Hostname: page-component-78c5997874-g7gxr Total loading time: 0 Render date: 2024-11-16T20:17:43.426Z Has data issue: false hasContentIssue false
  • English
  • Français

Depression in Gulf War veterans: a systematic review and meta-analysis

Published online by Cambridge University Press:  20 February 2015

J. D. Blore ,
M. R. Sim ,
A. B. Forbes ,
M. C. Creamer  and
H. L. Kelsall
J. D. Blore
Affiliation:
Faculty of Medicine, Nursing and Health Sciences, Monash Centre for Occupational and Environmental Health (MonCOEH), School of Public Health and Preventive Medicine, Monash University, L5, The Alfred Centre, Melbourne, VIC, Australia Faculty of Medicine, Dentistry and Health Sciences, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC, Australia
M. R. Sim
Affiliation:
Faculty of Medicine, Nursing and Health Sciences, Monash Centre for Occupational and Environmental Health (MonCOEH), School of Public Health and Preventive Medicine, Monash University, L5, The Alfred Centre, Melbourne, VIC, Australia
A. B. Forbes
Affiliation:
Faculty of Medicine, Nursing and Health Sciences, School of Public Health and Preventive Medicine, Monash University, L6, The Alfred Centre, VIC, Australia
M. C. Creamer
Affiliation:
Department of Psychiatry, Australian Centre for Posttraumatic Mental Health, The University of Melbourne, Parkville, VIC, Australia
H. L. Kelsall*
Affiliation:
Faculty of Medicine, Nursing and Health Sciences, Monash Centre for Occupational and Environmental Health (MonCOEH), School of Public Health and Preventive Medicine, Monash University, L5, The Alfred Centre, Melbourne, VIC, Australia
*
* Address for correspondence: Dr H. L. Kelsall, Monash Centre for Occupational and Environmental Health (MonCOEH), Monash University, The Alfred Centre, Commercial Road, Melbourne, VIC 3004, Australia. (Email: [email protected])
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Although post-traumatic stress disorder (PTSD) has been a focus of attention in 1990/1991 Gulf War veterans, the excess risk of depression has not been clearly identified. We investigated this through a systematic review and meta-analysis of studies comparing depression in Gulf War veterans to depression in a comparison group of non-deployed military personnel.

Method

Multiple electronic databases and grey literature were searched from 1990 to 2012. Studies were assessed for eligibility and risk of bias according to established criteria.

Results

Of 14 098 titles and abstracts assessed, 14 studies met the inclusion criteria. Gulf War veterans had over twice the odds of experiencing depression [odds ratio (OR) 2.28, 95% confidence interval (CI) 1.88–2.76] and dysthymia or chronic dysphoria (OR 2.39, 95% CI 2.0–2.86) compared to non-deployed military personnel. This finding was robust in sensitivity analyses, and to differences in overall risk of bias and psychological measures used.

Conclusions

Despite divergent methodologies between studies, depression and dysthymia were twice as common in Gulf War veterans and are important medical conditions for clinicians and policymakers to be aware of in managing Gulf War veterans’ health.

