Prolonged exposure, paroxetine and the combination in the treatment of PTSD following a motor vehicle accident. A randomized clinical trial - The "TRAKT" study

State of the Science: Prolonged exposure therapy for the treatment of posttraumatic stress disorder

Prolonged exposure therapy (PE) is a well-established first-line treatment for posttraumatic stress disorder (PTSD) that is based on emotional processing theory. PE has been rigorously evaluated and tested in a large number of clinical trials in many countries covering a wide range of trauma populations. In this review, we summarize the evidence base supporting the efficacy of PE across populations, including adults with sexual assault-related PTSD and mixed trauma-related PTSD, military populations, and adolescents. We highlight important strengths and gaps in the research on PE with individuals from marginalized communities. We discuss the efficacy of PE on associated psychopathology and in the presence of the most commonly comorbid conditions, either alone or integrated with other treatments. In addition, we provide an overview of research examining strategies to augment PE. Much of this work remains preliminary, but numerous trials have tested PE in combination with other psychological or pharmacological approaches, interventions to facilitate extinction learning, and behavioral approaches, in the hopes of further increasing the efficiency and efficacy of PE. There are now several trials testing PE in novel formats that may have advantages over standard in-person PE, such as lower dropout and increased scalability. We examine this recent work on new models of delivering PE, including massed treatment, telehealth, and brief adaptations for primary care, all of which have the potential to increase access to PE. Finally, we highlight several promising areas for future research.

Histamine H1 receptors in dentate gyrus-projecting cholinergic neurons of the medial septum suppress contextual fear retrieval in mice

Fear memory is essential for survival and adaptation, yet excessive fear memories can lead to emotional disabilities and mental disorders. Despite previous researches have indicated that histamine H1 receptor (H1R) exerts critical and intricate effects on fear memory, the role of H1R is still not clarified. Here, we show that deletion of H1R gene in medial septum (MS) but not other cholinergic neurons selectively enhances contextual fear memory without affecting cued memory by differentially activating the dentate gyrus (DG) neurons in mice. H1R in cholinergic neurons mediates the contextual fear retrieval rather than consolidation by decreasing acetylcholine release pattern in DG. Furthermore, selective knockdown of H1R in the MS is sufficient to enhance contextual fear memory by manipulating the retrieval-induced neurons in DG. Our results suggest that H1R in MS cholinergic neurons is critical for contextual fear retrieval, and could be a potential therapeutic target for individuals with fear-related disorders.

[Pharmacological treatment of posttraumatic stress disorder]

In addition to trauma-focussed psychotherapy, pharmacological treatment is often unavoidable, especially in patients with severe posttraumatic stress disorder (PTSD). As long as comorbid disorders do not dictate the pharmacotherapy approach, sertraline and paroxetine, along with other off-label prescribable substances approved in Germany, can be used for the treatment of PTSD. Venlafaxine, in particular, has shown good effectiveness in studies, whereas risperidone has shown lower effectiveness in augmentation. Overall, only a small to medium effect size is to be expected for all substances. Psychopharmacotherapy plays an important role in addressing sleep disorders, which are highly prevalent in PTSD. Treatment of trauma-related nightmares can be attempted with doxazosin or clonidine. In contrast, there are limited empirical data available for sleep disorders associated with PTSD, but the pharmacological treatment of insomnia can provide some guidance.

Enhancing massed prolonged exposure with cannabidiol to improve posttraumatic stress disorder: Design and methodology of a pilot randomized clinical trial

Background

The impact of posttraumatic stress disorder (PTSD) is substantial and often results in pervasive functional impairments. Although evidence-based treatments for PTSD are established, there remains room for improvement as many individuals continue to meet diagnostic criteria even after successful treatment completion. Cannabidiol (CBD) has attracted considerable attention based on its potential to treat a myriad of health conditions. CBD may decrease anxiety and facilitate extinction learning processes, two critical targets of trauma-focused psychotherapies. We present the design and methods for a pilot randomized clinical trial to examine the combination of CBD and prolonged exposure for PTSD.

Methods

Participants (n = 24) will be randomized to CBD or placebo for 18 days delivered in combination with ten daily prolonged exposure sessions over two weeks. The study medication will be Epidiolex® (250 mg BID). The PTSD Checklist for DSM-5 will be the primary outcome to assess PTSD severity at baseline, during treatment, and at 1-month follow-up. Blood, saliva, and heart rate will be collected during treatment to assess intervention effects on biological outcomes related to PTSD and the endocannabinoid system.

Results

Consistent with the purpose of a pilot, our goals are to evaluate the feasibility of study procedures, safety of the intervention, and the preliminary effect of CBD to inform a larger trial. Descriptive and inferential statistics will be used to address study aims.

Conclusion

Findings will inform decision making on combining CBD with behavioral interventions for PTSD to enhance outcomes and mitigate the morbidity of this debilitating condition.

The Management of Posttraumatic Stress Disorder and Acute Stress Disorder: Synopsis of the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline

DESCRIPTION

The U.S. Department of Veterans Affairs (VA) and Department of Defense (DoD) worked together to revise the 2017 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. This article summarizes the 2023 clinical practice guideline (CPG) and its development process, focusing on assessments and treatments for which evidence was sufficient to support a recommendation for or against.

METHODS

Subject experts from both departments developed 12 key questions and reviewed the published literature after a systematic search using the PICOTS (population, intervention, comparator, outcomes, timing of outcomes measurement, and setting) method. The evidence was then evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. Recommendations were made after consensus was reached; they were based on quality and strength of evidence and informed by other factors, including feasibility and patient perspectives. Once the draft was peer reviewed by an external group of experts and their inputs were incorporated, the final document was completed.

RECOMMENDATIONS

The revised CPG includes 34 recommendations in the following 5 topic areas: assessment and diagnosis, prevention, treatment, treatment of nightmares, and treatment of posttraumatic stress disorder (PTSD) with co-occurring conditions. Six recommendations on PTSD treatment were rated as strong. The CPG recommends use of specific manualized psychotherapies over pharmacotherapy; prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing psychotherapy; paroxetine, sertraline, or venlafaxine; and secure video teleconferencing to deliver recommended psychotherapy when that therapy has been validated for use with video teleconferencing or when other options are unavailable. The CPG also recommends against use of benzodiazepines, cannabis, or cannabis-derived products. Providers are encouraged to use this guideline to support evidence-based, patient-centered care and shared decision making to optimize individuals' health outcomes and quality of life.

