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Research Service, Boston Veterans Affairs (VA) Healthcare System, Brockton, Massachusetts, Massachusetts Mental Health Center Public Academic Psychiatry Division of the Beth Israel Deaconess Medical Center Department of Psychiatry, Harvard Medical School Department of Psychiatry, Harvard Institute of Psychiatric Epidemiology and Genetics and Psychology Department, Boston University, Boston, Massachusetts
Environmental Epidemiology Service, Department of Veterans Affairs, Washington, DC
Veterans Affairs Medical Center, Boston and Department of Medicine, Division of Pulmonary and Critical Care Medicine, Boston University School of Medicine, West Roxbury, Massachusetts
Psychiatry Service, VA San Diego Health Care System and University of California, San Diego, California
VA South Central (VISN 16) Mental Illness Research, Education and Clinical Center, New Orleans Veterans Affairs Medical Center and Department of Psychiatry and Neurology, Tulane University School of Medicine, New Orleans, Louisiana
Cooperative Studies Program Coordinating Center, Hines Veterans Affairs Hospital, Hines, Illinois
University of Colorado Health Outcomes Program and Department of Preventive Medicine and Biometrics, Aurora, Colorado
Veterans Health Administration, Department of Veterans Affairs, and Uniformed Services for the Health Sciences, Washington, DC
Medical and Research Services, St Louis Department of Veterans Affairs Medical Center and Department of Internal Medicine, Division of General Medical Sciences, Washington University School of Medicine, St Louis, Missouri, USA
Correspondence: Dr Rosemary Toomey, Toomey, Psychology Department, Boston University, 648 Beacon Street, 6th Floor, Boston, MA 02215, USA. Tel: +1 617 358 3048; fax: +1 617 358 1380; email: rosemary_toomey{at}hms.harvard.edu
Funding detailed in Acknowledgements.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Aims To assess the prevalence of warera onset mental disorders in US veterans deployed to the Gulf War and in non-deployed veterans 10 years after the war.
Method Mental disorders were diagnosed using structured clinical interviews. Standard questionnaires assessed symptoms and quality of life.
Results Gulf War-era onset mental disorders were more prevalent in deployed veterans (18.1%, n=1061) compared with non-deployed veterans (8.9%, n=1128). The prevalence of depression and anxiety declined 10 years later in both groups, but remained higher in the deployed group, who also reported more symptoms and a lower quality of life than the non-deployed group. Remission of depression may be related to the presence of comorbid psychiatric disorders and level of education. Remission of anxiety was related to treatment with medication.
Conclusions Gulf War deployment was associated with an increased prevalence of mental disorders, psychological symptoms and a lower quality of life beginning during the war and persisting at a lower rate 10 years later.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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METHOD |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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For the examination phase of the study, a list of potential participants was created by random selection from the 11 441 deployed and 9476 non-deployed veterans who participated in the 1995 study, stratified by deployment status and region of last known residence at the time of the original survey (based on home telephone area code). Potential participants were assigned to the participating Veterans Affairs (VA) medical centre closest to their home. Participating medical centres were located in Albuquerque, Baltimore, Birmingham, Boston, Cincinnati, Hines (Chicago), Houston, Miami, Minneapolis, New Orleans, New York, Portland (Oregon), Richmond, Salt Lake City, San Diego and St Louis. Recruitment packages that included an introductory letter, a detailed explanation of the purpose and nature of the study, a letter of intent form and a pre-addressed stamped return envelope were mailed to the veterans. Because of lower participation among non-deployed veterans, an additional 799 were solicited to obtain examined groups of equal size.
Signed letters of intent were returned to the Hines VA Cooperative Studies Program Coordinating Center, which forwarded them to the participating VA medical centre to which the veteran was assigned. Site personnel then contacted the participant and scheduled the examination. Travel, hotel, per diem costs and an honorarium of $200 were provided by the research project. The protocol and consent form were approved by the Hines Cooperative Studies Program Human Rights Committee and the institutional review board at each individual site and at the Brockton Veterans Affairs Medical Center. Participants gave signed informed consent shortly before the start of the examination.
