Addressing the Impacts of Climate Change on Mental Health and Well-Being

学科分类：医学（综合）

中国|英语

来源: American Public Health Association

【 摘 要 】

Abstract

Climate change is widely presaged as the most serious threat to public health in the 21st century while also being recognized as an opportunity to advance the public’s health. The increasing incidence of devastating climate-related disasters (e.g., hurricanes, floods, droughts, wildfires, and heat waves) demonstrates that no part of the planet or group of people are safe from the pervasive effects of such events. Factors such as age, race, socioeconomic status, migration status, and/or living with acute stress, a physical disability, or mental health or substance use disorders make individuals and groups more vulnerable to the effects of climate change, especially in low-resource settings with fragile infrastructures such as those frequently found in developing countries. Current threats of climate change to the Earth’s physical environment and essential actions needed for adaptation and mitigation are widely acknowledged. Many stakeholders around the world and in the United States have highlighted the effects of climate change on human health, inequities in response, and steps that can mitigate impacts and adapt public health systems (and other societal infrastructures) toward a new “climate normal.” However, immediate and ongoing threats to mental health and well-being have yet to be equally addressed and prioritized. This policy statement integrates existing global and U.S. efforts and calls on all stakeholders to actively prioritize, implement, and finance actions that more comprehensively address climate change impacts on mental health, well-being, and resilience (both structural and psychosocial) with cultural sensitivity. It serves as APHA’s only proposed or existing policy statement on this topic to date.

Relationship to Existing APHA Policy Statements

Twenty-six APHA policy statements are relevant to this proposed policy because of their explicit explanation of, or brief reference to, the effects of climate change on health, mental health, and/or specific groups. No policy statement to date is comprehensive in its attention to the effects of climate change on mental health, which is the goal of this statement. The 26 existing policy statements below were selected because of their relevance to three main content areas:

U.S. and/or global public health approaches to climate change

• APHAPolicy Statement 20157: Public Health Opportunities to Address the Health Effects of Climate Change
• APHA Policy Statement 20078: Addressing the Urgent Threat of Global Climate Change to Public Health and the Environment
• APHA Policy Statement 9510: Global Climate Change
• APHA Policy Statement 201512: Ensuring That Trade Agreements Promote Public Health

Links among public health systems, health systems, health policies, and climate change

• APHA Policy Statement 201210: Promoting Health Impact Assessment to Achieve Health in All Policies
• APHA Policy Statement 200911: Public Health’s Critical Role in Health Reform in the United States
• APHA Policy Statement 20089: Strengthening Health Systems in Developing Countries
• APHA Policy Statement 20171: Supporting Research and Evidence-Based Public Health Practice in State and Local Health Agencies
• APHA Policy Statement 201013: American Public Health Association Child Health Policy for the United States

Links among the environment, health, mental health, and climate change

• APHA Policy Statement 20038: Supporting a Nationwide Environmental Health Tracking Network to Identify Links Between the Environment and Human Health
• APHA Policy Statement 20042: Reducing Health Disparities in People with Disabilities through Improved Environmental Programmatic and Service Access
• APHA Policy Statement 201415: Support for Social Determinants of Behavioral Health and Pathways for Integrated and Better Public Health
• APHA Policy Statement 201710: Protecting Children’s Environmental Health: A Comprehensive Framework
• APHA Policy Statement< 20137: Improving Health and Wellness through Access to Nature
• APHA Policy Statement 20069: Response to Disasters: Protection of Rescue and Recovery Workers, Volunteers, and Residents Responding to Disasters
• APHA Policy Statement 20093: Food Crises: Addressing the Current Crisis and Preventing the Next One
• APHA Policy Statement 200712: Toward a Healthy Sustainable Food System
• APHA Policy Statement 201711: Public Health Opportunities to Address the Health Effects of Air Pollution
• APHA Policy Statement 200017: Confirming Need for Protective National Health Based Air Quality Standards
• APHA Policy Statement 200012: Reducing the Rising Rates of Asthma
• APHA Policy Statement 20125: The Environmental and Occupational Health Impacts of High-Volume Hydraulic Fracturing of Unconventional Gas Reserves
• APHA Policy Statement 20126: Anticipating and Addressing Sources of Pollution to Preserve Coastal Watersheds, Coastal Waters, and Human Health
• APHA Policy Statement 20147: Preventing Environmental and Occupational Health Effects of Diesel Exhaust
• APHA Policy Statement 20046: Affirming The Necessity of a Secure, Sustainable and Health Protective Energy Policy
• APHA Policy Statement 20099: Improving Health Through Transportation and Land-Use Policies

