Date:  Jan. 23, 2013




No 'One Size Fits All' Approach to Vets' Chronic Multisymptom Illness;

Treatment Should Be Tailored to Each Individual, Involve Team-Based Approaches


WASHINGTON — There is no single therapy or universal treatment approach that will help all veterans experiencing chronic multisymptom illness (CMI), says a new report from the Institute of Medicine.  The U.S. Department of Veterans Affairs should customize care with an array of therapies tailored to each former service member's needs, said the committee that wrote the report. 


VA should harness the potential of existing programs such as post-deployment patient-aligned care teams (PD-PACTS) to improve CMI care, the report added.  The department should also pursue a new strategy of creating "CMI champions" to help its health care providers better serve patients with complex symptoms and needs, the committee said.


To boost the department's ability to identify former service members with CMI, VA's electronic health record should prompt health care providers to ask patients about symptoms that characterize CMI.  Veterans should undergo a comprehensive health examination immediately after they leave active duty, and the results of these exams should be available to clinicians both within and outside the VA health system to ensure continuity of care.


"Based on the voluminous evidence we reviewed, our committee cannot recommend using one universal therapy to manage the health of veterans with chronic multisymptom illness, and we reject a 'one size fits all' treatment approach," said committee chair Bernard M. Rosof, chair, board of directors, Huntington Hospital, Huntington, N.Y.  "Instead, we endorse individualized health care management plans as the best approach for treating this very real, highly diverse condition."


Written as part of IOM's congressionally mandated Gulf War and Health series, the report presents a comprehensive evaluation of the various treatments for CMI and recommends the best approaches to managing veterans' care.  The committee defined CMI as the presence of a spectrum of chronic symptoms in at least two of six categories -- fatigue, mood and cognition, musculoskeletal, gastrointestinal, respiratory, and neurologic -- experienced for at least six months. 


CMI shares characteristics with other conditions marked by chronic, medically unexplained symptoms, but its symptoms are not fully captured by other recognized syndromes.  Formerly dubbed Gulf War Syndrome, CMI affects roughly one-third of veterans of the 1991 Persian Gulf War.  Many personnel who served in the more recent conflicts in Iraq and Afghanistan have reported similar symptoms.  In comparison, conditions involving chronic, unexplained symptoms affect roughly one-fourth of the general U.S. population.  The cause or causes of CMI probably will never be fully determined, the committee said, but this does not undermine the legitimacy of vet­erans’ reports of symptoms.


To help tailor care to individual needs, VA should establish a CMI-focused PD-PACT, the report says.  PD-PACTs represent a relatively new model of care within the VA health system that involves managing patients' care through teams of providers that may include a project manager, primary care physicians, nurses, mental health cli­nicians, social workers, and other specialists. 


The committee's review of treatment options determined that many veterans may benefit from cognitive behavioral therapy and from medications such as selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors.  Other interventions and approaches, such as biofeedback, acupuncture, St. John’s wort, aerobic exercise, motivational interviewing, and multimodal therapies, could hold promise but lack robust scien­tific evidence of their effectiveness.  VA should fund and conduct studies of these interventions to determine their usefulness for CMI.


Creating the new position of "CMI champion" at each VA medical center would provide clinicians an internal resource of information and advice about how best to serve patients with CMI, the report says.  Champions should be knowledgeable about the variety of therapeutic options, have easy access to a team of consulting clinicians, and be trained in commu­nication skills. 


The study was sponsored by the U.S. Department of Veterans Affairs.  Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides objective, evidence-based advice to policymakers, health professionals, the private sector, and the public.  The Institute of Medicine, National Academy of Sciences, National Academy of Engineering, and National Research Council together make up the private, nonprofit National Academies.  For more information, visit or  A committee roster follows.



Christine Stencel, Senior Media Relations Officer

Shaquanna Shields, Media Relations Assistant

Office of News and Public Information

202-334-2138; e-mail


Additional resources:

Report in Brief

Project Website

Pre-publication copies of Gulf War and Health Volume 9: Treatment for Chronic Multisymptom Illness are available from the National Academies Press on the Internet at or by calling tel. 202-334-3313 or 1-800-624-6242.  Reporters may obtain a copy from the Office of News and Public Information (contacts listed above).

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Board on the Health of Select Populations


Committee on Gulf War and Health: Treatment of Chronic Multisymptom Illness

Bernard M. Rosof, M.D. (chair)


Board of Directors
Huntington Hospital
Huntington, N.Y.

Diana D. Cardenas, M.H.A.
Professor and Chair
Department of Rehabilitation Medicine
Leonard M. Miller School of Medicine
University of Miami

Frank V. deGruy III, M.D.
Woodward-Chisholm Professor and Chair
Department of Family Medicine
School of Medicine
University of Colorado


Douglas A. Drossman, M.D.

Adjunct Professor of Medicine;

Co-Director Emeritus

Psychiatry Center for Functional GI and Motility Disorders
School of Medicine
University of North Carolina; and

Drossman Center for the Education and Practice of Biopsychosocial Care
Chapel Hill, N.C.


Francesca Dwamena, M.D.

Professor and Acting Chair
Department of Medicine
Michigan State University
East Lansing


Javier I. Escobar, M.D.

Associate Dean for Global Health

University of Medicine and Dentistry of New Jersey

New Brunswick


Wayne Gordon, Ph.D.

Jack Nash Professor and Vice Chair

Department of Rehabilitation Medicine
Mount Sinai School of Medicine
New York City


Isabel V. Hoverman, M.D.

Austin Internal Medicine Associates L.L.P.
Austin, Texas


Wayne Jonas, M.D.

President and CEO
Samueli Institute
Alexandria, Va.


Joanna G. Katzmann, M.D.

Associate Professor

Department of Neurosurgery
School of Medicine
University of New Mexico



Elaine L. Larson, Ph.D.

Associate Dean for Research

School of Nursing

Columbia University

New York City


Stephen R. Mitchell, M.D.

Dean of Medical Education
School of Medicine

Georgetown University
Washington, D.C.


Karen A. Robinson, Ph.D.

Assistant Professor

Departments of Medicine, Epidemiology, and Health Policy and Management

Johns Hopkins University



Kasisomayajula Viswanath, Ph.D.

Associate Professor
Department of Society, Human Development, and Health
Harvard School of Public Health


Lori Zoellner, Ph.D.

Associate Professor
Department of Psychology
University of Washington




Abigail Mitchell, Ph.D.

Study Director