Chapter 2The Pre-Travel ConsultationCounseling & Advice for Travelers
Mental Health & Travel
International travel is stressful. Stressors vary to some extent with the type of travel, short-term travel likely offering the least stress and frequent travel and expatriation the most. Given the stressors of travel, preexisting psychiatric disorders can recur, and latent, undiagnosed problems can become apparent for the first time.
OCCURRENCE IN TRAVELERS
Incidence data based on population surveys of travelers are nonexistent. Data from clinical populations include the following:
- Patel et al. conducted a study of urgent repatriation of British diplomats and found that 11% of medical evacuations were “nonphysical,” or psychological in nature. Using the authors’ data, an overall incident rate of 0.34% for psychological evacuations occurred for their population. Of these, 41% were for some form of depression.
- Another study examined psychiatric evacuations over a 5-year period in the US Foreign Service population from 1982 through 1986. Using an unpublished estimate of the population served in this study, an overall incidence rate of 0.16% for psychiatric evacuations occurred. Of these, fully 50% were for substance abuse or affective disorder. Mania and hypomanic states accounted for 2.8% of these evacuations.
- Streltzer studied psychiatric emergencies in travelers to Hawaii and estimated a rate of 0.22% for tourists and 2.25% for transient travelers versus a rate of 1.25% for nontravelers. In order of decreasing frequency, diagnoses in this population were schizophrenia, alcohol abuse, anxiety reactions, and depression.
THE PRE-TRAVEL CONSULTATION AND MENTAL HEALTH EVALUATION
Any pre-travel consultation should include a mental health screening, especially for those planning extended travel or residence in a foreign country. Since travel medicine specialists rarely have mental health credentials, a full mental health inquiry with mental status examination and a psychiatric review of symptoms would not be practicable or productive. Rather, a brief inquiry aimed at eliciting previously diagnosed psychiatric disorders should be undertaken. To introduce this portion of the consultation and to elicit the most cooperation, the practitioner could enumerate the following facts:
- International travel is stressful for everyone and has been associated with the emergence or reemergence of mental health problems.
- The availability of culturally compatible mental health services varies widely.
- Laws regarding the use of illicit substances can be severe in some countries.
The practitioner can then ask about factors that might indicate a mental health problem:
- Any previously treated or diagnosed psychiatric disorders and the type of treatment involved (inpatient, outpatient, medications).
- Current treatment for any psychiatric disorders and their nature.
- Current or past use of illicit substances.
- Any diagnosis of substance use disorder, or suggestion from medical service providers, friends, or family that the traveler might be using alcohol or other substances to excess.
- Any immediate family history of serious mental health problems.
In general, any history of inpatient treatment, psychotic episode, violent or suicidal behavior, affective disorder (including mania, hypomania, or major depression), any treatment for substance use problems, and any current treatments would warrant further evaluation by a mental health professional, preferably one who has had some experience in problems relating to international travel. On occasion, the patient’s mental status upon examination may be notably abnormal, which would also warrant a referral.
Other issues that may be encountered and should be addressed during the pre-travel consultation include the following:
- Customs regulations: Traveling through customs with medications for personal use can be problematic in countries where those medications are prohibited. It is always wise to carry them in their original containers, along with a letter from the prescribing physician indicating that the medications have been prescribed for medical reasons. Even with these precautions, problems may still occur at customs. Occasionally the country’s embassy can be helpful prior to travel, but their advice may not be reliable. A health care provider in the destination country may be able to provide guidance about medication restrictions.
- Psychotropic medication refills: Obtaining these medications while living overseas can be problematic, as availability or even legality of the medication varies from country to country. Again, a check with the country’s embassy may be helpful, as would a check with a reputable in-country pharmacy or health care provider.
- Measuring drug levels: Locating laboratory facilities for the determination of lithium levels or for other mood-stabilizing medications may be challenging and should be investigated prior to travel. High temperatures and increased sweating could lead to toxicity, even on the same dose.
- Mefloquine: In general, patients with mental health issues should not be prescribed mefloquine for malarial chemoprophylaxis because of its potential for neuropsychiatric side effects.
- Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) meetings: Currently sober patients with substance use disorders should consider seeking out AA and NA meetings, depending upon their length of stay and stability of their sobriety.
- Sexual activity: An increase in sexual activity is often associated with international travel, along with casual and unprotected sex (see Chapter 3, Perspectives: Sex and Tourism). A frank discussion of sexual activity and its associated risks and precautions should be undertaken.
- Evacuation insurance: Travelers with mental health problems should consider travel health and medical evacuation insurance for emergencies when abroad.
POST-TRAVEL MENTAL HEALTH ISSUES
Travel health practitioners may be in a unique position to inquire about traumatic experiences a traveler might have had that may lead to posttraumatic stress disorder (PTSD). Travelers continuously exposed to high levels of stress, such as disaster relief workers, may experience a subclinical syndrome of PTSD.
If the traveler has had such an experience, clinicians should inquire about possible symptoms:
- Reexperiencing the event could include recurrent and intrusive recollections or distressing dreams of the event or feeling as if the event is happening again.
- Avoidance symptoms can include avoiding thoughts, feelings, activities, places, or people that lead to memories of the event.
- Arousal symptoms can include difficulty sleeping or concentrating, irritability, or an exaggerated startle response.
As symptoms may occur months or even years after an event, education about the possibility of having such symptoms in the future is worthwhile. If there is any doubt about a possible reaction to a traumatic event, referral to a psychiatrist is warranted.
- Benedek DM, Wynn GH. Clinical manual for management of PTSD. Arlington, VA: American Psychiatric Publishing, Inc.; 2011.
- Liese B, Mundt KA, Dell LD, Nagy L, Demure B. Medical insurance claims associated with international business travel. Occup Environ Med. 1997 Jul;54(7):499–503.
- Patel D, Easmon CJ, Dow C, Snashall DC, Seed PT. Medical repatriation of British diplomats resident overseas. J Travel Med. 2000 Mar–Apr;7(2):64–9.
- Streltzer J. Psychiatric emergencies in travelers to Hawaii. Compr Psychiatry. 1979 Sep–Oct;20(5):463–8.
- Valk TH. Psychiatric and psychosocial counseling of the international traveler and expatriate family. Shoreland’s Travel Medicine Monthly. 1998;2(7):1, 3–5, 10.
- Valk TH. Psychiatric medical evacuations within the Foreign Service. Foreign Serv Med Bull. 1988;268:9–11.