Stellate ganglion block

1. Introduction

Version followed: stellate ganglion block (SGB) as an off-label, adjunctive procedure for PTSD, as evaluated in the US Army sham-controlled trial (Rae Olmsted et al., 2020, JAMA Psychiatry) and as described by US military/VA, Australian DVA and Canadian CADTH evidence documents; regulatory and service status as of October 2026 (checked 16 October 2026) per the sources listed. Delivery is described at a descriptive level only. No drugs, doses, schedules, injection technique or anatomical approach are given.

What it is. SGB is an image-guided anaesthetic injection near a cluster of sympathetic nerves in the neck. It is done by a physician (in the trials, physicians in interdisciplinary pain management centres) in an outpatient setting. It has long been used for complex regional pain syndrome, migraine and hot flushes, and has been proposed as an adjunct for chronic PTSD that has not responded to standard treatment. [source: PHCoE Evidence Brief 2021; Rae Olmsted et al. 2020] Psychiatric News calls its PTSD use off-label. It has been used for pain for close to a century and for PTSD for nearly two decades. [source: Psychiatric News 2024]

How change is supposed to happen. The proposed rationale is that PTSD involves overactivity of the sympathetic (fight-or-flight) nervous system, and that temporarily blocking this pathway 'resets' hyperarousal. The DoD Psychological Health Center of Excellence says the mechanism is unknown and that the proposed explanations are hypotheses. [source: PHCoE Evidence Brief 2021] Commercial providers say more, calling PTSD "a biological injury that can be seen through brain scans" (Stella marketing page). That is the clinic's own claim, not an established finding. [source: Stella Mental Health PTSD page]

This is not a psychotherapy. The psychotherapist does not deliver SGB. This guide is for the therapist working alongside the physician or clinic: answering clients' questions, supporting informed consent, continuing trauma-focused psychotherapy, monitoring and passing on effects, and crisis planning. [synthesis]

Evidence status (as of October 2026)

Rae Olmsted et al. 2020 (JAMA Psychiatry 77(2):130–138): a multisite, blinded, sham-controlled RCT at three US Army pain centres (2016–2018). It randomised 113 active-duty service members (100 men, 13 women) on stable psychotropic medication with at least moderate PTSD symptoms, 2:1 to SGB or sham. On the CAPS-5 at 8 weeks, adjusted mean change was −12.6 points with SGB and −6.1 with sham (P = .01). The authors say the mild-to-moderate baseline severity and short follow-up limit generalisability, and that SGB "merits further trials" as an adjunct. Exclusions included prior SGB, moderate or severe TBI, some psychiatric and substance use disorders, and suicidal ideation in the previous 2 months. [source: RTI publication page]
Earlier Navy trial (Hanling et al. 2016; first presented as a 2015 pain-medicine conference poster led by McLay): 42 service members. Symptoms improved in both groups, with no significant difference between SGB and sham. The lead author suggested earlier positive reports might reflect placebo effects. [source: Newswise 2015; PHCoE Evidence Brief 2021] These look like the same trial reported twice. [uncertain: inferred from matching sample and setting]
Limitations named by DoD: treating physicians were not blinded, side effects may have revealed allocation to participants, and inclusion criteria were narrow. [source: PHCoE Evidence Brief 2021]
Reviews: a 2021 systematic review (Kerzner et al., Chronic Stress) found 17 studies, about 88% of them in PTSD. Its two RCTs disagreed, and it called for larger studies. [source: IASP summary of Kerzner et al. 2021] CADTH (Li & Loshak; year not shown on the CADTH page [uncertain]) called the evidence inconclusive and safety data limited. [source: CADTH key messages] Australia's Department of Veterans' Affairs rapid evidence assessment (Fear et al., December 2023) rested on a single high-risk-of-bias RCT. Its authors were "not in a position to recommend" SGB for PTSD. [source: Centre for Evidence summary of DVA report] A 2024 Psychopharmacology Bulletin review (Hasoon et al.) is much more positive in tone. Only the abstract is drawn on. [uncertain]
Uncontrolled clinic data: a single-clinic retrospective analysis (Lipov, 2022, Pain Physician) of more than 300 patients reported that 81% improved by at least 10 points on the PTSD Checklist. It had no control group, and the author leads a commercial provider. [source: Psychiatric News 2024]
Ongoing and later trials: a VA multisite, triple-blind, placebo-controlled trial (Lim et al., Contemporary Clinical Trials, December 2025; NCT05169190) with a sham arm, an untreated arm and an objective startle measure. [source: Centre for Evidence summary] A registered trial of SGB to augment trauma-focused therapy in veterans (NCT05107752). [uncertain: registry title only] A protocol for SGB to prevent PTSD after emergency eye-trauma surgery (Gao et al. 2025, Frontiers in Medicine). [source: Frontiers protocol] Results of these trials are not reported in the cited sources [uncertain].
How long effects last is unclear. One military case series suggested effects fade after about a month. A larger analysis reported at least three months. [source: Psychiatric News 2024] VA says long-term effects are unknown. [source: VA Health Affairs page 2021]

