Pharmacotherapy for post-traumatic stress disorder: systematic review and meta-analysis

Dissociable consequences of moderate and high volume stress are mediated by the differential energetic demands of stress

Exposure to traumatic stress leads to persistent, deleterious behavioral and biological changes in both human and non-human species. The effects of stress are not always consistent, however, as exposure to different stressors often leads to heterogeneous effects. The intensity of the stressor may be a key factor in determining the consequences of stress. While it is difficult to quantify intensity for many stress types, electric shock exposure provides us with a stressor that has quantifiable parameters (presentation length x intensity x number = shock volume). Therefore, to test the procedural differences in shock volume that may account for some reported heterogeneity, we used two common shock procedures. Learned helplessness is a commonly reported behavioral outcome, highlighted by a deficit in subsequent shuttle-box escape, which requires a relatively high-volume stress (HVS) of about 100 uncontrollable shocks. Conversely, stress-enhanced fear learning (SEFL) is another common behavioral outcome that requires a relatively moderate-volume stress (MVS) of only 15 shocks. We exposed rats to HVS, MVS, or no stress (NS) and examined the effects on subsequent fear learning and normal weight gain. We found doubly dissociable effects of the two levels of stress. MVS enhanced contextual fear learning but did not impact weight, while HVS produced the opposite pattern. In other words, more stress does not simply lead to greater impairment. We then tested the hypothesis that the different stress-induced sequalae arouse from an energetic challenge imposed on the hippocampus by HVS but not MVS. HVS rats that consumed a glucose solution did exhibit SEFL. Furthermore, rats exposed to MVS and glucoprivated during single-trial context conditioning did not exhibit SEFL. Consistent with the hypothesis that the inability of HVS to enhance fear learning is because of an impact on the hippocampus, HVS did enhance hippocampus-independent auditory fear learning. Finally, we provide evidence that stressors of different volumes produce dissociable changes in glutamate receptor proteins in the basolateral amygdala (BLA) and dorsal hippocampus (DH). The data indicate that while the intensity of stress is a critical determinant of stress-induced phenotypes that effect is nonlinear.

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.

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.

Fluoxetine protects against inflammation and promotes autophagy in mice model of post-traumatic stress disorder

Post-traumatic stress disorder is a major public health problem due to its frequency, chronicity, and disability that impact daily life. Studies have evidenced that the activation/inhibition of autophagy and excessive activation of microglia have a relationship with PTSD. For this purpose, C57BL/6 mice were employed to establish the post-traumatic stress disorder pathology mice model by conditioned fear and single prolonged stress (CF + SPS). Fluoxetine and PLX3397 were administered. PTSD-like behaviors were alleviated following fluoxetine treatment, evidenced via open field and conditioned fear test. Autophagy-associated proteins were upregulated, and inflammation factors were reduced after fluoxetine treatment. Microglia depletion mice showed a lower inflammatory level. In conclusion, fluoxetine can promote autophagy and inhibit neuroinflammation in mice model of PTSD, providing a theoretical basis for fluoxetine in treating PTSD.

Psychopharmacoepidemiology of antidepressant medications among homeless and unstably housed service users in the Veterans Affairs healthcare system

OBJECTIVE

This study conducted a pharmacoepidemiologic examination of antidepressant prescription patterns in homeless and unstably housed (HUH) populations.

METHODS

Data were analyzed on over 2.6 million veterans from the U.S. Department of Veterans Affairs (VA), the largest provider of healthcare for HUH veterans and a system that does not require healthcare insurance.

RESULTS

Multivariable analyses revealed that HUH veterans with depression and PTSD were less likely to receive an antidepressant Rx compared to their stably housed (SH) counterparts with these conditions (OR = 0.77, 99% CI = 0.74-0.79; and OR = 0.87, 99% CI = 0.84-0.90, respectively). Antidepressants were mostly prescribed in specialty mental health care settings, but HUH veterans were less likely to be prescribed antidepressants in primary care settings than SH veterans. In the total sample, the 40-49 age group, female sex, VA service-connected disability, outpatient mental health visits, and emergency department visits were positively associated with any antidepressant Rx. Nearly all psychiatric diagnoses were more associated with prescription of selective serotonin reuptake inhibitors/serotonin and norepinephrine reuptake inhibitors (SSRIs/SNRIs) than tricyclic antidepressants.

CONCLUSION

These findings highlight socioeconomic disparities in antidepressant Rx in a healthcare system that does not rely on insurance and suggest clinical challenges with antidepressant prescriptions in HUH populations.

Integrating human brain proteomes with genome-wide association data implicates novel proteins in post-traumatic stress disorder

Genome-wide association studies (GWAS) have identified several risk loci for post-traumatic stress disorder (PTSD); however, how they confer PTSD risk remains unclear. We aimed to identify genes that confer PTSD risk through their effects on brain protein abundance to provide new insights into PTSD pathogenesis. To that end, we integrated human brain proteomes with PTSD GWAS results to perform a proteome-wide association study (PWAS) of PTSD, followed by Mendelian randomization, using a discovery and confirmatory study design. Brain proteomes (N = 525) were profiled from the dorsolateral prefrontal cortex using mass spectrometry. The Million Veteran Program (MVP) PTSD GWAS (n = 186,689) was used for the discovery PWAS, and the Psychiatric Genomics Consortium PTSD GWAS (n = 174,659) was used for the confirmatory PWAS. To understand whether genes identified at the protein-level were also evident at the transcript-level, we performed a transcriptome-wide association study (TWAS) using human brain transcriptomes (N = 888) and the MVP PTSD GWAS results. We identified 11 genes that contribute to PTSD pathogenesis via their respective cis-regulated brain protein abundance. Seven of 11 genes (64%) replicated in the confirmatory PWAS and 4 of 11 also had their cis-regulated brain mRNA levels associated with PTSD. High confidence level was assigned to 9 of 11 genes after considering evidence from the confirmatory PWAS and TWAS. Most of the identified genes are expressed in other PTSD-relevant brain regions and several are preferentially expressed in excitatory neurons, astrocytes, and oligodendrocyte precursor cells. These genes are novel, promising targets for mechanistic and therapeutic studies to find new treatments for PTSD.

Post-trauma behavioral phenotype predicts the degree of vulnerability to fear relapse after extinction in male rats

Current treatments for trauma-related disorders remain ineffective for many patients.^1,2 Fear extinction deficiency is a prominent feature of these diseases,³ and many behavioral treatments rely on extinction training.^4,5 However, in many patients, therapy is followed by a relapse of symptoms, and the underpinnings of such interindividual variations in vulnerability to relapse remain unknown.^6-8 Here, we modeled interindividual differences in post-therapy fear relapse with an ethologically relevant trauma recovery paradigm. After fear conditioning, male rats underwent fear extinction while foraging in a large enriched arena, permitting the expression of a wide spectrum of behaviors. An automated multidimensional behavioral assessment revealed that post-conditioning fear response profiles clustered into two groups: some animals expressed fear by freezing more, whereas others darted more, as if fleeing from danger. Remarkably, the tendency of an animal to dart or to freeze after CS presentation during the first extinction session was, respectively, associated with stronger or weaker fear renewal. Moreover, genome-wide transcriptional profiling revealed that these groups differentially regulated specific sets of genes, some of which were previously implicated in anxiety and trauma-related disorders. Our results suggest that post-trauma behavioral phenotypes and the associated gene expression landscapes can serve as markers of fear relapse susceptibility and thus may be instrumental for future development of more effective treatments for psychiatric patients.

Effects of a psychedelic 5-HT2A receptor agonist on anxiety-related behavior and fear processing in mice

Psychedelic-assisted psychotherapy gained considerable interest as a novel treatment strategy for fear-related mental disorders but the underlying mechanism remains poorly understood. The serotonin 2A (5-HT2A) receptor is a key target underlying the effects of psychedelics on emotional arousal but its role in fear processing remains controversial. Using the psychedelic 5-HT2A/5-HT2C receptor agonist 2,5-dimethoxy-4-iodoamphetamine (DOI) and 5-HT2A receptor knockout (KO) mice we investigated the effect of 5-HT2A receptor activation on emotional processing. We show that DOI administration did not impair performance in a spontaneous alternation task but reduced anxiety-like avoidance behavior in the elevated plus maze and elevated zero maze tasks. Moreover, we found that DOI did not block memory recall but diminished fear expression in a passive avoidance task. Likewise, DOI administration reduced fear expression in an auditory fear conditioning paradigm, while it did not affect retention of fear extinction when administered prior to extinction learning. The effect of DOI on fear expression was abolished in 5-HT2A receptor KO mice. Administration of DOI induced a significant increase of c-Fos expression in specific amygdalar nuclei. Moreover, local infusion of the 5-HT2A receptor antagonist M100907 into the amygdala reversed the effect of systemic administration of DOI on fear expression while local administration of DOI into the amygdala was sufficient to suppress fear expression. Our data demonstrate that activation of 5-HT2A receptors in the amygdala suppresses fear expression but provide no evidence for an effect on retention of fear extinction.

