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Bertolini F, Robertson L, Bisson JI, Meader N, Churchill R, Ostuzzi G, Stein DJ, Williams T, Barbui C. Early pharmacological interventions for prevention of post-traumatic stress disorder (PTSD) in individuals experiencing acute traumatic stress symptoms. Cochrane Database Syst Rev 2024; 5:CD013613. [PMID: 38767196 PMCID: PMC11103774 DOI: 10.1002/14651858.cd013613.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Acute traumatic stress symptoms may develop in people who have been exposed to a traumatic event. Although they are usually self-limiting in time, some people develop post-traumatic stress disorder (PTSD), a severe and debilitating condition. Pharmacological interventions have been proposed for acute symptoms to act as an indicated prevention measure for PTSD development. As many individuals will spontaneously remit, these interventions should balance efficacy and tolerability. OBJECTIVES To assess the efficacy and acceptability of early pharmacological interventions for prevention of PTSD in adults experiencing acute traumatic stress symptoms. SEARCH METHODS We searched the Cochrane Common Mental Disorders Controlled Trial Register (CCMDCTR), CENTRAL, MEDLINE, Embase and two other databases. We checked the reference lists of all included studies and relevant systematic reviews. The search was last updated on 23 January 2023. SELECTION CRITERIA We included randomised controlled trials on adults exposed to any kind of traumatic event and presenting acute traumatic stress symptoms, without restriction on their severity. We considered comparisons of any medication with placebo, or with another medication. We excluded trials that investigated medications as an augmentation to psychotherapy. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. Using a random-effects model, we analysed dichotomous data as risk ratios (RR) and calculated the number needed to treat for an additional beneficial/harmful outcome (NNTB/NNTH). We analysed continuous data as mean differences (MD) or standardised mean differences (SMD). Our primary outcomes were PTSD severity and dropouts due to adverse events. Secondary outcomes included PTSD rate, functional disability and quality of life. MAIN RESULTS We included eight studies that considered four interventions (escitalopram, hydrocortisone, intranasal oxytocin, temazepam) and involved a total of 779 participants. The largest trial contributed 353 participants and the next largest, 120 and 118 participants respectively. The trials enrolled participants admitted to trauma centres or emergency departments. The risk of bias in the included studies was generally low except for attrition rate, which we rated as high-risk. We could meta-analyse data for two comparisons: escitalopram versus placebo (but limited to secondary outcomes) and hydrocortisone versus placebo. One study compared escitalopram to placebo at our primary time point of three months after the traumatic event. There was inconclusive evidence of any difference in terms of PTSD severity (mean difference (MD) on the Clinician-Administered PTSD Scale (CAPS, score range 0 to 136) -11.35, 95% confidence interval (CI) -24.56 to 1.86; 1 study, 23 participants; very low-certainty evidence), dropouts due to adverse events (no participant left the study early due to adverse events; 1 study, 31 participants; very low-certainty evidence) and PTSD rates (RR 0.59, 95% CI 0.03 to 13.08; NNTB 37, 95% CI NNTB 15 to NNTH 1; 1 study, 23 participants; very low-certainty evidence). The study did not assess functional disability or quality of life. Three studies compared hydrocortisone to placebo at our primary time point of three months after the traumatic event. We found inconclusive evidence on whether hydrocortisone was more effective in reducing the severity of PTSD symptoms compared to placebo (MD on CAPS -7.53, 95% CI -25.20 to 10.13; I2 = 85%; 3 studies, 136 participants; very low-certainty evidence) and whether it reduced the risk of developing PTSD (RR 0.47, 95% CI 0.09 to 2.38; NNTB 14, 95% CI NNTB 8 to NNTH 5; I2 = 36%; 3 studies, 136 participants; very low-certainty evidence). Evidence on the risk of dropping out due to adverse events is inconclusive (RR 3.19, 95% CI 0.13 to 75.43; 2 studies, 182 participants; low-certainty evidence) and it is unclear whether hydrocortisone might improve quality of life (MD on the SF-36 (score range 0 to 136, higher is better) 19.70, 95% CI -1.10 to 40.50; 1 study, 43 participants; very low-certainty evidence). No study assessed functional disability. AUTHORS' CONCLUSIONS This review provides uncertain evidence regarding the use of escitalopram, hydrocortisone, intranasal oxytocin and temazepam for people with acute stress symptoms. It is therefore unclear whether these pharmacological interventions exert a positive or negative effect in this population. It is important to note that acute traumatic stress symptoms are often limited in time, and that the lack of data prevents the careful assessment of expected benefits against side effects that is therefore required. To yield stronger conclusions regarding both positive and negative outcomes, larger sample sizes are required. A common operational framework of criteria for inclusion and baseline assessment might help in better understanding who, if anyone, benefits from an intervention. As symptom severity alone does not provide the full picture of the impact of exposure to trauma, assessment of quality of life and functional impairment would provide a more comprehensive picture of the effects of the interventions. The assessment and reporting of side effects may facilitate a more comprehensive understanding of tolerability.