Treating posttraumatic stress disorder and alcohol use disorder comorbidity: Current pharmacological therapies and the future of MDMA-integrated psychotherapy

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) frequently co-occur in patients who have experienced trauma. This comorbidity leads to a vicious cycle where PTSD symptoms beget heavy drinking and vice versa. There are no FDA-approved medications to treat PTSD-AUD; therefore, individuals suffering from this comorbidity are treated with medication approved to treat the disorders separately or with off-label pharmacological interventions. However, these medications are limited in their efficacy for treating PTSD-AUD comorbidity. Emerging research on the nonclassical psychedelic drug 3,4-methylenedioxymethamphetamine (MDMA) suggests that it may be an effective drug used in conjunction with psychotherapy. The following reviews the current research for clinical pharmacotherapies, as well as MDMA-integrative psychotherapy as they pertain to PTSD and AUD in isolation and co-occurrence. Future directions for the role of psychedelic-integrative therapy for the treatment of this comorbidity are discussed.

Exposure to self-reported traumatic events and probable PTSD in a national sample of Poles: Why does Poland's PTSD prevalence differ from other national estimates?

BACKGROUND

There is a lack of studies on trauma exposure and PTSD prevalence in Poland on representative samples. Available data from studies on convenient samples show very high rates of probable PTSD compared with relevant estimates in other countries.

OBJECTIVE

This study aimed to measure the exposure to self-report traumatic events (PTEs) and to estimate the current rate of prevalence of probable posttraumatic stress disorder (PTSD) in accordance with DSM-5 criteria in a population-based sample of Poles. Additionally, the link between PTSD intensity and level of life satisfaction was investigated.

METHOD

A representative sample of 1,598 adult Poles was recruited. Probable PTSD was assessed with the Posttraumatic Diagnostic Scale for DSM-5 (PDS-5) and the Satisfaction with Life Scale (SWLS) was also used.

RESULTS

The findings showed that 60.3% of Poles had experienced at least one PTE and 31.1% of those who had been exposed to trauma reported symptoms of PTSD. At the level of the entire sample, the obtained rate for probable PTSD was 18.8%. The traumatic events with the highest probabilities of PTSD symptoms were child abuse and sexual assault. Levels of life satisfaction were significantly lower in the group of participants with probable PTSD.

CONCLUSIONS

We found that the current prevalence of probable PTSD in Poland is intriguingly high relative to rates reported in comparable representative samples from other countries across the world. Possible mechanisms are discussed, including a lack of social acknowledgement of WWII and other traumas as well as poor access to trauma-focused care. We hope that this research may inspire more studies investigating cross-national differences in PTSD and trauma exposure.

Alleviating anxiety and taming trauma: Novel pharmacotherapeutics for anxiety disorders and posttraumatic stress disorder

Psychiatric disorders associated with psychological trauma, stress and anxiety are a highly prevalent and increasing cause of morbidity worldwide. Current therapeutic approaches, including medication, are effective in alleviating symptoms of anxiety disorders and posttraumatic stress disorder (PTSD), at least in some individuals, but have unwanted side-effects and do not resolve underlying pathophysiology. After a period of stagnation, there is renewed enthusiasm from public, academic and commercial parties in designing and developing drug treatments for these disorders. Here, we aim to provide a snapshot of the current state of this field that is written for neuropharmacologists, but also practicing clinicians and the interested lay-reader. After introducing currently available drug treatments, we summarize recent/ongoing clinical assessment of novel medicines for anxiety and PTSD, grouped according to primary neurochemical targets and their potential to produce acute and/or enduring therapeutic effects. The evaluation of putative treatments targeting monoamine (including psychedelics), GABA, glutamate, cannabinoid, cholinergic and neuropeptide systems, amongst others, are discussed. We emphasize the importance of designing and clinically assessing new medications based on a firm understanding of the underlying neurobiology stemming from the rapid advances being made in neuroscience. This includes harnessing neuroplasticity to bring about lasting beneficial changes in the brain rather than - as many current medications do - produce a transient attenuation of symptoms, as exemplified by combining psychotropic/cognitive enhancing drugs with psychotherapeutic approaches. We conclude by noting some of the other emerging trends in this promising new phase of drug development.

Sex-specific role of hippocampal NMDA-Erk-mTOR signaling in fear extinction of adolescent mice

Adolescence is a key phase of development for perturbations in fear extinction, with inability to adequately manage fear a potent factor for developing psychiatric disorders in adulthood. However, while behavioral correlates of adolescent fear regulation are established to a degree, molecular mediators of extinction learning in adolescence remain largely unknown. In this study, we observed fear acquisition and fear extinction (across 4 and 7 days) of adolescent and adult mice of both sexes and investigated how hippocampal levels of different plasticity markers relate to extinction learning. While fear was acquired evenly in males and females of both ages, fear extinction was found to be impaired in adolescent males. We also observed lower levels of GluA1, GLUN2A and GLUN2B subunits in male adolescents following fear acquisition, with an increase in their expression, as well as the activity of Erk-mTOR pathway over subsequent extinction sessions, which was paralleled with improved extinction learning. On the other hand, we detected no changes in plasticity-related proteins after fear acquisition in females, with alterations in GluA1, GluA4 and GLUN2B levels across fear extinction sessions. Additionally, we did not discern any pattern regarding the Erk-mTOR activity in female mice associated with their extinction performance. Overall, our research identifies sex-specific synaptic properties in the hippocampus that underlie developmentally regulated differences in fear extinction learning. We also point out hippocampal NMDA-Erk-mTOR signaling as the driving force behind successful fear extinction in male adolescents, highlighting this pathway as a potential therapeutic target for fear-related disorders in the adolescent population.

