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. 2024 Nov 6;55(3):385–396. doi: 10.3233/NRE-230236

Optimizing clinical outcomes with stellate ganglion block and trauma-informed care: A review article

Shauna Springer a,*, Paul Whitmer b, Morgan Steinlin c, Lindsey Gray d, Jason Blankfield e
Editors: David X Cifu, Sidney R Hinds
PMCID: PMC11613001  PMID: 38995805

Abstract

BACKGROUND:

For decades, thousands of active-duty service members have sought treatment for trauma exposure. Stellate ganglion block (SGB) is a fast-acting nerve block documented in medical literature for nearly a century that has shown promise as a potentially life-altering treatment for post-traumatic stress (PTS).

OBJECTIVE:

This review aims to answer the practical questions of those who support individuals suffering from trauma: (1) SGB’s safety profile (2) efficacy data (3) potential advantages and limitations, (4) a cross-cultural application example, (5) and the use of SGB in combination with talk therapy to optimize clinical outcomes.

METHODS:

The current body of literature, to include several large case series, meta-analyses, and a sufficiently powered randomized controlled trial, were reviewed, and presented to describe the history of SGB for emotional trauma symptoms and address the objectives of this review.

RESULTS:

Critical consideration is given to the safety and efficacy data on SGB and the evolution in safety-related technologies. Advantages such as decreased barriers to care, rapid onset, and decreased dropout and limitations such as treatment non-response, potential adverse effects, and misconceptions about the treatment are then described. Finally, the cross-cultural application of SGB is explored based on the deployment of SGB in Israel.

CONCLUSION:

SGB is associated with level 1B evidence and a reassuring safety profile. Evolving the model of care through the combined use of effective biological treatments like SGB with trauma informed talk therapy offers a hopeful path forward for supporting those who suffer from post-traumatic stress.

Keywords: Stellate ganglion block, SGB, post-traumatic stress disorder, PTSD, combat stress disorder, nerve block, military health, veterans health

1. Introduction

Recent decades have seen a surge of interest in biological interventions for psychological challenges. Within the military community, stellate ganglion block (SGB) has emerged as a promising new treatment option for addressing symptoms of post-traumatic stress. SGB involves injecting a widely used anesthetic medication into a bundle of nerves a few inches above the collarbone to temporarily block nerve conduction. The procedure takes between 3–5 hours in a clinic with the injection requiring about 15–20 minutes.

Historically, SGB has been performed by pain physicians to address complaints such as complex regional pain syndrome, shingles, and phantom limb pain. In more recent years, pioneering clinician-researchers have deployed SGB to reduce symptoms of hyper-arousal and avoidance in military and veteran patients suffering from post-traumatic stress (Alino et al., 2013; Alkire et al., 2015; Lipov et al., 2022; Lynch et al., 2016; McLean, 2015; Mulvaney et al., 2014; Rae-Olmsted et al., 2020).

Within the array of biological treatment options, SGB is unique for two reasons. First, in comparison to many other treatments, such as Transcranial Magnetic Stimulation (TMS) and Hyperbaric Oxygen Therapy (HBOT), SGB is delivered over one or two sessions, as opposed to multiple sessions over many months. Second, in comparison to other medicine-based interventions, such as Ketamine and other emerging psychedelic treatments, SGB does not involve a psychoactive component.

Once confined to experimental investigations, SGB has become relatively more mainstream within the military and veterans’ affairs health systems. Currently, SGB is provided at several military hospitals including Walter Reed National Military Medical Center, Tripler Army Medical Center, Womack Army Medical Center, Landstuhl Regional Medical Center, and at several VA facilities, at the discretion of local VA leadership. However, many who support the military and veteran community are unfamiliar with SGB and would benefit from greater awareness of this new treatment option.

