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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

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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.

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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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