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

Narrative Exposure Therapy versus treatment as usual in a sample of trauma survivors who live under ongoing threat of violence in Rio de Janeiro, Brazil: study protocol for a randomised controlled trial

BACKGROUND

One in three individuals who live in Rio de Janeiro experience a traumatic event within a period of 12 months. In the favelas particularly, trauma exposure is ongoing. Psychological sequalae include posttraumatic stress disorder (PTSD), depression and other mental disorders. Trauma-focused therapy approaches have emerged as the treatment of choice when the dangerous events are over, but symptoms have remained for an extended time period. Ideally, the victim is in a safe context during treatment. However, frequently, survivors cannot escape from situations characterised by ongoing threat and traumatic stress. The aim of this study is to research the effectiveness of Narrative Exposure Therapy in a sample of PTSD patients living under these conditions.

METHODS

Individuals fulfilling the criteria for PTSD and who live in conditions of ongoing community violence (i.e. in the favelas) in Rio de Janeiro will be randomly assigned to one of two treatments: Narrative Exposure Therapy (NET) or treatment as usual (TAU). Clinical endpoints will be primarily PTSD and secondarily symptoms of shutdown dissociation, depression, substance involvement  and functionality.

DISCUSSION

Effective treatment for PTSD patients who live in unsafe conditions could substantially reduce suffering of individuals and their families in Brazil. Based on this result, the extent to which such interventions may be useful as a first step in tackling the consequences of violence on a global scale will be discussed.

TRIAL REGISTRATION

Deutsches Register Klinischer Studien (German Clinical Trials Register) DRKS00017843 . Registered on September 24, 2019.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

A Randomized Controlled Trial of Repeated Ketamine Administration for Chronic Posttraumatic Stress Disorder

OBJECTIVE

Posttraumatic stress disorder (PTSD) is a chronic and disabling disorder, for which available pharmacotherapies have limited efficacy. The authors' previous proof-of-concept randomized controlled trial of single-dose intravenous ketamine infusion in individuals with PTSD showed significant and rapid PTSD symptom reduction 24 hours postinfusion. The present study is the first randomized controlled trial to test the efficacy and safety of repeated intravenous ketamine infusions for the treatment of chronic PTSD.

METHODS

Individuals with chronic PTSD (N=30) were randomly assigned (1:1) to receive six infusions of ketamine (0.5 mg/kg) or midazolam (0.045 mg/kg) (psychoactive placebo control) over 2 consecutive weeks. Clinician-rated and self-report assessments were administered 24 hours after the first infusion and at weekly visits. The primary outcome measure was change in PTSD symptom severity, as assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), from baseline to 2 weeks (after completion of all infusions). Secondary outcome measures included the Impact of Event Scale-Revised, the Montgomery-Åsberg Depression Rating Scale (MADRS), and side effect measures.

RESULTS

The ketamine group showed a significantly greater improvement in CAPS-5 and MADRS total scores than the midazolam group from baseline to week 2. At week 2, the mean CAPS-5 total score was 11.88 points (SE=3.96) lower in the ketamine group than in the midazolam group (d=1.13, 95% CI=0.36, 1.91). Sixty-seven percent of participants in the ketamine group were treatment responders, compared with 20% in the midazolam group. Among ketamine responders, the median time to loss of response was 27.5 days following the 2-week course of infusions. Ketamine infusions were well tolerated overall, without serious adverse events.

CONCLUSIONS

This randomized controlled trial provides the first evidence of efficacy of repeated ketamine infusions in reducing symptom severity in individuals with chronic PTSD. Further studies are warranted to understand ketamine's full potential as a treatment for chronic PTSD.

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

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

Cannabis use and posttraumatic stress disorder comorbidity: Epidemiology, biology and the potential for novel treatment approaches

Cannabis use is increasing among some demographics in the United States and is tightly linked to anxiety, trauma, and stress reactivity at the epidemiological and biological level. Stress-coping motives are highly cited reasons for cannabis use. However, with increased cannabis use comes the increased susceptibility for cannabis use disorder (CUD). Indeed, CUD is highly comorbid with posttraumatic stress disorder (PTSD). Importantly, endogenous cannabinoid signaling systems play a key role in the regulation of stress reactivity and anxiety regulation, and preclinical data suggest deficiencies in this signaling system could contribute to the development of stress-related psychopathology. Furthermore, endocannabinoid deficiency states, either pre-existing or induced by trauma exposure, could provide explanatory insights into the high rates of comorbid cannabis use in patients with PTSD. Here we review clinical and preclinical literature related to the cannabis use-PTSD comorbidity, the role of endocannabinoids in the regulation of stress reactivity, and potential therapeutic implications of recent work in this area.

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

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

The efficacy of memantine in the treatment of civilian posttraumatic stress disorder: an open-label trial

Background: Currently, there is a paucity of pharmacological treatment options for posttraumatic stress disorder (PTSD), and the development of a novel pharmacotherapeutic approach has become a matter of great interest. Objective: We conducted a 12-week open-label clinical trial to examine the efficacy and safety of memantine, an N-methyl-D-aspartate receptor antagonist, in the treatment of civilian PTSD. Method: Thirteen adult patients with DSM-IV PTSD, all civilian women, were enrolled. They were monitored at an ambulatory care facility every week until 4 weeks and then every 4 weeks until 12 weeks. Memantine was added to each patient's current medication, with the initial dosage of 5 mg/day and then titrated. Concomitant medications were essentially kept unchanged during the trial. The primary outcome was PTSD diagnosis and severity assessed with the Posttraumatic Diagnostic Scale (PDS). Results: Of the 13 cases, one dropped out and two were discarded due to the protocol deviation, and the analysis was done for the remaining 10. Mean PDS total scores decreased from 32.3 ± 9.7 at baseline to 12.2 ± 7.9 at endpoint, which was statistically significant with a large effect (paired t-test: p = .002, d = 1.35); intrusion, avoidance, hyperarousal symptoms were all significantly improved from baseline to endpoint. Six patients no longer fulfilled the diagnostic criteria of PTSD at endpoint. Some adverse, but not serious, effects possibly related to memantine were observed, including sleep problems, sleepiness, sedation, weight change and hypotension. Conclusions: Memantine significantly reduced PTSD symptoms in civilian female PTSD patients and the drug was well tolerated. Future randomized controlled trials are necessary to verify the efficacy and safety of memantine in the treatment of PTSD.

