How to Select Veterans With PTSD for Hyperbaric Oxygen Therapy
How do clinicians identify which veterans with combat-associated posttraumatic stress disorder are appropriate candidates for hyperbaric oxygen therapy?
Some veterans with chronic combat-associated posttraumatic stress disorder remain substantially impaired despite psychotherapy and medication treatment. This guide applies to clinicians considering referral for the specific medical-grade hyperbaric oxygen therapy protocol studied in treatment-refractory veterans without known traumatic brain injury.
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Confirm chronic combat-associated PTSD
Identify male veterans aged 25 to 60 years with combat-associated posttraumatic stress disorder lasting 5 or more years. In the trial, patients also had to continue meeting Clinician Administered PTSD Scale for DSM-5 diagnostic criteria for PTSD with a CAPS-5 score greater than 20.
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Verify inadequate response to standard treatment
Reserve consideration for patients with persistent residual debilitating PTSD symptoms after at least 1 course of trauma-focused psychotherapy and pharmacotherapy. The study population was specifically treatment refractory rather than treatment naive.
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Screen for exclusions that make the protocol inapplicable
Do not apply this protocol to patients with a history of traumatic brain injury or other known brain pathology, because those patients were excluded from the trial. Also exclude active malignancy, substance or alcohol misuse at baseline except prescribed cannabis, active manic or psychotic episodes, serious current suicidal ideation, severe or unstable physical disorders, major cognitive deficits at baseline, previous HBOT, chest, ear, or sinus pathologies incompatible with pressure changes, active smoking, inability to perform an awake brain MRI, or inability to read and sign informed consent.
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Complete baseline multidisciplinary assessment
Before referral or treatment initiation, perform the same baseline workup used in the study: medical history review, physical examination, clinical interview by 2 senior clinicians, psychiatric evaluation by a psychiatrist, questionnaires, and brain MRI. This establishes protocol fit and identifies exclusionary findings such as occult brain pathology or MRI contraindications.
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Set expectations for protocol intensity and follow-through
Explain that the evidence comes from a 60-session course delivered daily, 5 days per week, with completion generally limited to 14 weeks if sessions are missed. The article emphasizes that patients should be committed to the full course of at least 60 sessions because symptom worsening and memory surfacing may occur during treatment.
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Refer only to a medical-standard PTSD-capable hyperbaric center
Use centers with professional multidisciplinary medical teams and staff trained in PTSD-specific challenges. The authors specifically caution against extrapolating these results to nonmedical grade facilities, variations of monoplaces, home-use chambers, or clinics without professionals experienced in PTSD treatment.
Clinical Considerations
- The trial included only male veterans aged 25 to 60 years with combat-associated PTSD lasting at least 5 years, so generalizability outside that population is uncertain.
- Patients with known traumatic brain injury were excluded, so the protocol should not be assumed to apply to veterans with comorbid TBI.
- The study population had substantial symptom burden and had not improved with prior psychotherapy and pharmacotherapy, which may limit applicability to less refractory cases.
- Follow-up lasted 3 months in this trial, so the guide does not establish the disorder's longer-term course after treatment.
Bottom Line
Consider HBOT only for carefully screened, treatment-refractory veterans with chronic combat-associated posttraumatic stress disorder who match the trial population and can receive care in a medical-grade hyperbaric center with PTSD expertise.
