Psychiatric disorders can be grouped into several classes, such as mood disorders that is, depression and bipolar disorder ; anxiety disorders that is, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, PTSD, and social phobia ; disorders involving perceptions of physical symptoms and health, which are called somatoform disorders for example, hypochondriasis and somatization disorder ; and substance use disorders for example, abuse of and dependence on drugs and alcohol. The specification of characteristics of mental diagnoses has made research on their incidence and prevalence possible, so that there are guidelines differentiating them from transient experiences of distress or sadness that do not signify the presence of mental disease.
Major depression, a type of mood disorder, is characterized by lifelong vulnerability to episodes of depressed mood and loss of interest and pleasure in daily activities accompanied by other symptoms such as sleeping too little or too much, reduced appetite and weight loss or increased appetite and weight gain, restlessness, irritability, difficulty concentrating, feeling guilty, hopeless or worthless, and thoughts of suicide or death.
A major depressive episode is categorized as major depressive disorder MDD or, when it accompanies mania, as bipolar disorder.
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PTSD is a subtype of anxiety disorder. PTSD is diagnosed on the basis of exposure to a traumatic event.
After this exposure, the person experiences a specific constellation of symptoms such as severe distress on recollection of the event, avoidance of reminders of the situation, numbing of general responsiveness, and such signs of hyperarousal as irritability, sleep disturbance, or exaggerated startle reflexes. The presence of a few PTSD symptoms after a trauma is common and does not signify the presence of disease, but the presence of the full syndrome itself is much less common and is associated with significant disability.
Substance abuse is defined as a maladaptive pattern of substance use there are many types of abused substances, but alcohol abuse is the most common that results in a failure to fulfill major social roles such as work or family-care performance , that involves use of the substance despite physical hazards and in association with legal consequences, and that involves use despite deleterious social and interpersonal consequences. Substance use disorders include substance abuse and substance dependence. Substance abuse is defined as a maladaptive pattern of substance use that results in a failure to fulfill major social roles such as work or family-care performance , that involves use of the substance despite physical hazards and in association with legal consequences, and that involves use despite deleterious social and interpersonal consequences.
There are many types of substances for which abuse and dependence can be diagnosed; in most societies nicotine dependence is the most common and hazardous substance use disorder, currently responsible for half a billion deaths a year worldwide Ezzati and Lopez, The studies of Gulf War veterans were generally limited, however, to assessment of the use of alcohol and illegal drugs, and therefore, the committee restricts its comments to these substances. The prevalence of those disorders among young and middle-aged adults in the general population has now been addressed in several large studies, including the National Survey of Drug Use and Health, the National Epidemiologic Survey on Alcohol and Related Conditions, and the US National Comorbidity Survey Replication, a nationally representative face-to-face household survey conducted from February to April Kessler et al.
The most recent data show that the prevalence estimates for all anxiety disorders were It should be noted that there is substantial variation by gender, and also by age group, even within the limited age range covered. It is also well established that because of difficulties associated with recall, lifetime prevalences tend to provide underestimates of the likelihood that an individual has had a particular condition, and recall about whether the condition has occurred in the last 12 months is more accurate Susser and Shrout, The prevalence estimates for the general population are generally higher than those in deployed veterans exposed to combat and much higher than in the control nondeployed veteran populations.
As noted above, this is partly explained by a healthy warrior outcome. Thus, both military screening and self-selection are likely to ensure that individuals enter the military with better mental and physical health than the general population.
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Primary studies were those in which veterans were categorized as deployed, not deployed, or deployed to a nonwar zone for example, Germany. To diagnose psychiatric disorders, primary studies also included an in-person standardized diagnostic interview. Others used interviews administered by trained lay interviewers, such as the Composite International Diagnostic Interview CIDI , a comprehensive and standardized diagnostic interview that is very widely used. The CIDI has been adapted to many forms that limit the diagnoses covered and the length of interview, and these alternative forms often produce less precise diagnoses.
