Quality of Life in Gulf War Veterans: the Influence of Recency and Persistence of Psychiatric Morbidity

  • Breanna K. Wright
  • Helen L. Kelsall
  • Malcolm R. Sim
  • David M. Clarke


Important contributors to quality of life (QOL), such as psychosocial factors, have received limited exploration in veteran populations, in contrast to a significant amount of research focused on health-related quality of life (HRQL). This study investigated QOL and HRQL amongst Gulf War veterans compared with an era-military comparison group 20 years after the 1990/91 Gulf War, and whether psychiatric status over time and psychiatric comorbidities predicted QOL and HRQL. We then investigated which of a range of psychological health, physical health and social factors contribute greatest to QOL. Psychological interviews and postal questionnaires were administered to a cohort of Gulf War veterans and a military-era comparison group in 2000–02 and 2011–12. Gulf War veterans had poorer QOL and HRQL compared with a military comparison group, but the pattern of factors that influenced QOL was the same for both groups. Poorer QOL and HRQL were significantly associated with more recent and persistent psychiatric morbidity over time. Further analyses showed that affective disorders, followed by anxiety disorders had the largest impact on QOL and HRQL, and that QOL and HRQL were negatively affected by each additional psychiatric diagnosis. The importance of these findings was highlighted in a structural equation model that revealed psychological health contributed most to QOL, social support contributed a moderate amount, but physical health contributed only a very small amount. QOL in veterans is an important issue even many years after deployment and psychological health plays a predominant role in QOL.


Quality of life Wellbeing Gulf War Veterans Military psychology Psychological health 


Compliance with Ethical Standards

Conflict of Interest

The authors declare no conflicts of interest.


The article has been produced using funding provided by the Australian Department of Veterans’ Affairs. However, the views expressed in the article do not necessarily represent the views of the Minister for Veterans’ Affairs or the Department of Veterans’ Affairs. The Commonwealth does not give any warranty nor accept any liability in relation to the contents of this work.