Keywords

DepressionGulf Warmeta-analysissystematic reviewveterans
Type
Review Article
Information
Psychological Medicine , Volume 45 , Issue 8 , June 2015 , pp. 1565 - 1580
Copyright
Copyright © Commonwealth of Australia 2015 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Barendregt, JJ, Doi, SA (n.d.). MetaXL User Guide, Version 1.1 (www.epigear.com). Accessed 2 November 2012.Google Scholar
Beck, AT, Steer, RA, Carbin, MG (1988). Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clinical Psychology Review 8, 77–100.CrossRefGoogle Scholar
Carlson, K, Kehle, S, Meis, L, Greer, N, MacDonald, R, Rutks, I, Wilt, TJ (2009). The Assessment and Treatment of Individuals with History of Traumatic Brain Injury and Post-Traumatic Stress Disorder: A Systematic Review of the Evidence. Department of Veterans Affairs (US): Washington, DC (www.ncbi.nlm.nih.gov/books/NBK49144/). Accessed 10 April 2013.Google ScholarPubMed
Derogatis, LR, Savitz, KL (1999). The SCL-90-R, Brief Symptom Inventory, and matching clinical rating scales. In The Use of Psychological Testing for Treatment Planning and Outcomes Assessment (ed. Maruish, M. E.), pp. 679–724. Erlbaum: Mahwah, NJ.Google Scholar
Fiedler, N, Ozakinci, G, Hallman, W, Wartenberg, D, Brewer, NT, Barrett, DH, Kipen, HM (2006). Military deployment to the Gulf War as a risk factor for psychiatric illness among US troops. British Journal of Psychiatry 188, 453–459.Google Scholar
Gadermann, AM, Engel, CC, Naifeh, JA, Nock, MK, Petukhova, M, Santiago, PN, Wu, B, Zaslavsky, AM, Kessler, RC (2012). Prevalence of DSM-IV major depression among U.S. military personnel: meta-analysis and simulation. Military Medicine 177, 47–59.Google Scholar
Gilbody, S, Richards, D, Brealey, S, Hewitt, C (2007). Screening for depression in medical settings with the Patient Health Questionnaire (PHQ): a diagnostic meta-analysis. Journal of General Internal Medicine 22, 1596–1602.Google Scholar
Glass, DC, Sim, MR, Kelsall, HL, Ikin, JF, McKenzie, D, Forbes, A, Ittak, P (2006). What was different about exposures reported by male Australian Gulf War veterans during the 1991 Gulf War compared with exposures reported for other deployments? Military Medicine 171, 632–638.Google Scholar
Goss Gilroy Inc. (1998). Health Study of Canadian Forces Personnel Involved in the 1991 Conflict in the Persian Gulf. Gulf War Illness Advisory Committee: Ottawa.Google Scholar
Gray, GC, Reed, RJ, Kaiser, KS, Smith, TC, Gastanaga, VM (2002). Self-reported symptoms and medical conditions among 11,868 Gulf War-era veterans: the Seabee Health Study. American Journal of Epidemiology 155, 1033–1044.Google Scholar
Higgins, JPT, Altman, DG, Gøtzsche, PC, Jüni, P, Moher, D, Oxman, AD, Savovic, J, Schulz, KF, Weeks, L, Sterne, JA; Cochrane Bias Methods Group; Cochrane Statistical Methods Group (2011). The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. British Medical Journal 343, d5928.CrossRefGoogle ScholarPubMed
Higgins, JPT, Green, S (eds) (2011). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration (www.cochrane-handbook.org). Accessed 1 November 2012.Google Scholar
Higgins, JPT, Thompson, SG, Deeks, JJ, Altman, DG (2003). Measuring inconsistency in meta-analyses. British Medical Journal 327, 557–560.Google Scholar
