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Impact of psychological problems in chemical warfare survivors with severe ophthalmologic complication, a cross sectional study
Health and Quality of Life Outcomesvolume 10, Article number: 36 (2012)
Sulfur mustard (SM) has been used as a chemical warfare agent since the early twentieth century. Despite the large number of studies that have investigated SM induced ocular injuries, few of those studies have also focused on the psychological health status of victims. This study has evaluated the most prominent influences on the psychological health status of patients with severe SM induced ocular injuries.
This descriptive study was conducted on 149 Iranian war veterans with severe SM induced eye injuries. The psychological health status of all patients was assessed using the Iranian standardized Symptom Check List 90-Revised (SCL90-R) questionnaire. The results of patients' Global Severity Index (GSI) were compared with the optimal cut-off point of 0.4 that has previously been calculated for GSI in Iranian community. The Mann-Whitney U test, T tests and effect sizes (using Cohen's d) were employed as statistical methods. Data were analyzed using SPSS software.
The mean age of patients was 44.86 (SD = 8.7) and mean duration of disease was 21.58 (SD = 1.20) years. Rate of exposure was once in 99 (66.4%) cases. The mean GSI (1.46) of the study group was higher compared to standardized cut off point (0.4) of the Iranian community. The results of this study showed that the mean of total GSI score was higher in participants with lower educational levels (effect size = 0.507), unemployment (effect size = 0.464) and having more than 3 children (effect size = 0.62). Among the participants, 87 (58.4%) cases had a positive psychological history for hospitalization or receiving outpatient cares previously and 62 (41.6%) cases had a negative psychological history. In addition, the mean of GSI in participants with negative psychological history was lower than those with positive psychological history (Mean Change Difference = -0.621 with SD = 0.120). There was a significant difference between positive and negative psychological history with respect to GSI (P < 0.001).
The study showed that severe ophthalmologic complications in chemical survivors are accompanied with destructive effects on psychological health status. Appropriate management may improve psychological health status in these patients.
Since the early twentieth century, sulfur mustard (SM) (2, 2'-dichlorodiethyl sulfide, HD) has been used as a chemical warfare agent. The use of chemical weapons in the conflicts around the world is a breach of international law and a serious violation of human rights . More than 100,000 Iranians have been injured by SM and majorities are still suffering from long term complications of exposure. Severe long-term effects on various organs may appear or continue for decades after exposure .
SM may induce many chronic and delayed destructive lesions in the ocular surface and cornea, leading to progressive visual deterioration and ocular irritation . Chronic and long term ocular discomfort and the constant fear from impending blindness induce a continuous and long lasting distress that may cause different types of psychological disorders . The psychological sequela in military veterans may persist as long as 50 years after exposure to mustard gas . Psychological symptoms including depression, anxiety, somatization, behavioral disorders (phobia and fear from closed spaces), decreased sexual affinity, aggressiveness, sleep disorders, and early tiredness were more common in SM exposed patients [6, 7].
As great stressors, wars have a major effect on psychological health status and overall quality of life. In a survey that has reviewed 60 studies, mean psychological disorders in a normal population were 3.6% before the World War Ι, but reached up to 20% after the war . In 72 wars, the overall General Health Questionnaire [GHQ] scores of injured men were significantly changed, suggesting relative psychological vulnerability . Veterans with full PTSD reported reduced physical health, higher rates of chronic illness and disability, greater functional impairment, and higher likelihood of health care supports . In a large sample of Gulf War veterans with verifiable exposure to nerve or mustard gas, female, nonwhite, and older individuals were more likely to have a mental disorder and reported poorer current health status . These situations warrant long term and expensive psychosocial supports . Blanchard et al. also showed that veterans of the first gulf war (GW1) had a higher prevalence of psychiatric disorders . With respect of quality of life, the St. George Respiratory Questionnaire showed poor quality of life in patients with chronic obstructive lung disease induced by chemical warfare . PTSD can also affect quality of life, impairing psychosocial and occupational functioning as well as overall well-being . PTSD can appear 10-20 years after a primary war-related trauma but may be overlooked or ignored. Somatic symptoms can develop along with PTSD into a seriously complicated condition that requires skilled management .
