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Exposure to climate events and mental health: Risk and protective factors from the California Health Interview Survey

  • Daniel Zhao,

    Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Writing – original draft, Writing – review & editing

    Affiliation Department of Psychiatry, Maimonides Medical Center, Brooklyn, New York, United States of America

  • Elissa Epel,

    Roles Investigation, Methodology, Writing – review & editing

    Affiliation Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, California, United States of America

  • Elaine Allen,

    Roles Formal analysis, Methodology, Writing – review & editing

    Affiliation Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America

  • Alison R. Hwong

    Roles Conceptualization, Methodology, Project administration, Supervision, Validation, Writing – original draft, Writing – review & editing

    arhwong@stanford.edu

    Affiliations Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, California, United States of America, Department of Psychiatry and Behavioral Sciences, Stanford School of Medicine, Palo Alto, California, United States of America, Psychiatry Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, United States of America

Abstract

There is increasing awareness of the effects of climate change on mental health, but more work on understanding risk and protective factors is needed. The 2021 California Health Interview Survey included new questions about exposure to extreme weather events and mental health responses. This study aims to identify how individual factors and neighborhood social cohesion are associated with negative mental health effects of exposure to extreme weather events. In this cross-sectional, representative study, we used data from the 2021 California Health Interview Survey to analyze the association between respondent characteristics and self-report of negative mental health effects following exposure to extreme weather events. Univariate and multivariate logistic regression models were used, adjusting for individual-level sociodemographics and measures of neighborhood social cohesion. We found that 53% of the sample reported being affected by climate events (n = 12,955), and of these, 22.8% (n = 2,955) reported a negative impact on their mental health. Respondents who were younger, White, female, college-educated, or living in a rural area were more likely to report adverse mental health effects of climate events for themselves or household members. Individuals who had experienced property damage were much more likely to report negative mental health effects due to climate events [property damage adjusted OR 3.73, 95% CI 2.82–3.76]. This study identifies subgroups that may have higher vulnerability to the mental health effects of climate change events. Future research is needed to develop targeted prevention and outreach interventions to these subgroups to build individual- and community-level resilience.

Introduction

Climate change is the defining public health crisis of the 21st century, with both direct and indirect effects on mental health [1]. Directly experiencing extreme weather events (e.g., hurricanes, wildfires, and floods) has been linked to elevated levels of anxiety, depression, and post-traumatic stress disorder [2]. Chronic climate change events, such as sea level rise and drought, have also been associated with an increase in mental health issues, from psychological distress to suicide risk [2, 3]. Climate change also has indirect effects on mental health by leading to threats to one’s livelihood, such as economic loss, displacement, and migration, which can have profound consequences for mental well-being [4, 5].

In addition, there is an increasing understanding of the mental health effects of climate change from a health equity lens. Climate change amplifies existing disparities in access to healthcare along racial, ethnic, sex, and socioeconomic lines, with low-income and racially/ethnically minoritized groups at the greatest risk of health harms from climate change despite typically contributing the least to greenhouse gas emissions [6, 7]. Children and adolescents also appear to experience a disproportionate burden of mental health consequences, reporting increased levels of anxiety and depression from the existential threat of climate change compared to adults [8]. In a large 2021 survey of youth across ten different countries, 59% of respondents said that they were either very or extremely worried about climate change and experienced feelings of betrayal due to inadequate government response [9].

However, many questions remain unanswered regarding individual and community factors affecting climate change-related mental health outcomes. Previous survey studies on climate change and mental health have either focused on a single acute climate disaster, such as Hurricane Katrina [10, 11], or required linking meteorological and behavioral health datasets [1214] and inferring causal effects. The focus on an isolated climate disaster can address mental health responses to a specific localized weather event, and data linkages can reveal important timescale and geolocated effects. However, these studies often do not capture how respondents are personally affected by climate events, such as experiencing damage to one’s home. In addition, the emphasis on an acute climate disaster does not reflect how mental health is affected by chronic climate change, which is characterized by gradual change with multiple events and fluctuations in severity over time [11, 15]. Finally, less attention has been paid to the impact of climate change on mental health in the setting of community factors, such as social cohesion and trust in one’s community, which may serve as buffers to distress and represent opportunities to support collective psychosocial resilience [16].

