The Australian Vietnam Veterans Health Study: II. self-reported health of veterans compared with the Australian population

Histopathological Alterations in the Livers of Chronic Hepatitis Patients Exposed to Agent Orange/Dioxin in Vietnam

We investigated changes in some laboratory indices and the liver histology of chronic hepatitis patients who were exposed to dioxin. In 2014, we collected liver biopsy samples for histopathological examination from 33 chronic hepatitis patients living around the Da Nang Airbase, which is a dioxin-contaminated area due to the herbicide spraying in Vietnam. Dioxin exposure was measured by its levels in the blood. METAVIR classification was used to clarify the liver fibrosis stage. Laboratory tests included ten biochemical and six hematological indices that were measured in the blood. A regression linear model and binary logistic regression were used for data analysis. The observed alterations in the liver at the histological level mainly comprised hydropic degenerative hepatocytes, lymphocytes and polynuclear leukocytes surrounding the liver cells and granular and lipoic degeneration. In addition, increased TCDD levels were associated with increasing aminotransferase (AST), alanine aminotransferase, protein and total bilirubin levels and liver fibrosis stage. Similarly, increased TEQ-PCDD/Fs levels were associated with higher levels of AST and protein and liver fibrosis stage. In conclusion, dioxin exposure altered the liver histology and increased some biochemical marker indices and the liver fibrosis stage of chronic hepatitis patients living in dioxin-contaminated areas in Da Nang, Vietnam.

Study protocol for a prospective, longitudinal cohort study investigating the medical and psychosocial outcomes of UK combat casualties from the Afghanistan war: the ADVANCE Study

INTRODUCTION

The Afghanistan war (2003-2014) was a unique period in military medicine. Many service personnel survived injuries of a severity that would have been fatal at any other time in history; the long-term health outcomes of such injuries are unknown. The ArmeD SerVices TrAuma and RehabilitatioN OutComE (ADVANCE) study aims to determine the long-term effects on both medical and psychosocial health of servicemen surviving this severe combat related trauma.

METHODS AND ANALYSIS

ADVANCE is a prospective cohort study. 1200 Afghanistan-deployed male UK military personnel and veterans will be recruited and will be studied at 0, 3, 6, 10, 15 and 20 years. Half are personnel who sustained combat trauma; a comparison group of the same size has been frequency matched based on deployment to Afghanistan, age, sex, service, rank and role. Participants undergo a series of physical health tests and questionnaires through which information is collected on cardiovascular disease (CVD), CVD risk factors, musculoskeletal disease, mental health, functional and social outcomes, quality of life, employment and mortality.

ETHICS AND DISSEMINATION

The ADVANCE Study has approval from the Ministry of Defence Research Ethics Committee (protocol no:357/PPE/12) agreed 15 January 2013. Its results will be disseminated through manuscripts in clinical/academic journals and presentations at professional conferences, and through participant and stakeholder communications.

TRIAL REGISTRATION NUMBER

The ADVANCE Study is registered at ISRCTN ID: ISRCTN57285353.

Healthy workers or less healthy leavers? Mortality in military veterans

BACKGROUND

The 'healthy worker effect' predicts that longer employment is positively associated with reduced mortality, but few studies have examined mortality in military veterans irrespective of exposure to conflict.

AIMS

To examine mortality in a large national cohort of Scottish veterans by length of service.

METHODS

Retrospective cohort study comparing survival in up to 30-year follow-up among 57 000 veterans and 173 000 people with no record of service, matched for age, sex and area of residence, who were born between 1945 and 1985. We compared antecedent diagnoses in the two groups to provide information on probable risk factors.

RESULTS

By the end of follow-up, 3520 (6%) veterans had died, compared with 10 947 (6%) non-veterans. Cox proportional hazard analysis confirmed no significant difference overall unadjusted or after adjusting for deprivation. On subgroup analysis, those who left prematurely (early service leavers) were at significantly increased risk of death (hazard ratio (HR) 1.16, 95% confidence interval (CI) 1.09-1.24, P < 0.001), although the increase became non-significant after adjusting for socioeconomic status (HR 1.05, 95% CI 0.99-1.12). Longer-serving veterans were at significantly lower risk of death than non-veterans; the risk decreased both with length of service and in more recent birth cohorts. Smoking-related disease was the greatest contributor to increased mortality in early leavers.

