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Climate change and mental health: risks, impacts and priority actions

Climate change and mental health: risks, impacts and priority actions Background: This article provides an overview of the current and projected climate change risks and impacts to mental health and provides recommendations for priority actions to address the mental health consequences of climate change. Discussion and conclusion: The authors argue the following three points: firstly, while attribution of mental health outcomes to specific climate change risks remains challenging, there are a number of opportunities available to advance the field of mental health and climate change with more empirical research in this domain; secondly, the risks and impacts of climate change on mental health are already rapidly accelerating, resulting in a number of direct, indirect, and overarching effects that disproportionally affect those who are most marginalized; and, thirdly, interven- tions to address climate change and mental health need to be coordinated and rooted in active hope in order to tackle the problem in a holistic manner. This discussion paper concludes with recommendations for priority actions to address the mental health consequences of climate change. Keywords: Climate change, Mental health, Attribution, Mitigation, Adaptation Background climate change include the risks and impacts to mental It is well understood that human health is threatened by health—the focus of this article. the impacts of climate change [1–3]. In the 2017 Lan- Mental health refers not just to mental illness, mental cet Countdown on Climate Change and Health, authors problems, and mental disorders, but also includes states state: “The human symptoms of climate change are of mental wellness, emotional resilience and psychoso- unequivocal and potentially irreversible—affecting the cial wellbeing [8–11]. Psychosocial wellbeing is the inter- health of populations around the world today” [4]. Cli- play between social and psychological conditions that mate change is no longer a looming threat but rather a shape human welfare; a broad term which encompasses destructive reality with dire predictions for the future. the states of being mentally healthy, experiencing mental The World Health Organization (WHO) estimates an problems, and mental illness [7, 10]. increase of 250,000 excess deaths per year between 2030 Investigating the current state of evidence and knowl- and 2050 due to the “well understood impacts of climate edge about the climate change impacts to mental health, change” [5]. Impacts include heat-related morbidity and this article pays particular attention to the inequitable mortality, increases in vector-borne diseases (e.g. den- impacts of climate change on the mental health of mar- gue fever, malaria), increased respiratory illness, and ginalized and vulnerable populations. We argue the fol- morbidity and mortality due to extreme weather events lowing three points: firstly, while attribution of mental [6, 7]. The lesser-known, and often overlooked, effects of health outcomes to specific climate change risks remains challenging, there are a number of opportunities avail- able to advance the field of mental health and climate change with more empirical research in this domain; sec- *Correspondence: katie.hayes@mail.utoronto.ca ondly, the risks and impacts of climate change on men- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, tal health are already rapidly accelerating, resulting in a Canada number of direct, indirect, and overarching effects that Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Hayes et al. Int J Ment Health Syst (2018) 12:28 Page 2 of 12 disproportionally affect those who are most marginal - optimism, and foster a sense of meaning and personal ized; and finally, interventions to address climate change growth (otherwise referred to as post-traumatic growth) and mental health need to be coordinated and rooted as people band together to salvage, rebuild, and console in active hope in order to tackle the problem in a holis- amongst the chaos and loss of a changing climate [30, 31]. tic manner. This paper explores each of these facets and concludes with recommendations to enhance the state Climate change and health inequity of knowledge and actions on climate change and mental It is well understood that climate change augments exist- health. Before diving into the topic area, a brief overview ing inequalities, rendering those most marginalized at of climate change and health effects are noted in the sec - greater peril to the health consequences of a changing tions below. climate [4, 32, 33]. In fact, the first key message from the Lancet’s Countdown on Climate Change and Health Climate change and health report emphasizes the disproportionate impact climate An extensive body of research continues to strengthen change has on the world’s most marginalized people knowledge about the impact of climate change on physi- and the consequential impacts this has on these popu- cal health, including for example, a rise in vector-borne, lations if social and environment justice concerns are water and food-borne diseases; an increase in acute and not addressed [4]. Watts et  al. state: “By undermining chronic respiratory conditions (including asthma and the social and environmental determinants that under- allergies); and, heat-related and extreme weather-related pin good health, climate change exacerbates social, eco- morbidity and mortality [2–4, 12]. Indirect health impli- nomic, and demographic inequalities, with the impacts cations that are increasingly recognised in global reports eventually felt by all populations” [4]. Those who are at on climate change and health include illness related to greatest risk to the effects of climate change are those food and water safety, under-nutrition related to food who are most marginalized based on socially and envi- insecurity, malignant melanoma from UV exposure, and ronmentally mediated factors, such as socioeconomic chronic kidney disease from dehydration [4]. In late 2017, status, culture, gender, race, employment, and education the Lancet released its first, full tracking report on cli - [15, 34]. Marginalized groups who tend to be the most mate change and health. In this report, there is an explicit affected by the mental and physical health implications of request for more information on, and actions to address, climate change are: Indigenous peoples, children, seniors, the “often-unseen” impacts of climate change on human women, people with low-socioeconomic status, outdoor health, notably, the mental health consequences of cli- labourers, racialized people, immigrants, and people mate change [4]. with pre-existing health conditions [2, 3, 7, 13, 22, 23, 33, 35, 36]. Importantly, these marginalized groups are Climate change and mental health not homogenous. People may experience intersections The expanding research literature on climate change and of marginalization based on a variety of the above social mental health includes increasing evidence that extreme indicators. weather events—which are more frequent, intense, and complex under a changing climate—can trigger post- Exploring the relationship between mental health traumatic stress disorder (PTSD), major depressive dis- and climate change order (MDD), anxiety, depression, complicated grief, An updated overview of recent evidence on the mental survivor guilt, vicarious trauma, recovery fatigue, sub- health implications of climate change is timely given the stance abuse, and suicidal ideation [13–26]. Incremental ongoing, rapid expansion of research in the broad field climate changes, such as rising temperatures, rising sea of health and climate change as well as increasing pub- levels, and episodic drought, can change natural land- lic concern about climate change trends and risks. Since scapes, disrupt food and water resources, change agricul- 2007, media reports on climate change and health have tural conditions, change land use and habitation, weaken increased by 78% and the academic literature on climate infrastructure and give rise to financial and relationship and health issues has tripled [4]. There is also increas - stress, increase risks of violence and aggression, and ing public and academic recognition of the extent to displacement of entire communities [4, 18, 23, 27, 28]. which rising global temperatures threaten planetary and The overarching threats of a changing climate, can also human health [38, 39]. While public awareness about incite despair and hopelessness as actions to address the the health implications of climate change continues to ‘wicked problem’ of climate change seem intangible or grow, the topic of mental health is frequently absent from insignificant in comparison to the scale and magnitude of the threats [29]. Paradoxically, these same disastrous This article builds on an earlier overview of mental health and climate circumstances may also inspire altruism, compassion, change by Fritze et al. [37]. Hayes et al. Int J Ment Health Syst (2018) 12:28 Page 3 of 12 this discourse. In some ways, this reflects the global dis - is that while we cannot say with certainty that any one course, where, in comparison to physical health, mental specific extreme weather event is directly caused by cli - health in general has been neglected. mate change; we do know that because of climate change, Globally, the prevalence of mental health issues is extreme weather is more generally on the rise, mak- extremely high even without considering the added men- ing extreme weather events more frequent, intense, and tal health consequences of a changing climate. Based complex. In other words, climate change therefore ‘loads on a 10-year systematic analysis of global burden of dis- the dice’ for more weather extremes. ease from 1990 to 2010, Murray et  al. find that mental Within the disaster mental health literature, the links illness comprises 7.8% of the global burden of disease between extreme weather events and mental health [40]. Mental and behavioural disorders also account for effects are well established (see for example [51–59]). the greatest global burden of years lived with a disabil- However, many of these studies tend not to connect ity (YLDs) [41]. Vigo et al. contend that these figures are extreme weather to a changing climate—instead referring actually much higher if co-morbidities related to mental to extreme weather events as natural disasters rather than illness are considered within burden of illness studies and events linked to anthropogenic climate change. Studies if a more accurate definition of mental illness is used, a within this domain tend to focus on mental health out- definition that includes health behaviours like self-harm comes of specific hazard events (e.g. the 2004 Tsunami in and suicide [42]. The failure of global investment in men - Malaysia, Hurricane Katrina in 2005; Southern Alberta tal health care to address the consequences and impacts floods in 2013) positioning each hazard as an isolated of rapidly escalating levels of mental illness has been incident unconnected to the wicked problem of climate described as a “global tragedy” reflecting a long “legacy change. The risk of overlooking or minimizing the role of the neglect and marginalization of mental health” [41]. of climate change within these hazardous events is that Similarly, authors from the 2016 Lancet report on sus- this creates a reactive culture of emergency response that tainable development and global mental health describe inhibits appropriate and effective adaptation planning the state of mental health as the “most neglected of all and preparation for complex emergencies that a changing human health conditions” and a “failure of humanity climate can create. [43]. The inattention to mental health is of particular An additional concern is that much of the disaster men- concern in the field of climate change and mental health tal health research has traditionally focussed on three given the evidence that psychological impacts from any distinct phases (the emergency and crisis stage, the post- form of disaster exceed physical injury by 40–1 [44], and impact stage, and the rehabilitation and recovery phase) that since 2000 the frequency of climate change-related [56], while little attention has been paid to psychosocial weather disasters has increased by 46% [4]. Crucially, it phenomena that can occur during the pre-disaster phase. is the most marginalized who are especially vulnerable Such phenomena include, for example, heightened anxi- to climate change’s impacts on mental health. As McMi- ety levels, feelings of impending doom, hopelessness, and chael notes, climate change acts as a health “threat ampli- fatalism that can be triggered by approaching extreme fier”, compounding existing social injustices [32]. There events or associated weather warnings; and which may is, therefore, a strong case for continuing to explore and also be amplified due to the perceived risk of subacute, communicate research and policy learning about the environmental changes like rising temperatures and epi- relationship between climate change and mental health— sodic droughts [13, 20, 22]. especially as the topic area pertains to health equity. Key challenges of attributing climate change to mental Discussion health Part 1. Exploring the challenges and opportunities Attribution related to climate change and mental health of attribution can be challenging for four key reasons: firstly, there The lack of attention to the topic of climate change is a risk of pathologising common transitory distress and mental health is often imputed to the challenges responses to abnormal events and underdiagnosing men- of attribution. Attribution in this case is the scientific tal health effects of a changing climate; secondly, there association between greenhouse gas emissions and mete- is a wide array of potential climate change and mental orological change on the one hand, and between climate health outcomes related to a changing climate; thirdly, change-related meteorological change and mental health there is substantial scope with respect to the timing of effects on the other. There is now an increasingly strong the climate change effects on mental health, thus causal body of literature which highlights the causal linkages links become harder to determine; and finally, attribution between climate change and extreme weather events (see related to climate change and mental health is not well [45–50]). One of the key messages within this literature Hayes et al. Int J Ment Health Syst (2018) 12:28 Page 4 of 12 understood because of the complex interaction between post-event, these authors found an increase in mental mental health and other social determinants of health. health disorders as time progressed [65]. For example, There is a simultaneous risk of pathologising ‘normal’ PTSD increased from 14.9% at 5–8 months to 20.9% after responses to a changing climate and of underdiagnos- 1 year. Anderson et al. suggest that psychosocial impacts ing the real mental health effects of a changing climate. tend to peak within the first-year, post-extreme weather Pathologising ‘normal’ responses to disaster situations event [67]. Tunstall et  al. on the other hand, found that may result in a failure to differentiate between mild tran - residents who experience significant flooding self-report sitional distress or grief and more severe, persistent men- long-term psychosocial impacts (namely anxiety when tal health problems. Both overinflating or underinflating it rains) from 2.5 to 5  years post-flooding [51]. A recent mental health outcomes associated with climate change news article suggests that over 7000 people who experi- can lead to erroneous prevalence estimates and skewed enced Hurricane Katrina in 2005 are still receiving men- assumptions about mental health service needs. A further tal health care for trauma associated with the Hurricane consideration noted by Whaley in the aftermath of Hur- [68]. Noting that psychosocial health outcomes can have ricane Katrina is that in some cases medical professionals latent effects, or that these outcomes can occur as a result did not assess pre-existing mental health conditions and, of sequelae, knowing how and when to study the cli- therefore, attributed disaster trauma as a typical stress mate change-related impacts and psychosocial outcomes response, or alternatively diagnosed patients with stress becomes increasingly challenging—especially if the aim is response when in fact there were much larger mental to demonstrate the magnitude and attribution of effects. health issues related to the effects of the Hurricane that Distilling the precise impact of climate change on went undiagnosed [60]. Crucially important to consider mental health can be difficult to separate from other is that pre-existing mental health conditions or problems social determinants. As Watts et  al. note, measuring the can be exacerbated or even triggered by changes in cli- impacts of climate change on mental health is challeng- mate [9, 61]. ing not only because of attribution but also because of the As noted earlier, mental health includes states of men- “complicated nature of mental health, which embraces a tal wellness as well as mental problems and disorders. diverse array of outcomes (e.g. anxiety and mood disor- With this in mind, the current application of tools to ders), many of which co-occur and all of which vary with assess mental health have some limitations. Researchers contexts and during lifetimes. Mental health impacts are tend to conceptualize mental health solely as mental ill- often products of long and complex causal pathways, ness and mental problems, administering surveys using many of which can be traced back to distal but potent validated instruments that assess mental health prob- root causes, such as famine, war, and poverty, of which lems and issues like: generalized anxiety disorder (using climate change is an accelerator” [4]. Mental health, like the general anxiety disorder, GAD-2 questionnaire), physical health, is shaped by social and ecological factors PTSD (PCL-6 checklist), and psychological distress (via that can influence—and often amplify—other determi - the general health questionnaire, GHQ-12) following an nants of health, like a changing climate. extreme weather event [52, 53, 62–66]. Few empirical studies that use these survey methods capture positive Opportunities of attributing mental health to climate change psychological consequences of extreme weather events, It is important to locate climate change within the dis- like feelings of compassion, altruism, sense of meaning, course on mental health because the frequency, intensity, post-traumatic growth, or even increased acceptance of duration, and complexity of climate change effects is on climate change and engagement with climate mitigation. the rise and thus climate-related mental health outcomes This information can elucidate the complexity of mental are also increasing—adding to the already burgeoning health impacts from a changing climate and also help to burden of mental illness and mental problems globally. understand any predisposing factors that may influence Acknowledging the mental health consequences of cli- positive mental health outcomes and build psychosocial mate change helps the mental health community to dis- resilience. cern and anticipate patterns of mental illness, like for Timing of psychosocial implications from climate example PTSD following extreme weather events. Also, related hazards poses another challenge. Scholars have an understanding of the unequal impacts of climate discovered wide-ranging timeframes for the psychosocial change on marginalized groups supports public health impacts to manifest. Azuma et al. find that the incidence prevention strategies that seek to protect those most sus- of psychological disorders (including PTSD) tended to ceptible to mental illness and mental problems. be most significant within 6  months after a flood [62]. There is a risk that climate-related psychosocial con - Kessler et  al. conducted interviews with Hurricane sequences may become diluted in the high prevalence Katrina survivors 5–8  months post-event and 1-year of mental health disorders globally; therefore, there is a Hayes et al. Int J Ment Health Syst (2018) 12:28 Page 5 of 12 need for additional research within the specific domain communities; and, better planning for mental health of climate change and mental health. If there is a better response and mental health systems resiliency. understanding of the linkages between climate change and mental health, there are more opportunities to Part 2. Current risks and impacts of climate change understand and address climate change and mental on mental health health via actions rooted in climate change mitigation It is challenging for people to recognise changes in cli- and adaptation that support psychosocial resilience. Spe- mate because these changes appear distant or abstract— cifically, the field requires more empirical research on the especially because climate is often confused or lost in mental health consequences of climate change, especially perceptions about weather or seasonal change [23]. The as this research relates to marginalized communities and influential sociologist Anthony Giddens refers to this the risks and impacts associated with chronic climate space and time distancing of the climate change prob- change-related hazards and consequences (like sea-level lem as the Giddens Paradox [70]. The Giddens Paradox rise, rising temperatures, and ecological degradation). To states that: “since the dangers posed by global warming address the overarching interplay of social and environ- aren’t tangible, immediate or visible in the course of day- mental determinants of health that can magnify climate to-day life, many will sit on their hands and do nothing change-related risks on mental health, a health equity of a concrete nature about them. Yet waiting until such approach to this area of study is required. Secondly, there dangers become visible and acute—in the shape of catas- is a need to better understand climate change-related trophes that are irrefutably the result of climate change— hazards within the context of mental health sequelae. before being stirred to serious action will be too late” Research in this area could help to explore the complex- (p. 2). Marshall contends that part of the time and space ity of climate change and mental health attribution by distancing of the climate change problem, and thus the recognizing the role of predisposing mental health con- reluctance to act, is reinforced by the Western political ditions while also taking into account the perceived and discourse on climate change as a future-facing problem actual risks and impacts related to a changing climate. that intentionally overlooks the centuries of industrializa- This type of research can support a better understanding tion, fossil fuel consumption, and land degradation that of the triggers and timing of climate change-related men- contribute to anthropogenic climate change [71]. Mar- tal health effects as well as support policy and program shall calls for a reckoning with this discourse by noting: development for mental health resources. “Climate change is a future problem. But it is also Attributing mental health outcomes to climate a past problem and a present problem. It is better change also presents opportunities to assess, build, and thought of as a developing process of long-term dete- strengthen mental health systems. In 2015, the World rioration, called, by some psychologists, a “creeping Health Organization (WHO) set forth the framework problem.” The lack of a definite beginning, end, or for building climate resilient health systems [69]. This deadline requires that we create our own timeline. framework provides guidance for health professionals to Not surprisingly, we do so in ways that remove the predict, prevent, and prepare for climate change-related compulsion to act. We allow just enough history to shocks with the ultimate aim of protecting population- make it seem