travel and mental health
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Travel and Mental Health
Level MLaura Kravitz
Principal Lecturer of Clinical Practice
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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
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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
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In the past travel was used as a treatment forn mental illness.
History
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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?
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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?
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Often chronic, relentless illness
Quality of life
Carers and families
Today-why should the mentally ill want to travel?
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Health insurance Prophylactic treatments Medicines available overseas Approach to treatment Exacerbation of existing illness during travel Specific illnesses associated with pilgrimage
Problems
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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
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Cover existing conditions-including mental illness
Eg. All Clear Orbis Free Spirit J&M Medicover
Specialist Policies
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Members (who need not have a diagnosis of bipolar) may apply for highly specialised service
MDF-the Bipolar Association
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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
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Transfer to inappropriate medicines Medicines with adverse effects lead to poor
adherence Interactions with other current medicines
If medicines are not available
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Schizophrenia-NICE Newer medicines Patient centred Psychological treatments Treatment resistant?
Approach to treatment-some UK examples
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Watchful waiting Newer medicines Psychological treatment ECT in exceptional circumstances
Depression-NICE
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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
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Associated with travel related illness
Associated with prophylactic medicines?
Associated with stress?
Confusion in travellers
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‘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’?
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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
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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
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……..difficult to predict
Especially in an emergency situation
However………
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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
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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
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Psychological treatments Discourage alcohol Limited use of medicines-increase chances
of events such as DVT
Recommend that airlines improve communication and information
Treatment
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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
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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
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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
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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?
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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?
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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
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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?
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YU 44 year old male Paranoid schizophrenia Prescribed clozapine 300mg bd Travelling to Spain for 2/52
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Patient WW, aged 23 female History of depression, no current medication Travelling around Africa for 6/52, alone