This is the final article in a three-part series on the epidemic of traumatic brain injury among those who served. Read part one here and part two here.
Brandon Alt's transition from combat Marine to college student was stormy -- the Afghanistan veteran fought headaches and pain, memory loss, a bad temper.
Then came the seizures, knocking him to the ground, paralyzing him for dark, lost stretches of time.
Like many post-9/11 vets, Alt believed his symptoms were related to post-traumatic stress. The infantry Marine had provided security for Army dustoff operations near Marjah, protecting medics and helping retrieve the gruesomely wounded, usually under heavy fire -- a harrowing experience that left its scars.
The seizures were a clue, however, that something other than PTSD might be going on in Alt's brain. While seizures can be caused by psychological trauma, they are more commonly linked to a physical problem such as chemical imbalance, tumor or stroke. In Alt's case, they were attributed to a traumatic brain injury, or TBI, caused by the numerous bumps and blast exposure he experienced while deployed.
Prior to his first grand mal seizure, the kind that causes muscle contractions and loss of consciousness, Alt never had been seen by a neurologist or received a brain scan. A glance at a post-seizure MRI was all it took for a physician to tell Alt he had a TBI.
Four years of trying nearly everything, from conventional medicine to non-traditional therapies, followed. Cannabidiol and medical marijuana. Anti-seizure medications. Antidepressants. Antipsychotics. But finally he found a treatment that let him sleep again, revived his energy levels, boosted his memory and stopped the seizures. He hasn't had one since 2018.
"I'd had multiple overdoses. I was suicidal all the time. I felt like there was no way that I was ever going to get better and that I was just screwed up," Alt said during an interview from his home in Denver. "It took a podcast for me to figure out what helped. How scary is that?"
For years, treatment for traumatic brain injury has proven elusive. First, military leadership was hesitant to confront the problem, then slow to act. But even when decisions were made to start more aggressively combating the burgeoning issue that was blighting so many veterans, medical science was far behind. Brain damage is irreversible, and most treatments and therapies seek to address symptoms and restore function by training the brain to operate differently.
As Generation Z appears hesitant to enlist in part because of the possibility of physical injury or psychological trauma, the Defense Department is moving to embrace a brain health approach it hopes will serve current members well now and prevent head injuries in future troops, unveiling a new strategy this year that could reshape how the agency handles TBI.
"We want you in for the long haul. We want you to have a highly functional and productive life when you leave the military," said Katherine Lee, a senior health policy analyst with DoD and a force behind the department's recently unveiled brain health strategy. "These monitoring programs, documentation of brain threats, understanding the late and long-term effects [of injury] and putting mitigation strategies in place is based on trying to have you perform at your highest levels."
And as the nearly 460,000 service members and veterans with TBI age, understanding the lasting effects, treating TBI and providing long-term care will be key to helping them live full lives, according to advocates and physicians.
But for affected service members and veterans, there are signs that effective treatment is beginning to come into view. Medical research is finally yielding results in the area of concussion detection as well as treatment.
One treatment that might be able to do more than manage symptoms -- hormone replacement therapy.
Alt learned about that treatment from a podcast featuring Dr. Mark Gordon, a family medicine physician at the University of Southern California, who has studied hormone replacement and reducing inflammation as treatments for TBI. TBI often impacts the pituitary gland, harming hormone production and causing a cascade of medical ailments for those afflicted.
Alt had his hormone levels checked and was put on human growth hormone as well as testosterone. Having tried so many different things across the years, he wasn't too optimistic.
Three weeks later, his mood and energy levels lifted. He slept better. And in eight weeks, he reached a "natural state of homeostasis."
"I felt foggy and depressed and anxiety-ridden and wasn't getting any sleep from the time I got out of the Marine Corps in 2012 until 2018 ... that's when I finally started hormone replacement therapy full time, and I'm not going to stop until I die," Alt said.
More than 400,000 brain injuries have been diagnosed in U.S. troops in the past 20 years, but many more service members and veterans likely were affected. According to Alex Balbir, director of independence service at the Wounded Warrior Project, slow response by the government to these injuries and a lack of medical knowledge about TBI produced a "very large group" of veterans with undiagnosed brain injuries from early in the Iraq and Afghanistan wars.
Desperate for relief and frustrated with conventional treatment options, service members and veterans have pursued -- and continue to seek -- therapies for their symptoms, often with a spaghetti-against-the-wall approach. Meditation and mindfulness, acupuncture, craniosacral massage, psychedelics, herbal remedies and supplements, hyperbaric oxygen therapy -- anything that sticks to improve cognition and decrease the frustration and pain they are experiencing.
And given that traumatic brain injury is a major risk factor for suicide, one would think the DoD and VA, which faced rising suicide rates for two decades and poured millions into programs to prevent suicides, would incorporate outreach and specialty services for troops and veterans with TBI into their suicide prevention strategies.