Mental health assessment
Mental health was assessed using two methods: structured clinical
interviews, yielding mental disorder diagnoses; and paper-and-pencil,
self-report measures of current symptoms. In the structured interviews,
participants were asked about their lifetime experience of different symptoms,
including the times when symptom constellations started and stopped. With
these data, onset prevalence for disorders was calculated for the period
ranging from 1 January 1991 to 30 July 1993, which encompasses the period from
the beginning of the conflict to the date beyond which no further deployment
to the Middle East occurred. Disorders with an onset during this period are
referred to as Gulf War-era onset disorders. To assess the course of these
mental disorders, prevalence rates were assessed for war-era onset disorders
still present within 1 year of the current study, approximately 10 years after
the resolution of the Gulf War. We also calculated the prevalence of disorders
with onset prior to January 1991 and overall lifetime prevalence.
Mental disorders
Diagnoses of post-traumatic stress disorder (PTSD) were made with the
Clinician Administered PTSD Scale (CAPS;
Blake et al, 1995), a
structured interview yielding PTSD diagnoses according to DSM–IV
criteria (American Psychiatric Association,
1994). Participants first indicated their exposure to stressful
life events on a standard life events checklist; a follow-up interview then
assessed whether these events met criterion A (exposure to a traumatic event).
This assessment was not externally validated through record review. The
participant was then asked to choose the two most stressful of the events
reported. The symptom interview focused on the presence of any PTSD symptoms
related to the two events, over the veteran's lifetime as well as in the past
month. Symptoms were assessed regardless of whether the selected events met
criterion A, but the disorder was only diagnosed if both criterion A and the
symptom criteria were met. Participants could receive up to two diagnoses of
PTSD associated with the two events; however, cases of PTSD in the time
intervals discussed above were calculated per individual. We asked whether
events were related to the Gulf War. In assessing the presence of war-era
onset PTSD 10 years after the war, we assured that PTSD diagnoses were linked
by event (e.g. if a person had war-era onset PTSD from event 1, we checked the
duration of the PTSD related to event 1 to determine whether it was present 10
years later). The remaining DSM–IV Axis I psychiatric diagnoses were
made using the Composite International Diagnostic Interview (CIDI;
Andrews & Peters, 1988), a
computerised structured interview which yields diagnoses based on DSM–IV
criteria. Diagnoses were then categorised according to the DSM–IV
classification system.
Symptoms
Current psychiatric symptom severity was assessed using three scales.
Higher scores on all three scales indicate greater symptoms. The PTSD
Checklist (Blanchard et al,
1996) was used to assess PTSD symptoms in the past month using 17
items rated on a scale of 1 to 5. We report the mean total score and the
percentage of probable PTSD cases, defined by a total score of 50 or greater.
The Beck Depression Inventory II (BDI–II;
Beck et al, 1996) was
used to assess depressive symptoms in the past 2 weeks using 21 items rated on
a scale of 0 to 3. We report the mean total score and the percentage of cases
in the following categories of depression severity: minimal (total score
0–13), mild (14–19), moderate (20–28) and severe
(29–63). The Beck Anxiety Inventory (BAI;
Beck & Steer, 1993) was
used to assess anxious symptoms in the past week using 21 items rated on a
scale of 0 to 3. We report the mean total score and the percentage of cases in
the following categories of anxiety severity: minimal (total score 0–7),
mild (8–15), moderate (16–25) and severe (26–63).
Quality of life
Healthcare quality of life
The 36-item Short Form Health Survey (SF–36;
McHorney et al, 1993;
Ware et al, 1993;
Kazis et al, 1998)
was used to assess mental health-related quality of life in the 4 weeks
preceding the evaluation. Items focused on current perception of health and
normal daily functioning were rated on a Likert scale, and were summed into
physical and mental component scores. Scores were standardised to a mean of 50
and standard deviation of 10; higher scores indicate better quality of life.