Problem Statement

The world’s authoritative body on climate change, the Intergovernmental Panel on Climate Change (IPCC), defines this threat as “a change in the state of the climate that can be identified [statistically] by changes in the mean and/or the variability of its properties and that persists for an extended period, typically decades or longer.”[1] The IPCC affirms that warming of the climate system is unequivocal: the atmosphere and oceans have warmed, snow and ice have diminished, and sea levels have risen.[1] The panel further concludes that virtually all such warming since the mid-1800s is the result of human activities.[2]

Despite ratification (formal consent or adoption) of the 2015 Paris Agreement on Climate Change[3] by 187 countries (including the United States) to help slow global warming to no more than 1.5 C by the end of the 21st century, concentrations of greenhouse gases in the atmosphere have reached new highs.[4] Preliminary data for 2018 show that these gases have continued to rise and are linked to changes in the Earth’s climate, including increases in atmospheric and oceanic warming, ocean acidification, and rising sea levels.[4] The years 2015 through 2018 constituted the four hottest on record, and the highest ocean temperatures on record were reported in 2017–2018.[4] Ocean acidification is increasing due to the ocean absorbing more carbon dioxide from the atmosphere (causing stress on marine life), and sea levels are rising as a result of thermal expansion of warming oceans and unprecedented melting of glaciers and ice sheets.[4] Natural disasters and climate-related events—hurricanes, typhoons, tsunamis, droughts, wildfires, floods, and extreme heat—increased by an estimated 46% between 2000 and 2017[4] and continued to be prevalent in 2018. Examples include the 2017 hurricane season in the United States and the Caribbean and, in 2018, the Pacific typhoon season; prolonged droughts in California, the southwestern region of the United States, and parts of Europe and Africa; severe flooding in regions around the world; and unprecedented heat waves in Japan and Europe. Climatic changes were also associated with unprecedented wildfire severities in California during 2017–2018, Spain and Portugal in 2017, and Sweden and Greece in 2018.[5,6]

Although impacts of climate change and climate-related events are present globally, climate change most severely affects groups already vulnerable due to geography, poverty, age, gender, indigenous status, migration status,[7–10] preexisting environmental conditions (e.g., unhealthy air, water, and living conditions and weak emergency preparedness),[7–10] physical disabilities, and/or preexisting health, mental health, and/or substance use disorders.[5,7–10] Professionals who address the immediate and longer-term effects of climate change (e.g., first responders, journalists, health care workers) are also more vulnerable.[9–12] Women (and especially widows) are often more emotionally affected than men after a climate change event, partly due to increased stress brought on by expanded responsibilities such as providing increased caregiving for children and elderly parents, assuming traditional male responsibilities, facing financial hardships, and defending against violence (e.g., in relocation camps).[9,10,13,14] Men may struggle with feelings of guilt, inadequacy, and stigma associated with their inability to work and provide for their family after a climate-related event. Communities located in ecologically sensitive areas (e.g., areas that lack water or are vulnerable to sea level rise, storm surges, and/or melting sea ice) are often the least able to prepare for, respond to, and fully recover from extreme climate-related events.[5,8,10,15,16]

Climate change and climate-related events are associated with a wide scope of impacts that affect human well-being, or the satisfaction people feel with life when they are functioning effectively and when their psychological, emotional, economic, and social needs are being met in positive ways.[17] Such impacts can be (1) social and economic (e.g., border displacement, migration, and/or homelessness; water shortages; hunger or malnutrition; impoverishment or unemployment; increased levels of conflict, hostility, intergroup aggression or violence, or crime; and loss of social cohesion),[5,8,9,16,18] (2) emotional (e.g., psychosocial distress, grief, depression, feelings of helplessness and fear, and survivor guilt; development of mental health and/or substance use disorders; recovery fatigue; and loss of social support structures),[8,9,16] (3) cognitive (e.g., confusion, lack of concentration, and memory loss), or (4) behavioral (e.g., loss of a sense of control, nightmares, disruption of eating and/or sleeping, changes in sexual activity, and dysfunctional behavior due to impaired cognitive development, especially among children).[8,9,19] Climate change and climate-related events can also result in altered effectiveness of psychiatric medications,[8] spiritual distress (e.g., loss of faith or meaning of life, feelings of fatalism), and death or suicide.[8,9]