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Affiliation(s)
- Federico Bertolini
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Lindsay Robertson
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Jonathan I Bisson
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Nicholas Meader
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Rachel Churchill
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Giovanni Ostuzzi
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Dan J Stein
- SAMRC Unit on Risk & Resilience in Mental Disorders, Dept of Psychiatry & Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Taryn Williams
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Corrado Barbui
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
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Bertolini F, Robertson L, Bisson JI, Meader N, Churchill R, Ostuzzi G, Stein DJ, Williams T, Barbui C. Early pharmacological interventions for universal prevention of post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev 2022; 2:CD013443. [PMID: 35141873 PMCID: PMC8829470 DOI: 10.1002/14651858.cd013443.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Post-traumatic stress disorder (PTSD) is a severe and debilitating condition. Several pharmacological interventions have been proposed with the aim to prevent or mitigate it. These interventions should balance efficacy and tolerability, given that not all individuals exposed to a traumatic event will develop PTSD. There are different possible approaches to preventing PTSD; universal prevention is aimed at individuals at risk of developing PTSD on the basis of having been exposed to a traumatic event, irrespective of whether they are showing signs of psychological difficulties. OBJECTIVES To assess the efficacy and acceptability of pharmacological interventions for universal prevention of PTSD in adults exposed to a traumatic event. SEARCH METHODS We searched the Cochrane Common Mental Disorders Controlled Trial Register (CCMDCTR), CENTRAL, MEDLINE, Embase, two other databases and two trials registers (November 2020). We checked the reference lists of all included studies and relevant systematic reviews. The search was last updated on 13 November 2020. SELECTION CRITERIA We included randomised clinical trials on adults exposed to any kind of traumatic event. We considered comparisons of any medication with placebo or with another medication. We excluded trials that investigated medications as an augmentation to psychotherapy. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. In a random-effects model, we analysed dichotomous data as risk ratios (RR) and number needed to treat for an additional beneficial/harmful outcome (NNTB/NNTH). We analysed continuous data as mean differences (MD) or standardised mean differences (SMD). MAIN RESULTS We included 13 studies which considered eight interventions (hydrocortisone, propranolol, dexamethasone, omega-3 fatty acids, gabapentin, paroxetine, PulmoCare enteral formula, Oxepa enteral formula and 5-hydroxytryptophan) and involved 2023 participants, with a single trial contributing 1244 participants. Eight studies enrolled participants from emergency departments or trauma centres or similar settings. Participants were exposed to a range of both intentional and unintentional traumatic events. Five studies considered participants in the context of intensive care units with traumatic events consisting of severe physical illness. Our concerns about risk of bias in the included studies were mostly due to high attrition and possible selective reporting. We could meta-analyse data for two comparisons: hydrocortisone versus placebo, but limited to secondary outcomes; and propranolol versus placebo. No study compared hydrocortisone to placebo at the primary endpoint of three months after the traumatic event. The evidence on whether propranolol was more effective in reducing the severity of PTSD symptoms compared to placebo at three months after the traumatic event is inconclusive, because of serious risk of bias amongst the included studies, serious inconsistency amongst the studies' results, and very serious imprecision of the estimate of effect (SMD -0.51, 95% confidence interval (CI) -1.61 to 0.59; I2 = 83%; 3 studies, 86 participants; very low-certainty evidence). No study provided data on dropout rates due to side effects at three months post-traumatic event. The evidence on whether propranolol was more effective than placebo in reducing the probability of experiencing PTSD at three months after the traumatic event is inconclusive, because of serious risk of bias amongst the included studies, and very serious imprecision of the estimate of effect (RR 0.77, 95% CI 0.31 to 1.92; 3 studies, 88 participants; very low-certainty evidence). No study assessed functional disability or quality of life. Only one study compared gabapentin to placebo at the primary endpoint of three months after the traumatic event, with inconclusive evidence in terms of both PTSD severity and probability of experiencing PTSD, because of imprecision of the effect estimate, serious risk of bias and serious imprecision (very low-certainty evidence). We found no data on dropout rates due to side effects, functional disability or quality of life. For the remaining comparisons, the available data are inconclusive or missing in terms of PTSD severity reduction and dropout rates due to adverse events. No study assessed functional disability. AUTHORS' CONCLUSIONS This review provides uncertain evidence only regarding the use of hydrocortisone, propranolol, dexamethasone, omega-3 fatty acids, gabapentin, paroxetine, PulmoCare formula, Oxepa formula, or 5-hydroxytryptophan as universal PTSD prevention strategies. Future research might benefit from larger samples, better reporting of side effects and inclusion of quality of life and functioning measures.