Hoy, D, Brooks, P, Woolf, A, Blyth, F, March, L, Bain, C, Baker, P, Smith, E, Buchbinder, R (2012). Assessing risk of bias in prevalence studies: modification of an existing tool and evidence of interrater agreement. Journal of Clinical Epidemiology 65, 934–939.Google Scholar
Ikin, JF, McKenzie, DP, Creamer, MC, McFarlane, AC, Kelsall, HL, Glass, DC, Forbes, AB, Horsley, KWA, Harrex, WK, Sim, MR (2005). War zone stress without direct combat: the Australian naval experience of the Gulf War. Journal of Traumatic Stress 18, 193–204.Google Scholar
Ikin, JF, Sim, M, Creamer, M, Forbes, A, Mckenzie, D, Kelsall, H, Glass, DC, McFarlane, AC, Abramson, MJ, Ittak, P, Dwyer, T, Blizzard, L, Delaney, KR, Horsley, KW, Harrex, WK, Schwarz, H (2004). War-related psychological stressors and risk of psychological disorders in Australian veterans of the 1991 Gulf War. British Journal of Psychiatry 185, 116–126.Google Scholar
Iowa Persian Gulf Study Group (1997). Self-reported illness and health status among Gulf War veterans: a population-based study. Journal of the American Medical Association 277, 238–245.CrossRefGoogle Scholar
Ishoy, T, Knop, J, Suadicani, P, Guldager, B, Appleyard, M, Gyntelberg, F (2004). Increased psychological distress among Danish Gulf War veterans – without evidence for a neurotoxic background. The Danish Gulf War Study. Danish Medical Bulletin 51, 108–113.Google Scholar
Kang, HK, Li, B, Mahan, CM, Eisen, SA, Engel, CC (2009). Health of US veterans of 1991 Gulf War: a follow-up survey in 10 years. Journal of Occupational and Environmental Medicine 51, 401–410.Google Scholar
Kang, HK, Mahan, CM, Lee, KY, Magee, CA, Murphy, FM (2000). Illnesses among United States veterans of the Gulf War: a population-based survey of 30,000 veterans. Journal of Occupational and Environmental Medicine 42, 491–501.Google Scholar
Kroenke, K, Spitzer, RL (2002). The PHQ-9: a new depression diagnostic and severity measure. Psychiatric Annals 32, 509–515.Google Scholar
Magruder, KM, Yeager, DE (2009). The prevalence of PTSD across war eras and the effect of deployment on PTSD: a systematic review and meta-analysis. Psychiatric Annals 39, 778–788.Google Scholar
McCauley, LA, Lasarev, M, Sticker, D, Rischitelli, DG, Spencer, PS (2002). Illness experience of Gulf War veterans possibly exposed to chemical warfare agents. American Journal of Preventative Medicine 23, 200–206.Google Scholar
McKenzie, DP, Ikin, J, McFarlane, A, Creamer, M, Forbes, A, Kelsall, H, Glass, DC, Ittak, P, Sim, MR (2004). Psychological health of Australian veterans of the 1991 Gulf War: an assessment using the SF-12, GHQ-12 and PCL-S. Psychological Medicine 34, 1419–1430.Google Scholar
Mitchell, AJ, Vaze, A, Rao, S (2009). Clinical diagnosis of depression in primary care: a meta-analysis. Lancet 374, 609–619.CrossRefGoogle ScholarPubMed
Moher, D, Liberati, A, Tetzlaff, J, Altman, DG; PRISMA Group (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Medicine 6, e1000097.CrossRefGoogle ScholarPubMed
Perconte, ST, Wilson, AT, Pontius, EB, Dietrick, AL, Spiro, KJ (1993). Psychological and war stress symptoms among deployed and non-deployed reservists following the Persian Gulf War. Military Medicine 158, 516–521.Google Scholar
Ramchand, R, Karney, BR, Osilla, KC, Burns, RM, Caldarone, LB (2008). Prevalence of PTSD, depression, and TBI among returning service members. In Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery (ed. Tanielian, T. L. and Jaycox, L. H.), pp. 35–85. RAND Corporation: Santa Monica, CA.Google Scholar