Regulatory and service status (checked 16 October 2026)

United States: no FDA approval specific to PTSD is documented for SGB in the cited sources [uncertain]. It is a physician-performed procedure using medicines approved for other uses, and its PTSD use is described as off-label. [source: Psychiatric News 2024] The 2017 VA/DoD PTSD guideline found "insufficient evidence to recommend for or against SGB", and DoD's evidence brief concluded it was not recommended for PTSD in the Military Health System. [source: PHCoE Evidence Brief 2021] The 2023 VA/DoD guideline keeps a neither-for-nor-against position: its Recommendation 24 lists SGB among somatic therapies for which there is insufficient evidence to recommend for or against use in PTSD (with rTMS, tDCS, neurofeedback, hyperbaric oxygen and others), and its research priorities call for studies of SGB with active control conditions. [source: Schnurr et al. 2024, Annals of Internal Medicine synopsis of the 2023 VA/DoD guideline] The TREAT PTSD Act (H.R. 1947, introduced 6 March 2025) would require VA and DoD to provide SGB to eligible veterans and service members and to update the guideline to list it "as a therapy option" [source: H.R. 1947 text]; a bill tracker lists it as still in committee [source: PolicySoup H.R. 1947 page] [uncertain: secondary]. Inside VA, each facility decides whether to offer SGB, and VA describes it as experimental where offered. Long Beach VA has run an SGB clinic since 2017. [source: VA Health Affairs page 2021]
Australia: DVA's December 2023 assessment does not recommend SGB for PTSD. [source: Centre for Evidence summary]
Canada: CADTH called the evidence inconclusive and found no guideline supporting or opposing SGB. [source: CADTH key messages]
UK and EU: no NICE, MHRA or EMA position on SGB for PTSD was found in the sources consulted. [uncertain]

Commercial clinics and marketing claims

Stella: clinics in several US states, plus "Certified" partner sites, market SGB and a branded variant called "Dual Sympathetic Reset" (DSR). The PTSD page relies on testimonials ("relief came quickly", and an "immediate and positive impact"). It cites an internal responder-based patient study and calls its treatments "proven". It says nothing on regulatory status or off-label use. The only side effect mentioned is a testimonial describing Horner's syndrome as a temporary, expected effect. Psychotherapy is not required. Its chief medical officer is Lipov. Patients pay out of pocket. [source: Stella Mental Health PTSD page; Psychiatric News 2024]
Stellate Institute: co-founded in 2021 by two co-authors of the 2020 RCT. Many civilian pain clinics also offer SGB for PTSD. [source: Psychiatric News 2024]
The lead RCT author advises checking that a referral clinic is reputable. [source: Psychiatric News 2024] Clinic claims of 'proven', near-instant or lasting cures go beyond the published sham-controlled evidence. [synthesis]

