importance of mental health research paper

Why the reliance on data? Findings and statistics from research studies can impact us emotionally, add credibility to an article, and ground us in the real world. However, the importance of research findings reaches far beyond providing knowledge to the general population. Research and evaluation studies — those studies that assess a program’s impact — are integral to promoting mental health and reducing the burden of mental illness in different populations.

Mental health research identifies biopsychosocial factors — how biological, psychological and social functioning are interacting — detecting trends and social determinants in population health. That data greatly informs the current state of mental health in the U.S. and around the world. Findings from such studies also influence fields such as public health, health care and education. For example, mental health research and evaluation can impact public health policies by assisting public health professionals in strategizing policies to improve population mental health.

Research helps us understand how to best promote mental health in different populations. From its definition to how it discussed, mental health is seen differently in every community. Thus, mental health research and evaluation not only reveals mental health trends but also informs us about how to best promote mental health in different racial and ethnic populations. What does mental health look like in this community? Is there stigma associated with mental health challenges? How do individuals in the community view those with mental illness? These are the types of questions mental health research can answer.

Data aids us in understanding whether the mental health services and resources that are available meet mental health needs. Many times the communities where needs are the greatest are the ones where there are limited services and resources available. Mental health research and evaluation informs public health professionals and other relevant stakeholders of the gaps that currently exist so they can prioritize policies and strategies for communities where gaps are the greatest.

Research establishes evidence for the effectiveness of public health policies and programs. Mental health research and evaluation help develop evidence for the effectiveness of healthcare policies and strategies as well as mental health promotion programs. This evidence is crucial for showcasing the value and return on investment for programs and policies, which can justify local, state and federal expenditures. For example, mental health research studies evaluating the impact of Mental Health First Aid (MHFA) have revealed that individuals taking the course show increases in knowledge about mental health, greater confidence to assist others in distress, and improvements in their own mental wellbeing. They have been fundamental in assisting organizations and instructors in securing grant funding to bring MHFA to their communities.

The findings from mental health research and evaluation studies provide crucial information about the specific needs within communities and the impacts of public education programs like MHFA. These studies provide guidance on how best to improve mental health in different contexts and ensure financial investments go towards programs proven to improve population mental health and reduce the burden of mental illness in the U.S.

In 2021, in a reaffirmation of its dedication and commitment to mental health and substance use research and community impact, Mental Health First Aid USA introduced MHFA Research Advisors. The group advises and assists Mental Health First Aid USA on ongoing research and future opportunities related to individual MHFA programs, including Youth MHFA, teen MHFA and MHFA at Work.

Through this advisory group and evaluation efforts at large, Mental Health First Aid USA will #BeTheDifference for mental health research and evaluation across communities in the US.

Learn more about MHFA Research Advisors and how you can share your research with us.

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Mental well-being and mental distress, measuring mental well-being in people with mental illness, mental well-being and mental health services, mental well-being and mental illness, should mental well-being be used to support the commissioning and delivery of mental health services, conclusions, mental well-being: an important outcome for mental health services.

Published online by Cambridge University Press:  02 January 2018

Mental well-being is being used as an outcome measure in mental health services. The recent Chief Medical Officer's (CMO's) report raised questions about mental well-being in people with mental illness, including how to measure it. We discuss whether mental well-being has prognostic significance or other utility in this context.

The World Health Organization defines mental well-being as an individual's ability to develop their potential, work productively and creatively, build strong and positive relationships with others and contribute to their community. 1 This view distinguishes subjective happiness or life satisfaction (hedonic well-being) from positive psychological functioning (eudaimonic well-being). The mental well-being literature can be confusing as many similar-sounding terms are used interchangeably: social or mental capital, positive mental health, psychological or subjective well-being. The WHO definition of mental well-being is concerned exclusively with positive mental health states, and this approach is also evident in the way that terminology is used in UK policy documents. Nevertheless, it is sometimes unclear whether the term ‘mental well-being’ implies the absence of mental illness or distress. Well-being has been trumpeted as a measure of national prosperity, and linked to improved physical and mental health. It has been identified as a public health target and criterion for commissioning and assessing mental health services. Reference Davies 2 But questions remain about the relationship between mental illness and mental well-being, and about the potential for diverting resources away from evidence-based treatments for mental disorders. These issues were highlighted in the recent Chief Medical Officer (CMO) report on public mental health that challenged the empirical grounds for extending mental well-being into clinical commissioning and argued against mental well-being ‘receiving priority funding over better established fields, including quality of life’. Reference Davies 2

Mental disorders are characterised by psychopathology, distress and impaired functioning. Huppert Reference Huppert 3 and others argued that mental disorders (‘languishing’) and mental well-being (‘flourishing’) were opposite ends of a single dimension. However, further work has shown that, although correlated, mental illness and mental well-being are independent phenomena. Secondary analysis of data on over 7000 adults from the 2007 Adult Psychiatric Morbidity Survey (APMS) demonstrated that associations with well-being scores were not significantly altered by adjusting for comorbid mental disorder. Reference Weich, Brugha, King, McManus, Bebbington and Jenkins 4 These findings were consistent with those from other studies that indicate that mental well-being is more than just the absence of mental illness symptoms and distress, and that (although correlated) mental well-being and mental distress are independent of one another. The APMS findings also showed that at least moderately high levels of well-being may be achieved in the context of mental illness, which is salient when considering whether mental well-being should be a routine outcome measure in mental health services. Reference Weich, Brugha, King, McManus, Bebbington and Jenkins 4 Evidence detailed later in this editorial also supports this conclusion. However, we know less about the determinants and variability of mental well-being among those who experience mental health problems than in the general population. As mental illnesses typically relapse and remit, mental well-being may vary with the phase of illness and the number, frequency or duration of relapses.

Evaluating interventions to improve mental well-being in people with mental illness depends on valid measurement, but there is only limited evidence to guide the assessment of mental well-being in this context. Reference Davies 2 This is a significant barrier to studying mental well-being and its potential determinants in people with mental illness. Reference Davies 2 Since mental well-being is a state of positive mental health, measures should comprise positively phrased items, such as those which make up the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS), Reference Tennant, Hiller, Fishwick, Platt, Joseph and Weich 5 WHO-Five Well-Being Index (WHO-5) Reference Bech, Olsen, Kjoller and Rasmussen 6 and the Satisfaction with Life Scale. Reference Kobau, Sniezek, Zack, Lucas and Burns 7

Although generic measures of mental well-being have been used for people with mental illness, their validity in these populations has rarely been evaluated; we do not know whether responses to generic mental well-being items may be biased by the experience of past or current mental illness. Only the WHO-5 has been validated in English in mental illness, specifically in affective and anxiety disorders. Reference Newnham, Hooke and Page 8 The Subjective Well-being under Neuroleptic Treatment Scale (SWN) Reference Vothknecht, Meijer, Zwinderman, Kikkert, Dekker and van Beveren 9 was developed for people with schizophrenia receiving antipsychotics. However, one-half of this scale comprises negatively worded items and it covers domains that are not central to mental well-being, including physical functioning. WEMWBS, despite being recommended by healthcare organisations for measuring mental well-being in the context of mental illness, has only been validated in non-clinical populations in the UK.

The 2011 UK government document No Health without Mental Health emphasised mental well-being as an important service outcome as part of patient-centred, recovery-focused care. 10 However, judging services according to mental well-being outcomes rather than changes in symptoms and disability is not self-evidently consistent with their traditional mission: the consequences of doing so need to be considered carefully. Measuring mental well-being routinely may alter therapeutic relationships in unintended ways. There is a risk that in prioritising mental well-being, professionals might be excused from achieving more challenging outcomes, namely alleviating symptoms and reducing disability. Reference Davies 2

We would argue that two conditions must be met to justify the routine assessment of mental well-being among mental health service users. First, evidence is needed that mental well-being modifies the risk of onset, recovery from or recurrence of episodes of mental illness; in other words that it has prognostic significance in terms of mental health, social functioning or use of healthcare. Second, it must be shown that mental well-being is independent of mental illness and social functioning and therefore unlikely to be captured by measures that assess either of these phenomena.