We have previously reported on the physical component scores
(Eisen et al, 2005),
and report on only the mental component in this paper.
General quality of life
The Quality of Life Inventory (QoLI;
Frisch, 1994) was used to
measure general life satisfaction. It enquires about 16 areas of life, which
are rated by participants on importance to their overall happiness and
satisfaction with the area. The 16 areas of life in the inventory are health,
self-esteem, goals and values, money, work, play, learning, creativity,
helping, love, friends, children, relatives, home, neighbourhood and
community.
Combat exposure
The Combat Exposure Scale (CES; Wolfe
et al, 1998) was expanded from the original version of
the scale (Gallops et al,
1981), which focuses on the presence and frequency of a range of
war-zone stressors. Expanded items reflect war-zone events specific to service
in the Gulf War, which in some cases extend beyond combat. Given that
traditional combat in the Gulf War lasted only 5 days and did not involve all
personnel, the expanded items inquire about less traditional war-zone events
compared to the original items. The questionnaire was self-administered, and
participants responded whether they experienced each event on the list. The
responses are `no' (rated 0), `once or twice' (1) or `three or more times'
(2). The total score on all 33 items was used as a measure of war-zone
stressor exposure.
Training and quality control
Research assistants received CIDI training from Dr L. N. Robins and her
staff (Dr Robins is the author of the Diagnostic Interview Schedule on which
the CIDI is based). Training in use of the CAPS was conducted by Dr Frank
Weathers of the Brockton Psychometrics Laboratory, Brockton, Massachusetts,
USA; one of the creators of the interview, and he co-rated 20 CAPS interviews
for interrater reliability. One of the authors (R.T.) supervised ongoing
ratings and overall quality through weekly calls and periodic reviews.
Statistical analyses
Sample size calculations and participant recruitment efforts for this
project were based on the predicted prevalence of disease among veterans. The
achieved sample size provided 80% power to detect prevalence differences of
2.0% for PTSD (assumed deployed veterans prevalence 2.8%, non-deployed
veterans 0.8%), and a mean difference of 1.5 (s.d.=10) for the SF–36
mental component scores. Interrater reliability was assessed with intraclass
correlations for CAPS continuous variables (frequency and intensity) for
symptom clusters and individual symptoms and with kappa coefficients for PTSD
diagnoses.
The sampling design is a stratified random sample with unequal probabilities of selection within combinations of the strata: deployment status, gender and duty type (active service v. reserve or National Guard). Therefore, population prevalence or mean estimates for all analyses were obtained using SUDAAN software developed for the analysis of complex survey data (SUDAAN release 9.0, Research Triangle Institute, North Carolina, USA). Sample weights used in SUDAAN were based on the probability of selection combined with the probability of response. For continuous outcomes, t-tests and linear regression models compared mean responses between groups. Logistic regression models were developed for dichotomous and ordinal polytomous outcomes. The covariates considered in the multiple regression models were age, gender, ethnicity (White v. other), years of education (less than 12 years v. 12 years or more), duty type (active v. reservist/National Guard), service branch (army/marine v. navy/air force) and rank (enlisted v. officer). Candidate covariates were deleted for particular models when they caused computational problems preventing model calculation. Odds ratios, 95% confidence intervals and P values are reported for dichotomous outcomes. Comparisons of categorical data and continuous data with adjustment for covariates were based on the Wald F-statistic. For continuous data without adjustments, P values were based on the two-sample t-test.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Participation rates
Of the 1996 deployed veterans who were solicited to participate, 53% (1061)
were examined; of 2883 non-deployed veterans who were solicited to
participate, 39% (1128) were examined. Despite intensive efforts, 12.8% of
deployed veterans and 15.2% of non-deployed veterans were not located. In
addition, 34.1% of locatable deployed veterans and 45.6% of non-deployed
veterans either never returned their participation letter, or an examination
could not be scheduled. Because of the lower participation rates by
non-deployed veterans, more people in this category (n=799) were
recruited to achieve the desired sample size of 1000 per group.