The quality of life in this group of patients has previously been evaluated by Mousavi et al. and the presence of a current psychological problem has reported in 32.9% of all patients . Indeed, these two studies are part of a national needs assessment project for war survivors. In the present study, the SCL-90-R was used to evaluate all 9 psychological dimensions and the global severity index (GSI) of the same group of patients. The results of this study may help to identify social or individual factors that are effective on psychological health status of patients suffering from severe eye injuries induced by chemical agents. In doing so, the present paper reports both somatic and psychosomatic symptoms experienced by war survivors, which has been somewhat neglected in the current medical literature.
Study design and participants
This descriptive cross sectional study was conducted on 149 participants with eye injuries due to SM exposure. The exposures were confirmed based on the documented previous military history and medical records of participants. Based on the chart of the Iranian Ophthalmic Foundation of Martyrs and Veterans Affairs , those veterans who were categorized as severe SM induced ocular involvement were invited to participate in this study from all provinces of Iran. Common ocular findings in this group include corneal ischemia, vascular abnormalities, neovascularization, melting, thinning, hyaline deposition, or diffuse corneal opacity . The study methodology was approved by the Ethics Committee of the Janbazan Medical and Engineering Research Center (JMERC) and Shahed University, Tehran, Iran. Written informed consent was provided to all participants before the study, or the participants were otherwise excluded.
Demographic characteristics, SM and wartime exposure, and psychological health status data were collected from the participants. The demographic information included age, level of education, marital status, employment status, number of the children, and frequency of exposure to SM. Additional war related injuries or co-morbidity and a history of any psychological visit/treatment were also recorded. All participants were examined by both an ophthalmologist and a psychologist. All data were recorded in separate professional forms. The SCL-90-R questionnaire  was used in this study and the psychological health status of all patients was evaluated by three psychologists with identical training. The SCL90-R questionnaire includes 90 questions on 9 different psychological dimensions: 1) somatization, 2) obsessive-compulsive, 3) interpersonal sensitivity, 4) depression, 5) anxiety, 6) anger-hostility, 7) phobic anxiety, 8) paranoid ideation, and 9) psychoticism. The severities of psychological discomfort were graded as normal, mild, moderate, severe, or very severe . The psychological interviews took about 30-45 minutes in a private environment.
Principles and values
SCL90-R test has previously been standardized for Iran with acceptable validity and reliability [24, 25]. GSI score was used for evaluation of psychological health status in this study. GSI score was calculated using the sums of the nine symptom dimensions plus the seven additional items not included in any of the dimension scores, and dividing those sums by the total number of items to which the individual responded. Those participants who had previously received psychological cares (hospitalization/outpatients) were considered as positive psychological history, otherwise considered as negative psychological history. The mean score of Positive Symptom Total (PST) and Positive Symptom Distress Index (PSDI) were used to compare the participants with negative and positive psychological history. The PST is a count of all the items with non-zero responses and reveals the number of symptoms that the respondent reports experiencing. The PSDI is the sum of the values of the items receiving non-zero responses divided by the PST. This index provides information about the average level of distress the respondent experiences . An optimal cut-off point" of 0.4 was considered based on the standardized test results for Iran [24, 25].
Descriptive analyses were carried out to explore the data. To determine the relationships between dependent and independent variables, Mann-Whitney U test, and T test were performed. The effect sizes of each individual item were calculated based on the Cohen's d test. Cohen's d is an effect size index used in conjunction with other statistical tests such as T test to determine the standardized difference between the two means concerning the magnitude of sample size . Analysis of all data was performed using the SPSS software and a P ≤ 0.05 was considered significant.
149 patients were included in this study. The mean age of the patients at the time of study was 44.86 (SD ± 8.7) years and the ages ranged from 21 to 75 years. The mean age of the patients at the time of injury was 23.32 (SD ± 8.5) years. 69 (46.3%) had attained primary or secondary levels and the 80 (53.7%) had acquired higher education. The majority of participants were married (99.3%). Reproductive history showed that all married survivors had children. More than half of survivors 90 (60.4%) were unemployed. More than two-thirds (66.4%) of the survivors had only one contact history to mustard gas during the war. Co-morbidity was reported in 74 cases (49.7%). A positive psychological history of hospitalization or outpatient cares were recorded in 87 (58.4%) and a negative history in 62 (41.6%) of the cases. Demographic characteristics of the participants are demonstrated in Table 1.