Although the behavioural and psychosocial determinants of mental well-being may not necessarily resemble those of mental illness, mental well-being is associated with specific forms of psychopathology – examples are discussed below. However, the evidence base is generally limited by substantial methodological variation (including the use of different and often unvalidated measures of mental well-being) and a dearth of longitudinal studies, inhibiting understanding of cause and effect. Reference Davies 2

Anxiety and depression

Maintaining high levels of mental well-being is likely to be difficult in the presence of symptoms of anxiety and depression. However, recent longitudinal data demonstrate that this may be more complicated than (simply) covariance. A recent study of over 1000 Australian in- and day patients with depression or anxiety demonstrated that an intervention (giving feedback during psychological treatment) improved depressive symptoms but not mental well-being, Reference Newnham, Hooke and Page 11 supporting the view that these are independent outcomes.

There is a wealth of cross-sectional evidence linking sleep problems and mental well-being, but less robust evidence of longitudinal associations. A small, prospective study of 75 university students Reference Pilcher, Ginter and Sadowsky 12 found no significant prospective improvements in life satisfaction among those whose sleep increased in duration or quality over 3-month follow-up. Those who reported a reduction in daily sleep quality over 3 months were significantly more likely to report a reduction in life satisfaction ( P <0.01). Reference Pilcher, Ginter and Sadowsky 12 Nonetheless, poor mental well-being in the context of sleep problems may not be associated with greater need for psychiatric care. A cross-sectional general population study of over 8000 Australians found that although the 5% with insomnia were significantly more likely to have poor mental well-being (odds ratio (OR) = 2.34, 95% CI 1.11–4.93) and visited their general practitioner more often (OR = 1.57, 95% CI 1.06–2.33), insomnia was not significantly associated with use of psychotropic medication or hospital admission. Reference Bin, Marshall and Glozier 13

Delusions and hallucinations

Mental well-being is inversely associated with psychotic symptoms. In 83 out-patients with schizophrenia, psychotic symptoms were negatively correlated with quality of life, but interestingly this association was confounded by insight, Reference Rocca, Castagna, Mongini, Montemagni and Bogetto 14 demonstrating the complexity of the relationship between mental well-being and mental illness. Among people with first-episode psychosis, admission to hospital was associated with better quality of life Reference Renwick, Jackson, Foley, Owens, Ramperti and Behan 15 suggesting that illness severity per se may not automatically predict well-being; better mental well-being might also reflect the quality and intensity of care received.

Social functioning and healthcare use

Social functioning is correlated with psychopathology but may be independent of mental well-being. Psychiatric out-patients with serious mental illness in remission demonstrated higher functioning scores but not higher well-being compared with similar patients not in remission, although this used the limited SWN to measure mental well-being. Reference Pinna, Deriu, Lepori, Maccioni, Milia and Sarritzu 16

Healthcare use and mental well-being may also be independent. A 2-year structured rehabilitation programme for those with serious mental illness led to improved quality of life and psychosocial functioning in those who met their rehabilitation goals v. those who had not. However, there were no significant differences in healthcare use between the two groups at 2-year follow-up. Reference Svedberg, Svensson, Hansson and Jormfeldt 17

Valid methods of evaluating healthcare interventions are required to support payment by results, and National Health Service providers are required to collect patient-reported outcomes and experiences in part to prevent ‘gaming’ to maximise income. Mental well-being could serve as a patient-rated outcome measure, but the dearth of validated measures in people with serious mental illness remains a major concern. The CMO has sensibly encouraged policy makers and commissioners to heed the uncertainty surrounding mental well-being, warning that ‘wellbeing policy is running ahead of the evidence’. Reference Davies 2 However, existing evidence suggests that symptomatic and functional outcomes, needs for care and service use appear to be independent of mental well-being to varying degrees. Therefore, mental well-being is not captured completely by existing measures of these states. Mental well-being also has strong conceptual resonances with recovery from mental illness, including notions of hope, purpose and fulfilment, and may be similarly valued by patients. Taken together, these could represent significant arguments for mental well-being as a distinct service outcome in its own right. However, the utility of measuring mental well-being routinely in mental health services has not yet been established. Further research is needed to validate measures of mental well-being in people with serious mental illness, determine the usefulness (and costs) of routinely measuring mental well-being in this population, and to explore the views of patients on the relative importance attached to different service outcomes.

The place of mental well-being in the delivery of mental healthcare remains uncertain and the CMO has stated categorically that this should not be part of current clinical commissioning. Nevertheless, mental well-being is an important public health heuristic and has clear resonances with concepts underpinning recovery from mental illness. The evidence base linking mental well-being and mental illness remains poorly developed, but we believe that two conditions for measuring mental well-being in mental health services have been at least partly met. It appears that mental well-being may be associated with onset, recovery and/or recurrence of episodes of mental illness although the actual detail of these associations is complex; and that it is at least partly independent of symptoms, social functioning or need for mental healthcare. Mental well-being is not fully captured by measures of these phenomena.

However, there are two important caveats. First, it is essential to validate measures of mental well-being in people with serious mental illness, and to know more about the (relative) value that patients place on mental well-being as a service outcome. And second, mental well-being must not be allowed to supersede other outcomes and obscure the imperative to deliver the most effective evidence-based treatments to those with mental illness.

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• Published: 10 May 2023

Mental health awareness: uniting advocacy and research

Nature Mental Health volume  1 ,  pages 295–296 ( 2023 ) Cite this article

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Mental Health Month has been observed to reduce the stigma that is associated with mental illness and to educate the public and encourage individuals to make their mental health and wellbeing a priority. It is an important moment to bring the strengths of advocacy groups and researchers together to promote mental health awareness and to improve equity.

Observances have become a popular tool to garner media and notice for topics deserving attention, from medical conditions to public health concerns, commemoration of notable events, or celebration of cultural groups. Codifying the scope and needs connected to an issue or illness through awareness campaigns can provide opportunities for imparting useful information, reducing stigma and marshalling support for policy change. The impact of awareness campaigns can be difficult to measure beyond tallying social media mentions or news stories. Effective advocacy, however, extends beyond traffic and paves the way for the creation of knowledge and partnerships among allies and with those whose interests are being represented. When the magnitude of an issue and the potential for improvement are great and are matched by broad involvement and recognition by stakeholders, the possibility for impact is also great.

Held annually in May, Mental Health Month , also called Mental Health Awareness Month, is an observance with such reach, resonating with many people. Nearly everyone has experience with the challenges that are associated with mental health, either first-hand or through loved ones or in their community. There is a need for education, support and initiative to improve our understanding of the causes of mental health disorders and to increase the availability of resources for prevention and treatment. Mental Health Month also offers the possibility of bringing together groups who often work in parallel, such as mental health advocates and mental health research organizations, that can mutually benefit from each other’s functions and expertise.

Mental Health Month was first established in the US in 1949 by the National Mental Health Association, now known as Mental Health America . At a time more often associated with the outset of the Cold War and Marshall Plan than setting an agenda for domestic mental health and wellbeing advocacy, in the more than 70 years since, Mental Health Month has grown into an international event designed to reduce exclusion, stigma and discrimination against people with mental health conditions or disorders. Mental Health America are joined by other prominent mental health advocacy groups to sponsor related observances: Mental Health Awareness Week Canada (1–7 May, 2023) and Europe (22–28 May, 2023); and federal agencies such as the Substance Use Abuse and Mental Health Services Administration ( SAMSHA ) in the US, promoting related public education platforms, including National Prevention Week (7–13 May, 2023).

Observances and awareness campaigns also provide occasions to put mental health in context. Increasing acknowledgment of the role of social determinants, for example, as mechanisms that can increase vulnerability for developing disorders and that drive disparities in mental health are an important framework to underscore as part of promoting mental health awareness. Given the complex and broad scope of people, disorders, conditions and issues under the umbrella of mental health, observances also give us the chance to focus more closely on specific problems or experiences. The theme for Mental Health Month in 2023 is ‘Look Around, Look Within’, which emphasizes the interdependence of mental health and wellness with an individual’s internal and external experiences and environments.

“The ‘Look Around, Look Within’ theme builds on the growing recognition that all humans have mental health needs and that our available resources to build resilience and heal come in many forms — including in the natural world,” explains Jennifer Bright, Mental Health America Board Chair and President of Momentum Health Strategies. “Mental Health America’s strategic plan, focused on NextGen Prevention, carries a similar theme — that the social factors supporting mental health are essential building blocks. These encompass basic needs like healthy food, stable housing, and access to treatment and supports, but they also include spirituality, connection with peers with lived experience, and safe and natural spaces.”