This review aims to answer the practical questions of those who support individuals suffering from trauma. In addition to describing the history of SGB for emotional trauma symptoms, this article will address: (1) its safety profile (2) efficacy data (3) potential advantages and limitations, (4) cross-cultural application based on its deployment in Israel, (5) and the use of SGB in combination with talk therapy to optimize clinical outcomes.

2. History and evolution of SGB for trauma

As early as 1947, SGB showed promise for treating psychological challenges in three documented cases of depression (Karnosh & Gardner, 1947) but no follow up studies were conducted. Decades later, a 1990 case study by Lebovits and colleagues (Lebovits, Yarmush & Lefkowitz, 1990) documented the treatment of a 15-year-old female gunshot wound survivor. A series of 13 SGB injections and sessions with a psychologist resulted in PTSD symptoms that “improved remarkably.”

The research on SGB gained momentum following a case study of an armed robbery survivor published by Lipov in 2008 (Lipov et al., 2008). The focus of SGB now began to shift towards alleviation of post-traumatic stress symptoms, with a focus on the US military personnel returning from Iraq and Afghanistan afflicted with the “signature wounds” of war - PTSD and TBI. In 2014, Mulvaney and colleagues treated trauma symptoms in 166 active duty servicemembers with very promising results (Mulvaney et al., 2014) and Navaie and colleagues published the first systematic review of SGB for trauma, showing positive outcome convergence across multiple published case study reports.

Meanwhile, the Long Beach VA became a hub for innovation within the Department of Veterans Affairs. In 2015, VA researchers presented the first neuroimaging case study showing changes in the amygdala following delivery of SGB for PTSD (Alkire et al., 2015). During the same year, Dr. Brian McLean, an active-duty Army physician at Tripler Army Medical Center in Hawaii, published the finding that within a sample of 250 active duty servicemembers, 100% were satisfied with the procedure and 100% would recommend SGB to a friend with similar symptoms (McLean, 2015).

While excitement about SGB was steadily growing, the initial RCT of SGB gave pause to some (Hanling et al., 2016). Based on a total of 42 participants, results showed similar improvement in both the active treatment and placebo groups. Since its publication, this study has been criticized for its small size, sub-optimal dose of anesthetic, sampling and methodological limitations. For instance, Summers and Nevins point out that “the use of an inappropriate placebo, and a randomization ratio that over-weighted the placebo group” are additional “possible reasons for a lack of positive results in this small trial” (Summers & Nevin, 2017).

The RCT that brought “level 1B” evidence to SGB for trauma was published in JAMA Psychiatry in 2020. In a sample of 113 individuals (100 males, 13 females) treated at three military hospitals, this study showed that SGB is effective in reducing PTSD symptom severity, based on CAPS-5 outcomes.

Incomplete information about SGB has likely hindered its acceptance. For example, a search of “SGB” and “Department of Veterans Affairs” yields an outdated evidence brief entitled “Effectiveness of Stellate Ganglion Block for Treatment of PTSD” (VA/HSR& D Evidence Synthesis Program, accessed online September 21, 2023). Published in 2017, this brief fails to reflect the 2020 Randomized Controlled Trial that established level 1B evidence for SGB as a treatment for trauma symptoms. As a second example, UptoDate, a searchable database of treatments, excludes virtually the entire SGB literature, including multiple large-sample case studies and outcomes studies, weighing the inadequately powered 2016 trial of 42 participants equally to the adequately powered 2020 RCT. Any clinician hoping to understand the state of innovation for SGB would be informed that “randomized trials have shown mixed results (Stein et al., 2023).”

The process and application of SGB is evolving at a rapid pace. A conventional SGB procedure involves a single injection made on the right side of the neck, along the cervical nerve chain, near the C6 level. Clinician-researchers focused on the use of SGB for trauma symptoms have evolved the conventional SGB protocol to include a second injection made at the superior cervical ganglion (C3 level) (Lipov et al., 2022) and injections made on the left side at least 24 hours after right side intervention (Mulvaney et al., 2022). This dual-level SGB procedure has been termed by some as “dual sympathetic reset” SGB (or “DSR SGB”) or as “dual sympathetic block” (DSB) to differentiate it from the conventional single-level SGB.

