International travel is stressful. Stressors vary to some extent with the type of travel; short-term tourist travel likely offers the least stress and frequent travel and expatriation 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, short-term travelers may suffer from anxiety and aggravated depressive symptoms triggered by jet lag, fatigue, and work or family pressures. Remaining aware of these issues is important for providers when evaluating the ill patient who may have trouble distinguishing physical and psychological problems after travel.
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 Using an unpublished estimate of the population served in this study, an overall incidence rate of 0.16% for psychiatric evacuations occurred.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 (those arriving in Hawaii with no immediate plans to leave) 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.
- Quigley et al. studied repatriations over a 2-year period (2010–2012) comparing American-sponsored college students studying abroad with American-sponsored corporate business travelers and expatriates. They found a 23-times higher rate of repatriation because of mental health problems for the student population. In this population of repatriated students, in order of decreasing frequency, diagnoses were mood disorders, personality disorders, substance abuse, eating disorders, and schizophrenia or other psychotic disorders.
The PreTravel Consultation and Mental Health Evaluation
Any pretravel 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. 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 pretravel consultation include the following:
- Availability of culturally compatible mental health treatment in the destination country for long-term travelers or expatriates.
- Customs regulations: Traveling through customs with medications for personal use can be problematic in countries where those medications are prohibited. What substances are prohibited in any given country varies. Stimulants frequently used for attention deficit disorders, such as amphetamine or methylphenidate, may be problematic, along with narcotics. This list is not exhaustive, and travelers should check with the host country’s embassy if anything is questionable. A health care provider or pharmacist in the destination country may also be able to provide guidance about medication restrictions. It is always wise to carry medications 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.
- 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 ambient temperatures and increased sweating could lead to lithium 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. Please see the discussion of mefloquine in Chapter 3, Malaria.
- 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. AA and NA maintain, by country, lists of such meetings on their websites, although availability can change. Language of meetings should also be checked.
- Evacuation insurance: Travelers with mental health problems should consider travel health and medical evacuation insurance that does not exclude psychiatric evacuations 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 acute stress disorder (ASD) or posttraumatic stress disorder (PTSD). Travelers exposed to life-threatening events, such as disaster relief workers or war correspondents, may experience subclinical or outright ASD or PTSD.
If the traveler has had such experiences, clinicians should inquire about possible symptoms:
- Reexperiencing the event can include recurrent, intrusive recollections, distressing dreams of the event, and 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.
- Changes in mood or cognition associated with the event can include diminished interest in activities, inability to experience positive emotions, or an inability to remember significant details of the event.
- Arousal symptoms can include 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 psychiatrist 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.
- Feinstein A, Owen J, Blair N. A hazardous profession: war, journalists, and psychopathology. Am J Psychiatry. 2002 Sep;159(9):1570–5. [PMID:12202279]
- 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. [PMID:9282127]
- 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. [PMID:10759571]
- Quigley RL, Copeland R. Mental health and study abroad: incidence and mitigation strategies. Oral presentation at: 13th Conference of the International Society of Travel Medicine; 2013 May 19-23; Maastricht, The Netherlands.
- Streltzer J. Psychiatric emergencies in travelers to Hawaii. Compr Psychiatry. 1979 Sep-Oct;20(5): 463–8. [PMID:487802]
- Valk TH. Psychiatric medical evacuations within the Foreign Service. Foreign Serv Med Bull. 1988;268: 9–11.
- Valk TH. Psychiatric disorders of travel In: Keystone JS, Freedman DO, Kozarsky PE, Connor BA, Nothdurft HO, editors. Travel Medicine. 3rd ed. Philadelphia: Saunders Elsevier; 2013. pp. 439–48.
Thomas H. Valk