The Veteran population has been known to deal with co-morbid chronic pain and PTSD. As a result, they use healthcare services at a higher rate than those Veterans with pain or PTSD alone which leads to an amplified burden on healthcare systems. tDCS is a painless brain stimulation treatment that uses direct electrical currents (at a constant, low-intensity level) to stimulate specific parts of the brain and help modulate neuronal activity. This study hypothesizes that our short-term therapy-focused treatment program coupled with tDCS administrations will aid in the reduction of chronic pain and PTSD symptoms. Secondly, the investigators intend to examine any relationships between BDNF reduction in reported pain and PTSD and related mental health symptoms. Subjects will be identified from the Emory Healthcare Veterans Program (EHVP-IOP) Veterans and Service members seeking psychiatric treatment for mental health issues including PTSD.
The Veteran population has been known to deal with co-morbid chronic pain and PTSD. As a result, they use healthcare services at a higher rate than those Veterans with pain or PTSD alone which leads to an amplified burden on healthcare systems. In the process of seeking relief and treatment in the healthcare systems, Veterans may use opioid medications to treat chronic pain which puts them at risk for harmful consequences. This study will be an open trial providing a non-opioid, self-administered, effective pain intervention as part of an effective mental health treatment program. A transcranial direct current stimulation (tDCS) device will be utilized in combination with a cognitive-behavioral therapy (CBT) focused intensive outpatient program (IOP). Additionally, blood and saliva will be collected during this study to perform brain derived neurotropic factor (BDNF) assays comparing outcomes from specific visits: pre-treatment (tx), mid-tx, and post-tx. The study will take place at the Brain Health Center (BHC) located at 12 Executive Park in the Veterans Program Department. Subjects will be identified from the Emory Healthcare Veterans Program (EHVP-IOP) Veterans and Service members seeking psychiatric treatment for mental health issues. Incoming patients will be screened for this study and consented prior to the start of their treatment program participation. An electronic consent will be conducted using the REDCap e-Consent framework. A partial waiver of consent is requested to be able to review identifiable information to determine a potential subject's eligibility status. This study hypothesizes that our short-term therapy-focused treatment program coupled with tDCS administrations will aid in the reduction of chronic pain . Secondly, we intend to examine reductions in PTSD and related mental health symptoms and any relationships between BDNF reduction in reported pain and PTSD and related mental health symptoms.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
TREATMENT
Masking
NONE
Enrollment
38
tDCS is a painless brain stimulation treatment that uses direct electrical currents (at a constant, low-intensity level) to stimulate specific parts of the brain and help modulate neuronal activity. Participants will receive a series of tDCS treatments during the Intensive Outpatient Program (IOP) coupled with blood and saliva collections. Participants will administer a stimulation session via the Soterix 1x1 tDCS mini-CT Stimulator, after being provided a single-use code to unlock the device by the research staff once proper contact quality is achieved. After the participant enters the unlock code, the screen on the device will show a timer that counts down the minutes until the end of the session. After 20 min, the device will turn off automatically and the study staff will instruct the participant to remove the headset and discard the sponges and to store safely all materials for the next session.
Emory Division of Psychiatry
Atlanta, Georgia, United States
Changes in Defense and Veterans Pain Rating Scale (DVPRS)
The DVPRS assesses chronic pain using a visual analogue scale of 0 to 10 including general level of pain, and assessment of interference with daily activities, mood, sleep, and stress. It is widely used in clinical care and research and has demonstrated reliability and validity within the military and Veteran population. This is a clinical measure collected per standard of care at intake. However, this measure will be collected for research purposes at additional timepoints, include each tDCS session, 1-10, and all follow-up visits.
Time frame: Intake, Days 1,3, 5 and 12 of intervention and at months 1, 3, 6, 9, and 12 of follow-up
Changes in PROMIS 3a pain intensity
The Patient-Reported Outcomes Measurement Information System (PROMIS) Pain 3a Intensity instrument assesses how much a person hurts via the following 3 questions rated on a 1 (no pain) to 5 (very severe) point scale: "In the past 7 days: How intense was your pain at its worst? How intense was your average pain? What is your level of pain right now?" Per the PROMIS measure website, "The Pain Intensity short form is universal rather than disease- specific. The first two items within the short form assess pain intensity over the past seven days while the last item asks patient to rate their pain intensity 'right now'." This is a research-specific measure collected for enrolled participants only and will take approximately 10 minutes to complete. Patient-reported outcome (PRO) measures use answers that patients provide to questions to produce numeric values which indicate patients' state of wellbeing or suffering as well as their ability or lack of ability to function.
