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Suggested Citation:"Front Matter." Institute of Medicine. 2013. Gulf War and Health: Treatment for Chronic Multisymptom Illness. Washington, DC: The National Academies Press. doi: 10.17226/13539.
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GULF WAR and HEALTH

Treatment for
Chronic Multisymptom Illness

Committee on Gulf War and Health:
Treatment for Chronic Multisymptom Illness

Board on the Health of Select Populations

INSTITUTE OF MEDICINE

OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Gulf War and Health: Treatment for Chronic Multisymptom Illness. Washington, DC: The National Academies Press. doi: 10.17226/13539.
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THE NATIONAL ACADEMIES PRESS    500 Fifth Street, NW     Washington, DC 20001

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

This study was supported by Contract VA241-P-2024 between the National Academy of Sciences and the Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the organizations or agencies that provided support for the project.

International Standard Book Number-13: 978-0-309-27802-7

International Standard Book Number-10: 0-309-27802-3

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For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.

Copyright 2013 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

Suggested citation: IOM (Institute of Medicine). 2013. Gulf War and Health: Treatment for Chronic Multisymptom Illness. Washington, DC: The National Academies Press.

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Gulf War and Health: Treatment for Chronic Multisymptom Illness. Washington, DC: The National Academies Press. doi: 10.17226/13539.
×

“Knowing is not enough; we must apply.
Willing is not enough; we must do.”

—Goethe

image

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

Advising the Nation. Improving Health.

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Gulf War and Health: Treatment for Chronic Multisymptom Illness. Washington, DC: The National Academies Press. doi: 10.17226/13539.
×

THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering, and Medicine

The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.

The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering.

The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.

The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.

www.national-academies.org

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Gulf War and Health: Treatment for Chronic Multisymptom Illness. Washington, DC: The National Academies Press. doi: 10.17226/13539.
×

COMMITTEE ON GULF WAR AND HEALTH:
TREATMENT FOR CHRONIC MULTISYMPTOM ILLNESS

BERNARD M. ROSOF (Chair), Chairman, Board of Directors, Huntington Hospital, Huntington, NY

DIANA D. CARDENAS, Professor and Chair, Department of Rehabilitation Medicine, University of Miami Leonard M. Miller School of Medicine, Miami, FL

FRANK V. deGRUY, Woodward-Chrisholm Professor and Chair, Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO

DOUGLAS A. DROSSMAN, Adjunct Professor of Medicine and Psychiatry, Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina School of Medicine, and Drossman Center for the Education and Practice of Biopsychosocial Care, Chapel Hill, NC

FRANCESCA C. DWAMENA, Professor and Acting Chair, Department of Medicine, Michigan State University, East Lansing, MI

JAVIER I. ESCOBAR, Associate Dean for Global Health, University of Medicine & Dentistry of New Jersey, New Brunswick, NJ

WAYNE A. GORDON, Jack Nash Professor and Vice Chair, Department of Rehabilitation Medicine, Mount Sinai School of Medicine, New York, NY

ISABEL V. HOVERMAN, Physician, Austin Internal Medicine Associates, LLP, Austin, TX

WAYNE JONAS, President and CEO, Samueli Institute, Alexandria, VA

JOANNA G. KATZMAN, Associate Professor, Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, NM

ELAINE L. LARSON, Associate Dean for Research, Columbia University School of Nursing, New York, NY

STEPHEN RAY MITCHELL, Dean of Medical Education, Georgetown University School of Medicine, Washington, DC

KAREN A. ROBINSON, Assistant Professor, Departments of Medicine, Epidemiology, and Health Policy and Management, Johns Hopkins University, Baltimore, MD

KASISOMAYAJULA VISWANATH, Associate Professor, Department of Society, Human Development, and Health, Harvard School of Public Health, Boston, MA

LORI ZOELLNER, Associate Professor, Department of Psychology, University of Washington, Seattle, WA

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Gulf War and Health: Treatment for Chronic Multisymptom Illness. Washington, DC: The National Academies Press. doi: 10.17226/13539.
×

Staff

ABIGAIL MITCHELL, Study Director

CARY HAVER, Associate Program Officer

JONATHAN SCHMELZER, Senior Program Assistant

NORMAN GROSSBLATT, Senior Editor

GARY WALKER, Financial Officer

JIM BANIHASHEMI, Financial Officer

FREDERICK ERDTMANN, Director, Board on the Health of Select Populations

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Gulf War and Health: Treatment for Chronic Multisymptom Illness. Washington, DC: The National Academies Press. doi: 10.17226/13539.
×

