Early pharmacological interventions for prevention of post-traumatic stress disorder (PTSD) in individuals experiencing acute traumatic stress symptoms.

BACKGROUND: Acute traumatic stress symptoms may develop in people who have been exposed to a traumatic event. Although they are usually self-limiting in time, some people develop post-traumatic stress disorder (PTSD), a severe and debilitating condition. Pharmacological interventions have been proposed for acute symptoms to act as an indicated prevention measure for PTSD development. As many individuals will spontaneously remit, these interventions should balance efficacy and tolerability. OBJECTIVES: To assess the efficacy and acceptability of early pharmacological interventions for prevention of PTSD in adults experiencing acute traumatic stress symptoms. SEARCH METHODS: We searched the Cochrane Common Mental Disorders Controlled Trial Register (CCMDCTR), CENTRAL, MEDLINE, Embase and two other databases. We checked the reference lists of all included studies and relevant systematic reviews. The search was last updated on 23 January 2023. SELECTION CRITERIA: We included randomised controlled trials on adults exposed to any kind of traumatic event and presenting acute traumatic stress symptoms, without restriction on their severity. We considered comparisons of any medication with placebo, or with another medication. We excluded trials that investigated medications as an augmentation to psychotherapy. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures. Using a random-effects model, we analysed dichotomous data as risk ratios (RR) and calculated the number needed to treat for an additional beneficial/harmful outcome (NNTB/NNTH). We analysed continuous data as mean differences (MD) or standardised mean differences (SMD). Our primary outcomes were PTSD severity and dropouts due to adverse events. Secondary outcomes included PTSD rate, functional disability and quality of life. MAIN RESULTS: We included eight studies that considered four interventions (escitalopram, hydrocortisone, intranasal oxytocin, temazepam) and involved a total of 779 participants. The largest trial contributed 353 participants and the next largest, 120 and 118 participants respectively. The trials enrolled participants admitted to trauma centres or emergency departments. The risk of bias in the included studies was generally low except for attrition rate, which we rated as high-risk. We could meta-analyse data for two comparisons: escitalopram versus placebo (but limited to secondary outcomes) and hydrocortisone versus placebo. One study compared escitalopram to placebo at our primary time point of three months after the traumatic event. There was inconclusive evidence of any difference in terms of PTSD severity (mean difference (MD) on the Clinician-Administered PTSD Scale (CAPS, score range 0 to 136) -11.35, 95% confidence interval (CI) -24.56 to 1.86; 1 study, 23 participants; very low-certainty evidence), dropouts due to adverse events (no participant left the study early due to adverse events; 1 study, 31 participants; very low-certainty evidence) and PTSD rates (RR 0.59, 95% CI 0.03 to 13.08; NNTB 37, 95% CI NNTB 15 to NNTH 1; 1 study, 23 participants; very low-certainty evidence). The study did not assess functional disability or quality of life. Three studies compared hydrocortisone to placebo at our primary time point of three months after the traumatic event. We found inconclusive evidence on whether hydrocortisone was more effective in reducing the severity of PTSD symptoms compared to placebo (MD on CAPS -7.53, 95% CI -25.20 to 10.13; I2 = 85%; 3 studies, 136 participants; very low-certainty evidence) and whether it reduced the risk of developing PTSD (RR 0.47, 95% CI 0.09 to 2.38; NNTB 14, 95% CI NNTB 8 to NNTH 5; I2 = 36%; 3 studies, 136 participants; very low-certainty evidence). Evidence on the risk of dropping out due to adverse events is inconclusive (RR 3.19, 95% CI 0.13 to 75.43; 2 studies, 182 participants; low-certainty evidence) and it is unclear whether hydrocortisone might improve quality of life (MD on the SF-36 (score range 0 to 136, higher is better) 19.70, 95% CI -1.10 to 40.50; 1 study, 43 participants; very low-certainty evidence). No study assessed functional disability. AUTHORS' CONCLUSIONS: This review provides uncertain evidence regarding the use of escitalopram, hydrocortisone, intranasal oxytocin and temazepam for people with acute stress symptoms. It is therefore unclear whether these pharmacological interventions exert a positive or negative effect in this population. It is important to note that acute traumatic stress symptoms are often limited in time, and that the lack of data prevents the careful assessment of expected benefits against side effects that is therefore required. To yield stronger conclusions regarding both positive and negative outcomes, larger sample sizes are required. A common operational framework of criteria for inclusion and baseline assessment might help in better understanding who, if anyone, benefits from an intervention. As symptom severity alone does not provide the full picture of the impact of exposure to trauma, assessment of quality of life and functional impairment would provide a more comprehensive picture of the effects of the interventions. The assessment and reporting of side effects may facilitate a more comprehensive understanding of tolerability.