In general, most chemical warfare survivors had at least 3 to 5 symptoms related to SM exposure. The mean percentage of general severity index based on data bank of the Veterans and Martyrs Affairs Foundation was 58.85% (SD = 14.8). Mean duration of SM exposure was 21.58 years (SD = 1.2).
The mean of GSI in survivors of chemical warfare with ophthalmologic complications was 1.46 (SD = 0.72), Higher mean scores were present in the somatization 1.98 (SD = 0.84), obsessive-compulsive disorder 1.51 (SD = 0.85), anxiety 1.56 (SD = 0.86), and depression 1.51 (SD = 0.81) categories. Lower mean scores were recorded in the psychoticism 1.00 (SD = 0.72) and phobic anxiety 1.02 (SD = 0.84) categories. Confidence interval (CI) parameter indicates the reliability of these estimations (Table 2).
Demographic and psychological characteristics
The results of this study showed that in participants who had lower education levels, the mean of total GSI scores (effect size = 0.507), somatization (effect size = 0.475), obsessive-compulsive (effect size = 0.519), interpersonal sensitivity (effect size = 0.493), depression (effect size = 0.608), anxiety (effect size = 0.582), anger hostility (effect size = 0.356), and phobic anxiety (effect size = 0.445) were higher versus those with higher education levels (Table 3).
In participant who had more than 2 children, the mean of total GSI scores (effect size = 0.062), somatization (effect size = 0.055), obsessive-compulsive (effect size = 0.102), interpersonal sensitivity (effect size = 0.502), depression (effect size = 0.058), anxiety (effect size = 0.702), anger hostility (effect size = 0.607), and phobic anxiety (effect size = 0.062) were higher versus those with less than 2 children (Table 3).
In unemployed participants, the mean of total GSI scores (effect size = 0.464), interpersonal sensitivity (effect size = 0.501), depression (effect size = 0.427), phobic anxiety (effect size = 0.382), and psychoticism scores (effect size = 0.348), were higher versus the employed participants (Table 3).
In patients who had experienced co- morbidity or had experienced more than one exposure to SM, the mean of total GSI scores and all other 9 dimensions of psychological status were not higher versus those without co-morbidity or less frequent exposure to SM (Table 3).
The mean of total GSI scores and all other 9 dimensions of psychological statuses, total PSDI and total PST were higher in participants with positive psychological history versus those with negative psychological history. Confidence Interval (CI) parameter indicates the reliability of these estimations (Table 4).
The mean GSI in survivors of chemical warfare with ophthalmologic complications was 1.46 (SD = 0.72), which was higher compared to standardized cut-off point (0.4) for Iranian community [24, 25]. Based on the SCL-90, the greatest psychological problems were in the categories of somatization, obsessive-compulsive, anxiety and depression.
Since the eyes play an important role in normal function, vision-related psychological health status is an important area that needs to be further understood [27, 28]. Given the constant fear that SM survivors have of SM induced blindness, any instability in their psychological status is not surprising .
GSI scores were reported by Derogatis in 1002 psychiatric outpatients and 310 psychiatric inpatients and 719 non-patients as 1.32 ± 0.72, 1.36 ± 0.86 and 0.3 ± 0.31 respectively . Similarly, the GSI score of those in our studied population with a positive psychological history was higher compared to cases with negative psychological history.
Neiria et al. reported a mean GSI level of 0.45 in the veterans' cases in contrast with 0.33 in the controls . In another study by Schnurr et al (1996) that looked at individuals exposed to SM during World War II, GSI score was 0.62 . All these scores are lower than the present study. The better scores may be due to better health care services in the countries where the studies were performed or the longer duration between the time of exposure and the study.
In gulf war veterans, PTSD and hospitalization for depression were reported significantly more by deployed troops stationed closer to the explosion site of chemical agents than by non-deployed troops that were farther . The present study revealed that GSI score were worst in those who had a positive psychological history. Torben Ishoy et al. reported a significant correlation between GSI scores and participation in the Gulf War conflict, especially in the categories of obsessive-compulsion and depression, but not for phobic anxiety, paranoid ideation, and psychoticism . In survivors of the Kosovo war, being a refugee was associated with a higher likelihood of having social anxiety disorder, and major depressive disorder . According to the study done by Bramsen et al, higher suicidal thoughts, and depression were associated with GSI scores above 1 in World War II survivors . In the present study, the highest mean scores were in the categories of somatization, anxiety, and depression and the lowest ones were in the categories of psychoticism and phobic anxiety.
