. Results: A total of 16,768 children participated in the camps (mean age 9.4 ± 2.36; 50% male). Trauma-related functioning/well-being improved from day 1 to day 5 (b = 8.44 ± 0.04; p < 0.0001). Older children improved more (b = 0.22 ± 0.01; p < 0.0001). Children in man-made ongoing trauma (war/refugees) situations responded stronger than those after natural disasters (b = 2.24 ± 0.05; p < 0.0001). Negligible effects for gender and the number of days between a traumatic event and the start of camp were found. Conclusions: This is the first study to show in a large and diverse sample that secondary prevention to promote resilience and prevent mental health concerns after a disaster for children is associated with improvements in trauma-related functioning/well-being. Delaying delivery of the intervention did not affect outcomes. Given the uncontrolled nature of the study and lack of long-term outcomes, more studies are needed to corroborate the current findings.

The relationship between early administration of morphine or nitrous oxide gas and PTSD symptom development

BACKGROUND

Posttraumatic Stress Disorder (PTSD) is a debilitating mental health disorder. Certain drugs, such as morphine and nitrous oxide gas (N₂O), are administered to individuals who just experienced a traumatic event (e.g., soldiers, injured civilians). It is therefore crucial to understand if they incidentally affect PTSD symptom development. Furthermore, such observations could pave the way for the development of pharmacological prevention strategies of PTSD.

METHODS

In this prospective population-based cohort study (n = 2,070), we examined the relationship between morphine or N₂O administration during childbirth, and subsequent childbirth-related PTSD symptoms at eight weeks postpartum. Pain during labour, prior PTSD symptoms, and birth medical severity were included as covariates in the analyses.

RESULTS

In women who developed PTSD symptoms, N₂O administration during childbirth predicted reduced PTSD symptom severity (p < .001, small to medium effect size). A similar tendency was observed for morphine, but was not significant (p < .065, null to small effect size). Both drugs predicted increased PTSD symptoms when combined with severe pain during labour.

LIMITATIONS

This study was observational, thus drug administration was not randomised. Additionally, PTSD symptoms were self-reported.

CONCLUSIONS

Peritraumatic N₂O administration may reduce subsequent PTSD symptom severity and thus be a potential avenue for PTSD secondary prevention. This might also be the case for morphine. However, the role of severe peritraumatic pain in context of drug administration deserves further investigation.

Posttraumatic Stress in Children After Injury: The Role of Acute Pain and Opioid Medication Use

OBJECTIVES

After injury, many children experience posttraumatic stress symptoms (PTSS) that negatively impact recovery. Acute pain and PTSS share neurobiological pathways, and acute dosage of morphine has been linked to reduced PTSS in naturalistic studies. However, the complex interactions between pain, morphine and other opioid use, and PTSS have yet to be investigated in robust pediatric samples.This prospective, longitudinal study examined relationships between acute pain, opioid medications, and PTSS after pediatric injury.

METHODS

Ninety-six children aged 8 to 13 years (mean = 10.60, SD = 1.71), hospitalized for unintentional injury, completed assessments at baseline (T1) and 12 weeks (T2) later. Pain ratings and opioid administration data were obtained via chart review.

RESULTS

Structural equation modeling revealed that worst pain endorsed during hospitalization was positively associated with concurrent and later PTSS when controlling for evidence-based risk factors (ie, age, sex, prior trauma history, traumatic appraisals of injury event, heart rate). Neither opioid medications overall nor morphine specifically (milligram/kilogram/day) administered during hospitalization mediated the relationship between pain and T2 PTSS.

CONCLUSIONS

Pain during hospitalization may increase susceptibility for persistent PTSS above and beyond the influence of other empirical risk factors. Findings suggest that pain assessment may be a useful addition to pediatric PTSS screening tools and highlight the need for additional research on pharmacological secondary prevention approaches. Given that inadequate pain control and persistent PTSS each hinder recovery and long-term functioning, better understanding of interactions between acute pain and PTSS after injury is essential for improving screening, prevention, and early intervention efforts.

Pharmacological prevention and early treatment of post-traumatic stress disorder and acute stress disorder: a systematic review and meta-analysis

Post-traumatic stress disorder (PTSD) is a common mental disorder associated with significant distress and reduced functioning. Its occurrence after a severe traumatic event and association with characteristic neurobiological changes make PTSD a good candidate for pharmacological prevention and early treatment. The primary aim for this systematic review and meta-analysis was to assess whether pharmacological interventions when compared to placebo, or other pharmacological/psychosocial interventions resulted in a clinically significant reduction or prevention of symptoms, improved functioning or quality of life, presence of disorder, or adverse effects. A systematic search was undertaken to identify RCTs, which used early pharmacotherapy (within three months of a traumatic event) to prevent and treat PTSD and acute stress disorder (ASD) in children and adults. Using Cochrane Collaboration methodology, RCTs were identified and rated for risk of bias. Available data was pooled to calculate risk ratios (RR) for PTSD prevalence and standardised mean differences (SMD) for PTSD severity. 19 RCTs met the inclusion criteria; 16 studies with adult participants and three with children. The methodological quality of most trials was low. Only hydrocortisone in adults was found to be superior to placebo (3 studies, n = 88, RR: 0.21 (CI 0.05 to 0.89)) although this was in populations with severe physical illness, raising concerns about generalisability. No significant effects were found for the other pharmacotherapies investigated (propranolol, oxytocin, gabapentin, fish oil (1470 mg DHA/147 mg EPA), fish oil (224 mg DHA/22.4 mg EPA), dexamethasone, escitalopram, imipramine and chloral hydrate). Hydrocortisone shows the most promise, of pharmacotherapies subjected to RCTs, as an emerging intervention in the prevention of PTSD within three months after trauma and should be a target for further investigation. The limited evidence for hydrocortisone and its adverse effects mean it cannot be recommended for routine use, but, it could be considered as a preventative intervention for people with severe physical illness or injury, shortly after a traumatic event, as long as there are no contraindications. More research is needed using larger, high quality RCTs to establish the most efficacious use of hydrocortisone in different populations and optimal dosing, dosing window and route. There is currently a lack of evidence to suggest that other pharmacological agents are likely to be effective.

