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Physical Health, Mental Health, and Utilization of Complementary and Alternative Medicine Services Among Gulf War Veterans

Holliday, Stephanie Brooks PhD; Hull, Amanda PhD; Lockwood, Courtney PhD; Eickhoff, Christine MS; Sullivan, Patrick MS; Reinhard, Matthew PsyD

doi: 10.1097/MLR.0000000000000223
Brief Report

Background: Gulf War veterans represent a unique subset of the veteran population. It has been challenging to identify interventions that result in improvements in physical and mental health for this population. Recently, there has been recognition of a potential role for complementary and alternative medicine (CAM) interventions.

Objectives: This paper examines the characteristics of Gulf War and non-Gulf War veterans referred to a CAM clinic, and explores the utilization of services by this population.

Method and Subjects: Participants included 226 veterans enrolled in a CAM clinic at a Veterans Affairs medical center, 42 of whom were Gulf War veterans. Self-report measures of physical/mental health were administered, and service utilization was obtained from participants’ medical records for a 6-month period.

Results: Gulf War veterans enrolled in the program reported more severe physical and mental health symptoms than non-Gulf War veterans. However, examining only veterans who participated in services in the 6 months following enrollment, the 2 groups reported similar symptom severity. Both groups were similar in their attendance of individual acupuncture and iRest® yoga nidra, although Gulf War veterans attended fewer sessions of group acupuncture.

Conclusions: Although Gulf War veterans who enroll in a CAM program may have more severe symptoms than non-Gulf War veterans, those who actually participate in services are similar to non-Gulf War veterans on these measures. These groups also differ in their pattern of service utilization. Future research should explore the reasons for these differences, and to identify ways to promote treatment engagement with this population.

War Related Illness and Injury Study Center, Washington DC VA Medical Center, Washington, DC

The authors declare no conflict of interest.

Reprints: Stephanie Brooks Holliday, PhD, War Related Illness and Injury Study Center, Washington DC VA Medical Center, 50 Irving St NW, Washington, DC 20422. E-mail:

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The use of CAM with veterans has recently received greater attention as a treatment option. For instance, there has been interest in the provision of CAM interventions within Department of Veterans Affairs (VA) specialty mental health clinics1 and within specific patient populations (eg, individuals with chronic pain, cancer, or posttraumatic stress disorder).2,3

There has also been an effort to describe factors associated with CAM utilization, including the role of certain demographic factors, aspects of health behavior, and lifestyle-related factors.4 Among these factors are military experiences, including deployment.4 However, this is a relatively new area of research.

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Gulf War veterans (defined for this study as deployment to Operation Desert Shield and/or Operation Desert Storm) represent a unique subset of the veteran population. In addition to concerns regarding chronic multisymptom illness (CMI)—that is, the presence of multiple diverse symptoms (eg, pain, cognitive difficulties, mood disturbances) —the prevalence of specific categories of health concerns has received a great deal of attention.5 For instance, research has established an increased rate and greater severity of mental health symptomotology (eg, posttraumatic stress disorder, depression), more persistent physical and mental health-related problems, and lower health-related quality of life among this population.5–8

It has been challenging to identify interventions that result in improvements in physical and mental health for veterans of this era. Medical, psychological, and psychosocial interventions have yielded mixed effects on mental and physical health within this population.9,10 In response, a recent Institute of Medicine publication focused on CMI in Gulf War veterans has called for more rigorous intervention research—including studies of CAM interventions.11 CAM interventions may be particularly well suited for Gulf War veterans, especially as these services are associated with benefits in multiple health-related domains.12–21 However, little is known about even basic aspects of CAM service utilization in Gulf War veterans, including patterns of treatment engagement and utilization.

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The aforementioned studies underscore the challenges faced by Gulf War veterans with respect to symptom severity, symptom complexity, and difficulty identifying effective services. Given that CAM interventions may hold promise for this group, it is useful to understand the characteristics of Gulf War veterans seeking CAM services, and compare their pattern of engagement in CAM to that of veterans from other eras.

To address these questions, this study examines the characteristics of Gulf War and non-Gulf War veterans enrolled in the Integrative Health and Wellness (IHW) Program, a CAM clinic within the War Related Illness and Injury Study Center at the Washington, DC VA Medical Center. More specifically, this study aimed to examine physical and mental health-related differences between Gulf War and non-Gulf War veterans who enrolled in the IHW Program, including differences between these groups with respect to depression, anxiety, pain, and sleep-related issues.

