Skip to main content Accessibility help

Depression in Gulf War veterans: a systematic review and meta-analysis

  • J. D. Blore (a1) (a2), M. R. Sim (a1), A. B. Forbes (a3), M. C. Creamer (a4) and H. L. Kelsall (a1)...



Although post-traumatic stress disorder (PTSD) has been a focus of attention in 1990/1991 Gulf War veterans, the excess risk of depression has not been clearly identified. We investigated this through a systematic review and meta-analysis of studies comparing depression in Gulf War veterans to depression in a comparison group of non-deployed military personnel.


Multiple electronic databases and grey literature were searched from 1990 to 2012. Studies were assessed for eligibility and risk of bias according to established criteria.


Of 14 098 titles and abstracts assessed, 14 studies met the inclusion criteria. Gulf War veterans had over twice the odds of experiencing depression [odds ratio (OR) 2.28, 95% confidence interval (CI) 1.88–2.76] and dysthymia or chronic dysphoria (OR 2.39, 95% CI 2.0–2.86) compared to non-deployed military personnel. This finding was robust in sensitivity analyses, and to differences in overall risk of bias and psychological measures used.


Despite divergent methodologies between studies, depression and dysthymia were twice as common in Gulf War veterans and are important medical conditions for clinicians and policymakers to be aware of in managing Gulf War veterans’ health.


Corresponding author

* Address for correspondence: Dr H. L. Kelsall, Monash Centre for Occupational and Environmental Health (MonCOEH), Monash University, The Alfred Centre, Commercial Road, Melbourne, VIC 3004, Australia. (Email:


Hide All
Barendregt, JJ, Doi, SA (n.d.). MetaXL User Guide, Version 1.1 ( Accessed 2 November 2012.
Beck, AT, Steer, RA, Carbin, MG (1988). Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clinical Psychology Review 8, 77100.
Carlson, K, Kehle, S, Meis, L, Greer, N, MacDonald, R, Rutks, I, Wilt, TJ (2009). The Assessment and Treatment of Individuals with History of Traumatic Brain Injury and Post-Traumatic Stress Disorder: A Systematic Review of the Evidence. Department of Veterans Affairs (US): Washington, DC ( Accessed 10 April 2013.
Derogatis, LR, Savitz, KL (1999). The SCL-90-R, Brief Symptom Inventory, and matching clinical rating scales. In The Use of Psychological Testing for Treatment Planning and Outcomes Assessment (ed. Maruish, M. E.), pp. 679724. Erlbaum: Mahwah, NJ.
Fiedler, N, Ozakinci, G, Hallman, W, Wartenberg, D, Brewer, NT, Barrett, DH, Kipen, HM (2006). Military deployment to the Gulf War as a risk factor for psychiatric illness among US troops. British Journal of Psychiatry 188, 453459.
Gadermann, AM, Engel, CC, Naifeh, JA, Nock, MK, Petukhova, M, Santiago, PN, Wu, B, Zaslavsky, AM, Kessler, RC (2012). Prevalence of DSM-IV major depression among U.S. military personnel: meta-analysis and simulation. Military Medicine 177, 4759.
Gilbody, S, Richards, D, Brealey, S, Hewitt, C (2007). Screening for depression in medical settings with the Patient Health Questionnaire (PHQ): a diagnostic meta-analysis. Journal of General Internal Medicine 22, 15961602.
Glass, DC, Sim, MR, Kelsall, HL, Ikin, JF, McKenzie, D, Forbes, A, Ittak, P (2006). What was different about exposures reported by male Australian Gulf War veterans during the 1991 Gulf War compared with exposures reported for other deployments? Military Medicine 171, 632638.
Goss Gilroy Inc. (1998). Health Study of Canadian Forces Personnel Involved in the 1991 Conflict in the Persian Gulf. Gulf War Illness Advisory Committee: Ottawa.
Gray, GC, Reed, RJ, Kaiser, KS, Smith, TC, Gastanaga, VM (2002). Self-reported symptoms and medical conditions among 11,868 Gulf War-era veterans: the Seabee Health Study. American Journal of Epidemiology 155, 10331044.
Higgins, JPT, Altman, DG, Gøtzsche, PC, Jüni, P, Moher, D, Oxman, AD, Savovic, J, Schulz, KF, Weeks, L, Sterne, JA; Cochrane Bias Methods Group; Cochrane Statistical Methods Group (2011). The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. British Medical Journal 343, d5928.
Higgins, JPT, Green, S (eds) (2011). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration ( Accessed 1 November 2012.
Higgins, JPT, Thompson, SG, Deeks, JJ, Altman, DG (2003). Measuring inconsistency in meta-analyses. British Medical Journal 327, 557560.
Hoy, D, Brooks, P, Woolf, A, Blyth, F, March, L, Bain, C, Baker, P, Smith, E, Buchbinder, R (2012). Assessing risk of bias in prevalence studies: modification of an existing tool and evidence of interrater agreement. Journal of Clinical Epidemiology 65, 934939.
Ikin, JF, McKenzie, DP, Creamer, MC, McFarlane, AC, Kelsall, HL, Glass, DC, Forbes, AB, Horsley, KWA, Harrex, WK, Sim, MR (2005). War zone stress without direct combat: the Australian naval experience of the Gulf War. Journal of Traumatic Stress 18, 193204.
Ikin, JF, Sim, M, Creamer, M, Forbes, A, Mckenzie, D, Kelsall, H, Glass, DC, McFarlane, AC, Abramson, MJ, Ittak, P, Dwyer, T, Blizzard, L, Delaney, KR, Horsley, KW, Harrex, WK, Schwarz, H (2004). War-related psychological stressors and risk of psychological disorders in Australian veterans of the 1991 Gulf War. British Journal of Psychiatry 185, 116126.
Iowa Persian Gulf Study Group (1997). Self-reported illness and health status among Gulf War veterans: a population-based study. Journal of the American Medical Association 277, 238245.
Ishoy, T, Knop, J, Suadicani, P, Guldager, B, Appleyard, M, Gyntelberg, F (2004). Increased psychological distress among Danish Gulf War veterans – without evidence for a neurotoxic background. The Danish Gulf War Study. Danish Medical Bulletin 51, 108113.
Kang, HK, Li, B, Mahan, CM, Eisen, SA, Engel, CC (2009). Health of US veterans of 1991 Gulf War: a follow-up survey in 10 years. Journal of Occupational and Environmental Medicine 51, 401410.