Secondary studies typically failed to use diagnostic interviews to diagnose mental health disorders and often screened for mental health disorders using symptom checklists such as the PTSD Checklist developed by the VA. Moreover, there was often a nested case-control study of mental health characteristics in the primary epidemiologic cohort studies that used direct-interview techniques. In Volume 4 , eight primary studies were reviewed that used direct-interviews of the large Gulf War cohorts described in Chapter 3.
Black et al. The initial cohort study had uncovered higher than anticipated levels of anxiety; therefore, this analysis of the interview data looked more carefully into the features of anxiety in that population.
Additional structured questions identified medical conditions and military preparedness. Compared with nondeployed veterans, deployed veterans had a twofold increase in the prevalence of generalized anxiety disorder, panic disorder, PTSD, and any anxiety disorder OR 2. Anxious Gulf War veterans were more likely to have had a pre-existing psychiatric condition, to have taken psychotropic medications, or to have had a psychiatric hospitalization prior to deployment.
Anxiety conditions were comorbid with several psychiatric and medical conditions, particularly symptoms of cognitive dysfunction, any depression, major depression, and symptoms of fibromyalgia. Barrett et al. PTSD-positive veterans had a mean score of The PTSD score was significantly associated with decreased functioning and quality of life, as well as increased reporting of symptoms and medical conditions. In a nested case-comparison study, Black et al. They used the SCID with a random group of veterans drawn from strata of the PRIME-MD-interviewed group who reported one or more of the following symptom-based conditions during their previous interview: depression major or minor depression , widespread chronic pain established criteria for generalized, severe, and chronic pain , and cognitive dysfunction amnesia or cognitive impairment of a moderate and prolonged intensity.
Veterans were stratified by each symptom combination one, two, or all and by deployed or nondeployed status. Controls had not met screening criteria for any of these conditions and might have been deployed or not deployed. The veterans were selected randomly for interview from each stratum to optimize the match between cases and controls. Level of functioning was assessed using the SF The Whiteley Index was used to determine hypochondriasis.
There were few diagnostic differences between the depressed deployed and the depressed nondeployed veterans, except for lifetime and current PTSD OR 4. The deployed depressed veterans were also more likely to have a diagnosis of any lifetime, but not current, substance-use disorder OR 2. What was most surprising about the direct interview analysis was that there was little difference between the deployed and the nondeployed veterans in aspects of depression; the largest difference was found in the prevalence of any anxiety disorder In the interview cohort, It was interesting to note that PTSD symptoms showed a dose-response relationship to intensity of war stress, whereas the chronic fatigue symptoms did not show any relationship to war stress.
Estimates of PTSD as determined by a cutoff score of 50 or above tracked rates of stressors closely. Deployment, but not war stress, was associated with chronic fatigue symptoms. Wolfe et al. From those cohorts, stratified random samples were selected for closer study with direct interview of the Fort Devens cohort, 73 of the New Orleans cohort, and 48 of the Germany deployed. Current PTSD time 2 was diagnosed in 8. Health status and function were lower in the Gulf War deployed cohorts than the Germany deployed cohort The prevalence of the other eight psychiatric disorders was similar between the three groups.
Compared with the PTSD prevalence in the general population 7. A strength of this study is that it is characterized by direct interview.
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In another analysis of these data Wolfe et al. Responders at time 2 were more likely to be younger, belong to racial minorities, and be deployed; however, the absence of differences in PTSD rates due to those characteristics indicates a lack of selection bias at time 2. Brailey et al. A subset of received a followup assessment an average of 16 months later. They showed increased rates of depression 6.
The authors correlated war stress with those symptoms and found that the higher the war-zone stress, the more severe the depressive and anxiety symptoms. Ikin et al. Those interview data were used with postal questionnaire data to form a complete workup of Gulf War veterans, and comparison veterans.
Both the veterans and the controls completed the health assessment and the postal questionnaire.
