The Department of Defense's Persian Gulf War registry year 2000: an examination of veterans' health status

This study examined the health status of 46,633 Persian Gulf War theater veterans who received full clinical evaluations in the Department of Defense's Gulf War Comprehensive Clinical Evaluation Program (CCEP) as of spring 2000. Clinical data analyzed included demographic information, 15 health symptoms, 19 wartime exposures, and primary and secondary physician-determined medical diagnoses based on International Classification of Diseases, 9th Revision, Clinical Modification, criteria. Findings and discussions are arrayed, by gender, with comparative 1996 data from the Department of Veterans Affairs Health Examination Registry Program. Many veterans reported fewer physical symptoms now than during the time of the Gulf War. Many endorsed symptoms of joint pain, fatigue, weight change, and sleep disturbances. Most reported exposure to diesel fuel and the nerve agent antidote pyridostigmine bromide; far fewer female veterans reported combat involvement. The most frequent primary or secondary diagnosed medical conditions were musculoskeletal/connective tissue diseases, ill-defined conditions, and mental disorders. Female veterans were diagnosed more frequently with mental disorders. Symptom endorsement and diagnosis rates between the CCEP and the Department of Veterans Affairs registry were not dissimilar. Overall, the self-reported general health of veterans with symptoms was much poorer (females had higher rates of "fair to poor" health than males) than that of veterans with no reported symptoms.     

Innovation in veterans' health care and assistance: the Department of Veterans Affairs 10 years after the Gulf War

The Department of Veterans Affairs (VA) has responded to significant challenges in treating and compensating Persian Gulf War veterans by adapting existing programs and developing new ones. The VA established a Gulf War health examination registry and expanded existing "Vet Centers" to provide assistance to Gulf War veterans. Health care eligibility income limitations were eliminated. Outreach efforts included a national newsletter, veterans' organization briefings, and other products. The VA is developing targeted training programs and continuing medical education for health care providers. Numerous major research initiatives have begun. Innovations include the establishment of environmental hazards research centers, clinical demonstration projects, and centers for the study of war-related illness. These efforts required increased coordination among federal agencies and collaboration with other countries. In a precedent-setting development, Congress gave the VA authority to compensate certain veterans with undiagnosed illnesses. Veterans from future conflicts and peacekeeping missions can expect improved services from the VA as a result of these initiatives.     

Health and functioning among four war eras of U.S. veterans: examining the impact of war cohort membership,socioeconomic status,mental health,and disease prevalence

This analysis examines the self-rated health and functioning of World War II, Vietnam era, Korean Conflict, and Persian Gulf War veterans participating in the Veteran Identity Program Survey 2001. The results indicate that although World War II veterans are more likely to report poor health status and functioning, Vietnam-era veterans report more difficulty with specific activities of daily living and instrumental activities of daily living than any other era of veterans. These relationships remain when controlling for race/ethnicity, socioeconomic status, disease prevalence, and mental health status. These findings suggest that there are characteristics unique to the Vietnam experience that negatively affect this cohort of veterans. We suggest that further analysis examine the specific pathways through which the experience of being a Vietnam veteran affects health. In the meantime, health and social service planning within the Department of Veterans Affairs should explore the services that should be developed and targeted to this cohort of veterans so that they may remain independent in the community.     

The health status of Gulf War veterans: lessons learned from the Department of Veterans Affairs Health Registry.

OBJECTIVE: To describe the demographic characteristics and postwar health status of U.S. Gulf War veterans who participated in the Department of Veterans Affairs health examination registry program. DESIGN: Case records of 52,835 veterans who participated in a standardized health examination program were reviewed. SETTING: Participants volunteered for physical examinations at a Department of Veterans Affairs medical treatment facility from August 1992 to September 1996. SUBJECTS: U.S. Gulf War veterans deployed to southwest Asia between August 1990 and 1996. MAIN OUTCOME MEASURE: Demographic, military, symptom, and International Classification of Diseases, Ninth Revision, Clinical Modification, diagnostic categories. RESULTS: A wide variety of symptoms and diagnoses were reported without apparent internal variation by military characteristics (branch and service component). The frequency of symptoms (fatigue, skin rash, headache, muscle and joint pain, and memory loss) reported increased over time, whereas the proportion of individuals with physician-diagnosed illnesses remained fairly constant. No single category of disease increased or decreased substantially over time. CONCLUSIONS: Veterans have experienced a wide variety of health problems since their Gulf War service. These problems, in aggregate, are different from what has been seen in other armed conflicts. The Department of Veterans Affairs registry is a very large case series and has failed to identify a single, unique syndrome or new illness after Gulf War service. An epidemiologic study would better define the prevalence of specific symptoms and medical conditions among Gulf War veterans and to what extent any of the conditions identified are associated with Gulf War military service. The knowledge provided by such studies would be important to development of preventive measures and future deployment medical surveillance planning.     

