Do mental disorders matter? A study of absenteeism among care seeking Gulf War veterans with ill defined conditions and musculoskeletal disorders.

AIMS: To investigate the extent that common psychological conditions contribute to lost work among individuals with musculoskeletal and ill defined conditions. METHODS: Cross sectional health and work related survey evaluating Gulf War veterans seeking Department of Defense health care for Gulf War related health concerns. Ordered probit models were used to study whether a provider diagnosed musculoskeletal condition (ICD-9 codes 710-739) or "signs, symptoms, and ill defined conditions" (ICD-9 codes 780-799) have an effect on recent lost work over the previous 90 days in the presence of one or more psychological conditions (ICD-9 codes 290-320) after controlling for sociodemographic variables. RESULTS: Bivariate analyses revealed that musculoskeletal conditions, ill defined conditions, and psychological conditions were positively associated with lost work. Multivariate analyses showed an independent effect of both psychological conditions and musculoskeletal conditions. A significant interaction existed between psychological conditions and musculoskeletal conditions: the presence of a coexisting psychological condition considerably increased the likelihood that a musculoskeletal disorder resulted in lost work, or vice versa. CONCLUSIONS: Psychological conditions appear to be an important contributor to absenteeism among individuals with musculoskeletal and ill defined conditions. A limitation of the cross sectional design was the inability to sequence the onset of conditions.

A multicenter two by two factorial trial of cognitive behavioral therapy and aerobic exercise for Gulf War veterans' illnesses: design of a veterans affairs cooperative study (CSP #470).

The Department of Veterans Affairs (VA) Cooperative Studies Program (CSP) Study #470 is a 2 x 2 factorial trial designed to evaluate the hypothesis that both cognitive behavioral therapy (CBT) and aerobic exercise will significantly improve physical function in participants with Gulf War veterans' illnesses (GWVI), and that adding CBT to aerobic exercise will provide further incremental benefit. One thousand three hundred fifty-six veterans will be randomized to one of four treatment arms: CBT plus aerobic exercise plus usual and customary care, aerobic exercise plus usual and customary care, CBT plus usual and customary care, or usual and customary care alone. The study duration is 2.5 years with 1.5 years of intake and 1 year of follow-up. The primary outcome measure is the proportion of veterans improved more than seven units on the physical component summary (PCS) scale of the Short Form Health Survey for Veterans (SF-36V) measured 12 months after randomization. This generic quality-of-life measure was chosen because there is no disease-specific measure for GWVI and the symptoms of GWVI span a wide range of physical manifestations that are related to the domains covered by the PCS scale. Sample size was determined to detect all six pairwise comparisons between the four treatment arms with 90% power and a Bonferroni adjustment for an overall type I error of 0.05 or 0.05/6 = 0.0083. CSP #470 was initiated in May 1999 in 18 VA and two Department of Defense medical centers. To date this represents the largest randomized trial designed to evaluate treatments for individuals with unexplained physical symptoms. This paper will focus on the rationale and unique features of the study design. Control Clin Trials 2001;22:310-332

Clinician attributions for symptoms and treatment of Gulf War-related health concerns.

BACKGROUND: Several clinical syndromes are defined solely on the basis of symptoms, absent an identifiable medical etiology. When evaluating and treating individuals with these syndromes, clinicians' beliefs might shape decisions regarding referral, diagnostic testing, and treatment. To assess clinician beliefs about the etiology and treatment of "Gulf War illness," we surveyed a sample of general internal medicine clinicians (GIMCs) and mental health clinicians (MHCs). METHODS: Clinicians (77 GIMCs and 214 MHCs) at the Veterans Affairs Puget Sound Health Care System, Seattle, Wash, and the Veterans Affairs Medical Center in Portland, Ore, responded to a mailed survey of their beliefs about Gulf War illness. RESULTS: Compared with GIMCs, MHCs were more likely to believe that Gulf War illness was the result of a "physical disorder" and that symptoms resulted from viruses or bacteria, immunizations, exposure to toxins, chemical weapons, or a combination of toxins and stress (P <.05). Conversely, GIMCs were more likely than MHCs to believe that Gulf War illness was a "mental disorder" and that symptoms were due to stress or posttraumatic stress disorder (P <.05). In addition, MHCs were more likely to endorse biological interventions to treat Gulf War illness (P <.01), whereas GIMCs were more likely to endorse psychological interventions. CONCLUSIONS: Clinicians' beliefs about the etiology and effective treatment of Gulf War illness vary and thus might contribute to the multiple referrals often reported by Gulf War veterans. Health care models for Gulf War veterans and others with symptom-based disorders necessitate collaborative interdisciplinary approaches.

