Travel and Mental Health

Level MLaura Kravitz

Principal Lecturer of Clinical Practice

Critically evaluate the difficulties that people with a mental illness face when travelling

Analyse the role of the pharmacist in improving patients’ access to travel

Learning Outcomes

Bar-El, Y et al (2000) Jerusalem Syndrome British Journal of Psychiatry 2000, 176, 86-90

Bor, R(2007) Psychological factors in airline passenger and crew behaviour: a clinical overview Travel Medicine and Infectious Disease 2007, 5, 201-216

Chen LH, Wilson ME, Schlangenhauf P (2007) Controversies and misconceptions in malaria chemoprophylaxis for travelers JAMA 2007.297(20):2251-2263

Habib, AG; Tambyah, PA; (2004) Confusion in travellers Travel Medicine and Infectious Disease 2004, 2, 23-25

McIntosh, IB; Swanson, V; Power, KG; Raeside, F; Dempster, C(1990) Anxiety and health problems related to air travel J Travel Med 1998; 5:198-204

Potasman, I; Beny, A; Seligman, H (2000) Neuropsychiatric problems in 2,500 long-term young travellers to the tropics J Travel Med 2000; 7:5-9

Savage, G (1900); The use and abuse of travel in the treatment of mental disorders Medici-psychological Association Meeting , 21st November 1900

Schlagenhauf, P; Johnson, R; Scwartz, E; Nothdurft HD; Steffen R (2009) Evaluation of mood profiles during malaria chemoprophylaxis J Trav Med vol16, Issue 2, 2009, 42-5

Siegel-Itzkovich, J (1999) Israel prepares for Jerusalem syndrome BMJ vol 318 484

Ref

In the past travel was used as a treatment forn mental illness.

History

Few other choices All mental illness was grouped as a single

entity (often simply ‘neurotic illness’) Mind over matter seemed a good option

Removed difficult patients! Avoided ‘certification’ (as a lunatic!) Some thought that this ‘neurosis’ may be

caused by physical illness, which may resolve in the sea air

Why was this seen as a good idea?

Many believed that it did! Some mental illnesses will remiss when

stressors are removed A treatment taken by the affluent only, so

more likely to be supported Many reports of suicide, notably patients

throwing themselves from boats or buildings

Did it work?

Often chronic, relentless illness

Quality of life

Carers and families

Today-why should the mentally ill want to travel?

Health insurance Prophylactic treatments Medicines available overseas Approach to treatment Exacerbation of existing illness during travel Specific illnesses associated with pilgrimage

Problems

Within the European Union-EHIC Outside the EU Private Insurance policies tend to exclude

existing conditions and also those conditions which may be considered related.

Health Insurance

Cover existing conditions-including mental illness

Eg. All Clear Orbis Free Spirit J&M Medicover

Specialist Policies

Members (who need not have a diagnosis of bipolar) may apply for highly specialised service

MDF-the Bipolar Association

The UK has seen enormous growth in research and development since the introduction of ‘Care in the Community’.

Not necessarily matched overseas-even in developed countries. Particularly marked where patients pay the actual cost of medicines

Prophylaxis and medicines available abroad

Transfer to inappropriate medicines Medicines with adverse effects lead to poor

adherence Interactions with other current medicines

If medicines are not available

Schizophrenia-NICE Newer medicines Patient centred Psychological treatments Treatment resistant?

Approach to treatment-some UK examples

Watchful waiting Newer medicines Psychological treatment ECT in exceptional circumstances

Depression-NICE

ECT used more widely in countries across Africa, also for broader range of conditions

Psychological treatments may not be available. Even where they are there may be issues associated with language

Overseas

Associated with travel related illness

Associated with prophylactic medicines?

Associated with stress?

Confusion in travellers

‘jet lag’ ; alteration of circadian rhythm-especially on long haul

? Antimalarials Alcohol Some travel associated illness, many

reports with typhoid Use of illicit medicines

What is likely to cause ‘confusion’?

Long haul travel is known to exacerbate existing conditions

‘homesickness’ Fear associated with means of travel Many travel to recover from a period of

stress

Stress associated with air travel

Some passengers regress to infantile behaviour-fighting over seats/ deck chairs

Disinhibited behaviour-sexual; revealing information about themselves; dress

Existing physical and mental stressors

How travel affects behaviour

……..difficult to predict

Especially in an emergency situation

However………

Affects 10-40% of travellers-phobia Dismissed by many health professionals Classified as a psychiatric condition May signal the presence of other conditions-

eg depression, anxiety Some are unable to fly Somatic symptoms Limited evidence of success of programmes

Fear of Flying

Many (40+ %) sufferers have other phobias

What is the fear of?CrashingEnclosed spaceLack of controlLack of knowledge of process-what do air

traffic control do?

Fear of flying-continued

Psychological treatments Discourage alcohol Limited use of medicines-increase chances

of events such as DVT

Recommend that airlines improve communication and information

Treatment

Associated with pilgrimages-not just to Jerusalem Patients may believe that they are a prominent

religious figure pilgrimages-most frequently reported in Christian pilgrims who believe that they are Jesus or Mary

Seen to act strangely-sometimes patients have no previous psychiatric history, however more often seen in patients with a history of psychosis

Link with excitement at being close to religious sites

Jerusalem Syndrome

Anxiety, nervousness, tension A desire to be alone in a holy site Fashioning ‘religious’ clothing Making individual processions to holy sites Making confused speeches at holy places Occasionally trying to move stones/

furniture at the sites → other pilgrims attacking them.

Symptoms

Typically no visual or auditory hallucinations Patients tend to know who and where they

are Condition normally resolves after 5-7 days if

the patient leaves the holy site Encourage patient not to isolate themselves

from their group

Treatment

Long haul patients Very religious people People who come from backgrounds where

they do not typically experience the large numbers seen at holy sites

Who is more likely to experience JS?

Particularly mefloquineSuicide warning on malaria pills after Cambridge

student's death-Daily Telegraph By Celia Hall, Medical Editor

Published: 12:01AM BST 28 Aug 2002Roche, the company that makes Larium, the malaria drug,

said yesterday that it has added the risk of suicide to its list of warnings to travellers prescribed the pills.

The warning states: "Rare cases of suicidal ideation [thoughts] and suicide have been reported though no relationship to drug administration has been confirmed."

What is the truth about malaria prophylaxis and mental health?

Very mixed Controlled studies suggest that serious

neuropsychiatric adverse effects no different from control

Why else may people who have been travelling display psychiatric symptoms?

Evidence

Patient HJ 24 female History of depression, known cannabis user Current medicines: Sertraline 100mg om Backpacking in Far East for a year

What can pharmacists do?

YU 44 year old male Paranoid schizophrenia Prescribed clozapine 300mg bd Travelling to Spain for 2/52

Patient WW, aged 23 female History of depression, no current medication Travelling around Africa for 6/52, alone