In Summer, Always Ask

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CLINICAL REFLECTIONS

America was baking in the summer of 2024. Where I practice in the Washington, DC, region, we had our hottest summer, with the temperature exceeding 100 °F for more than 6 days. Many more days reached 100 degrees or higher on the heat index. Unfortunately, data points to increasingly hot daily highs (Figure).

FIGURE. Area of the Contiguous 48 States With Unusually Hot Summer Temperatures, 1910-2023

Last summer, an older female patient came to see me. She had received a diagnosis of schizophrenia and has been stable on clozapine for years. Her older brother regularly brings her to her appointments; that visit was on the hottest day of the summer. She looked weak, tired, and unsteady, and she was holding her stomach as if she was experiencing mild cramping. Some water helped.

Older adults with schizophrenia on antipsychotics are known to be at the highest mortality risk in heat waves. I asked my patient and her brother how they were coping with the heat. He said, “It has been terrible. I sweat all night long. She will not run the air conditioner in her bedroom.”

Alarmed, I asked, “Is there air conditioning in the rest of the house?”

He said, “No, my air conditioner makes too much noise, so I cannot use it. If I keep it on, I cannot sleep at night. I just use the fan. My sister will not even let me turn her AC on.”

That day, the heat index was projected to be more than 105 °F. I asked if there were trees in the neighborhood near their house. He said, “Not really.”

Many individuals with serious mental illness live in impoverished areas where the tree cover is scant, if any, and housing is substandard. Further, their body heat regulation is less effective due to some medications, including antipsychotics and anticholinergics. Patients with schizophrenia sometimes have thermo-perception dysfunction and feel cold when it is hot, and thus they dress in layers. Let us not forget the comorbid medical conditions in this cohort: hypertension, diabetes, and cardiovascular and respiratory diseases. I immediately became concerned about my patient.

Educating Patients and Their Caregivers

I told my patient and her brother that heat waves are silent killers. Extreme heat can make a person sick quickly. I told them about a man in Phoenix, Arizona, who wandered away from his family and was missing for 2 hours in 115 °F heat. When he was finally found on the ground in a nearby field, he was deceased.¹

The brother was shocked, as he had not understood the dangers and consequences of the heat. “She even tries to go out walking in the day wearing extra clothes and will not stay indoors,” he added. Clearly, the situation was desperate; she must not be wandering away from their house. If she did, she would soon perish, just like the man in Phoenix.

I further explained: “The body cannot cool itself well in the heat, and when you are too hot, you get extremely sick. If she goes out in the sun, it is even hotter than the weathercaster says by 10 or 15 °F. Especially in more clothes, she cannot survive that. Whatever it takes, you must prevent her from going outdoors. If she does not listen to you and goes outdoors, you must call for emergency services, such as 911. She would have to be hospitalized.”

Then I tried to find solutions. “Fans are not helpful in 95 °F heat. All they do is make you hotter because you cannot cool down in the usual ways. Air conditioning is essential to survive at these elevated heat levels,” I explained. “Could you get your air conditioner fixed or replaced?”

He agreed. “Yes, I have the funds and know where to get it done right away.”

Health Risks Associated With Heat

In summer, we need to ask our patients how they cope with the heat and inform them of the risks and dangers, because they often do not know about them. Individuals such as my patient and her brother are at elevated risk for heat illness, as are babies, small children, pregnant individuals, those with cardiorespiratory disease or diabetes, and less advantaged individuals.² Indeed, a major review has shown that patients with preexisting heart disease have an increased risk of sudden death on high heat days from out-of-hospital cardiac arrest, where there is almost no chance to resuscitate them.³ Other reports show that heat waves impact fetal development, especially in the first trimester.⁴

The number of emergency department visits from suicide attempts increases in the heat. Other psychiatric issues that are impacted by high temperatures include interpersonal conflict, firearm injuries, relapse to substance use disorders, depression, and anxiety. Also, many chronic medical conditions are exacerbated by the silent and potentially fatal effects of heat on our brains and organ systems.^5,6

Our patients with serious mental illness often have comorbid hypertension and diabetes, which means they have decreased capillary microcirculation in the skin.⁷ This, in part, could explain their reduced ability to remove heat by radiation and perspiration cooling, putting our patients at higher risk in heat waves.

When I moved to Washington, DC, to start my residency in 1974, the average temperature was more than 2 °F cooler, and the average humidity was 8% to 10% less than it is now. It is not surprising that these days we experience many more high heat days and warmer nights. Hot days followed by warmer nights can be exhausting because rest is more difficult to obtain. By the third day of a heat wave, our heat resilience fades. That is when deaths start to mount.

Advice and Tips for Patients

There are many simple tips patients can employ, and we should remind them of the options they have in these heat waves. For instance, patients should hydrate and avoid alcohol and other intoxicants. When outdoors, they should stay out of the sun, look for shade, and wear a hat. Window shades should be down/closed to help keep the indoors cool. Use the air conditioner first and, if needed, add a fan, but do not use only a fan. If air conditioning is not available at their home, suggest individuals go to cooling centers, food stores, swimming pools, or even the movies to cool down. Using these cooling strategies several hours a day can really help, but they are not the only answers.

TABLE. The 5 Van Susteren P’s

Patients who leverage medications should take them regularly to help them stay stable. In turn, they will be better able to take care of themselves. In some hot countries, individuals might even take 3 or 4 showers a day to help cool off or nap during the hottest period of the day. Finally, provide patients with resources, such as “How to Survive Extreme Heat,”⁷ so they are empowered to take care of themselves and their family.

Being Aware and Taking Responsibility

Our weather is becoming increasingly difficult, partially because of environmental issues. Psychiatrist Lise Van Susteren, MD, believes that patients and clinicians can help address the climate crisis and developed the 5 Ps—Personal, Professional, Public, Politics, and Protest—each with suggested actionable items (Table). If we all make small changes, together they can result in enormous changes overall.³ In the meantime, we must always ask patients the right questions to ensure their safety in extreme heat.

Dr Petersen is an assistant clinical professor of psychiatry at Georgetown University and practices inpatient and outpatient care at Medstar Washington Hospital Center. He is also on the steering committee of the Climate Psychiatry Alliance.

References

1. Meadows J, Mansour A, Gatto MR, et al. Mental illness and increased vulnerability to negative health effects from extreme heat events: a systematic review. Psychiatry Res. 2024;332:115678.

2. Dodgen D, Donato D, Kelly N, et al. Mental health and well-being. In: US Global Change Research Program. The Impacts of Climate Change on Human Health in the United States: A Scientific Assessment. Skyhorse; 2018:217-246.

3. Kang SH, Oh IY, Heo J, et al. Heat, heat waves, and out-of-hospital cardiac arrest. Int J Cardiol. 2016;221:232-237.

4. Effects of climate and environment on perinatal and reproductive health care (2023-002JMWH). J Midwifery Womens Health. 2023;68(3):409-410.

5. Basu R, Gavin L, Pearson D, et al. Examining the association between apparent temperature and mental health-related emergency room visits in California. Am J Epidemiol. 2018;187(4):726-735.

6. Michel SJ, Wang H, Selvarajah S, et al. Investigating the relationship between weather and violence in Baltimore, Maryland, USA. Injury. 2016;47(1):272-276.

7. Strain WD, Paldánius PM. Diabetes, cardiovascular disease and the microcirculation. Cardiovasc Diabetol. 2018;17(1):57.