Good morning. I'm Stephen Peterson, a Senior Psychiatrist at the MedStar Washington Hospital Center practicing inpatient and outpatient at our facility here in Washington, DC. Now, we have four other presenters, and we're all members of the Climate Psychiatry Alliance, which is an activist organization with over 550 members. We have no disclosures, and the objectives I will go over as we introduce the panel. And the abstract is something good to read when you have some more time. I want to begin then with a brief overview of climate change and mental health impacts, as well as our unique role as psychiatrists in dealing with these problems we face. My colleague will follow, discussing these core areas. Dr. Cheru Iyer will talk about climate disruption and how it impacts various stress, how it results in various stress disorders, PTSD, GND, major depression, and so on. Dr. Ben Liu will follow next by doing neuropsychiatric effects of air pollution, because we reordered the presentation, and the role of climate change across the lifespan. Dr. Wartzel will do heat and mental illness. And at the end, and I'm sorry, Dr. Janet Lewis will be forth discussing psychotrophic syndrome. She's going to bring us home, talking about our changing relationship to the natural world. All right. Now, air pollution, well, first of all, let me just say this. We of the climate psychiatry understand that climate change is a central issue for mankind. Recent research at Harvard showed that almost one in five people died prematurely due to air pollution from fossil fuels. That's more than 8 million a year. In fact, 90% of people across the earth breathe polluted, unhealthy air. Not only do we see dire health impacts from traumatic injury, heat illness, heat stroke, but we also see exacerbations of chronic illnesses like respiratory, cardiovascular, and metabolic disorders with resultant morbidity and mortality. Indeed, there are many ramifications that our speakers will tell you about today, air pollution, temperature rise, and extreme weather. Consider the pandemic related to our overcrowding of the planet, living in close proximity to other species. The disruption by powerful hurricanes, tornado outbreaks, droughts, wildfires, floods present enormous challenges. Think of the slow yet inexorable sea rise. This will certainly result in huge effects for those of the island nations and coastal areas of the world. They'll be losing not only lives, but some who survive homes, livelihoods, habitats. Similarly, we've seen what prolonged drought can do to one country, such as Syria from 2006 to 2009. A violent uprising occurred in 2011, and subsequently, we've seen a decade of revolution, warfare, famine, and mass exodus from Syria, resulting in many refugees. Then along came 2020, which I like to refer to as a year to end all years. Once the pandemic took off, in a few short weeks, recall how our lives were radically transformed. Most disasters now are a single event that has time limited, but this world pandemic has been continuous with many facets. Unhealed racial wounds ripped across America after the death of, the tragic death of George Floyd. And during the summer, months-long heat waves settled in the southern U.S. Wildfires erupted in the west coast due to conditions of high winds with low humidity. Many lost their homes to the fires, and others their homes and livelihoods. More hurricanes arose in the tropics this year than ever before, and five struck the Louisiana coast this past summer. Now, even after single disasters, we know from Dr. Morgenstein, the Disaster Committee, and others, that mental health impacts are the most pervasive and that long-lasting. Not surprisingly, the mental health effects of what's been called the 2020 mega disaster are profound and keep happening. Underlying all of this is climate change. Okay, now think of climate change as over decades, and this change is causing short-term extreme weather events that are more intense and more frequent. Now, Dr. Janet Lewis, in her presentation, will define and talk about a hyper object, so I won't go into that right now. But let's go to the drivers of climate change. The rise of greenhouse gases. Even though we're increasingly aware of this problem, the beat goes on. Consider America. We've got five percent of the world's population, and utilizing one-fourth of the available energy, and consequently, we're causing one-fourth of greenhouse gas emissions. Indeed, fossil fuels still account for two-thirds of all electricity produced in the world, and it's the primary energy source for most of our needs. Changing course is going to take decades. Now, the 2020 pandemic slowdown did result in a five percent decrease of emissions, but that was just a blip, and we're right back at it again. Consider the population explosion. We've gone from a few million hunter-gatherers occupying the planet to seven and a half billion currently, and we're projected to go to 10 billion by 2050. Now, according to a thoughtful economist, Professor Das Gupta at Cambridge, we would be better off with half our current number, something like 0.5 to 5 billion, in order to have a sustainable population for the long term. But that's not where we are or where we're going. There's just too many people. Okay, as regards feedback loops, there are perhaps 40 identified. The three most widely known are, of course, fossil fuel use causing CO2 and methane rise and the heat, and so there's demand for more air conditioning, need more electricity, more fossil fuel used to produce the electricity. That's the feedback. Secondly, deforestation, meaning the massive release of the greenhouse gases, rising temperature, more likely to have more forest fires. The third is melting the polar ice, such that less sunlight is reflected back to space and poles are warming two times faster than the rest of the planet. The result is a loss of permafrost. Now, since 1900, an estimated 10% of the permafrost has been lost, and we know what happens when permafrost thaws because bacteria, archaebacteria, create CO2 and methane. This is ominous because it's estimated that twice as much carbon is trapped within permafrost as in the atmosphere now. Right. So, extreme weather is becoming the norm. Ironically, one founding member of the Climate Psychiatry Alliance is living in an area, as is Dr. Ben Liu, thought to be at lower risk for the rising heat, the Pacific Northwest. But where Dr. Pollack and Ben Liu live, just south of Portland, during the last nine months, there had been a series of extreme weather disruptions. He chronically chronicled these events eloquently in several issues of Psych News, and here's a brief summary. In September of 2020, frequent windstorms and hot, dry conditions led to wildfires burning all over the state. The outbreaks creating eerie smoke-filled skies that ranged from gray to brown to red to yellow, accompanied by the worst air quality in the world for a few days. Breathing outdoors, of course, was hazardous. He and his family were on alert to evacuate when nearby fires threatened them, but fortunately, the winds shifted at the last moment. They were shut in with vents sealed for almost two weeks by the many wildfires. Then, in January, an atmospheric river from enormous moisture carried high aloft, proceeded to drop many inches of rainfall with accompanying winds that led to flooding and power outages across most of the area. A month later, a cold front with freezing rain brought a historic ice storm with one to two inch of ice buildup from the freezing rain collapsing many trees throughout the region and power lines. Most of Dr. Pollack's trees were lost, especially a cherished backyard family chestnut tree they planted when they moved in 43 years ago. Locally, the power outage meant 90 homes were unable to pump water from wells. Leaking from several homes with burst pipes drained the water supply from the reservoir. Dr. Pollack and family were stressed, but were more concerned with others less fortunate. Their neighbors rallied to help one another, which was heartening. Okay. Two of our CPA members, Dr. Richardson and Dr. Jim Schultz, and others have addressed this in the publications listed here. They said hurricanes are among the most ferocious disaster events, causing widespread destruction and harm. They disrupt routines and cause psychological distress for our patients and even for healthy individuals with new onset, they produce new onset disorders. The psychological effects are more frequent in medical effects after hurricanes. Storms are stronger, wetter, and slower moving now because of climate change as they pass over populated areas. Consider the slow moving Hurricane Dorian that devastated the Ibaco Island in the Bahamas. This major disaster resulted in hundreds lost and survivors were severely psychologically traumatized. Fortunately, the eye was able to stall over the town for a period to afford some time to seek better shelter in two structures, so some were saved. And the severe weather now is becoming far more severe and causing more psychological harm. Those were their main points. The authors note that we psychiatrists have a valuable role making personal disaster preparations, helping others, our patients and other caregivers learn about disaster preparedness, assist to minimize trauma exposure, and also improve coping skills and foster resilience in the patients and the public. All right, let me just mention a very important facet of all this is too long have minorities, persons of color, and other vulnerable groups been disadvantaged with regard to climate. Racial justice, energy justice, and climate justice should go hand in hand. Dr. Shalanda Baker, a new leader in the government, says social compassion must inform technological progress. This is especially important in our history. Just give me, let me give you two examples. African Americans in general are 75% more likely to live in fence line communities situated near polluting facilities of hazardous waste. These persons are much more likely to have asthma, heart disease, premature deaths, and cancer. One example of many, there was a disadvantaged community of African Americans in Philadelphia located across from a hazardous petrochemical plant. Over time, this community endured many illnesses and losses. They took notice and stood up to the corporation, to politicians, and the uncaring public, frankly. With persistence, courageous effort, they eventually prevailed and closed the plant down. Now, we should all follow their brave example. After all, one day, aren't we all going to be in a similar boat? Or are we in one now? Okay. So, what do we need to do? Quickly, reduce emissions of greenhouse gases by 8% per year. Revise energy production such that we can produce zero carbon by 2050. We have to develop new ways to, using clean energy to live. We need to plant an area the size of America with appropriate forest cover, hence producing almost a sixth of the greenhouse gases we've produced in the last 200 years. But it's got to be an appropriate forest, not just planting a few trees. We need to eat two-thirds of animal foods. I mean, sorry. We need to eat two-thirds less animal foods. Two meals a day should just be plant-based diet, as per the man who wrote, We Are the Weather. It's a great book. This will save us enormous amounts of greenhouse gases. Just eating meat once a day will make a huge difference if we could move to that. We need to protect the reefs and oceans to try to prevent the sixth extinction. We need to reduce population to more sustainable levels somehow and begin to live in harmony with nature and one another. Okay, so there is hope for the future. We've rejoined the Paris Accords. The world's biggest economies are trying to reduce air pollution. And even China, to its credit, reduced air pollution for a decade from 2013 and probably saved millions of lives by changing from coal to gas-produced electricity. We all need to focus on the problem more and more, yes, but we all need to make efforts to persuade friends, family, our patients, and the public. Now let me conclude by saying this statement from a wonderful article listed below. We can muster the effort and investment over the next 10 to 15 years to reach it in time to avert the worst of climate change. We can have clean air, clean spaces, clean energy, a prosperous economy, and a stable climate. All the things we want if we're just willing to do work. Thank you very much. And we'll now move to the next speaker. Okay. So you've already heard from Dr. Peterson about many of the crucial issues that we face regarding climate change and how it's impacting our lives and what we need to do to tackle it. I'd like to focus in particular about severe climate disruptions and how that will affect mental health and how we need to address these issues in particular. First, let me begin by saying climate disruption is happening now. This is not something that we can say we'll be projecting into the future. This is not something that we can say we should worry about at some point when warming happens. This is actually occurring today. And it's important to emphasize that climate change as it occurs will increase the rate of climate disasters. And that means things that we're going to actually experience and we are currently experiencing. A couple of simple examples. For instance, we can expect to see an increase in extreme heat events. For obvious reasons with melting ice, we should expect to see coastal flooding increase as well and increased flood events along coastlines. The Clausius-Clapeyron equation, to use a little bit of physics, helps predict that with increasing temperature from 1 to 1.5 degrees centigrade in our atmosphere, the atmosphere actually can take on more water vapor and more water pressure. And so that means essentially the atmosphere will contain more water in it. And so for extreme events like hurricanes or tropical cyclones or extreme rainfalls, you can expect more wetter serious climate disruptions and more frequent climate disruptions because of that extra contained energy and water in the atmosphere. And its ability to take on increased water vapor also creates a water vapor pressure deficit, which therefore causes drying of the ground because of the evaporation of water from plants and the ground. And that increases the rate of severe fires, which we've also seen in our current climate. And unfortunately, the Clausius-Clapeyron equation is not a linear equation. So as heat continues to rise, the amount of vapor pressure in the air rises non-linearly. So we can expect things to get only increasingly worse as we move forward. To give you a kind of sense of the scale of what we're looking at, the NOAA here in the United States has been tracking billion-dollar disasters, disasters that actually incur costs in 1980 dollars, inflation adjusted, of a billion dollars or more, and have been tracking this consistently since 1980. There have been 124 of such disasters in Texas alone, and the average number of billion-year disasters has been around seven when you start counting back as far as 1980. But if you look since just the last five to six years, that average has increased from seven to 15. And that's just the last couple of years. 2020 not only was a pandemic year, but more concerningly, had the highest number of United States billion-dollar disasters in recorded history since 1980 of 22. And it's only going higher. So this is a real severe problem that we're facing here. And you know, I don't want to say we're just looking here at the United States. If you look at the world, cyclones across the world from 1970 to the projected numbers in 2030 are also increasingly affecting populations across the world. Here you see the number of people being affected by the various tropical cyclones across the world, and you can see this number increasing significantly over this period of time. And if you look at flooding as well, particularly in Asia and Africa, severe increase in the number of people affected yearly in thousands of people from 1970 to 2030. So this is a real significant impact, and one that is basically right now, not something that we are projecting distantly into the future. Now, a lot of people say, okay, fine, these numbers are increasing, but do we really know this is because of human-caused climate change? And this is where a whole field of science is actually addressing this. There've been over 170 studies since 2004 that have looked specifically at climate disasters to determine whether or not these are being caused by human-induced climate change or natural variations in climate. And the vast majority of these studies has demonstrated that the weather events that we're seeing are being caused by, are being worsened by human-induced climate change rather than just natural variation. Obviously, the science is still evolving. It's hard to be able to take large-scale processes like climate change and boil it down to a local event like a climate disaster. But as the science improves, and as our statistical ability to evaluate these improves, we can continue to see more and more attribution of these climate disasters to human-induced climate change. Now, as far as the mental health effect of these climate disasters, unfortunately, these are largely predictable and something that we shouldn't think of surprising, but I want to make sure to emphasize some of the key factors here. First of all, climate disasters are a source of acute trauma. That's no surprise. And certainly, in people who have been pre-traumatized or being traumatized by a climate disaster, you can expect to see acute stress disorders, post-traumatic stress disorder. You're going to see a generational translation, potentially, of mental health issues in terms of pregnant females who might be in the midst of a acute trauma caused by a climate disaster, passing on potential mental health liability to the next generation because of what they're experiencing, what the next generation is experiencing in utero. Obviously, people die in climate disaster, which is going to cause problems from as simple as bereavement to more complicated grief. Heat waves, in particular, have shown a statistical correlation to increased levels of violence and heat waves, apart from just the natural increase that we're going to see in climate change, but the disastrous heat waves that we're going to start to see more frequently can result in spikes in violence and therefore, of course, a secondary trauma to just the heat itself, as well as an increase in substance use disorders and substance use, especially alcohol. Drought is something that we expect to see a significant increase on. Many of us in urban environments may not necessarily recognize this, but definitely, in rural environments, suicide risk, especially with failure in crops, is an extremely high risk factor. There's been a severe increase in suicide rates in India, in particular, with recent droughts, and we can only expect to see this increase further. After the initial disaster resolves, mental health effects can continue for an extended period of time. It's the last thing to actually improve after an initial disaster. We can expect to see the obvious things like depression and anxiety increase in rates, but we'd expect potentially to see behavioral problems in children, especially in separation from adults, and increased rates of psychiatric hospitalizations, for which there is a clear correlation between climate disasters and seeing higher rates of people with mental illness being hospitalized after the climate disaster. Now, these effects on mental health from climate change occur in the context of a socio-demographic environment that's important to recognize as well. In the middle of this slide, you see how climate drivers and climate change can lead to exposure and ultimately mental health outcomes, as well as other health outcomes, of course, but all of these are wrapped around by other social and behavioral contexts and environmental context. And the vulnerability of a population that's experiencing a climate disaster can largely depend on the environmental or institutional context that these people live in, as well as the socio-demographic and socio-economic context that people have, both in terms of risk factors that they may have in an ongoing basis, as well as their increased vulnerability to a disaster such as a climate disaster. In particular, we can look at social determinants of vulnerability in three main ways. Number one is exposure. Certain people, based on their socio-demographic context, can be exposed more significantly to a climate disaster than other people in terms of where they live or the kind of things that are around them, whether you live in a coastline versus inland, whether you live in a farm community or an urban community, your exposure to a climate disaster will be different. Sensitivity in terms of a person's either individual or community-based sensitivity to being affected by a climate disaster obviously can be very different. Certain people are going to be hit more hard by a climate disaster than other people based on their socio-demographic context. And their ability to adapt after an actual disaster occurs is going to vary as well. Some people, individuals, communities, institutions are going to be more able to bounce back, so to speak, when a disaster occurs, and other people may never bounce back. And that's something that we need to take into account as well. And all of these vulnerabilities ultimately lead to mental health impacts from the climate disasters that are going to be occurring. So to be more specific about some of these vulnerable populations, obviously the one for us as psychiatrists and mental health professionals should be the most concerned of are people with mental illness. People with mental illness who take psychiatric medications, especially the antipsychotic medicines and heat waves can have impaired heat regulation and therefore be more sensitive to the effect of heat waves. And people with mental illness, unfortunately, are impacted on a daily basis by lower socioeconomic status, stigma, and more dependence on infrastructure to be able to maintain their daily livelihoods. And so their ability to bounce back from a climate disaster is going to be impaired. So our population that we treat on a daily basis are the ones that may be potentially amongst the most vulnerable. Children, obviously, will be more vulnerable as well because they're more sensitive to changes in their caregiver status or their routine, and those can be really affected by climate disasters. First responders are doubly traumatized, first, because they're exposed to the actual trauma, the actual climate disaster, and then second, they can be secondarily traumatized by the effects that they see in the people that arrive. We've seen this increasingly in first responders during the COVID crisis, and we can expect, unfortunately, to see this in the mental health effect on first responders in climate disasters to occur in the future as well. Things that we can clearly identify as increased vulnerability, people with lower socioeconomic status, people who are homeless, people who are refugees and have insecure housing. Racial and ethnic minorities, of course, already face structural racism, and so that racism may potentially elevate or increase in the context of a climate disaster and will place them and make it harder for them to have adaptive capacity. And they may be more sensitive based on where they actually physically live, often due to structural racism. They may live in environments that are gonna be impacted more by climate disasters, so we should definitely pay attention to the fact that the location of racial and ethnic minorities and their access to mental health care is gonna be significantly impacted. And the elderly and chronically ill, unsurprisingly, will have more exposure and more sensitivity to a climate disaster as well, so these are also very vulnerable populations. So how do we prepare? We know climate disruption is happening. We know that it will continue to happen and only get worse. How do we try to make sure as mental health professionals that we're ready for this? The most obvious, of course, is making sure that mental health interventions are available for people after a disaster occurs. So many of you hopefully are aware of psychological first aid, which is a easily distributable package of information as well as skillsets to give to communities and populations to help address psychological harm caused by climate disruptions. Crisis counseling is largely along those lines as well, and these are well-established evidence-based treatments. For those of us in consultation with us on psychiatry, we'll likely see increasing amounts of patients who are physically injured or physically ill due to climate disruption, and we will have to address the acute stress or PTSD syndromes when they present themselves in a medical hospital setting. And we need to improve our disaster mental health infrastructure. We need to improve our infrastructure as a whole, but in particular, the mental health community tends to not be as able to identify the infrastructure around disasters, and we tend to unfortunately pick up the pieces too late rather than be ready in advance for the disasters that are to come. But more so than what we do before a disaster to prepare for the disaster and what happens next is what we do in general to improve communities, improve institutions, improve people to be more resilient, to be more self-efficacious, to have greater community support even before the disaster occurs. Adaptive capacity for vulnerable populations requires us to address this and make sure that we provide mental health interventions even before the actual disaster happens. The CDC in particular has addressed this issue with what it calls BRACE, and this is a toolkit that's available through the CDC to help improve resilience to climate disruptions in vulnerable communities. And it's a five-step process, but it's also a cycle. And to build resilience against climate effects, we have to start by forecasting potential impact, assessing vulnerabilities, project what the disease burden in our case, the mental health burden is gonna be to a particular community, assess the public health interventions that exist and start developing and implementing an adaptation plan to help address the barriers or the potential vulnerabilities that may exist in the population. And then do ongoing evaluation and quality improvement of the activities that we take into place and see how that then affects our future ability to address vulnerabilities and climate impacts. We need to involve both people at the individual level, at the organizational level, at the institutional level, and especially at the community level. And there's a number of different things that we need to talk about in terms of resilience to climate disruption. First, we need to develop skills, trauma-informed skills, just for people to be aware that traumas do exist, that mental health trauma is a thing, that symptoms of mental health impacts on climate disruption are things that we need to be looking for. Part of resilience development is presencing skills, is being aware of cognitive distortion and being able to use coping skills, self-regulation, connection to nature and other supports to be able to... Social supports to be able to know how to adapt when these things occur in advance, as well as purposing skills, which I think may be in some ways the most important to address meaning, values, and hope when disasters happen and do that in advance so that people are aware that when a disaster happens, they can attach to these ideas of meaning, value, and hope, both as individuals, but also as institutions and communities. We need to expand dissemination of a lot of these things. So psychological first aid or the trauma-informed skills or the skills developments that I just discussed, we need to spread this out across communities. And that's easier said than done. So that's where internet-based solutions or app-based solutions have been increasingly tested to be able to roll out these kinds of things in an easy-to-access way for the general population. We need to have community-based providers or peer providers that are trained to provide these kinds of skillsets, both in terms of resilience as well as adaptation, so that this can be disseminated widely because there's not enough of us psychiatrists to be able to do this. And we need to really strengthen community and social network cohesiveness. I think we live in a society that's increasingly separated, especially in the context of COVID where we're all socially distancing. We need to be able to connect more to be more resilient for climate disasters. And we absolutely need more research. This idea of resilience is still in many ways in its infancy when discussing especially the mental health impacts of climate disasters. And we're gonna need to be able to understand what are the evidence-based means we can use to make sure that when a climate disaster happens, we are ready and we're able to bounce back. So in summary, climate change and climate disasters are happening now. This is not something that we can wait on. This is something that's happening right now. And climate disruptions clearly affect mental health due not only to the acute trauma of the event, but a number of other associated factors. Vulnerable populations are clearly differentially affected because they may have greater exposure, greater sensitivity to disasters, as well as differences in their ability to adaptively cope with disasters. And we need to address the mental health effects of climate disruption, both with pre-disaster and post-disaster interventions. Pre-disaster interventions in particular addressing the issue of community resilience, which is gonna need skill development, more dissemination, stronger communities, and especially research. Now we'll move on to the next presenter. So big thank you to Dr. Peterson for pulling us together on this presentation and to Dr. Elizabeth Haas for her contributions to this air pollution presentation, which she previously gave. And so we're first gonna talk about the scale of this issue, whereas Dr. Iyer talked about disasters and vulnerability and resilience to more acute disasters. Like this one, in contrast, is about air pollution, which is this insidious, really frightening cause of extreme mortality. It has numerous contributing causes and burning fossil fuels is the most significant contributor. CO2 is well-recognized as the most significant greenhouse gas, exacerbating global warming. But we should note in this bottom image on the right, bottom right, the EPA also identifies six common air pollutants that we really need to take heat of. So these include ozone, sulfur dioxide, nitrogen dioxide, and particulate matter 2.5 specifically, slightly smaller, the 2.5 micron size particulates compared to the PM 10 microns, which are also hazardous to some extent, but not quite classified as a criteria, one of the six criteria air pollutants. And so on that map on the bottom right, you see the areas in blue, which have areas that exceed the recommended air quality standards. And if you check your internet browser and you're looking for like the air quality, usually it will show you at least five of these six criteria air pollutants, like lead does might not show up, but all the others, including PM 2.5 will show up. And so you look at the bottom left figure and this is showing that they estimate that every year there are 7 million deaths that you can attribute to air pollution. And there's a range including in this next slide, you'll see 5.5 million deaths that they attribute in 2013, but there are more updated numbers that I will show you in another four slides from 2018 that use more updated models to show that even PM 2.5 on its own is attributed to a significant number of deaths. So on the order of 8 million per year. So regardless of preponderance of studies on air pollution and mortality find that air pollution ranks in the top five risk factors for mortality, and especially in emerging economies, such as India and China, which are shown in red on this table, on this map. So this is a slide showing the excess number of deaths from cardiovascular disease attributable to air pollution alone by location. And so you'll see that the deaths are heightened in urbanized areas in the darker red in Europe here from this pretty seminal study by Lelleveld in 2019. So these deaths cluster around urban areas where there is more air pollution of all kinds. And just a quick note that, you know, children are suffering unnecessary asthma and respiratory illness leading to about 20 million emergency room visits per year. And so children are certainly an overrepresented population among those suffering by air pollution. And their alveoli are more susceptible to air pollution as they're developing. So this table is just to kind of give you a sense of where PM 2.5 is being generated. So highlighted in the gray highlighter is what's already just naturally existing in the atmosphere, which is a minority. You see 80% plus is essentially from either directly or kind of indirectly related to carbon, to fossil fuel combustion. So these deadlier PM 2.5 particles I'll show you later, penetrate deeper into the lung alveoli, but just know that, like for example, whereas for most regions, except for the Middle East and Central East and Eastern Europe, natural sources have shown higher contribution in PM 10 rather than in PM 2.5. The certain other pieces of this pie chart, including the unspecified source of human origin, industry and traffic have shown higher contribution to in PM 2.5 rather than in PM 10. So this indicates that the influence of natural sources is relatively high on PM 10 rather than PM 2.5, whereas the combustion, the fossil fuel combustion sources are more important in PM 2.5 than in PM 10. So this is a study that the organization Healthcare Without Harm did an excellent email information distribution for. So this is a pretty important study showing that the PM 2.5 in ambient air pollution, so looking solely at the PM 2.5, solely from fossil fuel combustion and how that influences higher rates of premature mortality. And so they found that 8 million people died in 2018 from fossil fuel pollution, which is significantly higher than previous research suggested, like in my previous slides showing 7 million or 5.5 million. And so the dose response function that the authors chose reflects the latest scientific research, including studies at lower concentrations and at higher concentrations than previously reported. And so this is from that study. And so the estimate of over 8 million deaths in 2018 means that air pollution from burning fossil fuels like coal and diesel was responsible for about one in five deaths worldwide. And so to put this number in perspective, it is three times more than all of the following causes of death combined in 2018, HIV and AIDS, tuberculosis and malaria. So notably the burden of disease is higher than previously thought in low income regions, for example, Asia, but also in high income regions like North America. So the significant increase in mortality is linked to higher vulnerability at both lower and higher concentrations of PM 2.5 than previously understood. This is a nice table that Dr. Haas previously shared as well from the Air Quality Life Index. And it shows that the years of life expectancy lost in different countries due to air pollution in 1998 in light blue, whereas in the dark blue it's shown in 2016. And so on the left, these are countries where the PM increased and the mortality has increased. And on the right, these are countries where the particulate matter 2.5 has decreased. So here is a, we'll just quickly glance over this slide, but it's also from the AQLI at University of Chicago. And this is a case of a severely air polluted country, China, which improved its air quality drastically within half of a decade. And so just to kind of give you a sense that, yes, things can change very quickly, especially if things are really bad. And so I forgot to mention earlier that the AQLI basically estimated that with the higher particulates, basically China is showing four years of reduced life expectancy, if you average it out. And so on the left, they show that if reductions continue to be sustained, China's people can expect to live some two years longer. And so second section is on the anatomy of particulate matter. So we'll show you, we'll zoom in with an electron microscope. And so this first slide, before we get into the actual anatomy of a particle, I just want to highlight the six. The six in yellow are the criteria air pollutants that I mentioned that are monitored by the EPA. And so particulate matter is one of the six. And then as we get to our third section today, the various studies will talk about some nitrogen oxides, sulfur dioxides, ozone as being hazardous in different ways to neuropsychiatric conditions. I would like to spend a moment to talk about, well, polyaromatic hydrocarbons, which I have in teal circled, because these are components of particulate matter. And they are a major product of fossil fuel combustion. So it is mostly the polyaromatic hydrocarbons that are produced along with CO2 as we burn these fossil fuels that form the core elements of air pollution particles. And after various combustion processes, you have gas phases and you have the particulate bound polyaromatic hydrocarbons. And so with a majority of anywhere from about 60 to 97% of atmospheric polyaromatic hydrocarbons adsorbed onto particulate matter 2.5. So it's important to know that constitution of PM 2.5. And so PAHs, the hydrocarbons, they interact with PM and then there are 16 of them that are listed as priority pollutants to regard for adverse health effects with benzopyrene classified as carcinogenic and numerous others as probably carcinogenic. They cross the placental barrier and they have been shown to lead to developmental toxicity as well as intrauterine growth retardation. And then even more, there are negative effects of these hydrocarbons observed later in developments, low IQ and behavioral problems in addition to allergies and asthma. So we already talked about the six criteria air pollutants in yellow and then in orange, it's just to not forget that carbon dioxide is another product of fossil fuel combustion and that methane is a very potent greenhouse gas as well. So this image just gives you a sense of the size that we're talking about. So the PM 10s, the PM 2.5s, and then even smaller, the ultra fine particles, which in many studies, they identify this as the PM 0.1 microns, which means you could put 25 of the 0.1 ultra fine particles into a PM 2.5 and you can put four PM 2.5s into one PM 10. And then you can put five of these PM 10s into a human hair, a human hair, which is 50 microns. These are small particles. And so ultra fine particles, you can see in this electron micrograph on the left, and then that, you know, it's so small that you wouldn't even put them on the image on the right where you have, where you do see PM 2.5 is kind of falling in between the size of a virus and a red blood cell. And then PM 10s just being just a little bit bigger than a red blood cell. So ultra fine particles are found to a large extent in urban air as both singlet and aggregated particles. So kind of paralleling poly aromatic hydrocarbons, these are also very much bound to the particulate matters, PM 2.5 and PM 10. So I will just go through here quickly. I will just say that PM, the ultra fine PMs, the 0.1, they are so small that you measure them by the quantity of particles rather than the mass. But because there are so many of these PM 0.1s absorbed onto other air pollution particles, they have a huge surface area and a huge potential for, you know, interacting and causing their toxic effects. But it's also harder to measure because there's heterogeneity in how they get measured. So, but there is one example of a specific condition was with pregnant women exposed to the PM 0.1s having increased risk of low birth weight, especially in those living within 50 meters of heavy traffic. So here, so I'm gonna move on to this slide and there's a whole lot of chemistry going on in this figure. And it's just to say there are, there is organic carbon already in the atmosphere. And then there is elemental carbon, which is produced from combustion of fossil fuel. And they combine and they stick to each other. And then ultimately these add up to form the larger PM 2.5 and PM 10 micron particles. Kind of like the Dr. Seuss comic, Euro the Turtle, where you have carbon all the way down, carbon sticking on carbon, sticking on other metals and molecules and generating and then sticking onto your lung surface, generating oxidative radicals. So finally, this is the section with a bunch of tables showing the neuropsychiatric effects of air pollution. This is a pretty busy slide. And I'm just gonna summarize. You would start at the bottom, looking at these three pathways, two of which are indirect and one of which is direct. And then these ultimately kind of funnel into common pathways that show the proposed concept of how air pollution contributes to neurological and mental disorders. So ultimately, ultimately, dysregulated microglia, if you, if you look at in the middle of this of this flowchart, the dysregulated microglia are central to neurotoxicity by releasing neurotoxic cytokines, you know, like TNF alpha, IL-1 beta, as well as different reactive oxygen species, like different oxygen-free radicals. And so dysregulated microglia represent a hallmark of most neurological complications, as well as some mental disorders. And to summarize, the general downstream effects, air pollution affects a number of vital processes in the brain, such as impaired neurotransmitter signaling, higher levels of cerebral cytokines, activation of neuronal immune cells and disruption of the blood-brain barrier, as well as higher oxidative stress levels. So, you know, this is kind of a, this is a kind of an introductory slide to the next few slides, of which I will highlight, I'll land on the ones that are bolded because there were more meta-analyses of these. And there's just more certainty with those conditions of autism, dementia, and stroke. So, so cardiovascular effects of air pollution are, you know, already very well known to most healthcare professionals, maybe not as well as we would want, but, but there's under-recognition of the impact of air pollution on disorders that we treat as psychiatrists. And so the ones listed on the left. And so to reiterate from the prior slide, neurotoxic mechanisms of air particulates include systemic inflammation and brain oxidative stress. And so for stroke, this figure from a 2018 review shows estimates for population attributable risk of cerebrovascular disease associated with air pollution worldwide. And so of concern is that this association is stronger in low and middle income countries. And separately, I'll just mention it has nothing to do with this, this image. It's from a 2015 study, but it was a quite a large meta-analysis looking at 28 countries, 94 studies. And there were 6.2 million events finding stroke hospitalization or stroke mortality to be associated with the short-term, even a short-term increase in levels of PM 2.5 with a confidence interval of, with a relative risk of 1.011 and a confidence interval of 1.011 to 1.012 per 10 micrograms per meter cubed increase in PM 2.5, which that's pretty profound because many countries, including China have, have many multiples of 10 microgram per meter cubed increase in PM 2.5. And so short-term increases in PM 2.5, sulfur dioxide and nitrogen dioxide were all shown to increase the relative risk. And this is ischemic stroke is the greater thing that has increased. Although hemorrhagic stroke also is increased as well, possibly due to the weakening of vasculature from the buildup of these particulates and, and all the inflammation processes. So dementia is a, is a, been studied a little more. There's two meta-analyses I mentioned here, this, this forest plots in the bottom is for the second study. And so they're both pretty recent and they show an increase in overall dementia, but particularly Alzheimer's dementia. If you look on the far right column where Alzheimer's is studied, the studies are more, it's a subset of the data, but it shows a higher hazards ratio and a higher odds ratio. And so mechanistically explaining the association there, we should say there are numerous additional studies that do identify cardiovascular disease, stroke, most notably as, as being kind of a crucial mediating mediator between air pollutants and overall risk for dementia, including vascular dementia. But we shouldn't lose sight of the fact that living in areas with high levels of air pollution has been linked to markers of neuroinflammation and neuropathology that are associated with neurodegenerative conditions, such as Alzheimer's disease like brain pathologies. So the mechanism of pathophysiology that increases Alzheimer's is unclear, but we can say at least that chronic air pollution confers neurotoxic effects over time with neuronal damage and loss. And there are many forms of cognitive dysfunction that have been studied and even specifically in association with higher levels of PM2.5. I can list a few including global cognitive function. So episodic memory, reasoning, verbal learning and fluency, visual spatial ability, and even working memory and orientation. Here's a clip from an abstract of a, of a large study about cognitive deficits in 19,400 plus women between the ages of 70 to 81 showing that high PM2.5 and high PM10 levels over seven years confers the equivalent of aging cognitively by two extra years as, as measured on their cognitive tests. And then autism. So, so there are a few meta-analyses and highlighted in yellow, I just hope you don't get confused, but highlighted in yellow, I just wanted to say, show you that these were kind of negative studies. At least the confidence interval was not quite there. So, so up at top, it seems to be the largest study and this one was positive. So Chun 2020 found that maternal exposure to ambient air pollution and autism in children had a, had a correlation. And so there is some evidence for PM2.5 and then weaker evidence for nitrous dioxide, whereas there's little evidence for PM10 and ozone. And so I only show the PM2.5 and NO2 And then in the, in that middle study by Flores Peugeot, they didn't find statistical significance based on their confidence intervals, but they did show a trend towards stronger associations between the PM2.5 and nitrogen dioxide during pregnancy and even more so for after pregnancy in those first, that first one year of life for the, for the infants. And, but that was based on a subset of their studies and, but worth showing. So, so finally Lam et al in 2016, they looked at different, different pollutants as well. And then they found that with prenatal exposure to particulate matters and autism, there was an increased odds ratio for PM2.5 more so than PM10. And then here's a specific example of an autism study. This was in Los Angeles, a group by, with Heidi Volk at UCLA. They saw that both PM2.5 and PM10 had a full standard deviation outside of a normal air pollution exposure for households closer to the Los Angeles freeways, basically conferred two times the risk of autism when, when the kids were exposed in utero and during the first year of life to the PM2.5 and PM10. And there's other studies that also show an association between autism and diesel fuel. So, so I won't go into those, but fossil fuel combustion has hazards on our health and on autism. And so depression, anxiety this is the, this is the area that is a little more, you know, inconclusive with conflicting results. I mean, there are plenty of studies positive studies showing concerns for even new onset depression. But in this most recent most updated meta-analysis by Fan 2020, it was largely negative. And again, the yellow highlighted particulates are the negative ones. So the only one that showed a clear, a more statistically significant trend was the short-term nitrous dioxide exposure showing an increased risk of depression. But, and then just noting that there was, there still is difficulty interpreting the results due to high heterogeneity between studies. But, but Fan's negative study did have, it outperformed a retracted meta-analysis by a group with Gu, the author was Gu in 2019, just the prior one year prior. But note, but of notes, if this group Fan shown in the table had used older random effects models, then they would have also shown long and short-term PM 2.5 exposure as having a risk for depression. And that would have been consistent with the prior positive findings. And then at the bottom here, there's a study on anxiety and, and just to note that it will depression and anxiety, but basically what they found higher PM 2.5 window exposure windows led to higher odds ratios of anxiety and, and depressive symptoms, moderate to severe anxiety and depressive symptoms with increased odds ratios. And they looked at these exposure windows up to four years. And I will move to the next slide. So this is my last slide. And so, you know, Dr. Haas actually mentioned a few of these before, and this table is adapted from her presentation. So I just will point out then let's just go in groups of two. I really won't go into the details for the sake of time, but the first two are additional like large studies on depression, which were positive. So Kermode's a glue 2017 looked at 41,000 women on average age, 66.6 years old. And the odds ratios for the ozone wasn't the hazard ratio was increased. Whereas Kim in 2016, they looked in Seoul, Korea at depression and they found that there was an association between risk of depression and the two year long air air pollution exposure. So increased hazards ratios with PM 2.5. So that's the first two on depression. The third and fourth are about suicide attempts, which those are large studies, but but there needs to be more studies on that area. And then, and then finally, the last two, the fifth and sixth rows, speak to schizophrenia, which also needs more studying. But these were pretty interesting, intriguing studies to look at psychotic experiences in the UK, in the study by Newberry, and then in China, for hospital admissions for psych for psychotic presentations. So, and both of those were looking at nitrous dioxide rather than the PM 2.5 that we've been talking about. So thank you. It's good to be here with everyone. Virtually, I'll be turning off my video for the remainder of the presentation. I have no conflicts of interest to report. The certain psychotradic was coined by Glenn Albrecht and refers to psychological reactions to our relationship with the natural world or the more than human world. The term natural world is a bit absurd. I'll keep using it. It's become a convention. But I want to point out that it may imply that nature is separate from us, which of course isn't the case. We're an animal part of nature in natural systems. You and I right now are breathing oxygen that was released by plants. We have guts full of bacteria. We're able to think as though we stand apart from the natural world, but that's a mental construction and it's not realistic. So we have basic benefits from our relationship with the natural world, as I mentioned, and there are also a host of other benefits that have been demonstrated from greater involvement with the natural world. Greenness of one's environment is associated with lower mortality. I list here a couple of very large studies in this regard. The James study is based on data from the United States Nurses Health Study, a study using prospective health data on over 108,000 women. They adjusted for age and smoking and socioeconomic status and greenness around homes, which can be detected with satellite data on relatively cloudless days, found that there's an association between greenness and lower mortality. The Vinod study had a similar result. It's a study on over 4 million adults who are in the Swiss national cohort. They compared greenness around one's residence with all-cause mortality, controlling for socioeconomic status and looking at air pollution, and they found residential greenness reduced the risk of mortality independently of air pollution and noise pollution. Wilderness camp literature reports positive effects, especially on social bonding. There are studies looking at positive social, positive cognitive effects, as well as positive effects on people with ADHD, and there's a study demonstrating decreased rumination with natural settings. What are the mechanisms of these beneficial effects? The biophilia hypothesis, which was coined by E.O. Wilson in 1984, holds that there's an inborn love for nature and natural environments driven by genetic and evolutionary forces, and there have also been many other hypotheses. Two prominent ones are the stress reduction theory by Ulrich, which suggests that landscapes that create hospitable conditions for human survival, such as views of water, moderate diversity of vegetation and animal life, decrease arousal and alarm states at a pre-conscious level in human beings. The attention restoration theory by Kaplan and Kaplan hypothesizes that natural environments allow for periods of cognitive rest that can alternate with periods of cognitive demand, and that this is useful for optimal frontal lobe functioning. There are also discussions about the involvement of the immune system, both in response to microorganisms and in response to volatile organic compounds emitted by plants, and of course green spaces have cleaner air. Psychological frameworks for understanding our relationship with the natural world have been based largely on understandings of attachment. Place attachment, sense of place, place identity have all been researched, and within the psychoanalytic literature there's discussion of experiencing the natural environment as a parent and now having to face that mother earth has limits. A classic so-called psychoterratic syndrome is solastalgia. This term was coined by the philosopher Glenn Albrecht. It combines the latin word for comfort with the greek word for pain. It's a nostalgia while still at home. Distress when the environment no longer affords the same solace. There is research support for this concept. There are reports from indigenous people many of whom are losing their lands, and I want to particularly draw your attention to a study by Renee Lertzman which is titled The Myth of Apathy. She studied Great Lakes residents doing semi-structured psychoanalytic interviews, psychodynamic interviews, and she identified that even though these were people who were not particularly environmentally active, in their descriptions of their relationship with their surroundings, they were describing an arrested mourning. So what looks like apathy can actually be a kind of thwarted grief. There are numerous sources of so-called eco-anxiety or climate anxiety. In terms of our physical reality, there are threats to anything that one might care about. There's the disorientation in and grief over the changing world, what gets called solastalgia, as well as the uncertainty, worries for children and grandchildren, loss of imagined legacies, and then there's the social reality where we can all experience cognitive dissonance from our inevitable participation in practices that we know to be damaging, such as our fossil fuel systems and systems having to do with animal agriculture. But what data do we have about how people are actually reacting to these realities? One important source is the several years of global warming surveys of Americans done by Yale in conjunction with George Mason University. They described six groups of respondents termed the dismissive, doubtful, disengaged, cautious, concerned, and alarmed. Over time, these groupings have been moving toward the left of this figure, and now the majority of Americans are concerned or alarmed about global warming. This evolution of attitudes suggests that there's an ambivalence getting worked on rather than that people are in vastly different tribes. A majority of Americans are worried about harm from extreme weather events in their local area. In this December 2018 survey, this worry was particularly about extreme heat, flooding, droughts, and water shortages. As we might expect, there's a range of negative emotions associated with climate change. Among those who think that climate change is happening in this December 2018 survey, 63% are disgusted, 62% feel helpless, 62% afraid, 58% angry, 54% outraged. At the time of this particular survey in December 2018, only 52% were reporting feeling hopeful. But if you do the math, you can see that hopefulness can coexist with disgust, helplessness, fear, anger, and outrage, which is hopeful. But how do these feelings about climate change correspond to mental health? An important study in this regard just came out in 2021. Ogden Bode et al. surveyed over 10,000 people in 25 countries and found that negative climate-related emotions are positively associated with insomnia symptoms and negatively related to self-rated mental health. Now causality isn't clear here and the relationship between negative emotions about climate-related risks and mental health is likely complex, but this does support the appropriate involvement of mental health professionals with climate concerns of individuals. Climate change is a unique stressor. It has an immense and collective scale, great temporal, geographical, social, ecological uncertainty, and increasingly unmistakable climate-related events affecting individuals' lives. Climate change has been called a hyperobject, a term created by Morton in 2013. A hyperobject is something that has coherence and vitality, but it's so distributed through space and time and with ourselves existing inside of it that it is in a sense impossible to completely comprehend. Nevertheless, we participate in influencing it and its effects. So what attitudes, understandings, and skills, tools, do therapists need in order to be able to work with climate material? We need our own spaces for coming to terms with this material ourselves and with each other. We're in the same situation as our patients. Mental health professionals have caused to be as disoriented as others in confronting the realities of climate change, but we do have understandings and skills that are pathways out of disorientation. Programs of didactics, curricula, and CME are being developed, and they can have a processing component in them. Groups of mental health professionals are organically forming in many places to process climate material, and dyads, where one professional is a mentor to another in this work, are also forming. In addition, there are informational resources. I particularly note here the Climate Psychiatry Alliance website and the Climate Psychology Alliance website, but as I said, doing this on one's own is not enough. We need to be able to process this with other people. Oh, that's what therapists need to be doing on their own. How about in the room with the patient? What do we need? We need to be able to affirm the reality of climate change with people and to affirm its significance. It's important for us to have a both-end appreciation of the possible coexistence of mental health issues and understandable climate-related distress. It's very important that we don't pathologize climate-related anxiety and upset, but at the same time, we have to recognize that there are often coexisting mental health issues that also have to be appreciated. It's important to be able to appreciate the reality that we're dealing with a problem here that's collective, and the solutions are collective. We tend to have a cultural bias towards thinking in terms of individuals, and certainly in our work, most of us are working with individuals, but we're going to be part of helping people to think more about how to join with collectives in addressing this. The mental health professional needs to appreciate disavowal. Disavowal is a defense mechanism, a kind of denial, where we both know and don't know something at the same time. We're all in the process of emerging from disavowal when it comes to climate change. There are no climate perfect people. Nobody has this perfectly integrated into their lives and lifestyles, and that's an important attitude to be able to convey in working with patients. The developmental stage metaphor is useful. This is understanding that our dealing with climate change is kind of akin to a child entering a new stage of development, and this produces the necessary attitude of having patience with ourselves and with others as we're all working to come to terms with this, and having the expectation that with struggle we can come to terms with this. A humanistic stance in therapy is useful. We're all in this together. It's a human dilemma that we're all participating in, and with a humanistic stance, we can say things to patients like, yes, many of us are struggling with. It's also important because this is a topic that can kind of by definition be a bit overwhelming. It's important to keep in mind that patients are in need of all sorts of containment in dealing with this material. Relational containment, the kind of containment that comes when one is aligning with one's values, with sources of meaning, the containment that comes with engagement, actually working on things that one cares about, containment from religious traditions, containment from narratives, stories. The story around climate change is typically that we're in a time of transition. Joanna Macy calls it the great turning. And I don't list it here, but cognitive containment is also very useful. When you understand that we're part of a complex system and complex systems are capable of going through what's called emergence, where they can get to new patterns that work. And here's some more tools that are useful for the mental health clinician in dealing with this material. An understanding of climate communication is useful. This is something that's particularly studied at Yale and there's a large literature and research base in it. For instance, if you understand that the climate dismissive patient, which is 7% of the population, people who can be quite vehemently, vociferously, contrary to the scientific consensus about climate change. When you understand that people who are climate dismissive tend to be politically conservative, they tend to particularly identify with the principle of individual liberty, then you can work to authentically appreciate the patient's values and be able to talk in terms of tradition and preservation and individual liberty, as well as the more liberal constellation of values, things like care and progress. And in that way, prevent a polarization because when things polarize, then there's just a tendency for people to entrench in their particular camps. And speaking of polarization, another useful tool is climate dialectics. Climate material, because it's so overwhelming and can be so charged, tends to almost prismatically divide things up into polarities. A dialectic is any pair of seemingly opposed concepts that are actually both important. And when they're both explored and the relationship between them is explored, it can be generative. There's room for creative solutions. There are a whole myriad of these climate-related dialectics. Some of the main ones are listed here, climate reality and social reality, individual agency and collective agency, certainty and uncertainty, hope and hopelessness, nature is comfort and nature is threat. And for example, in working with one of these, such as hope and hopelessness, the tension there with hope and hopelessness is that hope is essential, but seemingly impossible. Many destructive processes are already hopelessly underway. This is true. When we resist the temptation though to simplistically ally with hope or hopelessness, new forms of hope can emerge. There's something called realistic hope coined by, the term coined by Jonathan Lear in a book. No, that term is coined by Weingarten, Martha Weingarten, and the term radical hope, coined by Jonathan Lear in a book. Managing these dialectics is key to working with climate material, not allowing a collapse into either pole, avoid splitting or dissociation. So people can then have adaptive creative thinking. Another important tool we're going to be called upon to use is the understanding of continuous traumatic stress. We tend to think of trauma as existing in the past, and a trauma disorder is when the past is inappropriately intruding on the present. But what if the trauma is in the future? Research on soldiers supports the notion of pre-traumatic stress. And there is a descriptive literature on the concept of continuous traumatic stress, where people are dealing with trauma that is past, present, and future. There are many people in these circumstances, but more people are going to be in these situations because of repeated disasters and climate migrations. So it's incumbent on us to understand more about working with continuous traumatic stress. People in these circumstances can have arousal and avoidance looking very much like PTSD, but their preoccupation typically is with current and future safety rather than past events. What has been gleaned in the work in these settings is that the therapeutic task is helping the patient in learning to discriminate between stimuli that represent real, immediate, substantial threat and other stimuli. If the therapist is in some denial about the actual threats, then it will seriously interfere with the work. So just to make it clear why it's important for us to be able to work more with climate material, I'm just mentioning here a variety of presentations clinicians are encountering. Number one, a patient suffers repeated wildfires, expects more to come, and the psychiatrist lives in the same fire-stricken region. Number two, a patient has decided not to have children because of climate change, distressing their spouse and threatening the marriage. How do we help people think about childbearing decisions? Number three, a patient vociferously dismisses climate realities. What's our obligation here given the reality of the public health threat? Number four, a patient believes human-made climate change is real, but seems to be ignoring significant climate threats. For example, not getting an air conditioner in their bedroom despite hotter summers when they have a mood disorder and should be protecting their sleep. How do we help people in working with disavowal? Number five, a patient expresses distress and anxiety about die-offs of species and the future of humanity. How do we help with this kind of anxiety? Number six, a young adult involved in self-destructive behaviors expresses hopelessness about a future for themselves in a damaged world. How might self-destructive behavior in the context of knowledge of possible negative futures, how do we deal, how do we understand and deal with that? An adolescent patient confronts you about your generation's complicity in the climate crisis. And number eight, a parent asks advice about how to speak with his children about climate change. All of these presentations are occurring now in clinicians' offices. And there's every reason to think we'll be seeing increasing numbers of patients in these circumstances. Lastly, I just want to mention, Dr. Ahir already did a terrific job in talking about community resilience. It's going to be incumbent upon us to help people move toward thinking in terms of group resilience, in terms of the collective, since this is a collective problem with collective solutions. So in conclusion, our involvement with climate change material calls upon many skills we already have, and we can work together to extend those skills to here, to this time in history. Thank you. So, hi, again, my name is Josh Wurzel. I'm a resident in psychiatry at the University of Rochester, and I am very interested in the relationship of climate on mental health, specifically in my talk today, Mental Health in a Warming World. I'm going to talk about some of the epidemiology and neuroscience of the effects of increasing ambient temperatures on mental health. I have no disclosures or any conflicts of interest. So let's get to it. Ladies and gentlemen, the facts are that it's getting very hot out there. 2020 just matched 2016 as the hottest year on record. And since the dawning of the 21st century, we have now broken the hottest year on record five times. Given the likelihood that we're going to continue to see increasing temperatures with global warming, it's our duty as psychiatric clinicians to identify how these rising temperatures are going to impact our patients and to try to plan accordingly. So I have three learning objectives for you today. The first, and these can be broken down into epidemiology and neuroscience. First, I'd like you to be able to describe the relationship of ambient temperature with the prevalence of mental health disorders. And two, I'd like you to be able to describe how psychiatric patients are more prone to thermodysregulation than healthy controls. And finally, under neuroscience, I'd like you to be able to describe the role of serotonin and other neurotransmitters in thermoregulation. So let's start with the first one, looking at the relationship of temperature with the prevalence of mental health disorders. So here we're looking at mental health conditions in the context of heat waves. And heat waves are periods of hot weather, that is temperatures that are outside of historical averages for that year, that area for that part of the year. And they typically last more than two days. Heat waves are clearly bad for mental health. There's an extensive literature looking at how violent behaviors increase during heat waves. And here we're just looking at one representative study. Carlton and colleagues found that when temperatures increased abruptly during heat waves, there was a corresponding linear increase in the rate of violent crime and rape. These data are just looking in the US, but they've repeated this in multiple countries across the globe, and the trends are virtually the same. This trend's also been found to be true for violent suicides as well. This association between increased temperature and worse mental health seems to extend to seasonal variation as well. Violent suicides increase in men and women during the spring and summer months. And you can see here on the far left, this study is looking at average monthly suicide rates in Italy over the course of a decade. But other mental health conditions also seem to fare worse during the warmer months. So in the middle here, we have an Egyptian hospital study looking at admission rates for mania. And we can see that there's a clear increase in admissions during the spring and summer. The same is also true for admissions for PTSD symptoms in this New Jersey hospital study, this veterans hospital study on the right. But not all mental health conditions get worse during the warmer months. In fact, the very same Egyptian hospital study looked at unipolar non-seasonal depression, and they identified that there was a significant decrease in admissions for those patients during the spring and summer. A similar trend was observed over a two-year period in patients with bulimia in a Vancouver study where they identified that patients during the spring and summer had a decrease in reports of binging and purging behaviors. So in summary, regarding this first learning objective, the effects of heat on mental health are quite varied. We see that heat waves and seasonal fluctuations can be deleterious for certain psychiatric conditions, but for some conditions such as depression, there may be some seasonal benefit. But how do we explain why psychiatric conditions are affected by ambient heat in the first place? Well, to begin to parse this, let's move on to our second learning objective, which is to explore the epidemiology of how psychiatric patients are more prone to thermodysregulation. So we've known about depressed patients having trouble thermoregulating for actually quite some time. Going all the way back to 1890, Vigoro found that depressed patients had lower skin conductance, which is a measure of sweating. And you can see here on the right, galvanic skin conductance to test this. This has actually since also been observed in patients with bipolar disorder, depressed patients with panic disorder, and even patients prior to attempting suicide. And interestingly, it's also been found that depressed patients on average have increased core body temperatures relative to non-depressed patients. We've also known for quite some time that patients with schizophrenia have difficulties with thermoregulating. In fact, prior to the neuroleptic era, hot and cold hydrotherapy were among some of the most commonly used treatments for these patients. And here you can see a patient in the 1930s or 40s strapped into a tub, because they noticed that there was difficulty with thermoregulation in these patients. So when we look at data from the pre-neuroleptic era, we see that schizophrenic patients were noted to have decreased baseline temperatures. They were noted to have desynchrony of their circadian peaks in body temperature, and they also had impaired ability to cool during heat stress. And this is thought to be due to dysfunction in the peripheral and central neuropathways in these patients. Now, one might expect from these findings that there's also going to be issues with these patients having mortality from heat waves. And in fact, there is a growing literature that shows that psychiatric patients are at greater risk for heat-related issues. In fact, these patients are three times more likely to suffer heat wave-related mortality compared to non-psychiatric patient controls. This risk is further increased for patients who are bedridden or have limited mobility, who have decreased ability to care for themselves, if they're socially isolated, and if they have medical comorbidities such as cardiovascular disease or pulmonary disease. We also know that to top all of this off, some of our psychotropic medications, such as serotonergic drugs, alter thermoregulation. So a common side effect of antidepressants is diaphoresis. We see this in around 10% of patients on SSRIs and 14% of patients on TCAs. This chart on the right here shows the incidence of diaphoresis with commonly prescribed antidepressants, and you can see there's quite a range. We're also well aware that these drugs in excess are implicated in the pathogenesis of serotonin syndrome. Now, the hyperthermia associated with serotonin syndrome is quite complex, and the pathophysiology likely has to do somewhat with which serotonin receptors are stimulated in the hypothalamus, as well as other peripheral effects of serotonin. And interestingly, the body temperature of depressed patients seems to correct and normalize when they have undergone treatment with SSRIs, and in fact, this correction in their body temperature has been associated with remission of their depression symptoms. But other psychotropic agents also affect thermoregulation. Antipsychotics, antihistamines, and anticholinergics all decrease heat elimination through the parasympathetic modulation that they cause, and patients on these agents have even been found to have increased odds of being hospitalized for heat-related issues when they're on these medications. In one study conducted in France, patients hospitalized with heat stroke or hyperthermia were assessed for what medications they were on at the time. And the study identified that relative to age-matched control patients, patients on antipsychotics had six times the odds of being hospitalized for heat stroke or hyperthermia. This may be due to how dopaminergic antagonists alter central acting temperature homeostasis in these patients. They also identified that patients on anticholinergics had 4.6 times the odds of being hospitalized for heat stroke or hyperthermia relative to controls. And this may be due to how anticholinergics affect sweat secretion. So in summary, with respect to this second learning objective, many psychiatric patients have thermodysregulation. This is likely related to why psychiatric patients are more prone to heat-related mortality during heat waves. While thermoregulation may improve with certain medications such as serotonergic antidepressants, others such as antipsychotics and anticholinergics may heighten patients' risks of heat wave mortality. So finally, let's move on to our last learning objective, which is to describe the neuroscience of how these neurotransmitters implicated in mental illness can play a role in maintaining healthy thermoregulation. Serotonin is instrumental in the thermoregulatory process of the body, and here's how it works. We'll walk through it. Thermosensitive proteins in the skin will conduct signals through lamina 1 in the dorsal horn, up through the spinal cord and the spinal brachial pathway, and that's here shown in red. Then in the brainstem, this stimulates the lateral spinal brachial nucleus, which among other things will synapse onto the dorsal raffine nuclei, which is here shown in green, and that's the main source of serotonin in the brain. The dorsal raffine nuclei then will send serotonin to the body's main thermostat, the hypothalamus. The hypothalamus contains multiple regions that are responsible for controlling temperature. For example, in the preoptic area, here shown in red, you have controls of heat dissipation through panting and vasodilation. And, oh, sorry, yep, and then in the posterior area, in light blue, they will control heat conservation through vasoconstriction and shivering. Depending upon what part of the hypothalamus is stimulated by the dorsal raffine nuclei, you can get different thermoregulatory processes that are set in motion. Now, relevant to the role of serotonin in the context of this presentation, there've been some really elegant studies in animals to flesh out the role of ambient temperature in this pathway. For example, in this study, two groups of rats were exposed to different ambient temperatures, one at 23 degrees Celsius, which is shown here in blue, and the other at 37 degrees Celsius, shown in red. After close to two hours at these temperatures, the researchers recorded the rat's core body temperatures, here recorded on the x-axis, and they harvested the rat's brains to find the dorsal raffine nuclei. They then identified the serotonergic neurons, and they looked for the transcriptional activity of these neurons using the marker CFOS. They counted the number of CFOS-positive neurons, here shown on the y-axis, and compared the two groups. And as you can see, the core body temperature of the rats was strongly linearly correlated with the activity of serotonergic neurons in the dorsal raffine nuclei. Now, other neurotransmitters are also critically involved in thermoregulation. Neuroepinephrine and epinephrine control peripheral vasoconstriction through alpha signaling. It also stimulates, neuroepinephrine also stimulates brown fat to promote thermogenesis. Acetylcholine will bind to muscarinic receptors to control the release of sweat in the peripheral nervous system. GABA inhibition of the peripheral vasoconstriction in the body leads to tonic vasodilation and cooling. And glutamate is the primary neurotransmitter that communicates excitatory information about ambient heat through the spinal brachial pathway. So in summary, with respect to this third learning objective, serotonin plays a crucial role in maintaining thermoregulation. It does this by directly stimulating the temperature homeostatic centers in the hypothalamus. And we saw that there is a direct correlation between ambient heat and serotonin production in the dorsal raffine nuclei. We also reviewed how a number of other neurotransmitters play critical roles in temperature modulation, both peripherally and centrally. So we've covered a whole heck of a lot in a short period of time. So let's just recap some of the core conclusions. First, many psychiatric disorders are affected by ambient heat. Many are made worse, but some including depression may improve. Second, many psychiatric patients have difficulties with thermoregulation, which places them at increased risk of heat-related illnesses, such as heat stroke and hyperthermia. Some psychotropic medications such as SSRIs may improve heat regulation, while other medications such as antipsychotics and anticholinergics may exacerbate it. And lastly, we reviewed the neuroscience of how neurotransmitters implicated in mental illness are involved with thermoregulation. And this may explain why our patients, whoops, may explain why our patients have difficulties thermoregulating. Serotonin plays a crucial role in modulating the hypothalamus' centers for temperature homeostasis, and other neurotransmitters play peripheral and central roles in regulating the body temperature. So given everything that I've said, what does this all mean for global warming? Well, for one, there seems to be no question that increased temperatures are going to affect the prevalence of many psychiatric disorders that are affected by heat. Some, like violence and suicide, are likely gonna worsen. And others, on the other hand, such as depression, may improve. That said, global warming is certainly going to lead to increased stress and likely traumas on a familial and societal level, unlike things that our species has seen in millennia. All of this can add a whole slew of unknown variables to the neurochemical impacts of heat that will affect our patients with mental health conditions. As mental health providers, we need to make sure that our patients get climate-controlled housing, and we also need to be mindful that our medications can perhaps even worsen their baseline thermal dysregulation. And of course, we need to advocate for trying to slow down, if not stop, global warming. So finally, I just wanna make a couple thank yous. First to Dr. Peterson and my co-speakers and other members of the Climate Psychiatry Alliance, who are my colleagues, trying to advocate for the impact of climate change on mental health. I'd like to thank Dr. Norton, who was my original research mentor, who really opened my eyes to this whole field. And lastly, Dr. Lee, who's my chair at the University of Rochester, who has been so supportive of my research. And here's my bibliography, if you would like to peruse for any additional information. Thank you so much. ♪♪

climate change

mental health

climate disasters

stress disorders

depression

anxiety

vulnerable populations

air pollution

neurological health disorders

autism

dementia

stroke

Alzheimer's disease