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Affiliation(s)
- Federico Bertolini
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Lindsay Robertson
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Jonathan I Bisson
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Nicholas Meader
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Rachel Churchill
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Giovanni Ostuzzi
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Dan J Stein
- Department of Psychiatry and Mental Health, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- MRC Unit on Risk & Resilience in Mental Disorders, University of Cape Town, Cape Town, South Africa
| | - Taryn Williams
- Department of Psychiatry and Mental Health, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Corrado Barbui
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Italy
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The efficacy of escitalopram in major depressive disorder: a multicenter randomized, placebo-controlled double-blind study. Int Clin Psychopharmacol 2021; 36:133-139. [PMID: 33779577 DOI: 10.1097/yic.0000000000000350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of the study was to conduct a multicenter randomized double-blinded placebo-controlled clinical study to evaluate the efficacy of a generic form of escitalopram in treating major depressive disorder (MDD). A total of 390 MDD patients admitted to hospitals in six cities in China were randomized to receive the generic version of escitalopram, the proprietary form of escitalopram (Lexapro) or placebo. During the 8-week treatment, the Hamilton rating scale for depression-17 (HAM-D17), Hamilton Anxiety Rating Scale (HAMA), Montgomery-Åsberg Depression Rating Scale (MADRS), Clinical Global Impressions scale (CGI), current visual analogue scale pain levels (VAS-P1) and Sheehan Disability Scale (SDS) assessments were performed at week 0, 1, 2, 4, 6 and 8 to evaluate treatment responses. HAM-D17, MADRS, HAMA and CGI-S levels of patients who received escitalopram or Lexapro decreased steadily during 8 weeks' treatment, whereas the placebo group showed a relatively smaller reduction of these levels (P < 0.001). SDS and VAS-P1 both decreased after treatment with generic escitalopram or proprietary escitalopram Lexapro. Our results indicated that both the generic escitalopram and proprietary escitalopram Lexapro had potent efficacy in treating MDD.
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Bryant RA. A critical review of mechanisms of adaptation to trauma: Implications for early interventions for posttraumatic stress disorder. Clin Psychol Rev 2021; 85:101981. [PMID: 33588312 DOI: 10.1016/j.cpr.2021.101981] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 11/23/2020] [Accepted: 01/19/2021] [Indexed: 10/22/2022]
Abstract
Although many attempts have been made to limit development of posttraumatic stress disorder (PTSD) by early intervention after trauma exposure, these attempts have achieved only modest success. This review critiques the biological and cognitive strategies used for early intervention and outlines the extent to which they have prevented PTSD. The major predictors of PTSD are reviewed, with an emphasis on potential mechanisms that may underpin the transition from acute stress reaction to development of PTSD. This review highlights that there is a wide range of biological and cognitive factors that have been shown to predict PTSD. Despite this, the major attempts at early intervention have focused on strategies that attempt to augment extinction processes or alter appraisals in the acute period. The documented predictors of PTSD indicate that a broader range of potential strategies could be explored to limit PTSD. The evidence that people follow different trajectories of stress response following trauma and there is a wide array of acute predictors of PTSD indicates that a flexible and tailored approach needs to be investigated to evaluate more effective early intervention strategies.
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von Känel R, Schmid JP, Meister-Langraf RE, Barth J, Znoj H, Schnyder U, Princip M, Pazhenkottil AP. Pharmacotherapy in the Management of Anxiety and Pain During Acute Coronary Syndromes and the Risk of Developing Symptoms of Posttraumatic Stress Disorder. J Am Heart Assoc 2021; 10:e018762. [PMID: 33432839 PMCID: PMC7955310 DOI: 10.1161/jaha.120.018762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background Benzodiazepines and morphine are given during acute coronary syndromes (ACSs) to alleviate anxiety and pain, and β‐blockers may also reduce pain. ACS may induce posttraumatic stress disorder (PTSD) symptoms (PTSS). When taken during trauma other than ACS, benzodiazepines increase the risk of PTSS, but it is unknown if benzodiazepines increase the risk of PTSS in ACS. We examined the effects of drug exposure during ACS on the development of PTSS. Methods and Results Study participants were 154 patients with a verified ACS. Baseline demographics, clinical variables, and psychological measures were obtained through a medical history, through a psychometric assessment, and from patient records, and used as covariates in linear regression analysis. Three months after ACS, the severity of PTSS was assessed with the Clinician‐Administered PTSD Scale. During ACS, 37.7% of patients were exposed to benzodiazepines, whereas 72.1% were exposed to morphine and 88.3% were exposed to β‐blockers, but only 7.1% were exposed to antidepressants. Eighteen (11.7%) patients developed clinical PTSD. Adjusting for all covariates, benzodiazepine use was significantly associated with the Clinician‐Administered PTSD Scale total severity score (unstandardized coefficient B [SE], 0.589 [0.274]; partial r=0.18; P=0.032) and the reexperiencing subscore (B [SE], 0.433 [0.217]; partial r=0.17; P=0.047). Patients exposed to benzodiazepines had an almost 4‐fold increased relative risk of developing clinical PTSD, adjusting for acute stress disorder symptoms (odds ratio, 3.75; 95% CI, 1.31–10.77). Morphine, β‐blockers, and antidepressants showed no predictive value. Conclusions Notwithstanding short‐term antianxiety effects during ACS, benzodiazepine use might increase the risk of ACS‐induced PTSS with clinical significance, thereby compromising patients' quality of life and prognosis. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01781247.
