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Psychiatric Disorder in Veterans of the Persian Gulf War of 1991

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Psychiatric Disorder in Veterans of the Persian Gulf War of 1991 BRITISH JOURNAL OF PSYCHIATRY (2003), 182, 391^403 REVIEW ARTICLE Psychiatric disorder in veterans of the Persian Gulf DESERT SHIELD oror DESERTSHIELD oror GULF WAR oror GULF SYNDROME oror War of 1991 GULF WAR SYNDROME oror PERSIANPERSIAN GULF WAR oror PERSIAN GULF SYNDROME. References of identified Systematic review studies were searched for further studies. Specialist Gulf veterans’ illnesses research NICOLA J. STIMPSON, HOLLIE V. THOMAS, ALISON L. WEIGHTMAN, websites (US Department of Defense Center FRANK DUNSTAN and GLYN LEWIS for Deployment Health Research site and the Walter Reed Army Medical Center Gulf War database) and more-general Gulf web- sites were also searched for any additional Background Veterans ofthe Persian Since the end of the Persian Gulf War of references. Researchers who had expressed Gulf War of1991have reported symptoms 1991, its veterans have reported a range an interest in Gulf veterans’ illness research of health complaints attributed to service were contacted for any non-published in- attributed to their military service. during the war. These veterans report an formation. There was no restriction on the Aims ToToreview review all studies comparing increased prevalence of a whole range of identification of studies in terms of publica- common symptoms compared with other tion status or language. This search strategy the prevalence of psychiatric disorders in service personnel who were not deployed was first applied to data published up to the Gulf War veterans and in a comparison to the Gulf. end of 1998 (nn¼4156) and then repeated to group of service personnelnotdeployedto It is now widely recognised that the end of May 2001 (nn¼1231).1231). the Gulf War. exposure to combat and other wartime Studies were included if they contained experiences can have both short-term and data on veterans who had been deployed to MethodMethod Studies of military personnel long-term psychological effects. These the Gulf War on military, medical or peace- deployed to the Gulf published between psychological consequences are varied, but keeping grounds (i.e. those involved in the concept of post-traumatic stress dis- operations Desert Shield, Desert Storm, 1990 and 2001were identified from order (PTSD) has arisen to describe the Granby or Desert Peace). Any study design electronic databases.Reference lists and syndrome of intrusive thoughts, flashbacks, was eligible for inclusion provided that an websites were searched and key hyperarousal and numbing that can occur appropriate control or comparison group researchers were contacted for after exposure to any traumatic event, was included to compare the prevalence of information. AtotalA total of 2296 abstracts and including those common in wartime. psychiatric disorder. The Persian Gulf War was brief and The 5387 abstracts identified by the 409 complete articles were reviewed and there were relatively few casualties among original search were screened by N.J.S. data were extracted independently by the troops deployed on behalf of the United and the 2296 that remained eligible were two members ofthe researchteam. Nations. Nevertheless, a number of aspects examined by two members of the research of the war exposed service personnel to team to decide whether they might meet ResultsResults The prevalence of psychiatric traumatic and stressful events: these in- our inclusion criteria. Printed copies of disorderin 20 studies of Gulf WarWarveterans veterans cluded the risk of chemical and biological 409 papers were then obtained and examin- was compared with the prevalence in the warfare, exposure to combat, and dealing ed by two members of the research team to with prisoners and dead and wounded Iraqi confirm eligibility and extract data. comparison group. Prevalence of post- soldiers. This paper describes a systematic In our original search we also included traumatic stress disorder (PTSD) and review of studies that have compared the studies that compared ill and well Gulf common mental disorder were higher in prevalence of psychiatric disorder in Gulf War veterans, but these were excluded the Gulf War veterans.Heterogeneity War veterans with its prevalence in a com- from the review reported here. Studies were between studies was significant, but all parison group who were not deployed to also excluded if they measured simulated the Gulf (non-Gulf veterans). exposures, if they measurednon-health- reported thisincreasedthis increased prevalence. related outcomes, or if the study population Conclusions Veterans ofthe Persian included inhabitants of the Persian Gulf METHOD states rather than deployed military, Gulf War reported an increased medical or peace-keeping