At the time of this review, there are two landmark studies underway. The Department of Veterans Affairs is conducting a four-year, multi-site, two-phase, three-arm, triple-blind, waitlist and placebo controlled prospective randomized controlled trial (RCT) of SGB for PTSD (Alkire, 2022). In addition, NYU Langone Health (Glimcher, NCT05534126) is currently conducting a randomized, double blind, placebo-controlled study using pre- and post-SGB fMRI scans to examine the effects of SGB on neural activity and symptoms in participants with post-traumatic stress disorder.

3. Safety of SGB

SGB uses a non-psychoactive medication that is injected at a specific site. The terminal half-life of ropivacaine is 2.3±0.8 hours and the terminal half-life of bupivacaine is 4.6±2.6 hours (P = 0.04) (Kopacz et al., 1994). Thus, like the Novocain used in countless dental practices, it is washed out of the body quickly. It does not impact whole-body health systems in the same way as orally ingested medications - indeed, it is considered a prime example of a “precision-medicine” intervention (Lynch, 2020). In comparison, SSRIs and other orally ingested medications impact the entire body system, including the liver, where they are processed. Further, current front-line medications for trauma symptoms may bring several troubling side effects, including sexual dysfunction, nausea, headaches, diarrhea, sleep difficulties, and weight gain or loss (Ferguson, 2001). A properly placed SGB injection does not carry any documented side effects, based on nearly a century of research and practice.

A review of the specific safety profile of SGB requires some thoughtful consideration of a widespread misunderstanding about the concepts of “FDA approval” and “off-label use.” The medication used in SGB - typically Ropivicaine or Bupivicaine - is a commonly used anesthetic that has been approved by the FDA for use with a variety of pain conditions. It is used every day for countless women to provide epidurals during childbirth.

The application of medications that are “FDA approved” for one indication for a variety of other conditions is commonplace in medical practice, and especially so within psychiatric treatment settings. A study within an outpatient psychiatry department showed that of 980 drugs, 387 (39.5%) drugs were prescribed in off-label manner and within a sample group of 250 patients, 198 (79.2%) of patients received at least one off-label drug (Kharadi et al., 2015). So, it is important to dis-entangle “not FDA approved” for a given clinical indication vs. “untested and unsafe.”

SGB has been the subject of research for approximately 100 years and its safety properties are well documented. In one study that was specifically focused on safety and potential side effects, over 45,000 participants received SGB (Wulf & Maier, 1992). This study was conducted before the use of guided imagery techniques, and the incidence of severe side effects, even when SGB was performed blindly, was 1.7 per thousand participants. Of the severe side effects, most were reversible with anticonvulsant medications and intubation procedures.

Improper placement of the injection, specifically inadvertent subarachnoid or intra-arterial injection, though extremely rare, can result in seizures or pneumothorax. However, just like the epidurals placed routinely in women during childbirth, a properly placed injection carries no known negative long-term side effects. The bottom line: the danger of serious side effects does not lie in the medication but in the placement of the injection. The risk of adverse events due to SGB injections is most dependent upon the administering physician’s competency and skill in targeting the correct anatomic location. Therefore, careful screening, vetting, and training of administering physicians is paramount for ensuring patient safety.

The use of imagery guidance has been a critical evolution in safety protocols as this provides the best picture of the anatomy and subdermal vasculature and does not expose patients to radiation (Aleanakian et al., 2020; Ghai et al., 2016). A 2015 study by Dr. Brian McLean, an active-duty military physician who treated 250 soldiers with SGB showed no long-term negative side effects (McLean, 2015). Similarly, in a recent multi-site, randomized controlled trial, published in JAMA Psychiatry, researchers describe SGB as a “safe, routine procedure” (Rae-Olmsted et al., 2020).

