Suicides, homicides, accidents, and undetermined deaths in the U.S. military: comparisons to the U.S. population and by military separation status.

PURPOSE: To compare rates of external causes of mortality among individuals who served in the military (before and after separation from the military) to the U.S. METHODS: This retrospective cohort study examined all 3.9 million service members who served from 2002 to 2007. External cause mortality data from 2002 to 2009 were used to calculate standardized mortality ratios. Negative binomial regression compared differences in the mortality rates for pre- and post-separation. RESULTS: Accident and suicide mortality rates were highest among cohort members under 30 years of age, and most of the accident and suicide rates for these younger individuals exceeded expectation given the U.S. population mortality rates. Military suicide rates began below the expected U.S. rate in 2002 but exceeded the U.S. rate by 2009. Accident, homicide, and undetermined mortality rates remained below the U.S. rates throughout the study period. Mortality rates for all external causes were significantly higher among separated individuals compared with those who did not separate. Mortality rates for individuals after separation from service decreased over time but remained higher than the rates for those who had not separated from service. CONCLUSIONS: Higher rates of death for all external causes of mortality after separation suggest prevention opportunities. Future research should examine how preseparation characteristics and experiences may predict postseparation adverse outcomes to inform transition programs.

Risk of motor vehicle accident death among 1.3 million veterans of the Iraq and Afghanistan wars.

OBJECTIVE: We conducted a cohort study of recent wartime veterans to determine the postservice mortality risk due to motor vehicle accidents (MVAs). METHODS: Veterans were identified from the Defense Manpower Data Center records. Deployment to te Iraq or Afghanistan war zone was determined from the Contingency Tracking System. Vital status of 317,581 deployed and 964,493 nondeployed veterans was followed from their discharge dates between 2001 to 2007 until earlier of date of death or December 31, 2009. Underlying causes of death were obtained from the National Death Index Plus. RESULTS: Based on 9,353 deaths (deployed, 1,650; nondeployed, 7,703), of which 779 were MVA deaths as drivers (166; 613), both cohorts had 25 to 24% lower mortality risk from all causes but had 44 to 45% higher risk of MVA deaths relative to the U.S. general population. The higher MVA mortality risk was not associated with deployment to the war zone. After controlling for age, sex, race, marital status, branch of service, and rank, the risk for deployed veterans was comparable to that of nondeployed veterans (hazard ratio = 0.91; 95% confidence interval, 0.77-1.09). CONCLUSIONS: Veterans exhibit significantly higher risk of MVA deaths compared to the U.S. general population. However, deployment to the Iraq or Afghanistan war was not associated with the excess risk.

Suicide Risk Among Wounded U.S. Service Members.

The association between suicide and combat injuries sustained during the wars in Iraq and Afghanistan was examined. A retrospective population-based cohort design was conducted using official military records to identify combat injuries (October 7, 2001, to December 31, 2007). Those who were injured during combat had higher crude suicide rates than those who deployed and were not injured (incidence rate ratio [IRR] = 1.50; confidence interval [CI] = 1.06, 2.12), or never deployed (IRR = 1.46; CI = 1.04, 2.06). After adjusting for demographics, these findings were no longer statistically significant. Although our data did not support an elevated suicide risk among wounded service members, additional research is needed to examine the impact of injury severity.

All-Cause Mortality Among US Veterans of the Persian Gulf War: 13-Year Follow-up.

OBJECTIVE: We determined cause-specific mortality prevalence and risks of Gulf War deployed and nondeployed veterans to determine if deployed veterans were at greater risk than nondeployed veterans for death overall or because of certain diseases or conditions up to 13 years after conflict subsided. METHODS: Follow-up began when the veteran left the Gulf War theater or May 1, 1991, and ended on the date of death or December 31, 2004. We studied 621   901 veterans who served in the 1990-1991 Persian Gulf War and 746   247 veterans who served but were not deployed during the Gulf War. We used Cox proportional hazard models to calculate rate ratios adjusted for age at entry to follow-up, length of follow-up, race, sex, branch of service, and military unit. We compared the mortality of (1) Gulf War veterans with non-Gulf War veterans and (2) Gulf War army veterans potentially exposed to nerve agents at Khamisiyah in March 1991 with those not exposed. We compared standardized mortality ratios of deployed and nondeployed Gulf War veterans with the US population. RESULTS: Male Gulf War veterans had a lower risk of mortality than male non-Gulf War veterans (adjusted rate ratio [aRR] = 0.97; 95% confidence interval [CI], 0.95-0.99), and female Gulf War veterans had a higher risk of mortality than female non-Gulf War veterans (aRR = 1.15; 95% CI, 1.03-1.28). Khamisiyah-exposed Gulf War army veterans had >3 times the risk of mortality from cirrhosis of the liver than nonexposed army Gulf War veterans (aRR = 3.73; 95% CI, 1.64-8.48). Compared with the US population, female Gulf War veterans had a 60% higher risk of suicide and male Gulf War veterans had a lower risk of suicide (standardized mortality ratio = 0.84; 95% CI, 0.80-0.88). CONCLUSION: The vital status and mortality risk of Gulf War and non-Gulf War veterans should continue to be investigated.

