Prevention of Posttraumatic Stress Disorder (PTSD) With Early Hydrocortisone Treatment: Pilot

Posttraumatic stress disorder (PTSD) is the fourth most common psychiatric disorder and is estimated to affect more than ten million American children and adults at some point in their lives. Although a number of pre-, peri-, and acute phase post-trauma variables (e.g., prior trauma history, subjective life threat, injury) have been shown to increase one's risk of developing PTSD, initial psychological reaction to a traumatic event is an imperfect predictor of subsequent diagnosis. In addition, early psychological interventions have generally proven ineffective, and in some cases, detrimental with regards to subsequent symptomatology. In light of this, researchers have recently begun to examine possible pharmacological interventions that could be administered in the acute phase of responding to trauma to prevent or reduce the severity of subsequent post-traumatic stress.

Biopsychological research has frequently (but not always) indicated that patients with PTSD excrete lower levels of cortisol than similarly-exposed trauma victims who do not develop PTSD. Further, recent research has shown that lower cortisol levels present soon after a trauma are associated with increased risk for developing PTSD symptoms. These results suggest that higher levels of cortisol during and immediately after a traumatic event may buffer the development of PTSD symptoms. In addition, preliminary findings have suggested that exogenously elevating patients' levels of cortisol during and immediately following trauma results in decreased incidence of PTSD. However, these data were collected on relatively small samples of trauma patients with confounding medical conditions (e.g., shock, cardiac surgery, or paralysis). A randomized controlled trial (RCT) is necessary to determine the efficacy of early cortisol administration at buffering the development of post-traumatic stress in a heterogeneous trauma sample.

Prior to conducting a large-scale RCT, it is necessary to pilot test the efficacy of early cortisol treatment at reducing or preventing PTSD symptoms in a representative sample of heterogeneous trauma victims. The proposed research is designed to examine the efficacy of hydrocortisone (commercially-available cortisol) in preventing post-traumatic stress in a small-scale, randomized, double-blind trial. More specifically, incidence of PTSD and comorbid disorders (i.e., mood, anxiety and substance abuse/dependence disorders), severity of symptoms, health-related quality of life, and hormonal correlates of distress will be prospectively examined in trauma victims who are randomly assigned to receive either a course of hydrocortisone or placebo within 12 hours of the traumatic event. As psychological and physiological reactions to trauma may develop over a number of months post-trauma, prospective follow-up will allow us to examine the efficacy of cortisol administration at reducing both early as well as delayed development of symptoms. The proposed research will provide pilot data and effect size estimates for a subsequent large-scale trial, should pilot results be promising.

Specific objectives of the proposed research include:

1. Examination of the effects of early (within 12 hours of trauma) cortisol administration on subsequent symptoms of PTSD in trauma victims. Specifically, victims admitted to the Level 1 trauma unit of a local hospital will be randomly assigned to receive double-blind, low-dose cortisol (20mg, twice daily: bid) or placebo for ten days plus a 6-day taper period. Symptoms of psychopathology will be measured at 1- and 3-months post-trauma. Secondary analyses will examine the effects of cortisol on disorders commonly comorbid with PTSD (i.e., anxiety, mood, and substance abuse/dependence disorders) and on health-related quality of life.
2. Examination of the extent to which early cortisol administration influences the relationship between preexisting and trauma-related factors and psychophysiological responses to trauma. In particular, as lifetime incidence of psychopathology, prior trauma exposure, and injury severity have been associated with increased risk for PTSD, we will examine whether this relationship is weakened in patients receiving the cortisol regimen. Due to budgetary constraints of the R34 mechanism and the exploratory nature of the proposed research, we will not be able to recruit enough participants to sufficiently examine this objective, and it is thus considered a secondary aim. However, results will be used to strengthen and guide the design of a subsequent R01 proposal.