Testing the Science behind the VA’s TBI/PTSD Treatments
Back when Trent Lott was the senior Senator from Mississippi, he said during Congressional hearings on treating veteran brain wounds that “It’s funny in a sad way that I can get HBOT for my race horses but not for Veterans.”
SEN Lott retired in 2007 and twenty years later his sentiment is still true, but with a twist. Not only are horses still getting healed with HBOT, but Veterans are probably going to get access under VA coverage to powerful psychedelics and dissociative hallucinogens while Congress continues to punt on using a safe, effective, scientifically validated, and widely available and inexpensive treatment.
But we expect “more research” from a VA that claims on its web page: “We are the world’s leading research and educational center of excellence on PTSD and traumatic stress.” Notice they don’t say “We excel in clinical care” or “We cure what ails them and give them their lives back.” No, their measure of excellence is research and education. Perhaps in terms of amount of money spent, but in no way sufficient for the needs of the Veteran.
A note on VA “success” with suicide prevention: More than 161,000 Veterans have died by suicide since 2001, and veteran suicide remains the second-leading cause of death among Veterans aged 45 and under. There have been 22+ consecutive years of a minimum of 6,000 annual suicides. The trend continues upward.
Here’s a critical and often underreported finding: Roughly 39% of Veterans succumbing to suicide were in VA care — or ~2,500 of the 6,398 who died in 2023 had recent VHA contact. On average, 7 suicides per day were among Veterans who had received VHA care in 2021 or 2022.
Spending figures are as alarming as the suicide epidemic. The VA’s mental health budget (which houses suicide prevention spending) grew from roughly $2.4B in FY2000 to $16.6B in FY2024 — a nearly 7x increase. The most reliable confirmed figures are: $15.0B for mental health including suicide prevention in FY2023, rising to $16.6B in FY2024, with $559M specifically for suicide prevention outreach programs and an estimated $2.5B in suicide-specific medical treatment.
The DoD’s equivalent if the NICoE, the National Intrepid Center of Excellence. The NICoE, located in Bethesda, Maryland, is the headquarters of the Defense Intrepid Network for TBI and Brain Health (Defense Intrepid Network). The Intrepid Network is based on the holistic, patient-centered interdisciplinary model of care. In addition to the NICoE, the Intrepid Network includes 10 Intrepid Spirit Centers: Fort Belvoir, VA; Camp Lejeune, NC; Fort Campbell, KY; Fort Bragg, NC; Fort Hood, TX; Joint Base Lewis-McChord, WA; Camp Pendleton, CA; Eglin Air Force Base, FL; Fort Carson, CO; and Fort Bliss, TX.
A Short Tutorial [NOTE: the following focuses on the VA, but the MHA/DoD is little different in their focus, for about a month of treatment, on symptoms. Virtually no conversation occurs in either the DoD or the VA about healing the brain wound. A recent report from a participant in a NICoE cohort of 4 SOF patients was that the experience was soothing and led to some relief and return to active duty, but that the symptoms returned soon after release.]
The VA has formally designated roughly 15–20 therapies as “evidence-based psychotherapies.” To date, 15 of these have been disseminated through the VA’s national initiative, and more than 8,000 staff have been trained in one or more of these therapies. However, the strength of the RCT evidence behind them varies considerably, and a significant number of therapies used in VA clinical settings have little or no RCT support in veteran populations specifically. Their top tier interventions are primarily pharmaceutical and psychological: Cognitive Processing Therapy (CPT), Prolonged Exposure (PE), Eye Movement Desensitization and Reprocessing (EMDR), and Cognitive Behavioral Conjoint Therapy (CBCT) for couples.
