Veterans Affairs committee  If I may add, I agree with everything Dr. Nevin just said. The analogy in the United States is Agent Orange, the defoliant that was used in Vietnam. Really, mefloquine is one of a number of toxic exposures but it's the one we're focused on today. The Agent Orange analogy was, “Oh, that was nothing, it's all in your head.”

Veterans Affairs committee  This is my recommendation; stop mefloquine use completely. I disagree with Dr. Nevin. I don't think it should be used as a drug of last resort. I don't think it should be used at all. If somebody can't tolerate mefloquine, don't send them to a malarious area, send them to Antarctica.

Veterans Affairs committee  If I may briefly add to that, another population that has taken the medication is journalists, because they have often gone and followed the military. We don't have a good study there, but many journalists I talked to said they took it the first time but would never take it again.

Veterans Affairs committee  The medication that you're referring to, Chantix, has been associated with a lot of neuropsychiatric side effects; another one, Zyban, or Wellbutrin, much less so. I don't prescribe Chantix to my psychiatric patients because they're coming to me because they have suicidal thoughts and ideation.

Veterans Affairs committee  If I may add—

Veterans Affairs committee  —l took your question to refer to local drugs of abuse and we do see opiates in combat areas or Afghanistan. We see methamphetamines mailed over there. In Somalia it was khat. We don't know a lot about the interaction with drugs of abuse and mefloquine, but based on what we do know we would expect their effects on the liver, the effects on the kidney, the effects on the brain probably have a synergistic, negative effect on the brain.

Veterans Affairs committee  I'll add to that. One of the real challenges is knowing how to treat it. Unfortunately, mefloquine is still used in the Peace Corps. I've had the unfortunate luxury of seeing a number of returning Peace Corps volunteers, who sometimes have been medevaced out with psychosis. The question is, do you treat them with an antipsychotic agent, or is that contraindicated?

Veterans Affairs committee  Maybe I could take that question. First of all, there is absolutely minimal research done, so we can't tell you the sample sizes. A lot of the research that was done initially was rat research. By the way, it was done on male rats, so if we talk about female service members—which is a whole different discussion about effects on pregnancy and reproduction—we have no information.

Veterans Affairs committee  May I respond?

Veterans Affairs committee  Yes. In the past, one reason we used mefloquine was because of cost issues, and also it was believed that people would be more compliant with a once-weekly dosage. However, the cost is little compared to the cost of lives or things like massacres. In terms of compliance, what we find is that people are less compliant with mefloquine because they've heard about it and the scary side effects, so they don't take it and are more likely to develop malaria.

Veterans Affairs committee  The most important thing is to have a high index of suspicion that somebody may have been exposed to mefloquine and then to ask the person if they had been on an anti-malarial, was it a daily dose, Malarone or doxycycline, or a weekly medication. Soldiers and other service members know that if it's weekly, it's mefloquine.

Veterans Affairs committee  Good afternoon. It's a real pleasure to be here today. One slight correction, it's Dr. Elspeth Ritchie.

Veterans Affairs committee  That's a good Scottish name, and the Ritchie side came over, and we were in Canada before the American Revolution, so my roots go way back with you. But today I'm going to tell you a story. It's going to be a brief story, but it will cover some 25 years. I was an army psychiatrist until my retirement in 2010.