Elizabeth Haase, MD

The American Psychiatric Association (APA) meeting for 2021 was virtual again this year. Was this disappointing, a relief, or both? Disrupted routines offer us the chance to consider alternatives to long-standing traditions and seize new opportunities to change our habits for the better.

One observation about virtual APA meetings is that they have shown us the way to a more sustainable psychiatry. Remote work, decreased travel, and virtual meetings all substantially reduce GHG (greenhouse gases) emissions, and thereby contribute to needed environmental relief. For example, holding the 2020 APA annual meeting virtually saved the GHG equivalent of burning 500 acres of dense forest or 22 million pounds of coal.

 Similar analyses have shown that a single international conference can use as much COe2 (carbon dioxide equivalent) as a whole city for a year.

 We also see firsthand, however, that transferring activities online reduces the quality of interpersonal connection and can contribute to professional stress. Working towards a more sustainable way of living also includes caring for that which sustains us as individuals. We face a puzzle: how might psychiatry proceed with its conferences and maintain human connections while also promoting 

The Ethical Imperative to Alter Annual Conferences

According to current scientific consensus, rapid decarbonization of all activities is required to prevent the worst outcomes of climate change. The Intergovernmental Panel on Climate Change has projected that climate change will have severe mental health effects. These will include the traumas caused by natural disasters, violence, and heat; indirect effects of particulate matter and ozone; eutrophication of the water supply; environmental toxins; and other impacts on human health. Already 

disadvantaged populations will bear the largest brunt

The US healthcare system is responsible for 10% of all GHG emissions.

 While there is little data on the carbon footprint of US psychiatry as a whole, research in the United Kingdom, using national health system data, has documented the GHG emissions from various components of its own behavioral health activities. The largest portion of the carbon footprint comes from buildings and pharmaceuticals. Mitigation efforts there are focusing on avoiding unnecessary pharmaceutical use and waste, shared and smaller office use, and using more social-based and nature-based treatments.

psychiatric practices’ carbon excesses.

 estimated that the US healthcare system’s carbon footprint per year causes between 405,000 and 470,000 disability adjusted life years—about a year of disability for every 2275 visits to the doctor or hospital. If we really seek to do no harm, this is unacceptable hypocrisy in our practice. The APA has asserted its determination to respond to climate change’s health effects in its position statement,

, and its recent formation of a Climate Committee within its structure. As physicians and psychiatrists, we have an ethical obligation not only to participate, but also to lead the way in decarbonization efforts.

Another facet of our ethical duty to act sustainably involves social contagion: the phenomenon of unconscious imitation, deliberate adherence to new norms, and improved ability to behave in ways about which one had been ambivalent, as a result of the modeling of others. Social contagion has important effects on health, as has been demonstrated in obesity.

 In terms of sustainability, social contagion occurs with behaviors like adoption of clean energy technologies.

Decades ago, cigarette advertisements by the tobacco industry that depicted doctors smoking carried implicit, but powerful messages. Eventually cigarette advertisements were banned, and medical organizations vigorously distanced themselves from the tobacco industry. As with smoking, doctors are trusted sources of health-related information on climate change, creating additional ethical implications for our 

 It is likely that it will be easier for other medical organizations to overhaul their conferences if psychiatry has led the way. It will be easier for individual psychiatrists to alter their own practices after national organizations take these steps. And it will be easier for psychiatric patients to engage in sustainability when they see their doctors taking action, and so on. Through these social contagions, sustainable change is likely to occur.

How and Why to Increase Social Interaction in Virtual Conferences

Though we have a clear ethical mandate to mitigate climate change through decarbonization, we must work on both 

 to stressful circumstances. If mitigation efforts decrease our ability to adapt (eg decreasing our well-being and thereby our resilience), then we are not responding to climate change in a way that sustains both planetary needs and our own needs. Mitigation and adaptation, though often discussed separately, are in practice intertwined, and must be addressed together. The reduction of GHG emissions in psychiatry can only be usefully done while addressing the associated changes in work and life that may affect individual and societal resilience.

