By Andrea Petersen
As the pandemic grinds on, psychologists and psychiatrists are bracing for rising rates of post traumatic stress disorder. The concern comes as a wave of potential treatments for PTSD are on the horizon.
Psychologists and psychiatrists say new treatments for PTSD, some of which involve combining psychotherapy and drugs, are sorely needed, as some Covid-19 survivors and front-line workers grapple with the disorder.
Only around 20% to 30% of people who take the medications that are FDA-approved to treat the disorder, the antidepressants Zoloft and Paxil, achieve complete remission. The most evidence-based talk therapies for trauma are effective for about half of patients. Skilled therapists who can deliver those treatments are in short supply in some parts of the country.
Scientists are seeing early positive studies combining psychotherapy with certain drugs, including MDMA (known as the street drug Ecstasy), to enhance the treatments’ efficacy. A growing body of research shows that transcranial magnetic stimulation, which uses a high-powered magnet placed on the scalp to stimulate neurons in certain parts of the brain, can ease PTSD symptoms. Early research is finding that ketamine, a version of which the Food and Drug Administration approved last year for treatment-resistant depression, also can alleviate PTSD.
Already, some studies are finding elevated rates of PTSD among health-care workers and young people. In a study published in August in the journal Psychological Trauma that surveyed 270 health-care professionals in Greece in April, 16.7% met criteria for a diagnosis of PTSD. A survey of nearly 900 18-to-30 year-olds conducted between April 13 and May 19 found that about 32% of young adults had high levels of PTSD symptoms, with those expressing more loneliness and worries about Covid most affected. The study was published in the journal Psychiatry Research in June.
Doctors say people who have had severe Covid-19 infections are likely to face a higher risk, too. A meta-analysis published in May in the Lancet found that about 32% of patients who had the coronavirus SARS during that earlier outbreak had PTSD about three years after their acute illnesses.
“Front line workers have direct trauma exposure, witnessing people dying in pretty large numbers, or where they had to make some really difficult decisions about who they give resources to,” says Tanja Jovanovic, professor of psychiatry at Wayne State University in Detroit. “The more traumas you have, the higher your symptoms.”
Only a fraction of people who experience or witness a life-threatening traumatic event develop PTSD. The numbers vary depending on the study and the type of trauma—whether from combat, a sexual assault or a car accident, for example, but researchers say that, in general, about 10% to 20% of people do. The disorder is characterized by nightmares, flashbacks, difficulty sleeping, avoidance of situations that remind the person of the trauma and other symptoms that last for more than one month and impair functioning.
“If you’re irritable and you can’t sleep and you have nightmares, it’s hard to maintain relationships or a job,” says Dr. Jovanovic. People with PTSD have a greater risk of substance abuse, physical health problems and suicide, notes Barbara Rothbaum, professor of psychiatry and director of the Emory Healthcare veteran’s program and trauma and anxiety recovery program at Emory University School of Medicine.
People who have pre-existing mental health issues, like anxiety or depression, are more likely to develop PTSD after a trauma, says Murray Stein, a professor of psychiatry at the University of California, San Diego and a staff psychiatrist at the VA San Diego Healthcare System. The risk for PTSD is about 40% to 50% genetic, says Kerry Ressler, chief scientific officer at McLean Hospital and a professor of psychiatry at Harvard Medical School.
Michael Skinner says he has been dealing with PTSD since the early 1990s, the result of childhood abuse. The trauma “just overwhelmed me,” he says. Mr. Skinner became unable to work, his marriage fell apart and he attempted suicide twice. He spent years bouncing between therapists and trying various medications without getting much relief before he found a therapist who specializes in treating trauma. This treatment, he says, helped. So has connecting with other survivors of childhood abuse in support groups. In recent years, he has continued to see therapists off and on.
“I have found peace in my life. I have found joy,” says Mr. Skinner, a 66-year-old musician in Goffstown, N.H. But he still has nightmares and sometimes “the emotional triggers come out of nowhere,” he says. “This stuff is with me every day and every night.”
The most effective psychotherapies for PTSD are cognitive processing therapy and prolonged exposure therapy, versions of cognitive behavioral therapy. In cognitive processing therapy, people learn to challenge thoughts and beliefs that fuel PTSD symptoms. In prolonged exposure, people recount their trauma to a therapist many times and visit places that remind them of the traumatic experience. “Folks with PTSD, they avoid thinking about [the traumatic event], they avoid all reminders, so then it festers and haunts them,” says Dr. Rothbaum. “We help them confront the memories and reminders in a therapeutic environment.”
Researchers are trying to make psychotherapy more effective. Kim Felingham, chair of clinical psychology at the University of Melbourne, is conducting a randomized controlled trial combining prolonged exposure with aerobic exercise. Participants doing the intervention ride an exercise bicycle for 20 minutes before beginning their therapy session. Aerobic exercise boosts the levels of a protein called brain-derived neurotrophic factor, or BDNF. In studies, higher levels of BDNF improve fear extinction learning. Extinction learning is part of how scientists believe exposure therapy works in people: with repeated exposure to traumatic memories in a safe space, people with PTSD learn not to fear their traumatic memories.
Scientists are also combining therapy with medications to boost efficacy. The use of MDMA combined with psychotherapy is being studied in two Phase 3 clinical trials, says Rick Doblin, executive director of the Multidisciplinary Association for Psychedelic Studies, the nonprofit funding the research. In a review of six Phase 2 studies published in 2019 in the journal Psychopharmacology, 54% of participants who received two treatments, each of which included a dose of MDMA and an eight-hour psychotherapy session where patients relayed their traumatic experiences, no longer met criteria for PTSD, compared with 23% of participants who received psychotherapy and a placebo. About 40% of people who received the MDMA treatment reported side effects including anxiety, headaches and nausea.
“MDMA allows people to engage trustingly with other people in a therapeutic context,” says Boadie W. Dunlop, director of the Mood and Anxiety Disorders Program at Emory University School of Medicine, who is an investigator on studies involving MDMA. Researchers are examining other drugs, including the steroid dexamethasone and D-cycloserine, a medication used for tuberculosis, in combination with psychotherapy to treat PTSD.
SOURCE : WALL STREET JOURNAL