On the front lines against PTSD

USAMRMC leads the way in research to prevent, diagnose and treat service members’ psychological injuries.

by Col. Dennis McGurk, Lt. Cmdr. Christopher Steele, Capt. Leonard D. Skipper,

Dr. Ronda Renosky and Dr. Ronald L. Hoover

Post-traumatic stress disorder (PTSD) has been called one of the “signature wounds” of the wars in Iraq and Afghanistan. The U.S. Army Medical Research and Materiel Command (USAMRMC) has been at the forefront of documenting the prevalence and impact of PTSD on Soldiers and the joint warfighter, and developing interventions to prevent or address it.

USAMRMC is the Army’s medical materiel developer, with responsibility for research, development and acquisition and medical logistics management. In 2004, researchers from the Walter Reed Army Institute of Research (WRAIR), a subcommand of USAMRMC, published a study in the New England Journal of Medicine indicating that roughly 20 percent of Soldiers in several brigade combat teams (BCTs) met screening criteria for symptoms consistent with PTSD following deployment to Iraq and Afghanistan. A 2010 study showed that 24 percent of Soldiers in a different BCT met screening criteria for PTSD 12 months after returning from a combat deployment to Iraq.

These and other studies, in addition to continued tracking by the Armed Forces Health Surveillance Branch of the Defense Health Agency’s Public Health Division, show that the impact of PTSD continues to be a strain on our Soldiers, more than 35 years after the American Psychiatric Association officially recognized PTSD in the third edition of its Diagnostic and Statistical Manual of Mental Disorders, published in 1980.

Many Soldiers who have PTSD are unable to do their military jobs and either leave service voluntarily or are medically retired. Gen. Mark A. Milley, chief of staff of the Army, has been clear that operational units must focus on readiness as their No. 1 priority. The loss of trained, combat-experienced Soldiers directly impacts unit readiness and puts greater pressure on the Army to rapidly train new Soldiers.

USAMRMC and its subordinate units continue to conduct research to mitigate service members’ risk of and vulnerability to traumatic exposures that can cause PTSD. Additionally, extensive research focuses on developing rapid diagnostic procedures and tools, and on ensuring that care providers are armed with evidence-based treatment to facilitate recovery and fully prepare service members to return to duty with confidence in their ability to perform effectively.

Within the command, the Military Operational Medicine Research Program (MOMRP) is responsible for developing effective medical countermeasures against operational stressors and for preventing physical and psychological injuries during training and operations in order to maximize the health, readiness and performance of service members and their families. The MOMRP manages Army Medicine and Defense Health Program funding that supports the planning, programming and budgeting of psychological and behavioral health research. The MOMRP actively collaborates with the U.S. Department of Veterans Affairs (VA) and the National Institute for Mental Health (NIMH) as part of the National Research Action Plan. The national plan is a coordinated, multiagency response to the 2012 White House call for increased access to behavioral health care for veterans, service members and military families. All three agencies serve the same population, although usually at different times during and after their military service or affiliation.

In response to precipitously increasing numbers of behavioral health issues among service members, Congress initiated significant increases in research funding in 2007. Since then, MOMRP has managed more than $500 million and funded more than 300 projects to better understand PTSD and to help prevent and treat it. The MOMRP also plays an integral role in developing and supporting implementation of PTSD care across the military health system, in VA hospitals and in community behavioral health care facilities that treat service members and veterans.

Retired Command Sgt. Maj. Sam Rhodes was diagnosed with PTSD after serving 30 straight months deployed to Iraq starting in 2003. Upon returning home, he discovered that horses helped him regroup. Now, he runs a nonprofit organization, The Warrior Outreach Ranch, which helps veterans and their families reconnect and relax by learning to deal with horses. (U.S. Army Reserve Photo by Maj. Michelle Lunato/released)

SUPPORTING PSYCHOLOGICAL HEALTH

The MOMRP has four major areas of emphasis on Soldiers’ and veterans’ psychological health that affect readiness directly:

Promoting the psychological adaptability of service members in the face of operational demands by improving their resilience, which in turn promotes readiness.

Research in this area includes the development and testing of training methods that enhance resilience. Examples include developing empowerment skills that build on inherent psychological strengths, training approaches that leverage leadership for better learning, and small-group cohesion building. Training in mindfulness and biofeedback skills can also improve awareness of and control over physiological and cognitive processes, as these skills help regulate emotions and general distress and make it easier to adapt to situational stressors.

In 2009, WRAIR tested a one-hour post-deployment training session that focused on improving psychological resilience by harnessing service members’ inherent abilities. Specifically, the training aimed to teach Soldiers to recognize and anticipate normal reactions to stressful circumstances and to manage those reactions effectively in training, operations, combat and when transitioning from deployment to home. In three group-randomized trials, the WRAIR team demonstrated that the training improved behavioral health. The researchers found that units completing this interactive resilience training within one week of returning from deployment showed greater readiness to conduct their mission 12 months later, in comparison with units that received only education about human stress responses and ways to address those responses.

