The Impact of Climate Change on Mental Health and Emotional Wellbeing: A Narrative Review of Current Evidence, and its Implications.

Converging global evidence highlights the dire consequences of climate change for human mental health and wellbeing. This paper summarises literature across relevant disciplines to provide a comprehensive narrative review of the multiple pathways through which climate change interacts with mental health and wellbeing. Climate change acts as a risk amplifier by disrupting the conditions known to support good mental health, including socioeconomic, cultural and environmental conditions, and living and working conditions. The disruptive influence of rising global temperatures and extreme weather events, such as experiencing a heatwave or water insecurity, compounds existing stressors experienced by individuals and communities. This has deleterious effects on people's mental health and is particularly acute for those groups already disadvantaged within and across countries. Awareness and experiences of escalating climate threats and climate inaction can generate understandable psychological distress; though strong emotional responses can also motivate climate action. We highlight opportunities to support individuals and communities to cope with and act on climate change. Consideration of the multiple and interconnected pathways of climate impacts and their influence on mental health determinants must inform evidence-based interventions. Appropriate action that centres climate justice can reduce the current and future mental health burden, while simultaneously improving the conditions that nurture wellbeing and equality. The presented evidence adds further weight to the need for decisive climate action by decision makers across all scales.

Green care in psychiatry.

Engagement with natural environments is associated with improved health and well-being in the general population. This has implications for mental healthcare. Implementation of targeted nature-based interventions (green care) meets recovery needs and would enable research to develop, clarifying what works best for whom.

Predictive accuracy of risk scales following self-harm: multicentre, prospective cohort study.

BackgroundScales are widely used in psychiatric assessments following self-harm. Robust evidence for their diagnostic use is lacking.AimsTo evaluate the performance of risk scales (Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS scale, Modified SAD PERSONS scale, Barratt Impulsiveness Scale); and patient and clinician estimates of risk in identifying patients who repeat self-harm within 6 months.MethodA multisite prospective cohort study was conducted of adults aged 18 years and over referred to liaison psychiatry services following self-harm. Scale a priori cut-offs were evaluated using diagnostic accuracy statistics. The area under the curve (AUC) was used to determine optimal cut-offs and compare global accuracy.ResultsIn total, 483 episodes of self-harm were included in the study. The episode-based 6-month repetition rate was 30% (n = 145). Sensitivity ranged from 1% (95% CI 0-5) for the SAD PERSONS scale, to 97% (95% CI 93-99) for the Manchester Self-Harm Rule. Positive predictive values ranged from 13% (95% CI 2-47) for the Modified SAD PERSONS Scale to 47% (95% CI 41-53) for the clinician assessment of risk. The AUC ranged from 0.55 (95% CI 0.50-0.61) for the SAD PERSONS scale to 0.74 (95% CI 0.69-0.79) for the clinician global scale. The remaining scales performed significantly worse than clinician and patient estimates of risk (P<0.001).ConclusionsRisk scales following self-harm have limited clinical utility and may waste valuable resources. Most scales performed no better than clinician or patient ratings of risk. Some performed considerably worse. Positive predictive values were modest. In line with national guidelines, risk scales should not be used to determine patient management or predict self-harm.

A systematic review of the prevalence and odds of domestic abuse victimization among people with dementia.

Little is known about the prevalence of domestic abuse in later life or after the onset of dementia. Given the expanding population of dementia sufferers, it is imperative to identify the degree to which domestic abuse occurs within this population. The aim of this study was to establish the prevalence (lifetime and past year), odds, and trajectory of domestic abuse victimization among people with dementia. Systematic searches of 20 electronic databases were performed from inception to June 2016, using a pre-defined search strategy for English language articles containing data on the prevalence and/or odds of adult lifetime or past year domestic abuse among people with dementia. Six studies met the inclusion criteria. Among patients with dementia, the past year median prevalence of physical and psychological domestic abuse victimization is 11% and 19%, respectively. Findings from cross-sectional studies show an increased odds of domestic abuse among people with dementia vs those without. Trajectory information indicated that domestic abuse was more prevalent in relationships with a pre-morbid history of abuse. The lack of research into this area is highlighted by the small number of includable studies. There is a need for further research into the impact of dementia on domestic abuse.

