By Sandra Basu
WASHINGTON — While the science of traumatic brain injury (TBI) is growing, clinical understanding still lags behind conditions such as post-traumatic stress disorder (PTSD), where there is years of research.
“Understanding the way the brain works, especially a brain that is traumatized, is extremely hard,” explained Navy Capt. Mike Colston, MD, director of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. “With PTSD, we at least have a long history of looking at people who are traumatized and a long history of treatment intervention, so I think the science is more developed for that reason.”
In fact, added Amy Street, PhD, deputy director of the VHA National Center for Post-traumatic Stress Disorder Women’s Health Sciences Division, “TBI is something that we have become so much more aware of in the recent conflicts in Iraq and Afghanistan.”
Street and Colston were among the officials who spoke at a Senate committee hearing on the current state of research, diagnosis and treatment for PTSD and TBI. Lawmakers were seeking an update on the agencies’ efforts in these areas.
“With a significant impact that both PTS[D] and TBI have made on our servicemembers and veterans it is vitally important that we better understand through well-developed medical research the causes of PTS[D] and TBI and develop appropriate measures to treat and eventually prevent [them],” said Sen. Lindsey Graham (R-SC), chairman of the Senate Armed Services Subcommittee on Personnel.
Colston told lawmakers that the centerpiece of DoD’s mental health research efforts is the National Research Action Plan (NRAP), which also involves the VA, Department of Health and Human Services and Department of Education.
The initiative has improved understanding of PTSD and TBI, according to Colston, who added that unanswered questions remain.
“One challenge is ascertaining why PTSD, TBI, depression, substance use disorders and chronic pain all present together,” he said.
Longitudinal research efforts, such as the Millennium Cohort Study and a 15-year study on TBI that is underway, should aid understanding, Colston added.
When it comes to programs addressing mental health, DCoE estimates more than 200 programs receive DoD funding to provide both clinical and nonclinical psychological health or TBI services for troops and family members.
Now, DCoE “is halfway through a five-year effort” to evaluate the “psychological health and TBI programs for effectiveness,: Colston told the subcommittee.
Lawmakers also asked about funding for care of patients with TBI and PTSD.
National Intrepid Center of Excellence Director Capt. Walter Greenhalgh, MD, responded that many troops continue to suffer, even after the drawdown of resources in Iraq and Afghanistan, and that their long-term care is essential.
“This is a long-term commitment, and that is where the nature of the type of support definitely changes,” Greenhalgh said.
As for the VA, Street noted that the agency recently held its first annual Brain Trust: Pathways to InnoVAtion event on TBI and PTSD. The conference included participation from other federal agencies, as well as the sports industry, private sector, veterans and community partners.
“Issues related to brain health and head trauma transcend the veteran and military community, impacting all Americans,” she emphasized.
Street also said VA is using technology to increase availability of mental healthcare for rural veterans who might not have easy access.
Pursuing technological advances to reach rural veterans is critical, agreed Sen. Angus King (I-ME), adding, “I want to encourage you in the strongest possible terms to pursue these technological advances because time is not on our side.”
MST and PTSD
Lawmakers also wanted to know about the relationship between military sexual trauma (MST) and PTSD, as well as VA’s handling of MST. Street testified that a background of MST has a “particularly strong association with PTSD.”
“Research data from veteran samples indicate that experiences of MST are an equal or stronger predictor of PTSD as compared to other military-related stressors, including exposure to combat,” Street pointed out.
She said that VA’s policy is that all veterans receiving healthcare be screened for MST experiences, and those who disclose such a history are offered a referral for mental health services.
Sen. Kirsten Gillibrand (D-NY), who has advocated for legislation targeting MST, expressed concern about men with MST who may be more reluctant to seek care.
Colston agreed that getting male troops in care for MST is challenging, noting, “Men are less apt to engage in care for sexual assault.”
Gillibrand said this is why she is concerned that the suicide rate among male survivors could be higher.
“For many survivors, instead of seeking treatment, they just commit suicide,” she said.
A facility-specific survey found that 138 of 140 VA facilities reported shortages of medical officers, with psychiatry and primary care positions being the most frequently listed.
When Terrence O’Neil, MD, retired as chief of nephrology at the James H. Quillen VAMC in Johnson City in December 2016, he left in his wake decades of work treating kidney disease—nearly 35 years in the Air Force and DoD, plus 11 more at VA.