Key Clinical Interest Outcomes of Pharmaceutical Administration for Veterans With Post-Traumatic Stress Disorder Based on Pooled Evidences of 36 Randomised Controlled Trials With 2,331 Adults

Background: The effects of drug treatment on veterans, who have a high risk of post-traumatic stress disorder (PTSD), are not clear, and the guidelines are different from the recommendations of the recent meta-analysis. Our goal was to find the efficacy and frequencies of complications of drugs that can treat PTSD in veterans. Method: We searched Ovid MEDLINE, Ovid Embase, The Cochrane Library and Web of Science until January 1, 2020. The outcomes were designed as the change of PTSD total scale, subsymptom score, response rate, frequencies of complications outcomes, and acceptability. Results: We included a total of 36 randomised controlled trials with a total of 2,331 adults. In terms of overall effect, drug treatment is more effective than placebo in change in total PTSD symptoms scale (SMD = -0.24, 95% CI [-0.42, -0.06]) and response (RR = 1.66, 95% CI [1.01, 2.72]). However, in terms of frequencies of complications, drugs generally had a higher withdrawal rate (RR = 1.02, 95% CI [0.86, 1.20]) and a higher frequencies of complications (RR = 1.72, 95% CI [1.20, 2.47]) than placebo. Risperidone showed a good curative effect in change in total PTSD symptoms scale (SMD = -0.22, 95% CI [-0.43, 0.00]) and acceptability (RR = 1.31, 95% CI [0.82, 2.59]). The drugs acting on 5-HT receptors, our results showed that symptoms of hyper-arousal (SMD = -0.54, 95% CI [-0.86, -0.21]), symptoms of re-experiencing (SMD = -0.62, 95% CI [-0.86, -0.39]) and symptoms of avoidance (SMD = -0.53, 95% CI [- 0.77,-0.3]), The drugs acting on dopamine receptors, our results showed that symptoms of re-experiencing (SMD = -0.35, 95% CI [-0.55, -0.16]) and the drugs acting on α2 receptor has a significant effect on reducing total PTSD symptoms scale (SMD = -0.34, 95% CI [-0.62, -0.06]). Conclusion: Drug therapy can effectively treat PTSD, but its frequencies of complications should be considered. Different from the guidelines for adult PTSD, this study supports atypical antipsychotics, selective serotonin reuptake inhibitors and receptors that act on 5-HT and dopamine for the treatment of PTSD in veterans. Based on evidence among these drugs, the risperidone is the most effective for veterans, otherwise, sertraline is used as an alternative.

Aplnr knockout mice display sex-specific changes in conditioned fear

The G-protein-coupled receptor APLNR and its ligands apelin and ELABELA/TODDLER/apela comprise the apelinergic system, a signaling pathway that is critical during development and physiological homeostasis. Targeted regulation of the receptor has been proposed to treat several important diseases including heart failure, pulmonary arterial hypertension and metabolic syndrome. The apelinergic system is widely expressed within the central nervous system (CNS). However, the role of this system in the CNS has not been completely elucidated. Utilizing an Aplnr knockout mouse model, we report here results from tests of sensory ability, locomotion, reward preference, social preference, learning and memory, and anxiety. We find that knockout of Aplnr leads to significant effects on acoustic startle response and sex-specific effects on conditioned fear responses without significant changes in baseline anxiety. In particular, male Aplnr knockout mice display enhanced context- and cue-dependent fear responses. Our results complement previous reports that exogenous Apelin administration reduced conditioned fear and freezing responses in rodent models, and future studies will explore the therapeutic benefit of APLNR-targeted drugs in rodent models of PTSD.

Projections from Infralimbic Cortex to Paraventricular Thalamus Mediate Fear Extinction Retrieval

The paraventricular nucleus of the thalamus (PVT), which serves as a hub, receives dense projections from the medial prefrontal cortex (mPFC) and projects to the lateral division of central amygdala (CeL). The infralimbic (IL) cortex plays a crucial role in encoding and recalling fear extinction memory. Here, we found that neurons in the PVT and IL were strongly activated during fear extinction retrieval. Silencing PVT neurons inhibited extinction retrieval at recent time point (24 h after extinction), while activating them promoted extinction retrieval at remote time point (7 d after extinction), suggesting a critical role of the PVT in extinction retrieval. In the mPFC-PVT circuit, projections from IL rather than prelimbic cortex to the PVT were dominant, and disrupting the IL-PVT projection suppressed extinction retrieval. Moreover, the axons of PVT neurons preferentially projected to the CeL. Silencing the PVT-CeL circuit also suppressed extinction retrieval. Together, our findings reveal a new neural circuit for fear extinction retrieval outside the classical IL-amygdala circuit.

Transcutaneous cervical vagal nerve stimulation reduces sympathetic responses to stress in posttraumatic stress disorder: A double-blind, randomized, sham controlled trial

OBJECTIVE

Exacerbated autonomic responses to acute stress are prevalent in posttraumatic stress disorder (PTSD). The purpose of this study was to assess the effects of transcutaneous cervical VNS (tcVNS) on autonomic responses to acute stress in patients with PTSD. The authors hypothesized tcVNS would reduce the sympathetic response to stress compared to a sham device.

METHODS

Using a randomized double-blind approach, we studied the effects of tcVNS on physiological responses to stress in patients with PTSD (n = 25) using noninvasive sensing modalities. Participants received either sham (n = 12) or active tcVNS (n = 13) after exposure to acute personalized traumatic script stress and mental stress (public speech, mental arithmetic) over a three-day protocol. Physiological parameters related to sympathetic responses to stress were investigated.

RESULTS

Relative to sham, tcVNS paired to traumatic script stress decreased sympathetic function as measured by: decreased heart rate (adjusted β = -5.7%; 95% CI: ±3.6%, effect size d = 0.43, p < 0.01), increased photoplethysmogram amplitude (peripheral vasodilation) (30.8%; ±28%, 0.29, p < 0.05), and increased pulse arrival time (vascular function) (6.3%; ±1.9%, 0.57, p < 0.0001). Similar (p < 0.05) autonomic, cardiovascular, and vascular effects were observed when tcVNS was applied after mental stress or without acute stress.

CONCLUSION

tcVNS attenuates sympathetic arousal associated with stress related to traumatic memories as well as mental stress in patients with PTSD, with effects persisting throughout multiple traumatic stress and stimulation testing days. These findings show that tcVNS has beneficial effects on the underlying neurophysiology of PTSD. Such autonomic metrics may also be evaluated in daily life settings in tandem with tcVNS therapy to provide closed-loop delivery and measure efficacy.ClinicalTrials.gov Registration # NCT02992899.

Pharmacological treatments for adults with post-traumatic stress disorder: A network meta-analysis of comparative efficacy and acceptability

BACKGROUND

The purpose of this study was to compare efficacy and acceptability among drug treatments for adults with post-traumatic stress disorder (PTSD) through a systematic review, random-effects pairwise and network meta-analyses.

METHODS

Double-blind randomized controlled trials comparing pharmacological interventions for adults with PTSD were searched from database inception through Aug. 28, 2018, on Cochrane (Central), Embase, LILACS, PILOTS, PsycINFO, PubMed, and Web of Science. Clinical trial registries and the websites of pharmaceutical companies were also searched. The GRADE system was used to assess the quality of the evidence.

