Chapter 3 Environmental Hazards & Other Noninfectious Health Risks
International travel is stressful. Stressors vary to some extent with the type of travel: short-term tourist travel likely creates the least stress, whereas frequent travel, humanitarian and disaster work, and expatriation cause the most. Given the stressors of travel, preexisting psychiatric disorders can recur, latent or undiagnosed problems can become apparent, and new problems can arise. In addition, jet lag, fatigue, and work or family pressures can trigger anxiety and aggravate depressive symptoms in short-term travelers.
OCCURRENCE IN TRAVELERS
Incidence data based on population surveys of travelers are nonexistent. Data from clinical populations include the following:
- In a study of British diplomats, 11% of medical evacuations were “nonphysical,” or psychological in nature. Of those evacuated for psychological reasons, 71% were in their 20s. There was an overall incidence of 0.3% for psychological evacuations. Of these, 41% were for depression.
- In a study of the US Foreign Service from 1982 through 1986, the incidence of psychiatric evacuations was 0.2%. Of these, 50% were for substance abuse or affective disorder. Evacuations for mania and hypomanic states accounted for 3%.
- A study of psychiatric emergencies in travelers to Hawaii estimated a rate of 0.2% for tourists and 2% for transient travelers (those arriving in Hawaii with no immediate plans to leave) versus 1% for residents. In order of decreasing frequency, diagnoses in this population were schizophrenia, alcohol abuse, anxiety reaction, and depression.
THE PRETRAVEL CONSULTATION AND MENTAL HEALTH EVALUATION
Any pretravel consultation should include a mental health screening, especially for the following groups: those planning extended or frequent travel; participants in humanitarian or disaster relief work; and anyone intending to take up long-term or semipermanent residence in another country. As travel medicine specialists rarely have mental health credentials, 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, practitioners can enumerate these 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 should then ask about indicators of overt or underlying mental health problems:
- Previously treated or diagnosed psychiatric disorders (including any associated with prior travel) and the type of treatment involved (inpatient, outpatient, medications)
- Current psychiatric disorders and treatment
- Current or past use of illicit substances
- Substance use disorder (formally diagnosed) or suggestions from health care providers, friends, or family that the traveler might be using alcohol or other substances to excess
- Serious mental health problems in the immediate family
In general, any history of inpatient treatment, psychotic episodes, 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 experienced in handling problems related to international travel. On occasion, a patient’s mental status during the pretravel consultation may be notably abnormal, which would also warrant a referral.
People with mental health issues may face several challenges and barriers to healthy travel. Pretravel health care providers should be prepared to discuss the following topics:
- Mental health treatment. Culturally compatible mental health treatment for long-term travelers or expatriates may be difficult to find in the destination country, requiring assistance from a mental health professional with overseas experience.
- Importation of psychotropic medications. Customs regulations in some countries prohibit importation of medications used to treat mental health disorders. Officials may confiscate schedule II drugs such as narcotics or stimulants (including amphetamines and methylphenidate) commonly used to treat attention deficit disorder. Rules vary by country and travelers should check with the host country’s embassy in advance of travel. Health care providers (including pharmacists) in the destination country may be able to provide guidance to colleagues about medication restrictions. Advise travelers to carry medications in their original containers, along with a letter from the prescribing physician indicating the medical reason for the prescription. Remind them that even if they adhere to these guidelines, customs officials may seize their medication.
- Refilling prescriptions. Obtaining refills of psychotropic medications while living overseas can be problematic, as availability or even legality of these drugs varies from country to country. Again, checking with the country’s embassy may be helpful, as would checking with a reputable in-country pharmacy or health care provider. Sometimes visiting friends or relatives or other members of the company or organization traveling can bring additional medication.
- Laboratory monitoring of medication levels. Locating in-country laboratory facilities capable of measuring levels of lithium or other mood-stabilizing medications can be challenging. Travelers should not assume stability of levels, particularly in environments with high ambient temperatures. Increased perspiration can lead to lithium toxicity, even on a consistent dose.
- Contraindicated medications. Because of its potential for neuropsychiatric side effects, patients with mental health issues should not take mefloquine for malaria prophylaxis. Please see the discussion of mefloquine in Chapter 4, Malaria.
- Support groups. Currently sober patients with substance use disorders may wish to attend Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) meetings while overseas. AA and NA maintain lists of meetings, by country, on their websites. Travelers should confirm availability and language of meetings in advance.
- Medical evacuation insurance. Travelers with mental health problems should consider purchasing international travel health and medical evacuation policies that include coverage for psychiatric emergencies.
STRESSORS AND COUNTERMEASURES
Jet lag is a common, manageable stressor for most international travelers. Readers can find more details about this condition—and what to do about it—in Chapter 8, Jet Lag. Almost anyone visiting a foreign culture can experience culture shock. With culture shock, travelers lose their sense of mastery over their environment, and even routine tasks of everyday life become a challenge. Separation from family and support systems, unfamiliar behavior and language, and new threats to health and safety can aggravate this condition. Foreknowledge of the phenomenon will help minimize the stress experienced, as will advance study of the culture, language, health and security threats, and their countermeasures. Fortunately, for most travelers culture shock is a limited syndrome that does not usually go beyond variations in mood, energy, sleep, and attitudes toward the host country culture as might be seen in an adjustment disorder. Symptoms lasting beyond 12 months may require assessment.
Regular exercise, moderation in the use of intoxicants, adequate sleep and nutrition, and use of relaxation techniques such as meditation, yoga, or biofeedback can be useful methods to reduce the stress associated with international travel.
POSTTRAVEL MENTAL HEALTH ISSUES
Travelers who witness traumatic and life-threatening events can experience acute stress disorder (ASD) or posttraumatic stress disorder (PTSD). The work performed by humanitarian aid or disaster relief workers or war correspondents increases their risk of developing subclinical or outright ASD or PTSD. If a traveler has had traumatic experiences, clinicians should inquire about:
- Recurrent, intrusive recollections, distressing dreams, and feeling as if the event is happening repeatedly
- Avoiding thoughts, feelings, activities, places, or people that lead to memories of the event
- Diminished interest in activities, inability to experience positive emotions, or an inability to remember significant details of the event
- Difficulty sleeping or concentrating, irritability, or an exaggerated startle response
As symptoms of PTSD 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 concern about a possible reaction to a traumatic event, referral to a mental health professional is warranted.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
- Benedek DM, Wynn GH. Clinical manual for management of PTSD. Arlington, VA: American Psychiatric Publishing, Inc.; 2011.
- Bonny-Noach H, Sagiv-Alayoff M. Rescuing Israeli travellers: effects of substance abuse, mental health, geographic region of rescue, gender and age of rescuees. J Travel Med. 2017 Sep 1;24(5).
- Feinstein A, Owen J, Blair N. A hazardous profession: war, journalists, and psychopathology. Am J Psychiatry. 2002 Sep; 159(9):1570–5.
- Felkai P, Kurimay T. Patients with mental problems—the most defenseless travellers. J Travel Med. 2017 Sep 1;24(5).
- Felkai P, Debreceni EO, Kurimay T. Travelers with mental problems—the most defenseless travelers. J Travel Med. 2017 Sep 1; 24(5).
- 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 medical evacuations within the Foreign Service. Foreign Serv Med Bull. 1988; 268: 9–11.