International travel is often a stressful experience. Travellers face separation from family and familiar social support systems, and must deal with the impact of foreign cultures and languages, as well as bewildering, unfamiliar threats to health and safety. Coping with high levels of stress may result in physical, social and psychological problems. Those who encounter a greater range of stress factors may be at greater risk for psychological problems. Under the stress of travel, pre-existing mental disorders can be exacerbated. Furthermore, for those people with a predisposition towards mental disorder, such a disorder may emerge for the first time during travel.
Physicians caring for people in their home countries or overseas should be aware of the differences (both within and between countries) in the availability of mental health resources (for example, emergency facilities, staff, beds and investigative facilities) as well as in the type and quality of medication. Culturally compatible clinicians and support staff may be rare or non-existent, and they may not understand the native language of the traveller, so access to interpreters may be necessary. The legal environment within which a clinician practises may also vary widely. Laws dealing with the use of illicit substances vary considerably and penalties may, in some countries, be quite severe. As a result of these differences in the infrastructure for providing mental health care and in legal systems, the first decision a clinician may have to make is whether the traveller’s care can be managed at the travel destination or whether the traveller requires repatriation.
While managing mental disorders, health care providers should remain aware of – and ensure protection of, and respect for – the rights of people with mental disorders, in keeping with international covenants and national laws. This should include informing individuals about their rights regarding their treatment, their health condition and treatment options, and obtaining consent for all diagnostic and treatment interventions as appropriate.
Mental disorders are not rare among travellers. Overall, mental health issues are among the leading causes of ill health among travellers, and “psychiatric emergency” is one of the most common medical reasons for air evacuation, along with injury and cardiovascular disease.
Precautions when undertaking travel
Although some of the events that cause stress cannot be predicted, taking precautions may reduce travel-related stress. Travellers should gather proper information before travel (for example, on the nature of their journey, such as the mode of travel or the journey length, or on the characteristics of their destination and the expected difficulties); this will enable them to maintain their self-confidence and to cope with the unfamiliar. It also allows them to develop strategies to minimize risks. Gathering information before travel helps to reduce the risk of suffering psychological disturbances or aggravating a pre-existing mental disorder.
Neuropsychiatric disturbances (seizures, psychosis and encephalopathy) occur in approximately 1 in 10 000 travellers receiving mefloquine prophylaxis for malaria. Patients with a recent history of neuropsychiatric disorder, including depression, generalized anxiety disorder, or psychotic or seizure disorder, should be prescribed an alternative regimen.
Travellers subject to stress and anxiety, especially concerning air travel, should be helped to develop coping mechanisms. Individuals who are afraid of flying may be referred to specialized courses run by airlines, if available.
Given the potential consequences of a psychiatric emergency arising while travelling overseas, enquiry into psychiatric history or treatment should be a standard part of any pre-travel consultation. Travellers with a significant history of mental disorder should receive specific medical and psychological advice. Those using psychotropic medication should continue the medication while travelling. In certain countries it is a criminal offence to carry a prescription psychotropic medication (for example, benzodiazepine) without proof of prescription. It is thus highly advisable that travellers carry a letter from a physician certifying the need for drugs or other medical items (Chapter 1), or both, as well as documents about their clinical conditions and details about treatment, such as copies of prescriptions. All these documents should be ideally in a language that is understood in the country of travel. Travellers who will be abroad for long periods of time (for example, expatriates or business travellers) can be taught self-monitoring techniques and stress-reduction strategies before departure or during their stay. If drug misuse is suspected, the large variation in the legal status of drug misuse among countries should be emphasized.
If the appropriate precautions are taken, most people affected by a mental disorder whose condition is stable and who are under the supervision of a medical specialist are able to travel abroad.
- Anxiety disorders
- Mood disorders and suicide attempts
- Psychotic disorders
- Disorders due to psychoactive substance use
Other relevant areas of concern
- Air rage
- Culture shock and reverse culture shock