Outbreaks of medically unexplained physical symptoms after military action, terrorist threat, or technological disaster.

Medically unexplained physical symptoms (MUPS) may present a challenge to clinicians, disaster response organizations, and scientists after future military actions, terrorist threats, or technological disasters. Polarized public discussion over science, policy, and media evidence following such incidents may reinforce the notion of cover-ups, create mutual doctor-patient mistrust, amplify symptom-related psychosocial distress and disability, and lead to unnecessary use of services. Under these circumstances, the clinician must always show respect, empathy, and validation for a patient's concerns. A skeptical attitude may induce efforts by patients to "prove" their symptoms are "real." If MUPS are discounted as a "non-problem," they may become a much bigger public health problem when patients feel their symptoms and concerns have been discounted by unfeeling government clinicians, and patient "horror stories" become grist for media and political mills.

Demographic, physical, and mental health factors associated with deployment of U.S. Army soldiers to the Persian Gulf.

A total of 675,626 active duty Army soldiers who were known to be at risk for deployment to the Persian Gulf were followed from 1980 through the Persian Gulf War. Hospitalization histories for the entire cohort and Health Risk Appraisal surveys for a subset of 374 soldiers were used to evaluate prewar distress, health, and behaviors. Deployers were less likely to have had any prewar hospitalizations or hospitalization for a condition commonly reported among Gulf War veterans or to report experiences of depression/suicidal ideation. Deployers reported greater satisfaction with life and relationships but displayed greater tendencies toward risk-taking, such as drunk driving, speeding, and failure to wear safety belts. Deployed veterans were more likely to receive hazardous duty pay and to be hospitalized for an injury than nondeployed Gulf War-era veterans. If distress is a predictor of postwar morbidity, it is likely attributable to experiences occurring during or after the war and not related to prewar exposures or health status. Postwar excess injury risk may be explained in part by a propensity for greater risk-taking, which was evident before and persisted throughout the war.

Rehabilitative care of war-related health concerns.

The objective of this study was to pilot the effectiveness of a 3-week rehabilitative intervention that used medical review, graded exercise, education on Gulf War exposures, active coping, and nutrition to improve disability and related distress for Gulf War veterans with persistent symptoms. One hundred and nine veterans were assessed at program entry and exit and at 1 and 3 months after program completion. Outcomes were physical symptoms, quality of life, physical health concern, and psychosocial distress--contrasted across time and demographic groups. After treatment, veterans showed modest and global improvements; women were more likely than men to show improvement. The finding that Gulf War veterans who completed specialized rehabilitative management experienced modest, short-term improvements is encouraging, given that veterans of the conflict remain concerned about their future health. Controlled studies are needed.

Relationship of physical symptoms to posttraumatic stress disorder among veterans seeking care for gulf war-related health concerns.

