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Evaluation of the U.S. Department of Defense Persian Gulf Comprehensive Clinical Evaluation Program EXECUTIVE SUMMARY In July 1994, the U.S. Department of Defense (DoD) asked the Institute of Medicine (IOM) to establish a committee to evaluate its Comprehensive Clinical Evaluation Program (CCEP). Since their return from service in the Persian Gulf region during Operations Desert Shield and Desert Storm, some active-duty military personnel and veterans have reported a variety of health problems that they perceived to be associated with their senice in that region. The DoD instituted the CCEP in June 1994 to evaluate and treat the health problems of these active-duty personnel. The DoD then asked the IOM committee to evaluate the protocol for the clinical evaluations and to comment on the interpretation of the CCEP results that have been obtained so far. In addition, the committee was asked to make recommendations relevant to the conduct of the clinical evaluations in the future and to the broader program of the DoD Persian Gulf health studies, if appropriate. The purpose of this report on the CCEP is to provide a comprehensive evaluation of the major issues that the committee has identified since its first meeting in October 1994. The CCEP is a compassionate and comprehensive effort to address the clinical needs of thousands of active-duty personnel who served in the Persian Gulf War. The CCEP clinical protocol is a thorough, systematic approach to the diagnosis of a wide spectrum of diseases. A specific medical diagnosis or diagnoses can be reached for most patients by using the CCEP protocol. The DoD has made conscientious efforts to build consistency and quality assurance into this program at the many medical treatment facilities and regional medical

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2 EVALUATION OF THE U.S. DEPARTMENT OF DEFENSE PERSIAN GULF COMPREHENSIVE CLINICAL EVALUA TION PROGRAM centers across the country. This nationwide effort was implemented relatively quickly. The committee commends the DoD for its efforts to provide high- quality medical care in the CCEP and the success it has achieved to date in developing the infrastructure necessary to efficiently contact, schedule, refer, and track thousands of patients through the system. Of the first 10,020 CCEP patients, 37% were diagnosed with a psychiatric condition, most commonly depression or posttraumatic stress disorder. Many of the psychiatric diseases found in the CCEP population have both physical and psychological symptoms and manifestations. The IOM committee encourages the DoD to emphasize in its future reports that psychosocial stressors can produce physical and psychological effects that are as real and potentially devastating as physical, chemical, or biological stressors. The committee also encourages the DoD to emphasize that effective treatments exist for many of these psychiatric disorders. There is currently no clinical evidence in the CCEP for a previously unknown, serious illness among Persian Gulf veterans. If there were a new or unique illness or syndrome among Persian Gulf veterans that could cause serious impairment in a high proportion of veterans at risk, it would probably be detectable in the population of 10,020 CCEP patients. On the other hand, if an unknown illness were mild or only affected a small proportion of veterans at risk, it might not be detectable in a case series, no matter how large. The DoD and the U.S. Department of Veterans Affairs (DVA) are sponsoring several large research studies that may provide more definitive answers as to whether there is a new, unique Persian Gulf Syndrome. The CCEP was not, however, designed to answer epidemiological questions. Instead, it was designed as a medical evaluation and treatment program. In a recent report on 10,020 patients, the DoD compares the symptoms and diagnoses in the CCEP with the symptoms and diagnoses in several community-based and clinically based populations. The committee concludes that interpretations based on comparisons with other populations should be made with great caution and only with the explicit recognition of the limitations of the CCEP as a self- selected case series. The CCEP results do have considerable clinical utility, and they could be used to address many important questions from a descriptive perspective. The results of the CCEP can and should be used for several purposes including ( 1) educating Persian Gulf veterans and the physicians caring for them, (2) improving the medical protocol itself, and (3) evaluating patient outcomes. The medical findings of the CCEP should be distributed promptly to all CCEP primary care physicians. The medical findings of the CCEP would also be of considerable value and interest to physicians in the DVA system and in the community.