CONCLUSIONS

Among longer-serving veterans, there was evidence of a HWE partly attributable to selective attrition of early service leavers, but birth cohort analysis suggests improvements over time which may also reflect a causal effect of improved in-service health promotion.

The Relationship between Military Combat and Cardiovascular Risk: A Systematic Review and Meta-Analysis

Background and Objectives

Cardiovascular disease (CVD) is a leading cause of death among military veterans with several reports suggesting a link between combat and related traumatic injury (TI) to an increased CVD risk. The aim of this paper is to conduct a widespread systematic review and meta-analysis of the relationship between military combat ± TI to CVD and its associated risk factors.

Methods

PubMed, EmbaseProQuest, Cinahl databases and Cochrane Reviews were examined for all published observational studies (any language) reporting on CVD risk and outcomes, following military combat exposure ± TI versus a comparative nonexposed control population. Two investigators independently extracted data. Data quality was rated and rated using the 20-item AXIS Critical Appraisal Tool. The risk of bias (ROB using the ROBANS 6 item tool) and strength of evidence (SOE) were also critically appraised.

Results

From 4499 citations, 26 studies (14 cross sectional and 12 cohort; 78–100% male) met the inclusion criteria. The follow up period ranged from 1 to 43.6 years with a sample size ranging from 19 to 621901 participants in the combat group. Combat-related TI was associated with a significantly increased risk for CVD (RR 1.80: 95% CI 1.24–2.62; I² = 59%, p = 0.002) and coronary heart disease (CHD)-related death (risk ratio 1.57: 95% CI 1.35–1.83; I² = 0%, p = 0.77: p < 0.0001), although the SOE was low. Military combat (without TI) was linked to a marginal, yet significantly lower pooled risk (low SOE) of cardiovascular death in the active combat versus control population (RR 0.90: CI 0.83–0.98; I² = 47%, p = 0.02). There was insufficient evidence linking combat ± TI to any other cardiovascular outcomes or risk factors.

Conclusion

There is low SOE to support a link between combat-related TI and both cardiovascular and CHD-related mortality. There is insufficient evidence to support a positive association between military combat ± any other adverse cardiovascular outcomes or risk factors. Data from well conducted prospective cohort studies following combat are needed.

Spirometric Pulmonary Restriction in Herbicide-Exposed U.S. Vietnam War Veterans

Spirometric restriction in herbicide-exposed U.S. Army Chemical Corps Vietnam War veterans was examined because no published research on this topic in Vietnam War veterans exists. Spirometry was conducted on 468 veterans who served in chemical operations in a 2013 study assessing the association between chronic obstructive pulmonary disease (COPD) and herbicide exposure. Exposure was verified based on blood serum values of 2,3,7,8-tetrachlorodibenzo-p-dioxin. Further, the association between herbicide exposure and spirometry restriction (forced expiratory volume in one second (FEV₁)/forced vital capacity (FVC) ≥ lower limit of normal (LLN) and FVC < LLN) was tested after adjustment for military characteristics, selected anthropometrics, and other predictors using multivariable regression. Spirometric restriction in herbicide sprayers (15.7%, 95% CI: 10.6, 20.9) was almost twice that of nonsprayers (9.91%, 95% CI: 5.9, 13.9) (p = 0.081). While spirometric restriction was not significantly associated with herbicide exposure (adjusted odds ratio (aOR) = 1.64, 95% CI: 0.82, 3.29) despite the greater prevalence of restriction in sprayers versus nonsprayers, spirometric restriction was significantly associated with race/ethnicity (aOR = 3.04, 95% CI: 1.36, 6.79) and waist circumference (aOR = 2.46, 95% CI: 1.25, 4.85). Because restrictive pulmonary disease may result from chemically-induced inflammation or sensitivity, research on chemical exposures and restriction in veterans should continue. Future study should include full pulmonary function testing, targeted research designs, and a wider set of explanatory variables in analysis, such as other determinants of health.

The mental health of sons and daughters of Australian Vietnam veterans

Background

War service increases the risk of post-traumatic stress disorder (PTSD) to combatants, and has been shown to increase the risk of PTSD in their offspring. The extent to which there is an excess compared with the general population is not yet established, nor whether PTSD increases the risk of other psychiatric problems.

