International travel and expatriation can be stressful for everyone involved. This stress is intensified by a lack of familiar support systems, separation from family and friends, changes in daily routines, unfamiliar surroundings and the presence of strangers, time zone changes, jet lag/sleep deprivation, language barriers, and culture shock. Persons with preexisting psychiatric disorders may be more susceptible to these stressors.
Fitness to Travel
Travelers (and/or family members) with psychiatric disorders should assess their suitability for long-term travel or expatriation, being especially aware of the following:
- Increased frequency of travel can lead to increased chance of relapse.
- Expatriation involves greater risk of relapse than short-term, infrequent travel.
Persons with a history of the following may be at significant risk of relapse:
- Psychosis or bizarre behavior in the past
- Conditions that involved danger to one's self or to others
- Long-term or debilitating disorders, such as with schizophrenia spectrum disorders, including schizophrenia
- Conditions that usually require (or have required) hospitalization
Discuss the following issues with the mental health care provider:
- Need for medical evacuation insurance, ensuring that the evacuation service does not exclude current or previous psychiatric disorders
- Availability of adequate mental health services, providers, and facilities at the destination
- Availability of reliable laboratory facilities to assess blood levels and potential side effects associated with some psychotropic medications
- Ability to legally carry needed medication to the destination without problems with customs or destination country laws. (Some medications may contain ingredients that are illegal in some countries.)
- Ability to carry sufficient quantity of medications for the entire trip (Traveler should carry prescriptions and provider a letter stating the need for medications.)
- Ability to obtain medications in the destination, if needed for long-term travelers or expatriates
Travelers should carry contact information for a trusted person (e.g., friend, relative, or health care provider) knowledgeable about their condition in the event that their mental health deteriorates during travel. A "Power of Attorney" should be considered because mental health laws differ in each country and some countries can detain and treat a person without consent.
Types of Preexisting Psychiatric Disorders
A bipolar disorder manic episode may result in a marked impairment of functioning, in psychotic features, and/or hospitalization. Persons with bipolar disorder who have successfully complied with long-term treatment and maintained mood stability are more likely to have success as expatriates, as long as treatment regimens can be continued in their new countries. A manic episode and, to a lesser extent, a hypomanic episode, with the usual hazardous combination of abundant energy and lack of judgement can be very damaging to an individual and adversely affect an overseas trip or work environment. Lithium, one of a number of mood stabilizing medications, is particularly sensitive to changes in diet, climate, and exercise; the traveler should be familiar with the symptoms of excessive lithium levels.
Major depression can be problematic, although the period between onset of the earliest symptoms and frank depression is usually weeks to months. Long-term stability, compliance with treatment, and insight into and acceptance of the problem are important components of success as an expatriate. Any discernable patterns of recurrence help predict time of increased risk. The past occurrence of psychotic symptoms, prominent suicidal ideation, and/or prior suicide attempts increases the risk incurred with relapse. An infrequently used class of antidepressants (monoamine oxidase inhibitors; MAOIs) requires certain dietary restrictions because they may cause dangerously high blood pressure when taken with certain foods or medications.
Alcohol and Drug Abuse
Alcohol and drug abuse disorders are characterized by relapses; thus, although long-term sobriety (on the order of years) is important and habitual use of appropriate 12-step programs is generally a good sign, continued stability is not guaranteed. These persons should acknowledge, without rationalization, how the disorder affects their work and social lives. The use of certain drugs in some countries is considered a crime that bears dire consequences; therefore, travelers should be aware of the possible legal consequences in the case of a relapse.
Medical Assistance Abroad
Travelers with preexisting psychiatric disorders should work with a health care provider and/or mental health care provider at home to locate and contact appropriate culturally compatible mental health professionals and facilities at destinations prior to travel. The availability of language-compatible 12-step programs should also be determined, if appropriate. Depending on the situation, it may be necessary for home-based providers to maintain regular contact with in-country providers. Travelers must also know where and how to obtain medications and laboratory testing, if necessary, to treat ongoing conditions.
Use stress relief techniques, maintain usual routines, comply with treatment regimens, recognize and avoid trigger situations that may exacerbate the above conditions, and recognize early warning signs to facilitate early intervention.