The VAH has earned a bad reputation for treating PTSD with piles of pills. Why do they persist in doing this? Are there any medications or techniques that work better? What should they do instead?
I worked for the VA over 40 years ago when we didn’t have the diagnosis “PTSD”. We definitely had the patients, mostly young veterans just back from Vietnam. At that time there were very few medicines available to treat a “psychiatric” problem, and we didn’t understand what was wrong. Veterans with flashbacks were diagnosed “schizophrenic” and put on thorazine, mellaril, or haldol. One officer I saw had episodes of violence, was labeled “manic-depressive”, and put on lithium. Those medications calmed their nerves, but kept them in a haze, dysfunctional.
The one thing we did that seemed to help was create groups just for Vietnam veterans where they felt supported and could talk. Talking is cheap and it still works.
Fast-forward 40 years and what has changed?
- We know PTSD is a physical injury caused by stress chemicals run amok in your brain.
- We know the sympathetic nervous system plays a vital role in producing those stress chemicals.
- We have medications that block those chemicals and can reverse many of the symptoms.
- We have procedures to help reset the sympathetic nervous system.
- We know what parts of the brain are most effected: the amygdala (in charge of fear related emotions) and prefrontal cortex (in charge of controlling the amygdala—among other duties)
- We have medications that reactivate the prefrontal cortex so it can resume control of the amygdala.
- We have procedures that can do the same.
- We know how traumatic memories are laid down, and how they are triggered.
- We have medications that work to reset those triggers when used with exposure therapy.
- We have medications that can prevent PTSD if used in a protected setting.
How should we treat PTSD?
- The best medicine available for PTSD is the alpha-blocker Prazosin. It blocks the stress chemicals that cause PTSD, normalizes your sleep, calms your nerves, and gets rid of nightmares. Side effects like low blood pressure and sedation tend to self-correct over time. Luckily the VA has backed this trend, and this is one thing they do RIGHT.
- Stellate Ganglion Blocks can shut down an overactive sympathetic nervous system with one, or sometimes two, injections. Not yet approved for PTSD but may be available if you pay out of pocket at the Anesthesia Department in a hospital near you.
- Service dogs are great for calming veterans down, but are not yet approved for PTSD. They are widely available through many local projects, but you’ll probably have to wait, and they are pricey. Check out the internet for financial help.
- Antidepressants (Prozac, Paxil, Zoloft, Lexapro, Celexa, Remeron, Effexor, Cymbalta, Trazodone, etc.) can reboot the prefrontal cortex, (which controls the amygdala and defuses not only depression but also rage.) These work well in some people, but may have side effects, including sexual problems and more nightmares.
- Another approach to improved self-control is meditation/mindfulness. Some VA facilities are now offering classes. It’s a side effect free approach to rewiring your brain, and research shows that meditation can calm your sympathetic nervous system, improve the functioning of the prefrontal cortex, and actually enlarge other parts of your brain involved in attention and emotional control.
- New approaches to Exposure Therapy use medications (D-cycloserene, propranolol, medical MJ, and MDMA) to disconnect triggers from traumatic memories. These are not available at most VA facilities—although some veterans have been known to use their own.
- Trans-Cranial Magnetic Stimulation has been shown to reduce both depression and traumatic flashbacks, but it’s not yet approved for PTSD.
- Propranolol and medical MJ may PREVENT PTSD if given immediately following a trauma, especially in folks who develop Acute Stress. But this needs to happen in a protected setting since the person will be slowed and not able to protect themself on meds. That may be why this preventative approach is rarely used in combat zones, but it has been tested after natural disasters and found helpful.
So why can’t we get the newest treatments?
The FDA bureaucracy. The FDA has not yet approved many of the treatments mentioned above, or at least not for PTSD. Some are approved for other diagnoses.
- Stellate Ganglion Block is approved for chronic pain and severe sweating, but not for PTSD.
- Service dogs are approved for physical disabilities, but not for PTSD.
- Trans-Cranial Magnetic Stimulation is in use for depression and autism, but still experimental for PTSD.
- MDMA and medical MJ are still illegal at the Federal level.
Without government approval, the VA doctors treating PTSD can’t use or recommend these medications and procedures.
The VA focus on symptom control. Because of the stigma and fear our country exhibits toward most mental health issues, the VA is dedicated to protecting all of us through strict control of violent symptoms. That means their first job is to keep veterans calm so there is no way they can act violent.
Nowadays the doctors use the newer antipsychotics (Zyprexa, Seroquel, Risperdal, Abilify, Geodon, etc. and their generics), which may be somewhat less sedating than the old, but they still have many side effects. These include impaired cognition, increased fat and body weight, and increased blood sugar.
But if our veterans could access improved treatments that act on the cause and relieve their symptoms, the VA wouldn’t need to use so many drugs.
How do we change this situation?
We’ve already accomplished the first step, throwing a spotlight on the VA problem, but now we need to focus on the FDA approvals, and that requires research on the treatments that we need.
The FDA won’t approve anything that isn’t backed by scientific research. We need to push for more research on Stellate Ganglion Blocks, Trans-Cranial Magnetic Stimulation, medical MJ, and Service Dogs for PTSD.
There’s a new bill in the Senate (S.320) for innovative medical research. Pay attention to its passage through the Health, Education, Labor, and Pensions committee. You can check how your elected officials vote on this and other veteran related bills at: https://www.opencongress.org/vote.
Until things loosen up, what can you do? If you have the money, you can seek out private treatment. But if you’re stuck at your local VA clinic and the treatment you need is unavailable there but is available in a community nearby, you can request that the VA purchase community medical care. Guidelines for purchased care are here: http://www.va.gov/PURCHASEDCARE/programs/veterans/nonvacare/index.asp