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Elspeth Cameron Ritchie – U.S.

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SGT Scapegoat? The Latest on Lariam and the Sergeantht_robert_bales_hi_res_thg_120316_wgecritchie

Mon, 22 Jul 2013 11:45:55 +0000

What a difference a month can make. In late June, I published “A Smoking Pillbox,” about a report of a soldier with a history of traumatic brain injury, who after taking Lariam (mefloquine), had gunned down 16 Afghan civilians. Another post followed, with more details from an FDA “adverse event report”. These reports seemed to point to Army Staff Sergeant Robert Bales — who has pled guilty to killing the Afghans in March 2012 — but there was no response from either his lawyer or the Army to requests for comment. But last week, things broke open. The Seattle Times and Seattle Weekly have published comments from his lawyer, John Browne, saying that Bales had taken mefloquine while he was in Iraq. Bales reported he took “whatever they gave me” in Afghanistan, but he does not recall what that was. Browne says that the medical records from Afghanistan are incomplete. Still no comment from the Army, to the best of my knowledge. What does this all mean? Mefloquine had been used widely in Iraq at the beginning of the war. But its use there, beginning in 2003, was deeply controversial, with a flurry of reports in the media linking the drug to violence and suicide. In response, the military scaled back its use of mefloquine significantly, and by late 2004, Army policy stated “personnel in Iraq will not take malaria chemoprophylaxis medication”. Could mefloquine use from that long ago have contributed to the massacre? We are learning more and more about long-term effects of mefloquine: — Roche, manufacturer of the drug, now warns of “long-lasting serious mental-health problems” and even “irreversible” neurological conditions linked to it. — Mefloquine has been found to be neurotoxic: like lead and mercury, it is capable of permanently damaging brain cells. — And we know that related quinoline drugs can be especially toxic to the limbic system, causing injury to the emotional and memory centers of the brain. Could permanent, but nearly undetectable brain damage from mefloquine, combined with a traumatic brain injury, alcohol, and steroids,

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The Sergeant-Lariam Link Seems to Grow Strongerht_robert_bales_hi_res_thg_120316_wgecritchie

Mon, 08 Jul 2013 10:56:05 +0000

Several weeks ago I filed a post here on Battleland  linking U.S. Army Staff Sergeant Robert Bales to possible use of the anti-malarial drug Lariam. He is the soldier who pled guilty last month to killing 16 Afghan civilians in March 2012. The post was based on a heavily-redacted report of adverse events, or negative side-effects, compiled by the drug’s manufacturer, Roche, and submitted to drug regulators. My colleague, Dr. Remington Nevin, had received that initial report from the group Action Lariam for Irish Soldiers ( as part of a larger release of files from the Irish Medicines Board. Knowing that Roche would have shared this report with international regulators, Dr. Nevin subsequently requested the corresponding FDA report through a Freedom of Information Act (FOIA) request, and recently received it. The unredacted report indicates Roche received the original adverse event report from a pharmacist, which we did not know before. The report says: Initial Information for this Spontaneous case, AER number 1054403, was received on 29/Mar/2012 from a Pharmacist and concerns a patient of unknown demographics who was treated with Mefloquine Hydrochloride (Lariam) for an unknown indication. Medical history included TBI (Traumatic brain injury). No concurrent illnesses were reported. No concomitant medications or past drugs were reported. On an unknown date, the patient started Mefloquine Hydrochloride (dose, form and frequency not reported). On an unknown date the patient who was a soldier in the US Army developed homicidal behavior and led to Homicide killing 17 Afghanis. It was reported that this patient was administered Mefloquine in direct contradiction to US military rules that Mefloquine should not be given to soldiers who had suffered TBI (Traumatic brain injury) due to its propensity to cross blood brain barriers inciting psychotic, homicidal or suicidal behavior. The outcome of Homicide was not Reported. There was insufficient information regarding the therapy ongoing status of Mefloquine Hydrochloride. The reported did not provide the seriousness criteria of the event of Homicide and its causal relationship with Mefloquine Hydrochloride. The company assessed the event of Homicide as medically significant. No

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Pondering PTSD Progresscrpicecritchie

