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UPMC CPSP Annual Conference

November 5, 2021

David A. Pollack, MD

Professor Emeritus for Public Policy

Oregon Health & Science University

• The presenter has no conflicts to disclose.

• He is a founding member of the Climate Psychiatry Alliance, serves on the Steering Committee of the Medical Society Consortium on Climate and Health, and is active in the American Psychiatric Association’s initiatives on climate and mental health.

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At the conclusion of this session, the participantwill be able to:

• Recognizethe realityof theclimatecrisis (CC) and its impacton health.

• Recognizepsychiatricconditionsand other MH impacts that emerge from and/or are affected by CC.

• Recognizepsychological factors that contribute to the refusal to acknowledgethe reality and urgencyof CC.

• Recognize immediateand urgent mental health and public health impactsof CC.

• Recognize ethical and public health duties for mental health professionals to speak outabout these threats and to advocate for rational policies to address the threats to healthposed by CC.

• Understand roles that psychiatrists and other mental health professionals should perform in facilitating recovery from immediateand longerterm CC related disasters.

• Becomemotivated and haveopportunities to determine how to prepare forand work to mitigate, prevent, and reverse mental health consequencesof CC.

• Becomeaware of available resources to facilitatesuch public health and mental health activities.

• Recognize how CC is a major social determinant of health and mental health and that building communityresilience is a key component in the public mental health effort to address the health risks of CC.

• Haveyou been exposed to extremeweather events in the past 5 years? What mental health impacts did you notice/experience?

• Do you see any evidence of longer term climatic changes whereyou live?

• What environmental factors do you connect to negative mental health outcomes?

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• Link to NEJM module

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Image© Task force reporthttp://ecoamerica.org/wp-content/uploads/2017/03/ea-apa-psych-report-web.pdf

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• Acute/chronic traumatic stress and somatic neuropsychiatric impacts contribute to a wide range of psychiatric conditions associated with the Climate Crisis:

• Direct with immediateeffect (e.g., heat waves)

• Indirect in the short term (e.g., floods, tornadoes, hurricanes)

• Indirect in the long term (e.g., sea level rise, prolonged drought, deforestation, mass migration)

• Although individual prevention/treatment is important, system change is the greatest need!

• Heat Related Impacts

• Air Pollution and Anxiety

• Exposure to Neurotoxicants

• Anxiety, Mood, and Trauma Syndromes

• Impacts on children/youth

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• Increased risk of aggression/violence:

• 4% increase in interpersonal violence, 14% increase in civic conflict

• Increased risk of suicide

• Increased risk of cerebrovascular illness, including strokes

• Increased risk of dehydration, hyperthermia and death in persons with chronic illness, esp. persons with chronic psychiatric illnesses (3X more likely to die than general population)

• Tendencies to be less mindful aboutexposure risks

• Medications reduce body’s internal thermoregulatory function

• Advise patients to limit exposureand increase hydration (CPA website extreme heat toolkits)

• Bidirectional relationship between acute respiratory distressand psychological symptoms/conditions (e.g., anxiety, panic)

• Chronic exposure to air pollutants ➔increased risk and degree of respiratory conditions➔greater risk of anxiety symptoms

• Preexisting anxiety➔greater risk of respiratory distress, e.g., hyperventilation associated with panic attacks

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• Neurotoxicants (e.g., particulate matter, mercury) in air pollution ➔developmental disabilities in infants/children and cognitive impairment (including dementia) in adults

• Various neurotoxicants derived from fossil fuel and other sources of pollution also present in soil and water, all of which can➔neuro-psychiatricconditions

• Increased infectious disease outbreaks in broaderareas can➔cognitive impairment and movement disorders

• Climate-sensitive water related illnesses ➔neurological impacts

• Soil contaminants and increased CO2➔decreased nutritive value of grains and other food crops as well as various illnesses, some with impact on cognitive function

• Best treatment: prevention, i.e., elimination of pollutants, esp. fossil fuels

• Eco-anxiety much more prevalentwith numerous manifestations• Solastalgia, Ecological grief, Pre-traumaticstressdisorder,

Depression• Most affected are not irrational, have few impairments in

functioning, and DO NOT HAVE PSYCHIATRIC ILLNESS, and therefore, no need for meds or psychotherapy, unless impaired.

