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Head Games

Published: 02/06/2012 - Filed under: Home » Archive » 2012 » June 2012 » Lifestyle » Home » Features »

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Got the tickets? Check. The itinerary? Check. Laptop and smartphone? Check. Most business travelers have some kind of a checklist to help get them ready for a trip. Near the top of the list for most of us are things to do with our physical health. Do l need any medications? Do I have my running shoes? Should I get that tooth checked out at the dentist before embarking? While physical symptoms of illness and stress rise to the top of the list pretty quickly for the imminent traveler, another hazard lurks beneath the surface and remains largely unseen. 

Mental or behavioral health issues are surprisingly common among travelers, and while they don’t make for engaging dinner-time conversation, they are important to a traveler’s health, a company’s business productivity, and a travel department’s duty of care policies. 

Behavioral health problems can be slippery to track. Unlike an ulcer or other stress-induced condition, they are unpredictable and can catch you off-guard, regardless of whether you are currently on medication or have never been on any. 

When travelling, the “lack of familiar support systems, disrupted daily routines, language barriers, culture shock, and unexpected situations intensify stress levels rather than alleviate them,” according to a 2011 publication by the International Association for Medical Assistance to Travelers (IAMAT) entitled My Travel Mental Health Checklist – Travel Stress. “Travel also forces you to give up your sense of control,” the IAMAT report states.  This can trigger underlying health conditions or exacerbate current ones, bringing them to the forefront. 

“Travel health” is a vast frontier in the world of business travel, and doctors trained in travel medicine diagnose and treat travel-related illnesses. (An internal medicine or family physician is usually not trained in travel-related issues). 

Sleep disruption, poor diet and nutrition, climate changes, a lack of physical exercise, stressful schedules at the destination, difficult driving conditions, jet lag, unfamiliarity with a foreign country’s customs, increased alcohol intake, and even  homesickness can all play havoc with a traveler’s mind and body.

These multiple stressors can provoke a kind of “toxic stew,” which can then manifest as panic attacks, anxiety, disorientation, mood swings or depression. Repeated exposure to stressful conditions can cause traveler burnout. 

When the body is stressed, the mind can become disoriented. When the mind is affected, the body responds with symptoms of distress. The human being is a package, and travel stress can make it go awry. 

Taking Responsibility

We all understand that as individuals, we are responsible for our own health. However, a travel department’s policy can mitigate unforeseen risks associated with traveler health and safety. By being pro-active in the provision of comfort and health incentives and allowing for real-time assistance to travelers in distress, travel managers can create a strong duty of care ethic and save costs associated with unforeseen health risks. 

Traveler health issues can derail business productivity for days and sometimes weeks, and drive up insurance costs. A 1997 World Bank study demonstrated a direct correlation between the frequency of business travel and the filing of mental health claims; similarly, a later study showed spouses of frequent business travelers filing higher rates of mental health claims than those of non-travelers. The impact of business travel on a family’s mental health can cost a company hundreds of thousands of dollars in failed assignments.

While keeping up with vaccinations and physical health assessments is important, some companies support and encourage the frequent traveler by offering increased meal allowances to cover the expense of healthier foods, or allow employees to rent bikes and take yoga classes on the road. Some provide a convenient mini-workout kit (which includes a video and a resistance band). Other companies provide detailed “what to expect” information and access to an assistance company. With these tools, travelers can better manage their expectations and be prepared.

Analyze, Not Stigmatize

According to the World Health Organization (WHO), “given the potential consequences of a psychiatric emergency arising while traveling overseas, enquiry into the psychiatric history or treatment should be a standard part of any pre-travel consultation.” 

Behavioral health issues are increasingly on the radar of organizations and companies. Three years ago, the International Society of Travel Medicine (ISTM) created a behavioral health sub-group to address issues of international business travel and health. “Travel is uniquely stressful,” says Dr. Thomas Valk, chairperson of ISTM’s Psychological Health of Travelers Interest Group in Marshall, VA.

“One of the problems we face is that clinical data regarding how mental health issues affect the business travel community comes mostly from expat populations. For example, in one study of the US State Department, 28 percent of medical evacuations among  the Foreign Service population were due to substance use disorders, followed by affective disorders, such as depression,” he says.

“Companies would be wise to examine pre-existing mental health problems in pre-travel screenings,” Valk continues. “For example, while a low percentage of the populace has manic depressive disorder or bipolar disease, it is one of the hardest conditions to stabilize while overseas. When mania triggers an episode, a single employee can bring an overseas business location to a grinding halt. It can be days, even weeks before an employee even agrees to get psychiatric care.”

Similarly, panic attacks have and do occur in people with absolutely no prior history. The question is, how can a panic attack, which is an “acute response to psychological stress,” be managed? The person is often bewildered, and has a sudden onset of symptoms including a pounding heart, difficult breathing and a sense of lightheadedness. “There is also a feeling of absolute and total dread, which can run for several minutes, scaring the employee considerably,” explains Valk. 

