Mental Health on Expeditions

Introduction

In the context of operating in challenging outdoor environments mental health can be viewed from two opposing perspectives. On the one hand wild, outdoor environments have been found to boost mental health & wellbeing in supported, low-stress scenarios.¹ However, sometimes the demands of expedition life, coupled with pre-existing mental health issues, may be difficult for some people to navigate and lead to significant difficulties. Individual response to a given scenario differs widely.² (Leach, 2016). Medical professionals themselves are faced with their own personal challenges when operating in remote outdoor environments and therefore must be aware of their own needs and vulnerabilities alongside practicing excellent self-care.

The Incidence and Impact Mental health problems on expeditions

There remains a dearth of literature around mental health incidents on expeditions. The most comprehensive study to date is from 2004 – 2008 with doctors recording illness and injury during 232 expeditions.³ From 16 reported psychiatric incidents, there were 13 exacerbations of previously diagnosed depressive illness, 1 case of acute psychosis, and 2 cases of ‘hysteria’ (please note, hysteria is not a recognised diagnosis!).

This data makes a strong case for the need to identify any participants who has diagnosed depressive illness (or indeed any long-term mental disorder) in advance of deployment via pre-expedition medical questionnaires. This can be challenging as non-disclosure is common, with one study recording rates of declared predeparture mental health history of between 0.95 and 1.5%. (Ref 0.1) Given that around 25% of people in the UK experience some form of mental health problem in a given year (Ref 0.2) this is likely to be a gross underestimate of the true disease burden. Non-disclosure is likely driven by both high levels of stigma around mental illness and concern by participants that they may be excluded from the expedition and it remains a challenging issue in pre-expedition screening.

Raleigh International is an organisation that takes large numbers of young people (‘venturers’) overseas to work on community, environmental and trekking projects. A detailed unpublished review of their medical incident data in 2018 examined a total of 2119 medical incidents across their global operations. Whilst only 3.5% of medical incidents overall related to mental health problems, it represented 66% of cases deemed serious enough for the venturer to be removed from the programme and returned home. Therefore, the impact of mental health conditions in these environments must not be underestimated. (Ref 0.3)

Psychological morbidity Vs psychiatric disorder

Expeditions can be roller coaster rides of emotional highs and lows. Identifying when a normal, adaptive human emotional response to a given stressor becomes truly pathological can be challenging.

Applying the biopsychosocial template can help us to formulate the reasons why certain individuals are at risk of mental health problems, why these present in the wilderness setting, what factors causes them to persist (rather than get better) and what the protective factors might be. This is a broader understanding of the context to what is happening rather than applying a neat and often overly reductionist ‘diagnostic label’. In the literature these are termed predisposing, precipitating, perpetuating and protective factors. (Ref 0.4)

Recognising Specific psychiatric disorders: key features

The following criteria are based on the latest International Classification in ICD-11 (Ref 0.4) which replaced ICD-10 in 2020.

Depression

The concurrent presence of 5 or more out of the following symptoms which must occur

• Most of the day
• Nearly ever day
• For at least 2 weeks

1. ‘Depressed mood’ (feeling low)
2. Marked loss of interest or pleasure in almost all activities (anhedonia)
3. Significant (unintentional) weight loss or change in appetite
4. Insomnia or hypersomnia (sleeping too little or too much)
5. psychomotor agitation or retardation (physically underactive or overactive)
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive or inappropriate guilt
8. Reduced ability to think or concentrate or indecisiveness
9. Recurrent thoughts of death or suicide (suicidal ideation)

Screening questionnaires were previously widely used in the diagnosis and monitoring of depression including Patient Health Questionnaire-9 and Beck Depression Inventory. Whilst these can be a helpful ‘guide’ they are no longer routinely recommended in the 2022 NICE Depression guidelines (ref 0.6) 

Generalised Anxiety Disorder (GAD)

• Marked symptoms of anxiety manifested by ‘general apprehensiveness’ or ‘excessive worry’ about negative events occurring in several aspects of everyday life.
• Associated features may include:
  • Restlessness
  • Palpitations,
  • Sweating
  • Trembling
  • Difficulty concentrating
  • Sleep disturbance.
• Symptoms should be present for at least ‘several months’

Acute psychosis (includes schizophrenia, mania, drug-induced psychosis).

