higher prevalences of major depression (OR 3.67, 95% CI 3.0-4.4), chronic dysphoria, and anxiety. Anxiety and depression were more severe in lower income veterans.

The studies of psychologic outcomes in Australian Gulf War veterans were distinguished by inclusion of the entire deployed population and the use of direct assessments. McKenzie et al. (2004) used the SF-12, the PCL-M, and the GHQ-12 (12-item version of the General Health Questionnaire) to assess 1,424 male Gulf War veterans (86.5% Navy) and 1,548 male Australian Defence Force members who were not deployed to the Gulf War. On those self-rating instruments, the Gulf War-deployed had overall poorer psychologic health and more PTSD-like symptoms than control veterans. The psychologic distress increased with age in the comparison group but decreased with age in the Gulf War veterans (that is, the young Gulf War veterans had the worst psychologic ill-health). Moreover, the perceived level of exposure to war stress was associated with both psychologic ill-health and PTSD-like symptoms, although very few experienced direct combat.

Ikin et al. (2004) conducted a comprehensive health assessment of the same (Australian) cohort, including an interview-administered psychologic health assessment with the Composite International Diagnostic Interview (CIDI), a structured interview of demonstrated reliability and validity. The CIDI data allowed them to make an estimate of pre-Gulf War disorder, post-Gulf War disorder, and current (last 12 months) disorder. Those interview data were used with postal questionnaire data to form a complete workup of 1,381 Gulf War veterans, and 1,377 comparison veterans. Both the veterans and the controls completed both the health assessment and the postal questionnaire. The two groups were demographically similar, although the Gulf War veterans were significantly younger, more likely to have been in the Navy, and less highly ranked than the comparison veterans. The two veteran groups were similar in prevalence of prewar psychiatric disorders. However, the Gulf War veterans were more likely than the comparison group to have developed any disorder after the war (31% vs 21%). The greatest risks were for the anxiety disorders (for example, PTSD: OR 3.9, 95% CI 2.3-6.5), major depression (OR 1.6, 95% CI 1.3-2.0), and alcohol dependence/abuse (OR 1.5, 95% CI 1.2-2.0); the rates of somatic disorders were low in both groups. In addition, the Gulf War group was 2-5 times more likely to have anxiety, PTSD, obsessive-compulsive disorder (OCD), social phobia, or panic, than the comparison group in the preceding 12 months. On average, the Gulf War veterans had twice as many current psychiatric disorders as the comparison veterans. The strengths of this study were the large sample, the comparable control group, the use of well-validated psychologic interviews, and the analyzed participation bias, which was estimated to be low.

A study of DOD postwar hospitalizations for mental disorders (June, 1991-September 30, 1993) using 10 categories from the International Classification of Diseases, 9th Revision, Clinical Modification, 6th Edition (ICD-9-CM) was conducted by Dlugosz and colleagues (1999). It compared all active-duty personnel during the Gulf War era (n = 1,984,996) with those who did not serve. It also sought to identify risk factors for hospitalization. Nearly half the postwar hospitalizations were for alcohol-related disorders. Gulf War veterans were at greater risk for hospitalizations than nondeployed veterans due to drug-related disorders (RR 1.29, 95% CI 1.10-1.52) and acute reactions to stress (RR 1.45, 95% CI 1.08-1.94). Adjustments were made for age, sex, and military service branch. Although the database of ICD-9 codes does not allow determination of whether stress reactions expressly included PTSD, the authors noted that if posttraumatic stress was diagnosed, it would probably have been coded as an unspecified acute reaction to stress (ICD-9 code 308.9). Alcohol-related diagnoses were not increased. Exposure to the ground war in Iraq was associated with a greater risk of alcohol-related hospitalizations in



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