Methods

A national sample of 133 sons and 182 daughters of a cohort of 179 Australian Vietnam veterans' families were assessed in person, using structured psychiatric interviews. The prevalence of trauma exposures, DSM-IV (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition) diagnoses and suicidality were compared with the Australian Bureau of Statistics' 2007 National Survey of Mental Health and Wellbeing data matched for age and sex. The risk of mental health problems potentially attributable to PTSD was also assessed.

Results

Sons and daughters were more likely than population expectations to report exposures to natural disasters, fire or explosions and transport accidents, and sons more likely to report exposure to toxic chemicals whereas daughters were more likely to report sexual assault. Sons and daughters had higher prevalences of alcohol and other substance dependence, depression and anxiety, and PTSD, and children's PTSD was associated with substance dependence, depression and suicidal ideation. There were strong associations between children's PTSD and comorbid conditions of substance use disorders, depression and anxiety.

Conclusions

Higher rates of mental health problems in veterans' families, together with comorbidity with PTSD and the link between veterans' and children's PTSD, suggest that the effects of trauma may continue into subsequent generations.

Growing up with a father with PTSD: The family emotional climate of the children of Australian Vietnam veterans

A non-clinical sample of male Australian Vietnam veterans, their wives, and adult offspring were interviewed in-person in a national epidemiological study to assess the relationship between the mental ill-health of veterans and the emotional climate of the family while the children were growing up. Veterans were assessed 17 years before their children using standardised psychiatric diagnostic interviews. Family emotional climate was assessed using offspring ratings of parental attachment, and codings of positive and negative family relationship styles based on five minute speech samples provided by the offspring. Sons and daughters had different views of their mothers and fathers, and were less positive towards their fathers particularly if he had posttraumatic stress disorder (PTSD). Veteran PTSD and depression significantly negatively impacted the family emotional climate, while mothers' mental health was not related. Veteran PTSD symptoms were lowest in secure attachment to the veteran and highest in inconsistent attachment for both sons and daughters, but were not related to attachment to the mother. Veteran PTSD was related to daughters' but not sons' perceptions of family emotional climate. The impact of veterans' PTSD on their families' emotional climate is more marked for daughters than sons.

Agent Orange exposure and risk of death in Korean Vietnam veterans: Korean Veterans Health Study

BACKGROUND

Agent Orange (AO) was a mixture of phenoxy herbicides, containing several dioxin impurities including 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD). Various military herbicides, including AO, were sprayed by the US military and allied forces for military purposes during the Vietnam War. This study was performed to identify the associations between the AO exposure and mortality in Korean Vietnam veterans.

METHODS

From 1 January 1992 to 31 December 2005, 180 639 Korean Vietnam veterans were followed up for vital status and cause of death. The AO exposure index was based on the proximity of the veteran's unit to AO-sprayed areas, using a geographical information system-based model. The adjusted hazard ratios and 95% confidence intervals were calculated by Cox's proportional hazard model.

RESULTS

The mortality from all causes of death was elevated with AO exposure. The deaths due to all sites of cancers combined and some specific cancers, including cancers of the stomach, small intestine, liver, larynx, lung, bladder and thyroid gland, as well as chronic myeloid leukaemia, were positively associated with AO exposure. The deaths from angina pectoris, chronic obstructive pulmonary disease and liver disease including liver cirrhosis were also increased with an increasing AO exposure.

CONCLUSIONS

Overall, this study suggests that AO/TCDD exposure may account for mortality from various diseases even several decades after exposure. Further research is needed to better understand the long-term effects of AO/TCDD exposure on human health.

Veterans' physical health

How individuals age is affected by life experiences. What we know today about aging has been largely shaped by a generation who experienced the special circumstances of wartime in their formative years. In this review, we investigate the research question, "What is known about the physical health of Canadian veterans?" In answering this question, we summarize the literature on Canadian Veterans but also include international literature on the physical health of American and Australian Veterans, along with some information from reports from Great Britain and other parts of Europe. Areas in which veterans perhaps fare worse than civilians of similar age include general health, hearing loss, musculoskeletal disorders, infections, cirrhosis, skin conditions, stomach conditions, neurologic conditions, and cardiovascular disease. The differing effects of combat on female veterans are also summarized. The healthy warrior effect is discussed along with its impact on research findings and the importance of choosing an appropriate control group.