  1. Andrews, F., & Withey, S. (1976). Social indicators of well-being: Americans' perceptions of life quality. New York: Plenum.CrossRefGoogle Scholar
  2. Andrews, G., Slade, T., & Issakidis, C. (2002). Deconstructing current comorbidity: data from the Australian national survey of mental health and well-being. The British Journal of Psychiatry, 181(4), 306–314.CrossRefGoogle Scholar
  3. Bennett, S., Perkins, S., Lane, K., Deer, M., Brater, D., & Murray, M. (2001). Social support and health-related quality of life in chronic heart failure patients. Quality of Life Research, 10(8), 671–682.CrossRefGoogle Scholar
  4. Britton, P. C., Ouimette, P. C., & Bossarte, R. M. (2012). The effect of depression on the association between military service and life satisfaction. Quality of Life Research, 21(10), 1857–1862.CrossRefGoogle Scholar
  5. Chan, Y.-F., Huang, H., Bradley, K., & Unützer, J. (2014). Referral for substance abuse treatment and depression improvement among patients with co-occurring disorders seeking behavioral health services in primary care. Journal of Substance Abuse Treatment, 46, 106–112. Scholar
  6. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale: Erlbaum.Google Scholar
  7. Cubo, E., Rojo, A., Ramos, S., Quintana, S., Gonzalez, M., Kompoliti, K., et al. (2002). The importance of educational and psychological factors in Parkinson's disease quality of life. European Journal of Neurology, 9(6), 589–593.CrossRefGoogle Scholar
  8. Der-Martirosian, C., Cordasco, K. M., & Washington, D. L. (2013). Health-related quality of life and comorbidity among older women veterans in the United States. Quality of Life Research, 22(10), 2749–2756.CrossRefGoogle Scholar
  9. Duffy, S. A., Terrell, J. E., Valenstein, M., Ronis, D. L., Copeland, L. A., & Connors, M. (2002). Effect of smoking, alcohol, and depression on the quality of life of head and neck cancer patients. General Hospital Psychiatry, 24(3), 140–147.CrossRefGoogle Scholar
  10. Engel Jr., C. C., Liu, X., McCarthy, B. D., Miller, R. F., & Ursano, R. (2000). Relationship of physical symptoms to posttraumatic stress disorder among veterans seeking care for Gulf War-related health concerns. Psychosomatic Medicine, 62(6), 739–745.CrossRefGoogle Scholar
  11. Forman-Hoffman, V. L., Carney, C. P., Sampson, T. R., Peloso, P. M., Woolson, R. F., Black, D. W., et al. (2005). Mental health comorbidity patterns and impact on quality of life among veterans serving during the first Gulf War. Quality of Life Research: an International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation, 14(10), 2303–2314.CrossRefGoogle Scholar
  12. Foster, J., Powell, J., Marshall, E., & Peters, T. (1999). Quality of life in alcohol-dependent subjects – a review. Quality of Life Research, 8(3), 255–261.CrossRefGoogle Scholar
  13. Gallant, M. P. (2003). The influence of social support on chronic illness self-management: a review and directions for research. Health Education & Behavior, 30(2), 170–195.CrossRefGoogle Scholar
  14. Gill, T. M., & Feinstein, A. R. (1994). A critical appraisal of the quality of quality-of-life measurements. JAMA: the Journal of the American Medical Association, 272(8), 619–626.CrossRefGoogle Scholar
  15. Golden, J., Conroy, R. M., & Lawlor, B. A. (2009). Social support network structure in older people: underlying dimensions and association with psychological and physical health. Psychology, Health & Medicine, 14(3), 280–290. Scholar
  16. Guyatt, G. (1997). Insights and limitations from health-related quality of life research. Journal of General Internal Medicine, 12(11), 720–721.CrossRefGoogle Scholar
  17. Hawthorne, G., Herrman, H., & Murphy, B. (2006). Interpreting the WHOQOL-BREF: preliminary population norms and effect sizes. Social Indicators Research, 77(1), 37–59.CrossRefGoogle Scholar
  18. Holahan, C. J., & Moos, R. H. (1981). Social support and psychological distress: a longitudinal analysis. Journal of Abnormal Psychology, 90(4), 365.CrossRefGoogle Scholar
  19. Hu, L. t., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Structural Equation Modeling: a Multidisciplinary Journal, 6(1), 1–55.CrossRefGoogle Scholar
  20. Ikin, J. F., Sim, M., Creamer, M., Forbes, A., McKenzie, D., Kelsall, H., et al. (2004). War-related psychological stressors and risk of psychological disorders in Australian veterans of the 1991 Gulf War. British Journal of Psychiatry, 185(2), 116–126.CrossRefGoogle Scholar
  21. Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: validity of a brief depression severity measure. (Research Support, Non-U.S. Gov't Validation Studies). Journal of General Internal Medicine, 16(9), 606–613.CrossRefGoogle Scholar
  22. McKenzie, D. P., Ikin, J. F., McFarlane, A. C., Creamer, M., Forbes, A. B., Kelsall, H. L., et al. (2004). Psychological health of Australian veterans of the 1991 Gulf War: an assessment using the SF-12, GHQ-12 and PCL-S. Psychological Medicine, 34(08), 1419–1430.CrossRefGoogle Scholar
  23. Mendlowicz, M. V., & Stein, M. B. (2000). Quality of life in individuals with anxiety disorders. American Journal of Psychiatry, 157(5), 669–682.CrossRefGoogle Scholar
  24. Muldoon, M. F., Barger, S. D., Flory, J. D., & Manuck, S. B. (1998). What are quality of life measurements measuring? British Medical Journal, 316, 542–544.CrossRefGoogle Scholar