Tue, 25 Jun 2013 12:06:14 +0000

The beauty of last Saturday morning, so close by the Capitol’s gleaming dome, made the incongruity of discussing post-traumatic stress disorder all the more startling. But that’s what we were there to do by commemorating National PTSD Awareness Day. Sufferers and those trying to cure them spoke out. The star of the show was Jerry Yellin, 89, who had enlisted at 18 during World War II. He flew P-51 missions over Japan and lost 16 comrades before returning home, at 21, a changed man. He recounted his personal experience as a sufferer of PTSD for 30 years, during a time when PTSD was not even clinically recognized. He was plagued by addiction, and drifted through life. Finally, he discovered transcendental meditation, which allowed him to subdue his demons and begin to achieve some semblance of calm. Speaker after speaker talked about PTSD, suicide, and the importance of getting help before it’s too late. Thomas Mahaney from the non-profit Honor for ALL organization hosted, with Dr. Maryam Navaie of Advance Health Solutions, a co-sponsor of the event, serving as emcee. The repercussions of wars are already well-known. Still, it was deeply affecting to hear family members, including Kristy Kaufmann, Amber Wandtke (Mrs. Virginia 2013), and Gregg Keesling speak about the toll PTSD has taken on their families. Dr. Eugene Lipov of Chicago Medical Innovations discussed stellate ganglion block, an anesthetic procedure, which he has found incredibly effective for the condition. “PTSD has been around for a very long time,” he said. “It has been viewed as a weakness of the soul, a psychiatric or mental disorder and the like. Those views have limited value when it comes to effective treatment, which is sorely lacking.” I spoke of the discomfort many service members have with traditional treatments for PTSD or other mental health disorders, a recurring problem many of us dealing with hurting troops have witnessed. So I discussed complementary and alternative medicine, which is often an attractive and low-threat way of enticing service members to actually seek treatment. Peter Duffy, a retired Army

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A Smoking Pillbox: Evidence that Sgt. Bales May Have Been on Lariam2021083161ecritchie

Thu, 20 Jun 2013 12:46:29 +0000

New evidence has surfaced that Army Staff Sergeant Robert Bales may have been on mefloquine during his March, 2012, rampage that killed 16 Afghan civilians. I first wondered if Bales had been on the anti-malarial agent, also known by its trade name, Lariam, on March 20, 2012, a week after the massacre. I noted that “this medication has been increasingly associated with neuropsychiatric side effects, including depression, psychosis, and suicidal ideation.” A number of other media outlets picked up the story. But that was just a working hypothesis, absent evidence on Bales’ use of the drug. Strangely, the government never confirmed — or denied — that he had been given Lariam. My colleague and co-author of a paper on the subject of mefloquine and forensic psychiatry, Dr. Remington Nevin, recently obtained a so-called “adverse event report.” That’s a document describing a negative side-effect to a medication. This particular document details a “medically confirmed” event of homicide by a Soldier taking mefloquine. Nevin got the report from Action Lariam for Irish Soldiers (reach them at, for the Irish network RTÉ. The broadcaster prepared a report on the possible links between Lariam and suicides among Irish peace-keeping soldiers. We have been unable to determine who wrote the initial report, but generally they’re turned in by physicians or others involved in the case. The document suggests that on March 29, 2012, Roche, Lariam’s maker, received a report that someone involved in the homicide of 17 civilians had been taking mefloquine. On April 11, Roche forwarded the document on to the FDA, as it is required to do. Here is the key passage from the much longer document, which has the relevant parts highlighted: Homicide [REDACTED] A patient of unknown demographics started on mefloquine (therapy details unspecified) for an unknown indication. After an unspecified duration, the patient who was a soldier experienced homicidal behaviour which led to homicidal killing of 17 [REDACTED]. It was reported that the patient was suffering from traumatic brain injury (TBI) and was administered mefloquine against military rule (mefloquine is directly contraindicated

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Some Hope Amid the Calendar’s Grim Pagesphoto-10ecritchie

Wed, 19 Jun 2013 11:36:38 +0000

June is PTSD Awareness Month. May was Mental Health Awareness Month. September will be Suicide Awareness Month. More public-service announcements about “seeking help is a sign of strength.” Despite the monthly exhortations, most service members do not seek help for PTSD or the related illness of depression. They fear that treatment will end their careers. A plethora of efforts has not reduced the suicide rate in service members. So what is newsworthy or new? One organization, Honor for All, is hosting an event June 22 here in Washington, D.C. General Ray Odierno, the Army chief of staff, is scheduled to speak. While I look forward to such events, I am cynical about whether speeches or awareness can reduce PTSD and suicide. What is exciting, for me, are the new treatments for PTSD. We have written about Complementary and Alternative Medicine in a series in Psychiatric Annals, a leading purveyor of continuing medical education for psychiatrists. For the last six months, we have discussed and debated acupuncture, stellate ganglion block, virtual reality, yoga, and other as-yet unproven treatments as possible therapies. They offer promising avenues for research, hope for the afflicted, and a promise from mental-health professionals that we will not quit until we can better help those with PTSD. This month’s article is on the benefits of service members training service dogs for other service members, a program called Warrior Canine Connection. “Serving humankind for 30,000 years” is its motto. Soldiers and Marines who will not go near a shrink are very quick to warm to a fluffy puppy or young retriever. Training dogs to aid others with PTSD seems to help diminish their own PTSD symptoms. The mechanism of action appears to be through the neurotransmitter oxytocin, what some call the “love hormone.” Ironic that it might also pull double-duty in helping those suffering from the mental wounds of war.