Effects of propranolol on the modification of trauma memory reconsolidation in PTSD patients: A systematic review and meta-analysis

Post-traumatic stress disorder (PTSD) develops after an exposure to a life-threatening event and is characterized by intrusive memories. According to memory reconsolidation theory retrieval of memory under certain conditions leads to its labilization and subsequent re-storage which could be disrupted by drugs. Propranolol has been the most commonly investigated drug for memory reconsolidation therapy in clinical trials. Intervention with propranolol have shown mixed results in PTSD patients with some studies showing improvement in symptoms while other failing to replicate these findings. We conducted a systematic review and meta-analysis to determine the efficacy of trauma memory disruption by propranolol on PTSD symptoms and physiological responses in PTSD patients. 3224 publications were assessed for eligibility. Seven studies on effects of propranolol on PTSD symptoms and 3 studies on effects of propranolol on physiological responses were incorporated in the meta-analyses. Overall, results indicate that propranolol did not show a beneficial effect on PTSD symptoms (standardized mean difference: 1.29; 95% CI = -2.16 - 0.17). Similarly, propranolol did not influence skin conductance (standardized mean difference: 0.77; 95% CI = -1.85 - 0.31) or EMG response (standardized mean difference: 0.16; 95% CI = -0.65 - 0.33). However, propranolol significantly reduced heart rate after trauma memory recall compared to placebo (standardized mean difference: 0.67; 95% CI = -1.27 to -0.07). This study finds a lack of evidence for the efficacy of propranolol on traumatic memory disruption, in PTSD patients, to recommend its routine clinical use. However, a high level of heterogeneity, variation in propranolol dosage and inadequate sample sizes mean that these findings require cautious interpretation.

Laboratory models of post-traumatic stress disorder: The elusive bridge to translation

Post-traumatic stress disorder (PTSD) is a debilitating mental illness composed of a heterogeneous collection of symptom clusters. The unique nature of PTSD as arising from a precipitating traumatic event helps simplify cross-species translational research modeling the neurobehavioral effects of stress and fear. However, the neurobiological progress on these complex neural circuits informed by animal models has yet to produce novel, evidence-based clinical treatment for PTSD. Here, we provide a comprehensive overview of popular laboratory models of PTSD and provide concrete ideas for improving the validity and clinical translational value of basic research efforts in humans. We detail modifications to simplified animal paradigms to account for myriad cognitive factors affected in PTSD, which may contribute to abnormalities in regulating fear. We further describe new avenues for integrating different areas of psychological research underserved by animal models of PTSD. This includes incorporating emerging trends in the cognitive neuroscience of episodic memory, emotion regulation, social-emotional processes, and PTSD subtyping to provide a more comprehensive recapitulation of the human experience to trauma in laboratory research.

Ifenprodil tartrate treatment of adolescents with post-traumatic stress disorder: A double-blind, placebo-controlled trial

BACKGROUND

Several lines of evidence suggest that glutamatergic neurotransmission via the N-methyl-D-aspartate (NMDA) receptor plays a role in certain behavioral manifestations common to Post-Traumatic Stress Disorder (PTSD). Ifenprodil tartrate is a neuroprotective agent that binds to the GluN2B subunit of the NMDA receptor. The aim of this study is to confirm whether ifenprodil tartrate is effective in the adolescent PTSD patients.

METHODS

This is a randomized, double-blind, placebo-controlled trial. Ten adolescent (13 to 18 years old) PTSD patients were randomized into two arms: placebo (n = 4), 40 mg/day ifenprodil tartrate (n = 6) for 4 weeks. All of the patients were assessed by IES-R-J (Primary outcome measure), TSCC-J, CDRS-R, DSRS-C-J and CGI-I.

RESULTS

A comparison of baseline IES-R-J total scores and 4-week end-point scores showed a mild trend of improvement (p = 0.0895) and the difference score was -9.314. A comparison of baseline scores and 2-week intermediate-point scores showed that IES-R-J hyperarousal subscores and TSCC-J subscores (dissociation subscores, sexual concerns subscores) improved significantly. A comparison of baseline TSCC-J sexual concerns subscores and 4-week end-point scores improved significantly.

CONCLUSIONS

Our study may prove to be an short-term effective alternative safe treatment for adolescent patients with PTSD.

Metabolomics analysis of post-traumatic stress disorder symptoms in World Trade Center responders

Metabolomics has yielded promising insights into the pathophysiology of post-traumatic stress disorder (PTSD). The current study expands understanding of the systems-level effects of metabolites by using global metabolomics and complex lipid profiling in plasma samples from 124 World Trade Center responders (56 PTSD, 68 control) on 1628 metabolites. Differential metabolomics analysis identified hexosylceramide HCER(26:1) associated with PTSD at FDR < 0.1. The multi-metabolite composite score achieved an AUC of 0.839 for PTSD versus unaffected control classification. Independent component analysis identified three metabolomic modules significantly associated with PTSD. These modules were significantly enriched in bile acid metabolism, fatty acid metabolism and pregnenolone steroids, which are involved in innate immunity, inflammatory process and neuronal excitability, respectively. Integrative analysis of metabolomics and our prior proteomics datasets on subsample of 96 responders identified seven proteomic modules significantly correlated with metabolic modules. Overall, our findings shed light on the molecular alterations and identify metabolomic-proteomic signatures associated with PTSD by using machine learning and network approaches to enhance understanding of the pathways implicated in PTSD. If present results are confirmed in follow-up studies, they may inform development of novel treatments.

Diverse therapeutic developments for post-traumatic stress disorder (PTSD) indicate common mechanisms of memory modulation

Post-traumatic stress disorder (PTSD), characterized by abnormally persistent and distressing memories, is a chronic debilitating condition in need of new treatment options. Current treatment guidelines recommend psychotherapy as first line management with only two drugs, sertraline and paroxetine, approved by U.S. Food and Drug Administration (FDA) for treatment of PTSD. These drugs have limited efficacy as they only reduce symptoms related to depression and anxiety without producing permanent remission. PTSD remains a significant public health problem with high morbidity and mortality requiring major advances in therapeutics. Early evidence has emerged for the beneficial effects of psychedelics particularly in combination with psychotherapy for management of PTSD, including psilocybin, MDMA, LSD, cannabinoids, ayahuasca and ketamine. MDMA and psilocybin reduce barrier to therapy by increasing trust between therapist and patient, thus allowing for modification of trauma related memories. Furthermore, research into the memory reconsolidation mechanisms has allowed for identification of various pharmacological targets to disrupt abnormally persistent memories. A number of pre-clinical and clinical studies have investigated novel and re-purposed pharmacological agents to disrupt fear memory in PTSD. Novel therapeutic approaches like neuropeptide Y, oxytocin, cannabinoids and neuroactive steroids have also shown potential for PTSD treatment. Here, we focus on the role of fear memory in the pathophysiology of PTSD and propose that many of these new therapeutic strategies produce benefits through the effect on fear memory. Evaluation of recent research findings suggests that while a number of drugs have shown promising results in preclinical studies and pilot clinical trials, the evidence from large scale clinical trials would be needed for these drugs to be incorporated in clinical practice.