The Therapies With the Strongest RCT Evidence
The VA/DoD 2023 Clinical Practice Guideline recommends three specific trauma-focused psychotherapies — Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and Eye Movement Desensitization and Reprocessing (EMDR) — as the most effective treatments for PTSD, supported by the strongest clinical trial evidence. Beyond those three, the VA’s top interventions with meaningful RCT backing include:
- Cognitive Behavioral Therapy for Depression (CBT-D) — extensive RCT support
- Behavioral Activation Therapy (BAT) — RCT-supported for depression
- Cognitive Behavioral Therapy for Insomnia (CBT-I) — strong RCT support
- Acceptance and Commitment Therapy (ACT) — growing RCT base
- Interpersonal Therapy (IPT) — RCT-supported, primarily for depression
- Motivational Interviewing (MI) — RCT-supported for substance use
- CBT for Substance Use Disorder (CBT-SUD) — RCT-supported
- Contingency Management (CM) — RCT-supported for stimulant/cannabis use
- Written Exposure Therapy (WET) — some RCT support, but newer and more limited
- Dialectical Behavior Therapy (DBT) — RCT support primarily from non-veteran populations
The Critical Caveat: “Evidence-Based” Doesn’t Always Mean RCT-Proven in Veterans
This is the key tension. A 2012 systematic review found only 29 RCTs of psychosocial interventions for veterans, with evidence for trauma-focused therapies for PTSD and “some evidence” for psychological interventions for borderline personality disorder, depression, insomnia, and panic — but the methodological quality of many studies was less than optimal.
The Institute of Medicine concluded that the evidence is still “inadequate to address the specific interventions, settings, and lengths of treatment that are applicable in the veteran population.” Most RCTs establishing the evidence base for therapies like CBT and IPT were conducted on civilian populations — the VA then adopted them based on that general evidence.
The Uncomfortable Reality About Even the “Proven” Therapies
A review published in JAMA found that the VA/DoD’s front-line PTSD treatments — CPT and PE — don’t work for up to two-thirds of patients, despite being recommended as preferred treatments in clinical practice guidelines. And real-world effectiveness data from the VA itself is sobering: among 265,566 veterans initiating mental healthcare, PTSD symptom improvement was “similar and modest” for both CPT and PE in practice, with researchers concluding that “research to further improve PTSD care is critical.”
Therapies Widely Used With Weak or No Veteran-Specific RCT Evidence
The VA also covers and widely uses:
- Complementary and integrative health approaches — VA covers eleven complementary therapies including acupuncture, Battlefield Acupuncture, biofeedback, clinical hypnosis, guided imagery, massage therapy, meditation, Tai Chi/Qigong, and yoga — most of which have very limited RCT evidence in veterans specifically, though use increased 70% over three years.
- Group therapy — widely used but knowledge of group approaches has lagged behind individual treatment approaches, and knowledge about group treatment for PTSD is limited due to the complexity of conducting RCTs in the group treatment context
- And, of course, Psychopharmacology, aka drugs. There are only two drugs approved for use with PTSD, and none for use with TBI. Known risks associated with black-box labeled drugs prescribed in the VA include documented cases of an estimated 109,000 Veteran opioid overuse deaths. VA stridency about “HBOT is too risky” ignores both their record of treating Veterans like guniea pigs where drugs are concerned, and the fact that Veterans treated with HBOT report extinction of suicidal ideation. Also, only one fully HBOT-treated Veteran in over 12,500 cases has succumbed to suicide.
Bottom Line
As long as the VA and DoD persist in treating TBI and PTSD like Mental Health problems — psychological issues rather than physiological damage — the trends won’t improve. Of the 15+ formally designated VA evidence-based psychotherapies, roughly 3–5 (PE, CPT, EMDR, CBT-D, CBT-I) have some RCT evidence specifically in or including veteran populations. The rest lean on civilian-population RCTs or have more limited trial evidence. And even the best-studied treatments fail a substantial proportion of veterans, which is a recognized crisis driving ongoing VA research into new approaches.
END NOTE: The states are voting to do the job the VA and DoD continue to ignore:
Green States -14 enacted Hyperbaric Oxygen Therapy (HBOT) state bills, 7 funded over $33 million
Yellow States -10 draft HBOT legislation states, five (OR, IA, MI, NY, NJ) with bills drafted into State Legislative Committee
Note: Twenty-four (24) total HBOT legislative effort states represent an estimated 195 million Americans, 58% of the US population, 10.8 million Veterans, 65% of the total US Veteran population. Over half of all Americans and nearly two-thirds of US Veterans now live in HBOT active (enacted and drafting) states.
Our knowledge of brain wounds and how to heal them has “exploded” in the last decade. The medical universe is mired in old notions about the brain and how to heal brain wounds. We can help in their education by allowing and funding State hospitals and clinics to use HBOT to heal TBI/PTSD while Congress and the VA and DoD catch up.
HBOT Heals Brains, Stops Suicides, Restores Lives. TreatNOW
Information provided by TreatNOW.org does not constitute a medical recommendation. It is intended for informational purposes only, and no claims, either real or implied, are being made.