Food-Derived Opioid Peptides in Human Health: A Review.

World Health Organization data suggest that stress, depression, and anxiety have a noticeable prevalence and are becoming some of the most common causes of disability in the Western world. Stress-related disorders are considered to be a challenge for the healthcare system with their great economic and social impact. The knowledge on these conditions is not very clear among many people, as a high proportion of patients do not respond to the currently available medications for targeting the monoaminergic system. In addition, the use of clinical drugs is also associated with various side effects such as vomiting, dizziness, sedation, nausea, constipation, and many more, which prevents their effective use. Therefore, opioid peptides derived from food sources are becoming one of the safe and natural alternatives because of their production from natural sources such as animals and plant proteins. The requirement for screening and considering dietary proteins as a source of bioactive peptides is highlighted to understand their potential roles in stress-related disorders as a part of a diet or as a drug complementing therapeutic prescription. In this review, we discussed current knowledge on opioid endogenous and exogenous peptides concentrating on their production, purification, and related studies. To fully understand their potential in stress-related conditions, either as a drug or as a therapeutic part of a diet prescription, the need to screen more dietary proteins as a source of novel opioid peptides is emphasized.

Pharmacological prevention and early treatment of post-traumatic stress disorder and acute stress disorder: a systematic review and meta-analysis.

Post-traumatic stress disorder (PTSD) is a common mental disorder associated with significant distress and reduced functioning. Its occurrence after a severe traumatic event and association with characteristic neurobiological changes make PTSD a good candidate for pharmacological prevention and early treatment. The primary aim for this systematic review and meta-analysis was to assess whether pharmacological interventions when compared to placebo, or other pharmacological/psychosocial interventions resulted in a clinically significant reduction or prevention of symptoms, improved functioning or quality of life, presence of disorder, or adverse effects. A systematic search was undertaken to identify RCTs, which used early pharmacotherapy (within three months of a traumatic event) to prevent and treat PTSD and acute stress disorder (ASD) in children and adults. Using Cochrane Collaboration methodology, RCTs were identified and rated for risk of bias. Available data was pooled to calculate risk ratios (RR) for PTSD prevalence and standardised mean differences (SMD) for PTSD severity. 19 RCTs met the inclusion criteria; 16 studies with adult participants and three with children. The methodological quality of most trials was low. Only hydrocortisone in adults was found to be superior to placebo (3 studies, n = 88, RR: 0.21 (CI 0.05 to 0.89)) although this was in populations with severe physical illness, raising concerns about generalisability. No significant effects were found for the other pharmacotherapies investigated (propranolol, oxytocin, gabapentin, fish oil (1470 mg DHA/147 mg EPA), fish oil (224 mg DHA/22.4 mg EPA), dexamethasone, escitalopram, imipramine and chloral hydrate). Hydrocortisone shows the most promise, of pharmacotherapies subjected to RCTs, as an emerging intervention in the prevention of PTSD within three months after trauma and should be a target for further investigation. The limited evidence for hydrocortisone and its adverse effects mean it cannot be recommended for routine use, but, it could be considered as a preventative intervention for people with severe physical illness or injury, shortly after a traumatic event, as long as there are no contraindications. More research is needed using larger, high quality RCTs to establish the most efficacious use of hydrocortisone in different populations and optimal dosing, dosing window and route. There is currently a lack of evidence to suggest that other pharmacological agents are likely to be effective.