Participation bias
Historical military service data, obtained in 1991 for all solicited
veterans from the US Department of Defense's Manpower Data Center, were used
to evaluate participation bias on socio-demographic variables. We compared
participants and non-participants in each group (deployed and non-deployed)
and then used the Breslow–Day homogeneity of odds ratios test to assess
the hypothesis that the odds ratios generated for the two groups were
equal.
Participation bias for demographic characteristics is reported in more detail elsewhere (Eisen et al, 2005). Briefly, we found that participants were nearly 2 years older than non-participants, and that White people, women, reservists and National Guard members were significantly more likely to participate. In addition, officers and army personnel were more likely to participate than non-officer and non-army personnel, although these differences were not uniformly significant. We also calculated participation bias for mental health characteristics available from the 1995 survey. Dichotomous data were available on smoking (`Have you smoked in the past 12 months?'), drinking (`Do you drink alcohol?'), depression (`Have you experienced in the past year: difficulty getting to sleep; excessive sleepiness; awaken feeling tired; anxious, irritable, or upset; been depressed or blue; difficulty concentrating or reasoning, memory loss?' `Have you experienced in the past 6 months: unintended loss of more than 10 pounds, unintended gain of more than 10 pounds?') and PTSD symptom severity (the PTSD Checklist). Participants did not differ from non-participants in each group on smoking, drinking, weight loss or PTSD symptom severity. Participants in each group more frequently reported the other mood symptoms; however, the degree of participation bias did not differ quantitatively between the groups. The only characteristic that yielded a statistically significant difference in the odds ratios generated by the two groups was 1995 active duty status (Eisen et al, 2005). Overall, the degree of participation bias was independent of deployment status.
Reliability of CAPS
Interrater reliability was calculated for 32 continuous CAPS symptom
variables (frequency and intensity ratings for symptom clusters B, C and D,
and total symptoms, current and lifetime, for two events). Excellent
interrater reliability was demonstrated by high (0.90 or higher) intraclass
correlations for 31 of these variables and one moderately high (0.86)
intraclass correlation (event 1 cluster C intensity). The kappa coefficient
was 0.77 for the diagnosis of current PTSD and 0.79 for the diagnosis of
lifetime PTSD, indicating good reliability.
Prevalence of all war-related mental disorders
The prevalence of any one Gulf War-era onset mental disorder (i.e. reported
initial onset between 1 January 1991 and 30 July 1993) was significantly
higher among the deployed veterans than among the non-deployed veterans
(Table 1). The broader
categories of mood disorders and anxiety disorders were also significantly
more prevalent among the former group. Specific disorders within those
categories that were significantly more prevalent among the deployed veterans
compared with non-deployed veterans were major depression, PTSD, panic
disorder and specific phobias. Of the deployed veterans with a PTSD onset in
the war-era, in 93% of cases the PTSD was related to a Gulf War event. Two
less common disorders also differed significantly between groups: pain
disorder was significantly more common in the deployed veteran group, and
brief psychotic disorder was significantly more common among the non-deployed
veterans.
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Prevalence of war-related mental disorders 10 years later
War-era onset disorders that were significantly more prevalent among
deployed veterans than among non-deployed veterans and had a prevalence of at
least 1% in both groups were examined for their continued presence in the year
prior to the examination (i.e. if the disorder began during the war, was it
currently active within 1 year of our examination, approximately 10 years
later). In the case of recurrent episodes of major depression, there would
have been an initial episode in the war-era and an episode in the year prior
to the examination, however, the episodes might have come and gone in the
intervening period. We combined non-PTSD anxiety disorders into one group to
yield a larger event rate for further analyses. Using our whole sample,
war-era onset major depression continued to be significantly more prevalent 10
years later in the deployed veterans group (3.2%) compared with the
non-deployed group (0.8%, adjusted P=0.01)
(Fig. 1). Comparing the odds
ratios representing degree of remission, deployed veterans were 3.33 times
more likely to be in an episode of depression 10 years later, whereas
non-deployed veterans were significantly more likely to be in current
remission (P=0.048). To determine whether severity of initial
depression at the time of the war might have differed in the two groups, we
examined the severity of depression (mild, moderate, severe) during that
period and found that it did not differ between the two groups
(P=0.89). We also examined the presence of comorbid psychiatric
disorders with warera onset. There was a trend for deployed veterans with
depression to be more likely to have a comorbid psychiatric disorder (45.6%)
than non-deployed veterans with depression (25.8%, P=0.11) and the
deployed group displayed a trend for having more anxiety disorders, including
PTSD (P=0.07).
