Standing Committee on Veterans Affairs ACVA Ï NUMBER 116 Ï 1st SESSION Ï 42nd PARLIAMENT EVIDENCE Wednesday, May 1, 2019 Chair Mr. Neil Ellis 1 Standing Committee on Veterans Affairs Wednesday, May 1, 2019 Fast-forward, we returned home. We were using less mefloquine. The murders, murder-suicides at Fort Bragg happened in 2002, Ï (1535) shortly after we had gone into Afghanistan. I was part of a team [English] asked to look at mefloquine; could this be related? At that time, again we didn't know very much about mefloquine. Various studies The Chair (Mr. Neil Ellis (Bay of Quinte, Lib.)): Pursuant to said one in 4,000, one in 10,000, one in 18,000 people may have Standing Order 108(2), a study of the effects of mefloquine use neuropsychiatric effects from mefloquine. We were just told or knew among Canadian veterans today, we have Dr. Ritchie as an about the short-term effects. We studied the indexed cases—you may individual; and from The Quinism Foundation, Dr. Nevin. or may not remember—Staff Sergeant Nieves, who killed his wife and then himself; Master Sergeant Wright, who killed his wife, We'll start with Dr. Ritchie. The floor is yours. hanged himself in a jail cell six months later, apparently Dr. Elspeth Ritchie (As an Individual): Good afternoon, hallucinating; and Staff Sergeant Brandon Floyd, who had been Chairman and members of the committee. It is a real pleasure to off mefloquine for six months when he killed his wife and then be here today. himself. 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 We looked at a lot of factors, but again, back then we didn't think wars produce both physical and psychological reactions to a war, and about long-term effects of mefloquine. When you stop most we often don't know which it is. You remember shell shock from medications, the effects go away. We found a combination of things World War I, or the Gulf War syndrome more recently, with which responsible for the murder-suicides, which included marital fidelity we've gone round and round. 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 short version of the presentation is that many things we have the neuropsychiatric effects of mefloquine. 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 Moving quickly through time, I retired from the army in 2010. country a young solider was evacuated, acutely psychotic, we Staff Sergeant Bales committed the atrocities in early 2012, and I believe secondary to the effects of mefloquine. immediately thought of mefloquine. During that intervening period the U.S. Army's use of mefloquine had declined precipitously, I worked mainly with the American forces, although I was asked although it was still being used. Another factor was that headquarters to evaluate Corporal Matchee after his suicide attempt. He was in a repeatedly said we had to screen and document the screening of coma so I could not evaluate him. soldiers to make sure they didn't have mental illness or traumatic brain injury. Over and over again our systems found problems with During our time there we spent a lot of time discussing the the way we screened and documented soldiers for mental illness, dangers of malaria, and the neuropsychiatric short-term effects of traumatic brain injury, anxiety or suicide. Of course, during that time mefloquine became apparent to us, but we did not think about the period from about 2004 to 2010, our suicide rate in the army long-term effects at that time. doubled. 2 ACVA-116 May 1, 2019 Ï (1540) 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 After my retirement, my most recent work has been with the VA many cases we don't have the science. We haven't done the studies. as a psychiatrist. I cannot speak for the VA here, but I will say that You might ask me how mefloquine affects women differently, to we started to look through the risks at the War Related Illness and which I might say, “Well, I think it does; we have some studies...”, or Injury Study Center. We looked at soldiers and other veterans in the you might ask why mefloquine toxicity is so prominent in veterans U.S. who we thought may have suffered long-term effects from from Somalia and maybe less so in other conflicts. I have some mefloquine. We found a variety of diagnoses. We found very seldom hypotheses, but I don't have all the answers. a clear picture, but certainly a lot of veterans who ascribed their symptoms to mefloquine. There are, however, a couple of things I'm very sure of. One is that Although I've been retired from the army since 2010, I've been in both the U.S. and Canada, we need to do a better job of screening very active in veterans' and military issues. I have followed the veterans for exposure to mefloquine. That would be fairly simple. mefloquine controversy closely. Just last week one of my newest books came out, entitled Veteran Psychiatry in the US. We cover a Ï (1545) whole range of issues for veterans, including toxic exposures. My colleague Dr. Nevin has a chapter on the effects of mefloquine. 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 I would like to leave you with a couple of thoughts. One is that, that include dizziness and nystagmus? 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 The other question that I'm very clear on is that you have some physical and psychological reactions. At the conference we just had percentage of your veterans who will have significant and permanent on mefloquine, my colleague Dr. Kudler, who is a world-renowned problems because of mefloquine. I cannot tell you the exact expert in post-traumatic stress disorder, talked about how 40 or 45 percentage and I cannot tell you who they are. Based on all of the years ago, nobody believed in PTSD, post-traumatic stress disorder. work that Dr. Nevin and I, and others, have done, you have veterans Later on, we had people who thought traumatic brain injury wasn't a who have suffered permanent injury. I think it is critically important factor. Over and over again, you hear case reports or discussions that for you all to identify those veterans. gradually lead to recognition. This question about the long-term effects is something that has As a psychiatrist I see a lot of people who are suicidal; that's my puzzled me. Back when I was in Somalia or at Fort Bragg, and we bread and butter. One of the things I've seen over and over with were trying to figure out why Sergeant Floyd would have murdered people suffering from mefloquine toxicity is they don't know where his wife and then himself, being apparently very paranoid and the suicidal feelings are coming from. They want to jump in front of psychotic at the time, we didn't have a mechanism to understand that. a bus, they want to stab themselves or sometimes they want to kill Now we have more ideas about how the drug may affect the brain their family. It can be just so helpful to them to know that this isn't stem and other parts of the brain to cause both neurologic and just them; it's that they've been poisoned by a drug and that's why psychological problems. 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 I would like to close with an example that's very relevant to me in medication.” The relief that veterans get is enormous. 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 With that, let me conclude my remarks. 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— I'll be happy to take your questions. Some of your questions I thorazine, haloperidol or haldol, risperdal, quetiapine and olanza- won't be able to answer because they're either outside my scope or pine; there's a range of them.