Mousavi et al. reported the mean GSI scores of war-related bilateral lower limb amputees to be 0.88. The scores in all 9 dimensions of SCL-90 were lower than the present study . Therefore, the worse GSI scores in this survey signify poorer psychological health status in chemical warfare survivors with ophthalmologic complications. This might be due to the progressive nature of the chemical agents induced injuries, compared to constant nature of the defects on extremities .
Based on the findings of this study, and considering effect of sample size (Cohen's d), there were better psychological health status and lower GSI scores in patients who were employed and had higher levels of education. Aside from SM toxicity, these findings seem logical and no explanations are needed. There were poor psychological health status and higher GSI scores in patients who had higher number of children. Of course lower Cohen's d indicates a necessity of larger sample size in this regard. In the case of the impact of higher number of children on worsening of psychological health status, in addition to SM effects, this factor may influenced on subsistence and economical living of each family head and more fear from inability to manage the living expenses with higher numbers of children. There were poor psychological health status and higher GSI scores in patients who had a history of psychological disorder. For evaluating of SM impacts on worsening of psychological health status after exposure one may needs the previous psychological data of same types that lacked in this study. So the actual relevance of exposure and worsening of psychological symptoms should be outlined cautiously, especially without having any familial psychological history that we were encountered as a limitation in this study. The results of this study revealed that the mean of total GSI scores and all other 9 dimensions of psychological status, were not higher in patients who had experienced co- morbidity. This may be due to the more important effects of vision on living independently in contrast to the other comorbidities. In addition there were no worst psychological health statuses in total GSI scores and in all other 9 dimensions, in patients who had experienced more than one exposure to SM. This finding suggests that most of the fears may come from the first exposure. However, this is in contrast to a study of 24 men who volunteered to participate in sulfur mustard chamber tests. In that study, the number of exposures to SM was the only factor that predicted lifetime full or sub-diagnostic forms of PTSD . Co-morbidity was not associated with higher GSI scores. This finding might reflect the importance of the ocular injuries and its impact on the health of survivors in comparison with damage to other organs. On the other hand these unexpected findings in recent two items may be due to the effect of sample size (lower Cohen's d).
The strength of this study is its ability to uncover the individual and social factors affecting mental health status in soldiers with exposure to chemical munitions. The weakness of this study was the lack of a control group. Also this experience was a descriptive study and we could not find significant association between different variables possibly due to small effect size. Supplementary researches with controls and/or greater sample size may be helpful for any further conclusion.
The findings of this study confirm the destructive effects of chemical warfare agents on the psychological health status of the victims. The results especially emphasize the possibility that SM induced ocular injury can trigger changes in psychological health status for decades. Based on the associations found in this study, increasing educational levels, and bearing fewer children and creation of appropriate jobs may provide a more sweet life by reducing mental stress in these patients.
Ocular injuries induced by SM, aside from systemic insult may trigger destructive effects on psychological health status of victims. Identification of this high risk population and providing appropriate set-up and suitable educations may help to improve psychological health status in these patients.
General Health Questionnaire
Global severity index
Janbazan Medical and Engineering Research Center
Positive Symptom Distress Index
Positive Symptom Total
Post-Traumatic Stress Disorder
Symptom Check List 90-Revised
Hu H, Cook-Deegan R, Shukri A: The use of chemical weapons, Conducting an investigation using survey epidemiology. JAMA 1989, 262: 640–643. 10.1001/jama.1989.03430050056026
Kehe K, Balszuweit F, Emmler J, Kreppel H, Jochum M, Thiermann H: Sulfur mustard research-strategies for the development of improved medical therapy. Eplasty 2008, 8: e32.