Psychosocial, Demographic, and Illness-Related Factors Associated With Acute Traumatic Stress Responses in Parents of Children With a Serious Illness or Injury.

This study investigated factors associated with acute stress symptoms in parents of seriously ill children across a range of illnesses and treatment settings within a pediatric hospital setting. It was hypothesized that psychosocial variables would be more strongly associated with acute stress responses than demographic and child illness variables. Participants were 115 mothers and 56 fathers of children treated within the oncology, cardiology, and intensive care departments of a pediatric hospital. Acute stress, psychosocial, demographic, and medical data were collected within the first 4 weeks of the child's hospital admission. A robust hierarchical regression model revealed that psychosocial factors significantly explained 36.8% of the variance in parent acute stress responses (p < .001); demographic variables significantly added a further 4.5% (p = .022), but illness-related factors did not contribute to the model. Findings support the implementation of a general psychosocial screening approach for parents across the wider hospital system, and that psychosocial risk factors may be targeted in interventions across different illnesses and treatment settings to improve parent outcomes.

Prevention of Trauma and Stressor-Related Disorders: A Review.

Posttraumatic stress disorder (PTSD) is a common, frequently chronic, and disabling condition which, along with acute stress disorder (ASD), is categorized as a trauma- and stressor-related disorder by the DSM-5. These disorders are unique in requiring exposure to a severe stressor, which implies that potential sufferers could be identified and helped before developing a disorder. Research on prevention strategies for stress-related disorders has taken a number of avenues, including intervention before and after trauma and the use of both psychosocial and somatic approaches. Despite advances in neurobiological understanding of response to trauma, clinical evidence for preventive interventions remains sparse. This review provides an overview of prevention approaches and summarizes the existing literature on prevention of ASD and PTSD, including clinical and preclinical studies. Given the potential benefits to trauma survivors and society, the development of effective preventive interventions should be given greater priority. Resources should be directed to adequately test promising interventions in clinical trials, and research should be conducted according to translational research principles in which preclinical research informs the design of clinical studies.

Pharmacological prevention of post-traumatic stress disorder and acute stress disorder: a systematic review and meta-analysis.

BACKGROUND: An increasing number of studies have investigated the pharmacological prevention of post-traumatic stress disorder (PTSD) and acute stress disorder (ASD). This is the first systematic review to examine the effects of pharmacotherapies (eg, ß blockers, hydrocortisone, and selective serotonin re-uptake inhibitors) given within the first month after a traumatic or aversive event to prevent PTSD or ASD compared with no pharmacotherapy or placebo control. METHODS: A systematic literature search in PubMed, PsycINFO, Embase, and the Cochrane database of randomised trials was done. Studies included randomised controlled trials, controlled clinical trials, and cohort studies; their overall quality was low to moderate. We computed the pooled incidence risk ratio (IRR): the risk of incidence of PTSD or ASD in the pharmacotherapy groups relative to the incidence of PTSD or ASD in the control groups. Additionally, we computed Hedges'g effect sizes for PTSD or ASD continuous outcomes. FINDINGS: 15 studies met inclusion criteria (1765 individuals). Pharmacotherapy was more effective in preventing PTSD or ASD than placebo or no intervention (14 studies, 1705 individuals, IRR 0·65, 95% CI 0·55-0·78; number needed to treat 11·36), although no effect was found when only randomised controlled trials were included (ten studies, 300 individuals, IRR 0·69, 95% CI 0·40-1·21). Hydrocortisone showed a large effect in reducing the risk of PTSD (five studies, 164 individuals, IRR 0·38, 95% CI 0·16-0·92). INTERPRETATION: No firm evidence was found for the efficacy of all early pharmacotherapies in the prevention of PTSD or ASD, but hydrocortisone reduced the risk of developing PTSD. The small number of studies and their limited methodological quality cast uncertainty about the effects. FUNDING: None.

