## Mefloquine and Neuropsychiatric Toxicity ### Mechanism and Risk Profile **Key Point:** Mefloquine is notorious for causing neuropsychiatric adverse effects, including depression, anxiety, psychosis, and suicidal ideation, particularly in patients with pre-existing psychiatric conditions. ### Neuropsychiatric Adverse Effects of Mefloquine **High-Yield:** The FDA issued a black box warning for mefloquine due to: - Acute psychiatric symptoms (anxiety, paranoia, hallucinations) - Chronic neuropsychiatric effects (depression, suicidal thoughts) - Dizziness and vertigo - Sleep disturbances and nightmares - Seizures (rare) ### Contraindications and Precautions | Condition | Mefloquine | Chloroquine | Artemether | Atovaquone-Proguanil | | --- | --- | --- | --- | --- | | Psychiatric disorder | **Contraindicated** | Caution | Safe | Safe | | Seizure disorder | Contraindicated | Caution | Safe | Safe | | Cardiac arrhythmia | Caution | Caution | Safe | Safe | | G6PD deficiency | Caution | Caution | Caution | Safe | **Clinical Pearl:** Mefloquine should be avoided in military personnel, pilots, and individuals in high-stress occupations due to the risk of impaired judgment and neuropsychiatric complications. ### Dosing and Timing - Mefloquine is given as a single dose (750 mg base) or divided doses - Neuropsychiatric effects can occur during prophylaxis or treatment - Symptoms may persist weeks to months after discontinuation **Warning:** Do NOT confuse mefloquine with chloroquine; chloroquine is safer psychiatrically but has other toxicities (retinopathy, cardiomyopathy).
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