Request for Information Summary Report: Mental Health and Substance Use Wellbeing in the Context of Climate Change and Health Equity
SAMHSA sought feedback on SAMHSA's Role in Possible Agency Actions Regarding Mental Health and Substance Use Wellbeing in the Context of Climate Change and Health Equity. The requested input included lessons learned from past climate-related emergencies, potential top priorities concerning climate change and health equity, research priorities, resources, and collaboration with governmental and non-governmental partners. Feedback was for informational and planning purposes only and was not a solicitation for applications or an obligation on the part of the government to provide support for any ideas identified in response to it.
Key Ideas
Climate change is a social determinant of mental health
Climate-related environmental change impacts on social determinants of health, including food. The World Health Organization (WHO) considers climate change a social determinant of mental health – reflecting the view that risk factors for developing mental health disorders are strongly associated with social inequities. This includes implications for climate change as a social determinant of substance use, which is an emerging area of research.
Behavioral health systems must become “climate-informed”
The urgency for behavioral health services providers to become “climate-informed” cannot be understated. SAMHSA should champion the concept of “climate-informed behavioral health,” similar to the promotion of “trauma-informed behavioral health.”
Intergenerational trauma will be one of the layered effects of climate-related environmental change
The psychological consequences and footprint of emergencies and disasters are much longer and wider than other factors managed by emergency systems. Through their direct effects on children and families and the indirect effects of community culture and cohesion loss, climate change events precipitate intergenerational trauma. Supports should be developed for people and communities migrating due to climate change as they transition to new locations, rebuild and cope with the effect of displacement and loss of sense of belonging. Commenters also recognized the experiences of people and communities whose identities and livelihoods are deeply tied to particular places and generational practices, some of which may be imperiled by climate change-related changes. A focus on intergenerational trauma (inclusive of collective and historical trauma) by SAMHSA may promote opportunities for behavioral health professionals to understand, support and develop interventions that foster intergenerational resilience as part of climate-informed public behavioral health services.
Key Recommendations
Develop a SAMHSA Climate Action Plan
Respondents suggested that SAMHSA should develop an agency-wide climate action plan to serve as a roadmap for change and integration of climate-informed behavioral health in SAMHSA research, programs, contracts, technical assistance, and reports. SAMHSA should evaluate where climate change mitigation, adaptation, and resilience can be integrated. This includes all Centers and Offices, the work of regional offices (especially in high-risk areas), and a focus on overcoming inequities and vulnerabilities experienced in throughout the United States, inclusive of territories and tribal nations.
Respondents suggested strategies that can be helpful to meaningfully engage, convene, and facilitate strategy discussions across diverse groups of stakeholders on the impacts of an issue as broad and urgent as climate change. The following mechanisms were suggested: practitioner trainings; public messages; surveillance systems; roundtables; digital listening.
Respondents expressed that, when possible, those receiving services and delivering services also should have a chance to be part of collaboration on these topics. This is a way to deeply understand what’s working, what isn’t, what the barriers to effective work are, and perhaps what can be done to remedy the situation. The Community-Based Participatory Model of research was suggested as a framework that might be useful to understand and address emerging clinical issues in a variety of communities, age groups, and linguistic groups.
Create a Climate Change and Behavioral Health Clearinghouse and Technical Assistance Center & Incorporate Climate-Informed Guidance into SAMHSA Grants
Responders suggested that SAMHSA should establish and manage a system to provide technical assistance to behavioral health professionals, practitioners, and grantees on how to integrate climate change anxiety, preparedness, coping, and resilience into substance use and mental health programming. This technical assistance system should support, promote, and enhance health equity in all aspects of the technical assistance and training delivered to grantees. Commenters emphasized that all aspects of human life are impacted by climate change so all SAMHSA programs should include climate change awareness, mitigation, or adaptation strategies across all programs for all grant recipients. Through a newly developed Climate Change and Behavioral Health Clearinghouse and Technical Assistance Center SAMHSA can help to normalize the issue.
Respondents emphasized that SAMHSA should highlight the importance of climate change to its grant recipients. Ideas for how included:
- Allow providers to engage in primary prevention and mitigation across grant streams, in addition to tertiary treatment strategies.
- Incorporate climate-related data resources into grant/funding applications and ask applicants to respond to how they will incorporate climate-informed behavioral health activities with a focus on populations expected to be disproportionately impacted.
- Allow for some costs that help behavioral health providers, especially smaller ones, to reduce their emissions footprint and invest in renewable energy.
Incorporate Public Behavioral Health Approaches to Promote Resilience
SAMHSA has a responsibility to focus on both individual and community interventions and activities that promote climate-informed behavioral health and population-wide climate resilience. Request for information responders suggested that SAMHSA should support increased resources and allowable costs that shift behavioral health systems toward public behavioral health strategies for mental health promotion, substance use prevention, community-level response, and community-based mental health resilience. Many aspects of the mental health and substance use-related impacts of climate change affect the population as a whole (e.g., emotional reactions to the phenomena of climate change such as climate anxiety [i.e., distress related to worries about the effects of climate change], ecological grief and others, population effects of higher temperatures on mental function); respondents expressed that these impacts cannot be addressed within the existing SAMHSA structure. Respondents discussed that current emphasis on behavioral health diagnoses fails to be adequately descriptive or flexible in response to climate or disaster-related emergencies.
