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Prof. dr.HM Joesoef Simbolon, SpKJ(K)
Mental Health & Travel
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DESCRIPTION
Although most travelers complete their journeyswith 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 longerjourneys to more remote and strange
environments can increase the psychological
stresses for travelers.
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RISK FACTORS
Certain drugs can increase the risk of a psychiatricreaction. People with underlying psychiatric disordersshould not receive the antimalarial medication mefloquine(Lariam). The neuropsychiatric side effects associatedwith mefloquine may become pronounced in thesepatients. Neuropsychiatric side effects may also be
compounded when mefloquine is administeredconcurrently with the antiretroviral medication efavirenz(Sustiva), which also carries the risk of neurologictoxicity. Elderly travelers and travelers with memory orcognitive 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 beenfound to be a trigger for psychiatric symptoms intravelers.
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Stress can trigger or exacerbate psychiatricreactions 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 ofcontrol, financial difficulties, or a traumatic event,
such as a serious illness or viewing disturbing sights,
can have behavioral and psychosocial
consequences.
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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.
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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% hadsymptoms 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.
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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 followingconditions 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:
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Preexisting psychiatric diagnoses, such as depression oranxiety disorders
History of psychosis in the traveler or a close familymember
History of suicide attempts
Evidence of depressed mood at assessment
Exposure to prior traumas (such as disasters, severeinjury, abuse, assault), particularly before travel thatcould 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 preparefor and enjoy their travel
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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:
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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 vacationtime, particularly if they recognize signs of stress or
exhaustion in themselves.
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DURING TRAVEL
Severe mental illness occurring abroad can beextremely 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 psychiatricfacilities 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.
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POST-TRAVEL MENTAL HEALTH
EVALUATION
Returning travelers may have experienced physicalillnesses, personal difficulties, or traumas that couldresult in psychiatric reactions. Travel-related injuries anddiseases that affect quality of life can also have profoundand long-term psychiatric effects. Even in the absence of
trauma, some returning long-term travelers reportexperiencing reverse culture shock after their return,characterized by feelings of disorientation, unfamiliarity,and loss of confidence. Approximately 36% of aidworkers report depression shortly after returning home,
and as many as 60% of returned aid workers havereported feeling predominantly negative emotions onreturning home, even though many reported that theirtime overseas was positive and fulfilling.
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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
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Post-travel evaluations should
assess:
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 aspsoriasis, atopic dermatitis, and urticaria, which can
be exacerbated by stress
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Clinicians should be aware that some travelersmay be reluctant to acknowledge psychiatric
symptoms or distress. For example, many
cultures have stigmas associated with
experiencing or disclosing behaviors associatedwith 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 havepsychiatric diagnoses noted on their medical
records.
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Regardless of the type or duration of travel andwhether 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 beencouraged to seek appropriate treatment or
counseling
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Thank You