Parental involvement in the war in Croatia 1991-1995 and suicidality in Croatian male adolescents

Aim

To investigate the association between parental war involvement and different indicators of psychosocial distress in a community sample of early adolescents ten years after the war in Croatia 1991-1995.

Methods

A total of 695 adolescents were screened with a self-report questionnaire assessing parental war involvement, sociodemographic characteristics, and alcohol and drug consumption. Personality traits were assessed with the Junior Eysenck Personality Questionnaire; depressive symptoms with the Children’s Depression Inventory (CDI); and unintentional injuries, physical fighting, and bullying with the World Health Organization survey Health Behavior in School-aged Children. Suicidal ideation was assessed with three dichotomous items. Suicidal attempts were assessed with one dichotomous item.

Results

Out of 348 boys and 347 girls who were included in the analysis, 57.7% had at least one veteran parent. Male children of war veterans had higher rates of unintentional injuries (odds ratio [OR], 1.2; 95% confidence interval [CI], 0.56 to 2.63) and more frequent affirmative responses across the full suicidal spectrum (thoughts about death – OR, 2.1; 95% CI, 1.02 to 4.3; thoughts about suicide – OR, 5; 95% CI, 1.72 to 14.66; suicide attempts – OR, 3.6; 95% CI, 1.03 to 12.67). In boys, thoughts about suicide and unintentional injuries were associated with parental war involvement even after logistic regression. However, girls were less likely to be affected by parental war involvement, and only exhibited signs of psychopathology on the CDI total score.

Conclusion

Parental war involvement was associated with negative psychosocial sequels for male children. This relationship is possibly mediated by some kind of identification or secondary traumatization. Suicidality and unintentional injuries are nonspecific markers for a broad range of psychosocial distresses, which is why the suggested target group for preventive interventions should be veteran parents as vectors of this distress.

The physical and mental health of Australian Vietnam veterans 3 decades after the war and its relation to military service, combat, and post-traumatic stress disorder

The long-term health consequences of war service remain unclear, despite burgeoning scientific interest. A longitudinal cohort study of a random sample of Australian Vietnam veterans was designed to assess veterans' postwar physical and mental health 36 years after the war (2005-2006) and to examine its relation to Army service, combat, and post-traumatic stress disorder (PTSD) assessed 14 years previously (1990-1993). Prevalences in veterans (n = 450) were compared with those in the Australian general population. Veterans' Army service and data from the first assessments were evaluated using multivariate logistic regression prediction modeling. Veterans' general health and some health risk factors were poorer and medical consultation rates were higher than Australian population expectations. Of 67 long-term conditions, the prevalences of 47 were higher and the prevalences of 4 were lower when compared with population expectations. Half of all veterans took some form of medication for mental well-being. The prevalence of psychiatric diagnoses exceeded Australian population expectations. Military and war service characteristics and age were the most frequent predictors of physical health endpoints, while PTSD was most strongly associated with psychiatric diagnoses. Draftees had better physical health than regular enlistees but no better mental health. Army service and war-related PTSD are associated with risk of illness in later life among Australian Vietnam veterans.

Trauma, PTSD, and physical health: an epidemiological study of Australian Vietnam veterans

OBJECTIVE

This study aimed to examine the relative contributions to physical health of combat trauma exposure and posttraumatic stress disorder (PTSD), which have both been implicated separately in poorer physical health but whose unconfounded effects have not been teased out.

METHODS

Data from an epidemiological study of Australian Vietnam veterans, which used personal interviews and standardized physical and psychiatric health assessments, provided the means to assess the independent and joint effects of psychological trauma exposure and PTSD on a wide range of self-reported measures of physical health. Trauma exposure was measured by published scales of combat exposure and peritraumatic dissociation. Logistic regression modeling was used to assess the relative importance of trauma exposure and PTSD to health while controlling for a set of potential confounders including standardized psychiatric diagnoses.

RESULTS

Greater health service usage and more recent health actions were associated more strongly with PTSD, which was also associated with a range of illness conditions coded by the World Health Organization International Classification of Diseases, 9th Edition (asthma, eczema, arthritis, back and other musculoskeletal disorders, and hypertension) both before and after controlling for potential confounders. In contrast, combat exposure and peritraumatic dissociation were more weakly associated with a limited number of unconfounded physical health outcomes.