Overlapping with Mental Health Month, Mental Health Foundation sponsors Mental Health Week in the UK (15–21 May, 2023), dedicating this year to raising awareness around anxiety. It shares an individual-centered approach to advocacy. In addition to providing toolkits and resources that point to how prevalent stress and anxiety can be to reduce stigma, it also promotes the accessibility of coping strategies for managing anxiety. As part of the Mental Health Awareness Week campaign, Mental Health Foundation and others use the international symbol of wearing a green ribbon or clothing to physically raise awareness around mental health. Nature Mental Health also incorporates the symbol of the green ribbon on the cover of this month’s issue and as our journal theme color. Green evokes the ideas of vitality, growth, new beginnings and hope — powerful imagery in mental health awareness.

Alongside stories, sponsorships and social media resources, mental health advocacy toolkits and strategy documents include fact sheets and messaging that are shaped and informed by research. Yet, there is often a perception that a divide exists between the mental health advocacy and research spaces, but observances such as Mental Health Month can bridge the two.

According to Lea Milligan, Chief Executive Officer of MQ: Transforming Mental Health , an international mental health research organization, there are complementary approaches and priorities in advocacy and research: “Mental health research can be used to bolster awareness by providing evidence-based information and resources that can help individuals and communities better understand mental health and the factors that contribute to mental health problems. This can include information on risk factors, prevention strategies, and available treatments.”

In addition, increased efforts to involve people with lived experience of mental illness in the research enterprise is a goal that is well-served through connection with advocacy. “While MQ is primarily focused on promoting mental health research, it also recognizes the importance of advocacy in advancing the mental health agenda” suggests Milligan. “MQ advocates for increased funding and support for mental health research, as well as policies that promote mental health and wellbeing. Additionally, MQ seeks to empower individuals with lived experience of mental health conditions to be involved in research and advocacy efforts, and to have their voices heard in the development of policies and programs that affect their lives. MQ provides resources and support for individuals with lived experience who wish to be involved in research or advocacy efforts, including training programs, research grants, and opportunities to participate in research studies.”

Involvement or engagement is certainly one of the most important metrics of advocacy. By strengthening collaboration between advocacy and research organizations and identifying the mutual areas of benefit, such as engagement and increased funding, we may find new ways to green light mental health awareness and action toward mental health equity.

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• http://orcid.org/0000-0002-3609-9407 Derek K Tracy 1 , 2 , 3 , 4 ,
• Christopher Hilton 1 , 5
• 1 West London NHS Trust , London , UK
• 2 Brunel Medical School , Brunel University , London , UK
• 3 Institute of Psychiatry, Psychology, and Neuroscience , King's College London , London , UK
• 4 Department of Psychiatry , Imperial College London , London , UK
• 5 Department of Public Health , Imperial College London , London , UK
• Correspondence to Professor Derek K Tracy; derek.tracy{at}nhs.net

https://doi.org/10.1136/leader-2024-001052

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• productivity
• mental health
• continuous improvement
• learning organisation

‘ Productivity isn’t everything, but in the long run, it’s almost everything ’—Paul Krugman, Nobel Laureate (Economics)

Why such clinical ambivalence towards a word?

Productivity is a dirty little word for many in healthcare. There is something corporate, industrial with a soviet-twist, and anathematic to many clinicians’ sense of why they entered their professions. It smacks of management-speak, with inferred anxieties about the presumptive need for ‘more’, and has been described as ‘ a subject guaranteed to kill the attention of clinicians and patients’ . 1 It also has a flavour of insensitivity in an era of a fatigued workforce with rising levels of reported burn-out and staff quitting healthcare and industrial action over pay and conditions.

Perhaps clarity over definitions and phrasing is key. The Office for National Statistics (ONS) is often considered the most authoritative source for NHS productivity performance data, and defines productivity as how well healthcare creates outputs (eg, outpatient appointments) from inputs (such as investment in staff and medication). 3 However, outputs in healthcare are more complex than in some other industries. Activities per person-hour may be a crude measure for national economic performance, but in healthcare doing more does not always mean more people getting better . For this reason, the ONS typically measures ‘quality adjusted’ outputs when reporting public service healthcare productivity. 4 Similarly, the King’s Fund nuances productivity definitions to include the quality of the output, such as patient outcomes, as a defining factor. 5

Anecdotally, when, as a leadership team, we posted a question to a room of over 50 senior staff, we observed cynicism at the need for ‘cost improvement programmes’. However less than half agreed that their own service ‘worked in the most efficient way’, and a desire for efficiency improvements on the back of this was unanimous. Clinicians may find themselves more aligned with a related narrative that translates this to the words of enhancing quality, safety and patient experience, in their native language of research, innovation and QI.

Postpandemic money and staff: the questions are not going away

The issue certainly has contemporary resonance. As the dust settles and a postpandemic world emerges with a return of most clinical services, a light is being shone the growing costs of healthcare, and additional investments made during this period.

UK data show an increase in health spending of over £20 billion per annum after pandemic. 6 Analysis from the Institute for Fiscal Studies highlighted staffing increases from almost 16% in consultant numbers to just under 25% in junior doctors between 2019 and 2023. Yet, with this extra money and staff, there has been no evident-related improvement in key markers such as waiting times or outpatient appointment numbers offered. In fact, many markers have deteriorated, with reported overall satisfaction in the NHS at its lowest level for 40 years. 7

More specifically, in our NHS Integrated Care System, North West London, recorded referral activity in mental health services has not grown at the same rate as additional investment in the past 5 years ( figure 1 ). Although there may be numerous factors to account for this, the divergence between investment and activity is as an apparent ‘productivity gap’ that warrants careful examination.

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Adult mental health (MH) expenditure and referral activity in the North West London (NWL) Integrated Care System. Figure created by the authors based on publicly available information in the July 2024 NWL ICB (Integrated Care Board) report. 25

Commissioners can point to real-terms increases in investment, however, crude temperature checks usually affirm that neither patients nor clinicians feel any uplift or positive change; indeed, the popular narrative typically remains one of service decline.

In the USA, the profitability of health systems has been under pressure due to rising costs and labour shortages, and measures to tackle rising costs by improving productivity and implementing technological solutions, including the adoption of artificial intelligence (AI) within workflows, are seek across the industry 8 —suggesting that the productivity narrative is not unique to the UK’s system of taxpayer-funded healthcare.

What is happening? One can put forth various putative explanations: the nature of the work has changed after pandemic, with rising clinical need and complexity; there is presenteeism among a low-morale workforce feeling under the cosh; inflation is an inevitable outcome of a crumbling infrastructure. Or are we looking at the wrong things?

Amanda Pritchard, the chief executive of NHS England, has argued that routine measurements fail to capture community care and diagnostics and—crucially we believe—where there has been improvement to care quality rather than quantity delivered. 9 Against what many expect on the topic, healthcare systems are typically very lean on managers; as an example, in the UK, they account for about 2% of the public healthcare workforce against a national corporate average closer to 10%. 10 Perhaps this is just too thin to effectively manage these complex systems.

Recent Think Tank blogs and healthcare industry publications are abuzz with the topic: writing for the King’s Fund, Siva Anandaciva noted the number of dedicated productivity reviews in recent years, how it remains a political priority, and, provocatively, that ‘ if we really knew what was going on with NHS productivity, we wouldn’t be talking about it so much’ . 11 Thea Stein, the chief executive of the Nuffield Trust, wrote recently, ‘ Politicians are clear, as are the Treasury, that they want an answer to why productivity is falling. ’ 12 Aligning with this, at a Nuffield Trust summit in March 2024, the British health secretary Victoria Atkins stated, ‘By the summer NHS England will start reporting against new productivity metrics, not only at national level but also across integrated care boards and trusts…[with] new incentives to reward providers which hit productivity targets,’ promising reinvestment for those who meet these. 13 Like it or loath it, productivity is here to stay in healthcare.

Mental health exceptionalism

When it comes to productivity, mental health has typically claimed exceptionalism. How much easier, goes the cry, to measure the number of completed hip replacements, complication rates from cardiac stent insertions or improvement in forced expiratory volume in 1 s to a bronchodilator medication. Far harder, it is posited, is weighing sunshine in mental health and capturing what is sometimes argued to be the realm of the subjective inner mind. This might have some truth to it, but those working in physical health services will likely push back that they remain held accountable to delivery targets on waiting times and financial envelopes more than care quality.

