Awareness of mental health is improving, however it still has a long way to go as illustrated by some of the statistics below.
One in four people in Britain will experience a mental health problem in any given year and this background prevalence means that it is almost certain that someone within in your expedition, whether this is a member of staff or a participant, will have a mental health condition.
Therefore it is important to know how best you can help!
Lots of expedition and wilderness medicine courses and lectures, focus upon things such as trauma, altitude, extremes of temperature and tropical disease. These are important, however much of what you may encounter day-to-day on expedition is likely to focus on primary care and mental health, whether this is informally through helping someone achieve their objective for the day, or more formally by managing someone with worsening suicidal ideation.
Despite suicide being the leading cause of death in young men, incredibly only £9.75 is spent per capita on research into mental health compared with £1,571 per capita for cancer.
Q: What can be done pre-departure?
A: Each participant and staff member that is going on the expedition should complete a medical self-declaration form. Sometimes this may also have been counter-signed and verified by the participants GP.
Some organisations will host a face-to-face pre-departure training day. This can allow the expedition medic to meet and chat with the participants to confirm their medical history and whether they are taking any medications. Alternatively it may be that this process has to occur over the phone, but it must happen prior to meeting in the airport- the last thing you want is to find out that someone is having worsening thoughts of self harm at the check-in desk at Gatwick.
This can be a real problem on expedition and not just confined to mental health problems. Participants may feel that they will be judged by the company providing the trip, its staff or other participants. Most often they fear that they will not be allowed to join the expedition.
Q: What can be done to avoid this?
A: It is important to listen and address the participants ideas, concerns and expectations. As the medic you should explain about confidentiality but also that information must be shared appropriately between team members to minimise risk.
You should explain that the aim of medical discussion pre-departure is not to stop individuals from going on the expedition but to optimise any issues pre-departure to reduce the risk of any problems during their trip.
Sometimes creating a contract between the participant, medic and expedition leader can be useful to address:
What is considered acceptable behaviour?
What should the participant do if they feel they cannot cope?
What will be the consequences of crossing the pre-determined boundaries?
This may be repatriation so it is important to consider this and ensure that everyone has travel insurance that covers repatriation for mental and physical health conditions.
Certain things, that may come up during you pre-departure screening, should alert you to the fact that a participant should probably not join the expedition.
The following RED FLAGS would certainly prompt the need for further information gathering:
Recent inpatient admission or section under the Mental Health Act
Poor medication compliance
Patient requiring depot medication (suggests poor compliance)
Psychosis or previous psychotic episodes
Recently started medication and still under regular specialist review or need regular monitoring (e.g. Lithium)
N.B. Lithium toxicity can be an issue in hot countries or when someone is over-exerting themselves and discussion must be had with patients that are taking this to reduce the chances of this happening
Suicidal ideation and/or plans
Previous history of self harm or attempted suicide
Rapid weight loss or features of Anorexia Nervosa ( participants will need to be stable for 1-2 years with satisfactory BMI)
Drug or EtOH addiction
Expeditions can be challenging for many reasons. Participants may be tired, hungry or jet-lagged. They may not be used to sleeping in a tent with other people. They can no longer interact with their friends on social media or contact home. The thought of going to the toilet in a hole and not washing properly may be a significant concern and they may be regretting their choice to come in the first place.
If you add these pressures to someone who is already suffering with a mental health condition, this may trigger a relapse or worsening of their symptoms. It is therefore important to identify and be alert to this and agree a set of coping mechanisms if at all possible.
Simple non-medical interventions can often help participants overcome these challenges, for example:
Progressive muscle relaxation
Having a “quiet area” at camp
Having a buddy system
Giving the individual a team role or task to give them a distraction and a sense of purpose can also be useful e.g. cook for the day. This needs to be timed correctly and will depend on an individual's personality and the context of their worsening symptoms.
Overall it is important to try and help the participant regain control and equip them with tools with which they can manage the rest of the expedition.
At this stage it may be prudent to re-iterate any ground rules and advise that if they become a danger to themselves or others, they may need to be taken to “Place of Safety” or be repatriated.
Adults or young people with mental health conditions may be vulnerable and more prone to exploitation. Participants are going to have much more time on their hands to think about life back home.
Safeguarding concerns may emerge during the expedition and participants may chose to confide in either yourself as the medic, another participant or another member of the expedition team.
It is therefore important for organisations to have a safeguarding policy and a nominated safeguarding lead. This may end up being you in the field and there needs to be a robust follow up and handover process to inform the participant’s GP and social services back in the UK if needed.
What about you?
As the medic on a trip, you will be doing the same as the participants, however once they finish and set up camp, you may still be working and dealing with various health complaints.
It is important to make time for yourself, whether this is through arranging a designated clinic time or by doing something that you enjoy alongside the expedition such as photography or yoga. Without this you are at risk of fatigue and burnout!
It goes without saying that this is also important in your day job back home!
Thats all for today's blog but if you have enjoyed reading why not listen to our podcast: http://anchor.fm/thewildernessmedicpodcast
Join me for a chat with Dr Lucy Obolensky, a multi-talented GP, A&E and HEMS doctor, who has worked on some fantastic projects, including being the medic for Planet Earth.
Yes...She has even looked after our national treasure Sir David Attenborough!
In this episode we discuss getting involved in expedition medicine, some of the challenges with working in remote environments and why you should always bring dessert to a dinner party!
You can also see what I have been up to at the SWMUK conference 2019 by watching this short video:
Until next time,