Which somatic approach has the most evidence for preventing Post-Traumatic Stress Disorder (PTSD) symptoms?

Hydrocortisone Has the Most Evidence for Preventing PTSD Symptoms

Based on the available evidence, hydrocortisone (Answer B) demonstrates the strongest evidence among somatic approaches for preventing PTSD symptoms, with moderate quality evidence showing it reduces PTSD onset (RR 0.17; 95% CI 0.05 to 0.56), meaning 7-13 patients need treatment to prevent one case of PTSD. 1

Evidence for Each Somatic Approach

Hydrocortisone - Strongest Evidence

• Four randomized controlled trials with 165 participants demonstrated moderate quality evidence for hydrocortisone's efficacy in preventing PTSD onset 1
• Three of four trials showed hydrocortisone was more effective than placebo in reducing PTSD symptoms after a median of 4.5 months post-trauma 1
• The guideline literature specifically identifies hydrocortisone as one of three medications evaluated for early administration, though noting "limited benefit" in the 2005 context 2

Propranolol - Limited and Conflicting Evidence

• Three trials with 118 participants showed no significant benefit for preventing PTSD onset (RR 0.62; 95% CI 0.24 to 1.59; P = 0.32), representing low quality evidence 1
• The 2005 guideline explicitly states that propranolol, hydrocortisone, and benzodiazepines were found to be "of limited benefit" for preventing chronic PTSD 2
• A 2021 study found propranolol was not more effective than placebo one week post-treatment, though it may benefit patients with severe PTSD symptoms (PCL-S ≥65) at 3-month follow-up 3
• Propranolol has been studied only for prevention immediately post-trauma, not for chronic PTSD treatment 4

SSRIs - No Prevention Evidence

• SSRIs (sertraline, paroxetine) have strong evidence for treating established chronic PTSD, not preventing it 2
• A single trial of escitalopram showed no evidence of superiority over placebo in preventing PTSD onset 1
• The guideline literature consistently positions SSRIs as treatment for chronic PTSD, with FDA indication for sertraline and paroxetine 2

Ketamine and Albuterol - No Evidence

• Neither ketamine nor albuterol are mentioned in any of the provided evidence for PTSD prevention
• These agents are not part of the established pharmacological approaches evaluated for PTSD prevention 2, 1

Critical Context and Limitations

Overall Medication Efficacy for Prevention

• The 2005 guideline emphasizes that early medication administration (benzodiazepines, propranolol, and hydrocortisone) has been found to be "of limited benefit" overall 2
• More recent systematic review data (2014) provides moderate quality evidence specifically for hydrocortisone, distinguishing it from the other agents 1

Quality of Evidence Concerns

• Seven of nine included trials in the Cochrane review were at high risk of bias, with issues including differential drop-outs, unclear allocation concealment, and possible confounding 1
• The findings are based on few small studies with multiple limitations, necessitating further research 1

Practical Considerations

• Drop-outs due to treatment-emergent side effects were low for all agents tested 1
• The evidence base for secondary prevention (post-trauma interventions) is more established than primary prevention strategies 5

The answer is B. Hydrocortisone, as it is the only somatic approach with moderate quality evidence demonstrating efficacy in preventing PTSD onset, despite the overall limited benefit of pharmacological prevention strategies compared to psychological interventions like brief CBT 1, 2.