To address these gaps, we utilized data from the California Health Interview Survey (CHIS), a state-level survey with over 24,000 respondents [17]. We examined a new set of questions included in the 2021 CHIS, which asked respondents whether they had experienced extreme weather events and whether their mental health or the mental health of household members had been adversely affected by these events. To our knowledge, this is the first United States (U.S.) state-wide panel survey that directly asks about climate change-related mental health effects, providing normative state-wide data on climate-related distress levels from a large, diverse sample of respondents. In addition, this survey is notable for capturing data from a state that has shouldered a significant burden of climate events, including wildfires and floods, in recent years, particularly 2020 and 2021 [18, 19], roughly the past two years that the survey assessed. This analysis aims to address previous gaps in the literature on mental health effects of climate change by incorporating CHIS-specific data on risk factors, such as property damage, and on protective factors, such as social cohesion, into modelling the effects of climate change on mental health.

Materials and methods

Data and study population

This was a cross-sectional analysis of data from the 2021 California Health Interview Survey, or CHIS [https://healthpolicy.ucla.edu/chis/Pages/default.aspx]. CHIS, the U.S’s largest state health survey, used multistage geographic stratification and random-digit dialing via landline and cell phone to interview California households in English, Spanish, Mandarin, Cantonese, Korean, Vietnamese, and Tagalog [17]. Data collection began March 18, 2021 and ended December 31, 2021. Participants ages 18 and older were included in this study. The 2021 data contained new questions on exposure to extreme weather events and the impact of these events on mental health. All measures were self-reported except where explicitly noted.

Ethics Statement: This study did not require Institutional Review Board approval at the University of California, San Francisco because it used de-identified data, which does not meet the definition of human subjects research. The CHIS ensures informed consent through a thorough process in which participants are informed about the survey’s purpose, the voluntary nature of participation, and the confidentiality of their responses [20].

Measures

For the main analysis, the primary outcome was the negative effect of climate change on mental health, which was measured in a two-part question (see S1 Text for details). Respondents were asked, “The next set of questions are about potentially hazardous weather-related events that are increasing in California, including extreme heat waves, flooding, wildfires, smoke from wildfires, and the public safety power shutoffs of electricity to prevent a wildfire. In the past two years, have you or members of your household personally experienced any of these events?” Respondents who marked yes were then asked, “Was your mental health (or the mental health of members of your household) harmed by any of these events?”.

Covariates

We evaluated the association between the self-reported adverse effects of climate change events on mental health and predictor variables of age (ages 18–29, 30–39, 40–49, 50–64, older than 65), sex (male, female), marital status (married, never married, other/separated/divorced/living with partner), race (African American Non-Hispanic, American Indian/Alaskan Native NH, Asian NH, White NH, Hispanic, Other), proficiency in English (speak only English, not well/not at all, very well/well), education level (college degree or above, some college, high school education, < high school education), percent of federal poverty level (300% FPL or above, 200–299% FPL, 100–199% FPL, 0–99% FPL), urbanicity (urban, suburban, mixed, rural), damage to property (no, yes), current housing situation (very unstable, fairly unstable, somewhat unstable, fairly stable, very stable), trust in neighbors (strongly disagree, disagree, agree, strongly agree), feeling safe in neighborhood (all the time, most of the time, some of the time, none of the time), willingness to help neighbors (strongly disagree, disagree, agree, strongly agree), and volunteered in the past 12 months (no, yes). Respondents’ race was categorized according to the US Census 2000 definitions to enable calculation and comparison of population-based rates across studies. The categories included African American, American Indian/Alaskan Native, Asian, White, Hispanic, and Other. These classifications were selected by the respondents during the survey process. These predictor variables were also used as covariates in the multivariate regression models and were selected based on prior literature suggesting that they may mediate the association between climate change and mental health.

Statistical analyses

We used univariate logistic regression models to evaluate the odds of answering “YES” to the question “Was your mental health (or the mental health of members of your household) harmed by any of these [extreme weather] events?” based on individual-level factors. We then used multivariate logistic regression models to assess the patterns of reporting adverse impact of climate events on mental health. Each model was mutually adjusted for all other covariates, meaning that the association of each covariate with the outcome was adjusted for the presence of all other covariates in the model. All analyses incorporated survey weights supplied by CHIS to account for the sampling design and generate accurate variance estimates [20]. Two-sided p <0.05 was considered statistically significant. All analyses were performed using R 4.2.2.

Results

This study included 24,453 respondents. Of these, 11,498 (47.0%) said they were not affected by climate events and were thus removed from the subsequent analyses. Of the remaining 12,955 respondents (53.0%), 2,955 (22.8%) reported that their mental health was harmed by climate events. These respondents were more likely to be younger, White, female, college-educated, proficient in English, and residing in rural areas (see Table 1).