CONCLUSIONS

This study provided evidence that PTSD, rather than combat exposure and peritraumatic dissociation, is associated with a pattern of physical health outcomes that is consistent with altered inflammatory responsiveness.

Vietnam military service history and prostate cancer

Background

Three decades after US and Australian forces withdrew from Vietnam, there has been much public interest in the health consequences of service in Vietnam. One controversial question is whether the risk of prostate cancer amongst Vietnam veterans is increased. This paper examines relationships between military history, family history and risk of prostate cancer in a population-based case control study.

Methods

Cases were selected from the Cancer Registry of Western Australia as incident cases of histologically-confirmed prostate cancer, and controls were age-matched and selected from the Western Australian electoral roll. Study participants were asked to report any military service history and details about that service.

Results

Between January 2001 and September 2002, 606 cases and 471 controls aged between 40–75 years were recruited. An increased prostate cancer risk was observed in men reporting they were deployed in Vietnam although this was not statistically significant (OR = 2.12; 95% CI 0.88–5.06). An increased risk was also observed in men reporting prostate cancer in fathers (OR = 1.90; 95% CI 1.20–3.00) or brothers (OR = 2.05; 95% CI 1.20–3.50) diagnosed with prostate cancer.

Conclusion

These findings support a positive association between prostate cancer and military service history in the Vietnam war and a first degree relative family history of prostate cancer.

Posttraumatic stress disorder: do electrical startle responses and thyroid function usefully supplement self-report? A study of Vietnam War veterans

OBJECTIVE

To investigate the usefulness of electrical startle responses and thyroid function as supplements to self-report measures of posttraumatic stress disorder (PTSD).

METHOD

Invitations were sent to all New Zealand Vietnam War veterans known to be living in North Canterbury; 50 responded and the 35 living in or near Christchurch were included. Self-report measures of PTSD (the Davidson Trauma Scale (DTS) and the Symptom Check List (SCL-90-R) ), an eye blink electrical startle response and thyroid function were measured. The DTS was re-administered one to two weeks later to assess short-term test-retest reliability. Six months later the DTS and the electrical startle response were measured again.

RESULTS

The veterans reported a wide range of PTSD severity, with 15/35 reporting prior diagnosis of PTSD. The DTS showed high short-term test-retest reliability (r = 0.93) and a moderate correlation after 6 months (r = 0.73). It also showed sensitivity to change; in one to two weeks the scores increased by nearly half a standard deviation, possibly because of an imminent "homecoming" march. The DTS and a PTSD scale from the SCL-90-R were highly correlated (r = 0.89). The total triiodothyronine (T3) to free thyroxine (T4) ratio measure of thyroid function correlated poorly with self-report (r < or = 0.27). The electrical startle response also correlated poorly with self-report (r < or = 0.26), showed low internal consistency between left and right sides (r = 0.43), and correlated 0.39 over six months. It was disliked by the veterans and had increased slightly at 6 month follow-up, perhaps because of sensitization.

CONCLUSIONS

The DTS was reliable and correlated highly with the SCL-90-R PTSD scale. Neither thyroid function nor eye blink electrical startle correlated with each other or with self-report, and reliability was not good for electrical startle. These two measures do not appear to add anything useful to the assessment of PTSD.

Screening for trauma histories, posttraumatic stress disorder (PTSD), and subthreshold PTSD in psychiatric outpatients

The ability of the Structured Clinical Interview for DSM-IV (SCID) posttraumatic stress disorder (PTSD) module's screening question to identify individuals with PTSD or subthreshold PTSD was examined. First, the screen's sensitivity for detecting a trauma history was determined. Second, the incremental validity of a more thorough trauma assessment was examined by determining how many individuals responded negatively to the screen but then were diagnosed with PTSD or subthreshold PTSD. Last, the optimal SCID termination point for assessing subthreshold PTSD was determined. Using a trauma list increased the number of participants reporting a trauma; however, the SCID screen captured almost all individuals who had PTSD or subthreshold PTSD. When one screens for subthreshold PTSD, the SCID can be terminated on failure to meet Criterion B.