Developing objective tools to assist in the diagnosis of PTSD.

Current diagnostic methods for PTSD rely on patients’ own reports of symptoms. Symptoms often vary greatly from one patient to the next, and the subjective nature of self-reporting can complicate behavioral health providers’ evaluations. Additionally, other factors can influence patients’ self-reports, including concerns about PTSD carrying a stigma that could hurt their career progression, potential medical discharge and longer-term disability status.

One of MOMRP’s major current efforts focuses on developing a blood-based laboratory test that behavioral health professionals can use to aid in PTSD diagnosis so as not to rely solely on subjective self-reporting of symptoms. The goal is to have an objective platform, consisting of a biomarker assay and blood analyzer that can easily identify markers of illness from blood components, such as metabolic proteins, genetic markers and common biometric data. This screening tool will be used in military medical treatment facilities. Later uses will be to assess the trajectory of disease, PTSD subtypes, treatment matching and optimization, and response to treatment.

These advances fit well with the White House Precision Medicine Initiative launched in 2015. They also aim to accelerate biomedical discoveries and provide clinicians with new tools and therapies to select treatments, taking into account individual differences in genes, symptoms, environments and lifestyles. Within five to 10 years, when trials validate the blood-based PTSD test and it comes into common use by DOD behavioral health providers, the test will bolster readiness by ensuring that those who have PTSD are identified early, receive the best treatment and return to duty with confidence that they are psychologically ready for their missions.

A traumatic brain injury patient walks through a virtual reality scenario at the Computer Assisted Rehabilitation Environment Laboratory at the National Intrepid Center of Excellence in Bethesda, Maryland, in March. Cameras track the patient's movements and supply data to physical therapists. Similar approaches seeking to optimize treatment are being explored through the White House Precision Medicine Initiative, which aims to provide clinicians with new tools for treatment selection, taking into account differing symptoms, environments and lifestyles. (U.S. Air Force photo by J.M. Eddins Jr.)

A traumatic brain injury patient walks through a virtual reality scenario at the Computer Assisted Rehabilitation Environment Laboratory at the National Intrepid Center of Excellence in Bethesda, Maryland, in March. Cameras track the patient’s movements and supply data to physical therapists. Similar approaches seeking to optimize treatment are being explored through the White House Precision Medicine Initiative, which aims to provide clinicians with new tools for treatment selection, taking into account differing symptoms, environments and lifestyles. (U.S. Air Force photo by J.M. Eddins Jr.)

Improving treatment of PTSD.

Two main evidence-based psychotherapies are currently in use across the military health system. The first is prolonged exposure (PE) therapy, which gradually exposes an individual to varying trauma-related sensory cues within a safe environment to reduce the intensity of emotional and physiological activation and arousal associated with the traumatic events. The second is cognitive processing therapy (CPT), which focuses on processing memories of traumatic events but without targeted exposure to trauma-related cues.

Both therapies have been used extensively and have been shown to be effective in civilian populations. MOMRP’s research into the use of PE and CPT in treating military populations found that both therapies were effective but less so than for civilians.

One challenge of PE therapy is that the standard treatment protocol is 15 weekly 90-minute sessions. It can be very challenging for service members to complete the entire protocol because of job and family obligations, as well as deployments and permanent change-of-station requirements. To address the challenge of lengthy treatment protocols, MOMRP funded a study that demonstrated that three weeks of daily PE, for 90 minutes each day, was as effective as 15 weekly sessions, dramatically shortening recovery time.

There is also room for improvement in medications for PTSD. There are only two approved by the U.S. Food and Drug Administration for treatment of PTSD, and neither has been evaluated for its efficacy in treating service members. Both medications were developed to treat depression, are less than 50 percent effective in reducing symptoms of PTSD and have side effects, such as sexual dysfunction, that often cause service members to reject taking them.

To address the paucity of approved PTSD medications, USAMRMC hosted a state-of-the-science meeting in June in Shepherdstown, West Virginia. About 130 military leaders, academicians, researchers and pharmaceutical industry representatives from the fields of psychiatry, psychology, neurobiology, biochemistry and the development of psychiatric medication met to discuss the pathophysiology of PTSD, with the goal of identifying new targets for therapeutic medications. Findings included identifying and prioritizing research into seven candidate drugs or compounds to treat PTSD.

MOMRP also funds studies that use complementary and alternative medicine approaches to treat PTSD, including meditation, yoga, exercise, acupuncture and canine-assisted therapy. In most cases, the interventions would be used in conjunction with trauma-focused psychotherapy. If these additional efforts prove effective, many combat-experienced warfighters will be able to return to their units, and ultimately readiness will improve.

