Veteran Suicides Fuel Widespread Demands for Answers
As the Congress, VA, CDC and the Obama Administration address the issue, recent neuroimaging studies point to effective diagnostic tools available for PTSD and TBI — two common conditions among suicide victims.
Parsing out who has PTSD, who has TBI, and who has both is a critical issue for veterans.
On July 7, 2016, the Department of Veterans Affairs released its official accounting of suicide deaths among Veterans. On average, 20 veterans committed suicide each day in 2014. Prior estimates had set the number at 22 per day, but the reality is equally chilling.
Whether the suicide rate is 20 per day, 22 per day, or one per day, it indicates we are not doing enough for our veterans who are suffering and these statistics are fueling a demand for answers.
Demographics and data mining help us to see that posttraumatic stress disorder (PTSD), and traumatic brain injury (TBI) have a significant contribution to the sense of despair and futility that lead veterans to take their own lives. A sense of hopelessness for those veterans with TBI may stem from the common medical assertion that there is no treatment for TBI. In addition, veterans with PTSD or depression are often reluctant to seek help because they feel PTSD and depression are not real brain disorders, but a failure of character. Shame, guilt, fear of medications, and a lack of confidence in the therapies offered are also factors that keep veterans isolated, alone, and untreated.1-3
Meanwhile, neuroscientists are catching up, and beginning to understand how the biology of the brain impacts behavior. Through advancements in neurodiagnostic tools, like single photon emission computed tomography (SPECT), two common conditions among veterans can now be distinguished with a very high accuracy rate: post traumatic stress disorder and traumatic brain injury.
The PTSD vs TBI Challenge
Brain injury and emotional trauma are often the most common stressors that lead to the high suicide rate among Veterans. To date, however, the medical and psychiatric communities haven't been able to successfully diagnose or treat either PTSD or TBI with any real consistency.
1. First, it is difficult to distinguish TBI from PTSD based on symptoms alone.
2. Second, current treatments for TBI and PTSD have been only marginally effective, if at all.
While some trivialize the significance of PTSD for Veterans and returning war fighters, studies show more than 90% of military personnel witnessed a traumatizing event in the battlefield.4 Fortunately, not all of those personnel developed PTSD. Current estimates indicate that 13.5% of returning military report persistent PTSD symptoms.5 Similarly, many estimates of the incidence of TBI have been put forth. According to the Congressional Budget Office, an estimated 400,000 service men and women have TBI or PTSD.6
Alas, among the 400,000 or more Veterans with either TBI or PTSD, there is tremendous overlap both in terms of diagnosis and of symptomatology. The overlap is estimated to be 33% to 42%,7 but may be considerably higher.
A study of patients in the VA system revealed 73% of patients who reported TBI were also co-morbid for PTSD.8 Whether this is actual diagnostic overlap or the result of poor instruments for differentiating the two entities remains a critical question for the Department of Veterans Affairs (VA). It is likely that both alternatives contribute to this situation. For example, several of the questions in the Clinician-Administered PTSD scale9 identify symptoms that also could be a result of TBI, such as sleep difficulties, irritability, poor concentration, memory difficulties, anhedonia, and social isolation. As an indirect consequence of this conundrum, patients in the VA system are often diagnosed with only one or the other, and the comorbidity is ignored.6
Parsing out who has PTSD, who has TBI, and who has both is a critical issue for veterans. In the September 2015 issue of Brain Imaging and Behavior, a landmark paper on this question was published by a multi-center team of clinician-scientists.10 This group examined the neuroimaging data of 196 military and Veteran patients who had undergone SPECT imaging, which is a functional neuroimaging modality based on the intimate relation between neuronal activity and local oxygenated blood perfusion (the same principle upon which functional magnetic resonance imaging or fMRI is based).
The clinically-established diagnoses of the patients in the study included: 115 individuals with mild-to-moderate TBI, 36 with PTSD, and 45 with comorbid PTSD and TBI.10 When the areas of the brain involved in the default mode network11 were examined, a striking difference emerged. TBI could be distinguished from PTSD using SPECT with 94% accuracy (sensitivity = 92%, specificity = 85%). In addition, the ability to distinguish PTSD from co-morbid TBI+PTSD was 92% (sensitivity = 87%, specificity = 83%).10 The receiver operating characteristic curves hug the left wall of the graph, unlike most diagnostic tests for TBI or PTSD.