Response inhibition and serotonin in autism: a functional MRI study using acute tryptophan depletion.

It has been suggested that the restricted, stereotyped and repetitive behaviours typically found in autism are underpinned by deficits of inhibitory control. The biological basis of this is unknown but may include differences in the modulatory role of neurotransmitters, such as serotonin, which are implicated in the condition. However, this has never been tested directly. We therefore assessed the modifying role of serotonin on inhibitory brain function during a Go/No-Go task in 14 adults with autism and normal intelligence and 14 control subjects that did not differ in gender, age and intelligence. We undertook a double-blind, placebo-controlled, crossover trial of acute tryptophan depletion using functional magnetic resonance imaging. Following sham, adults with autism relative to controls had reduced activation in key inhibitory regions of inferior frontal cortex and thalamus, but increased activation of caudate and cerebellum. However, brain activation was modulated in opposite ways by depletion in each group. Within autistic individuals depletion upregulated fronto-thalamic activations and downregulated striato-cerebellar activations toward control sham levels, completely 'normalizing' the fronto-cerebellar dysfunctions. The opposite pattern occurred in controls. Moreover, the severity of autism was related to the degree of differential modulation by depletion within frontal, striatal and thalamic regions. Our findings demonstrate that individuals with autism have abnormal inhibitory networks, and that serotonin has a differential, opposite, effect on them in adults with and without autism. Together these factors may partially explain the severity of autistic behaviours and/or provide a novel (tractable) treatment target.

Factors associated with interest in psychiatry in UK medical students: qualitative study.

AIMS AND METHOD: This study aimed to explore factors that positively influence UK medical students' interest in psychiatry. Delegates and committee members of the National Student Psychiatry Conference 2018 were invited to participate in individual semi-structured interviews. Nine interviews were conducted. Qualitative data were analysed using thematic analysis. RESULTS: Four core themes emerged: psychiatry education and exposure, role of a psychiatrist, fitting in, and factors external to medical school. All students had some degree of interest in mental health before medical school, but placement and extra-curricular factors were strongly influential. IMPLICATIONS: Interest in psychiatry may be promoted by facilitating student exposure to enthusiastic psychiatrists and psychiatry subspecialties, encouraging extra-curricular activities and identifying early those with pre-existing interest in mental health on admission to medical school. Aspects of psychiatry that should be promoted include the potential to make a positive difference to patients' lives and the teamworking elements of the specialty.

Temperature-related deaths in people with psychosis, dementia and substance misuse.

BACKGROUND: Climate change is expected to have significant effects on human health, partly through an increase in extreme events such as heatwaves. People with mental illness may be at particular risk. AIMS: To estimate risk conferred by high ambient temperature on patients with psychosis, dementia and substance misuse. METHOD: We applied time-series regression analysis to data from a nationally representative primary care cohort study. Relative risk of death per 1°C increase in temperature was calculated above a threshold. RESULTS: Patients with mental illness showed an overall increase in risk of death of 4.9% (95% CI 2.0-7.8) per 1°C increase in temperature above the 93rd percentile of the annual temperature distribution. Younger patients and those with a primary diagnosis of substance misuse demonstrated greatest mortality risk. CONCLUSIONS: The increased risk of death during hot weather in patients with psychosis, dementia and substance misuse has implications for public health strategies during heatwaves.

Psychosocial impact of the summer 2007 floods in England.