Diagnostic status and treatment recommendations for Persian Gulf War Veterans with multiple nonspecific symptoms.

BACKGROUND: Unexplained symptoms have frequently been observed in deployed Persian Gulf War veterans (GWVs). Using factor analysis, the Centers for Disease Control and Prevention (CDC) has established criteria for Gulf War illness (GWI). We report here on the prevalence of GWI, identify comorbidities, and compare these with those of veterans without GWI. METHODS: GWVs who consented to complete questionnaires and laboratory measures were given complete physical and mental health examinations. Outcome measures included CDC criteria for GWI, the Medical Outcomes Study Short Form 36 (SF-36), clinical and laboratory evaluations, and structured psychiatric interviews. RESULTS: One hundred twenty GWVs were enrolled, and 89 received complete physical and mental health examinations; 83% met CDC criteria for GWI. Veterans with GWI (1) were older, (2) reported more combat exposure, (3) scored higher on measures of depression, post-traumatic stress disorder, and fibromyalgia, and (4) had poorer health-related quality of life. More than half had anxiety or depressive disorders, and 93% had at least one medical and/or psychiatric diagnosis. The SF-36 predicted mental health status with a positive predictive value of 81.58. By adding the Hamilton D rating for depression, the positive predictive value increased to 88.57. INTERPRETATION: The CDC criteria accurately identified GWVs negative for GWI. Most GWVs were positive for GWI. Neither CDC criteria nor CDC severity rankings distinguish between veterans with psychiatric syndromes and those without: both groups endorsed the same symptoms. More than half of those with GWI had a treatable anxiety or depressive disorder. The SF-36 was a valid predictor of mental health status, particularly when paired with the Hamilton depression interview.     

Does filing a post-traumatic stress disorder disability claim promote mental health care participation among veterans?

This study examined the impact of participation in the Department of Veterans Affairs (VA) disability system on health care use by veterans filing disability claims on the basis of post-traumatic stress disorder (PTSD). VA administrative databases were used to examine health care use in 3-month intervals before, during, and after veterans' filing of PTSD disability claims. Subjects were all veterans using some VA health care who filed PTSD claims between 1997 and 1999 in a large Midwestern region. PTSD claimants used more medical and mental health services after filing a disability claim, compared with the preapplication period. Continuation of elevated mental health care use after claim determination occurred only for those veterans whose claims were approved. Use of VA mental health care before the disability examination was associated with an increased likelihood of claim approval. For veterans with PTSD, disability system participation may both promote and be promoted by receipt of mental health care.     

The war-related illness and injury study centers: a resource for deployment-related health concerns

Combat veterans often return from deployment having experienced a wide range of exposures, symptoms, and medical conditions. The Department of Veterans Affairs established war-related illness and injury study centers to serve combat veterans with unexplained illnesses. We report the exposures, clinical status, and utilization of 53 combat veterans who participated in the National Referral Program (NRP) from January 2002 until March 2004. Participants were primarily male (81%) and served in the Persian Gulf War (79%). Common diagnoses were chronic fatigue syndrome (n = 23, 43%), neurotic depression (n = 21, 40%), and post-traumatic stress disorder (n = 20, 38%). Self-reported exposures related to weaponry, disease prophylaxis, environmental hazards, stress, and poor hygiene. A small increase in mean SF-36V mental component scores (2.8 points, p = 0.009) and use of rehabilitation therapies (1.6 additional visits, p = 0.018) followed the NRP referral. The small gain in mental function suggests that the NRP may benefit combat veterans with long and complex medical histories.     

