95% CI 2.2-8.9). Participation in combat was strongly associated with the development of various manifestations of anxiety: PTSD (OR 2.1, 95% CI 1.7-4.2), panic disorder (OR 6.2, 95% CI 3.0-13.0), and GAD (OR 2.1, 95% CI 1.2-3.5).

Using self-reports of symptoms occurring after 1990 from 1296 male UK veterans deployed to the Gulf War compared with 12,364 male UK veterans who were fit for duty but not deployed to the gulf, Simmons et al. (2004) found significantly (p < 0.001) increased risks of depression (OR 16.1, 95% CI 12.7-20.4); anxiety, stress, or sleep disturbance (OR 10.8, 95% CI 8.7-13.5); mood swings, aggression, or irritability (OR 16.1, 95% CI 13.2-19.7); and PTSD and associated symptoms (OR 34.9, 95% CI 20.8-58.7). ORs were adjusted for age at the time of the survey, service and rank at the time of the war, serving status at the time of the survey, alcohol consumption, and smoking. The questionnaire for the study focused on reproduction and child health but included open-ended questions about new medical problems or changes in health experienced by the veterans since 1990. However, confidence in the findings is weakened by the retrospective nature of the study and the relatively poor response rate (53% of Gulf War veterans and 42% of non-Gulf War veterans).

Dlugosz et al. (1999) examined risk factors for hospitalization for a mental disorder after service in the Gulf War. In active-duty men (n = 1,775,236) and women (n = 209,760) in the U.S. Army, Air Force, Navy, and Marine Corps, the investigators identified 30,539 initial postwar hospitalizations with a principal discharge diagnosis of a mental disorder by using the DMDC hospitalization database grouped into 10 ICD-9 codes. A sample of the military hospital charts was reviewed to assess reliability of the diagnoses in the large database files. Using Cox proportional-hazards regression models, the investigators examined the association between Gulf War deployment and hospitalization for mental disorders. Adjusted incidence risk ratios showed that being deployed in combat or combat support units but not being in the ground war in Iraq or Kuwait in February 1991 was associated with an increased risk of hospitalization because of acute reactions to stress (risk ratio 1.57, 95% CI 1.11-2.22). Veterans who had served in combat troops or combat support troops during the ground war were not at increased risk for hospitalizations for mood, neurotic disorders, personality disorders, adjustment disorders, or acute stress reactions. Moreover, Gulf War veterans were not significantly different from their nondeployed counterparts with regard to psychiatric comorbidities at the time of initial hospitalization.

Patterns of comorbid psychiatric disorders in veterans of the Gulf War were also reported by Forman-Hoffman et al. (2005). In Phase I, data were obtained from the Iowa Gulf War Study conducted in 1995-1996 on a stratified random sample of 3695 Gulf War-deployed and elsewhere-deployed military personnel who resided in Iowa and participated in a telephone survey. In Phase II, 374 veterans from Phase I who had symptoms of cognitive dysfunction, depression or chronic widespread pain and 228 veterans who did not have any of these conditions, received in-person assessments in 1999-2002. Assessment included administration of the Anxiety Sensitivity Index for depressive and anxious symptoms, the Mini-Mississippi Index for PTSD, the Barsky Amplification Scale for social support and somatization symptoms, and the SF-36 for personality traits, pain, and health-related quality of life and the SCID-IV. Mental-health comorbidity was based on a diagnosis of at least two current mental disorders from the SCID-IV and independent psychiatrist review in which the psychiatrist was blinded to case and deployment status. Of the 602 surveyed veterans, 32% had a current mental disorder, primarily anxiety disorders (22.4%), depressive disorders (14.2%), and substance-use disorders (5.9%). Over 35% of veterans with a current mental disorder had at least one other co-occurring mental



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