European Commission project: European Guideline for Target Group-Oriented Psychosocial Aftercare-Implementation.

After disasters, the individual health and well-being of first responders and affected population are affected for years. Therefore, psychosocial help is needed. Although most victims recover on their own, a minority of survivors, members of rescue teams, or relatives develop long-term, disaster-related psychic disorders, such as post-traumatic stress disorder (PTSD). This subgroup especially should receive timely and appropriate psychosocial help. Many European countries offer post-disaster psychosocial care from a variety of caregivers (i.e., professionals and volunteers, non-governmental organizations, church or commercial organizations). Therefore, European standards for providing post-disaster psychosocial support currently is required. This article describes the project European Guideline for Target Group-Oriented Psychosocial Aftercare-Implementation, supported by the European Commission.

Clinical inquiries: what is the most effective way to relieve symptoms of acute stress disorder?

Cognitive Behavioral Therapy (CBT) that emphasizes exposure-based treatment is the most effective intervention for adults with acute stress disorder (ASD). Exposure-based therapy reduces symptoms in adults with ASD more than CBT that focuses on cognitive restructuring; both therapies are better than no treatment at all. Avoid drug treatment within 4 weeks of appearance of symptoms, unless distress is too severe to be managed with psychological treatment alone.

Stage fright in singers: three reaction types.

Drawing on both my own personal experience and that of many colleagues and pupils, I shall describe three kinds of reactions to stage fright. The first is the primarily mental reaction of derealization, which involves feeling cut off from fear and decreasing body awareness. The second and third reactions to stage fright involve (a) increased and (b) decreased muscle tonus and their associated breathing patterns. Furthermore, I shall indicate how singers manage to pull themselves together through the very act of producing their first tones.

Prevención de secuelas psicológicas en niños con quemaduras graves / Prevention of psychological sequelae in severely burnt children

con el objetivo de evaluar la incidencia del Trastorno de estrés Agudo (T.E.A.) y el trastorno de Estrés postraumático (T.E.P.T.) en niños con quemaduras graves, se realizó una primera evaluación del niño en el primer mes de sucedido el evento traumático (período 1) y dos evaluaciones más en el período 2 (2do. y 3er. mes) y en el período 3 4to y 5to. mes). Dado que no existe un instrumento validado para el estudio de T.E.A y T. E.P.T., se diseñaron dos entrevistas psicológicas basadas en los criterios del Manual diagnóstico y estadístico de los trastornos mentales (DSM IV). Se estudiaron 69 niños con quemaduras graves (grupo I, II, III y IV, según clasificación de Garces), edad de 0 a 15 años (mediana 4 años), 43 por ciento F y 57 por ciento M. Los resultados fueron los siguientes: en el periodo 1, 18 por ciento de los pacientes presentaron T.E.A. y 82 por ciento Sintomatología poliforfa. En este período treinta (30) pacientes fueron no evalubles, dado que estaban en Asistencia Respiratoria Mecánica. En el perído 2; 8 por ciento de los pacientes presentaron T.E.P.T.; 92 por ciento sintomatología polimorfa. cinco (5) pacientes fueron no evaluables, dado que continuaban ARM. En el período 3; 28 por ciento presentó Sintomatología Polimorfa y el resto ningún trastorno emocional. Todos los pacientes fueron evaluados. Se realizaron intervenciones psicoeducativas, graficas y dramatizaciones con el niño (adaptadas al estado clínico del mismo). Conclusión: los resultados sugieren que la evaluación e intervenciones psicológicas tempranas de niños que vivieron un evento traumático podrían tener un efecto preventivo de secuelas psicológicas tempranas de niños que vivieron un evento traumático podrían tener un efecto preventivo de secuelas psicológicas asociadas al evento.

