Participants

This was a cross-sectional case-control study. For the selection of cases, study staff reviewed all the available records in the Foundation of Martyrs and Veterans Affairs in Sardasht to identify male civilians who were chemical war victims. There were 1336 registered male chemical war victims in Sardasht. They were recruited for the initial screening. The screener included items from the DSM-IV-TR ⁴⁷ criteria A (stressor) for PTSD ^{Reference Hashemian, Khoshnood, Desai, Falahati, Kasl and Southwick10} assessing if during exposure to the war: the chemical war victim was confronted with an actual or threat of death or injury; and if the individual expressed feeling of hopelessness and fear. The people who screened positive on both items were recruited for the study along with their wives. Next, the husband-wife couples were screened for participation eligibility based on the following criteria: history of chronic disease or a malignancy; history of chronic diseases or malignancies among other members of the family; presence of any other chemical war victims or disabled persons living with the family. Couples who responded ‘no’ to all the aforementioned criteria were eligible to take part in the study. Of the 176 case-couples who met study eligibility criteria, 150 (85.2%) agreed to sign an informed consent form and participated in the study. For selection of couples in the control group, systematic random sampling was used and we selected 156 couples from a list of residents in Sardasht. The control couples met the same aforementioned eligibility criteria and were matched with the case couples by age, direct exposure to the destruction and material losses of war as a traumatic life event and indirect exposure to socioeconomic disadvantages of war and military drafting of family members and/or friends. The difference between the case and control couples had to do with the exposure of the husband in the case couples to chemical warfare during the Iraq-Iran war.

Outcome measure

We used the Mississippi Scale for Combat-Related PTSD (M-PTSD) ^{Reference Keane, Caddell and Taylor48} to measure the study outcome variable. The M-PTSD was originally developed by Keane and colleagues ^{Reference Keane, Caddell and Taylor48} and was later revised by Norris et al. ^{Reference Norris and Perilla49} The M-PTSD is a 39-item self-report measure of combat-related PTSD. It takes 10-15 min to administer, and includes items related to: re-experiencing symptoms of the traumatic event, such as intrusive memories and recurrent nightmares, which reflects DSM-IV criterion B for PTSD; engaging in protective reactions, such as avoidance of the stimuli associated with the trauma and emotional numbing, which reflects DSM-IV criterion C for PTSD; and experiencing arousal symptoms, such as startled responses and hypervigilance, which reflects DSM-IV criterion D for PTSD.

Respondents were asked to rate how they felt about each item using 5-point Likert-scale response categories. Responses were summed to provide an index of PTSD-symptom severity score ranging from 39 to 195; a higher score indicating more severe symptoms of PTSD. The original 35-item scale was tested among samples of veterans seeking treatment, and has been shown to have high reliability (Cronbach α = 94) ^{Reference Keane, Caddell and Taylor48} and validity. ^{Reference McFall, Smith, Roszell, Tarver and Malas50} Goodarzi ^{Reference Goodarzi51} validated the Persian/Farsi version for the Iranian population (2003) and reported high internal consistency (Cronbach α = 0.91) and cross-cultural validity. Keane et al reported that a cut-off score of 107 has a sensitivity of 93% and a specificity of 89%. ^{Reference Keane, Caddell and Taylor48} However, it has been reported that the scale is vulnerable to faking and therefore a cut-off score of 121 has been suggested. ^{Reference Lyons, Caddell, Pittman, Rawls and Perrin52} Although the sensitivity of this cut-off score is good (0.95), its specificity is compromised (0.45). A cut-off score that would optimise both sensitivity and specificity has not been reported. ^{Reference Shalev, Freedman, Peri, Brandes and Sahar53}

Statistical analysis

We used SPSS software version 11.5 for Windows to calculate measures of central tendency including mean, median and measures of dispersion such as standard deviation to provide univariate analysis of the study's main variables. In order to test the study hypotheses, we used independent t-tests, Pearson's correlation and chi-squared tests. P⩽0.05 was set as the statistically significant level.