Kang, HK, Mahan, CM, Lee, KY, Magee, CA, Murphy, FM (2000). Illnesses among United States veterans of the Gulf War: a population-based survey of 30,000 veterans. Journal of Occupational and Environmental Medicine 42, 491501.
Kroenke, K, Spitzer, RL (2002). The PHQ-9: a new depression diagnostic and severity measure. Psychiatric Annals 32, 509515.
Magruder, KM, Yeager, DE (2009). The prevalence of PTSD across war eras and the effect of deployment on PTSD: a systematic review and meta-analysis. Psychiatric Annals 39, 778788.
McCauley, LA, Lasarev, M, Sticker, D, Rischitelli, DG, Spencer, PS (2002). Illness experience of Gulf War veterans possibly exposed to chemical warfare agents. American Journal of Preventative Medicine 23, 200206.
McKenzie, DP, Ikin, J, McFarlane, A, Creamer, M, Forbes, A, Kelsall, H, Glass, DC, Ittak, P, Sim, MR (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, 14191430.
Mitchell, AJ, Vaze, A, Rao, S (2009). Clinical diagnosis of depression in primary care: a meta-analysis. Lancet 374, 609619.
Moher, D, Liberati, A, Tetzlaff, J, Altman, DG; PRISMA Group (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Medicine 6, e1000097.
Perconte, ST, Wilson, AT, Pontius, EB, Dietrick, AL, Spiro, KJ (1993). Psychological and war stress symptoms among deployed and non-deployed reservists following the Persian Gulf War. Military Medicine 158, 516521.
Ramchand, R, Karney, BR, Osilla, KC, Burns, RM, Caldarone, LB (2008). Prevalence of PTSD, depression, and TBI among returning service members. In Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery (ed. Tanielian, T. L. and Jaycox, L. H.), pp. 3585. RAND Corporation: Santa Monica, CA.
Robins, LN, Wing, J, Wittchen, HU, Helzer, JE, Babor, TF, Burke, J, Farmer, A, Jablenski, A, Pickens, R, Regier, DA, Sartorius, N, Towle, LH (1988). The Composite International Diagnostic Interview: an epidemiologic instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Archives of General Psychiatry 45, 10691077.
Spitzer, RL, Williams, JB, Kroenke, K, Linzer, M, Hahn, SR, Brody, D, Johnson, JG (1994). Utility of a new procedure for diagnosing mental disorders in primary care. Journal of the American Medical Association 272, 17491756.
Steele, L (2000). Prevalence and patterns of Gulf War illness in Kansas veterans: association of symptoms with characteristics of person, place, and time of military service. American Journal of Epidemiology 152, 9921002.
Stimpson, NJ, Thomas, HV, Weightman, AL, Dunstan, F, Lewis, G (2003). Psychiatric disorder in veterans of the Persian Gulf War of 1991. Systematic review. British Journal of Psychiatry 182, 391403.
Sutker, PB, Uddo, M, Brailey, K, Allain, AN (1993). War-zone trauma and stress-related symptoms in Operation Desert Shield/Storm (ODS) returnees. Journal of Social Issues 49, 3350.
Sutker, PB, Davis, JM, Uddo, M, Ditta, SR (1995). Assessment of psychological distress in Persian Gulf troops: ethnicity and gender comparisons. Journal of Personality Assessment 64, 415427.
Toomey, R, Kang, HK, Karlinsky, J, Baker, DG, Vasterling, JJ, Alpern, R, Reda, DJ, Henderson, WG, Murphy, FM, Eisen, SA (2007). Mental health of US Gulf War veterans 10 years after the war. British Journal of Psychiatry 190, 385393.
Vos, T, Flaxman, AD, Naghavi, M, Lozano, R, Michaud, C, Ezzati, M, Shibuya, K, Salomon, JA, Abdalla, S, Aboyans, V, Abraham, J, Ackerman, I, Aggarwal, R, Ahn, SY, Ali, MK, Alvarado, M, Anderson, HR, Anderson, LM, Andrews, KG, Atkinson, C, Baddour, LM, Bahalim, AN, Barker-Collo, S, Barrero, LH, Bartels, DH, Basáñez, MG, Baxter, A, Bell, ML, Benjamin, EJ, Bennett, D, Bernabé, E, Bhalla, K, Bhandari, B, Bikbov, B, Bin Abdulhak, A, Birbeck, G, Black, JA, Blencowe, H, Blore, JD, Blyth, F, Bolliger, I, Bonaventure, A, Boufous, S, Bourne, R, Boussinesq, M, Braithwaite, T, Brayne, C, Bridgett, L, Brooker, S, Brooks, P, Brugha, TS, Bryan-Hancock, C, Bucello, C, Buchbinder, R, Buckle, G, Budke, CM, Burch, M, Burney, P, Burstein, R, Calabria, B, Campbell, B, Canter, CE, Carabin, H, Carapetis, J, Carmona, L, Cella, C, Charlson, F, Chen, H, Cheng, AT, Chou, D, Chugh, SS, Coffeng, LE, Colan, SD, Colquhoun, S, Colson, KE, Condon, J, Connor, MD, Cooper, LT, Corriere, M, Cortinovis, M, de