Reviewers

This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards of objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following for their review of the report:

Niloofar Afari, University of California, San Diego

Melvin S. Blanchard, Washington University School of Medicine

Paul W. Brandt-Rauf, University of Illinois at Chicago School of Public Health

Sandro Galea, Columbia University Mailman School of Public Health

Naomi L. Gerber, George Mason University

Thomas V. Holohan, Clinical Evaluation, LLC; formerly Veterans Health Administration

David R. Nerenz, Henry Ford Health System

Eliseo J. Perez-Stable, University of California, San Francisco

Karen S. Quigley, Northeastern University and Edith Nourse Rogers Memorial VA Medical Center

Sandra J. W. Smeeding, Veterans Affairs Salt Lake City Health Care System

Nancy Fugate Woods, University of Washington School of Nursing

Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2013. Gulf War and Health: Treatment for Chronic Multisymptom Illness. Washington, DC: The National Academies Press. doi: 10.17226/13539.
×

Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of the report was overseen by Lynn R. Goldman, Dean, the George Washington University School of Public Health and Health Services, and Enriqueta C. Bond, President Emeritus, Burroughs Wellcome Fund. Appointed by the National Research Council and the Institute of Medicine, respectively, they were responsible for making certain that an independent examination of the report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of the report rests entirely with the authoring committee and the institution.

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Gulf War and Health: Treatment for Chronic Multisymptom Illness. Washington, DC: The National Academies Press. doi: 10.17226/13539.
×

Preface

The committee was convened to review, evaluate, and summarize the available scientific and medical literature regarding the best treatments for chronic multisymptom illness (CMI) in Gulf War veterans. We accepted that responsibility in recognition of the personal and family sacrifices that all soldiers—both deployed and nondeployed—undertake in times of conflict. About 700,000 military personnel served in the 1991 Gulf War, and as of September 2011, about 2.6 million military personnel had been deployed to the Iraq and Afghanistan wars. There is no script for the stresses that are endured; they are personal and many. The committee was most appreciative of the willingness of many veterans to share their experiences and thoughts with us so that we would be better prepared to move forward with our task. We undertook a thorough review of the studies1 already completed by the Institute of Medicine (IOM) on this general topic and then expanded the evidence base by conducting a systematic search of the available scientific and medical literature regarding the best treatments for CMI. The committee evaluated the evidence by using the scientifically rigorous process detailed in this report. As we approached the task at hand, we stood firm on the concerns for patient-centered care and our abilities to communicate our thoughts, conclusions, and recommendations to all interested audiences.

_____________

1IOM (Institute of Medicine). 2001. Gulf War Veterans: Treating Symptoms and Syndromes. Washington, DC: National Academy Press; IOM. 2010. Gulf War and Health, Volume 8: Update of Health Effects of Serving in the Gulf War. Washington, DC: The National Academies Press.

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Gulf War and Health: Treatment for Chronic Multisymptom Illness. Washington, DC: The National Academies Press. doi: 10.17226/13539.
×

To focus our efforts, we defined CMI as the presence of a spectrum of chronic symptoms experienced for 6 months or longer in at least two of six categories—fatigue, mood and cognition, musculoskeletal, gastrointestinal, respiratory, and neurologic—that may overlap with but are not fully captured by known syndromes (such as irritable bowel syndrome, chronic fatigue syndrome, and fibromyalgia) or other diagnoses.

Our review of the literature revealed that specific etiologic agents or histopathologic findings often are not associated with such symptoms, and the causes of many of the symptoms ascribed to CMI remain unknown. However, the lack of diagnostic and etiologic clarity does not undermine the legitimacy of the reports of the symptoms. The multiple manifestations of the symptoms make directed treatment more challenging, and clinicians are often frustrated by the difficulties in managing care for people who have CMI. However, for veterans whose function and life satisfaction are limited by their symptoms, it remains no less important.