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Affiliation(s)
- Roland von Känel
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine University Hospital ZurichUniversity of Zurich Switzerland
| | - Jean-Paul Schmid
- Department of Cardiology Clinic Barmelweid Barmelweid Switzerland
| | - Rebecca E Meister-Langraf
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine University Hospital ZurichUniversity of Zurich Switzerland.,Clienia Schlössli AG Oetwil am See, Zurich Switzerland
| | - Jürgen Barth
- Complementary and Integrative Medicine University Hospital ZurichUniversity of Zurich Switzerland
| | - Hansjörg Znoj
- Department of Health Psychology and Behavioral Medicine University of Bern Switzerland
| | | | - Mary Princip
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine University Hospital ZurichUniversity of Zurich Switzerland
| | - Aju P Pazhenkottil
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine University Hospital ZurichUniversity of Zurich Switzerland.,Department of Cardiology University Hospital ZurichUniversity of Zurich Switzerland.,Cardiac Imaging Department of Nuclear Medicine University Hospital ZurichUniversity of Zurich Switzerland
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Cohen H, Zohar J, Carmi L. Effects of agomelatine on behaviour, circadian expression of period 1 and period 2 clock genes and neuroplastic markers in the predator scent stress rat model of PTSD. World J Biol Psychiatry 2020; 21:255-273. [PMID: 30230406 DOI: 10.1080/15622975.2018.1523560] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Objectives: The therapeutic value of the antidepressant agomelatine in the aftermath of traumatic experience and early post-reminder has been questioned. Herein, agomelatine, its vehicle or melatonin agonist were administered either acutely 1 h post-stressor or repeatedly (7 days) after early post-reminder in a post-traumatic stress rat model (PSS) using the scent of predator urine.Methods: Behavioural responses, and brain molecular and morphological changes were evaluated after each treatment procedure in PSS-exposed and unexposed rats.Results: When administered immediately after PSS, agomelatine induced a significant reduction of anxiety-like behaviour as assessed in the elevated-plus-maze and acoustic startle response at 8 days post-administration. Concomitantly, agomelatine significantly decreased Per1/Per2 expression in the CA1/CA3 areas, suprachiasmatic nucleus and basolateral amygdala, thereby partially restoring genes expression overregulated by PSS. Agomelatine further significantly increased cell growth and facilitated dendritic growth and arbour in dentate gyrus (DG) granule and apical CA1 cells and upregulated brain-derived neurotrophic factor protein in the DG and cortex III versus vehicle. When administered early post-reminder over 7 days before testing, agomelatine was ineffective on behavioural responses pattern, molecular and morphological changes induced by PSS.Conclusions: These findings suggest that agomelatine may be a potential agent in the acute aftermath of traumatic stress exposure.
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Affiliation(s)
- Hagit Cohen
- Beer-Sheva Mental Health Center, The State of Israel Ministry of Health, Anxiety and Stress Research Unit, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Joseph Zohar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lior Carmi
- School of Psychological Sciences, Tel Aviv University, Tel Aviv, Israel
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Cannabinoids as an Emerging Therapy for Posttraumatic Stress Disorder and Substance Use Disorders. J Clin Neurophysiol 2020; 37:28-34. [PMID: 31895187 DOI: 10.1097/wnp.0000000000000612] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Posttraumatic Stress Disorder (PTSD) is a leading psychiatric disorder that mainly affects military and veteran populations but can occur in anyone affected by trauma. PTSD treatment remains difficult for physicians because most patients with PTSD do not respond to current pharmacological treatment. Psychotherapy is effective, but time consuming and expensive. Substance use disorder is often concurrent with PTSD, which leads to a significant challenge for PTSD treatment. Cannabis has recently received widespread attention for the potential to help many patient populations. Cannabis has been reported as a coping tool for patients with PTSD and preliminary legalization data indicate Cannabis use may reduce the use of more harmful drugs, such as opioids. Rigorous clinical studies of Cannabis could establish whether Cannabis-based medicines can be integrated into treatment regimens for both PTSD and substance use disorder patients.
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Pharmacological prevention and early treatment of post-traumatic stress disorder and acute stress disorder: a systematic review and meta-analysis. Transl Psychiatry 2019; 9:334. [PMID: 31819037 PMCID: PMC6901463 DOI: 10.1038/s41398-019-0673-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 11/05/2019] [Accepted: 11/07/2019] [Indexed: 12/29/2022] Open
Abstract
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.
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Koek RJ, Luong TN. Theranostic pharmacology in PTSD: Neurobiology and timing. Prog Neuropsychopharmacol Biol Psychiatry 2019; 90:245-263. [PMID: 30529001 DOI: 10.1016/j.pnpbp.2018.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 11/17/2018] [Accepted: 12/05/2018] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Ralph J Koek
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Sepulveda Ambulatory Care Center, VA Greater Los Angeles Healthcare System, North Hills, CA, USA.
| | - Tinh N Luong
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Olive View Medical Center, Sylmar, CA, USA
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Danborg P, Valdersdorf M, Gøtzsche P. Long-term harms from previous use of selective serotonin reuptake inhibitors: A systematic review. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2019; 30:59-71. [PMID: 30714974 PMCID: PMC6839490 DOI: 10.3233/jrs-180046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Millions of people are treated with antidepressants like selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). This clinical practice is based on short-term trials that have exaggerated the benefits and underestimated the harms. We also know too little about long-term harms. AIM To assess harms of SSRIs and SNRIs that persist after end of drug intake. METHODS Systematic review of placebo-controlled randomised trials of any length in patients with a psychiatric diagnosis and a follow-up of at least six months. Our primary outcomes were mortality, functional outcomes, quality of life and core psychiatric events. We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials and checked the references for eligible articles. One researcher extracted data and another checked the data extraction. RESULTS Our searches returned 9,153 unique records. We included 22 papers for 12 trials on SSRIs. Median intervention and follow-up periods were 15 and 52 weeks, respectively. Median number of randomised participants was 51; only two trials had a drop-out rate below 20%.Outcome reporting was less thorough during follow-up than for the intervention period and only two trials maintained the blind during follow-up. All authors concluded that the drugs were not beneficial in the long term.All trials reported harms outcomes selectively or did not report any. Only two trials reported on any of our primary outcomes (school attendance and number of heavy drinking days). CONCLUSION The randomised trials currently available cannot be used to investigate persistent harms of antidepressants.