Robins, LN, Wing, J, Wittchen, HU, Helzer, JE, Babor, TF, Burke, J, Farmer, A, Jablenski, A, Pickens, R, Regier, DA, Sartorius, N, Towle, LH (1988). The Composite International Diagnostic Interview: an epidemiologic instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Archives of General Psychiatry 45, 1069–1077.Google Scholar
Spitzer, RL, Williams, JB, Kroenke, K, Linzer, M, Hahn, SR, Brody, D, Johnson, JG (1994). Utility of a new procedure for diagnosing mental disorders in primary care. Journal of the American Medical Association 272, 1749–1756.CrossRefGoogle ScholarPubMed
Steele, L (2000). Prevalence and patterns of Gulf War illness in Kansas veterans: association of symptoms with characteristics of person, place, and time of military service. American Journal of Epidemiology 152, 992–1002.Google Scholar
Stimpson, NJ, Thomas, HV, Weightman, AL, Dunstan, F, Lewis, G (2003). Psychiatric disorder in veterans of the Persian Gulf War of 1991. Systematic review. British Journal of Psychiatry 182, 391–403.CrossRefGoogle ScholarPubMed
Sutker, PB, Uddo, M, Brailey, K, Allain, AN (1993). War-zone trauma and stress-related symptoms in Operation Desert Shield/Storm (ODS) returnees. Journal of Social Issues 49, 33–50.Google Scholar
Sutker, PB, Davis, JM, Uddo, M, Ditta, SR (1995). Assessment of psychological distress in Persian Gulf troops: ethnicity and gender comparisons. Journal of Personality Assessment 64, 415–427.CrossRefGoogle ScholarPubMed
Toomey, R, Kang, HK, Karlinsky, J, Baker, DG, Vasterling, JJ, Alpern, R, Reda, DJ, Henderson, WG, Murphy, FM, Eisen, SA (2007). Mental health of US Gulf War veterans 10 years after the war. British Journal of Psychiatry 190, 385–393.Google Scholar
Vos, T, Flaxman, AD, Naghavi, M, Lozano, R, Michaud, C, Ezzati, M, Shibuya, K, Salomon, JA, Abdalla, S, Aboyans, V, Abraham, J, Ackerman, I, Aggarwal, R, Ahn, SY, Ali, MK, Alvarado, M, Anderson, HR, Anderson, LM, Andrews, KG, Atkinson, C, Baddour, LM, Bahalim, AN, Barker-Collo, S, Barrero, LH, Bartels, DH, Basáñez, MG, Baxter, A, Bell, ML, Benjamin, EJ, Bennett, D, Bernabé, E, Bhalla, K, Bhandari, B, Bikbov, B, Bin Abdulhak, A, Birbeck, G, Black, JA, Blencowe, H, Blore, JD, Blyth, F, Bolliger, I, Bonaventure, A, Boufous, S, Bourne, R, Boussinesq, M, Braithwaite, T, Brayne, C, Bridgett, L, Brooker, S, Brooks, P, Brugha, TS, Bryan-Hancock, C, Bucello, C, Buchbinder, R, Buckle, G, Budke, CM, Burch, M, Burney, P, Burstein, R, Calabria, B, Campbell, B, Canter, CE, Carabin, H, Carapetis, J, Carmona, L, Cella, C, Charlson, F, Chen, H, Cheng, AT, Chou, D, Chugh, SS, Coffeng, LE, Colan, SD, Colquhoun, S, Colson, KE, Condon, J, Connor, MD, Cooper, LT, Corriere, M, Cortinovis, M, de Vaccaro, KC, Couser, W, Cowie, BC, Criqui, MH, Cross, M, Dabhadkar, KC, Dahiya, M, Dahodwala, N, Damsere-Derry, J, Danaei, G, Davis, A, De Leo, D, Degenhardt, L, Dellavalle, R, Delossantos, A, Denenberg, J, Derrett, S, Des