Another way of understanding this point is the concept of the triple bottom line, wherein effects on the environment, effects on people and society, and effects on financial viability are each considered to represent a bottom line that must be adequately addressed.

 Connection is a foundational component of wellbeing and resilience. So, we have to ask, “How are online activities affecting our human connections?”

From the perspective of knowledge acquisition, 2-way exchange promotes learning,

 with some aspects (eg asking questions) actually improved online.

 Perhaps the most difficult component of a conference to simulate in the virtual setting is the social networking experience. Over 80% of APA conference attendees value networking opportunities, as well as the opportunity to collaborate and understand new science, technologies, healthcare opportunities, and treatments, according to the unpublished Annual Meeting 2019 survey. This reflects widespread experience in other sectors. A recent study conducted by the International Marine Conservation Congresses (IMCCs) surveyed 100 participants at 2 of their conferences.﻿One of the major takeaways from this survey was that respondents generally felt that networking, communication, and brainstorming are more successful when done in person.

 Networking is also a common concern in the business sector, with 85% of 

 indicating that they build stronger and more meaningful business relationships at in-person conferences.

 Many of the papers cited particularly mention chance social interactions that have a more spontaneous, intimate, and creative quality than other professional exchanges. Perhaps the greatest difficulty with virtual meetings comes from the decrease in spontaneous reciprocal interactions and the shared social exchanges that occur so easily face-to-face, whether in full conversation or impromptu moments of social engagement.

Mechanisms of In-Person vs Virtual Interpersonal Effects

The mechanisms underlying differences between in-person and virtual experiences can be considered in terms of biologic systems, and understandings of presence and mindfulness.

. Redcay and Schilbach provide a useful review of neuroscientific understandings of the mechanisms of social interaction.

 Studies have demonstrated that the mentalizing, mirror neuron, and reward systems are important in dynamic (second-person) social interactions. Through these interpersonal exchanges, studies show that participants build up a shared representation in these neural systems that brings them into conceptual alignment over the course of an interaction. Social interactions have been shown to automatically coordinate synchronous movements, mimicry of facial expressions, and eye contact, and to guide language development and linguistic learning. They have also been shown to promote turn-taking and agreement about what to call things.

Interpersonal interactions have been studied in social interaction science through both second-person and third-person techniques. In a third-person technique, the brain is studied as someone observes a social image such as a video of someone waving. In second-person techniques, there is a social engagement between 2 people, whether real or perceived, that is reciprocal and in real time. This may take the form of an avatar that is gaze responsive, or a live partner in person or by video.

The networks involved in social exchanges are not as activated by third-person (listener or observer) social interactions unless the observer is asked to think about the mental states of the other. When there is greater perception of the other’s responsiveness to oneself in a human way (eg, when an avatar responds with eye movements that are contingent on the participant, but not in perfect alignment), the reward system is engaged in the social exchange to a greater degree. Joint attention, mutual gaze, and motor synchrony have also been shown to be important for such mutual social engagement. Those with larger social networks engage the reward network during joint attention games, while those with smaller social networks engage the mentalizing network more in social exchanges that involve rejection, supporting the idea that interpersonal interaction, whether positive or negative, builds reward responses and mental representations.

From the point of view of social communication science, virtual meetings may bend towards placing the participant in a social observer status, because there are fewer opportunities for mutual social exchange. The ways in which dynamic modes of exchange lead to visual-motor stimulation, behavioral synchronization, activation of language centers, and greater activation of reward networks may provide some explanation for why individuals generally believe live meetings provide greater collaboration and networking.

At the same time, those with different neurological profiles may do worse in the live setting. Many anxious individuals find live conferences overwhelming. A study of adults with autistic spectrum disorder shows hyperconnectivity in social processing areas during spontaneous conversation compared with vocal repetition. For those who may experience unpredictable or spontaneous social interactions as more difficult due to this overload, a remote experience may facilitate engagement.

. In research on social presence, face-to-face communication is found to make contributions to individual well-being and relational closeness.