Heroic Bonus: This Study Cost Taxpayers Nothing
It may be surprising to learn that this research cost the taxpayer exactly zero dollars. Unlike Department of Defense or National Institutes of Health research studies, which cost millions of tax dollars, this study was done on a completely volunteer basis. Although the first author, Dr. Cyrus Raji, received a federally-funded salary as a resident in Radiology, his time and effort on this study was entirely voluntary outside of his regular duties. The remainder of the team donated their time or was supported by foundation or non-profit organizations.
The first author, and pivotal physician-scientist in this work, was a resident in Radiology at University of California-Los Angeles at the time of this study. Dr. Raji had distinguished himself while a medical student at University of Pittsburgh School of Medicine, participating in critical work on the neuroimaging and diagnostics of Alzheimer disease. Dr. Raji perfected the analysis process of functional brain scans to dissect the hazy clouds of activity counts (which often are portrayed as grey blobs, earning the moniker “unclear medicine”) into discrete anatomical areas which can be statistically analyzed.
Co-author Dr. Daniel G. Amen, who heads up a nationwide system of neuroimaging and diagnostic clinics, has been a pioneer in SPECT neuroimaging and has often taken slings and arrows of criticism.12 One criticism has been the absence of research to support his claims about SPECT neuroimaging as a diagnostic tool. That criticism no longer holds any water. Dr. Amen has now assembled a large multisite psychiatric database of more than 100 000 brain scans, which is available for retrospective analysis. This is the single largest and most comprehensive database in the world, containing, not only imaging, but extensive diagnostic evaluations, questionnaire data, demographics, and often quantitative electroencephalogram (qEEG) data.
Joining the study, all heroes in their own right, include: Dr. Robert Tarzwell of the University of British Columbia, who is a rising star, and double-board certified in Nuclear Medicine and Psychiatry; Dr. Andrew Newberg at Thomas Jefferson University who has explored the intersection between neurology and spiritualism with neuroimaging; Dr. Kristen Willeumier and Mr. Derek Taylor who were key players in Dr. Amen's research program. I rounded out the team with expertise in psychiatry, neuroimaging, and the published literature on TBI in the military.
Cutting Edge Treatments for TBI and PTSD
Now that we can potentially correctly separate and identify TBI and PTSD, what can we offer to the brave men and women who have served our country? New treatments for TBI are emerging. A program of supplements and omega-3 fatty acids has been shown to reduce symptoms and improve neurological function.13 Exciting evidence is emerging on the benefit of infrared light, particularly multi-Watt infrared laser, in the treatment of TBI.14 Infrared light, if it has the correct power, frequency, pulsing rate, and is correctly targeted can stimulate the brain's own healing processes via growth factors and other mechanisms.
Work in my research laboratory has shown that only infrared light in the 6-13 Watt range is able to penetrate human skin,15 so milliWatt light emitting diode (LED) systems probably provide little benefit. We have shown that multi-Watt infrared laser can produce significant clinical improvement and positive changes on functional neuroimaging.16
Infrared light therapy may have benefit in PTSD and depression, as well. Our preliminary data on PTSD-related symptoms in our patients with TBI show a robust response.14 In collaboration with a team at Massachusetts General Hospital, we have begun to explore the use of infrared light in depression.17 We have started a GoFundMe project18 to provide this innovative infrared light therapy to veterans. We believe our Servicemen and Servicewomen deserve an opportunity to receive a life-changing treatment.
About the Author
Theodore A. Henderson, MD, PhD, specializes in the diagnosis and successful treatment of complex psychiatric cases. A noted researcher, Dr. Henderson is also the co-Founder of Neuro-Laser Foundation, and guest editor for PLOS One, Journal of the American Medical Association, Journal of Nuclear Medicine and the Journal of Neuropsychiatry and Clinical Neurosciences. Learn more at www.TBI.care or call 720-493-1101.
1. USA Today website. http://www.usatoday.com/story/news/nation/2016/07/07/veterans-suicides-young-men-women/86755132/. Accessed July 7, 2016.