  25. Pirkola, S., Saarni, S., Suvisaari, J., Elovainio, M., Partonen, T., Aalto, A.-M., et al. (2009). General health and quality-of-life measures in active, recent, and comorbid mental disorders: a population-based health 2000 study. Comprehensive Psychiatry, 50(2), 108–114.CrossRefGoogle Scholar
  26. Proctor, S. P., Harley, R., Wolfe, J., Heeren, T., & White, R. F. (2001). Health-related quality of life in Persian Gulf War veterans. Military Medicine, 166(6), 510–519.CrossRefGoogle Scholar
  27. Sareen, J., Cox, B. J., Stein, M. B., Afifi, T. O., Fleet, C., & Asmundson, G. J. (2007). Physical and mental comorbidity, disability, and suicidal behavior associated with posttraumatic stress disorder in a large community sample. Psychosomatic Medicine, 69(3), 242–248.CrossRefGoogle Scholar
  28. Schwarz, N., & Clore, G. L. (1983). Mood, misattribution, and judgments of well-being: informative and directive functions of affective States. Journal of Personality and Social Psychology, 45(3), 513.CrossRefGoogle Scholar
  29. Sherbourne, C. D., & Stewart, A. L. (1991). The MOS social support survey. Social Science and Medicine, 32, 705–714.CrossRefGoogle Scholar
  30. Singh, J., Mattoo, S. K., Sharan, P., & Basu, D. (2005). Quality of life and its correlates in patients with dual diagnosis of bipolar affective disorder and substance dependence. Bipolar Disorders, 7(2), 187–191.CrossRefGoogle Scholar
  31. Slade, T., Johnston, A., Oakley Browne, M. A., Andrews, G., & Whiteford, H. (2009). 2007 national survey of mental health and wellbeing: methods and key findings. Australasian Psychiatry, 43(7), 594–605.Google Scholar
  32. Smith, K. W., Avis, N. E., & Assmann, S. F. (1999). Distinguishing between quality of life and health status in quality of life research: a meta-analysis. Quality of Life Research, 8(5), 447–459.CrossRefGoogle Scholar
  33. Surìs, A., Lind, L., Kashner, T. M., & Borman, P. D. (2007). Mental health, quality of life, and health functioning in women veterans differential outcomes associated with military and civilian sexual assault. Journal of Interpersonal Violence, 22(2), 179–197.CrossRefGoogle Scholar
  34. Teesson, M., Slade, T., & Mills, K. (2009). Comorbidity in Australia: findings of the 2007 national survey of mental health and wellbeing. Australian and New Zealand Journal of Psychiatry, 43(7), 606–614.CrossRefGoogle Scholar
  35. The WHOQOL Group. (1998). Development of the World Health Organization WHOQOL-bref quality of life assessment. Psychological Medicine, 28, 551–558.CrossRefGoogle Scholar
  36. Toomey, R., Kang, H. K., Karlinsky, J., Baker, D. G., Vasterling, J. J., Alpern, R., et al. (2007). Mental health of US Gulf War veterans 10 years after the war. The British Journal of Psychiatry, 190(5), 385–393.CrossRefGoogle Scholar
  37. Voelker, M. D., Saag, K. G., Schwartz, D. A., Chrischilles, E., Clarke, W. R., Woolson, R. F., et al. (2002). Health-related quality of life in Gulf War era military personnel. American Journal of Epidemiology, 155(10), 899–907.CrossRefGoogle Scholar
  38. Volk, R. J., Cantor, S. B., Steinbauer, J. R., & Cass, A. R. (1997). Alcohol use disorders, consumption patterns, and health-related quality of life of primary care patients. Alcoholism: Clinical and Experimental Research, 21(5), 899–905.CrossRefGoogle Scholar
  39. Von Korff, M., Ormel, J., Keefe, F. J., & Dworkin, S. F. (1992). Grading the severity of chronic pain. Pain, 50, 133–149.CrossRefGoogle Scholar
  40. Wang, P. S., Berglund, P., Olfson, M., Pincus, H. A., Wells, K. B., & Kessler, R. C. (2005). Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 603–613.CrossRefGoogle Scholar
  41. Ware Jr., J. E., Kosinski, M., & Keller, S. D. (1996). A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Medical Care, 34(3), 220–233.CrossRefGoogle Scholar
  42. Weathers, F. W., Litz, B. T., Herman, D. S., Huska, J. A., & Keane, T. M. (1993). The PTSD checklist (PCL): reliability, validity, and diagnostic utility. Paper presented at the 9th Annual Conference of the International Society for Traumatic Stress Studies. San Antonio.Google Scholar
  43. Wittchen, H. (1994). Reliability and validity studies of the WHO-composite international diagnostic interview (CIDI): a critical review. Journal of Psychiatric Research, 28(1), 57–84.CrossRefGoogle Scholar
  44. Wolfe, J., Proctor, S. P., Erickson, D. J., Heeren, T., Friedman, M. J., Huang, M. T., et al. (1999). Relationship of psychiatric status to Gulf War Veterans' health problems. Psychosomatic Medicine, 61(4), 532–540.CrossRefGoogle Scholar
  45. World Health Organisation. (1997). Composite international diagnostic interview CIDI auto 2.1 administrator's guide and reference. Geneva: World Health Organisation.Google Scholar

Copyright information

© Springer Science+Business Media B.V., part of Springer Nature and The International Society for Quality-of-Life Studies (ISQOLS) 2018

Authors and Affiliations

  • Breanna K. Wright
    • 1
    • 2
  • Helen L. Kelsall
    • 1
  • Malcolm R. Sim
    • 1
  • David M. Clarke
    • 3
  1. 1.Monash Centre for Occupational and Environmental Health (MonCOEH), Department of Epidemiology & Preventive MedicineMonash UniversityMelbourneAustralia
  2. 2.The Alfred CentreMelbourneAustralia
  3. 3.Department of Psychiatry, Monash Medical CentreMonash UniversityMelbourneAustralia

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