Main findings

Our study showed that male civilians who were directly exposed to chemical warfare during the Iraq-Iran war had higher level of PTSD symptoms compared with their non-exposed counterparts. Tavalaei et al also reported that the prevalence of PTSD symptoms among Iranian chemical warfare victims was as high as 90%. ^{Reference Tavallaie, Assari, Najafi, Habibi and Ghanei7} Several other studies have demonstrated high rates of PTSD symptoms among war veterans. ^{Reference Hashemian, Khoshnood, Desai, Falahati, Kasl and Southwick10,Reference Ford, Schnurr, Friedman, Green, Adams and Jex12,Reference Schnurr, Ford, Friedman, Green and Dain14,Reference Jankowski, Schnurr, Adams, Green, Ford and Friedman15} This is an important finding since PTSD has been reported to be a risk factor for developing dementia, ^{Reference Yaffe, Vittinghoff, Lindquist, Barnes, Covinsky and Neylan54} diminished quality of life ^{Reference Zatzick, Marmar, Weiss, Browner, Metzler and Golding55,Reference Ouimette, Coolhart, Sugarman, Funderburk, Zelman and Dornau56} problems readjusting to community life; ^{Reference Sayer, Noorbaloochi, Frazier, Carlson, Gravely and Murdoch57} and more alcohol consumption and illicit drug use. ^{Reference Ouimette, Coolhart, Sugarman, Funderburk, Zelman and Dornau56} Coordinated treatment and policy efforts and intervention procedures could improve the functioning and well-being of chemical war victims. Moreover, clinicians should be alert that chemical war victims with PTSD could suffer from comorbid medical problems and undertake health-compromising risky behaviours. Therefore, they should recommend regular physical check-ups, offer regular screening for substance misuse and provide adequate referrals. ^{Reference Dirkzwager, van der Velden, Grievink and Yzermans58}

As demonstrated in the results, the rate and intensity of PTSD symptoms among wives in the case group were significantly higher than those in the wives in the control group where husbands were not affected by chemical warfare. This pattern was evident by higher representation of wives in the case group across cut-off points (>121 and >107; P<0.5). Moreover, nearly all the wives in the case group (96.6%) reported suffering from moderate or severe PTSD symptoms. In the control group, this rate was 72.4%, and the difference between the two groups was statistically significant (P<0.5). Also, across all the PTSD symptom subscales, including ‘frequently haunted by memories’, ‘problems in personal relationships’, ‘inability to control emotional feelings’ and ‘lack of depression’, the mean scores for the PTSD symptoms of the wives in the case group were higher than the mean scores of their counterparts in the control group (P<0.5) (Table 3). These findings corroborate previous empirical results that report a high level of secondary PTSD among the spouses of warfare victims. ^{Reference Francisković, Stevanović, Jelusić, Roganović, Klarić and Grković59} It also adds to the existing knowledge by highlighting the extra burden that the wives of chemical warfare victims endure. The physical and psychological consequences of these burdens, if left uncontrolled or unchecked, can have significant adverse health consequences not only for the wife as a caregiver but also for the patient (i.e. husband) if and when proper caregiving is threatened. Therefore, identification of the level and intensity of secondary PTSD symptoms among wives of chemical war victims should be the first step towards the development of strategies to offset caregiver burden among this group. In this respect, primary care physicians should keep wives of chemical war victims under their constant attention, regularly screen them for undetected mental, emotional and physical stress, and provide them with proper referrals as needed. Home-based interventions can provide creative and culturally accepted options to overcome the burden of care for this population. It could also be of value in lowering medical costs and sustaining effective care for chemical war victims and their wives.

Furthermore, family psychologists who provide care to chemical war victims must also address the trauma experienced by these individuals’ wives. They should assist both of them so that they recover from their ordeals together. ^{Reference Figley34} The salience of effective social supports and the benefits of empowering wives of war victims to manage the sociopsychological burdens of caregiving are included among the interventions suggested. ^{Reference Al-Turkait and Ohaer60} These types of therapeutically induced interventions may provide a buffer against relationship distress caused by caregiver burden. ^{Reference Renshaw, Rodrigues and Jones39}

Nevertheless, it is important to note the high rate of PTSD-like symptoms in the wives of non-affected husbands. This could be attributed to these women's experiences of the war's brutality and the overall life-threatening situation in Sardasht during the war. As was mentioned earlier, all the participants in the study were civilians (residents) of Sardasht who were exposed to extensive bombardments during the Iraq-Iran war and its direct and indirect socioeconomic consequences, with the exception that husbands in the case group were exposed to chemical warfare. The high rate of PTSD-like symptoms among the wives in the control group therefore could be the long-lasting result of a war that left women living in Sardasht vulnerable to the symptoms of PTSD. Further studies are needed to identify other sociopsychological characteristics of these women and how they may be related to the reporting of PTSD symptoms among women living in Sardasht.

