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Farnoosh Hashemian, MPH; Kaveh Khoshnood, PhD; Mayur M. Desai, PhD, MPH; Farahnaz Falahati, MD; Stanislav Kasl, PhD; Steven Southwick, MD

JAMA. 2006;296:560-566.

Context  In the 1980-1988 Iran-Iraq War, extensive use of chemical weapons resulted in high rates of morbidity and mortality. While much is known about the physical consequences of chemical warfare, there is a paucity of information about the long-term effects of chemical attacks on mental health.

Objective  To assess the long-term psychological impact of chemical warfare on a civilian population.

Design, Setting, and Participants  Cross-sectional randomized survey conducted in July 2004 of 153 civilians in 3 towns exposed to warfare in northwestern Iran: Oshnaviyeh (low-intensity conventional warfare), Rabat (high-intensity conventional warfare), and Sardasht (both high-intensity conventional warfare and chemical weapons).

Main Outcome Measures  Full or partial posttraumatic stress disorder (PTSD) diagnosis, anxiety symptoms, and depressive symptoms were assessed using Farsi versions of the Clinician-Administered PTSD Scale, Hamilton Scale for Anxiety, and Beck Depression Inventory, respectively.

Results  Overall participation rate was 93%. Respondents had a mean age of 45 years and were all of Kurdish ethnicity. Among individuals exposed to both high-intensity warfare and chemical weapons, prevalence rates for lifetime PTSD, current PTSD, major anxiety symptoms, and severe depressive symptoms were 59%, 33%, 65%, and 41%, respectively. Among the low-intensity warfare group, the corresponding rates were 8%, 2%, 18%, and 6%, respectively, while intermediate rates were found among those exposed to high-intensity warfare but not to chemical weapons (31%, 8%, 26%, and 12%, respectively). Compared with individuals exposed to low-intensity warfare, those exposed to both high-intensity warfare and chemical weapons were at higher risk for lifetime PTSD (odds ratio [OR], 18.6; 95% confidence interval [CI], 5.8-59.4), current PTSD (OR, 27.4; 95% CI, 3.4-218.2), increased anxiety symptoms (OR, 14.6; 95% CI, 6.0-35.6), and increased depressive symptoms (OR, 7.2; 95% CI, 3.3-15.9). Exposure to high-intensity warfare but not to chemical weapons was also significantly associated with lifetime PTSD (OR, 5.4; 95% CI, 1.7-17.6), compared with those in the low-intensity warfare group. Further, compared with individuals exposed to high-intensity warfare alone, those exposed to both high-intensity warfare and chemical weapons were at higher risk for lifetime PTSD (OR, 3.4; 95% CI, 1.5-7.4), current PTSD (OR, 6.2; 95% CI, 2.0-20.1), increased anxiety symptoms (OR, 5.6; 95% CI, 2.5-12.6), and increased depressive symptoms (OR, 3.7; 95% CI, 1.8-7.2).

Conclusion  Exposure to chemical warfare is an extreme traumatic event that has long-lasting adverse consequences on mental health.

Author Affiliations: Department of Epidemiology and Public Health, (Ms Hashemian and Drs Khoshnood, Desai, and Kasl) and Department of Psychiatry (Drs Desai and Southwick), Yale University School of Medicine, New Haven, Conn; Northeast Program Evaluation Center and Mental Illness Research, Education, and Clinical Center (Dr Desai) and National Center for PTSD (Dr Southwick), VA Connecticut Healthcare System, West Haven, Conn; and Chemical Warfare Victims Unit, Organization of Veterans Affairs, Tehran, Iran (Dr Falahati).

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