Further, mental health research journals are filled with nothing but clinical measurement and change. Indeed, much of it in recent times has been a rebuttal to a perceived different form of mental health exceptionalism: stigma. There is a contemporary emphasis on how data from mental health research highlight that health outcomes are as good as in the management of any comparable physical health field. But this has seldom seemed to translate into service delivery in terms of wide-scale use of clinical data outside of specific, often non-real-world, research trials.

One result is that we end up tracking and reporting process key performance indicators, such as mean duration of inpatient admission. These tell us something , but perhaps have little value to clinicians or patients, and tell us less than we would like about care quality. 14 For example, counting the number of times the patient has been ‘seen’ raises the question of what this actually means : in terms of a mental illness, repeated clinical reviews might ultimately be a measure of ineffective care, when a successful intervention may arguably result in the need for fewer contacts.

This ambiguity and a sense that routinely collected data matter little are too often compounded by information technology (IT) systems that seem to hinder rather than help busy clinicians. In our organisation, we demonstrated that it takes an average of 27 clicks of a computer mouse to complete the mandated measurement of ‘recording and outcoming’ an appointment in our mature electronic record system. Frustratingly, only if this series of actions were taken could this activity be counted by our number-crunching colleagues who generate reports of our productivity. After all this work—if it is done, and done properly—out pops one of a handful of data points such as ‘attended’, ‘did not attend’ and so forth, with little nuance. The UK government commissioned Dr Geraldine Strathdee (former National Clinical Director for Mental Health) to undertake a rapid review to improve the way data and information are used in relation to patient safety in mental health inpatient settings and pathways—her observations were damning 15 :

When we first established the review, one of our assumptions was that the data burden on staff was too high and that we would need to make recommendations to reduce it. However, we were not prepared for the sheer scale of the issue… it was common for frontline nursing and clinical staff to spend as much as half their shifts in the office entering data. We were told by Trust leaders that roughly half of their analysts’ time was used to flow data to national and local data sets instead of providing support for quality improvement to frontline staff.

Harder still to measure, even with simplistic appointment models of attend/did not attend, is the impact of multiprofessional care. This is particularly pertinent in mental health services that require biopsychosocial assessments and interventions with a team-based approach to treatment. This includes ‘activity’ that may be purchased by healthcare systems but are less amenable to capture with their technology or IT systems, due to delivery by partner agencies, voluntary sector organisations and increasingly by peers with lived experience. The indirect input of clinicians providing consultation, supervision and direction through other team members has been clearly described for psychiatrists for over 20 years, and arguably has been reborn in the UK’s national community framework. 16 ‘Advice and guidance’ into primary care-led integrated neighbourhood teams is expected to support a wider and more flexible cohort of patients in the lowest acuity setting—but this ‘activity’, which for some professionals may amount to the majority of their working week, is rarely adequately recorded.

Part of this harks back, in the UK and many other countries, to a mental health ‘block contract’ funding model that has traditionally side stepped the need to capture ‘billable’ work for each individual ‘customer’. Rather, an approximated large amount of money with which to deliver care to a given population is allocated. While perhaps simpler, it may disincentivise the kinds of granular activity recording that can generate ‘profits’, and arguably innovation and quality of care. Further, there are data suggesting that the model typically keeps mental health organisations ‘within budget’ as they work to this rather than trying to show performance data, with any surpluses skimmed off into a system control total for inevitably overspending acute healthcare. This is changing, and perhaps that is to be welcomed. The question is what our key measurements will be. Worldwide, the majority of countries fall short of WHO-recommended levels of mental health investment, however, even where investments are made based on billable specialist activities and interventions, this may be at the expense of community and grassroots activities and primary care-based mental health, which may also impact on societal mental health. 17

Over the years, there have been attempts to redress this with varying degrees of success. In the UK, the phrases ‘clustering’, ‘HoNOS’ (Health of the Nation Outcome Scale, a mandated but poorly completed and used attempt at developing a universal clinician-reported outcome measure) and ‘payment by results’ risk triggering traumatic angry responses from mental health clinicians forced to fill out forms on their patients that were argued to map little onto clinical states, added nothing to care, yet formed the basis of putative payment ‘tariffs’. The inevitable outcomes were poor completion and ‘gaming’ of data. In the coming years, a revised UK mental health ‘currency’ is planned which maps nationally captured coded mental health activity data against pricing for core mental health services delivered, 18 and it remains to be seen if the same problems will recur. More contemporaneously has been the slow and inconsistent rise of clinical outcome measurements.

One of the largest growth areas in mental health services in the UK over the last 15 years has been the development of Improving Access to Psychological Therapies (IAPT)—now known as ‘Talking Therapies’—services under the last Labour government from 2008. The hypothesis of economist Lord Layard, the father of the service, was that tackling common mental disorders with evidence-based interventions would positively impact on well-being and productivity of the workforce, improving employment rates and reducing welfare costs. Unsurprisingly perhaps, IAPT is one of the few areas where ‘recovery’, measured using validated tools such as Patient Health Questionnaire-9 and Generalized Anxiety Dirorder-7, is robustly captured. In 2022–2023, there were 672 000 individuals who completed treatment in IAPT services, with 49.9% of these individuals achieving ‘recovery’. 19

For traditional mental health services, there is more work to do, and we are currently seeing a move towards DIALOG, and a reasoned desire for consistency across services for several cross-comparative and longitudinal reasons. Nevertheless, with few exceptions and despite these slow shifts, in what might sound a strange and uncomfortable statement to utter aloud, in 2024 we are not able to consistently measure and report clinical change in our patients.

Ways forward

So why should we care, and what should we do? We argue that productivity clearly matters, and mental health exceptionalism needs to end. Any complexity in the clinical field needs to be appropriately addressed with the right markers. In our opinion, to get the progress we need, movement is needed in three directions.

First, clinicians need to be engaged in discussions on productivity. While we are awash with QI teams, data suggest we are not really embedding them into how organisations think and learn, and adequately empowering frontline staff to make changes they know will be effective. 1 We believe that this is a two-way responsibility: managers need to create this space, but frontline staff need to step into it and inform this discussion. Research is unambiguous that an uninvolved workforce with low morale just perform less well. 20 It is not just that it is the right thing to engage staff—of course it is—but this shift cannot succeed without this. Without their voices, we are too liable to default to easier-to-measure but less meaningful process markers, such as mean duration of stay.

In our own services, in West London NHS Trust, we are seeking to engage our workforce at all levels in the accurate capture of their work, both in terms of valuing their outputs (‘Your time counts—let’s make sure it’s counted’ ) ( figure 2 ) as well as outcomes , engaging with services to incorporate clinician and patient-reported measurements (such as DIALOG) into all our work. By combining the efforts of our clinical, operational management, transformation and business intelligence professionals, we have implemented successive rounds of incremental improvement focusing on improved activity capture, targeted interventions and high-impact service redesign—with the key focus of protecting investment in our services by seeking to eliminate the perceived ‘productivity gap’.

West London National Health Service (NHS) Trust’s ‘Your time counts’ posters and visual graphics for staff. Photograph copyright of the authors, graphic used with permission of West London NHS Trust.

Clinicians have an intuitive, inherent understanding of what makes a ‘good’ or ‘bad’ service, and insights into where things are, or are not working, and/or captured by data. Appropriately supported, they can be effective champions of change, and instigators of more effective initiatives and innovations. We also advocate ‘quick wins’ to show (and showcase), in a manner to how QI typically operates, how together we can attain more productive services, and how this can be of immediate gain. Examples are too numerous to fully list, but might include changing to electronic communication instead of posted letters for patients who prefer this, intelligent rostering of community visits to minimise travel requirements and instigating more effective job plans that more thoughtfully and effectively lay out clinical expectations in a way that provides better and more compassionate care, or harnessing tools such as predictive analytics to identify impending crisis and improve case load prioritisation.

