Victoria Colliver / San Francisco Chronicle & Conn Hallinan / Dispatches From The Edge – 2011-06-25 02:13:58
http://www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2011/06/22/MNQ91K0MQ9.DTL
Brains of Vets with PTSD Can Change as They Age
Victoria Colliver / San Francisco Chronicle
SAN FRANCISCO (June 22, 2011) — Combat veterans with post-traumatic stress disorder are more likely to have dementia, cardiac problems and structural changes in the brain as they get older than veterans without PTSD, according to new research.
The findings, which for the most part resulted from research at the San Francisco Veterans Affairs Medical Center, raise concerns about the overall health of aging veterans, but hold promise for the potential of helping to treat these diseases.
“Our concern is that veterans who honorably serve our country … are at greater risk of developing Alzheimer’s disease and over the next 10 to 20 years we will see a lot of Alzheimer’s in the veteran population,” said Dr. Michael Weiner, director of the Center for Imaging of Neurodegenerative Diseases at the Veterans Affairs Medical Center.
The impact of combat on the brain as it ages will be at the center of the fourth annual “Brain at War” conference Thursday at the Marines’ Memorial Club in San Francisco.
Much of the research to be presented during the daylong conference was conducted at the city’s Veterans Affairs hospital and funded through San Francisco’s Northern California Institute for Research and Education, the largest VA research institute in the country and the nation’s leading neuroscience research institute.
Effects of PTSD
Of the 2 million Americans who have served in the current wars in Iraq and Afghanistan, at least 400,000. or as much as 20 percent, have developed or are at risk of developing PTSD, a psychological condition caused by exposure to severe trauma.
Some 23 million veterans, like many people, will later face more common illnesses, such as cancer, heart disease and Alzheimer’s, as a function of aging. But a growing body of work shows these diseases may be exacerbated by traumatic stress, the researchers found.
For example, veterans with PTSD are two to three times more likely to develop heart disease than those who do not have the disorder.
“These are young men and women, most of whom do not yet have heart disease,” said Dr. Beth Cohen, a staff physician at the hospital, in a statement about her research. “If we can learn why they are at greater risk now, we can find ways to help avoid heart disease later in life.”
Unlike heart disease, no effective ways to prevent or treat Alzheimer’s disease yet exist, but researchers are studying soldiers’ brains to learn more about how combat-related stress affects the brain’s biology and increases the chance of developing Alzheimer’s.
They have found that a section of the hippocampus — the part of the brain that is devoted to short-term memory and learning new things — is significantly smaller in veterans with PTSD. Researchers are trying to determine if this smaller section can grow over time with therapy and treatment for stress.
“It’s possible new stem cells, new brain cells are made, or it’s possible the existing neurons or cells get plumper or have more synapses and connection,” said Weiner, also professor of medicine, radiology, psychiatry and neurology at UCSF. “Nobody knows. Our ability to probe the brain and understand these mechanisms is really limited.”
A Veteran’s Story
Weiner and his colleagues at the VA hope their research will help veterans like 37-year-old Ben Sykes, who enlisted in the Marine Corps after Sept. 11, 2001, and was among the first troops to move into Baghdad and then into Saddam Hussein’s primary palace in Tikrit in 2003.
When Sykes returned to civilian life and his previous career as an interaction Web designer, he found himself trying to re-create the intensity of combat through drinking and extreme sports.
“I have read the greatest pharmacy on the planet is your hypothalamus,” said Sykes, referring to the part of the brain responsible for certain metabolic processes and secretion of some hormones. “It changes your body’s chemistry. I was hooked and was just looking for the next rush.”
Sykes did not recognize his classic symptoms of PTSD until his family pushed him to get help. Now, after years of therapy and treatment at the VA, Sykes believes he has few lingering effects other than an occasional feeling of impending panic that comes when he smells burning odors or realizes he’s seated with his back to a door.
Still, he is grateful for how far he’s come and appreciates the continued work of the VA in researching the long-term health effects of PTSD on veterans.
“Humans are amazing in the sense they adapt to anything,” he said.
The Brain at War
The fourth annual “Brain at War” conference, to be held Thursday, will look at research that suggests post-traumatic stress disorder, or PTSD, has potentially long-term ill effects on the brain and body. Here are some of the findings by researchers at the San Francisco Veterans Affairs Medical Center:
PTSD and heart disease: Veterans of the current wars in Iraq and Afghanistan who have been diagnosed with PTSD and other mental health issues have two to three times the rate of heart disease risk factors compared with veterans without those diagnoses.
