Travel Risks for Those With Serious Mental Illness

Introduction: It has been known for a long time in the French-speaking, but not the English-speaking literature that travel can exacerbate pre-existing psychosis. The purpose of this article was to review the literature on this subject and present recommendations for prevention. Methods: For this narrative review of the literature on travel risks in individuals with pre-existing psychosis, appropriate terms were used to search Google Scholar, and all identified English, French, and Polish references were investigated. Results: Potential psychotogenic stresses of travel were found to be: mental confusion due to rapid transition into unfamiliar roles, physical discomfort and malaise seeding delusional beliefs, reawakening of old fears, loss of usual supports, overuse of substances to quiet fears, irregular scheduling or interruption of medications, jet lag with insomnia and hormonal shifts, the shock of acculturation, and unaccustomed interpersonal encounters. Women and the elderly were at greatest risk for symptom escalation related to travel. Conclusion: Travel risks need to be recognized and anticipated in vulnerable populations because many travel stressors are preventable.

erratic wandering, loud speech with no obvious addressee, emotional outbursts) is frequently seen in airports.The draw of airports and rail stations may be that they represent the pain of interpersonal separations as well as the hope of potential reunions. 12For someone starting out on a trip, the crowds, hubbub, and general arousal of the airport experience initiate a chain of uncertainty and bewilderment that can culminate in psychosis. 13For individuals with pre-existing psychotic illness, the airport environment can engender a delusional mood, a source of delusional thinking. 14lcohol is often used to assuage fears associated with travel, and this in itself constitutes an important travel-associated mental health risk. 15The use of alcohol and drugs of abuse can elicit psychiatric symptoms and can aggravate dehydration, motion sickness, and temperature-related illness. 16,17The best known sequelae of alcohol-triggered mental disturbance during travel are loss of inhibition and explosive anger (i.e., air rage). 18The more psychologically compromised someone is prior to travel, the more susceptible that person is to substance-related decompensation during travel.
The use of one's own therapeutic drugs bears risks as well by increasing the danger of thrombosis and pulmonary embolism on long flights. 19,20Travelers may also suffer adverse effects from immunizations or prophylactic travel drugs, some of which are known to produce psychotic symptoms in some individuals. 21It has been estimated that 1 in 10 000 to 15 000 users of mefloquine (used for malaria prophylaxis when traveling to countries where malaria is endemic) suffers from neuropsychiatric reactions, which can last from a few minutes to several weeks. 8,22The reaction usually takes the form of confusion and disorientation. 23Routine antipsychotic drug regimens can cause skin reactions at destinations where the sun is unaccustomedly strong 24 and such reactions can be misinterpreted in a delusional way. 25Any new symptom can act as a kernel for the formation of delusions in vulnerable individuals. 26ase Example: Travel Erotomania A patient who attended the women's Clinic for psychosis felt nauseous on the first leg of a journey by airplane.She developed the idea that the pilot was deliberately making her ill so that he would have an excuse to be with her when the plane landed.She was convinced that he had fallen instantaneously in love with her when he saw her board the plane.
Erotomania has been viewed as a delusion that fulfils an emotional need, 27 a need for affection that is reinforced by the loneliness and apprehension of travel, a vulnerable state Klaus Conrad called das trema. 26In this state, an ill feeling can be easily misinterpreted in a self-referential fashion (e.g., "The pilot is making me sick on purpose.") The original physical sensation can suddenly acquire extraordinary significance (e.g., "This is uncanny") and, perhaps result in reasoning biases such as premature "jumping to conclusions" 28 and believing oneself to be the center of attention of important others (the pilot). 29

