March 23, 2011 — Early administration of low-dose hydrocortisone in the emergency department may reduce the risk for subsequent post-traumatic stress disorder (PTSD) symptoms in adult patients with severe trauma and may be particularly effective in those without a history of mental health treatment, results from a small pilot study suggest. March 23, 2011 — Early administration of low-dose hydrocortisone in the emergency department may reduce the risk for subsequent post-traumatic stress disorder (PTSD) symptoms in adult patients with severe trauma and may be particularly effective in those without a history of mental health treatment, results from a small pilot study suggest.
Presented here at the American Psychosomatic Society 69th Annual Scientific Meeting, the randomized, double-blind, placebo-controlled trial conducted by investigators from Kent State University, Kent, Ohio, showed that patients who received a regimen of 20 mg of hydrocortisone twice daily, initiated within 12 hours of hospital admission, exhibited significantly fewer PTSD symptoms than patients in a placebo group at both 1- and 3-month follow-up time points.
“These results provide preliminary support for the efficacy of hydrocortisone as a secondary intervention in adult trauma victims. However, it seems that perhaps it might be most efficacious in adults who do not have significant prior psychopathology,” principal investigator Douglas Delahanty, PhD, told conference delegates.
Dr. Douglas Delahanty
According to Dr. Delahanty, 2 earlier pilot studies by German researchers — 1 in patients with septic shock and the other in individuals undergoing cardiac surgery — suggest that intravenous administration of hydrocortisone over a period of 6 days plus taper decreased the incidence of PTSD.
However, he added, “it is not clear whether hydrocortisone administered soon after a traumatic event is efficacious in decreasing or buffering PTSD in a heterogeneous group of trauma victims.”
For the study, 65 trauma victims from a single center deemed at high risk of developing PTSD were randomly assigned to receive a 10-day regimen of 20 mg of hydrocortisone (n = 31) or a placebo pill (n = 34) twice daily. Study participants had sustained their injuries through a variety of traumatic events, including motor vehicle accidents, falls, and assaults.
Study medications were administered within 12 hours after the traumatic event, and follow-up assessments occurred in participants’ homes at 1- and 3-month follow-up.
The study’s primary outcome measure was the Clinician Administered PTSD Scale (CAPS) at 1 and 3 months. Secondary endpoints included measures of depression and quality of life, as measured by the Center for Epidemiological Studies-Depression scale and self-reported quality of life with the Short-Form Health Survey, respectively.
There were no baseline differences between groups in demographic characteristics or any study variables except for age. The placebo group, Dr. Delahanty said, was significantly older than the active treatment group (33.8 years vs 27.2 years); therefore, all analyses were adjusted for age.
At 1 month and 3 months post-trauma, there were no significant differences between the study groups with respect to the number of participants meeting PTSD diagnostic criteria, perhaps because of the small number of participants meeting full criteria.
However, the investigators found that patients who received hydrocortisone reported significantly fewer and less severe PTSD symptoms than patients in the placebo group, as measured by total CAPS scores at both time points.
“The hydrocortisone group was significantly lower at all time points than the placebo group, and this [greater than 10-point] difference in the CAPS suggests that not only are our results statistically significant, but also very likely clinically meaningful,” said Dr. Delahanty.
Less Depression, Better Quality of Life
He also noted that patients who received hydrocortisone had lower depression scores at both follow-ups and that their quality of life improved over time.
A further analysis examining potential differences in response by mental health history found that patients who had never sought previous mental health services had a more robust response to hydrocortisone.
These encouraging results, said Dr. Delahanty, warrant further research to investigate whether this treatment approach would mitigate PTSD risk in other types of acute trauma, such as rape or combat, and to determine optimal timing of treatment and dose.
Dr. Delahanty noted that hydrocortisone is an immunosuppressant that could potentially affect healing. Therefore, the investigators chose to go with a very low dose. However, he said, there is a “valid argument that a higher dose might be more efficacious.”
He added that it is possible that administering the hydrocortisone at a later time point may also be effective and might eliminate some of the challenges of attempting to deliver a drug to mitigate PTSD risk when the priority is stabilizing injured patients.
“As we modify our hypothesis regarding how PTSD develops and if you consider it is not so much the idea that you are at risk — not due to what happens immediately following the trauma but in the days and weeks following an event as you go back and forth reliving and reconsolidating memories — there might be an argument that you could recruit patients at a later time point, say maybe at 24 hours or 36 hours later. So I’m not completely sold on the idea that you have to initiate the medication immediately following the trauma,” said Dr. Delahanty.
Need for Effective Prevention
Commenting on the study, Judith Andersen, PhD, from the Center for Integrated Healthcare at the Department of Veterans Affairs Medical Center in Syracuse, New York, said there is a need to have simple, effective interventions to prevent PTSD and that the study by Dr. Delahanty and colleagues is “promising” in this regard.
Dr. Judith Andersen
She noted that the beta-blocker propanolol has also shown some efficacy in PTSD prevention by interrupting reconsolidation of traumatic memories through protein synthesis inhibition. However, she added, some concerns have been raised in the media that the drug would “erase” memories, which could be particularly critical for victims of rape or assault if they were unable to identify a perpetrator.
However, she added, this concern is unfounded.
“The fear pathways in PTSD get abnormally laid down and once that abnormal pattern has been established it is very hard to change. Propanolol appears to prevent this process from happening and it appears hydrocortisone may also have a similar effect. However, these drugs don’t erase memory — rather, they prevent the overproduction of stress hormones that may be hazardous,” said Dr. Andersen.
Dr. Delahanty has disclosed no relevant financial relationships.
American Psychosomatic Society (APS) 69th Annual Scientific Meeting: Abstract 1755. Presented March 10, 2011.
Authors and Disclosures
A veteran health and medical journalist, Caroline is the News Editor for Medscape Psychiatry. During her career she has edited and written for publications aimed at both physician and consumer audiences. She helped launch, and was the Editor of Health Digest, a national, award-winning Canadian consumer health publication. She was also National Editor of the Heart & Stroke Foundation of Canada’s Web site before joining Medscape Medical News in 2005. She is the recipient of the 2008 American Academy of Neurology Journalism Fellowship Award and the 2010 National Press Foundation Alzheimer’s Disease Fellowship.
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Low-Dose Hydrocortisone May Cut PTSD Risk in Trauma Patients
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