PTSD and the hippocampus: Research using magnetic resonate imaging, or MRI, at the VA hospital have shown the hippocampus, the part of the brain that stores memory, is significantly smaller in the brains of veterans with PTSD.
PTSD and dementia: Older veterans with PTSD are almost twice as likely as veterans without such trauma to develop dementia.
Source: Northern California Institute for Research and Education-Veterans Health Research Institute
E-mail Victoria Colliver at vcolliver@sfchronicle.com.
(c) © 2011 Hearst Communications Inc.
The Wars Come Home: The Traumatic Brain Injury Epidemic
Conn Hallinan /
Dispatches From The Edge
(June 20, 2011) — “We are facing a massive mental health problem as a result of our wars in Iraq and Afghanistan. As a country we have not responded adequately to the problem. Unless we act urgently and wisely, we will be dealing with an epidemic of service related psychological wounds for years to come.
”
— Bobby Muller, President Veterans for America


“The multiple nature of it [multiple tours and longer deployments] is unprecedented. People just get blasted and blasted and blasted.”


— Maj. Connie Johnmeyer, 332nd Medical Group


According to official Defense Department (DOD) figures, 332,000 soldiers have suffered brain injuries since 2000, although most independent experts estimate that the number is over 400,000. Many of these are mild traumatic brain injuries (mTBI), a term that is profoundly misleading.
As David Hovda, director of the Brain Injury Research Center at the University of California at Los Angeles, points out, “I don’t know what makes it ‘mild,’ because it can evolve into anxiety disorders, personality changes, and depression.” It can also set off a constellation of physical disabilities from chronic pain to sexual dysfunction and insomnia.
MTBI is defined as any incident that produces unconsciousness lasting for up to a half hour or creates an altered state consciousness. It is the signature wound for the wars in Iraq and Afghanistan, where roadside bombs are the principal weapon for insurgents.
Most soldiers recover from mTBI, but between five and 15 percent do not. According to Dr. Elaine Peskind of the University of Washington Medical School, “The estimate of the number who returned with symptomatic mild traumatic brain injury due to blast exposure has varied from the official VA [Veterans Administration] number of 9 percent officially diagnosed with mTBI to over 20 percent, and, I think, ultimately it will be higher than that.”
Serious consequences from mTBI are increased when troops are subjected to multiple explosions and “just get blasted and blasted and blasted,” in the words of Maj. Connie Johnmeyer. Out of two million troops who have served in Iraq and Afghanistan, over 800,000 have had multiple deployments, many up to five times or more.
But mTBI is difficult to diagnose because it does not show up on standard CAT scans and MRIs. “Our scans show nothing,” says Dr. Michael Weiner, professor of radiology, psychiatry and neurology at the University of California at San Francisco and director of the Center for Imaging Neurodegenerative Disease at the Veteran’s Administration Medical Center.
They do now.
An MRI set to track the flow of water through the brain’s neurons, has turned up anomalies that indicate the presence of mTBI. However, the military has blocked informing patients of results of the research, and if history is any guide, the Pentagon will do its best to shelve or ignore the results.
The DOD has long resisted the diagnosis of mTBI, as it has avoided paying for a successful — but expensive — way to treat it. The price of that resistance is escalating suicide rates and domestic violence incidents among returning soldiers. In 2010, almost as many soldiers committed suicide as fell in battle.
MTBI is hardly new. Some 5.3 million people in the US are currently hospitalized or in residential facilities because of it, and its social consequences are severe.
A Mt. Sinai Hospital study of 100 homeless men in New York found that 80 percent of them had suffered brain trauma, much of it from child abuse. A study of 5,000 homeless people in New Haven discovered that those who had suffered a blow that knocked them unconscious or into an altered state were twice as likely to have alcohol and drug problems and to be depressed.
It also found mTBI injuries were correlated with suicide attempts, panic attacks, and obsessive-compulsive disorders. And a recent study by Dr. Elaine Peskind of the University of Washington School of Medicine found that mTBI is a risk factor for developing Alzheimer’s disease.
In spite of the documented consequences of mTBI, the military has been extremely tardy in dealing with it. Part of the problem is military culture itself. The Pentagon found that 60 percent of the soldiers who suffered from the symptoms of mTBI refused help because they feared their unit leaders would treat them differently. Many were also afraid that if they reported their condition it would prevent them from getting jobs as police and fire fighters after they got out of the service.
