Complexity, Lack of Approved Therapies Challenges PTSD, TBI Treatment

by U.S. Medicine

November 10, 2014

By Sandra Basu

WASHINGTON – When the American Psychiatric Association first added post-traumatic stress disorder (PTSD) to its Diagnostic and Statistical Manual of Mental Disorders in 1980, it was quite controversial.

In fact, Matthew Friedman, PhD, senior adviser to the VA’s National Center for Posttraumatic Stress Disorder and its former executive director, noted that, when the center was first established in 1989, PTSD wasn’t at all universally recognized.

“When we started 25 years ago, PTSD was a very controversial diagnosis,” Friedman told U.S. Medicine. “You had very distinguished elders, respected experts in psychology and psychiatry who were very skeptical about PTSD.”

Army Col. Michael J. Roy, left, who oversees the exposure therapy at Walter Reed Army Medical Center, conducts a demonstration of a life-like simulator that represents a new form of post-traumatic stress disorder treatment with Army Sgt. Lenearo Ashford, Technical Services Branch, Uniformed Services University, in 2008. DoD photo by John J. Kruzel

Army Col. Michael J. Roy, left, who oversees the exposure therapy at Walter Reed Army Medical Center, conducts a demonstration of a life-like simulator that represents a new form of post-traumatic stress disorder treatment with Army Sgt. Lenearo Ashford, Technical Services Branch, Uniformed Services University, in 2008. DoD photo by John J. Kruzel

Since those days, the public’s recognition of the existence of conditions such as PTSD and TBI has shifted, especially when co-existing with challenges such as depression and suicidality. While cutting edge research continues to explore how better to diagnose and treat these conditions, policymakers and researchers recognize much more work lies ahead in grappling with these conditions. 

Understanding of PTSD:

VA’s National Center for PTSD celebrated its 25th anniversary in August. Friedman and Paula Schnurr, PhD, the center’s acting executive director, said several key events over the years have shaped the understanding of PTSD.

One such event, Schnurr cited, was the National Vietnam Veterans’ Readjustment Study (NVVRS). Congress ordered this study in 1983 to investigate PTSD and psychological problems experienced by Vietnam veterans.

“That was a game-changer, because we had the report come out in 1988 suggesting that the prevalence of PTSD in the cohort in the ’80s was still 15%, and the lifetime prevalence was about 30%. Those were very significant numbers,” she told U.S. Medicine.

Since then, research has evolved. Schnurr said one of the major accomplishments for VA was the development of a gold standard interview for PTSD, created in 1989 by personnel across several disciplines.

“Everyone pitched in to develop this instrument, and I believe that helped change the field in many ways. It gave us a reliable and valid measure that helped advance the research, that gave us the best diagnosis for clinical practice and essentially paved the way for additional instruments,” Schnurr said.

What lies ahead is the nation’s first brain tissue repository, created by the National Center for PTSD, that officials predict will advance the field of PTSD research. Friedman said the brain bank will be a multi-site consortium with tissue-receiving sites in Boston and San Antonio and an intramural research program. While there are brain banks around the nation, none is dedicated specifically to PTSD research, she explained.

“There is a limit to what you can learn from brain imaging. The only way to move beyond that is to actually look at the post-mortem tissue,” Friedman explained.

Officials also point to the Consortium to Alleviate PTSD, which was awarded $45 million over five years by DoD and VA. The consortium is led by the University of Texas Health Science Center at San Antonio and the VA National Center for PTSD and seeks to advance PTSD diagnosis, prevention and treatment.

Still, challenges in caring for troops and veterans continue for DoD and VA. A 2014 Institute of Medicine (IoM) report on PTSD points out that an estimated 8% of current and former servicemembers deployed to Iraq and Afghanistan have a PTSD diagnosis. Moreover, the preliminary findings of the National Vietnam Veterans Longitudinal Study found that the estimated prevalence of combat Vietnam veterans who continue to suffer from PTSD decades after the war ended is 11.2%.

The IoM recommends DoD and VA “develop an integrated, coordinated, and comprehensive PTSD management strategy that plans for the growing burden of PTSD for servicemembers, veterans, and their families, including female veterans and minority group members. “

TBI Treatment

While penetrating TBI was known in previous wars, mild TBI, often induced by blast injury, has taken the spotlight in the most recent conflicts.

Overall, the Armed Forces Health Surveillance Center estimates more than 307,000 total diagnoses of TBI in the military since 2000 with about 82% of those mTBI. About 80% of the total TBI diagnoses since 2000 have occurred outside deployment. Officials say they believe, however, that the overall mTBI numbers are probably higher than the statistics indicate.

“We are much better at picking up cases of [mild] TBI now than we were in 2000. Initially, when deployments were taking place, our ability to recognize and diagnose TBI was not as good as it is today,” Defense Centers of Excellence for Psychological Health and TBI Director Navy Capt. Richard F. Stoltz, PhD, said last month at a TBI conference.

Researchers have been grappling with the complex nature of these injuries, according to Stoltz, who pointed to a 2009 study of 340 troops who deployed in Iraq or Afghanistan finding that most of the study participants did not have only an mTBI diagnosis or only a PTSD diagnosis. Of the 227 who had mTBI, only 5.3% had solely a mTBI diagnosis, and of the 232 of 340 with PTSD, only 3% of those had PTSD alone. The others had multiple issues.

Moreover, symptoms of PTSD and TBI often overlap between the two conditions.

“It emphasizes the importance that we understand the need for integrated care,” Stoltz said.

Stuart Hoffman, PhD, VA’s scientific program manager for brain injury, discussed at that conference how physical/mental rest and education currently are the only validated “treatments” for mTBI. No Food and Drug Administration-approved therapies exist, thus far.

Many areas of ongoing mTBI research hold promise, however, Hoffman suggested.

“We are working together to improve the diagnostic criteria for TBI. Right now, we don’t really have any good definition for mild TBI and we are working on it,” he said.

Among the initiatives that will shape TBI research is a presidential executive order in 2012 directing DoD, VA and HHS to develop a National Research Action Plan on PTSD, other mental health conditions and TBI “to improve the coordination of agency research into these conditions and reduce the number of affected men and women through better prevention, diagnosis, and treatment.”

Announced along with that NRAP was the Chronic Effects of Neurotrauma Consortium, a program funded by DoD and VA and involving federal and private research institutions; it seeks to document the longterm effects of mTBI.

Meanwhile, officials say a milestone was accomplished when DoD established the first brain tissue repository in 2013 aimed at helping researchers better understand traumatic battlefield injuries.

At the TBI conference, Daniel Perl, MD, who directs the Center for Neuroscience and Regenerative Medicine’s Brain Tissue Repository for TBI, pointed to the challenges that brain injuries pose to the medical community, including the difficulty in identifying which patient will suffer from persistent symptoms from mTBI. He said that “access to these brain tissues,” will be an important avenue to try to sort out many of the questions facing TBI researchers.

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