FDA Black Box, VA Red Ink? A Successful Service-Connected Disability Claim for Chronic Neuropsychiatric Adverse Effects From Mefloquine.

More veterans are likely to present to the VA with service-connected claims for adverse effects related to exposure to a prophylactic antimalarial drug commonly used by the military for more than 2 decades.

U.S. Military Surveillance of Mental Disorders, 1998-2013.

OBJECTIVE: Feature articles in the Medical Surveillance Monthly Report (MSMR) reflect the U.S. military's health surveillance priorities. This study examined whether the recent rise in the number of ambulatory encounters for mental disorders in the U.S. military associated with the Iraq and Afghanistan wars was reflected in a proportional increase in MSMR feature articles on this topic. METHODS: Articles published in the MSMR from January 1998 to December 2013 were examined to categorize feature articles according to health outcome. The proportion of articles by topic of outcome was compared with the proportion of all ambulatory encounters by category of disorder. RESULTS: Mental disorders constituted 13% of ambulatory encounters and were the topic of 11% of 329 feature articles during the period, a statistically nonsignificant difference. CONCLUSIONS: The increased number of encounters for mental disorders has been met with a proportional but delayed increase in the number of MSMR feature articles focusing on these disorders.

A review of the use of stellate ganglion block in the treatment of PTSD.

Current treatments for PTSD are often not effective or acceptable to the patient. There are a number of emerging new treatments. One promising new one is stellate ganglion block, an anesthetic treatment for pain which relieves symptoms of severe and chronic PTSD in some patients. The focus of this chapter is to summarize clinical evidence available for the effectiveness of cervical sympathetic ganglion injection called stellate ganglion block (SGB), as well as demonstrate possible clinical applications of its use. Cervical sympathetic blockade involves injecting a local anesthetic next to a group of nerves (ganglion) in the neck. The technique has been used clinically since 1925 with very few side effects. Finally, the neurobiology of SGB is discussed. Challenges to the use of SGB include the lack of randomized clinical trials and practitioners familiar with the use of SGB for PTSD.

Psychiatric side effects of mefloquine: applications to forensic psychiatry.

Mefloquine (previously marketed in the United States as Lariam®) is an antimalarial medication with potent psychotropic potential. Severe psychiatric side effects due to mefloquine intoxication are well documented, including anxiety, panic attacks, paranoia, persecutory delusions, dissociative psychosis, and anterograde amnesia. Exposure to the drug has been associated with acts of violence and suicide. In this article, we discuss the history of mefloquine use and describe plausible mechanisms of its psychotropic action. Mefloquine intoxication has not yet been successfully advanced in legal proceedings as a defense or as a mitigating factor, but it appears likely that it eventually will be. Considerations for the application of claims of mefloquine intoxication in forensic settings are discussed.

Suicide and the United States army: perspectives from the former psychiatry consultant to the army surgeon general.

The suicide rate of active-duty soldiers doubled between 2003 and 2010. In response, the Department of Defense and the United States Army improved their data collection methods to better understand the causes of military suicides. As retired colonel Dr. Elspeth Cameron Ritchie writes, unit history and the accumulation of stressors-from relationship problems to chronic pain-are significant suicide risk factors among soldiers. But, she argues, Army officials must use this knowledge to design more-effective strategies for suicide reduction, including limiting access to weapons, especially post-deployment, and better connecting soldiers with their communities.

U.S. military enlisted accession mental health screening: history and current practice.

Through the stimulus of war and concerns about neuropsychiatric disability, the U.S. military developed methods to rapidly screen the mental health of World War I and II draftees. Intelligence testing and brief psychiatric screening expanded the accession physical examination and underwent revision to identify only gross mental health disability. Supplemental psychiatric evaluations and written psychological screening tools were abandoned after postwar assessments; they demonstrated poor predictive power in evaluating recruit service capacity for combat environments. Currently, only three mental health accession tools are used to screen applicants before their entrance into military service, namely, educational achievement, cognitive testing, and a cursory psychiatric evaluation. The Navy and Air Force use a fourth screening measure during entry-level training. Educational attainment with high school graduation has been the strongest predictor of finishing a service term. The purpose of this article is to provide both a historical review and a review of testing efforts.

Update on combat psychiatry: from the battle front to the home front and back again.

The U.S. military has long emphasized the principles of prevention and early intervention in preparing for and treating those afflicted by the psychological wounds of war. This article opens with lessons learned by the U.S. military through wartime during the past century. Current practice in the military's employment of stress control teams is reviewed. Updates in the military efforts in Operation Iraqi Freedom and Operation Enduring Freedom to prevent and to limit psychological casualties are stressed. Misconduct has occurred in this conflict; future steps to reduce aberrant behavior by soldiers are discussed. The challenges of reintegration at home, by both healthy and wounded soldiers, are highlighted.

A missing element in disaster mental health: behavioral health surveillance for first responders.

Considerable literature exists on surveillance for medical effects of responses to a disaster but there is a dearth of information on conducting surveillance of behavioral health effects for first responders. This article reviews the literature and rationale behind behavioral health surveillance in the context of medical surveillance of first responders, examines special populations and ethical issues, discusses a model currently used by the U.S. military, discusses unresolved issues, and concludes with some practical suggestions.

Psychiatry and the military: an update.

