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january/february 2007

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PTSD/SUBSTANCE ABUSE COMMITTEE REPORT
The VA Falls Short

BY TOM BERGER, CHAIR

According to a GAO report issued in November 2006, the Department of Veterans Affairs did not spend all of the extra $300 million it had budgeted to increase mental health services and failed to keep track of how some of the money was used. The VA launched a plan in 2004 to improve its mental health services for veterans with Post-traumatic Stress Disorder and substance-abuse problems. To fill gaps in services, the department added $100 million for mental health initiatives in 2005 and an additional $200 million in 2006. That money was to be distributed to its regional networks of hospitals, medical centers, and clinics for new services.

But the VA fell short of the spending by $12 million in 2005 and about $42 million in fiscal 2006, the GAO report said. It distributed $35 million in 2005 to its 21 health care networks but didn’t inform the networks that the money was supposed to be used for mental health initiatives. VA medical centers returned $46 million to headquarters because they couldn’t spend the money in fiscal 2006.

In addition, the VA cannot determine to what extent about $112 million was spent on mental health services improvements or new services in 2006. In September 2006 the VA said that it had increased funding for mental health services, hired 100 additional counselors, and was not overwhelmed by the rising demand.

The money is only a portion of what VA spends on mental health. The VA planned to spend about $2 billion on mental health services in FY 2006. But the additional spending from existing funds on what VA dubbed its Mental Health Care Strategic Plan was trumpeted by VA as a way to eliminate gaps in mental health services now and in the future.

ON THE DRUG FRONT

If you were still recovering from your turkey-induced coma on the Sunday immediately following Thanksgiving and your TV was locked onto CBS, you probably saw the 60 Minutes report on Army research that’s looking at whether the blood-pressure drug propranolol can be used to treat PTSD. Propanolol belongs to that class of drugs known as beta blockers that are already being used to treat anxiety disorders such as performance jitters in public speakers.

Studies funded by the Army will look at whether propranolol can reduce veterans’ emotional responses to certain memories by cutting down on the accompanying adrenaline rush, according to Dr. Scott Orr, a researcher at the VA Medical Center in Manchester, New Hampshire. As some of us know, stress hormones such as adrenaline play a big role in PTSD.

A post-traumatic stress event amounts to a spectacular breakdown of what is normally a very helpful mechanism in which emotional components are bundled with a memory. Threats of any kind—especially life-threatening ones—trigger the release of the fight-or-flight chemical neurotransmitter acetylcholine. Add more stress, and the brain’s neurons fire faster (i.e., they produce more chemicals) and more efficiently. In the fight-or-flight example, adrenaline not only helps you escape, but strengthens that emotional component to make sure you won’t forget. But extremely traumatic events can unleash a torrent of these stress hormones that sear the memory into the brain because the brain cannot release enough of certain other chemicals to help buffer or reduce the fight-or-flight response, even after the threat has passed. Too much of these stress hormones can permanently alter the structure of our brain, disrupt the neurochemical balance, and lead to PTSD problems.

Enter propanolol. The drug blunts the impact of stress hormones on the small, emotional control center in the middle of the brain, the amygdala. As a result, the brain is able to encode the traumatic memory as a factual event—just a horrible memory—rather than as the panic-inducing “freak-out” in consciousness that chronic sufferers of PTSD endure. According to a report in Stars and Stripes, people given the drug during preliminary tests were observed to have reduced physiological responses (such as heart rates) to certain memories. Dr. Orr is looking for Afghan and Iraq War veterans to participate in the research. But as of yet, we have had no word on any possible side effects with the use of the drug in this treatment modality.

Meanwhile, Israeli neurobiologist Dr. Hermona Soreq has developed a drug to block PTSD at the DNA level. Called Monarsen (after her nickname “Mona”), it stops the brain’s neurochemical imbalances by blocking production of one of the buffering compounds, a persistent, fast-moving version that appears only during stressful situations. Monarsen, in effect, handcuffs the DNA blueprint, or gene, from being actively turned into a biologically active protein. According to Dr. Soreq, “We try to block the bottom of the gene expression pyramid—the proteins, the stress hormones such as cortisol or adrenaline. Since you have one gene at the top of the pyramid controlling everything, why not aim there?” That precision, according to the researcher, enables the drug to be administered in smaller doses with fewer possible side effects.

In our opinion, both drug therapies raise serious bioethical and moral questions.

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