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Table 1. Characteristics of respondents to the question, “Was your mental health (or the mental health of members of your household) harmed by any of these [extreme weather] events?”.

Source: CHIS 2021.

https://doi.org/10.1371/journal.pclm.0000387.t001

Unadjusted and adjusted odds ratios from logistic regressions modelling the effects of climate events on mental health are presented in Table 2.

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Table 2. Unadjusted and adjusted odds of responding “yes” to the question, “Was your mental health (or the mental health of members of your household) harmed by any of these [extreme weather] events?”.

Source: CHIS 2021. Notes: 1 OR = Odds Ratio, CI = Confidence Interval.

https://doi.org/10.1371/journal.pclm.0000387.t002

Respondents aged 18–29 years (adjusted OR: 1.84, 95% CI 1.53–2.22), 30–39 years (aOR; 2.26 95% CI 1.94–2.64), 40–49 years (aOR: 1.90 95% CI 1.63–2.22), and 50–64 years (aOR: 1.39, 95% CI 1.23–1.59) were all more likely to report adverse mental health effects due to climate events than respondents aged 65 years and above in both univariate and multivariate models.

Compared to White respondents, those who identified as African-American (aOR: 0.38, 95% CI 0.27–0.53), Asian (aOR: 0.52, 95% CI 0.43–0.61), or Hispanic (aOR: 0.68, 95% CI 0.59–0.78) were less likely to report negative mental health effects of climate events. Additionally, female respondents had higher odds of reporting their mental health being affected by climate events compared to male respondents (aOR: 1.27, 95% CI 1.15–1.39).

Respondents who obtained a college degree or above were more likely to report negative mental health due to climate change events compared to respondents who completed less than a high school education (aOR: 1.65, 95% CI 1.17–2.36). There was a higher likelihood of reporting negative mental health due to climate events among respondents who were separated, divorced, or living with a partner compared to married respondents (aOR: 1.14, 95% CI 1.02–1.27). Respondents living in rural areas (vs. urban dwellers aOR: 1.46, 95% CI 1.28–1.66) and those who experienced property damage due to climate events (vs. no property damage aOR: 3.26, 95% CI 2.82–3.76) also had higher odds of reporting that their mental health was adversely affected by climate events. Having fairly or somewhat stable housing (compared to very stable) was associated with an increased likelihood of reporting harm to mental health due to climate events (fairly stable aOR: 1.18, 95% CI 1.06–1.32; somewhat stable aOR: 1.32, 95% CI 1.12, 1.56).

In univariate models, respondents who were willing to help their neighbors were less likely to report negative mental health effects of climate change compared to respondents with low willingness to help their neighbors (strongly agree OR: 0.44, 95% CI 0.34–0.57; agree OR: 0.51, 95% CI 0.40–0.65). Respondents who trusted their neighbors also were less likely to report negative mental health effects of climate change compared to respondents who had low trust in neighbors (strongly agree OR: 0.49, 95% CI 0.38–0.64, agree OR: 0.53, 95% CI 0.42–0.68). Lastly, respondents who felt safe in their neighborhood (all the time OR: 0.32, 95% CI 0.23–0.46; most of the time OR: 0.50, 95% CI 0.35–0.71; some of the time OR 0.69, 95% CI 0.47–1.00) were less likely to report negative mental health effects of climate change compared to respondents who did not feel safe in their neighborhood any of the time. However, these effects for measures of neighborhood social cohesion did not persist in multivariate models. By contrast, respondents who led or organized volunteering efforts in one’s community in the past 12 months had significantly higher odds of reporting negative mental health effects from climate events in both univariate and multivariate models compared to respondents who did not volunteer in the past 12 months (aOR: 1.55, 95% CI 1.38–1.75)

Discussion

In a large representative sample of California adults, over half reported being affected by an extreme weather event in the past 2 years. Nearly 23% of those exposed to climate events reported mental health consequences. Those who identified as White, female, ages 30–39, or well-educated were more likely to report poor mental health related to climate events. Those who lived in rural areas and experienced property damage were also more likely to report adverse mental health outcomes from climate events. These sociodemographic factors were found to be significant even in adjusted models, suggesting that these factors independently and robustly are associated with more self-reported negative climate change-related mental health outcomes.