 Interestingly, video chat is associated with more loneliness and greater difficulty with relationship maintenance than phone call communication. While technical issues that interfere with conversation flow and physical immobility are possible reasons for this, another is that “the heightened cue environment might render what is missing more salient.”

It is undeniable that the sense of presence is different in person than over a computer. In a conference room, our senses are overwhelmed with noise, temperature, smell, the look of the place and the attendees. This occurs in 3 dimensions and in the entire conference room at once: the feel of the carpet or the hard chair; the act of our physical body movement as we are engaged in choosing where to sit or moving across the room; the taste of stale bagels and bad coffee, etc. While this experience can be stressful, it can often be a positive stress. In the actual conference room, we are pulled by our senses to be in the present moment when we walk in. The growing literature on mindfulness, reflected in dialectical behavior therapy, somatic experiencing, and other methods, shows that being in the present moment feels good and helps us navigate challenging feelings and emotions.

 room virtually, we are not pulled into the present moment, nor do our senses snap to attention, making us as alert and present as possible. In our tiny boxes, often with a virtual background, often with our video and audio off, we are present only as a digital marker. Unless we are the speaker, we can surf the web, multitask, and daydream in a way we would be less likely to do if we were attending in person. What kind of individual and collective focus is lost as we participate from our own private cells? If we do put energy into being present, how well can we connect to others on the screen? Even if we decide to focus on one face amidst the scores of faces on the grid, that individual will probably not be directing their attention to us at the same time. Trying to engage in the nonverbal communication dance, likely orchestrated by our mirror neuronal system, probably does not compute in larger group virtual meetings.

How can we connect better in virtual space? Based upon what we know, continued innovation is needed in our use of virtual environments, finding ways for the machine to cue and engage the participant, to add unexpected fun things to being online. Respecting the mirror neuron system, we can create opportunities within the larger meetings for very small meetings. For example, the break times can be expanded to include 10 to 15 minute slots, where 2 participants are randomly assigned to a breakout room and get to know each other a bit. Or, if some resist that amount of spontaneity, the breakout rooms could be arranged in advance, maximum of 4 participants, based on common professional interest, location, or hobbies. Some other efforts to improve upon the virtual networking are including social activities such as virtual Peloton group rides, 

, virtual talent shows, or even karaoke events that can all be conducted remotely.

What is our profession to do? We have a tradition of large in-person conferences that have provided education, networking, collegial bonding, impromptu educational exchanges, a break from the day-to-day work environment, opportunities for new perspectives, and a crucial financial influx for the APA—but it all contributes to 

, the most serious public health offender of our time. How do we maintain and further support the positive aspects of conferences while doing our duty to decarbonize?

An important consideration is the location of conferences. In their analysis, Wortzel et al calculated the optimal location for an APA meeting using a statistical model that plots exactly where the meeting should be to generate the least amount of carbon, even if that point turns out to be a location in the middle of the ocean, as well as an analysis of the carbon footprints of the last 40 APA locations using the demographics of current attendees.

 They found that the Northeastern US is the most environmentally sound place to meet, even accounting for those who must fly cross country to be there. Emissions can be reduced over two-thirds if meetings are held in this corridor, easily fulfilling the level of emissions rollbacks suggested by the Paris Accord.

However, this solution has its drawbacks. Even with an optimal location, non-US attendees at the APA conference must generate significant emissions to attend in person. Clearly, we must get away from a one-size-fits-all way of thinking and be innovative. A virtual option can help mitigate this concern. It may become unsustainable for western US psychiatrists to come to the meeting if they must fly 5 times further than their peers, so accommodations in terms of carbon offsets, reduced meeting costs for this group, and intermittent meetings might meet the needs of all.

As travel is the largest carbon emission component of conferences, an additional solution is the use of more regional conferences. These would provide all the advantages of in-person interactions—social collegial contact, networking, impromptu learning—while also drastically reducing the GHG emissions. Perhaps these conferences could have something of a hybrid model, with big name speakers being virtually included. These multiple conferences might even benefit the APA financially, and may even attract more participants, if they can be made sufficiently attractive.

