Malaria drug links elite soldier suicides

By MARK BENJAMIN and DAN OLMSTED WASHINGTON, Sept. 7 (UPI) -- A startling pattern of violence and suicide by America's most elite soldiers has followed their use of a controversial anti-malaria drug, an investigation by United Press International and CNN has found.

The government already warns that the drug, called Lariam, might cause long-term mental problems -- including aggression and suicide.

Six Special Forces soldiers who took their lives are all believed to have taken the drug, according to the UPI-CNN investigation. The cable news network broadcast a segment on the joint investigation Tuesday.

Sen. Dianne Feinstein voiced concern about Lariam and the Special Forces suicides. The California Democrat had previously written key government officials seeking an urgent review of Lariam use.

"I have long been concerned about the use of the drug Lariam for service members and other U.S. government employees deployed abroad," Feinstein told UPI. "Now, there is an indication that Lariam may have contributed to the suicides of some of our nation's elite troops.

"The Department of Defense, and all other government agencies that give this drug to their employees, should immediately reassess their decision to use Lariam and look for alternatives that can protect our troops without causing dangerous side effects."

The Pentagon announced in February that it is investigating whether there is a link between the drug and any soldier suicides. But it defends Lariam, known generically as mefloquine, as both highly effective and safe for soldiers to take. Army medical officials declined requests for an interview but said in a written statement, "We have no data that indicate that Lariam was a factor in any Army suicides in Operation Iraqi Freedom and Operation Enduring Freedom (Afghanistan)."

Instead, the Army said, the deaths were linked to "failed personal relationships, financial crises, legal difficulties and mental problems like depression and psychosis" -- the same factors that trigger suicide in the general public, magnified by ready access to guns.

The psychotic behavior and suicides are particularly jarring because Special Forces soldiers are highly trained and psychologically vetted. An Army study in 2000 showed Special Forces soldiers produce more of a chemical in the brain that helps them cope with and recover from extreme duress.

"It's just antithetical to their whole practice of their craft to suddenly lose control, become depressed, paranoid, hallucinate and become suicidal," said Dr. Paul Ragan, associate professor of psychiatry at Vanderbilt University and a former military psychiatrist. "You have to look for some exogenous factor, some outside factor, something new in the mix that will change how they've otherwise been able to operate."

Those deaths then raise concerns about the tens of thousands of soldiers who have taken Lariam during the war on terrorism -- and about dozens of suicides and a handful of murders among troops while overseas or after returning home.

The pattern also suggests that the Army might have missed the cause of three murder-suicides involving Special Forces soldiers at Fort Bragg, N.C., in the summer of 2002. A report by the Army surgeon general's office blamed marital problems for all the deaths and called Lariam an unlikely factor. But the report did not consider physical or mental problems among the three Special Forces soldiers, described by family and friends, that fit side effects from Lariam.

The UPI/CNN investigation found three more suicides by Special Forces soldiers -- all of them Green Berets believed to have taken Lariam. None appears to have had acute marital problems, combat stress or other personal issues that would help explain their sudden plunge into violence.

- A 43-year-old Special Forces weapons sergeant killed himself in 1997 in Ecuador, where he was helping train Ecuadorian Special Forces. Engaged to be married, he smilingly picked up a gun and shot himself in the head in front of two fellow soldiers.

- A Special Forces sergeant killed himself in July 2003 in the Washington suburb of Alexandria, Va. Happily married and expecting his first child, Tyler Whiffen, 32, went to the woods behind his condominium and shot himself in the head. "He wasn't depressed at all," said Karla Whiffen, his widow and mother of his 6-month-old son. "In fact, I have never known anyone to enjoy life so much. For him to take his life was so out of the blue. Nothing has surfaced that would make this anything but this drug." Whiffen took Lariam in Afghanistan.

- The most recent case involved Special Forces Chief Warrant Officer William Howell, 36, who served in Iraq and killed himself after returning to Fort Carson, Colo. His wife, Laura, also reported no marital problems. He killed himself in March after stalking her around their yard with a gun and pointing it in her face. He shot himself when police arrived.

"I knew my husband, I knew who he was. I know what he was," said Laura Howell. "The only difference was one pill. A little white pill that he took. There was nothing else in his life that was different, in his job, nothing. And there was no accumulative effect of anything in his life that would lead to suicide."

