Military Operational Medicine Research Program US ARMY MEDICAL

Military Operational Medicine Research Program US ARMY MEDICAL RESEARCH AND MATERIEL COMMAND Science to Soldier PTSD Treatment Overview CAPT Doug Forcino Director, Military Operational Medicine Research Program LTC Dennis Mc. Gurk Deputy Director, Military Operational Medicine Research Program 24 June 2014 10/15/2021 11: 37 AM UNCLASSIFIED Slide 1 of 12

Military Operational Medicine Research Program US ARMY MEDICAL RESEARCH AND MATERIEL COMMAND Science to Soldier MISSION: Develop effective medical countermeasures against combat and operational stressors to maximize Warrior health, performance and fitness PSYCHOLOGICAL HEALTH AND RESILIENCE INJURY PREVENTION AND REDUCTION THREATS Posttraumatic Stress Disorder (PTSD) Suicide Behavior Combat and Operational Stress (Resilience as the Countermeasure) Family Transitions and Separations Alcohol/Other Drug Use Problems Violence within the Military Concussion (m. TBI) THREATS Acoustic Trauma Blast Overpressure Blunt Head and Body Traumatic Brain Injury Face, Eye and Spinal Cord Injury Musculoskeletal Injury Toxic Gas Inhalation Laser Eye Injury PHYSIOLOGICAL HEALTH THREATS Malnutrition Dehydration Sustained Fatiguing Work (Physical/Mental) Sleep Deficit & Circadian Desynchrony Distributed/Continuous Operations Dietary Supplements 10/15/2021 11: 37 AM UNCLASSIFIED ENVIRONMENTAL HEALTH AND PROTECTION THREATS Toxic Industrial Chemicals and Materials Dust and Air Pollution Altitude and Hypoxia Cold Stress AND Heat Stress Protective Equipment/Clothing Slide 2 of 12

Military Operational Medicine Research Program US ARMY MEDICAL RESEARCH AND MATERIEL COMMAND Science to Soldier MRMC Managed Psychological Health Research 10/15/2021 11: 37 AM UNCLASSIFIED Slide 3 of 12

Military Operational Medicine Research Program US ARMY MEDICAL RESEARCH AND MATERIEL COMMAND Science to Soldier PTSD Joint Integrated Research Approach FY 13 Foundational Science • Identification of normal and abnormal genomic, proteomic, and neurobiological mechanisms • Understand substrates of emotion, cognition, learning, memory, extinction, adaption/plasticity, and their role in disease onset and treatment response Epidemiology • Identify measures of underlying dysfunction, risk factors, and resilience • Development of general and PTSD- specific data bases for long term monitoring of health status, PTSD trajectories, and comorbidities PTSD disease processes , pathology and neurobiological mechanisms • Validated models (including pre-clinical) for PTSD, including risk and resilience factors, symptom onset, recovery and disorder trajectories interplay between PTSD and other comorbid disorders biology and environmental exposures in resilience and the disease process 10/15/2021 11: 37 AM • Understanding of • Understanding • Understand interplay of 37 (NIH) 12 (VA) 6 (Do. D) N = 55 Etiology 51 (NIH) 11 (VA) 8 (Do. D) N = 70 Prevention and Screening Treatment • New and repurposed psychotherapies, • Prevention: • New and repurposed medications, and • Education, training and psychotherapies, risk prevention/ medications, combination and resilience building combination treatments that are • Stigma & barriers treatments that are optimized and • Interventions optimized andbriefer • Treatment approaches • Treatment • Screening: address co-morbidities • PDHRA/Quality of Lifeapproaches address • Early screen/ • Methods for guiding co-morbidities assessment • MST • Assessment: • In-theater • Objective/Self personalized treatments • Methods for guiding personalized • Long-term recovery tracking treatments report/automated • Long-term technology tracking • Standardized/ Biomarkers • Treatment Optimization • Diagnostic advances 21 (NIH) 50 (VA) 24 (Do. D) N= 95 UNCLASSIFIED 7 (NIH) 5 (VA) 33 (Do. D) N = 45 recovery 30 (NIH) 42 (VA) 77 (Do. D) N = 149 Services Research • Access, quality and outcomes of care • Maintaining treatment fidelity in • Effective methods for disseminating best practice information and increasing adoption by providers • mental health service utilization factors • Modes of care delivery: telemedicine, internet, etc. • Continuity of care models 20 (NIH) 40 (VA) 26 (Do. D) N= 86 Slide 4 of 12