Health effects in Army Gulf War veterans possibly exposed to chemical munitions destruction at Khamisiyah, Iraq: Part I. Morbidity associated with potential exposure

In March 1991, U.S. troops detonated the Khamisiyah, Iraq, ammunition depot, possibly releasing two chemical warfare agents, sarin and cyclosarin. The long-term health effects associated with possible exposure to these chemical warfare agents are unknown. This study was undertaken to investigate whether possible exposure was associated with morbidity among Army Gulf War veterans using morbidity data for 5,555 Army veterans who were deployed to the Gulf region. Responses to 86 self-assessed health measures, as reported in the 1995 Department of Veterans Affairs National Health Survey of Gulf War Era Veterans, were evaluated. We found little association between potential exposure and health, after adjustment for demographic variables, and conclude that potential exposure to sarin or cyclosarin at Khamisiyah does not seem to have adversely affected self-perceived health status, as evidenced by a wide range of health measures.     

Medical follow-up of Persian Gulf War Veterans with severe medically unexplained fatigue: a preliminary study.

An important question for researchers interested in long-term consequences of military service is the health outcome of symptomatic Persian Gulf War Veterans. From an original group of 76 Gulf War Veterans who received the diagnosis of severe fatiguing illness, we attempted to get 58 veterans to return to our center for a second evaluation. Thirteen returned. Two had recovered by the time of revisit, but the rest remained ill; however, only one was so ill as to be unable to work. The data suggest that the medical consequences of serving in the Persian Gulf are not transient. The difficulty in getting veterans to return to our center suggests potential problems in the proposed nation-wide longitudinal health outcome study of Persian Gulf War Veterans.     

Long-term effects of military service on mental health among veterans of the Vietnam War era

Comparing outcomes of veterans who served in Vietnam and those who served elsewhere, we examined treatment of post-traumatic stress disorder, treatment of other mental health conditions, psychiatric treatment location, and six mental health well-being measures. The analytic sample consisted of nationally representative data from the 2001 National Survey of Veterans. Analyses included multivariate logistic regression that controlled for sociodemographic characteristics. Of Vietnam War-era veterans in the National Survey of Veterans (N = 7,914), 3,937 served in Vietnam and 3,977 served elsewhere. These veterans were stratified into < 60 years of age (N = 6,141) and > or = 60 years of age (N = 1,766). Veterans who served in Vietnam had notably poorer mental health than did those who served elsewhere. There were striking mental health differences between younger and older veterans; younger veterans had substantially worse measures of mental health. These results suggest greater resource needs among younger Vietnam War veterans. Clinicians and the Department of Veterans Affairs should focus on mental health services for younger veterans.     

Self-reported health of Persian Gulf War veterans: a comparison of help-seeking and randomly ascertained cases

The objective of this study was to compare self-selected Persian Gulf War veterans attending a health assessment program with veterans ascertained in an epidemiological study to determine why Gulf War veterans do, or do not, present for clinical assessment. A postal survey was sent to randomly selected United Kingdom Armed Forces personnel who served in the Persian Gulf conflict. Outcome measures included a symptom checklist, health perception, physical functioning, psychological distress, post-traumatic stress symptoms, and health attributions. A total of 173 survey respondents had also attended the Medical Assessment Program (MAP). MAP attendees were more likely to be female, older, and working part time or not working at all. They had poorer health perception and reported higher levels of illness, and they differed in terms of their health attributions. The belief that one had Gulf War syndrome and attributing health problems to Gulf War service were the most powerful predictors of MAP attendance, even when controlling for the level of physical functioning. The findings suggest that health beliefs rather than symptoms are more important predictors of attendance of an assessment program and that Gulf War veterans who attended the MAP have different characteristics than those who did not. This suggests that MAP patients are unrepresentative of the wider deployment to the Persian Gulf.     

Incarceration and veterans of the first Gulf War

OBJECTIVE: This study investigated the prevalence of incarceration and the association with deployment among veterans of the first Persian Gulf War (GW). METHODS: A structured telephone interview of military personnel from Iowa deployed to the Persian Gulf and a comparison sample of nondeployed military personnel was conducted. The interview consisted of validated questions, validated instruments, and investigator-derived questions to assess relevant medical and psychiatric conditions. A total of 4,886 subjects were randomly drawn from one of four study domains, i.e., GW regular military, GW National Guard/Reserve, non-GW regular military, or non-GW National Guard/Reserve. Symptoms of medical conditions, psychiatric disorders, and health care utilization were the main outcome measures. RESULTS: Nearly one-quarter (845 of 3,695 subjects, 22.9%) had been incarcerated at some point before the interview ("ever incarcerated"). Ever incarcerated veterans had a higher frequency of psychiatric and medical comorbidity and higher rates of health care utilization. Ever incarcerated status was associated with male gender, enlisted rank, lower educational levels, low levels of military preparedness, discharge from service, cigarette smoking, antisocial traits, court martial and/or other military discipline, having seen a mental health professional, and having used illegal drugs. GW veterans who participated in combat had a modestly higher risk for incarceration after the GW than did noncombatants (odds ratio, 1.6; 95% confidence interval, 1.0-2.5). CONCLUSIONS: Military recruits with a history of incarceration more often displayed problematic behaviors, more often developed psychiatric/medical conditions, and had high rates of health care utilization. A history of incarceration may be a behavioral marker for substance abuse, antisocial behavior, and mental illness. Importantly, GW deployment carried no increased risk of subsequent incarceration overall.     