Reaching One's Destination
Certain specific travel destinations, such as the end points of pilgrimages or sites of personal significance to individuals, have historically been associated with transient, or sometimes more long-lasting, psychotic reactions such as the "Jerusalem syndrome." [30][31][32][33] This phenomenon occurs when individuals identify with characters in holy texts or come to believe that they have a political or God-given mission that must be accomplished upon arrival at symbolically-weighted locations.
Because individuals with pre-existing psychotic illness rarely find the financial means to travel for recreation, when they do travel, it is most often for formal events such as weddings or funerals.The nature and meaning of the event, and especially the individuals they are exposed to, may be sufficient to trigger psychosis.
Case Example: Relapse Induced by Interpersonal Stress A patient from the women's clinic whose illness was stable traveled with her husband and daughter to celebrate her mother-in-law's birthday in another town.She had not seen her mother-in-law since her first psychotic episode a decade earlier at which time the two women had bitterly quarreled.Barely into the visit, the patient began to re-experience psychotic symptoms.Forced relationships with individuals encountered while traveling can trigger overwhelming social anxiety.Travel also entails unaccustomed accommodations that may provoke distress and fuel delusional thinking (e.g., "They are laughing at me.I can hear whispers through the wall.") Unfamiliar situations are well known for inducing paranoid thinking. 346][37][38] For mental health service users, this means not only separation from family and friends but also from trusted care providers and health resources.Broken attachments include places as well as people. 39,40Travel dramatically disturbs both animate and inanimate worlds, and individuals who have left home feel not only the loss of significant others, but also of the sights, sounds, smells, customs, and social milieu of familiar surroundings.Without emotional anchors such as one's own language, monetary system, transportation system, or shopping procedures, culture shock and disorientation can easily ensue.The loss of a familiar environment can be as distressing as the loss of a person, leading, by a similar trajectory, to homesickness, nostalgia, and a sense of diminished belonging. 41It is not unusual for an unfamiliar place to be perceived as hostile and threatening, especially if one is vulnerable to the misinterpretation of sensory perceptions. 34Marcheschi et al 42 found that, in people with severe mental illness living in supported housing, perceived physical and social factors in their environments determined approximately one third of the variance in the quality of their lives.The loss of a habitual social or occupational role while traveling (even the often stigmatized role of psychiatric patient) can lead to a sense of rootlessness and lost identity, 43 which looms especially large for individuals with personal experience of psychosis.Changes in temperature, climate, sunlight, or altitude also contribute to feelings of dislocation that lead, initially, to somatic discomfort.When the landscape also changes and familiar objects and rituals disappear, vulnerable individuals may subsequently experience fear that leads to misinterpretations of the inner (hallucinations) and outer (delusions) environment.
Like stress of any kind, acculturative stress increases the risk for psychosis. 44One form of acculturative stress is the fear of getting the language or customs of another country wrong and being laughed at. 45,46Individuals such as those with mental illness who have previously been exposed to stigmatizing attitudes are especially vulnerable to perceived ridicule and loss of face. 47

Post Travel Jet Lag
Reports in the literature have frequently noted an association between lack of sleep and emotional distress. 48Insomnia is aggravated by long distance travel and jet lag, which can trigger psychotic relapse.][52][53][54] Jet lag is thought to exacerbate psychotic conditions by disrupting the biological circadian system, and, in very vulnerable individuals, it can even precipitate de novo psychosis. 51,52Jet lag is associated with the greatest risk when multiple time zones are crossed in the same journey.The severity and extent of the physical, neurological, and emotional symptoms associated with jet lag also depend on the direction and speed of travel.It is easier to adjust to a longer day than to a shorter one, so that travel westward elicits less pronounced jet lag. 55On average, the rate of adaptation is approximately half a day per hour of time difference westwards, and 1 day per hour of the time difference eastwards. 56In individuals with prior mental illness, circadian rhythms may already be disrupted 57 ; research has linked polymorphisms or dysregulations of clock genes to schizophrenia. 58,59One cause (or effect) is the quasi-nocturnal lifestyle led by many individuals with schizophrenia, which contributes to a limited exposure to light.It also limits exposure to social zeitgebers, which are interpersonal events that regulate circadian rhythms and synchronize them with the environment. 60ircadian disruption, sleep onset insomnia, and difficulties in maintaining sleep in patients with schizophrenia may also be related to deficits in melatonin, leading to overactivity of the dopamine system.Melatonin deficits also result in dysfunction of the gamma-aminobutyric acid (GABA)-ergic system involved in sleep-wake signaling. 61

