The most vulnerable travelers: patients with mental disorders

Severe mental illness occurring abroad is a difficult situation for patients, their families, and the local medical community. Patients with mental problems are stigmatized due to both their mental illness and the fact that they are foreigners in an unfamiliar country 1. The appropriate treatment is often delayed, while patients are often dealt with in a manner that violates their human rights. Repatriation, which is associated with a better outcome of the mental disorder 2, is often delayed due to the lack of international protocols for the transportation and treatment of mentally ill travelers.

Acute travel-induced psychotic attacks are a well-known phenomenon in travelers without a previous history of psychosis. Young adults may experience their first psychiatric episode abroad 3. Elderly people are also susceptible to these attacks 4. Patients with a pre-existing mental illness almost never seek for pre-travel advice, so the prevention of any acute exacerbation is difficult. Specialists in travel medicine usually have little experience with these issues as they usually focus on infectious diseases.

There is research evidence that 11.3% of travelers experience some kind of psychiatric problem, with 2.5% suffering from severe psychosis and 1.2% requiring more than two months of therapy at home 5,6. The acute psychotic attacks represent about one fifth of travel-related psychiatric problems. Psycho-organic problems during leisure activities are as high as 5% 7. In a French sample, 15–20% of repatriations were due to psychiatric illness. These problems were predominant in long-term travelers, migrants or expatriates.

According to international standards, public transportation should not be used for acute psychotic patients, unless stabilized on medication and accompanied by a knowledgeable companion 8. Most travel insurance policies exclude treatment and repatriation costs incurred due to acute mental illness.

Modifying the approach to this issue by police, airport security, and insurance companies represents a challenge for psychiatrists. We believe that a clear set of guidelines, similar to those recently published by the WPA on other mental health issues 1,9,10,11, could help in detecting and managing the traveler with mental disorders abroad. An appropriate preparation of people with mental disorders who have to travel and the application of a protocol for repatriation when needed should decrease the reluctance of insurance companies to cover these patients.

The issue, however, is more complex than it may appear. In fact, while it is probably true that many clinicians have difficulties to memorize, recall and correctly apply operational diagnostic criteria, it should not be taken for granted that they will not have problems to memorize, recall and correctly apply prototypes proposed by a diagnostic system. Many clinicians are reluctant to change the templates of mental disorders they have built up in their mind along the years. Being influenced by those templates, they may selectively catch or recall the various features of a prototype, or may read in a prototype description elements which are not actually there. Moreover, the expectation that a given patient will present the various components of a prototype may lead the clinician to infer the presence of clinical aspects which do not actually appear in that patient. Finally, a clinician may conclude that a patient matches a given prototype because several elements of the prototype description are present, while another clinician may conclude that the same patient does not match that prototype because some other aspects are absent. These are indeed the biases that the operational approach aimed to correct, and the risk of a return to the diagnostic chaos preceding the publication of the DSM-III should not be overlooked.