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Affiliation(s)
- P.B. Danborg
- Nordic Cochrane Centre, Rigshospitalet, Copenhagen, Denmark
| | - M. Valdersdorf
- Nordic Cochrane Centre, Rigshospitalet, Copenhagen, Denmark
| | - P.C. Gøtzsche
- Nordic Cochrane Centre, Rigshospitalet, Copenhagen, Denmark
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Effects of Selective Serotonin Reuptake Inhibitors on the Shock-Induced Ultrasonic Vocalization of Rats in Different Experimental Designs. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/b978-0-12-809600-0.00029-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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12
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Dworkin ER, Bergman HE, Walton TO, Walker DD, Kaysen DL. Co-Occurring Post-Traumatic Stress Disorder and Alcohol Use Disorder in U.S. Military and Veteran Populations. Alcohol Res 2018; 39:161-169. [PMID: 31198655 PMCID: PMC6561402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Co-occurring post-traumatic stress disorder (PTSD) and alcohol use disorder (AUD) are costly and consequential public health problems that negatively affect the health and well-being of U.S. military service members and veterans. The disproportionate burden of comorbid PTSD and AUD among U.S. military service members and veterans may be due to unique factors associated with military service, such as aspects of military culture, deployment, and trauma exposure. This review addresses the prevalence of co-occurring PTSD and AUD in military and veteran populations, population-specific factors that contribute to development of the comorbid conditions, and evidence-based treatments that have promise for addressing these conditions in military and veteran populations. Future directions for research and practice relevant to military and veteran populations are discussed.
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Cohen H, Zohar J, Kaplan Z, Arnt J. Adjunctive treatment with brexpiprazole and escitalopram reduces behavioral stress responses and increase hypothalamic NPY immunoreactivity in a rat model of PTSD-like symptoms. Eur Neuropsychopharmacol 2018; 28:63-74. [PMID: 29224968 DOI: 10.1016/j.euroneuro.2017.11.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 10/19/2017] [Accepted: 11/23/2017] [Indexed: 10/18/2022]
Abstract
The study explored effects of brexpiprazole (partial D2/5-HT1A agonist, 5-HT2A and α1B/2C-adrenoceptor antagonist) in rats exposed to predator scent stress (PSS), a proposed model of PTSD-like phenotype. Brexpiprazole (3.0mg/kg, PO), escitalopram (5.0mg/kg, IP) and their combination were administered twice daily for 14 days, starting 14 days after exposure to PSS or sham-PSS, shortly after a situational stress reminder. One day after last treatment behavioral responsivity was assessed. Brexpiprazole+escitalopram-treated rats spent more time in open arms, entered open arms more often and exhibited a lower anxiety index in the elevated plus maze than vehicle-treated, PSS-exposed rats. Adjunct brexpiprazole+escitalopram treatment reduced startle amplitude, compared with vehicle-treated, PSS-exposed rats. Treatment with either drug alone did not attenuate anxiety-like behaviors following PSS exposure. Use of cut-off behavioral criteria confirmed that adjunct treatment shifted prevalence of PSS-exposed rats from extreme towards minimal behavioral responders. One day following behavioral tests, brains were prepared for immunohistochemical analysis of number of BDNF-positive cells and of NPY-positive cells/fibers. PSS exposure decreased BDNF levels in hippocampus, but this was not affected by drug treatments. PSS exposure decreased number of NPY positive cells/fibers in paraventricular and arcuate nuclei of hypothalamus. Adjunct treatment with brexpiprazole+escitalopram increased NPY in PSS- and sham-exposed rats. Treatment with brexpiprazole alone had no effects, while treatment with escitalopram alone increased NPY in the arcuate nucleus of PSS-exposed rats. In conclusion, treatment with brexpiprazole+escitalopram may be an effective intervention for the attenuation of PTSD-like stress responses, which in part may be mediated by activating NPY function.
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Affiliation(s)
- Hagit Cohen
- Anxiety and Stress Research Unit, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Joseph Zohar
- The Chaim Sheba Medical Center, Sackler Medical School, Tel-Aviv University, Tel Hashomer, Israel
| | - Zeev Kaplan
- Anxiety and Stress Research Unit, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Jørn Arnt
- Synaptic Transmission, H. Lundbeck A/S, Ottiliavej 9, DK-2500 Valby, Denmark; Sunred Pharma Consulting ApS, Svend Gonges Vej 11A, DK-2680 Solrod Strand, Denmark.