Second, too often information systems are not supporting—and indeed are potentially hurting—clinician engagement. There is a perversity, therefore, that in order to evidence improved productivity, our activities to actually do so distract from the clinical jobs at hand. To our knowledge, no healthcare system (and no mental health system in particular) has mastered the art of passive data capture—where the labours of staff are captured invisibly. This needs to be recognised. Well-intentioned policy documents such as the NHS Workforce Plan 21 speak aspirationally of how ‘ AI (artificial intelligence) can free up staff time and improve efficiency’ , and ‘ robotic process…available 24/7 and can undertake tasks 4–10 times faster with fewer errors ’. Such statements are frankly just liable to antagonise a workforce faced with multiple electronic patient records that do not adequately speak to each other. Perverse incentives reward (and require) staff spending more time on active data entry away from direct patient care: if that is what we measure, then we cannot complain when it is the outcome. A more realistic and honest approach is required, remedying or ameliorating where possible—and aspiring to a passive recording approach—and in the mean time being honest with staff where IT remains part of a problem. Further, organisations have perhaps been slow to fully tap into other forms of rich information that is often outside of traditional hard-coded databases. Immediate examples include better use of quantitative and qualitative intelligence from patients, carers, and staff feedback, experience and explicit insight gathering.

Third, managers and leaders need to be cognisant of how such discussions can feel in a stretched, tired and sometimes disillusioned workforce. We agree with the Nuffield Trust that there is a lack of shared understanding on this topic, 12 and leaders need to breach this divide. Frontline staff roles might keep them blind-sighted to broader regional or national conversations and tariffs. Here is where managers and leaders have a key role informing and guiding what might be within a team, service or organisation’s gift to set up or agree with a commissioner, regional or national regulator or others, and what might not be, with a need to adhere to relevant agreed targets. One critical factor must be to ensure that all data captured are fed back in a digestible way to the staff that enter it, and in a way which allows them to benchmark themselves with their peers. Too often data captured are scrutinised in aggregate at boards and by external oversight meetings, yet the staff members themselves never see or learn to understand it. Nothing is more demoralising than knowing you are working much harder than your immediate colleague, especially if they are paid more through an agency assignment—but perhaps shining a light on this with dashboards visible to all allows staff to compare their workload and self-correct? One US healthcare provider based in New York state (Summit Health) describes this approach as ‘measured accountability’. 22

Increased productivity should have us working smarter, not harder, and evidencing the great work that is already occurring. It must benefit clinicians, the care and services they provide and ultimately patient outcomes, and not just help fulfil a Board paper’s integrated performance report. The lead author was recently struck by one of our organisation’s staff posters that said ‘Kindness counts’: this is true, and part of our values, but to turn this around, we do not count kindness as any form of measure. Norrish et al have argued that social capital is as important as financial capital in healthcare, 23 and writing in this journal, Klaber et al have recently emphasised that placing kindness at the centre of leadership is underused yet essential to advance care and build productive services. 24 Bravery might be required in letting some erstwhile activities and measurements fall by the wayside, rather than the current model that seems to just acquire new things to add to our measurement.

We believe that there is a necessary yet healthy conversation that can be had. Its time has come, but—and perhaps here is mental health’s strength—it needs to be held in the right way with our staff and patients.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

• Berwick DM ,
• Whittington J
• The King’s Fund
• Kirkpatrick I ,
• Anandaciva S
• Phillips DM
• Strathdee G
• Lund C , et al
• ↵ NHS talking therapies, for anxiety and depression, annual reports, 2022-23 . London, UK NHS Digital ; 2024 .
• Loeppke R , et al
• Norrish A ,
• Biller-Andorno N ,
• Ryan P , et al
• Mountford J ,
• North West London ICB

X @derektracy1, @@drchrishilton

Contributors The authors both conceived of and wrote the editorial.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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Climate change and mental health: Position paper of the European Psychiatric Association

Lasse brandt.

1 Department of Psychiatry and Psychotherapy, Charité – Universitätsmedizin Berlin, Charité Campus Mitte, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany

2 German Center for Mental Health (DZPG), Germany

Kristina Adorjan

3 Department of Psychiatry and Psychotherapy, School of Medicine, Ludwig-Maximilians-University of Munich, Munich, Germany

4 University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland

Kirsten Catthoor

5 Estates-General of Mental Health, Kortenberg, Belgium

6 Flemish Association of Psychiatry, Kortenberg, Belgium

7 Collaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp, Antwerp, Belgium

8 Ziekenhuis Netwerk Antwerpen, Psychiatrisch Ziekenhuis Stuivenberg, Antwerp, Belgium

Eka Chkonia

9 Department of Psychiatry, Tbilisi State Medical University, Tbilisi, Georgia

Peter Falkai

Andrea fiorillo.

10 Department of Mental Health, Collaborating Centre for Research and Training, University of Campania “L. Vanvitelli” & WHO, Naples, Italy

Tomasz M. Gondek

11 Iter Psychology Practices, Wroclaw, Poland

Jessica Newberry Le Vay

12 Institute of Global Health Innovation, Faculty of Medicine, Imperial College London, London, UK

13 Grantham Institute - Climate Change and the Environment, Faculty of Natural Sciences, Imperial College London, London, UK

Martina Rojnic

14 University Hospital Centre Zagreb, Zagreb, Croatia

15 School of Medicine, University of Zagreb, Zagreb, Croatia

Andreas Meyer-Lindenberg

16 Central Institute of Mental Health, Department of Psychiatry and Psychotherapy, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany

Andreas Heinz

17 Bernstein Center of Computational Neuroscience, Berlin, Germany

18 Berlin School of Mind and Brain, Berlin, Germany

19 Faculty of Medicine and Social Sciences, University of Antwerp, Wilrijk, Belgium

Jurjen J. Luykx

20 Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, The Netherlands

21 Department of Psychiatry, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands

22 Outpatient Bipolar Disorders Clinic, GGZ InGeest Mental Healthcare, Amsterdam, The Netherlands

Climate change is one of the greatest threats to health that societies face and can adversely affect mental health. Given the current lack of a European consensus paper on the interplay between climate change and mental health, we signal a need for a pan-European position paper about this topic, written by stakeholders working in mental health care.

On behalf of the European Psychiatric Association (EPA), we give recommendations to make mental health care, research, and education more sustainable based on a narrative review of the literature.

Examples of sustainable mental healthcare comprise preventive strategies, interdisciplinary collaborations, evidence-based patient care, addressing social determinants of mental health, maintaining health services during extreme weather events, optimising use of resources, and sustainable facility management. In mental health research, sustainable strategies include investigating the impact of climate change on mental health, promoting research on climate change interventions, strengthening the evidence base for mental health-care recommendations, evaluating the allocation of research funding, and establishing evidence-based definitions and clinical approaches for emerging issues such as ‘eco-distress’. Regarding mental health education, planetary health, which refers to human health and how it is intertwined with ecosystems, may be integrated into educational courses.

Conclusions

The EPA is committed to combat climate change as the latter poses a threat to the future of mental health care. The current EPA position paper on climate change and mental health may be of interest to a diverse readership of stakeholders, including clinicians, researchers, educators, patients, and policymakers.

Introduction

Climate change is among the anthropogenic processes with the most critical impact on the equilibrium of Earth’s systems. The United Nations Framework Convention on Climate Change defines climate change as the change of climate, which is attributed directly or indirectly to human activity that alters the composition of the global atmosphere [ 1 ]. Notably, the change in climate is in addition to natural climate variability observed over comparable time periods and caused by human activity [ 1 ]. Environmental studies indicate that Earth is now outside of a safe operating space for humanity and that anthropogenic effects such as climate change, loss of biodiversity, and pollution interact and show aggregate effects on Earth’s systems [ 2 ]. Carbon dioxide and other greenhouse gas (GHG) emissions, such as methane, contribute significantly to the rising global surface temperatures [ 3 ]. According to the United Nations’ Intergovernmental Panel on Climate Change (IPCC), the world is currently experiencing the largest increase in the Earth’s surface temperature in over 2000 years [ 3 ]. Heat extremes, that is, temperatures exceeding previous maxima, have been observed in most inhabited regions of the world and there is unequivocal evidence for the human contribution to heat extremes [ 3 ]. These heat extremes are associated with risks to physical and mental health [ 4 ]. Vulnerable groups, such as young children and older people over the age of 65 years, are particularly affected by the increase in heatwaves [ 5 ]. Climate change leads to an increase in extreme weather and disasters and causes worsening of existing inequalities regarding psychosocial and economic factors [ 5 ].

