PracticeUpdate Conference Series European Congress of Psychiatry 2019

To Date, Only Hydrocortisone Shows Promise for Pharmacologic Prevention of PTSD Currently, results are limited to patients with severe physical illness. A mong all the pharmacologic therapies that have been evaluated to help prevent post-traumatic stress disorder (PTSD), only hydrocortisone shows evidence of efficacy. This is the main finding of a meta-analysis presented at this meeting. “The prevalence of PTSD in high-risk populations is extremely high, estimated at around 15%,” presenter Laurence Astill Wright, a CT1 psychiatry trainee at the University of York in the United Kingdom, told Elsevier’s PracticeUpdate . “PTSD is also associated with huge physical and psychiatric comorbidity, including substance abuse and suicide. Preventing the formation of PTSD in high-risk groups could vastly improve these psychiatric outcomes. Furthermore, PTSD remains a promising condition for pharmacological prevention, as it is likely that memory consolidation is particularly vulnerable to disruption in the 6 hours after trauma. Thus, it might be possible to prevent the over-consolidation of memories that we see in PTSD using pharmacological agents.” The investigators conducted a systematic review of the literature and identified 19 randomized controlled trials that used early pharmacotherapy within 3 months of a traumatic event to prevent or treat PTSD or acute stress disorder in children and adults. Of these studies, 15 were conducted in adults and four in children. Among all the pharmacologic interventions evaluated, including propranolol, oxy- tocin, gabapentin, docosahexaenoic acid, fish oil, escitalopram, imipramine and chloral hydrate, only hydrocortisone in adults was found to be statistically superior to placebo, an effect that was demonstrated in three studies (n=88, risk ratio 0.21; confidence interval 0.05−0.89). These studies comprised populations with severe physical illness, which raises the question as to whether the findings are general- izable to a less impaired group. “Our work supports additional research investigating the preventative effect of hydrocortisone, but there remains insufficient evidence to recommend its admin- istration routinely,” said Wright. “Even in the short term, hydrocortisone use can produce numerous adverse effects, ranging from congestive cardiac failure to insomnia. Of the studies we considered, some reported no side effects. while others reported dizziness and an increased rate of infection/septic shock, hyperglycemia and hypernatremia. Thus, the potential benefit of the medication must be balanced against the potential side effects. Patients may also be reluctant to receive hydrocortisone in the absence of symptoms.” On the other hand, he continued, “Hydrocortisone remains the most promising target for further investigation and, due to its low cost and widespread availability, it has great potential for large-scale administration in disaster settings as part of the operational response to traumatic events. “Our research was hindered by the small number of studies evaluating certain therapies and by the methodological limitations of many randomized controlled trials, raising concerns about possible risk of bias,” Wright said. There is therefore an ongoing need for large-scale randomized controlled trials to fully evaluate the role of hydrocortisone in the prevention of PTSD. Other additional promising therapies, such as oxytocin, should also be evaluated in this manner.

tools seem to indicate remission or whose scores are in a mild range. “Given the DSM [Diagnostic and Statistical Manual of Mental Disorders] criteria for depression, patients can have as many as three depressive symptoms and not meet the criteria for major depressive disorder,” he continued. “Consider if those three symptoms might be some sleep disturbance, indecisive- ness and low energy. Symptom checklists have their limitations and do not assess functionality. So, the study authors are onto something. It is necessary to ask patients about their current functioning. For depressed patients, asking if they are getting things accomplished is one of the best questions to ask and a good basis for determining improvement.” Dr. Butler also noted, however, that, “depression can and often is a very debil- itating experience, which erodes patients’ confidence and undermines their belief in their efficacy. The instruments used in this investigation rely on patients’ subjec- tive perceptions, which may be clouded by their experience of depression. This is where the conveyance of hope and encouragement and motivational mes- saging by the primary care physician plays a significant role in helping patients re-engage activities at school, home, on the job, or in the community.”

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EPA 2019 • PRACTICEUPDATE CONFERENCE SERIES 15