Social Information Processing in Anger Expression and Partner Violence in Returning U.S. Veterans.

We examined social information processing factors that could represent pathways through which posttraumatic stress disorder (PTSD) symptoms relate to anger expression and intimate partner violence (IPV) perpetration in returning U.S. veterans. The sample included 92 male Operation Enduring Freedom/Operation Iraqi Freedom veterans, primarily Caucasian (77.4%), with smaller numbers of African American, Asian, Hispanic or Latino, American Indian or Alaskan Native, and other minority participants (9.7%, 2.2%, 2.2%, 3.2%, and 5.3% respectively). The average age was 40.37 (SD = 9.63) years. Data were collected through self-report questionnaires (PTSD Checklist, State-Trait Anger Expression Scale, Revised Conflict Tactics Scales) and the Articulated Thoughts in Simulated Situations experimental protocol. Laboratory-based assessment of cognitive biases and hostile attributions were tested as mediators of associations between PTSD symptoms and anger expression and IPV. Among the PTSD symptom clusters, hyperarousal symptoms were most strongly associated with anger expression (r = .50) and IPV perpetration (r = .27). Cognitive biases mediated associations between PTSD total scores and 3 of 4 PTSD cluster scores as well as anger expression. Hostile attribution biases were also associated with IPV perpetration (r = .23). We discuss the implications of these findings for understanding social information processing mechanisms for the relationship between PTSD symptoms and aggression.

Risk of Suicide Among US Military Service Members Following Operation Enduring Freedom or Operation Iraqi Freedom Deployment and Separation From the US Military.

IMPORTANCE: A pressing question in military suicide prevention research is whether deployment in support of Operation Enduring Freedom or Operation Iraqi Freedom relates to suicide risk. Prior smaller studies report differing results and often have not included suicides that occurred after separation from military service. OBJECTIVE: To examine the association between deployment and suicide among all 3.9 million US military personnel who served during Operation Enduring Freedom or Operation Iraqi Freedom, including suicides that occurred after separation. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort design used administrative data to identify dates of deployment for all service members (October 7, 2001, to December 31, 2007) and suicide data (October 7, 2001, to December 31, 2009) to estimate rates of suicide-specific mortality. Hazard ratios were estimated from time-dependent Cox proportional hazards regression models to compare deployed service members with those who did not deploy. MAIN OUTCOMES AND MEASURES: Suicide mortality from the Department of Defense Medical Mortality Registry and the National Death Index. RESULTS: Deployment was not associated with the rate of suicide (hazard ratio, 0.96; 99% CI, 0.87-1.05). There was an increased rate of suicide associated with separation from military service (hazard ratio, 1.63; 99% CI, 1.50-1.77), regardless of whether service members had deployed or not. Rates of suicide were also elevated for service members who separated with less than 4 years of military service or who did not separate with an honorable discharge. CONCLUSIONS AND RELEVANCE: Findings do not support an association between deployment and suicide mortality in this cohort. Early military separation (<4 years) and discharge that is not honorable were suicide risk factors.

Suicide risk among 1.3 million veterans who were on active duty during the Iraq and Afghanistan wars.

