We appreciate the thoughtful commentary on our article evaluating nightmares in United States military personnel with sleep disturbances.1,2 At the San Antonio Military Health System Sleep Disorders Center, which is the largest sleep laboratory in the Department of Defense, we are aware of the high rate of patients affected by nightmares and the associated clinical and nocturnal distress that nightmares cause. This has led us to having a focus on this sleep disorder in our clinical practice and research on parasomnias to include nightmares and a novel parasomnia, trauma associated sleep disorder.3,4
In our clinical experience, as well as the other sleep physicians who work in our sleep disorders center, none of us have diagnosed a patient with a persistent clinical sleep disorder, nightmares or otherwise, related to mefloquine toxicity. It is relevant to point out that the United States military recognized the neuropsychiatric side effects associated with mefloquine and use of this medication has decreased dramatically since 2008.5 Further, as noted by the lead author of the Cochrane Review,6 Dr. Tickell-Painter, “the review clarifies that these are symptoms reported by people taking mefloquine and not formal psychiatric diagnoses. Serious side effects with mefloquine seem to be rare, less than 1% of users.”7 Thus, while the symptoms of bad dreams or nightmares are a well-known side effect of this medication, their persistence is rare.
We did not specifically evaluate the impact of medications which are commonly associated with nightmares (ie, bupropion, selective serotonin reuptake inhibitors, selective norepinephrine reuptake inhibitors, propranolol, etc.). In the article cited by Dr. Nevin regarding the persistence of nightmares after taking mefloquine, this study included a total of 73 patients from a Danish national registry who self-reported symptoms.8 After 3 years, 9 (12%) of the respondents noted nightmares; however, as the frequency, severity, and associated characteristics were not delineated, to include the criteria for nightmares, it is unknown if this finding represented a persistent side effect or was within the spectrum of bad dreams that occur in a general population.
Ultimately, in order to better address nightmares, which are an under-reported, under-addressed disorder,9 and increased in individuals with war experiences,10 a systematic study in both military personnel and veterans is indicated. This is especially relevant noting the association with nightmares and suicidality.11 This study should account for trauma exposure and deployments, military duties, and comorbid disorders (ie, posttraumatic stress disorder, traumatic brain injury, anxiety, depression, etc.) as well as medications.
All work was performed at Wilford Hall Ambulatory Surgical Center, JBSA-Lackland, Texas. All authors have seen and approved the manuscript. The auithors report no conflicts of interest. The opinions and assertions in this manuscript are those of the authors and do not represent those of the Department of the Air Force, Department of the Army, Department of Defense, or the United States government.
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