Peptide LCGA-17 Attenuates Behavioral and Neurochemical Deficits in Rodent Models of PTSD and Depression

We have previously described the LCGA-17 peptide as a novel anxiolytic and antidepressant candidate that acts through the α2δ VGCC (voltage-gated calcium channel) subunit with putative synergism with GABA-A receptors. The current study tested the potential efficacy of acute and chronic intranasal (i.n.) LCGA-17 (0.05 mg/kg and 0.5 mg/kg) in rats on predator odor-induced conditioned place aversion (POCPA), a model of post-traumatic stress disorder (PTSD), and chronic unpredictable stress (CUS) that produce a range of behavioral and physiological changes that parallel symptoms of depression in humans. CUS and LCGA-17 treatment effects were tested in the sucrose preference (SPT) social interaction (SI), female urine sniffing (FUST), novelty-suppressed feeding (NSFT), and forced swim (FST) tests. Analysis of the catecholamines content in brain structures after CUS was carried out using HPLC. The efficacy of i.n. LCGA-17 was also assessed using the Elevated plus-maze (EPM) and FST. Acute LCGA-17 administration showed anxiolytic and antidepressant effects in EPM and FST, similar to diazepam and ketamine, respectively. In the POCPA study, LCGA-17 significantly reduced place aversion, with efficacy greater than doxazosin. After CUS, chronic LCGA-17 administration reversed stress-induced alterations in numerous behavioral tests (SI, FUST, SPT, and FST), producing significant anxiolytic and antidepressant effects. Finally, LCGA-17 restored the norepinephrine levels in the hippocampus following stress. Together, these results support the further development of the LCGA-17 peptide as a rapid-acting anxiolytic and antidepressant.

To BDZ or not to BDZ? That is the question! Is there reliable scientific evidence for or against using benzodiazepines in the aftermath of potentially traumatic events for the prevention of PTSD? A systematic review and meta-analysis

BACKGROUND

Most international guidelines suggest that benzodiazepines (BDZs) may be inefficient or iatrogenic in the aftermath of a potentially traumatic event (PTE). The goal of this study was to assess the strength of the evidence on whether the use of BDZs in the aftermath of a PTE negatively affects the incidence and severity of post-traumatic stress disorder (PTSD).

METHODS

We systematically scrutinized the ISI Web of Knowledge, MEDLINE, SCOPUS, and PTSDpubs electronic databases in addition to citation searching. We included original studies providing data about the development of PTSD in adults after BDZ administration in the aftermath of a PTE. We screened 387 abstracts and selected eight studies for the qualitative synthesis and seven for the meta-analysis. We performed two separate meta-analyses, one for randomized clinical trials (RCTs) and the other for cohort studies. Heterogeneity between studies was evaluated with Higgins I² statistic and tested using the χ². This study was registered at PROSPERO (number 127170).

RESULTS

The meta-analysis of the cohort studies showed an increased risk of PTSD in patients who received BDZs compared to those who did not (risk ratio (RR) = 1.53; 95% confidence interval (CI): 1.05-2.23) with a modest heterogeneity among studies (I² = 41.8, p = 0.143). Regarding the RCTs, the combined measure revealed a tendency toward an increased severity of the PTSD symptoms (standardized mean difference (SMD): 0.24; 95% CI: 0.32-0.79).

CONCLUSION

The studies reviewed showed a possible harmful effect of BDZs when used immediately after a PTE. However, these conclusions were based on a small number of studies of poor to moderate methodological quality.

Pharmacotherapy for post traumatic stress disorder (PTSD)

BACKGROUND

Posttraumatic stress disorder (PTSD) is a prevalent and disabling disorder. Evidence that PTSD is characterised by specific psychobiological dysfunctions has contributed to a growing interest in the use of medication in its treatment.

OBJECTIVES

To assess the effects of medication for reducing PTSD symptoms in adults with PTSD.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 11, November 2020); MEDLINE (1946-), Embase (1974-), PsycINFO (1967-) and PTSDPubs (all available years) either directly or via the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR). We also searched international trial registers. The date of the latest search was 13 November 2020.

SELECTION CRITERIA

All randomised controlled trials (RCTs) of pharmacotherapy for adults with PTSD.

DATA COLLECTION AND ANALYSIS

Three review authors (TW, JI, and NP) independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. We contacted investigators to obtain missing data. We stratified summary statistics by medication class, and by medication agent for all medications. We calculated dichotomous and continuous measures using a random-effects model, and assessed heterogeneity.

MAIN RESULTS

We include 66 RCTs in the review (range: 13 days to 28 weeks; 7442 participants; age range 18 to 85 years) and 54 in the meta-analysis.  For the primary outcome of treatment response, we found evidence of beneficial effect for selective serotonin reuptake inhibitors (SSRIs) compared with placebo (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.59 to 0.74; 8 studies, 1078 participants), which improved PTSD symptoms in 58% of SSRI participants compared with 35% of placebo participants, based on moderate-certainty evidence.  For this outcome we also found evidence of beneficial effect for the noradrenergic and specific serotonergic antidepressant (NaSSA) mirtazapine: (RR 0.45, 95% CI 0.22 to 0.94; 1 study, 26 participants) in 65% of people on mirtazapine compared with 22% of placebo participants, and for the tricyclic antidepressant (TCA) amitriptyline (RR 0.60, 95% CI 0.38 to 0.96; 1 study, 40 participants) in 50% of amitriptyline participants compared with 17% of placebo participants, which improved PTSD symptoms. These outcomes are based on low-certainty evidence. There was however no evidence of beneficial effect for the number of participants who improved with the antipsychotics (RR 0.51, 95% CI 0.16 to 1.67; 2 studies, 43 participants) compared to placebo, based on very low-certainty evidence. For the outcome of treatment withdrawal, we found evidence of a harm for the individual SSRI agents compared with placebo (RR 1.41, 95% CI 1.07 to 1.87; 14 studies, 2399 participants). Withdrawals were also higher for the separate SSRI paroxetine group compared to the placebo group (RR 1.55, 95% CI 1.05 to 2.29; 5 studies, 1101 participants). Nonetheless, the absolute proportion of individuals dropping out from treatment due to adverse events in the SSRI groups was low (9%), based on moderate-certainty evidence. For the rest of the medications compared to placebo, we did not find evidence of harm for individuals dropping out from treatment due to adverse events.

AUTHORS' CONCLUSIONS

The findings of this review support the conclusion that SSRIs improve PTSD symptoms; they are first-line agents for the pharmacotherapy of PTSD, based on moderate-certainty evidence. The NaSSA mirtazapine and the TCA amitriptyline may also improve PTSD symptoms, but this is based on low-certainty evidence. In addition, we found no evidence of benefit for the number of participants who improved following treatment with the antipsychotic group compared to placebo, based on very low-certainty evidence. There remain important gaps in the evidence base, and a continued need for more effective agents in the management of PTSD.

Four Questions Nurses Can Ask to Predict PTSD 1 Year After a Motor Vehicle Crash

BACKGROUND

The role of nurses in screening for posttraumatic stress disorder is crucial in trauma units.

OBJECTIVES

To create and evaluate an easy and brief tool for nurses to predict chronic posttraumatic stress disorder 1 year after a motor vehicle crash.

METHODS

We performed a 1-year follow-up multicenter study from 2007 to 2015, including 274 patients injured in a motor vehicle crash who were hospitalized in an orthopedic trauma unit. Nurses administered the DEPITAC questionnaire. Posttraumatic stress disorder was measured by the Post-Traumatic Stress Disorder Checklist of symptoms during the first year following the crash. A multivariable logistic regression model was implemented to select items significantly associated with posttraumatic stress disorder to improve the DEPITAC questionnaire. Predictive performance to predict posttraumatic stress disorder 1 year after the motor vehicle crash was examined for these different models.

RESULTS

Of 274 patients studied, a total of 75.9% completed the questionnaire at 1 year of follow-up. We found that only two questions and two simple elements of the patient's medical record (other injury or a person dying during the crash, perception of vital threat, number of children, and length of stay in trauma) predicted posttraumatic stress disorder 1 year after a motor vehicle crash.

CONCLUSIONS

The brevity of this evaluation, simple scoring rules, and screening test performance suggest that this new screening tool can be easily administered in the acute care setting by nurses.

Protocol for individual participant data meta-analysis of interventions for post-traumatic stress

INTRODUCTION

Several evidence-based treatments are effective for post-traumatic stress disorder (PTSD), yet a substantial proportion of patients do not respond or dropout of treatment. We describe the protocol for a systematic review and individual participant data meta-analysis (IPD-MA) aimed at assessing the effectiveness and adverse effects of psychotherapy and pharmacotherapy interventions for treating PTSD. Additionally, we seek to examine moderators and predictors of treatment outcomes.

