Mental Health in Travelers | Yellow Book

Introduction

International travel is stressful. Stressors vary to some extent with the type of travel. Short-term, infrequent tourist travel likely creates the least stress, whereas frequent travel, humanitarian and disaster work, and expatriation cause the most. The stressors of travel can cause preexisting psychiatric disorders to recur, latent or undiagnosed problems to become apparent, and new problems to arise. In addition, jet lag, fatigue, travel during a pandemic, epidemic, or outbreak, and work or family pressures can trigger anxiety and aggravate depressive symptoms in travelers.

Occurrence of mental health problems in travelers

Epidemiological, survey-based data on the rate at which mental health problems occur in travelers is lacking. However, data from clinical populations, those travelers who sought mental health care, include a study of British diplomats, in which 11% of medical evacuations were psychological in nature. In this study, among people evacuated for psychological reasons, 71% were in their 20s; the overall incidence for psychological evacuations was 0.3%, 41% of which were for depression. In a study of the U.S. Foreign Service from 1982 through 1986, the incidence of psychiatric evacuations was 0.2%. Of these, 50% were for substance use or affective disorder. Evacuations for mania and hypomanic states accounted for 3% of psychiatric evacuations.

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 (non-traveling) residents of Hawaii. The study listed diagnoses in this population, in order of decreasing frequency, as schizophrenia, alcohol abuse, anxiety reaction, and depression. Finally, researchers in a landscape analysis of travel-related psychosis generated a rough calculation of the incidence for psychiatric hospitalization of tourists to a destination of high religious significance (i.e., Jerusalem). They noted 19.7 cases per 100,000; ≥3.5% of these were psychotic episodes without prior psychiatric history.

The pre-travel consultation and mental health evaluation

Travel medicine specialists should include some basic mental health screening in every pre-travel consultation. Travelers planning extended or frequent travel, participants in humanitarian or disaster relief work, and people intending to take up long-term or semipermanent residence in another country warrant particular attention.

Because travel medicine specialists rarely have mental health credentials, they should use a brief inquiry aimed at eliciting previously diagnosed psychiatric disorders. To introduce this portion of the consultation and to elicit the most cooperation, practitioners can enumerate that international travel is stressful for everyone and has been associated with the emergence or re-emergence of mental health problems; the availability of culturally compatible mental health services varies widely; and laws regarding the use of illicit substances can be severe in some countries.

Areas to cover are listed in Box 1.11.1 and include whether the traveler previously experienced, was treated for, or was diagnosed with a psychiatric disorder, including any associated with prior travel, and the type of treatment (inpatient, outpatient, or medications) involved, if any. Also inquire about current psychiatric disorders and treatment and whether any members of their immediate family have serious mental health problems. In addition, ask travelers about current or past use of illicit substances and whether they have a formally diagnosed substance use disorder or if healthcare professionals, friends, or family have suggested that the traveler might be using alcohol or other substances to excess.

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 or prior treatments warrant further evaluation by a mental health professional, preferably a professional experienced in handling problems related to international travel. On occasion, a patient’s mental status during the pre-travel consultation will be notably abnormal, which also should prompt a referral to a mental health professional for further evaluation.

Although not strictly a psychiatric issue, travelers aged 65 years or older should be queried about their cognitive function. Any traveler with memory issues should be given a formal cognitive function screen, such as the Mini Mental State Examination. Should such a screening indicate impairment, a referral to a neurologist should be made.

Box 1.11.1

Challenges and barriers to healthy travel

People with mental health issues might face several challenges and barriers to healthy travel. Be prepared to discuss and help the traveler manage the following situations.

Contraindicated medications

Mefloquine can cause neuropsychiatric side effects. Avoid prescribing mefloquine for malaria prophylaxis to patients with mental health issues. In addition, a patient with psychotic disorder should not be given tafenoquine for chemoprophylaxis. Further, psychiatric illness represents a warning for tafenoquine in the radical cure situation (see the discussion of mefloquine and tafenoquine in the Malaria chapter).

Laboratory monitoring of medication levels

For travelers who need routine laboratory testing to measure levels of lithium or other mood-stabilizing medications, healthcare professionals should make them aware that they could face challenges in locating in-country laboratory facilities capable of this testing. Inform travelers that medication levels might fluctuate, particularly in environments with high ambient temperatures, because increased perspiration can lead to lithium toxicity, even on a consistent dose.