The World Health Organization (WHO) estimates that between 20% and 40% of populations affected by natural disasters will experience mild psychological distress, and 30% to 50% will experience moderate to severe psychological distress.[20] While support from family, friends, and communities makes recovery possible for many, others need professional help. For example, in the United States, 49% of Hurricane Katrina survivors in New Orleans developed an anxiety or mood disorder, one in six people developed posttraumatic stress disorder (PTSD), and reports of suicidal ideation and suicide more than doubled.[21] After Hurricane Sandy in New York City and New Jersey, high levels of depression, anxiety, and PTSD were recorded in the short term, and high levels of psychological trauma were still experienced four years later.[22] Similar results were observed in Houston, Texas, after Hurricane Harvey.[23] Widespread psychological trauma continues to be reported after Hurricane Maria in Puerto Rico, with the suicide rate continuing to rise in 2019.[24]

A systematic review of literature published between 1994 and 2014 revealed consistent evidence across both developing and developed countries that flooding has led to increased rates of PTSD, anxiety, depression, and use of psychotropic medication.[25] Studies on the effects of heat waves have documented many negative outcomes, including heightened mortality and morbidity among people with mental health disorders,[8,9,16,26] altered effectiveness of psychiatric medications,[8,26] a rise in homicide rates,[9,18] increases in suicide and violence,[9,18,26,27] and an increased risk for hospitalization and death among individuals with dementia.[9,26] Poor air quality (which often accompanies higher ambient temperatures) has been linked to increased rates of childhood depression and anxiety and reduced functioning among people with Alzheimer’s disease, Parkinson’s disease, amyotrophic lateral sclerosis, and autism.[8,19,28] Evidence across continents suggests that droughts in rural communities place farmers (especially male farmers) at risk for high rates of depression and suicide.[29] Research on the 2017–2018 California wildfires suggests that effects on mental health and well-being were similar to those arising from other extreme weather events.[30]

These impacts on mental health and well-being are considerable when placed in the context of the general burden of mental health conditions. Globally, mental health conditions are the leading causes of increased years lived with disability and (together with cardiovascular and circulatory diseases) disability-adjusted life-years.[31] WHO estimates that one in four individuals will experience a mental health condition during their lifetime.[32] Yet, a major gap exists because fewer than one third of people in need will receive professional help.[32] In developing countries, WHO estimates this treatment gap to be about 75%.[32] In the United States, 44.7 million adults (one in six overall) live with a mental health disorder, but only 19.2 million (43.1% of those in need) receive mental health services.[33]

Spending and investment in mental health services are not proportional to the existing and projected burden of mental health disorders. Currently, the global economic cost of mental health disorders is estimated at $2.5 trillion, and this figure is expected to double by 2030.[34] Globally, public expenditures on mental health average $2.50 per capita, with a low of $0.02 per capita in low-income countries and a high of $80.24 in high-income countries.[35] In addition, the mental health workforce averages nine workers per 100,000 population globally, with 1.6 workers per 100,000 population in low-income countries and 71.7 workers per 100,000 population in high-income countries.[35] These numbers show that an adequate workforce is critical to future spending determinations and service provision for the underserved.

Examples of global and U.S. efforts to encourage building service system infrastructure and capacity to better meet mental health and substance use needs in general, and specifically with regard to climate change, include the United Nations 2030 Agenda for Sustainable Development,[36] the United Nations Universal Health Coverage Political Declaration,[37] the Astana Declaration on Primary Health Care,[38] the WHO Comprehensive Mental Health Action Plan (and related initiatives),[32,39] health care reform in the United States (via the Affordable Care Act and the Mental Health and Parity and Addictions Equity Act),[40] and new financial investments for action to combat climate change by global institutions such as the World Bank (which has pledged $200 billion to do so in 2021–2025).[41]

Despite the documented negative effects of climate change on mental health and well-being, many people demonstrate remarkable resilience and even may experience “posttraumatic growth,” namely increased confidence in coping, closeness and connection with others, and the capacity to develop new meaning or hope.[42] This policy statement is intended to motivate the prioritization and implementation of actions that can further facilitate positive mental health and well-being outcomes as related to climate change and climate-related events. Because a large part of this motivation is intertwined with the complex politics surrounding climate change,[43] this statement is also intended to help facilitate the positive political will needed to reach such outcomes.