METHOD AND ANALYSIS

This IPD-MA includes randomised controlled trials comparing psychotherapy and pharmacotherapy interventions for PTSD. PubMed, Embase, PsycINFO, PTSDpubs and CENTRAL will be screened up till the 11th of January 2021. The target population is adults with above-threshold baseline PTSD symptoms on any standardised self-report measure. Trials will only be eligible if at least 70% of the study sample have been diagnosed with PTSD by means of a structured clinical interview. The primary outcomes of this IPD-MA are PTSD symptom severity, and response rate. Secondary outcomes include treatment dropout and adverse effects. Two independent reviewers will screen major bibliographic databases and past reviews. Authors will be contacted to contribute their participant-level datasets. Datasets will be merged into a master dataset. A one-stage IPD-MA will be conducted focusing on the effects of psychological and pharmacological interventions on PTSD symptom severity, response rate, treatment dropout and adverse effects. Subsequent analyses will focus on examining the effect of moderators and predictors of treatment outcomes. These will include sociodemographic, treatment-related, symptom-related, resilience, intervention, trauma and combat-related characteristics. By determining the individual factors that influence the effectiveness of specific PTSD treatments, we will gain insight into personalised treatment options for PTSD.

ETHICS AND DISSEMINATION

Specific ethics approval for an IPD-MA is not required as this study entails secondary analysis of existing anonymised data. The results of this study will be published in peer-reviewed scientific journals and presentations.

Cognitive impairment and World Trade Centre-related exposures

On 11 September 2001 the World Trade Center (WTC) in New York was attacked by terrorists, causing the collapse of multiple buildings including the iconic 110-story 'Twin Towers'. Thousands of people died that day from the collapse of the buildings, fires, falling from the buildings, falling debris, or other related accidents. Survivors of the attacks, those who worked in search and rescue during and after the buildings collapsed, and those working in recovery and clean-up operations were exposed to severe psychological stressors. Concurrently, these 'WTC-affected' individuals breathed and ingested a mixture of organic and particulate neurotoxins and pro-inflammogens generated as a result of the attack and building collapse. Twenty years later, researchers have documented neurocognitive and motor dysfunctions that resemble the typical features of neurodegenerative disease in some WTC responders at midlife. Cortical atrophy, which usually manifests later in life, has also been observed in this population. Evidence indicates that neurocognitive symptoms and corresponding brain atrophy are associated with both physical exposures at the WTC and chronic post-traumatic stress disorder, including regularly re-experiencing traumatic memories of the events while awake or during sleep. Despite these findings, little is understood about the long-term effects of these physical and mental exposures on the brain health of WTC-affected individuals, and the potential for neurocognitive disorders. Here, we review the existing evidence concerning neurological outcomes in WTC-affected individuals, with the aim of contextualizing this research for policymakers, researchers and clinicians and educating WTC-affected individuals and their friends and families. We conclude by providing a rationale and recommendations for monitoring the neurological health of WTC-affected individuals.

The efficacy of psychotherapies and pharmacotherapies for mental disorders in adults: an umbrella review and meta-analytic evaluation of recent meta-analyses

Mental disorders represent a worldwide public health concern. Psychotherapies and pharmacotherapies are recommended as first line treatments. However, evidence has emerged that their efficacy may be overestimated, due to a variety of shortcomings in clinical trials (e.g., publication bias, weak control conditions such as waiting list). We performed an umbrella review of recent meta-analyses of randomized controlled trials (RCTs) of psychotherapies and pharmacotherapies for the main mental disorders in adults. We selected meta-analyses that formally assessed risk of bias or quality of studies, excluded weak comparators, and used effect sizes for target symptoms as primary outcome. We searched PubMed and PsycINFO and individual records of the Cochrane Library for meta-analyses published between January 2014 and March 2021 comparing psychotherapies or pharmacotherapies with placebo or treatment-as-usual (TAU), or psychotherapies vs. pharmacotherapies head-to-head, or the combination of psychotherapy with pharmacotherapy to either monotherapy. One hundred and two meta-analyses, encompassing 3,782 RCTs and 650,514 patients, were included, covering depressive disorders, anxiety disorders, post-traumatic stress disorder, obsessive-compulsive disorder, somatoform disorders, eating disorders, attention-deficit/hyperactivity disorder, substance use disorders, insomnia, schizophrenia spectrum disorders, and bipolar disorder. Across disorders and treatments, the majority of effect sizes for target symptoms were small. A random effect meta-analytic evaluation of the effect sizes reported by the largest meta-analyses per disorder yielded a standardized mean difference (SMD) of 0.34 (95% CI: 0.26-0.42) for psychotherapies and 0.36 (95% CI: 0.32-0.41) for pharmacotherapies compared with placebo or TAU. The SMD for head-to-head comparisons of psychotherapies vs. pharmacotherapies was 0.11 (95% CI: -0.05 to 0.26). The SMD for the combined treatment compared with either monotherapy was 0.31 (95% CI: 0.19-0.44). Risk of bias was often high. After more than half a century of research, thousands of RCTs and millions of invested funds, the effect sizes of psychotherapies and pharmacotherapies for mental disorders are limited, suggesting a ceiling effect for treatment research as presently conducted. A paradigm shift in research seems to be required to achieve further progress.

Electroacupuncture alleviates anxiety and modulates amygdala CRH/CRHR1 signaling in single prolonged stress mice

BACKGROUND

Post-traumatic stress disorder (PTSD) is an anxiety-related psychiatric disorder, manifesting high comorbidity with anxiety disorders. Its underlying neurobiological mechanisms have been associated with hypothalamic-pituitary-adrenal (HPA) axis dysfunction and stress hormones. Corticotropin-releasing hormone (CRH) is a primary stress hormone, expressed in the hypothalamus and amygdala. Electroacupuncture (EA) can improve mood disorders, but its mechanisms have not been fully elucidated. The aim of this study was to observe the effect of EA on PTSD and explore the related mechanisms.

METHODS

We used single prolonged stress (SPS) mice to establish a PTSD model, and EA was performed after SPS or 7 days later for a week. Then we observed their fear and anxiety-like behavior through cue-induced fear condition tests, open field test and the elevated zero maze. CRH and CRH receptor 1 (CRHR1) protein levels in the amygdala were measured in SPS mice after EA intervention.

RESULTS

We found that EA at ST36 and GV20 improved fear and anxiety behavior in SPS mice. The amygdala CRH and CRHR1 protein levels increased in the SPS mice, and this effect was reversed by the EA intervention. CRHR1 inhibition by the CRHR1 antagonist NBI 27914 alleviated anxiety behavior in SPS mice.

CONCLUSION

CRH/CRHR1 signaling in the amygdala may contribute to the anxiolytic effect of EA in SPS mice.

Neurocircuitry basis of the opioid use disorder-post-traumatic stress disorder comorbid state: conceptual analyses using a dimensional framework

Understanding the interface between opioid use disorder (OUD) and post-traumatic stress disorder (PTSD) is challenging. By use of a dimensional framework, such as research domain criteria, convergent and targetable neurobiological processes in OUD-PTSD comorbidity can be identified. We hypothesise that, in OUD-PTSD, circuitry that is implicated in two research domain criteria systems (ie, negative valence and cognitive control) underpins dysregulation of incentive salience, negative emotionality, and executive function. We also propose that the OUD-PTSD state might be systematically investigated with approaches outlined within a neuroclinical assessment framework for addictions and PTSD. Our dimensional analysis of the OUD-PTSD state shows how first-line therapeutic approaches (ie, partial μ-type opioid receptor [MOR1] agonism) modulate overlapping neurobiological and clinical features and also provides mechanistic rationale for evaluating polytherapeutic strategies (ie, partial MOR1 agonism, κ-type opioid receptor [KOR1] antagonism, and α-2A adrenergic receptor [ADRA2A] agonism). A combination of these therapeutic mechanisms is projected to facilitate recovery in patients with OUD-PTSD by mitigating negative valence states and enhancing executive control.

The randomized clinical trial results of the anxiety treatment in patients with somatoform dysfunction and neurotic disorders

The existing treatments for somatoform dysfunction (SfD), reaction to severe stress (RSS), and adjustment disorders (AjD) are insufficiently effective and safe. Anxiolytic drug Tenoten proved effective in clinical trials (CT). The aim of this multicenter double-blind placebo-controlled randomized CT was to investigate the safety and efficacy of Tenoten in the treatment of anxiety in adults with SfD, RSS, AjD and other neurotic disorders (oNDs). 390 adult patients with SfD, RSS and AjD or oNDs with the Hospital Anxiety and Depression scale-anxiety (HADS-A) score ≥ 11 were randomized into 4 groups (n = 127 in Tenoten group 1 (4 tablets/day); n = 131 in Tenoten group 3 (8 tablets/day), n = 132 in combined Placebo group 2 + 4). The changes from baseline in the mean Hamilton Anxiety Rating Scale (HAM-A) score in groups 1 and 3 after 12 weeks were the primary outcome. The decrease of the HAM-A score from 18.81 ± 5.81 to 7.26 ± 4.63 (in group 1) and from 18.38 ± 4.3 to 6.40 ± 4.02 (in group 3) was observed post-treatment (p_{group 1/placebo} = 0.0055, p_{group 3/placebo} < 0.0001). Overall, 46 adverse events (28 in the Tenoten groups and 18 in the Placebo) were reported without any difference between the study groups. Tenoten performed significantly more effective than placebo in the anxiety treatment of adults with SfD, RSS, AjD and oNDs (clinicaltrials.gov NCT03036293).