OBJECTIVES: Studies of the relationship of posttraumatic stress disorder (PTSD) to physical symptoms in war veterans consistently show a positive relationship. However, traumatic experiences causing PTSD may correlate with other war exposures and medical illnesses potentially accounting for those symptoms. METHODS: We analyzed data obtained from 21,244 Gulf War veterans seeking care for war-related health concerns to assess the relationship of PTSD to physical symptoms independent of environmental exposure reports and medical illness. At assessment, veterans provided demographic information and checklists of 15 common physical symptoms and 20 wartime environmental exposures. Up to seven ICD-9 provider diagnoses were ranked in order of estimated clinical significance. The relationship of provider-diagnosed PTSD to various physical symptoms and to the total symptom count was then determined in bivariate and multivariate analyses. RESULTS: Veterans diagnosed with PTSD endorsed an average of 6.7 (SD = 3.9) physical symptoms, those with a non-PTSD psychological condition endorsed 5.3 (3.5), those with medical illness endorsed 4.3 (3.4), and a group diagnosed as "healthy" endorsed 1.2 (2.2). For every symptom, the proportion of veterans reporting the symptom was highest in those with PTSD, second highest in those with any psychological condition, third highest in those with any medical illness, and lowest in those labeled as healthy. The PTSD-symptom count relationship was independent of demographic characteristics, veteran-reported environmental exposures, and comorbid medical conditions, even when symptoms overlapping with those of PTSD were excluded. CONCLUSIONS: PTSD diminishes the general health perceptions of care-seeking Gulf War veterans. Clinicians should carefully consider PTSD when evaluating Gulf War veterans with vague, multiple, or medically unexplained physical symptoms.

Psychological conditions diagnosed among veterans seeking Department of Defense Care for Gulf War-related health concerns.

The Comprehensive Clinical Evaluation Program is a US military program that provides a voluntary, clinically oriented evaluation for Gulf War health concerns. This article presents administrative data on psychological conditions (as coded using the International Classification of Diseases, 9th Revision) from the first year of the program. The most commonly diagnosed psychological conditions were medically unexplained physical-symptom syndromes; depression and anxiety, including post-traumatic stress disorder; and alcohol abuse or dependence. Psychological conditions were significantly related to a higher number of workdays lost, and the 19% of veterans with a primary diagnosis of a psychological condition reported 28% of the lost workdays among veteran who participated. Stressful Gulf War experiences were weakly but significantly related to psychological conditions. We conclude that among Gulf War veterans seeking evaluation for Gulf War-related health concerns, psychological conditions are common and are associated with important occupational morbidity.

Psychiatric syndromes in Persian Gulf War veterans: an association of handling dead bodies with somatoform disorders.

BACKGROUND: Traumatic combat experience has been associated with the development of posttraumatic stress disorder, but there have been few studies about the association of military combat experience and the development of somatoform disorders. METHODS: The authors evaluated 131 referred Gulf War veterans for medical and psychiatric syndromes thought related to their involvement in the Gulf War. Patients completed questionnaires regarding their traumatic experiences and were interviewed using the Structured Clinical Interview for DSM III-R. RESULTS: For the sample, 69% had axis I conditions. Major depression, undifferentiated somatoform and posttraumatic stress disorders were the most common diagnoses. Reports of traumatic events were associated with both posttraumatic stress disorder (p < 0.05) and somatoform diagnoses (p < 0.05). Veterans who handled dead bodies had a 3-fold risk of receiving a somatoform diagnosis (p < 0.05). CONCLUSIONS: Psychiatric syndromes may explain some medical complaints following involvement in the Persian Gulf War. The results suggest that some psychological and nonspecific somatic symptoms persisting since the Gulf War may be related to exposure to psychological trauma.

Multidisciplinary treatment of persistent symptoms after Gulf War service.