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Beyer C, Cappetta K, Johnson JA, Bloch MH. Meta-analysis: Risk of hyperhidrosis with second-generation antidepressants. Depress Anxiety 2017; 34:1134-1146. [PMID: 28881483 DOI: 10.1002/da.22680] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 05/23/2017] [Accepted: 05/26/2017] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Our goal was to quantify the risk of hyperhidrosis associated with commonly used antidepressant agents and examine the impact of medication class, pharmacodynamics, and dose on risk of hyperhidrosis. METHODS We conducted a PubMed search to identify all double-blind, randomized, placebo-controlled trials examining the efficacy of second-generation antidepressant medications in the treatment of adults with a depressive disorder, anxiety disorders, or obsessive-compulsive disorder. We used a random-effects meta-analysis to examine the pooled risk ratio of hyperhidrosis reported as a side effect in adults treated with second-generation antidepressants compared to placebo. We used stratified subgroup analysis and metaregression to examine the effects of medication type, class, dosage, indication, and receptor affinity profile on the measured risk of hyperhidrosis. RESULTS We identified 76 trials involving 28,544 subjects. There was no significant difference in the risk of hyperhidrosis between serotonin-norepinephrine reuptake inhibitors (SNRI) [risk ratio (RR) = 3.17, 95% CI: 2.63-3.82] and selective serotonin reuptake inhibitors (SSRI) (RR = 2.93, 95% CI: 2.46-3.47) medications compared to placebo. All antidepressant medications were associated with a significantly increased risk of hyperhidrosis except fluvoxamine (RR = 0.56, 95% CI: 0.12-2.53), bupropion (RR = 1.23, 95% CI: 0.57-2.67), and vortioxetine (RR = 1.35, 95% CI: 0.79-2.33). The dose of SSRI/SNRI medications was not significantly associated with the risk of hyperhidrosis. Increased risk of hyperhidrosis was associated with increased affinity of SSRI/SNRI medications to the dopamine transporter. CONCLUSION Risk of hyperhidrosis was significantly increased with most antidepressant medications but was associated with dopamine transporter affinity.
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Affiliation(s)
- Chad Beyer
- Department of Psychiatry, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | | | - Jessica A Johnson
- Child Study Centre, Yale University School of Medicine, New Haven, CT, USA
| | - Michael H Bloch
- Department of Psychiatry, Yale University, New Haven, CT, USA
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Lipinska G, Thomas KGF. Better Sleep in a Strange Bed? Sleep Quality in South African Women with Posttraumatic Stress Disorder. Front Psychol 2017; 8:1555. [PMID: 28955274 PMCID: PMC5601006 DOI: 10.3389/fpsyg.2017.01555] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 08/25/2017] [Indexed: 11/13/2022] Open
Abstract
Although individuals diagnosed with posttraumatic stress disorder (PTSD) regularly report subjective sleep disruption, many studies using objective measures (e.g., polysomnography) report no PTSD-related sleep disruption. To account for these inconsistencies, some authors hypothesize that PTSD-diagnosed individuals have sleep-state misperception; that is, they self-report experiencing poor sleep quality, but objectively sleep relatively normally. We tested this sleep-state misperception hypothesis, collecting data on subjectively-reported sleep quality (in the home, and in the laboratory) and on objectively-measured, laboratory-based, sleep quality in PTSD-diagnosed participants from low socioeconomic status South African communities. Women with PTSD (n = 21), with trauma exposure but no PTSD (TE; n = 19), and healthy controls (HC; n = 20) completed questionnaires on their average sleep quality in the past 30 days, and on their sleep quality after a night (8 h) of polysomnographic-monitored sleep in the laboratory. PTSD-diagnosed individuals reported poorer everyday subjective sleep quality than TE and HC individuals. In the laboratory, however, there were no between-group differences in subjective sleep quality, and few between-group differences in objective sleep quality (PTSD-diagnosed individuals only had decreased sleep depth). Furthermore, whereas measures of laboratory-based objective and subjective sleep quality correlated significantly, especially in PTSD-diagnosed individuals, there were few significant associations between objective sleep measures and everyday subjective sleep quality. Taken together, these findings suggest that PTSD-diagnosed individuals likely experienced better sleep quality in the laboratory than at home. Descriptive observations corroborated this interpretation, with almost half the sample rating their laboratory sleep (which they described as “safe” and “quiet”) as better than their home sleep (which was experienced in an atmosphere marked by high levels of violence and nighttime noise). These findings disconfirm the sleep-state misperception hypothesis as related to PTSD, and suggest that the laboratory environment may influence sleep quality positively in these individuals. Many investigations of sleep in PTSD do not consider the influence of the laboratory environment. Our findings suggest that future studies in this field should consider that sleep-state misperception may be an artifact of the laboratory setting, especially when samples are drawn from communities where violence and crime are an everyday reality.
