Mental Health on Expeditions
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.
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. Medical professionals themselves are faced with challenges when operating in remote outdoor environments and therefore must be aware of their own needs and vulnerabilities alongside practicing excellent self-care.
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.
Recognising Specific psychiatric disorders:
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.
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
‘Depressed mood’ (feeling low)
Marked loss of interest or pleasure in almost all activities (anhedonia)
Significant (unintentional) weight loss or change in appetite
Insomnia or hypersomnia (sleeping too little or too much)
psychomotor agitation or retardation (physically underactive or overactive)
Fatigue or loss of energy
Feelings of worthlessness or excessive or inappropriate guilt
Reduced ability to think or concentrate or indecisiveness
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.
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.
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. 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.