Our results reveal key contextual factors in understanding the disproportionate impact of adverse climate change-related mental health effects on vulnerable populations. These findings suggest that there may be two different groups that are disproportionately affected by climate change: those who have high levels of education, which may reflect higher levels of awareness and education around climate change, and those living in rural areas, who may have experienced more directly damaging effects of climate change such as property loss or impacts to agricultural livelihoods. This is relevant from a public health lens, as patients who reside in remote settings and/or are physically displaced already have well-documented disparities in healthcare access, satisfaction, utilization, and quality [21, 22]. These results contrast with previous reports that climate change uniformly amplifies existing health disparities across racial, ethnic, sex, and socioeconomic lines. The underlying mechanism for mental health disparities in these two broad high risk-groups may be very different [15, 2326]. It is also important to note, however, that studies have not consistently found that well-resourced or high-income people are more sensitive to or aware of climate change’s effects. For example, in a large global study, younger respondents in India, the Philippines, and Brazil were most likely to report worry about climate change and its impact on functioning, while rates in the US and UK were lower [9]. This suggests that sensitivity to climate change may vary widely based on regional and socioeconomic contexts.

Furthermore, these findings identify mental health disparities with different sociodemographic patterns than physical health disparities related to climate change. Though elderly populations are considered at higher risk of adverse physical health effects of climate change—due to thermoregulation and mobility challenges in extreme heat, for example—our findings reflect that older adults were less likely to report adverse climate change-related mental health effects [3, 27, 28]. The age-stratified effects show greatest reported distress in younger adults and lowest distress in older adults due to exposure to climate events. These results mirror the age gradient from other national surveys on climate anxiety, but this is a novel demonstration of reported mental health impacts after exposure to climate events [29]. These effects may reflect the greater impact on young adults who will be more affected by climate change across their lifespans, but may also reflect lower resilience and resources among younger adults during stressors. These findings mirror other patterns of mental health disorder prevalence and impacts from disasters, such as the rates of depression and anxiety during the coronavirus pandemic, which were dramatically higher in younger than older adults [30].

We also find that respondents with low English proficiency and racialized minorities such as Asians, African-Americans, and Hispanics were less likely to report adverse mental health effects due to climate change. This finding contrasts with prior literature noting higher levels of concern about climate change among Hispanic and Black Americans compared to White Americans [31]. This is also striking given the wealth of literature indicating that non-White minority groups, especially in North America, face disproportionate effects from climate events. For instance, heatwave studies in the US have indicated significantly higher morbidity and mortality rates among African Americans during extreme heat events, such as the Los Angeles and Chicago heatwaves [32]. Additionally, the majority of the agricultural workforce in California consists of those from Hispanic/Latino backgrounds who face an elevated risk of health impacts from occupational heat exposure [33]. Furthermore, immigrants and people of color have higher susceptibility to extreme heat due to a number of social factors, including higher rates of unemployment, lower incomes, and language barriers when trying to access resources [33]. This may underscore the notion that the most vulnerable groups may also be less likely to report mental health impacts, possibly due to cultural differences in expressing mental health concerns, or a focus on immediate physical health risks.

Additionally, our findings indicate that individuals with incomes at 0–99% of the federal poverty level (FPL) reported higher rates of adverse mental health consequences due to climate change. Low-income populations are particularly susceptible to climate change effects because they often have limited resources for adaptation and recovery. For instance, poorer households lack the financial means to implement protective measures or recover from damage caused by extreme weather events. Ultimately, these populations are more likely to live in areas prone to environmental hazards and have less access to healthcare and social services, exacerbating the mental health impacts of climate change [34].

We also find that respondents aged 30–39 years were more likely to report adverse climate change-related mental health effects compared to respondents aged 65 years or above. There is a hypothesis that this age group may be most likely to be raising young children and therefore have additional concerns about planetary health for their children’s futures (sometimes referred to as the “green parenthood effect”) [35, 36]. Though this may suggest greater awareness of climate change among certain subgroups, our results also may reflect specific groups whose mental health is disproportionately affected by climate change, and who require additional support and outreach.

Our study highlights that measures of neighborhood social cohesion, such as trust in and willingness to help neighbors, as well as perceived safety of neighborhood, may be protective factors against adverse mental health outcomes. Previous work has demonstrated that social cohesion appears to buffer the effects of stressful life events on both adolescent and adult mental health [37]. It also has been noted that after mass trauma events, social networks can improve a person’s ability to obtain information necessary for disaster recovery and sharing of resources for coping. For instance, Stain et al. found that strong communal bonds can mitigate adverse psychological effects of extreme environmental conditions [38]. Our findings suggest that social cohesion and community resilience remain important resources in recovery after a climate disaster, and represent key opportunities for public health interventions [39].