Behavioral and pharmacological interventions for the prevention and treatment of psychiatric disorders with children exposed to maltreatment

There is a well-established relation between exposure to child maltreatment and the onset and course of multiple, comorbid psychiatric disorders. Given the heterogeneous clinical presentations at the time services are initiated, interventions for children exposed to maltreatment need to be highly effective to curtail the lifelong burden and public health costs attributable to psychiatric disorders. The current review describes the most effective, well-researched, and widely-used behavioral and pharmacological interventions for preventing and treating a range of psychiatric disorders common in children exposed to maltreatment. Detailed descriptions of each intervention, including their target population, indicated age range, hypothesized mechanisms of action, and effectiveness demonstrated through randomized controlled trials research, are presented. Current limitations of these interventions are noted to guide specific directions for future research aiming to optimize both treatment effectiveness and efficiency with children and families exposed to maltreatment. Strategic and programmatic future research can continue the substantial progress that has been made in the prevention and treatment of psychiatric disorders for children exposed to maltreatment.

Assessing the hidden burden of psychiatric disease in patients with nonepileptic seizures

Nonepileptic seizures are commonly associated with psychiatric comorbidities, and specifically PTSD. Despite increased prevalence of psychiatric disease noted on referral of patients to our dedicated clinic for nonepileptic seizures, we found even higher rates of comorbid psychiatric disease or significant symptomatology after our initial clinic intakes, whereby patients are formally evaluated by a behavioral health provider, in addition to an epileptologist. After intake, an additional 21% of patients were identified as having PTSD or significant trauma-related symptoms, an additional 7% of patients were identified with significant anxiety or panic-related symptoms, and an additional 11% of patients were identified with significant depressive symptoms. While highly effective treatment of nonepileptic seizures remains elusive, well-developed treatment paradigms with proven efficacy exist for depression, anxiety, and PTSD. Eliciting these psychiatric comorbidities and pursuing targeted treatments, especially for those patients that do not have easy access to providers with dedicated expertise in the management of nonepileptic seizures, may be a more easily scalable and implementable treatment modality for these patients.

Stress management versus cognitive restructuring in trauma-affected refugees - A follow-up study on a pragmatic randomised trial

BACKGROUND

There is a lack of research and consensus with respect to long-term effective treatments for trauma-affected refugees. The purpose of this follow-up study of a randomised clinical trial was to investigate the effectiveness of Stress Management (SM) versus Cognitive Restructuring (CR) in treating trauma-affected refugees, six and 18 months post-treatment, respectively.

METHODS

From a total of 126 refugees with PTSD, the intention-to-treat sample in the original trial, 74 patients were present at the six-month follow-up (SM; n = 37, CR; n = 37) and 34 patients at the 18-month follow-up (SM; n = 14, CR; n = 20). During the trial, the patients had been offered a total of 16 psychotherapy sessions and 10 sessions with a medical doctor.

RESULTS

Mixed regression analyses at six and 18-month follow-up showed a non-significant small reduction in PTSD symptoms at both follow-up points with no significant between-group differences between the two psychotherapeutic interventions. Statistically significant between-group treatment effects were, however, observed with the patients receiving SM having significantly reduced symptoms of somatisation measured by the Symptom Checklist (β = 0.40), depression (β = 0.29) and anxiety (β = 0.37) (measured by the Hamilton Depression and Anxiety ratings) at 18 months post-treatment compared to the CR group.

LIMITATIONS

Limitations to the present study include the dropout rate at follow-up(s).

CONCLUSIONS

The findings suggest that the consolidation of coping strategies including relaxation, attention-diversion and behavioural activation in SM appears to be more beneficial than CR in reducing long-term somatisation, depression and anxiety symptoms for this population.

Stem Cell Therapy for Post-Traumatic Stress Disorder: A Novel Therapeutic Approach

Stem cell therapy is a rapidly evolving field of regenerative medicine being employed for the management of various central nervous system disorders. The ability to self-renew, differentiate into specialized cells, and integrate into neuronal networks has positioned stem cells as an ideal mechanism for the treatment of epilepsy. Epilepsy is characterized by repetitive seizures caused by imbalance in the GABA and glutamate neurotransmission following neuronal damage. Stem cells provide benefit by reducing the glutamate excitotoxicity and strengthening the GABAergic inter-neuron connections. Similar to the abnormal neuroanatomic location in epilepsy, post-traumatic stress disorder (PTSD) is caused by hyperarousal in the amygdala and decreased activity of the hippocampus and medial prefrontal cortex. Thus, stem cells could be used to modulate neuronal interconnectivity. In this review, we provide a rationale for the use of stem cell therapy in the treatment of PTSD.

Yoga as an Integrative Therapy for Mental Health Concerns: An Overview of Current Research Evidence

Background: Because the prevalence of mental health concerns is high and access or full responsiveness to pharmacological or psychotherapeutic treatment for many individuals is low, there has been increased interest in yoga as a potential therapy for many mental health concerns. Approach: We synthesize and critique current research on the efficacy of yoga relative to pharmacological approaches for anxiety disorders, mood disorders, posttraumatic stress disorder, obsessive-compulsive disorder, and eating disorders. Results: Yoga has been tested mostly as a complementary treatment to standard psychiatric and psychotherapeutic approaches. Findings from efficacy trials largely support the notion that yoga can help reduce symptoms of many psychiatric conditions, including anxiety, depression, and PTSD symptoms, above and beyond the effects achieved by standard pharmacological treatments alone; however, most evidence is of poor to moderate quality. Plausible transdiagnostic bottom-up and top-down mechanisms of yoga’s therapeutic effects have been advanced but remain untested. Conclusions: While results should be considered preliminary until more rigorous evidence is available, yoga appears to have the potential to provide many people suffering with psychiatric symptoms additional relief at relatively little cost. Yoga may be a viable complementary therapy to psychiatric and psychotherapeutic approaches for people with mental health challenges.

Personalization of Treatment for Patients with Childhood-Abuse-Related Posttraumatic Stress Disorder

BACKGROUND

Differences in effectiveness among treatments for posttraumatic stress disorder (PTSD) are typically small. Given the variation between patients in treatment response, personalization offers a new way to improve treatment outcomes. The aim of this study was to identify predictors of psychotherapy outcome in PTSD and to combine these into a personalized advantage index (PAI).

METHODS

We used data from a recent randomized controlled trial comparing prolonged exposure (PE; n = 48), intensified PE (iPE; n = 51), and skills training (STAIR), followed by PE (n = 50) in 149 patients with childhood-abuse-related PTSD (CA-PTSD). Outcome measures were clinician-assessed and self-reported PTSD symptoms. Predictors were identified in the exposure therapies (PE and iPE) and STAIR+PE separately using random forests and subsequent bootstrap procedures. Next, these predictors were used to calculate PAI and to retrospectively determine optimal and suboptimal treatment in a leave-one-out cross-validation approach.

RESULTS

More depressive symptoms, less social support, more axis-1 diagnoses, and higher severity of childhood sexual abuse were predictors of worse treatment outcomes in PE and iPE. More emotion regulation difficulties, lower general health status, and higher baseline PTSD symptoms were predictors of worse treatment outcomes in STAIR+PE. Randomization to optimal treatment based on these predictors resulted in more improvement than suboptimal treatment in clinician assessed (Cohens' d = 0.55) and self-reported PTSD symptoms (Cohens' d = 0.47).

CONCLUSION

Personalization based on PAI is a promising tool to improve therapy outcomes in patients with CA-PTSD. Further studies are needed to replicate findings in prospective studies.