RESULTS

The systematic review included 58 studies comprising 6766 patients randomized to 26 different interventions. Regarding efficacy, topiramate (SMD = -0.57; 95%CrI: -1.07,-0.10), risperidone (SMD = -0.53; 95%CrI: -0.93,-0.15), quetiapine (SMD = -0.59; 95%CrI: -1.06,-0.11), paroxetine (SMD = -0.35; 95%CrI: -0.48,-0.21), venlafaxine (SMD = -0.25; 95%CrI: -0.44,-0.05), fluoxetine (SMD = -0.28; 95%CrI: -0.46,-0.08), and sertraline (SMD = -0.21; 95%CrI: -0.33,-0.09) outperformed placebo. Moreover, phenelzine (RR = 3.39; 95%CrI: 1.43,11.09), lamotrigine (RR = 4.39; 95%CrI: 1.18,26.38), and fluoxetine (RR = 1.28%CrI: 1.01,1.59) outperformed placebo in terms of acceptability.

CONCLUSIONS

The NMA supports topiramate, risperidone, quetiapine, paroxetine, venlafaxine, fluoxetine and sertraline as effective pharmacological choices for the treatment of PTSD. Quetiapine and topiramate have the shortcoming of relying on a few small studies, but the clinically meaningful change in symptoms is noteworthy and merits further investigation. Among the pharmacological treatments with evidence of efficacy compared to placebo, fluoxetine achieved a relatively high rank regarding acceptability. To the best of our knowledge, this is the largest contemporary NMA on the subject and the addition of new medications is an important extension of previous meta-analyses, enabling a larger number of drug comparisons.

Randomized Controlled Trial of Riluzole Augmentation for Posttraumatic Stress Disorder: Efficacy of a Glutamatergic Modulator for Antidepressant-Resistant Symptoms

OBJECTIVE

Current pharmacologic treatments for posttraumatic stress disorder (PTSD) have shown limited efficacy, prompting a call to investigate new classes of medications. The current study investigated the efficacy of glutamate modulation with riluzole augmentation for combat-related PTSD symptoms resistant to treatment with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs).

METHODS

A randomized, double-blind, placebo-controlled, parallel trial was conducted at Walter Reed National Military Medical Center and Syracuse VA Medical Center between December 2013 and November 2017. Veterans and active duty service members with combat-related PTSD (per the Clinician Administered PTSD Scale [CAPS]) who were not responsive to SSRI or SNRI pharmacotherapy were randomized to 8-week augmentation with a starting dose of 100 mg/d of riluzole (n = 36) or placebo (n = 38) and assessed weekly for PTSD symptoms, anxiety, depression, disability, and side effects.

RESULTS

Intent-to-treat analyses (N = 74) of the primary outcome (CAPS for DSM-IV) showed no significant between-group difference in change in overall PTSD symptoms (F = 0.64, P = .422), with a small effect size (d = 0.25). There was clinically significant within-group improvement in overall PTSD symptoms in both groups, with a greater mean (SD) decrease in CAPS score in the riluzole group (-21.1 [18.9]) than in the placebo group (-16.7 [17.2]). Exploratory analyses of PTSD symptom clusters showed significantly greater improvement on hyperarousal symptoms in the riluzole group as measured by the PTSD Checklist-Specific-Subscale D (d = 0.48) and near-significant findings on the CAPS Subscale D. Riluzole augmentation was not superior to placebo on change in depression, anxiety, or disability severity.

CONCLUSIONS

Although preliminary, the exploratory findings of this study offer some evidence that riluzole augmentation of an SSRI or SNRI may selectively improve PTSD hyperarousal symptoms without changes in overall PTSD symptoms, depression, anxiety, or disability. Additional investigation of the mechanism of the efficacy of riluzole for hyperarousal symptoms is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02155829.

Novel Pharmacological Targets for Combat PTSD-Metabolism, Inflammation, The Gut Microbiome, and Mitochondrial Dysfunction

INTRODUCTION

Current pharmacological treatments of post-traumatic stress disorder (PTSD) have limited efficacy. Although the diagnosis is based on psychopathological criteria, it is frequently accompanied by somatic comorbidities and perhaps "accelerated biological aging," suggesting widespread physical concomitants. Such physiological comorbidities may affect core PTSD symptoms but are rarely the focus of therapeutic trials.

METHODS

To elucidate the potential involvement of metabolism, inflammation, and mitochondrial function in PTSD, we integrate findings and mechanistic models from the DOD-sponsored "Systems Biology of PTSD Study" with previous data on these topics.

RESULTS

Data implicate inter-linked dysregulations in metabolism, inflammation, mitochondrial function, and perhaps the gut microbiome in PTSD. Several inadequately tested targets of pharmacological intervention are proposed, including insulin sensitizers, lipid regulators, anti-inflammatories, and mitochondrial biogenesis modulators.

CONCLUSIONS

Systemic pathologies that are intricately involved in brain functioning and behavior may not only contribute to somatic comorbidities in PTSD, but may represent novel targets for treating core psychiatric symptoms.

[Sports Activity and Mental Diseases]

Current meta-analyses demonstrate convincing evidence regarding the efficacy of exercise on depression, insomnia, anxiety disorders, schizophrenia and ADHD. However, exercise and sports therapy approaches for patients with psychological disorders are mostly integrated in psychiatric inpatient or rehabilitation settings, but not applied in the outpatient sector. Thus, the German Health sector does not take the advantage of the compelling therapeutic effects of exercise. This review covers the theoretical and empirical fundamentals of the effects of exercise and illustrates practical implications by means of the presentation of the group-therapeutic exercise program ImPuls, that was specifically designed for patients with psychological disorders in outpatient settings. ImPuls integrates current evidence of the effects of exercise (type of sport, duration, frequency, intensity) and the facilitation of motivational and volitional strategies to support patients to integrate exercise in their daily life routines.

Interventions for adults with a history of complex traumatic events: the INCiTE mixed-methods systematic review

BACKGROUND

People with a history of complex traumatic events typically experience trauma and stressor disorders and additional mental comorbidities. It is not known if existing evidence-based treatments are effective and acceptable for this group of people.

OBJECTIVE

To identify candidate psychological and non-pharmacological treatments for future research.

DESIGN

Mixed-methods systematic review.

PARTICIPANTS

Adults aged ≥ 18 years with a history of complex traumatic events.

INTERVENTIONS

Psychological interventions versus control or active control; pharmacological interventions versus placebo.

MAIN OUTCOME MEASURES

Post-traumatic stress disorder symptoms, common mental health problems and attrition.

DATA SOURCES

Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 onwards); Cochrane Central Register of Controlled Trials (CENTRAL) (from inception); EMBASE (1974 to 2017 week 16); International Pharmaceutical Abstracts (1970 onwards); MEDLINE and MEDLINE Epub Ahead of Print and In-Process & Other Non-Indexed Citations (1946 to present); Published International Literature on Traumatic Stress (PILOTS) (1987 onwards); PsycINFO (1806 to April week 2 2017); and Science Citation Index (1900 onwards). Searches were conducted between April and August 2017.

REVIEW METHODS

Eligible studies were singly screened and disagreements were resolved at consensus meetings. The risk of bias was assessed using the Cochrane risk-of-bias tool and a bespoke version of a quality appraisal checklist used by the National Institute for Health and Care Excellence. A meta-analysis was conducted across all populations for each intervention category and for population subgroups. Moderators of effectiveness were assessed using metaregression and a component network meta-analysis. A qualitative synthesis was undertaken to summarise the acceptability of interventions with the relevance of findings assessed by the GRADE-CERQual checklist.

