Treating PTSD as an injury

Sean Mulvaney spent nine years as a Navy SEAL officer and then later became an Army physician, serving as the battalion and brigade surgeon with several Army Special Operations units.

Working with SEALS, Green Berets and Marines, Mulvaney treated many of them for injuries – but also saw many who had post-traumatic stress disorder (PTSD).

“They all had security clearances. They were all worried about having the stigma of PTSD,” Mulvaney said. “They were all worried about seeking treatment for PTSD and admitting that they had something going on.”

One of Mulvaney’s patients, who served in Desert Storm, had crashed his car while taking Seroquel, an anti-psychotic drug used to treat nightmares in PTSD. The patient also was seeing an Army psychiatrist, but nothing was helping him.

“He said, ‘Help me. I’ll do anything. Help me,’” said Mulvaney, who promised to keep on the lookout for anything he thought would help the patient. Two weeks later at a conference, Mulvaney was shown a newspaper article by someone he didn’t know at the time about a doctor in Chicago using a stellate ganglion block (SGB) to treat women’s hot flashes.

“He said, ‘Do you think this could have anything to do with treating PTSD?' another segue that I thought was just incredible,” said Mulvaney, who reached out to the doctor in Chicago to get his input on using the procedure to treat PTSD. When he returned from the conference, Mulvaney asked his patient if he was willing to undergo an SGB.

“His symptoms resolved on the table,” Mulvaney said. “He said, ‘I haven’t felt this good since high school.’ I remember that quote. I’ll never forget it.”

Mulvaney, now a staff physician with Regenerative Orthopedics and Sports Medicine in Annapolis, Md., has continued to use the procedure with great success and spent part of March 8 briefing The American Legion TBI/PTSD Committee during the organization’s annual Washington Conference in the nation’s capital.

According to Mulvaney’s website, SBG uses an injection of a long-acting local anesthetic, using ultrasound or fluoroscopic guidance, in the right side of the neck around the main nerve that controls the “fight or flight” response (the sympathetic nervous system). The nerve, which is a two-way conduit, connects the parts of the brain that control the fight or flight response (referred to as the central autonomic network) to the rest of the body. Blocking off the traffic in the cervical sympathetic chain is believed to allow the parts of the brain that control the fight or flight response to completely reset, resulting in long-term relief of the associated anxiety symptoms.

Mulvaney said he has delivered more than 1,400 treatments. Around one third of those have needed just one procedure, while the other two thirds retrigger from time to time and require multiple treatments. A study by Mulvaney and others on the procedure’s successful use with PTSD was published in JAMA Psychiatry in 2019.

What Mulvaney has seen in patients using SGB is “statistically significant improvements across the board in neuro-cognitive function: reaction time, memory, executive function – all the test batteries. It’s the first treatment of its kind that shows it actually improves combat survivability.”

Mulvaney said he currently is working with members of Congress on passage of the Treatment and Relief through Emerging and Accessible Therapy for (TREAT) PTSD Act, which would require the Department of Veterans Affairs to provide SGB therapy to veterans diagnosed with PTSD.

“People treating folks with PTSD have their treatment failures,” Mulvaney said. “I see people routinely on five psychoactive medications, including highly addictive ones. Including ones where if you stop taking them you could die. They’ve been through multiple inpatient and outpatient treatment programs.

“If they’ve failed after everything else that anybody else feels like doing, if they’re still in a bad place … consider stellate ganglion block.”

Mulvaney said he prefers to use post-traumatic stress injury over PTSD. “I treat this like an injury,” he said. “If you come in with this, I don’t care how you got it,” he said. “And when you set the optic that this is an injury and I expect you to get better, you’re halfway home to making these people better.”

Former Special Assistant to the President on Veterans’ Issues Drew Trojanowski briefed the committee on the upcoming release of the President’s Roadmap to Empower Veterans and End a National Tragedy of Suicide (PREVENTS). The comprehensive strategy, which will be released March 30, will include the federal government working with state and local agencies, and private and nonprofit entities to provide veterans with much-needed services, while also advancing the understanding of causal factors of veteran suicide.

Trojanowski served in U.S. Army Special Operations and currently is Arizona State University’s assistant vice president of strategic initiatives for the ASU Knowledge Enterprise. He said PREVENTS has two major components: a research arm and a community aspect.

“The community side of this is we need to have organizations that exist to able to work with (veteran service organizations), work with VA, work in this area that they call the social determinants of health,” Trojanowski said. “There are a lot of things that impact your life that have nothing to do specifically with service. It could be a lot of environmental conditions. So how do you create a lens from which an organization isn’t the provider of services, but is coordinating the services – all those activities that already exist?”

Finding a “vaccine for suicide” means identifying and intervening early, Trojanowski said. He noted that 70 percent of veteran suicides are by an individual who have never set foot inside a VA facility. “That’s not a VA problem. That’s an everyone else problem,” he said.

TBI/PTSD Committee Vice Chairman Ralph Bozella agreed. “Suicide is a community problem. It’s a personal problem. It’s a family problem,” he said.

Trojanowski said recognizing a veteran who is suicidal likely will happen at a personal level. “The person that’s going to figure out that something’s wrong with you isn’t the guy who’s at the VA,” he said. “It’s going to be your smoking, drinking, shooting, fishing, hanging out buddy. And then you need to empower them with information to be able to get you where you need to go.”

The committee also heard from representatives from TruGenomix, a veteran-owned genomics company that has patented a PTSD genomic biomarker blood test to identify an individual’s predisposition to develop PTSD. The company developed the test through years of research using samples from 9/11 first responders, military personnel, Holocaust survivors and their descendants.

The test identifies three specific biomarkers that have been shown to be differentially regulated in a person with PTSD

“It’s literally what is going on in your brain biochemistry and understanding it at the genetic level,” said TruGenomix Chief Science Officer Tshaka Cunningham, who previously served as VA’s scientific program manager for the Aging and Neurodegenerative Diseases Rehabilitation Research Program. “And then we generate a report … on those levels of the genes that your clinician can then use to better assess your overall risk and hopefully one day stage your severity of disease.”

TruGenomix Chief Medical Officer Anne Naclerio spent 30 years in the U.S. Army in positions such as Chief of Clinical Operations for the Regional Health Command Atlantic, Deputy Surgeon for the U.S. Army in Europe and the Command Surgeon for the Army National Guard.

She said the self-reporting test is “not yet a diagnostic by FDA standards but is a (Clinical Laboratory Improvement Amendments)-approved, lab-developed test. Our current diagnostic tools are not the best. They’re limited by one thing: You have to come in to take them.”

Naclerio said those in the military who may be suffering from PTSD tend to play down their condition “because you want to finish your career. You don’t want to get boarded out, or you don’t want to be taken out of the fight. You want to go back with your team, and you want to remain deployable for your career purposes.”

Cunningham said TruGenomix begun engaging VA about a study that would involve 3,000 veterans who would be given the test and then tracked over a two-year period.

Cunningham also asked that The American Legion advocate on behalf of TruGenomix “to get this (test) out into use, into clinicians’ hands to start letting them assess it.”