Time frame: Day 1 and 12 of intervention and at months 1, 3, 6, 9, and 12 of follow-up
Changes in PROMIS 8a pain interference
The PROMIS Pain Interference instrument measures the self-reported consequences of pain on relevant aspects of a person's life and may include the extent to which pain hinders engagement with social, cognitive, emotional, physical, and recreational activities via 8 items. Pain Interference also incorporates items probing sleep and enjoyment in life, though the item bank only contains one sleep item. The Pain Interference short form is universal rather than disease-specific. The Pain Interference items utilize a 7-day recall period (items include the phrase "the past 7 days"). Items are rated on a 1 (not at all) to 5 (very much) point scale, such as the following questions: In the past 7 days, "How much did pain interfere with your day-to-day activities?" "How much did pain interfere with the things you usually do for fun?" etc.
Time frame: Day 1 and 12 of intervention and at months 1, 3, 6, 9, and 12 of follow-up
Changes in PTSD Checklist- PCL-5
The PCL-5 is a 20-item self-report measure of PTSD severity in the past month with 4 subscales: Intrusion symptoms (items 1- 5); Avoidance symptoms (items 6-7); negative cognitions and mood symptoms (items 8-14) and Hyperarousal symptoms (items 15-20). Each item ranges from 0 (not at all) to 4 (extremely). Cut points and psychometrics are pulled from the most recent studies on the new PCL-5. This is a clinical measure collected per standard of care.
Time frame: Days 1 through 12 of intervention and at months 1, 3, 6, 9, and 12 of follow-up
Changes in BDNF in saliva
Collection of saliva will be done pre tDCS, prior to the Therapy Session, and post-Therapy Session. Saliva will be assayed to examine Brain-derived neurotrophic factor (BDNF) and change in BDNF over the intervention session. The study team will collect these samples from all participants to test feasibility and reliability of saliva as a clinically useful BDNF source.
Time frame: Days 2, 5 and 11 of the intervention
Changes in BDNF in blood
Collection of blood will be done pre tDCS, prior to the Therapy Session, and post-Therapy Session. Blood will be assayed to examine Brain-derived neurotrophic factor (BDNF) and change in BDNF over the intervention session.
Time frame: Days 2, 5 and 11 of the intervention
PTSD Checklist - Stressor-Specific Version (PCL-5
The PCL-5 is a 20-item self-report measure of PTSD severity in the past month with 4 subscales: Intrusion symptoms (items 1- 5); Avoidance symptoms (items 6-7); negative cognitions and mood symptoms (items 8-14) and Hyperarousal symptoms (items 15-20). Each item ranges from 0 (not at all) to 4 (extremely). Cut points and psychometrics are pulled from the most recent studies on the new PCL-5.
Time frame: Intake, Days 1,3, 5 and 12 of intervention and at months 1, 3, 6, 9, and 12 of follow-up
Patient Health Questionnaire- 9 (PHQ-9)
The PHQ-9 is a 9 item, well-validated measure of depression and secondary outcome. The PHQ-9 assesses symptoms of major depression in the past two weeks from 0 (not at all) to 3 (nearly every day) and has excellent internal and test-retest reliability as well as construct and criterion validity (80). The PHQ-9 is effective in detecting treatment changes in depression in PC settings.
Time frame: Intake, Days 1,3, 5 and 12 of intervention
Change in Clinician Administered PTSD Scale-5 (CAPS5)
CAPS is an interview measure of PTSD severity that is collected for the purposes of the clinical treatment program (standard of care). Current PTSD will be assessed by assessors in relation to the trauma that is currently most upsetting. The CAPS-5 has excellent psychometrics and requires about 45 minutes to complete. 20% of CAPS will be rated by a second rater to ensure reliability.
Time frame: Intake, Day 1 of treatment and month 3 follow up
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