In a clinical demonstration of conventional single-injection SGB conducted by VA Long Beach physicians, more than 185 treatments were given with no harmful effects (VHA National Center for Healthcare Advancement and Partnerships). And in the largest SGB study to date, within a sample of 327 patients treated at Stella, there were no significant adverse events that required admission to a hospital. One case of post-SGB hypertension resolved after 3 hours, and other minor after-effects such as temporary hoarseness, and difficulty swallowing spontaneously resolved within 12 hours of the injection (Lipov et al., 2022).

4. Efficacy of SGB

Across the full range of existing case reports and studies, the efficacy of SGB for symptoms of trauma ranges from 70–83% of treated patients seeing clinically significant positive outcomes (Mulvaney et al., 2014; Navaie et al., 2014; Lipov et al., 2022). In a recent review from Kerzner and colleagues, across ten studies representing just over 200 patients collectively, the mean percentage of improvement of PTSD symptoms ranged between 30–70% improvement (Kerzner et al., 2021) as shown in Table 1.

Table 1.

Efficacy of 1 round of SGB for PTSD symptoms across 10 publications

graphic file with name nre-55-nre230236-g001.jpg
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Table reproduced with permission, originally sourced from: Kerzner J, Liu H, Demchenko I, Sussman D, Wijeysundera DN, Kennedy SH, Ladha KS, Bhat V. Stellate Ganglion Block for Psychiatric Disorders: A Systematic Review of the Clinical Research Landscape. Chronic Stress (Thousand Oaks). 2021 Dec 8;5:24705470211055176. doi: 10.1177/24705470211055176. PMID: 34901677; PMCID: PMC8664306.

And in the largest retrospective study to date, published a year after Kerzner and colleagues’ review, within a sample of 327 patients treated from 2016–2020, over 80% of patients experienced a 10-point drop in the PCL-4, the threshold for a clinically meaningful response as defined by the National Center for PTSD. Moreover, the average decrease in the PCL score for men and women was 28.59 and 29.2 respectively, a magnitude of change that is nearly three times higher than the established “clinically significant outcome” according to the National Center for PTSD (Lipov et al., 2022). These results converge with a similar Australian multi-center study of 99 civilian patients, conducted in four Australian cities (Sydney, Brisbane, Perth and Melbourne). In this study, the average decrease in PCL scores was 23.69 for males (n = 49) and 21.64 for females (n = 50). Convergent with the United States study, statistically significant improvements in symptoms were observed regardless of the type of trauma (Verrills et al., 2023).

Other recent research has shown that SGB reduces anxiety (as measured by the GAD-7) by half in a retrospective study of 285 patients (Lynch et al., 2023) and may be helpful in alleviating PTSD symptoms in patients following cardiac arrest (Agarwal, NCT04582396).

5. Advantages of SGB

There are several potential advantages associated with using SGB as a treatment for psychological challenges as well as some potential limitations.

5.1. Decreased barriers to care

Conventional trauma-focused treatments “do not work for all patients, and many may refuse them” (Alkire, 2022). Stigma associated with mental health challenges and seeking treatment is a substantial barrier to care. Many service members and veterans are reluctant to take medications and pursue trauma-focused, exposure-based talk therapy, given a cultural mindset that can be at odds with, or overtly distrustful of, mainstream mental health interventions (Cheney et al., 2018). The concept of post-traumatic stress as a “disorder” vs. an “injury” is meaningfully different. Whereas a “disorder” is often seen as a permanent label for a condition that must be managed over time, an “injury” may not carry a stigma and suggests the possibility of healing. A recent survey of 1025 individuals, representing both patients and clinic or website visitors, explored the impact of stigma around a PTSD diagnosis. Gender was distributed equally (50.4% were female and 49.6% were male) and within each gender, approximately half had been diagnosed with PTSD (51.6% of females and 48.4% of male respondents). Over two-thirds of respondents agreed that a name change from PTSD (“Post Traumatic Stress Disorder”) to PTSI (“Post Traumatic Stress Injury”) would reduce the stigma associated with the term PTSD. Over half agreed that making this change would increase their hope of finding a solution and their likelihood of seeking care (Lipov, 2023). As such, offering SGB for trauma may provide stigma-free access to care for many who suffer.

