The case of an individual with bipolar disorder is reported where travel between continents leads to marked changes in both mood and Facebook usage. The study by Do Nascimento et al. noted individuals who are likely to have BD have Facebook usage heavily influenced by their mood. Individuals were noted to tend to seek this social network when they were sad, worried/anxious and happy, primarily as a form of distraction in emotional moments [1]. There are studies that show that bipolar patients are at risk of develop an affective episode when they travel across time zones [2]. Rosen et al. reported on a new psychological malady referred to as an ‘‘iDisorder’’ which was defined as the negative relationship between technology usage and psychological health [3].

Do Nascimento comments that in periods of mania, people demonstrate high impulsivity and may become more sensitive to what is external to them and have a low threshold of tolerance for frustration. They note difficulty for bipolar individuals to effectively select what should or should not be disclosed drawing on the idea that everything that pertains to their life is important and must be shared [1].

A 55 year old married professional travelled from Australia to South America on vacation. He had an established history of bipolar affective disorder type 1 and was in treatment with a psychiatrist with monthly visits. He spent 28 h in flight on a westerly route involving two international flights of 14 h duration and a 4 hour stop over between the legs in the Middle East. He left Australia at 20:00 h and arrived in South America at 14:30 h (local time). He used 10 mg olanzapine early in the first leg to promote sleep. Despite the use of routine medication, sleep was hard to initiate and sustain on the first three nights at the new destination. On the first night 50 mg of quetiapine was used and 10 mg of olanzapine on the second and third night. His regular medication was lithium 900 mg, valproate 500 mg and escitalopram 20 mg, all daily.

At a later interview, both he and his partner reported a period of disturbed mood and increased energy with noticeable changes in behaviour including feeling rested after only a few hours of sleep, racing thoughts, distractibility and increased goal-directed activity. As is often the case, the individual’s partner was the first to pick up on symptoms in particular irritability and sleep issues [4]. She was observed to say to her husband “whenever you get unsettled, you go (retreat) to your computer”.

Increased internet use was a particular focus of the increased activity, more specifically Facebook usage. Facebook time averaged three to four hours per day in total. More revealing than usual posts were made with respect to aspects of personal life. Friends not seen for years were sent friend requests. There was a mild sense of grandiosity in that the posts were seen to be of assistance to others in some ways. There was a driven-ness to use the internet in any “spare” moments despite the fact that the user was on holiday. More contacts were made with family members both by telephone and internet. More concerning, irritability lead to some altercations with others in the streets of a bustling major city. There was a near assault by a young South American woman who did not want the empty seat next to her taken by an impulsive and driven tourist. The noise of traffic including the persistence honking of horns added to the bipolar individual’s sense of hypervigilance. In general the stimulation offered by a big city was counter to the patient’s needs to settle and stabilise. The additional sensation-seeking aspects of being a tourist do not help in this situation.

The patient managed to return home to Australia after a disrupted holiday where his behavioural issues were managed in conjunction with his wife. She was able to contact his psychiatrist in Australia and increase doses of valproate as well as commence regular olanzapine as a “rescue” medication. There was concern about taking the flight home but it was managed with 5mg olanzapine qid prn according to the patient’s level of sedation as discussed with the treating psychiatrist.

There is promising biological research on the links between mood, sleep and the sleep-wake cycle. For example, a group in Korea has developed a screening method to detect animals vulnerable to bipolar disorder, observing the relationship between the recoveries of the normal sleep-wake cycle in mice after switching the light-dark cycle using the drug quinpirole. Jung et al suggest quinpirole-induced hyperactivity is an animal model of bipolar disorder and that individuals who have difficulties in adaptation to circadian rhythm disruption may be vulnerable to bipolar disorder [5].

There were psychosocial factors contributing to this episode of hypomania including factors before, during and after travel. The stress of preparing a business for a period of absence can be intense with the need to cover one’s duties during an absence and having an increased workload before leave. The international journey itself is now quite stressful with high levels of security and screening as well as the inherent fears associated with security issues. Arrival in a new location causes a rush of stimulation and a need to quickly take in information like the way to use new transport systems and even attempt new languages.

The risk to traveller/patient safety posed by these episodes should not be underestimated and most psychiatrists can recall cases where high risks to patients following frank psychiatric illness were generated by the combination of travel, stress to human psychophysiology and vulnerability to mood disorder. Inder et al. provide excellent guidance for practitioners on the full range of treatment advice including psychoeducation, flight scheduling, medication adherence and usage as well as specific sleep advice [6]. The opportunity for some couple counseling should not be overlooked in this setting. At a clinical level, there is a very important opportunity for doctors to counsel patients prior to overseas travel in order to help avoid serious bipolar episodes. A golden rule of psychiatry is to not foster avoidance but encourage individuals to work though their symptoms via effective treatment. Hence patients should most often be encouraged to travel but with the best possible biopsychosocial treatments.