We hope that our recommendations will make a difference in the lives of people who have CMI. It is clear that this condition has adversely affected the health and well-being of a substantial number of our veterans and their families. Anecdotal reports appear regularly in the mass media.2 We encourage the Department of Veterans Affairs (VA) to apply the principles set forth in this report, including at a minimum adequate resources to ensure early entry into the VA health care system and adherence to the principles of patient-centered and compassionate care, shared decision making, and regular clinical follow-up as necessary. Our veterans deserve the very best health care.

The committee thanks everyone who presented and participated in discussions during the public meetings, which informed our work and helped us to develop our approach to and thought process regarding the statement of task. The wide variety of viewpoints were expressed during those information sessions provided valuable insight into the complexity of medical treatment for CMI in Gulf War veterans. The time and effort to travel to the public meetings and prepare written materials and statements are greatly appreciated.

The committee is particularly appreciative of the many Gulf War veterans who spoke and submitted written accounts of their experiences in the gulf and on their return to the United States. They provided valuable understanding of the symptoms and medical conditions of CMI and of medical treatment for it as experienced by the many men and women who served in the Gulf War.

The committee also owes a debt of gratitude to the following persons who traveled to and presented valuable information at our public meetings:

_____________

2For example, Kristof, N. D. 2012. War wounds. New York Times, August 10, SR1.

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Gulf War and Health: Treatment for Chronic Multisymptom Illness. Washington, DC: The National Academies Press. doi: 10.17226/13539.
×

Caroline Blaum, University of Michigan Health System; Daniel Clauw, University of Michigan Health System; Jeffery Dusek, Abbott Northwestern Hospital; Charles Engel, Deployment Health Clinical Center; Beatrice Golomb, University of California, San Diego, School of Medicine and San Diego VA Medical Center; Stephen Hunt, VA Puget Sound Health Care System; Kenneth Kendler, Virginia Commonwealth University; Kurt Kroenke, Regenstrief Institute; Ronald Poropatich, US Army Medical Research and Materiel Command; and Matt Reinhard, War-Related Illness and Injury Study Center, Washington, DC.

The committee thanks Patrick Furey of Consumersphere, a consultant who provided an analysis of the social media discussion surrounding CMI in veterans of the Gulf War. We also thank Michael Peterson and Terry Walters, of the VA Office of Public Health, for providing helpful background information.

I would like to thank the committee members for their time commitment to this important project, their diligence in reviewing every detail of complex issues, and their sensitivity to the concerns of our veterans. Finally, I thank the IOM staff for their thoroughness, knowledge, research expertise, and guidance throughout this journey to try to make a contribution to the understanding of a complex subject.

Bernard M. Rosof, Chair

Committee on Gulf War and Health:

Treatment for Chronic Multisymptom Illness

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Gulf War and Health: Treatment for Chronic Multisymptom Illness. Washington, DC: The National Academies Press. doi: 10.17226/13539.
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Suggested Citation:"Front Matter." Institute of Medicine. 2013. Gulf War and Health: Treatment for Chronic Multisymptom Illness. Washington, DC: The National Academies Press. doi: 10.17226/13539.
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Abbreviations and Acronyms

AACH American Academy on Communication in Healthcare
ACP American College of Physicians
AHRQ Agency for Healthcare Research and Quality
ALS amyotrophic lateral sclerosis
AMSTAR Assessment of Multiple Systematic Reviews
AOC alteration of consciousness
APA American Psychiatric Association
   
BMI body mass index
   
CACTUS Classical Acupuncture Treatment for People with Unexplained Symptoms
CAM complementary and alternative medicine
CBOC community-based outpatient clinic
CBT cognitive behavioral therapy
CDC Centers for Disease Control and Prevention
CFS chronic fatigue syndrome
CI confidence interval
CINAHL Cumulative Index to Nursing and Allied Health Literature
CMI chronic multisymptom illness
CPAP continuous positive airway pressure
CPG clinical practice guideline
CQI continuous quality improvement
CRT cognitive rehabilitation therapy
   
Suggested Citation:"Front Matter." Institute of Medicine. 2013. Gulf War and Health: Treatment for Chronic Multisymptom Illness. Washington, DC: The National Academies Press. doi: 10.17226/13539.
×
DARE Database of Abstracts of Reviews of Effects
DNA deoxyribonucleic acid
DOD Department of Defense
DSM Diagnostic and Statistical Manual of Mental Disorders
DU depleted uranium
   