Who Is Most Vulnerable?
Increasing age is associated with increasing neurological and sensory vulnerability.This means that the elderly have a lower risk threshold for the stresses of travel. 62Disrupted circadian rhythms are slower to recover in older age and are thus more likely to lead to psychiatric symptoms. 63omen are more susceptible than men to both the motion sickness of travel by sea, 64 and to the desynchronization of body rhythms in jet lag syndromes.The latter disrupt cyclical hormonal patterns and, in this way, lower the threshold for psychotic manifestations. 65The literature on gender differences in circadian patterns in young and older adults is, however, conflicting, because not all studies have controlled for the effects of age. 66

Preventing Travel-Related Psychiatric Problems Practical Issues
Careful pre-travel screening and preparation can obviate many problems, 67 and have proven to be effective. 68ndividuals with pre-existing psychotic conditions are usually not expert travelers and often need guidance with respect to passports, visas, and pre-travel immunizations. 69They may need help with a number of practical planning issues such as choice of luggage, appropriate clothing for the intended destination, and adapters for electronic devices.Novice travelers may need information about what can and cannot be brought on board airplanes and what will be required during airport screening.Patients who receive monthly disability payments will need to organize a bridging arrangement to cover the period of travel.Patients should be advised to obtain sufficient cash and travelers' checks or an ATM card in advance and to purchase a pocket travel dictionary of useful phrases in the language of the host country.Medical insurance coverage for travel and for the stay in the country of destination also needs to be pre-arranged.For potentially unstable patients, medical insurance that covers the cost of hospital treatment in a foreign country and the cost of potential repatriation needs to be in place. 70dications and Medical Care Travelers should have with them copies of all their prescriptions.Explanatory letters from physicians may also be helpful because some countries have been known to refuse entry to travelers with a history of psychosis.All documents should be understandable in the different countries of transit and destination (e.g., such records should use generic names of medications).Patients should be advised to pack necessities such as medications in a carry-on bag in case checked luggage arrival is delayed.
It is advisable for care providers to liaise with providers at the destination site so that travelers have easy access to psychiatric care should it prove necessary.For individuals who receive depot antipsychotic injections, arrangements will need to be made for receipt of the injection at an appropriate site.Arrangements also need to be made for monitoring blood tests for patients being treated with clozapine or lithium.Clozapine is usually dispensed in amounts that cover only the period between blood tests; it is critical to cover the whole travel period because interruption of clozapine can lead to rapid relapse. 71nticipating travel stress, rehearsing responses to potential stressors, and practicing relaxation and breathing exercises are all helpful preparatory interventions.It can be useful to provide literature about the problems of jet lag or sea sickness, 72 to recommend, for instance, adequate sleep prior to travel, a ship cabin at water level or an airplane seat over the wings. 73requent consumption of light, soft, bland, low-fat, and low-acid food can minimize symptoms of motion sickness.For individuals who are more than usually prone to nausea, medications such as scopolamine can be prescribed.They are most effective when taken ahead of time although they may cause side effects (e.g., blurred vision, drowsiness, dry mouth) about which patients should be informed. 73Antacids can be helpful for stomach upset. 73Breathing exercises, regular stretches, abstinence from alcohol and plentiful fluid intake (not caffeinated) minimize the dehydrating effects of flight.It may be helpful to advise patients to bring books and magazines to read because sharing a close space with unfamiliar persons during a long airplane flight may prove intensely stressful. 74olice Records Patients with a police record (e.g., individuals who have been brought to hospital by police for psychiatric assessment at some point in the past) need to ascertain whether this will block access to their country of destination.It is important for such patients to know that old police records can be sealed or expunged upon request. 75ase Example: Being Stopped at the Border One Canadian patient, wanting to visit her parents who lived across the border in the United States, was turned back because she had once called the police, many years earlier, thinking she was being attacked.The call had resulted in a hospitalization with a subsequent police record of which she had not been aware.

