Mental Health and Diving

Words by Lorie Laroche and Dr. Neal W Pollock

Health is a state of overall physical, mental, and social wellness. Good mental health involves the ability to live to one’s full potential, to face normal life stressors, to work productively, and to be able to contribute to the community. It includes at least some social engagement but also normal mood fluctuations. Poor mental health may be indicated by severe or persistent anger, anxiety, or depression, and difficulty or inability to function socially or professionally.

Mental health levels range on a spectrum from healthy to ill, and can vary over both short and long terms, depending on a variety of factors including personality, life events, social support, and stressors. One can have poor mental health and not be ill or have a mental illness and still be in good mental health. For example, a person can have an anxiety disorder and, with proper care, feel and function well in daily life. 

Participating in diving has merit, including socializing and physical engagement with the environment. Research has demonstrated a positive impact of water and outdoor/nature spaces in overall wellbeing, as well as with mental health conditions like depression, anxiety, and post-traumatic stress disorder (PTSD). Given this, it is reasonable to expect that an increasing number of people with mental health conditions will be interested in participating in
diving activities.

All divers must be able to think clearly, make sound decisions, and effectively manage events occurring around and during diving activities. It is incumbent upon them to ensure that their participation is safe. This includes reflecting on their mental and physical state before every dive. The stigma and discrimination related to mental health problems can present a barrier to speaking about mental health issues. For divers, these fears can include being denied a medical fitness certificate or being rejected by a dive buddy or group. However, withholding information regarding mental health issues can put both divers and their partners at greater risk. 

Mental health conditions can affect anyone, regardless of age, income, or culture. It is estimated that 20% of the worldwide population lives with a mental health condition. Although there are no known data, divers are likely to be similarly affected by such conditions as non-divers. Open communication about mental health concerns and careful consideration of their potential implications for diving is important to help protect both individuals and the diving community.

Anxiety & Depression

The two most commonly diagnosed mental health disorders are anxiety and depression. In 2016, these conditions were diagnosed in approximately 4% of the population worldwide. Approximately 1 in 8 adults will experience symptoms that would meet the criteria for a mood or anxiety disorder diagnosis at some point in their lifetime. Many people will experience both conditions simultaneously.

Depressive disorders range in intensity from mild (feeling persistently “low”) to severe (major depression). This class of conditions includes bipolar disorder (previously known as manic-depressive disorder), seasonal affective disorder, postpartum depression, persistent depressive disorder, and major depressive disorder. Common symptoms include lingering low mood, loss of interest in previously enjoyed activities, changes in appetite (increased or decreased), disordered sleep (difficulty falling asleep, staying asleep, or sleeping too much or too little), low energy, increased irritability, and trouble concentrating. 

Anxiety disorders manifest in a variety of forms including phobias, panic disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder, social anxiety, and generalized anxiety. Symptoms can include apprehension (feeling of dread or of being “on edge”), tension (headaches, trembling, difficulty or inability to relax), avoidance (of situations that could trigger anxiety), autonomic overactivity (dizziness, trembling, rapid breathing, rapid heart rate, gastrointestinal upset), and undue fatigue. Experiencing symptoms of depression or anxiety on most days in a two-week period is usually a sign that a consultation with a professional is needed. 

The two most common treatment options for depression and anxiety are psychotherapy and medications. In Canada, most people (93%) with a diagnosed mood or anxiety disorder are taking or have taken prescription medication to treat their condition.

Scuba diving affects a person’s physiological state through immersion, direct pressure, breathing gas composition, physical activity, and thermal and psychological stressors. The hyperbaric environment may also alter the effect of some medications. For example, some medications can lower the threshold for oxygen toxicity, making drug actions an important consideration for anyone diving. 

There is little research evidence regarding diving while using medications for mental health conditions. As such, recommendations are often vague, and sometimes prohibitively absolute or dismissive. For example, the United Kingdom Diving Medical Committee states, “The concerns are that a diver who is suffering from depression may not be able to function in the water due to anxiety, poor concentration and decision-making, or the irrational decision to use diving as a form of suicide. This would put the sufferer and his or her buddy at risk.” While this may be true in some cases, it is likely extreme as a blanket position. The risk of self-harm is greatest during the acute phase of depression but given the core symptoms—loss of interest in activities, lack of energy, and low motivation—participation in diving may be less likely by persons in such a phase. 

Individuals wanting to dive while managing a mental health condition first need to have a sound understanding of the effects of the condition and its treatment when not diving. Once the baseline has been established, medical evaluation by or consultation with a physician trained in diving medicine would be beneficial. If an individual and his or her medical providers believe it is reasonable to pursue diving, options can be considered. Initial exposures should be conservative in time and depth to more safely assess and manage any unexpected or untoward developments. A slow progression towards less restricted diving would be best to maintain safety. 

Recommendations

An individualized medical assessment is important to establish meaningful recommendations that patients are more likely to follow. Individuals who choose to ignore recommendations or withhold information about potential issues from those who should be made aware can increase risk to more than themselves. Extra protection is in place when partners and support personnel understand risk factors and know how to manage potential events. The sharing of information can be encouraged by increasing knowledge of and comfort in discussing mental health issues.

Research is needed to address substantial knowledge gaps concerning mental health and diving. Notable are the possible interactions between mental health conditions, medications, and diving. Data in this area is virtually non-existent since diving is relatively uncommon and therefore a low priority for investigators. A reasonable early step would be to evaluate the interaction between diving and the most frequently prescribed medications and dosages. 

Research findings would allow for a more informed evaluation of risk by both medical practitioners and current or potential divers. They could also help guide improvements in diving education and training. Efforts to facilitate non-judgmental attitudes and open communication could also increase the likelihood of obtaining accurate and representative diver data pertaining to mental health. Collectively, these steps could reduce unwarranted preconceptions, improve community readiness, and ultimately increase diving safety. 

About the Authors:

Ms. Lorie Laroche is a Social Worker, Research & Development Officer at Carleton University in Ottawa, Ontario, a part-time Professor in Social Work at the University of Ottawa, and an Affiliate Trauma Counsellor for Morneau Shepell.

Dr. Neal W Pollock is an Associate Professor in Kinesiology at Université Laval, Québec, and Research Chair in the Hyperbaric Medicine Unit, Emergency Department, CISSS Chaudière-Appalaches
(CHAU-Hôtel-Dieu de Lévis), Lévis, QC.