• First line of treatment: encourage engagement in constructive, collective activities associated with addressing the climate crisis or interconnected issues of concern in theircommunities, e.g., economic, racial, social justice.

• Numerous opportunities for social action (e.g., environmental activism) & emotional support groups (e.g., Good Grief Network & Climate Cafes)

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• Various conditions created/exacerbated including:• PTSD, depression, anxiety, phobias, sleep disorders,

attachmentdisorders, substanceabuse, as well as cognitive impacts of exposure to neurotoxicants.

• Resulting problems impact emotional regulation, cognition, learning, behavior, language development, & academic performance, all of which predispose to adverse adult MH outcomes.

• Children/Youth have high levels of concern about CC• They are worried, confused, scared, and angry• Meaning-focused coping➔well-being & environmental

engagement• Those in developing world suffer “first and worst”• Educating adults about how to talk to children about these

issues is essential.

• Children and youth are uniquely vulnerable, given their integration within broader social and familial contexts, the formative nature of their psychological development, and existential concerns as they will be faced with the effects of climatechange for many years to come. [Hrabok 2020]

• Ecological anxiety and strong emotions linked to the anticipation of future losses will likely increase in prevalence, and may particularly impact children and youth who are currently growing up with ‘doom and gloom’ narratives. [Clayton 2017]

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• Worldwide, floods and drought are the most frequentextreme climate-related disasters with a potential that might affect children and adolescent mental health. [Magalhaes *not yet peer-reviewed]

• A school-based survey administered 5-9 months after HurricaneMaria (Puerto Rico 2017) found that 83.9% of youths saw housesdamaged, 57.8% had a friend or family member leave the island,and 32.3% experienced shortages of food or water. Overall, 7.2%of youths (n = 6900) reported clinically significant symptoms ofPTSD. [Orengo-Aguayo 2019]

• Experiencing a natural disaster before the age of 5 is associatedwith an increased risk of mental health disorders in adulthood,particularly anxiety disorders, but not substance use disorders.[Maclean 2016]

• Not only is the prevalence of mental health conditions following disasters elevated in children, but the effects on children's mental health have further complicating factors. Children experience a loss of agency, friendship networks, familiar space, and disillusionment with societal response post-disaster [Mort 2018], with increased existential anxiety described in adolescents. [Weems 2016]

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• Transformational Resilience as a community level public health intervention

• Duty to warn

• Duty to train

• Duty to protect

• Health sector carbon footprint

• Denial as a societal defense mechanism

• Mass migration

• Positive impacts of contact with nature

Executive Summary 2016, U.S. Global ChangeResearch Program

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The Social Determinants of Mental Health

Reduced Options, “Poor Choices”

Behavioral Risk Factors Physiologic Stress Responses Psychological Stress

Architecture of RiskAdverse Health Outcomes

Poor Mental Health, Mental Illnesses, Substance Use Disorders, Morbidity, Disability, Early Mortality

Public Policies(laws, ordinances, rules, regulations, court decisions,

etc.)

Social Norms(attitudes, biases, opinionsof onegroup toward another)

Adverse Features of the Built Environment

Neighborhood Disorder, Disarray,

or Disconnection

Exposure to Air, Water, or Soil Pollution

Exposure to the Impacts of Global Climate Change

Homelessness, Poor Housing Quality,

Housing Instability

Food Insecurity, Poor Dietary Quality

Poor or Unequal Access to Transportation

Poor or Unequal Access to Insurance

or Health Care

Low Education, Poor Education Quality,

Educational Inequality

Unemployment, Under-Employment,

Job Insecurity

Poverty, Income Inequality, Wealth Inequality

Area-Level Poverty, Concentrated

Neighborhood Poverty

Adverse Early Life Experiences, Childhood

Maltreatment

Discrimination and Social Exclusion / Social

Isolation

Exposure to Conflict,Violence, Shootings,War, Migration, etc.

Interaction and Involvement with the

Criminal Justice System

Unfair and Unjust Distribution of Opportunity(in terms of power, empowerment, voice, access to resources, etc.)