BACKGROUND: The summer of 2007 was the wettest in the UK since records began in 1914 and resulted in severe flooding in several regions. We carried out a health impact assessment using population-based surveys to assess the prevalence of and risk factors for the psychosocial consequences of this flooding in the United Kingdom. METHODS: Surveys were conducted in two regions using postal, online, telephone questionnaires and face-to-face interviews. Exposure variables included the presence of flood water in the home, evacuation and disruption to essential services (incident management variables), perceived impact of the floods on finances, house values and perceived health concerns. Validated tools were used to assess psychosocial outcome (mental health symptoms): psychological distress (GHQ-12), anxiety (GAD-7), depression (PHQ-9) and probable post-traumatic stress disorder (PTSD checklist-shortform). Multivariable logistic regression was used to describe the association between water level in the home, psychological exposure variables and incident management variables, and each mental health symptom, adjusted for age, sex, presence of an existing medical condition, employment status, area and data collection method. RESULTS: The prevalence of all mental health symptoms was two to five-fold higher among individuals affected by flood water in the home. People who perceived negative impact on finances were more likely to report psychological distress (OR 2.5, 1.8-3.4), probable anxiety (OR 1.8, 1.3-2.7) probable depression (OR 2.0, 1.3-2.9) and probable PTSD (OR 3.2, 2.0-5.2). Disruption to essential services increased adverse psychological outcomes by two to three-fold. Evacuation was associated with some increase in psychological distress but not significantly for the other three measures. CONCLUSION: The psychosocial and mental health impact of flooding is a growing public health concern and improved strategies for minimising disruption to essential services and financial worries need to be built in to emergency preparedness and response systems. Public Health Agencies should address the underlying predictors of adverse psychosocial and mental health when providing information and advice to people who are or are likely to be affected by flooding.

Using electronic patient records to assess the impact of swine flu (influenza H1N1) on mental health patients.

BACKGROUND: Electronic patient records are increasingly used in primary care research, but rarely in psychiatric research. Little is known about how people with pre-existing mental illness respond to public health threats. AIMS: To outline the swine flu related concerns and behaviours of mental health patients and to determine whether marked concern was associated with any specific demographic or diagnostic groups. METHODS: We searched a database containing electronic patient records from a large mental health trust for references to swine flu made between 15 April and 15 July 2009. Thematic analysis was used to code swine flu related concerns and behaviours. A case-control approach sought to determine whether there were demographic or diagnostic associations with expressing moderate/severe concern about swine flu. RESULTS: A range of swine flu related behaviours were noted and considerable impact was recorded for some patients. Children and patients with neurotic and somatoform disorders were over-represented amongst those expressing moderate/severe swine flu concerns. CONCLUSION: Research databases using electronic clinical records are a useful way to track responses to emerging public health threats. Children receiving mental health care and patients with neurotic and somatoform disorders may be particularly psychologically vulnerable to infectious disease epidemics.

The Readiness of Psychiatrists to Implement Psychedelic-Assisted Psychotherapy.

Introduction: Psychedelic-assisted psychotherapy is a promising approach in psychiatry; evidence is growing and it may not be long before mainstream services are expected to offer it to selected patients. This pilot study examined the attitudes and knowledge of NHS psychiatrists of all levels towards psychedelic-assisted psychotherapy and explored potential barriers and facilitators to its implementation. Methods: A mixed-methods approach was adopted, using a cross-sectional survey and focus groups. All psychiatrists in one NHS mental health trust were approached by email to participate. The survey was analysed using a simple descriptive approach and thematic analysis was used for the focus groups. Results: Eighty-three (25.7%) psychiatrists participated in the survey. All psychiatrists were familiar with one or more psychedelic substances. Although 77.2% felt that there should be a role for controlled or therapeutic use of psychedelics, trainees appeared better informed than non-training grade psychiatrists. Psychiatrists of all grades did not feel prepared to participate in the delivery of psychedelic-assisted psychotherapy. Thematic analysis of the focus groups identified three main themes in relation to psychedelic-assisted psychotherapy: "need for knowledge," "openness to change," and "uncertainty." Discussion: NHS psychiatrists are positive about the potential for psychedelic-assisted therapy to advance psychiatric practise. However, psychiatrists are lacking in confidence or preparedness to implement this treatment should it become a mainstream option and significant training needs were identified. Thematic analysis highlighted the need for societal shifts as well as professional ones.