Pharmacological strategies for post-traumatic stress disorder (PTSD): From animal to clinical studies

Post-traumatic stress disorder (PTSD) is a disabling psychiatric condition with a critical familiar, personal, and social impact. Patients diagnosed with PTSD show various symptoms, including anxiety, depression, psychotic episodes, and sleep disturbances, complicating their therapeutic management. Only sertraline and paroxetine, two selective serotonin reuptake inhibitors, are approved by different international agencies to treat PTSD. In addition, these drugs are generally combined with psychotherapy to achieve positive results. However, these pharmacological strategies present limited efficacy. Nearly half of the PTSD patients do not experience remission of symptoms, possibly due to the high prevalence of psychiatric comorbidities. Therefore, in clinical practice, other off-label medications are common, even though the effectiveness of these drugs needs to be further investigated. In this line, antipsychotics, antiepileptics, adrenergic blockers, benzodiazepines, and other emerging pharmacological agents have aroused interest as potential therapeutic tools to improve some specific symptoms of PTSD. Thus, this review is focused on the most widely used drugs for the pharmacological treatment of PTSD with a translational approach, including clinical and preclinical studies, to emphasize the need to develop safer and more effective medications.

Less dropout from prolonged exposure sessions prescribed at least twice weekly: A meta-analysis and systematic review of randomized controlled trials

Trauma-focused psychotherapies, such as prolonged exposure (PE), are strongly recommended to treat posttraumatic stress disorder due to their effects in reducing symptoms. However, such therapies may also suffer from high dropout rates. To investigate how clients might benefit from trauma-focused therapy while minimizing dropout, we conducted a meta-analysis of 1,508 adults from 35 randomized controlled trials (RCTs) of outpatient PE programs to evaluate treatment frequency as a predictor of dropout. When an RCT prescribed PE sessions at least twice weekly compared to less frequently, the dropout rate was significantly lower at 21.0%, 95% CI [13.9%, 30.4%], compared to 34.0%, 95% CI [28.9%, 39.4%], OR = 0.52, 95% CI [0.30, 0.89], p = .018. It was not possible to draw causal conclusions, as only one RCT compared two PE treatment frequencies head-to-head. Nonetheless, the findings remained significant after controlling for study characteristics. These data invite reconsideration of the common practice of weekly psychotherapy in favor of twice-weekly sessions in standard outpatient treatment.

A comparison of prolonged exposure therapy, pharmacotherapy, and their combination for PTSD: What works best and for whom; study protocol for a randomized trial

BACKGROUND

Several efficacious psychological and pharmacological treatments for posttraumatic stress disorder (PTSD) are available; however, the comparative effectiveness of these treatments represents a major gap in the literature. The proposed study will compare the effectiveness of two leading PTSD treatments - Prolonged Exposure (PE) therapy and pharmacotherapy with paroxetine or venlafaxine extended release - as well as the combination of PE and medication.

METHODS

In a randomized clinical trial, veterans with PTSD (N = 450) recruited across six Veterans Affairs Medical Centers will complete assessments at baseline, mid-treatment (Week 7), post-treatment (Week 14), and follow-up (Weeks 27 and 40). The primary outcome will be change in (both clinician-rated and self-reported) PTSD severity. Depression symptoms, quality of life, and functioning will also be measured and examined as secondary outcomes. Baseline demographic and clinical data will be used to develop "personalized advantage indices" (PAIs), with the goal of identifying who is most likely to benefit from which treatment.

CONCLUSIONS

This planned trial will yield findings to directly inform clinical practice guidelines for PTSD, by providing comparative effectiveness data to support recommendations about what can be considered the "first-line" treatment option(s) for PTSD. Further, findings from this trial have the potential to guide treatment planning for individual patients, through implementation of PAIs developed from study data, in service of "personalized medicine."

TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT04961190.

The Effectiveness of Behavioral Interventions in Adults with Post-Traumatic Stress Disorder during Clinical Rehabilitation: A Rapid Review

BACKGROUND

This review examined the effectiveness of behavioral interventions for adults with post-traumatic stress disorder (PTSD) triggered by physical injury or medical trauma. It discusses implications in support of rehabilitation management for COVID-19 survivors diagnosed with PTSD.

METHODS

This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Interim Guidance from the Cochrane Rapid Reviews Methods Group. The authors searched for randomized control trials in PubMed, Embase, and CENTRAL databases up to 31 March 2021.

RESULTS

Five studies (n = 459) met the inclusion criteria. Each study measured a different comparison of interventions. The certainty of the evidence was judged to be very low for all outcomes. Post-traumatic stress disorder symptom reduction was found to be in favor of trauma-focused cognitive-behavioral therapy, cognitive therapy, and cognitive-behavioral therapy. Cognitive function improvements were observed in favor of the cognitive processing therapy control intervention.

CONCLUSIONS

Overall, there is uncertainty about whether behavioral interventions are effective in reducing PTSD symptoms and improving functioning and quality of life when the disorder is triggered by a physical or medical trauma rather than a psychological trauma. Further research should investigate their efficacy in the context of rehabilitation management and gather evidence on this population.

"Will it work for me?" Developing patient-friendly graphical displays of posttraumatic stress disorder treatment effectiveness

The goal of this study was to create simple visual displays to help patients understand the benefits of evidence-based treatment for posttraumatic stress disorder (PTSD). We reviewed randomized trials of the most effective individual, trauma-focused psychotherapies and first-line antidepressants for adults with PTSD. The analytic sample included 65 treatment arms from 41 trials. We used binomial logistic regression to estimate the proportion of participants who lost their PTSD diagnosis at posttreatment and created a sample icon array to display these estimates. We provide a range of estimates (0-100) based on varying the percentage of the sample with a military affiliation. The percentage of participants who no longer met the diagnostic criteria for PTSD among civilian populations was 64.3% for trauma-focused treatment, 56.9% for SSRI/SNRI, and 16.7% for waitlist/minimal attention. For military populations, the proportions of participants who no longer met the diagnostic criteria were 44.2%, 36.7%, and 8.1%, respectively. We present icon arrays for 0%, 7%, 50%, and 100% military affiliation displaying 100 icons, a portion of which were shaded to indicate the number of participants that no longer met the PTSD criteria following treatment. After evidence-based treatment, between one third and two thirds of participants no longer met the PTSD criteria. Providers can use the icon array developed in this study with patients to facilitate communication regarding PTSD treatment effectiveness.