The suicides since Sept. 11, 2001, identified by the UPI-CNN investigation are the only Special Forces suicides during that period, according to the Army. It could provide no data on Special Forces suicides before then or on the number of Special Forces soldiers who have taken the drug.

Lariam has physical and mental side effects. A cluster of physical symptoms also appeared in the pattern of Special Forces soldiers who committed suicide, matching those noted by the Food and Drug Administration, including diarrhea, rash, headaches, trembling and night sweats.

For example, after taking Lariam in Iraq, Bill Howell specifically complained of ringing in the ears, panic attacks, headaches, diarrhea, vomiting, skin rash and tingling and numbness in his hands and feet. All are listed under adverse reactions on Lariam's official product label.

The Department of Veterans Affairs recently alerted every doctor in the VA healthcare system to be on the lookout for soldiers suffering mental or physical problems from taking Lariam, even if the service members had not taken the drug for a long time.

This summer, a Navy doctor at a Pentagon treatment facility in San Diego has begun to diagnose service members with permanent brain-stem damage and fingered Lariam as the apparent culprit. One Special Forces soldier diagnosed with that permanent damage said Lariam has given him homicidal and suicidal urges.

"I can tell you from my own personal experience that it goes from zero to 100 very quickly," said this active-duty soldier, who asked not to be identified for fear of retribution. "You're ready to take that plunge into hurting someone or hurting and killing yourself, and it comes on unbelievably quickly. It's just a sudden thought it's the right thing to do. You'll get a mental picture, and it's in full color."

He said that after taking the drug he attacked his wife and considered suicide for the first time.

The 1997 apparent suicide of a Special Forces soldier uncovered in the UPI-CNN investigation involved a Green Beret weapons sergeant who was in a room with two other soldiers at a base near Quito, Ecuador.

"He had picked up the team sergeant's weapon. He looked at the team sergeant and asked if it was loaded. Then he looked at my other friend, smiled, and pulled the trigger," said Justin Schuman, a former Army staff sergeant who retired in June. Schuman was not in the room during the shooting but was present when the medical helicopter arrived. He said the two soldiers who were in the room at the time immediately described what happened.

"We were at a loss. We really had no idea what possessed him to do that," Schuman said. "We knew there were some stressors in his life. He was about to get remarried, but there was nothing in particular. Nobody mentioned Lariam."

Schuman said he and the two soldiers who were present decided to portray the incident as an accident.

"We told Army investigators that it was an accidental discharge because (we feared) they would have denied his family all his benefits. Because he never said anything about suicide, we just played it off as if he was playing suicide."

But it could not have been an accident, he said. "There really is no more trained person in the world than a trained (Special Forces) weapons sergeant. I can't tell you that it was the Lariam, but he was on Lariam at the time and he committed suicide right in front of us in a very bizarre way."

Last year, the FDA ordered that all patients given Lariam be told in writing about rare reports of suicide, along with psychiatric side effects that have been reported to last "long after" someone stops taking it. The FDA says it does not know if Lariam caused any of the reported suicides.

While malaria can be deadly, there are other drugs that prevent it. A recent study showed that 29 percent of people taking Lariam had some kind of mental problem -- twice the rate of a similar malaria drug.

The violent behavior that accompanied all but one of the Special Forces suicides raises troubling issues because experts say that a drug that could trigger homicide should not be prescribed to anyone. Karla Whiffen said her husband shoved her on two separate occasions -- once knocking her to the ground -- after returning from Afghanistan, something he had never done before.

Laura Howell said her husband punched her "four or five times in the head" before he went to get the gun he ultimately used to kill himself. He had struck her once before, when he was taking steroids to bulk up. "He was very sensitive to chemicals. Anything that had a side effect to it, he would get it," she said.

At Fort Bragg, none of the three Special Forces soldiers involved in the murder-suicides in 2002 had any known history of domestic violence, according to family, friends and police. Experts said it is rare for a domestic homicide not to be preceded by an escalating pattern of violent abuse.

