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Studies of the use of medications or debriefing to prevent post-traumatic stress disorder (PTSD) in traumatized people have had disappointing results, perhaps because of the intervention's timing or because participants were unlikely to develop PTSD (e.g., did not have acute stress disorder). Researchers in Israel randomized 296 adults who had been exposed to motor vehicle accidents, terrorist attacks, or other traumas to four treatment conditions for 12 weeks. Participants had PTSD symptoms but did not meet the duration criterion for formal diagnosis (82% met all symptomatic criteria).
Participants could decline one or two treatments. Treatments were prolonged exposure (PE; imaginal and in vivo exposure and breathing-control training [paced diaphragmatic breathing]); trauma-focused cognitive therapy (CT); double-blind drug therapy (20 mg/day escitalopram vs. pill placebo); or waiting list (WL). At 5 months, PE and CT recipients were significantly less likely to have PTSD (prevalence, 18%–21%) than those assigned to escitalopram, placebo, or WL (prevalence, 56%–62%).
Symptomatic WL patients were offered delayed PE after 5 months. At 9 months, PTSD prevalence remained significantly higher with escitalopram and placebo (42%–47%), but decreased in the WL group to that of the PE and CT groups (21%–23%). Patients with only some baseline PTSD symptoms did equally well regardless of assignment.
Shalev AY et al. Prevention of posttraumatic stress disorder by early treatment: Results from the Jerusalem Trauma Outreach and Prevention study. Arch Gen Psychiatry 2011 Oct 3; [e-pub ahead of print]. (http://dx.doi.org/10.1001/archgenpsychiatry.2011.127)
Comment
One could argue that these researchers were studying treatment of evolving PTSD, not prevention of PTSD in an at-risk group. Still, a moderate antidepressant dose seems to not alter the risk for full-blown PTSD and to produce worse outcomes at 9 months than prolonged exposure and cognitive therapy. PE and CT seem very effective for short-term PTSD symptoms, but people with few PTSD symptoms seem not to need these interventions. Soon after catastrophic events that affect a large number of people, those with PTSD symptoms should be offered PE or CT. If resources are limited, treatment can be deferred for some (e.g., those who do not yet want it), with the understanding that later treatment works but delays the start of recovery.