On 25 March 2015 the Australian Senate initiated an inquiry into the mental health of Australian Defence Force serving personnel. The Committee heard testimony from Major Stuart McCarthy and Dr Jane Quinn on the adverse health impacts of mefloquine on 1 September 2015. The Committee’s final report was published on 17 March 2016, making as series of findings and recommendations in relation to the ADF’s use of mefloquine.
The following recommendations were made in relation to mefloquine:
4.79 The committee recommends that Defence and DVA contact ADF members and veterans who have been administered mefloquine hydrochloride (mefloquine) during their service to advise them of the possible short-term and long-term side effects and that all ADF members and veterans who have been administered mefloquine during their service be given access to neurological assessment.
4.80 The committee recommends that the report for the Inspector General of the Australian Defence Force’s inquiry to determine whether any failures in military justice have occurred regarding the Australia Defence Force’s use of mefloquine be published immediately following the completion of the inquiry.
Chapter 4 – Mental Health Services
Chapter 4 of the report made a series of findings in relation to mefloquine:
4.6 A number of submissions commented on the importance of recognising that mental ill-health can be caused by neurological issues (structural, biochemical, or electrical abnormalities in the brain). Major Stuart McCarthy told the committee that, despite advances in neurological science in treatment and rehabilitation, insufficient emphasis is given to neurology as a causative factor of mental ill-health and that medical practitioners are reluctant to investigate neurological causes for what appear to be psychiatric or psychological problems:
…there has been a growing awareness of physical injuries as causes of neurological damage, with symptoms including cognitive impairment, for example blast causing TBI…Advances in neurological science in treatmentand rehabilitation for physical injuries have been prominent, however insufficient emphasis is given to neurology as a causative factor. Despite these advances, many veterans experience problems in seeking appropriate diagnosis, treatment and support for more complex neuro-psychiatric injuries or illnesses due to a reluctance by medical practitioners to investigate neurological causes for ostensibly “psychiatric” or “psychological” problems. Neurological symptoms are often initially dismissed as “psychological”.
Traumatic Brain Injuries
4.7 A number of submitters asserted that Traumatic Brain Injuries (TBIs), also referred to as Post-Concussion Syndrome (PCS), should be recognised as a possible cause or contributing factor when diagnosing and treating ADF members’ and veterans’ symptoms of mental ill-health. The Alliance of Defence Service Organisations explained that the symptoms of TBI can be very similar to the symptoms of PTSD and that incorrect diagnosis can lead to poor outcomes:
… symptoms [of PCS] which remained largely undetected until they had actually returned home and began to manifest themselves when veterans started having difficulty in functioning as efficiently as they had prior to deployment…this begs the question whether PCS is masking symptoms of PTSD or vice versa and possibly confusing the nature of treatment regimes and rehabilitation programmes. Such a crossover of symptoms plus the delayed effect reported by Zeitzer et al, along with any potential masking effects could have the potential to adversely affect and complicate the successful condition-focussed rehabilitation of injured service personnel who have suffered a close traumatic brain injury or PTSD.
4.8 Defence advised the committee that it has ‘specific policies in place’ for the care and management of patients with PTSD and TBI. DVA assured the committee that it is aware of emerging issues regarding TBI and its impact on mental health, noting that ‘mild traumatic brain injury has come under increasing attention by military medicine’ and that its ‘symptoms may mask PTSD’.
4.9 The committee received evidence regarding the neuro-psychiatric effects of mefloquine hydrochloride (mefloquine), an anti-malarial drug used to prevent and treat certain forms of malaria. Major McCarthy informed the committee that there is extensive research providing evidence that quinolones, including mefloquine, can cause brain injuries that result in neuropsychiatric symptoms. Dr Jane Quinn explained that:
The parts of the brain that it works on are the areas of the brain that are affected in the chronic disease state caused by mefloquine toxicity, which can be described as a limbic encephalopathy, with vestibulopathy—if you will pardon the long terms. That basically translates to a disorder of the part of the brain that governs anxiety, fear and normal cognitive processing, associated with the part of the brain that deals with balance. A majority of symptoms that have been presented in long-term chronically affected individuals are rage, extreme anxiety, paranoia, auditory or visual hallucinations, vestibular disorder—balance disorders, tinnitus. In a military setting, a lot of those kinds of neuropsychiatric side effects really cross-reference very closely with those that present in PTSD, for example. There has been some concern in the medical profession that there is a subset of individuals whose clinical symptoms of PTSD are exacerbated by having taken mefloquine or that their disease state is actually caused by the drug they have taken and not by classic PTSD at all. It is a very complex neurological condition. It has only been well-characterised in the medical literature in the past eight years, I would say, but it is now well-characterised, and a diagnosis can be made.