Hallucinogenic drugs and their potential for treating fear-related disorders: Through the lens of fear extinction

Fear-related disorders, mainly phobias and post-traumatic stress disorder, are highly prevalent, debilitating disorders that pose a significant public health problem. They are characterized by aberrant processing of aversive experiences and dysregulated fear extinction, leading to excessive expression of fear and diminished quality of life. The gold standard for treating fear-related disorders is extinction-based exposure therapy (ET), shown to be ineffective for up to 35% of subjects. Moreover, ET combined with traditional pharmacological treatments for fear-related disorders, such as selective serotonin reuptake inhibitors, offers no further advantage to patients. This prompted the search for ways to improve ET outcomes, with current research focused on pharmacological agents that can augment ET by strengthening fear extinction learning. Hallucinogenic drugs promote reprocessing of fear-imbued memories and induce positive mood and openness, relieving anxiety and enabling the necessary emotional engagement during psychotherapeutic interventions. Mechanistically, hallucinogens induce dynamic structural and functional neuroplastic changes across the fear extinction circuitry and temper amygdala's hyperreactivity to threat-related stimuli, effectively mitigating one of the hallmarks of fear-related disorders. This paper provides the first comprehensive review of hallucinogens' potential to alleviate symptoms of fear-related disorders by focusing on their effects on fear extinction and the underlying molecular mechanisms. We overview both preclinical and clinical studies and emphasize the advantages of hallucinogenic drugs over current first-line treatments. We highlight 3,4-methylenedioxymethamphetamine and ketamine as the most effective therapeutics for fear-related disorders and discuss the potential molecular mechanisms responsible for their potency with implications for improving hallucinogen-assisted psychotherapy.

Interpersonal psychotherapy versus sertraline for women with posttraumatic stress disorder following recent sexual assault: a randomized clinical trial

Background: Sexual assault often triggers posttraumatic stress disorder (PTSD), a potentially chronic severe mental disorder. Most guidelines recommend selective serotonin reuptake inhibitors (SSRIs) and trauma-focused psychotherapies as treatment options. Interpersonal Psychotherapy (IPT), adapted for PTSD (IPT-PTSD), focuses on interpersonal consequences of trauma rather than confronting the trauma itself. Studies have found IPT-PTSD efficaciously reduced PTSD symptoms with limited attrition. No efficacy trials have compared IPT-PTSD and SSRI. We hypothesized IPT would reduce PTSD, anxiety, and depressive symptoms more than sertraline among women with PTSD following a recent sexual assault. Objectives: To compare the efficacy of IPT-PTSD to SSRI sertraline in a 14-week randomized clinical trial for women with PTSD following a recent sexual assault. Methods: Seventy-four women with PTSD who had suffered sexual assault in the last six months were randomly assigned to 14 weeks of IPT-PTSD (n = 39) or sertraline (n = 35). Instruments assessed PTSD, anxiety, and depressive symptoms. This randomized clinical trial was conducted in São Paulo, Brazil, using the Clinician-Administered PTSD Scale-5 (CAPS-5) as the primary outcome measure. Results: Both treatments significantly reduced PTSD, anxiety, and depressive symptoms, without between-group outcome differences. CAPS-5 mean decreased from 42.5 (SD = 9.4) to 27.1 (SD = 15.9) with sertraline and from 42.6 (SD = 9.1) to 29.1 (SD = 15.5) with IPT-PTSD. Attrition was high in both arms (p = .40). Conclusions: This trial showed within-group improvements without differences between IPT-PTSD and sertraline treatment of PTSD. Our findings suggest that non-exposure-based psychotherapies may benefit patients with PTSD, although we did not directly compare these treatments to an exposure therapy. Brazilian Clinical Trials Registry RBR-3z474z.

PTSD: Past, present and future implications for China

There has been a long history since human beings began to realize the existence of post-traumatic symptoms. Posttraumatic stress disorder (PTSD), a diagnostic category adopted in 1980 in the Diagnostic and Statistical Manual of Mental Disorders-Ⅲ, described typical clusters of psychiatric symptoms occurring after traumatic events. Abundant researches have helped deepen the understanding of PTSD in terms of epidemiological features, biological mechanisms, and treatment options. The prevalence of PTSD in general population ranged from 6.4% to 7.8% and was significantly higher among groups who underwent major public traumatic events. There has been a long way in the studies of animal models and genetic characteristics of PTSD. However, the high comorbidity with other stress-related psychiatric disorders and complexity in the pathogenesis of PTSD hindered the effort to find specific biological targets for PTSD. Neuroimage was widely used to elucidate the underlying neurophysiological mechanisms of PTSD. Functional MRI studies have showed that PTSD was linked to medial prefrontal cortex, anterior cingulate cortex and sub-cortical structures like amygdala and hippocampus, and to explore the functional connectivity among these brain areas which might reveal the possible neurobiological mechanism related to PTSD symptoms. For now, cognitive behavior therapy-based psychotherapy, including combination with adjunctive medication, showed evident treatment effects on PTSD. The emergence of more effective PTSD pharmacotherapies awaits novel biomarkers from further fundamental research. Several natural disasters and emergencies have inevitably increased the possibility of suffering from PTSD in the last two decades, making it critical to strengthen PTSD research in China. To boost PTSD study in China, the following suggestions might be helpful: (1) establishing a national psychological trauma recover project, and (2) exploring the mechanisms of PTSD with joint effort and strengthening the indigenized treatment of PTSD.

Pharmacological therapy for post-traumatic stress disorder: a systematic review and meta-analysis of monotherapy, augmentation and head-to-head approaches

Background: Pharmacological approaches are widely used for post-traumatic stress disorder (PTSD) despite uncertainty over efficacy. Objectives: To determine the efficacy of all pharmacological approaches, including monotherapy, augmentation and head-to-head approaches (drug versus drug, drug versus psychotherapy), in reducing PTSD symptom severity. Method: A systematic review and meta-analysis of randomised controlled trials were undertaken; 115 studies were included. Results: Selective serotonin reuptake inhibitors (SSRIs) were found to be statistically superior to placebo in reduction of PTSD symptoms but the effect size was small (standardised mean difference -0.28, 95% CI -0.39 to -0.17). For individual monotherapy agents compared to placebo in two or more studies, we found small statistically significant evidence for the antidepressants fluoxetine, paroxetine, sertraline, venlafaxine and the antipsychotic quetiapine. For pharmacological augmentation, we found small statistically significant evidence for prazosin and risperidone. Conclusions: Some medications have a small positive effect on reducing PTSD symptom severity and can be considered as potential monotherapy treatments; these include fluoxetine, paroxetine, sertraline, venlafaxine and quetiapine. Two medications, prazosin and risperidone, also have a small positive effect when used to augment pharmacological monotherapy. There was no evidence of superiority for one intervention over another in the small number of head-to-head comparison studies.

