Mental health crises can happen anywhere. But what happens if you’re stuck in the middle of the ocean?
Between 2009 and 2019, there were 212 overboard incidents – when a guest or crew member goes over the edge of a ship – according to statistics compiled for Cruise Lines International Association by consulting firm G.P. Wild (International) Limited. “In discussions with cruise line representatives, they indicated that in every case where the cause of the (overboard) was established following a careful investigation it was found to be the result of an intentional or reckless act,” the report said, noting that motives could not be determined in some cases.
There were also numerous reports of suspected suicides among crew trapped at sea during the COVID-19 pandemic. And while cruise lines have protocols and services in place to support to guests and crew members, some experts say they are lacking.
Cruise ships feature a range of amenities, from roller coasters and go-kart tracks to spas and dining, but passengers may not always know where to find mental health resources on board.
‘It’s really, really, really needed’
Cruise ships may be designed to prioritize fun and relaxation, but not everyone responds the same to that approach.
For some passengers, being around family members or away from their day-to-day routine can be stressful, said Dr. Tia Dole, Chief 988 Suicide & Crisis Lifeline Officer at Vibrant Emotional Health. “But for other people who might have been struggling with their mental health … going on a vacation actually takes you out of your environment, it makes you feel better,” she said.
The widespread presence of alcohol and gambling in onboard casinos may also prove challenging for some travelers, said Dr. Michelle Riba, a clinical professor at the University of Michigan Medical School’s Department of Psychiatry and former president of the American Psychiatric Association.
“People have to be self-reflective and talk to their loved ones about how problematic it might be to be on a ship where there’s easy access to that,” she said.
And when it comes to the kinds of overboard incidents that appear in news reports with some frequency, she said jumping into the water has perhaps been featured prominently in films and TV shows, and cruises may provide another “access point” to impulsive suicides.
Travis Heggie, a professor at Bowling Green State University who studies tourist health and safety issues, said it’s difficult to draw concrete comparisons, however, between rates at sea and on land due to a lack of comprehensive statistics. Riba added that it would be hard to compare the two, given varying demographics and other factors.
Still, suicide on cruise ships is a “growing concern” for Heggie, among both guests and crew. He has recommended adding mental health care to cruise ship infirmaries in his research.
“It’s really, really, really needed,” he said.
Dole also emphasized that “the reasons why people die by suicide are as unique as a fingerprint” and said it’s important not to generalize.
“The circumstances that lead up to completed suicide, and the things that sort of push people over the edge are incredibly unique,” she said.
Do cruise ships have mental health resources?
If passengers find themselves in need of mental health support during a cruise, some lines do have resources available.
Passengers sailing with Carnival Corp., the parent company of brands including Carnival Cruise Line, Princess Cruises and Holland America Line, can contact onboard medical staff “who are available 24/7 for mental health support and other medical needs,” a spokesperson for the company said in an email.
“With a referral from the shipboard medical team, guests may also access tele-psychiatrist services for face-to-face consultations with these licensed specialists within 24 hours if needed,” the spokesperson added. The consultations are offered through a third-party company that connects passengers with U.S.-based psychiatrists (the company did not respond to USA TODAY’s request for comment).
While training in mental health care varies among onboard medical staff, they can “fulfill recommendations made by the psychiatrists.” There is a pharmacy on board with many medications used to treat mental health problems, and those not carried on the vessel can be ordered in a port.
Like other medical care, passengers have to pay for any costs associated with mental health services. “Travel insurance coverage varies by provider and typically covers acute-need services but usually includes limitations for pre-existing illnesses,” the spokesperson said. “We urge travelers to contact travel insurance providers directly for specific terms and conditions.”
Crew members can also see psychiatrists via telehealth with a referral from the onboard medical team. The company also has an employee assistance program that allows them to access free mental health services.
Royal Caribbean Group, another major cruise line operator, and Cruise Lines International Association, the industry’s leading trade group, did not answer questions regarding onboard mental health resources before publishing. Norwegian Cruise Line Holdings Ltd. did not respond to a request for comment.
Cruise ships may also quarantine passengers deemed to be a threat to themselves or others, according to Michael Winkleman, a maritime attorney with Lipcon, Margulies & Winkleman, P.A.
“Our team of onboard medical professionals safeguards the health and well-being of our guests and crew (including mental health), which may include placing a patient under secure watch in the medical center or in a cabin depending on the risk,” the Carnival Corp. spokesperson said.
While there are major differences – namely, being in the middle of the ocean – Winkleman said there are some commonalities between cruise lines’ approach and that of hotels or resorts, which often do not have on-site mental health providers. “They are just expecting to provide a fun, safe vacation for their guests,” he said.
Crises on cruises, like an overboard incident, for example, may also get outsized attention given their setting, Heggie added. “People are expecting to go and have a good time and have the vacation or holiday mindset, and, ‘Oh, something bad happened.’ “
However, Winkleman said he thinks cruise lines “could do a lot more” to provide mental health support to crew, many of whom work rigorous schedules on months-long contracts.
How passengers can care for their mental health
Travelers can take proactive steps to care for their mental health before a trip if need be. If passengers have a mental health provider, Dole recommends speaking with them beforehand and making sure they have any medication they might need.
Passengers can also reach out to their therapists mid-cruise to schedule a session as needed – though state laws regarding telehealth vary and could prevent them from accessing care. “But generally speaking, it’s really about where the person resides,” Dole said. “So (if) you’re on a work trip, and you’re like, ‘I need to see my therapist,’ they’ll see you.”
Riba noted that it may be more difficult to coordinate than at home with spotty cell service and possible time differences.
The 9-8-8 Suicide & Crisis Lifeline also works in U.S. states as well as territories like Puerto Rico and the U.S. Virgin Islands.
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Checking in with your fellow travelers can also be helpful. Dole said, “One of the biggest clues someone is struggling” is a change in behavior. Typically, that takes the form of withdrawal, but it could also manifest in people engaging in risky or dangerous behaviors.
“‘I noticed something is different,’” she suggested saying. “‘Is there something happening that you feel comfortable talking to me about?’ And that that’s not going to make people be defensive as much as, ‘What’s wrong? Are you okay? What’s happening?’”
Dole recommended framing the question in a way that avoids sounding judgmental or accusatory. “But actually asking the question, especially for young people, can save someone’s life,” she said.
If you or someone you know may be struggling with suicidal thoughts, you can call 988 any time day or night, or chat online. Crisis Text Line also provides free, 24/7, confidential support via text message to people in crisis when they dial 741741.
Nathan Diller is a consumer travel reporter for USA TODAY based in Nashville. You can reach him at ndiller@usatoday.com.