This study also aimed to examine the influence of Gulf War veteran status on service utilization defined broadly (ie, participation in any service), as well as utilization of 3 specific services: individual acupuncture, group auricular acupuncture, and iRest® yoga nidra.

Finally, analyses were conducted utilizing the subgroup of veterans who attended at least 1 service during their first 6 months to determine whether Gulf War veteran status was associated with number of sessions attended within this subgroup.

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This study involved veterans enrolled in the IHW Program, which was developed with an accompanying research protocol with local institutional review approval. The program is described in Figure 1. As noted, this study focuses on the utilization of individual acupuncture, group auricular acupuncture, and iRest yoga nidra.



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Participants included 226 veterans enrolled in the IHW Program between August 2012 and August 2013. To be eligible for the study, veterans had to be at least 18 years of age. Exclusion criteria included current involvement in meditation or acupuncture services or self-reported pregnancy.

The mean age of participants was approximately 50 years old. Most participants were male, African American, and Army veterans (Table 1). All participants identified pain-related or mental health-related issues as their primary health concerns on the Measure Yourself Medical Outcome Profile-2.22 Participants included veterans from a number of military eras, and dates of military separation ranged from 1945 to 2014. Forty-two participants identified as Gulf War veterans (18.58%). Veterans who did not deploy during Operations Desert Shield or Desert Storm were considered non-Gulf War veterans.



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Veterans completed several self-report measures regarding aspects of physical and mental health.

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Beck Depression Inventory-II

The Beck Depression Inventory-II23 is a measure of depressive symptoms (eg, sadness, hopelessness, sleep/appetite disturbances) over the past 2 weeks. This measure has demonstrated strong internal consistency (≥0.88), good test-retest reliability (0.73–0.96), and strong convergent validity with other depression measures.24

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Defense and Veterans Pain Rating Scale

The Defense and Veterans Pain Rating Scale is a 4-question scale that assesses current pain intensity on a 0–10 scale.25 Patients rate how pain has affected activity, sleep, mood, and stress over the past 24 hours. Total scores are obtained by averaging the responses across items, and range from 0 to 10.

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Pain Disability Questionnaire (PDQ)

The PDQ26 comprises 15 questions that assess functional difficulties related to pain (eg, ability to work or engage in personal care, impact of pain on social function). Previous research has defined mild/moderate pain disability to include scores from 0 to 70; severe to include scores from 71 to 100; and extreme to include scores from 101 to 150.27

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Insomnia Severity Index (ISI)

The ISI is a reliable and valid 7-item measure designed to measure sleep quality during the previous month.28 Scores range from 0 to 28, with scores ≥8 suggesting clinical insomnia.

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Perceived Stress Scale

The Perceived Stress Scale is a 10-item measure of subjective distress.29 It measures the degree to which situations over the past month are appraised as unpredictable, uncontrollable, and overwhelming. Higher scores indicate a greater degree of perceived stress.

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Medical Record Data

Data regarding service attendance were obtained from participants’ medical records. This included information regarding the number and type of appointments attended through the IHW Program.

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This study was conducted under local institutional review approval. During the orientation session, veterans who consented to participate in this study completed baseline study measures (before participating in services).

The program and procedures are detailed in Figure 1. As indicated, participant medical records were reviewed to determine the number and type of IHW services they attended during each follow-up period. This study focuses on the first 6 months of IHW participation. Of note, not all veterans participated in services during this period.

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Data Analysis

χ2 analyses and independent measures t tests were conducted to compare Gulf War and non-Gulf War veterans on demographic variables and baseline symptom severity. These analyses were conducted for the full sample (N=226), and for the subsample of veterans who attended at least 1 service during their first 6 months in the clinic (“service users”; n=163). χ2 analyses were conducted to examine the relationship between Gulf War veteran status and enrollment in services within the larger sample. Within the subsample service users, independent measures t tests were conducted to examine differences in the number of sessions attended.

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Initial analyses revealed no differences in age or sex for Gulf War veterans and non-Gulf War veterans. There was a significant difference in the racial composition of the groups: Gulf War veterans had a significantly lower proportion of individuals in the “other” category (P<0.05) (Table 1).

