The evaluation of psychosocial health, particularly across different cultural groups, is fraught with complexities. Many mental health problems may ‘syndrome differently’ in different cultures. For instance, we mentioned a brief rating scale for depression, but a perennial debate with regard to major depression is whether the high levels of somatisation (expressing distress through physical symptoms) among South East Asians and the high levels of ‘psychologisation’ (expressing distress through psychological symptoms) among North Americans constitute variations within the broad syndrome of depression, or in fact quite distinct disorders18.

The most common way of identifying or diagnosing mental health syndromes is through a clinical interview or standardized psychometric questionnaire. The former often takes considerable training, but can be guided by structured interview schedules, and these could be used by another crew member or through telehealth practitioners. However, individual’s responses to such interviews and the use of established questionnaires may also be problematic. A psychometric assessment instrument is never valid and reliable of itself; these attributes always exist relative to the population samples it has been used on.   A psychometric assessment for anxiety may have excellent specificity and sensitivity in a French sample, but the translated versions (even if it is perfectly accurately translated) may not work in the same way for a different linguistic or cultural group who construe and express their mental health problems differently. Very few psychometric instruments that assess mental health problems have been extensively used across cultural groups to allow us to be reasonably confident of their validity and reliability, while at the same time being short and simple to administer.

One of the few mental health measures that has been used across many cultural groups and shown to be valid is the General Health Questionnaire (GHQ) which comes in various versions; and its short form - the GHQ 12 – is as good a measure as is available. However, the trade off with its validity is its lack of ability to diagnose the exact nature of the mental health problem; rather it can detect the extent of a mental health difficulty along a continuum. It also suggests levels of scoring along this continuum which may be of a clinical severity to warrant intervention of some type, but doesn’t automatically place people into a category of “you have a problem”, or “you don’t have a problem”. This of course reflects more of a psychological and a medical (categorical) approach to diagnosis, but also allows reported measures to determine how an individual varies along a continuum over time. The GHQ 12 can be downloaded and a wide range of linguistic versions are available. It can be self-administered or used by any crew member who would like to help another crew member to establish how severe their distress is, although as noted the consequences of using it may be problematic. If a seafarer is labelled as having a “psychiatric problem”, they may be discharged by their company at the earliest opportunity, and this may be far from home, potentially making a problem into a crisis. Thus, the identification of significant mental health problems at sea will require sensitivity, confidentiality and back-up from people who have a real likelihood of being able to effectively intervene.

 Usually at sea treatment options for mental health problems are limited. Furthermore, some forms of psychopharmacology may promote dependence and may also affect attention and performance at sea. It is generally accepted that long-term prescription of psychoactive medication is not desirable for the majority of mental health problems, and evidence-based clinical guidelines developed through centres of excellence, such as NICE (the UK’s National Institute for Clinical Excellence) recommend psychological interventions as the first line of response for common mental health problems, such as depression.

Before even identifying the extent or nature of a mental health problem, it is often necessary to identify when such problems might exist, and some indications of this may come from aspects of work and social behaviour. According to the UK Health and Safety Executive27, behavioural signs of stress may include rushing around, skipping or rushing meals, swings in mood, worsening work relationships, irritability, becoming more indecisive, confused thinking and forgetfulness. Increases in smoking or drinking and drug abuse may all be associated with poor attempts to coping with stress. Increased complaints about health and feeling tired all of the time may also occur. Physical symptoms may include headaches, problems with the digestive system (indigestion, stomach pains, ulcers) as well as increased blood pressure with its corollary, an increase in cardiovascular disease (including stroke).

 

 Integrated occupational health systems for promoting, protecting and responding to psychosocial maritime health

There has been a timely call for a better integrated approach to maritime health by Jensen et al.28 and the advent of telehealth presents the prospects for health monitoring to move beyond the screening-out ‘Medicals’ approach to incorporating ongoing psychological and biological monitoring of crew onboard through regular checks and individually tailored advice ranging from personal health care and fitness to continual professional and self-development modules. Such a holistic approach can seek to combine each of the elements described in Figure 1, although obviously this requires high-level buy-in both attitudinally and in terms of resources and funding.  

The relationship between health and work is changing and becoming more complex: not only is their inter-relatedness being increasingly recognised, but in high-income economies more people in aging populations want to continue in work for longer, even when they have significant health problems29. The ideas of a ‘right to work’ and of ‘managing health problems at work’ may also permeate the maritime industry in time. As UN Secretary-General Ban Ki-moon stated on World Mental Health Day, 2010, “there can be no health without mental health”, and as we have indicated mental health and performance are bedfellows. So too are the many behaviour factors – from diet, to exercise, to relaxation – which are strongly implicated in serious physical illnesses, such as cardiovascular disease.