Frank Larkin, a retired Navy SEAL who now works as the chief operating officer at the suicide prevention organization Warrior Call, lost his son to suicide. Like his dad, Ryan Larkin was a Navy SEAL, with the younger Larkin serving as an explosives breacher in Iraq and Afghanistan. When he returned home after multiple deployments, his parents found him "void of all emotion," "wearing a mask," his smile all but gone, according to Frank Larkin.
Diagnosed with post-traumatic stress disorder, or PTSD, Ryan was prescribed dozens of medications to a point where he told his father, "I don't even feel like I'm in my own body."
But Ryan insisted doctors were missing something physically wrong with his brain. He asked his father to donate his body to scientific research if something ever happened to him. When Ryan died by suicide, physicians autopsied his brain at Walter Reed National Military Medical Center and found a microscopic tear, too small to be spotted in scans of a living person.
The finding began to provide some answers for Frank Larkin and gave him a new mission -- to push the government to better understand the connection between TBI and suicide and make sure troops would get help.
"I just don't want anybody else to have to walk this path, and one of the things that keeps me up at night is, I've learned that my son's story is not unique," Larkin said. "Invisible wounds are not invisible to those that suffer from them every day or to their families who are desperately trying to help them."
Suicide is a complex issue with many contributing elements, but a study published earlier this year found the suicide rate among veterans diagnosed with a mild TBI was three times higher than the general population. Those with moderate to severe brain injuries were five times more likely to die by suicide.
Yet a suicide prevention committee announced by Defense Secretary Lloyd Austin in May has no neuroscientists, Larkin noted. Suicide has traditionally been considered a psychiatric issue, so Larkin argued research pointing to a physical cause like TBI is seen as "disruptive" by mental health providers.
"Some of the practitioners, the clinicians, welcome this information, because it explains why this has been so hard for them," Larkin said. "But others see it as a threat to how they've been treating patients."
But for those suffering the effects of traumatic brain injury -- headaches, short attention spans, memory loss, irritability, mood swings, vision, hearing and/or balance issues -- help may begin with a simple conversation with a primary care physician.
And how doctors treat TBI is moving beyond rest and a gradual return or rehabilitation and prevention of further injury, to treatment.
While the research and treatments still remain "behind," they are "catching up," said Dr. Brent Masel, a neurology professor at the University of Texas in Galveston and the national medical director for the Brain Injury Association of America.
"Something good usually comes out of something bad, and the good that has come out of the wars and the NFL is the recognition that concussion -- which is just a euphemism for mild brain injury -- is a real deal. It's not something you just shake off and go back to play or back into battle, and there's a lot of people with significant issues," Masel said.
Hormone replacement, treatment focused on sleep and physical activity along with physical, occupational and vocational rehabilitation, cognitive therapy -- i.e., brain games and puzzles -- and psychological counseling are all showing signs of success.
Hormone replacement in particular looks promising for treating some patients with TBI, but Masel said that many physicians don't prescribe it because they aren't aware of it or find it too challenging to diagnose or costly to prescribe.
A blow to the brain often affects the pituitary gland, disrupting hormonal production in up to two-thirds of patients with TBI. This can affect testosterone and estrogen levels as well as human growth hormone, a basic lifelong human body need, according to Masel. Fix the neuroendocrine dysfunction and patients improve.
"People who are growth hormone deficient will frequently complain of excessive fatigue, brain fog, irritability, weight gain," Masel said. "When people have a true growth hormone deficiency and get it replaced, the phrase they say, they tell you, is, 'I got my life back.'"
Masel, who conducts research on hormone replacement therapy for TBI, said hormone deficiency can be a hassle to diagnose and is expensive, but he tests his patients for it and encourages service members and vets who are affected to pursue treatment.
"It's the real deal. [Hormone replacement therapy] is probably the biggest that's been proven to make a difference. Otherwise, medications? There's not much out there," Masel said.
Tim Murphy, a former Navy psychologist who runs Fortis Future, a nonprofit health program near Pittsburgh that provides comprehensive services to veterans, service members and first responders with physical and mental health conditions, said in his practice, clinicians see veterans with traumatic brain injury symptoms who have never been asked by their physicians whether they had a head injury.
Doctors in emergency rooms and elsewhere should be asking patients about their military and sports histories, Murphy said.
"Patient comes in, 'I can't find the answers, my memory, my attention, my concentration is gone - must be something wrong with me psychologically.' But wait a minute, you had this head injury, and since then, your memory has been a problem, your attention. You're not mentally broke; you have some physical reasons for this," Murphy said.
Fortis Future's approach to treatment includes medical treatments, therapy, physical fitness and outdoor recreation -- a holistic plan of attack that Murphy says is effective for many of his patients. But he also sees a mission to educate medical providers on military-specific injuries and health needs.
"There's a massive shortage of psychologists nationwide, period. But the number of psychologists who have experience with military issues is microscopic," said Murphy, who sat on the House Veterans Affairs Committee and was an advocate for mental health issues while serving in Congress from 2003 to 2017. "The VA could be doing more, letting other people help them and training [civilian] providers to ask the right questions."