Research suggests that individuals commonly describe persistent symptoms or syndromes after a war. After the Persian Gulf War, the Department of Veterans Affairs and the Department of Defense initiated registries and expedited health care for those with Gulf War-related health concerns. At Walter Reed Army Medical Center, the Gulf War Health Center was created in mid-1994 to contribute a continuum of care for those with Gulf War-related health problems. The purpose of this report is to describe the Gulf War Health Center's Specialized Care Program, a 3-week intensive outpatient multidisciplinary treatment program for people with persistent, disabling Gulf War-related symptoms. The program uses an evidence-based model of multidisciplinary care employed at chronic pain centers internationally and shown to yield stable improvements in pain, mood, health care use, and return to work rates. A patient is described to illustrate how the program works. Finally, a Deployment Medicine Treatment Center is proposed, a multidisciplinary treatment center like the Specialized Care Program that would offer care to those with persistent, disabling symptoms after all future deployments.

A randomized, double-blind crossover trial of sertraline in women with chronic pelvic pain.

The efficacy of antidepressants as analgesics for a range of chronic pain problems is well documented. However, a controlled trial of an antidepressant for women with chronic pelvic pain has not yet been published. We randomized 23 women from a general gynecology clinic to either double-blind sertraline or placebo. Measures of psychological function, pain, and functional disability were taken at baseline and 6 weeks. After a 2-week washout, the groups were crossed-over and the same measures were done over the next 6 weeks. There were no significant improvements in pain or functional disability noted on sertraline compared to placebo. Studies involving larger samples of patients are needed to confirm these findings.

The threat of biological weapons. Prophylaxis and mitigation of psychological and social consequences.

The microbial world is mysterious, threatening, and frightening to most people. The stressors associated with a biological terrorist attack could create high numbers of acute and potentially chronic psychiatric casualties who must be recognized, diagnosed, and treated to facilitate triage and medical care. Media communications, planning for quarantine and decontamination, and the role of community leaders are important to the mitigation of psychological consequences. Physicians will need to accurately diagnose anxiety, depression, bereavement, and organic brain syndromes to provide treatment, reassurance, and the relief of pain.

Factors related to dissociation among patients with gastrointestinal complaints.

OBJECTIVES: Several recent reports have suggested that the process of dissociation is independently associated with several distressing conditions such as psychiatric diagnoses, somatization, current psychological distress, and past sexual and physical victimization. These studies, however, have not taken into account possible shared variance between these variables. Is dissociation uniquely related to each of these outcomes or do they, as a group, have common underlying factors that account for the relationship with dissociation? METHOD: As part of a larger study of gastroenterology clinic patients with irritable bowel syndrome and patients with inflammatory bowel disease (n = 103), we used stepwise multiple regression to select the factors most associated with dissociation, while controlling for the effects of other variables. Variable domains included demographics, psychiatric diagnoses, personality factors, functional disability, and trauma history. These domains as well as individual variables within these domains were systematically evaluated for their unique contribution to the prediction of dissociation as measured by the Dissociative Experiences Scale (DES). RESULTS: The best multivariable model for estimating dissociation magnitude included severe child sexual abuse, perceived physical disability, and lifetime dysthymia, alcoholism, and generalized anxiety disorder. These factors accounted for 37% of the variance in DES score and increased the correct classification of patients as either low-, middle-, or high-level dissociators. CONCLUSIONS: Dissociation among this convenience sample of IBS and IBD patients is a long-term coping pattern that is associated primarily with past sexual trauma, chronic emotional distress, alcoholism, and physical disability. Prospective studies are needed to test whether these findings also occur in other more generalizable samples.

Back pain in primary care: predictors of high health-care costs.

