Elizabeth Haase, MD

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.

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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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Association of black carbon with cognition among children in a prospective birth cohort study

Association of traffic-related air pollution with children’s neurobehavioral function in Quanzhou, China

Effects of prenatal exposure to air pollutants (polycyclic aromatic hydrocarbons) on the development of brain white matter, cognition and behavior in later childhood

Multiple threats to child health from fossil fuel combustion: impacts of air pollution and climate change

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Air pollution, a rising environmental risk factor for cognition, neuroinflammation and neurodegeneration: the clinical impact on children and beyond

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Cerebrospinal fluid biomarkers in highly exposed PM 2.5 urbanites: the risk of Alzheimer and Parkinson diseases in young Mexico City residents

Air pollution and mortality in the Medicare population

Pulmonary health effects of air pollution

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Exposure to particulate air pollution and cognitive decline in older women

Ambient air pollution and neurotoxicity on brain structure: evidence from Women’s Health Initiative Memory Study

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Biomarkers of exposure to polycyclic aromatic hydrocarbons and cognitive function among elderly in the United States (National and Nutritional Examination Survey: 2001-2002)

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Particulate air pollutants, APOE alleles and their contributions to cognitive impairment in older women and to amyloidogenesis in experimental models

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Are noise and air pollution related to the incidence of dementia? A cohort study in London, England

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Dementia prevention, intervention and care

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.

Author | Elizabeth Haase, MD

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