Pharmacological-assisted Psychotherapy for Post-Traumatic Stress Disorder: a systematic review and meta-analysis

Background: Pharmacological-assisted psychotherapies, using conventional and novel drug agents, are increasingly being used both in clinical and experimental research settings, respectively. Objective: To determine the efficacy of conventional and novel pharmacological-assisted psychotherapies in reducing PTSD symptom severity. Method: A systematic review and meta-analysis of randomised-controlled trials were undertaken; 21 studies were included. Results: MDMA-assisted therapy was found to statistically superior to active and inactive placebo-assisted therapy in reduction of PTSD symptoms (standardised mean difference -1.09, 95% CI -1.60 to -0.58). There was no evidence of superiority over placebo for any other intervention. Conclusions: MDMA-assisted therapy demonstrated an impressive effect size; however, it is difficult to have confidence at this stage in this intervention due to the small numbers of participants included, and more research in this area is needed. There was no evidence to support the efficacy of any other drug-assisted interventions.

Early discontinuation of pharmacotherapy in U.S. veterans diagnosed with PTSD and the role of psychotherapy

More than 50% of individuals who enter treatment for posttraumatic stress disorder (PTSD) are prescribed a psychotropic medication. To date, however, data are limited regarding the prevalence and determinants of discontinuation of psychotropic medication in this population. To address this gap, we analyzed data from 154,953 veterans newly diagnosed with PTSD who were seeking VA treatment and followed them for one year to identify the prevalence and determinants of medication discontinuation. A hazard analysis was conducted to identify factors associated with discontinuation of antidepressant, anxiolytic/hypnotic and antipsychotic medications. Binomial regressions examined the role of these factors in early discontinuation (within 30 days). Results revealed that 71.8% of veterans discontinued medication treatment within 180 days, and 34.6% within 30 days. The strongest risk factors associated with discontinuing medication were no engagement in adjunctive psychotherapy and prescription of a single medication. Older veterans were less likely than younger veterans to discontinue treatment. Similar risk factors were associated with medication discontinuation in the first 30 days. These results suggest that psychiatric comorbidities, age, and race are key risk factors for poor medication adherence, and underscore the importance of early intervention and patient education in promoting adherence to pharmacotherapy for PTSD.

Pharmacotherapeutic considerations for the treatment of posttraumatic stress disorder during and after pregnancy

Introduction: Posttraumatic stress disorder (PTSD) affects 3-4% of the pregnant and postpartum population. Despite its high prevalence, there has been very little research on how the disorder should be managed in this population. This is of importance as untreated PTSD has been associated with adverse outcomes both in pregnancy and in child development.Areas covered: In this article, the authors discuss the existing literature on the pharmacological treatment of PTSD. As guidelines and clinical trials in the treatment of perinatal PTSD are non-existent, they extrapolate the existing data from non-perinatal populations while considering the safety of medications in pregnancy and breastfeeding.Expert opinion: First-line treatment of perinatal PTSD ideally involves evidence-based psychotherapy rather than pharmacotherapy. However, pharmacotherapy may be required in situations of inadequate response, psychiatric co-morbidities, limited access to psychotherapy, or patient preference. The first-line pharmacotherapy options are the antidepressants sertraline, paroxetine, fluoxetine, and venlafaxine. Of these medications, sertraline has the best safety profile in pregnancy and postpartum and is thus the preferred agent. Clinical studies and consensus guidelines in the treatment of perinatal PTSD are needed given the high prevalence of the disorder and the significant risks associated with inadequate treatment.

Quetiapine augmentation of prolonged exposure therapy in veterans with PTSD and a history of mild traumatic brain injury: design and methodology of a pilot study

BACKGROUND

Selective serotonergic reuptake inhibitors (SSRIs) are first-line pharmacologic treatments for patients with posttraumatic stress disorder (PTSD), but must be given over extended period of time before the onset of action. The use of SSRIs in PTSD patients with mild traumatic brain injury (mTBI) is problematic since SSRIs could exacerbate post-concussion syndrome (PCS) symptoms. VA/DOD guidelines identify trauma-focused psychotherapy as the best evidence-based treatment for PTSD, but overall effectiveness is limited by reduced levels of patient engagement and retention. A previous study from this research group suggested that quetiapine monotherapy, but not risperidone or valproate, could increase engagement in trauma-focused psychotherapy.

METHODS

We report the study protocol of a pilot study funded under the South-Central Mental Illness Research, Education, and Clinical Center pilot study program from the U.S. Department of Veterans Affairs. This randomized, open-label study was designed to evaluate the feasibility of completing a randomized trial of quetiapine vs. treatment as usual to promote patient engagement in PTSD patients with a history of mTBI.

DISCUSSION

We expect that the success of this ongoing study should provide us with the preliminary data necessary to design a full-scale randomized trial. Positive efficacy results in a full- scale trial should inform new VA guidelines for clinical practice by showing that quetiapine-related improvements in patient engagement and retention may be the most effective approach to assure that VA resources achieve the best possible outcome for veterans.

TRIAL REGISTRATION

NCT04280965 .

Processing of Positive Memories Technique (PPMT) for Posttraumatic Stress Disorder: A Primer

Despite substantial evidence linking posttraumatic stress disorder (PTSD) and positive memory processes, existing trauma research and clinical work focuses primarily on traumatic memories. In light of this limitation, Contractor and colleagues proposed a conceptual model linking PTSD to positive memories; this provided the backdrop to develop a manualized positive memory therapy protocol for trauma-exposed individuals (Processing of Positive Memories Technique; PPMT). In the current study, we first present justification for developing PPMT by outlining the role of positive memories in trauma theories, as well as empirical evidence and intervention research linking trauma/PTSD to positive memory processes. Next, we provide information on the preliminary PPMT protocol by outlining (1) theoretical foundations; (2) intervention strategies PPMT draws from; (3) objectives; and (4) a session-by-session description of goals, content, and homework assignments. Finally, we end by highlighting some (1) unique features and advantages of PPMT such as integrating well-supported experimental and cognitive psychology research into intervention research, bridging the gap between basic science and applied research, and being tailored to PTSD's unique symptomatology; and (2) directions for future research. The aim of this paper was to provide a primer on PPMT to facilitate its empirical examination and applicability in PTSD research and clinical work.