PURPOSE: We conducted a retrospective cohort mortality study to determine the postservice suicide risk of recent wartime veterans comparing them with the US general population as well as comparing deployed veterans to nondeployed veterans. METHODS: Veterans were identified from the Defense Manpower Data Center records, and deployment to Iraq or Afghanistan war zone was determined from the Contingency Tracking System. Vital status of 317,581 deployed and 964,493 nondeployed veterans was followed from the time of discharge to December 31, 2009. Underlying causes of death were obtained from the National Death Index Plus. RESULTS: Based on 9353 deaths (deployed, 1650; nondeployed, 7703), of which 1868 were suicide deaths (351; 1517), both veteran cohorts had 24% to 25% lower mortality risk from all causes combined but had 41% to 61% higher risk of suicide relative to the US general population. However, the suicide risk was not associated with a history of deployment to the war zone. After controlling for age, sex, race, marital status, branch of service, and rank, deployed veterans showed a lower risk of suicide compared with nondeployed veterans (hazard ratio, 0.84; 95% confidence interval, 0.75-0.95). Multiple deployments were not associated with the excess suicide risk among deployed veterans (hazard ratio, 1.00; 95% confidence interval, 0.79-1.28). CONCLUSIONS: Veterans exhibit significantly higher suicide risk compared with the US general population. However, deployment to the Iraq or Afghanistan war, by itself, was not associated with the excess suicide risk.

PTSD diagnoses among Iraq and Afghanistan veterans: comparison of administrative data to chart review.

To guide budgetary and policy-level decisions, the U.S. Department of Veterans Affairs (VA) produces quarterly reports that count the number of Iraq and Afghanistan veterans with International Classification of Diseases, 9(th) Revision, Clinical Modification (ICD-9-CM) codes for posttraumatic stress disorder (PTSD; 309.81) in their electronic medical record administrative data. We explored the accuracy of VA administrative data (i.e., diagnostic codes used for billing purposes), by comparing it to chart review evidence of PTSD (i.e., medical progress notes and all other clinical documentation contained in the entire VA medical record). We reviewed VA electronic medical records for a nationwide sample of 1,000 Iraq and Afghanistan veterans with at least one ICD-9-CM code for PTSD in their VA administrative data. Among veterans sampled, 99.9% had 2 or more ICD-9-CM codes for PTSD. Reviewing all VA electronic medical record notes for these 1,000 veterans for the full course of their VA health care history revealed that PTSD was diagnosed by a mental health provider for 89.6%, refuted for 5.6%, and PTSD was never evaluated by a mental health provider for 4.8%. VA treatment notes for the 12 months preceding chart review showed that 661 veterans sampled received a VA PTSD diagnosis during that 12-month timeframe, and of these 555 were diagnosed by a mental health provider (83.9%). Thus, the presence of an ICD-9-CM code for PTSD approximated diagnoses by VA mental health providers across time points (89.6% for entire treatment history and 83.9% for 12 months prior to chart review). Administrative data offer large-scale means to track diagnoses and treatment utilization; however, their limitations are many, including the inability to detect false-negatives.

HealthViEWS: mortality study of female US Vietnam era veterans, 1965-2010.

We conducted a retrospective study among 4,734 women who served in the US military in Vietnam (Vietnam cohort), 2,062 women who served in countries near Vietnam (near-Vietnam cohort), and 5,313 nondeployed US military women (US cohort) to evaluate the associations of mortality outcomes with Vietnam War service. Veterans were identified from military records and followed for 40 years through December 31, 2010. Information on underlying causes of death was obtained from death certificates and the National Death Index. Based on 2,743 deaths, all 3 veteran cohorts had lower mortality risk from all causes combined and from several major causes, such as diabetes mellitus, heart disease, chronic obstructive pulmonary disease, and nervous system disease relative to comparable US women. However, excess deaths from motor vehicle accidents were observed in the Vietnam cohort (standardized mortality ratio = 3.67, 95% confidence interval (CI): 2.30, 5.56) and in the US cohort (standardized mortality ratio = 1.91, 95% CI: 1.02, 3.27). More than two-thirds of women in the study were military nurses. Nurses in the Vietnam cohort had a 2-fold higher risk of pancreatic cancer death (adjusted relative risk = 2.07, 95% CI: 1.00, 4.25) and an almost 5-fold higher risk of brain cancer death compared with nurses in the US cohort (adjusted relative risk = 4.61, 95% CI: 1.27, 16.83). Findings of all-cause and motor vehicle accident deaths among female Vietnam veterans were consistent with patterns of postwar mortality risk among other war veterans.

Self-reported post-exertional fatigue in Gulf War veterans: roles of autonomic testing.