RESULTS

One hundred and four randomised controlled trials and nine non-randomised controlled trials were included. For the qualitative acceptability review, 4324 records were identified and nine studies were included. The population subgroups were veterans, childhood sexual abuse victims, war affected, refugees and domestic violence victims. Psychological interventions were superior to the control post treatment for reducing post-traumatic stress disorder symptoms (standardised mean difference -0.90, 95% confidence interval -1.14 to -0.66; number of trials = 39) and also for associated symptoms of depression, but not anxiety. Trauma-focused therapies were the most effective interventions across all populations for post-traumatic stress disorder and depression. Multicomponent and trauma-focused interventions were effective for negative self-concept. Phase-based approaches were also superior to the control for post-traumatic stress disorder and depression and showed the most benefit for managing emotional dysregulation and interpersonal problems. Only antipsychotic medication was effective for reducing post-traumatic stress disorder symptoms; medications were not effective for mental comorbidities. Eight qualitative studies were included. Interventions were more acceptable if service users could identify benefits and if they were delivered in ways that accommodated their personal and social needs.

LIMITATIONS

Assessments about long-term effectiveness of interventions were not possible. Studies that included outcomes related to comorbid psychiatric states, such as borderline personality disorder, and populations from prisons and humanitarian crises were under-represented.

CONCLUSIONS

Evidence-based psychological interventions are effective and acceptable post treatment for reducing post-traumatic stress disorder symptoms and depression and anxiety in people with complex trauma. These interventions were less effective in veterans and had less of an impact on symptoms associated with complex post-traumatic stress disorder.

FUTURE WORK

Definitive trials of phase-based versus non-phase-based interventions with long-term follow-up for post-traumatic stress disorder and associated mental comorbidities.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017055523.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 43. See the NIHR Journals Library website for further project information.

Animal models for the discovery of novel drugs for post-traumatic stress disorder

INTRODUCTION

Existing pharmacological treatments for PTSD are limited and have been used primarily because of their effectiveness in other psychiatric conditions. To generate novel, PTSD specific pharmacotherapy, researchers must utilize animal models to assess the efficacy of experimental drugs.

AREAS COVERED

This review includes a discussion of factors that should be considered when developing an animal model of PTSD, as well as descriptions of the most commonly used models. Researchers have utilized physical stressors, psychological stressors, or a combination of the two to induce PTSD-like physiological and behavioral sequelae in animals. Such models have provided researchers with a valuable tool to examine the neurobiological mechanisms underlying the condition.

EXPERT OPINION

PTSD is a heterogeneous disorder that manifests as different symptom clusters in different individuals. Thus, there cannot be a one-size-fits-all approach to modeling the disorder in animals. Preclinical investigators must adopt a concentrated effort aimed at modeling specific PTSD subtypes and the distinct symptom profiles that result from specific types of human trauma. Moreover, researchers have focused so much on modeling a single PTSD syndrome in animals that studies examining only specific facets of the disorder are largely ignored. Future research employing animal models of PTSD requires greater focus on the nuances of PTSD.

Cannabis and Complex Posttraumatic Stress Disorder: A Narrative Review With Considerations of Benefits and Harms

Despite substantial controversies concerning patients' reports of benefits from cannabis for posttraumatic stress disorder (PTSD) and inconsistent research findings regarding its efficacy and adverse risks, some states have already recognized PTSD as a qualifying condition for medical cannabis. Consequently, medical cannabis can also be provided for patients with complex PTSD who experience additional posttraumatic symptoms of affective dysregulation, negative perception of the self, and difficulties in relationships due to a history of repetitive trauma. In this article, we explore cannabis use in relation to benefits versus harms that might occur relative to specific complex PTSD symptoms and comorbidities. Whereas some symptoms related to PTSD per se (e.g., anxiety, insomnia, nightmares) may be benefited, others that are more characteristic of complex PTSD (e.g., dissociation, reckless behavior, and substance abuse associated with dysregulated affect) may be aggravated. Therefore, clinicians treating patients with complex PTSD who use or seek cannabis should carefully assess patients' motivations and the impacts of particular use patterns on specific symptoms. Clinicians and patients should be aware of and fully discuss the significant number of potential adverse effects of cannabis use, several of which might impede patients' participation in beneficial psychotherapeutic, social, and medical interventions.

Complementary and alternative therapies for post-traumatic stress disorder: A protocol for systematic review and network meta-analysis

BACKGROUND

Post-traumatic stress disorder (PTSD) is a psychiatric disorder. While bringing psychologic pain to patients, it also damages their social function, which is a great threat to people's life and health. Complementary and alternative medicine (CAM) therapies have been used clinically to treat PTSD; however, the selection strategies of different CAM interventions in clinical practice is still uncertain, and the purpose of this study is to evaluate the efficacy and acceptability of different CAM therapies using systematic review and network meta-analysis.

METHODS

According to the strategy, the authors will retrieve a total of 7 electronic databases by June 2020. After a series of screening, the 2 researchers will use Aggregate Data Drug Information System and Stata software to analyze the data extracted from randomized controlled trials of CAM therapies for the PTSD. Finally, the evidence grade of the results will be evaluated.

RESULTS

This study will provide a reliable evidence for the selection of CAM therapies for PTSD.

CONCLUSION

The results of this study will provide references for evaluating the influence of different CAM therapies for PTSD, and provide decision-making references for clinical research.

Prevalence and determinants of post-traumatic stress disorder among road traffic accident survivors: a prospective survey at selected hospitals in southern Ethiopia

BACKGROUND

Post-traumatic stress disorder (PTSD) is prevalent among road traffic accident survivors (RTA), yet the psychological welfare of the persons has largely been ignored as health care professionals focus more on managing physical injuries. Many literatures from other parts of the world have addressed the issue of post-traumatic stress disorder among road traffic accident survivors, but such studies are mostly unavailable in sub-Saharan Africa, especially in Ethiopia. Therefore, this study examined the prevalence and determinants of PTSD among RTA survivors attending selected hospitals in southern Ethiopia.

METHODS

Institution based cross-sectional study design was employed from April 1/2018-Sep 30/2019. Data were collected from a sample of consecutively selected 423 RTA survivors through an interviewer-administered technique. A pre-tested post-traumatic stress disorder Checklist-Specific version (PCL-S) tool was used to screen PTSD. Data were entered and analysed using SPSS 22 software. A logistic regression model was fitted to identify determinants of PTSD. An adjusted odds ratio (AOR) with a 95% confidence interval was computed to determine the level of significance with a p-value of less than 0.05.

RESULT

A total of 416 participants were included in the study and the response rate was 98.6%. The prevalence of probable PTSD among RTA survivors was 15.4% (64). After adjusting for the effects of potential confounding variables; time since accident (30-90 days) (AOR = 0.33; 95%CI (0.15, 0.73), history of previous road traffic accident (AOR = 2.67; 95%CI (1.23, 5.77), depressive symptoms (AOR = 2.5, 95% CI (1.10, 6.10)) and common mental disorder (AOR = 12.78, 95% CI (5.56, 29.36)) were significant determinants of PTSD.