Addressing sleep issues -- bad habits, disrupted sleep, nightmares or poor quality sleep common in those with head injuries -- also has been proven to show improvement in function and symptoms, he added, and physical activity is an absolute must. Paraphrasing other experts in the field, "You have to exercise your brain and exercise your body ... but of the two, exercising your body is the most important," Masel said.
Therapies help, too -- traditional approaches that include physical, occupational and speech therapy but also brain training, like BrainHQ -- a computer-based program that has shown to improve function and reaction time that is widely used throughout DoD and VA treatment facilities, including the National Intrepid Center of Excellence and its affiliate Intrepid Spirit Centers.
Non-traditional therapies, such as art therapy, music therapy and even horse therapy, also have been known to help veterans with TBI, according to Balbir.
Grooming a horse during equine therapy can help with any dexterity issues caused by the brain injuries, and having a regularly scheduled appointment can help with emotional issues by giving injured veterans something to look forward to, he said.
"Even the most hardened Marines I've seen really benefit from equine therapy," Balbir said. "It's something that we never would have thought of in the past."
Alt, in addition to finding relief through hormone replacement therapy, also has come to think that psychological therapy is helpful for dealing with his memories of war as well as the problems he experienced after leaving the Marine Corps and his diagnosis.
"I used to be one of those hard-headed Marines, like PTSD is a f****** joke. Just f****** deal with it. You can figure it out on your own," he said. "And then I began taking it seriously, being like, 'Hey, maybe someone with a little bit more education on this kind of stuff can help me understand my own emotions.'"
DoD, VA Develop Game Plans
To prevent head injuries in military personnel, protect troops' brains and treat those already injured, the Defense Department rolled out a strategy this year targeting overall brain health.
The Defense Department's initiative, years in the making, has been described by health officials as a "paradigm shift" in the services' approach to brain preservation. The goal is to consider the overall exposure to injury across a member's career, with an aim toward reduction, instead of simply reacting to individual traumatic incidents.
The hope is that the focus on the brain can also yield improved cognitive performance, a potential benefit that means the effort would fall under the broader permanent military goal of making the force more lethal.
The Warfighter Brain Health Initiative Strategy and Action Plan calls for an initial cognitive assessment using the Army's Automated Neuropsychological Assessment Metrics test, annual physical and mental assessments, to establish a baseline of each service member's cognitive function. That info would help doctors figure out if there's an issue after an exposure to a blast or if a service member shows symptoms of brain injury after protracted exposure in the field.
The plan also seeks broader education on the effects of blasts and training to mitigate them and consistent treatment for those who have been injured. Ostensibly it's a big push to move past the "walk it off" era of TBI treatment that dictated the first decade of how the services dealt with the injuries.
The strategy established a threshold level for blast exposure, as registered on gauges worn by special operations forces, to alert users of possible injury. And it calls for a program to track cognitive function among troops and treatment or training when problems arise.
"The plan is large ... it traverses the operational environment and the medical environment. It talks about threats to our brain cells that are in our training environments, our sports environments, on duty, etc.," Lee, the DoD policy analyst who helped draft the plan, said.
The Department of Veterans Affairs, which has helped manage the Defense and Veterans Brain Injury Center since its creation in 1992, maintains a vast brain bank to study the effects of injury on brain and spinal cords. It was a partner in the discovery of chronic traumatic encephalopathy, a disease associated with repeated concussion, found in professional athletes and some veterans.
Despite two decades of research and millions spent, however, tangible solutions from the government have vexed patients as well as providers.
"It would be very interesting [to] figure out how much money's been spent on traumatic brain injury and post traumatic stress research since this whole thing started and what do we have for it? For PTSD, nothing. For TBI, a device that is in some ERs and is nowhere near being fielded," said retired Army Vice Chief of Staff Gen. Peter Chiarelli, who, after retiring from the service, ran a nonprofit organization, One Mind, focused on brain health.
Headway also is being made in developing tools for detection and diagnosis of head injuries. In 2021, the Food and Drug Administration approved a rapid test that can measure blood plasma for biological markers that develop as a result of brain injury, a tool currently used in some hospitals to determine whether additional imaging is needed and treatment should begin. Other experimental or emerging treatments that hold promise include stem-cell-based therapies and microbiome treatments, medications and nanomedicine.
Still, more help is needed.
Dr. Robert Labutta, a former Army neurologist who later served as an adviser to the Defense and Veterans Brain Injury Center, said the wars in Iraq and Afghanistan have propelled advancements in the understanding, prevention and treatment of brain injuries "faster than we would have realized," but the research has not advanced nearly fast enough to help many of those affected.
"Do we wish we would be further along in the past 12 to 15 years? Yes, but we have come a long way," Labutta said.
Military.com reporter Amanda Miller contributed to this report.
Patricia Kime can be reached at Patricia.Kime@Military.com. Follow her on Twitter @patriciakime
Rebecca Kheel can be reached at Rebecca.Kheel@Military.com. Follow her on Twitter @reporterkheel
Related: They Said the Rise in Military Suicide Is a Mystery. Traumatic Brain Injury May Be an Answer.