In-flight psychiatric emergencies: What you should know

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Although they are rare, in-flight psychiatric emergencies occur because of large numbers of passengers, nonstop flights over longer distances, delayed flights, cramped cabins, and/or alcohol consumption.1,2 Psychiatric symptoms and substance intoxication/withdrawal each represent up to 3% of all in-flight emergencies, and in most cases (90%), the primary presentation is acute anxiety.1,2 Common in-flight psychiatric differential diagnoses include depression, psychosis, personality disorders, and somatization.1

When a passenger requires medical or psychiatric treatment, the flight crew often requests aid from any trained medical professionals who are on board to augment their capabilities and resources (eg, the flight crew’s training, ground-based medical support).1 In the United States, off-duty medical professionals are not legally required to assist during an in-flight medical emergency.1 The Aviation Medical Assistance Act of 1998 protects passengers who provide medical assistance from liability, except in cases of gross negligence or willful misconduct.1,3 Flights outside of the United States are governed by a complex combination of public and private international laws.1 Here I suggest how to initiate care during in-flight psychiatric emergencies, and offer therapeutic options to employ for a passenger who is exhibiting psychiatric symptoms.

What to do first

Before volunteering to assist in a mental health emergency, consider your capabilities and limitations. Do not volunteer if you are under the influence of alcohol, illicit substances, or any medications (prescription or over-the-counter) that could affect your judgment.

Inform the flight crew that you are a mental health clinician, and outline your current clinical expertise. While the flight crew obtains the medical emergency kit, work to establish rapport with the passenger to identify the psychiatric problem and help de-escalate the situation. Initiate care by1:

  • eliciting a psychiatric history
  • inquiring about any use of alcohol, illicit substances, or other mood-altering substances (eg, type, amount, and time of use)
  • identifying any use of psychotropic medications (eg, doses, last dose taken, and if these agents are on the aircraft).

The Federal Aviation Administration has minimum requirements for the contents of medical emergency kits aboard US airlines.1,4 However, they are not required to contain antipsychotics, naloxone, or benzodiazepines.1,4 Although you may have limited medical resources at your disposal, you can still help passengers in the following ways1:

Monitor vital signs and mental status changes, identify signs and symptoms of intoxication or withdrawal, and assess for respiratory distress. Provide reassurance to the passenger if appropriate.1

Administer naloxone (if available) for suspected opioid ingestion.1 Antiemetics, which are available in these medical kits, can be used if needed. Encourage passengers to remain hydrated and use oxygen as needed.

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