CONCLUSION

The prevalence of probable PTSD in the current study was high (15.4%). Time since accident, history of a previous road traffic accident, having depressive symptoms and common mental disorder were significant determinants of PTSD. RTA survivors attending adult Emergency and orthopedic clinics need to be screened for PTSD and get appropriate management.

Reviewing the Potential of Psychedelics for the Treatment of PTSD

There are few medications with demonstrated efficacy for the treatment of posttraumatic stress disorder (PTSD). Treatment guidelines have unequivocally designated psychotherapy as a first line treatment for PTSD. Yet, even after psychotherapy, PTSD often remains a chronic illness, with high rates of psychiatric and medical comorbidity. Meanwhile, the search for and development of drugs with new mechanisms of action has stalled. Therefore, there is an urgent need to explore not just novel compounds but novel approaches for the treatment of PTSD. A promising new approach involves the use of psychedelic drugs. Within the past few years, 2 psychedelics have received breakthrough designations for psychiatric indications from the US Food and Drug Administration, and several psychedelics are currently being investigated for the treatment of PTSD. This review discusses 4 types of compounds: 3,4-methylenedioxymethamphetamine, ketamine, classical psychedelics (e.g., psilocybin and lysergic acid diethylamide), and cannabinoids. We describe the therapeutic rationale, the setting in which they are being administered, and their current state of evidence in the treatment of PTSD. Each compound provides unique qualities for the treatment of PTSD, from their use to rapidly target symptoms to their use as adjuncts to facilitate psychotherapeutic treatments. Several questions are formulated that outline an agenda for future research.

Dysregulation of inflammation, neurobiology, and cognitive function in PTSD: an integrative review

Compelling evidence from animal and human research suggest a strong link between inflammation and posttraumatic stress disorder (PTSD). Furthermore, recent findings support compromised neurocognitive function as a key feature of PTSD, particularly with deficits in attention and processing speed, executive function, and memory. These cognitive domains are supported by brain structures and neural pathways that are disrupted in PTSD and which are implicated in fear learning and extinction processes. The disruption of these supporting structures potentially results from their interaction with inflammation. Thus, the converging evidence supports a model of inflammatory dysregulation and cognitive dysfunction as combined mechanisms underpinning PTSD symptomatology. In this review, we summarize evidence of dysregulated inflammation in PTSD and further explore how the neurobiological underpinnings of PTSD, in the context of fear learning and extinction acquisition and recall, may interact with inflammation. We then present evidence for cognitive dysfunction in PTSD, highlighting findings from human work. Potential therapeutic approaches utilizing novel pharmacological and behavioral interventions that target inflammation and cognition also are discussed.

Measurement Strategies for Evidence-Based Antidepressants for Posttraumatic Stress Disorder Delivery: Trends and Associations with Patient-Reported Outcomes

We sought to develop a quality standard for the prescription of antidepressants for posttraumatic stress disorder (PTSD) that is both consistent with the underlying evidence supporting antidepressants as a treatment for PTSD and associated with the best levels of symptom improvement. We quantified antidepressant initiation during the first year of PTSD treatment in a 10-year national cohort of Department of Veterans Affairs (VA) users, and compared outcomes in a subgroup who completed patient-reported outcome measurement (PROM) as part of routine practice. We added progressively stringent measurement requirements. Prescribing quality for PTSD in the VA was stable over time. Use of PROM was rare in the case of antidepressant treatment, limiting our assessment of outcomes.

Comparative Efficacy and Acceptability of Pharmaceutical Management for Adults With Post-Traumatic Stress Disorder: A Systematic Review and Meta-Analysis

The current clinical guidelines on post-traumatic stress disorder (PTSD) recommend selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) of drugs. However, there is uncertainty about the efficacy of other drugs and selecting which treatments work best for which patients. This meta-analysis evaluated efficacy and acceptability of pharmaceutical management for adults with PTSD. Randomized-controlled trials, which reported active comparators and placebo-controlled trials of pharmaceutical management for adults with PTSD, from the Ovid Medline, EMBase, CENTRAL, PsycINFO, Ovid Health and Psychosocial Instruments, and ISIWeb of Science, were searched until June 21, 2019. In terms of efficacy, all active drugs demonstrated superior effect than placebo (SMD = -0.33; 95% CI, -0.43 to -0.23). The medications were superior to placebo in reducing the symptom of re-experiencing, avoidance, hyperarousal, depression, and anxiety. For acceptability, medicine interventions for PTSD showed no increase in all-cause discontinuation compared with placebo. Nevertheless, in terms of safety, medicine interventions indicated a higher risk of adverse effect compared with placebo (RR = 1.47, 95% CI: 1.24 to 1.75). Compared with placebo, the SSRIs and atypical antipsychotics drugs had significant efficacy whether in patients with severe or extremely severe PTSD status. However, only atypical antipsychotics (SMD = -0.29, 95% CI: -0.48 to -0.10) showed superior efficacy than placebo in veterans. Medication management could be effective in intervention of PTSD, which demonstrated a sufficient improvement in the core symptoms. This meta-analysis supports the status of SSRIs and SNRIs as recommended pharmacotherapy. However, patients with different clinical characteristics of PTSD should consider individualized drug management.

Perceived outcomes of psychedelic microdosing as self-managed therapies for mental and substance use disorders

RATIONALE

The regular consumption of very small doses of psychedelic drugs (known as microdosing) has been a source of growing media and community attention in recent years. However, there is currently limited clinical and social research evidence on the potential role of microdosing as therapies for mental and substance use disorders.

OBJECTIVES

This paper examined subjective experiences of microdosing psychedelics to improve mental health or to cease or reduce substance use, and examined sociodemographic and other covariates of perceived improvements in mental health that individuals attributed to microdosing.

METHODS

An international online survey was conducted in 2018 and examined people's experiences of using psychedelics for self-reported therapeutic or enhancement purposes. This paper focuses on 1102 respondents who reported current or past experience of psychedelic microdosing.

RESULTS

Twenty-one percent of respondents reported primarily microdosing as a therapy for depression, 7% for anxiety, 9% for other mental disorders and 2% for substance use cessation or reduction. Forty-four percent of respondents perceived that their mental health was "much better" as a consequence of microdosing. In a multivariate analysis, perceived improvements in mental health from microdosing were associated with a range of variables including gender, education, microdosing duration and motivations, and recent use of larger psychedelic doses.

CONCLUSIONS

Given the promising findings of clinical trials of standard psychedelic doses as mental health therapies, clinical microdosing research is needed to determine its potential role in psychiatric treatment, and ongoing social research to better understand the use of microdosing as self-managed mental health and substance use therapies.

