Climate Change and Mental Health

Climate change has never received the crisis treatment from our leaders, despite the fact that it carries the risk of destroying lives on a vastly greater scale than collapsed banks or collapsed buildings.

Naomi Klein¹

[[{"type":"media","view_mode":"media_crop","fid":"42439","attributes":{"alt":"© MACROVECTOR/SHUTTERSTOCK.COM","class":"media-image media-image-right","id":"media_crop_8823611697157","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4594","media_crop_rotate":"0","media_crop_scale_h":"215","media_crop_scale_w":"150","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"© MACROVECTOR/SHUTTERSTOCK.COM","typeof":"foaf:Image"}}]]Climate change has emerged as a major factor in the escalating patterns of extreme weather conditions. The effects are severe and global, affecting world economies, triggering migrations and wars, and having profound effects on mental and physical health. The consequences are not shared equally. Health inequity and inequality––manifested through poverty, low education levels, lack of food and water resources, and geographical location––all play a major role in determining the extent of these health effects as climate change exacerbates the risks these circumstances pose to a vulnerable population.²

The effects of climate change can be both direct and indirect. Heat waves, drought, storms, and floods have direct consequences. The indirect consequences of climate change include mass migrations, wars over depleted resources, and exacerbation of sectarian tensions. Consistent mental health consequences include trauma, chronic stress, anxiety, depression and exacerbation of comorbid psychopathology, and huge financial costs. Climate change is an emerging threat to the mental health of all of humanity.³

The purpose of this article is to highlight the mental health consequences of global warming. In the article “Extreme Weather Events and Mental Health: Tackling the Psychosocial Challenge,” Jyotsana Shukla⁴ describes the effects of climate change on mental health under the following categories: direct impact, indirect impact, and impact on children.

Direct impact

Rising temperatures appear to place a psychiatric strain on vulnerable groups who are at increased risk for adverse events. Higher rates of heat stroke with delirium are observed with neuropsychiatric sequelae of agitation, confusion, and death. Contributing factors are multiple. These may include less than adequate shelter from the heat, poor hydration, and increased heat-related adverse effects of antipsychotic medications.⁵ Rising temperatures have been correlated with increased aggression and domestic violence. This may well reflect agitation and despair in the presence of unbearable circumstances and lack of access to basic needs such as water, food, and tolerable living conditions. There is also evidence of elevated cortisol levels under conditions of extreme heat.⁶

Suicidal behavior has been observed to increase because of increasing climate-related uncertainty. The phenomenon of “farmer suicides” in India during droughts may be a consequence of extreme climate in poor agrarian communities.⁷ In Italy, higher levels of suicidal behavior are noted in the country’s northern towns where there has been significant variation in climate.⁸

Alcohol and drug abuse may also increase during heat waves. This is supported by statistics from Australia where higher rates of substance abuse, violence, family breakup, and suicide are seen after extreme weather events in rural and semi-rural areas.⁹

Direct consequences of severe climate disturbance are well documented. After the Asian Tsunami, the incidence of moderate to severe forms of psychiatric disorders including anxiety, depression, phobic disorders, and adjustment disorders was 30% to 50%.¹⁰ Among residents after Hurricane Katrina, the 30-day incidence of anxiety-mood disorders and PTSD was 49.1% and 26.4%, respectively.¹¹ The incidence of PTSD and self-harm increased over time, and even 2 years after the disaster, high psychiatric morbidity was evident in a representative sample of 815 prehurricane residents. In addition, persons with schizophrenia are at greater risk for acute exacerbation of the illness during periods of climatic disasters.¹²

Indirect impact of climate change

Major damage and displacement due to natural disasters disproportionately affect those who live in the developing world because of climatic vulnerability as well as a poorer infrastructure and emergency-response plans. These are also the groups most likely to be afflicted with psychiatric disorders and most vulnerable to natural disasters. In wealthier countries, the poor are still the most vulnerable. A recent report from the Center for American Progress expounds upon this idea of unequal impact, noting, “extreme weather exposes the neglect and underinvestment that low income communities experience year round from substandard housing, to fewer economic opportunities, to poor infrastructure, to exposure to hazardous waste.”¹³

It is estimated that by 2050, 200 million people worldwide will be displaced as a consequence of climate change–related phenomena. The displaced population may have to suffer place-based distress due to involuntary migration and may experience loss of connection to their home environment-a phenomenon referred to as “solastalgia.” This term is used to describe the alienation created by forced migration but also the sense of loss created by massive environmental destruction of one’s familiar environment and land.¹²

Adverse effects on children’s mental health

A significant concern is that future generations will respond to climate change–related information with feelings of hopelessness and despair.¹⁴ Children are especially prone to predisaster anxiety and post-trauma illness, which may be due to the direct effects of life-threatening circumstances and separation from family or the consequences of living with a long-term threat. In a survey of Australian children, researchers noted that “children are particularly concerned about the environment, they sense that their place in the world is under threat. One-half worried about not having enough water, 44% are nervous about the future of climate change, 43% are worried about air and water pollution and one-quarter believe the world will come to an end before they get older.”¹⁵ While Australia has been confronted with years of drought, the survey highlighted the anxiety created in the Australian children not just as a consequence of local climatic uncertainty but also in response to the broader anxiety created in these children by an awareness of global climatic change and the associated extreme weather induced disasters.