Predicting and Managing Treatment Non-Response in Posttraumatic Stress Disorder

PURPOSE OF REVIEW

This review aims to synthesize existing research regarding the definition of treatment resistance in posttraumatic stress disorder (PTSD), predictors of treatment non-response to first-line interventions, and emerging second-line PTSD treatment options into an accessible resource for the practicing clinician.

RECENT FINDINGS

The concept of treatment resistance in PTSD is currently poorly defined and operationalized. There are no well-established predictors of treatment non-response utilized in routine clinical care, but existing research identifies several potential candidate markers, including male gender, low social support, chronic and early life trauma exposure, comorbid psychiatric disorders, severe PTSD symptoms, and poor physical health. The most promising available treatment options for PTSD patients non-responsive to first-line psychotherapies and antidepressants include transcranial magnetic stimulation and ketamine infusion. Methylenedioxymethamphetamine-assisted psychotherapy also appears promising but is only available in a research context. These options require careful consideration of risks and benefits for a particular patient.

SUMMARY

More research is required to develop a robust, clinically-useful definition of treatment resistance in PTSD; identify reliable, readily assessable, and generalizable predictors of PTSD treatment non-response; and implement measurement and prediction in clinical settings to identify individuals unlikely to respond to first-line treatments and direct them to appropriate second-line treatments.

Implementation research for public sector mental health care scale-up (SMART-DAPPER): a sequential multiple, assignment randomized trial (SMART) of non-specialist-delivered psychotherapy and/or medication for major depressive disorder and posttraumatic stress disorder (DAPPER) integrated with outpatient care clinics at a county hospital in Kenya

BACKGROUND

Mental disorders are a leading cause of global disability, driven primarily by depression and anxiety. Most of the disease burden is in Low and Middle Income Countries (LMICs), where 75% of adults with mental disorders have no service access. Our research team has worked in western Kenya for nearly ten years. Primary care populations in Kenya have high prevalence of Major Depressive Disorder (MDD) and Posttraumatic Stress Disorder (PTSD). To address these treatment needs with a sustainable, scalable mental health care strategy, we are partnering with local and national mental health stakeholders in Kenya and Uganda to identify 1) evidence-based strategies for first-line and second-line treatment delivered by non-specialists integrated with primary care, 2) investigate presumed mediators of treatment outcome and 3) determine patient-level moderators of treatment effect to inform personalized, resource-efficient, non-specialist treatments and sequencing, with costing analyses. Our implementation approach is guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework.

METHODS/DESIGN

We will use a Sequential, Multiple Assignment Randomized Trial (SMART) to randomize 2710 patients from the outpatient clinics at Kisumu County Hospital (KCH) who have MDD, PTSD or both to either 12 weekly sessions of non-specialist-delivered Interpersonal Psychotherapy (IPT) or to 6 months of fluoxetine prescribed by a nurse or clinical officer. Participants who are not in remission at the conclusion of treatment will be re-randomized to receive the other treatment (IPT receives fluoxetine and vice versa) or to combination treatment (IPT and fluoxetine). The SMART-DAPPER Implementation Resource Team, (IRT) will drive the application of the EPIS model and adaptations during the course of the study to optimize the relevance of the data for generalizability and scale -up.

DISCUSSION

The results of this research will be significant in three ways: 1) they will determine the effectiveness of non-specialist delivered first- and second-line treatment for MDD and/or PTSD, 2) they will investigate key mechanisms of action for each treatment and 3) they will produce tailored adaptive treatment strategies essential for optimal sequencing of treatment for MDD and/or PTSD in low resource settings with associated cost information - a critical gap for addressing a leading global cause of disability.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03466346, registered March 15, 2018.

Medication versus trauma-focused psychotherapy for adults with posttraumatic stress disorder: A systematic review and meta-analysis

The goal of this study was to summarize evidence from head-to-head randomized trials for treatment of posttraumatic stress disorder (PTSD) in adults comparing trauma-focused psychotherapies and selective serotonin reuptake inhibitors (SSRIs) or serotonin/norepinephrine reuptake inhibitors (SNRIs) in a systematic review and meta-analysis. We conducted a search of multiple databases to identify trials comparing a trauma-focused psychotherapy (cognitive behavioral therapy, prolonged exposure, cognitive therapy, cognitive processing therapy or eye movement desensitization and reprocessing) to an SSRI or SNRI. Cochrane Risk of Bias 2.0 was used to assess risk of bias; high risk of bias trials were included only in sensitivity analyses. PTSD symptom reduction was the primary outcome. Four trials met inclusion criteria. Random effects meta-analysis of the two trials that were not high risk of bias showed no difference in PTSD symptom reduction, but a wide confidence interval, including effects favoring psychotherapy and effects favoring medication. Heterogeneity was high. Inclusion of the two high risk of bias trials did not change substantive conclusions. There is insufficient evidence to determine whether SSRIs or trauma-focused psychotherapies are more effective for PTSD symptom reduction among adults with PTSD.

Examining military population and trauma type as moderators of treatment outcome for first-line psychotherapies for PTSD: A meta-analysis

There is conflicting evidence as to whether military populations (i.e., veteran and active-duty military service members) demonstrate a poorer response to psychotherapy for posttraumatic stress disorder (PTSD) compared to civilians. Existing research may be complicated by the fact that treatment outcomes differences could be due to the type of trauma exposure (e.g., combat) or population differences (e.g., military culture). This meta-analysis evaluated PTSD treatment outcomes as a function of trauma type (combat v. assault v. mixed) and population (military v. civilian). Unlike previous meta-analyses, we focused exclusively on manualized, first-line psychotherapies for PTSD as defined by expert treatment guidelines. Treatment outcomes were large across trauma types and population; yet differences were observed between trauma and population subgroups. Military populations demonstrated poorer treatment outcomes compared to civilians. The combat and assault trauma subgroups had worse treatment outcomes compared to the mixed trauma subgroup, but differences were not observed between assault and combat subgroups. Higher attrition rates predicted poorer treatment outcomes, but did not vary between military populations and civilians. Overall, manualized, first-line psychotherapies for PTSD should continue to be used for civilians and military populations with various trauma types. However, greater emphasis should be placed on enhancing PTSD psychotherapies for military populations and on treatment retention across populations based on findings from this meta-analysis.