Given the importance of climate change for mental health(care) on the one hand and the lack of a European consensus paper on the interplay between climate change and mental health on the other, we signal a need for a pan-European position paper about this topic, written by stakeholders working in mental health care. The EPA is committed to combat climate change as the latter poses a threat to the future of mental health care. Therefore, on behalf of the EPA we give recommendations to make mental health care, research, and education more sustainable. To that end, we start the position paper by summarising the impact of climate change on mental health, then discuss strategies to increase sustainability in mental health care, and end by providing recommendations for people working in mental health patient care, research, and education across Europe.

We performed a narrative review of the literature. The databases PubMed, MEDLINE, and Web of Science were searched from database inception up until April 2024, without restrictions to language or country of origin of the study or publication date (search terms: “climate change” AND “mental health”). We manually searched references of the included studies and performed additional selective searches with a search engine (i.e., Google Scholar). We included original research and reviews focussing on climate change and mental health. The articles we retrieved were reviewed and qualitatively synthesised according to the effects of climate change on mental health.

Impact of climate change on mental health

The number of scientific articles on the impact of climate change on mental health has increased significantly over the last two decades [ 5 , 6 ], providing evidence of the negative effects of climate change on mental health [ 4 , 5 ]. Climate change can have a direct impact on mental health, for example through heat, extreme weather, disasters, and air pollution [ 7 , 8 ]. Indirect negative impacts include food insecurity, climate-associated migration, and climate inequality ( Figure 1 ). Direct and indirect consequences of climate change are interconnected and all pose threats to mental health, particularly for vulnerable groups with limited coping capacities and pre-existing mental disorders [ 4 ].

Direct and indirect effects of climate change, loss of biodiversity, and pollution (i.e. triple planetary crisis [ 9 ]) on mental health.

Climate change affects mental health across borders and there is a need for international psychiatric organisations and representatives to advocate for evidence-based positions and policies regarding climate change and mental health. The EPA aims to address this omission in the literature with the current position paper that includes recommendations for sustainability in mental health care, research, and education. The current position paper by the international task force of the EPA complements other position papers by national organisations such as the Royal College of Psychiatrists and the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) [ 7 , 10 ].

In the section below, we discuss the direct and indirect effects of extreme weather events, disasters, increases in ambient temperature, and air pollution on mental health as well as discuss forms of mental distress due to climate change. In keeping with the IPCC, we focus on climatic impact drivers, such as disasters (e.g. flooding) and extreme heat and highlight the available evidence [ 3 ]. Climate change is the focus of this position paper, but it is very important to note that climate change is connected to a multitude of other planetary-scale environmental processes and ecological crises, such as loss of biodiversity [ 2 ].

Extreme weather events and disasters

Climate change is leading to an increase in extreme weather and disasters [ 5 ]. Extreme weather events include floods, storms, fires, and droughts [ 5 ]. Extreme weather events can reach the scale of disasters, threatening physical integrity and destroying livelihoods and critical infrastructure [ 3 , 5 ].

Extreme weather events and disasters can result in significant mental distress via different pathways [ 4 , 11 , 12 ]. These pathways include the experience of mortal danger, the threat to livelihoods, limited access to health care, and involuntary relocation, as well as the loss of property, work, and social support [ 4 , 11 ]. The mental symptom severity depends on the extent to which the person is affected by the environmental event [ 11 , 12 ] and the symptoms can last for years [ 13 ]. A recent systematic review of studies from South and Southeast Asia identified risk factors in demographic, economic, health, disaster exposure, psychological, and community factor domains. For example, the following were found to be risk factors for mental health disorders in the recent systematic review: severity of disaster exposure, lower education, and financial stress [ 14 ].

The prevalence of post-traumatic stress disorder (PTSD) increases after disasters [ 15 , 16 ]. After Hurricane Katrina, one in three residents of New Orleans showed symptoms of PTSD [ 16 ]. Symptoms of anxiety, psychosis, and depression including suicidal thoughts may increase following extreme weather and disasters [ 12 , 17 , 18 ]. Floods are among the most frequently recorded extreme weather events worldwide [ 7 , 19 ]. One year after a flood in England, 36% of the regional population suffered from PTSD, around a quarter suffered from anxiety disorders and a fifth from depression [ 20 ]. In follow-up studies, the persistence of symptoms in those affected by the floods was demonstrated even after several years [ 13 ]. The prevalence of depression and anxiety symptoms was two to five times higher in people who were affected by flooding at home than in people who were not affected by flooding [ 21 ]. In another example, it was highlighted that half of the residents of New Orleans suffered from an affective or anxiety disorder in the 30 days following Hurricane Katrina [ 16 ].

There is also an increased prevalence of affective disorders following droughts, bushfires, and forest fires [ 4 , 17 , 18 ]. Droughts are increasing in severity and frequency due to climate change [ 7 ] and droughts are a major driver of climate-associated migration [ 22 ]. As a result of droughts, vulnerable groups, such as women, individuals with low socioeconomic status, minors, and older individuals, are at increased risk of mental health problems [ 4 ]. There are also indications of increases in alcohol and other substance use and domestic violence following disasters [ 4 ].

Increases in ambient temperature

Since the end of the nineteenth century, the average global surface temperature has increased according to data since 1850 [ 23 ]. The rise in temperature has been especially fast over the past fifty years, with an increase in average global surface temperature of 0.2°C per decade [ 3 , 24 ]. Compared with the average global surface temperature, Europe is warming even faster [ 3 , 24 ]. Europe’s land areas were 2.04 to 2.10°C warmer in the past 10 years than during the pre-industrial period [ 3 , 24 ]. Temperatures are projected to increase further, particularly in north-eastern Europe, northern Scandinavia, and inland areas of Mediterranean countries, while slower increases in temperature are projected for western Europe [ 3 , 24 ]. The increase in temperature includes average global surface temperature as well as heat extremes. Both aspects are associated with negative mental health outcomes [ 3 ].

Heat has emerged as one of the most comprehensively studied aspects of climate change in the context of mental health [ 5 ]. In the general population, periods of heat are associated with increases in mental health problems, such as stress and negative emotions [ 25 ]. Heat leads to increased mortality [ 26 ] and psychiatric disorders are a leading risk factor for heat-related deaths [ 27 , 28 ]. An increased mortality risk was identified for organic mental illnesses such as dementia [ 26 ]. In vulnerable persons, such as persons with mental disorders, the potential impact of medication on regulation of body temperature, fluid balance, and electrolytes should be assessed [ 28 , 29 ].

A recent meta-analysis reported that at high ambient temperatures an increase in average temperature by 1 degree Celsius is associated with a 0.9% increase in mental health morbidity [ 26 ]. Another recent systematic review indicated that individuals with mental disorders were at risk of increased morbidity and mortality compared with individuals without mental disorders over a single day with high temperatures [ 30 ]. In addition, both global warming and heat waves are associated with increases in acute admissions to psychiatric clinics and emergency departments [ 26 , 31 , 32 ].

These findings raise the question if involuntary admissions might increase due to climate-associated factors. Studies in one region in Greece and one city in Italy indeed indicate that maximum temperatures are positively associated with involuntary admissions [ 33 , 34 ]. Unpublished work based on numerous weather stations and thousands of involuntary admissions in the Netherlands indicates that mean average temperature is positively associated with involuntary admissions, with projected increases in involuntary admissions owing to climate change of up to 60 yearly by 2050 (manuscript submitted).

Heat is also associated with more aggression among inpatients [ 35 , 36 ]. A dose-response relationship was found between increasing heat and increasing aggressive incidents in inpatient settings [ 36 ]. Possible reasons for this correlation are insufficient opportunities to lower the temperature in inpatient settings, which may lead to reduced quality of sleep as well as limited opportunities for physical activities during heat, which may increase tension [ 35 , 36 ].

The effects of heat on suicide rates have also been examined [ 31 , 37 , 38 ]. Using data from several decades for the USA and Mexico, it was shown that suicide rates increased by 0.7% in the USA and 2.1% in Mexico when the average monthly temperature rose by 1°C [ 37 ]. The authors predicted, based on a progression of climate change, that 9,000 to 40,000 additional suicides could occur in the United States and Mexico due to temperature increases by 2050 [ 37 ].

More research is needed to differentiate between the effects of heat waves and increased average temperatures on mental health as well as investigate potential non-linear relationships between temperature and adverse mental health effects (e.g. an average increase from 20°C to 21°C may be associated with different effects than an increase from 40°C to 41°C).

