Expat mental health

No worries, this is not going to be a self-reflective breakdown piece.

While thinking about expat health, I came across reference to a 1998 study of the incidence of depression and personality disorders in long-term expats.  Drawing on interviews with 397 expats in 37 countries over 20 years, they documented high rates of affective and adjustment disorders as compared to normal incidences.  Risk factors included a prior history of psychological consultation, family history, and prior depression.

This was echoed by CDC’s GeoSentinal Surveillance network.  Founded in 1997, GeoSentinal is a worldwide network of specialized clinics, each contributing data on travel-related illnesses and trip information back to the central database.  They report that, of 4000 expat records, 18% of all clinic visits were for psychological disorders, mainly stress, depression, and anxiety.

More generally, the Chestnut Group Study in 2011 reported nearly triple the incidence of mental health disorders among expatriates as compared with the general population.  These included internalizing (depression, anxiety, sleep disorders), externalizing (conduct disorders, impulse control), and substance abuse problems.

Triple the risk!  While i've seen instances,  i had no idea it was so common. 

This could result from factors apart from simply being an expat.  For example, are the people who throw themselves happily into foreign assignments also the types prone to personality disorders (selection bias).  But the Big 5 Determinants of Expatriate Success suggest the opposite: long term expats are emotionally stable, extraverted, open, agreeable, and conscientious. 

Self-assured chameleons, not fragile flowers.

The other possibility is that the experience of being an expat leads to expression of bad personality traits.  Here, the authors suggest many contributing factors:

• Cultural dislocation
• Stress
• High demand for adjustment and adaptation
• Emotional disruption
• Loss of ‘containing ‘ features of the home environment
• Normalization of bad behaviours
• Less social pressure setting limits
• Loneliness, isolation

This feels much closer to the mark.  At one time or another, I have experienced almost all of these feelings.  Most pass, but I can see where they could take over one’s life.

A good summary of the literature can be found in Borwein’s presentation. 

And, if you suffer these problems, there are clinics available that specialize in treating expat health problems.

Entrepreneurs are another group who might fit the same set of environmental triggers: do they have the same set of disorders, the same heightened risks?  I’m still giving the literature a read, but was intrigued by this passage from a 1985 Harvard Business Review article, The Dark Side of Entrepreneurship:

Many entrepreneurs have personality traits and behaviors that allow them to succeed in their businesses; however, these same traits can often prove detrimental.  Many entrepreneurs distrust the world around them and fear being a victim; they scan the environment anticipating the worst; they can lose sight of the reality of situations. Ill consequences can be augmented when joined with a need for control. ... Many entrepreneurial behaviors are a result of the psychological defenses people use: they idealize, then vilify to extremes, project problems onto others, deny responsibility, or flee into actions...Instead of fighting the entrepreneur's idiosyncrasies, managers should adapt to them and regard developing them as a challenge…

‘Bottom line, as I said at the outset: I’m doing fine, but the documented risks really are sobering.

Thinking ahead about expat health

An expat’s biggest risk is ill health.  Most of the inconveniences, from visas to language, can be solved with time, money, and persistence.  But a bout of sickness or an accident requiring hospitalization can precipitate a real crisis.   Do you know how the health care system works and how to access care should you need it?  Will anyone realize that you’ve been injured; can anyone help during your convalescence?

Equally worrisome is the other side of the coin: if something were to happen to someone at home, how would you know and how could you help?

The healthcare needs of expats are growing quickly.  A recent survey reports:

There are over 50 million expatriates, and by 2020 this will be 60 million. 232 million people now live away from their country of birth. Between one in two and one in three expatriates has no international health insurance, although a minority is covered by domestic health insurance. Several countries seek to get expatriates and migrants to pay for healthcare or have compulsory health insurance.

The Boy Scouts have it right: Be Prepared.

Its important to think through the scenarios, put sensible measures in place.   Then you will have the processes, resources, and contingencies available should you ever have to rely on them.

‘A few thoughts from my experiences that may point you in the right direction (expathealth.org also offers relevant news and many practical tips):

1. Stay Healthy.

Eat healthy, get exercise and sleep, keep life bounded and in balance.  Avoid unsafe situations or foods, get an annual checkup and keep vaccinations current.  In short, stay ahead of problems before they grow into emergencies.

Expat life is inherently stressful, and good mental health practices are also important to consider and maintain.

