PTSD and Suicide: How SGB Can Reduce Symptoms
PTSD and Suicide Rates
Suicidal ideation is one of the most severe mental health issues that affects millions each year. In 2023, suicide is estimated to account for 1.4% of deaths worldwide, making it among one of the leading causes of premature death. September is the National Suicidal Prevention Month in the US. It is a time to commemorate the lives lost to suicide, acknowledge the millions who have experienced or been impacted by suicidal thoughts, and learn about resources and treatments that may help prevent suicide.
In a case series published this month, Stella's Chief Medical Officer, Dr. Eugene Lipov examined the Dual sympathetic Reset (DSR)'s effects on reducing suicidal ideation in a series of 254 PTSD patients, concluding that this advanced stellate ganglion block protocol may provide significant reduction in suicidal ideation as well as other symptoms of PTSD, including comorbid symptoms of depression and anxiety.
Why Is PTSD Linked to a Higher Risk of Suicide?
PTSD (Post-Traumatic Stress Disorder) is strongly linked to an increased risk of suicide due to several interconnected factors. The persistent re-experiencing of traumatic events, coupled with intense emotional and physical reactions, can lead to overwhelming feelings of hopelessness, guilt, and despair. Individuals with PTSD often struggle with severe anxiety, depression, and emotional numbness, which can make daily life feel unbearable. The disorder frequently disrupts sleep patterns, relationships, and overall functioning, leading to social isolation and a diminished sense of self-worth. Additionally, PTSD can alter brain chemistry and stress responses, potentially impairing decision-making abilities and emotional regulation. The combination of these psychological and physiological factors, along with potential substance abuse issues that may develop as coping mechanisms, creates a perfect storm that significantly increases suicide risk. Many PTSD sufferers also experience survivor's guilt or feel they are a burden to others, further contributing to suicidal ideation. The chronic nature of PTSD symptoms, if left untreated, can wear down an individual's resilience and hope for recovery, making suicide seem like an escape from their persistent psychological pain.
Background Information to Understand the Findings:
SGB Treatment and Its Effect on PTSD
The stellate ganglion block (SGB) is a procedure that involves the injection of a local anesthetic into the area surrounding the stellate ganglion, a bundle of sympathetic nerves that are located in the neck. SGB has been used for years as a pain-management treatment, but has emerged as an effective treatment for PTSD in recent years through research and clinical practice. A 2017 systematic review including 32 publications found that SGB has significant potential benefit in PTSD patients[1].
More recently, in 2020, a multisite, sham-controlled, randomized trial was conducted in 113 active-duty service members with PTSD symptoms. The findings revealed that two SGB treatments, two weeks apart, were effective in reducing PTSD total symptom severity over 8 weeks, with an adjusted mean symptom change two times greater in the SGB group compared to the sham group[2].
DSR, an adaptation of SGB by Dr. Eugene Lipov
The traditional SGB is an injection at the C6 level vertebra of the spine on the right side of stellate ganglion. After years of clinical practice, Dr. Lipov discovered that by adding an injection at the C4 level on the same side of the neck, it increased the success rate of treating PTSD symptoms from 70-75% to 81%. Moreover, although the traditional SGB has shown to be safe and effective in treating PTSD, it is not always sufficient. As a result, a left-sided SGB may be used as a rescue procedure, if the right-sided SGB does not work.
A retrospective analysis of 147 PTSD patients supported this finding by comparing C6 SGB versus dual SGB at C6 and C4, with ultrasound guidance, on the right and left sides. Not only did both single and two-level SGB show safety and efficacy, but the dual-level SGB showed greater improvement than the standard SGB in the treatment of PTSD[3]. Dr. Lipov hence renamed the adapted SGB protocol the "Dual Sympathetic Reset", or DSR.
A Single Case Report that Predates the Case Series
In 2013, SGB was reported to successfully treat a suicidal patient with PTSD4 [4], which led to the conducting a case series study on a larger scale.