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Affiliation(s)
- Gosia Lipinska
- UCT Sleep Sciences and Applied Cognitive Science and Experimental Neuroscience Team, Department of Psychology, University of Cape TownCape Town, South Africa
| | - Kevin G F Thomas
- UCT Sleep Sciences and Applied Cognitive Science and Experimental Neuroscience Team, Department of Psychology, University of Cape TownCape Town, South Africa
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Birur B, Moore NC, Davis LL. An Evidence-Based Review of Early Intervention and Prevention of Posttraumatic Stress Disorder. Community Ment Health J 2017; 53:183-201. [PMID: 27470261 DOI: 10.1007/s10597-016-0047-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 07/22/2016] [Indexed: 12/13/2022]
Abstract
We present an evidence-based review of post-trauma interventions used to prevent posttraumatic stress disorder (PTSD). Literature search of PubMed from 1988 to March 2016 using keywords "Early Intervention AND Prevention of PTSD" yielded 142 articles, of which 52 intervention studies and 6 meta-analyses were included in our review. Trauma-focused cognitive behavioral therapy and modified prolonged exposure delivered within weeks of a potentially traumatic event for people showing signs of distress have the most evidence in the treatment of acute stress and early PTSD symptoms, and the prevention of PTSD. Even though several pharmacological agents have been tried, only hydrocortisone prior to high-risk surgery, severe traumatic injury, or during acute sepsis has adequate evidence for effectiveness in the reduction of acute stress symptoms and prevention of PTSD. There is an urgent need to determine the best targets for interventions after trauma to accelerate recovery and prevent PTSD.
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Affiliation(s)
- Badari Birur
- Department of Psychiatry, University of Alabama at Birmingham, 1713 6th Avenue South, Birmingham, AL, 35210, USA.
| | - Norman C Moore
- Department of Psychiatry, Quillen College of Medicine, East Tennessee State University, 70567, Johnson City, TN, 37614-1707, USA
| | - Lori L Davis
- Department of Psychiatry, University of Alabama at Birmingham, 1713 6th Avenue South, Birmingham, AL, 35210, USA.,VA Medical Center, 3701, Loop Road East, Tuscaloosa, AL, 35404, USA
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Birur B, Math SB, Fargason RE. A Review of Psychopharmacological Interventions Post-Disaster to Prevent Psychiatric Sequelae. PSYCHOPHARMACOLOGY BULLETIN 2017; 47:8-26. [PMID: 28138200 PMCID: PMC5274533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Disasters are mega-scale catastrophic events which cause trauma and mental health sequelae. A review of early pharmacological interventions for the prevention of psychiatric disorders following disasters is sorely needed. METHODS A literature search of "Psychiatric Sequelae AND Disasters", "Disaster mental health/Disaster psychiatry", "Psychotropics AND Disasters", and "Drug therapy AND Disasters" yielded 213 articles, 38 of which were included in the review. RESULTS Common post-disaster psychiatric conditions are: posttraumatic stress disorder (PTSD), depressive and anxiety disorders, substance use disorders and medically-unexplained psychological symptoms. Early psychopharmacological interventions to prevent PTSD provide promising evidence for hydrocortisone in medically ill trauma populations. Less robust benefits were noted for other pharmacological interventions. No reported trials have explored prevention of depression or other common post-disaster psychiatric conditions. CONCLUSION Hydrocortisone shows promise in preventing and reducing the psychiatric sequelae of PTSD following disasters. Further evaluation of hydrocortisone and other potentially beneficial psychopharmacological interventions are needed.
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Affiliation(s)
- Badari Birur
- Drs. Birur, MD, Assistant Professor, Fargason, MD, Department of Psychiatry and Behavioral Neurobiology, University of Alabama Birmingham, USA. Dr. Math, MD, Professor of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India
| | - Suresh Bada Math
- Drs. Birur, MD, Assistant Professor, Fargason, MD, Department of Psychiatry and Behavioral Neurobiology, University of Alabama Birmingham, USA. Dr. Math, MD, Professor of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India
| | - Rachel E Fargason
- Drs. Birur, MD, Assistant Professor, Fargason, MD, Department of Psychiatry and Behavioral Neurobiology, University of Alabama Birmingham, USA. Dr. Math, MD, Professor of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India
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Bryant RA. Acute stress disorder. Curr Opin Psychol 2017; 14:127-131. [PMID: 28813311 DOI: 10.1016/j.copsyc.2017.01.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 12/30/2016] [Accepted: 01/11/2017] [Indexed: 12/28/2022]
Abstract
Acute stress disorder (ASD) was introduced in DSM-IV to describe posttraumatic stress disorder (PTSD) symptoms that (a) occur in the initial month after trauma and (b) predict subsequent PTSD. Longitudinal studies have shown that most people who develop PTSD do not initially meet ASD criteria, which led to the decision in DSM-5 to limit the ASD diagnosis to describing acute stress reactions without any predictive function. Controlled trials have shown that trauma-focused cognitive behavior therapy is the treatment of choice for ASD, and is superior to pharmacological interventions. Recent longitudinal studies have challenged previous conceptualizations of the course of posttraumatic stress, and highlighted that people follow different trajectories of adaptation that are influenced by events that occur after the acute posttraumatic period.
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Affiliation(s)
- Richard A Bryant
- School of Psychology, University of New South Wales, Sydney, NSW 2052, Australia.