What mental health professionals and organisations should do to address climate change.

AIMS AND METHOD: The climate change emergency is also a mental healthcare emergency. We seek to provide a framework for what mental health professionals and organisations should do to make their practice more sustainable. RESULTS: There are ethical, legal and organisational imperatives to make mental healthcare more sustainable. Mental healthcare must be refocused with an emphasis on prevention, building social capital and community resilience. Patients must be empowered to manage their own mental health. Efficiencies should be found within the system. Low-carbon ways to deliver care must be found, measured and improved upon. Greater adaptability needs to be built into the system to mitigate the impact of climate change. Sustainability should be integrated into training programmes, and good examples of practice shared and celebrated. CLINICAL IMPLICATIONS: Mental health organisations and individuals must act now to prevent and adapt for the climate and ecological emergency. Sustainable practice is also good practice.

Inflammatory bowel disease psychological support pilot reduces inflammatory bowel disease symptoms and improves psychological wellbeing.

This prospective service evaluation aimed to determine if integrated psychological support for patients with inflammatory bowel disease (IBD) enhanced outcomes. 75 patients were assessed and treated by a specialist liaison psychiatric service between 2015 and 2017; 43 received psychiatric intervention alone, 32 were referred for psychological intervention by clinical health psychologist; 26 completed this. Pre-post data (n=15 available) included global impression, quality of life, and psychiatric and IBD symptom scores. Referrer/patient satisfaction and cost-effectiveness were retrospectively calculated. Psychological intervention led to reductions in IBD symptoms (ΔSIBD; p=0.003), alongside improvements in depression scores (ΔPHQ-9, p=0.006) and global impression (ΔCGI; p=0.046). Patient/referrer satisfaction was very high. Indicative data comparing service utilisation 1 year before and after engagement found reductions in outpatient appointments and in imaging. This small study suggests consideration of increased access to integrated psychological support services to improve outcomes and gather further evidence of efficacy.

Frequency and predictors of mass psychogenic illness.

BACKGROUND: Mass psychogenic illness refers to outbreaks of illness attributed to a toxic agent but for which no plausible organic cause is found. We determined the frequency and predictors of mass psychogenic illness within a sample of chemical incidents. METHODS: Information was collected on a random sample of 280 chemical incidents. We developed consensus operational criteria for mass psychogenic illness and estimated its frequency. We then assessed environmental, emergency, and health service indicators for their association with mass psychogenic illness. RESULTS: Nineteen "chemical incidents" were probable episodes of mass psychogenic illness. This represented 16% of incidents for which people reported symptoms and 7% of all incidents. Odor was a robust predictor of mass psychogenic illness. These illnesses were especially likely to occur in schools or healthcare facilities. CONCLUSIONS: A substantial minority of chemical incidents may be mass psychogenic illness.

Maturation of limbic regions in Asperger syndrome: a preliminary study using proton magnetic resonance spectroscopy and structural magnetic resonance imaging.

People with autistic spectrum disorders (ASD, including Asperger syndrome) may have developmental abnormalities in the amygdala-hippocampal complex (AHC). However, in vivo, age-related comparisons of both volume and neuronal integrity of the AHC have not yet been carried out in people with Asperger syndrome (AS) versus controls. We compared structure and metabolic activity of the right AHC of 22 individuals with AS and 22 healthy controls aged 10-50 years and examined the effects of age between groups. We used structural magnetic resonance imaging (sMRI) to measure the volume of the AHC, and magnetic resonance spectroscopy ((1)H-MRS) to measure concentrations of N-acetyl aspartate (NAA), creatine+phosphocreatine (Cr+PCr), myo-inositol (mI) and choline (Cho). The bulk volume of the amygdala and the hippocampus did not differ significantly between groups, but there was a significant difference in the effect of age on the hippocampus in controls. Compared with controls, young (but not older) people with AS had a significantly higher AHC concentration of NAA and a significantly higher NAA/Cr ratio. People with AS, but not controls, had a significant age-related reduction in NAA and the NAA/Cr ratio. Also, in people with AS, but not controls, there was a significant relationship between concentrations of choline and age so that choline concentrations reduced with age. We therefore suggest that people with AS have significant differences in neuronal and lipid membrane integrity and maturation of the AHC.

