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Cognitive Behavioral Therapy, Exercise Aid Gulf War Vets

But some veterans are skeptical of study results

TUESDAY, March 18, 2003 (HealthDayNews) -- Cognitive behavioral therapy and exercising seem to provide some relief from the symptoms of Gulf War veterans' illnesses.

The results of a new study, the first large-scale, multi-center trial to compare cognitive behavioral therapy (CBT) and exercise in these veterans, appear in the March 19 issue of the Journal of the American Medical Association.

"We really think it's a very important finding," says Dr. Nelda Wray, chief research and development officer for the U.S. Department of Veterans Affairs. "Only a small percentage responded but it was statistically significant, and those that did respond had a substantial improvement in their quality of life and state of well-being."

Veterans themselves are not overjoyed by the findings.

"I'm not saying it's a bad thing. It's obvious some people will benefit, but the study shows that it doesn't address the thing that's the root of the problem and that's the pain," says Steve Robinson, executive director of the National Gulf War Resource Center. "It teaches you how to cope."

Robinson is one of a group of veterans who came back from the 1990-1991 Gulf War with mysterious chronic pain, as well as cognitive problems and other symptoms. The collection of symptoms is now referred to as Gulf War Veterans' illnesses (GWVI). There is no known cause and no effective treatment.

There has also been some controversy among veterans over the use of psychosocial treatments such as cognitive behavior therapy in treating GWVI.

"If that's the first line offered, some veterans feel it's implying that it's psychosomatic," says Lea Steele, a senior health researcher at the Kansas Health Institute who has been studying Kansas Gulf War veterans since 1997. "The scientific evidence suggests that stress and psychiatric illness cannot account for GWVI. It's not primarily a stress disease."

Still, cognitive behavioral therapy has been shown to help with other chronic, multi-symptom illnesses such as fibromyalgia and chronic fatigue syndrome. And because there appears to be similarities between GWVI and chronic fatigue syndrome and fibromyalgia, Wray decided to approve a study on the subject.

In the study, 1,092 Gulf War veterans who reported having at least two of three symptoms (fatigue, pain and cognitive symptoms) for more than six months were randomly assigned to one of four groups: usual care; usual care plus cognitive behavioral therapy; usual care plus individual aerobic exercise training; and usual care plus cognitive behavioral therapy and aerobic exercise.

Cognitive behavioral therapy sessions occurred once a week for 12 weeks, with three to eight veterans attending each session. The group meetings lasted 60 to 90 minutes. Participants received training on problem-solving, assertiveness, how to deal with negative thought processes and more.

Each exercise session was an hour long and took place weekly for 12 weeks.

Participants were asked to practice the cognitive techniques they had learned and to continue exercising between sessions.

After one year, the biggest improvements in physical function were seen in the CBT group, with 18.5 percent of participants reporting benefits; 18.4 percent in the CBT-plus-aerobic exercise group reported improvements, while 11.5 percent in the usual care group and 11.7 percent in the aerobic exercise group experienced an improvement.

Exercise, either alone or in combination with CBT, also improved fatigue, distress, cognitive symptoms and mental health functioning. CBT alone significantly improved cognitive symptoms and mental health functioning. Neither treatment had a significant effect on pain, the study found.

While Robinson says that's all well and good, he's concerned about follow-up.

"My question is what about after one year? What about two years? Three years? Five years?" he says. "Once you're out of the loving care of a physician who listens to your every word and you're back dealing with people who don't believe your illnesses are real, you've still got the same problem. It's a temporary fix. The real problem is what's causing my illness or pain."

Wray says the study has given the Department of Veterans Affairs enough justification to start implementing similar programs at VA centers around the country.

"We're putting in place the mechanisms to disseminate these results to make sure all of our physicians are aware of the beneficial therapies and that they are in place," she says.

Some 200 physicians in the VA system specialize in Gulf War Veterans' illnesses. Psychologists and psychiatrists who are trained in CBT are already employed by the system, Wray says.

Wray is hopeful the program being adopted will have more success and will treat a broader spectrum of individuals -- the study participants tended to be very ill; many more veterans suffer from milder symptoms.

Others feel that the benefits will be limited.

"We would want to identify specific people that it was most useful for and recommend it because it appears to provide limited benefits to a limited number of people, and the goal would be to identify people who could benefit from it," Steele says.

More information

For more on Gulf War Veterans' illnesses, visit the National Gulf War Resource Center or the U.S. Department of Veterans Affairs.

The National Association of Cognitive-Behavioral Therapists has more on cognitive behavioral therapy.

SOURCES: Nelda Wray, M.D., M.P.H., chief research and development officer, Department of Veterans Affairs, Washington, D.C.; Lea Steele, Ph.D., senior health researcher, Kansas Health Institute, Topeka; Steven Robinson, executive director, National Gulf War Resource Center, Silver Spring, Md.; March 19, 2003, Journal of the American Medical Association
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