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Use of medication for depression and anxiety
We examined medication use at the time of assessment in veterans having
war-era onset mental disorders to determine whether those with remitted
disorders were being successfully treated with medication. Of the 44 veterans
(36 deployed, 8 non-deployed) with war-era onset depression who still met
criteria within a year of our assessment, there was no significant difference
in the percentage taking any antidepressant medication (deployed 17.1%,
non-deployed 33.4%; P=0.43), although nearly twice the number of
non-deployed veterans were taking medication. Of the 89 veterans with war-era
onset depression whose depression had remitted, those who had been deployed
(13.1%) were taking antidepressant medication at over twice the rate of
non-deployed veterans (5.2%), but these rates were not statistically different
(P=0.25). Overall, 14.9% of deployed veterans and 10.7% of
non-deployed veterans with war-era onset depression took medication for
depression at the time of their assessment. For those with any lifetime
depression, 20.7% of those who were deployed and 14.2% of those who were not
took medication for depression at the time of assessment.
Veterans diagnosed with PTSD and/or other anxiety disorders were examined for their use of both anti-anxiety and antidepressant medications, as both are commonly prescribed for anxiety disorders. We combined PTSD and other anxiety disorders for this analysis because the total sample size (n=135: PTSD only, n=73; other anxiety only, n=47; both, n=15) was similar to the sample size with warera onset depression (n=133) and we were concerned that by analysing PTSD (n=88) separately from other anxiety disorders (n=62) the cells would be too small for a meaningful analysis to be performed. Of the 78 veterans (deployed, n=61; non-deployed, n=17) with war-era onset anxiety disorders who still met criteria within 1 year of our assessment, a higher percentage of non-deployed (22.9%) than deployed (12.4%) veterans were taking medication for anxiety, but the rates were not statistically different (P=0.40). Of the 57 veterans with war-era onset anxiety whose disorders had remitted, significantly fewer deployed veterans (4.9%) took medication in comparison with non-deployed veterans (37.4%; P=0.02). Overall, 8.3% of deployed veterans and 26.6% of non-deployed veterans with war-era onset anxiety disorders were taking specific medication for anxiety at the time of assessment. For those with any lifetime anxiety disorder, 17.2% of deployed veterans and 15.4% of non-deployed veterans took medication for depression at the time of assessment. We conducted a Cochran–Mantel–Haenszel Test in SUDAAN using the entire cohort to examine if there was differential use of medication for anxiety in the two study groups. Among the deployed group there was no difference in medication usage between those with and without anxiety disorders, but among the non-deployed group those with anxiety disorders were 6.15 times more likely to take medications than those without an anxiety disorder (P=0.04).
Prevalence of mental disorders prior to the war and lifetime prevalence
We examined whether major depression, PTSD and non-PTSD anxiety disorders
with an onset prior to the Gulf War (before 1 January 1991) differed between
groups. There was no significant difference for depression (deployed 5.9%,
non-deployed 7.0%; P=0.97) or PTSD (deployed 3.9%, non-deployed 4.2%;
P=0.60), but the deployed group had significantly more non-PTSD
anxiety disorders (deployed 12.5%, non-deployed 9.2%; P=0.02). Having
had any one mental disorder with an onset prior to the war did not
differentiate the groups (deployed 25.9%, non-deployed 24.6%;
P=0.13).
