We used cross-sectional data from a health survey of veterans that was conducted 13 years after the end of the 1991 Gulf War to examine the relationships between PTSD, MDD, and alcohol consumption. Therefore, the cases of PTSD identified in this cohort of Gulf War and Gulf Era veterans represent those that occurred as a result of war-time trauma and that persisted for an extended time, combined with PTSD cases that resulted from traumatic experiences that may have occurred after the war.
PTSD is an anxiety disorder that can occur after someone experiences a traumatic event such as a combat experience, a motor vehicle crash, or sexual assault (27
). Symptoms of PTSD may include nightmares, intrusive thoughts, or other re-experiencing phenomena; the avoidance of situations that remind the person of the traumatic event; a feeling of numbness or being socially detached from family and friends; and hyperarousal (eg, feeling angry, irritable, and "on edge"; having difficulty concentrating). Hyperarousal or hypervigilance is characterized by a rapid and pronounced reaction to stressors, which may lead to a preoccupation with signs of threat and emotional distress. People with PTSD may have other challenges such as difficulties with employment, difficulties with relationships, or other health conditions (eg, depression, alcohol abuse, drug dependency) (27
Our findings indicate that, several years after the Gulf War ended, there was a high frequency of problem drinking among Gulf War and Gulf Era veterans who have PTSD, major depression, and other illnesses and health conditions. Psychological hypotheses about the relationship between alcohol abuse and PTSD often posit that PTSD precedes the development of alcohol abuse (14
). According to this hypothesis, alcohol problems may occur as a consequence of PTSD (16
). Excessive alcohol consumption and alcohol dependence may result from attempts to "self-medicate" or alleviate disturbing memories or other symptoms associated with PTSD. Alternatively, shared stressors such as war-time traumas may independently lead to both PTSD and problem drinking. This latter possibility has sometimes been referred to as the "shared stressor hypothesis" (16
). Because of its cross-sectional nature, our analysis does not provide evidence with which to determine which of these 2 hypotheses has more merit.
Our study, which was a national sample of Gulf War veterans, was conducted by using mail questionnaires and telephone interviews rather than face-to-face evaluations. The Iowa Gulf War Case Validation Study, conducted during 1999-2001, used face-to-face evaluations with 602 veterans sampled from a population-based survey of 4,886 military personnel and found that lifetime history of alcohol abuse or dependence was frequent among both deployed and nondeployed veterans who were depressed (68% and 52%, respectively). A study of the postwar hospitalization experience of US veterans who served in the 1991 Gulf War, which was based on medical records databases, found that alcohol dependence syndrome was the most frequent mental disorder; hospitalization rates for alcohol dependence were somewhat higher than those observed for other veterans from the same era who did not go to the Persian Gulf (standardized rate ratio = 1.19, 95% confidence interval, 1.10-1.30) (28
). PTSD, major depression, and other mental disorders have previously been studied in a sample of 1,061 deployed veterans and 1,128 nondeployed veterans who participated in the National Health Survey of Gulf War Era Veterans and Their Families (3
). The prevalence of depression and anxiety declined during a 10-year period among both groups but remained higher in the deployed group (3
Our study confirms that some veterans who experience MSI or CFS–like illness also experience problem drinking as a comorbid condition. The exposures that account for increased risks of MSI and CFS–like illness among Gulf War veterans are unknown but may include environmental factors such as pyridostigmine bromide or exposure to certain pesticides (10
). Many of the troops were exposed to an array of wartime and environmental exposures including psychological stress, solvents, fuels, and pesticides, pyridostigmine bromide pills given to protect troops from effects of nerve agents, smoke from oil-well fires, and prophylactic vaccines given to protect against anthrax and other infectious agents (10
Our study has limitations. The cross-sectional nature of the analysis prevents us from making inferences about the causality of the observed associations. Another limitation is that PTSD was assessed by using the PCL screening test rather than clinical interviews; therefore, misclassification of PTSD status may have occurred. Also, information was not collected about binge drinking, which has been found to be a risk factor in other military and veteran populations (29
). Furthermore, we relied on self-reported information about the frequency of alcohol use and problem drinking, which may have introduced social desirability bias; however, self-reported information about alcohol consumption has been found to be reliable and valid (30
). Finally, data were not collected on illicit drug use.
In summary, the results of this survey conducted during 2003-2005 indicate that veterans of the 1991 Gulf War, particularly those who have PTSD or MDD, have a higher frequency of heavy alcohol consumption and problem drinking. These findings underscore the importance of sustained efforts to provide access to evidence-based treatment programs and systems of care for veterans who abuse alcohol and who have PTSD and other war-related health conditions and illnesses (14