Another possibility is buying carbon offsets, whereby air flights are offset with financial contributions to other sustainability activities such as planting trees. But the purchasing of such offsets would not reap the benefits of behavioral contagion. We would still be setting the problematic example of routinely flying to distant cities for conferences. If we only undertake the buying of offsets without further evaluating our systems of behavior, we would be turning a blind eye to the extent of the problem and the need for extensive systems change.

The decarbonization of psychiatry cannot be delayed. At the same time, we have responsibilities to do this in ways that preserve or even strengthen the interpersonal and professional connections that are so necessary for individual health, group cohesion, and individual and collective resilience. In order to meet these obligations, we must deepen our understandings of bonding, of coregulation, and of shared purpose, particularly as applied to our uses of remote and in-person activities. Holding a 

 perspective, we are called to focus both on mitigation (reducing GHG) and on healthy adaptation (strengthening connections). Understanding this can help us to innovate means of preserving and strengthening the most important aspects of our activities while accepting the challenge of psychiatry’s decarbonization.

is clinical assistant professor in the Department of Psychiatry at the University of Rochester, NY, and in private practice in Penn Yan and Ithaca, NY.

is a staff psychiatrist at the Counseling and Psychological Services of the University of Pennsylvania, and has a Masters of Environmental Studies from the University of Pennsylvania; she is on the Steering Committee of the Climate Psychiatry Alliance.

is associate professor of psychiatry at the University of Nevada School of Medicine at Reno and acts as medical director at Carson Tahoe Health, Outpatient Behavioral Health Services.

is a medical student at the University of Pennsylvania School of Medicine.

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The Triple Bottom Line: Does It All Add Up

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Articles

How can psychiatry meet its ethical duty to mitigate climate change while also promoting collegiality at conferences?

Fostering Human Connection in a Sustainable Virtual World

COMMENTARY: FROM THE GROUP FOR THE ADVANCEMENT OF PSYCHIATRY CLIMATE COMMITTEE

As we prepare for the second online annual meeting of the 

, it is a safe bet that few of us are thinking how wonderful it is to stay at home. While online conferences have much to offer, many of us miss the collegial interactions and invigorating break from office routine.

At the same time, we have become accustomed to the efficiency of online meetings—the decreased time and cost of travel, the comforts of controlling what others see and do not see, and the chance to spend more time with family. The environmental benefits of online meetings are also enormous. Large conferences can 

 the carbon dioxide equivalent (CO2e) emissions of an entire city in a single week.

 on the carbon footprint of APA meetings, we found that by holding its 2020 Philadelphia meeting online, the APA saved roughly 20,000 metric tons CO2e emissions—the equivalent of burning 22 million pounds of coal or 500 acres of dense forest.

Psychiatrists increasingly appreciate the costs of this carbon. Climate change affects mental health in a myriad of ways, through temperature changes that 

 pharmaceutical safety and neurophysiology,

 existential stressors and eco-anxiety in a whole generation of young individuals, and climate-related traumas from forest fires to coastal flooding.

 Some of us are also aware of the degree to which we, the health care system, are the problem. American health care generates more greenhouse gases than many countries, and it 

 more than 400,000 disability-adjusted life-years annually.

 The APA has wisely recognized climate change as a top priority,

 and our response must be to reduce our carbon emissions—as well as respond to the damage they cause—bringing our practice in line with international goals for sustainability.

But sustainability is more than just cutting carbon emissions. Sustainability means creating a system where all of us can thrive—plants, animals, humans, and planet. This requires adequate financial resources, social justice, and social connectivity, while also decreasing the destruction of our planetary home. As we prepare for this second online meeting, it is an opportunity to reflect: Where can psychiatry become more sustainable? What can online meetings accomplish? What parts of in-person contact are important to retain, and how?

