Travel and Mental Health

Medevac Statistics

Although mental health is often an afterthought in travel medicine, in fact, the psychiatric impact of travel is an area of growing interest, not only because of the prevalence of international travelers from all sectors of the population, but also because of the changing nature of international travel. A recent Swiss travel clinic study of 22,584 travelers seeking pre-travel advice revealed the purposes of travel as follows: tourism, 81.5%; visiting friends and relatives, 7.8%; business, 5.6%; other (volunteer work, study, pilgrimage and so on), 5.1%. Although the majority of travel is still for tourism, increasingly, medical providers are called on to support people traveling for mission work, disaster relief, or military and para-military purposes. These changes make it critical for health providers involved in the support of travelers to be aware of common mental health problems that emerge during travel so that they can advise travelers on risks and offer effective support when problems emerge.

The World Health Organization recently drew attention to the importance of mental health issues for travel medicine, placing mental health disorders among the three major reasons for medical evacuation during travel (the other two being injury and cardiovascular accidents). Though statistics vary, the percentage of medevacked travelers who come back for psychiatric causes is between 6% and 11%.

In one large telephone survey of young travelers returning after travel to tropical countries, 11.3% reported some sort of psychiatric or psychological symptoms during travel. Unremarkably, the most common symptoms experienced were nonspecific symptoms such as sleep disturbance (53.1%), fatigue (48.7%), and dizziness (39.3%). But 2.5% of these people had had psychological symptoms they described as severe, and 1.2% had symptoms that lasted more than 2 months after return. Travelers who reported these symptoms were significantly (p < .001) more likely to have been on mefloquine prophylaxis for malaria. Consideration of the psychiatric impact of mefloquine (and chloroquine) on travelers should certainly be a factor in evaluating patients returning with psychiatric symptoms, especially symptoms of anxiety and/or psychosis.

A study of British diplomats found that 11% of all medevacs of travelers were for mental disorders. The most common causes for medevac were depression (41.2%), family crisis or “welfare” problems (23.5%), and debriefing following a critical incident (17.6%). In this study 5.9% were medevacked for alcohol-related problems.

Pre-departure Assessment and Advice: Risk Factors

While current knowledge does not allow us to make reliable predictions about the exact risk of the emergence of various mental health conditions, the destination, duration, and purpose of travel must be considered when advising patients at risk for mental disorder. For short-term travelers with a history of mental health disorders, the most important preparation would be a review of prior psychiatric history, consideration of recurrence and how it might be managed, and education on the risks of casual sex (which is common among travelers and has mental health implications) and excessive alcohol use. For longer-term travelers, more extensive pre-travel assessment can be helpful. This would involve a more detailed psychiatric and substance abuse history, a history of prior exposure to trauma, discussion of how needed medications will be obtained, and consideration of the closest available mental health support in the traveler's native language. It should also give consideration to “resilience factors” (see below). Helping travelers think these issues through in advance helps mitigate the effect of problems that arise during travel.

Aside from prior psychiatric history, the most important risk factor for the emergence of psychiatric disorders during travel is level of stress experienced, and international travel is often stressful. Psychosocial stressors have long been known to exacerbate psychiatric conditions in travelers, especially depression, bipolar disorder, and psychosis. People with a history of depression are vulnerable to a number of the stresses of travel, especially international travel with duration of more than a few weeks. The sleeplessness caused by travel across many time zones, unexpected delays, misunderstandings due to language and culture barriers, and interpersonal stresses created by travel can all contribute to depression, so travelers vulnerable to depression should be prepared to anticipate stressors, have a game plan for dealing with the unexpected, and know where to turn in case problems arise.

Anxious patients who are traveling to malarious areas must use alternatives to mefloquine and chloroquine for malaria prophylaxis. Travelers with a history of anxiety or panic who are headed for stressful circumstances should be not only warned of the increased risk presented by stressful circumstances but counseled to assess the level of support available to them during travel and to determine how they will be supported should problems arise.

Alcohol-use disorders are also exacerbated by the stress of travel, and people are known to drink more freely during travel. As a result, alcohol-use disorders are a common focus of mental health concern among both short- and long-term travelers. Evaluation of travelers should include inquiry as to a history of an alcohol-use disorder along with guidance for moderate use of alcohol while traveling abroad and the importance of keeping in touch with friends or relatives during travel.

Patients on medications for chronic psychiatric conditions should be sure they have adequate medication and that it is located in more than one place, so that even if one portion is lost, a backup interim supply will be available. Box 17.1 contains additional useful advice for patients with chronic psychiatric problems.

Pre-travel Evaluation of Resilience

Classically, mental health evaluations have focused primarily on the risk factors discussed above. In recent years, however, there has been an additional focus on assessing resilience, since resilience factors seem to play an important role in assessing the likelihood of the development of mental health problems. “Resilience” in this context refers to a person's ability to recover after lengthy periods of adversity or after a traumatic event.

Increasingly, resilience assessment and training has become a part of preparation for people going on humanitarian travel of medium-term (3-12 months) duration. The resilience factors, as identified by Southwick and Charney, are factors that the traveler can start incorporating into his or her way of life in order to maximize the chances of a successful travel experience. Some of the resilience factors identified by Southwick and Charney include identifying sturdy role models, seeking out a resilient mentor, using cognitive flexibility as a coping style (e.g., humor, acceptance, reframing), active problem solving, drawing from religious and spiritual resources, and finding meaning in adversity. Travel preparation oriented around resilience may lessen vulnerability to traumas during travel where there is a significant risk of exposure to hardship or traumatic events. Southwick and Charney's summary of 10 factors that they observed in resilient individuals can also inform evaluation of travelers ( Box 17.2 ).

A final component of helping patients with psychiatric vulnerabilities to travel safely involves assessment of possible resources for the patient at the destination. Making such an assessment can be a complex process, not only because psychiatric resources can be extremely difficult to locate in the developing world, but also because, even in the developed world, such resources may well be suitable only for short-term travelers. Long-term travelers will need psychiatric care delivered in their native language and even developed countries in Europe may not have clinicians willing to cater to English speakers for ongoing care. Patients should be cautioned that, if they plan to be in a foreign country for an extended period of time, arrangements must be made in advance for the support of chronic psychiatric problems.

Common Mental Health Problems among Travelers and How They Arise