and found that the higher the war-zone stress, the more severe the depressive and anxiety symptoms. Compared with nondeployed troops, troops who were assigned to high-risk activities, such as grave registration, showed a high prevalence of PTSD (0% vs 48%).

Ikin et al. (2004) conducted a comprehensive health assessment of 1424 male Gulf War veterans (86.5% Navy) and 1548 male Australian Defence Force members who were not deployed to the Gulf War, including an interview-administered psychological 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 1381 Gulf War veterans, and 1377 comparison veterans. Both the veterans and the controls completed 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 somatoform disorders (referred to as “any somatic disorders” by the study authors) were low in both groups (OR 1.9, 95% CI 0.8-4.5). In addition, the Gulf War group was significantly more likely to have any anxiety disorder (OR 2.2, 95% CI 1.6-3.2), PTSD (OR 4.1, 95% 2.4-7.2), obsessive-compulsive disorder (OCD) (OR 5.2, 95% CI 1.6-16.7), social phobia (OR 3.4, 955 CI 1.7-6.6), or panic disorder (OR 2.6, 95% CI 1.0-6.3), 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 psychological interviews, and the analyzed participation bias, which was estimated to be low.

A study of DoD postwar hospitalizations for mental disorders (June 1, 1991, to 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 men (RR 1.13, 95% CI 1.04-1.23). Serving as support for the ground war without being in direct combat was associated with a greater risk of drug-related hospitalizations in men (RR 1.42, 95% CI 1.03-1.96) and women (RR 3.61, 95% CI 1.70-7.66). The limitation of this study is that it examined only hospitalizations and thus was not representative of most psychiatric disorders that require outpatient treatment rather than hospitalization. It also did not include veterans who left the military after the Gulf War.

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