In summary, these results indicate that heat is a relevant factor for the mental health of individuals with and without pre-existing psychiatric conditions.

Air pollution

Air pollution includes pollutants such as small matter particles with a diameter of 2.5 microns or less (PM 2.5 ) and has been linked to climate change due to fossil fuel use, industrialisation, and urbanisation [ 5 , 7 , 10 ]. Air pollution may have a negative impact on cognitive functioning, including attention, memory, reading comprehension, verbal intelligence, and non-verbal intelligence [ 39 ].

In addition, studies suggested an increased risk of mental illness, that is, affective disorders such as depression, with air pollution [ 40 – 43 ]. A recent meta-analysis found that the exposure to air pollutants such as PM 2.5 and NO 2 may be associated with the onset of depression [ 44 ].

Recent publications discuss neuroinflammatory activation by pollutants as a possible mechanism for the link between air pollution and mental illness [ 40 ]. This possible neuroinflammatory mechanism in humans is supported by findings from animal models in which depression-like phenotypes were immunologically induced by pollutants [ 40 , 45 ]. However, research is needed to better understand the causal links between air pollution and mental illness [ 46 ].

Finally, there are interactions between climate change, mental and physical health, and social disadvantage. For example, it has been shown that the influence of local poverty, independently of individual income and educational level, correlates with the extent of mental impairment [ 47 , 48 ] and that poverty in the neighbourhood is also related to the extent of environmental pollution and reduced green spaces [ 49 ].

Mental distress due to climate change

Climate change can cause individual’s fears about the future, which can be associated with considerable distress [ 50 , 51 ]. ‘Eco-distress’ refers to negative emotions such as sadness, anger, fear, and hopelessness in relation to climate change and the loss of biodiversity [ 8 , 50 ]. ‘Climate anxiety’ is a term that partially overlaps in meaning with ‘eco-distress’. ‘Climate anxiety’ refers to a stressful expectation of being affected by climate change and is characterised by pronounced fears [ 10 , 52 – 54 ]. In this context, a survey was conducted in 2021 among 10,000 adolescents and young adults aged 16 to 25 years from ten countries [ 55 ]. In this survey, 59% of respondents stated that they were extremely or very concerned about climate change. In 45% of individuals, this concern was reported to have an impact on the person’s everyday functioning. These results underline the distress due to climate change in young people. The described forms of mental distress are different from psychological and emotional responses to the climate crisis that should not be pathologised and can be constructive and functional drivers of climate action [ 56 ].

The loss of biodiversity in combination with climate change and pollution has been described as the triple planetary crisis and highlights the relevance and interconnectedness of these important issues [ 9 ]. A recent systematic review shows that Indigenous Peoples are among the disproportionately affected groups by the negative impacts of loss of biodiversity [ 57 ]. The close ties between ecological habitats and Indigenous Peoples’ lived experiences may contribute to the disproportionate negative impact of biodiversity loss on Indigenous Peoples’ well-being [ 57 ].

Another term related to the loss of biodiversity is ‘solastalgia’. ‘Solastalgia’ refers to grief concerning the loss of natural habitats, activities, or traditions due to climate change [ 6 ]. Human physical and mental health is linked to the state of the natural habitat [ 7 ]. Thus, the loss of the natural habitat may negatively impact the mental health of its inhabitants [ 7 ]. Indications of ‘solastalgia’ have been detected among youth in Indonesia, Inuit communities in northern Canada, farmers in Australia, communities around the Great Barrier Reef, older individuals in the Torres Strait between Australia and New Guinea, and individuals from Ghana [ 6 , 58 ]. These findings illustrate the far-reaching consequences and existential threats of climate change and loss of biodiversity.

In the following sections, we will discuss strategies to increase sustainability in mental health care, with the goal of curtailing climate change, which in turn may improve planetary as well as mental health outcomes.

Towards more sustainable mental health care

Climate change is a challenge for mental health care that needs to be addressed in the key areas of patient care, research, and education [ 59 ].

The above-mentioned direct and indirect effects of climate change on mental health may lead to an increased need for mental health care. In particular, mental health-care needs may increase in the areas of stress-related disorders, affective disorders, and anxiety disorders. Care services must adapt to changes in the need for psychiatric and psychotherapeutic treatment. Care approaches should be sustainable and adaptable to meet the potentially increasing and changing needs of populations affected by climatic impact drivers [ 3 ].

At the same time, care providers, such as psychiatric and psychotherapeutic institutions, should aim to reduce their own contribution to climate change by increasing the efficiency and resource-conserving processes of their care provision and institutions. Reducing GHG emissions and consumption in care facilities will improve sustainability in mental health care. At the same time, GHG emission reductions alone may not make health care sustainable in the long run, as, for instance, emissions resulting from the use of medication also pose a burden on the environment [ 7 , 10 ]. Moreover, as mentioned in the introduction, while the scope of the current paper is on climate change, loss of biodiversity should be another important scope of healthcare systems in future endeavours to make healthcare more sustainable [ 7 , 10 ].

Below, we highlight strategies to increase sustainability in mental healthcare for the key areas of patient care, research, and education.

Patient care

Clinical processes related to patient care, such as emissions generated by inpatient facilities, contribute to increasing emissions and climate change. In this section, we outline mitigation strategies that aim to reduce emissions and adaption strategies that aim to render mental healthcare more resilient to climate change. Mitigation includes preventive strategies, evidence-based patient care, addressing social determinants, optimising the use of resources, and sustainable facility management measures. Adaption includes interdisciplinary cooperation and maintaining health services during extreme weather events. Of note, important strategies such as preventive strategies, evidence-based patient care, and addressing social determinants are relevant for both mitigation and adaption.

Mitigation in mental health care includes several measures. First, the most sustainable care is the care not needed to be given. Preventive strategies therefore play an important role in sustainable mental health care such as primary prevention of mental disorders and promotion of mental resilience [ 60 ]. Approaches that focus on reducing the likelihood of one day needing psychiatric or psychotherapeutic treatment, as well as approaches that address mental health vulnerabilities, are pivotal preventive strategies. For example, mental health services that implement targeted interventions to effectively address the evolving needs of individuals in an early stage could improve the sustainability of the health care system [ 60 ]. Furthermore, access to primary care, such as regular consultations with general practitioners, may support physical health as well as mental health [ 60 , 61 ]. Taken together, a public mental health approach is key to achieve prevention of mental disorders, promotion of mental resilience, and more sustainable healthcare [ 62 ].

Second, optimising guideline development processes is advisable (e.g. “living guidelines” that are characterised by frequent guideline updates based on the most current evidence) [ 63 ]. A more widespread implementation of “living guidelines” would support up-to-date clinical guidance in line with the rapidly evolving body of evidence in psychiatric research. Evidence-based mental health care based on the most recent data would enable efficient, resource-effective, and sustainable health care.

Third, strategies that promote resilience as well as increased attention to the social determinants of mental health, can reduce the need for inpatient and resource-intensive treatment. Empowerment (e.g. promoting health literacy, self-care, and peer support), access to psychotherapy, online consultations, supporting social networks, reducing poverty, reducing homelessness, reducing social isolation, and promoting employment are considered important steps towards sustainable mental health care [ 7 , 50 ]. Recent examples from countries such as Australia highlight the need to prepare for increased climate-associated migration and the mental health challenges posed by social and economic adversity [ 64 ]. Increased climate-associated migration highlights the importance of culturally sensitive psychiatric and psychotherapeutic interventions and language mediation. Individuals experiencing climate-associated migration may be a vulnerable population in the health care system due to psychosocial stressors before, during, and after migration [ 46 , 65 , 66 ].

Fourth, increasing access to green spaces for the general public as well as mental health institutions may have beneficial effects on well-being and mental health [ 7 ]. A recent umbrella review retrieved two meta-analyses examining green spaces and natural environments, detecting associations between increased green spaces and reduction of mental health symptoms, but results were limited due observational designs of a subset of the primary studies [ 46 ]. Further research is required to assess the effect of green and blue spaces on the incidence and severity of mental disorders such as affective disorders, anxiety disorders, and stress-related disorders [ 67 , 68 ].