During our panel discussion, “The Carbon Footprint of Cancelling the APA, a Virtual Match, and More: Impacts of Psychiatric Activity on Global Warming and How to Respond,” we will explore these issues, presenting research on the carbon footprint of residency interview travel by Daniel Brooks Bernstein and our research on the APA’s carbon footprint. We found that the carbon footprint of APA meetings may vary 3-fold by location in the United States, with northeastern locations optimally minimizing the aggregate 

. We also analyzed how the APA’s carbon footprint would change with different kinds of meetings—regional, online, and so on. For example, we have found that regional meetings could cut carbon emissions by 24% to 53%, and as much as 85% to 86% if nonregional attendees participated online.

Bernstein, a Stanford medical student, found that each of his classmates generated an average of 12,331 pounds of CO2 to complete their residency interviews, with 1 candidate generating as much as 44,000 pounds of CO2. Surely some of these flights are unnecessary to the development of these gifted doctors, especially given the climate and health costs of their travel.

Professional meetings are crucial for socialization, networking, mentoring, and learning. The casual conversations and meals that surround the program are important for the development of a professional identity and lead to creative advancement in clinical practice, research, and policy. Psychiatry especially prizes sustaining connections. But, in truth, many of our assumptions about what binds us to each other have been challenged by the ways we interact now through social media, telecommunications, and our recent rapid adjustment to telepsychiatry. The APA could achieve emissions reductions well within the target of the 

or residency interview procedure, which would help our profession fulfill the Hippocratic Oath to “do no harm.” Using our experiences from the past 2 years, we can find ways to make changes that not only maintain sustainable connections to one another and our patients, but also contribute to the sustainability of our planet.

The panel will also include an overview of the carbon footprint of US health care and a discussion of its sustainable solutions by Todd Sack, MD, FACP, and panel chair Elizabeth Haase, MD. We look forward to sharing ideas and discussing what psychiatry should relinquish and what must be retained as we innovate for new climate-changed realities.

 is a medical student at the University of Pennsylvania School of Medicine. 

is a resident at the University of Rochester School of Medicine. 

 is associate professor of psychiatry at the University of Nevada School of Medicine at Reno and acts as medical director at Carson Tahoe Health, Outpatient Behavioral Health Services.

1. Klöwer M, Hopkins D, Allen M, Higham J. An analysis of ways to decarbonize conference travel . . . 

2. Wortzel JR, Stashevsky A, Wortzel JD, et al. 

Estimation of the carbon footprint associated with attendees of the American Psychiatric Association annual meeting

3. Wortzel J, Haase E. The effects of rising global temperatures on mental health. 

https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2020.4b24

4. Hayes K, Blashki G, Wiseman J, et al. Climate change and mental health: risks, impacts and priority actions. 

Environmental impacts of the U.S. health care system and effects on public health

6. Ursano RJ, Morganstein JC, Cooper R. APA official actions: Position statement on mental health and climate change. APA Official Actions. 2017:1.❒

Sustainability is more than just cutting carbon emissions. It means creating a system where all of us can thrive—not just survive.

Can Psychiatry Sustain Connections While Hosting Sustainable Conferences?

By Elizabeth Haase, MD, for the Climate Psychiatry Alliance

All together, right now, no matter what it takes-only this attitude can unite our response to the climate catastrophe that is the imminent consequence of our many small everyday actions. And the APA Assembly seems to know it, rising in near unison to support all action papers addressing climate change at the May 2019 meeting in San Francisco. The action papers ask the APA to review the literature demonstrating climate-specific psychiatric impacts and to perform a study on how climate disruption will change psychiatric service needs in different regions of the United States. They provide for a climate mental health curriculum for residents and medical students, and will provide APA members and leaders with evidence-based conclusions and recommendations for best practices to help patients with climate distress and impacts of heat and fossil fuel pollution on the brain. A final action paper recommends a tool to assist psychiatric practices in creating sustainable policies and procedures.