2. Framework

SGB is not a staged therapy. The framework below follows the client's path through care, with the therapist's tasks at each point. [synthesis, built on the sources cited]

Phase	Goal	Therapist's tasks	Move on when
A. Client raises SGB	Respond accurately; keep the alliance	Find out what the client has heard; give balanced information; review how the client has fared with first-line trauma-focused treatment	Client wants a medical opinion, or decides not to pursue it
B. Referral and decision	Supported, informed choice	Suggest an assessment by the client's physician or psychiatrist and an evidence-based procedural service; help prepare questions; support shared decision-making	Physician has assessed; client has decided
C. Around the procedure	Safety and continuity	Agree a crisis plan; plan sessions around procedure days; take baseline measures	Procedure completed or declined
D. Follow-up (first weeks)	Track change; use any window of lower arousal	Repeat measures; ask about adverse effects and mood; pass concerns to the treating team; continue or start trauma-focused psychotherapy	Response is clear (or not)
E. Longer term	Durable recovery	Manage expectations about fading effects and repeat-procedure requests; keep up evidence-based psychotherapy	Planned ending as for the psychotherapy

Who delivers what: the physician or procedural team handles eligibility, consent for the procedure itself, delivery and medical follow-up. The psychotherapist handles psychoeducation, decision support, ongoing psychotherapy, monitoring and safety planning. [source: PHCoE Evidence Brief 2021; VA Health Affairs page 2021; synthesis]
Format in trials: a short outpatient course of procedures at a pain management centre, alongside the participants' usual PTSD care. Participants were on stable medication. [source: RTI publication page; Psychiatric News 2024] Frequency and dosing are left to the treating physician and are not described here.
Who was studied: mostly male active-duty service members with mild-to-moderate symptoms. People with recent suicidal ideation, moderate or severe TBI and some comorbidities were excluded. [source: RTI publication page] Results may not apply to civilians, women, severe or complex PTSD, or clients with current suicidality. [synthesis]

3. Guiding principles

First-line care comes first. VA describes SGB as an option for those who do not benefit from trauma-focused psychotherapy and medication, not a first-line treatment. In practice, check that evidence-based trauma therapy has been offered at adequate quality and length before treating SGB as the next step. [source: VA Health Affairs page 2021]
Represent the evidence as mixed. Two sham-controlled RCTs disagree, and reviews call the evidence inconclusive. In practice, avoid both 'it's a cure' and 'it's quackery'. [source: CADTH; Kerzner et al. 2021]
Stay in your scope. Medical eligibility, risks and technique belong to the physician. In practice, never advise for or against the procedure on medical grounds; refer the question on. [synthesis]
Name the claim's source. In practice, separate clinic marketing, uncontrolled case series and RCT results when talking with clients. [source: Stella page; Psychiatric News 2024]
Informed consent is ongoing. In practice, revisit the decision as new information or effects emerge. [synthesis]
Keep the psychotherapy going. Trial participants continued their usual care, and providers themselves suggest combining SGB with talk therapy. In practice, plan sessions through the procedure period rather than pausing. [source: Psychiatric News 2024]
Watch for avoidance dressed up as treatment. In practice, explore whether a biological 'reset' appeals partly as a way to avoid trauma processing, and do this without judgement. [synthesis]
Monitor and share. In practice, use standard measures before and after, and pass on adverse effects, mood changes and risk to the treating team with consent. [synthesis]
Safety does not stop. In practice, keep up risk assessment and a crisis plan throughout. Abrupt symptom change, either relief or relapse, can affect risk. [synthesis]
Watch fairness and cost. In practice, raise out-of-pocket costs, possible repeat procedures and the risk of exploitation of desperate clients. [source: Psychiatric News 2024; synthesis]