Increasing access to and use of behavioral health care by reducing stigma associated with PTSD and, more broadly, behavioral health care. Additionally, alternative forms of behavioral health care delivery are under evaluation through multiple research projects addressing the use of telemedicine, mobile applications and the internet.

Research is underway on the development of new methods for training behavioral health providers in the use of evidence-based interventions, with a focus on web-based learning modalities. One promising finding indicates that tele-behavioral health approaches, such as remote patient monitoring and mobile health platforms (for example, laptops, smartphone apps, tablets, etc.) appear to be as effective as in-person treatment. These methods offer alternatives where traditional mental health care is not easy to obtain, such as in rural areas, and are less likely to pose a stigma for some individuals, which makes it more likely that they will seek treatment.

The ultimate goal of this line of research is to determine the optimal methods and modes of delivering care by providing access to evidence-based clinical treatments that service members will be more likely to accept and use.

Col. Dennis McGurk welcomes attendees to the first Post-Traumatic Stress Disorder State of the Science Summit in Shepherdstown, West Virginia, June 13. The two-day meeting brought together experts to investigate new and current avenues in drug development to fight PTSD and related problems. Only two drugs are FDA-approved to treat PTSD, but their effectiveness is limited and their side effects often result in patients opting not to take the medication. (Photo by Crystal Maynard, U.S. Army Medical Materiel Development Activity Public Affairs)

Col. Dennis McGurk welcomes attendees to the first Post-Traumatic Stress Disorder State of the Science Summit in Shepherdstown, West Virginia, June 13. The two-day meeting brought together experts to investigate new and current avenues in drug development to fight PTSD and related problems. Only two drugs are FDA-approved to treat PTSD, but their effectiveness is limited and their side effects often result in patients opting not to take the medication. (Photo by Crystal Maynard, U.S. Army Medical Materiel Development Activity Public Affairs)

CONCLUSION

These efforts will directly improve readiness across DOD. In addition, the research will advance the science and clinical care of other populations of civilian trauma survivors, including those with occupational risk, those impacted by natural disasters and catastrophic accidents, and those who suffer severe trauma in the course of everyday living.

For more information, please visit the MOMRP website at https://momrp.amedd.army.mil.

COL. DENNIS MCGURK is director of the MOMRP at USAMRMC, Fort Detrick, Maryland. He holds a Ph.D. in experimental psychology from Texas Tech University. He was a distinguished military graduate in his ROTC class at Loyola College in Maryland while earning an M.S. in clinical psychology, and he holds a B.S. in psychology from the University of Delaware. He entered the military in 1990 as an infantryman in the U.S. Army Reserve and was commissioned as a Medical Service Corps officer in 1994. He has served as a platoon leader, operations officer, company commander, research branch chief and detachment commander and has deployed to Haiti, Kosovo, Iraq and Afghanistan. He is Level III certified in science and technology (S&T) management.

CMDR. CHRISTOPHER STEELE is deputy director of MOMRP. He received a Ph.D. from North Carolina State University in 2005 and accepted a commission as a U.S. Navy officer. He holds a B.S. in biology from King University. He served three years in the U.S. Army as an artilleryman and 12 years in the Army National Guard, serving in aviation, armor and engineering units as a noncommissioned officer in nuclear, biological and chemical operations and military intelligence. He has deployed to Iraq and Afghanistan. He is Level III certified in S&T management and Level I certified in program management, and is a member of the Navy Acquisition Corps.

CAPT. LEONARD D. SKIPPER is MOMRP’s deputy director for advanced development. He holds a Ph.D. in psychology from Capella University, an M.S. in human relations from the University of Oklahoma and a B.S. in psychology from the University of Maryland University College. After enlisting and receiving an honorable discharge from the U.S. Air Force, Skipper transitioned to the U.S. Army under the Blue to Green Program. As a member of the Medical Service Corps, he served as a research psychologist at WRAIR and as a medical product manager at the U.S. Army Medical Material Development Activity. He is Level III certified in program management, Level II certified in S&T management and Level I certified in information technology.

RONDA RENOSKY is the deputy portfolio manager of the Psychiatry and Clinical Psychology Disorders Portfolio at MOMRP. She holds a Ph.D. in biobehavioral health and an M.Ed. in rehabilitation counseling from The Pennsylvania State University. She completed a rehabilitation psychology traineeship at Johns Hopkins University’s Welch Center for Prevention, Epidemiology and Clinical Research and Johns Hopkins Hospital’s comprehensive rehabilitation unit.

RONALD L. HOOVER is the clinical and psychological health portfolio manager within MOMRP. A licensed clinical psychologist, he holds a Ph.D. in clinical psychology from the University of Cincinnati and a B.A. in biology from Wittenberg University. He is a retired captain from the Naval Reserve Intelligence Program.

This article will be published in the October – December 2017 Army AL&T magazine.

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