The Clinical Problems in Consultation Psychiatry (CPCP) presentation was given by resident psychiatrist Dr. Emily Morse, DO and was about prevention of Posttraumatic stressor disorder (PTSD) by using specific medications. One of the reasons I was curious about this turned out to be based on a wrong assumption. Our burn surgeons are very interested in optimizing recognition of PTSD in their patients and we’ve talked a little about how to operationalize that. I’ve noticed that they are also giving propranolol to some of their burn patients, and propranolol is one of the drugs which has been studied in preventing PTSD in trauma victims. It looks like it’s part of a study protocol.
I discovered later after checking ClinicalTrials.gov that their study has nothing to do with preventing PTSD but is about evaluating the safety of the beta blocker in burn patients generally.
Anyway, it turns out there there are several studies on prevention of PTSD, with two of the leading drugs being propranolol and hydrocortisone. As Dr. Morse pointed out, Acute Stress Disorder (ASD) has low sensitivity for predicting which patients who have ASD will go on to develop PTSD. The proposed mechanisms for how they might work are intriguing. I think one of many factors which might be troublesome with implementing protocols using these agents is the short time frame in which they need to be administered after the traumatic event, often within hours.
The studies have limitations, one of which is the small number of subjects and different methods of administration. I also wonder about the neuropsychiatric side effects of glucocorticoids which can include delirium, anxiety, and a host of others. Speaking of delirium, there is a risk of developing PTSD from the hallucinations and delusions. It’s ironic in this instance to propose using a substance to prevent PTSD arising from delirium which could actually turn out to cause it as well.
Qi and colleagues say, in a recent review in an open access journal, that we know a great deal about risk factors for PTSD. However,
“Despite such an abundance of potential risk indicators, this knowledge has not yet been translated into individual risk prediction. One shortcoming of research to date is the use of statistical modeling that does not properly account for within-group heterogeneities. Studies universally use central tendency statistics, thereby implying that groups studied (e.g., rape victims, accident victims) are inherently homogeneous. However, trauma-exposed individuals are inherently heterogeneous, each bringing to the event his or her own array of vulnerability factors, environmental pressures (and provisions), psychological outfit and subjective appraisal of the traumatic event. Recent studies have used advanced analytic methods to define within – individual (as opposed to group average) symptom trajectories as the outcome of interest, and used machine-learning algorithms to make risk predictions” .
Psychological debriefing is out because it was found to be harmful in some cases. Exposure-based Cognitive behavioral therapy (CBT) has the most evidence supporting it, but is not widely available. Further, it may not be necessary in most people with PTSD because many will recover without treatment of any kind. It seems to be best for those with acute PTSD.
The authors also point out that pharmacological interventions, according to a 2014 Cochrane Review, showed moderate efficacy for hydrocortisone and no evidence for propranolol, escitalopram, temazepam, and gabapentin. Importantly, there is no evidence for the efficacy of benzodiazepines, which more often exacerbated PTSD, leading to current guidelines recommending against their use. It amazes me how often I encounter patients with PTSD who are prescribed benzodiazepines.
They recommend the following:
“Studies reviewed above summarize the ‘clinical’ implementation of preventive interventions; that is, the provision of specialized treatment to survivors screened or formally diagnosed within a medical care model. Challenging the restricted setting and medical model, Zatzick et al. (2004, 2013) evaluated a stepped collaborative care model, which introduced care managers to address patients’ unique needs using intervention modalities as required (e.g., components of CBT, Motivation Interview, pharmacotherapy). The care team repeatedly measured patient’s symptoms and adjusted levels of care accordingly.”
Further, we should guide our efforts through better “…risk assessment, understanding pathogenesis, and matching intervention techniques.” It’s important to individualize treatment because of the inherent heterogeneity of the disorder.
How will I change my practice based on this CPCP? I think I’ll point to this practice-based learning activity and probably ask my colleagues to temper any enthusiasm they might have for preventing PTSD with drugs until we have better studies. Where exposure-based CBT is available, we can try to refer given the paucity of this resource in many rural areas. And I would recommend against prescription of any benzodiazepines.
Now this is practice-based learning and improvement. It’s relevant to my practice. It’s evidence-based. It cost me nearly nothing but my time. Well, it cost Dr. Morse her time and I and other learners were the happy recipients of the fruit of her efforts.
This is in every conceivable way, superior to Maintenance of Certification (MOC) and I ask the executive leaders at the American Board of Medical Specialties (ABMS) and at my own certification board, the American Board of Psychiatry and Neurology (ABPN) to rethink the current structure of MOC and listen to rank and file doctors who are struggling to take care of patients every day when we say that MOC is a waste of our time.
Further, consider signing the new petition regarding the American Board of Internal Medicine (ABIM) at this link. And view the video below, which outlines what physician leaders think about how the principle of lifelong learning could be embodied differently.
- Qi, W., et al. (2016). “Prevention of Post-Traumatic Stress Disorder After Trauma: Current Evidence and Future Directions.” Current Psychiatry Reports 18(2): 1-11.
Post-traumatic stress disorder (PTSD) is a frequent, tenacious, and disabling consequence of traumatic events. The disorder’s identifiable onset and early symptoms provide opportunities for early detection and prevention. Empirical findings and theoretical models have outlined specific risk factors and pathogenic processes leading to PTSD. Controlled studies have shown that theory-driven preventive interventions, such as cognitive behavioral therapy (CBT), or stress hormone-targeted pharmacological interventions, are efficacious in selected samples of survivors. However, the effectiveness of early clinical interventions remains unknown, and results obtained in aggregates (large groups) overlook individual heterogeneity in PTSD pathogenesis. We review current evidence of PTSD prevention and outline the need to improve the disorder’s early detection and intervention in individual-specific paths to chronic PTSD.
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