SALM4 negatively regulates NMDA receptor function and fear memory consolidation

Many synaptic adhesion molecules positively regulate synapse development and function, but relatively little is known about negative regulation. SALM4/Lrfn3 (synaptic adhesion-like molecule 4/leucine rich repeat and fibronectin type III domain containing 3) inhibits synapse development by suppressing other SALM family proteins, but whether SALM4 also inhibits synaptic function and specific behaviors remains unclear. Here we show that SALM4-knockout (Lrfn3^-/-) male mice display enhanced contextual fear memory consolidation (7-day post-training) but not acquisition or 1-day retention, and exhibit normal cued fear, spatial, and object-recognition memory. The Lrfn3^-/- hippocampus show increased currents of GluN2B-containing N-methyl-D-aspartate (NMDA) receptors (GluN2B-NMDARs), but not α-amino-3-hydroxy-5-methyl-4-isoxazole propionate (AMPA) receptors (AMPARs), which requires the presynaptic receptor tyrosine phosphatase PTPσ. Chronic treatment of Lrfn3^-/- mice with fluoxetine, a selective serotonin reuptake inhibitor used to treat excessive fear memory that directly inhibits GluN2B-NMDARs, normalizes NMDAR function and contextual fear memory consolidation in Lrfn3^-/- mice, although the GluN2B-specific NMDAR antagonist ifenprodil was not sufficient to reverse the enhanced fear memory consolidation. These results suggest that SALM4 suppresses excessive GluN2B-NMDAR (not AMPAR) function and fear memory consolidation (not acquisition).

Treatment Guidelines for PTSD: A Systematic Review

Background: The aim of this review was to assess the quality of international treatment guidelines for post-traumatic stress disorder (PTSD), and identify differences between guideline recommendations, with a focus on the treatment of nightmares. Methods: Guidelines were identified through electronic searches of MEDLINE, CINAHL, PubMed, Embase and Science Direct, as well as web-based searches of international guideline repositories, websites of psychiatric organisations and targeted web-searches for guidelines from the three most populous English-speaking countries in each continent. Data in relation to recommendations were extracted and the AGREE II criteria were applied to assess for quality. Results: Fourteen guidelines, published between 2004–2020, were identified for inclusion in this review. Only five were less than 5 years old. Three guidelines scored highly across all AGREE II domains, while others varied between domains. Most guidelines consider both psychological and pharmacological therapies as first-line in PTSD. All but one guideline recommended cognitive behavioural therapy (CBT) as first-line psychological treatment, and selective serotonin reuptake inhibitors (SSRIs) as first-line pharmacological treatment. Most guidelines do not mention the targeted treatment of nightmares as a symptom of PTSD. Prazosin is discussed in several guidelines for the treatment of nightmares, but recommendations vary widely. Most PTSD guidelines were deemed to be of good quality; however, many could be considered out of date. Recommendations for core PTSD symptoms do not differ greatly between guidelines. However, despite the availability of targeted treatments for nightmares, most guidelines do not adequately address this. Conclusions: Guidelines need to be kept current to maintain clinical utility. Improvements are most needed in the AGREE II key domains of ‘applicability’, ‘rigour of development’ and ‘stakeholder involvement’. Due to the treatment-resistant nature of nightmares, guideline development groups should consider producing more detailed recommendations for their targeted treatment. More high-quality trials are also required to provide a solid foundation for making these clinical recommendations for the management of nightmares in PTSD.

Tackling the global problem of traumatic stress in low-income countries: a pilot clinical trial comparing reconsolidation therapy to paroxetine in Nepal

BACKGROUND

Traumatic stress is a global mental health problem requiring novel, easily implemented treatment solutions. We compared the effectiveness and efficiency of Reconsolidation Therapy (RT) to the well-established antidepressant paroxetine, in reducing symptoms of traumatic stress among patients from Nepal, a low-income country.

METHODS

Forty-six adults with posttraumatic stress disorder (PTSD) were randomized to one of two groups. The reconsolidation blocker propranolol was administered 90 min before briefly recalling a traumatic memory with a therapist, weekly for six consecutive weeks. This was compared to daily paroxetine for 26 weeks. Self-reported PTSD symptoms were assessed blindly at the 7th, 13th, and 26th weeks.

RESULTS

An intent-to-treat analysis revealed a robust pre- to post-treatment main effect (β1 = - 4.83, 95% CI = [- 5.66, - 4.01], p < .001), whereby both groups improved, with Cohen's effect sizes of d = 2.34 (95% CI = [1.57, 3.12]) for paroxetine, and of 2.82 (95% CI = [1.98, 3.66]) for RT after 7 weeks, suggesting treatment effectiveness for both groups in a real-world setting. Three and six-month follow-up yielded further significant improvement in both groups, which did not differ from each other.

CONCLUSION

RT also displayed promising efficiency, considering that it had been discontinued weeks earlier while the paroxetine treatment was continued, as recommended. RT could be taught in low-income countries as part of the local therapeutic resources to treat the core symptoms of PTSD, provided that such results are replicated on a broader scale.

TRIAL REGISTRATION

ISRCTN34308454 (11/10/2017).

Consolidation/reconsolidation therapies for the prevention and treatment of PTSD and re-experiencing: a systematic review and meta-analysis

Translational research highlights the potential of novel 'memory consolidation/reconsolidation therapies' to treat re-experiencing symptoms and post-traumatic stress disorder (PTSD). This systematic review and meta-analysis assessed the efficacy of so-called memory consolidation/reconsolidation therapies in randomised controlled trials (RCTs) for prevention and treatment of PTSD and symptoms of re-experiencing in children and adults (PROSPERO: CRD42020171167). 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/re-experiencing severity. Twenty-five RCTs met inclusion criteria (16 prevention and nine treatment trials). The methodology of most studies had a significant risk of bias. We found a large effect of reconsolidation interventions in the treatment of PTSD (11 studies, n = 372, SMD: -1.42 (-2.25 to -0.58), and a smaller positive effect of consolidation interventions in the prevention of PTSD (12 studies, n = 2821, RR: 0.67 (0.50 to 0.90). Only three protocols (hydrocortisone for PTSD prevention, Reconsolidation of Traumatic Memories (RTM) for treatment of PTSD symptoms and cognitive task memory interference procedure with memory reactivation (MR) for intrusive memories) were superior to control. There is some emerging evidence of consolidation and reconsolidation therapies in the prevention and treatment of PTSD and intrusive memories specifically. Translational research should strictly adhere to protocols/procedures describing precise reconsolidation conditions (e.g. MR) to both increase the likelihood of positive findings and more confidently interpret negative findings of putative reconsolidation agents.

Pharmacotherapy of 1,044 inpatients with posttraumatic stress disorder: current status and trends in German-speaking countries

Posttraumatic stress disorder (PTSD) is a debilitating psychiatric disorder with limited approved pharmacological treatment options and high symptom burden. Therefore, real-life prescription patterns may differ from guideline recommendations, especially in psychiatric inpatient settings. The European Drug Safety Program in Psychiatry ("Arzneimittelsicherheit in der Psychiatrie", AMSP) collects inpatients' prescription rates cross-sectionally twice a year in German-speaking psychiatric hospitals. For this study, the AMSP database was screened for psychiatric inpatients with a primary diagnosis of PTSD between 2001 and 2017. N = 1,044 patients with a primary diagnosis of PTSD were identified with 89.9% taking psychotropics. The average prescription rate was 2.4 (standard deviation: 1.5) psychotropics per patient with high rates of antidepressant drugs (72.0%), antipsychotics drugs (58.4%) and tranquilizing drugs (29.3%). The presence of psychiatric comorbidities was associated with higher rates of psychotropic drug use. The most often prescribed substances were quetiapine (24.1% of all patients), lorazepam (18.1%) and mirtazapine (15.0%). The use of drugs approved for PTSD was low (sertraline 11.1%; paroxetine 3.7%). Prescription rates of second-generation antipsychotic drugs increased, while the use of tranquilizing drugs declined over the years. High prescription rates and extensive use of sedative medication suggest a symptom-driven prescription (e.g., hyperarousal, insomnia) that can only be explained to a minor extent by existing comorbidities. The observed discrepancy with existing guidelines underlines the need for effective pharmacological and psychological treatment options in psychiatric inpatient settings.

The effectiveness of a psycho-education intervention on mental health literacy in communities affected by the COVID-19 pandemic-a cluster randomized trial of 24 villages in central Uganda-a research protocol

Background

Literature shows a high prevalence of psychological distress (PD) as well as common mental disorders (CMD) such as major depressive disorders (MDD), generalized anxiety disorders (GAD), post-traumatic stress disorders (PTSD), and substance misuse disorders (SUD) among people exposed to disasters and pandemics like the COVID-19. Moreover, CMD are associated with increased mortality (mainly through suicide) and morbidity (loss of productivity). A number of countries have made deliberate efforts to identify and manage CMD in light of COVID-19. However, low levels of mental health literacy (MHL) manifested by the individual’s unawareness of CMD symptoms, limited human and mental health infrastructure resources, and high levels of mental illness stigma (MIS) are barriers to integration of mental health care in general health care during pandemics and epidemics such as the COVID-19.