EBI evidence-based information
ECHO Extension for Community Healthcare Outcomes
ECT electroconvulsive therapy
EMC enhanced medical care
EMDR eye-movement desensitization and reprocessing
   
FD functional dyspepsia
FDA Food and Drug Administration
FGID functional gastrointestinal disorder
FPOW former prisoner of war
FSS functional somatic syndrome
FY fiscal year
   
GET graded exercise therapy
GI gastrointestinal
GMT geographically adjusted income threshold
GWI Gulf War illness
GWV Gulf War–deployed veterans
GWVI Gulf War veterans illness
   
IBS irritable bowel syndrome
ICT information and communication technology
IHI Institute for Health Improvement
IOM Institute of Medicine
   
LOC loss of consciousness
   
ME myalgic encephalomyelitis
MI motivational interviewing
mTBI mild traumatic brain injury
MUPS medically unexplained physical symptoms
MUS medically unexplained symptoms
   
NHS National Health Service (UK)
NICE National Institute for Health and Clinical Excellence (UK)
NSAID nonsteroidal anti-inflammatory drug
   
Suggested Citation:"Front Matter." Institute of Medicine. 2013. Gulf War and Health: Treatment for Chronic Multisymptom Illness. Washington, DC: The National Academies Press. doi: 10.17226/13539.
×
OEF Operation Enduring Freedom
OIF Operation Iraqi Freedom
OND Operation New Dawn
OR odds ratio
   
PC primary care
PCMH patient-centered medical home
PCS postconcussive symptom
PD-PACT postdeployment patient-aligned care team
PIT psychodynamic interpersonal therapy
PTA posttraumatic amnesia
PTSD posttraumatic stress disorder
   
RAC VA Research Advisory Committee on Gulf War Veterans’ Illnesses
RCT randomized controlled trial
REAC-BS radioelectric asymmetric brain stimulation
REM rapid eye movement
RoB risk of bias
   
SCAN Specialty Care Access Network
SHAD Shipboard Hazard and Defense
SIGLE System for Information on Grey Literature in Europe
SNRI serotonin norepinephrine reuptake inhibitor
SSD somatic symptom disorder
SSRI selective serotonin reuptake inhibitor
   
TBI traumatic brain injury
TENS transcutaneous electric nerve stimulation
   
UK United Kingdom
   
VA Department of Veterans Affairs
VAMC VA medical center
VA-OIG VA Office of the Inspector General
VBA Veterans Benefits Administration
VHA Veterans Health Administration
VISN Veterans Integrated Service Network
   
WGO World Gastroenterology Organisation
WRIISC War-Related Illness and Injury Study Center
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Chronic multisymptom illness (CMI) is a serious condition that imposes an enormous burden of suffering on our nation's veterans. Veterans who have CMI often have physical symptoms (such as fatigue, joint and muscle pain, and gastrointestinal symptoms) and cognitive symptoms (such as memory difficulties). For the purposes of this report, the committee defined CMI as the presence of a spectrum of chronic symptoms experienced for 6 months or longer in at least two of six categories—fatigue, mood, and cognition, musculoskeletal, gastrointestinal, respiratory, and neurologic—that may overlap with but are not fully captured by known syndromes (such as CFS, fibromyalgia, and IBS) or other diagnoses. Despite considerable efforts by researchers in the United States and elsewhere, there is no consensus among physicians, researchers, and others as to the cause of CMI. There is a growing belief that no specific causal factor or agent will be identified. Many thousands of Gulf War veterans1 who have CMI live with sometimes debilitating symptoms and seek an effective way to manage their symptoms. Estimates of the numbers of 1991 Gulf War veterans who have CMI range from 175,000 to 250,000 (about 25-35% of the 1991 Gulf War veteran population), and there is evidence that CMI in 1991 Gulf War veterans may not resolve over time. Preliminary data suggest that CMI is occurring in veterans of the Iraq and Afghanistan wars as well.

In addition to summarizing the available scientific and medical literature regarding the best treatments for chronic multisymptom illness among Gulf War veterans, Gulf War and Health: Volume 9: Treatment for Chronic Multisymptom Illness recommends how best to disseminate this information throughout the VA to improve the care and benefits provided to veterans, recommends additional scientific studies and research initiatives to resolve areas of continuing scientific uncertainty and recommends such legislative or administrative action as the IOM deems appropriate in light of the results of its review.

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