The objective of this study was to describe the health care utilization and prospective predictors of high-cost primary-care back pain patients. In the primary-care clinics of a large, staff model health maintenance organization in western Washington State, 1059 subjects were selected from consecutive patients presenting for back pain. The design was a 1-year prospective cohort study. Patients' were interviewed 1 month after an index primary-care back pain visit. Costs (back pain and total) and utilization (back pain primary-care follow-up visits, back pain specialty visits, back pain hospitalizations, back pain radiologic procedures, and pain medicine fills) were tracked over the next 11 months. Predictors assessed at 1 month were back pain diagnosis (disc disorder/sciatica, arthritis, vs. other), chronic pain grade (measure of pain intensity and related dysfunction), pain persistence (days with pain in prior 6 months), depressive symptomatology, and back pain-related disability compensation (ever/never). For the sample, 21% of patients with back pain costs > or = $600 (high back pain costs) accounted for 66% of back pain costs, 42% of total costs, 55% of primary-care follow-up visits for back pain, 91% of back pain specialty visits, 100% of back pain hospitalizations, 51% of back pain radiologic procedures, and 52% of pain medicine fills. The 21% with total costs > or = $2700 (high total costs) accounted for 67.7% of total costs, 52% of back pain costs, 29% of primary-care follow-up visits for back pain, 66% of back pain specialty visits, 100% of back pain hospitalizations, 39% of back pain radiologic procedures, and 42% of pain medicine fills. Multivariable logistic regression analyses indicated that increasing chronic pain grade, more persistent pain, and disc disorder/sciatica were strong independent predictors of high total and high back pain costs. Increasing depressive symptoms significantly predicted high total but not high back pain costs. Back pain disability compensation predicted high back pain but not high total costs. A minority of primary-care back pain patients accounted for a majority of health-care costs. Patients with high back pain costs accounted for more back pain-related health-care utilization than did patients with high total costs. Factors predicting subsequent high costs suggest behavioral interventions targeting dysfunction, pain persistence, and depression may reduce health-care utilization and prevent accumulation of high health-care costs among primary-care back pain patients.

Mental health services in Army primary care: the need for a collaborative health care agenda.

Epidemiologic studies have shown that more than half of mentally ill patients in the United States receive their psychiatric care exclusively in primary care settings. This fraction may be even higher in the military due to concern over possible occupational repercussions resulting from use of specialty psychiatric care and specialist shortages. Collaboration between generalists and mental health care specialists could potentially improve mental health care delivery and reduce psychiatric disability for a large segment of the Army population who have a psychiatric disorder but may not seek specialty care. Collaborative efforts can reinforce military generalists' essential gate-keeping function, thereby decreasing unnecessary medical utilization and health care costs. The authors review the problems associated with mental health care delivery in primary care and provide examples of collaborative models previously studied or currently being explored. A four-part Army Primary Care-Mental Health Services Agenda is proposed, consisting of: (1) coordinated research including primary care-mental health services research and community-based epidemiologic studies; (2) formation of a primary care-mental health services advisory committee for aiding with policy and program development; (3) graduate and continuing medical education in primary care-mental health services emphasizing interdisciplinary collaborative skills; and (4) clinical implementation of feasible collaborative interdisciplinary mental health care models adapted to the range of unique Army primary care settings. The main goal of the Army Primary Care-Mental Health Services Agenda is to improve access to Army mental health care in the most efficacious and cost-effective way and to help minimize the organizational impact of disability related to psychosocial distress.

Posttraumatic stress disorder symptoms and precombat sexual and physical abuse in Desert Storm veterans.

The purpose of this research was to study the association between precombat sexual and physical abuse and combat-related posttraumatic stress disorder (PTSD) symptoms in a clinical sample of male and female Desert Storm veterans. Two hundred ninety-seven veterans provided data on precombat sexual and physical abuse, precombat psychiatric problems, sociodemographics, Desert Storm combat exposure, and PTSD symptomatology using the Mississippi Scale. Men reported significantly higher levels of combat exposure, and women described significantly more frequent precombat abuse. Precombat-abused veterans reported more frequent precombat psychiatric histories. Analysis of covariance revealed that gender significantly modified the impact of precombat abuse on combat-related and other PTSD symptomatology after adjusting for precombat psychiatric history and level of combat exposure. Specifically, females describing precombat abuse reported much greater PTSD symptomatology than did females denying precombat abuse. These results in conjunction with previous research suggest that a relationship between precombat abuse and combat-related PTSD may exist. Prospective, longitudinal studies of both men and women are needed.