American Journal of Epidemiology
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Vol. 170, No. 3
Advance Access publication June 29, 2009
The Physical and Mental Health of Australian Vietnam Veterans 3 Decades After
the War and Its Relation to Military Service, Combat, and Post-Traumatic Stress
Brian I. O’Toole*, Stanley V. Catts, Sue Outram, Katherine R. Pierse, and Jill Cockburny
Initially submitted February 24, 2009; accepted for publication May 5, 2009.
The long-term health consequences of war service remain unclear, despite burgeoning scientific interest.
A longitudinal cohort study of a random sample of Australian Vietnam veterans was designed to assess veterans’
postwar physical and mental health 36 years after the war (2005–2006) and to examine its relation to Army service,
combat, and post-traumatic stress disorder (PTSD) assessed 14 years previously (1990–1993). Prevalences in
veterans (n ¼ 450) were compared with those in the Australian general population. Veterans’ Army service and
data from the first assessments were evaluated using multivariate logistic regression prediction modeling. Veterans’
general healthand some healthrisk factors were poorer and medical consultation rates were higher than Australian
population expectations. Of 67 long-term conditions, the prevalences of 47 were higher and the prevalences of
4 were lower when compared with population expectations. Half of all veterans took some form of medication for
mental well-being. The prevalence of psychiatric diagnoses exceeded Australian population expectations. Military
and war service characteristics and age were the most frequent predictors of physical health endpoints, while
PTSD was most strongly associated with psychiatric diagnoses. Draftees had better physical health than regular
enlistees but no better mental health. Army service and war-related PTSD are associated with risk of illness in later
life among Australian Vietnam veterans.
combat disorders; health status; psychiatry; stress disorders, post-traumatic; veterans; Vietnam
Abbreviations: ABS, Australian Bureau of Statistics; CAPS, Clinician-Administered PTSD Scale; CI, confidence interval; CIDI,
Composite International Diagnostic Interview; CURF(s), Confidentialised Unit Record File(s); DSM-III-R, Diagnostic and Statistical
Manual of Mental Disorders, Third Edition, Revised; OR, odds ratio; PTSD, post-traumatic stress disorder; SD, standard deviation.
Australian military forces were deployed to Vietnam
from 1962 to 1972, making it the longest military conflict
experienced by Australia to date. The conflict placed
Australian men into longer periods of risk of contact with
the enemy than at any time in Australia’s history since the
Gallipoli Campaign (1). More than 50,000 Australians saw
service in Vietnam; over 500 lost their lives, and more than
2,500 sustained wounds.
Evidence that postwar survivors of combat continue to
suffer ill health (2) has accumulated from postwar studies
of military service members from World War II (3–7), the
Vietnam War (8–18), the Middle East conflict (19–21), and
the Persian Gulf War (22–31). Cross-sectional epidemio-
logic studies have been conducted in Australian veterans
of the Vietnam War (15–17), the Persian Gulf War (28,
29), and the Korean War (32). Each study showed that
chronic mental health problems, particularly post-traumatic
stress disorder (PTSD), anxiety, and depression, are preva-
lent in postwar military cohorts. This is broadly consistent
with findings from studies carried out in other allied coun-
tries, including the United States (33) and the United King-
dom (26, 30). The recency of the Iraq and Afghanistan
conflicts and the timing of earlier studies of the Vietnam
conflict have constrained follow-up periods to relatively
* Correspondence to Dr. Brian I. O’Toole, ANZAC Research Institute, Repatriation General Hospital Concord, New South Wales 2139, Australia
318 Am J Epidemiol 2009;170:318–330
by guest on May 10, 2011
short durations, with only a few studies extending over more
than 20 years—mostly retrospective studies of World War II
and Korean War cohorts (3–7).
If combat soldiers are similar to their background general
populations, it would be expected that the prevalence of
most physical health disorders would increase with age
while the prevalence of psychiatric disorders would decline
(34–36). Given the chronic nature of PTSD (37, 38) and
frequently observedcomorbid conditions (39–43) and a pos-
sible link between PTSD and physical health (14, 44, 45),
the question of aging veterans’ health remains important.
We studied the self-reported physical and mental health
of a cohort of Australian Vietnam veterans who were as-
sessed approximately 20 years and 34 years after the war.
We compared veterans’ health with that of the Australian
general population using official statistical data and exam-
ined the effect of relations between aspects of military and
Vietnam service and PTSD onveterans’ physical and mental
MATERIALS AND METHODS
Veterans were identified from a computer file developed
during Australian Agent Orange studies (46–48) that holds
the Army service numbers of all men who were posted to
Vietnam. From the total of 57,643 postings, after removing
duplicates, we selected a random sample of 1,000 numbers.
