Recommended Malaria Prophylaxis for Patient with Controlled Depression
For a patient with controlled depression traveling to a malaria-endemic area, atovaquone-proguanil (Malarone) is the preferred choice, as mefloquine is absolutely contraindicated due to its significant neuropsychiatric risks, even in patients with well-controlled psychiatric conditions.
Why Mefloquine Must Be Avoided
- Mefloquine should not be given to those with a history of serious psychiatric disorder, including depression 1
- The drug causes neuropsychiatric side effects including anxiety, depression, sleep disturbances, nightmares, hallucinations, and overt psychotic attacks in a significant proportion of users 1
- These severe neuropsychiatric effects occur in 1/10,000 to 1/15,000 during prophylactic treatment, with patients having personal or family history of psychiatric disorders being at substantially higher risk 2
- Prophylactic use of mefloquine was associated with significantly higher scores on scales for depression, anger, and fatigue compared to atovaquone plus proguanil 3
Why Atovaquone-Proguanil Is the Best Choice
- Atovaquone-proguanil provides 100% efficacy for prevention of P. falciparum malaria in nonimmune travelers, matching mefloquine's efficacy without the neuropsychiatric risks 4
- The combination was associated with significantly fewer neuropsychiatric adverse events than mefloquine in head-to-head trials 4, 3
- It is highly effective against drug-resistant strains of P. falciparum with no cross-resistance to other antimalarials 4
- The drug only needs to be continued for 7 days after leaving the malarious area (versus 4 weeks for other agents), improving adherence 4, 5
- Both atovaquone and proguanil are active against hepatic stages of P. falciparum, providing causal prophylaxis 4, 5
Alternative Options If Atovaquone-Proguanil Is Unavailable
- Doxycycline is the second-line choice for patients unable to take mefloquine, as it is recommended as an alternative for those visiting high-risk areas but unable to take other antimalarials 1, 6
- Doxycycline requires daily dosing of 100 mg starting 1-2 days before travel and continuing for 4 weeks after leaving the malarious area 7
- The main limitation is photosensitivity—patients must avoid excessive sun exposure 1, 6, 7
- Doxycycline can be used in patients with renal impairment as it is largely metabolized through the liver 6
Why Chloroquine Is Not Appropriate
- Chloroquine has limited efficacy in most malaria-endemic regions due to widespread resistance, particularly in sub-Saharan Africa and Southeast Asia 1
- While it has fewer neuropsychiatric side effects than mefloquine, its poor efficacy makes it unsuitable for most travel destinations 1
- Chloroquine combined with proguanil provides only 70% efficacy compared to 100% for atovaquone-proguanil 4
Critical Implementation Points
- Start atovaquone-proguanil 1-2 days before travel (unlike other agents requiring 1 week lead time) 4
- Take with food or milk to optimize absorption 7
- Continue daily during travel and for only 7 days after departure from the endemic area 4, 5
- Counsel the patient that no antimalarial provides 100% protection—mosquito avoidance measures remain essential 7