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OCR for page 29
EVALUATION OF THE U.S. DEPARTMENT OF DEFENSE PERSIAN 29
GULF COMPREHENSIVE CLINICAL EVALUATION PROGRAM
This could be particularly difficult with patients who have somatoform disorders,
substance abuse problems, and other debilitating psychiatric problems.
A 6-month follow-up evaluation at Walter Reed is planned for each SCC
patient. The SCC physicians should develop a set of relatively objective
measures of functional status for this evaluation. These could include (1)
appropriate utilization of medical care, (2) appropriate use of medications or
other methods to cope with symptoms, (3) general level of activities of daily
living, (4) employment status, and (5) status of interpersonal relationships.
The overall SCC program itself needs an evaluation component after several
of its graduates have returned for their 6-month reevaluations. Several issues
will need to be evaluated in light of the successes and barriers that the program
has experienced. These include eligibility criteria for patients; roles of the SCC
in a diagnostic reevaluation of patients; successful continuity of care of patients,
with shared responsibility by the SCC and MTFs; and the unique need for the
SCC, beyond the usual standard of a tertiary care medical center.
The committee believes that the DoD has taken a serious approach to the
treatment and rehabilitation of these impaired patients who have treatable,
chronic diseases. Because this program is very labor intensive, it is probably
very expensive on a per-patient basis. At the same time, the potential benefits
for each patient could be high, if successful rehabilitation of serious, long-term
impairment can be achieved. Subsequent evaluations of the SCC program
should investigate its costs and benefits, if possible.
If the SCC program is successful in improving the health and functional
status of its patients, perhaps the elements that are most effective in enabling the
patients to cope with their symptoms could be identified. Perhaps some of these
elements could be disseminated and integrated into existing MTF programs that
are close to where CCEP patients live and work. If soldiers could participate
in some type of therapeutic program, in combination with their regular jobs,
more individuals could participate. Some of the interventions that are part of
the SCC could probably be implemented by social workers, nurses, or chaplains
at the MTF level.
EPIDEMIOLOGIC RESEARCH RELEVANT TO THE CCEP
The DoD and DVA are performing or funding several epidemiologic studies
that may have implications for CCEP patients and their physicians. These
include (1) studies focusing on exposure assessment and (2) studies focusing on
health conditions among Persian Gulf veterans. The results of these studies may
be useful for making revisions or improvements in the CCEP medical protocol
itself, for example, to revise the standardized questionnaires or to add or delete
targeted lab tests. The study results may also be useful in the counseling and
OCR for page 30
30 EVALUATION OF THE U.S. DEPARTMENT OF DEFENSE PERSIAN
GULF COMPREHENSIVE CLINICAL EVALUATION PROGRAM
treatment of CCEP patients. Data from individuals in the CCEP are also being
used in some of these epidemiological studies. In these studies, the serious
limitations of the CCEP data for epidemiological purposes that were previously
identified must be kept in mind.
Exposure Assessment Research Relevant to the CCEP
Military personnel seeing in the Persian Gulf were potentially exposed to
a large number of physical, chemical, biological, and psychological stressors.
The DoD and DVA are performing or funding research on a variety of these
potential stressors. The CCEP population is serving as the study group for one
of these projects. Several different groups of Persian Gulf veterans are being
studied in the other projects (PGVCB, 1995a).
The most important exposure assessment research involves the development
of a geographical information system, which will contain data on the locations
of military units on a daily basis during the Persian Gulf conflict. Unit diaries,
where a unit consists of about 100 troops, were maintained on a daily basis for
all units (PGVCB, 1995a). Information on location down to the individual
service member was not recorded, but matches between units and individuals
can be made. The computerization of all unit locations, as a function of time,
is expected to be complete sometime in 1996 (PGVCB, 1995a). This database
will be a valuable asset to many of the health studies.
The DoD is currently analyzing potential exposures among the CCEP
population using unit of assignment codes (UICs). So far, there does not appear
to be a clustering of CCEP patients in particular UICs (DoD, 1995d). The IOM
committee encourages DoD to perform further investigations on the war and
postwar experiences of individuals in the UICs with higher rates of CCEP
participation. In addition, the committee encourages the DoD to investigate
exposures that were restricted to particular locations or special occupational
groups, such as troops who had direct combat exposure. The types of symptoms
and diseases in CCEP participants in these special groups and UICs could be
analyzed and contrasted with the symptoms and diagnoses of CCEP participants
in other units. One unavoidable drawback to the UIC approach to exposure
assessment, however, is that some of these units include as many as thousands
of service personnel. Because of this, the potential exposure to a particular
stressor, for which an entire unit may have been at risk, may not be applicable
to a particular individual.
OCR for page 31
EVALUATION OF THE U.S. DEPARTMENT OF DEFENSE PERSIAN 31
GULF COMPREHENSIVE CLINICAL EVALUATION PROGRAM
Health Outcome Research Relevant to the CCEP
Three general types of health research questions are relevant to the CCEP
population. First, how does the prevalence of symptoms and diseases, in
general, compare between Persian Gulf veterans and an appropriate control
population? Second, how does the prevalence of certain disease categories
compare between Persian Gulf veterans and an appropriate control population?
Here, there are at least three major disease categories that may merit research
attention: (1) psychiatric diseases and (2) musculoskeletal conditions, because
they are the most prevalent disease categories in the CCEP population, and (3)
poorly defined conditions, such as chronic fatigue syndrome, fibromyalgia, and
multiple chemical sensitivity. The third major research question is whether there
is clinical or epidemiological evidence for a new, unique Persian Gulf
Syndrome. Research relevant to the existence of a possible new syndrome has
been discussed in detail previously.
Several ongoing and planned research projects will compare the prevalence
of symptoms and diseases reported by Persian Gulf veterans with the prevalence
reported by control groups of nondeployed veterans (PGVCB, 1995a). Most of
these studies will acquire data on self-reported general or nonspecific symptoms,
such as fatigue, headache, and memory loss. Two of these studies include
physical examinations to validate self-reported symptoms in a subset of the study
groups (PGVCB, 1995a).
musculoskeletal conditions.
Psychiatric symptoms, such as depression, and neuropsychological
symptoms, such as memory loss, are very common in the CCEP population.
Several DoD, DVA, and U.S. Department of Health and Human Services
(DHHS) research projects are focused on these symptoms and on corresponding
diseases. These research projects were described earlier in some detail in the
section Psychiatric Conditions.
Several DVA and DHHS projects are investigating the prevalence of poorly
defined symptom complexes, such as chronic fatigue syndrome, fibromyalgia,
or multiple chemical sensitivity (PGVCB, 1995a). The prevalence of self-
reported symptoms relevant to these three conditions will be compared between
veterans deployed to the Persian Gulf and veterans deployed elsewhere.
None of these studies appears to emphasize
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Representative terms from entire chapter:
threshold limit