Comparative Efficacy and Acceptability of Pharmacological, Psychotherapeutic, and Combination Treatments in Adults With Posttraumatic Stress Disorder: A Network Meta-analysis

IMPORTANCE

Posttraumatic stress disorder (PTSD) is a prevalent mental disorder, with a high risk of chronicity, comorbidity, and functional impairment; PTSD is complicated to treat, and the debate on the best treatment approach is ongoing.

OBJECTIVE

To examine comparative outcomes and acceptability of psychotherapeutic and pharmacological treatments and their combinations in adults with PTSD.

DATA SOURCES

Embase, MEDLINE, PsycINFO, Cochrane Controlled Trials Register, and PSYNDEX were searched for studies published from January 1, 1980, to February 28, 2018. Reference lists of included studies and of previously published guidelines and systematic reviews were also searched.

STUDY SELECTION

Of 11 417 records identified, 12 published randomized clinical trials (RCTs) comprising 922 participants, contributing 23 direct comparisons between psychotherapeutic and pharmacological treatments or their combinations were included.

DATA EXTRACTION AND SYNTHESIS

Standardized mean differences (SMDs) and odds ratios were aggregated using random-effects network and pairwise meta-analyses. Risk of bias and indirectness was rated for each study, and network confidence was rated using the Confidence in Network Meta-Analysis framework.

MAIN OUTCOMES AND MEASURES

The primary outcome was the comparative benefit between 2 treatment approaches to PTSD symptom improvement, and secondary outcome was the comparative acceptability of the treatment approaches, as indicated by patient dropout rates before treatment termination.

RESULTS

No treatment approach was found to be superior at the end of treatment (for all, 95% CI included 0). At the last follow-up, psychotherapeutic treatments showed greater benefit than pharmacological treatments in both network (SMD, -0.83; 95% CI, -1.59 to -0.07) and pairwise (SMD, -0.63; 95% CI, -1.18 to -0.09, 3 RCTs) meta-analyses. No difference was found between combined treatments and psychotherapeutic treatments at long-term follow-up, and combined treatments were associated with better outcomes than pharmacological treatments in the network meta-analysis (SMD, -0.96; 95% CI, -1.87 to -0.04), but not in the pairwise meta-analysis, which included 2 RCTs (SMD, -1.02; 95% CI, -2.77 to 0.72). No evidence was found for differential acceptability of the 3 treatment approaches.

CONCLUSIONS AND RELEVANCE

These results suggest superiority of psychotherapeutic treatments over pharmacological treatments; network, but not pairwise, meta-analyses suggest superiority of combined treatments over pharmacological treatments in improving PTSD symptom severity in the long term. The scarcity of reported long-term findings hampers definite conclusions and demonstrates the need for robust evidence from large-scaled comparative trials providing long-term follow-up data.

Enhancing Completion of Cognitive Processing Therapy for Posttraumatic Stress Disorder with Quetiapine in Veterans with Mild Traumatic Brain Injury: a Case Series

To evaluate the outcomes of the antiarousal medications valproate, risperidone, and quetiapine on completion of treatment of cognitive processing therapy (CPT) for PTSD. A case series of fifty treatment-seeking adult (≥18 years) veterans with mild traumatic brain injury and combat-related PTSD who had unsuccessful trials of 2 or more first-line agents and previously declined treatment with trauma-focused therapy, seen at the psychiatric outpatient services of the local Polytrauma Rehabilitation Center from January 1, 2014, through December 31, 2017. Patients were prescribed valproate (n = 8), risperidone (n = 17), or quetiapine (n = 25) and were referred for individual weekly treatment with CPT. Outcome measurements of interest were measures of engagement and completion rate of CPT, PTSD Checklist total score (range, 0-80; higher scores indicate greater PTSD severity) and arousal subscale score (range, 0-24; higher scores indicate greater arousal severity), and clinical observations of sleep variables. Of the 50 patients included in the study, 48 (96%) were men; mean (SD) age was 36 (8) years. Eighteen (86%) patients initially receiving quetiapine and none taking valproate or risperidone became adequately engaged in and completed CPT. Among patients who completed CPT, the mean decrease in the PTSD Checklist score was 25 [95% CI, 30 to 20] and 9 (50%) patients no longer met criteria for PTSD. These preliminary findings support quetiapine as an adjunctive medication to facilitate CPT. A pragmatic trial is needed to evaluate the efficacy, safety, and feasibility of quetiapine to improve engagement in and completion rate of CPT.

Theranostic pharmacology in PTSD: Neurobiology and timing

Recent reviews and treatment guidelines regard trauma-focused cognitive-behavior therapies as the treatments of choice for chronic post-traumatic stress disorder (PTSD). However, many patients do not engage in this treatment when it is available, drop out before completion, or do not respond. Medications remain widely used, alone and in conjunction with psychotherapy, although the limitations of traditional monoamine-based pharmacotherapy are increasingly recognized. This article will review recent developments in psychopharmacology for PTSD, with a focus on current clinical data that apply putative neurobiologic mechanisms to medication use-i.e., a theranostic approach. A theranostic approach however, also requires consideration of timing, pre, peri or post trauma in conjunction with underlying dynamic processes affecting synaptic plasticity, the HPA axis, hippocampal activation, PFC-amygdala circuitry and fear memory.

Treatments of Posttraumatic Stress Disorder in Civilian Populations

PURPOSE OF REVIEW

Posttraumatic stress disorder is a chronic, heterogeneous disorder for which a multitude of psychotherapies, pharmaceuticals, and immerging treatment programs are available. Majority of efficacy studies focus on Caucasian male military populations, which may be a reason why not all patients respond to treatment with long-term positive outcomes. Additionally, effects of treatment on symptom clusters have been neglected. This work reviews treatment of PTSD and its symptom clusters exclusively in civilian populations, which have been historically under-examined in the literature.

