On November 10, The Center for Research on Ethical, Legal, and Social Implications of Psychiatric, Neurologic, and Behavioral Genetics (ELSI) held their monthly Friday Forum to discuss the ethics of genomic research on post-traumatic stress disorder.

Last Friday, CERA, which supports research on ELSI, hosted its monthly Friday Forum through Zoom focused on “The Genomics of PTSD Risk: Scientific and Ethical Perspectives”. To recognize the federal holiday of Veteran’s Day, it explored the genomics of post-traumatic stress disorder, or PTSD, especially in the United States military.

The forum was moderated by Josephine Johnston, a lawyer, bioethicist, senior research scholar at the Hastings Center, and a lecturer at the University of Otago, Dunedin, New Zealand. She is particularly interested in genetics, human reproduction, psychiatry, and neuroscience. The panel featured Dr. Murray B. Stein and Dr. Eric Juengst.

PTSD is a disorder that is caused by death, serious injury, sexual violence, or a similar threat. It results in stressful memories, dreams, and traumatic psychological reactions. PTSD has a history of being heavily stigmatized. It has been a huge goal of some to erase this stigma, mainly through continued research efforts. Continued PTSD research efforts have aimed to erase the stigma around PTSD by offering new insights into the disorder.

According to research, PTSD risk factors, or characteristics related to a higher chance of PTSD, include the duration of the traumatic event, individual traits, and their environment. Friday’s forum explored the role of genetics in PTSD diagnoses and the ethical implications of using genetic markers when studying PTSD risk.

Dr. Murray B. Stein is a Professor of Psychiatry and Public Health at the University of California San Diego, and a Staff Psychiatrist at the VA San Diego Healthcare System. He is an expert in the epidemiology, neurobiology, and treatment of anxiety disorders such as PTSD. His accomplishments include more than 800 peer-reviewed articles and federally-funded research for over 28 years. 

Dr. Stein talked briefly about the context surrounding PTSD. It is connected with a “life-altering event”. This event could be experienced firsthand, or through someone else – a close friend or someone you see go through the experience. This means first-responders are at a higher risk of developing PTSD. The predominant causes of PTSD in the US are forms of criminal victimization. Rape and domestic abuse, for example, lead to higher rates of PTSD in women overall, who are disproportionately affected with traumatic events. Other causes could be car accidents, childhood abuse, natural disasters, war, or terrorism. 

Dr. Stein then talked about the four core symptoms of PTSD – avoidance of reminiscent places and thoughts, hyperarousal, depression, and intrusion. A combination of these symptoms results in a diagnosis of PTSD. Rates of PTSD diagnosis are higher in some demographics, including women, military veterans, and Native Americans. He also mentioned that disorders are not isolated – if you have PTSD, you are more likely to develop another disorder. 

Dr. Stein then poses this important question: “Among people who are traumatized, what factors influence the likelihood of developing PTSD or not developing it?” In answering, he focused on gene variants associated with PTSD risk. Researchers use these to assign individuals a “polygenic risk score”, which tells how likely an individual is to develop PTSD.

Dr. Eric Juengst’s presentation continued with the idea of using polygenic information – which is related to traits influenced by two or more than two genes – to screen people for PTSD risks.  Dr. Juengst, a Professor of Social Medicine and Core Faculty in the Center for Bioethics at the University of North Carolina Chapel Hill, has worked in medical schools for around 50 years researching the ethics of human genomics. His talk explored interesting subtopics such as the genetic indications and the time of screenings, with afocus on the military. Based on Dr. Juengst’s published work on ethical issues of genetic screening for PTSD risk in the military, which he co-authored with Dr. Gabe Lazaro-Munoz, there is a standard of putting one’s group’s needs above personal needs in the military.

According to Dr. Juengst, military individuals have to constantly think about balancing their own goals with their groups’. They wish to be guaranteed two things – one, that they will be treated like their groupmates are, and two, that they are judged based on merit. For example, they expect that if they succeed, they will be promoted. But genetic risk screening potentially complicates these expectations. The screening would be used to assign soldiers to duties – those at high risk for PTSD would receive low-risk and low-stress assignments. But these assignments are made by commanders, who have to think about unit cohesion. Is it fair to the unit to hold back someone with high PTSD risk? Is it fair to those held back?

When exactly should these screenings take place? If they took place earlier, Dr. Juengst explained, certain units could be created solely for low-stress and low-risk duties. But these units would put high-risk people one step behind everyone else in the military, potentially putting them at a disadvantage with future employers. Since military life is inherently high risk, the ethics of conducting research in this environment are very complex.

After each panelist’s presentation, Dr. Johnston facilitated further conversation between the two panelists. She asked Dr. Stein to share context about Department for Veterans’ Affairs’ (VA) Million Veterans Program, a national health research program that included the creation of a genetic database. As part of the program, around a million veterans filled out questionnaires, granted access to their electronic health records, and gave blood samples. One rare aspect of this program was that the Army agreed this information would not be accessible to military leadership, to reassure the soldiers involved that their information was protected and private.  

Dr. Johnston further wondered how, other than helping identify high-risk individuals, this research could help direct resources toward those who need it. If the screenings occurred during service, it would be important to not just reassign individuals to less stressful tasks, but to also provide them with the resources that they need. Dr. Stein compared this to how people  cannot join the military due to their physique are provided exercise and diet programs so they can eventually qualify to enter. 

One audience member asked whether risk screening  results are shared with participants. Dr. Stein replied that the polygenic risk scores are not, because he feels they are too early in development. But he thinks it’s important to show that the genetic component to PTSD as part of destigmatizing the disorder.

Another question was what else these risk scores could be utilized for in the military besides screening for PTSD risk and directing resources.  Dr. Stein, who works in the mental health space, talked about the broad possibilities of polygenic risk scores beyond PTSD, such as calculating scores for other mental health issues like depression and suicidality, which disproportionately impact the military. According to Dr. Stein, “Once you have the DNA and there’s been a genome-wide genotyping, polygenic risk scores for an individual can be calculated for anything… [for example], heart disease.” While a large-scale implementation of polygenic risk scores is not yet clinically actionable, Dr. Stein has hope they will be in the future.  

Test tubes via Bwarchives.