Level M Laura Kravitz Principal Lecturer of Clinical Practice

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

Bar-El, Y et al (2000) Jerusalem Syndrome British Journal of Psychiatry 2000, 176, 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 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 longterm 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 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,

86-90

Infectious Disease 2004, 2, 23-25

Medici-psychological Association Meeting , 21st November 1900

42-5 Siegel-Itzkovich, J (1999) Israel prepares for Jerusalem syndrome BMJ vol 318 484

In the past travel was used as a treatment forn mental illness.

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

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

Often chronic, relentless illness Quality of life

Carers and families

Health insurance Prophylactic treatments Medicines available overseas Approach to treatment Exacerbation of existing illness during travel Specific illnesses associated with pilgrimage

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.

Cover existing conditions-including mental illness Eg. All Clear Orbis Free Spirit J&M Medicover

Members (who need not have a diagnosis of bipolar) may apply for highly specialised service

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

Transfer to inappropriate medicines Medicines with adverse effects lead to poor adherence Interactions with other current medicines

Schizophrenia-NICE Newer medicines Patient centred Psychological treatments Treatment resistant?

Watchful waiting Newer medicines Psychological treatment ECT in exceptional circumstances

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

Associated with travel related illness Associated with prophylactic medicines?

Associated with stress?

jet lag ; alteration of circadian rhythmespecially on long haul ? Antimalarials Alcohol Some travel associated illness, many reports with typhoid Use of illicit medicines

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

Some passengers regress to infantile behaviour-fighting over seats/ deck chairs Disinhibited behaviour-sexual; revealing information about themselves; dress Existing physical and mental stressors

..difficult to predict Especially in an emergency situation

Affects 10-40% of travellers-phobia Dismissed by many health professionals Classified as a psychiatric condition May signal the presence of other conditionseg depression, anxiety Some are unable to fly Somatic symptoms Limited evidence of success of programmes

Many (40+ %) sufferers have other phobias

What is the fear of? Crashing Enclosed space Lack of control Lack of knowledge of process-what do air traffic control do?

Psychological treatments Discourage alcohol Limited use of medicines-increase chances of events such as DVT Recommend that airlines improve communication and information

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

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.

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

Long haul patients Very religious people People who come from backgrounds where they do not typically experience the large numbers seen at holy sites

Particularly mefloquine Suicide warning on malaria pills after Cambridge student's death-Daily Telegraph

By Celia Hall, Medical Editor Published: 12:01AM BST 28 Aug 2002 Roche, 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."

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?

Patient HJ 24 female History of depression, known cannabis user Current medicines: Sertraline 100mg om Backpacking in Far East for a year

YU 44 year old male Paranoid schizophrenia Prescribed clozapine 300mg bd Travelling to Spain for 2/52

Patient WW, aged 23 female History of depression, no current medication Travelling around Africa for 6/52, alone