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War Stories: Psychiatrists on the Front Lines154956020ecritchie

Mon, 03 Jun 2013 11:44:41 +0000

Two of the most powerful workshops at the recent American Psychiatric Association annual meeting were the panels of psychiatrists talking about their personal experiences in war zones. They were part of the Military Track, a growing trend at the APA’s Annual Meeting, with a total of 45 military and VA-related sessions under a single umbrella. The news is often full of the travails of deployment of regular Service members, but military psychiatrists and other medical personnel have also deployed multiple times. The first of these sessions was Women at War and the second Personal Experiences in the Combat Zone. Each featured five speakers, with many of those who served discussing their deployments to Iraq or Afghanistan. As we assembled, Army captains Christine Wolfe hugged Christina Rumayor, who had last seen each other when they did the “left-seat, right seat” orientation ride in Sharana, Afghanistan, in 2012. I had audience members introduce themselves, and they included military and civilian psychiatrists, as well as several military spouses who were considering entering the service. A quartet of young Navy psychiatric residents attended, to learn how to prepare for their upcoming deployments. The speakers, including Army Lieut. Colonel Chris Ivany (who has my old job at the Office of the Army Surgeon General), described their work in theater and the diagnoses of service members they saw. The pictures of psychiatrists in battle dress uniforms in front of a tank added context for the civilians in the audience. They also shared personal reactions to having been separated from family, rocketed by mortared shells, and taking care of severely wounded service members and Iraqi and Afghanistan nationals. Other psychiatrists, including Army Major Sebastian Schnellbacher, reflected about being a father or a mother when deployed. How do you parent from a war zone? The female psychiatrists were in the glass-bowl atmosphere of the theater of war, where every movement was scrutinized. Female Soldiers had to travel everywhere with another female, to minimize the chances of sexual assault. This sounds like it makes sense, but it severely limited

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PTSD’s Vexations155447293ecritchie

Thu, 30 May 2013 11:23:04 +0000

Post-traumatic stress disorder has always been a controversial diagnosis, and so it was at last week’s annual gathering of the American Psychiatric Association. They date back to when the term “PTSD” was first listed in the Diagnostic and Statistical Manual (DSM) in 1980, after the end of the Vietnam War. The diagnostic criteria have just changed, as discussed in my recent post. Controversies on the issue surfaced at an overflow workshop that began with Harold Kudler, an esteemed PTSD researcher with the Department of Veterans Affairs. Dr. Kudler emphasized that whatever the controversies about nomenclature in the new DSM-5, the care of the patient should be at the center. He’s planning on posting about that here on Battleland in the near future. Other issues bubbled up during the workshop: Does “secondary PTSD” exist? Navy Lieutenant Jennifer Shippy explored the question of whether it could be caused: 1) by exposure to media; 2) in family members exposed to service members; and 3) in caretakers working with service members. Navy Captain Kevin Moore looked at PTSD from the commander’s point of view. Commanders want to take care of their patients while maintaining good order and discipline. Could other toxic insults, such as mefloquine (Lariam, an anti-malarial medication) toxicity have contributed to symptoms of PTSD for some Iraq and Afghanistan and other veterans? Physician-epidemiologist and former Army officer Remington Nevin added to that contentious discussion with some powerful evidence. I emphasized the need to develop treatments that Soldiers and Marines are willing to access. Younger service members do not like conventional evidence-based treatments. Medications have side-effects, including sexual dysfunction. Psychotherapy involves talking about the trauma, which many battle-hardened veterans are loath to do, especially to a civilian who has not been downrange. The newer alternative treatments — acupuncture, stellate ganglion block, yoga, trans cranial stimulation, omega fish oil, virtual therapy– are much better accepted by Soldiers and Marines. But there is not yet the scientific evidence to prove their worth. Is the label “PTSD” even right? Retired Army general Peter Chiarelli, retired Navy captain Bill

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Bringing the Uniform Out of the Closet165742096ecritchie

