Treating Gulf War Veterans' Illnesses—Are More Focused Studies Needed?

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Abstract
The Veterans Affairs (VA) Cooperative Study #470, a trial of cognitive behavioral therapy (CBT) and aerobic exercise for Gulf War veterans' illnesses (GWVI) reported in this issue of THE JOURNAL,1 is a remarkable achievement. It is the first credible trial of an intervention for symptomatic Gulf War veterans, and with 1092 individuals randomized at 20 sites, it is one of the largest trials of a psychotherapeutic intervention ever published. The study used a factorial design to randomize symptomatic veterans who received usual care, CBT, graded exercise therapy, or both in combination. The results suggest that CBT leads to a modest reduction in physical disability (the primary outcome measure), graded exercise has no such effect, and the combined treatments can lead to improvements in fatigue and cognitive symptoms but not pain. The modest effects shown in the primary outcome are difficult to interpret. Should all symptomatic veterans now be offered CBT or should further research attempt to refine the treatment? If graded exercise therapy is effective for some symptoms, are there subgroups of patients who would benefit from it more than from CBT?