Encouraging signs achieved by PTSD treatment using the tech that’s on your fridge door
How PTSD is handled in the future may be about to change with a new treatment offering hope for veterans suffering the effects of the debilitating disorder.
The spectre of a massive US warship, disabled and sitting low in the water within sight of my own vessel in the Persian Gulf, was truly shocking. The mighty US Navy guided-missile cruiser USS Princetonhad been wounded, its lower decks flooded, after striking two of the countless mines that infested the maritime conflict zone during the first Gulf War in early 1991.
Witnessing this relatively minor naval encounter as a navy doctor, working deep below the waterline in HMAS Sydney as we provided support to a US carrier group, left me on edge and uneasy.
Yet my experience of a typical working day during conflict was nothing compared to the horrors many Australians encountered so often during their service. This small dose of the relentless unpredictability of war I received as a non-combatant pales in comparison to the unthinkable trauma experienced by many of the patients I treated over the years.
Anzac Day leads me to reflect not only on my own war service but also – and especially so – on those whose minds continue to play out these visceral and often terrifying memories.
It is easy to forget that hundreds of Anzacs returned to Australia as broken men. After surviving the living hell of Gallipoli and battlefields across Europe, they suffered what, at the time, military doctors called “shell shock”. No effective treatment was available to them – certainly nothing approaching a cure – and many lived the rest of their lives in emotional destitution, some accused of cowardice.
We understand now that shell shock is post-traumatic stress disorder, or PTSD, and in the century or so since Gallipoli it has blighted the lives of some of our most storied and courageous warriors.
How PTSD is handled in the future, though, may be about to change. Many Australian soldiers, sailors and aviators might finally have access to a treatment that is looking very much like a potential cure. Hope could be at hand for thousands of Australians who have served our country and paid a heavy price for that service.
This promising new technology could deliver extraordinary results for veterans and, potentially, thousands of other Australians could benefit too. The early signs are very encouraging and, incredibly, that technology is sitting on fridge doors across the country – magnets.
The treatment is known as transcranial magnetic stimulation – or TMS – and it uses high-intensity magnetic fields to activate and potentially change the nerve pathways deep within the brain. Using TMS in combination with latest-generation MRI scanning now allows doctors to identify and target precisely nerve circuits that lead to the debilitating symptoms of post-traumatic stress disorder. These new protocols are delivering remission rates for this devastating condition of 90 per cent for the first time in major clinical trials.
PTSD often curses sufferers with feelings of severe anxiety, terrifying flashbacks and nightmares, disabling sleeplessness, and sometimes bouts of uncontrolled rage. There are many more distressing symptoms too. For many soldiers, sailors and aviators with PTSD, treatments have changed little for decades and involve talking therapy and medications.
Finding out just how common PTSD is in that group has proven difficult. PTSD becomes more likely with repeated exposure to battle conditions. Research suggests that as many as a quarter of those who have had several tours of Afghanistan or recent conflicts elsewhere in the Middle East suffer the condition. That is a terrible legacy.
Admiral Chris Barrie, former chief of the Australian Defence Force and now head of PTSD charity the Fearless Foundation, is deeply concerned about the effects of multiple deployments on our armed service members. “We’re seeing people sent to conflict zones again and again,” he says. “They’re exposed to traumatic situations repeatedly and that is a major risk for them.”
Admiral Barrie makes it clear that he’s concerned not only about Australia’s military personnel but also their families and loved ones. PTSD makes life hard for partners and children too, and can be poisonous for loving relationships. Working and holding life together can be an enormous challenge for those affected by PTSD. “Loved ones and children are suffering too,” Admiral Barrie says. “It’s heartbreaking.”
To date, success in curing PTSD has been patchy at best and many sufferers seek relief from their torments through alternative therapies elsewhere – often in illicit drugs and alcohol.
Advances in medical science now are bringing us closer to a detailed understanding of the changes in the anatomy and function of the brain that lead to PTSD. This knowledge not only has allowed the development of new treatments but also helps to understand why some people appear to have an innate resistance to developing PTSD while others seem to be vulnerable. The story of these advances is almost like that of military reconnaissance and intelligence gathering.
Professor Max Bennett, neuroscientist and founder of the Brain and Mind Centre at Sydney University, has been fascinated with PTSD throughout his long and distinguished career. His experiments have led us to a new and deeper understanding of PTSD and, importantly, how it might be cured.
“The most important experiment was one I did back in 2010,” Professor Bennett says. By exposing laboratory mice to stress and trauma his research showed that the amount of grey matter in the animals’ brain reduced significantly. The cause of these anatomical changes puzzled Professor Bennett and his team.
“We could look at what had changed in the grey matter, and what we discovered was … nothing. We measured every bloody possibility.” Examining the brain tissue under their standard bench microscopes had left them mystified.
After Professor Bennett’s researchers drew a blank, their sleuthing led them to the use of powerful electron microscopes to delve more deeply into the brain’s cells. To his astonishment they discovered that the nerve cells of the brain had lost their connections to other cells. These connections between brain cells are called synapses.
“We could quantitate exactly the extent of loss of grey matter with the extent of loss of synapses,” Professor Bennett says. The finding that grey matter in the brain shrank due to the loss of its connections to other brain cells explained not only the physical changes in the brain after severe stress, but also the reduction in activity thought to occur in areas deep in the brain in PTSD. Did Professor Bennett realise the significance of his discovery? “For me that was a big one,” he says.