Lifetime prevalence of depression did not differ between the groups (deployed 21.3%, non-deployed 18.2%; P=0.22). Lifetime prevalence of PTSD (deployed 10.8%, non-deployed 6.7%, P=0.01), non-PTSD anxiety disorders (deployed 16.9%, non-deployed 11.0%, P=0.0003) and one or more mental disorders (deployed 43.6%, non-deployed 35.5%, P=0.01) were all significantly higher in the deployed group compared with non-deployed veterans.
Predictors of war-related mental disorders
Given that the deployed veterans group displayed a greater prevalence of
Gulf War-era onset depression, PTSD and non-PTSD anxiety disorders compared
with the non-deployed veterans, logistic regression was employed to examine
predictors of these war-onset conditions. Simultaneous independent variables
included deployment, pre-1991 onset of any one mental disorder (representing
psychological vulnerability), combat (i.e. war-zone stressor) exposure, and
demographic factors (age, gender, ethnicity, educational attainment in 1991,
duty type, service branch and rank). For depression, pre-1991 mental disorder
(P=0.009), war-zone stressor exposure (P=0.002) and gender
(P=0.048) were significant. For PTSD, deployment was the only
significant independent variable (P=0.03). For non-PTSD anxiety
disorders, deployment (P=0.009), pre-1991 mental disorder
(P=0.008), war-zone stressor exposure (P=0.0008), gender
(P=0.0002) and duty type (P=0.0499) were all
significant.
Self-report of symptoms and quality of life
Participants in the deployed veterans group self-reported more severe
current symptoms of PTSD, depression and anxiety at the time of the assessment
(Table 2), compared with the
non-deployed group. Deployed veterans' mental component summary scores on the
SF–36 were significantly lower than the non-deployed veterans' scores
(50.0 v. 53.7), reflecting a more negative self-perception of mental
health-related quality of life. Deployed veterans also reported lower levels
of general life satisfaction on the QoLI than did non-deployed veterans, with
24.5% of the former group reporting below-average quality of life (v.
15.8%). When we examined groups on the 16 areas assessed in the QoLI, deployed
veterans reported significantly less satisfaction with the following seven
areas: health (P=0.0001), self-esteem (P=0.02), goals and
values (P=0.04), play (P=0.01), learning (P=0.001),
love (P=0.03) and children (P=0.049).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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We found that the prevalence of warera onset of mental disorders was significantly higher among deployed compared with non-deployed veterans; in particular, deployed veterans exhibited an increased prevalence of depression, PTSD and non-PTSD anxiety disorders, all of which had a prevalence over 1% in both groups. Ten years later, these cases of depression and non-PTSD anxiety disorders remained significantly more prevalent among deployed compared with non-deployed veterans. Post-traumatic stress disorder was over three times more prevalent among deployed veterans. As evidenced by these continued mental disorders as well as self-reported current symptoms of emotional distress, deployed veterans experienced more psychological distress and mental disorders than the non-deployed veterans both during deployment or immediately after the Gulf War, as well as 10 years later. Our results also indicate that deployment had multiple adverse effects on quality of life (health-related and non-health-related) 10 years later. However, whereas deployed veterans reported statistically significantly lower scores on the SF–36 mental component summary compared with the non-deployed group, the mean group difference of 3.9 fell short of the 4.0 group difference typically used with this measure as an index of clinical significance (Wyrwich et al, 1999). Likewise, mean totals on the symptom scales did not reach the clinically impaired range, although deployed veterans were more likely to be in clinically impaired categories on these scales than non-deployed veterans.