By contrast, those who report volunteering in one’s community were also more likely to report adverse mental health outcomes, possibly reflecting a group of respondents who are highly conscientious, with enhanced awareness of the climate crisis and its implications for planetary health. This is further corroborated by recent studies on the CHIS 2021 dataset; for instance, Le notes that for adolescents living in urban zip codes, civic engagement was associated with an increased odds of climate change anxiety [40].

Limitations

Our study is based on data from a single state and may not be generalizable to other U.S. states or locations. Additionally, zip code-level data were not publicly accessible, limiting analysis to rural, mixed, urban, and suburban categories. The study did not include adolescents and young children. Respondent sex was defined by “sex assigned on birth certificate”, a binary classification as opposed to gender, and one that does not encompass the full spectrum of gender identities. This simplification can result in a lack of representation and may affect the inclusivity and accuracy of our research findings. Future studies should consider more inclusive approaches to capture the diverse experiences related to gender.

It is important to acknowledge that some of the associations we found between sociodemographic characteristics and the reporting of adverse mental health effects may be influenced by a greater likelihood of reporting the harm and/or making the attribution, rather than a higher incidence of actual harm itself due to events. This is particularly plausible for subgroups identified in our study who may have higher education and therefore may be more aware of and sensitive to the impacts of climate change, leading to a higher propensity to report these effects. The primary outcome of the study measured the effects of climate change on mental health in a non-standardized manner. While the CHIS includes standardized questions on mental health, such as feeling depressed in the worst month and feeling depressed in the past 30 days, these questions do not explicitly link mental health to climate change or hazardous weather events and so were not included in analysis.

Lastly, the survey did not collect data on mental health impacts of climate events on those who were not directly impacted by events. However, these limitations should be balanced against the study’s relative strengths: utilizing a unique survey question about exposure and responses to extreme weather events, having a large and diverse sample size from the most populous U.S. state, and incorporating detailed data on sociodemographics, individual-level property damage, and social cohesion.

Policy implications

Our findings reveal opportunities for policy change targeting populations that are at greatest risk of adverse mental health outcomes from climate change events. Our study highlights that those who live in rural areas and have experienced property damage may benefit from targeted prevention and outreach. In light of recent and rapid increases in access to telehealth use, these findings point to opportunities to focus efforts on increasing access to mental health care for rural populations [41]. Those who identify as young, White, college-educated, or female also may need greater mental health support for climate change-related distress, and yet developing tailored resources for climate distress prevention and resilience will be needed to target different subgroups. Because the patterns of risks found may be influenced by a greater propensity to report and attribute mental health issues to climate events, more research is needed to understand which groups are more likely to self-report mental health effects due to climate change.

Broad-based public health and policy actions are needed to address the upstream drivers of climate change-related mental health effects. For instance, a focus on building affordable housing and ensuring it is not located in areas highly vulnerable to wildfires or floods is an important preventive approach. The development of drought-resistant crops and protection at the rural-wilderness interface will be a critical step in the commitment to protect rural communities that are at particularly high risk of exposure to the effects of climate change [42].

In addition, our research highlights the need to improve the collection and sharing of data to assess climate change-related mental health outcomes. There are a growing number of standardized measures of climate distress [43, 44]. Such data will inform and shape the rapidly evolving landscape for new climate policies. For example, Wheat et al. highlight potential areas of opportunity to document exposure to forces of nature among clinicians using novel International Classification of Diseases (ICD) diagnostic codes [45]. Doing so can help researchers generate novel data and map mental health symptoms onto climate exposure data to better capture clinical presentation and timescale of symptoms [46]. Ultimately, this work could provide valuable information to clinicians and public health advocates to better address the growing mental health needs associated with climate change.

Conclusion

Exposure to climate events can adversely affect mental health, and we find roughly half of a state population impacted by climate events, with one-fifth of them reporting mental health consequences. However, this effect is not distributed equitably or uniformly based on individual sociodemographics, and importantly can be buffered with stronger social capital. There remains an urgent need to reduce the inequitable harms of climate change on mental health through increasing access to care and targeting resources for vulnerable populations. Public health interventions with rigorous evaluations are needed to address the mental health impacts of increasingly frequent and severe climate events.

Supporting information

S1 Text. Questions from the 2021 California Health Interview Survey.

https://doi.org/10.1371/journal.pclm.0000387.s001

(DOC)

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