5.2. Onset of relief

An SGB procedure often brings immediate relief of many of the acute symptoms of trauma, with consistent efficacy rates higher than 70% across multiple studies (Kerzner et al., 2021). Comparatively, current first line interventions like trauma-focused talk therapy and medication require several weeks or even months to take effect (Alino et al., 2013). Commonly prescribed medications often require 4–8 weeks to take effect (Institute of Medicine, 2008), leaving individuals in continued distress or at higher risk for suicide for weeks or months. According to a study of 10,000 therapy cases, it often requires about six months of weekly talk therapy before 50% of patients show meaningful positive change, and upwards of a full year of weekly talk therapy for 75% of patients to achieve a positive outcome (Lambert et al., 2001).

Due to its rapid onset of relief, SGB may also help overcome long wait times for treatment. The United States has a shortage of mental health providers, including in many rural areas (Government Accountability Office, 2022). As a result, there are systems of care that are chronically understaffed and incapable of meeting the needs of patients in their respective geographic areas. The unfortunate consequence is long wait times for treatment or no treatment at all. Waiting can be fatal (Pizer & Prentice, 2011).

5.3. Decreased dropout from care

Exposure based talk therapies like Prolonged Exposure and Cognitive Processing Therapy have long been touted as “evidence-based,” “gold standard” treatments for military servicemembers and veterans. Yet both treatments are hindered by staggeringly high dropout rates.

In a large-scale randomized controlled trial of cognitive behavioral therapy for 255 female veterans diagnosed with PTSD (Schnurr et al., 2007), nearly 40% dropped out before completing treatment, and of those who completed treatment, about 60% still met criteria for a diagnosis of PTSD. Watts and colleagues explored retention of 1924 patients in exposure-based talk therapy programs in the Department of Veterans Affairs. Based on an “adequate dose” being completion of at least 8 out of 12 sessions in a full treatment protocol, just 2% received an adequate dose (Watts et al., 2014). In a second large sample of 796 veteran patients, only 7.9% (n = 59 patients) completed either CPT or PE (Mott et al., 2014). As Najavits (2015) summarizes, “[Prolonged Exposure and Cognitive Processing Therapy] are defined as gold-standard therapies for PTSD and showed positive outcomes and reasonable retention of patients in randomized controlled trials (RCTs). But an emerging picture based on real-world practice indicates substantial dropout”.

Medications have similar limitations. According to Alino and colleagues, SSRI medications, currently used as first line treatments for post-traumatic stress symptoms, have a high discontinuation rate, ranging from 30–50% (Institute of Medicine, 2008). Additionally, SSRIs and other oral medications are often imprecise and can lead to unwanted side effects and other adverse effects, including sexual dysfunction, nausea, headaches, diarrhea, sleep difficulties, and weight gain or loss (Ferguson, 2001). The emergence of these collateral problems can lead patients to discontinue taking these medications.

In comparison, the dropout rates for SGB are negligible because in many cases, patients benefit from a single treatment session. If a patient shows up for his or her first session, he or she gets treated, and in most cases, experiences substantial symptom relief. Removing small-scale studies, 1- or 2-person case analyses, and retrospective analyses from consideration, the 2020 randomized controlled trial of SGB for 113 individuals was associated with a completion rate of 95.6% (Rae-Olmsted et al., 2020) and two large nonrandomized open-label trials of SGB had completion rates of 86.7% (Lynch et al., 2016) and 90.9% (Mulvaney et al., 2022) respectively.

