A couple of months ago my partner told me that he has booked us a holiday. It was hardly unexpected; we’d been talking about it for a while, and I’d left him to research options and make the big decisions. Despite this, upon hearing he’d made a booking I burst into tears – not tears of joy and gratitude, either, but ones of overwhelming anxiety. All sorts of concerns were running around in my head. For a start, there was the money issue. With my sick pay running out soon, and no benefits as yet awarded, why were we even going on holiday? And with those benefits claims in progress, would I end up on the TV news being judged “not really sick/disabled” for going abroad? How could I brave the beach with all the medication-related weight I’d put on during the past year? And – most significantly – wasn’t long haul travel really bad news for anyone with bipolar?
I’ve got more a grip now (thankfully!). I’ve remembered that the flights are being paid for with “use them or lose them” Airmiles. I’ve got some perspective on the fact that Mr Persuasion has been very stressed and overworked lately, and as the main income-earner has every right to spend some of that income on holiday accommodation if he wishes. I’ve discussed it at length with my Consultant, who believes the benefits of going away outweigh the risks, and therefore supports the idea. My concerns about travel, however, continue to niggle on. The one thing all the books and websites about bipolar seem uniformly agreed upon is that long-distance travel is bad news. It’s taken me a lot of internet searches to feel that I have a good understanding of the situation, and a workable plan to minimise the risks of our holiday being ruined by an acute episode. I’ve therefore tried to pull all my learning together below, in the hope that it might save a fellow bipolar bear some legwork in the future.
- What exactly is the deal with long haul flights?
Most sources agree that long-distance air travel is an issue, and that this is connected with crossing time zones and disrupting circadian rhythms – although north/south travel within a time zone or two can still be problematic for those who find flying stressful. The general view is that flying west to east – which usually causes people far worse jet lag symptoms – is particularly tricky. The always useful psycheducation site cites two studies suggesting that symptoms of mania are more common when travelling east, while depression in more common travelling west. So for British bipolar people travelling to the Americas or the Caribbean, this means we may more likely to be depressed on our holidays, but (hypo)manic on our return; and vice versa for those crossing the Atlantic to visit Europe. These studies have apparently been carried out at Heathrow airport, which suggests the effects of west-east travel can occur even while on the flight! Minimising the effect of time zone changes, and trying to prevent or reduce jet lag, therefore seems a sensible preventative measure for the bipolar traveller.
- What about melatonin?
This was my first thought, because I know a number of frequent transatlantic flyers who swear by it for jet lag prevention. I talked it over with my psychiatrist, but after looking into the matter he was unwilling to prescribe it for me on the grounds that it’s not licensed for that use in the UK. In any event, a little internet reading reveals that despite the wide-spread belief among travellers that melatonin is very effective, few clinical studies support this, and we don’t really know enough about the safety, efficacy or optimum dose. Probably best not added into my existing medicinal cocktail, then.
- Jet lag management
This appears to be the only medically-approved approach, and relies on gradually changing the time of your sleep/wake patterns to gently bring you into line with the time in your destination. David J Milkowitz explains it very well in The Bipolar Disorder Survival Guide. “One way to combat this travel disruption is to gradually adjust your internal time clock to the new place you’re going, before you actually leave. So, over the course of the week before you travel to a later time zone, go to bed an hour earlier than usual, then an hour and a half, then 2 hours earlier, and so forth… This procedure usually works best if you’ll be in the new time zone for more than a few days.” To travel east to west to somewhere with an earlier time zone requires going to bed progressively later over several days. Being somewhat mathematically challenged, I’ve downloaded the JetLag Genie app which calculates this for you, based on your home and destination time zones. For anyone who relies on antipsychotics or hypnotics to get to sleep, this of course entails changing the time that they take their medication. I know that my quetiapine has a 3-4 hour window between swallowing it and sleep descending upon me, so I plan to use the drug as the mechanism for adjusting my sleep pattern. This will mean using the JetLag Genie bedtime as my reference point, and putting a reminder in my phone 4 hours before the Genie’s recommended bedtime.