Evidence-Based Strategies to Address the Problem

The science of climate-informed mental health continues to evolve. While no universally recognized body of literature on “best or evidence-based practices” exists to date, five tenets guide the quest to formally establish and expand strategies, practices, policies, and actions that can successfully combat the negative effects of climate change and climate-related events on mental health and well-being. First, there is considerable evidence that climate change and climate-related events impact mental health. Second, there is broad agreement that interventions and evaluations should target multiple levels (primary, secondary, and tertiary) of public health concerns, including the development and sustainability of resilience and posttraumatic growth.[8,9,44,45] Third, there is a considerable need to expand research and regularly implement tools that (1) provide evidence-based support for climate-informed planning of mental health services, especially in emergency, high-risk, and low resource settings and in the context of global and U.S. health care reforms[32,35,38,40,46,47]; (2) help predict those who are at high risk and vulnerable to effects of climate change and climate-related events (through efforts such as the United States Global Change Research Program) via mental health–specific indicators[8,10,46–48]; (3) help assess the effectiveness of preevent and postevent mental health interventions across settings and cultures[46,48] using instruments such as the Psychological Preparedness for Natural Disasters scale[49]; and (4) measure the impacts of climate adaptation on mental health.[50]

Fourth, a combination of frameworks and research that are ecological (e.g., at the individual, interpersonal, organizational, community, and policy levels) and multidisciplinary (e.g., mental health, health, public health, neuroscience, environmental studies, ecopsychology, ethics, social policy and planning, disaster risk reduction, workforce development, health promotion) is needed to compassionately, scientifically, and all-inclusively plan for and address the negative effects of climate change and climate-related events on mental health and well-being.[51] Finally, better strategies are needed to support and train professionals and paraprofessionals who help others deal with the effects of climate change and climate-related events on mental health,[52,53] including the mental health and physical effects they may experience.[11,12] For example, workers who receive preexposure disaster mental health training experience lower levels of PTSD and are better positioned to provide compassionate support to survivors.[54]

Professionals, paraprofessionals, volunteers, and students can benefit from becoming more climate informed so that they can better integrate projections about future mental health demands emanating from climate change into planning, capacity-building, and service needs.[8,16] The description that follows highlights some of the most promising and established strategies from (1) peer-reviewed articles and other types of research reports and (2) plans and initiatives developed and adopted by well-respected global and U.S. governmental authorities and policy- and consensus-building bodies.

Primary interventions are designed to help prevent and/or reduce exposure to climate-related risks that could have a negative impact on mental health and well-being. Three types of primary interventions are key: those that focus on environmental issues, those that focus on inequities and social injustices, and those that are mental health specific. Environmental approaches include reducing greenhouse gas emissions,[5] facilitating people’s engagement with nature[5,8,55] and climate action,[8] reducing exposures to construction in high-risk zones,[5,8] and climate-proofing property. People who engage with nature[55,56] and/or climate action[11] have been shown to experience “active hope,” which helps facilitate resilience and promote self-efficacy.[16] Green spaces have also been shown to facilitate development of social support and social cohesion within communities, factors that support positive mental health and psychosocial resilience.[8]

Primary interventions that focus on equity and social justice include addressing environmental, social, and health inequities (e.g., poverty and racism); strengthening social cohesion in vulnerable communities; monitoring the implementation of guidelines by local U.S. health departments that target health inequities,[8,11,51,57] and supporting tools that involve communities in solution building, such as participatory research methods.[58] Typically, communities characterized by inequity are not considered to be strongly resilient.[8] Interventions designed to redress inequities (e.g., lack of affordable housing and economic opportunities) and social injustices (e.g., fragmented or nonexistent community infrastructure and services) before climate-associated events occur have been shown to increase psychosocial resilience[8,59] and recovery[44] following such events. Strengthening social cohesion and social support helped promote recovery from trauma after Hurricane Katrina,[60] the 2003 French heat wave,[61,62] and the 2007 flooding event in the United Kingdom.[63] Also, participating in group interventions has been shown to reduce symptoms of anxiety associated with experiencing climate-related events.[51]