Hurricane Katrina: a psychosocial challenge

Within a community at risk for natural disasters related to climate change, the literature on PTSD and resilience offers useful practical information in terms of stress inoculation. The individuals most vulnerable to the mental health impacts are those with temperamental anxiety and prior trauma experiences that provoked PTSD. Further trauma is likely to exacerbate anxiety and diminish their capacity to cope effectively. The more resilient individuals are those who have come through prior trauma and coped reasonably well. These aspects of individuals in a community are identifiable and can be the focus for targeted interventions before natural disasters strike. These interventions can include management of anxiety and mood, cognitive behavioral coping-skills training, and stress-inoculation training.¹⁶

Hurricane Katrina provided a disaster situation that identified potentially successful approaches to meeting the mental health needs of displaced populations. It was clear that traditional disaster responses in the form of medical triage would be insufficient to meet the multiple issues at all system levels when faced with the consequences of a natural disaster.

Although many thousands of people were relocated to Houston and elsewhere, the focus in this article is on Arkansas because they had done pre-disaster planning. More than 1000 individuals displaced from Hurricane Katrina were relocated in Arkansas. Before the hurricane struck, there was anticipatory disaster planning involving collaboration between the Arkansas Department of Health and the Arkansas Chapter of Social Workers. A training manual was developed that outlined a mental health response and the creation of 7 stateside teams. These were interdisciplinary, composed of a team leader who was a licensed clinical social worker and 5 to 7 team members who were licensed mental health providers (eg, social workers, psychologists, and psychiatric nurses). The disaster mental health response to Hurricane Katrina’s displaced survivors intervened at 3 levels.

Micro level. All affected persons were assessed for PTSD. Disruptions in family functioning and loss of family support were quickly identified. Crisis interventions included:

• Assuring physical safety

• Providing security to interventions by ensuring confidentiality

• Allowing survivors to vent any and all emotional reactions without judgment

• Validating survivors’ experience through use of empathy and active listening

• Developing coping skills by predicting emotional issues that might arise in the aftermath of trauma

• Preparing for the future by providing practical information about available assistance within a given time frame

The structure of the housing camps created initial difficulties with implementing these services. This required flexibility on the part of the team to become part of the camp community. In a more casual setting, the team members were able to assess mental health needs and identify those at risk for PTSD and those who needed psychotherapy, psychiatric medications, or hospitalization.¹⁷ Connecting services with families was a challenge and required installation of phone banks and computer banks with Internet connections.

Mezzo level. Lack of transportation was never adequately addressed and again reflected the scattering of housing provided for the survivors.

Macro level. Many of the issues faced by the survivors of Hurricane Katrina were identical to those confronted by any refugee population. These included loss of close relatives, uncertain social status, difficult economic circumstances, strained relationships with the local community, nostalgia, and the longing for a lost community (all very reminiscent of solastalgia). In the Hurricane Katrina disaster, interventions were primarily focused on integrating the survivors who stayed into the Arkansas community as quickly as possible.

Although it fell short in some areas, the Arkansas plan is an excellent example of an organized, coordinated response. It was a setting in which one could see the value of confronting the reality of climate change–induced disasters with the kind of coordinated planning that will be required in the future to effectively respond to increasingly frequent extreme weather events.

Interventions

After any disaster, interventions need to occur simultaneously, not sequentially. Screening for PTSD is a priority before engaging in any kind of highly emotional debriefing. Psychotherapeutic and psychopharmacologic interventions identified as potentially helpful for patients with PTSD in more narrowly defined traumatized populations are likely to be valuable as part of the more comprehensive interventions required when confronted with the magnitude of climatic disasters.

Psychotherapeutic interventions in the immediate post-disaster phase of a climatic catastrophe include cognitive behavior therapy, prolonged exposure techniques, and stress inoculation. Specific components include breathing exercises, relaxation, thought stopping, role playing, and cognitive restructuring. The efficacy of these interventions in reducing PTSD symptoms has been documented in short-term studies with female victims of rape and combat veterans.^18,19 Both debriefing and exposure techniques need to be used cautiously in individuals with active PTSD or with a prior history of PTSD.

Psychopharmacologic interventions for PTSD that are applicable to natural disaster situations include the following²⁰:

• Antidepressants and SSRIs: SSRIs are the first-line medication for PTSD; tricyclic antidepressants have demonstrated efficacy with PTSD and acute stress response

• Anticonvulsants: divalproex, carbamazepine, and topiramate showed mixed results but may have value in reducing symptom recurrence

• Antipsychotics: may have a role when concurrent psychotic symptoms are present and when first-line approaches are ineffective

• Adrenergic inhibitors: preliminary evidence has shown benefit with the alpha-1 antagonist prazosin and with the alpha-2 agonist clonidine in combination with imipramine; beta-adrenergic blockade with propranolol used acutely may reduce some later symptoms of PTSD

The provision of psychopharmacologic interventions will not be met in post-disaster situations with traditional psychiatric care. There will be a need for primary care physicians, psychiatric nurses, and physician assistants to provide the majority of these interventions. In all the domains of assessment and psychotherapeutic and psychopharmacologic interventions, the psychiatrist’s role will likely be that of training, consulting, and supervising.

Conclusion

As a global community we are faced with the very real effects of climate change on our mental health. A decision to act decisively to minimize further global warming will require confronting our own patterns of consumption. We need to examine many of the economic beliefs that we live with in terms of the assumed benefits of endless growth. This growth currently is based on extracting the earth’s resources, with ever increasingly unpredictable methods that are escalating the trend of global warming, contributing to increasingly severe weather disturbance, and exacerbating all the associated mental health problems.

Disclosures:

Dr Lang is the Medical Director of Children’s Out-Patient Services at Davis Behavioral Health in Layton, UT, and is Adjunct Associate Clinical Professor in the department of psychiatry at the University of Utah Medical Center in Salt Lake City. He reports no conflicts of interest concerning the subject matter of this article.

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