Chapter 2The Pre-Travel ConsultationCounseling & Advice for Travelers

Victor Balaban

DESCRIPTION

Although most travelers complete their journeys with a manageable amount of stress, foreign travel can produce a wide range of psychiatric, behavioral, and neurologic issues in travelers. Any journey can produce challenges, but longer journeys to more remote and strange environments can increase the psychological stresses for travelers.

RISK FACTORS

Certain drugs can increase the risk of a psychiatric reaction. People with underlying psychiatric disorders should not receive the antimalarial medication mefloquine (Lariam). The neuropsychiatric side effects associated with mefloquine may become pronounced in these patients. Neuropsychiatric side effects may also be compounded when mefloquine is administered concurrently with the antiretroviral medication efavirenz (Sustiva), which also carries the risk of neurologic toxicity. Elderly travelers and travelers with memory or cognitive deficits may be more prone to develop delirium in flight, particularly when combined with dehydration, alcohol, or the use of sleep aids such as zolpidem (Ambien). The use of recreational drugs has also been found to be a trigger for psychiatric symptoms in travelers.

Stress can trigger or exacerbate psychiatric reactions in travelers with preexisting psychiatric or behavioral conditions. Even in travelers with no history of psychiatric problems, stressful events during travel, such as loneliness, a feeling of loss of control, financial difficulties, or a traumatic event, such as a serious illness or viewing disturbing sights, can have behavioral and psychosocial consequences.

OCCURRENCE AND RISK FOR TRAVELERS

Data are limited on the prevalence of travel-related psychiatric and neurologic disorders:

• Hartjes et al. conducted a web survey of 318 US study-abroad students and found that psychological distress was the second most commonly perceived travel health risk before travel and that 10% of students reported experiencing psychological distress during their travel, primarily loneliness, depression, or anxiety.
• In Potasman et al., a study of 2,500 Israeli long-term travelers to Southeast Asia found that 11% reported psychiatric or neurologic symptoms during travel, most commonly sleep disturbances, fatigue, and dizziness. Most symptoms were short-lived and transient, but 3% of travelers reported severe psychiatric or neurologic symptoms, and 1% had symptoms that lasted longer than 2 months.
• Patel et al. conducted a study of urgent repatriation of British diplomats and found that 41% of evacuations for nonphysical causes were due to depression.
• Adventure travelers in extreme settings, such as high-altitude mountain climbs and polar expeditions, may undergo psychiatric changes, including disturbed sleep, impaired cognitive ability, negative affect, and interpersonal tension and conflict. Studies of polar expeditions have found that approximately 5% of travelers meet criteria for psychiatric disorders (including substance-related and sleep disorders). Fagenholz et al. described 6 foreign trekkers treated at a rescue clinic in Nepal with an anxiety-related primary diagnosis and no history of anxiety-related disorders or other psychiatric disorders.

PRE-TRAVEL MENTAL HEALTH EVALUATION

Although it is not practical or appropriate to screen all travelers for potential mental health problems, the travel health provider should be alert for the following conditions and recommend follow-up or further screening, especially for long-term travel, people taking up residence overseas, or rescue workers. The following factors should be assessed:

• Preexisting psychiatric diagnoses, such as depression or anxiety disorders
• History of psychosis in the traveler or a close family member
• History of suicide attempts
• Evidence of depressed mood at assessment
• Exposure to prior traumas (such as disasters, severe injury, abuse, assault), particularly before travel that could involve reexposure to traumatic events or situations
• Recent major life stressors or emotional strain
• Use of medications that may have psychiatric or neurologic side effects
• Pre-travel anxieties and phobias that are severe enough to interfere with a patients’ ability to function or to prepare for and enjoy their travel

Long-term travelers, aid workers, military personnel, and other travelers likely to be exposed to stressful situations should be advised that the stresses and challenges they may face, particularly if combined with long hours of work, lack of sleep, or fatigue, can contribute to stress and anxiety. Long-term travelers should be encouraged to:

• Learn how to recognize signs of stress, exhaustion, depression, and anxiety in themselves.
• Take care of themselves physically by eating and exercising regularly.
• Use their full allotment of time off or annual vacation time, particularly if they recognize signs of stress or exhaustion in themselves.

DURING TRAVEL

Severe mental illness occurring abroad can be extremely stressful for travelers, their families, and people who try to care for them. Acute psychosis, leading to disruptive behavior, can land a traveler in jail in a developing country. Inpatient psychiatric facilities may be nonexistent or inadequate for a foreigner. It can be difficult to repatriate a psychotic person until the symptoms have been brought under control with medication. Someone will most often have to accompany the person home. Many evacuation insurance plans specifically exclude psychiatric illness from their coverage.