Medical-care costs associated with posttraumatic stress disorder in Vietnam veterans

OBJECTIVE

This study examined the relationship between medical-care costs of Vietnam veterans and predictor factors, including posttraumatic stress disorder (PTSD).

METHOD

We merged medical-care cost data from the Department of Veterans' Affairs and the Health Insurance Commission with data from an epidemiological study of 641 Australian Vietnam veterans. Posttraumatic stress disorder and other factors were examined as predictors of medical-care cost using regression analysis.

RESULTS

We found that a diagnosis of PTSD was associated with medical costs 60% higher than average. Those costs appeared to be partly associated with higher treatment costs for physical conditions in those with PTSD and also related mental health comorbidities. Major predictors of medical-care cost were age ($137 per year for each 5-year increase in age) and number of diagnoses reported ($81 to $112 per year for each diagnosis). Mental health factors such as depression ($14 per year for each symptom reported) and anxiety ($27 per year for each symptom reported) were also important predictors.

CONCLUSIONS

The findings indicate that, however they are incurred, high healthcare and, presumably, also economic and personal costs are associated with PTSD. There is an important social obligation as well as substantial economic reasons to deal with these problems. From both perspectives, continued efforts to identify and implement effective prevention and treatment programs are warranted.

Distress experienced by participants during an epidemiological survey of posttraumatic stress disorder

We examined the potential for epidemiological studies of mental disorders, specifically of posttraumatic stress disorder (PTSD), to cause further harm to participants involved. Of 1,000 randomly selected Australian Vietnam veterans, 641 agreed to participate in an epidemiological survey. Participants were asked about distress experienced during the interview when traumatic events were raised. Significant distress attributed to the interview was reported by 75.3% of those with current PTSD, 56.5% of those with past PTSD, and 20.6% of those with no PTSD diagnosis. Distress did not affect participants' use of medical services following the interview nor did it affect their willingness to continue participating in the study. We concluded that research interviews about PTSD may cause short-term distress, but found no evidence of long-term harm.

Combat, dissociation, and posttraumatic stress disorder in Australian Vietnam veterans

The specificity of various wartime stressors for different posttraumatic stress disorder (PTSD) symptoms is inconsistently reported in the literature. Combat, wounding, and peritraumatic dissociation have not been assessed together in their effects on each of the various PTSD symptom clusters. This cohort study of a random sample of male Australian Army Vietnam veterans yielded psychiatric assessments of 641 subjects. PTSD measures comprised symptom criteria for reexperiencing, numbing and avoidance, hyperarousal, and PTSD diagnosis both lifetime and current within the past month. Logistic regression is used to examine the effects of combat, wounding, and peritraumatic dissociation together on PTSD. Combat experiences comprised four components derived from a principal components analysis of combat experiences: direct combat exposure, exposure to death and injury, exposure to civilian death and injury, and exposure to mutilation. Each was differentially related to reexperiencing, avoidance, hyperarousal, and PTSD diagnosis. Being wounded was not related to lifetime or current PTSD and peritraumatic dissociation was related to all diagnostic components of PTSD in the presence of other variables.

Health of UK servicemen who served in Persian Gulf War

BACKGROUND

Various symptoms in military personnel in the Persian Gulf War 1990-91 have caused international speculation and concern. We investigated UK servicemen.

METHODS

We 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.

FINDINGS

There 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.

INTERPRETATION

Service 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.

Hearts and minds: suicide among United States combat troops in Vietnam, 1957-1973

The literature on suicides among military personnel in a combat zone remains anecdotal. Although one finds literary and journalistic accounts of the problem, it has not been systematically analyzed. This paper will examine suicides among American combat troops during their tour of duty in Vietnam. Utilizing statistical data from the Southeast Asia Combat Area Casualties Database (SACACD), the authors will survey its epidemiology among U.S. ground troops in Vietnam from 1957 to 1973. The results suggest that certain types of combat troops were significantly more likely than others to commit suicide. These findings not only provide important predictors for military health professionals in the assessment of suicide risk, they also raise disturbing questions about the nature of organized armed conflict.

Posttraumatic stress disorder and comorbidity in Australian Vietnam veterans: risk factors, chronicity and combat

OBJECTIVE

The objective of this study was to examine the relationship between combat-related posttraumatic stress disorder (PTSD) and comorbid DSM-III-R psychiatric diagnoses to determine commonalities in risk factors, relative onsets and the role of combat exposure.