Military Operational Medicine Research Program US ARMY MEDICAL RESEARCH AND MATERIEL COMMAND Science to Soldier Optimal Treatment Solutions 2 -Week Intensive Psychotherapy Program Focused Mainly on Active Duty Service Members Service Member Diagnosed with PTSD Genomic Diagnosis 10/15/2021 11: 37 AM • Prolonged Exposure Therapy /Cognitive Processing Therapy • Virtual Reality Augmentation of Psychotherapy • Pharmacologic Approaches for: Ø Sleep/Nightmares Ø Depression/Anxiety Ø Cognitive Enhancers Initial Research Validation Timeline (24 -36 months) Longer-Term Tele-Mental Health Treatments Focused on National Guard, Reservists, Veterans and Some Active Duty Service Members with Capability for Accommodating Schedule, Geographical, Stigma, and Other Barriers to Care • 8 -12 Week Treatment Protocol • Same Drug Therapy Options As 2 -Week Program • Office, Tele, or In-Home Individual Therapy • Facility-Based Group Therapy Approaches Biomarker Research Timeline (5 -7 years) • Diagnostic Biomarker • Personalized Treatment • Treatment Efficacy/Progress Evaluations UNCLASSIFIED Anticipated 80 -90% Recovery Rate Neurological Indicators of Improvement Slide 5 of 12

Military Operational Medicine Research Program US ARMY MEDICAL RESEARCH AND MATERIEL COMMAND Science to Soldier PTSD Treatment Research Foci There a limited number of evidence-based Psychotherapeutic Approaches for PTSD but numerous adaptations of these successful treatments are currently being researched, to include: Prolonged Exposure Therapy Studies: Compressed, web-based, in home, tele-health, combined with virtual reality, with adjunctive cognitive enhancer, compressed treatment, couples treatment, group therapy modality Cognitive Behavioral Therapy Studies: In home, tele-health, web-based Cognitive Processing Therapy Studies: Variable length protocols, group therapy modality, cognitive only, expressive writing only 10/15/2021 11: 37 AM UNCLASSIFIED Slide 6 of 12

Military Operational Medicine Research Program US ARMY MEDICAL RESEARCH AND MATERIEL COMMAND Science to Soldier PTSD Treatment Research Foci Psycho-pharmacologic Research: Psychotherapy Augmentation: Hydrocortisone, Ketamine, Propranolol, D-cyclosterine Identification/evaluation of novel compounds and repurposing of FDA approved drugs for treating PTSD: URB 597, Ganaxolone, Prazosin, Trazodone, Tramadol, Nepicastet, Riluzole Biomarker Research: • Development of an objective, blood-based PTSD diagnostic • Identification of the biologic processes and neurological networks in the brain associated with PTSD for early diagnosis of the disorder, identification of pharmacologic treatment targets, and optimizing the selection of interventions at the individual patient level 10/15/2021 11: 37 AM UNCLASSIFIED Slide 7 of 12

Military Operational Medicine Research Program US ARMY MEDICAL RESEARCH AND MATERIEL COMMAND Science to Soldier PTSD Treatment Research: Complementary and Alternative Medicine Approaches Mind Body Manipulative & Body -based Movement Natural Products Whole Medical Systems Spiritual Practices Other Neuro-feedback (EEG & f. MRI) Acupuncture Exercise and Antioxidants Omega-3 Supplement Stepped Care Acceptance & Commitment Therapy Canine Assisted Therapy Mindfulness/MBSR Acupressure Yoga Transcendental Meditation, TMS+CPT Trauma Releasing Exercises Heart Rate Variability Training EMDR Cog Behavioral Social Rhythm Therapy Neuro-modulation Therapy Mind-Body Bridging Stellate Ganglion Block Writing Therapy Meditation Sleep Focused Mind/Body Rehabilitation Relaxation Response Training 10/15/2021 11: 37 AM UNCLASSIFIED Slide 8 of 12

Military Operational Medicine Research Program US ARMY MEDICAL RESEARCH AND MATERIEL COMMAND Science to Soldier PTSD Treatment Research Foci Consortium to Alleviate PTSD (CAP): • Do. D/VA collaboration initiated in 2013 • $45 Million Dollar research effort • Objective: To identify and evaluate novel PTSD treatments for Active Duty and Veteran populations 10/15/2021 11: 37 AM UNCLASSIFIED Slide 9 of 12

Military Operational Medicine Research Program US ARMY MEDICAL RESEARCH AND MATERIEL COMMAND Science to Soldier CAPT Doug Forcino Research Area Director Military Operational Medicine Research Program Fort Detrick, MD 21702 301. 619. 7304 carroll. d. forcino. mil@mail. mil LTC Dennis Mc. Gurk Deputy Director MOMRP 301 -619 -2088 dennis. mcgurk. mil@mail. mil Ron Hoover, Ph. D PTSD Portfolio Manager MOMRP/GDIT 301. 619. 6602 ronald. l. hoover. ctr@mail. mil https: //momrp. amedd. army. mil 10/15/2021 11: 37 AM UNCLASSIFIED Slide 10 of 12