Even if soldiers wanted treatment, there are few resources available to them. “There are two things going on regarding vets,” says Col. (ret) Will Wilson, chair of the American Psychological Association’s Division 19 (Military Psychology). “One, there are not enough care providers available, and, two, there are not enough people focusing on the problem outside the military.”
Indeed, there are not enough military psychologists to treat the problem, and since the military pays below-market rates for civilian psychologists, up to 30 percent of private psychologists are unwilling to take on soldiers as patients. The cheapest and easiest solution is to shoot up the vets with drugs. A study by Veterans for America found that some soldiers were taking up to 20 different medications, many of which canceled out the effect of others.
The situation appears to be even worse for National Guard and Reserve units, who make up almost 50 percent of the troops deployed in Iraq and Afghanistan. The Veterans for America found that such troops “are experiencing rates of mental health problems 44 percent higher than their active duty counterparts” and that their health care is generally inferior.
A Harvard study found that 1.8 million vets under 65 have no health care or access to the Veterans Administration. “Most uninsured veterans are low-to-middle income workers who are too poor to afford private coverage but are not poor enough to qualify for Medicaid or free VA care,” the study found.
Treating mTBI injuries is difficult, but by no means impossible. Dr. Alisa Gean, chief of Neuroradiology at San Francisco General Hospital, who has worked with wounded soldiers at US Army’s Regional Medical Center at Landstuhl, Germany says the old conventional wisdom that brain damage was untreatable is wrong. “We now know that the brain can heal. It has an intrinsic plasticity that allows it to recover, and this is particularly true for the young brain.”
A recent study by the Massachusetts Institute of Technology found that “neurons in the adult brain can remodel their connections,” thus “overturning a century of prevailing thought.”
One method that has worked effectively is cognitive rehabilitation therapy (CRT) that retrains patients for tasks like counting, cooking, and memory. But CRT takes time and it can be expensive, ranging from $15,000 to $50,000 per patient. However, the DOD’s health program — Tricare — refuses to endorse CRT, because it says there is no scientific evidence that justifies the expense involved.
However, an investigation by T. Christian Miller of ProPublica and Daniel Zwerdling of National Public Radio found that the vast majority of researchers, even those associated with the DOD, sharply disagreed with Tricare’s evaluation of CRT. According to the two reporters, “A panel of 50 civilian and military brain specialists convened by the Pentagon unanimously concluded that cognitive therapy was an effective treatment and would help many brain damaged troops.”
The therapy is also endorsed by the National Institutes of Health, the National Academy of Neurophysiology and the British Society of Rehabilitative Medicine.
Instead of accepting the advice of its own researchers, however, Tricare hired ECRI — a company which had already done a study concluding that CRT was ineffective — to examine the therapy. But critics charge that the study was so narrow, and the assumptions behind it so loaded, that it was almost a given that the study would conclude the benefits of cognitive therapy were “inconclusive.” Outside researchers blasted the ECRI study, one of them describing it as “hooey” and “baloney.”
In spite of the criticism, then Deputy Secretary of Defense Gordon England concluded, “The rigor of the research… has not met the required standard.”
However, Miller and Zwerdling concluded that Tricare’s resistance to CRT was not about science, but the bottom dollar. According to the reporters, a Tricare-sponsored study found “that comprehensive rehabilitative therapy could cost as much as $51,480 per patient. By contrast, sending patients home from the hospital to get a weekly phone call from a therapist amounted to only $504 a patient.”
Defense Secretary Robert Gates has already made it clear that he intends to cut the military’s $50 billion annual health budget. No matter how effective CRT is, it’s not likely to get past the brass, who would rather spend the money on weapon systems than on healing the men and women who they so casually put in harm’s way.
So far, the military has put the clamps on the new MRI technique. Dr. David L. Brody, an author of the study, told the New York Times that researchers were blocked from giving the MRI results to patients. “We were specifically directed by the Department of Defense not to so,” adding, “It was anguishing for us, because as a doctor I would like to be able to help them in any way. But that was not the protocol we agreed to.”
Given that mTBI is so difficult to diagnose, and sufferers are many times told there is nothing wrong with them, that seems an especially cruel protocol. “Many of them [the doctors] were hoping we could give results to their care providers to document or validate their concerns.”
In the end it will come down to treatment, and whether the wounded vets will get the care they need, or sit by a phone and wait for their once a week call from a therapist.
Read Conn Hallinan at dispatchesfromtheedgeblog.wordpress.com
Posted in accordance with Title 17, Section 107, US Code, for noncommercial, educational purposes.