Cannabinoids as therapeutics for PTSD

Post-traumatic stress disorder (PTSD) is a complex disorder that involves dysregulation of multiple neurobiological systems. The traumatic stressor plays a causal role in producing psychological dysfunction and the pattern of findings suggests that the hypothalamic-pituitary-adrenal (HPA) axis, which is instrumental for stress adaptation, is critically dysfunctional in PTSD. Given the lack of understanding of the basic mechanisms and underlying pathways that cause the disorder and its heterogeneity, PTSD poses challenges for treatment. Targeting the endocannabinoid (ECB) system to treat mental disorders, and PTSD in particular, has been the focus of research and interest in recent years. The ECB system modulates multiple functions, and drugs enhancing ECB signaling have shown promise as potential therapeutic agents in stress effects and other psychiatric and medical conditions. In this review, we focus on the interaction between the ECB-HPA systems in animal models for PTSD and in patients with PTSD. We summarize evidence supporting the use of cannabinoids in preventing and treating PTSD in preclinical and clinical studies. As the HPA system plays a key role in the mediation of the stress response and the pathophysiology of PTSD, we describe preclinical studies suggesting that enhancing ECB signaling is consistent with decreasing PTSD symptoms and dysfunction of the HPA axis. Overall, we suggest that a pharmacological treatment targeted at one system (e.g., HPA) may not be very effective because of the heterogeneity of the disorder. There are abnormalities across different neurotransmitter systems in the pathophysiology of PTSD and none of these systems function uniformly among all patients with PTSD. Hence, conceptually, enhancing ECB signaling may be a more effective avenue for pharmacological treatment.

Evaluation of the Effect of Prazosin Treatment on α-2c Adrenoceptor and Apoptosis Protein Levels in the Predator Scent-Induced Rat Model of Post-Traumatic Stress Disorder

The predator scent-induced (PSI) stress model is a rat model used to mimic post-traumatic stress disorder (PTSD) symptoms in humans. There is growing evidence that prazosin, which blocks α-1 and is approved by the FDA as an anti-hypertensive drug, can potentially be of use in the treatment of PTSD-related sleep disorders. The aim of this study was to investigate the role of prazosin treatment on behavioral parameters (freezing time, total transitions, and rearing frequency measured from the open field; anxiety index, total entries and time spent in open arms calculated from the elevated plus maze), apoptotic proteins and α-2c-AR in fear memory reconsolidation in the PSI stress rat model. We used western blot analysis to determine the effect of prazosin (0.5 mg/kg/ip) on α-2c-AR and apoptotic protein expression changes in the frontal cortex, hippocampus, and amygdala. It was determined that in the stress group, there was increased freezing time and anxiety index, and decreased rearing frequency, total transitions, total entries, and time spent in open arms compared to the control groups. Following PSI-stress, pro-apoptotic (bax) protein expression levels increased and α-2c AR and anti-apoptotic protein (bcl-2) levels decreased in investigated all brain regions. The majority of stress-induced changes were recovered with prazosin treatment. The results of our study may potentially be useful in understanding the effect of prazosin treatment, given the fact that the amygdala, frontal cortex, and hippocampus regions are affected for stress conditions.

A Case of Comorbid PTSD and Posttraumatic OCD Treated with Sertraline-Aripiprazole Augmentation

Several studies report on traumatic history in Obsessive Compulsive Disorder (OCD) and comorbidity between Posttraumatic Stress Disorder (PTSD) and OCD. First-line pharmacological treatments for both OCD and PTSD are primarily based on antidepressants, including Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Noradrenaline Reuptake Inhibitors (SNRI) such as Venlafaxine for PTSD. Second-Generation Antipsychotic (SGA) augmentation has shown good outcomes for nonresponsive OCD cases. However, evidence on the use of SGA in PTSD is more limited. In the present paper, we report on comorbid OCD-PTSD successfully treated with aripiprazole augmentation of sertraline. Shared psychopathological and pharmacological aspects of the disorders are discussed.

Effectiveness and safety of ear acupuncture for trauma-related mental disorders after large-scale disasters: A PRISMA-compliant systematic review

BACKGROUND

Large-scale disasters such as earthquakes cause mental health problems in individuals and lead to serious economic burdens on their communities and societies. Effective, simple, and safe intervention is needed to manage survivors of large-scale disasters. The purpose of this systematic review was to summarize and evaluate clinical studies using ear acupuncture for psychological trauma-related disorders after large-scale disasters, to determine its effectiveness, safety, and feasibility.

METHODS

A comprehensive search of 15 electronic databases was conducted to collect relevant clinical studies up to November 2019. The methodological quality of the included studies was assessed using appropriate tools according to their study design.

RESULTS

In total, 10 studies including 3 randomized controlled trials (RCTs), 3 before-after studies, 1 case report, 1 qualitative research, and 2 reports of public mental health services were analyzed. Ear acupuncture improved overall post-traumatic stress disorder (PTSD) related symptoms in patients with PTSD after disasters. For insomnia in patients with PTSD, although ear acupuncture improved a few subscales of the Pittsburgh sleep quality index in an RCT, other outcomes including sleep diary, actigraph, and the insomnia severity index were not improved. The methodological quality of RCTs was generally low. Serious adverse events related to ear acupuncture were not reported.

CONCLUSION

In conclusion, we found limited evidence suggesting the benefits of ear acupuncture in trauma-related mental disorders after large-scale disasters. Because of the small number of studies included and their heterogeneity, we could not draw conclusions about its effectiveness and safety. As 1 of the medical resources available after large-scale disasters, ear acupuncture still needs to be studied further. Registry studies aimed at investigating the results of ear acupuncture at disaster sites may be considered.

PROSPERO REGISTRATION NUMBER

CRD42019134658.

Sleep therapeutics and neuropsychiatric illness

Alterations in sleep are extremely common in patients with neuropsychiatric illness. In addition, sleep disorders such as insomnia, obstructive sleep apnea, rapid eye movement sleep behavior disorder, and circadian rhythm disorders commonly occur at a rate greater than the general population in neuropsychiatric conditions. Historically, sleep problems have been viewed as symptoms of associated neuropsychiatric disorders. However, there is increasing evidence suggesting a complex inter-relationship with possible bidirectional causality. The inter-relatedness of these conditions represents an opportunity for understanding mechanisms and improving clinical treatment. To the extent that sleep problems affect neuropsychiatric conditions, it may be possible to address sleep problems and have a positive impact on the course of neuropsychiatric illnesses. Further, some treatments for sleep disorders have direct effects on neuropsychiatric illnesses that may be unrelated to their effects on sleep disorders. Similarly, neuropsychiatric conditions and their treatments can affect sleep and sleep disorders. This article reviews available evidence on the effects of therapies for sleep disorders on neuropsychiatric conditions and also secondarily considers the impacts of therapies for neuropsychiatric conditions on sleep. Primary goals of this review are to identify gaps in current research, to determine the extent to which the cross-therapeutic effects of these treatments help to elucidate therapeutic or pathological mechanisms, and to assist clinicians in optimizing therapeutic choice in patients with sleep disorders and neuropsychiatric conditions.

