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March is TBI awareness month. With politics dominate the newscasts these days, we might forget that every day at least 20 veterans commit suicide. Many believe post traumatic stress disorder (PTSD), and traumatic brain injury (TBI) have a significant contribution to the sense of despair and futility that lead these veterans to take their own lives. For the proud warrior, depression, anxiety, or the hopelessness of a diagnosis of TBI may contribute to their choice to end their life. 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. Fear of medications and a lack of confidence in the therapies offered by the Veterans Administration are also factors that keep veterans isolated and untreated.1-3
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. Indeed, the Veterans Administration admitted in September 2016 that it had mis-diagnosed thousands of veterans who had TBI.
- First, it is difficult to distinguish TBI from PTSD based on symptoms alone.
- Second, current treatments for TBI and PTSD have been only marginally effective and treatment for one condition can be dangerous in treating the other condition.
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 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
Separating 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, including Dr. Henderson.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.9 When the areas of the brain involved in the default mode network10 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%).9 This result was then replicated by the same group in a large civilian sample numbering in the tens of thousands11.
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. Exciting evidence is emerging on the benefit of infrared light, particularly multi-Watt infrared laser, in the treatment of TBI.12 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,13 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.14
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. We believe our Servicemen and Servicewomen deserve an opportunity to receive a life-changing treatment.
You can help too, by attending the inaugural fund-raising Gala on April 30th 2017. Go to www.TBI.care to learn more. I promise I won’t sing or play the sax.
- USA Today website. http://www.usatoday.com/story/news/nation/2016/07/07/veterans-suicides-young-men-women/86755132/. Accessed July 7, 2016.
- 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
- 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
- Hoge CW, Grossman SH, Auchterlonie JL, et al. PTSD treatment for soldiers after combat deployment: low utilization of mental health care and reasons for dropout. Psychiatric Services. 2014; 65(8):997-1004. doi:10.1176/appi.ps.201300307
- 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
- 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.
- 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.
- 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
- 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.
- 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
- 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).
- 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).
- 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.
14. 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.