2. Use the Buddy System.

I live independently, social and connected but not particularly stationary or scheduled.  If there were an emergency, it could be days before I was missed. 

Make sure that you stay c0onnected0 with someone who cares, and make it a daily habit to keep in touch about your plans, progress, and affect.  I use location-aware time-stamped messaging to send short updates to a key contact throughout the day: “Leaving on train from Amsterdam”, “Joining Robert for dinner”, “Made it home”. 

3. Register with a primary care clinic, then use it a few times.

Health care is good in Europe, but its organized, accessed, and paid for differently from place to place.  In the Netherlands and UK, patients access care through primary care physicians who you register with and who maintain my records and billing numbers.  If you have a minor complaint or illness, use the walk-in once or twice to get the hang of the system: when the walk-in hours are, how to fill a prescription, and how to access secondary providers like vision and dental clinics.  of course, know where the nearest hospital is located and the emergency services number (112 in Europe).

4. Check your coverage.

It can be a surprise to learn that expensive US health plans don’t cover lengthy overseas stays.  You may further need to pay for care yourself, then be reimbursed by your insurer.  I found that my life and disability insurance  had exclusions in some countries.  I found that plans can be extended with notification or a small rider for wider geographic coverage.

A local insurance plan (mandatory in the Netherlands) may be the best option.  But even then, you may need a further supplement for holiday travel.

If you need hospitalization or specialized treatment, allow enough time to set up a care plan and coverage.  I needed a long negotiation to secure coverage (in writing) and a referral from a US physician for a foot surgery.  Fortunately, the negotiated plan also covered temporary housing near the clinic and some transportation costs, which helped out a lot.

5.  Enable location tracking.

Make sure that someone can determine where you are.  Phones and tablets are GPS-Aware, and periodic location information can be stored or sent with a variety of apps.  Its reassuring to everyone if they can put a finger on where you are if you are long-overdue.

6. Stock your meds

Available over-the-counter meds and supplements vary widely from country to country, and remedies that you customarily rely on may not be available locally.  I keep some cold meds, throat lozenges, melatonin, low-dose aspirin, and a 60-day supply of prescription meds (eg: Lipitor) on hand, and help other expats replenish their cabinet when I visit the US.

7. Carry a notification ID.

This can range from a simple laminated printout to a full blown Medical ID bracelet or dogtag.  My card has my name, age, allergies, and emergency contacts: expanded information could include nationality, physician contacts, and chronic conditions or devices (eg: a pacemaker).

8. Know how to evac.

In a serious situation, facing extended hospitalization or rehabilitative treatments, you may need to go back to your home country.  Evacuation insurance can be useful: a friend suffered appendicitis and needed emergency surgery. It progressed to a serious abdominal infection, immobilizing him in Italy.  His US plan paid for a consult and progression to a flight back when his condition stabilized.  He had many months convalescence before he was fully recovered, but could have been pinned down alone in Europe without the cover.

Groynes, Chines, and Denes

April and May are filled with day’s off in Britain: Half-term breaks, bank holidays, commemorative celebrations, Easter.  They all start to run together: I’m still faintly surprised whenever someone reminds me not to make work calls on a holiday – it’s less effort than it used to be to set work aside and relax for the nicer portion of a day (especially if I can get free of VAT Reporting in favor of views to the Isle of Wight).

 

And, if you were wondering, a Chine is a steep-sided river valley, a Dene is a wooded valley, and a Groyne is a wall erected to prevent erosion.  All are common features of the Sandbanks – Bournemouth beachfront.

The locals don’t wander down in great numbers until after 2 pm, so there’s good time for a stroll and an ice cream if you arrive by noon.  The beach huts are still mostly unoccupied, although the ones that are open are starting to reveal their individual character and utility as I stop to peer inside.

 

I may still prefer life in the big cliff-top house though, with the panoramic views across the sea.

Lifeguard stations are open, following the California model of a big station with a mustached guard in a red tracksuit and binoculars bigger than wine-bottles.

 

TripAdvisor has ranked the 7-mile Bournemouth Beach as ‘best in the UK’ (nearby Swanage is ninth and Weymouth is eighth), and on a perfect warm Sunday, it’s pretty perfect.  A few more restaurants,  a few less cyclists and rules, but there’s not much else that could be improved.