• Demographic, geographic, social factors affect vulnerability to health/MH effectsof climatechange• Location, age, gender, SES, health status, disability• Existing systems of oppression

• Disadvantaged and vulnerablepopulations experience impacts “first and worst”

• Any efforts toward equity contribute to environmental justice• Human and civil rights, housing equity, food security,

transportation accessibility, law enforcement accountability, healthcare access, just energy transitions, etc, etc, etc.

Patz et al., 2014, JAMA; Schlosberg, 2014, Clim Change; Watts et al., 2015, Lancet;Yadav & Lal, 2018, J Arid Environ

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• Health risks derived primarily from fossil fuel and large scale animal production➔

• Increased atmospheric CO2,

• Increased global temperature,

• Rising sea levels,

• Air pollution,

• Other factors reflecting rapid and extreme changes in the environment

• These risks lead to acute and extreme events which have longer term physical, psychological, economic, social, and political impacts lasting longer than the acuteevents.

• Substantial and long-lasting

• Affect those who are more vulnerabledue, in part, to social inequities: “first and worst”,

• Require immediate and ongoing planning/implementation of efforts to combat acuteand chronic impacts

• Depend upon broad participation of health, public health, and mental health professionals

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• The impacts of CC are further exacerbated or poorly treated when denial of the reality or immediacy of CC drives social norms or public policies.

• The bio-psychological and psycho-social-spiritual impacts are interdependentand mutually reinforcing, thus increasing the degree of suffering and disability.

• These cumulative harms contribute to demoralization, apathy, and amotivation, processes that are antithetical to essential collective and corrective actions at the individual or community levels to mitigate, reverse, and prevent further impacts of CC.

• Essential and high priority responses to CC:

• Rapid reductions in carbonemissions

• Preparing human-built infrastructuresand natural resources to withstand and adapt to climate impacts

• Equally important, but generally unacknowledged and unaddressed is the urgent need to proactively build the capacity of individuals, families, organizations, and entire communities to cope with climate adversities without harming themselves, other people, or the natural environment.

• These adaptive efforts, aka Transformational Resilience, can also be catalysts to increasesocial, psychological, and ecological wellbeing.

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• The most harmful bio-psycho-social-spiritual impacts ofclimate disruption are due to persistent overwhelmingtoxic stresses, not just acute disasters.

• Even if we make essential changes soon enough to reverse the environmental impacts of CC, the psychological and psycho-social-spiritual impacts will continue and be slowest to recover.

• Comprehensive preventative Transformational Resilience initiatives must be rapidly launched at the community level world-wide, not only in areas directly affected by extreme acuteevents.

• Transformational Resilience initiatives must prevent maladaptive responses by empowering all adults and youth with the knowledge, skills, and attitudes (KSA) to:

• think and act in healthyways, even in ongoing unhealthy conditions

• use adversities as transformational catalysts to find meaning, direction, and hope in life, and

• remain actively involved in constructive pro-social and climate solution initiatives.

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• Collaborative efforts at individual, organization, and community levels to help all adults and youth learn and use:

• "Presencing": KSA about the neurobiology of traumaand toxic stress, body and mind regulation skills, and

• "Purposing": KSA that help people turn toward adversities, rather than attempting to deny or ignore them, AKA post-traumaticgrowth resilience skills.

• This requires broad participation from numerous areas of expertise, esp. MH and substance use, public health, psychological trauma and resilience building, environmental and social justice activism, K-12 and higher education, and faith communities.

• Talking aboutdistantconcepts (geographicor chronologic) is not effective.

• Simply listing innumerable potential harms is counterproductive (e.g., gun control, anti-vaccine).

• Focusing on what is in the listener’s best interest may be effective.

• Health impacts have been shown to be among the most effective concepts to move opinions.

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• Criteria to evaluate the extent to which health professionals have special obligations to advocate for actions to address Climate Change*

• Expertise

• Proximity

• Effectiveness

• Low cost or risk

• Unique

• Severity

• Public TrustMacPherson & Wynia: Should Health Professionals Speak Up to Reduce the Health Risks of Climate Change?AMA J. of Ethics, 2017

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• These criteria can be applied by providers who may face analogous challenges to decide whether they have responsibility to act to protect people who are not under their direct care, i.e., by advocating for and supporting population health initiatives.