Limitations
Our determination of the onset of mental disorders during the Gulf War era
was based on the participants' retrospective report, and their recall might
have been biased by their symptoms and later experiences. We did not
externally validate self-report of exposure to trauma (criterion A1). As
suggested by Frueh et al
(2005), self-report of combat
trauma in veterans may be exaggerated. However, our epidemiological sample is
more similar to that of Dohrenwend et al
(2006) than the
treatment-seeking sample of Frueh. Dohrenwend found that self-report of combat
exposure correlated highly with record-based evidence of combat exposure. Our
use of `state of the art' assessment of criterion A2 helps ensure the validity
of our ratings for the presence of criterion A. Although we demonstrated a
lack of participation bias for demographic characteristics and selected
queries regarding mood, we did not examine mental disorder diagnoses during
the postal and telephone survey portions of our study. Therefore, whether
increased mental disorders in the deployed group possibly reflected increased
participation among deployed veterans compared with non-deployed veterans is
addressed only indirectly through consideration of distress symptoms.
Causes of war-related psychological distress
The increase in psychological dysfunction in the deployed veterans could be
due to multiple factors. We examined the contribution of deployment status,
pre-war psychological vulnerability, combat exposure and demographic variables
on disorders with Gulf War-era onsets. Only deployment predicted war-era onset
of PTSD, and deployment also predicted war-era onsets of non-PTSD anxiety
disorders. The war-era onsets of non-PTSD anxiety and depressive disorders
were also associated with the presence of pre-war psychological vulnerability,
higher levels of combat exposure and female gender.
Exposure to traumatic events is a well-recognised hazard of war, and an acknowledged precipitant of psychiatric morbidity (Goldberg et al, 1990a,b; Kulka et al, 1990) and post-war syndromes (Hyams et al, 1996). However, because exposure to trauma does not uniformly lead to psychiatric morbidity (Green, 1994; Kessler et al, 1995) or increased symptom complaints (Eisen et al, 1991), individual vulnerability (Kulka et al, 1990; True et al, 1993; Kessler et al, 1995; Bromet et al, 1998; Roy et al, 1998; Shalev et al, 1998; Yehuda et al, 2000) is likely to be an important contributory factor. Consistent with prior research documenting that traumatic stress exposure is associated with disorders such as depression in addition to PTSD (Shalev et al, 1998), psychopathology in our cohort that began during the Gulf War era was not specific to PTSD but encompassed anxiety disorders more generally and depression. The development of these other disorders among deployed veterans might reflect the adverse psychological consequences of exposure to non-traumatic stressors associated with Gulf War participation, such as unexpected career and family disruption related to the rapid activation of an all-volunteer force with significant reservist and National Guard representation, uncertainty regarding anticipated chemical and biological warfare, or other deployment stressors (Nash, 2007). Our findings suggest that pre-existing mental disorders represent an individual vulnerability factor for the development of mental disorders during war deployment.
The classic way in which wars are thought to influence psychological well-being are the effects of exposure to combat-related traumatic stressors on the development of PTSD. Our interest in the more general effects of deployment across mental disorders led us to focus on onset during the interval of deployment rather than specific exposures to war-zone stressors. Thus, the war-era onset of PTSD cases does not overlap completely with traditional combat-related PTSD. Moreover, we did not externally validate self-report of combat experiences, which might have resulted in some overestimation of actual experiences (Dohrenwend et al, 2006; Frueh et al, 2005), nor did we capture combat-related PTSD cases with an onset later than 30 July 1993, which might have resulted in underestimation of PTSD cases. Nevertheless, our data demonstrate that deployment to the Gulf War did contribute to a greater onset of major depression, PTSD and other anxiety disorders, with some persisting problems in these veterans 10 years later. Perhaps a broader conceptualisation of the relationship between war deployment and psychological functioning than the link between combat stress and PTSD would better represent health consequences for our combat veterans. This expanded view might also help to explain how the experience of combat deployment could contribute to a reduced quality of life a decade after the war.
