Rhea Bell, ACP, BAppBus:ES, MBA candidate Lucia Antonucci, M.C., R. Psych
In Canada today, 1 in 4 paramedics (25%) will develop a mental health disorder, such as Post-Traumatic Stress Disorder (PTSD), Major Depressive Disorder (MDD), General Anxiety Disorder (GAD), Panic Disorder and/or a Substance Use Disorder due to nature of their occupational duties. Paramedics often experience repeated exposures to psychologically traumatic events, such as violence, human suffering and death. Furthermore, additional stressors may include unsafe and unhealthy workplace environments. With the onset of PTSD, paramedics are also at risk for high suicide rates, which are 5 times the current national average.  Paramedics and first responders across Canada are experiencing an emergent health crisis with few answers being suggested to help the people who help everyone else. This begs the question, with PTSD and accompanying mental health disorders on the rise in the paramedic profession, what types of treatment are out there to alleviate some of the suffering?
According to the American Psychiatric Association  PTSD is a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, or rape or who have been threatened with death, sexual violence or serious injury. PTSD as well as anxiety and depression can manifest differently in each individual. This may make it difficult for families, friends, and even the member themselves to identify the need for assessment and treatment of their symptoms.
Symptoms of PTSD can generally be grouped into four areas, these being intrusive memories, avoidance, negative changes in thinking and mood, and changes in physical and emotional reactions. Examples of these symptoms can include (but are not limited to):
- Recurrent, unwanted distressing memories of the traumatic event, or reliving it (flashbacks)
- Upsetting dreams or nightmares about the traumatic event/ trouble sleeping
- Severe emotional distress or physical reactions (nausea, vomiting, chest pain) to something that reminds you of the traumatic event
- Trying to avoid thinking or talking about the traumatic event
- Negative thoughts about yourself, other people or the world, hopelessness about the future
- Difficulty maintaining close relationships, feeling detached from family and friends
- Lack of interest in activities you once enjoyed
- Difficulty experiencing positive emotions, feeling emotionally numb
- Being easily startled or frightened, always being on guard for danger
- Irritability, angry outbursts or aggressive behavior
- Trouble concentrating, overwhelming guilt or shame
If your or someone you know is experiencing the above symptoms, please contact your physician for follow-up, further assessment and treatment. If it is an emergency crisis, please call 911.
PTSD Diagnostic Criteria
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there are specific criteria that will be assessed prior to any mental health diagnosis. The previously mentioned symptoms above will be investigated in greater detail and a diagnosis will then be determined based upon:
- Duration of the disturbance (symptoms) is more than 1 month.
- The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.
Moreover, PTSD is associated with high degrees of disability, making it difficult for an individual to maintain employment and social wellness. These individuals are shown to have poor social and family relationships, excessive absence from work and lower income, educational and occupational success.
When someone is diagnosed with an occupational stress injury, such as PTSD, there are several psychotherapy treatment modalities available to aid in symptom reduction and provide some relief to the member. Most of the currently used evidenced-based psychotherapies for PTSD are exposure-based therapies, such as Prolonged Exposure Therapy (PE), Eye-Movement Desensitization and Reprocessing (EMDR), and Cognitive-Behavioral Therapy (CBT). These modalities are directive and require the patient to relive the traumatic memory while learning a new cognitive framework.  These modalities should be carried out by trauma-informed treatment providers, preferably with experience in helping first responders. If the treatment provider is not comfortable and familiar with treating paramedics, it is recommended to find a different provider that has expertise with public service personnel (PSP).
Among the pharmacological interventions for PTSD are the use of selective-serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs) and tricyclic antidepressants (TCAs) . Despite numerous available antidepressant treatments, many patients do not respond to conventional treatments, which are known as “treatment-resistant’. Many of the above interventions also have significant side effects, which include agitation, indigestion, insomnia, loss of libido, drowsiness, weight gain, arrhythmias, even the potential for suicidal ideations. Unfortunately, it can be quite difficult to find the right dose and medication that reaches the therapeutic index for each individual patient. This begs the question, is there another modality that could be effective in treatment resistant PTSD? New research in the field of psychedelic-assisted therapy would say yes!
Psychedelics are increasingly being studied for the treatment of a range of psychiatric conditions. Psychedelics drugs refer to a category of compounds that can induce a wide range of psychological, cognitive, emotional and physical effects.  Psychoactive properties of psychedelic drugs within a psychotherapeutic treatment can assist by increasing the capacity for emotional and cognitive processing. Studies have shown that psychedelic treatment results in sustained improvements in PTSD and depression.[6, 8] For example, in a clinical trial by Feder, et al.,  that tested the efficacy and safety of Ketamine for the treatment of chronic PTSD, found changes in PTSD symptom severity, through ketamine-infusion treatment. More specifically, Ketamine-infusion was associated with significant and rapid reduction in PTSD symptoms and the reduction in comorbid depressive symptoms. They also noted an improvement in overall clinical presentation. .
Additional studies suggest that the effects of classical psychedelics, such as psilocybin have shown to decrease amygdala reactivity during emotional processing. [10,11] As patients with PTSD often show heightened amygdala reactivity, this may increase the ability to process traumatic memories. Other acute effects include increase in emotional empathy , increased insightfulness , reduced avoidance and increases in acceptance and connectedness  and emotional-breakthrough experiences , which has shown to be a key mediator in long-term psychological change in other mental disorders. The use of psychedelic compounds within a substance-assisted psychotherapy framework offers methods of integration with pharmacotherapies and psychotherapies. These substances may increase engagement with and the effectiveness of psychotherapeutic interventions due to a variety of psychological and neurobiological effects, as mentioned above.
With the ever-increasing numbers of PTSD diagnosis in the first responder community there is an outcry for help to better manage and even resolve the debilitating symptoms being experienced by the member. Exposure-based psychotherapies are unequivocally designated as the first-line intervention of PTSD, yet in many cases, PTSD remains a chronic illness with high rates of psychiatric and medical comorbidities. There continues to be an urgent need for novel interventions that can increase the efficacy for PTSD treatment. One of those unique and novel approaches to the treatment of PTSD is through the use of psychedelic drugs. Psychedelic-assisted psychotherapy should be considered and administered under the care of a multidisciplinary treatment team, which includes clinical oversight. Due to potential risks and side effects, it is not recommended to self-medicate with psychedelic drugs. If you or someone you may know is interested in participating or learning more about psychedelic-assisted therapy, a good place to start is the database of accredited therapists maintained by the Multidisciplinary Association for Psychedelic Studies. The association will help guide you towards practitioners and information in your surrounding area.
The Bottom Line
There is still so much to learn about psychedelic therapies for the use of treatment resistant PTSD in first responders. In saying that, the current and existing research is looking promising. Many organizations across the globe, including many here in Canada are working towards decriminalizing these substances so we can improve the lives of those affected by PTSD. Please stay tuned in to this important work, it might be just what we need to groove into a new age of mental health and support for us all!
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4) Mayo Clinic. (2022, February 24). Post-traumatic stress disorder (PTSD). Retrieved from Mayo Clinic Org: https://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/symptoms-causes/syc-20355967
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