familiar but not enough to create a level health by increasing health systems’ capacity to responsibility for our past emissions. We make it just cope, adapt, sustain, and strengthen in the wake of a current enough to accept that we need to do some- changing climate. While the framework overlooks the thing about it but put it just too far in the future to intricacies of mental health systems—like the current and require immediate action” [71]. prevailing lack of mental health infrastructure, funding, and resourcing globally—it does provide the necessary Noting the Giddens Paradox and the reckoning that guidance to build mental health systems resiliency. Artic- Marshall asks us to have with the “creeping problem” of ulating climate change as a determinant of mental health climate change, it becomes important to confront the not only brings awareness of the broad consequences of current mental health consequences related to climate climate change on health but also supports the enhance- change that are happening now [70, 71]. To do so, it is ment of mental health systems. useful to explore the conceptual framework of climate In sum, the key benefits of understanding the link - change and mental health developed by Berry et al. [15]. ages between climate change and mental health include: These authors organize climate change-related hazards enhanced knowledge of patterns of illness; an added into three categories: acute (flooding, hurricanes, etc.), emphasis on the global call to action to reduce and sub-acute (pervasive drought), and chronic (rising sea- address climate change risks and impacts; in-depth level, increasing temperatures). These climate change- knowledge of the risks and impacts to marginalized related hazards lead to a variety of direct, indirect, and Hayes et al. Int J Ment Health Syst (2018) 12:28 Page 6 of 12 overarching psychosocial consequences that are occur- of marginalised community members of New Orleans ring now—disproportionately affecting those most (mainly low-income, African American women) showed marginalized. probable signs of PTSD after Hurricane Katrina [82]. Direct psychosocial consequences of climate change While PTSD is often reported as one of the most include trauma related to extreme weather events, severe mental health impacts related to acute climate like floods, hurricanes, wildfires, and heat waves [15, change-related disasters, there have also been increasing 37]. Indirect mental health consequences of climate reports of suicide and suicidal ideation following extreme change occur through social, economic, and environ- weather events. Chand et  al. note one Italian study that mental disruptions (e.g. famine, civil conflict, displace - found higher rates of suicide in northern communities ment, and migration) related to a changing climate [15, with greater climate variability [72, 83].  Dodgen et  al. 37]. The overarching psychosocial consequences of cli - highlight the risk of homicide-suicides after extreme mate change relate to the long-term emotional distress weather events by noting the doubling of these incidents caused by awareness of the threats and impacts of climate following Hurricane Andrew in 1992 in Miami-Dade change on the current and future wellbeing of the earth County [74]. There is also observed evidence of increased and its inhabitants. The multidimensional climate change suicidal thoughts (from 2.8 to 6.4%) and plans to commit and mental health pathway leads to a variety of unequal suicide (from 1.0 to 2.5%) 18-months after an extreme psychosocial consequences explored below. weather event [74]. Notably, however, the overall evi- dence linking changing climate and suicide is still incon- Direct mental health consequences of climate change clusive. Studies on suicidality in natural disaster contexts, There is now an extensive and rapidly expanding body for example, vary considerably in study methodology and of research exploring the current mental health con- timeframes considered, with recent reviews indicating sequences of climate change-related extreme weather divergent trends in suicidality rates following exposure to events. Extreme heat events and humidity have been extreme events, ranging from an initial decline, to neu- noted to increase hospital admissions for mood and tral effects, all the way to a delayed increase in suicidality behavioural disorders, including schizophrenia, mania, [84]. and neurotic disorders [72, 73]. Scholars in the field On a deeper level, the psychological responses of com- note that heat-related mental health morbidity tends to munities and individuals to disasters are complex and occur most often in people with impaired thermoregu- varied and do not necessarily simply result in more men- lation, namely people with pre-existing mental health tal illnesses. Rebecca Solnit, in A Paradise Built in Hell, illness and problems, people taking prescription medica- usefully describes the complicated psychosocial conse- tions (specifically lithium, neuroleptic and anticholiner - quences that can arise after an extreme weather event gic drugs), and those with substance abuse (alcohol and as, “that sense of immersion in the moment and solidar- drugs) problems [35, 36, 74]. Extreme heat is also linked ity with others caused by the rupture in everyday life, an with an increased risk of wildfires, which also directly emotion graver than happiness but deeply positive. We impact mental health. Bryant et  al. mapped the psycho- don’t even have a language for this emotion, in which the logical outcomes of the Black Saturday bushfires in Victo - wonderful comes wrapped in the terrible, joy in sorrow, ria, Australia; in communities most at risk to the impacts courage in fear. We cannot welcome disaster, but we can of bushfires, these authors found incidences of PTSD, value the responses, both practical and psychological” psychological distress, and depression related to the fires [85]. Exploring the complexity of psychological responses [75]. in the book, Climate change and human well-being, The direct mental health consequences related to Weissbecker et al., discuss the full spectrum of psychoso- flooding and hurricanes are also well documented (see cial consequences of climate change-related events rang- [51–55, 60, 62, 76–81]). In a study of 30 locations in Eng- ing from mental illness to more positive experiences like land and Wales, Tunstall et  al. conducted interview sur- ‘Post Traumatic Growth’ (PTG), empathy, compassion, veys with residents affected by flooding. They found that altruism, and emotional resilience [25]. psychological impacts were more commonly reported than physical effects [51]. One study researching the Indirect mental health consequences of climate change psychosocial impacts following Hurricane Katrina esti- The indirect mental health consequences of climate mates that 20–35% of survivors experienced some form change can occur as a result of damages to physical of mental health issue following the disaster [60]. Galea and social infrastructure, physical health effects, food et  al. reported a 31.2% prevalence of anxiety-mood and water shortages, conflict, and displacement from disorders amongst Hurricane Katrina survivors [81], acute, subacute, and chronic climactic changes [15]. while Rhodes and Chan found that nearly half (47.7%) One of the most well-documented climate hazards Hayes et al. Int J Ment Health Syst (2018) 12:28 Page 7 of 12 that indirectly influences mental health is drought. At the community level the indirect mental health con- Long-term droughts affect food and water supplies sequences of climate change are understudied. These and can subsequently affect the economic and mental consequences may include things like a diminishment wellbeing of land-based workers, most often impact- in community cohesion, the loss of community identity, ing those living in rural and remote communities [58, threats to a sense of continuity and sense of belonging 86, 87]. In a quantitative analysis of drought and dis- as people are forced to move in and out of communi- tress in Australia over a 7-year period, authors found ties because of environmental stressors, and an under- that rural dwellers experience more distress due to the mining of cultural integrity if people have to leave their droughts than their urban counterparts [86]. In a sys- homelands [23]. Migration challenges the identity, sov- tematic review of the literature, authors note the most ereignty and heritage of people who have to leave their prominent causal pathway linking drought and mental homelands. It also challenges the integrity and continuity health is via the economic effects from land degrada - of people’s traditional ways of life. Threats to community tion [58]. These effects are most prominent amongst health also include an increased likelihood of criminal farmers whose economic livelihoods depend on envi- behaviour, violence and aggression as community mem- ronmental conditions. Exemplifying this, a 2008 study bers experience various stressors related to climate in New South Wales, Australia reports that nearly three change [23]. quarters of farmers report stress related to persistent drought [88]. Some authors also suggest that income Overarching psychosocial consequences of global climate insecurity related to drought increases the risk for sui- change cide among farmers [9, 89]. Awareness of the looming threats and current risks and Long-term drought has also been increasingly linked to impacts of climate change presents challenges to emo- conflict and forced migration, which can influence psy - tional and social wellbeing [37]. Since early 2007, envi- chosocial outcomes like the propensity for stress, PTSD, ronmental philosopher Glenn Albrecht and colleagues anxiety, and trauma [90]. The Institute for Environment have taken note of emotional distress related to the and Human Security of the United Nations University awareness of the overarching problem humans face as a estimates that migration due to climate change may vary result of global climate change [96]. Albrecht et  al. sug- drastically, citing estimates of between 25 million to 1 gest that this awareness contributes to ‘psychoterratic billion by 2050, with 200 million as the most frequently syndromes’. Psychoterratic syndromes include phenom- cited estimate [91]. The rise in the number of ‘climate ena such as ‘ecoanxiety’, ‘ecoparalysis’, and ‘solastalgia’. migrants’ has been identified as a significant risk by an ‘Ecoanxiety’ refers to the anxiety people face from con- increasing number of defence and security experts [92, stantly being surrounded by the wicked and threaten- 93]. Gleick postulates that the civil conflict in Syria can ing problems associated with a changing climate [96]. be traced to the agricultural failures in 2006–2009 and ‘Ecoparalysis’ refers to the complex feelings of not being the returning drought in 2011 [90]. In 2011, over 1.5 able to take effective action to significantly mitigate cli - million Syrians moved from rural, agricultural areas to mate change risks. ‘Solastalgia’ refers to “the distress and urban areas seeking refuge from the pervasive drought, isolation caused by the gradual removal of solace from failed agriculture, and lack of food and water [90]. Per- the present state of one’s home environment” [29]. The vasive ecological degradation, poor policy response to term ‘solastalgia’ is also commonly referred to through- water and food insecurity, and ongoing tensions between out much of the literature on climate change and mental rural and urban community members, have arguably all health to articulate the feelings associated with displace- contributed to civil unrest and ongoing conflict in Syria ment following a climate change-related extreme weather [90]. According to the United Nations, the number of dis- event [17]. This new vocabulary provides the language to placed Syrians has reached over 5 million people in the explore some of the broader mental health implications past 5  years [94]. Migration from a war-torn country to of escalating climate change risks. a host country where culture, language, and lifestyle may For many people, climate change is experienced by way be vastly different may also contribute to psychosocial of vicarious threats or as an existential threat to civilisa- malaise as displaced migrants can face stressors associ- tion [37]. People may experience vicarious threats when ated with xenophobia and racism from people in their they receive weather warnings related to future disaster new host country [90]. Conversely as Siriwardhana and seasons or when they hear about environmental stressors Stewart note, displacement may also support psychoso- experienced by people in other places. For many people, cial resilience by fostering hope and belonging for refu- this is largely how climate change is experienced—not gees in host countries where they feel welcomed, safe, as a direct threat, but as a global threat, often distant and experience better living conditions [95]. in time and place, or as a threat to our very way of life. Hayes et al. Int J Ment Health Syst (2018) 12:28 Page 8 of 12 Qualitative research finds evidence of some people being measures to enhance and protect mental health in the deeply affected by feelings of loss, helplessness, and frus - Sustainable Development Goals 2016–2030 [102]; efforts tration as they engage with the problems of global cli- by the Movement for Global Mental Health to increase mate change [97]. the holistic conceptualization of health to incorporate mental health [103]; the Sendai Framework, a 15-year Part 3: Priority actions to address climate change disaster risk reduction program [104]; and, the United and mental health Nations Human Settlement Program that promotes Acting on the health consequences of climate change sustainable urban development [105]. There is a need, requires actions rooted in both mitigation and adaptation however, to harness health and mental health related at all levels—from global to local—and from all sectors synergies amongst these global agreements since none and individuals. Climate change mitigation refers to over- of these in and of themselves will likely be sufficient to arching efforts to reduce greenhouse gas emissions and address the future risks and impacts of climate change. enhance carbon sinks to slow the speed, scale, and mag- Coordinated, collaborative efforts to address the men - nitude of climate change [98]. Key climate change mitiga- tal health implications of climate change not only require tion priorities include reducing energy demand (through policy frameworks but also concrete actions on behalf reduced consumption and increased energy efficiency); a of mental health practitioners. Such concrete actions swift and equitable transition from fossil fuels to renew- may include: communicating about climate change and able energy; reducing emissions from agriculture and mental health in a way that helps people to see that it is forestry; and strengthening land-based emissions seques- relevant and salient to them; advocacy for greenhouse tration. Climate change adaptation refers to interventions gas reductions in health care facilities and engagement that respond to the effects of climate change by adjust - in efforts to reduce the environmental footprint of the ing, moderating, and coping with the risks and impacts of health care sector; and, engaging in adaptation measures climate change [98]. Adaptation is ultimately affected by like preparing for and responding to extreme events. the capacity to adapt, which is the ability and willingness to respond to climate change mediated by individual and Psychological adaptation collective agency [99]. Adaptive capacity is determined by Psychological adaptation requires a set of responses, it things like: governance, economics, infrastructure, tech- requires an acknowledgement of the grave threats posed nology, information and skills, institutions, and equity by climate change and the profoundly consequential [100]. Examples of adaptation interventions that address global crisis. It requires coping strategies to manage the climate change and health include: surveillance and mon- feelings and thoughts that arise so that people can face itoring of disease burdens related to climate change and up to, and come to terms with, these threats and conse- health; education (e.g. public health promotion of the quences rather than avoiding the creeping problem of risks of vector-borne illness), and capacity building (e.g. climate change. It also requires behavioural and psycho- psychological first-aid, and surge capacities at hospitals logical engagement, in which people change and adjust and health care facilities); preparing for extreme weather their behaviour and lifestyle in order to reduce the threat events; and re-locating entire communities to geographic and protect themselves. areas where sea-level rise and frequent extreme weather Active hope—something Macy and Johnstone cham- events are less-likely to occur [7]. pion—supports psychological adaptation. Active hope is Within international approaches to combat climate required to move hopeful intentions from a passive state change there is a significant focus not only on mitiga - where waiting for someone else to take-on the task of tion but also adaptation. From the Paris Accord to the addressing the climate change problem is replaced with Lancet Countdown on Climate Change, to the Planetary an active process of climate change mitigation and adap- Manifesto and climate action marches—policy makers, tation behaviours [106]. The key point here is that hope academics, and the general population are taking steps alone cannot provide sufficient protection from the esca - to mitigate and adapt to the current threats and impacts lating risks of climate change. This active process occurs to preserve a future for the next generation [4, 39]. These when the reality of the problem is acknowledged as is actions, however, often fail to address the gap between the magnitude of the problem, intentions to address the stated goals of emissions reduction commitments and problem are set, and engaged actions take place. While the speed of actions required to keep global warming well these three steps may oversimplify the complexity of below 1.5–2 °C [101]. acting in the face of bureaucracy, climate denialism, or With a specific focus on mental health and climate downright avoidance and ignorance of the magnitude of change, there are a number of global programs in place the problem area, these three steps are indeed the pivot that indirectly address the topic area—like for example points of transformation. These pivot points, however, Hayes et al. Int J Ment Health Syst (2018) 12:28 Page 9 of 12 need to be upheld by global political will and policy can help people overcome feelings of hopelessness, anxi- commitments that tackle the problem at the appropri- ety, and ecoparalysis [109]. Koger et al. suggest: “if people ate scale and speed. To do so, public awareness of the feel a deep connection to places, wilderness, and other severity, magnitude and range of health impacts—cur- species, then threats to these others are much more likely rent and projected—is required to pressure governments to be viewed as personal issues” [109]. Other research and communities to act now. Also, discernible interven- on the restorative benefits of natural environments and tions are needed to demonstrate a tangible path forward settings has found that biodiversity in natural environ- to respond to the risks and impacts we face in a chang- ments is important for human health and wellbeing and ing climate. Examples of these types of interventions are has a particularly positive effect on mood, attention and explored below. cognition [110]. A common practice in Japan to reduce stress and anxiety is the practice of shinrin-yoku, other- wise referred to as forest bathing. In a study by Lee et al., Adaptation measures authors found that forest bathing resulted in decreased Adaptation measures that address the psychosocial cortisol levels, pulse rates, and negative feelings and sig- impacts of climate change come in a variety of forms, nificantly increased positive feelings [111]. Research on i.e. policies, practices, behavioral interventions, com- people’s interactions with nationally important ecosys- munity-based interventions, specific training, and phar - tems, like World Heritage Areas for example, highlights macotherapeutics. Some general approaches to address positive impacts including quality of life, a sense of place climate change-related mental health problems or ill- and belonging, self-identity, restoration and inspiration nesses include: primary care interventions, individual [112]. and group-based therapy, cognitive based interventions While there are a number of interventions to sup- (including cognitive based therapy, cognitive restructur- port psychosocial wellbeing within a changing climate, ing, and, stress inoculation training), and crisis coun- it is important to highlight that many of these interven- selling [67]. More broadly, emotional resiliency may be tions are still quite nascent and administered in ad hoc sustained by engaging with art, literature, and spiritual- fashion, and these interventions are mainly accessible in ity. In addition to the above, the list below contains some developed countries. Sustainable mental health care in specific priority adaptation mechanisms that ought to be developed and developing nations is urgently needed as considered to support population-level mental health in a the realities of climate change become more and more changing climate: apparent—especially for those most marginalized. Fur- ther, there are research needs in this domain where the • Policy responses: improving access and funding to efficacy and accessibility of mental health interventions- mental health care; related to climate change are assessed. • Surveillance and monitoring: administering epide- miological surveys after extreme weather events, and monitoring emergency department visits during heat Conclusion waves and following extreme weather events; Climate change affects mental health in a variety of • Practice: the application of a stepped-care approach direct, indirect, and overarching pathways—dispropor- to mental health that is often used in disaster men- tionately affecting those most marginalized. The mental tal health to support different levels of interventions health implications of climate change can result in men- depending on the timing of the disaster and the level tal problems and illness as well as affirmative psychoso - of distress (see [107, 108]); cial outcomes. While the timing and triggers associated • Preparation and response: climate change adapta- with climate change and mental health may vary, mak- tion/resilience planning in the mental health system; ing it challenging to establish the manifold links between • Community-based interventions: climate change climate change and mental health, the opportunities of resilience plans that address psychosocial wellbeing; attributing mental health to climate change support cli- and, mate mitigation as well as mental health action and psy- • Special training for care providers and first respond - chosocial resiliency. Global commitments, like the Paris ers: e.g. psychological first aid. Accord, the SDGs, and the Sendai Framework are needed to help advance global mental health and climate action; Other innovative approaches to addressing mental however, coordination amongst these commitments is health and wellbeing in a changing climate writ large required—as are concrete actions on behalf of health include experiencing and preserving nature. Koger et  al. practitioners—if the issue of mental health and a chang- suggest that environmental preservation provides people ing climate is to be efficiently and holistically addressed. with a sense of stewardship and personal investment that Further, a reckoning with social, environmental, and Hayes et al. 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Climate change and mental health: risks, impacts and priority actions

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Springer Journals
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Medicine & Public Health; Psychiatry; Clinical Psychology; Health Administration
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Abstract

Background: This article provides an overview of the current and projected climate change risks and impacts to mental health and provides recommendations for priority actions to address the mental health consequences of climate change. Discussion and conclusion: The authors argue the following three points: firstly, while attribution of mental health outcomes to specific climate change risks remains challenging, there are a number of opportunities available to advance the field of mental health and climate change with more empirical research in this domain; secondly, the risks and impacts of climate change on mental health are already rapidly accelerating, resulting in a number of direct, indirect, and overarching effects that disproportionally affect those who are most marginalized; and, thirdly, interven- tions to address climate change and mental health need to be coordinated and rooted in active hope in order to tackle the problem in a holistic manner. This discussion paper concludes with recommendations for priority actions to address the mental health consequences of climate change. Keywords: Climate change, Mental health, Attribution, Mitigation, Adaptation Background climate change include the risks and impacts to mental It is well understood that human health is threatened by health—the focus of this article. the impacts of climate change [1–3]. In the 2017 Lan- Mental health refers not just to mental illness, mental cet Countdown on Climate Change and Health, authors problems, and mental disorders, but also includes states state: “The human symptoms of climate change are of mental wellness, emotional resilience and psychoso- unequivocal and potentially irreversible—affecting the cial wellbeing [8–11]. Psychosocial wellbeing is the inter- health of populations around the world today” [4]. Cli- play between social and psychological conditions that mate change is no longer a looming threat but rather a shape human welfare; a broad term which encompasses destructive reality with dire predictions for the future. the states of being mentally healthy, experiencing mental The World Health Organization (WHO) estimates an problems, and mental illness [7, 10]. increase of 250,000 excess deaths per year between 2030 Investigating the current state of evidence and knowl- and 2050 due to the “well understood impacts of climate edge about the climate change impacts to mental health, change” [5]. Impacts include heat-related morbidity and this article pays particular attention to the inequitable mortality, increases in vector-borne diseases (e.g. den- impacts of climate change on the mental health of mar- gue fever, malaria), increased respiratory illness, and ginalized and vulnerable populations. We argue the fol- morbidity and mortality due to extreme weather events lowing three points: firstly, while attribution of mental [6, 7]. The lesser-known, and often overlooked, effects of health outcomes to specific climate change risks remains challenging, there are a number of opportunities avail- able to advance the field of mental health and climate change with more empirical research in this domain; sec- *Correspondence: katie.hayes@mail.utoronto.ca ondly, the risks and impacts of climate change on men- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, tal health are already rapidly accelerating, resulting in a Canada number of direct, indirect, and overarching effects that Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Hayes et al. Int J Ment Health Syst (2018) 12:28 Page 2 of 12 disproportionally affect those who are most marginal - optimism, and foster a sense of meaning and personal ized; and finally, interventions to address climate change growth (otherwise referred to as post-traumatic growth) and mental health need to be coordinated and rooted as people band together to salvage, rebuild, and console in active hope in order to tackle the problem in a holis- amongst the chaos and loss of a changing climate [30, 31]. tic manner. This paper explores each of these facets and concludes with recommendations to enhance the state Climate change and health inequity of knowledge and actions on climate change and mental It is well understood that climate change augments exist- health. Before diving into the topic area, a brief overview ing inequalities, rendering those most marginalized at of climate change and health effects are noted in the sec - greater peril to the health consequences of a changing tions below. climate [4, 32, 33]. In fact, the first key message from the Lancet’s Countdown on Climate Change and Health Climate change and health report emphasizes the disproportionate impact climate An extensive body of research continues to strengthen change has on the world’s most marginalized people knowledge about the impact of climate change on physi- and the consequential impacts this has on these popu- cal health, including for example, a rise in vector-borne, lations if social and environment justice concerns are water and food-borne diseases; an increase in acute and not addressed [4]. Watts et  al. state: “By undermining chronic respiratory conditions (including asthma and the social and environmental determinants that under- allergies); and, heat-related and extreme weather-related pin good health, climate change exacerbates social, eco- morbidity and mortality [2–4, 12]. Indirect health impli- nomic, and demographic inequalities, with the impacts cations that are increasingly recognised in global reports eventually felt by all populations” [4]. Those who are at on climate change and health include illness related to greatest risk to the effects of climate change are those food and water safety, under-nutrition related to food who are most marginalized based on socially and envi- insecurity, malignant melanoma from UV exposure, and ronmentally mediated factors, such as socioeconomic chronic kidney disease from dehydration [4]. In late 2017, status, culture, gender, race, employment, and education the Lancet released its first, full tracking report on cli - [15, 34]. Marginalized groups who tend to be the most mate change and health. In this report, there is an explicit affected by the mental and physical health implications of request for more information on, and actions to address, climate change are: Indigenous peoples, children, seniors, the “often-unseen” impacts of climate change on human women, people with low-socioeconomic status, outdoor health, notably, the mental health consequences of cli- labourers, racialized people, immigrants, and people mate change [4]. with pre-existing health conditions [2, 3, 7, 13, 22, 23, 33, 35, 36]. Importantly, these marginalized groups are Climate change and mental health not homogenous. People may experience intersections The expanding research literature on climate change and of marginalization based on a variety of the above social mental health includes increasing evidence that extreme indicators. weather events—which are more frequent, intense, and complex under a changing climate—can trigger post- Exploring the relationship between mental health traumatic stress disorder (PTSD), major depressive dis- and climate change order (MDD), anxiety, depression, complicated grief, An updated overview of recent evidence on the mental survivor guilt, vicarious trauma, recovery fatigue, sub- health implications of climate change is timely given the stance abuse, and suicidal ideation [13–26]. Incremental ongoing, rapid expansion of research in the broad field climate changes, such as rising temperatures, rising sea of health and climate change as well as increasing pub- levels, and episodic drought, can change natural land- lic concern about climate change trends and risks. Since scapes, disrupt food and water resources, change agricul- 2007, media reports on climate change and health have tural conditions, change land use and habitation, weaken increased by 78% and the academic literature on climate infrastructure and give rise to financial and relationship and health issues has tripled [4]. There is also increas - stress, increase risks of violence and aggression, and ing public and academic recognition of the extent to displacement of entire communities [4, 18, 23, 27, 28]. which rising global temperatures threaten planetary and The overarching threats of a changing climate, can also human health [38, 39]. While public awareness about incite despair and hopelessness as actions to address the the health implications of climate change continues to ‘wicked problem’ of climate change seem intangible or grow, the topic of mental health is frequently absent from insignificant in comparison to the scale and magnitude of the threats [29]. Paradoxically, these same disastrous This article builds on an earlier overview of mental health and climate circumstances may also inspire altruism, compassion, change by Fritze et al. [37]. Hayes et al. Int J Ment Health Syst (2018) 12:28 Page 3 of 12 this discourse. In some ways, this reflects the global dis - is that while we cannot say with certainty that any one course, where, in comparison to physical health, mental specific extreme weather event is directly caused by cli - health in general has been neglected. mate change; we do know that because of climate change, Globally, the prevalence of mental health issues is extreme weather is more generally on the rise, mak- extremely high even without considering the added men- ing extreme weather events more frequent, intense, and tal health consequences of a changing climate. Based complex. In other words, climate change therefore ‘loads on a 10-year systematic analysis of global burden of dis- the dice’ for more weather extremes. ease from 1990 to 2010, Murray et  al. find that mental Within the disaster mental health literature, the links illness comprises 7.8% of the global burden of disease between extreme weather events and mental health [40]. Mental and behavioural disorders also account for effects are well established (see for example [51–59]). the greatest global burden of years lived with a disabil- However, many of these studies tend not to connect ity (YLDs) [41]. Vigo et al. contend that these figures are extreme weather to a changing climate—instead referring actually much higher if co-morbidities related to mental to extreme weather events as natural disasters rather than illness are considered within burden of illness studies and events linked to anthropogenic climate change. Studies if a more accurate definition of mental illness is used, a within this domain tend to focus on mental health out- definition that includes health behaviours like self-harm comes of specific hazard events (e.g. the 2004 Tsunami in and suicide [42]. The failure of global investment in men - Malaysia, Hurricane Katrina in 2005; Southern Alberta tal health care to address the consequences and impacts floods in 2013) positioning each hazard as an isolated of rapidly escalating levels of mental illness has been incident unconnected to the wicked problem of climate described as a “global tragedy” reflecting a long “legacy change. The risk of overlooking or minimizing the role of the neglect and marginalization of mental health” [41]. of climate change within these hazardous events is that Similarly, authors from the 2016 Lancet report on sus- this creates a reactive culture of emergency response that tainable development and global mental health describe inhibits appropriate and effective adaptation planning the state of mental health as the “most neglected of all and preparation for complex emergencies that a changing human health conditions” and a “failure of humanity climate can create. [43]. The inattention to mental health is of particular An additional concern is that much of the disaster men- concern in the field of climate change and mental health tal health research has traditionally focussed on three given the evidence that psychological impacts from any distinct phases (the emergency and crisis stage, the post- form of disaster exceed physical injury by 40–1 [44], and impact stage, and the rehabilitation and recovery phase) that since 2000 the frequency of climate change-related [56], while little attention has been paid to psychosocial weather disasters has increased by 46% [4]. Crucially, it phenomena that can occur during the pre-disaster phase. is the most marginalized who are especially vulnerable Such phenomena include, for example, heightened anxi- to climate change’s impacts on mental health. As McMi- ety levels, feelings of impending doom, hopelessness, and chael notes, climate change acts as a health “threat ampli- fatalism that can be triggered by approaching extreme fier”, compounding existing social injustices [32]. There events or associated weather warnings; and which may is, therefore, a strong case for continuing to explore and also be amplified due to the perceived risk of subacute, communicate research and policy learning about the environmental changes like rising temperatures and epi- relationship between climate change and mental health— sodic droughts [13, 20, 22]. especially as the topic area pertains to health equity. Key challenges of attributing climate change to mental Discussion health Part 1. Exploring the challenges and opportunities Attribution related to climate change and mental health of attribution can be challenging for four key reasons: firstly, there The lack of attention to the topic of climate change is a risk of pathologising common transitory distress and mental health is often imputed to the challenges responses to abnormal events and underdiagnosing men- of attribution. Attribution in this case is the scientific tal health effects of a changing climate; secondly, there association between greenhouse gas emissions and mete- is a wide array of potential climate change and mental orological change on the one hand, and between climate health outcomes related to a changing climate; thirdly, change-related meteorological change and mental health there is substantial scope with respect to the timing of effects on the other. There is now an increasingly strong the climate change effects on mental health, thus causal body of literature which highlights the causal linkages links become harder to determine; and finally, attribution between climate change and extreme weather events (see related to climate change and mental health is not well [45–50]). One of the key messages within this literature Hayes et al. Int J Ment Health Syst (2018) 12:28 Page 4 of 12 understood because of the complex interaction between post-event, these authors found an increase in mental mental health and other social determinants of health. health disorders as time progressed [65]. For example, There is a simultaneous risk of pathologising ‘normal’ PTSD increased from 14.9% at 5–8 months to 20.9% after responses to a changing climate and of underdiagnos- 1 year. Anderson et al. suggest that psychosocial impacts ing the real mental health effects of a changing climate. tend to peak within the first-year, post-extreme weather Pathologising ‘normal’ responses to disaster situations event [67]. Tunstall et  al. on the other hand, found that may result in a failure to differentiate between mild tran - residents who experience significant flooding self-report sitional distress or grief and more severe, persistent men- long-term psychosocial impacts (namely anxiety when tal health problems. Both overinflating or underinflating it rains) from 2.5 to 5  years post-flooding [51]. A recent mental health outcomes associated with climate change news article suggests that over 7000 people who experi- can lead to erroneous prevalence estimates and skewed enced Hurricane Katrina in 2005 are still receiving men- assumptions about mental health service needs. A further tal health care for trauma associated with the Hurricane consideration noted by Whaley in the aftermath of Hur- [68]. Noting that psychosocial health outcomes can have ricane Katrina is that in some cases medical professionals latent effects, or that these outcomes can occur as a result did not assess pre-existing mental health conditions and, of sequelae, knowing how and when to study the cli- therefore, attributed disaster trauma as a typical stress mate change-related impacts and psychosocial outcomes response, or alternatively diagnosed patients with stress becomes increasingly challenging—especially if the aim is response when in fact there were much larger mental to demonstrate the magnitude and attribution of effects. health issues related to the effects of the Hurricane that Distilling the precise impact of climate change on went undiagnosed [60]. Crucially important to consider mental health can be difficult to separate from other is that pre-existing mental health conditions or problems social determinants. As Watts et  al. note, measuring the can be exacerbated or even triggered by changes in cli- impacts of climate change on mental health is challeng- mate [9, 61]. ing not only because of attribution but also because of the As noted earlier, mental health includes states of men- “complicated nature of mental health, which embraces a tal wellness as well as mental problems and disorders. diverse array of outcomes (e.g. anxiety and mood disor- With this in mind, the current application of tools to ders), many of which co-occur and all of which vary with assess mental health have some limitations. Researchers contexts and during lifetimes. Mental health impacts are tend to conceptualize mental health solely as mental ill- often products of long and complex causal pathways, ness and mental problems, administering surveys using many of which can be traced back to distal but potent validated instruments that assess mental health prob- root causes, such as famine, war, and poverty, of which lems and issues like: generalized anxiety disorder (using climate change is an accelerator” [4]. Mental health, like the general anxiety disorder, GAD-2 questionnaire), physical health, is shaped by social and ecological factors PTSD (PCL-6 checklist), and psychological distress (via that can influence—and often amplify—other determi - the general health questionnaire, GHQ-12) following an nants of health, like a changing climate. extreme weather event [52, 53, 62–66]. Few empirical studies that use these survey methods capture positive Opportunities of attributing mental health to climate change psychological consequences of extreme weather events, It is important to locate climate change within the dis- like feelings of compassion, altruism, sense of meaning, course on mental health because the frequency, intensity, post-traumatic growth, or even increased acceptance of duration, and complexity of climate change effects is on climate change and engagement with climate mitigation. the rise and thus climate-related mental health outcomes This information can elucidate the complexity of mental are also increasing—adding to the already burgeoning health impacts from a changing climate and also help to burden of mental illness and mental problems globally. understand any predisposing factors that may influence Acknowledging the mental health consequences of cli- positive mental health outcomes and build psychosocial mate change helps the mental health community to dis- resilience. cern and anticipate patterns of mental illness, like for Timing of psychosocial implications from climate example PTSD following extreme weather events. Also, related hazards poses another challenge. Scholars have an understanding of the unequal impacts of climate discovered wide-ranging timeframes for the psychosocial change on marginalized groups supports public health impacts to manifest. Azuma et al. find that the incidence prevention strategies that seek to protect those most sus- of psychological disorders (including PTSD) tended to ceptible to mental illness and mental problems. be most significant within 6  months after a flood [62]. There is a risk that climate-related psychosocial con - Kessler et  al. conducted interviews with Hurricane sequences may become diluted in the high prevalence Katrina survivors 5–8  months post-event and 1-year of mental health disorders globally; therefore, there is a Hayes et al. Int J Ment Health Syst (2018) 12:28 Page 5 of 12 need for additional research within the specific domain communities; and, better planning for mental health of climate change and mental health. If there is a better response and mental health systems resiliency. understanding of the linkages between climate change and mental health, there are more opportunities to Part 2. Current risks and impacts of climate change understand and address climate change and mental on mental health health via actions rooted in climate change mitigation It is challenging for people to recognise changes in cli- and adaptation that support psychosocial resilience. Spe- mate because these changes appear distant or abstract— cifically, the field requires more empirical research on the especially because climate is often confused or lost in mental health consequences of climate change, especially perceptions about weather or seasonal change [23]. The as this research relates to marginalized communities and influential sociologist Anthony Giddens refers to this the risks and impacts associated with chronic climate space and time distancing of the climate change prob- change-related hazards and consequences (like sea-level lem as the Giddens Paradox [70]. The Giddens Paradox rise, rising temperatures, and ecological degradation). To states that: “since the dangers posed by global warming address the overarching interplay of social and environ- aren’t tangible, immediate or visible in the course of day- mental determinants of health that can magnify climate to-day life, many will sit on their hands and do nothing change-related risks on mental health, a health equity of a concrete nature about them. Yet waiting until such approach to this area of study is required. Secondly, there dangers become visible and acute—in the shape of catas- is a need to better understand climate change-related trophes that are irrefutably the result of climate change— hazards within the context of mental health sequelae. before being stirred to serious action will be too late” Research in this area could help to explore the complex- (p. 2). Marshall contends that part of the time and space ity of climate change and mental health attribution by distancing of the climate change problem, and thus the recognizing the role of predisposing mental health con- reluctance to act, is reinforced by the Western political ditions while also taking into account the perceived and discourse on climate change as a future-facing problem actual risks and impacts related to a changing climate. that intentionally overlooks the centuries of industrializa- This type of research can support a better understanding tion, fossil fuel consumption, and land degradation that of the triggers and timing of climate change-related men- contribute to anthropogenic climate change [71]. Mar- tal health effects as well as support policy and program shall calls for a reckoning with this discourse by noting: development for mental health resources. “Climate change is a future problem. But it is also Attributing mental health outcomes to climate a past problem and a present problem. It is better change also presents opportunities to assess, build, and thought of as a developing process of long-term dete- strengthen mental health systems. In 2015, the World rioration, called, by some psychologists, a “creeping Health Organization (WHO) set forth the framework problem.” The lack of a definite beginning, end, or for building climate resilient health systems [69]. This deadline requires that we create our own timeline. framework provides guidance for health professionals to Not surprisingly, we do so in ways that remove the predict, prevent, and prepare for climate change-related compulsion to act. We allow just enough history to shocks with the ultimate aim of protecting population- make it seem familiar but not enough to create a level health by increasing health systems’ capacity to responsibility for our past emissions. We make it just cope, adapt, sustain, and strengthen in the wake of a current enough to accept that we need to do some- changing climate. While the framework overlooks the thing about it but put it just too far in the future to intricacies of mental health systems—like the current and require immediate action” [71]. prevailing lack of mental health infrastructure, funding, and resourcing globally—it does provide the necessary Noting the Giddens Paradox and the reckoning that guidance to build mental health systems resiliency. Artic- Marshall asks us to have with the “creeping problem” of ulating climate change as a determinant of mental health climate change, it becomes important to confront the not only brings awareness of the broad consequences of current mental health consequences related to climate climate change on health but also supports the enhance- change that are happening now [70, 71]. To do so, it is ment of mental health systems. useful to explore the conceptual framework of climate In sum, the key benefits of understanding the link - change and mental health developed by Berry et al. [15]. ages between climate change and mental health include: These authors organize climate change-related hazards enhanced knowledge of patterns of illness; an added into three categories: acute (flooding, hurricanes, etc.), emphasis on the global call to action to reduce and sub-acute (pervasive drought), and chronic (rising sea- address climate change risks and impacts; in-depth level, increasing temperatures). These climate change- knowledge of the risks and impacts to marginalized related hazards lead to a variety of direct, indirect, and Hayes et al. Int J Ment Health Syst (2018) 12:28 Page 6 of 12 overarching psychosocial consequences that are occur- of marginalised community members of New Orleans ring now—disproportionately affecting those most (mainly low-income, African American women) showed marginalized. probable signs of PTSD after Hurricane Katrina [82]. Direct psychosocial consequences of climate change While PTSD is often reported as one of the most include trauma related to extreme weather events, severe mental health impacts related to acute climate like floods, hurricanes, wildfires, and heat waves [15, change-related disasters, there have also been increasing 37]. Indirect mental health consequences of climate reports of suicide and suicidal ideation following extreme change occur through social, economic, and environ- weather events. Chand et  al. note one Italian study that mental disruptions (e.g. famine, civil conflict, displace - found higher rates of suicide in northern communities ment, and migration) related to a changing climate [15, with greater climate variability [72, 83].  Dodgen et  al. 37]. The overarching psychosocial consequences of cli - highlight the risk of homicide-suicides after extreme mate change relate to the long-term emotional distress weather events by noting the doubling of these incidents caused by awareness of the threats and impacts of climate following Hurricane Andrew in 1992 in Miami-Dade change on the current and future wellbeing of the earth County [74]. There is also observed evidence of increased and its inhabitants. The multidimensional climate change suicidal thoughts (from 2.8 to 6.4%) and plans to commit and mental health pathway leads to a variety of unequal suicide (from 1.0 to 2.5%) 18-months after an extreme psychosocial consequences explored below. weather event [74]. Notably, however, the overall evi- dence linking changing climate and suicide is still incon- Direct mental health consequences of climate change clusive. Studies on suicidality in natural disaster contexts, There is now an extensive and rapidly expanding body for example, vary considerably in study methodology and of research exploring the current mental health con- timeframes considered, with recent reviews indicating sequences of climate change-related extreme weather divergent trends in suicidality rates following exposure to events. Extreme heat events and humidity have been extreme events, ranging from an initial decline, to neu- noted to increase hospital admissions for mood and tral effects, all the way to a delayed increase in suicidality behavioural disorders, including schizophrenia, mania, [84]. and neurotic disorders [72, 73]. Scholars in the field On a deeper level, the psychological responses of com- note that heat-related mental health morbidity tends to munities and individuals to disasters are complex and occur most often in people with impaired thermoregu- varied and do not necessarily simply result in more men- lation, namely people with pre-existing mental health tal illnesses. Rebecca Solnit, in A Paradise Built in Hell, illness and problems, people taking prescription medica- usefully describes the complicated psychosocial conse- tions (specifically lithium, neuroleptic and anticholiner - quences that can arise after an extreme weather event gic drugs), and those with substance abuse (alcohol and as, “that sense of immersion in the moment and solidar- drugs) problems [35, 36, 74]. Extreme heat is also linked ity with others caused by the rupture in everyday life, an with an increased risk of wildfires, which also directly emotion graver than happiness but deeply positive. We impact mental health. Bryant et  al. mapped the psycho- don’t even have a language for this emotion, in which the logical outcomes of the Black Saturday bushfires in Victo - wonderful comes wrapped in the terrible, joy in sorrow, ria, Australia; in communities most at risk to the impacts courage in fear. We cannot welcome disaster, but we can of bushfires, these authors found incidences of PTSD, value the responses, both practical and psychological” psychological distress, and depression related to the fires [85]. Exploring the complexity of psychological responses [75]. in the book, Climate change and human well-being, The direct mental health consequences related to Weissbecker et al., discuss the full spectrum of psychoso- flooding and hurricanes are also well documented (see cial consequences of climate change-related events rang- [51–55, 60, 62, 76–81]). In a study of 30 locations in Eng- ing from mental illness to more positive experiences like land and Wales, Tunstall et  al. conducted interview sur- ‘Post Traumatic Growth’ (PTG), empathy, compassion, veys with residents affected by flooding. They found that altruism, and emotional resilience [25]. psychological impacts were more commonly reported than physical effects [51]. One study researching the Indirect mental health consequences of climate change psychosocial impacts following Hurricane Katrina esti- The indirect mental health consequences of climate mates that 20–35% of survivors experienced some form change can occur as a result of damages to physical of mental health issue following the disaster [60]. Galea and social infrastructure, physical health effects, food et  al. reported a 31.2% prevalence of anxiety-mood and water shortages, conflict, and displacement from disorders amongst Hurricane Katrina survivors [81], acute, subacute, and chronic climactic changes [15]. while Rhodes and Chan found that nearly half (47.7%) One of the most well-documented climate hazards Hayes et al. Int J Ment Health Syst (2018) 12:28 Page 7 of 12 that indirectly influences mental health is drought. At the community level the indirect mental health con- Long-term droughts affect food and water supplies sequences of climate change are understudied. These and can subsequently affect the economic and mental consequences may include things like a diminishment wellbeing of land-based workers, most often impact- in community cohesion, the loss of community identity, ing those living in rural and remote communities [58, threats to a sense of continuity and sense of belonging 86, 87]. In a quantitative analysis of drought and dis- as people are forced to move in and out of communi- tress in Australia over a 7-year period, authors found ties because of environmental stressors, and an under- that rural dwellers experience more distress due to the mining of cultural integrity if people have to leave their droughts than their urban counterparts [86]. In a sys- homelands [23]. Migration challenges the identity, sov- tematic review of the literature, authors note the most ereignty and heritage of people who have to leave their prominent causal pathway linking drought and mental homelands. It also challenges the integrity and continuity health is via the economic effects from land degrada - of people’s traditional ways of life. Threats to community tion [58]. These effects are most prominent amongst health also include an increased likelihood of criminal farmers whose economic livelihoods depend on envi- behaviour, violence and aggression as community mem- ronmental conditions. Exemplifying this, a 2008 study bers experience various stressors related to climate in New South Wales, Australia reports that nearly three change [23]. quarters of farmers report stress related to persistent drought [88]. Some authors also suggest that income Overarching psychosocial consequences of global climate insecurity related to drought increases the risk for sui- change cide among farmers [9, 89]. Awareness of the looming threats and current risks and Long-term drought has also been increasingly linked to impacts of climate change presents challenges to emo- conflict and forced migration, which can influence psy - tional and social wellbeing [37]. Since early 2007, envi- chosocial outcomes like the propensity for stress, PTSD, ronmental philosopher Glenn Albrecht and colleagues anxiety, and trauma [90]. The Institute for Environment have taken note of emotional distress related to the and Human Security of the United Nations University awareness of the overarching problem humans face as a estimates that migration due to climate change may vary result of global climate change [96]. Albrecht et  al. sug- drastically, citing estimates of between 25 million to 1 gest that this awareness contributes to ‘psychoterratic billion by 2050, with 200 million as the most frequently syndromes’. Psychoterratic syndromes include phenom- cited estimate [91]. The rise in the number of ‘climate ena such as ‘ecoanxiety’, ‘ecoparalysis’, and ‘solastalgia’. migrants’ has been identified as a significant risk by an ‘Ecoanxiety’ refers to the anxiety people face from con- increasing number of defence and security experts [92, stantly being surrounded by the wicked and threaten- 93]. Gleick postulates that the civil conflict in Syria can ing problems associated with a changing climate [96]. be traced to the agricultural failures in 2006–2009 and ‘Ecoparalysis’ refers to the complex feelings of not being the returning drought in 2011 [90]. In 2011, over 1.5 able to take effective action to significantly mitigate cli - million Syrians moved from rural, agricultural areas to mate change risks. ‘Solastalgia’ refers to “the distress and urban areas seeking refuge from the pervasive drought, isolation caused by the gradual removal of solace from failed agriculture, and lack of food and water [90]. Per- the present state of one’s home environment” [29]. The vasive ecological degradation, poor policy response to term ‘solastalgia’ is also commonly referred to through- water and food insecurity, and ongoing tensions between out much of the literature on climate change and mental rural and urban community members, have arguably all health to articulate the feelings associated with displace- contributed to civil unrest and ongoing conflict in Syria ment following a climate change-related extreme weather [90]. According to the United Nations, the number of dis- event [17]. This new vocabulary provides the language to placed Syrians has reached over 5 million people in the explore some of the broader mental health implications past 5  years [94]. Migration from a war-torn country to of escalating climate change risks. a host country where culture, language, and lifestyle may For many people, climate change is experienced by way be vastly different may also contribute to psychosocial of vicarious threats or as an existential threat to civilisa- malaise as displaced migrants can face stressors associ- tion [37]. People may experience vicarious threats when ated with xenophobia and racism from people in their they receive weather warnings related to future disaster new host country [90]. Conversely as Siriwardhana and seasons or when they hear about environmental stressors Stewart note, displacement may also support psychoso- experienced by people in other places. For many people, cial resilience by fostering hope and belonging for refu- this is largely how climate change is experienced—not gees in host countries where they feel welcomed, safe, as a direct threat, but as a global threat, often distant and experience better living conditions [95]. in time and place, or as a threat to our very way of life. Hayes et al. Int J Ment Health Syst (2018) 12:28 Page 8 of 12 Qualitative research finds evidence of some people being measures to enhance and protect mental health in the deeply affected by feelings of loss, helplessness, and frus - Sustainable Development Goals 2016–2030 [102]; efforts tration as they engage with the problems of global cli- by the Movement for Global Mental Health to increase mate change [97]. the holistic conceptualization of health to incorporate mental health [103]; the Sendai Framework, a 15-year Part 3: Priority actions to address climate change disaster risk reduction program [104]; and, the United and mental health Nations Human Settlement Program that promotes Acting on the health consequences of climate change sustainable urban development [105]. There is a need, requires actions rooted in both mitigation and adaptation however, to harness health and mental health related at all levels—from global to local—and from all sectors synergies amongst these global agreements since none and individuals. Climate change mitigation refers to over- of these in and of themselves will likely be sufficient to arching efforts to reduce greenhouse gas emissions and address the future risks and impacts of climate change. enhance carbon sinks to slow the speed, scale, and mag- Coordinated, collaborative efforts to address the men - nitude of climate change [98]. Key climate change mitiga- tal health implications of climate change not only require tion priorities include reducing energy demand (through policy frameworks but also concrete actions on behalf reduced consumption and increased energy efficiency); a of mental health practitioners. Such concrete actions swift and equitable transition from fossil fuels to renew- may include: communicating about climate change and able energy; reducing emissions from agriculture and mental health in a way that helps people to see that it is forestry; and strengthening land-based emissions seques- relevant and salient to them; advocacy for greenhouse tration. Climate change adaptation refers to interventions gas reductions in health care facilities and engagement that respond to the effects of climate change by adjust - in efforts to reduce the environmental footprint of the ing, moderating, and coping with the risks and impacts of health care sector; and, engaging in adaptation measures climate change [98]. Adaptation is ultimately affected by like preparing for and responding to extreme events. the capacity to adapt, which is the ability and willingness to respond to climate change mediated by individual and Psychological adaptation collective agency [99]. Adaptive capacity is determined by Psychological adaptation requires a set of responses, it things like: governance, economics, infrastructure, tech- requires an acknowledgement of the grave threats posed nology, information and skills, institutions, and equity by climate change and the profoundly consequential [100]. Examples of adaptation interventions that address global crisis. It requires coping strategies to manage the climate change and health include: surveillance and mon- feelings and thoughts that arise so that people can face itoring of disease burdens related to climate change and up to, and come to terms with, these threats and conse- health; education (e.g. public health promotion of the quences rather than avoiding the creeping problem of risks of vector-borne illness), and capacity building (e.g. climate change. It also requires behavioural and psycho- psychological first-aid, and surge capacities at hospitals logical engagement, in which people change and adjust and health care facilities); preparing for extreme weather their behaviour and lifestyle in order to reduce the threat events; and re-locating entire communities to geographic and protect themselves. areas where sea-level rise and frequent extreme weather Active hope—something Macy and Johnstone cham- events are less-likely to occur [7]. pion—supports psychological adaptation. Active hope is Within international approaches to combat climate required to move hopeful intentions from a passive state change there is a significant focus not only on mitiga - where waiting for someone else to take-on the task of tion but also adaptation. From the Paris Accord to the addressing the climate change problem is replaced with Lancet Countdown on Climate Change, to the Planetary an active process of climate change mitigation and adap- Manifesto and climate action marches—policy makers, tation behaviours [106]. The key point here is that hope academics, and the general population are taking steps alone cannot provide sufficient protection from the esca - to mitigate and adapt to the current threats and impacts lating risks of climate change. This active process occurs to preserve a future for the next generation [4, 39]. These when the reality of the problem is acknowledged as is actions, however, often fail to address the gap between the magnitude of the problem, intentions to address the stated goals of emissions reduction commitments and problem are set, and engaged actions take place. While the speed of actions required to keep global warming well these three steps may oversimplify the complexity of below 1.5–2 °C [101]. acting in the face of bureaucracy, climate denialism, or With a specific focus on mental health and climate downright avoidance and ignorance of the magnitude of change, there are a number of global programs in place the problem area, these three steps are indeed the pivot that indirectly address the topic area—like for example points of transformation. These pivot points, however, Hayes et al. Int J Ment Health Syst (2018) 12:28 Page 9 of 12 need to be upheld by global political will and policy can help people overcome feelings of hopelessness, anxi- commitments that tackle the problem at the appropri- ety, and ecoparalysis [109]. Koger et al. suggest: “if people ate scale and speed. To do so, public awareness of the feel a deep connection to places, wilderness, and other severity, magnitude and range of health impacts—cur- species, then threats to these others are much more likely rent and projected—is required to pressure governments to be viewed as personal issues” [109]. Other research and communities to act now. Also, discernible interven- on the restorative benefits of natural environments and tions are needed to demonstrate a tangible path forward settings has found that biodiversity in natural environ- to respond to the risks and impacts we face in a chang- ments is important for human health and wellbeing and ing climate. Examples of these types of interventions are has a particularly positive effect on mood, attention and explored below. cognition [110]. A common practice in Japan to reduce stress and anxiety is the practice of shinrin-yoku, other- wise referred to as forest bathing. In a study by Lee et al., Adaptation measures authors found that forest bathing resulted in decreased Adaptation measures that address the psychosocial cortisol levels, pulse rates, and negative feelings and sig- impacts of climate change come in a variety of forms, nificantly increased positive feelings [111]. Research on i.e. policies, practices, behavioral interventions, com- people’s interactions with nationally important ecosys- munity-based interventions, specific training, and phar - tems, like World Heritage Areas for example, highlights macotherapeutics. Some general approaches to address positive impacts including quality of life, a sense of place climate change-related mental health problems or ill- and belonging, self-identity, restoration and inspiration nesses include: primary care interventions, individual [112]. and group-based therapy, cognitive based interventions While there are a number of interventions to sup- (including cognitive based therapy, cognitive restructur- port psychosocial wellbeing within a changing climate, ing, and, stress inoculation training), and crisis coun- it is important to highlight that many of these interven- selling [67]. More broadly, emotional resiliency may be tions are still quite nascent and administered in ad hoc sustained by engaging with art, literature, and spiritual- fashion, and these interventions are mainly accessible in ity. In addition to the above, the list below contains some developed countries. Sustainable mental health care in specific priority adaptation mechanisms that ought to be developed and developing nations is urgently needed as considered to support population-level mental health in a the realities of climate change become more and more changing climate: apparent—especially for those most marginalized. Fur- ther, there are research needs in this domain where the • Policy responses: improving access and funding to efficacy and accessibility of mental health interventions- mental health care; related to climate change are assessed. • Surveillance and monitoring: administering epide- miological surveys after extreme weather events, and monitoring emergency department visits during heat Conclusion waves and following extreme weather events; Climate change affects mental health in a variety of • Practice: the application of a stepped-care approach direct, indirect, and overarching pathways—dispropor- to mental health that is often used in disaster men- tionately affecting those most marginalized. The mental tal health to support different levels of interventions health implications of climate change can result in men- depending on the timing of the disaster and the level tal problems and illness as well as affirmative psychoso - of distress (see [107, 108]); cial outcomes. While the timing and triggers associated • Preparation and response: climate change adapta- with climate change and mental health may vary, mak- tion/resilience planning in the mental health system; ing it challenging to establish the manifold links between • Community-based interventions: climate change climate change and mental health, the opportunities of resilience plans that address psychosocial wellbeing; attributing mental health to climate change support cli- and, mate mitigation as well as mental health action and psy- • Special training for care providers and first respond - chosocial resiliency. Global commitments, like the Paris ers: e.g. psychological first aid. Accord, the SDGs, and the Sendai Framework are needed to help advance global mental health and climate action; Other innovative approaches to addressing mental however, coordination amongst these commitments is health and wellbeing in a changing climate writ large required—as are concrete actions on behalf of health include experiencing and preserving nature. Koger et  al. practitioners—if the issue of mental health and a chang- suggest that environmental preservation provides people ing climate is to be efficiently and holistically addressed. with a sense of stewardship and personal investment that Further, a reckoning with social, environmental, and Hayes et al. 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International Journal of Mental Health Systems – Springer Journals

Published: Jun 1, 2018

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