Educating the traveler so they can recognize the warning signs of potential mental health issues (such as frequent unexplained crying spells, sudden changes in mood, and/or hyper-sensitivity), is vital. Another red flag is a decrease in cognitive functioning. In addition, travelers affected by depression or mania often make poor judgments. 

Assistance is a Call Away

Fortunately, there is help. “We’ve been researching behavioral health issues in corporate clients actively for the past 6-9 months,” notes Dr. Robert Quigley, regional medical director, Americas Region, at International SOS, an international healthcare, medical assistance, and security services company. “We receive four million calls a year for assistance, and behavioral health issues are very commonplace amongst these calls,” he says. “The behavioral health calls predominately originate from study abroad students. However they can also be from business travelers on short term or long term (relocation) assignments.”

In part, the issues facing global travelers are just a matter of sheer numbers. “There are millions of people on anti-anxiety drugs or who have been admitted into some kind of psychological therapy,” Quigley says.  “In the US, for example, of the 18 million students who attend college or university, almost 50 percent fall into this category. Extract from this group those students who go abroad wanting to escape their life, forget to take their medications while on their trip, and then are exposed to stressors that trigger their underlying health issues, and you can have a serious problem,” he recounts. “Many families send their kids abroad thinking a change of scenery will be good for them – but often, they are merely masking a problem that is not being dealt with.” 

The services of assistance companies are comprehensive and irreplaceable during a mental health crisis. “Just calling a doctor at an assistance company on a confidential help line can often be the singularly most immediate action that prevents a full-blown crisis from occurring,” Quigley adds.

What is the course of action after an employee or student places a call for assistance regarding behavioral health? Most important is the safety of the employee at hand, so stabilization of the situation comes first and foremost. An assessment is also made regarding the quality and availability of mental health care in the destination country. Here, understanding cross-cultural barriers among medical professionals is essential. In many cultures, mental health issues are simply not understood, and accompanied by a social stigma. Some clients have even been jailed for their “erratic behavior” rather than receiving proper medical attention.

If local health care is adequate, the patient is directed there. But if assistance company doctors decide there is a need to intervene, and repatriation is called for, then the patient is usually escorted back home on a commercial airliner with one family member/friend and one medical personnel. In extreme cases where the traveler may be at risk for inducing harm to himself or to others, as in cases of potential suicide, an air ambulance will be dispatched immediately with a full medical team experienced in behavioral health intervention.

Better Safe than Sorry

In another 2011 IAMAT report, Assuta Uffer-Marcolongo, IAMAT’s president, stated that “studies show that psychiatric emergencies are the leading cause for air evacuations along with injuries and cardiovascular diseases.” 

In light of this fact, it makes sense that travelers should be stable before a trip. “Going abroad adds so much stress to a person. When people change environments, behavior can change,” according to Susan Torroella, president of medical assistance at FrontierMEDEX, an integrated medical and security risk management firm in Baltimore, MD. “When you are stable, you can be better prepared. We often provide guidance to corporations prior to their travelers going abroad and also provide assistance to our clients once they are in country.”

When at your destination, try to keep a schedule that is not loaded with impossible deadlines. A rapid lifestyle, coupled with psychological stress induced from an employer’s high expectations of employee performance, can trigger mental health conditions. According to Torroella, some psychiatric cases have been costly. “One client in China developed a psychosis resulting in violence. In Jerusalem, a client developed a condition known as Jerusalem syndrome (a travel-induced psychosis).”

The issue of behavioral health medications is a huge topic in itself. “It’s best not to change any medications during the course of your trip unless advised by a physician,” cautions Torroella, “and to take your current medications on time. Both travel managers and travelers should be well-informed - for instance, which medications require a prescription? In some countries, certain psychotropic drugs are illegal to carry without documentation.”

Clear Policy = Duty of Care

According to an analysis in the 2011 Best Practice Report by the American Express Global Business Travel Advisory Services, “Attending to the safety and security of employees at home and abroad represents the biggest gap between corporate travel needs and existing policies today.” The report’s review of some 100 business travel policies showed that only 12 percent of those companies addressed the issue of traveler safety and security in a significant way. Also, “many companies have not reviewed travel policies in several years.”

In an increasingly fluid world of business travel, there is no better time than now to revise and modernize policy. “There should be an open dialogue in corporate travel departments, and particularly in scholastic study abroad programs, about behavioral health issues,” advises Quigley. “Travelers and students must act responsibly and disclose any pre-existing conditions; in this way, travel departments and student health departments can work with them and make necessary adjustments regarding any deployment.” Company travel policies must explicitly communicate what programs are available to employees; compliance with policy often depends on how clearly travel health directives are written

Although travelers can reduce anxiety by familiarizing themselves with their destination, the company’s travel department is usually the first line of defense. “Travel managers should know that cross-cultural training can make a huge impact in reducing the nervous tension that often accompanies travel,” says Torroella. “Incorporating an educational element into travel policy is a duty of care ethic.”    

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