Case Detail:
"The patient was a 35-year-old male with 8 years' time in service (Army) as a truck driver. He had two deployments to Iraq from 2004 to 2005 and 2007 to 2008. The patient also has a significant history of childhood physical abuse. During his first deployment to Iraq, the patient was involved in 4 separate convoys hit by improvised explosive devices and was involved in 8 firefights… He was admitted to the inpatient psychiatric ward 4 times between March 22, 2009, and November 15, 2010 for suicidality in the context of ETOH intoxication and PTSD symptoms.…The patient had been tried on the following psychotropics with little improvement during the course of his treatment: trazodone, Remeron, Celexa, Zoloft, risperidone, naltrexone (ETOH), disulfiram (ETOH), and lithium. During the patient's final say on the TAMC psychiatric inpatient ward, he scored 80 or 85 on his PCL-M. Two days after the procedure, he was discharged from the ward, his PCL-M having dropped to 18, and his suicidal ideation having completely resolved…"[4]
Methodology of the Study
254 patients who met criteria for being diagnosed for PTSD with suicidal ideation were evaluated for suicidal ideation via pre- and post-suicide risk assessments by using the Depressive Symptom Index - Suicidality Subscale (DSI-SS) as part of a pre- and post-treatment clinical interview. Further included were other psychiatric measures. Patients received DSRCSB as per clinic protocol.
Below is a list of all the psychometric testing scales that were measured in the study:
- DSI-SS: Depressive Symptom Index - Suicidality Subscale is a widely used test to detect and prevent suicidal ideation.
- PCL-5: The PTSD Checklist Version 5 is a 20-item self-reported questionnaire designed to assess PTSD symptomatology
- GAD-7: Generalized Anxiety Disorder-7 is a 7-item self-reported questionnaire designed for screening, diagnosis, and severity of anxiety
- PHQ-9: Patient Health Questionnaire-9 is a 9-item self-reported questionnaire designed to assess, screen and diagnose depression.
Key Results
Overall, the patients in the case series had an average DSI-SS reduction of 43.8%, PCL-5 reduction of 31.7%, GAD-7 reduction of 22.5%, and PHQ-9 reduction of 35.5%, following DSR SGB.
The Significance of the Case Series
The case series finds that DSR SGB is a safe and effective treatment that may reduce the risk of suicide in PTSD patients, based on the reduction of DSI-SS scores (43.8%). Additionally, the reduction of PCL-5, GAD-7 and PHQ-9 scores demonstrated that DSR SGB can effectively reduce PTSD symptoms as well as comorbid symptoms like anxiety and depression. These findings further prove that DSR SGB is a promising treatment for PTSD and may have life-changing effects on patients with severe symptoms.
To read the full case series, click this link.
Citations:
[1] Summers MR, Nevin RL. Stellate ganglion block in the treatment of post?traumatic stress disorder: A review of historical and recent literature. Pain Pract. 2017; 17: 546-553.
[2] Olmsted KLR, Bartoszek M, Mulvaney S, et al. Effect of stellate ganglion block treatment on posttraumatic stress disorder symptoms: a randomized clinical trial. JAMA Psychiatry. 2020; 77: 130-138.
[3] Mulvaney SW, Curtis KE, Ibrahim TS. Comparison C6 stellate ganglion versus C6 and C4 cervical sympathetic chain Anesth Pain Res, 2024 Volume 8 | Issue 3 | 4 of 4 © 2024 Eugene Lipov, et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License blocks for treatment of post-traumatic stress disorder (PTSD): analysis of 147 patients. J Neurol Disord Stroke. 2020; 7: 1163.
[4] Alino J, Kosatka D, McLean B, et al. Efficacy of stellate ganglion block in the treatment of anxiety symptoms from combat-related post-traumatic stress disorder: a case series. Mil Med. 2013; 178: 473-476.