5.4. Trauma-informed care

Finally, one of the most important advantages of SGB is its ability to deliver relief in a more compassionate way, when paired with trauma-informed talk therapy. While exposure therapies do not intend to re-traumatize patients, they may have this effect, nonetheless. For example, Rauch and colleagues describe a case example of “over-engagement” in a rape survivor who “began to feel as if she was being raped” during an exposure therapy session. Following the session, the patient reported “feeling like a failure because she had lost control during the exposure” (Rauch, 2006).

This is not an isolated case. For many patients, losing control in their bodies is not a matter of “over-engagement” but rather re-traumatization. SGB presents an alternative pathway to healing. A successful SGB procedure can restore calm and control in the body, ensuring that any paired trauma therapy occurs in the context of “physiological safety.” Related to this comparison, there is a meaningful difference between “trauma-focused therapy” and “trauma-informed therapy,” two terms that are often used interchangeably. A “trauma-focused therapist” is a therapist who focuses on resolving trauma symptoms as a primary driver of distress. However, a “trauma-informed therapist” is an individual that is committed to relieving trauma in a way that does not create further trauma. SGB presents trauma-informed therapists with a viable approach that can deliver healing in a more compassionate manner.

5.5. Cost savings

Another plausible advantage of SGB is a relatively lower cost associated with deploying SGB as an alternative to conventional treatments. SGB is delivered over an average span of one or two clinical days in comparison to lengthy treatments that may cost more over time. The efficiency with which SGB may eliminate the most distressing symptoms of trauma (Lipov et al., 2022; Mulvaney et al., 2014) and anxiety (Lynch, 2023) may reduce collective mental health risk at a significantly reduced cost. SGB might be considered as a low-risk, cost-effective alternative to relatively higher risk procedures such as ECT (electroconvulsive therapy) that are advocated for by some within various systems of care, such as the criminal justice system (Surya et al., 2015).

6. Limitations of SGB

6.1. Potential for non-response

Any given intervention has limitations and there is no single treatment that works for every individual. There are between 10–20% of patients for whom SGB does not seem to be effective.

As SGB providers continue to refine their methods, this percentage will improve but there will always be some non-responders. The fact that SGB can result in such dramatic, efficient positive outcomes for most people can be a limitation when positive effects are not achieved. Indeed, many patients have been referred to SGB as a “last resort” intervention when their hold on hope is tenuous at best.

The use of SGB as a “last resort” approach may warrant a critical analysis. Currently, SGB is typically deployed as a treatment for “refractory” post-traumatic stress symptoms (Kirkpatrick et al., 2023; Lipov et al., 2013). Within the Department of Veterans Affairs Healthcare System, the prevailing practice is the use of SGB “as an add-on therapy for individuals with PTSD who have not fully responded to conventional treatments.” (Department of Veterans Affairs, 2023). For patients who have not found success with a string of conventional treatments, there is always the possibility that if SGB does not work, patients may struggle with even greater feelings of hopelessness. This limitation is not specific to SGB, but rather to any treatment - whether it is TMS, Ketamine infusions, or any other approach that is used for “complex” or “refractory” cases. This evidence suggests the use of SGB as a first-line intervention may improve its efficacy.

6.2. Potential for adverse effects

To a qualified, well-trained provider, SGB is a minimally invasive procedure. Many pain physicians offer conventional SGB as a routine part of their practice. However, delivery of the dual-level sympathetic reset, where an injection is made at both the C3 and C6 levels, requires additional training and a higher level of physician skill. Ensuring that physicians are adept at using the most advanced imagery guided tools, which is currently ultrasound, rather than fluoroscopy, and confirming that treating physicians are skilled in visualizing the anatomy and placing the medications in the right place, is vital.

