Air travel can trigger mental health issues: Here’s how you can support your patients
Key Takeaways
Air travel can cause or exacerbate already-existing mental health issues like depression, anxiety, and psychosis. Some triggers are small spaces, lack of control, and fear of flying.
Experts say that social media allows people to capture and share passenger crises, which could influence future behavior and worsen mental health.
Healthcare providers must provide patients with tools for managing their mental health before and during air travel.
Recently, a woman on a flight claimed a fellow passenger was "not real." She was in hysterics as she exited the plane, which eventually caused a flight delay. Other passengers on the flight filmed her alleged mental breakdown, and the video ended up online. Although this is just the most recent case of someone acting out on a plane, it follows many other similar accounts. Raising the question, are more people really having mental health issues on flights? And if so, why?
There’s no denying that flying has become less comfortable—and not only because cabins are cramped (in fact, airline passenger advocacy groups claim that only 20% of the United States population can fit comfortably in most cabin seats). The flight experience, from the airport's chaos to the cabin's claustrophobia, can lead to distress, experts say.[][]
Passenger outbursts increased in frequency during the COVID-19 pandemic, according to the Associated Press. The surge in unruly passengers may have had a lot to do with pandemic stressors and people’s refusal to wear masks onboard. Still, many incidents are also a result of passenger mental health episodes—likely made worse by the harsh realities of air travel.[][]
The Association of Flight Attendants-CWA even wrote a statement in 2022 saying that the most violent passenger attacks had nothing to do with masks. That same year, the Federal Aviation Administration permanently established its Zero-Tolerance policy against unruly passengers.[][]
But where is this behavior coming from? According to Current Psychiatry, mental health crises make up 3% of all in-flight emergencies, and they’re triggered by plenty of issues, including cramped and busy cabins, long nonstop flights, and delayed flights. The research found that 90% of cases present as acute anxiety, with differential diagnoses including “depression, psychosis, personality disorders, and somatization.” Many people also struggle with anxiety related to turbulence, unknown sounds, and fear of terror attacks, according to Aerospace Medicine and Human Performance.[][]
“For many, flying causes a lot of anxiety, and those who already have anxiety, depression, or psychotic disorders [could] become symptomatic and act out before or during a flight due to stress,” says Christopher Hansen, LPC, CS, NCC, a licensed professional counselor and clinical supervisor at Thriveworks in San Antonio, TX.
According to Mollie Swillum, LCSW at Relief Mental Health in Oak Brook, IL, “Being on a flight also involves a loss of control, which can trigger trauma responses.” All of this fear and discomfort, she says, can lead to anger, which can play into anxiety responses, such as difficulty breathing, heart palpitations, tunnel vision, or even outbursts.
The impact of filming passengers during in-flight mental health episodes
Dr. Hansen says that social media apps like TikTok and Instagram are undoubtedly bringing many of these incidents to the fore.
A few recent examples of incidents caught on camera: One visibly frightened passenger demanded to be let off of a plane after saying she saw a person who was “not real”—possibly due to a mental health episode—while a man with a long history of mental health issues was detained by fellow passengers after threatening that there was going to be a “bloodbath” onboard. Some of these videos are even being meme-ified as though they are a form of entertainment rather than a representation of an individual’s potential mental health issues. Regarding the woman who claimed her fellow passenger was “not real,” Haley Hicks, LCSW, a social worker based in Dallas, TX, says, “In this particular case, it is possible that the passenger may have been experiencing a panic attack or another form of anxiety-related disorder. This could have been triggered by stress, fatigue, a fear of flying, or any number of other factors. We may never fully know what caused this person to have a breakdown, but it is important to remember that mental health issues are legitimate and should be treated with the same level of respect as any other medical issue.”
Research shows that social media also has power over how people and groups behave. In fact, says Ryan S. Sultan, MD, assistant professor of clinical psychiatry at Columbia University in New York, NY, “Social media is a backdoor into our minds that influences our behavior—at an unconscious level. Episodes [like the aforementioned] are likely to become contagious through social media. Capturing a person’s mental health episode is unkind to them and violates their privacy, even if the event was public.”[]
When videos like this circulate, the individual could suffer even more. “I think it's safe to say most people would experience the video as damaging to their wellbeing. At the margin, it might push some people to be suicidal,” Dr. Sultan adds.
Dr. Hansen explains that these issues have always been prevalent regardless of social media. Some of the behavior, he notes, comes down to the fact that “a lot of people self-medicate before flights, many times with alcohol or other drugs that can have adverse results.” In fact, alcohol consumption has been associated with acts of air rage, according to Psychiatric Bulletin.[]
Passengers aren’t the only people experiencing mental health issues. A pilot and aviation author, Chris Smith, penned an essay for Airways Magazine calling for improved access to mental health care for pilots.[]
Pilot depression and suicidal thoughts are not uncommon, according to Environmental Health. Many “manag[e] depressive symptoms perhaps without the possibility of treatment due to the fear of negative career impacts,” the authors write. The researchers even found that use of sleep aid medicines—meant to help pilots keep up with the demands of the job—was associated with higher levels of depression.[]
Beyond those experiencing acute mental health crises, The Travel and Tropical Medicine Manual, a resource that equips medical providers with knowledge around travel medicine, says that many frustrations stem from a “lack of courtesy and common sense.” The authors cite personal grooming tasks, unruly children, side effects of recreational and prescribed drugs, sleep deprivation, and jet lag as common triggers for unruly behavior on flights. []
Their recommendation?: Tell your patients to avoid confrontation with unruly passengers. “While airlines continue to work on ways to prevent, manage, and control passengers behaving badly, individual travelers who are affected should exit their seats if possible and quietly ask for assistance from a flight attendant, rather than directly confronting the person or persons creating the disturbance,” the authors write. If your patient is asking for ways to manage their own mental health while flying with other disturbed passengers, this might be a key recommendation.
How can healthcare providers (HCPs) support traveling patients—especially those with mental health struggles?
“Psychologists can play a supportive role in assisting patients who experience anxiety triggered specifically by flying,” Dr. Sultan says. “By teaching relaxation and mindfulness techniques, psychologists can empower patients with coping mechanisms to manage their anxiety effectively. Cognitive behavioral therapy (CBT) is also a valuable approach to treating anxiety and can provide patients with practical strategies to navigate their fear of flying.”
Dr. Sultan also says that HCPs should encourage patients to arrive early to the airport to eliminate extra stress and rushing and engage in mindfulness and relaxation techniques before the flight takes off.
“I also recommend instituting a safety plan where the patient has a person (therapist, if willing) that they can call while traveling or at the airport to help them through any sticking points. The mere knowledge that this plan is in place is often comforting enough for the patient,” Dr. Hansen suggests.
Getting a handle on mental health situations onboard should be an industry priority as well, Swillum says: “Training professionals in airports and on flights in Mental Health First Aid can be a great start to address these fears in a calm, de-escalating manner.”