Shalev Arieh Y, Ankri Yael, Israeli-Shalev Yossi, Peleg Tamar, Adessky Rhonda, Freedman Sara
Department of Psychiatry, Hadassah University Hospital, Kiriat Hadassah-Ein Kerem, Jerusalem, Israel.
Arch Gen Psychiatry. 2012 Feb;69(2):166-76. doi: 10.1001/archgenpsychiatry.2011.127. Epub 2011 Oct 3.
Preventing posttraumatic stress disorder (PTSD) is a pressing public health need.
To compare early and delayed exposure-based, cognitive, and pharmacological interventions for preventing PTSD.
Equipoise-stratified randomized controlled study.
Hadassah Hospital unselectively receives trauma survivors from Jerusalem and vicinity.
Consecutively admitted survivors of traumatic events were assessed by use of structured telephone interviews a mean (SD) 9.61 (3.91) days after the traumatic event. Survivors with symptoms of acute stress disorder were referred for clinical assessment. Survivors who met PTSD symptom criteria during the clinical assessment were invited to receive treatment.
Twelve weekly sessions of prolonged exposure (PE; n = 63), or cognitive therapy (CT; n = 40), or double blind treatment with 2 daily tablets of either escitalopram (10 mg) or placebo (selective serotonin reuptake inhibitor/placebo; n = 46), or 12 weeks in a waiting list group (n = 93). Treatment started a mean (SD) 29.8 (5.7) days after the traumatic event. Waiting list participants with PTSD after 12 weeks received PE a mean (SD) 151.8 (42.4) days after the traumatic event (delayed PE).
Proportion of participants with PTSD after treatment, as determined by the use of the Clinician-Administered PTSD Scale (CAPS) 5 and 9 months after the traumatic event. Treatment assignment and attendance were concealed from the clinicians who used the CAPS.
At 5 months, 21.6% of participants who received PE and 57.1% of comparable participants on the waiting list had PTSD (odds ratio [OR], 0.21 [95% CI, 0.09-0.46]). At 5 months, 20.0% of participants who received CT and 58.7% of comparable participants on the waiting list had PTSD (OR, 0.18 [CI, 0.06-0.48]). The PE group did not differ from the CT group with regard to PTSD outcome (OR, 0.87 [95% CI, 0.29-2.62]). The PTSD prevalence rates did not differ between the escitalopram and placebo subgroups (61.9% vs 55.6%; OR, 0.77 [95% CI, 0.21-2.77]). At 9 months, 20.8% of participants who received PE and 21.4% of participants on the waiting list had PTSD (OR, 1.04 [95% CI, 0.40-2.67]). Participants with partial PTSD before treatment onset did similarly well with and without treatment.
Prolonged exposure, CT, and delayed PE effectively prevent chronic PTSD in recent survivors. The lack of improvement from treatment with escitalopram requires further evaluation. Trauma-focused clinical interventions have no added benefit to survivors with subthreshold PTSD symptoms. Trial Registration clinicaltrials.gov Identifier: NCT00146900.
预防创伤后应激障碍（PTSD）是一项紧迫的公共卫生需求。
比较早期和延迟的基于暴露、认知及药物干预措施对预防PTSD的效果。
均衡分层随机对照研究。
哈达萨医院无差别地接收来自耶路撒冷及其周边地区的创伤幸存者。
创伤事件连续收治的幸存者在创伤事件发生后平均（标准差）9.61（3.91）天通过结构化电话访谈进行评估。有急性应激障碍症状的幸存者被转介进行临床评估。在临床评估中符合PTSD症状标准的幸存者被邀请接受治疗。
12次每周一次的延长暴露疗法（PE；n = 63）、认知疗法（CT；n = 40）、每日两片依他普仑（10 mg）或安慰剂的双盲治疗（选择性5-羟色胺再摄取抑制剂/安慰剂；n = 46），或12周的等待列表组（n = 93）。治疗在创伤事件发生后平均（标准差）29.8（5.7）天开始。等待列表组中12周后出现PTSD的参与者在创伤事件发生后平均（标准差）151.8（42.4）天接受PE（延迟PE）。
创伤事件发生后5个月和9个月使用临床医生施测的PTSD量表（CAPS）确定治疗后患有PTSD的参与者比例。使用CAPS的临床医生对治疗分配和参与情况不知情。
5个月时，接受PE的参与者中有21.6%患有PTSD，等待列表组中可比参与者的这一比例为57.1%（优势比[OR]，0.21[95%CI，0.09 - 0.46]）。5个月时，接受CT的参与者中有20.0%患有PTSD，等待列表组中可比参与者的这一比例为58.7%（OR，0.18[CI，0.06 - 0.48]）。在PTSD结局方面，PE组与CT组无差异（OR，0.87[95%CI，0.29 - 2.62]）。依他普仑组和安慰剂亚组的PTSD患病率无差异（61.9%对55.6%；OR，0.77[95%CI，0.21 - 2.77]）。9个月时，接受PE的参与者中有20.8%患有PTSD，等待列表组参与者的这一比例为21.4%（OR，1.04[95%CI，0.40 - 2.67]）。治疗开始前有部分PTSD症状的参与者接受治疗和未接受治疗的效果相似。
延长暴露疗法、CT和延迟PE能有效预防近期幸存者的慢性PTSD。依他普仑治疗未显示出改善效果，需要进一步评估。针对创伤的临床干预对有亚阈值PTSD症状的幸存者无额外益处。试验注册 clinicaltrials.gov标识符：NCT00146900。