The Army supplied the name and date of birth of each man
for tracing and contact. Addresses for wave 1 were gathered
through computerized searches of the Australian Electoral
Roll (voting, and hence registration, is compulsory in
Australia) and several government agencies and ex-service
organizations. In wave 2, the Department of Veterans’ Af-
fairs distributed mail to veterans; nonresponders were
sought through wave 1 addresses and addresses from the
Australian Electoral Roll. Wave 1 interviews occurred be-
tween July 1990 and February 1993, and wave 2 interviews
between April 2005 and November 2006. Wave 1 was con-
ducted an average of 21.96 years (standard deviation (SD),
1.91) after the service member’s first return to Australia and
wave 2 an average of 36.10 years (SD, 1.92) afterward, with
an average between-interview interval of 14.18 years (SD,
1.92). Deaths were identified through electronic searches of
the National Death Index (Australian Institute of Health and
Interview assessments comprised standardized question-
naires selected to permit direct comparison with national
population statistics. The questionnaires were administered
by trained clinical and research interviewers. In both waves,
we relied on Australian Bureau of Statistics (ABS) data and
methods used to gather national statistics on the health of
the Australian population at approximately corresponding
The content of the interviews in both waves comprised:
1) the ABS National Health Survey, assessing physical
health and associated risk factors, that was current at the time
(the 1989–90 National Health Survey (49) in wave 1 and the
2004–05 National Health Survey (50) in wave 2); 2) a 21-
item combat index (51); 3) assessment of combat-related
PTSD (the Structured Clinical Interview for DSM-III-R
(52), which is based on the Diagnostic and Statistical Man-
ual of Mental Disorders, Third Edition, Revised (DSM-III-
R), in wave 1 and the Clinician-Administered PTSD Scale
(CAPS) (53) in wave 2); and 4) assessment of general psy-
chiatric status (the Diagnostic Interview Schedule (54) in
wave 1 and the Composite International Diagnostic Inter-
view (CIDI) (55) in wave 2). For non-combat-related PTSD,
the appropriate module of the Diagnostic Interview Sched-
ule or CIDI was used. The version of the CIDI used was that
used by the ABS in 1997 in the first Australian National
Survey of Mental Health and Wellbeing (35, 56); these were
the only population mental health data extant at the time of
the wave 2 interviews.
The ABS 2004–05 National Health Survey included
a question on a subjective overview of health (the first ques-
tion in the SF-36 Health Survey (57)) and then proceeded to
a set of questions on recent health actions, health risk fac-
tors, and specific conditions that were of target interest to
the ABS: cancer, cardiovascular disease, asthma, arthritis,
and diabetes. The National Health Survey also included
categories for mental and behavioral problems, indepen-
dently of CIDI diagnoses. ‘‘Gate’’ questions (typically
‘‘Have you ever been told by a doctor or nurse that you have
had [condition]?’’) were followed by specific questions re-
garding age of onset, health actions taken, medications used,
whether the condition was injury-related, and so forth. The
survey then asked about long-term conditions that had lasted
or were likely to last for 6 months or more; this was fol-
lowed by a checklist of long-term or chronic conditions.
The ABS also provided the computerized Confidential-
ised Unit Record Files (CURFs) from the 2004–05 National
Health Survey and the National Survey of Mental Health
and Wellbeing for direct comparison with veteran data. This
permitted us to compare the numbers of cases of particular
illnesses (e.g., hypertension, depression) found among the
veterans with the expected numbers of cases based on the
Australian population for each age group. Physical and psy-
chiatric conditions were coded according to the World
Health Organization’s International Classification of Dis-
eases, Tenth Revision.
Prior to wave 1 fieldwork, with assistance from the
Australian Army, data on the cohort were extracted from
the Central Army Records Office and the Psychology Corps
Records Office. Data gathered included type of enlistment
(Regular enlistment vs. National Service conscription),
service details (postings, dates, service milestones), conduct
and casualty information, pre-enlistment education and
employment, and the results of Army psychology classifi-
cation tests. Included in these tests was the Army General
Classification Test, a test of general intelligence that was
found in earlier studies (58) to correlate highly (r ¼ 0.8)
with the Raven’s Progressive Matrices (59) and which was
periodically normed on Regular soldiers and scaled with
a mean of 10.5 and a standard deviation of 4.
Combat was assessed in 2 ways: 1) from veterans’ sub-
jective reports, using a 21-item combat scale (51) that was
administered at both waves, and 2) from Army records,
based on the roles that individual units had played, as de-
termined by military advisers to previous Australian studies
of Vietnam veterans (46–48). The Army combat index
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