To determine if objective evidence of autonomic dysfunction exists from a group of Gulf War veterans with self-reported post-exertional fatigue, we evaluated 16 Gulf War ill veterans and 12 Gulf War controls. Participants of the ill group had self- reported, unexplained chronic post-exertional fatigue and the illness symptoms had persisted for years until the current clinical study. The controls had no self-reported post-exertional fatigue either at the time of initial survey nor at the time of the current study. We intended to identify clinical autonomic disorders using autonomic and neurophysiologic testing in the clinical context. We compared the autonomic measures between the 2 groups on cardiovascular function at both baseline and head-up tilt, and sudomotor function. We identified 1 participant with orthostatic hypotension, 1 posture orthostatic tachycardia syndrome, 2 distal small fiber neuropathy, and 1 length dependent distal neuropathy affecting both large and small fiber in the ill group; whereas none of above definable diagnoses was noted in the controls. The ill group had a significantly higher baseline heart rate compared to controls. Compound autonomic scoring scale showed a significant higher score (95% CI of mean: 1.72-2.67) among ill group compared to controls (0.58-1.59). We conclude that objective autonomic testing is necessary for the evaluation of self-reported, unexplained post-exertional fatigue among some Gulf War veterans with multi-symptom illnesses. Our observation that ill veterans with self-reported post-exertional fatigue had objective autonomic measures that were worse than controls warrants validation in a larger clinical series.

Project VALOR: design and methods of a longitudinal registry of post-traumatic stress disorder (PTSD) in combat-exposed veterans in the Afghanistan and Iraqi military theaters of operations.

Few studies have investigated the natural history of post-traumatic stress disorder (PTSD). Project VALOR (Veterans' After-discharge Longitudinal Registry) was designed as a longitudinal patient registry assessing the course of combat-related PTSD among 1600 male and female Veterans who served in Operation Enduring Freedom (OEF) in Afghanistan or Operation Iraqi Freedom (OIF). Aims of the study include investigating patterns and predictors of progression or remission of PTSD and treatment utilization. The study design was based on recommendations from the Agency for Healthcare Quality and Research for longitudinal disease registries and used a pre-specified theoretical model to select the measurement domains for data collection and interpretation of forthcoming results. The registry will include 1200 male and female Veterans with a recent diagnosis of PTSD in the Department of Veteran Affairs (VA) electronic medical record and a comparison group of 400 Veterans without a medical record-based PTSD diagnosis, to also allow for case-control analyses. Data are collected from administrative databases, electronic medical records, a self-administered questionnaire, and a semi-structured diagnostic telephone interview. Project VALOR is a unique and timely registry study that will evaluate the clinical course of PTSD, psychosocial correlates, and health outcomes in a carefully selected cohort of returning OEF/OIF Veterans.

Selected Health Conditions Among Overweight, Obese, and Non-Obese Veterans of the 1991 Gulf War: Results from a Survey Conducted in 2003-2005.

BACKGROUND: Several health conditions and concerns have been reported to be increased among Gulf War veterans including post-traumatic stress disorder (PTSD), chronic fatigue syndrome (CFS), CFS-like illness, and unexplained multi-symptom illness (MSI). As the cohort of Gulf War veterans advance in age, they are likely to be at risk of not only certain deployment-related health conditions but also chronic diseases associated with lifestyle factors. METHODS: To clarify relationships between PTSD, CFS-like illness, MSI, and obesity, we analyzed data from a cross-sectional survey of health information among population-based samples of 15,000 Gulf War veterans and 15,000 veterans who served during the same era. Data had been collected from 9,970 respondents in 2003-2005 via a structured questionnaire or telephone survey. RESULTS: Based upon body mass index (BMI) estimated from self-reported information about height and weight, the percentages of Gulf War and Gulf Era veterans who were overweight (BMI 25 to ≤ 29.9), were 46.8% and 48.7%, respectively. The percentages who were obese (BMI ≥ 30) were 29.6% and 28.3%, respectively. Without adjustment for Gulf deployment status (Gulf War vs Gulf Era), age, sex, or other factors, PTSD, MSI, CFS-like illness, and other chronic health conditions were more common among obese veterans than those who were normal weight (BMI 18.5 to ≤ 24.9). In multivariate analyses, PTSD was positively associated with obesity after adjustment for age, sex, Gulf deployment status, rank, income, education, and current smoking. In the model for PTSD, the adjusted odds ratio for obesity was 1.5 (95% CI 1.2-1.8). No associations were observed between BMI categories and CFS-like illness or MSI in multivariate analysis. CONCLUSIONS: Gulf War and Gulf Era veterans who were obese were more likely to have certain chronic health conditions including PTSD. Associations between Gulf status and CFS-like illness and MSI identified in the 2003-2005 follow-up survey were not accounted for by group differences in the prevalence of overweight or obesity.

