However, according to Nevin, most troops didn’t receive those warnings or have logistical access to alternative medications while deployed. There was also no way for DOD medical personnel to identify ahead of time who was susceptible to the drug’s neurotoxicity, estimated to be anywhere from one-quarter to two-thirds of its users. “Instead, the military said, ‘Here’s your mefloquine, you’re getting on the plane, you may have some crazy dreams, but suck it up and drive on,’” said Nevin, who now serves as executive director of The Quinism Foundation, a group dedicated to supporting research on quinoline drugs. “So, we systematically ignored and undermined the critical safety warnings in the product insert.” After various international studies confirmed mefloquine’s potential for causing psychological illness, and a growing list of its neuropsychiatric adverse effects—including vertigo, tinnitus, insomnia, vivid nightmares, visual and auditory hallucinations, paranoia, seizures, mood swings and suicidal ideations—became more well known, Roche pulled the drug off U.S. shelves. Eventually, in 2013, the FDA issued its strongest “black box” warning, that mefloquine can cause long-lasting and even permanent damage, bringing an end to the DOD’s nearly quarter-century use of the drug. Exposure to antimalarial drugs has been introduced as a possible factor in several cases of violent murder over the past two decades. Cases include Army Staff Sgt. Robert Bales, who pleaded guilty to avoid the death penalty for slaying 16 Afghan civilians in Kandahar Province, Afghanistan, in March 2012, as well as four soldiers who killed their spouses over a six-week stretch in 2002 at Fort Bragg, N.C. This factor was also discussed when a group of soldiers from Fort Carson, Colo., were charged with manslaughter after 20 throwing an Iraqi man in the Tigris River in 2004. In a 2013 publication, Nevin and other military medical professionals argued that mefloquine can produce “derealization and depersonalization, compulsions toward dangerous objects, and morbid curiosity about death.” It can also produce dissociative effects that make someone performing violent acts think someone else is committing the crime. Unfortunately for veterans affected by mefloquine, the Department of Veterans Affairs does not recognize an association between the drug and negative mental health outcomes. This is, in part, because of a joint VA-DOD study that notes there are no significant associations between mefloquine and mental health issues. The 2018 publication, using data from a records study of 60,000 U.S. veterans who served between 2001 and 2008, found that reported negative physical and mental health outcomes are largely due to combat deployment exposure. However, context is key. Not only did the joint study rely solely on record reviews of self-reported symptoms, which is problematic since most troops don’t report psychiatric issues, but it was also not based on scientific diagnoses and did not have specific test subjects with a control group. Alarmingly, a 2015 clinicians book focusing on post-traumatic stress disorder and related diseases in combat veterans does note that the acute symptoms of mefloquine intoxication may mimic and be mistaken for a number of acute psychiatric disorders, including PTSD. “It’s really a hidden epidemic, because so few people attribute these problems to the drug—there’s always something else they attribute it to because it’s taken during deployment, where there’s so many other things happening,” said Nevin, who warned that VA disability examiners may be misattributing mefloquine intoxication to PTSD. DAV MAGAZINE | MARCH/APRIL 2020 | DAV.ORG