Climate change plays a pivotal role in the recent surge of wildfires, and their impact on mental health. How can you, as a clinician, help those impacted by these disasters, specifically children and adolescents?
“Anna,” a 5-year-old girl, presents to clinic with history of eczema, reactive airway disease, seasonal allergies, and concerns of behavior problems. Her mother reports that Anna has been more irritable with increased tantrums, defiant behavior, and sleep problems over past few months. Anna was looking forward to enjoying summer in Ohio, but in July this became difficult when the air quality index (AQI) reached level of 150s due to wildfires from Canada. Her mother remarked that Anna has been looking at the hazy sky and asking, “Is earth ending? And are we all going to die?” On interview with Anna, you find out that she has been worrying about smoky skies and wildfires. She says she hears about it on TV all the time when her father watches the news. She thinks the wildfires are near her and they are all in danger because her parents do not let her go outside a lot, although her parents reported the real reason is their worry about her reactive airway disease and allergies. When she does go outside, she feels frustrated as now because she “has to wear a mask outside, before it was just inside,” which has been leading her to have more defiant behavior and tantrums. She has been looking at the skies becoming darker and worries about it when she is going to bed. As a clinician, you begin to consider how can you help this child and family.
Increase in Wildfires and Global Impact
Climate change plays a pivotal role in the recent surge of both the frequency and intensity of wildfires. Rising temperatures, prolonged droughts, and heavy precipitation create favorable conditions for fires to spread and intensify rapidly. This issue is further escalated by human activities, including deforestation, changes in land use, and accidental ignitions. Recent statistics indicate that wildfires continue to have a substantial and lasting impact on the climate, livestock, human lives, and property. It has been reported that 8 million acres of United States land have been burned via wildfires by October 2020.1 As per Canada’s National Forestry Database spanning from 1990 to 2021, over 8000 fires occur each year, and burn an average of over 2.1 million hectares.2 In 2019, Australia witnessed the hottest year on record—1.5° Celsius above the mean for 1961 to 1990.3 This temperature rise was linked to occurrence of wildfires that consumed 12.4 million acres of land in 2019.
Wildfires pose an escalating public health hazard, as they generate an immense volume of smoke related pollution, including carbon monoxide, nitrous oxide, ozone, aromatic hydrocarbons, and particulate matter less than 2.5 μm in diameter (PM2.5).4 For us as psychiatrists and mental health clinicians, it is important to also consider their substantial impact on both physical and mental wellbeing of victims.
Wildfires and Physical Health
“Anna has a flare up of her reactive airway disease when she goes outside.”
Individuals and communities exposed to flames and smoke of wildfires experience significant physical consequences. The direct effects can lead to the injuries and fatalities, with firefighters and residents at risk of burns, respiratory issues, and other injuries while trying to combat or flee the blaze. Consistent evidence from many studies indicates that wildfire smoke exposure is associated with respiratory morbidity, with growing evidence also supporting an association with all-cause mortality. A meta-analysis of data from 2003 to 2010 in 10 cities in southern Europe found an increase in cardiovascular mortality associated with PM10 that was stronger on smoke-affected days than on nonaffected days.5 Wildfires increase particulate matter and reduce air quality, heightening the likelihood of respiratory and other health issues such as irritation in eyes, running nose, sore throat, headaches, new respiratory illness, and worsening of pre-existing conditions like asthma and chronic obstructive pulmonary disease (COPD).5 Inhaling wildfire smoke is linked to increases in outpatient visits, emergency visits, hospitalizations, and fatalities related to various respiratory problems.5 These adverse effects are unequally distributed among different subpopulations, with children, older adults, women, racial and ethnic minorities, individuals living in low socio-economic areas, and those with pre-existing health conditions facing the highest risk.6
Unraveling the Impact of Wildfires on Mental Health
“Anna has been worrying about danger now and in the future, is sleeping poorly, and has been reporting nightmares.”
Less is known about the mental health effects of wildfires. Exposure to wildfire disasters have been related to various mental health outcomes. Studies have suggested they increase the risk of posttraumatic stress disorder (PTSD) in pediatric and adult populations, which is attributed to witnessing homes burning, experiencing fear for one’s life or those of loved ones, losing loved ones, enduring substantial property damage, or perceiving a lack of support from family and friends. These symptoms have been shown to persist from 3 months up to 10 years post wildfire.7
Bryan et al found higher rates of various psychological symptoms longitudinally over 5 years following the devastation of the Victorian Black Saturday bushfire in Australia. They found higher rates of PTSD than nationally reported in the Australian 2007 National Survey of Mental Health and Wellbeing (8.7% versus 4.4%), and depression and severe distress observed 5 years following the disaster indicating that psychological symptoms continued to persist. In the same study, it was apparent that ongoing life stressors were a major factor in determining the ongoing mental health of survivors of the fires.8 Similarly, higher rates of PTSD (37%), depression (31%), anxiety (27%), and alcohol/substance use disorder (15%) were observed in students grade 7-12 in Fort McMurray, Alberta, 18 months after the 2016 wildfire.9,10 The same study also revealed evidence that low resilience was linked with substantially more severe mental health impacts from the wildfire.
