Cleaveland: Violence linked to malaria drug

A dangerous form of malaria exists in regions of Afghanistan that lie below 6,500 feet. To reduce the risk of infection, military and civilian personnel in these areas take protective medication such as mefloquine (Lariam) on a regular basis while in-country and for several weeks following return to the United States.

Malaria parasites develop resistance rapidly so that new medications must be devised that will be effective against the organisms. Army scientists developed mefloquine following the Vietnam War. Weekly dosage made the drug convenient for soldiers in the field. The drug has been widely used for more than 20 years for travelers in malarial regions of Asia and Africa. In recent years, violent behavior has been linked to taking the drug.

Depression, delusions, hallucinations, paranoia and thoughts of suicide or homicide are among the side effects of mefloquine. In the 1990s, British soldiers serving in Sierra Leone reported nightmares and hallucinations, which they attributed to the drug. Occasional reports described individuals whose behavior became bizarre or violent while taking mefloquine while traveling in malarial areas.

A CBS report in 2009 linked mefloquine to the murders of four wives by soldiers returning to Fort Bragg from overseas assignments. Two of the soldiers subsequently committed suicide. After 2009, the Army restricted mefloquine use to Afghanistan.

Did mefloquine or another prescription medication play a role in the massacre of Afghan civilians on March 11, 2012, allegedly by U.S. Army Sgt. Robert Bales?

According to a report in The Huffington Post, nine days following the killing of Afghan civilians, the Army ordered an emergency review of the use of mefloquine for American military personnel. So far, the identity of any medications that might have been taken by Sgt. Bales has not been disclosed.

Falciparum malaria, which is endemic to parts of Afghanistan, causes severe illness with a significant fatality rate. Three drugs or combinations are available for prevention. Each has a high rate of adverse reactions.

Mefloquine is unique for psychiatric side effects. These are considered rare. The manufacturer of mefloquine highlights possible "serious mental problems" at the top of the medication guide. The Cochrane Collection, a respected, international resource for analyses of drugs recently withdrew its file in relating to mefloquine use for prevention of malaria.

Reporting adverse drug reactions is voluntary in the United States. Physicians, clinics and patients may report suspected reactions to the Food and Drug Administration or to the drug's manufacturer. Manufacturers are required to forward all such reports to the FDA. A majority of reactions go unreported. A cause-and-effect relationship between a drug and a clinical event may not be evident. Patients often take multiple drugs simultaneously, making connections difficult. Providers may fear involvement in litigation should they report suspected serious reactions to a drug.

In a combat situation, where high levels of stress are routine, determining psychiatric consequences of a medication becomes especially difficult. In the case of mefloquine, a pattern of dangerous side effects has become apparent over the past decade. Use of the drug should be restricted to the treatment of Falciparum malaria when no other agent can be tolerated.

In the meantime, military medical authorities must evaluate all instances of sudden violent behavior among combat forces deployed in areas where malaria prophylaxis is used to determine the extent to which there is a possible link to mefloquine or to other prescribed drugs.

For civilians contemplating travel to areas where Falciparum malaria is a risk, the use of mefloquine must be questioned. Too many serious issues remain unresolved.

Contact Clif Cleaveland at cleaveland1000@comcast.net.

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