Mental health status in veterans residing in rural versus non-rural areas:results from the veterans'health study

Background:The majority of Veterans Affair(VA)hospitals are in urban areas.We examined whether veterans residing in rural areas have lower mental health service use and poorer mental health status.Methods:Veterans with at least 1 warzone deployment in central and northeastern Pennsylvania were randomly selected for an interview.Mental health status,including posttraumatic stress disorder(PTSD),major depression,alcohol abuse and mental health global severity,were assessed using structured interviews.Psychiatric service use was based on self-reported utilization in the past 12 months.Results were compared between veterans residing in rural and non-rural areas.Data were also analyzed using multivariate logistic regression to minimize the influence by confounding factors.Results:A total of 1730 subjects(55％of the eligible veterans)responded to the survey and 1692 of them had complete geocode information.Those that did not have this information(n=38),were excluded from some analyses.Veterans residing in rural areas were older,more often of the white race,married,and experienced fewer stressful events.In comparison to those residing in non-rural areas,veterans residing in rural areas had lower global mental health severity scores;they also had fewer mental health visits.In multivariate logistic regression,rural residence was associated with lower service use,but not with PTSD,major depression,alcohol abuse,and global mental health severity score after adjusting confounding factors(e.g.,age,gender,marital status and education).Conclusions:Rural residence is associated with lower mental health service use,but not with poor mental health in veterans with former warzone deployment,suggesting rural residence is possibly protective.     

The clinical experience of citalopram in the treatment of post-traumatic stress disorder: a report of two Persian Gulf War veterans

OBJECTIVE: To determine the efficacy of the antidepressant citalopram in the treatment of post-traumatic stress disorder (PTSD). METHOD: The cases of two Persian Gulf War veterans are described to illustrate the effects of citalopram in treating their PTSD symptoms. RESULTS: In these two clinical case studies, citalopram led to remission of some of the PTSD symptoms. CONCLUSION: More controlled studies are warranted to further prove the efficacy of citalopram as an agent of choice for the treatment of PTSD.     

Minnesota Multiphasic Personality Inventory-2 validity patterns: an elucidation of Gulf War syndrome

The potential effects of psychological distress on physical symptoms observed in Persian Gulf War veterans were evaluated in 48 veterans using neuropsychological evaluation that included personality assessment (the Minnesota Multiphasic Personality Inventory-2). Cluster analysis of the validity scales resulted in a solution with two viable subgroups. Members of cluster 1 had significantly higher scores on five Minnesota Multiphasic Personality Inventory-2 clinical scales, a measure of trait anxiety, and a number of subjective complaints, as well as lower scores on a task of attention. Neuropsychological functioning did not otherwise differ between the groups, Contributions of personality style in coping with physical and mental health stressors were indicated. Experience of distress appeared to be attributable to individual differences rather than factors that have been associated with the elusive Gulf War syndrome. Persian Gulf War veterans' emotional reactions to clinical laboratory findings, perceptions of exposure risks, war experience, and stress may represent a variation of post-traumatic stress disorder.     

Health care utilization and satisfaction concerning gender-specific health problems among military women

There is growing concern regarding the quality of gender-specific health care for military women in general and for female veterans of the Persian Gulf War in particular. This paper reports on health care utilization rates for gender-specific problems and describes differences in these rates among age, rank, and component groups of a randomly selected sample of military women. Study findings provide preliminary evidence for a closer examination of health care services for women within the armed forces, particularly within specific cohorts, to better target both services and policy.     

