WASHINGTON, DC—Nearly 1.5 million servicemembers have left active duty and become eligible for VA healthcare since the start of operations in Iraq and Afghanistan. As many as one third are returning with depression, PTSD, TBI, or a combination of the three. This has left VA with a dramatic increase in patients suffering from illnesses whose pathology is still not entirely understood.
Even the most expert physicians in this area admit that treatment of PTSD is in its infancy, and there are potentially beneficial therapies that remain unexplored or underexplored. At a PTSD roundtable discussion last month on Capitol Hill, legislators along with VA and DoD leadership heard about cutting-edge research into a number of treatments for PTSD.
Rep Bob Filner, D-CA, who chaired the roundtable, explained how he had suggested, only half-jokingly, to VA Secretary Eric Shinseki that the agency open up an Office of Revolution at VA headquarters, as a way to come to grips with new technologies in medicine and help disperse them throughout a beaurocracy. “There are large companies that promote innovation. Why should a beaurocracy not innovate?” Filner asked. “VA is not always known for its quick and open acceptance of new technologies.”
One innovation that many at the roundtable were already embracing is changing the term from PTSD to PTS. DoD has been actively trying to drop the word “disorder” from the diagnosis in the hopes that it would remove some of the stigma from the illness. The word “disorder,” some have noted, has a connotation that suggests something is deeply wrong that cannot be fixed. “This is a combat stress injury and it can be healed like an injury,” Filner said.
Repairing the Brain to Treat PTSD
No one has to remind Paul Harch, MD, to think of PTSD as an injury. He reminded the roundtable that traumatic brain injury is a wound to the brain and PTSD frequently results from that wound.
Harch has treated over 40 blast-injury related TBI patients who suffered from PTSD with a hyperbaric oxygen therapy (HBOT) protocol—most under a pilot trial at Louisiana State University. One session consisted of an hour in an HBOT chamber in an oxygen-rich environment of 1.5 atmospheres. Patients underwent a minimum of 40 sessions during a 30-day treatment protocol.
Results were dramatic. Patients saw an average 30% reduction in PTSD symptoms, a 15-point IQ increase, and a 51% decrease in depression symptoms. “No other protocol has had this kind of success this quickly,” Harch declared.
While the therapy has been around for over seven decades, it is only recently that the biological mechanism of the therapy has become understood, Harch explained in his testimony. The primary action of HBOT is in the DNA of injured cells. Single and repetitive treatment activates genes that code for growth and repair hormones and genes that inhibit inflammation. The net effect is growth of new blood vessels, increase in protein-rich supporting tissue, bone, and skin, and the healing of wounds regardless of location in the body. HBOT therapy helps the brain repair itself, which helps alleviate symptoms of PTSD and TBI.
Both VA and DoD have active research protocols looking at HBOT therapy for TBI and PTSD. The agencies have received an investigational drug clearance from FDA to conduct three trials on HBOT therapy. The first is a feasibility study, data from which should be available in January 2011, explained Kathy Helmick, senior executive director, Traumatic Brain Injury Director, TBI Clinical Standards of Care, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) “The second phase is a DARPA/VA/NAVY phase II study, which they are doing recruitment for right now.”
VA and DoD researchers have not actually treated anybody with HBOT therapy to date, Helmick said. However, another large trial is being carried out at military bases around the country. The trial is slated to begin in the fall and will enroll 300 patients in a randomized, controlled trial of HBOT therapy.
The Creation of Virtual Worlds
The online world created by Charles Levy, MD, does not look like much. In fact, it looks like a simple grocery store, complete with food to buy, shopping carts to push, and other shoppers to interact with. Sitting in front of a computer screen, a person can choose an avatar to manipulate, and make their way through the grocery store much as in real life. It is a simple errand for most people, but a stressful, complex task for someone suffering from emotional and cognitive problems.
“The vets that I treat, they have problems with memory and daily activities,” explained Levy, associate director of the Rehabilitation Outcomes Research Center at the University of Florida. “They have problems with cognitive tasks they might have to do—[dealing] with shopping and finding different items. They also face emotional challenges. We set it up so they’ll have a collision with another shopper. In a virtual world, you can do things that really aren’t possible in real-world therapy.You can practice things endlessly that you couldn’t do in a real grocery store. You can gather data as to what people’s responses are very precisely and you can use that as a teaching tool to see what they’re doing and how they might change their behavior.”