Reassuring and managing patients with concerns about swine flu: qualitative interviews with callers to NHS Direct.

BACKGROUND: During the early stages of the 2009 swine flu (influenza H1N1) outbreak, the large majority of patients who contacted the health services about the illness did not have it. In the UK, the NHS Direct telephone service was used by many of these patients. We used qualitative interviews to identify the main reasons why people approached NHS Direct with concerns about swine flu and to identify aspects of their contact which were reassuring, using a framework approach. METHODS: 33 patients participated in semi-structured interviews. All patients had telephoned NHS Direct between 11 and 14 May with concerns about swine flu and had been assessed as being unlikely to have the illness. RESULTS: Reasons for seeking advice about swine flu included: the presence of unexpectedly severe flu-like symptoms; uncertainties about how one can catch swine flu; concern about giving it to others; pressure from friends or employers; and seeking 'peace of mind.' Most participants found speaking to NHS Direct reassuring or useful. Helpful aspects included: having swine flu ruled out; receiving an alternative explanation for symptoms; clarification on how swine flu is transmitted; and the perceived credibility of NHS Direct. No-one reported anything that had increased their anxiety and only one participant subsequently sought additional advice about swine flu from elsewhere. CONCLUSIONS: Future major incidents involving other forms of chemical, biological or radiological hazards may also cause large numbers of unexposed people to seek health advice. Our data suggest that providing telephone triage and information is helpful in such instances, particularly where advice can be given via a trusted, pre-existing service.

Rural interhospital transfer of ST-elevation myocardial infarction patients for percutaneous coronary revascularization: the Stat Heart Program.

BACKGROUND: In Europe, interhospital transfer of ST-elevation myocardial infarction (STEMI) patients for primary percutaneous coronary intervention (PCI) from non-PCI-capable (STEMI-referral) to PCI-capable (STEMI-accepting) facilities has been shown to be a superior reperfusion strategy compared with on-site fibrinolysis. The feasibility of such programs in the United States remains poorly defined. METHODS AND RESULTS: We describe an observational cohort of 230 consecutive presumed STEMI patients who underwent interhospital transfer between January 2005 and March 2007 among 6 STEMI-referral and 2 STEMI-accepting hospitals in rural central Illinois. A standard treatment protocol using rapid interhospital transfer for primary PCI or rescue PCI after full-dose intravenous fibrinolysis (in event of unanticipated transfer delays) was initiated by the STEMI-referral emergency department physician. Three time intervals were evaluated: STEMI-referral care (door 1 to departure), transport time (door 1 departure to STEMI-accepting hospital arrival [door 2]), and STEMI-accepting hospital care (door 2 to balloon). Primary PCI was performed in 165 STEMI-confirmed patients (87.7%), whereas fibrinolysis was required in 16 patients (8.5%), with 56% undergoing rescue PCI. The median door 1-to-departure time was 46 minutes (25th and 75th percentiles, 32 and 62 minutes); approximately two thirds of this delay was attributable to the wait for transport arrival and departure. The transport and door 2-to-balloon times were 29 minutes (25th and 75th percentiles, 25 and 35 minutes) and 35 minutes (25th and 75th percentiles, 32 and 46 minutes), respectively. The door 1-to-balloon time was 117 minutes (25th and 75th percentiles, 98 and 137 minutes), with 12.2% and 58% of patients achieving a time of < or = 90 and < or = 120 minutes, respectively. No adverse clinical events occurred during interhospital transport. CONCLUSIONS: In rural US communities, emergency department physician-initiated interhospital transfer of STEMI patients for primary or rescue PCI is feasible and was safely executed with achievement of timely reperfusion when performed within coordinated healthcare networks.