6.3. Potential misconception of SGB as a “miracle cure”

A third limitation is that without clear messaging, SGB may be seen as a “miracle cure.” This mentality stems from the rapid onset of SGB and its generally high rates of efficacy. When individuals who have been locked into a continual state of fight or flight become suddenly calm again within their own bodies, they may perceive that they have just received a “cure.” While a burst of hope can propel some individuals into a meaningful and effective course of trauma-informed therapy, others may forgo further interventions. Addressing the underlying thinking and behavior, and more complex factors like the identity changes that are often associated with trauma, are a critical part of recovery.

To address this limitation, education about SGB must be clear on the following points:

  • •

    Healing from trauma is possible, but it requires active engagement. A passive approach of receiving SGB for a biological reset may not bring long-lasting relief.

  • •

    This is because trauma not only causes physiological changes, but also changes in how we think, behave, and respond in our relationships.

  • •

    Talk therapy aimed at processing the experience and meaning of a trauma is an important part of achieving long-term recovery.

  • •

    SGB is not a standalone treatment but rather an intervention that may enhance and accelerate the positive gains of trauma-informed talk therapy.

Finally, it is best if SGB is provided in the context of deep and respectful collaboration across interdisciplinary lines. In other words, the physicians who provide the SGB treatment and the behavioral health clinicians who provide co-therapy must see each other as two parts of a powerful combinatory care approach. Clinicians must be willing to refer to physicians so that their patients can begin therapy in a physiologically supported way and physicians must understand that therapeutic interventions are equally critical for patients’ healing.

7. Cross-cultural considerations: Deploying SGB for trauma in Israel

This next section of the paper is heavily based on clinical perceptions and experiences of a provider and Israeli Defense Forces (IDF) servicemember in Israel, who shares emerging, pre-published data around the use of SGB for patients in Israel.

The application of SGB as an intervention for trauma is gaining substantial interest in Israel. Every single person in Israel is either directly or indirectly connected to the subject of post-traumatic stress due to the country’s mandatory conscription. For everyday citizens, life is lived against the backdrop of trauma given the ever-present looming possibility of war and the daily triggers of continual, violent conflict within Israel and its neighboring countries. Further, Israel is home to a substantial percentage of first and second-generation Holocaust survivors, many of whom have never received treatment for their post-traumatic stress symptoms. Mainstream treatments cannot be sufficiently scaled to address the trauma burden within Israel’s population, resulting in the need for additional innovative treatment options.

Initially, the introduction of SGB met with skepticism, as it was unclear if US data on the efficacy of SGB for trauma would translate into Israel’s complex trauma ecosystem. Stella Israel performed its first successful DSR SGB treatment in May 2022. Each patient in Stella’s protocol receives a dual-level (DSR) right-side injection and a left side injection within two weeks. Thus far, there have been no medical complications. In Israel, Stella has only treated people who have received a formal diagnosis of PTSD or anxiety disorder from a licensed psychiatrist. Additionally, in Israel, Stella has very rarely treated individuals who aren’t actively involved with a trauma-focused therapy of their choice (EMDR, CBT, or other trauma-focused psychotherapies).

The data that has been collected in Israel has all been done prospectively, and the PCL was filled out by the individual pre-treatment, one week post, one month post, and three months post SGB. One week post SGB (n = 38), treated patients showed an average decrease of 13.6 points on the PCL. One-month post-SGB (n = 19), there was an average decrease of 22.58 points on the PCL. And finally, three months post SGB (n = 14), there was an average decrease of 30.57 points on the PCL. Whilst this data was taken in-house, it suggests that there may be significant progressive changes in the PCL results over 3 months, and we speculate that if the SGB works and the individual continues to do therapy, results can get better over time. While these sample sizes are small at present, Stella Israel will continue to collect data to determine whether this observed trend toward reductions in PCL scores over time holds.