• Curriculum development forall health disciplines, at all levels (undergraduate, graduate, and continuing education)

• Process and progress of curriculum developmentat OHSU and otheracademic health centers

• Global Consortium on Climateand Health Education

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• Clinical• Understand, prevent, and treat health and mental health impacts;

participate in social cohesion, facilitating community resilience, and other public health initiatives.

• Administrative• Reduce carbon utilization of small practices, clinics, hospitals, and

research facilities; participate in preparationand response foracute weather events and otherdisasters.

• Advocacy• Disabuse denial; disinvest in fossil fuels; develop and disseminate

climate and health impact statements and calls to action; and advise policy leaders.

• Research• Promote projects to address key questions relating to climate and

mental health.• Education

• Provide professional training and incorporate relevant and timelycontent into all health professional curricula at UME, GME, CMElevels.

• Persons with pre-existing chronic illnesses, e.g., persons w/ severe, persistent mental illnesses

• Indigenousand othercohorts tied to the land forwell-being, livelihood, cultural identity

• Low and middle income populations (and nations)

• Youngerpopulations

• Climate “first-responders”

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• Develop/test strategies for rapid/effective political & policy actions to support CC mitigation/ adaptation.

• Understand the component parts of the CC and MH system.

• Describe entire CC and MH system using a research–policy–communityco-design approach.

• Initiate small, prototype-testing group-level intervention studies to promote well-being & improve prevention & early intervention in CC-related MH & wellbeing

Berry, et al, The Case for Systems Thinking About Climate Change and Mental Health. Nature Climate Change, 2018

• Poor understanding of which factorsaffect vulnerability/resilience

• Little research re. interventions/policies designed to safeguard mental health

• Research to assist decision makers to develop robust evidence-based mitigation and adaptation policies/plans

• Addressing CC➔opportunities to shape/improve MH for the foreseeable future due to health co-benefits of transitioning to sustainable living methods

Berry, et al, The Case for Systems Thinking About Climate Change and Mental Health. Nature Climate Change, 2018

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• Clinical conditions impacted by CC

• Treatments for CC-related conditions/symptoms

• Community level interventions: feasibility, effectiveness

• Organizational responses to addressing CC clinical, administrative, training issues

• Training outcomes/effectiveness

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ClimateActions For Health:

• Meet and strengthen commitmentsof the Paris Climate Agreement.

• Transition rapidly away from use of fossil fuels to clean, safe, and renewableenergyand energyefficiency.

• Emphasize active transportation in transition to zero-carbon transportation systems.

• Promote healthy, sustainable, resilient farms/food systems, forests, & natural lands.

• Ensureaccess to safe and affordabledrinking water and a sustainablewater supply.

• Fund and support just transition for workers/communities adversely impacted by climatechange and the transition to a low-carbon economy.

Health Actions For Climate:

• Engage health sectorvoice in call forclimate action.

• Incorporate climate solutions into all health and public health systems.

• Build resilientcommunities in the face of climate change.

Financing these actions

• Invest in climateand health

2021: Specific Recommendations for DHHS

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• Sustainable Human video

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• Temperature Impacts

• Air Pollution and Anxiety

• Anxiety, Mood, and Trauma Syndromes

• Exposure to Neurotoxicants

• Impacts on children/youth

• Transformational Resilience as a community level public health intervention

• Duty to warn

• Duty to train

• Duty to protect

• Health sector carbon footprint

• Denial as a societal defense mechanism

• Mass migration

• Positive impacts of contact with nature

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• Health impacts of Climate Change are significant, current, expanding, and last to resolve.

• Health professionals have the skillsand obligation to participate in addressing impacts.

• Climate change is the ultimate, cross-cutting social/structural determinantof health, a slow moving mega-disaster.

• Ample opportunities for constructive engagement and positive change for us and society

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• “The splitting of the atom (also the over-extraction and consumption of fossil fuels, with excessive release of greenhouse gases into the environment), has changed everything, save our mode of thinking, and thus we drift toward unparalleled catastrophe.” Albert Einstein

• “Intellectuals solve problems, geniuses prevent them.”

• Let’s all become geniuses!

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