4. Intervention inventory

4.1 How the procedure is delivered (descriptive only; delivered by physicians)

Purpose: gives the therapist an accurate picture to share with clients. It is not instructions.
Steps (as sources describe): the client is assessed by the treating physician or clinic. In trials this happened in interdisciplinary pain management centres; in VA, a trained specialist performs SGB where local leadership offers it. [source: RTI publication page; VA Health Affairs page 2021] The procedure is an outpatient anaesthetic injection in the neck, done under image guidance. The Australian DVA report notes that adverse events are more likely when it is done without radiological guidance. [source: Centre for Evidence summary of DVA report] Numbness and other short-term effects wear off within hours, according to the lead trial author. [source: Psychiatric News 2024] Some services offer repeat procedures, and VA notes a second injection may help some people. [source: VA Health Affairs page 2021]
Risks, as sources state them:
- In the 2020 RCT, three adverse events were judged related to SGB: injection-site discomfort, a slow heart rate that resolved by itself, and temporary throat irritation. [source: CADTH key messages] Psychiatric News reports six adverse events among 113 participants, from injection-site pain and redness to low blood pressure. [source: Psychiatric News 2024]
- Eyelid drooping (part of Horner's syndrome, which clinics describe as an expected temporary effect), allergic reactions and brief convulsions were cited by a psychiatrist commentator. A commercial provider reports a complication rate of about 1 in 1,000 with his own protocol, which has not been independently verified. [source: Psychiatric News 2024; Stella page] [uncertain: no independent complication-rate data in the cited sources]
- A 2025 trial protocol lists the events it will monitor: neck pain, dizziness, tinnitus, respiratory depression, anaphylaxis, slow heart rate, haematoma, infection, severe arrhythmia and pneumothorax. These are monitored outcomes, not observed rates. [source: Gao et al. 2025 protocol]
- Long-term effects are unknown. [source: VA Health Affairs page 2021] Trial participants who were service members worried about handling weapons while the numbness lasted. [source: Psychiatric News 2024]
Watch for: clients who think the procedure is FDA-approved for PTSD, risk-free or permanent. Correct these beliefs gently and refer specific medical questions to the physician. [synthesis]
Example language (illustrative): "It's an injection in the neck given by a physician using imaging. The numbness wears off within hours, but how long any effect on PTSD lasts isn't known yet. Your doctor can tell you about the risks for you." [synthesis]

4.2 Responding when a client asks about SGB

Purpose: keep the alliance and support an accurate, unhurried decision. [synthesis]
Steps: (1) Ask what they have heard and where (a news story, a veteran network, a clinic advert). (2) Ask what they hope it will change. (3) Summarise the evidence in plain terms: one positive and one negative sham-controlled trial; reviews call the evidence inconclusive; it is not first-line and is used off-label. [source: Section 1 sources] (4) Review the trauma-focused treatment they have had (type, number of sessions, fidelity, why it ended). (5) Offer a medical review with their GP, psychiatrist or a reputable procedural service. (6) Agree to keep working in therapy whatever they decide. [synthesis]
Example language (illustrative): "It makes sense to look at every option. Can we go over what you've read, and then I'll tell you what the research shows so far?" / "The trials are mixed: one found benefit compared with a fake procedure and one didn't. Whether it's medically suitable for you is a question for a doctor, and I'm glad to help you get that opinion."
Watch for: hopelessness about psychotherapy, pressure from peers or partners, financial strain. It is working when the client can describe the uncertainty in their own words. [synthesis]

4.3 Psychoeducation on mechanism, evidence and marketing

Purpose: help the client weigh claims critically. [synthesis]
Steps: explain the proposed fight-or-flight rationale and that the mechanism is unknown. [source: PHCoE Evidence Brief 2021] Explain that improvement after a sham procedure is common (the sham group in the 2020 RCT also improved). [source: RTI publication page] Go through the clinic's website together if the client wishes, and separate testimonials and internal data from controlled trials. [source: Stella page; synthesis]
Example language (illustrative): "Testimonials tell us some people felt better. They can't tell us how many didn't, or whether the procedure itself caused the change."
Watch for: shaming the client for being interested. Keep curiosity and respect. [synthesis]