Jarlais, DC, Dharmaratne, SD, Dherani, M, Diaz-Torne, C, Dolk, H, Dorsey, ER, Driscoll, T, Duber, H, Ebel, B, Edmond, K, Elbaz, A, Ali, SE, Erskine, H, Erwin, PJ, Espindola, P, Ewoigbokhan, SE, Farzadfar, F, Feigin, V, Felson, DT, Ferrari, A, Ferri, CP, Fèvre, EM, Finucane, MM, Flaxman, S, Flood, L, Foreman, K, Forouzanfar, MH, Fowkes, FG, Franklin, R, Fransen, M, Freeman, MK, Gabbe, BJ, Gabriel, SE, Gakidou, E, Ganatra, HA, Garcia, B, Gaspari, F, Gillum, RF, Gmel, G, Gosselin, R, Grainger, R, Groeger, J, Guillemin, F, Gunnell, D, Gupta, R, Haagsma, J, Hagan, H, Halasa, YA, Hall, W, Haring, D, Haro, JM, Harrison, JE, Havmoeller, R, Hay, RJ, Higashi, H, Hill, C, Hoen, B, Hoffman, H, Hotez, PJ, Hoy, D, Huang, JJ, Ibeanusi, SE, Jacobsen, KH, James, SL, Jarvis, D, Jasrasaria, R, Jayaraman, S, Johns, N, Jonas, JB, Karthikeyan, G, Kassebaum, N, Kawakami, N, Keren, A, Khoo, JP, King, CH, Knowlton, LM, Kobusingye, O, Koranteng, A, Krishnamurthi, R, Lalloo, R, Laslett, LL, Lathlean, T, Leasher, JL, Lee, YY, Leigh, J, Lim, SS, Limb, E, Lin, JK, Lipnick, M, Lipshultz, SE, Liu, W, Loane, M, Ohno, SL, Lyons, R, Ma, J, Mabweijano, J, MacIntyre, MF, Malekzadeh, R, Mallinger, L, Manivannan, S, Marcenes, W, March, L, Margolis, DJ, Marks, GB, Marks, R, Matsumori, A, Matzopoulos, R, Mayosi, BM, McAnulty, JH, McDermott, MM, McGill, N, McGrath, J, Medina-Mora, ME, Meltzer, M, Mensah, GA, Merriman, TR, Meyer, AC, Miglioli, V, Miller, M, Miller, TR, Mitchell, PB, Mocumbi, AO, Moffitt, TE, Mokdad, AA, Monasta, L, Montico, M, Moradi-Lakeh, M, Moran, A, Morawska, L, Mori, R, Murdoch, ME, Mwaniki, MK, Naidoo, K, Nair, MN, Naldi, L, Narayan, KM, Nelson, PK, Nelson, RG, Nevitt, MC, Newton, CR, Nolte, S, Norman, P, Norman, R, O'Donnell, M, O'Hanlon, S, Olives, C, Omer, SB, Ortblad, K, Osborne, R, Ozgediz, D, Page, A, Pahari, B, Pandian, JD, Rivero, AP, Patten, SB, Pearce, N, Padilla, RP, Perez-Ruiz, F, Perico, N, Pesudovs, K, Phillips, D, Phillips, MR, Pierce, K, Pion, S, Polanczyk, GV, Polinder, S, Pope, CA III, Popova, S, Porrini, E, Pourmalek, F, Prince, M, Pullan, RL, Ramaiah, KD, Ranganathan, D, Razavi, H, Regan, M, Rehm, JT, Rein, DB, Remuzzi, G, Richardson, K, Rivara, FP, Roberts, T, Robinson, C, De Leòn, FR, Ronfani, L, Room, R, Rosenfeld, LC, Rushton, L, Sacco, RL, Saha, S, Sampson, U, Sanchez-Riera, L, Sanman, E, Schwebel, DC, Scott, JG, Segui-Gomez, M, Shahraz, S, Shepard, DS, Shin, H, Shivakoti, R, Singh, D, Singh, GM, Singh, JA, Singleton, J, Sleet, DA, Sliwa, K, Smith, E, Smith, JL, Stapelberg, NJ, Steer, A, Steiner, T, Stolk, WA, Stovner, LJ, Sudfeld, C, Syed, S, Tamburlini, G, Tavakkoli, M, Taylor, HR, Taylor, JA, Taylor, WJ, Thomas, B, Thomson, WM, Thurston, GD, Tleyjeh, IM, Tonelli, M, Towbin, JA, Truelsen, T, Tsilimbaris, MK, Ubeda, C, Undurraga, EA, van der Werf, MJ, van Os, J, Vavilala, MS, Venketasubramanian, N, Wang, M, Wang, W, Watt, K, Weatherall, DJ, Weinstock, MA, Weintraub, R, Weisskopf, MG, Weissman, MM, White, RA, Whiteford, H, Wiersma, ST, Wilkinson, JD, Williams, HC, Williams, SR, Witt, E, Wolfe, F, Woolf, AD, Wulf, S, Yeh, PH, Zaidi, AK, Zheng, ZJ, Zonies, D, Lopez, AD, Murray, CJ, AlMazroa, MA, Memish, ZA (2012). Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380, 2163–2196.Google Scholar
Wells, TS, Miller, SC, Adler, AB, Engel, CC, Smith, TC, Fairbank, JA (2011). Mental health impact of the Iraq and Afghanistan conflicts: a review of US research, service provision, and programmatic responses. International Review of Psychiatry 23, 144–152.CrossRefGoogle ScholarPubMed
Wolfe, J, Proctor, SP, Erickson, DJ, Heeren, T, Friedman, MJ, Huang, MT, Sutker, PB, Vasterling, JJ, White, RF (1999). Relationship of psychiatric status to Gulf War veterans’ health problems. Psychosomatic Medicine 61, 532–540.Google Scholar