The ‘containment’ of life onboard a ship has often been seen as problematic and indeed we have indicated some of the psychosocial challenges associated with it. However, this encapsulation also offers unique opportunities for the development of occupational health and performance programmes that more comprehensively integrate work and leisure. One area which may hold particular promise in this regard is positive psychology30 where the focus is on facilitating positive health, positive attitudes, positive work behaviour, rather than correcting or addressing a ‘lack of’, ‘failures’, ‘errors’ or ‘dysfunctions’. While beyond the scope of this chapter, we call on health and occupational practitioners in the maritime industry to more effectively utilise the characteristics of maritime work to develop intervention programmes that stimulate strengths, health and good work at sea, whilst also being responsive to the sort of health challenges and their multiple levels of contributing factors, that we have discussed here.

 The evaluation of psychosocial health, particularly across different cultural groups, is fraught with complexities. Many mental health problems may ‘syndrome differently’ in different cultures. For instance, we mentioned a brief rating scale for depression, but a perennial debate with regard to major depression is whether the high levels of somatisation (expressing distress through physical symptoms) among South East Asians and the high levels of ‘psychologisation’ (expressing distress through psychological symptoms) among North Americans constitute variations within the broad syndrome of depression, or in fact quite distinct disorders18.

The most common way of identifying or diagnosing mental health syndromes is through a clinical interview or standardized psychometric questionnaire. The former often takes considerable training, but can be guided by structured interview schedules, and these could be used by another crew member or through telehealth practitioners. However, individual’s responses to such interviews and the use of established questionnaires may also be problematic. A psychometric assessment instrument is never valid and reliable of itself; these attributes always exist relative to the population samples it has been used on.   A psychometric assessment for anxiety may have excellent specificity and sensitivity in a French sample, but the translated versions (even if it is perfectly accurately translated) may not work in the same way for a different linguistic or cultural group who construe and express their mental health problems differently. Very few psychometric instruments that assess mental health problems have been extensively used across cultural groups to allow us to be reasonably confident of their validity and reliability, while at the same time being short and simple to administer.

One of the few mental health measures that has been used across many cultural groups and shown to be valid is the General Health Questionnaire (GHQ) which comes in various versions; and its short form - the GHQ 12 – is as good a measure as is available. However, the trade off with its validity is its lack of ability to diagnose the exact nature of the mental health problem; rather it can detect the extent of a mental health difficulty along a continuum. It also suggests levels of scoring along this continuum which may be of a clinical severity to warrant intervention of some type, but doesn’t automatically place people into a category of “you have a problem”, or “you don’t have a problem”. This of course reflects more of a psychological and a medical (categorical) approach to diagnosis, but also allows reported measures to determine how an individual varies along a continuum over time. The GHQ 12 can be downloaded and a wide range of linguistic versions are available. It can be self-administered or used by any crew member who would like to help another crew member to establish how severe their distress is, although as noted the consequences of using it may be problematic. If a seafarer is labelled as having a “psychiatric problem”, they may be discharged by their company at the earliest opportunity, and this may be far from home, potentially making a problem into a crisis. Thus, the identification of significant mental health problems at sea will require sensitivity, confidentiality and back-up from people who have a real likelihood of being able to effectively intervene.

 Usually at sea treatment options for mental health problems are limited. Furthermore, some forms of psychopharmacology may promote dependence and may also affect attention and performance at sea. It is generally accepted that long-term prescription of psychoactive medication is not desirable for the majority of mental health problems, and evidence-based clinical guidelines developed through centres of excellence, such as NICE (the UK’s National Institute for Clinical Excellence) recommend psychological interventions as the first line of response for common mental health problems, such as depression.

Before even identifying the extent or nature of a mental health problem, it is often necessary to identify when such problems might exist, and some indications of this may come from aspects of work and social behaviour. According to the UK Health and Safety Executive27, behavioural signs of stress may include rushing around, skipping or rushing meals, swings in mood, worsening work relationships, irritability, becoming more indecisive, confused thinking and forgetfulness. Increases in smoking or drinking and drug abuse may all be associated with poor attempts to coping with stress. Increased complaints about health and feeling tired all of the time may also occur. Physical symptoms may include headaches, problems with the digestive system (indigestion, stomach pains, ulcers) as well as increased blood pressure with its corollary, an increase in cardiovascular disease (including stroke).