The United States has historically been concerned about the successful adjustment of its military members returning from war. These concerns are based on the recognition that war-zone exposures may have considerable negative emotional or behavior consequences. As the global war on terror continues, the United States military medical system will be required to address issues at the interface of psychiatry and the law. Despite clinical advances within the theater of war and at tertiary facilities in the United States, some military members will develop chronic and disabling mental illness as a result of traumatic exposure and exacerbated by the demands of the austere and dangerous operational environment. The extent to which violent and aggressive behavior in the aftermath of deployment can be attributed to combat experience remains an area of debate and ongoing investigation. However, experience suggests that a very small subgroup of the hundreds of thousands of war veterans deployed in conjunction with the current conflict in Iraq has already been involved in violent crimes. For this group, military forensic psychiatrists will be called on to make determinations of competency and criminal responsibility and to inform the courts about the potential contributions of war-related distress or disorder to criminal behavior. Though the overwhelming majority of war veterans will not be involved in criminal proceedings, a minority will develop career-ending (and in rare instances, life-ending) disabilities as a result of mental illness. For those who are no longer fit for duty, the military Physical Disability Evaluation System must make determinations of the extent to which future military performance and future civilian social and occupational function have been compromised. For a small yet highly visible minority of returning veterans, questions about the cause, precipitants, and manner of death will necessitate psychological autopsies. This article highlighted recent updates in military forensic psychiatry and the mechanisms through which answers to questions of disability and criminal culpability, and motivation underpinning self-injurious behavior, are determined within the United States military. As the global war on terror progresses, further experience and study of our country's judicial processes, disability system, and the policies and procedures governing psychological autopsies must evolve to meet these increasing demands.

"Just-in-time" mental health training and surveillance for the Project HOPE mission.

BACKGROUND: Immediately before the first sailing of the USS Mercy/Project HOPE relief mission to Southeast Asia, the mission leadership initiated presailing orientation and training and a program of survey-based health surveillance for mission participants. The training and surveillance efforts included a focus on mental health aspects of the mission. METHODS: At the conclusion of the predeployment mental health training, a voluntary, anonymous, predeployment survey was administered to members of the Project HOPE team. A second survey was administered approximately 3 months after return from the mission. The surveys were also administered before and after the second sailing of the USS Mercy/Project HOPE mission, although the training was not repeated. RESULTS: The sample size prevented statistical analysis of predeployment and postdeployment rates of illness; however, there was no evidence of incidence beyond population baseline rates. Responses to questions regarding perceptions of mission success and personal achievement were quite favorable, whereas specific questions regarding shipboard resources, training, and professional interactions were met with more variable responses. CONCLUSIONS: Response rates suggest a strong interest among participants in efforts to address the Project HOPE program and resources. They also suggest resilience among participants and areas for improvement in communication among participants.

Mass violence and early mental health intervention: a proposed application of best practice guidelines to chemical, biological, and radiological attacks.

Based on past episodes, there will be psychological sequelae to chemical, biological, and radiological attacks. Some of the psychological morbidity should be able to be ameliorated through planning and appropriate early intervention. Key components of early intervention are illustrated following a hypothetical scenario of a bomb and anthrax threat near the Pentagon. Many of these components, such as monitoring clear, consistent messages about health risks, are provided by physicians or politicians, not mental health providers, but have a serious impact on the mental health of the population. We hope that this scenario and the principles of response will prove useful to planners of emergency preparedness and responders in the case of an actual attack.

Military issues.

This article reviews of some of the lessons in trauma psychiatry learned by the US military through wartime and other trauma experiences during the past century. Current practice in the military's employment of stress control teams is reviewed. The military's efforts to prevent and limit psychological casualties, to include the care of battle casualties and prisoners of war (POWs), are addressed. Recent experiences that have informed further, and are shaping the military's approach to managing the psychological aftermath of trauma (such as the Sept. 11, 2001, attack on the Pentagon and the current war with Iraq) are included. Guidelines developed after 9/11, and articulated in the "Mass Violence and Early Intervention" conference are presented. Finally, current ideas on preparation for and intervention after weapons of mass destruction will be outlined.

Breastfeeding in the military: Part II. Resource and policy considerations.

Breastfeeding is widely acknowledged as the ideal form of nutrition for infants. Because of this, increasing the incidence and duration of breastfeeding is a major goal in Healthy People 2010. Part I of this series illustrated that the Department of Defense and its health care system, TRICARE, may not be meeting that goal, particularly after active duty mothers return to work. This study outlines the resources that would be required to optimally support breastfeeding after active duty mothers return to work. Selected policy implications of supporting breastfeeding are discussed, and recommendations for policy on breastfeeding are presented.

Breastfeeding in the military: Part I. Information and resources provided to service women.

Increasing the incidence and duration of breastfeeding is a major goal in Healthy People 2010. Little is known about the progress that the Department of Defense (DoD) health care system, TRICARE, has made toward reaching that goal. This study is the first of a two-part series that reviews DoD/TRICARE support for breastfeeding and discusses policy issues related to breastfeeding. Methods used include searches of MEDLINE, DoD/TRICARE documents, legislative and policy websites, and the Internet. A survey of DoD hospitals was also conducted. Based on the search results and survey, TRICARE may not be meeting the goals of Healthy People 2010. There is minimal policy guidance regarding breastfeeding. Programs are in place at most hospitals, but the quality and content varies greatly. After mothers return to work, support is meager. DOD/TRICARE may need to establish written policy guidelines and devote additional resources to adequately support breastfeeding.