Psychosis and autism: magnetic resonance imaging study of brain anatomy.

BACKGROUND: Autism-spectrum disorder is increasingly recognised, with recent studies estimating that 1% of children in South London are affected. However, the biology of comorbid mental health problems in people with autism-spectrum disorder is poorly understood. AIMS: To investigate the brain anatomy of people with autism-spectrum disorder with and without psychosis. METHOD: We used in vivo magnetic resonance imaging and compared 30 adults with autism-spectrum disorder (14 with a history psychosis) and 16 healthy controls. RESULTS: Compared with controls both autism-spectrum disorder groups had significantly less grey matter bilaterally in the temporal lobes and the cerebellum. In contrast, they had increased grey matter in striatal regions. However, those with psychosis also had a significant reduction in grey matter content of frontal and occipital regions. Contrary to our expectation, within autism-spectrum disorder, comparisons revealed that psychosis was associated with a reduction in grey matter of the right insular cortex and bilaterally in the cerebellum extending into the fusiform gyrus and the lingual gyrus. CONCLUSIONS: The presence of neurodevelopmental abnormalities normally associated with autism-spectrum disorder might represent an alternative 'entry-point' into a final common pathway of psychosis.

A functional magnetic resonance imaging study of inhibitory control in obsessive-compulsive disorder.

People with obsessive-compulsive disorder (OCD) have abnormalities in cognitive and motor inhibition, and it has been proposed that these are related to dysfunction of fronto-striatal circuits. However, nobody has investigated neuro-functional abnormalities during a range of inhibition tasks in adults with OCD. The aims of the study were to compare brain activation of people with OCD and controls during three tasks of inhibitory control. Ten unmedicated adults with OCD and 11 healthy controls performed three different tasks of motor and cognitive inhibitory control during event-related functional magnetic resonance imaging: a Go/No-go task (motor inhibition), a motor Stroop task (interference inhibition) and a Switch task (cognitive flexibility). People with OCD displayed significantly different patterns of brain activation compared to controls during all three tasks. During the Go/No-go and Switch experiments, people with OCD had underactivation in task-relevant orbitofrontal/dorsolateral prefrontal, striatal and thalamic regions. During the motor Stroop and Switch tasks, people with OCD also displayed underactivation in temporo-parietal areas. In the Go/No-go and motor Stroop tasks the OCD group showed increased activation compared to controls in cerebellum and predominantly posterior brain regions. OCD is associated with task-relevant fronto-striatal dysfunction during motor inhibition and cognitive switching. In addition, parieto-temporal dysfunction was observed during tasks with a higher attentional load.

Methodological challenges in assessing general population reactions in the immediate aftermath of a terrorist attack.

Assessing mental health needs following a disaster is important, particularly within high-risk groups such as first responders or individuals who found themselves directly caught up in the incident. Particularly following events involving widespread destruction, ingenuity and hard work are required to successfully study these issues. When considering responses among the general population following less devastating events such as a conventional terrorist attack, or following an event involving a chemical, biological, radiological or nuclear agent, other variables may become more relevant for determining the population's overall psychosocial well-being. Trust, perceived risk, sense of safety, willingness to take prophylaxis and unnecessary attendance at medical facilities will all be important in determining the overall psychological, medical, economic and political impact of such attacks. Assessing these variables can help government agencies and non-governmental organizations to adjust their communication and outreach efforts. As there is often a need to provide these data quickly, telephone surveys using short time-windows for data collection or which use quota samples are often required. It is unclear whether slower, more conventional and more expensive survey methods with better response rates would produce results different enough to these quicker and cheaper methods to have a major impact on any resulting policy decisions. This empirical question would benefit from further study.