Lisa Hull

Health of UK servicemen who served in Persian Gulf War

BACKGROUNDnVarious symptoms in military personnel in the Persian Gulf War 1990-91 have caused international speculation and concern. We investigated UK servicemen.nnnMETHODSnWe did a cross-sectional postal survey on a random sample of Gulf War veterans (Gulf War cohort, n=4248) and, stratified for age and rank, servicemen deployed to the Bosnia conflict (Bosnia cohort, n=4250) and those serving during the Gulf War but not deployed there (Era cohort, n=4246). We asked about deployment, exposures, symptoms, and illnesses. We analysed men only. Our outcome measures were physical health, functional capacity (SF-36), the general health questionnaire, the Centers for Disease Control and Prevention (CDC) multisymptom criteria for Gulf War illness, and post-traumatic stress reactions.nnnFINDINGSnThere were 8195 (65.1%) valid responses. The Gulf War cohort reported symptoms and disorders significantly more frequently than those in the Bosnia and Era cohorts, which were similar. Perception of physical health and ability were significantly worse in the Gulf War cohort than in the other cohorts, even after adjustment for confounders. Gulf War veterans were more likely than the Bosnia cohort to have substantial fatigue (odds ratio 2.2 [95% CI 1.9-2.6]), symptoms of post-traumatic stress (2.6 [1.9-3.4]), and psychological distress (1.6 [1.4-1.8]), and were nearly twice as likely to reach the CDC case definition (2.5 [2.2-2.8]). In the Gulf War, Bosnia, and Era cohorts, respectively, 61.9%, 36.8%, and 36.4% met the CDC criteria, which fell to 25.3%, 11.8%, and 12.2% for severe symptoms. Potentially harmful exposures were reported most frequently by the Gulf War cohort. All exposures showed associations with all of the outcome measures in the three cohorts. Exposures specific to the Gulf were associated with all outcomes. Vaccination against biological warfare and multiple routine vaccinations were associated with the CDC multisymptom syndrome in the Gulf War cohort.nnnINTERPRETATIONnService in the Gulf War was associated with various health problems over and above those associated with deployment to an unfamiliar hostile environment. Since associations of ill health with adverse events and exposures were found in all cohorts, however, they may not be unique and causally implicated in Gulf-War-related illness. A specific mechanism may link vaccination against biological warfare agents and later ill health, but the risks of illness must be considered against the protection of servicemen.

Is there a Gulf War syndrome

Summary Background UK veterans of the Gulf War report more ill health than servicemen who were not deployed to the Gulf War. We investigated whether the pattern of symptom reporting by veterans of the Gulf War differed from that in active servicemen who had not fought in the Gulf War or who had fought in other conflicts. Methods We used a population-based cross-sectional design. We sent a standardised survey that asked about 50 physical symptoms to three UK military cohorts; men who had served in the Gulf War, those who had served in the Bosnia conflict, and men who had been in active service but not deployed to the Gulf War (Era cohort). We used exploratory factor analysis to identify underlying factors and describe the factor structure of the symptoms reported in the Gulf War cohort. Confirmatory factor analysis was used to test the fit of this factor structure in the Bosnia and Era cohorts. Findings Three factors in the Gulf War cohort together accounted for about 20% of the common variance. We labelled the factors mood, respiratory system, and peripheral nervous system, according to the symptoms that loaded on to them. In the confirmatory factor analysis, the factor structure identified in the Gulf War cohort fitted reasonably well in the Bosnia and Era cohorts. Interpretation Although results from complex modelling procedures need to be interpreted with caution, our findings do not support a unique Gulf War syndrome. The mechanisms behind increased self-reporting of symptoms need further investigation. Lancet 1999; 353: 179‐82 See Commentary page ???

The prevalence of common mental disorders and PTSD in the UK military: using data from a clinical interview-based study

BackgroundThe mental health of the Armed Forces is an important issue of both academic and public interest. The aims of this study are to: a) assess the prevalence and risk factors for common mental disorders and post traumatic stress disorder (PTSD) symptoms, during the main fighting period of the Iraq War (TELIC 1) and later deployments to Iraq or elsewhere and enlistment status (regular or reserve), and b) compare the prevalence of depression, PTSD symptoms and suicidal ideation in regular and reserve UK Army personnel who deployed to Iraq with their US counterparts.MethodsParticipants were drawn from a large UK military health study using a standard two phase survey technique stratified by deployment status and engagement type. Participants undertook a structured telephone interview including the Patient Health Questionnaire (PHQ) and a short measure of PTSD (Primary Care PTSD, PC-PTSD). The response rate was 76% (821 participants).ResultsThe weighted prevalence of common mental disorders and PTSD symptoms was 27.2% and 4.8%, respectively. The most common diagnoses were alcohol abuse (18.0%) and neurotic disorders (13.5%). There was no health effect of deploying for regular personnel, but an increased risk of PTSD for reservists who deployed to Iraq and other recent deployments compared to reservists who did not deploy. The prevalence of depression, PTSD symptoms and subjective poor health were similar between regular US and UK Iraq combatants.ConclusionThe most common mental disorders in the UK military are alcohol abuse and neurotic disorders. The prevalence of PTSD symptoms remains low in the UK military, but reservists are at greater risk of psychiatric injury than regular personnel.

