Hostname: page-component-78c5997874-m6dg7 Total loading time: 0 Render date: 2024-11-14T07:27:59.231Z Has data issue: false hasContentIssue false

Author's reply

Published online by Cambridge University Press:  21 March 2019

Sharon A. M. Stevelink
Affiliation:
Lecturer in Epidemiology, King's College London, UK Email: [email protected]
Margaret Jones
Affiliation:
Senior Research Associate, King's College London, UK
Roberto J. Rona
Affiliation:
Professor of Public Health Medicine, King's College London, UK
Neil Greenberg
Affiliation:
Professor of Defence Mental Health, King's College London, UK
Nicola T. Fear
Affiliation:
Professor of Epidemiology, King's College London, UK.
Rights & Permissions [Opens in a new window]

Abstract

Type
Correspondence
Copyright
Copyright © The Royal College of Psychiatrists 2019 

We appreciate the interest Dr Remington Nevin has shown in our articleReference Stevelink, Jones, Hull, Pernet, MacCrimmon and Goodwin1 and thank you for giving us the opportunity to respond. Dr Remington Nevin claims that mefloquine exposure is an important confounder that we have failed to control for and that our lack of adjustment for this variable may have invalidated our conclusions. We respectfully disagree.

First, there is no empirical evidence that mefloquine use confounds the association between deployment-related exposures and post-traumatic stress disorder (PTSD), nor that PTSD is a specific side-effect of mefloquine use. Adverse reactions that are reported in the National Institute for Health and Care Excellence guidelines include anxiety, depression, sleep disorders, abnormal dreams, dizziness, headache, vomiting, digestive problems and skin reactions.2Reference Tuck and Williams4 A recent Cochrane review found a low incidence of side-effects among mefloquine users.Reference Tickell-Painter, Maayan, Saunders, Pace and Sinclair3 Further, mefloquine users do not report more frequent serious side-effects than more commonly used antimalarials such as atovaquone-proguanil or doxycycline.Reference Tickell-Painter, Maayan, Saunders, Pace and Sinclair3

Second, data from the UK's Defence Medical Information Capability Programme indicated that between 1 April 2007 and 31 March 2015, approximately 120 000 UK armed forces personnel were prescribed an antimalarial drug, of which around 17 000 were prescribed mefloquine (14%).5 When looking specifically at personnel who deployed to Afghanistan between 1 April 2007 and 31 December 2014, only 536 (0.4%) of the 131 000 of personnel who deployed were prescribed mefloquine. A further 12 908 (10%) were prescribed an unknown malarial prophylaxis. The available data relating to both prescription and use, which is determined by service policy,6 suggest that mefloquine is not the first-choice malarial prophylactic for UK armed forces personnel other than in circumstances where resistance to other medication is a factor. Hence, it is highly unlikely that mefloquine was prescribed to this 10%. Therefore, its infrequent use would mean that it cannot account for any substantial proportion of the PTSD identified in our study.

Third, adherence to treatment during deployment varies substantially but is generally found to be low to moderate (range 38–61%), further weakening any potential confounding effect of mefloquine antimalarial medication.Reference Brisson and Brisson7, Reference Kotwal, Wenzel, Sterling, Porter, Jordan and Petruccelli8 Although we could assess whether UK serving personnel were prescribed malarial prophylaxis as part of the health and well-being cohort study questionnaire, it is impossible to accurately assess through self-report whether personnel were compliant with the treatment regime and which medication was prescribed. Hence, even if prescription data were available, it would be difficult to identify the potentially marginal mental health and well-being impact of mefloquine particularly upon PTSD, as factors such as combat exposure have a direct effect.

Given the low prescription rate of mefloquine compounded with the low rates of adherence, it is implausible that mefloquine could have mimicked the pattern of associations of PTSD we observed with deployment, engagement type, serving status and combat role.

Declaration of interest:

All authors are based at King's College London which, for the purpose of this study and other military-related studies, receives funding from the UK Ministry of Defence (MoD). S.A.M.S., M.J. and R.J.R.’s salaries were totally or partially paid by the UK MoD. The UK MoD provides support to the Academic Department of Military Mental Health, and the salaries of N.G. and N.T.F. are covered totally or partly by this contribution.

References

1Stevelink, SAM, Jones, M, Hull, L, Pernet, D, MacCrimmon, S, Goodwin, L, et al. Mental health outcomes at the end of the British involvement in the Iraq and Afghanistan conflicts: a cohort study. Br J Psychiatry 2018; 213: 690–7.Google Scholar
2National Institute for Health and Care Excellence. Mefloquine. In British National Formulary (BNF). NICE, no date (https://bnf.nice.org.uk/drug/mefloquine.html#sideEffects).Google Scholar
3Tickell-Painter, M, Maayan, N, Saunders, R, Pace, C, Sinclair, D. Mefloquine for preventing malaria during travel to endemic areas. Cochrane Database Syst Rev 2017; 10: CD006491.Google Scholar
4Tuck, J, Williams, J (2016). Malaria protection in Sierra Leone during the Ebola outbreak 2014/15; the UK military experience with malaria chemoprophylaxis Sep 14-Feb 15. Travel Med Infect Dis 2016; 14: 471–4.Google Scholar
5Ministry of Defence. Mefloquine hydrochloride prescribing in the UK Armed Forces, 1 April 2007–31 March 2015. Ad Hoc Stat Bull 2016; 12 January (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/491134/20160112_Adhoc_Statistical_Bulletin_Mefloquine_prescribing_in_the_UK_Armed_Forces_-O.pdf).Google Scholar
6Surgeon General. Preventing Malaria in UK Armed Forces Personnel. Joint Service Publication 950, Part 1, Leaflet 3-3-1. Ministry of Defence, 2017 (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/650918/20170601-JSP_950_Lft_3-3-1_Prev_Mal_Mil_Pers_V2_01_Jun17_Endorsed-O.pdf).Google Scholar
7Brisson, M, Brisson, P. Compliance with antimalaria chemoprophylaxis in a combat zone. Am J Trop Med Hyg 2012; 86: 587–90.Google Scholar
8Kotwal, RS, Wenzel, RB, Sterling, RA, Porter, WD, Jordan, NN, Petruccelli, BP. An outbreak of malaria in US Army Rangers returning from Afghanistan. JAMA 2005; 293: 212–6.Google Scholar
Submit a response

eLetters

No eLetters have been published for this article.