Presentation is highly variable, but features may include positive and/or negative symptoms:

Positive symptoms:

• Hallucinations (perceptions in the absence of stimulus) – seeing or hearing things that objectively aren’t there.
• Delusions (fixed or falsely held beliefs) – may include a pervasive feeling that the individual is being controlled or that thoughts are inserted into their head, being withdrawn from them or are broadcast for others to hear
• Disordered speech and/or behaviour – a general lack of coherence, based around what they are normally like.

Negative symptoms:

• Blunted emotion
• Reduced speech
• Reduced motivation
• Self neglect and social withdrawal.

Acute Delerium

• Sudden behavioural change that develops over hours to days
• Symptoms fluctuate
• Can include:
  • Disorientation
  • Slow responses
  • Confusion
  • Drowsiness
  • Difficulty concentrating
  • Rambling or disorganised thinking

Hyperactive delirium – agitation, restlessness, wandering behaviour

Hypoactive delierum (more common) – lethargic, quiet, withdrawn.

Delirium is frequently triggered by a physical cause which could be anything from electrolyte imbalance to altitude illness to head injury. Therefore, patients require a full medical assessment.

Risk Assessment

Risk domains include:

• Risk to self
  • Suicide
  • Self harm
  • Self neglect (in austere environments this can be especially problematic and place a large burden on the rest of the expedition party).
• Risk to others
  • Aggression/ violence
  • Erratic behaviour endangering the group

A number of risk assessment tools have been developed, however they are ‘blunt instruments’ and no tool has been found to inform accurate prediction. (Ref 0.7)

The emphasis has shifted in recent years onto progressive questioning, weighing up of risk and protective factors and an individualised assessment of overall risk to make a reasoned judgement on whether that individuals is low, moderate or high risk. To inform this assessment it’s helpful to gather and corroborate information from different sources where possible (such as the patient, their tent mate, other observations by expedition staff, the patients doctor in their home country, their next of kin etc).

Confidentiality 

The assessment and management of mental health crises requires information gathering and sharing with the wider expedition team. Wherever possible it is important to do this with the expressed consent of the patient involved. Where this consent is not obtainable (i.e. the patient severely distressed or unable to engage) then share only the minimum information necessary to manage the situation and keep the patient safe, keeping their best interests at heart. (Ref 0.8). It’s common for other expedition members to want to know what is going on, but do not disclose details about the case unless you have consent, or there is an operational necessity to do so.

Wilderness Psychological First Aid (WPFA)

This has become an emerging field in its own right and has evolved out of conventional Psychological First Aid (PFA). It is a popular approach, although evidence for it’s effectiveness particularly in disaster and trauma settings remains lacking (ref 0.9) A range of different providers offer specific training on the initial assessment and management of mental health crises in the wilderness. Including:

https://www.survivefirstaid.com.au/acce – uses the ACCE Model developed by Dr Kate Baecher

https://wwsschool.com/psychological-first-aid Waypoint wilderness Survival school

https://www.mentalhealthwildernessfirstaid.ca/

The above courses are largely pitched at non-medically trained first responders and teach broad principles rather than specific medical management.

Laura McGladrey is a psychiatric nurse practitioner who frequently writes on this topic. Her 5 components of WPFA involve creating the following 5 conditions:

1. Safety – deactivate the fight and flight response.
2. Calm – be mindful of how you speak and act, calm yourself so that you can calm your patient.
3. Self-efficacy and collective efficacy- actively involve the patient in making a plan of action to avoid helplessness and victimhood.
4. Connection – use their name, build rapport, connect the patient in with loved ones and next of kin.
5. Hope – identify specific, accurate and positive facts about the situation. Remember suicide is a very permanent solution to a temporary problem. A positive approach benefits both the individual and the wider team.

(adapted from https://blog.nols.edu/2017/05/22/5-components-psychological-first-aid)

Provider Self-Care

Responding to the needs of others as an expedition medic can take it’s toll on your own mental health and wellbeing. Look after yourself! Here are Dr Will’s 5 top tips on managing the personal strain of expedition life.