Do military peacekeepers want to talk about their experiences? Perceived psychological support of UK military peacekeepers on return from deployment

Background: Little is known about what support the United Kingdom (UK) armed forces require when they return from operations. Aims: To investigate the perceived psychological support requirements for service personnel on peacekeeping deployments when they return home from operations and examine their views on the requirement for formal psychological debriefings. Methods: A retrospective cohort study examined the perceived psychological needs of 1202 UK peacekeepers on return from deployment. Participants were sent a questionnaire asking about their perceived needs relating to peacekeeping deployments from April 1991 to October 2000. Results: Results indicate that about two-thirds of peacekeepers spoke about their experiences. Most turned to informal networks, such as peers and family members, for support. Those who were highly distressed reported talking to medical and welfare services. Overall, speaking about experiences was associated with less psychological distress. Additionally, two thirds of the sample was in favour of a formalised psychological debriefing on return to the UK. Conclusions: This study suggests that most peacekeepers do not require formalised interventions on homecoming and that more distressed personnel are already accessing formalised support mechanisms. Additionally social support from peers and family appears useful and the UK military should foster all appropriate possibilities for such support. Declaration of Interest: The Stage 1 study was funded by the US Department of Defence (DoD) and the follow up study by the Medical Research Counsel (MRC). Neither the DoD nor MRCu2009had any input into the design, conduct, analysis or reporting of the study. The views expressed are not those of any US or UK governmental organisation. We thank Mr Nick Blatchley of MOD for help in identifying the cohorts.

Cognitive functioning and disturbances of mood in UK veterans of the Persian Gulf War: a comparative study

BACKGROUNDnComplaints of poor memory and concentration are common in veterans of the 1991 Persian Gulf War as are other symptoms. Despite a large research effort, such symptoms remain largely unexplained.nnnMETHODnA comprehensive battery of neuropsychological tests and rating scales was administered to 341 UK servicemen who were returnees from the Gulf War and peace keeping duties in Bosnia, plus non-deployed military controls. All were drawn from a large randomized survey. Most were selected on the basis of impaired physical functioning defined operationally.nnnRESULTSnGroup comparisons revealed an association between physical functioning and symptoms of depression, post-traumatic stress reactions, increased anger and subjective cognitive failures. Poorer performance on some general cognitive measures, sequencing and attention was also seen in association with being ill but virtually all differences disappeared after adjusting for depressed mood or multiple comparisons. Deployment was also associated with symptoms of post-traumatic stress and subjective cognitive failures, independently of health status, as well as minor general cognitive and constructional impairment. The latter remained significantly poorer in the Gulf group even after adjusting for depressed mood.nnnCONCLUSIONSnDisturbances of mood are more prominent than quantifiable cognitive deficits in Gulf War veterans and probably lead to subjective underestimation of ability. Task performance deficits can themselves be explained by depressed mood although the direction of causality cannot be inferred confidently. Reduced constructional ability cannot be explained in this way and could be an effect of Gulf-specific exposures.

The health effects of peace-keeping in the UK Armed Forces: Bosnia 1992-1996. Predictors of psychological symptoms.

BACKGROUNDnPeace-keeping duties are associated with unique stresses for military personnel. There have been few reports on the effects of peace-keeping on psychological health.nnnMETHODnWe used data from a cross-sectional study originally established to examine health effects of service in the Gulf War, which included a control group who had been deployed in Bosnia (N= 2049). This group was examined to establish which demographic, occupational, and deployment-related risk factors were associated with psychological distress measured on the General Health Questionnaire (GHQ-12) and stress symptoms akin to a post-traumatic stress reactions.nnnRESULTSnThe main risk factors for stress symptoms in the Bosnia group were--lower rank, being deployed early in the campaign, having more deployment-related exposures, and serving on staff duties. There was no protective effect of previous deployments to the Falklands or Northern Ireland, and time off following deployment was not protective. For GHQ-12 cases, the main risk factors were: female gender, lower rank, increased deployment-related exposures and serving on staff duties.nnnCONCLUSIONSnThis study suggests that stress symptoms and GHQ-12 cases, are strongly predicted both by experiences during deployment and demographic factors.