Objectives

For the proposed study, we will determine effectiveness of a psycho-education intervention delivered by village health team (VHT) members.

Methods

We will employ a cluster randomized trial design in 24 villages in central Uganda. We will collect baseline data to and document the prevalence of MHL, PD, MDD, PTSD, GAD, and SUD. We will distribute information education and communication materials (IEC) aimed at improving MHL to 420 adult individuals in the intervention arm (n = 12 villages). In the control arm (n = 12 villages), VHTs will distribute ministry of health COVID-19 information leaflets to 420 participants. Within 7 days of distributing the materials, research assistants will conduct a follow-up interview and assess for the same parameters (MHL, PD, MDD, PTSD, GAD, and SUD). We will use an intention to treat analysis to estimate the effectiveness of the psycho-education intervention.

Discussion

Findings from this research will guide policy and practice regarding the integration of mental health services in the community in the context of epidemic preparedness and response.

Trial registration

ClinicalTrials.govNCT04616989. Registered on 05 November 2020

Military-related posttraumatic stress disorder and mindfulness meditation: A systematic review and meta-analysis

PURPOSE

Posttraumatic stress disorder (PTSD) is a significant global mental health concern, especially in the military. This study aims to estimate the efficacy of mindfulness meditation in the treatment of military-related PTSD, by synthesizing evidences from randomized controlled trials.

METHODS

Five electronic databases (Pubmed, EBSCO Medline, Embase, PsychINFO and Cochrane Library) were searched for randomized controlled trials focusing on the treatment effect of mindfulness meditation on military-related PTSD. The selection of eligible studies was based on identical inclusion and exclusion criteria. Information about study characteristics, participant characteristics, intervention details, PTSD outcomes, as well as potential adverse effects was extracted from the included studies. Risk of bias of all the included studies was critically assessed using the Cochrane Collaboration's tool. R Statistical software was performed for data analysis.

RESULTS

A total of 1902 records were initially identified and screened. After duplicates removal and title & abstract review, finally, 19 articles in English language with 1326 participants were included through strict inclusion and exclusion criteria. The results revealed that mindfulness meditation had a significantly larger effect on alleviating military-related PTSD symptoms compared with control conditions, such as treatment as usual, present-centered group therapy and PTSD health education (standardized mean difference (SMD) = -0.33; 95% CI [-0.45, -0.21]; p < 0.0001). Mindfulness interventions with different control conditions (active or non-active control, SMD = -0.33, 95% CI [-0.46, -0.19]; SMD = -0.49, 95% CI [-0.88, -0.10], respectively), formats of delivery (group-based or individual-based, SMD = -0.30, 95% CI [-0.42, -0.17], SMD = -0.49, 95% CI [-0.90, -0.08], respectively) and intervention durations (short-term or standard duration, SMD = -0.27, 95% CI [-0.46, -0.08], SMD = -0.40, 95% CI [-0.58, -0.21], respectively) were equally effective in improving military-related PTSD symptoms.

CONCLUSION

Findings from this meta-analysis consolidate the efficacy and feasibility of mindfulness meditation in the treatment of military-related PTSD. Further evidence with higher quality and more rigorous design is needed in the future.

Predictors and trajectories of treatment response to SSRIs in patients suffering from PTSD

Paroxetine and sertraline are the only FDA approved drugs for treatment of posttraumatic stress disorder (PTSD). Although both drugs show better outcomes than placebo, not all patients benefit from treatment. We examined predictors and latent classes of SSRI treatment response in patients with PTSD. Symptom severity was measured over a 12-week period in 390 patients suffering from PTSD treated with open-label sertraline or paroxetine and a double-blinded placebo. First, growth curve modeling (GCM) was used to examine population-level predictors of treatment response. Second, growth mixture modeling (GMM) was used to group patients into latent classes based on their treatment response trajectories over time and to investigate predictors of latent class membership. Gender, childhood sexual trauma, and sexual assault as index trauma moderated the population-level treatment response using GCM. GMM identified three classes: fast responders, responders with low pretreatment symptom severity and responders with high pretreatment symptom severity. Class membership was predicted based on time since index trauma, severity of depression, and severity of anxiety. The study shows that higher severity of comorbid disorders does not result in an inferior response to treatment and suggests that patients with longer time since index trauma might particularly benefit from treatment with sertraline or paroxetine.

MDMA to Treat PTSD in Adults

Post-traumatic stress disorder (PTSD) has become one of the most common psychiatric diagnosis in the United States specifically within the veteran population. The current treatment options for this debilitating diagnosis include trauma-focused psychotherapies along with selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRI).¹ MDMA has recently been shown as a novel therapeutic agent with promisingly results in the treatment of PTSD. MDMA is a psychoactive compound traditionally categorized as a psychedelic amphetamine that deemed a Schedule I controlled substance in the 1980s. Prior to its status as a controlled substance, it was used by psychotherapists for an array of psychiatric issues. In more recent times, MDMA has resurfaced as a potential therapy for PTSD and the data produced from randomized, controlled trials back the desire for MDMA to be utilized as an effective pharmacologic therapy in conjunction with psychotherapy.².

Dopamine D1R-neuron cacna1c deficiency: a new model of extinction therapy-resistant post-traumatic stress

Post-traumatic stress disorder (PTSD) is characterized by persistent fear memory of remote traumatic events, mental re-experiencing of the trauma, long-term cognitive deficits, and PTSD-associated hippocampal dysfunction. Extinction-based therapeutic approaches acutely reduce fear. However, many patients eventually relapse to the original conditioned fear response. Thus, understanding the underlying molecular mechanisms of this condition is critical to developing new treatments for patients. Mutations in the neuropsychiatric risk gene CACNA1C, which encodes the Ca_v1.2 isoform of the L-type calcium channel, have been implicated in both PTSD and highly comorbid neuropsychiatric conditions, such as anxiety and depression. Here, we report that male mice with global heterozygous loss of cacna1c exhibit exacerbated contextual fear that persists at remote time points (up to 180 days after shock), despite successful acute extinction training, reminiscent of PTSD patients. Because dopamine has been implicated in contextual fear memory, and Ca_v1.2 is a downstream target of dopamine D1-receptor (D1R) signaling, we next generated mice with specific deletion of cacna1c from D1R-expressing neurons (D1-cacna1c^KO mice). Notably, D1-cacna1c^KO mice also show the same exaggerated remote contextual fear, as well as persistently elevated anxiety-like behavior and impaired spatial memory at remote time points, reminiscent of chronic anxiety in treatment-resistant PTSD. We also show that D1-cacna1c^KO mice exhibit elevated death of young hippocampal neurons, and that treatment with the neuroprotective agent P7C3-A20 eradicates persistent remote fear. Augmenting survival of young hippocampal neurons may thus provide an effective therapeutic approach for promoting durable remission of PTSD, particularly in patients with CACNA1C mutations or other genetic aberrations that impair calcium signaling or disrupt the survival of young hippocampal neurons.

Psilocybin and MDMA for the treatment of trauma-related psychopathology

This review examines the role of trauma in psychiatric morbidity and analogous psychoneurobiological changes. Trauma is a necessary criterion for Post-Traumatic Stress Disorder (PTSD), however, trauma history is highly correlated with a variety of psychiatric conditions. Some evidence suggests that Major Depressive Disorder (MDD) is the most common psychiatric condition that arises following trauma. Approximately 50% of PTSD cases present with co-morbid MDD. Overlapping symptomatology and neurobiology between these conditions underlie the debate over whether these phenomena result from problematic nosology or whether comorbid MDD + PTSD is a distinct phenotype of trauma-related psychopathology. Regardless, similar treatment approaches have been employed historically, with varying success. The drug-assisted psychotherapy treatment model, which combines pharmacological and psychotherapeutic approaches, is currently being trialled as a novel treatment approach in psychiatry. Both psilocybin- and 3,4-Methylenedioxymethamphetamine (MDMA)-assisted psychotherapy have received Food and Drug Administration 'breakthrough therapy' designation for the treatment of resistant MDD and PTSD, respectively. This paper reviews the therapeutic rationale of both psilocybin and MDMA for treating both trauma-related MDD and PTSD.