Successful primary interventions that are mental health specific include disseminating accurate information about potential climate change effects on mental health and well-being, encouraging self-help activities, and expanding service system capacity to target a variety of cultural needs[64,65]; addressing underlying risk factors contributing to vulnerability to climate change effects[8,16]; increasing training to raise awareness about mental health impacts and reduced stigma associated with experiencing climate change effects[8,16]; and building competencies to address the effects of climate change on multiple life dimensions.[8,16] Interventions that help develop psychological preparedness prior to a traumatic event (such as a climate event) result in fewer negative mental health and psychosocial outcomes, higher levels of situational preparedness, and reduced psychosocial stress.[8,44,45]

Secondary interventions are delivered immediately or shortly after a climate-related event to help prevent or limit the impact on mental health symptoms and to facilitate restoration of well-being as quickly as possible. Examples of successful approaches include delivering psychological first aid[16,64,65]; addressing mental health symptoms and/or disorders in community respite shelters, recreation centers, and drop-in centers[66]; delivering trauma-informed individual and group-based therapy, cognitive-behavioral therapy, stress inoculation training, and crisis counseling[16]; minimizing stress with respect to meeting basic needs by providing situation-specific support such as food, shelter/housing, postevent insurance and assistance with claim processing, relocation assistance, employment, and income[66–68]; planning and delivering comprehensive mental health and other support services during climate-related emergencies[65]; and providing services wherever people congregate, such as in emergency shelters, religious centers, and formal social service settings.[16] Tertiary interventions aim to help people manage more serious and longer-term mental health and well-being issues by engaging in longer-term professional mental health and/or substance use treatment.[68]

Reducing the negative mental health impacts following climate events often depends on how those affected can develop, enhance, and utilize personal resilience (the set of beliefs, attitudes, and behaviors that carry people through difficult times).[8,59] This resilience develops in the context of sociocultural and organizational networks[8,69] and can be cultivated by teaching coping skills, strengthening self-efficacy, and building cohesion and social support across communities.[8,16,42,69,70] Family social support has been shown to be critical in fostering resilience and postevent recovery among children and youth.[8] In addition, anniversary group interventions after a climate change event decrease lingering emotional symptoms.[71]

Several global and U.S.-based initiatives hold promise to better meet mental health and other support needs related to climate change and climate-related events. Globally, the United Nations 2030 Agenda for Sustainable Development (adopted by all UN member states in 2015, including the United States) incorporates 17 Sustainable Development Goals (SDGs) and 169 targets that governments pledge to achieve by 2030. These SDGs and targets include Target 3.4 (promoting mental health and well-being), Target 3.8 (achieving universal health coverage), and Goal 13 (taking urgent action to combat climate change and its impacts).[36] The Sendai Framework for Disaster Risk Reduction 2015–2030 describes the roles of national governments and other stakeholders to reduce disaster risks and losses and to “enhance [the provision of] psychosocial support and mental health services for all people in need.”[72] The Inter-Agency Standing Committee’s Guidelines for Mental Health and Psychosocial Support in Emergency Settings provides a framework for planning and coordinating recovery and rehabilitation interventions addressing the mental health and well-being of individuals in emergency situations.[65] Also, the Global Compact on Safe, Orderly and Regular Migration notes the importance of psychological and other counseling services and psychosocial assistance for migrant and refugee populations, including climate refugees.[73]

In the United States, the Climate and Health Program of the Centers for Disease Control and Prevention (CDC) provides critical guidance, technical support, and funding to prepare and protect the country from the harmful impacts of climate change. State and local health and public health departments are developing climate and health adaptation plans using the CDC’s Building Resilience Against Climate Change (BRACE) model to address mental health and well-being impacts of climate change.[74] Moreover, the American Psychological Association and ecoAmerica have developed evidence-based policy recommendations, including 26 strategies and technical assistance guidelines, to address the impacts of climate change on mental health and motivate action.[8]

This policy statement urges all stakeholders to engage in explicit actions to fully plan for and implement the initiatives, agreements, legislation, programs, and intervention strategies discussed here so that the negative effects of climate change and climate-related events on mental health and well-being can be more fully addressed both around the world and in the United States.