Fifth, care delivery systems and organisations need to reduce their climate impact. Based on data from the 2022 report of the Lancet Countdown on health and climate change, the GHG emissions per person from the health-care sector ranges between 250 to 1100 kilograms of carbon dioxide equivalent in European countries [ 5 ]. In comparison, the USA accounted for more than 1700 kilograms of carbon dioxide equivalent, which is 50 times the emissions of India, but the USA had the sixth lowest healthy life expectancy at birth among the countries in the 2022 report of the Lancet Countdown [ 5 ]. These findings illustrate the potential of high-quality health care with lower emissions [ 5 ]. Psychiatric hospitals in Europe account for a significant proportion of carbon dioxide emissions per capita, and the inpatient sector is more resource-intensive than the outpatient sector [ 69 ]. Strategies to optimise the use of resources in clinical care can include minimising the use of disposable products, using digital interventions in clinical practice, reducing less efficient administrative processes, increasing the proportion of outpatient care, and optimising the use of medications and materials according to guidelines (e.g. examining necessary pharmacological doses [ 7 , 70 – 74 ]). It would be important to estimate the effects and potentials of different approaches to monitor, evaluate, and optimise the use of resources in clinical care [ 7 ].

Sixth, facility management measures also apply to mental health facilities and include improvements in domains of energy management, mobility, recycling, waste, resource use, food, and procurement [ 6 , 69 , 74 ]. Clinics can adapt organisational structures, such as the introduction of a climate officer and regular resource use analyses. Inclusion of sustainability criteria in clinics’ procurement strategies and public communication strategies (e.g. resource use reports) could support sustainability.

Climate adaptation in mental health care includes several measures. First, in the context of climate change, interdisciplinary cooperation with medical disciplines such as internal medicine and other somatic disciplines is advisable, as climate change affects both physical and mental health. Individuals with pre-existing physical and mental disorders may be particularly vulnerable to the effects of climate change and the deterioration of physical and mental health [ 4 , 5 ]. Providing optimal medical care for people with mental and physical disorders is part of a sustainable mental health strategy.

Second, mental health services should prepare to deliver their services during extreme weather events and disasters to maintain contact with people who may no longer be able to physically reach mental health providers, for example by providing digital mental health services [ 7 , 50 ].

In conclusion, both mitigation and adaptation strategies are needed to achieve progress towards more sustainable mental health care.

In this section, we outline strategies to build understanding of the links between climate change, mental health, and mental healthcare in ways that can inform policy and practice and increase sustainability in mental healthcare research. Specifically, the outlined strategies include establishing evidence-based definitions and clinical approaches for emerging issues such as ‘eco-distress’, investigating the effects of climate change on mental health, promoting research regarding actions on climate change, strengthening the evidence base for policy recommendations, evaluating research funding allocation, and optimising research processes to reduce their emissions.

On a diagnostic level, emerging phenomena described as ‘eco-distress’, ‘solastalgia’, and ‘climate anxiety’ require further research to establish evidence-based definitions (e.g. field trials on diagnostic criteria) allowing for future epidemiological studies on the prevalence and impact. Indeed, clear, evidence-based definitions may help to differentiate between psychological and emotional responses to the climate crisis that are not mental health issues and types of distress that may be a mental health issue. For example, further research is needed regarding the possibility of certain types of eco-distress being a specific phobia [ 75 ] while other types of distress are not a mental health issue.

Next, there is a need for psychiatric research to further investigate the effects of climate change and related disasters on (mental) health and broader quality of life. It is important to identify protective and risk factors for environmental effects on mental disorders and quality of life. This may allow the development of targeted preventive strategies and interventions in the context of mental health care and planetary health. Within this context, vulnerable groups, such as individuals with few resources and pre-existing mental disorders, as well as populations affected by climate inequality, e.g., children and adolescents, should be particularly considered. Research is also needed to examine how environmental exposures in relatively poorer neighbourhoods and communities affect physical health and sleep quality, which in turn may affect mental health [ 49 , 76 ].

On an intervention level, climate mitigation and adaptation actions can simultaneously benefit mental health and mental healthcare [ 77 ]. Qualitative and quantitative research is needed to assess the expected benefits of climate action for mental health and mental health care. For example, it is important to further investigate the number of suicides that could be prevented if heat waves became less frequent. It would also be important to assess the economic burden of climate change on the mental health care system (specified for different geographical regions). Specific interventions need to be explored. Within this context, a systematic review has shown benefits of nature-based therapies for mental health outcomes [ 78 ]. Possibly, by raising more awareness of such benefits, psychiatric institutions may become more ecologically conscious and will thus be more inclined to promote biodiversity and reduce GHG. Importantly, given the high risks of bias in the included studies [ 78 ], we signal a need for high-quality, well-powered randomised-controlled trials examining the potential benefits of nature prescriptions for mental health outcomes.

National and international research funding and policy need to step up on this topic. Mental health research is needed to strengthen the evidence base for policy recommendations to inform how to best prevent and respond to the mental health impacts of climate change. Research funding must be allocated to projects focussing on climate change and mental health to support substantial progress in this urgent area of research. For research collaborations, it is recommended to collaborate globally with researchers and other stakeholders from different regions and different scientific disciplines to improve the relevance and applicability of research.

Finally, in line with improving the sustainability of clinical care processes described above, research processes in themselves should be optimised to reduce their emissions [ 79 – 81 ].

In this section, we outline sustainable aspects in health education. Climate change has a major impact on human physical and mental health, and information on this interaction should be included in the training of health professionals [ 6 , 7 ]. Planetary health is a relevant concept in the context of climate change since planetary health refers to the health of humans and how it depends on the state of the natural systems [ 82 ]. Clinically important aspects of planetary health, including the effects of climate change on mental health, should become a standard part of the curricula of medical programmes at universities. Aspects of planetary health may be integrated with educational courses, ranging from preclinical to clinical courses, which could reflect the interdisciplinary concept of planetary health [ 82 ]. Essential information on mental health and climate interactions could be part of advanced medical training, such as specialist training in psychiatry and psychotherapy. For example, training could include the impact of climate change on mental health and its implications for clinical care of the general population and vulnerable groups, both for medical students and psychiatry residents and staff.

Finally, how to reduce the impact of healthcare provision and research itself, should be learned by all health professionals. In that respect, ‘circularity’ strategies (including the steps ‘refuse, rethink, reduce, reuse, repair, refurbish, recycle, and recover’) may constitute a helpful guiding principle to reduce the footprint of one’s own care and care provided by the facility [ 83 ].

Limitations

Our position paper has several limitations. First, this position paper does not include a systematic review of the literature, which limits the comprehensiveness. In this position paper, we aimed to include findings from other systematic reviews and meta-analyses to develop the positions of the EPA based on recent evidence-based literature. Second, this paper communicates the position of the EPA. A future policy paper may be developed together with other stakeholders. Third, connections between climate change and mental health constitute a rapidly evolving field of research with heterogenous study designs, populations, outcome parameters, and preventive and interventional measures. Therefore, several statements and positions put forward by the EPA in the current position paper may not generalise to other geographical regions. Fourth, the focus of this position paper is on climate change. However, other related important environmental issues (e.g. loss of biodiversity) require further comprehensive analysis beyond the scope of this paper.

Conclusions and recommendations for stakeholders in mental health care, research, and education

The EPA is committed to focus on the important issue of climate change and mental health. In this position paper, we have provided a summary of evidence-based findings regarding the detrimental effects of climate change on mental health. Importantly, based on these findings, we highlighted sustainable recommendations for mental health care, research, and education. This position paper of the EPA includes guidance for a diverse readership of stakeholders in mental health care, research, and education.

The main recommendations are summarised in the table below.

Table of recommendations

The above recommendations may hopefully inspire scientific associations, healthcare facilities, and governments to address the interplay between climate change and mental healthcare. Clearly, they are 10 among many other conceivable actions with potential impact to mitigate environmental harm caused by mental healthcare and to adapt to the prognosticated increases in mental distress. Effective, inclusive, and sustainable multilateral actions on individual, social, and political levels are needed to tackle climate change, biodiversity loss, and pollution as promoted by the United Nations Environment Assembly [ 9 ]. Moreover, as has been demonstrated by the civil, human, and labour rights movements, societal transformations often start bottom-up. Therefore, in addition to action by governments and national and international societies, we need individuals within the mental health workforce to take local initiatives for a green transformation in mental healthcare to materialize in the years to come.

Financial support

This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

Competing interest

Lasse Brandt was supported by the German Research Foundation (grant number 428509362) and a member of the climate change and mental health taskforce of the DGPPN. All other authors declare none.