Lariam's manufacturer, Swiss pharmaceutical giant Hoffmann-La Roche, said in a statement by spokesman Terence Hurley that there is "no credible scientific evidence" linking Lariam to suicide, suicidal thinking or violent criminal conduct. The rate of serious mental and neurological side effects is "very low," he said, adding that "data from well-designed studies show Lariam to be safe and well-tolerated."

Hurley added: "The label has advised for many years that Lariam should be used with caution in patients with psychiatric disturbances and has disclosed, clearly, that depression and other neuropsychiatric events have been reported among patients who have used Lariam."

He also noted the Army developed the drug and said, "The Army has its own extensive knowledge base and experience with Lariam. As with all decisions regarding prescription medications, the decision about whether Lariam is appropriate for any individual patient -- whether soldier or civilian -- is a matter for the independent medical judgment of the prescribing physician."

Based on a three-month investigation, UPI reported in May 2002 that mounting evidence suggests Lariam has caused such severe mental problems that in a number of cases it has led to suicide

However, many substances have a specific side effect only a small segment of the population -- like peanut allergies. Could be that's the case with Lariam, especially since it is well known to have mental/neurological effects. Another possibility is that the combination of Lariam with something else that is now being given to these servicepeople triggers the effect in a certain subset of them -- new vaccines, a certain type of amphetamine prescribed to keep Special Forces guys going through long rigorous missions, or something else along those lines.

The military alternative to mefloquine is doxycycline, which has its own can of worms, most seriously that it is given daily vice weekly.

It is interesting that aviators must take doxy; even before this controversy they would be grounded for taking Lariam. The docs considered putting those of us who must retain FAA medicals on doxy, and decided after consulting FAA aeromedical that it would not have an impact on our physicals, as long as we were off the stuff before resuming flying. (My advice to anyone is do not tell your AME you have been on it).

If the guy is not targeting SF then why doesn't he acknowledge that a million Joes and Janes have been on mefloquine for months and years, and apart from the known side effects (particularly the nightmares), most have no problem, and suicide rates are in the normal range?

As far as Vet Centers are concerned... I dunno what yours is like there, but around here they are wall to wall wannabees and phonies, encouraged by lefty shrinks full of Lifton's tendentious drivel. There's one a few miles from my house -- it treats a bunch of bums with war stories they got from the TV in a homeless shelter somewhere. I wouldn't **** on it if it was on fire!

Anyway, the basic reason that the troops on the ground take Lariam is that it is easy to administer. My personal observation in Afghanistan was that in the low country, malaria was widespread among the locals and a common cause of child mortality. Of course they had everything else too: worms, meningitis, TB, bizarre suppurating abscesses; you name it. Other teams encountered cholera and typhus, presumably vectored by returning refugees; we did not. But I would place no stock in CDC statistics from Afghanistan, which has not had any kind of functioning public health system for 25 years, or Iraq, which was isolated for ten.

It's my impression that chloroquine-resistant malaria is becoming the dominant strain. It's not isolated in black Africa any more. (For instance, Indonesia has had cases on Java).

d.o.l.

Criminal Number 18F

some of the most rigorous psychological screening on earth

Oh, I wouldn't say that. The candidates nowadays must take a Wonderlic test, a Minnesota Multiphasic Personality Inventory, a Test of Adult Basic Education (Level A), and maybe one or two others.

The Wonderlic is an IQ test, full stop: it weeds out the dummies, nothing more. (It is a backup for the GT score (IQ) minumum standard). The MMPI is a personality test that produces several scales indicating where in a range of several personality traits a person finds himself. It is uncannily valid, and can catch people trying to fake the test. So it weeds out some of the quitters, glory seekers and personality disorders (pity they didn't have it when 'Jack' Idema joined up). The TABE just tests basic knowledge: it weeds out the ignorant, the very poorly educated, and those that have learning problems.

When I joined up they didn't have all these tests; instead you had to get a "crazy statement" from the crazy doctor that you were not a nutball. (This is still required for certain types of advanced training today, about which the less said the better). My "crazy doctor" was an AF Pshrink who was absolutely appalled to find himself in the presence of someone who would want to go, in his words, "running off killing snakes and eating people." When I explained that it was eating snakes and killing people, he reluctantly signed the statement for me.

Now, today's regime is certainly more comprehensive than that, and it's more than what other parts of the military do to people who are, mostly, already in the service with good records; but it's far from infallible.