POST-TRAVEL MENTAL HEALTH EVALUATION

Returning travelers may have experienced physical illnesses, personal difficulties, or traumas that could result in psychiatric reactions. Travel-related injuries and diseases that affect quality of life can also have profound and long-term psychiatric effects. Even in the absence of trauma, some returning long-term travelers report experiencing “reverse culture shock” after their return, characterized by feelings of disorientation, unfamiliarity, and loss of confidence. Approximately 36% of aid workers report depression shortly after returning home, and as many as 60% of returned aid workers have reported feeling predominantly negative emotions on returning home, even though many reported that their time overseas was positive and fulfilling.

Post-travel evaluations should assess:

• Behavioral and psychiatric symptoms, including:
  • Experiences during or soon after travel that have been painful or hard to reconcile or that still cause distress, anxiety, or avoidance
  • Persistent sleep disturbance or unusual fatigue
  • Excessive use of alcohol or drugs
  • Behavioral or interpersonal difficulties at home, school, or work, or in friendships or relationships
• Somatic symptoms that can also be indications of distress, including:
  • Unexplained somatic symptoms, such as headaches, backaches, or abdominal pain, and somatic disorders, such as fibromyalgia, chronic fatigue syndrome, temporomandibular disorder, and irritable bowel syndrome
  • Rashes, itching, and skin diseases, such as psoriasis, atopic dermatitis, and urticaria, which can be exacerbated by stress

Clinicians should be aware that some travelers may be reluctant to acknowledge psychiatric symptoms or distress. For example, many cultures have stigmas associated with experiencing or disclosing behaviors associated with mental illness, as well as different culturally appropriate ways of expressing grief, pain, and loss. In addition, some travelers may fear being penalized or stigmatized at work if they have psychiatric diagnoses noted on their medical records.

Regardless of the type or duration of travel and whether or not travelers appear to meet criteria for a psychiatric diagnosis, returned travelers who are having difficulties functioning or who appear to be unduly depressed or distressed should be encouraged to seek appropriate treatment or counseling.

BIBLIOGRAPHY

1. Balaban V. Psychological assessment of children in disasters and emergencies. Disasters. 2006 Jun;30(2):178–98.
2. Beny A, Paz A, Potasman I. Psychiatric problems in returning travelers: features and associations. J Travel Med. 2001 Sep–Oct;8(5):243–6.
3. Bhadelia N, Klotman M, Caplivski D. The HIV-positive traveler. Am J Med. 2007 Jul;120(7):574–80.
4. Bor R. Psychological factors in airline passenger and crew behaviour: a clinical overview. Travel Med Infect Dis. 2007 Jul;5(4):207–16.
5. Crofford LJ. Violence, stress, and somatic syndromes. Trauma Violence Abuse. 2007 Jul;8(3):299–313.
6. Espino CM, Sundstrom SM, Frick HL, Jacobs M, Peters M. International business travel: impact on families and travellers. Occup Environ Med. 2002 May;59(5):309–22.
7. Fagenholz PJ, Murray AF, Gutman JA, Findley JK, Harris NS. New-onset anxiety disorders at high altitude. Wilderness Environ Med. 2007 Winter;18(4):312–6.
8. Hartjes LB, Baumann LC, Henriques JB. Travel health risk perceptions and prevention behaviors of US study abroad students. J Travel Med. 2009 Sep–Oct;16(5):338–43.
9. Hochedez P, Vinsentini P, Ansart S, Caumes E. Changes in the pattern of health disorders diagnosed among two cohorts of French travelers to Nepal, 17 years apart. J Travel Med. 2004 Nov–Dec;11(6):341–6.
10. Lankester T. Health care of the long-term traveller. Travel Med Infect Dis. 2005 Aug;3(3):143–55.
11. Palinkas LA, Suedfeld P. Psychological effects of polar expeditions. Lancet. 2008 Jan 12;371(9607):153–63.
12. 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.
13. Potasman I, Beny A, Seligmann H. Neuropsychiatric problems in 2,500 long-term young travelers to the tropics. J Travel Med. 2000 Jan;7(1):5–9.
14. Reed CM. Travel recommendations for older adults. Clin Geriatr Med. 2007 Aug;23(3):687–713, ix.
15. Rolfe M, Tang CM, Sabally S, Todd JE, Sam EB, Hatib N’Jie AB. Psychosis and cannabis abuse in The Gambia. A case-control study. Br J Psychiatry. 1993 Dec;163:798–801.
16. Urpe M, Buggiani G, Lotti T. Stress and psychoneuroimmunologic factors in dermatology. Dermatol Clin. 2005 Oct;23(4):609–17.