Opposing Arguments/Evidence

Groups continue to emerge around the world and within the United States that question the credibility of climate science, dispute proposed actions to stop the impacts of climate change, openly do not support agreements or legislation that can help decrease threats of climate change to the environment, and/or disseminate information that is often perceived to be controversial. While skepticism is an important and healthy part of science and policy-making,[75] the bases for support, decision making, and service provision regarding any mental health, health, and/or public health need must be grounded in facts, fair-minded values, and actions that can result in appropriately targeted and equitable care.

Climate skeptics who challenge the results of otherwise highly respected climate research, such as that conducted by the IPCC, assert that there is no real consensus among the scientific community about the causes, or even the existence, of climate change.[76] These skeptics include about 27% of Americans.[77] Criticism of the IPCC’s position on climate change is questionable for a few reasons: (1) only 3% to 10% of climate scientists do not agree with the IPCC’s systematic reviews and conclusions[78]; (2) the IPCC’s systematic review of 6,000 scientific studies showed that the window of opportunity to limit global warming by adhering to the 2015 Paris Agreement’s 1.5 C target is rapidly closing[2]; and (3) IPCC reports are overwhelmingly supported by the national academies of science in at least 80 countries, as well as by other scientific bodies, earth scientists, climate researchers, biophysical scientists, and other literature reviews.[78]

Institutes, politically conservative think tanks and their supporters, and authors who disseminate information that supports denialism about climate change dismiss the negative effects it has on the environment and human beings and instead focus on the negative consequences that targeting climate change has on the economy and on business opportunities, processes, and/or innovation.[79,80] Similarly, many corporations both around the world and in the United States ideologically and financially support lobbying efforts against proposed and existing legislation, policies, and regulations that may limit their participation in and profit from activities that may otherwise minimize and/or prevent further negative effects of climate change.[81]

Long-standing value biases and clinical practices that prioritize treating physical health over mental health needs (or ignore mental health) in usual health care instances also contribute to the scope of skepticism about the impacts that climate change has on mental health and well-being. Historically, the treatment of physical health has been prioritized over mental health for a myriad of ideological, political, social, and economic reasons.[2,82,83] While this imbalance is increasingly being recognized and addressed in global (e.g., the Universal Health Coverage Political Declaration[38]) and U.S.-based (e.g., the Affordable Care Act and the Mental Health and Parity Addictions Equity Act[40]) efforts, it still is not standard for physical health and mental health needs to be viewed and addressed equitably. This inequity also applies to approaches taken to address the effects of climate change on health, mental health, and well-being.[8]

For all of these foregoing reasons and others described throughout this policy statement, all stakeholders are urged to begin to engage in and/or further develop dialogues and collaborative actions so that common ground can be reached to more effectively address short- and long-term effects that climate change and climate-related events have on mental health and well-being around the world and in the United States. Furthermore, the well-accepted scientific precautionary principle directs policymakers to fulfill their social responsibility to protect the public from exposure to harm whenever scientific investigation reveals a plausible risk.[84] The information described throughout this policy statement is such an indicator of the negative plausible risks of climate change and climate-related events for mental health and well-being.

Action Steps

APHA urges:

1. Global governments and the U.S. government; policymakers; program developers; service providers; public health, health, mental health, nonprofit, and business organizations; funders; communities at large; educators; researchers; advocates; the media; and all other interested stakeholders in the public and private sectors to prioritize and implement the recommendations of the United Nations 2030 Agenda for Sustainable Development; the Sendai Framework for Disaster Risk Reduction 2015–2030; the Global Compact on Safe, Orderly and Regular Migration; the 2015 Paris Agreement; the United Nations Universal Health Coverage Political Declaration; the Astana Declaration of Primary Care; the World Health Organization Mental Health Action Plan; and the Inter-Agency Standing Committee Guidelines for Mental Health and Psychosocial Support in Emergency Settings to e

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