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Symptom Severity

With respect to symptom severity, both Gulf War and non-Gulf War veterans reported moderate symptoms of depression, moderate symptoms of insomnia, moderate/severe pain and pain disability, and high levels of stress. Gulf War veterans reported more depressive symptoms than non-Gulf War veterans, as well as greater pain and pain-related disability. A trend toward greater severity of sleep impairment was observed on the ISI (Table 2).



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Service Utilization

χ2 analyses identified no differences in the proportion of Gulf War and non-Gulf War veterans engaged in any type of service (defined dichotomously as participation vs. no participation). Similarly, there were no differences in the utilization of specific services (defined dichotomously) by these 2 groups (Table 2).

Of the 226 veterans who enrolled in the IHW Program, 72.12% (n=163) utilized at least 1 service type during their first 6 months. On average, veterans attended approximately 6 sessions in their first month (M=5.74, SD=1.30, range=1–46). With respect to specific services, group acupuncture was most commonly attended, with a mean of 2.46 sessions attended (SD=3.68, range=0–21), followed by individual acupuncture (M=1.87, SD=2.71, range=0–12) and iRest (M=1.30, SD=3.25, range=0–21).

Preliminary analyses indicated that within this subsample of service users, Gulf War and non-Gulf War veterans did not differ significantly with respect to symptom severity, although there was a trend toward Gulf War veterans endorsing more severe pain disability (PDQ). It is important to note that these analyses may have been underpowered due to the smaller proportion of Gulf War veterans in this subsample (18.40%). Independent measures t tests indicated that Gulf War veterans attended significantly fewer sessions of group acupuncture. There were no significant differences with respect to other services or total sessions attended (Table 3).



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This study provides an initial investigation into CAM utilization by Gulf War veterans. Results demonstrated that, when examining all individuals enrolled in the IHW Program, Gulf War veterans reported more severe symptoms of depression, pain, and sleep-related disturbances. However, examining only those individuals who chose to participate in services in the 6 months following their enrollment, Gulf War veterans were similar to non-Gulf War veterans on these measures. Therefore, although Gulf War veterans considering CAM may experience more serious physical/mental health symptomology on average, the symptom severity of those who decide to participate in services appears consistent across war era. However, it is also important to consider whether the lack of results is due to greater variability in the symptoms of service users or the reduced sample size.

Regarding service utilization for those who actually participated in services, Gulf War veterans were largely similar to other veterans with respect to overall program participation (ie, attending at least 1 session of any service) and utilization of each types of service (ie, iRest yoga nidra, individual acupuncture, group acupuncture). Similarly, examining the subset of veterans who attended at least 1 session during their first 6 months in the program, there were no differences between Gulf War and non-Gulf War veterans with respect to individual acupuncture or iRest yoga nidra. However, Gulf War veterans attended fewer sessions of group acupuncture. Although this may be due to reluctance or unfamiliarity associated with group therapies, iRest was also a group intervention and no difference in utilization was seen. It may be that Gulf War veterans prefer to attend an individual service when the option is available.

It is important to acknowledge the limitations of this study. First, this study only examined veterans who were referred to the IHW Program and subsequently decided to enroll in services. Veterans referred to this program may differ systematically in some way from other veterans, as referral to this program suggests that either the veteran or the referring provider identified this program as an important addition to the veteran’s care. In addition, Gulf War veterans may have also deployed to other conflicts, making this a somewhat heterogeneous group. Finally, this sample differs in important ways from the larger veteran population (eg, higher proportion of females, higher education level, and higher proportion of African Americans).30 In part, this is due to the demographic characteristics of the urban area in which this VA is located. However, this may also reflect certain factors that increase a veteran’s willingness to seek CAM services.

Therefore, this study provides a preliminary analysis of patterns of CAM service utilization among Gulf War veterans. It is essential for future studies to examine the factors that may impact these patterns (eg, sex, education, attitudes toward treatment). Future studies may also examine whether participation in CAM services is associated with improvements in mental and physical health-related domains, and how to promote treatment engagement for this important population of veterans.

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complementary and alternative medicine; Gulf War; veterans; pain; mental health

© 2014 by Lippincott Williams & Wilkins.