1. Try to spend some time alone each day to regroup through quiet contemplation/reflection/reading a book/meditation/taking a walk. This is particularly important for the introverts amongst us who may find being around other people all day quite draining. On a busy expedition this may mean opportunistically snatching a few minutes where you can. In case there’s an emergency always tell people where you’re going, don’t stray too far from camp and take a radio or mobile phone with you.
2. Keep your strength up by making sure you sleep and eat well wherever you can. This is especially important on demanding physical challenges.
3. Find a confidante. Identify another member of staff who can chat things through with you and arrange regular debriefs together. This can help you process some of the negative emotion that being in close confines with other people will inevitably generate. Make sure your conversation remains kind and respectful and doesn’t descend into a bitching session about all the other members of the group!
4. Model vulnerability. It’s ok not to feel ok. If you are having an ‘off day’ or are really feeling the heat or the altitude, then it’s ok to let the rest of the group know you may be more short-tempered than usual. You are the medic and others will expect you to be strong but you are still, after all, only human. This approach has the added benefit of giving others permission to feel: creating an open dialogue for them to disclose difficulties they may be having rather than bottling them up.
5. Having said that – don’t be a moaning Minnie! Yes, let people know how rough you’re feeling, but avoid dwelling on this all day long. Chances are, everyone else is feeling it too and there is also a place for getting your head down, putting one pole in front of the other and pushing on.

References

1 Fullam, J., Hunt. H., Lovell, R., Husk.k et al (2021) Nature on Prescription. European Centre for Environment and Human Health, University of Exeter College of Medicine and Health, U.K

2 Jacoby, R., Barsky, K., Porat, T., Harel, S., Miller.t . and Goldzweig, G (2021) Individual stress response patterns: preliminary findings and possible implications. Public Library of Science (PLoS 1). Vol 16:8

3 Lyon, R. and Wiggins, C. (2010) ‘Expedition medicine – the risk of illness and injury’ Wilderness & Environmental Medicine, Vol 4:318-24

4 Coryell, W. (2021) Depressive Disorders. MSD Manual. Online [Available]: www.msdmanuals.com/professional/psychiatric-disorders/mood-disorders/depressive-disorders#v1028038

5 Sahebi, A., Yousefi, A., Abdi, K. et al (2021). The prevalence of Post-traumatic stress disorder among health care workers during the Covid-19 pandemic: an umbrella review and meta-analysis. Frontiers in Psychiatry. Vol 12: 764738

Additional References:

• Moore, J (2008) Mental Health Issues on Expedition. Wilderness & Environmental Medicine. Vo, 19, Issue 3 pp220-221.
• https://www.time-to-change.org.uk/ website accessed January 2023.
• Thank you to Katie Beck for sharing this data.
• Havighurst SS, Downey L. Clinical Reasoning for Child and Adolescent Mental Health Practitioners: The Mindful Formulation. Clinical Child Psychology and Psychiatry. 2009;14(2):251-271.
• Gaebel W, Stricker J, Kerst A. Changes from ICD-10 to ICD-11 and future directions in psychiatric classification
. Dialogues Clin Neurosci. 2020 Mar;22(1):7-15. doi: 10.31887/DCNS.2020.22.1/wgaebel. PMID: 32699501; PMCID: PMC7365296.
• Depression in adults:treatment and management NICE guideline NG222. Puglished: 29 June 2022.
• GMC Good Medical Practice Published 25^th March 2013 https://www.gmc-uk.org/-/media/documents/good-medical-practice—english-20200128_pdf-51527435.pdf
• SinclairL, Leach R. Exploring thoughts of suicide BMJ 2017; 356 :j1128 doi:10.1136/bmj.j1128
• Dieltjens, Tessa & Moonens, Inge & Van Praet, Koen & De Buck, Emmy & Vandekerckhove, Philippe. (2014). A Systematic Literature Search on Psychological First Aid: Lack of Evidence to Develop Guidelines. PloS one. 9. e114714. 10.1371/journal.pone.0114714.