RECENT FINDINGS

Exposure therapy stands at the forefront of successful PTSD treatment and offers a more cost-effective solution to pharmacotherapy; however, refugees and patients with comorbid depression may not experience such strong benefits. For exposure therapy and other forms of psychotherapy, non-inferiority studies point to promise of internet-delivered and telemedicine-based methods for reaching populations that may not have access to in-person care. SSRIs are the most widely used pharmaceutical treatment for PTSD; moderate initial benefits are observed yet long-term retention and outcomes may be enhanced by adjunct treatment. Again, refugees are a group that experiences lesser benefit. Research has begun to explore efficacy of treatments for individual symptom clusters, with hyperarousal benefiting most from currently available modalities. Avoidance, intrusion, negative thoughts and beliefs, and dissociation are symptoms requiring more research for focused interventions. Treatment of PTSD has evolved to (1) include equivalent proportions of men and women, along with focused female-exclusive cohorts; (2) explore novel methods of treatment online and in various cultural contexts; and (3) less focus on medication as evidenced by current clinical trials. In addition to further efficacy and safety studies in more diverse ethnic populations, work is needed to examine what therapies are best for targeting specific symptom clusters of PTSD. This research will drive precision treatment, and such research is beginning to point towards underlying mechanisms of pathology and change.

Efficacy of Prolonged Exposure Therapy, Sertraline Hydrochloride, and Their Combination Among Combat Veterans With Posttraumatic Stress Disorder: A Randomized Clinical Trial

Importance

Meta-analyses of treatments for posttraumatic stress disorder (PTSD) suggest that trauma-focused psychotherapies produce greater benefits than antidepressant medications alone.

Objective

To determine the relative efficacy of prolonged exposure therapy plus placebo, prolonged exposure therapy plus sertraline hydrochloride, and sertraline plus enhanced medication management in the treatment of PTSD.

Design, Setting, and Participants

The Prolonged Exposure and Sertraline Trial was a randomized, multisite, 24-week clinical trial conducted at the Veterans Affairs Ann Arbor Healthcare System, Veterans Affairs San Diego Healthcare System, Ralph H. Johnson Veterans Affairs Medical Center, and Massachusetts General Hospital Home Base Veterans Program between January 26, 2012, and May 9, 2016. Participants and clinicians were blinded to pill condition, and outcome evaluators were blinded to assignment. Participants completed assessments at weeks 0 (intake), 6, 12, 24, and 52 (follow-up). Participants (N = 223) were service members or veterans of the Iraq and/or Afghanistan wars with combat-related PTSD and significant impairment (Clinician-Administered PTSD Scale score, ≥50) of at least 3 months' duration. Analyses were on an intent-to-treat basis.

Intervention

Participants completed up to thirteen 90-minute sessions of prolonged exposure therapy by week 24. Sertraline dosage was titrated during a 10-week period and continued until week 24; medication management was manualized.

Main Outcomes and Measures

The primary outcome was symptom severity of PTSD in the past month as assessed by the Clinician-Administered PTSD Scale score at week 24.

Results

Of 223 randomized participants, 149 completed the study at 24 weeks, and 207 (180 men and 27 women; mean [SD] age, 34.5 [8.3 years]) were included in the intent-to-treat analysis. Modified intent-to-treat analysis using a mixed model of repeated measures showed that PTSD symptoms decreased significantly during the 24 weeks (sertraline plus enhanced medication management, 33.8 points; prolonged exposure therapy plus sertraline, 32.7 points; and prolonged exposure therapy plus placebo, 29.4 points; β,-9.39; 95% CI, -11.62 to -7.16; P < .001); however, slopes did not differ by treatment group (prolonged exposure therapy plus placebo group, -9.39; sertraline plus enhanced medication management group, -10.37; and prolonged exposure therapy plus sertraline group, -9.99; P = .81).

Conclusions and Relevance

No difference in change in PTSD symptoms or symptom severity at 24 weeks was found between sertraline plus enhanced medication management, prolonged exposure therapy plus placebo, and prolonged exposure therapy plus sertraline.

Trial Registration

ClinicalTrials.gov Identifier: NCT01524133.

Posttraumatic stress disorder and positive memories: Clinical considerations

Encoding and retrieval difficulties, and avoidance of both traumatic and positive memories, are associated with posttraumatic stress disorder (PTSD) symptoms. However, most PTSD research and clinical work has solely examined the role of traumatic memories in the maintenance/resolution of PTSD symptoms. This review provides a comprehensive discussion of the literature on positive memories and PTSD. First, we review theories and evidence on the relations between trauma, PTSD, and memory processes (particularly positive memories). Next, we propose a conceptual model that integrates evidence from experimental and positive/memory-based intervention research and highlights hypothesized mechanisms underlying the potential effectiveness of targeting positive memories in PTSD interventions. Specifically, we discuss how targeting positive memories could (1) increase positive affect and reduce negative affect, (2) correct negative cognitions, (3) increase specificity of retrieving autobiographical memories, and (4) be effectively integrated/sequenced with and enhance the effects of trauma-focused interventions. Lastly, we suggest clinical research avenues for investigating the relations between positive memories and PTSD, to possibly alter the current PTSD intervention paradigm focused only on traumatic memories. Overall, our proposed model drawing from experimental and intervention research, and outlining potential effects of targeting positive memories to reduce PTSD severity, needs further empirical investigation.

Age As Moderator of Emotional Stroop Task Performance in Posttraumatic Stress Disorder (PTSD)

Emotional Stroop task (EST) has been extensively used to investigate attentional processes in posttraumatic stress disorder (PTSD). Even though aging significantly changes the dynamics of emotion-cognition interactions, very little is known about its role in shaping EST performance in PTSD patients. In the present study we tested a uniquely large sample of motor vehicle accident victims. Data of 194 participants (75.3% female; mean age = 36.64 years, SD = 12.3) were included in the analysis, out of which 136 (70.1%) were diagnosed with PTSD. Prior to the psychiatric assessment, participants completed the pictorial version of EST (neutral, positive, negative, and accidents photos were presented). Comparison of the PTSD and control groups revealed a specific increase in reaction times (RTs) related to the exposure of trauma-related material. At the same time, previously unreported, moderating effects of age were also discovered. Older participants, in contrast to the younger group, showed no increase in RTs and interference scores in trials where accident photos were presented. Our study points to the key role of age as a previously understudied factor modifying EST performance in PTSD patients.