personnel. prevalence of PTSD and common mental Data search All identified papers that fulfilled the disorder compared with other active Studies between January 1990 and May pre-stated inclusion criteria were cate- service personnel not deployed to the 2001 were identified from a range of elec- gorised by health outcome. Forty-nine tronic databases, including EMBASE, Med- studies included data on psychiatric dis- Gulf.These findings are attributable to the line, ASSIA, SIGLE, PsycINFO, CancerLit, order, 29 of which reported on Gulf War increase in psychologically traumatic HealthSTAR, Dissertation, Abstracts, veterans and an external comparison events in wartime. Current Contents, Health and Psychosocial group of non-Gulf War veterans. We Instruments, CINAHL and Biological further restricted the studies to those with Declaration of interest Funded bybyFunded Abstracts. Keywords used to identify the a limited range of outcomes concerned the UKMedical Research Council. studies were: DESERT STORM oror with psychiatric disorder (20 studies). The 391 Downloaded from https://www.cambridge.org/core. 02 Oct 2021 at 10:49:16, subject to the Cambridge Core terms of use. STIMPSON ET AL outcomes we chose to include were as often difficult to establish from published 1998; Proctor etetalal, 1998; Stuart & Bliese, follows:follows: articles, and this – together with the wide 1998; Gray etetalal, 1999; Ishoy etetalal,, 1999;1999; variety of scales that were used – can intro- UnwinUnwin etetalal, 1999; Wolfe etetalal, 1999; Bar- (a)(a)PTSDPTSD diagnosed using a recognised duce difficulties in performing a quantita- tone, 2000; Kang etetalal, 2000; Steele, standardised assessment; tive synthesis. Using ratio measures to 2000; Cherry etetalal, 2001). We excluded (b)(b)commoncommon mental disorder: depression or estimate association should be less sensitive nine other studies that included data on anxiety diagnosed using a recognised to the different case definitions and psychiatric disorder in Gulf War veterans standardised assessment; or self- measures used in the constituent studies. but did not meet our inclusion criteria: five reported symptoms of depression repeated results already included, three did recorded on a checklist; RREESUSULLTTSS not include any of the psychiatric outcomes (c)(c)problemsproblems related to alcohol misuse. defined above, and one compared Gulf vet- The systematic review process is shown in erans with reported illness with a compari- We have chosen to use the term ‘common Fig. 1. We identified 20 primary studies son sample (further details available from mental disorder’ (Goldberg & Huxley, that investigated the association between the authors upon request). 1992) to refer to the common symptoms deployment to the Gulf War and psychi- Table 1 summarises the studies we of depression and anxiety that are seen in atric disorder (Perconte etetalal, 1993; Sutker identified. All are best described as cross- the community and reflect the use of assess- etetalal, 1993, 1994; Stretch etetalal,, 19961996aa,,bb;; sectional surveys. Some studies, for exam- ments such as the General Health Ques- Iowa Persian Gulf Study Group, 1997; ple those by Kang etetalal (2000), Unwin etetalal tionnaire (GHQ; Goldberg & Williams, Pierce, 1997; Stuart & Halverson, 1997; (1999) and Ishoy etetalal (1999), resemble 1988) and the Symptom Checklist (and its Goss Gilroy Inc., 1998; Holmes etetalal,, cohort studies, as the population was derivatives) (Derogatis etet alal,, 1974;1974; Derogatis, 1977; Derogatis & Spencer, 1982).1982). Data extraction Data relating to the studies’ main hypo- theses and to methodological quality were extracted independently by two members of the research team. Information on the methodological quality of the individual studies included the response rate, the potential of selection bias in the sampling of the study participants, the potential bias in the measurement of outcomes, the availability of data on confounders, and any adjustment for such variables. Statistical analysis Summary odds ratio and risk ratios were calculated with a random-effects model using the inverse variance method. The degree of heterogeneity was assessed using the chi-squared test within a fixed-effects model. All analyses were performed using the METAN command (Bradburn etetalal,, 1998) in Stata version 6 (StataCorp, 1999). We chose this approach because of the inherent heterogeneity in the data. In particular, we were combining studies with a variety of outcome measures. A random- effects model assumes that the studies in a meta-analysis are sampled from a distribu- tion of effect sizes, which are estimated from the data in the meta-analysis. In contrast, a fixed-effects model assumes that all the studies are sampled from a population with the same effect estimate. We chose to perform analyses on di- chotomous outcomes because
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