This study aimed to assess psychological distress among people who exposed to mustard gas in Sardash, Iran. The findings showed that the exposed civilians had a higher degree of psychological symptoms as compared to the controls. The global severity index (GSI) in the exposed group was significantly higher than the control group; mean values (SD) were 1.31 (0.68), 1.16 (0.70), respectively (P = 0.04). No surprisingly a recent publication from Iran also revealed that the mean GSI in survivors of chemical warfare with ophthalmologic complications was higher than standardized cut-off point for Iranian community . Similarly, a Danish study among subjects who had been deployed in the Persian Gulf reported that the mean values of the GSI in Gulf War veterans were higher than controls; the mean values (SD) were 0.20 (0.26) and 0.12 (0.17), respectively (P < 0.001) . It has been suggested that the increased psychological distress in Danish veterans was due to mentally distressing environment and not the neurotoxic exposure. However, lower scores in the Danish study compared with the present study might be due to several reasons. For instance, perhaps the Danish authorities implemented some effective clinical and social interventions for the Golf War veterans while we did not. Other reasons might include the fact that the Danish veterans were healthier than the Iranian civilians. There is evidence that of 34000 Iranians examined 13–20 years after exposure to SM, it was found that a considerable percentage are suffering from long term complications from exposure involving the lungs (42.5%), eyes (39%), and skin (24.5%) .
The results of this study showed that there were significant differences in hostility, anxiety, obsessive-compulsive, somatization and depression among the exposed and the control groups. The Danish study showed that, six dimensions on the SCL-90 including obsessive-compulsive, depression, interpersonal sensitivity, anxiety and hostility were associated with being a Gulf War veteran . Interestingly both studies (the Danish and our study) did not find any significant differences in phobic, paranoid, and psychoticism among the cases and the controls. Perhaps these findings suggest that such psychological disorders are not related to neurotoxi exposure.
The development of psychiatric disorders among chemical victims is often due to severe sequelae. Studies have shown that there is strong association between physical illness with subsequent disability and psychiatric disorders in chemical warfare survivors [23–25]. Thus, one might argue that the higher rate of mental health problems in chemical warfare patients might be due to the higher rate of morbidities among this community . There is evidence that exposure to mustard gas can cause both early toxic and long-term adverse health effects . In addition it seems that exposure to war; adverse physical health consequences and fear of the future represent an additive effect for involved and persistent mental health . However, the Sardasht-Iran Cohort Study was designed to compare those who were afflicted by sulfur mustard exposure to those who were not. Intensive conventional warfare took place in both Sardasht and Rabat, but the Sardasht cohort was comprised of victims, while the control group from Rabat was not necessarily victims (i.e., physically wounded by the conflict). Therefore, chemical burns produce more of the persistent psychological symptoms than the bullet wounds of conventional warfare.
The impact of demographic factors (other than age and being in the exposed group) on psychological health status was very little (see Table 2). Such observation indicates that the most important factor for developing psychological problems is exposure to sulfur mustard gas. Every effort to destroy such weapons seems very relevant to public’s health worldwide.
Finally, while logically the more severe exposure seems to be accompanied with more psychological problems, our study did not show that the severity of exposure affects the severity of psychological disturbances. It seems that the other confounding factors involved in this regard and needs further investigations.
This study had some limitations. Firstly, as noted, because of similar religion, culture, language and nutritional habits, Rabat civilians were considered as control group to compare to Sardasht exposed individuals. Since Rabat civilians themselves probably suffered from this incident and war as a big trauma indirectly so the results of this study cannot be considered as a comparison between sulfur mustard exposed and a normal population. Secondly, this study did not differentiate between the psychological symptoms induced by sulfur mustard itself and the symptoms induced by the horror and the fears in the city from heavy explosions. Thus the results should be interpreted with some cautions.