The Assembly’s bold actions place the APA squarely on the right path to educate a new generation of psychiatrists for sustainable psychiatry and prepare them for coming climate mental health challenges. As recent studies demonstrate, their action comes just in time to respond to increases in suicide that will counterbalance the positive influence of “all existing suicide prevention programs” (Burke, 2018) and double rates of dementia (Cacciottolo, 2017), among other critical impacts.

Joint Reference Committee 2 moved the papers, under Chair Dr Mary Ann Schaepper, who voiced her excitement to “lead forward on climate change and mental health,” noting, “My sister, an environmental activist, is proud of me!” Younger members of JRC2 helped articulate the urgent need for action. Dr Jorien Breur made it clear that “the mental health consequences of climate change are occurring here and now.” Dr Hector Colon-Rivera, APA Hispanic Caucus President, spoke to the importance of “a well-structured public health system to address these effects” in supporting an action paper asking for climate service-need research. He continued, “Our field of psychiatry should move forward with strategies that could bring resilience as well as reduce inequities for our patients. There is a need to mainstream research efforts on climate change in order to systematically collect data on adverse effects of climate change on mental health.”

Members of the Climate Psychiatry Alliance, a group that has been working for several years on how psychiatry can respond to climate disruption, collaborated with members of the Assembly in the writing of these action papers. The CPA group also led 13 presentations at the meeting, addressing everything from the latest translational psychiatry research on how air pollution damages neuronal function to the uses of nature in psychiatric treatment.

CPA members kicked off the APA meeting with an 8 AM presentation Saturday morning, “Climate 101,” led by Chair Dr Anne Richardson. In other presentations, Dr J. C. Chen of USC reviewed the epidemiological evidence connecting greenhouse gases and dementia. Dr Pamela Lein from UC Davis showed preliminary results on microglial activation with exposure to traffic-based pollution. Dr Lise Van Susteren played the sounds of birds and rain to relax an overflow crowd in a panel on incorporating nature into psychiatric practice. Small groups then engaged in enthusiastic brainstorming and shared the ways they might incorporate nature-based practices into their work. Drs Janet Lewis and Elizabeth Haase explored theoretical and technical approaches to working psychotherapeutically with the extreme emotions generated by the existential threats of climate. Dr CabÃ¡n-AlemÃ¡n gave a lecture showing how climate change interacts with social determinants of mental health such as poverty, systemic oppression, and structural racism, particularly as manifest in Puerto Rico after Hurricane Maria. Along the way, Drs Alex Trope, David Pollack, and Robin Cooper and many international experts from outside psychiatry led panels on ways the APA can innovate and advocate for a more sustainable path, including panels on Refugees, Sustainable Psychiatry and a healing path for “Good Enough Mother Earth.”

Building on the meeting theme “Revitalizing Psychiatry: Disrupt, Include, Engage and Innovate,” the meetings gave opportunities for groups and caucuses with shared concern for the environment, climate change, equity, and justice to build alliances and begin longer conversations. As the United States stalls on climate action despite the hundreds of billions of dollars already lost to climate disruptions in weather and food supplies for our great nation, these actions are a much needed part of a program forward, one based on science and sane concern for the welfare of our children.

All together, right now, no matter what it takes-only this attitude can unite our response to the climate catastrophe that is the imminent consequence of our many small everyday actions.

It Takes a Village to Take Care of a Planet

 moved at the speed of a “football field per second.” Visiting San Francisco (ironically, to hear my beautiful daughter present her environmental research at an academic meeting), I could avoid air quality in the “hazardous” range by at most 30% by staying indoors. But we could not hike together or have a cafÃ© lunch without burning pain in our heads, skin, and lungs. Day after day, the air remained an ugly yellow-grey, thick with air pollution particles.

The particles that make up air pollution are organized by size, from ultrafine particles (UFPs) 1 micron in diameter to PM 2.5 and PM 10, which are 25 and 100 times larger, respectively. They share a similar structure: various (poly) circular (aromatic) hydrocarbons (PAHs) with a high surface charge bind to a core of organic carbon-the carbon naturally in the air-that attracts heavy me- tal ions and oxidative elements, which allows them to aggregate into the particles of various sizes (

Ultrafine particles and PM 2.5’s enter the brain by mechanisms that include vascular uptake and transport across the blood-brain barrier and retrograde neuronal transport similar to the herpes virus, along both pulmonary nerves that track to the vagal system and through the olfactory bulb. Ultrafine particles can penetrate the cell nucleus, causing both epigenetic changes and oxidatative damage.