Shohrati M, Peyman M, Peyman A, Davoudi M, Ghanei M: Cutaneous and ocular late complications of sulfur mustard in Iranian veterans. Cutan Ocul Toxicol 2007, 26: 73–81. 10.1080/15569520701212399
Ghasemi H, Ghazanfari T, Ghassemi-Broumand M, Javadi MA, Babaei M, Soroush MR, et al.: Long term ocular consequenses of Sulfur mustard in seriously eye injured war veterans. Cutan Ocul Toxicol 2009, 28: 71–77. 10.1080/15569520902913936
Ford JD, Schnurr PP, Friedman MJ, Green BL, Adams G, Jex S: Posttraumatic stress disorder symptoms, physical health, and health care utilization 50 years after repeated exposure to a toxic gas. J Trauma Stress 2004, 17: 185–194. 10.1023/B:JOTS.0000029261.23634.87
Bullman T, Kang H: A fifty year mortality follow-up study of veterans exposed to low level chemical warfare agent, mustard gGas. Ann Epidemiol 2000, 10: 333–338. 10.1016/S1047-2797(00)00060-0
Stuart JA, Murray KM, Ursano RJ, Wright KM: The Department of Defense's Persian Gulf War registry year 2000: an examination of veterans' health status. Mil Med 2002, 167: 121–128.
Dohrenwend BP, Dohrenwend BS: Perspectives on the past and future of psychiatric epidemiology. The 1981 Rema Lapouse Lecture. Am J Public Health 1982, 72: 1271–1279. 10.2105/AJPH.72.11.1271
Hume F, Summerfield D: After the war in Nicaragua: a psychosocial study of war wounded ex-combatants. Med War 1994, 10: 4–25. 10.1080/07488009408409136
Schnurr PP, Ford JD, Friedman MJ, Green BL, Dain BJ, Sengupta A: Predictors and outcomes of posttraumatic stress disorder in World War II veterans exposed to mustard gas. J Consult Clin Psychol 2000, 68: 258–268.
Stuart JA, Ursano RJ, Fullerton CS, Norwood AE, Murray K: Belief in exposure to terrorist agents: reported exposure to nerve or mustard gas by Gulf War veterans. J Nerv Ment Dis 2003, 191: 431–436. 10.1097/01.NMD.0000081634.28356.6B
Jankowski MK, Schnurr PP, Adams GA, Green BL, Ford JD, Friedman MJ: A mediational model of PTSD in World War II veterans exposed to mustard gas. J Trauma Stress 2004, 17: 303–310. 10.1023/B:JOTS.0000038478.63664.5f
Blanchard MS, Eisen SA, Alpern R, Karlinsky J, Toomey R, Reda DJ, et al.: Chronic multisymptom illness complex in Gulf War I veterans 10 years later. Am J Epidemiol 2006, 163: 66–75.
Attaran D, Khajedaloui M, Jafarzadeh R, Mazloomi M: Health-related quality of life in patients with chemical warfare-induced chronic obstructive pulmonary disease. Arch Iran Med 2006, 9: 359–363.
Schnurr PP, Lunney CA, Bovin MJ, Marx BP: Posttraumatic stress disorder and quality of life: extension of findings to veterans of the wars in Iraq and Afghanistan. Clin Psychol Rev 2009, 29: 727–735. 10.1016/j.cpr.2009.08.006
Sodemann M, Svabo A, Jacobsen A: The hardest battles begin after the war. Ugeskr Laeger 2010, 172: 141–144.
Egelko S, Galanter M, Dermatis H, Jurewicz E, Jamison A, Dingle S, et al.: Improved psychological status in a modified therapeutic community for homeless MICA men. J Addict Dis 2002, 21: 75–92. 10.1300/J069v21n02_07
Elsenbruch S, Benson S, Hahn S, Tan S, Mann K, Pleger K, et al.: Determinants of emotional distress in women with polycystic ovary syndrome. Hum Reprod 2006, 21: 1092–1099.