2. Stecker T, Shiner B, Watts BV, et al. Treatment-seeking barriers for veterans of the Iraq and Afghanistan conflicts who screen positive for PTSD. Psychiatric Services. 2013; 64(3):280-283. doi:10.1176/appi.ps.001372012
3. Bryan CJ, Morrow CE, Etienne N, Ray-Sannerud B. Guilt, shame, and suicidal ideation in a military outpatient clinical sample. Depression and Anxiety. 2013; 30(1):55-60. doi:10.1002/da.22002
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5. Dursa EK, Reinhard MJ, Barth SK, Schneiderman AI. Prevalence of a Positive Screen for PTSD Among OEF/OIF and OEF/OIF-Era Veterans in a Large Population-Based Cohort. Journal of Traumatic Stress. 2014; 27(5):542-549. doi:10.1002/jts.21956
6. Congressional Budget Office. The Veterans Health Administration's Treatment of PTSD and Traumatic Brain Injury Among Recent Combat Veterans. 2012. The Congress of the United States, Washington, D.C.
7. Lew HL. Rehabilitation needs of an increasing population of patients: Traumatic brain injury, polytrauma, and blast-related injuries. Journal of Rehabilitation Research and Development. 2005;42(4):xiii-xvi.
8. Taylor BC, Hagel EM, Carlson KF, et al. Prevalence and costs of co-occurring traumatic brain injury with and without psychiatric disturbance and pain among Afghanistan and Iraq War Veteran V.A. users. Medical Care. 2012;50(4):342-346. doi:10.1097/MLR.0b013e318245a558
9. Blake DD, Weathers FW, Nagy LM, et al. National Center for Posttraumatic Stress Disorder. 1998. http://www.clintools.com/victims/resources/assessment/ptsd/protected/CAPSIV.pdf. (Accessed November 16, 2015).
10. Raji CA, Willeumier K, Taylor D, et al. Functional neuroimaging with default mode network regions distinguishes PTSD from TBI in a military veteran population. Brain Imaging Behav. 2015;9(3):527-34.
11. Raichle ME, MacLeod AM, Snyder AZ, et al. A default mode of brain function. Proceedings of the National Academy of Sciences of the United States of America. 2001;98(2):676-682. doi:10.1073/pnas.98.2.676
12. Tucker, N. Daniel Amen is the most popular psychiatrist in America: To most researchers and scientists that's a very bad thing. Washington Post. August 9, 2012. https://www.washingtonpost.com/lifestyle/magazine/daniel-amen-is-the-most-popular-psychiatrist-in-america-to-most-researchers-and-scientists-thats-a-very-bad-thing/2012/08/07/467ed52c-c540-11e1-8c16-5080b717c13e_story.html (Accessed July 7, 2016).
13. Amen DG, Taylor DV, Ojala K, et al. Effects of brain-directed nutrients on cerebral blood flow and neuropsychological testing: a randomized, double-blind, placebo-controlled, crossover trial. Adv Mind Body Med. 2013;27(2):24-33.
14. Morries LD, Cassano P, Henderson TA. Treatments for traumatic brain injury with emphasis on transcranial near-infrared laser phototherapy. Neuropsychiatr Dis Treat. 2015;11:2159-75. https://www.dovepress.com/treatments-for-traumatic-brain-injury-with-emphasis-on-transcranial-ne-peer-reviewed-article-NDT (Accessed August 25, 2016).
15. Henderson TA, Morries LD. Near-infrared photonic energy penetration: can infrared phototherapy effectively reach the human brain? Neuropsychiatr Dis Treat. 2015;11:2191-208. https://www.dovepress.com/near-infrared-photonic-energy-penetration-can-infrared-phototherapy-ef-peer-reviewed-article-NDT (Accessed August 25, 2016).
16. Henderson TA, Morries LD. SPECT Perfusion Imaging Demonstrates Improvement of Traumatic Brain Injury With Transcranial Near-infrared Laser Phototherapy. Adv Mind Body Med. 2015;29(4):27-33.
17. Cassano P, Petrie SR, Hamblin MR, et al. Review of transcranial photobiomodulation for major depressive disorder: targeting brain metabolism, inflammation, oxidative stress, and neurogenesis. Neurophotonics. 2016;3(3):031404.