METHOD

An epidemiological cohort study using standardised psychiatric, social and health interviews was undertaken with a national random sample of male Australian Army Vietnam veterans. Interviews and searches of military records yielded risk factors for PTSD, which were examined for association with each psychiatric diagnosis. Relative onsets of PTSD and each Diagnostic Interview Schedule diagnosis were compared. Comorbidity odds ratios were adjusted for combat exposure effects using logistic regression, and the relation between each diagnosis and combat was assessed after controlling for PTSD.

RESULTS

Commonality of risk factor profile was evident for several diagnoses, and for many their onset preceded PTSD onset. Combat was independently related to only a few diagnoses after controlling for PTSD, and PTSD remained strongly associated with several conditions after controlling for combat exposure.

CONCLUSIONS

The analysis suggests that the disorders that may constitute risk factors or vulnerabilities for PTSD comprise depression and dysthymia, antisocial personality disorder, agoraphobia and simple phobia, while those that may be consequent on PTSD are panic and generalised anxiety disorder, drug use disorders and somatoform pain disorder. Alcohol and drug use disorders and social phobia may have a mixed aetiology, while obsessive-compulsive disorder may be serendipitously related to PTSD through an association with risk of combat. Gambling disorder is unrelated.

Risk factors for posttraumatic stress disorder in Australian Vietnam veterans

OBJECTIVE

The aims of this paper are to determine the risk factors for combat-related posttraumatic stress disorder (PTSD) and to examine the relative contribution of pre-military factors, pre-trauma psychiatric diagnoses, military factors such as combat posting, and combat and casualty stress exposure.

METHOD

An epidemiological cohort study using standardised psychiatric, social and health interviews was undertaken with a national random sample of male Australian Army Vietnam veterans. Multivariate logistic regression was used to examine the relative contribution of factors derived from interview and from military records in four categories: pre-enlistment circumstances including home life, education, major life stress; pre-Vietnam psychiatric diagnoses; military experiences before and during Vietnam; and combat and stress experiences.

RESULTS

Of the 128 data items examined, significant associations were found for 39, in addition to combat stress. Pre-enlistment items accounted for about 3% of the deviance towards PTSD diagnosis, pre-enlistment psychiatric diagnosis about 13%, military variables about 7% and combat stress about 18%; all factors together accounted for 42%.

CONCLUSIONS

The results confirm that pre-military and military variables make only a small but significant contribution to PTSD either alone or after controlling for combat stress; that psychiatric diagnoses of depression, dysthymia and agoraphobia make strong contributions to PTSD; but that combat stress makes the largest contribution even after controlling for the effects of other variables. Psychiatric diagnoses and combat stress appear to be independent in their effects on PTSD.

Australian Vietnam veterans: factors contributing to psychosocial problems

OBJECTIVE

The objective of the present paper is to present comprehensive models of the current psychosocial morbidity of Australian Vietnam veterans. Seldom has research in this area attempted to 'untangle' direct and indirect influences on current functioning via possible pre-army, Vietnam and homecoming pathways.

METHOD

The Australian Vietnam Veterans' Health Study gathered data on a sample of 641 veterans throughout Australia drawn randomly from army Vietnam tour lists of the era. The data arose from interview and army records of the era, and fall into four temporal categories: pre-army, Vietnam service, homecoming after Vietnam, and current state. Path analysis models of the veterans' current psychological morbidities and social wellbeing are used to identify direct aetiological influences of earlier era constructs on current state, free of confounding by indirect (often selection) effects.

RESULTS

Our results indicate that psychological morbidity (particularly posttraumatic stress disorder) is largely influenced by combat and poor homecoming experiences, although pre-military characteristics do play some direct roles in symptomatology. Social dysfunction measures show smaller effects of the Vietnam War, which may be accounted for by an indirect association with Vietnam-related psychological morbidity. Some social measures show evidence of compensatory influences of combat, high combat leading to social dysfunction because of morbidity, but simultaneously being associated with healthier social disposition (possibly because of increased exservice activity).

CONCLUSIONS

For Australian Vietnam veterans, combat-related and homecoming effects persist on a range of psychosocial endpoints 20-30 years after exposure. These effects are not explicable in terms of veterans pre-Vietnam characteristics.