It was a big one indeed. For many years psychiatrists and scientists had been at a loss to explain why PTSD happened and, indeed, whether it represented a change in the brain’s structure, its function, or both. An understanding of a change in the very structure of the brain after traumatic exposure begged the question: Could the changes be reversed?
“I quite serendipitously gave a talk up on the Sunshine Coast and discovered there was terrible PTSD there because many returning Diggers had gone to the coast to escape, for recreation,” he says.
On Queensland’s Sunshine Coast, Professor Bennett set up a scientific partnership with Professor Jim Lagopoulos, who had moved to Queensland from Melbourne. Together they established the Brain and Mind Hub. Professor Lagopoulos is a world-renowned neurophysiologist – an expert in the function of the brain. Professor Lagopoulos says our understanding of PTSD has changed rapidly over the past few years.
“There are two really big changes that I’ve seen in the last five to 10 years,” he says. “Number one is that we have a much better understanding of the circuits in the brain that are affected in PTSD. We often see a very selective loss of nerve cells and synapses in very specific locations.”
These are new and fundamental insights that have changed our understanding of PTSD. Rather than the condition being an emotional reaction, it seems that exposure to severe trauma severs many of the links between nerve cells in the brain and alters the way the brain works in a fundamental way. TMS works by directly stimulating dormant nerve cells, and stimulating them to re-establish their connections in a healthy way.
“Knowing all of that has been the catalyst for some of the new treatments that we’ve got, which I think are head and shoulders above the older treatments,” Professor Lagopoulos says. “There’s no doubt that MRI has been revolutionary. It is giving us a better appreciation of some of the damage caused in circuits and functional networks in the brain. We’re getting a better picture of the very specific functional networks that are impacted by PTSD, and that’s incredible.”
For decades we have known that conditions such as severe depression respond well to electro-convulsive therapy, also known as ECT, or shock treatment. Whereas shock treatment uses an electric current to affect the whole brain, magnetic stimulation now can be targeted with precision using the same “navigation” techniques used in brain surgery.
“As crude as it was, and obviously it has a stigma associated with it too, shock treatment can produce spectacular outcomes in people who are at their absolute lowest,” Professor Lagopoulos says. “But even if you put aside the logistics of getting an ECT treatment done, such as the general anaesthetic, it still has one very significant side-effect – the potential impact on memory, and it’s a very significant side-effect.”
TMS does not seem to cause memory loss. TMS is non-invasive and works by applying a magnetic coil close to the head that delivers magnetic pulses that stimulate nerve cells deep in the brain. No anaesthetic is required. Magnetic stimulation moved from the realm of research to established treatment two decades ago for the treatment of depression.Its use as a therapy was approved by the US Food and Drug Administration in 2008. TMS is approved by Australia’s Therapeutic Goods Administration and is already used for treatment of depression around the country.
When introduced, TMS was a cumbersome and time-consuming treatment. Up to six weeks of daily treatment – taking as much as an hour at a time during a session – was required, and results were good but not spectacular. “We typically saw about 50 per cent of people get better,” Professor Lagopoulos says. “About 10 to 15 per cent of people regress after that and they can have maintenance therapy. When you’re in the seat for an hour, and this happens every day for a month, well, that’s a real slog.”
Things are changing fast. “In the last couple of years there’ve been really exciting developments in terms of the protocols,” Professor Lagopoulos says. His clinic is using accelerated treatments known as “theta burst”, where the treatment time is measured in minutes.
“If you do more than one stimulation per day, you get a better outcome. So rather than coming in for one protocol, so one stimulation session per day, we invite people to come in for two and three simulations per day,” Professor Lagopoulos says. “So you come in, you get measured up, you’re put in a seat, and the stimulation literally takes 3½ minutes.
“The person gets up off the chair, stretches their legs, goes away, has a glass of water, and about an hour later we invite them back into the chair, and they can have another stimulation, and then they can go away again. People can have intensive treatment where we stimulate the brain 10 times in one day, with 50-minute sessions in between, every day for a week.”
The results from trials of these new protocols in the US are very hopeful for people affected by PTSD. “The results are striking. For people who have multiple stimulation sessions the rate of remission goes way up. Clinical trials conducted at Stanford University show remission rates of over 90 per cent.” TMS appears to be safe and the major side-effect seems to be the occasional mild headache that resolves quickly.
For thousands of Australians affected by PTSD, help can still be hard to find. This troubles Admiral Chris Barrie. “The stories I am still hearing are disappointing. The system seems to be more concerned with controlling cost than clinical outcomes. Waiting times for treatment are so long that four years isn’t uncommon.”
Like many of us who provide healthcare to Australia’s soldiers, sailors and aviators – and our veteran community – Admiral Barrie is optimistic. “For me, hope springs eternal,” he says. “If we can put research and treatment together, the thing we might be able to do is find a cure once and for all.”
Lest we forget.
Professor Steve Robson works at the Australian National University Medical School, has served as president of the AMA and is a board member of the National Health and Medical Research Council. He served as a Medical Officer in the Royal Australian Navy in the first Gulf War for which he received a citation for meritorious service.
To join the conversation, please log in. Don't have an account? Register
Join the conversation, you are commenting as Logout