4.4 Supporting informed consent and shared decision-making

Purpose: help the client get from the physician the information they need. The physician obtains the consent for the procedure itself. [synthesis]
Steps: help the client write down questions: Who performs it, and what are their training and experience? Is image guidance used? [source: DVA via Centre for Evidence] What adverse effects happen, and how often in this clinic? What is the evidence for PTSD specifically, and is this use off-label? What is the total cost, and are repeat procedures expected? What happens if it doesn't help? Is psychotherapy coordinated? Which outcomes do they measure? Then explore values and preferences. In the US, note that VA facilities may or may not offer SGB, and military clients may face specific rules about weapons and duty after the procedure. [source: VA Health Affairs page 2021; Psychiatric News 2024; synthesis]
Example language (illustrative): "Would it help to make a list of questions for the clinic together, so you leave the appointment with what you need?"
Watch for: high-pressure sales, package deals or upfront payment for many procedures, and clinics that discourage ongoing therapy. Raise these with the client as concerns. [synthesis]

4.5 Integrating trauma-focused psychotherapy before, during and after

Purpose: keep first-line, evidence-based treatment at the centre. If arousal drops, use that window for processing. [synthesis] Providers favour combining SGB with talk therapy, and a registered trial is testing SGB to augment trauma-focused therapy. [source: Psychiatric News 2024; NCT05107752 title, uncertain]
Steps: before: stabilisation, a case formulation and baseline measures. During the procedure period: avoid starting intensive exposure on the procedure day itself, and liaise with the team about timing. [synthesis] After: if hyperarousal eases, consider starting or resuming a recommended trauma-focused therapy (e.g. prolonged exposure, cognitive processing therapy, EMDR, trauma-focused CBT). Follow the standard contraindication, consent and safety steps for exposure work. [source: Psychiatric News 2024 notes evidence-based therapies such as prolonged exposure; synthesis]
Example language (illustrative): "If your startle and sleep ease up after the procedure, that may be a good time to tackle the memories we've been circling."
Watch for: the client stopping therapy because they feel 'fixed'. Plan a review rather than an abrupt ending. [synthesis]

4.6 Monitoring outcomes and passing on adverse effects and mood changes

Purpose: make response and harms visible to the client and the treating team. [synthesis]
Steps: take baseline and repeat measures with a validated self-report PTSD checklist (the trials used the PCL and the clinician-rated CAPS-5) plus depression and risk measures, at baseline, in the first weeks and around one to three months. [source: RTI publication page; synthesis] At each session ask about new physical symptoms after the procedure (e.g. persistent hoarseness, breathing or swallowing difficulty, neck swelling, dizziness, fainting, seizure-like episodes, signs of infection), and about mood, sleep, irritability, dissociation, substance use and suicidal thinking. Urgent physical symptoms mean urgent medical care. With consent, send the treating physician and the prescriber a brief written summary of changes and concerns. [source: risk list in 4.1; synthesis]
Example language (illustrative): "Since the procedure, have you noticed anything physically different, like voice changes, trouble swallowing, dizziness? And how has your mood been day to day?"
Watch for: relapse when effects fade. A quick, dramatic change in either direction is a cue to check risk. [source: Psychiatric News 2024 on fading effects; synthesis]

4.7 Crisis and safety planning

Purpose: maintain safety through hope, procedure and possible disappointment. [synthesis]
Steps: before referral, carry out a standard risk assessment. Note that trials excluded people with recent suicidal ideation, so evidence for this group is absent. [source: RTI publication page] Update a written safety plan: warning signs, coping steps, contacts, crisis lines, and lethal-means counselling about safe storage or removal. Pay particular attention to firearms in military and veteran clients. Agree what happens if the procedure doesn't help or effects wear off, and who the client contacts for medical problems after the procedure. [synthesis]
Example language (illustrative): "Let's plan for the possibility that it doesn't work, or works and then fades, so that disappointment doesn't catch you off guard."
Watch for: pinning everything on one procedure. Hope that collapses can raise risk. [synthesis]

