Hyperbaric Oxygen Therapy for Post Traumatic Stress Disorder - a Pragmatic, Double Blinded Randomized Trial

Overview

Post-traumatic stress disorder (PTSD), affecting approximately 6% of the general population and up to one-third of individuals exposed to combat zones and disasters, is a significant contributor to morbidity and mortality among IDF personnel. Hyperbaric oxygen therapy (HBOT), in which patients breathe oxygen at a partial pressure higher than 1 atmosphere in a hyperbaric chamber, has been investigated in the context of treating a wide range of neuropsychiatric disorders, including PTSD and mild traumatic brain injury (mTBI). Four controlled studies conducted in patients with mTBI, about half of whom also suffered from PTSD, have yielded conflicting conclusions regarding the potential efficacy of hyperbaric therapy. A single study involving approximately 30 patients with PTSD without mTBI demonstrated significant clinical improvement; however, it was characterized by several methodological limitations-chief among them the absence of blinding or a placebo control. None of the studies conducted to date have reported long-term findings (beyond one year), included patients with a short duration of symptoms ("early PTSD"), or included female participants. The aim of the proposed study is to conduct a prospective, double-blind, controlled investigation of the biological effect of hyperbaric therapy in PTSD, continuously throughout the hyperbaric treatment course, at the end of treatment, and during a substantial follow-up period of two years after treatment completion. We intend to include adult participants who are capable of providing informed consent and who meet DSM-5 diagnostic criteria for PTSD. In order to maintain a pragmatic study with high external validity, exclusion criteria will be limited to those indicating risk (concrete suicidality, or a history of manic or psychotic disorder) or factors likely to impair treatment efficacy (incompatibility with hyperbaric chamber treatment, inability to complete the full treatment protocol, or pregnancy). Participants who miss a substantial number of treatments (five consecutively or one-third of the total treatments) will be withdrawn from the study. The primary outcome measure will be the CAPS-5 questionnaire. In addition, PTSD symptom questionnaires, surveys assessing cognitive, executive, affective functioning, and health-related quality of life will be administered. An exploratory outcome will focus on sleep quantity and quality and physiological monitoring using wearable devices, currently considered the most promising biomarker in the context of PTSD. Following enrollment and the provision of informed consent, balanced randomization will be performed with respect to covariates previously described as potential confounders (such as age, duration, and severity of symptoms, …). Participants will receive 60 hyperbaric treatments, five days per week, at either 2.0 atmospheres or 2.5 atmospheres. Both the participants and the evaluating clinical staff will be blinded to treatment allocation.

Interventions

• Procedure Hyperbaric Oxygen Therapy
  The treatment will be carried out in a HAUX STARMED multi-place pressure chamber (by HAUX LIFESUPPORT SYSTEMS, Cuxhaven, Germany) containing three sections (12+2+6 places, respectively). Ambulatory blood pressure measurement will be performed by an ambulatory blood pressure monitor (ABPM) model F11 (by SUNTECH). Measurement of sleep continuity and physiological monitoring will be performed using a combined pulse-oxymetry and accelerometry wearable device such as the Oura ring (Oulu. Finland).

Primary outcome measures

• Primary Outcome [Time frame: 12 weeks]

Secondary outcome measures (7)

• Secondary Outcome [Time frame: 12 weeks]
• Secondary Outcome [Time frame: 12 weeks]
• Secondary Outcome [Time frame: 12 weeks]
• Secondary Outcome [Time frame: 12 weeks]
• Secondary Outcome [Time frame: 12 weeks]
• Secondary Outcome [Time frame: 12 weeks]
• Secondary Outcome [Time frame: 12 weeks]

Eligibility criteria

Inclusion criteria

• Age over 18 years and up to 80 years
• Ability to understand the researcher's explanation and give informed consent.
• Any sex or gender (unlike previous studies, a significant effort will be made to include women in this study)
• A diagnosis of PTSD according to DSM-5 criteria with a severity that warrants discharge from military service.

Exclusion criteria

• The lack of ability to attend 120 daily (5 times/week) treatments at the INMI
• Current or past psychotic disorder
• Evidence of active suicidal ideation
• Evidence of past or present manic disorder
• Difficulty equalizing pressures, including pulmonary emphysema, significant sinusoidal obstruction, eustachian tube dysfunction, or an pneumothorax that is not drained.
• Known or suspected pregnancy.

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Randomized

Model

Parallel assignment

Masking

Quadruple blind

Primary purpose

Treatment

Study locations

Israel · 1 center

• Yarpa 112 — Ramat Gan

Publications

• 18. Doenyas-Barak K, Kutz I, Levi G, Lang E, Beberashvili I, Efrati S. Hyperbaric Oxygen Therapy for Veterans With Treatment-resistant PTSD: A Longitudinal Follow-up Study. Mil Med. 2023 Jul 22;188(7-8):e2227-33. 19. Doenyas-Barak K, Kutz I, Lang E, Levi G, Efrati S. Memory surfacing among veterans with PTSD receiving hyperbaric oxygen therapy. Undersea Hyperb Med. 2023;50(4):395-401. 20. Hoge CW,
• 12. Jones MW, Brett K, Han N, Wyatt HA. Hyperbaric Physics. StatPearls. Treasure Island (FL): StatPearls Publishing; 2023. 13. Wolf EG, Prye J, Michaelson R, Brower G, Profenna L, Boneta O. Hyperbaric side effects in a traumatic brain injury randomized clinical trial. Undersea Hyperb Med. 2012 Dec;39(6):1075-82. 14. Weaver LK, Wilson SH, Lindblad AS, Churchill S, Deru K, Price RC, et al. Hyperbari
• 6. Davis LL, Schein J, Cloutier M, Gagnon-Sanschagrin P, Maitland J, Urganus A, et al. The economic burden of posttraumatic stress disorder in the united states from a societal perspective. J Clin Psychiatry. 2022 Apr 25;83(3). 7. Mayer Y, Shiffman N, Bergmann E, Natoor M, Khazen S, Lurie I, et al. Mental Health Outcomes of Arab and Jewish Populations in Israel a Month after the Mass Trauma Events
• 1. Parr NJ, Anderson J, Veazie S. Evidence Brief: Hyperbaric Oxygen Therapy for Traumatic Brain Injury and/or Post-traumatic Stress Disorder. Washington (DC): Department of Veterans Affairs (US); 2021. 2. Andrews SR, Harch PG. Systematic review and dosage analysis: hyperbaric oxygen therapy efficacy in the treatment of posttraumatic stress disorder. Front Neurol. 2024 May 31;15:1360311. 3. Mozayen

Identifiers

NCT: NCT07473362 · 2436-2024

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