As long as medicine and war have existed, combat has provided an open lab for the study of human trauma—mental and physical—and its long-term effects. Researchers have spent decades searching for answers about what exactly deployment does to the human brain, especially for those who return with traumatic brain injuries and PTSD.
But when it comes to helpful treatment for veterans, many questions remain unanswered. The Translational Research Center for TBI and Stress Disorders, or TRACTS, is working to change that. Based at the VA Boston Health Care System, TRACTS aims to get a better understanding of what veterans who suffer from both a TBI and a co-occurring stress disorder like PTSD experience daily.
TRACTS co-directors Dr. Cate Fortier and Dr. William Milberg joined GBH’s All Things Considered host Arun Rath to share the program’s research. What follows is a lightly edited transcript of the conversation.
Arun Rath: Dr. Fortier, let’s start with you. We gave a very brief introduction to what TRACTS is working towards, but it sounds much deeper than that. Can you go into a bit more detail about how your work differs from past studies of head injuries?
Dr. Cate Fortier: We’ve been doing this work at the Boston VA since 2009, and we saw our first veteran participant in 2010. What makes TRACTS really unique is the comprehensive nature of the evaluation that we undertake with each and every veteran that comes through the door, so the study is really unprecedented in terms of the detail of analysis that we do.
Folks actually spend the entire day with us, they come in fasting for a blood draw and a physical exam first thing in the morning, and they’re there all day undergoing all kinds of assessments. Not only are we interested in military experience in deployment and combat and how that impacts veterans’ health, but we’re really interested in taking a more holistic approach to this.
We feel that you really need to understand who the veteran was before they enlisted in military service, how that military service impacted them, and who they are now, returning home and readjusting after military service. We take a holistic, person-centered approach to our research.
Rath: Tell us a bit more about that. What are the kinds of data that you’re getting that are missed by a less holistic approach?
Dr. William Milberg: In most of these studies—and there’s a lot of reasons for this—they focus on one particular diagnosis and treat everything else as secondary. In many of the studies and in literature around traumatic brain injury, assessments of other problems that may occur at the same time, like mental health or psychiatric issues, are done with very, very simple and brief assessments.
The same thing is true for studies that may focus on the psychiatric disorders; they may ask one question about the presence of a TBI and not much more. This is true for both civilian and military studies in both of these areas.
What we were able to do was study all of these problems with great detail and with great rigor, so everything from a detailed assessment of depression, post-traumatic stress disorder, anxiety, substance abuse, alcohol, and previous history in earlier life. Because it didn’t really exist in the form that we needed it, we created our own assessment of military traumatic brain injury.
We also draw blood and look at cardiometabolic problems—the same kinds of things that you might look at when you go for your physical checkup, but we also extract DNA. We look at genes and how those genes change. We look at various components of the blood molecules in the blood, and we do an extremely comprehensive MRI brain imaging. We get all of this information from the same people they brought in in the morning at 7:30. They don’t leave until 5 or 6 in the evening when we collect all this data for each individual.
Rath: And now, you’ve studied the impact in around a thousand post-9/11 vets, right?
Dr. Fortier: That’s true. We have a center here in Boston, which is our primary site, and we also have a site in Houston, Texas. Between those two sites, we’ve seen approximately a thousand veterans for a baseline evaluation that Dr. Milberg described, but we also follow them longitudinally, so importantly, we follow how their health, brains and psychological status change over time. We get to see how this all plays out over time.
Dr. Milberg: We brought back a very large number—almost 400 after two years and again for seven years. We’re beginning to get people in for their ten-year evaluation, and we have the very good fortune of having a very high rate of return to the study. Eventually, we will have an extremely detailed picture, not only of when we first enroll the participants but also of how they change with age and over time.
Rath: Do we have a sense yet of how this generation of post-9/11 vets differs from past generations?
Dr. Fortier: I think we have a lot of insight into how the post-9/11 veterans differ from previous generations of veterans. The primary factor is the high level of exposure to IEDs during combat.
