TEN NON-PHARMACEUTICAL THERPAIES THAT MAY CHANGE THE TREATMENT OF VETERANS WITH POST-TRAUMATIC STRESS
David Shulkin M.D. - March 16, 2021
Approximately a half a million veterans suffer from symptoms of post-traumatic stress. Yet the treatment of this condition remains challenging. Adding to this, many veterans unfortunately don’t receive any treatment at all. The facts are that 45 percent of veterans, six months after their diagnosis, have not received treatment for PTSD (1). This Policy Vets piece will discuss reasons why the treatments have been challenging and review some of the newer therapies that are now becoming available and expanding our treatment options.
Medications in the treatment of PTSD have a role, but are not necessarily the treatment of choice. The VA/DoD guidelines on PTSD recommend non-medication therapies as first line over pharmacotherapy (2). The reason for this is that some patients simply do not experience symptom relief with medications and others have side effects that can be worse than the condition itself. Addiction and abuse has also been associated with medications, such as benzodiazepines, used for this condition. Other drugs too have fallen out of favor. Prazosin was once considered the preferred initial therapy for PTSD, but that is no longer the case (3).
The Commander John Scott Hanson Veterans Mental Health Improvement Act was enacted into law in 2020. It provides for a number of much needed enhancements to the VA’s behavioral healthcare system. Included in the law is a requirement for VA to expand the number of mental health professionals and to enhance access to care through telehealth. Also included in the legislation is a requirement for VA to broaden their offerings for conditions such as post-traumatic stress by piloting new innovations in treatment.
With a renewed focus on non-pharmacologic therapies for post-traumatic stress, Policy Vets will review ten of the most promising of these therapies below:
In a simplistic way, the brain can be viewed as a complex electrical system that controls the functions of the human body. When the heart rhythm is irregular, pacemakers are often used to regulate cardiac activity. In a similar way, it makes sense that electrical stimulation of the nervous system can change physical and behavioral outcomes.
The impact of neuromodulation may be clearest with neurologic conditions such as headache. FDA has cleared use of an external vagal nerve stimulator for prevention and treatment of cluster headache and treatment of acute migraine headaches (4). Studies are also showing that non-invasive cervical vagal nerve stimulation using these devices may alleviate trauma symptoms by reducing sympathetic reactivity (5,6). Neuromodulation may be an increasingly important tool as a non-pharmaceutical options for post-traumatic stress expand.
2. Digital Therapeutics
Digital therapeutics are a new way of treating conditions such as post-traumatic stress. Behavioral improvements can be seen with the use of these tools (7). VA was an early adopter of digital tools with the introduction of PTSD Coach (8). This is an app that consists of 17 different tools that provides education, assessments, exercises and activities for veterans experiencing post-traumatic stress. VA early on recognized the value of approaches that integrate cognitive behavioral therapies as an approach to the treatment of these patients (9). A number of newer companies have developed app based treatments that have data showing their effectiveness in reduced depressive symptoms, anxiety, and stress (10). These tools use a combination of cognitive behavioral therapies, mindfulness and positive psychology to deliver treatments for behavioral conditions and to improve well-being.
3. Respiratory Modulation Therapy
Post-traumatic stress has been found to be associated with carbon dioxide hypersensitivity. Fortunately there is now a treatment option that has been shown to normalize carbon dioxide in a 28 day treatment regimen. Patients using this home device help regulate breathing in 17 minute treatment twice a day and have shown real improvements in panic and post traumatic associated symptoms. In a study at the Palo Alto VA, 80% of veterans who used a respiratory modulation device achieved meaningful improvement in their post-traumatic symptoms and 50% of veterans had remission of their condition six months after treatment (11).
