Mefloquine – time for change as inquiry hears evidence of harmful side effects experienced by those in the armed forces

The distressing psychiatric side effects of anti-malarial drug mefloquine have long been known, yet the drug has been routinely issued to British soldiers since 1993. As a public inquiry into use of mefloquine hears evidence from the Ministry of Defence (MoD) which now accepts the potential harm caused to those serving in the armed forces, the time has surely come for far tighter controls on its use.

When I was community pharmacist it was generally regarded that mefloquine (also known as Lariam) was the anti-malarial drug of last resort due to the particularly nasty risk of side effects such as psychosis, hallucinations and suicidal ideation. Studies have shown that mefloquine side effects can be long lasting. It therefore came as a great surprise to me to find that mefloquine has been routinely issued since 1993 to British soldiers and sometimes as first line treatment.

Over the last 20 years mefloquine has been implicated in a number of military murders, suicides and acts of self-harm. In 1993, Canadian peacekeepers prescribed mefloquine whilst in Somalia beat, tortured and shot two local teenagers. In 2000, Lance Corporal Kristian Shelmerdine, the Parachute Regiment, shot himself in the arm while serving in Sierra Leone, he blamed the incident on the drug. In 2002, four US soldiers based at Fort Bragg (three of whom recently returned from Afghanistan, where troops were given mefloquine) killed their wives.

The UK has been slow to wake up to the dangers of mefloquine compared to other armed forces’ around the world. In 2013, the US military declared it a drug of last resort and US Special Forces do not use it at all. The French military, with a large presence in malarial regions, have never issued mefloquine to their soldiers. Defence ministries in Germany, Netherlands, Denmark and Canada have either banned the use of mefloquine or use it as a last resort.

The continued use of a mefloquine by our armed forces simply makes no sense when other anti-malarials of equal efficacy such, as doxycycline and Malarone, are available.

Following safety concerns voiced by military personnel, The House of Commons Defence Committee announced a public inquiry into the use of mefloquine in September 2015. The last of the public investigations took place on 12 January, with the following key points emerging from the session:

• It was accepted by the MoD that there is no geographical area where mefloquine is absolutely essential.
• Manufacturer guidance states that mefloquine should only be prescribed following an individual risk assessment and it should not be given to those with a history of depression or other psychiatric disorders.
• The Defence Committee received evidence that soldiers were given mefloquine with their kit bag and/or without a prior risk assessment.
• MoD policy from 2004-2005 required a risk assessment to take place prior to prescribing mefloquine.
• In 2013 the MoD set up the Defence Primary Healthcare Organisation to ensure healthcare policy was implemented.
• The MoD accepted that there was no guarantee that all soldiers who received mefloquine had a proper prior risk assessment.
• The MoD accepted there may have been instances where soldiers had incorrectly received mefloquine and suffered harm. The MoD encouraged such individuals to get in touch to consider assistance.

It is well known that those serving in our armed forces are at risk of mental health problems due to the stresses of armed combat and the traumatic life and death scenarios they face whilst on active service. It is shocking therefore that for so long a drug that can in some cause
psychosis, depression and anxiety has been routinely prescribed to our soldiers, in many cases without any assessment of the risk to individuals. Whilst the MoD’s policy is that mefloquine should not be used as a first line treatment and risk assessments should be carried out before it is prescribed, clearly this is not happening in practice.

The MoD’s acceptance that soldiers have suffered harm as a result is a step forward. Certainly it seems likely that in some cases at least, soldiers may have a medical negligence claim where, in breach of the duty of care they were owed, they were given mefloquine and suffered psychiatric injury and/or consequential financial loss as a result. This will be a small comfort to those suffering mental ill health, some of whom may not have realised that the anti-malarial drug had a role to play.

I would hope that the UK armed forces will now look carefully at the use of mefloquine and ensure that it is only used in exceptional circumstances. Where it is used MoD policy needs to be strictly adhered to, to ensure that soldiers, to whom they owe a duty of care, are not exposed to unnecessary risk.