Issues in the Research and Application of Chemo-prophylactic drugs in the treatment of Traumatic Stress

Convened by Dr Jeanette Kennett, Dr Neil Levy and Dr Jessica Wolfendale (Centre for Applied Philosophy and Public Ethics, University of Melbourne) at the University of Melbourne on 15-16 February 2006.

<download (pdf - 31kb)> the policy paper.

Report on the workshop
Research is currently going ahead into chemo-prophylactic drugs that would minimise individuals' affective response to traumatic events, and thereby inhibit the strength and intensity of traumatic memories. Research into the beta-blocker propanolol, for example, has shown promising results in the reduction of Post-Traumatic Stress Disorder symptoms in car-crash victims. The rationale behind this research is that such drugs would be useful for individuals who must face traumatic events as part of their work, such as military personnel, police and fire-fighters, as well as providing a possible way of preventing and treating Post Traumatic Stress Disorder more generally. Given that the immense financial, physical and psychological cost of PTSD to individuals and communities, it is essential to examine the effectiveness of these drugs and the ethical implications of their use before they are utilised.

The research and development of these drugs raises issues for philosophy and for psychologists and psychiatrists working in the area of traumatic stress. To explore these issues, this workshop brought together academics from philosophy, psychology and psychiatry together with researchers working directly with PTSD patients in the context of the military, the police and in criminology. This broad range of perspectives encouraged fascinating and productive discussion of the workshop topic. Issues discussed included the possible impact of these drugs on the perception of victims of trauma, duty of care obligations in high-stress occupations, potential uses of these drugs in crime prevention and victim recovery, how military personnel should be prepared for combat, and how these drugs might impact on relationships between mental health practitioners and their patients. Other issues discussed included the relationship between trauma, memory and emotions such as regret and guilt and the impact of these drugs on moral agency and decision-making.

Dr Adam Guastella and Dr Richard Bryant presented new research into the impact of the drugs D-Cycloserine and glutamate on fear extinction. Dr Guastella discussed his experiments on the effect of D-Cycloserine and indicated directions for future research to clarify the impact of this drug on human fear conditioning and extinction. Dr Bryant discussed the nature of PTSD, fear conditioning models and the effectiveness of treatments such as cognitive behaviour therapy. He outlined the findings of a trial using glutamate that showed promise in enhancing fear reduction. He argued that once questions of timing, dosage and adverse learning were addressed, the potential benefits included reduced therapy time and costs, and an increase in compliance.

Dr Keith Horsley of the Department of Veterans' Affairs described the historical uses of alcohol in the military. He argued that alcohol has long been used as a way of preparing military personnel for combat and as a method of managing the stress of combat. He pointed out that the term chemo-prophylactic refers not only to the new drugs currently being researched but to prophylactic methods that have been used for hundreds of years, indicating that the military has long recognised a duty of care to prepare military personnel for combat stress and to help them recover from combat.

COL Tony Cotton representing the Australian Defence Force gave an overview of some of the ethical questions that need to be answered when considering the use of these drugs in workplaces. For example, he argued that given the potential safety gains from the use of chemo-prophylactic drugs, it needs to be established if there is any morally significant difference between using these drugs to prevent traumatic stress in the workplace, and other commonly accepted safety measures, e.g., safety vests. He argued that in order to gain a clear understanding of the ethical framework that should guide discussion of these issues, there should be consultation and collaboration between ethicists, workplace professionals, and psychiatrists and psychologists.

Professor Mark Creamer from the Centre for Posttraumatic Health at the University of Melbourne explored some of the duty of care issues surrounding the prevention of mental health problems in the aftermath of traumatic exposure, with particular reference to the use of pharmacological interventions (often referred to as chemoprophylaxis). He clarified the different issues that arise from considering the use of pharmacological interventions as a prophylactic compared to their use after a traumatic event. He pointed out, for example, that since PTSD afflicts only about 5% of individuals, it is hard to justify an invasive intervention that would either be irrelevant or possibly harmful for the majority of the population. He argued that appropriateness of chemoprophylaxis should only be considered in the context of the availability and efficacy of other preventive options, and should never be considered a replacement for alternative treatments.