Longitudinal health study of US 1991 Gulf War veterans: changes in health status at 10-year follow-up.

The authors assessed changes in the health status of US 1991 Gulf War-era veterans from a 1995 baseline survey to a 2005 follow-up survey, using repeated measurement data from 5,469 deployed Gulf War veterans and 3,353 nondeployed Gulf War-era veterans who participated in both surveys. Prevalence differences in health status between the 2 surveys were estimated for adverse health indices and chronic diseases for each veteran group. Persistence risk ratios and incidence risk ratios were calculated after adjustment for demographic and military service characteristics through Mantel-Haenszel stratified analysis. At 10-year follow-up, deployed veterans were more likely to report persistent poor health, as measured by the health indices (functional impairment, limitation of activities, repeated clinic visits, recurrent hospitalizations, perception of health as fair or poor, chronic fatigue syndrome-like illness, and posttraumatic stress disorder), than nondeployed veterans. Additionally, deployed veterans were more likely to experience new onset of adverse health (as measured by the indices) and certain chronic diseases than were nondeployed veterans. During the 10-year period from 1995 to 2005, the health of deployed veterans worsened in comparison with nondeployed veterans because of a higher rate of new onset of various health outcomes and greater persistence of previously reported adverse health on the indices.

Alcohol use and selected health conditions of 1991 Gulf War veterans: survey results, 2003-2005.

INTRODUCTION: A sizable literature has analyzed the frequency of alcohol consumption and patterns of drinking among veterans. However, few studies have examined patterns of alcohol use in veterans of the first Gulf War or factors associated with problem drinking in this population. We examined the frequency and patterns of alcohol use in male and female veterans who served in the 1991 Gulf War or during the same era and the relationships between alcohol use and selected health conditions. METHODS: We analyzed data from a follow-up survey of health information among population-based samples of 15,000 Gulf War and 15,000 Gulf Era veterans. Data had been collected from 9,970 respondents during 2003 through 2005 via a structured questionnaire or telephone survey. RESULTS: Posttraumatic stress disorder (PTSD), major depressive disorder (MDD), unexplained multisymptom illness (MSI), and chronic fatigue syndrome (CFS)-like illness were more frequent among veterans with problem drinking than those without problem drinking. Approximately 28% of Gulf War veterans with problem drinking had PTSD compared with 13% of Gulf War veterans without problem drinking. In multivariate analysis, problem drinking was positively associated with PTSD, MDD, unexplained MSI, and CFS-like illness after adjustment for age, sex, race/ethnicity, branch of service, rank, and Gulf status. Veterans who were problem drinkers were 2.7 times as likely to have PTSD as veterans who were not problem drinkers. CONCLUSION: These findings indicate that access to evidence-based treatment programs and systems of care should be provided for veterans who abuse alcohol and who have PTSD and other war-related health conditions and illnesses.

Investigating the risk of cancer in 1990-1991 US Gulf War veterans with the use of state cancer registry data.

PURPOSE: The purpose of this study was to determine whether proportional cancer incidence is greater among Gulf War veterans compared with non-Gulf War veterans. METHODS: Files obtained from the Defense Manpower Data Center included data for 621,902 veterans who were deployed to the Persian Gulf during the 1990 to 1991 Gulf War (August 2, 1990, to March 1, 1991) and 746,248 non-Gulf War veteran controls. Identification of veterans who received a cancer diagnosis between 1991 and 2006 was accomplished through record linkage of the Defense Manpower Data Center dataset with files from 28 state cancer registries and the Department of Veterans Affairs Central Cancer Registry. By the use of logistic regression, proportional incidence ratios adjusted for demographic and military characteristics were calculated by comparing the proportion of a specific cancer among all cancers in the Gulf War veterans to the proportion of that specific cancer among all cancers in the non-Gulf War veterans. RESULTS: Only lung cancer showed a statistically significant relative excess among Gulf War veterans compared with non-Gulf War veterans (adjusted proportional incidence ratios, 1.15; 95% confidence interval, 1.03-1.29). When adjusted for race, age, and sex, the overall proportion of cancers among Gulf War and non-Gulf War veterans was similar (odds ratio, 0.99; 95% CI, 0.96-1.02). CONCLUSIONS: With the exception of lung cancer, there is little evidence of excess risk of cancer associated with Gulf War deployment. A follow-up study is warranted to confirm this finding and to evaluate the role of greater smoking rates among deployed personnel.

