Good afternoon, Chairman and members of the committee. It is a real pleasure to be here today.
I would like to share the perspective of a military psychiatrist, which is what I was for many years. I have been around mefloquine, and consistently been uninformed as to the toxic effects of mefloquine.
Normally, when I give a presentation, I start with World War I and roll up through World War II, Korea and Vietnam. In the interest of time I will truncate that today and I will start with Somalia, but all wars produce both physical and psychological reactions to a war, and we often don't know which it is. You remember shell shock from World War I, or the Gulf War syndrome more recently, with which we've gone round and round.
The short version of the presentation is that many things we have seen over the last 30 years that we thought were psychological we can now attribute, partially or completely, to the effects of mefloquine. With regard to Somalia, I deployed there early in Operation Restore Hope, as an army psychiatrist, a young major. I deployed with the 528th combat stress control team out of Fort Bragg. Our purpose was to diagnose, treat and evaluate combat stress control reactions.
We knew very little about mefloquine then. The day I got into the country a young solider was evacuated, acutely psychotic, we believe secondary to the effects of mefloquine.
I worked mainly with the American forces, although I was asked to evaluate Corporal Matchee after his suicide attempt. He was in a coma so I could not evaluate him.
During our time there we spent a lot of time discussing the dangers of malaria, and the neuropsychiatric short-term effects of mefloquine became apparent to us, but we did not think about the long-term effects at that time.
Fast-forward, we returned home. We were using less mefloquine. The murders, murder-suicides at Fort Bragg happened in 2002, shortly after we had gone into Afghanistan. I was part of a team asked to look at mefloquine; could this be related? At that time, again we didn't know very much about mefloquine. Various studies said one in 4,000, one in 10,000, one in 18,000 people may have neuropsychiatric effects from mefloquine. We were just told or knew about the short-term effects. We studied the indexed cases—you may or may not remember—Staff Sergeant Nieves, who killed his wife and then himself; Master Sergeant Wright, who killed his wife, hanged himself in a jail cell six months later, apparently hallucinating; and Staff Sergeant Brandon Floyd, who had been off mefloquine for six months when he killed his wife and then himself.
We looked at a lot of factors, but again, back then we didn't think about long-term effects of mefloquine. When you stop most medications, the effects go away. We found a combination of things responsible for the murder-suicides, which included marital fidelity and rapid operations tempo, but I got interested in mefloquine as a result of both those experiences. Back in 2004 I presented a paper on the neuropsychiatric effects of mefloquine.
Moving quickly through time, I retired from the army in 2010. Staff Sergeant Bales committed the atrocities in early 2012, and I immediately thought of mefloquine. During that intervening period the U.S. Army's use of mefloquine had declined precipitously, although it was still being used. Another factor was that headquarters repeatedly said we had to screen and document the screening of soldiers to make sure they didn't have mental illness or traumatic brain injury. Over and over again our systems found problems with the way we screened and documented soldiers for mental illness, traumatic brain injury, anxiety or suicide. Of course, during that time period from about 2004 to 2010, our suicide rate in the army doubled.
After my retirement, my most recent work has been with the VA as a psychiatrist. I cannot speak for the VA here, but I will say that we started to look through the risks at the War Related Illness and Injury Study Center. We looked at soldiers and other veterans in the U.S. who we thought may have suffered long-term effects from mefloquine. We found a variety of diagnoses. We found very seldom a clear picture, but certainly a lot of veterans who ascribed their symptoms to mefloquine.
Although I've been retired from the army since 2010, I've been very active in veterans' and military issues. I have followed the mefloquine controversy closely. Just last week one of my newest books came out, entitled Veteran Psychiatry in the US. We cover a whole range of issues for veterans, including toxic exposures. My colleague Dr. Nevin has a chapter on the effects of mefloquine.
I would like to leave you with a couple of thoughts. One is that, again, every war has produced physical and psychological reactions that we don't understand at the time. I think the last 20...or going back to Somalia or longer. After a period of time, there are both physical and psychological reactions. At the conference we just had on mefloquine, my colleague Dr. Kudler, who is a world-renowned expert in post-traumatic stress disorder, talked about how 40 or 45 years ago, nobody believed in PTSD, post-traumatic stress disorder. Later on, we had people who thought traumatic brain injury wasn't a factor. Over and over again, you hear case reports or discussions that gradually lead to recognition.
This question about the long-term effects is something that has puzzled me. Back when I was in Somalia or at Fort Bragg, and we were trying to figure out why Sergeant Floyd would have murdered his wife and then himself, being apparently very paranoid and psychotic at the time, we didn't have a mechanism to understand that. Now we have more ideas about how the drug may affect the brain stem and other parts of the brain to cause both neurologic and psychological problems.
I would like to close with an example that's very relevant to me in my current sitting. I'm chair of psychiatry at a hospital in Washington, D.C. I'm not speaking on their behalf, so I won't go into that in detail. As a psychiatrist, however, I work with a lot of patients who have been on antipsychotics in the past or who are on antipsychotics now. You're familiar with these medications—thorazine, haloperidol or haldol, risperdal, quetiapine and olanzapine; there's a range of them. We know they cause such short-term effects as dystonia, which is a rapid clamping of the muscle, or extrapyramidal symptoms, or akathisia, a lot of muscle movements. We also now know that they cause long-term problems such as tardive dyskinesia. You've perhaps all heard of that. That's TD, the oral buccal movements of the mouth or the tongue. If you go to a nursing home, you will often see the repeat movement. We know that these symptoms wax and wane over time, but when the medication is stopped, they may not go away. They may get worse. I'm not saying that the long-term effects of mefloquine toxicity are the same as tardive dyskinesia. Rather, that's a model that can be used. There are short-term effects that may stop when the drug goes away, but then there can be long-term effects.
As we move into the question and answer period, I know that you'll ask me many questions I don't know the answer to, because in many cases we don't have the science. We haven't done the studies. You might ask me how mefloquine affects women differently, to which I might say, “Well, I think it does; we have some studies...”, or you might ask why mefloquine toxicity is so prominent in veterans from Somalia and maybe less so in other conflicts. I have some hypotheses, but I don't have all the answers.
There are, however, a couple of things I'm very sure of. One is that in both the U.S. and Canada, we need to do a better job of screening veterans for exposure to mefloquine. That would be fairly simple.
Have you ever taken the once-a-week anti-malaria pill? As a follow-up to that, have you ever experienced a variety of symptoms that include dizziness and nystagmus?
The other question that I'm very clear on is that you have some percentage of your veterans who will have significant and permanent problems because of mefloquine. I cannot tell you the exact percentage and I cannot tell you who they are. Based on all of the work that Dr. Nevin and I, and others, have done, you have veterans who have suffered permanent injury. I think it is critically important for you all to identify those veterans.
As a psychiatrist I see a lot of people who are suicidal; that's my bread and butter. One of the things I've seen over and over with people suffering from mefloquine toxicity is they don't know where the suicidal feelings are coming from. They want to jump in front of a bus, they want to stab themselves or sometimes they want to kill their family. It can be just so helpful to them to know that this isn't just them; it's that they've been poisoned by a drug and that's why they're feeling this way. Just knowing about that exposure can be very helpful in having them say, “Okay, it's not just me. It's the medication.” The relief that veterans get is enormous.
With that, let me conclude my remarks.
I'll be happy to take your questions. Some of your questions I won't be able to answer because they're either outside my scope or we don't know, and some I may defer to Dr. Nevin to answer.
Thank you very much for your attention.