Dr Doris McIlwain discussed the relationship between our emotional responses to trauma and the moral self. She raised concerns that tampering with individual's affective responses to traumatic events (particularly when they may have caused such events) would alter the development of backward-looking moral emotions such as regret, shame and guilt. This concern was developed further by Dr Jeanette Kennett, who argued that many of our moral concepts rely on emotional memory - memory that often has a specific emotional 'sting'. Attempting to modify painful emotions may also modify our backward-looking moral judgements and thereby affect our forward-looking resolutions to pursue moral change. Furthermore, emotional responsiveness is a central part of moral development and moral judgement. Tampering with such responsiveness could therefore affect individual's ability to comprehend the impact of their actions on others, their ability to assess the morally relevant aspects of situations and could alter their responsiveness to other's needs.

Dr Jessica Wolfendale discussed the differences between PTSD caused by witnessing traumatic events and PTSD resulting from being causally involved in traumatic events. She argued that this distinction is of particular concern in the military, since military personnel must be prepared to kill if necessary and that this killing takes place in a context that requires a substantial moral justification. She argued that killing is a source of PTSD for some military personnel, and the use of drugs to dampen emotional responses to trauma would mask the moral implications of such trauma and larger moral issues about how military personnel are prepared for killing.

Jillian Craigie gave an overview on research into the impact of drugs such as propanolol that block certain forms of emotional arousal on moral reasoning, emotional memory and decision-making. She discussed several studies that have shown that propanolol can have an impact on decision-making in ways that could also affect individuals' moral judgements. She argued that these findings raise concerns that the use of anti-trauma drugs, particularly prophylactically, could alter moral judgement in ways that could have serious and unforeseen repercussions on behaviour and judgement in ethically sensitive contexts such as in the military.

Group Captain Leonard Lambeth from the Australian Defence Force explored ethical perspectives on the use of different drug treatments for PTSD. He argued that psychotropic medications for traumatic stress are only a part of a wide variety of available treatments, all of which should be considered when discussing the appropriateness and ethical implications of drug treatments. He discussed the importance of the doctor-patient relationship in deciding how to treat PTSD, and argued that while using psychotropic medications might seem like an easy solution to the problem of PTSD, they must not undermine doctor's views of their patients as whole individuals.

Dr John Sutton examined arguments against tampering with memory and emotional affect. He argued that many such arguments are based on a false belief in the unified nature of memory (particularly autobiographical memory) and the self. He argued that before we can assess the ethical implications of drugs that tamper with memory and emotional responses, we must have a clearer picture of how memory functions, and how the different forms of memory might be affected.

Professor Alexander McFarlane discussed the nature and progress of PTSD. He noted that treatment and prevention for PTSD could take place during pre-exposure, prolonged exposure and post-trauma phases. He argued that considering the use of chemo-prophylactics must take into account issues of the optimal timing of interventions, and the biological complexity of PTSD and the different physical and psychological effects of different pharmacological treatments. He pointed out that the general reluctance of people to take medications is likely to count against the wide scale usage of a chemo-prophylaxis unless it had some beneficial impact on performance. This indicates a need for a more general understanding of the nature of fear and an understanding of the nature of the injuries that trauma can cause.

Dr Toni Makkai and Damon Muller from the Australian Institute of Criminology raised issues about the treatment and prevention of crime. It has long been known, for example, that many of those who commit violence have themselves been victims of violence at some point in the past, and that trauma likely contributes to the intergenerational transmission of violence. The use of anti-trauma drugs therefore has implications for the prevention of crime as well as for the treatment of victims of crime.

Over the two days the workshop provided an intellectually stimulating venue for exploring the issues raised by research into these drugs. The participants' different backgrounds and perspectives enhanced our understanding of the different areas of concern, such as ethical constraints on research, appropriate doctor-patient relationships and the potential impact of these drugs in different contexts. The workshop sessions were structured to provide time for vigorous and informed discussion of the papers, and this was very successful.

The workshop papers are currently being prepared for publication.