Studies of the effects of these air pollution particles show dramatic effects across the lifespan, including impaired fetal growth in utero and smaller head circumference at birth, decreased scores for verbal and nonverbal intelligence, memory restriction, and poor performance on tests of visual reaction time, pursuit aiming, and others by ages 8 to 11 years.

There are associations with a wide range of developmental disorders including autism, ADHD, learning disorders and other disorders of child behavior.

 and her colleagues studied infants born near high-polluting coal plants in Beijing, Krakow, and New York.

 Their work demonstrated that these babies had developmental delay, lower IQs, more anxiety, depression, and inattention, and reduced brain white matter, all of which correlated with levels of PAH-DNA.

In parallel to Perera’s work on the topic, 

 noting that dogs in Mexico City developed dementia-like behaviors at an early age, began a series of autopsy studies of children killed in traffic accidents in Mexico City and compared them with children who died in less polluted areas. Their findings indicate a wide variety of neuropathological changes similar to those seen in Alzheimer disease.

, her group found that compared with children from clean air environments children in Mexico City exhibit systemic and brain inflammation and low cerebrospinal fluid AÎ²1-42 as well as the breakdown of nasal, olfactory, alveolar-capillary, duodenal, and blood-brain barriers.

 Volumetric and metabolic brain changes, attention and short-term memory deficits, and hallmarks of Alzheimer and Parkinson disease were also seen.

Using transmission electron microscopy, the researchers documented UFPs-strongly magnetic combustion-derived nanoparticles (CDNPs)-present in the neurons, glia, choroid plexus, and neurovascular units of young Mexico City residents compared with matched clean air controls. CDNPs were associated with pathology in mitochondria, endoplasmic reticulum, mitochondria-endoplasmic reticulum contacts (MERCs), axons, and dendrites. The researchers concluded that “exposed children and young adults need early neuroprotection and multidisciplinary prevention efforts to modify the course of Alzheimer disease at early stages.”

With the frequent fires and increasing carbon in the air, many American adults now also have urgent questions for their doctors about how air pollution may be affecting their health, and for their psychiatrists, their brains. Fortunately, there is a beautifully curated and frequently updated source for all the articles documenting these effects, run by 

Utah Physicians for a Healthy Environment

The systemic inflammatory reaction to air pollution is similar to that of cigarette smoke and raises mortality at any level of the air pollution index, even those rated acceptable by the EPA.

 Air pollution increases the risk for pulmonary illnesses, particularly asthma and COPD.

 Moreover, it is associated with stroke and myocardial infarction; cancers such as brain, breast, lung, prostate, stomach, and childhood leukemia; and other physical illness.

Increasingly, the psychological stress of being unable to escape exposure to air pollution contributes to morbidity. The total mortality burden of particle and ozone pollution is estimated at 5.5 million premature deaths per year.

 In the US, the cost of air pollution damage has been estimated at $131 billion per year, most due to health effects, and would be expected to climb this year.

The link between air pollution and dementia is similarly dire, with further evidence of impact found in several large studies published in 2017 and 2018. Previous studies have established strong associations between air pollution exposure and cognitive decline in older adults. 

 assessed the rate of cognitive decline in 19,409 women. Serial assessments were done every 2 years over 7 years. For every 10-point increase in EPA air quality score, there was a .02 point decline on global cognitive score. While this may not sound calamitous, this difference is equivalent to 2-years’ increase in age.

