Posttraumatic stress disorder, or PTSD, has been described as “complex somatic, cognitive, affective, and behavioral effects of psychological trauma.” PTSD symptoms are characterized by flashbacks, nightmares, anxiety, depression, avoidance of reminders of the original trauma, and sleep disturbance that lead to social and interpersonal dysfunction.
Triggers of PTSD include:
- War and warfare
- Working as a first-responder
- Childhood abuse
- Domestic abuse
- Serious accidents and traumatic events
- Physical assault
- Sexual assault
- Adverse childbirth experiences, including stillbirth
- The sudden death of a loved one
PTSD is not a rare occurrence and can affect anyone. 60% of men and 50% of women experience trauma at least once in their lives. Women are more likely to experience sexual abuse, whereas men experience more accidents, physical assaults, combat, or witness death or injury. 7-8% of Americans have PTSD, and 8 million adults have PTSD per year. PTSD is especially common in the military and first responders (police, firemen, EMT). Per the Veterans Affairs, 11-20% of those who served in Operations Enduring Freedom and Iraqi Freedom have PTSD. It is estimated that 30% of Vietnam War Veterans have had PTSD in their lifetime. 23% of women have reported sexual assault while in the military, and 55% of women and 38% of men have experienced sexual harassment while in the military. Over half of all veterans with military sexual trauma are men. In 2017, 6,769 sexual assaults were reported in the military. In 2012, it is estimated that more than 22,000 sexual assaults were initially not reported. A recent study about the military suggested that the depression and PTSD following sexual assault in the military is as severe as the depression and PTSD following childhood sexual abuse.
Higher rates of PTSD have been found in certain subgroups in the United States. A cross sectional study among Cambodian refugees (N=586, 99% faced near death due to starvation and 90% had a family member or friend murdered) showed that even after 2 decades of resettling in the United States, 62% of individuals met criteria for PTSD in the previous year. Indigenous Native Americans was another group that PTSD was common in (prevalence 14.2-16.1%).
PTSD in women is most commonly caused by sexual assault. A randomized study with sample size of 4008 women revealed that 69% of women were exposed to a traumatic event, and 36% witnessed homicide or victims of sexual or aggravated assault. The lifetime prevalence of PTSD in this sample was 12.1%.
There is high psychiatric comorbidity in individuals with PTSD. According to a national comorbidity survey of 5877 people aged 15-54 with PTSD, 16% had one coexisting psychiatric disorder, 17% had two psychiatric disorders, and 50% had three or more psychiatric disorders. A Canadian study showed that depression is two to four times more likely to be prevalent in those with PTSD.
Research has shown that PTSD has been associated with a wide range of health issues, including cardiovascular, respiratory, and type II diabetes in women. Alzheimer’s and dementia also have some association with PTSD. A cohort study of nearly 6500 adults involved in cleaning the debris following the 2001 World Trade Center attack showed a higher incidence of heart attacks and stroke in people with PTSD.
Treatment for PTSD can be difficult. Only one third of patients show recovery at one-year follow-up, and one third are still symptomatic a decade after enduring the initial trauma. Psychotherapy and medical management are important, but frequently, there are many treatment resistant cases that we see. Combination therapy of medications and psychotherapy have been shown to improve outcome more so than either treatment alone.
Ketamine, an anesthetic drug that has amnestic and analgesic properties, has been shown to be a viable treatment option for PTSD. Patients typically ask what are the risks/side effects of ketamine. Despite a subanesthetic dose being safe, there are potential side effects and risks of a ketamine infusion. An individual may feel intoxicated or have an “out of body” experience, have blurry vision, dizziness, drowsiness, nightmares, or jerky muscle movements. Nausea and vomiting are also common side effects, but the chances of these are minimized with the use of pre-infusion ondansetron (Zofran), which is a potent anti-emetic. We also use normal saline for hydration, which also minimizes the risk of post-procedural issues. We recommend adequate hydration up until 2 hours before a ketamine infusion. Patients with abnormal heart rhythms or low ejection fraction are not good candidates for ketamine as it can directly depress the myocardium. Individuals with brain masses/tumors are at higher risk for increased intracranial pressure and are therefore not appropriate candidates for ketamine. Individuals with a history of increased intraocular pressure, for example, from glaucoma are also not good candidates for ketamine. Individuals who are currently dependent or abusing substances including alcohol, opiates, or illicit drugs are not appropriate candidates for ketamine as well.
A randomized control trial from JAMA 2014, in which groups were divided into those receiving ketamine infusions versus a group receiving midazolam (a benzodiazepine typically used for anxiolysis before surgical cases), revealed that the ketamine group experienced significant and rapid reduction in PTSD symptom severity compared to the midazolam group. The ketamine group also showed improvement in comorbid depressive symptoms, as well as improvement overall clinically. Ketamine was well tolerated at the dose used in the study (0.5mg/kg) without dissociative symptoms.
The San Francisco Veterans Affairs Medical Center recently began a ketamine infusion program for veterans with PTSD that have failed first, second, and third lines of treatment. So far, the results have been “impressive.” There is talk of ketamine infusions being used more frequently at VA hospitals to improve outcomes.
It is important to know that despite numerous research studies (that we did not go into detail in this article), ketamine is not a replacement for medications or psychotherapy, or being under the care of a psychologist/psychiatrist/counselor. Ketamine infusions are simply adjunctive therapy, with the potential hope that less medication will be needed and individuals will have improved mood, energy, and functionality. It is important to let your primary care physician or behavioral health provider know if you are considering undergoing ketamine therapy for PTSD or depression. Most essential, if you or a loved one is struggling with PTSD, speak with your PCP or psychiatrist.