Veterans Affairs committee  I want to jump in and talk about, coming back to your point, informed consent. I don't know whether that 5% is really informed. If you look at the Peace Corps, they traditionally have been offered their choice of medications, and more recently they're supposed to be warned about the side effects of mefloquine.

Veterans Affairs committee  Sir, obviously, your question is a good one, and somewhat rhetorical. I believe we would all want to do what's best for our veterans, and give them the benefit of the doubt. One thing we haven't touched on here is the possible harmful side effects of the wrong treatment. We try to distinguish mefloquine toxicity, or quinism.

Veterans Affairs committee  Usually the information on people not taking it is anecdotal because if you're ordered to take it you're not going to raise your hand and say you're not taking this. However, I believe, Dr. Nevin, you have some data on malaria emergence. Can you speak a little more to that?

Veterans Affairs committee  This is an area we disagree on, and we disagree on a few. I don't think service members should be deployed on mefloquine at all, not just because of the risk to themselves, but because of the risk to others. For a long time we have not had aviators fly on mefloquine. It's against the rules.

Veterans Affairs committee  The argument for a long time was that mefloquine is taken on a weekly basis rather than a daily basis, therefore compliance will be better, therefore you don't have to have as big a pill bottle. If you're going for 180 days you have a weekly dose instead of 180 pills. That's part of the reason the military kept using it.

Veterans Affairs committee  Yes, I'll add something quickly. I think the whole concept of informed consent for a military member is problematic. In the past, people have been given a handful of pills on the plane. Even now, if you want to achieve rank, if you want to do well in your career and not be staying stateside, you're going to take the medication.

Veterans Affairs committee  Women in the military, by and large, are of child-bearing age, so you're concerned about things like pregnancy and breastfeeding. We have a little bit of data that the use of mefloquine causes a higher rate of miscarriage in Somalia veterans. Women who are deployed are not supposed to be pregnant, but sometimes they're pregnant before they go and they don't pick it up in time, and sometimes they get pregnant when they're there.

Veterans Affairs committee  Yes, I think we are. Our technology is fairly crude right now. We've gone from CAT scans, to MRIs to PET scans and SPECT scans. One thing we looked at in the study at the VA was some of the more sensitive ways of looking at things. They're sensitive, but we don't necessarily know what the answer is.

Veterans Affairs committee  You maybe asking the same question, but as a clinician and as a psychiatrist, let me say how I put it together. There are lots of drugs, either illegal or legal, that cause things like hallucinations—things like LSD. There are things like PCP that cause hallucinations. PCP can also cause long-term problems.

Veterans Affairs committee  I think we could each spend two hours answering that question. I think what might work is if I try and then turn it over to Dr. Nevin. One of the things in the U.S. military that we've seen since 9/11 is that there are many programs trying to do early identification of post-traumatic stress disorder, traumatic brain injury and other psychological consequences of war.

Veterans Affairs committee  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.

Veterans Affairs committee  If I may add, the number one disability in the Veterans Health Administration is mental disorders. A lot of that is PTSD, a lot of that is depression, and some is psychosis. In my experience it's relatively easy to get a mental health diagnosis. Of course, the DSM has been changing.

Veterans Affairs committee  Yes. First of all, it's really exciting to have this conversation. I've worked with the Canadian Forces many times in many places. I would like to continue the conversation. What we have seen in the areas of PTSD and suicide is that often the U.S. has been there first with larger forces and has seen the problems first.

Veterans Affairs committee  And quickly, if I could add, it would reach the family members. It's often the family members who are very concerned, very affected, and likely would be very interested in such an outreach.

Veterans Affairs committee  Perhaps I could add to it. I think both Dr. Nevin and I would be happy to advise or consult with a group, if you pulled one together to look at this issue, and that's often where it starts, with a review of the science. There is sometimes bias. In some cases people do feel, again, that this is a hysterical reaction.