Many sites also suggest limiting/changing exposure to sunlight and food. I’ve decided I won’t be doing any of the food solutions, because making major changes in diet in the lead up to travel and on the flight is probably inadvisable for someone with a mood disorder, especially if they are on lithium. Light exposure seems more promising: for east to west travel, it is recommended that you expose yourself to light in the late afternoon and evening if you can, whilst avoiding light in the morning as much as possible (that’s assuming we have any actual sunlight in London in March; clearly I won’t be able to get evening sunlight, although if you had a SAD light box you could do this quite easily). The reverse (unsurprisingly) holds true for flying west to east, when you should try to expose yourself to light in the morning and avoid light in the evening as much as possible. JetLag Genie will also provides advice on this, which seems helpful.
- Taking meds abroad
There’s lots of good general advice out there about the practicalities of taking prescribed meds abroad. One excellent suggestion which I have come across in several places is to take twice as many meds as you need, just in case you lose some, and to always make sure you have at least one batch in your hand luggage. That way if your plane is delayed, you won’t have the trauma of not being able to take your meds when needed because they are locked down in the hold. Sounds obvious, but in order to be able to take double quantities abroad, you need to order extra repeat prescriptions to pick up in the week before you go. To avoid any complications with the local authorities, most sources suggest carrying meds only in their original containers, and possible with documentary evidence from your doctor that they are prescribed for you. This is going to take a bit of getting my head around as I am totally reliant on my dossette box to take the right number of pills per day – Mr Persuasion is just going to have to supervise me to make sure I take the right number of pills at the right time.
- Lithium on holiday
Lithium is always a big issue for travellers. Thankfully my psychiatrist feels my blood serum level is high enough for me to able to move the doses around to match my new time zone, without messing too much with the therapeutic effect. The key thing will be to remain sufficiently hydrated – both in the dryness of the aeroplane cabin and in the heat of my destination – to prevent that blood concentration from increasing too much. I have asked Mr P both to help me make sure that we have bottled water to hand at all times, and to look out for any symptoms of lithium toxicity (which is unlikely, but I’d rather he checked out any dopiness, lack of co-ordination and slurred speech with a physician, rather than just assuming I’ve been at the beachside cocktail bar).
- Travel insurance and treatment abroad
Mr P and I have general travel insurance including medical cover, but of course as a major pre-existing condition my bipolar is not covered. Bipolar UK have found a couple of companies who will cover bipolar people for possible treatment abroad, but they are not cheap. I asked one company how much it would cost to cover me for my 10 day trip, using the special code from the Bipolar UK website, and was quoted almost £150 – or more than £14 per day– which I have decided is unaffordable. I am confident Mr Persuasion can help me self-manage any symptoms if necessary. In any event, I have seen a fairly recent World Health Organisation survey into mental health in the country I am visiting, which found that there is no psychiatric hospital available, very limited training in mental health for medical staff, and no concept of human rights in mental health treatment. So all in all, I’m not sure what I would be paying for, given that I am not sure I would want to avail myself of treatment locally anyway. (Although if I do start to exhibit symptoms of lithium poisoning, Mr P is under instruction to get me to a hospital, and forget the money.) I would suggest that it’s worth checking out what medical provision is available for people with mental health disorders in your destination; most developed countries are OK, but you might be surprised about the lack of services in, for example, some Eastern European countries.
- Sticking to routines
Another common piece of advice is that bipolar travellers should as much as possible keep up with normal routines. Not just medications, but activities that support their mental health and promote recovery, such as exercise and bedtimes. To be honest, I’m not sure how realistic this is – isn’t part of the therapeutic benefit of holidays that people get a break from their routines and come back refreshed? As long as I get some exercise – and I plan on getting plenty of swimming done as well as some hiking – that should be plenty. I’ll be aiming to get to bed around the same time each night, but again I won’t hesitate to stay up later or get up earlier if that facilitates going on a once-in-a-lifetime day trip.
So what have I missed? Does anyone have any other useful suggestions? No pressure, but I’m almost ready to pack my suitcase….