4.10 In 2013, the United States Food and Drug Administration gave mefloquine its strictest warning, known as a black box warning, ‘due to risk of serious psychiatric and nerve side effects. Major McCarthy told the committee that, following the issue of the black box warning, the commander of US Army Special Operations Command ordered that mefloquine no longer be used. Furthermore, Major McCarthy noted that US members exhibiting symptoms of toxicity undergo medical assessment and that mefloquine is listed on the US Department of Veterans’ Affairs ‘deployment exposures’ website.
4.11 Major McCarthy called for the introduction of a mefloquine veterans outreach program. The program would include identifying all ADF members administered mefloquine during their service; funding further research regarding mefloquine toxicity; raising awareness and education regarding mefloquine toxicity; training health staff in the diagnosis, treatment, rehabilitation of mefloquine toxicity; and providing social support for veterans and their families. Major McCarthy also called for a ‘full, independent inquiry into mefloquine use in the ADF and its impact on veterans and their families, including the conduct of clinical trials by the [Army Malaria Institute], the involvement of the manufacturer, decisions by senior ADF leadership and the involvement of foreign governments and organisations’.
4.12 Defence advised the committee that mefloquine is one of three anti-malarial medications approved by the Therapeutic Goods Administration (TGA) for malaria prevention in our region and that ‘it is Defence’s third line agent, meaning it is only used when one of the other two medications is not appropriate’. Defence assured the committee that mefloquine ‘is only prescribed in accordance with TGA approved product information and Defence health policy’.
4.13 Defence acknowledged that both short-term and long-term side-effects can result from mefloquine use and that those suffering from these side-effects can claim compensation:
While in the majority of cases the side-effects associated with mefloquine disappear after ceasing the medication, Defence accepts that some people do continue to experience on-going issues. Those who claim to have ongoing problems linked to side-effects from the use of mefloquine are provided with appropriate medical treatment including specialist referral, assessment and treatment. Further to this ADF members who are diagnosed as suffering longer term or permanent side-effects from mefloquine use can also claim compensation through the Department of Veterans Affairs (DVA) if the mefloquine was prescribed for service reasons.
4.14 Defence noted that the ‘vast majority of ADF members have never been prescribed mefloquine’, with an average of 25 members per year ‘who demonstrated such intolerance to other anti-malarial medication as to warrant being prescribed mefloquine’. Defence stated that ‘less than one per cent of ADF members currently deployed and receiving anti-malarials are taking mefloquine’ and that ‘within Defence mefloquine is prescribed at a significantly lower rate than in the general community’.
4.77 It is essential that ADF members and veterans who have incurred neurological damage are correctly diagnosed and given appropriate treatment to ensure that they can achieve the best possible outcomes. The committee is concerned by evidence that insufficient consideration is being given to neurology as a causative factor for mental ill-health in ADF members and veterans.
4.78 The committee is also concerned by the evidence it received regarding the neuropsychiatric effects of mefloquine. The committee acknowledges that mefloquine is used by Defence as a third line agent and that it is administered to a small percentage of the deployed population. However, it is essential that those ADF members and veterans who have been administered mefloquine are made aware of the possible short-term and long-term side effects and are given access to appropriate neurological assessment, particularly if they have exhibited symptoms of mental ill-health. The committee notes that the Inspector General of the Australian Defence Force is currently conducting an investigation into matters regarding the use of mefloquine.
Additional Comments from the Australian Greens
The report included additional comments from the Australian Greens:
1.8 The inquiry heard disturbing evidence from veterans regarding the administration of the anti-malarial drug to ADF personnel. Allegations were made regarding the unethical administration of mefloquine to ADF personnel, particularly during ADF operations in Timor Leste.
1.9 Defence sought to allay the fears of veterans in a public statement issued on 30 November 2015. However, this public statement only provides figures about the rate of administration in the last five years, and obfuscates the issue of administration to veterans in Timor Leste. The public statement also fails to rule out that mefloquine was ever administered at levels above that now recommended by the Therapeutic Goods Administration; or that mefloquine was ever administered without the fully informed consent of ADF personnel.
1.10 The unanswered questions regarding the administration of mefloquine warrant further investigation. That similar issues have arisen regarding the administration of mefloquine to veterans of Australian allies gives further weight to the need for the issue to be further examined. The Australian Greens support the recommendation for the report of the Inspector General of the ADF to be published. However, without knowing the scope of the inquiry by the Inspector General, the Australian Greens feel compelled to clarify the extent of information that should be made public by Defence.
1.11 That Defence provide a full report to the committee on the administration of mefloquine and related anti-malarial drugs to ADF members, including the number of ADF members administered these drugs, their consent to this administration, and the dosage administered.
1.12 That, pending the report to the committee by Defence, the matter of administration of mefloquine and related anti-malarial drugs to ADF members is the subject of further inquiry by the committee.