Plus, any psychological test or review is a snapshot of a moment in time. I think most of us can, from our own experience as friends, supervisors, etc., attest to the power of (for instance) a love affair, especially in the throes of starting or ending, to screw up even an orderly and disciplined life.

Right now, malaria prophylaxis is saving American lives. (All the main theaters of the GWOT are in malaria season this very minute). That doesn't mean we can't learn from study, but I want to remind everybody that the decision when the best scientific evidence is in may well be, to take the hits we take from mefloquine psychosis (the literature online says 1 in 15,000 or 20,000 users, which is a VERY high level of such a serious side effect), rather than risk the hits that malaria will give us.

d.o.l.

Criminal Number 18F

None of the 9 SF soldiers had significant life reverses unless coming home is considered life reverses.

One of them, whom I won't name here, found somebody's Size 14 Air Jordans under his marriage bed -- figuratively speaking. Normally an SF guy can dissociate in a situation like that and reason it out to the point that he knows he's going to be laughing with his buddies about it in a year. But not everyone can, all the time.

d.o.l.

Criminal Number 18F

I guess I ought to read up more on malaria and its severity. I had it twice before age 5 (living in Rwanda) and don't seem to have suffered any ill effects, so I don't think of it as a big killer -- though I hear it is, at least among the native populations of 3rd World countries who don't have access to high quality medical care.

The weird thing is how the suicides and homicides seem to be heavily concentrated among Special Forces, when 1) lots of other servicepeople are taking this drug (along with other drugs, vaccines, etc.) and 2) they are psychologically screened to a higher level than most other military units. Sure they've got more stressful missions, but that's always been the case, and I don't recall hearing about rashes of suicides or homicides among them in the past.

I report, y'all in the thread decide.

Mefloquine References in the medical press. Just to add to the joy, Africa now has produced a mefloquine-resistant strain of plamodium falciparum. This reference is a collection of clinical reports, mostly of mefloquine toxicity of one type or another, and applied research, indicating some of the possible molecular-level causes for such. Interesting stuff. Lay people can generally understand the clinical reports (maybe with an occasional nose-in to the medical dictionary) but for a lot of the lab stuff, you had best have your science chops honed to college-frosh level.
Current Prophylaxis for malaria; this has a bit of "on the one hand... on the other hand..." to it. What it illustrates to me is the difficulty that even civilian practitioners are having balancing effectiveness vs. risk on prophylactic medicines. There are no zero-risk options.
A Canadian "Myths and Facts" document, curiously hosted in Australia, and promoting use of mefloquine.
Advice for GPs in Britain. Some good links here, interesting information. NB that one of the links says "mefloquine is contraindicated in airline pilots" or words to that effect. This is not due to mefloquine psychosis, but because of another side effect that is insidiously dangerous to aviators, to wit, vertigo.

I tried to pick a mixed bag of foreign and US links rather than link to "all CDC all the time." All should be able to see that while there is definitely substance to the side effect story, that isn't the only side to the story.

About 200 million people will sicken with malaria in 2004 and about 2 million of them will die. Most of these victims are young people and children in Africa, but there are a few Americans on the list every year.

d.o.l.

Criminal Number 18F

"If the guy is not targeting SF then why doesn't he acknowledge that a million Joes and Janes have been on mefloquine for months and years"

Mark has acknowledged this in many of his previous pieces on the military and Lariam. He also acknowledged this on the CNN segment. If you watched the segment, Paula Zahn wanted to go down the "cover-up" path, but he did not give her what she was looking for. The current suicide rate in Iraq is currently at its lowest point ever and whether or not that is due to the stoppage of mefloquin or implementation of a mental health program, who knows at this point. I'm just damn glad the rate has dropped.

"As far as Vet Centers are concerned"
I should've been more clear in the terminology. The Gulf War Resource Center headed by Steve Robinson has done a significant amount of work on behalf of the veterans in getting many "unexplained" illnesses and the associated problems in front of Congress in order to receive benefits for the soldiers and their families. Lariam toxicity is the latest illness to be recognized by the VA and has awarded the first claim (80%) several weeks ago. This is no small feat considering how long it took the Army to acknowledge the problems associated with the first Gulf War as well as with Vietnam.

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