Preventive psychiatry, a forgotten chapter in the history of mental health, is trying to make a comeback. One area in which it is being explored is post-traumatic stress disorder. This condition represents an excellent opportunity for prevention because of the so-called golden hours: the period between experiencing a traumatic event and the onset of PTSD. It represents a window of opportunity for medical intervention to set the brain on a path toward recovery.
Consolidating memories is an essential function for the human brain. This process involves stabilizing memories and allowing them to ripen and mature. After a traumatic event, the consolidation process can go into overdrive, lending traumatic memories their unforgettable quality and allowing them to invade a survivor’s life, weeks and months later, in an intrusive and highly visual manner.
Could disrupting memory consolidation in the golden hours prevent the onset of PTSD?
Researchers from the University of Oxford tried to answer that question using an unusual prevention strategy — the computer game Tetris. Engaging in a visually absorbing task soon after surviving trauma could, they hypothesized, distract the brain and prevent it from over-consolidating those early visual memories of trauma.
The team recruited 71 individuals who survived motor vehicle crashes while they were still in the emergency department. Half of them were asked to think about the worst moments of the accident and then were asked to play Tetris for 20 minutes. The other half were asked to write down a log of what they had done since coming to the hospital.
The results, which were published in the journal Molecular Psychiatry, are promising. When compared to the log completers, participants who played Tetris were less likely to report post-trauma intrusive memories and related psychological distress in the week that followed their car accident.
For centuries, prevention was an essential part of mental health care. By the mid-1950s, this approach was thriving. But in the ensuing decades, skeptical politicians, the changing role of psychiatrists, and the growing popularity of psychiatric medication pushed preventive psychiatry to the sidelines.
This means that today, conversations about PTSD typically focus on treatment: better pills or more powerful talk therapies. Research into the cause of PTSD tends to focus on gene deletions, abnormal brain structures, and neurotransmitters gone awry.
But doctors like me who work on the front lines of PTSD are feeling the limitations of that focus.
At any given moment in the United States, 6.3 million people are living with PTSD. Eighty percent of PTSD sufferers have at least one other psychiatric condition, typically depression, alcoholism, or drug abuse, and all carry a higher risk of death by suicide. Not only is PTSD difficult to live with, it also increases the risk for obesity, cancer, heart disease, and more.
We have treatments that work. Symptom improvement has been reported in up to 60 percent of individuals with PTSD who engage in such interventions. Unfortunately, only one-third of people with PTSD receive such treatments. Left untreated for a year or more, their chances of being symptom free are drastically reduced.
It’s understandable why the pendulum might be swinging back toward prevention. My fear is that preventive psychiatry’s comeback will fail if we don’t learn from the mistakes of the past. Here are three hurdles we need to overcome to successfully prevent PTSD in the 21st century.
Solid evidence. Earlier attempts at prevention relied more on rhetoric and theory than sound evidence. This shaky scientific foundation led to the demise of such efforts. Fortunately, today’s preventive PTSD research is meeting a higher standard. The Oxford study joins a growing body of evidence that has been conducted with a level of scientific precision that was missing from prior preventive efforts. Other golden-hour interventions that show promise include hydrocortisone, delivered as a pill or an intravenous treatment; short-term opioids to aggressively reduce pain after physical trauma; and a modified prolonged exposure (the gold standard in talk therapy for PTSD) intervention for delivery within hours after a trauma.
Shift in research funding. Funding agencies need to make a long term commitment to the research and development efforts that will be required to thoroughly test these innovations. Unfortunately, less than 5 percent of American health spending is on prevention. A tangible shift in the way we spend health care dollars will be needed for golden-hour interventions to earn a position on the frontlines of clinical care.
Ethical concerns. Most people who experience a traumatic event do not develop PTSD. How, then, would we ethically determine who should receive a golden-hour intervention after trauma? A one-size-fits-all approach would clearly be an overreach. Another conundrum would be how to seek consent for a treatment to prevent a condition that a patient doesn’t yet have. Still, scientists won’t get the chance to engage in these important debates if golden-hour innovations never get to see the light of day. Reassuringly, the Tetris intervention offers a very favorable benefit-risk profile with very little chance of harm but a potentially considerable upside.
PTSD is a pressing public health concern. In addition to the potentially devastating human suffering, people living with PTSD miss an average of four days of work per month, resulting in a loss of almost $3 billion dollars per year in productivity in the United States alone.
In the end, the toll this condition takes in the United States and around the globe favors the argument that an ounce of PTSD prevention is truly worth more than a pound of cure.
Shaili Jain, M.D., is a psychiatrist and PTSD specialist at Stanford University and the author of “Unspeakable: An Intimate Portrait of Posttraumatic Stress” (Harper, 2019).