Hobfoll's stress model of conservation of resources (Hobfoll, 1989) provides one perspective on the multiple impacts of stress. This model posits that individuals, when confronted with stress, try to minimise their net loss of resources. Stress involves a loss or potential loss of resources, including object resources (e.g. a home), conditions (e.g. a marriage, a state of peace), personal characteristics (e.g. an optimistic view of the world) and energies (e.g. time). Deployment is a condition involving loss of resources regardless of whether combat trauma was experienced. Coping itself depletes resources that may or may not offset the original loss of resources, and `loss spirals' may develop when people have limited resources to offset an initial loss, or when coping reduces available resources needed to fend off future losses. For example, in relation to our findings, war stress (traumatic or non-traumatic) involves a loss of resources. Someone with optimistic tendencies has a resource to help buffer the loss of other resources related to war stress. In contrast, someone with pessimistic tendencies may require additional resources to offset their pessimism and insure protection against the development of additional depressive symptoms. For either person, energy spent on offsetting the loss of resources due to deployment may take away from investment in various domains ensuring enhanced quality of life.
Medication use
We examined the likelihood of remission of war-era onset disorders in
deployed v. non-deployed veterans. Depression was less likely to
remit among deployed than non-deployed veterans, although the levels of
antidepressant use in the two groups were similar. To explore possible
explanations of these differential remission rates, we compared the study
groups on the severity of the depression during the Gulf War era, as well as
on the presence of comorbid war-era mental disorders. The severity of
depression in the two groups did not differ. Depressed deployed veterans were
twice as likely as depressed non-deployed veterans to have comorbid war-era
onset mental disorders. The presence of these comorbid disorders could explain
the reduced likelihood of remission of depression in the deployed veterans
group. Trivedi et al
(2006) identified predictors
of remission in out-patients with major depressive disorder. Participants who
were White, female, employed, or had higher levels of education or income had
higher remission rates for depression, whereas longer index episodes, more
concurrent psychiatric disorders, more general medical disorders and lower
baseline function and quality of life were associated with lower remission
rates. Thus, increased comorbidity and lower levels of education among our
deployed veterans could have contributed to lower remission rates of
depression. Parker et al
(2000) examined 12-month
outcome in 182 persons with major depression. Non-recovery at 12 months was
predicted most consistently by higher baseline levels of anxiety and
depression; high trait anxiety and a lifetime anxiety disorder; disordered
personality function; and self-reported exposure to acute and enduring
stressors at baseline assessment. The more complicated clinical presentation
of multiple comorbidities associated with exposure to war stressors in our
deployed veterans group might have contributed to their continued depression
compared with the non-deployed group.
Anxiety disorders were equally likely to remit in the two groups, but non-deployed veterans with anxiety in remission were more likely to be taking medication than deployed veterans in remission. Indeed, in the entire cohort, non-deployed veterans with anxiety disorders were more likely to take medication for these disorders than deployed veterans with anxiety disorders. The reason for this treatment disparity is unclear and we do not know whether the deployed veterans were less likely to be prescribed medication for anxiety disorders or were less likely to take anti-anxiety medication compared with the non-deployed group.
Implications of the study
The prevalence of Gulf War-era depression, anxiety – and even PTSD to
some extent – abates with time. The prevalence of all these conditions
decreased among both our study groups 10 years after the Gulf War compared
with the rates that were found in immediate proximity to the war. Continued
depression in deployed veterans appears partially resistant to remission
despite comparable levels of medication use in the two groups; however,
anxiety disorders might possibly remit further in deployed veterans with
greater use of medications. The presence of comorbid psychiatric disorders may
make it less likely that depression will remit. We do not know the extent to
which the groups might or might not have differed in their use of
psychological treatments for these conditions, but the findings point to the
need for adequate follow-up mental healthcare for veterans with persistent
mental illnesses following major military operational deployments.
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ACKNOWLEDGMENTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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We acknowledge the staff at the Brockton Psychometrics Laboratory, Brockton, Massachusetts: Lisa James and Zachary Warren, research assistants; Michael Lyons, PhD, Frank Weathers, PhD, and Marie Walbridge, PhD, consultants. Finally, we thank the participating veterans and their families for their time and effort.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Received for publication November 15, 2005. Revision received August 21, 2006. Accepted for publication November 6, 2006.
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