A comparison of MDMA-assisted psychotherapy to non-assisted psychotherapy in treatment-resistant PTSD: A systematic review and meta-analysis

RATIONALE

Novel, evidence-based treatments are required for treatment-resistant post-traumatic stress disorder (PTSD). 3,4-Methylenedioxymethamphetamine (MDMA) has beneficially augmented psychotherapy in several small clinical trials.

OBJECTIVE

To review the use of MDMA-assisted psychotherapy in treatment-resistant PTSD.

METHODS

Systematic searches of four databases were conducted from inception to February 2020. A meta-analysis was performed on trials which were double-blinded, randomised, and compared MDMA-assisted psychotherapy to psychotherapy and placebo. The primary outcomes were the differences in Clinician Administered PTSD Scale (CAPS-IV) score and Beck's Depression Inventory (BDI). Secondary outcome measures included neurocognitive and physical adverse effects, at the time, and within 7 days of intervention.

RESULTS

Four randomised controlled trials (RCTs) met inclusion criteria. When compared to active placebo, intervention groups taking 75 mg (MD -46.90; 95% (confidence intervals) CI -58.78, -35.02), 125 mg (MD -20.98; 95% CI -34.35, -7.61) but not 100 mg (MD -12.90; 95% CI -36.09, 10.29) of MDMA with psychotherapy, had significant decreases in CAPS-IV scores, as did the inactive placebo arm (MD -33.20; 95% CI -40.53, -25.87). A significant decrease in BDI when compared to active placebo (MD -10.80; 95% CI -20.39, -1.21) was only observed at 75 mg. Compared to placebo, participants reported significantly more episodes of low mood, nausea and jaw-clenching during sessions and lack of appetite after 7 days.

CONCLUSION

These results demonstrate potential therapeutic benefit with minimal physical and neurocognitive risk for the use of MDMA-assisted psychotherapy in TR-PTSD, despite little effect on Beck's Depression Inventory. Better powered RCTs are required to investigate further.

INTERNATIONAL PROSPECTIVE REGISTER OF SYSTEMATIC REVIEWS

CRD42019109132 available online at www.crd.york.ac.uk/prospero.

Impaired executive function exacerbates neural markers of posttraumatic stress disorder

BACKGROUND

A major obstacle in understanding and treating posttraumatic stress disorder (PTSD) is its clinical and neurobiological heterogeneity. To address this barrier, the field has become increasingly interested in identifying subtypes of PTSD based on dysfunction in neural networks alongside cognitive impairments that may underlie the development and maintenance of symptoms. The current study aimed to determine if subtypes of PTSD, based on normative-based cognitive dysfunction across multiple domains, have unique neural network signatures.

METHODS

In a sample of 271 veterans (90% male) that completed both neuropsychological testing and resting-state fMRI, two complementary, whole-brain functional connectivity analyses explored the link between brain functioning, PTSD symptoms, and cognition.

RESULTS

At the network level, PTSD symptom severity was associated with reduced negative coupling between the limbic network (LN) and frontal-parietal control network (FPCN), driven specifically by the dorsolateral prefrontal cortex and amygdala Hubs of Dysfunction. Further, this relationship was uniquely moderated by executive function (EF). Specifically, those with PTSD and impaired EF had the strongest marker of LN-FPCN dysregulation, while those with above-average EF did not exhibit PTSD-related dysregulation of these networks.

CONCLUSION

These results suggest that poor executive functioning, alongside LN-FPCN dysregulation, may represent a neurocognitive subtype of PTSD.

Optimizing treatment for comorbid borderline personality disorder and posttraumatic stress disorder: A systematic review of psychotherapeutic approaches and treatment efficacy

Comorbid borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) is a severe and complicated clinical presentation characterized by especially high rates of suicide, healthcare utilization, and psychosocial impairment. Although guidelines exist for treating each of these disorders alone, there remains limited guidance on the optimal treatment in cases where BPD and PTSD co-occur. Therefore, this systematic review synthesizes the existing research on the treatment of BPD-PTSD with the aim of optimizing treatment for this population. First, the prevalence and clinical severity of comorbid BPD-PTSD is reviewed. Next, we describe the results of our systematic review, which identified 21 articles that examined treatment outcomes in the context of BPD-PTSD or subclinical BPD-PTSD. Based on our results, we describe existing psychotherapeutic approaches, including BPD-specific treatments, trauma-focused and non-trauma-focused treatments for PTSD, and stage-based treatments for BPD-PTSD. We also summarize BPD-PTSD treatment outcomes, including whether each disorder interferes with treatment and recovery of the other. Results related to treatment safety and concerns regarding conducting trauma-focused treatment for BPD-PTSD are addressed. We end by highlighting important gaps in the literature and provide recommendations for further research.

Ketamine-50 years in use: from anesthesia to rapid antidepressant effects and neurobiological mechanisms

Over the past 50 years, ketamine has solidified its position in both human and veterinary medicine as an important anesthetic with many uses. More recently, ketamine has been studied and used for several new indications, ranging from chronic pain to drug addiction and post-traumatic stress disorder. The discovery of the rapid-acting antidepressant effects of ketamine has resulted in a surge of interest towards understanding the precise mechanisms driving its effects. Indeed, ketamine may have had the largest impact for advancements in the research and treatment of psychiatric disorders in the past few decades. While intense research efforts have been aimed towards uncovering the molecular targets underlying ketamine's effects in treating depression, the underlying neurobiological mechanisms remain elusive. These efforts are made more difficult by ketamine's complex dose-dependent effects on molecular mechanisms, multiple pharmacologically active metabolites, and a mechanism of action associated with the facilitation of synaptic plasticity. This review aims to provide a brief overview of the different uses of ketamine, with an emphasis on examining ketamine's rapid antidepressant effects spanning molecular, cellular, and network levels. Another focus of the review is to offer a perspective on studies related to the different doses of ketamine used in antidepressant research. Finally, the review discusses some of the latest hypotheses concerning ketamine's action.

Preventing the onset of post traumatic stress disorder

Post-traumatic stress disorder (PTSD) is a common mental health condition that requires exposure to a traumatic event. This provides unique opportunities for prevention that are not available for other disorders. The aim of this review was to undertake a systematic review and evaluation of randomized controlled trials (RCTs) of interventions designed to prevent PTSD in adults. Searches involving Cochrane, Embase, Medline, PsycINFO, PILOTS and Pubmed databases were undertaken to identify RCTs of pre-incident preparedness and post-incident interventions until May 2019. Six pre-incident and 69 post-incident trials were identified that could be included in meta-analyses. The overall quality of the evidence was low. There was emerging evidence that some interventions may be helpful but an absence of evidence for any intervention that can be strongly recommended for universal, selected or indicated prevention before or within the first three months of a traumatic event. The strongest results were found for cognitive-behavioural therapy with a trauma focus (CBT-T) in individuals with a diagnosis of acute stress disorder which supports calls to detect and treat individuals with significant symptoms rather than providing blanket preventative interventions. Further research is required to optimally configure existing interventions with some evidence of effect and to develop novel interventions to address this major public health issue.

Efficacy of Vortioxetine Monotherapy for Posttraumatic Stress Disorder: A Randomized, Placebo-Controlled Trial

PURPOSE/BACKGROUND

There are few efficacious pharmacological treatments for posttraumatic stress disorder (PTSD) and many patients fail to benefit from existing treatments. Vortioxetine, a recently developed antidepressant, acts as a serotonin modulator through inhibition of the serotonin transporter and actions at multiple types of serotonin receptors. Its unique pharmacodynamic profile suggests it may have efficacy for the treatment of PTSD.

METHODS/PROCEDURES

We conducted a 12-week placebo-controlled, randomized clinical trial of vortioxetine (flexibly dosed from 10 to 20 mg/d) versus placebo in adults with PTSD. The primary outcome was change from baseline in the past-month version of the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), analyzed using a mixed-model repeated-measures analysis of variance.

FINDINGS/RESULTS

Forty-one patients were randomized, and 32 (78%) completed the 12 weeks of treatment. The mean reduction in CAPS-5 scores at week 12 did not significantly differ between the 2 arms; the effect size for the difference in changes between vortioxetine and placebo on CAPS-5 total scores at week 12 was Cohen d = 0.29. However, at week 8, the drug-placebo difference was d = 0.78, which met the multivariate criteria for statistical significance, P = 0.014.

IMPLICATIONS/CONCLUSIONS

In this study of 41 patients, vortioxetine did not demonstrate superiority over placebo for adults with PTSD. Future PTSD trials may benefit from stratifying the randomization based on number of years since the index traumatic event and a history of failure to respond to treatment.