The impact of unintentional pediatric trauma: a review of pain, acute stress, and posttraumatic stress.

This article reviews current research on acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) resulting from pediatric simple (i.e., single, unpredictable, and unintentional) physical injury and how pain may act as both a trigger and a coexisting symptom. Although several studies have explored predictors of ASD and PTSD, as well as the relationship between these conditions in adults, there is less research on ASD and PTSD in children and adolescents. This review highlights the importance of early detection of pain and acute stress symptoms resulting from pediatric unintentional physical injury in the hopes of preventing long-term negative outcomes, such as the potential development of PTSD and associated academic, social, and psychological problems.

Psychophysiological effects of human-animal interaction: theoretical issues and long-term interaction effects.

This paper reviews literature published on the psychophysiological effects of long-term human-animal interaction (i.e., pet ownership, pet adoption). A literature search was conducted using PsycInfo and Medline databases. Although the available evidence is far from being consistent, it can be concluded that, in some cases, long-term relationships with animals may moderate baseline physiological variables, particularly blood pressure. Results proved more coherent in studies where animals were adopted by owners as part of the procedure. This paper examines existing hypotheses seeking to account for these effects and the supporting evidence. Two major hypotheses have been suggested to explain the psychophysiological effects of long-term interaction, namely (1) stress-buffering effects of noncritical social support provided by pets; and (2) classical conditioning of relaxation. These mechanisms may partially account for the long-term health outcomes observed in a number of human-animal interaction studies.

Mothers' recollections of the Paediatric Intensive Care Unit: associations with psychopathology and views on follow up.

The aim of this study was to establish rates of posttraumatic stress symptoms in mothers after a child's admission to a Paediatric Intensive Care Unit (PICU) and their views on the potential value of a follow up appointment with PICU staff. Thirty-four mothers completed the Parental Stressor Scale:PICU, the General Health Questionnaire (GHQ-28) and the Impact of Event Scale, 8 months after discharge. In total 18/34 (53%) scored > or =5 on the GHQ-28 and 6/32 (18%) of the sample scored in the severe range (>35) on the Impact of Event Scale. Distress was associated with retrospective reports of stress experienced during admission (p < 0.001) but not with other demographic or medical variables. Mothers who talked about their feelings at the time of the admission had lower posttraumatic stress scores at 8 months (p = 0.02) and 25/34 (74%) mothers would have appreciated the offer of a follow up appointment. Screening for distress during admission with the Parental Stressor Scale:PICU may identify those mothers in greatest need of psychological support. Mothers' recollections of the Paediatric Intensive Care Unit: Associations with psychopathology and views on follow up.

Psychological care in trauma patients.

The clinician manages trauma patients in the emergency room, operation theatre, intensive care unit and trauma ward with an endeavour to provide best possible treatment for physical injuries. At the same time, it is equally important to give adequate attention to behavioural and psychological aspects associated with the event. Knowledge of the predisposing factors and their management helps the clinician to prevent or manage these psychological problems. Various causes of psychological disturbances in trauma patients have been highlighted. These include pain, the sudden and unexpected nature of events and the procedures and interventions necessary to resuscitate and stabilise the patient. The ICU and trauma ward environment, sleep and sensory deprivation, impact of injury on CNS, medications and associated pre-morbid conditions are also significant factors. Specific problems that concern the traumatised patients are helplessness, humiliation, threat to body image and mental symptoms. The patients react to these stressors by various defence mechanisms like conservation withdrawal, denial, regression, anger, anxiety and depression. Some of them develop delirium or even more severe problems like acute stress disorder or post-traumatic stress disorder. Physical, pharmacological or psychological interventions can be performed to prevent or minimise these problems in trauma patients. These include adequate pain relief, prevention of sensory and sleep deprivation, providing familiar surroundings, careful explanations and reassurance to the patient, psychotherapy and pharmacological treatment whenever required.