The two groups were demographically similar, although the Gulf War veterans were significantly younger, more likely to have been in the Navy, and less highly ranked than the comparison veterans. The two veteran groups were similar in prevalence of prewar psychiatric disorders. In addition, the Gulf War group was significantly more likely to have any anxiety disorder OR 2. On average, the Gulf War veterans had twice as many current psychiatric disorders as the comparison veterans.
The strengths of this study were the large sample, the comparable control group, the use of well-validated psychological interviews, and the analyzed participation bias, which was estimated to be low. A study of DoD postwar hospitalizations for mental disorders June 1, , to September 30, using 10 categories from the International Classification of Diseases, 9th revision, Clinical Modification, 6th edition ICDCM was conducted by Dlugosz and colleagues It also sought to identify risk factors for hospitalization.
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Nearly half the postwar hospitalizations were for alcohol-related disorders. Gulf War veterans were at greater risk for hospitalizations than nondeployed veterans due to drug-related disorders RR 1. Adjustments were made for age, sex, and military service branch. Although the database of ICD-9 codes does not allow determination of whether stress reactions expressly included PTSD, the authors noted that if posttraumatic stress was diagnosed, it would probably have been coded as an unspecified acute reaction to stress ICD-9 code Alcohol-related diagnoses were not increased.
Exposure to the ground war in Iraq was associated with a greater risk of alcohol-related hospitalizations in men RR 1.
Serving as support for the ground war without being in direct combat was associated with a greater risk of drug-related hospitalizations in men RR 1. The limitation of this study is that it examined only hospitalizations and thus was not representative of most psychiatric disorders that require outpatient treatment rather than hospitalization. It also did not include veterans who left the military after the Gulf War. Findings on many other major cohorts of Gulf War veterans support what has been found in primary studies Gray et al.
In the UK cohort studied by Unwin et al. They found that some symptoms were about times more likely in deployed than in two nondeployed groups. The magnitude of the increase is consistent with that seen in the primary studies. Several other secondary studies have found an association between serving in the Gulf War and psychiatric disorders Holmes et al. Goss Gilroy assessed all Canadian Gulf War veterans deployed to the war zone and a comparison group of nondeployed veterans with a mail questionnaire. Anxiety and depression were more severe in lower-income veterans. The instruments described below are self-administered screening questionnaires.
McKenzie et al.
On those self-rating instruments, the Gulf War-deployed had overall poorer psychological health OR 1. The psychological distress increased with age in the comparison group but decreased with age in the Gulf War veterans that is, the youngest Gulf War veterans had the worst psychological ill health. Moreover, the perceived level of exposure to war stress was associated with both psychological ill health and PTSD-like symptoms, although very few experienced direct combat. The Update committee identified four new primary studies Fiedler et al.
Individuals who had a known disease or serious medical condition were excluded from the study. One-month prevalences of DSM-IV disorders were assessed using the WHO schedule of clinical assessment in neuropsychiatry, a clinician-administered interview on which they achieved good inter-rater reliability. This is the only study that used a clinician-administered interview and reported kappa values for inter-rater reliability.
It was also unique in that it compared rates of unexplained physical disability between veterans who served in the Gulf and veterans who served in other wars. Compared with disabled veterans from Bosnia or era veterans, disabled Gulf War veterans were no more likely to have an alcohol-related disorder OR 1. When compared to nondisabled Gulf War veterans, disabled Gulf War veterans were at increased risk only for anxiety disorders OR 6.
The authors inferred that psychiatric disorders do not explain the elevation in self-reported ill health in Gulf War veterans. This study also compared disabled with nondisabled Gulf War veterans. It should be noted, however, that the prevalences of some specific disorders—notably PTSD and alcohol-related disorders—were not significantly different between the disabled and nondisabled veterans.
This study used the largest random sample of US Gulf War deployed and era veterans in which a layperson-administered structured interview was used to assess month prevalences of psychiatric disorders. When compared with era veterans, those deployed to the Gulf War had significantly higher prevalences of psychiatric disorders. Thus, there were increases in the prevalence of MDD Comparing all deployed veterans with nondeployed veterans, the OR for anxiety disorder was 1.