The emotional reaction known as solastalgia, which refers to grieving over alterations in the natural environment, has been correlated with levels of psychological distress after a wildfire occurrence.7 The existing literature also indicates that there is an association of increased alcohol or drug use post fires; those with likely generalized anxiety disorder were 3 times more likely to present with a drug related problem.7,8 Findings from systematic review by Isaac et al suggest that the most prevalent problem in survivors is sleep disturbances, with insomnia (ranging between 63% to 72.5%) and nightmares (ranging between 33.3% to 46.5%), being the most prevalent difficulties reported in these populations when assessed 1 to 10 months later.11 Additionally, a study of South Korea Gangwon wildfire survivors documented various post disasters responses which included somatic responses (76.2%) followed by insomnia (59.2%), anxiety (50%), chest tightness (34%), grief (33%), flashbacks (33%), and depression (32.5%).12
Strategies to Cope With Climate Distress
It is imperative to recognize the additive economic losses and ongoing stress as individuals try to rebuild their lives in the aftermath of wildfires. Communities face unique stress related to the rapid and unpredictable nature of wildfires, inflicting colossal damage. Evacuation orders may be issued with minimal notice, placing individuals under pressure to make critical decisions rapidly. Other sudden traumatic changes requiring rapid adaptation include loss of home, employment, reenrolling children at new school if forced to relocate, and worsening of preexisting medical conditions. Talking with patients about how to prepare ahead of time can help reduce anxiety, for example knowing their risk of wildfire and making evacuation plans.
“Anna’s mother reports that Anna has been talking about being scared of beasts that are going to come and get her.”
Wildfires can also have a profound impact on children, often triggering death anxiety. The sight of raging flames and upheaval of their familiar surroundings can cause a sense of betrayal and can evoke sense of fear and vulnerability. Metaphors used by adults to depict wildfires can further intensify the anxieties. Description of fires as “monsters” and “beasts” can reinforce their view of the event as something ominous and outside their ability to cope. Discussing death with children is a sensitive topic and requires careful consideration. While many parents chose not to talk to child about death for many reasons—such as desire to protect child from bad news, not feeling confident to talk about death, or belief in commonly held myths like children under the age of 10 are not aware about death or that discussing death may lead to severe depression in the child. Research has showed that parents who discussed death with their child reflected positively on having had this discussion with their child. In such cases, parents reported that talking about death was a mean of minimizing the child’s fear and resulted in creating an open atmosphere within the family and helped the family grow closer.13
During the immediate wake of wildfires, it is important to restore a sense of safety and security. It is advisable to connect with loved ones and embrace hope and optimism that circumstances will improve. It is important to seek social support and stay connected with others in the community as well.
Educating communities about climate change and related distress is crucial to spread awareness of its mental health effects. Enhanced community level education can include topics such as informational campaigns during wildfire events about AQI, impact of wildfires on physical and mental health, getting clean air in one’s home and knowledge about mask fitting and use.14
It is important to acknowledge and talk about anxiety about climate change itself to normalize the emotional response. Awareness of stress reduction techniques such as meditation, relaxation exercises, and so on can be very helpful. Mental health resources in such communities can provide ongoing support, but it is also important to think about population-wide resilience training. Since the effects of wildfires can be long lasting, recovery programs must be developed to address the long term needs of survivors and their communities.
“Anna’s mom thinks about the conversation she had with her friend, who was caught in a wildfire—the terror of being stuck behind other vehicles and not knowing whether yours would be the next to be hit by embers and flames. Containing her own fear so that it does not unconscious resonate with that of her daughter becomes a priority in her processing of Anna’s distress.”
Parents and teachers are tasked with addressing these events with children. While these conversations can be challenging, engaging in them can foster resilience and hold significant importance for children’s wellbeing in the face of tragic events. The children’s book, Coco’s Fire: Turning Climate Anxiety into Climate Action, provides guidance to parents for how to conduct such conversations through the story of a squirrel struggling with wildfire-based fears. While talking to children, keep an open and supportive environment to provide them the opportunity to ask questions. Acknowledge and validate their thoughts, feelings, and emotions. Children who have history of trauma or losses are susceptible to prolonged or intense reactions upon encountering news or images of wildfires. Limit children’s exposure to television programs and social media displaying frightening images. Monitor the physical symptoms of anxiety such headaches and stomachaches, and seek support of mental health professionals if symptoms continue to persist.15
More important than anything else to prevent wildfire-related mental health impacts is addressing climate change and wildfires. This requires robust policies at state and federal levels to reduce both cause and effect. Policymakers must prioritize investments in renewable energy resources, preserve green infrastructure, and focus on resources for early detection of wildfires and community preparedness. We can learn from the past and use it as an asset for our present and strategic future planning, but also can use radical hope, defined as positive action in which the outcome is not certain, to take collective and political action.