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Ahl R, Sjolin G, Mohseni S. Does early beta-blockade in isolated severe traumatic brain injury reduce the risk of post traumatic depression? Injury 2017; 48:101-105. [PMID: 27817882 DOI: 10.1016/j.injury.2016.10.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 10/09/2016] [Accepted: 10/28/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Depressive symptoms occur in approximately half of trauma patients, negatively impacting on functional outcome and quality of life following severe head injury. Pontine noradrenaline has been shown to increase upon trauma and associated β-adrenergic receptor activation appears to consolidate memory formation of traumatic events. Blocking adrenergic activity reduces physiological stress responses during recall of traumatic memories and impairs memory, implying a potential therapeutic role of β-blockers. This study examines the effect of pre-admission β-blockade on post-traumatic depression. METHODS All adult trauma patients (≥18 years) with severe, isolated traumatic brain injury (intracranial Abbreviated Injury Scale score (AIS) ≥3 and extracranial AIS <3) were recruited from the trauma registry of an urban university hospital between 2007 and 2011. Exclusion criteria were in-hospital deaths and prescription of antidepressants up to one year prior to admission. Pre- and post-admission β-blocker and antidepressant therapy data was requested from the national drugs registry. Post-traumatic depression was defined as the prescription of antidepressants within one year of trauma. Patients with and without pre-admission β-blockers were matched 1:1 by age, gender, Glasgow Coma Scale, Injury Severity Score and head AIS. Analysis was carried out using McNemar's and Student's t-test for categorical and continuous data, respectively. RESULTS A total of 545 patients met the study criteria. Of these, 15% (n=80) were prescribed β-blockers. After propensity matching, 80 matched pairs were analyzed. 33% (n=26) of non β-blocked patients developed post-traumatic depression, compared to only 18% (n=14) in the β-blocked group (p=0.04). There were no significant differences in ICU (mean days: 5.8 (SD 10.5) vs. 5.6 (SD 7.2), p=0.85) or hospital length of stay (mean days: 21 (SD 21) vs. 21 (SD 20), p=0.94) between cohorts. CONCLUSION β-blockade appears to act prophylactically and significantly reduces the risk of post-traumatic depression in patients suffering from isolated severe traumatic brain injuries. Further prospective randomized studies are warranted to validate this finding.
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Affiliation(s)
- Rebecka Ahl
- Karolinska University Hospital, Division of Trauma and Emergency Surgery, Department of Surgery, 171 76, Stockholm, Sweden; School of Medical Sciences, Orebro University, Fakultetsgatan 1, 702 81, Orebro, Sweden.
| | - Gabriel Sjolin
- Orebro University Hospital, Division of Trauma and Emergency Surgery, Department of Surgery, 701 85, Orebro, Sweden.
| | - Shahin Mohseni
- Karolinska University Hospital, Division of Trauma and Emergency Surgery, Department of Surgery, 171 76, Stockholm, Sweden; Orebro University Hospital, Division of Trauma and Emergency Surgery, Department of Surgery, 701 85, Orebro, Sweden; School of Medical Sciences, Orebro University, Fakultetsgatan 1, 702 81, Orebro, Sweden.
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Thomas E, Stein DJ. Novel pharmacological treatment strategies for posttraumatic stress disorder. Expert Rev Clin Pharmacol 2016; 10:167-177. [PMID: 27835034 DOI: 10.1080/17512433.2017.1260001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION A wide range of medications have been studied for posttraumatic stress disorder (PTSD) and a number are registered for this indication. Nevertheless, current pharmacotherapies are only partially effective in some patients, and are minimally effective in others. Thus novel treatment avenues need to be explored. Areas covered: In considering novel pharmacological agents for the treatment of PTSD, this paper takes a translational approach. We outline how advances in our understanding of the underlying neurobiology of PTSD may inform the identification of potential new treatment targets, including glutamatergic, noradrenergic and opioid pathways. Expert commentary: Continued investigation of the neural substrates and signalling pathways involved in responses to trauma may inform the development of novel treatment targets for future drug development for PTSD. However, the translation of preclinical findings to clinical practice is likely to be complex and gradual.
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Affiliation(s)
- Eileen Thomas
- a Division of Consultation Liaison, Department of Psychiatry and Mental Health , University of Cape Town , Cape Town , South Africa
| | - Dan J Stein
- b US/UCT MRC Unit on Anxiety and Stress Disorders, Department of Psychiatry and Mental Health , University of Cape Town , Cape Town , South Africa
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Abstract
Post-traumatic stress disorder (PTSD) is a frequent, tenacious, and disabling consequence of traumatic events. The disorder's identifiable onset and early symptoms provide opportunities for early detection and prevention. Empirical findings and theoretical models have outlined specific risk factors and pathogenic processes leading to PTSD. Controlled studies have shown that theory-driven preventive interventions, such as cognitive behavioral therapy (CBT), or stress hormone-targeted pharmacological interventions, are efficacious in selected samples of survivors. However, the effectiveness of early clinical interventions remains unknown, and results obtained in aggregates (large groups) overlook individual heterogeneity in PTSD pathogenesis. We review current evidence of PTSD prevention and outline the need to improve the disorder's early detection and intervention in individual-specific paths to chronic PTSD.
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Affiliation(s)
- Wei Qi
- Department of Psychiatry, New York University School of Medicine, 1 Park Ave, 8th Floor, 8-256, New York, USA.
| | - Martin Gevonden
- Department of Psychiatry, New York University School of Medicine, 1 Park Ave, 8th Floor, 8-256, New York, USA.
| | - Arieh Shalev
- Department of Psychiatry, New York University School of Medicine, 1 Park Ave, 8th Floor, 8-256, New York, USA.
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