Given that many locations are regularly experiencing increases in particle count that are 5 to 20 times higher than this, one might extrapolate to 1- to 4-point drops in global cognitive scoring every 6 years in several affected areas, if this linear relationship were to hold. Using MRI studies and data from EPA monitoring sites, 

 looked at 1403 women aged 71 to 89 years. The researchers found that independent of clinical characteristics, region, lifestyle, and demographics, those in each incrementally higher quartile of cumulative PM 2.5 exposure over 10 years lacked an additional 6.63 cubic centimeters of brain compared with controls, equivalent to 2 degrees of aging.

 found that digital symbol substitution test (DSST) scores in 1764 elderly adults declined 1.8% for every 1% increase in urinary 1-hydroxypyrene, a gold standard for PAH exposure. This study controlled for alcohol and tobacco use, medications and medical conditions, and exercise. This study is also notable because both DSST and urinary PAH are acute measures that vary within a single day, highlighting the potential for population-wide acute cognitive impairment when air pollution worsens suddenly, as it does with large fires.

 completed a large study, this time with a translational arm. They looked at cognitive decline in older women in the 

 Study exposed to the top quartile of PM 2.5 particulates for the 3 years. The risk of global cognitive decline and all-cause dementia was 81% and 92% higher, respectively, in those women with top PM 2.5 exposure. This risk rose to the remarkably high hazard ratios of 3.95 for cognitive decline and 2.95 for all-cause dementia for women carrying ApoE 4/4 alleles.

Most recently, in the more naturalistic setting of looking at records of primary care practices in London, 

 found a 40% increase in incident diagnoses of dementia associated with top quartile nitrogen dioxide and PM 2.5 concentrations. This cohort study looked at 130,978 adults aged 50 to 79 years where a new diagnosis of dementia was noted between 2005 and 2013.

Comparable risk factors for dementia include lower education, hearing loss, isolation, depression, hypertension, diabetes, obesity, smoking, and inactivity (

 Air pollution is bad for your brain to this level of significance. How can it be that many psychiatrists do not routinely educate patients about this, let alone work with them on strategies to participate in the reduction of air pollution in their homes, their communities, and their country?

Patients should know about the importance of air pollution for the brain. They can learn to track local air quality levels through sites such as 

 shows air pollution data through color-coded maps and the air quality index (AQI). 

 is a website promoting the sale of air quality sensors, but posts air quality results for those willing to register their devices on a dynamic map in real time. Patients may also be advised, particularly if they have respiratory illness or live in a high-risk area, to purchase an air purifier capable of filtering small air particles (reviewed here: 

https://thewirecutter.com/reviews/best-air-purifier/

At a professional level, we must advocate for clean air policies that reduce fossil fuel combustion as avidly as we work for smoking cessation. While it can be harder to conceptualize one’s oil heater as a toxin comparable to a cigarette, we must find ways to connect these dots in our own minds and in those of our patients, so that the mental image associated with the word “inhale” is as closely connected to fossil fuel use as to the puff of smoke at the end of a cigarette. These conceptual changes can be difficult to make but are facilitated by concrete visible measures such as tracking AQI data in one’s home. Such measures shift awareness and begin a process of reflection that precedes personal change.

Air pollution is inextricably linked to climate change, which is the result of fossil fuel combustion and the cause of temperature and wind and weather changes that make large fires ever more likely. We cannot protect our patients without protecting our planet. This means a personal and professional commitment to green our activities by considering the carbon effects of how we do our work. We can reduce the carbon footprint of our inpatient units, through smaller units, efficiencies of staff transport, and other measures. We can consider alternatives when we use medications with particularly large carbon footprints or changing medications often. We can lessen the distance and frequency of travel both for ourselves and for our patients by living close to our work sites and by taking ourselves to rural settings rather than having each patient come to us. We can bring our personal and our profession’s financial practices in line with this awareness, divesting of assets that worsen patient health in direct and significant ways.

Dr Haase is Associate Professor of Psychiatry, University of Nevada School of Medicine at Reno, and Medical Director, Carson Tahoe Outpatient Behavioral Health.

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We cannot protect our patients without protecting our planet. This means a personal and professional commitment to green our activities by considering the carbon effects of how we do our work.

Elizabeth Haase, MD

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