Reported chemical sensitivities in a health survey of United Kingdon military personnel

Objective: To report the prevalence of self reported chemical sensitivities in three cohorts of United Kingdom service personnel. Method: Cross sectional postal survey of three cohorts of United Kingdom military personnel comprising Gulf veterans (n=3531), those who had served in Bosnia (n=2050), and those serving during the Gulf war but not deployed there (Era cohort, n=2614). Results: Sensitivity to at least one everyday chemical was reported by a considerable proportion of all three cohorts, and particularly by veterans of the Gulf war (Era: 14%; Bosnia: 13%; Gulf: 28%). Conclusion: Reported chemical sensitivities were common in all three military cohorts. Our understanding of chemical sensitivities remains limited and objective evidence for a causal link between low level exposures to chemicals and reported symptoms is lacking. Given their frequency in the population, further work in this area is necessary.

Anger, psychopathology and cognitive inhibition: a study of UK servicemen

A link between anger and psychopathology, and aggression and cognitive impairment has been postulated. This study examined the relationships between anger, psychopathology, and neurocognitive function in a military sample of 136 men without overt brain disease. A battery of neurocognitive tests was administered, including the State-Trait Anger Expression Inventory (STAXI), which recognises different experience and expression components of anger. Significant positive correlations between anger and psychopathogical measures were revealed, with the exception of anger control which exhibited a negative relationship. Correlations between anger measures and neuropsychological variables were weaker, few were significant, and no specific pattern emerged. Structural equation modelling indicated that psychopathogical variables and their relationship with neurocognitive variables, rather than anger, contributed significantly to the model. We propose that anger appears to be a manifestation of non-specific psychopathology (anxiety and depression), and that any relationship between anger and cognitive function is likely to be mediated through depression.

Evaluation of neuromuscular symptoms in uk Gulf War veterans: A controlled study

Objectives: To determine whether Gulf War veterans with neuromuscular symptoms that included weakness and fatigue had either 1) objective correlates for muscle weakness or fatigue; or 2) any etiologic explanation for such symptoms; and if so, 3) whether such objective measures or etiologic mechanisms were specific to Gulf War service. Methods: Forty-nine ill Gulf War veterans with more than four neuromuscular symptoms (Gulf-ill) were compared with 26 Gulf-well veterans, 13 symptomatic Bosnian veterans (Bosnia-ill), and 22 symptomatic troops who were not deployed to the Gulf (Era-ill). Quantitative myometry was used to objectively measure weakness and fatigue. Subjects had an ischemic forearm exercise test, a subanaerobic bicycle exercise test, and a muscle biopsy. Results: Quantitative strength and fatigue measures did not correlate with self-perception of weakness or fatigue for any of our groups. No specific muscle biopsy abnormalities were found. There was no defect of adenylate deaminase or glycogenolysis found. Gulf-ill subjects did find the subanaerobic bicycle exercise more effortful and generated significantly higher plasma lactate concentrations compared with Gulf-well subjects. Conclusion: Because complaints of weakness and fatigue in unwell servicemen do not correlate with actual weakness or fatigue, explanations for these symptoms must lie outside of the neuromuscular system. Increased lactate production during subanaerobic bicycle exercise reflects mitochondrial inefficiency, but it is unclear whether this reflects mitochondrial damage sustained during Gulf War service or inactivity secondary to ill health.

Dichotomous factor analysis of symptoms reported by UK and US veterans of the 1991 Gulf War

BackgroundFactor analysis is one of the most used statistical techniques to analyze the inter-relationships among symptoms reported by Gulf War veterans. The objective of this study was to apply factor analyses to binary symptom data from the UK study of Gulf War illness and the US Air Force study of Gulf War veterans, and to compare the symptom domains derived from the distinct samples.MethodsUK veterans of the 1991 Gulf War (n = 3,454), individuals deployed to Bosnia on U.N. peacekeeping operations (n = 1,979) and Gulf War-era servicemen (n = 2,577) who were not deployed to the Gulf were surveyed in 1997–1998, and US 1991 Gulf War veterans from four Air Force units (n = 1,163) were surveyed in 1995 to collect health characteristics including symptoms. Each sample was randomly split in half for exploratory and confirmatory dichotomous factor analyses with promax oblique rotation.ResultsFour correlated factors were identified in each of the samples. Three factors (Respiratory, Mood-Cognition, Peripheral Nervous) overlapped considerably across the UK cohorts. The Gastrointestinal/Urogenital factor in the UK Gulf cohort was noticeably different from the Gastrointestinal factor identified from the Bosnia and Era cohorts. Symptoms from Gulf War UK and U.S cohorts yielded similar Gastrointestinal, Respiratory and Mood-Cognition factors, despite differences in symptom inventories between the two surveys. A Musculoskeletal factor was only elicited from the US Gulf sample.ConclusionFindings of this report are consistent with those from other factor analysis studies that identified similar symptom dimensions between Gulf and non-Gulf War veterans, except that the Gastrointestinal factor in Gulf veterans included other symptom types. Correlations among factors raise the question as to whether there is a general illness, even if not unique to Gulf veterans, representing the common pathway underlying the identified factors. Hierarchical factor analysis models may be useful to address this issue.