The Institute of Medicine's independent scientific assessment of Gulf War health issues

The Institute of Medicine has frequently been the source of expert advice to the government and others on questions related to health and medicine. Such has been the case as Congress, federal agencies, and veterans attempt to resolve conflicts and develop policies to address the health concerns of Persian Gulf War veterans. Twelve reports issued by Institute of Medicine committees address what is known about exposures and illnesses in Gulf War veterans and what additional information is needed, how clinical programs for Gulf War veterans could be improved, and what strategies could help prevent or better address similar health problems in the future. The Institute of Medicine reports recommend guidelines and interventions to treat sufferers of medically unexplained symptoms, longitudinal studies to measure changes in health status, and improved risk communication. They emphasize the need for the maintenance of retrievable electronic records of baseline health status, of exposures, and of health events that occur during a service member's career.     

Accessibility and acceptability of the Department of Veteran Affairs health care: diverse veterans' perspectives

OBJECTIVES: Diverse veteran's perspectives on the accessibility and acceptability of the Department of Veteran Affairs (VA) health services are presented. METHODS: The qualitative methodology uses 16 focus groups (N = 178) stratified by war cohort (World War II and Korean Conflict versus Vietnam War and Persian Gulf War) and four ethnic/racial categories (African American, Asian American, European American, Hispanic American). RESULTS: Five themes emerged regarding veterans' health care expectations: (1) better information regarding available services, (2) sense of deserved benefits, (3) concern about welfare stigma, (4) importance of physician attentiveness, and (5) staff respect for patients as veterans. Although veterans' ethnic/racial backgrounds differentiated their military experiences, it was the informants' veteran identity that framed what they expected of VA health services. CONCLUSIONS: Accessibility and acceptability of VA health care is related to veterans' perspectives of the nature of their entitlement to service. Provider education and customer service strategies should consider the identified factors to increase access to VA as well as improve veterans' acceptance of the care.     

The role of the sand in chemical warfare agent exposure among Persian Gulf War veterans: Al Eskan disease and "dirty dust"

The purpose of this paper is to inquire into the relationship between Al Eskan disease and the probable exposure to chemical warfare agents by Persian Gulf War veterans. Al Eskan disease, first reported in 1991, compromises the body's immunological defense and is a result of the pathogenic properties of the extremely fine, dusty sand located in the central and eastern region of the Arabian peninsula. The disease manifests with localized expression of multisystem disorder. Signs and symptoms of Al Eskan disease have been termed by the news media "Persian Gulf syndrome." The dust becomes a warfare agent when toxic chemicals are microimpregnated into inert particles. The "dirty dust" concept, that the toxicity of an agent could be enhanced by absorption into inactive particles, dates from World War I. A growing body of evidence shows that coalition forces have encountered Iraqi chemical warfare in the theater of operation/Persian Gulf War to a much greater extent than early U.S. Department of Defense information had indicated. Veterans of that war were exposed to chemical warfare agents in the form of direct (deliberate) attacks by chemical weapons, such as missiles and mines, and indirect (accidental) contamination from demolished munition production plants and storage areas, or otherwise. We conclude that the microimpregnated sand particles in the theater of operation/Persian Gulf War depleted the immune system and simultaneously acted as vehicles for low-intensity exposure to chemical warfare agents and had a modifying-intensifying effect on the toxicity of exposed individuals. We recommend recognition of a new term, "dirty sand," as a subcategory of dirty dust/dusty chemical warfare agents. Our ongoing research efforts to investigate the health impact of chemical warfare agent exposure among Persian Gulf War veterans suggest that Al Eskan disease is a plausible and preeminent explanation for the preponderance of Persian Gulf War illnesses.     

The influence of military service on outpatient care use among racial/ethnic groups in Department of Veterans Affairs medical centers

This study examines race-specific military service effects on outpatient care utilization in the Department of Veterans Affairs (VA) using data from the 1992 National Survey of Veterans. The study population consisted of 4,791 male veterans. After controlling for predisposing, enabling, and need variables, black veterans were 3.7 times more likely than white veterans to use VA outpatient care. Veterans discharged from the military for medical release were less likely to use VA outpatient care (odds ratio = 0.76) than veterans discharged at the end of their normal terms. Hispanic veterans discharged for medical release were 5.3 times more likely than white veterans discharged for the same reason to use VA outpatient care. Korean conflict and mixed war period veterans were more likely to use VA outpatient care than World War II veterans. Racial/ethnic differences in military service characteristics influence the use of VA outpatient care and should be understood in delivering outpatient care to veterans.