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

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

Changes in Post-traumatic Stress Disorder Service Connection Among Veterans Under Age 55: An 18-Year Ecological Cohort Study

INTRODUCTION

Mandatory, age-based re-evaluations for post-traumatic stress disorder (PTSD) service connection contribute substantially to the Veterans Benefits Administration's work load, accounting for almost 43% of the 168,013 assessments for PTSD disability done in Fiscal Year 2017 alone. The impact of these re-evaluations on Veterans' disability benefits has not been described.

MATERIALS AND METHODS

The study is an 18-year, ecological, ambispective cohort of 620 men and 970 women receiving Department of Veterans Affairs PTSD disability benefits. Veterans were representatively sampled within gender; all were eligible for PTSD disability re-evaluations at least once because of age. Outcomes included the percentage whose PTSD service connection was discontinued, reduced, re-instated, or restored. We also examined total disability ratings among those with discontinued or reduced PTSD service connection. Subgroup analyses examined potential predictors of discontinued PTSD service connection, including service era, race/ethnicity, trauma exposure type, and chart diagnoses of PTSD or serious mental illness. Our institution's Internal Review Board reviewed and approved the study.

RESULTS

Over the 18 years, 32 (5.2%) men and 180 (18.6%) women had their PTSD service connection discontinued; among them, the reinstatement rate was 50% for men and 34.3% for women. Six men (1%) and 23 (2.4%) women had their PTSD disability ratings reduced; ratings were restored for 50.0% of men and 57.1% of women. Overall, Veterans who lost their PTSD service connection tended to maintain or increase their total disability rating. Predictors of discontinued PTSD service connection for men were service after the Vietnam Conflict and not having a Veterans Health Administration chart diagnosis of PTSD; for women, predictors were African American or black race, Hispanic ethnicity, no combat or military sexual assault history, no chart diagnosis of PTSD, and persistent serious mental illness. However, compared to other women who lost their PTSD service connection, African American and Hispanic women, women with no combat or military sexual assault history, and women with persistent serious illness had higher mean total disability ratings. For both men and women who lost their PTSD service connection, those without a PTSD chart diagnosis had lower mean total disability ratings than did their counterparts.

CONCLUSIONS

Particularly for men, discontinuing or reducing PTSD service connection in this cohort was rare and often reversed. Regardless of gender, most Veterans with discontinued PTSD service connection did not experience reductions in their overall, total disability rating. Cost-benefit analyses could help determine if mandated, age-based re-evaluations of PTSD service connection are cost-effective.

[Handling posttraumatic stress disorder : Showing weakness means you lose]

BACKGROUND

In prehospital medicine, psychological stress is common and part of the profession. On the one hand, this implies resilience; on the other hand, posttraumatic stress disorder (PTSD) can develop under the high psychological strain.

OBJECTIVES

The goal was to obtain an overview of the problem awareness among health care workers in prehospital medicine and identify possible networks for psychological trauma in Germany. The authors searched the internet in general and MEDLINE using key words.

RESULTS

PTSD among health care workers in prehospital medicine is rare but can be severe. Generally speaking, help for traumatized helpers is possible in Germany and several institutions offer help. Most victims do not use the offered help, which is not well organized for health care workers. The German Interdisciplinary Association for Intensive Care and Emergency Medicine founded a new section "perspective resilience" in order to offer better help.

CONCLUSIONS

Stress and psychological strain are common in health care workers in prehospital medicine, although most of the symptoms will resolve spontaneously. Nevertheless, after a psychological event, it is not possible to predict the course of the symptoms and the awareness among helpers is still low. To find the right therapy at the right time is critical. We still need better education and better networks in this area. Furthermore, research in this field is rare.

Behavioral effects of buspirone in a mouse model of posttraumatic stress disorder

Buspirone presents a unique profile of action, which involves activation of 5-HT_1A receptors and complex effects on D₂-like dopaminergic receptors. This medication is studied in terms of potential clinical repositioning to conditions that are associated with dopaminergic dysfunctions including schizophrenia and substance use disorder. Buspirone antagonizes D₃ and D₄ receptors, however, depending on the dose it differentially interacts with D₂ receptors. Previously, we reported that some of D₂/D₃ dopaminergic agonists attenuate PTSD-like behavioral symptoms in mice. Here we investigated whether buspirone could also affect PTSD-like symptoms. We used the single prolonged stress (mSPS) protocol to induce PTSD-like behavior in adult male CD-1 mice. Buspirone (0.5, 2, or 10 mg/kg, i.p.) was injected for 15 consecutive days. The subjects were repeatedly examined in a variety of behavioral tests measuring conditioned freezing response, antidepressant-like effects, anxiety, and ultrasonic vocal response to the restraint stress. Mouse SPS resulted in prolonged immobility in the forced swim test and freezing in the fear-conditioning test, and produced symptoms of anxiety. Buspirone dose-dependently decreased the exaggerated freezing response in mice, but only at the dose of 2 mg/kg exhibited the anxiolytic-like effect in the elevated plus maze test. Buspirone reduced the number of ultrasonic calls in mSPS-exposed mice but revealed no antidepressant-like effect in the forced swim test. Present data suggest some positive effects of buspirone in the treatment of selected PTSD-like symptoms and prompt for its further clinical evaluation.

Treatment of posttraumatic stress disorder: Focus on pharmacotherapy

Current clinical practice guidelines for the treatment of posttraumatic stress disorder offer varying recommendations regarding the use of pharmacotherapy. Many direct head-to-head comparisons of pharmacotherapy are lacking, and recommendations are based on meta-analyses and small trials. While selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors are considered first-line pharmacotherapy, clear distinctions do not exist when considering other classes of psychotropic medications. Ultimately, when selecting an appropriate medication for a patient diagnosed with posttraumatic stress disorder, the clinician needs to consider the current symptomatology being experienced, comorbid conditions, and evidence for efficacy of specific treatments prior to initiating medications.

Long-Term Clinical and Neuronuclear Imaging Sequelae of Cancer Therapy, Trauma, and Brain Injury

Neuronuclear imaging has been used for several decades in the study of primary neurodegenerative conditions, such as dementia and parkinsonian syndromes, both for research and for clinical purposes. There has been a relative paucity of applications of neuronuclear imaging to evaluate nonneurodegenerative conditions that can also have long-term effects on cognition and function. This article summarizes clinical and imaging aspects of 3 such conditions that have garnered considerable attention in recent years: cancer- and chemotherapy-related cognitive impairment, posttraumatic stress disorder, and traumatic brain injury. Further, we describe current research using neuroimaging tools aimed to better understand the relationships between the clinical presentations and brain structure and function in these conditions.

Early Interventions for the Prevention of Posttraumatic Stress Symptoms in Survivors of Critical Illness: A Qualitative Systematic Review

OBJECTIVES

Posttraumatic stress disorder among survivors of critical illness is of public health importance, as it is common and reduces patient quality of life. The objective of this systematic review was to collate the world's literature on interventions aimed at preventing posttraumatic stress disorder among survivors of critical illness.

DATA SOURCES

We performed a search of CENTRAL, MEDLINE, EMBASE, CINAHL, and clinical trials registry platforms, with no restriction to language using a comprehensive strategy.

