Mental Illness in a Shipboard Environment

At any moment, 500 million people worldwide struggle with some sort of mental illness. One in four people will experience psychiatric symptoms at some point in their lives. These symptoms can arise from emotional distress, imbalance in brain chemicals, disease, or physical damage to the brain.

Some symptoms of mental illness can include:

• Feeling sad or down
• Confused thinking or reduced ability to concentrate
• Excessive fears or worries, or extreme feelings of guilt
• Extreme mood changes of highs and lows
• Significant tiredness, low energy, or problems sleeping
• Inability to cope with daily problems or stress
• Trouble understanding and relating to situations and to people
• Excessive anger, hostility, or violence
• Suicidal thinking

Most of the time, people can manage symptoms on their own- mental illness is not usually a barrier to a healthy, productive life. Healthy supports that can help people manage mild psychiatric illness include friends and family, medical care, and spiritual or religious communities. In most cases these are sufficient to help someone manage their symptoms.

Sometimes, however, it takes more effort to manage and overcome psychiatric symptoms, and they can become severe enough to require further professional help. Depending on the situation, medical treatment, mental health therapy, psychiatric intervention, or even temporary hospitalization may be required.

Psychosis is one example of the sort of severe symptom that can sometimes manifest with many different types of mental illness and brain injury. Psychosis can involve hallucinations (hearing, seeing, or otherwise sensing things that other people do not) or delusions (having irrational beliefs that are not based in reality). When mental or medical illness result in psychosis, it is referred to as a psychotic break- an event that can be extremely frightening and confusing for both the individual and those around him. The individual may feel that he is no longer in control of himself, and the people around him may fear for his safety or their own.

Often the symptoms of mental illness can be manageable under peaceful, comfortable conditions; but get worse during periods of stress. A shipboard environment provides a number of unique and stressful conditions that can dramatically increase the severity and nature of psychiatric symptoms, whether they are a result of mental illness or medical conditions.

Examples of these stressors include:

• Isolation: spending long periods of time at sea with little social interaction
• Separation from support system: no access to friends, family, or other comforts of home
• Tight deadlines: the need to accomplish important tasks very quickly
• Physical exhaustion: physically and mentally demanding work
• Sameness: boredom, lack of stimulation, and repetitive tasks
• Small, enclosed spaces: tight confines that can feel oppressive

In addition, the types of support resources that most often help relieve emotional distress- medical, emotional, and spiritual resources- are necessarily limited at sea. When everyone is focused on their missions, they are less able to observe one another for signs of emotional, mental, or medical distress. Under such stressful conditions, underlying mental illness or brain injury can become apparent, and existing symptoms can become worse.

Complicating matters is a reluctance of crewmembers to report any mental or emotional stress they are experiencing. As with other medical issues, crew may be afraid of losing their jobs if they report their symptoms. They may be afraid of becoming “blacklisted” due to their illness, especially if they have family who rely on their vessel income. Additionally, many people may fear appearing weak in front of their peers.

As a result, many symptoms of mental illness or emotional distress may go unreported for months or even years as the crewmember suffers in silence without seeking help.

If a crewmember seems to be exhibiting signs of emotional distress, mental illness, or psychosis, the first priority should be a medical examination. Since many symptoms can arise from medical issues, the crewmember should be assessed for injury or illness. However, only an experienced mental health professional can diagnose mental illness.

Treatment of severe mental health symptoms can take time. The duration of treatment is greatly lessened, and the treatment more successful, when the individual has access to the emotional and social supports he would normally have (while not at sea). Help from friends and family is one primary driver of recovery from psychiatric symptoms. Treatment is also faster and more effective when provided by mental health professionals from the individual’s own culture and in his native language. As a result, repatriation should always be considered for a crewmember experiencing a mental health crisis.

For severe symptoms, including psychosis, shipboard medical care may not be sufficient. In this case, medical staff should focus on de-escalation- keeping the crewmember calm and safe- until he can be repatriated to his home country for more directed treatment. This may involve temporary relief from work duties, providing a quiet and calm environment, or (in severe cases) temporary sedation.

Sometimes immediate hospitalization may be required in order to de-escalate and stabilize the crewmember.

While occasionally necessary for the safety of the crewmember, immediate hospitalization can present complications. Often a psychotic episode is brief and responds well to emergency treatment, but at times an underlying illness may mean a longer period of emergency supervision. In the United States (US), doctors have the authority to keep patients under observation if they consider the patient a risk to himself or others, or incapable of making rational decisions.

Particularly in psychiatric cases, US physicians are given full control of the patient’s care. This may mean a doctor or hospital could hold an ill crewmember for longer than stabilization and repatriation would normally require. This can result in greater distress to the crewmember, a longer time before he may be reunited with his support network and culturally appropriate care, and increased logistical difficulties when he is cleared to travel.

As a result, hospitalization in the US should be considered only for very short-term stabilization in the event the crewmember cannot be stabilized on board. The goal of mental health treatment should be the same as with any illness or injury: immediate safety and stabilization before returning to duties or repatriation. Repatriation and treatment in the crewmember’s home country will ultimately be more effective, safer, and less costly than an extended stay in a foreign hospital system.