4.8 Conversations about ambivalence and repeat procedures

Purpose: explore mixed feelings without steering the medical decision. [synthesis]
Steps: use reflective, motivational-interviewing-style listening about pros and cons, cost and repeat-procedure plans. Bring medical questions back to the physician. Never advise the client to have, avoid or repeat the procedure, or to change medication. [synthesis]
Example language (illustrative): "Part of you wants to try it now, and part of you worries about cost and whether it lasts. Shall we look at both sides?"
Watch for: repeated procedures standing in for engagement with psychotherapy. [synthesis]

4.9 Collaborative care and after the procedure ends

Purpose: keep care coordinated and plan for the longer term. [synthesis]
Steps: with consent, contact the procedural clinic and the prescriber, agree who monitors what, and share outcome data. Once the procedural course has ended, consolidate gains with relapse-prevention work and keep up evidence-based psychotherapy. [synthesis]
Example language (illustrative): "With your OK, I'd like to send the clinic a short note on how you've been doing, so we're all working from the same picture."
Watch for: fragmented care between private clinics and public services. [synthesis]

5. Handling problems

The sources do not address psychotherapy problems specifically, so the guidance below is [synthesis] except where cited.

Client sees SGB as a way to avoid trauma work: name the avoidance pattern gently and explore it, and keep the referral open. Frame the procedure, if they have it, as possibly making therapy easier rather than replacing it. Providers themselves describe it as an adjunct. [source: Psychiatric News 2024; RTI publication page]
Client is angry that therapy 'failed' and wants a fix: validate the frustration and review the quality of past treatment (was it a recommended trauma-focused therapy at adequate dose and fidelity?). Offer a different evidence-based option as well as the medical referral. This counts as a rupture: repair it by owning your part and asking what they need.
Client distrusts the therapist's caution as 'gatekeeping': be transparent that you are not the decision-maker, share the sources, and support a second medical opinion.
Client has already booked at a commercial clinic: don't argue. Help them ask the consent questions in 4.4, agree monitoring and crisis plans, and keep sessions going.
Dramatic early improvement: celebrate it cautiously. Plan relapse prevention and use the window for trauma-focused work. Prepare the client for effects possibly fading. [source: Psychiatric News 2024 on uncertain durability]
No improvement, or relapse: normalise this (the sham-controlled trials were mixed). Screen for hopelessness and suicidality, update the safety plan, and revisit the overall treatment plan with the team. [source: Newswise 2015; RTI publication page]
Physical adverse effects reported in session: for breathing or swallowing difficulty, neck swelling, chest symptoms, fainting or seizure-like events, direct the client to urgent or emergency care. For non-urgent effects, direct them to the procedural clinic. Document it and inform the team with consent. [source: risk list in 4.1]
Mood changes, dissociation or increased suicidality afterwards: carry out a risk assessment, follow the crisis plan, and inform the treating physician and prescriber. Don't attribute the change to the procedure yourself; report what you observe.
Repeated procedures and financial strain: explore cost, debt and pressure. Bring repeat-procedure questions back to the physician. Raise concerns about high-pressure sales.
Pressure from peers, partners or the military community: explore whose decision it is and support the client's own choice.
Client stops coming to therapy after the procedure: send a planned check-in and offer a review session. Keep a door-open message on file.
Therapist's own scepticism or enthusiasm: check in supervision whether your views are steering the client. Keep to accurate, attributed information.
Ethical points: stay within your professional scope, document the information you gave and the referrals you made, and get consent before sharing information with clinics. Don't endorse or receive referral fees from commercial providers.

Sources

Sources:

Cited indirectly [uncertain]: Hanling et al. 2016 (Navy RCT, as described by PHCoE); Lipov 2022, Pain Physician (as described by Psychiatric News); VA/DoD PTSD Clinical Practice Guideline 2017 (as quoted by PHCoE) and 2023 (through the Annals of Internal Medicine synopsis listed above); ClinicalTrials.gov NCT05107752 and NCT05427500 (titles only).

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