Upon Arrival
Light is known to be the most important entrainer of circadian rhythm.When flying west, exposure to bright light in the evening and avoidance of light in the morning (e.g., by using eye shades or dark glasses) is recommended to induce a phase delay and, thus, minimize jet lag.When flying east, exposure to light in the morning and avoidance of light in the evening induce a circadian phase advance. 4The WHO 4 recommends a minimum block of 4 hours of sleep during the local nightknown as "anchor sleep"-to adapt to the new time zone.Day naps (with eye shades and earplugs) may help; a short nap upon arrival is especially strategic if feasible.Short-acting hypnotics may help with insomnia.WHO also recommends avoiding strenuous exercise during the 2 hours before attempting sleep; otherwise exercise, food consumption, and the taking of medication need to be adapted to the local time.Alertness-enhancing drugs (e.g., coffee, modafinil) are not recommended for individuals with pre-existing psychotic illness. 4elatonin is a chronobiotic (able to change the hands on the circadian clock) that is secreted by the pineal gland and turned off by light.It is available commercially in some countries, but WHO cautions that manufacturing methods are not standardized across the world. 4A Cochrane Review found that melatonin was effective in countering the effects of jet lag and was safe for short-term use (for up to 4 days after arrival at one's destination).The recommended dose is 2 to 5 mg taken 2 to 3 hours before bedtime.No evidence of benefit has been found when melatonin is taken prior to travel, however. 76Melatonin reduces the latency of sleep onset, increases sleep efficiency, and increases sleep duration. 77It may also have antidepressant effects, 78 useful in vulnerable populations.

Discussion
Travel, even when embarked on for the purpose of relaxation and enjoyment, can prove so stressful for individuals with pre-existing severe mental illness that it can result in psychotic relapse.Susceptible individuals adapt poorly to stressors and initial maladaptive responses can lead to more persistent forms of illness. 79Unpredictability of the stress is an important mediating factor; a stressor that is unexpected is especially difficult to adapt to and usually has relatively more severe consequences for the person.One hypothesis is that persons with serious mental illness are particularly

What Is Already Known?
It is well known that stress, insomnia, substance use, jet lag, and specific destinations can provoke psychotic reactions in vulnerable individuals.

What This Study Adds?
This review elaborates on the stresses of travel, adding unfamiliarity, loss of support, physical discomfort, new drugs, and interrupted medication schedules into the mix of psychotogenic risk factors.It also makes recommendations on how these can be avoided.

Review Highlights
stressed by events that they perceive as uncontrollable and that are seen as threats.Such events can leave a person feeling victimized, exploited, and powerless. 80Sudden losses have also been shown to lead to considerable subjective distress in this population. 81Travel often presents with unpredicted contingencies and with situations in which people can easily feel that they have lost their moorings and their ability to control what happens next.Many problems of travel can, however, be anticipated, thus markedly reducing the sense of loss and powerlessness.
Individuals differ in their susceptibility to stressors and this includes travel stress.The hypothalamic pituitary adrenal axis in women differs from that of men, rendering women more susceptible than men because of stronger and more prolonged secretion of steroids in response to stress. 79

Conclusion
Travel is a life event that carries potential risk for individuals with prior mental illness, especially for the elderly and for women.As long as the risks are recognized and anticipated, most stressors encountered during travel can be prepared for in advance and obviated.

Conflict of Interest Disclosures
No conflict of interest.

Ethical Approval
This review did not require institutional ethics approval.

Funding/Support
This review received no funding or external support.