Mousavi B, Soroush MR, Montazeri A: Quality of life in chemical warfare survivors with ophthalmologic injuries: the first results from Iran Chemical Warfare Victims Health Assessment Study. Health Qual Life Outcomes 2009, 7: 2. 19; 2 10.1186/1477-7525-7-2
Ghassemi-Broumand M, Aslani J, Emadi SN: Delayed Ocular, Pulmonary, And Cutaneous Complications Of Mustards In Patients In The City Of Sardasht, IRAN. Cutan Ocul Toxicol 2008, 27(4):295–305. 10.1080/15569520802327807
Ghasemi H, Ghazanfari T, Ghassemi-Broumand M, Javadi MA, Babaei M, Soroush MR, et al.: Long-term ocular consequences of sulfur mustard in seriously eye-injured war veterans. Cutan Ocul Toxicol 2009, 28: 71–77. 10.1080/15569520902913936
Derogatis LR, Melisaratos N: The Brief Symptom Inventory: an introductory report. Psychol Med 1983, 13: 595–605. 10.1017/S0033291700048017
Schmitz N, Hartkamp N, Kiuse J, Franke GH, Reister G, Tress W: The Symptom Check-List-90-R (SCL-90-R): a German validation study. Qual Life Res 2000, 9: 185–193. 10.1023/A:1008931926181
Bakhshaie J, Sharifi V, Amini J: Exploratory Factor Analysis of SCL90-R Symptoms Relevant to Psychosis. Iranian journal of psychiatry 2011, 6(4):128–132.
Mirzaee R: Evaluation of the Reliability and Validity of SCL-90 test in Iran. In MSc Dissertation in Psychology and Behavioral Sciences. Tehran: University of Tehran; 1979.
Cohen J: A power primer. Psychol Bull 1992, 112(1):155–159.
Elliott DB, Pesudovs K, Mallinson T: Vision-related quality of life. Optom Vis Sci 2007, 84: 656–658. 10.1097/OPX.0b013e31814db01e
Swamy BN, Chia EM, Wang JJ, Rochtchina E, Mitchell P: Correlation between vision- and health-related quality of life scores. Acta Ophthalmol 2009, 87: 335–339. 10.1111/j.1755-3768.2008.01203.x
Ghasemi H, Ghazanfari T, Babaei M, Soroush M, Yaraee R, Ghassemi-Broumand M, et al.: Long-term Ocular Complications Of Sulfur Mustard In The Civilian Victims Of Sardasht. Iran Cutan Ocul Toxicol 2008, 27(4):317–326. 10.1080/15569520802404382
Neria Y, Solomon Z, Ginzsurg K, Dekel R: Sensation seeking, wartime performance, and long-term adjustment among Israeli war veterans. Personality and Individual Differences 2000, 29: 921–932. 10.1016/S0191-8869(99)00243-3
Schnurr PP, Friedman MJ, Green BL: Post-traumatic stress disorder among World War II mustard gas test participants. Mil Med 1996, 161(3):131–136.
McCauley LA, Lasarev M, Sticker D, Rischitelli DG, Spencer PS: Illness experience of Gulf War veterans possibly exposed to chemical warfare agents. Am J Prev Med 2002, 23: 200–206. 10.1016/S0749-3797(02)00497-X
Ishoy T, Knop J, Suadicani P, Guldager B, Appleyard M, Gyntelberg F: Increased psychological distress among Danish Gulf War veterans-without evidence for a neurotoxic background, The Danish Gulf War Study. Dan Med Bull 2004, 51: 108–113.
Kashdan TB, Morina N, Priebe S: Post-traumatic stress disorder, social anxiety disorder, and depression in survivors of the Kosovo War: experiential avoidance as a contributor to distress and quality of life. J Anxiety Disord 2009, 23: 185–196. 10.1016/j.janxdis.2008.06.006
Bramsen I, Deeg DJ, Van derPE, Fransman S: Wartime stressors and mental health symptoms as predictors of late-life mortality in World War II survivors. J Affect Disord 2007, 103: 121–129. 10.1016/j.jad.2007.01.014
Mousavi B: Quality of life in war related bilateral lower limb amputation and their spouses. The Asian Symposium on Safe Community Congress, Tailand 2007.
The authors kindly thank the Iranian Foundation of Martyr and Veterans Affairs, Janbazan Medical and Engineering Research Center (JMERC), and Shahed University School of Medicine for supporting this study. We also offer our best regards and wishes to those chemical veterans who participated in this study despite their severe complications and disabilities.
The authors declare that they have no competing interests.
Gh G: Substantial contributions to conception and design; HG: Final approval of the version to be published and corresponding author; BM: Revising the manuscript critically for important intellectual content; MR S: Conceived of the study, and participated in its design and coordination; PR: Interpretation of data; FJ design surveys and experiments; MMN: Analysis and interpretation of data; SAM: Study design and patients evaluation; M SN: Acquisition of data and. involved in drafting the manuscript. All authors read and approved the final manuscript.