STUDY SELECTION

Study inclusion criteria were as follows: 1) adult human subjects, 2) patients treated in an ICU setting, 3) intervention arm aimed at reducing posttraumatic stress disorder symptoms, 4) use of a control arm, and 5) an outcome measure assessing development of acute stress or posttraumatic stress disorder symptoms.

DATA EXTRACTION

We performed a qualitative analysis to collate and summarize effects of identified interventions according to the recommended methodology from the Cochrane Handbook.

DATA SYNTHESIS

Seventeen studies met all inclusion and no exclusion criteria. There was heterogeneity in interventions and outcome measures used. All studies had some concern for risk of bias as per the Cochrane tool for assessing risk of bias. In eight of 12 studies (67%) testing early interventions (i.e., initiated in the ICU course) and one of five studies (20%) testing delayed interventions following ICU discharge, posttraumatic stress disorder symptoms were decreased among the intervention group compared with controls.

CONCLUSIONS

Despite a paucity of high-quality clinical investigations, the preponderance of evidence to date suggests that 1) posttraumatic stress disorder among survivors of critical illness may be preventable and 2) early interventions may be the most effective.

Resilience as a translational endpoint in the treatment of PTSD

Resilience is a neurobiological entity that shapes an individual's response to trauma. Resilience has been implicated as the principal mediator in the development of mental illness following exposure to trauma. Although animal models have traditionally defined resilience as molecular and behavioral changes in stress responsive circuits following trauma, this concept needs to be further clarified for both research and clinical use. Here, we analyze the construct of resilience from a translational perspective and review optimal measurement methods and models. We also seek to distinguish between resilience, stress vulnerability, and posttraumatic growth. We propose that resilience can be quantified as a multifactorial determinant of physiological parameters, epigenetic modulators, and neurobiological candidate markers. This multifactorial definition can determine PTSD risk before and after trauma exposure. From this perspective, we propose the use of an 'R Factor' analogous to Spearman's g factor for intelligence to denote these multifactorial determinants. In addition, we also propose a novel concept called 'resilience reserve', analogous to Stern's cognitive reserve, to summarize the sum total of physiological processes that protect and compensate for the effect of trauma. We propose the development and application of challenge tasks to measure 'resilience reserve' and guide the assessment and monitoring of 'R Factor' as a biomarker for PTSD.

Internet-delivered computerized cognitive & affective remediation training for the treatment of acute and chronic posttraumatic stress disorder: Two randomized clinical trials

Treatment of posttraumatic stress disorder (PTSD) is time and cost-intensive. New, readily implementable interventions are needed. Two parallel randomized clinical trials tested if cognitive/affective computerized training improves cognitive/affective functions and PTSD symptoms in acute (N = 80) and chronic PTSD (N = 84). Adults age 18-65 were recruited from an Israeli hospital emergency room (acute) or from across the United States (chronic). Individuals were randomized to an active intervention (acute N = 50, chronic N = 48) that adaptively trains cognition and an affective positivity bias, or a control intervention (acute N = 30, chronic N = 36) of engaging computer games. Participants, blind to assignment, completed exercises at home for 30 min/day over 30 days (acute) or 45 min/day over 45 days (chronic). Primary outcomes were computerized cognitive/affective function metrics. Secondary outcomes were Clinician-Administered PTSD Scale (CAPS) total scores. In chronic PTSD, the active arm demonstrated facilitated speed of fearful face identification (F = 20.96, q < 0.001; d = 1.21) and a trend towards improvement in total PTSD symptoms (F = 2.91, p = 0.09, d = 0.47), which was due to improvement in re-experiencing symptoms (F = 6.14, p = 0.015; d = 0.73). Better cognitive performance at baseline moderated the training effect and was associated with more favorable improvements on both metrics. Cognitive and affective training does not have widespread benefit on symptoms and cognitive/affective functions in PTSD. Future studies targeting re-experiencing a priori, stratifying on cognitive capacity, and with modified methods to infer on mechanisms and optimized training parameters may be warranted. ClinicalTrials.gov Identifiers: NCT01694316 &NCT02085512.

Efficacy and safety of ear acupuncture for trauma-related disorders after large-scale disasters: A protocol of systematic review

BACKGROUND

This systematic review protocol describes the methods that will be used to evaluate the efficacy and safety of ear acupuncture for trauma-related disorders after large-scale disasters.

METHODS AND ANALYSIS

The following electronic databases will be searched up to May 2019 without language or publication status restrictions: Medline, EMBASE, the Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, and PsycARTICLES. We will also search Korean, Chinese, and Japanese databases. Any clinical studies with original data related to ear acupuncture for trauma-related disorders after large-scale disaster will be included. Traumatic stress-related symptoms will be assessed as primary outcomes. Depression, anxiety, adverse events, and total effective rate will be evaluated as secondary outcomes. Two researchers will independently perform the study selection, data extraction, and assessment of study quality. Descriptive analyses of the details of participants, interventions, and outcomes for all included studies will be conducted. Data synthesis and analysis will be performed using RevMan version 5.3. The methodological quality of the included studies will be evaluated according to the study design.

ETHICS AND DISSEMINATION

Ethical approval is not required because individual patient data are not included. The findings of this systematic review will be disseminated through a peer-reviewed publication or conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42019134658.

Using patient-reported outcomes to understand the effectiveness of guideline-concordant care for post-traumatic stress disorder in clinical practice

RATIONALE

Identifying predictors of improvement amongst patients receiving routine treatment for post-traumatic stress disorder (PTSD) could provide information about factors that influence the clinical effectiveness of guideline-concordant care. This study builds on prior work by accounting for delivery of specific evidence-based treatments (EBTs) for PTSD while identifying potential predictors of clinical improvement using patient-reported outcomes measurement.

METHOD

Our sample consisted of 2 643 US Department of Veterans Affairs (VA) outpatients who initiated treatment for PTSD between 2008 and 2013 and received at least four PTSD checklist (PCL) measurements over 12 weeks. We obtained PCL data as well as demographic, diagnostic, and health services use information from the VA corporate data warehouse. We used latent trajectory analysis to identify classes of patients based on PCL scores, then determined demographic, diagnostic, and treatment predictors of membership in each class.

RESULTS

Patients who met our PCL-based inclusion criteria were far more likely than those who did not receive EBTs. We identified two latent trajectories of PTSD symptoms. Patients in the substantial improvement group (25.9%) had a mean decrease in PCL score of 16.24, whereas patients in the modest improvement group improved by a mean of 8.09 points. However, there were few differences between the groups, and our model to predict group membership was only slightly better than chance (area under the curve [AUC] = 0.55). Of the 64 covariates we tested, the only robust individual predictor of improvement was gender, with men having lower odds of being in the substantial improvement group compared with women (odds ratio [OR] 0.76; 95% confidence interval [CI] 0.58-0.96).

CONCLUSION

VA patients with PTSD can realize significant improvement in routine clinical practice. Although available medical records-based variables were generally insufficient to predict improvement trajectory, this study did indicate that men have lower odds of substantial improvement than women.