Since beginning the SGB treatment in Israel, Stella has provided SGB to terror victims, victims of sexual abuse, veterans, and individuals with significant childhood trauma. The ages have ranged from 17–65 and have included both males and females. Stella Israel is currently exploring whether there are differences in outcomes depending on the trauma type, and the high-trauma environment in Israel will most likely allow us to get a much better understanding of what works for who as our research and practice in Israel continues to advance.

8. Evolving the model of care: Integrating SGB as a first-line mental health treatment option

While many healthcare systems suffer from fragmented care, some systems of care have long deployed interdisciplinary treatment teams. Cross-disciplinary collaboration has been a strong element of treatments provided at certain military medical facilities, and entities like the National Intrepid Center of Excellence (NICoE). The emergence of new biological treatment options like SGB will help support the value of increasingly interdisciplinary approaches.

The latest research on SGB has evolved into an investigation of how SGB works with talk therapy. For example, Peterson and colleagues (2022) explored how SGB may enhance the outcomes of Prolonged Exposure Therapy (PE). The researchers became interested in investigating this combined care approach as they note that PE is “sometimes associated with high dropout rates, limited tolerability, and temporary symptom exacerbation during treatment.” Each patient received a single rather than dual level SGB and 10 sessions of Prolonged Exposure over a two-week period. Though the sample size of this non-randomized clinical trial was small (N = 12), results were promising. More than 90% achieved a clinically significant change on the PCL-5 (i.e., ≥10 points) by session 10, and half no longer met the diagnostic criteria for PTSD per the Clinician-Administered PTSD Scale for DSM-5 at 1-month follow-up. The researchers note that this “combined treatment approach provides promising results for improving the tolerability of trauma-focused therapies, reducing symptom severity, and increasing PTSD remission rates.” (Peterson et al., 2022).

At the time of this review, researchers at RUSH University (Held, NCT055341262) and Ohio State University College of Medicine (Bryan, NCT05107752) are recruiting for studies that will examine whether SGB improves outcomes when it is combined with cognitive processing therapy (CPT).

9. Conclusions

The high rate of suicide in the military and veteran community has been continuously spotlighted in countless academic and popular press publications. Despite the emphasis of these publications, and progressively mounting urgency for novel treatment options, psychiatric practice has changed little. The current standard of care for the treatment of post-traumatic stress centers on SSRI medication and exposure-based talk therapies. This standard is associated with generally poor engagement, high discontinuation and dropout rates, and relatively slow onset for relief of symptoms (Najavits, 2015). SGB is a proven treatment for emotional trauma symptoms that is now widely available.

SGB is not a “silver bullet”, but it may optimize clinical outcomes when delivered before culturally competent, trauma-informed talk therapy. In a paradoxical way, deploying this minimally invasive treatment as a first line approach, rather than a treatment of last resort, may deliver more compassionate care. Since SGB is associated with level 1B evidence and a reassuring safety profile, it is critical that clinicians embrace responsible innovation, as SGB may prevent unnecessary feelings of hopelessness or being broken which many service members and veterans experience.

Declaration of interest

Shauna Springer, Ph.D., and Jason Blankfield are part of a startup company (Stella) that utilizes SGB as one of several biological treatment modalities that it offers to its patients. Dr. Springer is a co-founder of the company and a member of its medical advisory board and Jason Blankfield is an employee of the company. This review paper is not sponsored by the company, but the company may benefit from increased public awareness of SGB as a treatment option for psychological symptoms. The other three contributing authors, Paul Whitmer, Morgan Steinlin, and Lindsey Gray, have no relevant disclosures.

Experimental subjects

No experimental procedures were performed on human or animal subjects.

Ethical considerations

This review article is exempt from Institutional Review Board approval.

Informed consent

Informed consent was not required for the purposes of this review article.

Data sharing policy

All relevant data that was accessed to complete the review presented were compliant with the PLOS data availability guidelines prior to submission.

Reporting guidelines

This article adheres to the EQUATOR Network reporting guidelines relevant to the research design.

Acknowledgments

The authors have no acknowledgments.

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