Medical evacuation insurance

Encourage travelers with mental health issues to consider purchasing international travel health and medical evacuation insurance policies that include coverage for psychiatric emergencies. Caution the traveler that many medical evacuation policies exclude psychiatric emergencies or evacuation for preexisting conditions.

Mental health treatment

Long-term travelers and expatriates might have difficulty finding culturally compatible mental health treatment in the destination country. Counsel these travelers to seek assistance from a mental health professional with overseas experience.

Use of telehealth services

The COVID-19 pandemic, coupled with internet availability, resulted in the increased use of teletherapy. Travelers with current psychiatric disorders should consider making arrangements ahead of time to have regular teletherapy/ follow-up sessions with their mental health provider during their travels.

Refilling prescriptions

Long-term travelers and expatriates might have difficulty obtaining refills of psychotropic medications while living overseas because the availability, or even legality, of these drugs varies from country to country (see Traveling with Prohibited or Restricted Medications). Travelers should check with the U.S. embassy in the country or with a reputable in-country pharmacy or healthcare professional. As permitted by local laws, long-term travelers can have visiting friends, relatives, or other members of their company or organization bring additional medication.

Support groups

Currently sober travelers with substance use disorders might want to attend Alcoholics Anonymous (AA), Narcotics Anonymous (NA), or comparable meetings while overseas. AA and NA websites provide lists of meetings by country. Travelers should confirm availability and language of meetings in advance.

Traveling with psychotropic medications

Customs regulations in some countries prohibit importation of medications used to treat mental health disorders. Customs officials might confiscate Schedule II drugs such as narcotics or stimulants commonly used to treat attention deficit disorders, including amphetamines and methylphenidate. Rules vary by country, and travelers should check with the U.S. embassy in the country before traveling. Healthcare professionals, including pharmacists, in the destination country might 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 customs officials might seize their medication even if they adhere to these guidelines.

Stressors and countermeasures

Culture shock

Nearly anyone visiting a foreign culture can experience culture shock. Culture shock is the term that defines the common reactions a traveler has to being in a foreign culture. 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 syndrome. Foreknowledge of the phenomenon will help minimize the stress experienced, as will advance study of the culture, language, and health and security threats and countermeasures.

For most travelers, culture shock is limited and does not usually go beyond variations in mood, energy, sleep, and attitudes toward the host country culture, as in an adjustment disorder. Advise travelers that symptoms lasting >12 months could require assessment. In addition, suggest regular exercise, moderation in intoxicant use, adequate sleep and nutrition, and relaxation techniques (e.g., meditation, yoga, biofeedback) to help reduce the stress associated with international travel.

Jet lag disorder

Jet lag is a common, manageable stressor for most international travelers. Travelers and travel medicine specialists can find more details about this condition and what to do about it in Jet Lag Disorder.

Travel during a pandemic

Travel during a pandemic, epidemic, outbreak, or even to an area with an endemic infectious disease, may exacerbate travel-associated stress (e.g., border closures, testing or vaccination requirements, need for additional protective measures). Any steps travelers can take to gain some measure of control over their personal health and to mitigate the risk of becoming infected might help assuage some of this stress. To help, the travel medicine specialist should be ready to discuss the latest information on such matters, including vaccinations, medications, and infection avoidance measures.

Post-travel mental health issues

Generally speaking, every post-travel consultation should include an inquiry concerning mental health problems that may have occurred during travel. In particular, travelers who witness or who are directly involved in traumatic or life-threatening events can experience acute stress disorder (ASD) or post-traumatic stress disorder (PTSD). Examples of such events include motor vehicle accidents, assault or rape, terrorist incidents, natural disasters, war, or repeated exposures to gruesome details of a previously occurring traumatic event. The work performed by humanitarian aid workers, disaster relief workers, and war correspondents increases their risk of developing subclinical or overt ASD or PTSD.

For travelers who have 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 may also be present.

Symptoms of PTSD usually occur within 3 months of the event, but additional symptoms can take months or even years to develop. Thus, healthcare professionals should educate returning travelers about the possibility of having such symptoms in the future. If there is any concern about a traveler’s possible reaction to a traumatic event, refer them to a mental health professional. Symptoms of ASD are similar to those of PTSD but develop within 3 days and resolve by 1 month after event exposure. About half of those with ASD go on to develop PTSD.

People who have lived away from their home culture for extended periods of time (e.g., expatriates and their families) can experience reverse culture shock, which includes symptoms and a clinical course like that of culture shock. For example, first-year college students who spent their high school years abroad might find their home culture strange upon return. Adults returning from abroad can experience a decreased standard of living or can find their home culture changed in unanticipated ways.