Neuropsychological functioning of U.S. Gulf War veterans 10 years after the war.

Many U.S. Gulf War-era veterans complained of poor cognition following the war. This study assessed neuropsychological functioning in veterans 10 years after the war through objective tests. 2189 Gulf War-era veterans (1061 deployed, 1128 non-deployed) were examined at 1 of 16 U.S. Veterans Affairs medical centers. Outcomes included neuropsychological domains derived from factor analysis and individual test scores. Deployed veterans performed significantly worse than non-deployed veterans on 2 of 8 factors (motor speed & sustained attention, analysis not corrected for multiple comparisons) and on 4 of 27 individual test variables (Trails A & B, California Verbal Learning Test-List B, and Continuous Performance Test sensitivity, with only Trails B surviving Bonferroni correction). Within deployed veterans, Khamisiyah exposure was negatively correlated with motor speed after controlling for emotional distress. Depressive symptoms and self-reported exposure to toxicants were independently and significantly associated with worse sustained attention. Other factors were also associated with self-reported exposures. The findings were not a result of differential effort across groups. Gulf War deployment is associated with subtle declines of motor speed and sustained attention, despite overall intact neuropsychological functioning. Evidence suggests that toxicant exposures influence both these functions, and depressive symptoms also influence attention.

Neurological mortality among U.S. veterans of the Persian Gulf War: 13-year follow-up.

BACKGROUND: This study focuses on long-term mortality, specifically brain cancer, amyotrophic lateral sclerosis (ALS), Parkinson's disease, and multiple sclerosis (MS) of 621,902 veterans who served in the 1990-1991 Persian Gulf War (GW), and 746,248 non-GW veterans. METHODS: Follow-up began with the date the veteran left the GW theater or May 1, 1991 and ended with the date of death or December 31, 2004. Cox proportional hazard models were used for analyses. RESULTS: Adjusted mortality rate ratios (aRR) of GW veterans compared to non-GW veterans were not statistically significant for brain cancer (aRR = 0.90, 95% confidence interval (CI): 0.73, 1.11), MS (aRR = 0.61, 95% CI: 0.23, 1.63), Parkinson's disease (aRR = 0.71, 95% CI: 0.17, 2.99), or ALS (aRR = 0.96, 95% CI: 0.56, 1.62). GW veterans potentially exposed to nerve agents for 2 or more days and GW veterans exposed to oil well fire smoke were at increased risk for brain cancer mortality (aRR = 2.71, 95% CI: 1.25, 5.87; aRR = 1.81, 95% CI: 1.00, 3.27; respectively). CONCLUSIONS: The risk of death due to ALS, MS, Parkinson's disease, and brain cancer was not associated with 1991 GW service in general. However, GW veterans potentially exposed to nerve agents at Khamisiyah, Iraq, and to oil well fire smoke had an increased risk of mortality due to brain cancer.

Health of US veterans of 1991 Gulf War: a follow-up survey in 10 years.

OBJECTIVE: To assess periodically the health status of a cohort of 1991 Gulf War veterans by comparing various health outcomes with those of their military peers who were not deployed to the Gulf. METHODS: We conducted a follow-up health survey to collect health information among population-based samples of 30,000 veterans (15,000 Gulf War veterans and 15,000 Gulf Era veterans) using a structured questionnaire. RESULTS: Gulf veterans reported significantly higher rates of unexplained multi-symptom illness, chronic fatigue syndrome-like illness, posttraumatic stress disorder, functional impairment, health care utilization, a majority of selected physical conditions and all mental disorders queried during the survey than did Gulf Era veteran controls. CONCLUSIONS: Fourteen years after deployment, 1991 Gulf War veterans continue to report a higher prevalence of many adverse health outcomes, compared with Gulf Era veterans.