Accelerated DNA methylation age: Associations with PTSD and neural integrity

BACKGROUND

Accumulating evidence suggests that posttraumatic stress disorder (PTSD) may accelerate cellular aging and lead to premature morbidity and neurocognitive decline.

METHODS

This study evaluated associations between PTSD and DNA methylation (DNAm) age using recently developed algorithms of cellular age by Horvath (2013) and Hannum et al. (2013). These estimates reflect accelerated aging when they exceed chronological age. We also examined if accelerated cellular age manifested in degraded neural integrity, indexed via diffusion tensor imaging.

RESULTS

Among 281 male and female veterans of the conflicts in Iraq and Afghanistan, DNAm age was strongly related to chronological age (rs ∼.88). Lifetime PTSD severity was associated with Hannum DNAm age estimates residualized for chronological age (β=.13, p=.032). Advanced DNAm age was associated with reduced integrity in the genu of the corpus callosum (β=-.17, p=.009) and indirectly linked to poorer working memory performance via this region (indirect β=-.05, p=.029). Horvath DNAm age estimates were not associated with PTSD or neural integrity.

CONCLUSIONS

Results provide novel support for PTSD-related accelerated aging in DNAm and extend the evidence base of known DNAm age correlates to the domains of neural integrity and cognition.

Adverse Childhood Experiences, Military Service, and Adult Health

INTRODUCTION

Prevalence of adverse childhood experiences (ACE) and associations with adult health may vary by gender and military service. This study compares the gender-specific prevalence of ACE by military service and determines the associations of ACE with adult health risk factors and health-related quality of life (HRQOL).

METHODS

This 2014 analysis used data from the 2011 and 2012 CDC Behavioral Risk Factor Surveillance System. Total ACE was operationalized as the number of reported ACE. Associations of total ACE with adult health risk factors were estimated using general linear models; associations with HRQOL were estimated using negative binomial regression. All analyses adjusted for age and race/ethnicity.

RESULTS

Those with military service had more total ACE than civilians. Higher ACE was associated with poorer HRQOL among women (physical health, military service, relative risk [RR]=1.20, 95% CI=1.09, 1.33; civilians, RR=1.18, 95% CI=1.17, 1.20; mental health, military service, RR=1.21, 95% CI=1.12, 1.32; civilians, RR=1.25, 95% CI=1.23, 1.26). Among men, these associations were somewhat attenuated in those with military service relative to civilians (physical health, military service, RR=1.13, 95% CI=1.09, 1.18; civilians, RR=1.20, 95% CI=1.17, 1.24; mental health, military service, RR=1.21, 95% CI=1.16, 1.27; civilians, RR=1.30, 95% CI=1.27, 1.34).

CONCLUSIONS

Relative to civilians, men and women with military service report more ACE, but associations of ACE with adult HRQOL are weaker among men with military service relative to civilians. There is a need to implement and disseminate evidence-based programs to prevent ACE and for research on the long-term health consequences of ACE in military populations.

Pharmacological prevention of post-traumatic stress disorder and acute stress disorder: a systematic review and meta-analysis

BACKGROUND

An increasing number of studies have investigated the pharmacological prevention of post-traumatic stress disorder (PTSD) and acute stress disorder (ASD). This is the first systematic review to examine the effects of pharmacotherapies (eg, β blockers, hydrocortisone, and selective serotonin re-uptake inhibitors) given within the first month after a traumatic or aversive event to prevent PTSD or ASD compared with no pharmacotherapy or placebo control.

METHODS

A systematic literature search in PubMed, PsycINFO, Embase, and the Cochrane database of randomised trials was done. Studies included randomised controlled trials, controlled clinical trials, and cohort studies; their overall quality was low to moderate. We computed the pooled incidence risk ratio (IRR): the risk of incidence of PTSD or ASD in the pharmacotherapy groups relative to the incidence of PTSD or ASD in the control groups. Additionally, we computed Hedges'g effect sizes for PTSD or ASD continuous outcomes.

FINDINGS

15 studies met inclusion criteria (1765 individuals). Pharmacotherapy was more effective in preventing PTSD or ASD than placebo or no intervention (14 studies, 1705 individuals, IRR 0·65, 95% CI 0·55-0·78; number needed to treat 11·36), although no effect was found when only randomised controlled trials were included (ten studies, 300 individuals, IRR 0·69, 95% CI 0·40-1·21). Hydrocortisone showed a large effect in reducing the risk of PTSD (five studies, 164 individuals, IRR 0·38, 95% CI 0·16-0·92).

INTERPRETATION

No firm evidence was found for the efficacy of all early pharmacotherapies in the prevention of PTSD or ASD, but hydrocortisone reduced the risk of developing PTSD. The small number of studies and their limited methodological quality cast uncertainty about the effects.

FUNDING

None.