“In the case of Anna, her psychiatrist tried not to talk about wildfires, but it did not help with behavioral problems or anxiety. As treatment advanced and the psychiatrist delved deeper into her anxiety, it became apparent that Anna’s father was deeply worried about wildfires and climate change too. Their ongoing discussions unveiled that he harbored significant worries regarding climate change, to the extent he had even contemplated not having another child due to these climate related concerns.
The psychiatrist tried a different approach, acknowledging and talking about climate change with the whole family, which helped provide a forum for Anna to feel validated in her feelings. Both the parents were invited in the sessions, encouraged to openly express their emotions, and explore how they could effectively support their child’s emotional responses and address the looming anxiety associated with wildfires while also providing Anna with a sense of safety.”
As wildfires increase in frequency and intensity, it is important to be aware of the physical and mental health impacts they have on patients. While for those directly impacted by wildfires, losing their house or forced displacement can cause symptoms related to anxiety, depression, and PTSD, even individuals far away can experience indirect mental health impacts including apprehension and anxiety about the future. There is a disproportionate higher impact on children, elderly, racial minorities, and those from lower socioeconomic strata. Being prepared, helping create awareness, and acknowledging the mental health impacts of wildfires and climate change as clinicians is crucial. We can help lead through this crisis.
Dr Malhi is a child psychiatrist in Wilmington, Delaware and is affiliated with ChristianaCare. Dr Marwaha is a child psychiatrist in Cleveland, Ohio and is affiliated with MetroHealth Medical Center.
1. Nelson R. US wildfires and mental illness stress health systems. Lancet. 2020;396(10262):1546-1547.
2. Canadian National Fire Database. Natural Resources Canada. Accessed October 6, 2023. https://cwfis.cfs.nrcan.gc.ca/ha/nfdb
3. Buchholz K. Australia is warming faster than global average. Statista. January 6, 2020. Accessed October 6, 2023. https://www.statista.com/chart/20404/mean-annual-temperature-anomaly-in-australia-and-the-world/
4. Why wildfire smoke is a health concern. EPA. Accessed October 6, 2023. https://www.epa.gov/wildfire-smoke-course/why-wildfire-smoke-health-concern
5. Reid CE, Brauer M, Johnston FH, et al. Critical review of health impacts of wildfire smoke exposure. Environ Health Perspect. 2016;124(9):1334-1343.
6. Eisenman DP, Galway LP. The mental health and well-being effects of wildfire smoke: a scoping review. BMC Public Health. 2022;22(1):2274.
7. To P, Eboreime E, Agyapong VIO. The impact of wildfires on mental health: a scoping review. Behav Sci (Basel). 2021;11(9):126.
8. Bryant RA, Gibbs L, Gallagher HC, et al. Longitudinal study of changing psychological outcomes following the Victorian black Saturday bushfires. Aust N Z J Psychiatry. 2018;52(6):542-551.
9. Brown MRG, Agyapong V, Greenshaw AJ, et al. Significant PTSD and other mental health effects present 18 months after the fort Mcmurray wildfire: findings from 3,070 grades 7-12 students. Front Psychiatry. 2019;10:623.
10. Papanikolaou V, Adamis D, Mellon RC, Prodromitis G. Psychological distress following wildfires disaster in a rural part of Greece: a case-control population-based study. Int J Emerg Ment Health. 2011;13(1):11-26.
11. Isaac F, Toukhsati SR, Di Benedetto M, Kennedy GA. A systematic review of the impact of wildfires on sleep disturbances. Int J Environ Res Public Health. 2021;18(19):10152.
12. Hong JS, Hyun SY, Lee JH, Sim M. Mental health effects of the Gangwon wildfires. BMC Public Health. 2022;22(1):1183.
13. van der Geest IM, van den Heuvel-Eibrink MM, van Vliet LM, et al. Talking about death with children with incurable cancer: perspectives from parents. J Pediatr. 2015;167(6):1320-1326.
14. Humphreys A, Walker EG, Bratman GN, Errett NA. What can we do when the smoke rolls in? An exploratory qualitative analysis of the impacts of rural wildfire smoke on mental health and wellbeing, and opportunities for adaptation. BMC Public Health. 2022;22(1):41.
15. Fassler D. Talking to children about wildfires and other natural disasters. American Academy of Child & Adolescent Psychiatry. Accessed October 6, 2023. https://www.aacap.org/App_Themes/AACAP/Docs/resource_centers/disaster/resource_group/resources/parents/Talking-Children-about-Wildfires-and-other-Natural-Disasters.pdf