Sometimes a patient might get into an altercation with one of the virtual shoppers and not understand why his or her actions are provoking anger in the computer-simulated shopper. With this program, the physician changes the viewpoint of the scenario, allowing the patient to see the altercation from the other shopper’s point of view, and better help them understand their actions and behavior.
Now that the world is built, Levy and his team are currently seeking funding to conduct a full trial of the virtual reality therapy. There are still many questions about how interaction with a virtual world affects the patient, Levy said, including how changing the avatar might affect patient’s mindset, and how much immersion is necessary to receive a therapeutic benefit.
Barbara Rothbaum, PhD, director of the Trauma and Anxiety Recovery Program at Emory University School of Medicine, has been looking at the deeper end of the immersion scale, helping create tailor-made virtual reality therapies to recreate traumatic combat scenarios.
“In exposure therapy, we help people confront their fears in a therapeutic manner,” Rothbaum explained. “The first time we applied virtual reality exposure therapy was with a virtual Vietnam. For veterans of the current conflict, we have a virtual Iraq. We try to match what the patient is describing. For example, if they’re describing driving down a desert highway in a Humvee and an IED hits on the right, we can recreate that.”
Of 20 veterans of Iraq who received virtual exposure therapy under a protocol at the San Diego Naval Medical Center, 16 no longer met the diagnostic criteria for PTSD after treatment, according to Rothbaum.
Her team is now examining combining the use of d-cycloserine (DCS) and exposure therapy. DCS is an antibiotic approved by FDA for tuberculosis that has been shown to facilitate the extinction of fear in animal models. In the first study combining the drug with virtual reality exposure therapy—a fear of heights trial using a virtual elevator—the DCS group showed significantly greater decrease in anxiety at the three-month follow-up. A study at Emory University is now underway combining DCS with the virtual Iraq.
“I think it’s really going to show a lot of promise in the next decades or so as we use a virtual world platform for many applications,” noted DoD’s Helmick. “This treatment is one of the most promising [especially in] return to duty applications.”
A Veteran’s Best Friend
Pet lovers can often be heard explaining how their dog or cat understands them in ways they can’t explain; that the animal picks up on emotions and moods that human beings are unaware of. Craig Love, senior study director at Westat, a DC-based research firm, believes this to not only be true, but clinically provable. Westat has teamed with NIH, Walter Reed, and the Psychiatric Service Dog Society to study the use of service dogs with veterans suffering from PTSD. Psychiatric service dogs are trained to assist with the management of symptoms of severe mental illness.
“The model we’re testing is a self-training model,” Love said. “What it does is engage a veteran with a dog trainer for a short period of time to get some assistance in how to handle the dog and manage public access. And it also helps the patient and the therapist figure out what the dog is telling the person. The dog will learn how the person is at baseline and so when the symptoms occur, when something is different, they know something is going to happen.
“One of the interesting things about PTS and mental illness is that there are symptoms that the dog can pick up on. We think it has something to do with the smell and the biochemical changes that take place. The dog will actually pre-warn a person if there’s an issue.”
Currently about 200 veterans from Vietnam, the Gulf War, OIF, and OEF are using psychiatric service dogs. In a survey of these veterans, 82% said their PTSD symptoms have lowered since acquiring the dog. Many veterans refer to the dog as a “suicide prevention dog.” Veterans have reported that their service dog will pick up on when they are feeling particularly depressed and volatile.
“Handlers get a better understanding of their illness and how to manage it,” Love stated. “There is a community of veterans who are sharing information, teaching each other how to use the dogs. These soldiers talk a lot about what the dog has done for them and they support each other. And this community is part of the [therapeutic] process.”
Currently there is no consistency in VA as to how medical programs train service dogs. Some VA independent living programs provide a small stipend to veterans to train their own service dog, but those programs are few and far between.
Westat has designed a study comparing veterans with dogs to those without, but that study is currently on hold. However, VA R&D is currently funding a study on the use of psychiatric service dogs and veterans.