The risk of traumatic brain injury concussion has increased tremendously in this generation of veterans, as you know well. They’ve also survived at much higher rates. Luckily, most of the injuries are mild TBIs or concussions rather than more moderate or severe injuries, but that’s the biggest difference between post-9/11 veterans and other generations.
The other thing that’s really critically important is that those brain injuries or concussions occur in a very traumatic, stressful environment. A lot of the work at TRACTS is focused on the idea that understanding the TBI is critical, but understanding the traumatic context in which it occurred and how that puts someone at greater risk for poor outcomes is essential to developing the best treatments.
Rath: It’s sobering to think about how we’ve gotten so much better in terms of emergency combat trauma medicine and saving so many lives, but that means so many more people surviving with these injuries.
Dr. Fortier: Right.
Dr. Milberg: I think one of the big puzzles that Congress and a lot of people within the Veterans Administration were concerned about when TRACTS really started was what happens to your central nervous system when you’re exposed to these large explosions, these IEDs. We really didn’t understand them. We had models of concussion, but this isn’t necessarily the same thing as a concussion.
Some of the studies that we’ve published show that there are separable effects from exposure to explosions from concussions themselves—that they’re really the brain and central nervous system reacting differently to the two kinds of effects on the brain.
Rath: And finally—this is a rather big question, and I understand that you’re still relatively early in this research—but in terms of the public policy impact, do you have a sense of what could be more effective treatments? And how can we get them out there to the people who need them?
Dr. Fortier: That’s a great question. That really is at the crux of our work, so we feel that because we’ve been studying this group of veterans for over a decade now—almost 15 years—we have come to understand some of their unique attributes that we discussed and that those do directly inform how to best develop and best test treatments.
What we think is the most important thing is that individual symptoms and individual diagnoses should not be treated in isolation because these veterans have had a unique experience and have been around a lot of blasts. They’ve been at high risk for head injury and for developing other health and mental health disorders. As a result, the traumatic brain injury often exacerbates that.
It’s most important to take a more transdiagnostic—or holistic, as we mentioned before—approach to treatment. We really relied on the veterans themselves to inform that. They frequently told us when they came back that they weren’t really ready for in-depth treatment of trauma.
In addition to that, they also felt that the health care that they received was very split and that they were being sent around from one clinic to another for their various problems. But no one was really understanding how those problems interacted and impacted their lives.
What we propose in TRACTS that is different is to treat veterans where they’re at and provide skills and other social support and factors that really applies across all different diagnostic categories. So basically, skills that could help any of us in our everyday lives, like problem-solving and emotional regulation, and then applying those skills regardless of exact clinical diagnosis to improve function.
The idea is to take a step back from singular diagnostic approaches, take a more transdiagnostic, holistic approach, and focus on that adjustment from military to civilian culture. I mean, it’s a tremendous change to leave the structure of the military and enter our very unstructured, chaotic civilian lives. We can provide some basic assistance on that cultural transition from military to civilian life to support our veterans better.
Dr. Milberg: The other part that’s interesting—and we really have not solved this problem—is that because this is a relatively young population, the average age of our veterans when we started this study was in their early 30s. Now, it’s gotten a little bit older, but they’re showing up with problems in many, many different medical areas.
They have a higher rate of issues that you might not see until later in life, related to metabolism and cardiovascular diseases, social and psychiatric issues, substance abuse issues that we’ve seen in alarming numbers and, in many cases, pain. These are adults who want to go back to their lives. They want to go back to their families. They want to go back to work. In many cases, they want to go back to school.
The way the healthcare system works is there’s going to be separate, individual appointments for every problem. In many cases, it’s very difficult for them to do this. They can’t get the treatment they need because it’s hard to fit into the way they’re trying to live their lives.
We have to figure out, given how expensive and difficult it is to deliver health care in general, how to accommodate this—where we know when someone comes in, there’s going to be many things behind the initial problem they’re reporting and they all need to be treated in the same person at the same time. Treatment needs to be integrated, and we really don’t have a good solution for doing that right now.