In our study there was no significant relationship between the PTSD symptoms of the wives and that of their husbands in the case group. This finding is similar to the results of Al-Turkait et al ^{Reference Al-Turkait and Ohaer60} who studied PTSD among the wives of military men who fought during the first Gulf War in Kuwait and found no association between the level of PTSD in the wives and their husbands. We also did not detect any association between the husbands’ degree of morbidity and disability (measured by the Bonyad-e Janbazan Morbidity Index) and the PTSD symptoms of their wives. We tested this secondary hypothesis because findings from the caregiver literature suggest that the level of PTSD symptoms among caregivers most likely depends on the functional status and cognitive function of the individual they are providing care for. ^{Reference Gure, Kabeto, Blaum and Langa61-Reference Davis, Sander, Struchen, Sherer, Nakase-Richardson and Malec63} Dekel et al ^{Reference Dekel, Solomon and Bleich37} have suggested that the level of distress among caregivers is more closely associated with perceived caregiver burden than with the level of the primary individual's physical impairment.

Perception of caregiver burden in a country such as Iran where the help-seeking journey starts at home could explain the lack of association between chemical war victims’ PTSD symptoms and those of their wives. In Iran, it is within the cultural norms and expecations that women provide proper care for their sick husbands or any other members of the family. Therefore, although providing continued home-care for a chemical war victim can be stressful and straining, for some women this may increase their sense of self-satisfaction, self-efficacy and confidence knowing that they have fulfillied the expected ‘female role’. The lack of association could also be reflective of the Islamic beliefs in the lives of wives/caregivers who participated in this study. The spiritual beliefs of these women could have provided them with a coping strategy that disassociates their mental health with that of the husbands. Further imperial investigations are needed to identify protective characteristics in women who care for their husbands who are chemical war victims including spirituality and self-efficacy.

Limitations

This study has several limitations and therefore the results should be interpreted with caution. First, study data were cross-sectional, limiting our ability to offer any causal inferences about the role of variables that were statistically significant. Second, data for this study were self-reported, therefore subject to response bias. Third, our data lack measures of different physical consequences of exposure to chemical agents in chemical war victims. The severity of the chemical war victims’ physical problems was measured only by the ‘disability percentage’, which had been determined by the Bonyad-e Janbazan Morbidity Index.

However, our study is the first to focus on the secondary PTSD symptoms of the wives of chemical war victims and its association with the PTSD symptoms of their husbands. In this study, we were unable to prove the proposed association between the PTSD symptoms of the chemical war victims and their wives in the case group beyond the probable role of caregiver burden. As mentioned earlier, this could be attributed to a pre-existing mental and psychological vulnerability among the wives because of their exposure to the war. Further investigations are needed to include data about the pre-existing psychological problems of wives in the analysis and interpretation process. These investigations may also benefit from a longitudinal design, inclusion of multi-item risk and protective predictors and the inclusion of social-related variables.

Implications

In our study, husbands (chemical war victims) in the case group had a significantly higher overall PTSD mean score than the husbands in the control group. Furthermore, wives of chemical war victims demonstrated higher rates of PTSD symptoms than the wives in the control group, and the difference between the two groups was statistically significant. There was no statistically significant association between the overall PTSD score of the husbands in the case group with the PTSD scores of their wives. Studies are needed to explore the characteristics of wives of chemical war victims including their physical, psychological, religious and coping styles, and how they change over time. Results of these studies can help to better understand these and other factors contributing to increased secondary PTSD symptoms or factors that buffer against it. Furthermore, interventions that coordinate clinical care and home-based care for chemical war victims are needed. Proper outcome evaluations of these and other relavent efforts are needed in order to develop more effective caregiver interventions for this population.