Vaccaro, KC, Couser, W, Cowie, BC, Criqui, MH, Cross, M, Dabhadkar, KC, Dahiya, M, Dahodwala, N, Damsere-Derry, J, Danaei, G, Davis, A, De Leo, D, Degenhardt, L, Dellavalle, R, Delossantos, A, Denenberg, J, Derrett, S, Des Jarlais, DC, Dharmaratne, SD, Dherani, M, Diaz-Torne, C, Dolk, H, Dorsey, ER, Driscoll, T, Duber, H, Ebel, B, Edmond, K, Elbaz, A, Ali, SE, Erskine, H, Erwin, PJ, Espindola, P, Ewoigbokhan, SE, Farzadfar, F, Feigin, V, Felson, DT, Ferrari, A, Ferri, CP, Fèvre, EM, Finucane, MM, Flaxman, S, Flood, L, Foreman, K, Forouzanfar, MH, Fowkes, FG, Franklin, R, Fransen, M, Freeman, MK, Gabbe, BJ, Gabriel, SE, Gakidou, E, Ganatra, HA, Garcia, B, Gaspari, F, Gillum, RF, Gmel, G, Gosselin, R, Grainger, R, Groeger, J, Guillemin, F, Gunnell, D, Gupta, R, Haagsma, J, Hagan, H, Halasa, YA, Hall, W, Haring, D, Haro, JM, Harrison, JE, Havmoeller, R, Hay, RJ, Higashi, H, Hill, C, Hoen, B, Hoffman, H, Hotez, PJ, Hoy, D, Huang, JJ, Ibeanusi, SE, Jacobsen, KH, James, SL, Jarvis, D, Jasrasaria, R, Jayaraman, S, Johns, N, Jonas, JB, Karthikeyan, G, Kassebaum, N, Kawakami, N, Keren, A, Khoo, JP, King, CH, Knowlton, LM, Kobusingye, O, Koranteng, A, Krishnamurthi, R, Lalloo, R, Laslett, LL, Lathlean, T, Leasher, JL, Lee, YY, Leigh, J, Lim, SS, Limb, E, Lin, JK, Lipnick, M, Lipshultz, SE, Liu, W, Loane, M, Ohno, SL, Lyons, R, Ma, J, Mabweijano, J, MacIntyre, MF, Malekzadeh, R, Mallinger, L, Manivannan, S, Marcenes, W, March, L, Margolis, DJ, Marks, GB, Marks, R, Matsumori, A, Matzopoulos, R, Mayosi, BM, McAnulty, JH, McDermott, MM, McGill, N, McGrath, J, Medina-Mora, ME, Meltzer, M, Mensah, GA, Merriman, TR, Meyer, AC, Miglioli, V, Miller, M, Miller, TR, Mitchell, PB, Mocumbi, AO, Moffitt, TE, Mokdad, AA, Monasta, L, Montico, M, Moradi-Lakeh, M, Moran, A, Morawska, L, Mori, R, Murdoch, ME, Mwaniki, MK, Naidoo, K, Nair, MN, Naldi, L, Narayan, KM, Nelson, PK, Nelson, RG, Nevitt, MC, Newton, CR, Nolte, S, Norman, P, Norman, R, O'Donnell, M, O'Hanlon, S, Olives, C, Omer, SB, Ortblad, K, Osborne, R, Ozgediz, D, Page, A, Pahari, B, Pandian, JD, Rivero, AP, Patten, SB, Pearce, N, Padilla, RP, Perez-Ruiz, F, Perico, N, Pesudovs, K, Phillips, D, Phillips, MR, Pierce, K, Pion, S, Polanczyk, GV, Polinder, S, Pope, CA III, Popova, S, Porrini, E, Pourmalek, F, Prince, M, Pullan, RL, Ramaiah, KD, Ranganathan, D, Razavi, H, Regan, M, Rehm, JT, Rein, DB, Remuzzi, G, Richardson, K, Rivara, FP, Roberts, T, Robinson, C, De Leòn, FR, Ronfani, L, Room, R, Rosenfeld, LC, Rushton, L, Sacco, RL, Saha, S, Sampson, U, Sanchez-Riera, L, Sanman, E, Schwebel, DC, Scott, JG, Segui-Gomez, M, Shahraz, S, Shepard, DS, Shin, H, Shivakoti, R, Singh, D, Singh, GM, Singh, JA, Singleton, J, Sleet, DA, Sliwa, K, Smith, E, Smith, JL, Stapelberg, NJ, Steer, A, Steiner, T, Stolk, WA, Stovner, LJ, Sudfeld, C, Syed, S, Tamburlini, G, Tavakkoli, M, Taylor, HR, Taylor, JA, Taylor, WJ, Thomas, B, Thomson, WM, Thurston, GD, Tleyjeh, IM, Tonelli, M, Towbin, JA, Truelsen, T, Tsilimbaris, MK, Ubeda, C, Undurraga, EA, van der Werf, MJ, van Os, J, Vavilala, MS, Venketasubramanian, N, Wang, M, Wang, W, Watt, K, Weatherall, DJ, Weinstock, MA, Weintraub, R, Weisskopf, MG, Weissman, MM, White, RA, Whiteford, H, Wiersma, ST, Wilkinson, JD, Williams, HC, Williams, SR, Witt, E, Wolfe, F, Woolf, AD, Wulf, S, Yeh, PH, Zaidi, AK, Zheng, ZJ, Zonies, D, Lopez, AD, Murray, CJ, AlMazroa, MA, Memish, ZA (2012). Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380, 21632196.
Wells, TS, Miller, SC, Adler, AB, Engel, CC, Smith, TC, Fairbank, JA (2011). Mental health impact of the Iraq and Afghanistan conflicts: a review of US research, service provision, and programmatic responses. International Review of Psychiatry 23, 144152.
Wolfe, J, Proctor, SP, Erickson, DJ, Heeren, T, Friedman, MJ, Huang, MT, Sutker, PB, Vasterling, JJ, White, RF (1999). Relationship of psychiatric status to Gulf War veterans’ health problems. Psychosomatic Medicine 61, 532540.



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed