Welcome. It's a pleasure to get to have this opportunity for the APA's Committee on Climate Change and Mental Health to present to you our talk, What's Climate Got to Do With It? What We Think Every Psychiatrist Should Know About How Climate Change Impacts Mental Health. It's my pleasure to get to introduce my co-speakers. I'll briefly introduce myself. My name is Josh Wortzel. I am the Chair of the APA's Committee on Climate Change and Mental Health. I also am honored to get to serve as the Vice Chair of ACAP's Resource Group on Climate Change. I serve on the National Nonprofit Climate Psychiatry Alliance's Steering Committee, and I also get to serve on the Think Tank Group for the Advancement of Psychiatry's Climate Committee. Jacob Lee, MD, is a member of our Committee on Climate Change and Mental Health at the APA. He's been instrumental in looking at how to green psychiatry, both through a paper that we wrote on reducing the carbon footprint of the APA's annual meeting and in writing a white paper on many other recommendations for the greening of psychiatry. Dr. Steve Sugden is an assistant professor at the University of Utah and has also been a vibrant member of our committee and is interested in the intersection of lifestyle psychiatry, disaster psychiatry, and climate change. We're going to start today with a brief overview of what we think are the essential blocks of what climate psychiatry is, and then we're going to do a deeper dive looking at disaster psychiatry and how we can green psychiatry. With that, we'll get started. I have a couple of housekeeping things to go over with you all, so forgive me as I read the screen and convey them to you. In support of improving patient care, the American Psychiatric Association is jointly accredited by the Accreditation Council for Continuing Medical Education, ACGME, the Accreditation Council for Pharmacy Education, ACPE, and the American Nurse Credentialing Center, ANCC, to provide continuing education for the healthcare team. The APA designates this live event for a maximum of 1.5 AMA PRA category 1 credits. Physicians should claim only the credit commensurate with the extent of their participation in this activity. Captioning for today's presentation is available. You can click to show captions at the bottom of your screen to enable. You can see that depicted here. Click the arrow and select view full transcript to open captions in a side window. Please feel free to submit your questions throughout the presentation by typing them into the question area, which is found in the lower portion of your control panel over here. We'll reserve 10 to 15 minutes at the end of the presentation for our Q&A. All right, let's get started. Many of you, if you're here, are familiar with the various ways that climate change is impacting our world, but for just some basic brief background, we know that 80% of humans alive today are impacted by food and water insecurity secondary to climate change. We know that temperatures are increasing. Earth's average temperature has increased 1.1 degrees Celsius since 1880, which is our benchmark of the pre-industrial era. When we look at even just the past quarter century, we've broken the hottest year on record six times, last year being the hottest year. When we look ahead to the future, we have estimated that we'll reach 1.5 degrees Celsius warmer by 2050, and depending upon what we're able to do with our carbon emissions, we're likely going to reach somewhere between 2 to 4 degrees Celsius by 2100. As you might imagine, many different organizations internationally have pointed out how vital it is for us to address climate change. The World Health Organization states that climate change is the greatest challenge of the 21st century, threatening human health and development. The longer we delay action, the greater the risks to human lives and health. The Lancet Countdown on Health and Climate Change stated that climate change, again, is also the greatest threat to global health in the 21st century. Following suit, the American Psychiatric Association has written a position statement in 2017 and revised in 2023, which states that the APA recognizes that climate change poses a threat to public health, including mental health. Those with mental health disorders are disproportionately impacted by the consequences of climate change. With some polling that the APA has done, we have some further information about individuals' anxiety about this. The majority of adults are anxious about climate change. 48% of adults agree that climate change is already impacting the mental health of Americans. A majority of adults are anxious about the impact that climate change will have on the planet. And Americans under 34 are more likely than older adults to believe that there are mental health impacts of climate change. We're going to talk more about this in a little bit, but just to show you that the ramifications of climate change are being felt right now. So in my talk, I'm going to go over a general overview of the impacts of climate change on mental health. As we indicated, there are a number of ways that climate change impacts health, from severe weather events, decreased water quality and quantity, spread of vector-borne illnesses, increased food insecurity and malnutrition, heat stress, asthma, allergies, and mental health consequences. And many of these overlap as a Venn diagram, but we'll focus on the mental health consequences. As a child psychiatrist, I'm particularly interested in climate change as a health emergency for children. And that's because children are dependent on their social systems and adult caregivers. There's an outsized impact of adverse events experienced in childhood. They're psychologically more vulnerable, have relative powerlessness and feel the betrayal of adults who are not doing more to help them. And there's also just the temporality of all of it. They're going to be around for more years in a hotter, wetter, more chaotic world. When we think about climate change, we also know that vulnerability is inequitable. We call climate change a threat multiplier because it compounds the impacts of other social determinants of health. Things like structural racism, health disparities, economic inequity, housing and infrastructural inequity, educational inequity, disabilities, including mental illness, and language barriers. So when we think then about how climate change is impacting mental health and health, it's both direct in impacts we'll talk about with how it impacts the brain, for example, but also as a threat multiplier and exacerbating other social determinants of health. So when we think about the mental health consequences of climate change, I like to break it down into three buckets, direct, indirect, and psychological effects. Under direct effects, today, our learning objectives will include describing the relationship of temperature with the prevalence of mental health disorders, describing how psychiatric patients are more prone to thermodysregulation at baseline, and describing the role of serotonin and other neurotransmitters in thermoregulation. Indirect effects include reviewing the neuropsychiatric sequelae of pollution, nutritional deficiencies, and vector-borne illnesses secondary to climate change, and psychological effects, reviewing the traumatic and existential impacts of climate change on mental health and what we might try to do about it. So with that, let's jump into the first learning objective describing the relationship of temperature with the prevalence of mental health disorders. So the data are pretty strong that heat waves are not great for mental health. Heat waves are periods of unseasonably warm temperatures for two days or more, and what we find is there's this linear relationship with increased temperature and increased rates of violence and rape, and also, while I don't have the graph here, suicide. When we look even at the warmer months of the year, we see that there are associations with higher psychiatric morbidity. This is a study looking at suicides in Italy over a 10-year period, and we see that when we look by the month of the year, the spring and summer months are when we have the highest numbers of suicides. This is a study in Egypt looking at hospitalizations for mania, and we see that the highest rates of hospitalization were in the spring and summer, and this is a study looking at a veterans hospital in New Jersey where hospitalizations for individuals with PTSD were highest during the spring and summer. So this is just scratching the surface of what's been shown epidemiologically, but hopefully what you've gotten a glimpse of in this first learning objective is that there are these temporal relationships between temperature and mental health outcomes, and there's a lot of work to be done in trying to understand why that might be. So that leads us to our second learning objective, which is describing some of what we know about psychiatric patients' difficulties with thermoregulation at baseline. We've known for quite some time that patients with depression have difficulties with thermoregulation. In fact, going all the way to way back to 1890, Vigoro had found that depressed patients had decreased skin conductance or sweating compared to healthy controls. This has since been observed in patients with bipolar disorder, patients with depression and panic disorder, and in suicidal patients. And interestingly, when we look at the core body temperatures of depressed patients at baseline, we find that they have an increased body temperature compared to healthy controls. Patients with schizophrenia have also been known for quite some time to have difficulties with their thermoregulation. This is a picture circa the 1930s and 40s where we see a patient undergoing hot or cold hydrotherapy. And that's because in this pre-neuroleptic era, schizophrenic patients were noted to have decreased baseline temperatures, dyssynchrony of their circadian peaks of temperature, impaired ability to cool during heat stress, which is thought to be due to dysfunction in both peripheral and central neuropathways in schizophrenia. Overall, we know that patients with mental illness have increased heat-related mortality compared to healthy controls. In fact, in this one study, they found that psychiatric patients had three times the risk of suffering heat wave-related mortality. So again, very quick overview, but hopefully in this second learning objective, you're appreciating that our psychiatric patients at baseline have difficulties with regulating their temperature and that this results in real morbidity and mortality changes when they're stressed with increased temperature. So moving on to our third learning objective, we're going to describe the role of serotonin and other neurotransmitters in thermoregulation, which may account for why our patients are more vulnerable. So serotonergic drugs, we know, alter thermoregulation. When we look at antidepressants, they can induce diaphoresis. 10% of patients on SSRIs experience this side effect and 14% on TCAs. This is a chart that just goes through a few other antidepressants and shows you that there's quite a range of the prevalence of or the incidence of sweating. These agents, when taken in excess, are implicated in the pathogenesis of serotonin syndrome and hyperthermia. And interestingly, when we look at patients who have depression and are on SSRIs, we see that their symptom improvement actually correlates to normalization of their temperature regulation. So they're able to regulate their temperatures better as their symptoms improve. Now, while SSRIs and serotonergic drugs may be beneficial for thermoregulation, a number of other ones may also be deleterious. Antipsychotics, antihistamines, and anticholinergics all decrease heat elimination through parasympathetic modulation. Patients on these agents have been found to have increased odds of hospitalization. Those on antipsychotics had six times the odds of being hospitalized during heat stress. This is thought to be due to altered central acting temperature homeostasis. And then those on anticholinergics had 4.6 times the odds due to likely decreased sweat production. But many neurotransmitters are involved with thermoregulation when we look at just the basic biology. Serotonin controls central heating and cooling homeostasis in the hypothalamus. I personally hadn't been familiar with this before delving into this literature, so I'll briefly walk you through how this pathway works. In the skin, there are thermosensitive proteins that conduct information to the brain through lamina 1 in the dorsal horn. This goes up through the spinal cord and spinal brachial pathway, which then synapses onto the lateral spinal brachial nucleus in the brain stem, shown here in blue. And then that synapses onto the dorsal raphe nucleus, which is one of the primary centers of dopamine in the brain. Sorry, not dopamine, serotonin in the brain. The hypothalamus is our primary thermostat, and the dorsal raphe nucleus is directly synapsing onto different domains within the hypothalamus to control temperature regulation. So for example, if the dorsal raphe nucleus simulates the preoptic area here shown in red, we have increased physiology for heat dissipation. So things like panting, less so in humans, but definitely in dogs, and vasodilation. And then if it stimulates the posterior area here shown in teal, we have physiology for heat conservation, so things like shivering and vasoconstriction. In addition to serotonin, norepinephrine and epinephrine control peripheral vasoconstriction through alpha 1 and alpha 2 signaling, and also stimulate brown fat to promote thermogenesis. Acetylcholine through M1 stimulation controls release of sweat. GABA is involved with tonic vasodilation and cooling. And glutamate is the primary neurotransmitter that conducts information about peripheral heat through the spinal thalamic pathway. So in this third learning objective, I hope what you're taking away is that many of the neurotransmitters that we tinker with with our medicines are fundamental to regulating temperature. Some of the medicines we prescribe like SSRIs may be beneficial, and many others like antipsychotics, anticholinergics, and antihistamines may be deleterious or impact our patient's ability to thermoregulate negatively. So I'd like to now move to some of the other ripples. We've been talking about the direct impacts of heat on the brain, but there are a number of other indirects of climate change that have significant effects on mental health. We'll be talking about airborne pollutants, nutritional deficiencies secondary to changes in atmospheric CO2, and changes in where vector-borne illnesses can exist due to climatic change. So airborne pollutants affect mental health in myriad ways, particularly fine particulate matter, PM2.5 microns, and then ozone, which can be produced from forest fires and fossil fuels. Just to give you a sense of how small this PM2.5 is, it's basically more than half or less than half the size of a red blood cell. If fetuses in utero are exposed to this, we find that they have higher risk for intrauterine growth restriction, preterm birth, and low birth weight. Children will have higher risks of developing developmental delays and reduced IQ, autism, ADHD, and behavioral disorders. In adulthood, we see that individuals will have increased risk of depression, suicide, bipolar disorder, and engaging in violent behaviors. In the geriatric age group, depending upon your lifetime exposure, you can have increased risk of dementias, overall an odds ratio of 1.16, and especially Alzheimer's, which is an odds ratio of 3.26. When we look at nutritional deficiencies, a lot of energy is put into understanding how reduced water and arable land is going to impact humanity, but I think it's interesting, unless talked about, how increased CO2 in the atmosphere has been shown to decrease the concentration of key macronutrients and micronutrients in our food crops, particularly protein, zinc, and iron. When we look at experimental data, so these are food crops that were grown in atmospheric conditions predicted by 2050, we find that there are changes in their concentrations of protein, iron, and zinc. Protein here shown in red, zinc in blue, and iron in gray. Overall, you see that there are 4 to 13% reductions in these three nutrients when crops are grown in the atmospheres predicted by 2050. Now, for parts of the world that have fortified foods, this is less of a concern, at least imminently, but much of humanity gets its nutrients directly from the food crops they grow. Iron deficiency and zinc deficiency have been shown to have significant psychiatric sequelae. Iron deficiency is associated with altered monoamine neurotransmitters and abnormal myelination, which has been associated with childhood and adolescent onset psychiatric disorders and cognitive developmental delays, increasing odds by 2 to 5 times as much when we look at case controls of those with iron deficiency and not. When we look at zinc deficiency, we see that zinc is involved with the regulation of endocrine, immune, and neuronal functions that, when zinc is deficient, are implicated in the pathophysiology of depression. There have been some fascinating case control studies as well where they've looked at those with depression and those healthy controls, and they found that there was a linear inverse relationship that the lower the zinc level, the more severely depressed patients were. And this has actually been looked at even experimentally in rodent models where they've depleted zinc, observed depressed behaviors, and then repleted and shown a return to normal function. We also know that as temperatures change and where there's moisture and all different types of changes to our environment, that that's going to impact where vector-borne illnesses will occur. Just as an example, these are maps of where Lyme disease is endemic. You can see in 1996 that it was really kind of constricted to this part of the Northeast, and it's since really ballooned outward. This is due to both where arthropods can live, their ectotherms, so dependent upon external temperatures, and where temperatures are in the right range, effects where they can survive, feed, and reproduce, but even the life cycle of the pathogens within these vectors. So, you know, thinking about Lyme disease, you know, ticks would be the arthropod, and the Lyme would be the pathogen. Oftentimes, the life cycles of these vectors are also accelerated by increased ambient temperature. The World Health Organization has identified 11 vector-borne diseases that are of major concern in the context of global warming, and most of those can cause encephalopathy or encephalitis, which can have neuropsychiatric sequelae, and they're associated with indirect increased levels of anxiety, depression, and insect phobias as well. So, suffice it to say for this fourth learning objective, looking at indirect effects of climate change, that the ripples are profound and go far beyond just the impact of temperature on the brain, whether it's the impact of air pollutants from the fossil fuels we burn to the nutritional content of our food due to how atmospheric concentrations of CO2 are changing to where different bugs that carry diseases will live and infect humans. And then finally, let's move to our fifth learning objective, looking at the psychological effects of climate change. So, we'll be reviewing the traumatic and existential impacts of climate change on mental health and a bit about what we can do about it. So, when we think about the types of traumatic climate change exposures, I break it down into three categories. There are acute exposures, so you think about a natural disaster that hits an area and the immediate aftermath, so things like Katrina. Chronic exposures, so recurrent or slow-moving disasters. This could be, for example, you know, New Orleans being hit by repeated hurricanes or, you know, the aftermath of Katrina years after. Could also be droughts like we see in the west and the southwest or slower-moving disasters. And then finally, vicarious exposures. A lot of us may not have experienced a natural disaster ourselves, but we are seeing on social media and hearing of loved ones who are undergoing them, and so we're witnessing the suffering of others and expecting that this might be our futures too. My colleague, Dr. Sugden, is going to be talking about more of the traumatic component of the psychological fallout of climate change, so I'm going to focus on this last one, the vicarious exposures. So, climate distress or, you know, the range of emotions that we feel about climate change is quite common. We know that 69% of Americans are at least somewhat worried about climate change. 29% are very worried. And when we look at youth, this is a study that was conducted a couple years ago in 10,000 young people, 16 to 25, in 10 countries, 84% are moderately worried about climate change or at least moderately worried, and 59% are very to extremely worried. That's twice the number, twice the percentage, rather, of adults. 45% of these young people say that their worries about climate change affect their daily life and functioning, and when we subdivide this a little further, looking at under-resourced countries, youth in those countries are actually even more affected on the daily. 50 to 74% say that they're affected by their worries. So, people want to talk about their distress about climate change, and I think as providers, we're only starting to scratch the surface of who those individuals might be. The Yale Program on Climate Change Communications does a number of surveys, I've shown some of their data already, but this was one where they surveyed Americans about their desire to talk about climate change and global warming in therapy. Overall, 8% of respondents reported at least some interest in being able to discuss this, but there were interesting differences by race and by age. So, when we look, the Hispanic respondents, 21% of them said that they were interested, 10% of Black respondents compared to 5% of White respondents. So, four and two times as many Hispanic and Black respondents, respectively, compared to White respondents. When we look at age, those who would identify as Gen Zers or Millennials, 13% said they were interested compared to 4% of those in the baby boomer population. So, three times as many younger people. As we think about these individuals with climate distress, as providers, we want to think about how we can help provide coping mechanisms for them. So, I'll talk a little bit now about some of what we can do to support patients with climate distress. There are three coping strategies that are currently in the literature. The first is problem-focused coping. This has to do with trying to get people engaged behaviorally in climate action or activism. I have here a picture of people planting trees, but this could be recycling drives, engaging with local chapters on political action. But we know that engaging in group activities is more powerful or effective than individual action for addressing climate distress. Emotion-focused coping has to do with cognitive reframing to de-emphasize the threat of climate change. Some of you may be familiar with the movie Don't Look Up. Basically, this is a large metaphor for what's going on with climate change, but it's an asteroid that's coming to hit Earth and all of the various ways that people cope with that incoming stressor, existential stressor. In that movie, we see on display a lot of maladaptive emotion-focused coping, where they try to downplay the emotions that they're facing. Ultimately, it leads them to not do anything really about it. But for individuals who are so overcome that they feel like the future is completely hopeless, that they feel like they're not able to even imagine a future for themselves, some of this emotion-focused coping can be helpful to perhaps manage some of that extreme emotional response. And then finally, meaning-focused coping. This draws on a person's beliefs, values, and goals to foster positive affect towards the stress of climate change. I have a picture here of a cross because there are certain religious and cultural groups that have different ideas like stewardship or that it's the responsibility of humans to step up to the plate to take care of the planet. But there are other non-religious ideologies as well, and even psychotherapies like Logotherapy from Viktor Frankl's or acceptance and commitment therapy that carry a similar idea of accepting a challenge and finding meaning in it. When we think about specifically how to support youth, I've been involved with some projects looking at how to create a space to talk with kids about their distress. We need to provide explicit opportunities where we ask them about if this is something they would want to talk about. We want to make sure that we're honest and age-appropriate when they ask us questions about climate change, to be curious and provide information that they may be seeking, and also to provide support for the thoughts and feelings that they may be having without going quickly to the place of minimization and saying, oh, you're worrying about this too much. That can feel very negating and distressing for children when they know how critical climate change is. This is a book that the Group for the Advancement of Psychiatry wrote in partnership with my brother and sister-in-law. It is an evidence-based approach to how to try to talk to children about climate change. It's available on Amazon, and it's also all money goes to research on climate change and mental health. But frankly, if we're going to help, you know, just like on an airplane, if you're going to help the person next to you with getting on their air mask, you've got to put yours on first. So, you know, we're inundated with news all the time about how climate change is coming for us, and so we need to make sure we're managing our distress too, monitoring our media diet, and the goal is not to eliminate negative feelings about climate change, but rather to acknowledge and validate them, to enhance our flexibility and resilience in the face of them, to try to foster self-efficacy and engagement, and to find an effective community where we can talk about it. There are groups for the lay public and mental health providers. I point you just to a couple, the Good Grief Network and Climate Cafes. There are also professional networks that you can connect with. This is the Climate Psychiatry Alliance that I'm a part of, but there's also its sister organization, the Climate Psychology Alliance, and there are a number of resources on their websites. And then go outside, get connected to the natural world. We know that green space can be very therapeutic, but it also can help with managing climate distress as well. Last thing I'll mention is that I think that as medical providers, we need to address the psychological defenses within our own specialty. Many physicians don't know about the impacts of climate change. They find that time constraints limit their discussions with patients or attempts to make changes sustainably in their own practice, and a lot of physicians feel powerless to make any difference in climate change and therefore engage in denial and repression when it comes to what they can do about the crisis. And I would even go so far as to say that many of us engage in a moral rationalization where, because we're providing good health care, perhaps we don't need to worry so much about our sustainability or impact on the world environmentally. I think that as psychiatrists who are well-versed in psychological defenses and helping people through them, that we have a very unique role to play in medicine in helping our colleagues become more sustainable. And Jacob or Dr. Lee will be talking more about that in his presentation. So briefly with this last learning objective, we talked about there are three different types of traumatic effects of climate change. We delve deeply into climate distress and to know that it is something that is common. It's particularly common among young people and that there are a number of ways we're trying to help support those with climate distress. So what are the primary takeaways from this talk that I hope you walk away with? Well, one, there are many psychiatric disorders that are affected by ambient heat. Psychiatric patients have difficulties thermoregulating at baseline, and the medicines we're prescribing can sometimes help but often exacerbate this. Neurotransmitters that are implicated in mental illness are often involved with thermoregulation, which may explain why thermodysregulation may occur in our patients. There are indirect effects of climate change in mental health. These include pollution, nutritional deficiencies, and zoonotic diseases that can have neuropsychiatric sequelae. Climate change impacts us psychologically through environmental traumas and existential dread, and many of us will be affected. And there are steps that we can take to try to offer support, including as mental health providers, with our patients, ourselves, and our colleagues. These are QR codes to resources that I hope you'll check out. This is the APA's Committee on Climate Change and Mental Health. Through the APA, it has its own website. The ACAP Resource Group has a website, and the Climate Psychiatry Alliance has a number of resources that are very helpful. These are some of the key references. All of my slides have the citation in the corner, and it's my pleasure to welcome our second speaker, Dr. Sugden. Thank you very much, and thank you very much for all of those who are still with us and who are checking out us virtually online. As mentioned, my name is Dr. Steve Sugden. I'm here at the University of Utah, and I'm honored to be able to join this panel to be able to talk about an ongoing challenge that we're all facing. If I could have the next slide. In my slide, I'll be talking about more of the implications of heat and then also with drought and deforestation and how that affects the immediacy of mental health. Next slide. So I teach a disaster preparedness course at the University of Utah, and we've been tracking the severity of disasters over the past five years that I've been teaching this course. The United States now is tracking disasters in the range of billions of dollars, and even lately, they've been starting to change their mnemonics or their value of $20 billion events. And then the reason why they're doing that is just the physical destruction of these natural disasters are becoming increasingly more intense. So within the 2023 timeframe, there was over $23 billion physical damage events within the United States. This does not take into consideration healthcare or a lot of those lingering effects that Dr. Wardle talked about with regards to lingering psychiatric effects. And so depending upon where you live, you can probably look on some of the scale and see where some of these events were that have impacted us last year. Hopefully 2024 is less than that, but if you were to track this each year, it seems like it's getting progressively worse. And for the record, 2021, we had five $20 billion events. The last year, we did not have as many. We only had one $20 billion event. Next slide. With this, I'm going to be transitioning into my heat. I can have the next slide. So many people have seen this slide, and it's a monitoring of the change in the Earth's core temperature. And when we talk about climate change, people frequently like to talk about, well, it's a natural ebbs and flows that we have periods of heat and we have periods of non-heat. If we just wait 10 years or 15 years, we'll go through back of time of non-heat periods. And although when we look at this, that can very well be the case through the 1980s, where we had these different periods of heat and cold and heat and cold. According to my eye, and I'm not a statistician, I am just an addiction psychiatrist, the trend from about 1980, although there are ups and downs, really looks like the overall pattern is that we're getting increasingly warmer. If we can go to the next slide, as mentioned by Dr. Wurzel, we've had six of the hottest temperatures just recently. And in fact, last year, we had the hottest temperature or the core temperature of the Earth ever recorded. And we had these events primarily between June of 2023 and August of 2023. And this is a map that was originally posted from the Washington Post. And it looked where these periods, where these hotter than normal temperatures were located. A lot of them are located within the regions of the oceans, but we still see hotter than normal periods up in Canada, Central, South America, Africa, regions within India, regions with Australia. Even though there were some relatively clean periods within the Midwest here within the United States. Next slide, please. Many people have seen variations of this slide. And this represents a modeling of if we continue our continued behaviors, or we make behaviors within our behaviors, where we might see our overall changes in climate within the next 70 years. Unfortunately, we, as a world, we are located in what's called that SSP-5, which is the model that shows that where we make the least amount of changes to our behaviors, where we find that we continue to be very reliant upon carbon dioxide, or carbon dioxide emission processes. If we were to adhere to the standards of the Paris Peace Climate Accord, that we would follow then the intermediate or the yellow graph. If we were to do even more than that, we could then see what some of those other improvements would be. And this really greatly impacts our health and our future health. And so I really want you to focus right now on the yellow graph, as well as the maroon, which is the very high graph. Next slide, please. So this is a fascinating study that came, that was published just in 2022, which looked at the emergency room visits within the United States between the years of 2000, excuse me, 2010 through 2019. And on the left, the one in the, that has more of the blue tones, this was where they marked how many emergency department visits occur within that healthcare, within those emergency department rooms over this nine-year period, 10-year period. And of course, where our high urban centers are is where you would expect to have the most amount of emergency department visits, and that's what this graph says. Well, this group of authors then overlaid that of when during this 10-year period, we had periods within the United States of extreme heat. And they defined extreme heat as less than 50 degrees Celsius versus hotter than 36.4 degrees Celsius, which is about 97, 98 degrees. They also overlapped this when we had extreme humidity. And this then is what we see on the right is on these periods of when we had these higher periods of temperature. If I can have the next slide. And so here, this is really when they started looking specifically for mental health. Essentially, all of our mental health, whether it was substance use disorder, anxiety disorders, mood disorders, schizophrenia, self-harm, childhood behavioral disorders, adult personality disorders, they had higher rates of hospitalizations or presentations to the emergency department for these specific disorders, the warmer and warmer it got. If you can click on the next slide, this then shows the pattern or the correlation factors that again, the higher or the warmer, the more humid temperatures that we had was this higher correlation of these psychiatric conditions. If we can have the next slide, please. This should read table two on the top left corner. This then looked at the mortality and morbidity rate of these specific mental health disorders. And again, there's a higher mortality and morbidity rate with increasing temperature for all of these psychiatric mental health disorders that we've been talking about. Next section. So it becomes now increasingly concerning what can we do that will mitigate this? Especially in lieu of that we've been having so much more heat waves, and we've been also having the length of our heat waves have been extending. So here on our left is since the 1960s over a 50 year period, how many heat waves per year have we been noticing? And again, throughout the United States, it's very consistent that we've been having increased the amount of heat waves in our largest cities within the United States. Here on the right, we also then show how long these heat waves have been going. So now not only are we having more heat waves, which was originally decided as six days per year, these now have increased in severity to where even having periods of heat waves of greater than 75 days. And we can see that these trends are gradually increasing. Next slide. This lists the top 50 cities that and their urban heat index, and not surprisingly, the cities that are the largest and have the most urban structures to them are the cities that have the worst heat index, which can then manifest or make those emergency department visits even that much more intense. So that people not only have hot days or humid days, if they're landlocked in these urban heat cities, it makes it that much worse. And so not surprisingly our most urban contact are cities that are most landlocked, New York, San Francisco, Miami, Chicago, where there isn't a chance to have more urban or green spaces are the ones that also have the highest heat index. Next slide. So there's many of us who remember 1995. I was still trying to get into med school at the time of 1995. So I don't recall the Chicago heat wave, the incident that I'm gonna be talking about. But I recently had found out that one of my colleagues who is involved with the climate health was an intern at Cook County Hospital doing this and gave me her perspective for this. And so in July of 1995, there was this period of intense heat that hit the United States. And why this became such a landmark case that we continue to study is in a period of about one week, there was over 850 deaths that were attributed to heat that affected the city of Chicago. This was just the city of Chicago, not other cities also expected similar consequences. Next slide. So here we look at the counties that had the highest amount of deaths or were the highest amount of deaths that occurred in this heat wave. And if you can click the next, it's interesting to compare this. On the right we then have the socioeconomic status. And it's not surprising that those communities within Chicago that had the worst socioeconomic status were also the ones that had the highest amounts of death rate, death within the Chicago heat wave. If we can go to the next slide, this breaks down specifically which were the populations that have the highest amount of heat deaths and they're outlined. And it's not surprising that also it was that 75 to 85 range population that had the highest amount of death. And it seemed to follow very much the same pattern that we had in COVID, which was where we had the greatest amount of deaths. And we think that disasters do not discriminate, but clearly we know that disasters discriminate and those who are affected with the highest or the lowest socioeconomic status are the greatest that are affected. And when we look at specifically what were the factors that where people were most affected, and this should be the next slide, it should be table four, sorry for not advancing that. The number one factor which was attributed to death rates was first the inability to care for themselves. Number two was if they lived alone. And number three, if they had a pre-existing mental condition. And when we look at what our behavioral health population, how many of our populations fit these dynamics? If I can get the next slide, it's interesting when you go back to the coronary report for the deaths in Chicago, the number one death was cardiac health. This was a great study that was by Borg et al that looked at the survivability of cardiac health or cardiac events and mental health. And it's not surprising that those who had the better mental health had the least amount of cardiac conditions. Conversely, those who have the most mental health conditions typically have the worst cardiac health and are more susceptible to these types of injuries. Next slide. So I mentioned the computer modeling. And again, if we look here on the left, this is the lower scenario, the RC4 4.5, which is also the SSPS-3 model, which is also the same model if we were to make the changes to meet the standards of the Paris-Pisa climate compared to what is our current trajectory if we do not make any changes to our carbon output. And it shows what are the predicted increases of changes in mortality rate or deaths per 100,000 by the end of 2000 and by the beginning of the next century. And again, most of these are predicted to be more cardiac complications. Though again, what we've just reviewed, just because they're cardiac complications, also the likelihood is that the majority of these cases also have extreme mental health conditions. And that is the reason of why we're having these increased challenges. And we can look again. This map is a manifestation of all of those areas that have been having worse heat index. It's an area that's been having hotter temperature. And it's really what our future is going to be if we aren't able to make some of the changes that are gonna be talked about by Dr. Lee here as soon as I'm done. Next slide. If heat wasn't fun enough or depressing enough, we'll now take on drought and deforestation, which seems to be a manifestation oftentimes of heat. If I can get the next slide. I live in the West and it seems like in the West, we've been having this perpetual drought for about the past 20 years. This was the drought map of May of 2022, where again, we saw a lot of the ramifications of extreme drought within the West Coast. Next slide. This is what the global drought map looked like within 2022. Again, we see a lot of impact within the West Coast and also the central parts within the United States, but at least we think we're the only part that's been affected in the world. South America has been greatly affected as well as Africa, regions within Europe, as well as our colleagues in Australia. Next map. This is what our drought map looked of in the spring of 2023. In the West, we had a lot of moisture, which kind of took us out of the extreme ranges, but we were still seeing this within the central regions within the United States. Next slide. When we look at what the impact of mental health is, this was a meta-analysis or a systematic review where they took about all of the different literature that has been involved within mental health and talks about drought. And it's interesting how many studies come to employment challenges that come from drought, which leads to drug, which leads to depression, which leads to stress, which leads to increased anxiety, which leads to loss of social networks, which leads to domestic violence and abuse, which leads to suicide. And this is really an intricate web that shows the ramifications of all of the mental health sequela that comes from all of this, the drought that we've been seeing. Next slide. Let's talk a little bit about the deforestation because we know that deforestation really is the number one cause of worsening carbon dioxide as well as greenhouse gases. Okay. And I have not been to Portugal. I would like to go to Portugal someday. In my family, we are huge soccer fans and I'd love to see all of the wonderful soccer stars that have come from Portugal. But it is interesting that currently we are losing about the size of Portugal in deforestation a year. And it's quite alarming. And the two most causes that are leading to the deforestation is the expansion of agricultural land. And number two is livestock grazing. When we look at what does that mean, about 25 or 26% of the greenhouse gas emissions are coming from some type of food production, whether it's from our livestock or our fish farms or for the crops to be able to support these. And we talk about the impact of how much carbon dioxide is produced to have a kilogram of beef. Essentially, we produce 60 kilograms of greenhouse gases just for that kilogram of beef. For a kilogram of cheese, that it's close to about 21% or 20, excuse me, 21 kilograms. And so when we talk about what is our food content or how we're using our land, this becomes significant. If we were to cut back merely on just how we use our land for our crops and our pastures, if we continue our current diet, essentially we are using both the equivalency of our land that covers the United States, North America, as well as Brazil, which is about 4.13 billion hectare acres. If we were to all adopt a plant-based diet, we could decrease that to about 1 billion hectare acres. That would give us 3.3 billion hectare acres that we could reforest and we could use that to help decrease a lot of our carbon dioxide emissions. There's been many scientists that have looked about if we've been trying to decrease our carbon dioxide by 2025 and studies have shown that if we don't address a significant food systems, that there is no way that we're gonna be able to achieve this. Next slide. It's also really important to know that, as I mentioned, those regions that have been significantly impacted by deforestation, these zones, also produce significant heat. Next slide. We also see that those regions of extreme deforestation also have worse mental health. I mentioned this, if we were to talk about changing our dietary patterns, there's been studies to show that if people were to decrease their utilization or have higher whole food diet, that they can also improve their dietary, they can also improve depression symptoms. And studies have even been shown that the number to treat with using a healthy diet is about 1.5 times can improve diet by, if we were just to change that for people, the number needed to treat is just four. And so not only is changing our diet what's best for the environment, it's also can be what's best for the human population. And so it can be a win-win effect. Next slide. With that, I appreciate your time and your attention and I turn it over to my colleague, Dr. Lee. Hello, thank you. Hopefully everybody can hear me okay. Someone can speak up, let me know if not. I really appreciate the introductions from the other two doctors, which I really think underline how important of an issue this is and how serious the impacts of health for our patients will be. I wanna take a pivot here and talk about what we as psychiatrists can do about this. This was covered a little bit in the other two presentations but that'll be the, for our final act here, that'll be kind of our main focus. Because of what we learned about how carbon pollution destabilizes our planet, about how much it endangers physical and mental health, it relates to our duty to do no harm. And psychiatrists may well realize or well appreciate that reducing our contributions to dangerous pollution is one of the more important things we can do to improve the health of our patients. Next slide, please. So members of professional organizations like the APA can advocate to reduce our greenhouse gas emissions. After all, all the global healthcare sector is responsible for about four and a half percent of all greenhouse gases. And that's a number that's rising. If we made healthcare its own country, it would rank as the seventh most polluting nation on earth. Next slide, please. Somehow the American healthcare industry is even more egregious here. About 8% of America's greenhouse gas results from healthcare sector. Next slide. And this directly contributes to about 600,000 disability adjusted life years annually from the emissions we create in providing healthcare to Americans. So this is a really substantial amount of harm that we are doing. To maintain the status quo is thus to cause hundreds of thousands of disability adjusted life years to be lost for Americans every year, which is obviously something we should strongly work to avoid. Next slide, please. So I want to kind of break down six areas in which psychiatrists can work to reduce the carbon pollution caused by our practice directly by our institutions and by our health systems. And all six of these points are covered in more detail in the white paper that myself, Dr. Wurzel and Dr. Elizabeth Haas had created. So the first of these six is to talk about changes in our annual conference practices. Next slide. After that, next slide, reduced flying to psychiatric residency match interviews, implementation of telepsychiatry, reduction of greenhouse gas emissions from our health systems, embedded carbon offsets, and finally, a quick word on enhanced adoption of recycling programs. Next slide, please. So let's talk about changes in our annual conference practices. Next slide. In November of 2019, the APA Climate Caucus proposed a policy to transition some of the APA's national meetings into virtual meetings. At the time, it was felt this wasn't possible, and our proposal was not adopted. Five months later, the APA held its first virtual national meeting during the COVID-19 pandemic. The technology was, as we had urged, already here. Analysis of the 2020 National Digital Meeting, which was performed by Dr. Wurzel and others, found about 90% reduction in emissions equivalent to saving 500 acres of dense forest or 22 million pounds of coal. In the context of the COVID-19 pandemic, reduced activities like reduced in-person conferences, reduced unnecessary commuter travel, meant there was an 8% reduction in greenhouse gases for 2020 overall across America, the most rapid one-year decline on record. When you look at similar organizations to the APA, say the American Geriatric Society, we see that other organizations have already decided to conduct their annual meetings virtually on alternate years. For the American Geriatric Society, their 2024 meeting will be virtual. Switching some or all meetings to virtual meetings would probably cause a pretty significant reduction of pollution, maybe more than almost any other change we can make. Next slide, please. In his 2021 Leaders Summit on Climate, the President talked to 40 world leaders, declaring America's goal of 50% reduction in emissions by 2030. With the passage of the Inflation Reduction Act and other legislation, every organization in America has access to additional funding and rebates to try and reduce our carbon pollution in line with that commitment. Unfortunately, the APA's annual meeting contracts are booked far in advance, and vendor contracts are signed five years in advance. Any plan we have to implement changes must work within the realities of this serious limitation. So if we want to work to reduce our pollution as psychiatrists, we need to also look at changes which can be made within meetings that are already planned. Next slide, please. I want to talk about some key interventions encouraged by the Lancet Planetary Health and also the UN's Sustainable Events Guide. So, in brief, be conscious about our carbon dioxide that might involve the APA releasing a after-event debrief, which looks at a few different elements of pollution. We could also work to be smart about our transportation, like choosing venues accessible by public transit, emphasizing public transit in the meeting materials that we hand out. You want to be intelligent also about the venue that we choose, and especially if we could prioritize hotels that are part of the Eco-Management and Audit Scheme or that performed well in the Hotel Carbon Measurement Initiative. Those are great ways to go to places that are relatively green when we bring our very large meeting to town. In terms of the food we serve, we can work to reduce meat offerings, provide vegetarian meals, and make sure they're regularly available. Even just physically reducing the size of a plate has been shown to reduce food waste, and at the end of an event, it could be it could be our practice to give our food to food charities or other food redistribution organizations. In terms of our materials, we can do a lot to reduce, reuse, and recycle here. So, this is like prohibiting disposable bottles, cans, plates, or other single-use items. Some organizations or meetings have started asking individual attendees to bring their own reusable water bottle and fill it up during the event. Also, instead of using plastic disposable goods, you could use washable plates and cutlery. You could implement limits on the amount of merchandise that some of these organizations are giving out, how many tote bags can one person have, and then we can also work to request some minimum packaging from suppliers. And then at the actual event itself, we want to make sure that there's recycling facilities available, and then as part of that debrief, we could list the amount of trash or waste that was generated at our event. So, models such as the wheel and spoke model are lower-carbon alternatives to virtual meetings, which combine regional APA areas of interest, such as food, water, and transportation, to create a more efficient and more sustainable way to meet the needs of the community. So, models such as the wheel and spoke model are lower-carbon alternatives to virtual meetings, which combine regional APA areas of interest, such as food, water, and transportation, to create a more sustainable way to meet the needs of the community. Next slide. So, models such as the wheel and spoke model are lower-carbon alternatives to virtual meetings, which combine regional APA areas into simultaneous regional meetings. So, the idea would be that we could stream content from a national meeting to various meetings that were occurring across the country, and there could also be the opportunity to network with people within our area. This could be the new paradigm for annual meetings. It could be something that alternates with the regular in-person annual meeting of the usual national kind. Next slide. Another idea would be to take the APA on tour to a series of consecutive regional meetings. I'll take the next slide a few times, thanks. So, the idea would be that some members would be able to travel around, perhaps some nationwide leading experts could travel around and provide some of the highlights or some of our keynote speaking, while regional presenters could give talks that are especially appropriate or relevant to their constituents. And then another idea that's grown in popularity is even if the APA annual meeting was maintained as an in-person physical meeting, moving other flagship psychiatric or related meetings to occur, say, the week after, two days before, in the same location, perhaps in other nearby hotels, that could significantly reduce pollution. So, if people were able to stay in, insert name of city, for a few days longer, rather than adding two additional cross-country flights, the carbon reduction could be significant. Next slide. I want to talk about reduced flying to psychiatric residency match interviews. Next slide. Medical school and residency applications typically involve multiple interviews across the region, or increasingly across the nation. Over the last decade, residency applicants have shown substantial increases in the amount of interviews they're attending, which of course increases cost and pollution. Click, please. In 2019 to 2020, over 35,000 medical students traveled across our country to interview for residency programs, bringing their carbon pollution up and up and up. Of course, estimates from small studies of resident applications found residents' carbon footprint reached nearly 500 pounds of carbon dioxide per interview. Click, please. Commercial aviation is the fastest growing source of greenhouse gas emissions and US flights already pollute 1 billion tons annually. Here, too, we see this opportunity for regional batching. So, we might start with virtual interviews for programs nationwide and then, for those who remain interested, they could be offered another round of interviews, the program, and these also could be batched geographically. So, if you had interest in multiple programs in the American South, perhaps similar to having the annual meeting, followed by related meetings, perhaps you would be able to batch some of your meetings that are geographically located next to each other, so that if you're flying across the country to go to Los Angeles, maybe you could also go to something in San Diego, rather than flying all the way back across the country and all the way back. So, this could be another way to save a lot of carbon pollution. Next slide. Let's talk about telepsychiatry here. Next slide. Travel contributes about 7% of the carbon emissions of the healthcare sector, but the distances that people travel to their medical visits really widely vary. This is something that I didn't have that much awareness of, of just how far some people are traveling to get their healthcare. Sometimes it's hundreds of miles for a single consultation. Next slide. So, average travel for, there's a study that looked at this, a location in rural Texas, where there was only one regional surgical consultation site. What they found is people were traveling over 1000 kilometers. They're producing 300 kilograms of carbon dioxide. We know that traveling is very polluting. You know, 400 grams of carbon dioxide or carbon dioxide is a lot of carbon dioxide. 400 grams of carbon dioxide or carbon dioxide equivalents per mile. So, you start to add that up over a, you know, sorry to mix my units here, but if you're traveling 1000 kilometers, like that's really going to add up. So, you know, we can see something like almost 300 kilograms of carbon dioxide pollution. So, that's really, really substantial. And then, of course, if our patients require airlifting, the pollution is massive. I want to talk about, next slide, this study that came out of UC Davis, looking at all the telemedicine visits that they added to their large system. And this is over the course of 17 years. What they found was that it saves significant amounts of time, energy, and money. So, let's just look at these numbers here. If you switch an in-person clinic visit to a telehealth, you're averaging something like 100 kilograms of carbon dioxide equivalents saved. You're saving your patients, maybe two hours each way, and can be over $100 sometimes for these extra long trips, including time missed from work over the extra length and extra time commitment from missed work. Next, please. The environmental costs of telemedicine are minimal when compared to those of operating a psychiatric office. If we try to look at, like, where is the breakdown? Obviously, if you were going to walk across the street to your office, then the difference between telehealth and in-person might not be as much. So, some statistical analysis has shown somewhere around the four-mile distance is where we start to have a break, wherein it becomes significantly beneficial to switch to a tele-encounter. I just want to bring up some other points here, like children and young people with agoraphobia, for instance, might really benefit from switching to electronic therapies. And then, yeah, it's a way to reduce our wait times. It reduces missed appointments, according to some studies. So, lots of benefits there. Next slide, please. Next, I'm going to talk about reduction in greenhouse gas emissions from health systems. Next slide. Greenhouse gas emissions from healthcare result from medical supplies, construction, the energy use from medical facilities, the investment portfolios of our healthcare employers or organizations, the supplies we use in healthcare, our food, our waste, the pharmaceuticals we make, transportation of goods, services, and personnel, and more. If we want to get a really good sense of how much we're polluting and how much our system is polluting, we need to use a cradle-to-grave emissions lifecycle analysis. That means we can't just look at a bottle of pills, which have arrived in our clinic, and say that that's carbon neutral, it's already here. We need to look at the manufacture, the distribution of these things, and look for places where we can reduce carbon footprint along the whole process of their manufacture, distribution, and application. Next slide. I want to point to this really helpful graph that I pulled from the Lancet Planetary Health. As you can see here, healthcare access and quality measures can be increased without necessarily increasing emissions per capita. I'll have a click. So you can see here, we can have better healthcare access and quality as you go higher up. 70 is better, 80 is better, 90 is the best. So you can have better healthcare access and quality, good healthcare for more people. However, click please. You can see that in the case of the United States, we are uniquely awful in terms of unnecessary emissions, leaving us plenty of room for carbon reduction. Just take a second and look. We have no peers here. The pollution and waste of healthcare in America is without equal on Earth, as we look at a ratio of our quality to the pollution we provide. Next slide, please. A roadmap for the kind of changes I'm talking about can be found in England's National Health Service, which is, by the way, the largest employer in Europe and the largest single-payer healthcare system on Earth. While continuing to provide services for 55 million people, click please, the Sustainable Development Unit was founded in 2008 to ensure the health service met its commitments under the UK's Climate Change Act. So after the UK Climate Change Act passed, they were able to significantly reduce their carbon footprint, and in January of 2020, NHS England announced they were going to be the world's first net zero health system. You know, there's a lot of similar efforts like this going around worldwide, trying to adapt our health systems so we can help people without hurting them. And efforts like this were up 5% in 2019 and continue to grow. The United States can follow in this footprint, but it's going to require individual and professional advocacy to push these changes. Next slide. Across the world, individual health professionals and their organizations have followed the NHS model and many health institutions are committed to divesting. Right now, there's been over $40 billion worth of assets divested from fossil fuels within American health institutions, and there's room for that to continue to grow. Our own organizations can, with encouragement, join in this worthwhile trend. I will mention here that thanks to advocacy and efforts from members, the American Psychiatric Association has largely divested from their carbon pollution investment portfolio, but our hospital systems, our other groups can follow in this worthwhile trend. Next slide. Programs like My Green Doctor can help organizations, even small organizations, reduce their carbon pollution. So My Green Doctor has these plans that you can use, kind of like a QI intervention that you can fit into the end of your rounds or other meetings that you already have, quick five minute bites that follow the model of QI that are already so familiar to many of our institutions and allow us to use that same familiar and already trusted system of quality improvement projects in order to improve our practices in terms of their sustainability. Next slide. Carbon offsets can reduce the APA's carbon footprint, so that can contribute to our global efforts to reduce emissions and combat climate change. So if we were to use carbon offsets, it would demonstrate the APA's commitment to environmental sustainability, and it would align with our permission to promote mental health and well-being for brain and mind. Implementing carbon offsets can enhance the APA's reputation and our public image, it can showcase our proactive approach to addressing the climate crisis, and it shows that we're doing something to address these climate concerns. But I want to talk about the understandable controversy around carbon offsets here. If an organization were to solely rely on carbon offsets, that could divert attention from other efforts which might reduce emissions at the source. It's almost always preferable to reduce emissions, rather than to just offset them. So we don't undermine our commitment to other sustainability efforts. And we'll talk about this more in a second, but parts of the carbon offset market are rather unregulated, there's a lack of universal standards, and it can be challenging to assess the quality and credibility of many offsets. There's also the fact that there's financial costs and the APA has financial strain. We need to make sure that we're balancing our financial priorities with the sustainability of our planet and the health of our patients. Next slide, please. These concerns can partially be addressed by purchasing carbon offsets which meet the UN's gold standard for sustainable development goals. Additionally, carbon offsets should almost never be used as a singular strategy to address our carbon pollution, but more so like part of a multifaceted approach, a diverse portfolio of carbon reduction or sustainable actions. Next slide. Last year, I'd like to just quickly talk about recycling, which helps reduce greenhouse gas emissions by reducing energy consumption and reducing use of virgin materials. Next slide. Globally, landfill contributions double the CO2 emissions of the entire aviation sector. Studies show that deforestation and landfills account for about a quarter of all the greenhouse gas pollution on Earth. Next slide. I want to look at this study, which looked at 633 hospitals nationwide and found that about two thirds found they were collecting 40% or less of what could be recycled. Next slide. Fortunately, about two thirds, perhaps a different two thirds, found that there was a plan or they expected that their hospital would expand plastic recycling in the next two years. So this is at least seemingly an area of growth. Next slide. Just a quick quote here from the Executive Director of the Health Care Plastics Recycling Council. Patient care areas often generate the highest volumes of plastic resources within the hospital, most of which is clean, free from patient contact and contamination. Special materials like Tyvek packaging, sterilization wrap, saline bottles, basins, and trays are all common patient care products that are easily recycled. Next slide. Next slide. I want to point to two dedicated plastic medical waste recycling pilots, one at Stanford, one at Chicago. They found it was best if we kept our interventions simple. We use behavioral change in order to implement our process and identified an in-house champion who wanted to champion the cause of recycling in their systems. They found that co-mingled or mixed material recycling, it's kind of like a marginal value. So there was real benefit to reducing the variety and complexity of our plastic materials, so that we had fewer streams of recycled goods. And then they found that when we had introduced plastic recycling, it supported broader sustainability initiatives like reducing their carbon footprint. Next slide. And just the last word here on there's a growing body of research analyzing and working to reduce the pollution associated with the manufacture, storage, and distribution of medications we use. Further study on this important topic is necessary and the APA has an opportunity to really demonstrate leadership here through its support or patronage of this research. There's many ways in which psychiatrists can reduce the harm we're causing through carbon pollution. We all have an ethical responsibility to reduce the death and disability caused by the pollution from the health care we provide to our patients. By working to improve our annual meeting, modernize our residency match interview, and support telehealth, psychiatrists can demonstrate environmental leadership. By encouraging our organization to reduce our pollution and carbon footprint, we can promote health and sustainability for our patients and communities. Thank you. Thank you so much Jacob and Steve. It's our pleasure now to have a brief Q&A session. I apologize we would have two more minutes if I had noticed that my mic wasn't working in the beginning. I'm looking now at the Q&A box. So our first question comes from Lewis. How would you suggest we convince legislators who are largely profit-oriented and developers about the critical nature of giving up carbon-based fuels in favor of renewable energy? Ours just finished a session with a law to hang on to coal production and burning so we could avoid blackouts, etc. Why don't you take that Jacob? Yeah so I'm happy to answer this one. I think that there was a point even quite recently. I'll use solar panels as a good example of an alternative to coal-fired power plants. So there perhaps was an argument 20-15 years ago because the cost per wattage of using solar was more expensive than coal and we needed to use moralistic arguments in order to try and convince people that this was right to save the planet or whatever. Fortunately the cost of solar panels has absolutely plummeted thanks to intentional programs to subsidize the cost research and development. The cost per watt of sustainable fuels, especially solar panels, has fallen and fallen and fallen and now especially with huge subsidy and rebate programs as part of the Inflation Reduction Act which puts forth billions and billions of dollars towards sustainable efforts. There are purely economic cases that new development should be, for instance, solar-based rather than coal-fired power plants. The only arguments for coal-fired power plants start to be arguments about things like jobs but on purely economic basis there is no longer, as of the last few years, there is no longer an economic argument to be made around things like coal-fired power plants. So I do think that the economics even for the purely profit-minded legislators are really starting to swing and I would just direct your legislators to resources that are available to communities or organizations especially through the Inflation Reduction Act. Thanks and I will just add that I think that so much of it has to do with lobbying and there are people with real invested interests in maintaining a carbon economy so hopefully we can move the dial on that. Our next question is from an anonymous attendee. If decarbonization is critical, why are we not allowed to even think about nuclear energy as an energy replacement source? I'm happy to just say briefly that I agree with you that there's a real stigma for nuclear energy, unfortunately. I don't know if we're not allowed to think of it as a source and certainly different parts of the world are thinking about that. Steve, do you have some thoughts on that? We can't hear you, Steve. No, not yet. I'm going to turn it over to Jacob and then see if you can change your mic setting. Yeah, so I'll say especially within the places and the organizations that I find myself in, the people who care most about the sustainability and health of our planet, there's a lot of negative stigma around nuclear energy. I'm not here to talk politics but I'll just say I think that nuclear energy, the best science shows that that should be a part of our energy portfolio and I think that there should be a dialogue about that especially if you look at places like France which is looking at next generation nuclear reactors which are expensive to build but are very energy efficient, provide huge amounts of energy for people in very safe ways. I do think that that is part of how we have a sustainable future and I do think there needs to be a move towards allowing this in the dialogue towards the mainstream acceptance of this. Steve? I was going to say the same thing as you. I think when you're in an all hands on deck approach, you have to take all hands because I think you're limiting yourself to an opportunity or an agent that might be very helpful in many markets. We have another question from Antonio. How can we treat patients affected by violence induced by heat? It's a very interesting question. I don't know necessarily if this is any different than any other behavioral dysregulation that we might see with other patients but rather just to inform our vulnerable patients or patients who may already have affect instability or have engaged in other violent behaviors that they may be susceptible to the impacts of heat. That would be my initial thoughts. Steve, do you have any thoughts? Yeah so I mean when they're in disaster planning they're starting to look at a lot more of these community resource programs and trying to see who are the vulnerable populations within said community. So then the big example would be like who are all the people who need insulin so we can make sure that we can have insulin but they're also starting to then identify who are the individuals who have mental health symptoms and how might we address needs for those people who have mental health symptoms and we could be proactive in setting. If we are projecting like increasing worsening temperatures, how do we make sure that they have cooling opportunities or how do we make sure that they have community around them so that they're not in isolation so that they have that support network around them to try to look at upstream interventions instead of just now that they are agitated, aggressive, how do we help them at that point in time? Jake, do you have some additional thoughts? Yeah so I'll definitely say you know at the core of it is we provide symptomatic relief for our patients you know if there's an act of aggression we manage that in similar ways you know at the source like Dr. Sugden just said. I will just point to in the state of Hawaii just as a model here there is a climate change and health working group that's currently doing a research project looking county by county for what people's exposure is to heat and looking at incidents of heat injury and heat stroke kind of to try and triage our care and that kind of provides a model I think that to some extent has been done on the mainland but is really relevant for I think a lot of different communities about trying to figure out where there are the greatest risks and trying to distribute our limited resources appropriately. I just point to organizations like FEMA which manages the nationwide heat shelter system and the various state EMAs. Those are really relevant organizations because they provide some of the on the ground resources for preventing heat related injuries in places like cooling centers. Thank you Jacob. I know we're at time but perhaps we have a couple extra minutes. We have two more questions. One's from Lucy. Are there dose dependent correlations seen with antipsychotic prescription use and thermal dysregulation? It's a fascinating question. Frankly I don't know if we have an answer to that. I can hypothesize that as you increase doses of certain antipsychotics that have more anticholinergic effects that you might sooner see some of the thermal dysregulation secondary to what receptors you're hitting and in a similar vein we may find that different antipsychotics have different potency in terms of how much they affect temperature regulation. Do you Steve or Jacob have any other thoughts about that question? Okay great research question though. And then our final question. You addressed many aspects of carbon dioxide mitigation. What about adaptation? Changing psychiatry to meet the many disasters, financial costs, refugees, traumas, etc. I'm especially interested in proactive ways to face climate disasters. Jacob. So I'm going to recognize I'm going to be talking about disaster psychiatry here so Dr. Sugden to definitely give a perspective here as well. One of the big interventions that I think is is relevant when we try to look at like adopting psychiatry to help with this. There's been a movement towards say the Community Mental Health Resilience Act. I'm sorry forgetting the name of this legislation but there's a move to try and support larger group things. Larger sessions for instance or preventative work within psychiatry. You know right now the paradigm for psychiatry is you pretty much get billed if you see one patient and provide services to one patient and maybe you expand that out to seeing a whole family at a time. And while there is some limited use of psychiatrists leading therapeutic groups, I think as a modality large-scale community resilience efforts are not financially considered within our system. It's not you know institutionalized. So a lot of providers aren't working in these community resilience spaces at disaster preparedness spaces because it's just not supported within the paradigm of how we're taught or how we reimburse so we can make this a sustainable part of our practice. So I think working on some community level efforts would be a way to kind of reform psychiatry or to legitimize those community efforts would be a way to help us better in that situation. You know and to kind of dovetail on that I think that psychiatry is one of those specialties that really has this opportunity to look at community mental health not just as an individual mental health. And to that end you know there many organizations are developing these empowered community programs which I kind of talked about where they are trying to develop these resilient action plans of how to help each community specifically. Hawaii is doing phenomenal with them especially since recent disasters have shown that they unfortunately are all by themselves out on the island. California has been doing that. Many other organizations are trying to many other states are trying to institute that. And again the idea is disasters will come. And so instead of saying disasters might come I mean every year we're having 20 to 31 billion dollar disaster events. And so then how do we work with our public health officials to be able to get involved with these empowered community programs or how do we get involved with the various states to be able to think about you know what is their their mental health plan when these disasters come and kind of change it more from an if but a when perspective. And I'll just say that I think that psychiatry as a whole is going to find that disaster psychiatry is not a subspecialty it becomes the bread and butter aspect of what we all do. And so I think that that's something we'll see over the course of the coming decades. On behalf of our committee it's such a pleasure again to get to have this opportunity to speak with you those that have attended in person well live in real time as well as those who will be attending after the fact. Thank you so much for your time and attention.

climate change

mental health

extreme heat waves

emergency department visits

mortality

vulnerable populations

elderly

low socioeconomic status

disasters

mitigation efforts

telepsychiatry

sustainability in healthcare