4. Adaptive Sports
The impact of participating in adaptive sports on post traumatic stress may be difficult to measure and demonstrate improved outcomes (12). Despite the lack of hard data, there is a good deal of anecdotal support from veterans for these activities. VA has been running a large number of adaptive sports events and these programs have been life changing for many veterans and are often part of a set of prescribed activities that can make a big difference in a veteran’s well-being. Due to budgetary constraints these programs are often limited in size since they are time intensive and expensive. Therefore not all veterans with symptoms of post-traumatic stress will realistically be able to benefit from this approach.
5. Pet Therapy
The relationship between humans and animals dates back as far as history is recorded. Yet despite a mountain of anecdotal reports on the positive impact of these relationships, the scientific data documenting the therapeutic effect has been lacking (13). There is some data showing the positive impact of equine therapy, emotional support dogs, and other animals in reducing stress, but most of these studies have lacked the academic rigor to achieve widespread professional acceptance (14). The Department of Veteran Affairs has embarked on a study of the impact of emotional support dogs on PTS (15), but for many veterans whose lives have been positively changed by their animal companions, there is little reason to wait for this data.
6. Image Rescripting Therapy
Image Rescripting Therapy may play a role in the successful resolution of post traumatic stress symptoms for some patients. In a study of 23 patients that had failed prolonged exposure therapy, 18 had full resolution of their symptoms with IRT (16).
7. Rapid Eye Movement Therapy
Numerous studies have found Rapid Eye Movement Therapy (REMT) to provide relief from a variety of symptoms associated with post traumatic stress disorder. Twelve randomized clinical trials shows that REMT was associated with decreases in negative emotions and imagery often associated with post-traumatic stress (17).
8. Hyperbaric Therapy
The results of hyperbaric treatment in veterans with PTSD are mixed. The concept behind the therapy is that high levels of concentrated oxygen may induce neuroplasticity and therefore improve brain function (18). Overall, my review of the many studies in this area suggests that while there is not consistent improvement in outcomes for PTS with hyperbaric treatments there are clearly a subgroup of patients that do experience clinically significant improvement in their condition.
9. Prolonged Exposure
Prolonged exposure therapy is in its simplest form a trauma focused form of psychotherapy. It has been studies a great deal and overall found to have a good evidence base for helping veterans with PTSD (19,20). However, there are a reasonable number of veterans that do not tolerate this therapy and therefore the discontinuation rate is not insignificant.
10. Virtual Reality
Using virtual reality tools may be considered a variation of prolonged exposure therapy, but there are a number of differences and new approaches being taken with this technology. Most studies of virtual reality therapy have been for treating anxiety, panic, and phobia, but there is some work that has been done with PTS patients as well. There is general has been similar results as prolonged exposure but virtual reality treatments potentially may have a lower treatment dropout rate (21).
The main scientific investigations of Virtual Reality Exposure Therapy (VRET) for treating social phobia, specific phobia, PTSD, and panic disorders are encouraging and demonstrate a similar effectiveness between both in vivo and in vitro exposures (22).
A final note from Policy Vets: Since the original posting of this article we have heard from a number of other people who have pointed out additional therapies that could have been included in this list. We agree that there are many other promising therapies out there and we encourage the active study and reporting of outcomes when they become available. Policy Vets believes that when it comes to conditions such as PTSD, where many veterans are still not receiving therapies that are completely effective, that veterans should have as many options available to them as possible. We believe in making innovative approaches to care available to veterans, as long as there is evidence that there will be no harm associated. That is why we have focused this piece on non-pharmacologic approaches.
While the 10 non-pharmacologic approaches to post-traumatic stress reviewed here are not the only ones available, they do represent some potentially promising and evidence based approaches to treatment. Other therapies such as stellate ganglion block, ketamine infusions, psychedelics, cannabis, and other pharmaceuticals and others, may have value but many are invasive or are associated with some limited to significant risk.
3. https://pubmed.ncbi.nlm.nih.gov/30306339/ and https://pubmed.ncbi.nlm.nih.gov/30641094/
11. Ostacher MJ, Investigation of the Freespira System in the treatment of PTSD. Unpublished data from the Palo Alto VA