Tue, 28 May 2013 12:23:29 +0000

The unveiling of the of American Psychiatric Association’s fifth edition of its Diagnostic and Statistical Manual of Mental Disorders – the key reference in how mental-health professionals diagnose mental ailments – dominated the headlines at the APA’s annual gathering in San Francisco last week. But it wasn’t the only thing going on. I’d like to highlight a fascinating symposium: Bringing the Uniform out of the Closet: Artistic and Clinical Perspectives of Gay Military Life Before and After “Don’t Ask, Don’t Tell,” sponsored by the Association of Gay and Lesbian Psychiatrists. Documentary photographer Vincent Cianni presented evocative photos and troubling stories from gay service members in his montage, Gays in the Military: How America Thanked Me. It was clear that what was supposed to be an improvement – 1993’s “Don’t Ask, Don’t Tell” policy — was anything but, for most gay service members. I reviewed gay mental health issues over the last 30 years, the first 28 of which I served as an active-duty Army psychiatrist. I began my career at Walter Reed as a psychiatry resident about the time that the Army began to test all personnel for HIV (then the HTLV virus). We would get planeloads of newly-diagnosed Soldiers, which the psychiatry residents screened upon arrival for thoughts of suicide. They continued on to the nurturing staff of Ward 52, whose members helped them cope with the impact of their diagnosis. We were always careful never to put anything about homosexuality—or other ways that they may have gotten HIV—because of concern about their careers. Nevertheless, confidentiality remained a huge issue. As military officers, we were supposed to report if someone was committing homosexual acts. As psychiatrists, we maintained discretion and did not (unless there was danger to self or others). However there was often confusion as to exactly what were the rules, and patients generally did not disclose “sexual identity” concerns to us. Of course, many military psychiatrists were gay. In a hospital setting, sexual identity often was an open secret to other staff. However, out in the “real

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An Easier PTSD Diagnosis4614113755_9cea448196_oecritchie

Tue, 14 May 2013 12:26:14 +0000

Being diagnosed with post-traumatic stress disorder could get easier following the upcoming annual meeting of the American Psychiatric Association where the group’s fifth edition of its Diagnostic and Statistical Manual (DSM-5) is slated to be released in San Francisco. DSM-5 has new guidelines and criteria for many psychiatric diagnoses. There is already lots of controversy about this latest revision. Here I’d like to focus on the diagnosis with most relevance for military service members and veterans: PTSD. Essentially the new criteria make it easier to meet the criteria for PTSD, by eliminating so called Criterion A-2, and by adding symptoms that make a PTSD diagnosis more likely. Criterion A-2 is the requirement that people experience extreme fear, helplessness and horror at the time of a traumatic incident. This is a good change. When the bomb goes off or they are shot at, most well-trained service members do not experience helplessness or horror. They are well-trained; they drag their wounded buddies to safety, lay down suppressing fire, and continue with the mission. But they still may have intrusive memories: seeing their friend’s heads blown off, or the dead children in the vicinity of the bomb blast. In the past, they did not strictly meet the criteria for PTSD, so they might get a related diagnosis like anxiety disorder, not otherwise specified (NOS). Added elements recognized in the PTSD diagnosis include: cognitive difficulties; depressive symptoms; and strong body reactions to smells or other triggers reminding them of the event. The big questions to me are — How and when these changes will affect the disability system? — Will the military and VA adopt the new changes? If so, when? — If adopted, will veterans who previously did not meet the earlier criteria for PTSD be re-evaluated? To add to the complexity, many service members receive multiple disability evaluations. They may receive a medical evaluation board (MEB). Then they may receive one or more TDRL (temporary disability retirement list) evaluations through the military. Then another one or more through the Department of Veterans’

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B-ing StrongBoston's Boylston Street Fully Reopens To Publicecritchie

Tue, 30 Apr 2013 12:43:41 +0000

BOSTON — Shortly after the Boston  bombings I posted a note here about the mental health effects of mass violence, which often go on for years and even decades. I had the wonderful opportunity last weekend to visit Boston to attend a Red Sox game. The journey took on incredible poignancy two weeks after the Boston bombings. I wanted to share a few thoughts, snapshots taken two weeks later. It was a gorgeous weekend in Boston. Clear blue sky, cool in the shade and warm in the sun. Tulips, magnolias, forsythias, cherry trees all in bloom. The type of days which broke us out of the chrysalis of crusted dirty snow, made us feel alive again, when I went there as an undergraduate. So many of us went to college there, or have kids who go to college there. Our hotel, the Westin Copley Place, overlooked the memorial where the finish line was two weeks ago. The Copley Plaza’s neighbors include Trinity Church, Old South Street Church, the Fairmont Copley Hotel, and the Boston Public Library. The square also now has hundreds of running shoes, names of the wounded and dead, and Boston Strong signs everywhere. Superficially everyone and everything looked great. There is little sign of property damage. Of course, 80% of the population was in Boston Red Sox hats and t-shirts.  There are still lots of news vans. Therapy dogs ambled around the sidewalk. A couple of girls held signs” I give hugs.” Few that I saw took them up on their offer. Underneath the surface, anxiety, past and present, clearly lurked. I asked everyone how the last two weeks were, half expecting to hear that the lockdown was an overreaction and was stupid. But by and large, of the maybe 30 folks I talked to, what I heard were comments like these: “It was really scary.” “I am glad they locked down. It was better that way, so that business owners themselves did not have to make the decision.” “I have not really processed it yet.” “I

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