Comments emphasized that developing a public mental health framework requires:
- Using a population health frame.
- Developing and leveraging partnerships on federal, state, territory, tribal nations, and local levels.
- Prioritizing research on the mental/substance use effects of climate change, especially on marginalized communities.
- Educating and informing the public with an emphasis on supporting climate resilience.
In addition, respondents pointed out that many current therapeutic responses to climate change distress have originated from indigenous, spiritual, and cultural practices developed by laypersons deeply immersed in environmental movements. These practices often share elements with evidence-based mental health treatments, but at the current time, there is no way for them to be tested, vetted, scaled up, or otherwise brought into the wheelhouse of national mental health care that is SAMHSA.
Organizations representing psychiatric and clinical psychology professionals expressed that they recognize the effects of climate change, its relevance in a variety of behavioral health contexts, and that they commit to supporting and collaborating with patients, communities, and other healthcare organizations engaged in efforts to mitigate the adverse human and mental health effects of climate change. They emphasized that psychiatrists and psychologists, among others, are uniquely positioned to help address the mental health effects of climate change and enhance communications that address the mental health risks of climate change that can result in sustained behavioral change. Respondents also noted connections between increased agency focus on health equity, behavioral health resilience, mitigation, work force development, and the current and future impacts of climate change. Climate stress is not equitably felt, with communities of color and communities with low incomes at greater risk of experiencing climate-related disasters.
Respondents emphasized that a protective factor for health care workers is adequate training and preparation. Therefore, building out a climate-informed behavioral health system that provides resources to an increasingly diverse behavioral health workforce is protective to both the behavioral health workforce and the communities they serve. Timely and tailored interventions need to be designed in such a way that they can be altered over time to meet current and evolving needs.
Enhance SAMHSA’s Collaboration with Partners to Inform Research
The need for research and integrated data collection and analysis across multiple federal agencies was emphasized in a majority of responses. Commenters supported research in general related to changes in prevalence of mental health and substance use disorders and sub-diagnostic levels of distress related to climate. Well-designed longer-term studies on specific trends regarding climate-related emergencies and disasters was “badly needed,” according to commenters. As well, respondents discussed need for research on the syndromic effects of heat on population mental health and substance use, along with disproportionate impact of heat-related illnesses and deaths among people with mental illnesses and substance use disorders. Respondents said that SAMHSA should seek to develop a repository of evidence-based strategies for climate action and climate change mitigation.
To meet these aims, it was suggested that SAMHSA invest in updating its data collection, management, analysis, and visualization infrastructure. In these efforts, SAMHSA should prioritize research that is guided by the principles of translational science with a focus on developing scientific support for development and implementation of effective programs. Plans to address impacts of climate change on mental health and substance use should carefully monitor the full range of potential impacts, including indirect impacts, and create programs that are designed to mitigate inequities in vulnerability to these impacts, using data to determine current and future needs that can help providers respond to community and individual needs.
Incorporate and Expand Resources
The impact of climate change on young people was a concern for many of the RFI commenters, who pointed to early research that showed that climate-related anxiety (some referred to it as eco-anxiety or eco-distress) is increasing, especially among children and young adults. Several ideas were shared as to why climate change is impacting young people more severely, but commenters also noted that more research is needed.
Expression of eco-distress is becoming more widespread and socially acceptable to voice, especially among children, youth, and young adults. It is essential to gain a better understanding of whether expression and recognition of such distress translates into overall higher morbidity and mortality and increased and possibly avoidable health service utilization, both of mental health and other health care services. In addition, this chronic anxiety is an emerging issue in behavioral health with unknown long-term consequences.
A common theme throughout the replies was around involving and empowering communities to be the leaders and decision makers for strategies that impacted them. This theme also came through with youth engagement, youth activism, and focusing on youth to increase mental health resiliency and community resiliency. One community member wrote about being “encouraged by (and perhaps even awakened by and educated by) the energy and positivity of the youth, who are (already) rallying in defense of the environment.”
Youth activism and youth programming that empowers youth to help problem solve in their communities have been shown to significantly reduce youth risk-taking behaviors and increase resiliency. It was suggested that SAMHSA needs to invest in youth education to build climate change resiliency and address inequities and then provide them with concrete ways they can help address the issues. Several repliers mentioned the need to increase surveillance, data, and implementation of policies, programs, and services that specifically address climate distress in youth.
Many commenters shared perspectives about education within the school system. Commenters emphasized the need to better support the mental health and wellbeing of young people in the face of climate change - including black, indigenous, people of color (BIPOC) youth. There were many recommendations related to developing school-based programming, family-based groups, and accessible community programming. Curricula where students learn ways that they can directly engage in climate change solutions may help mitigate developing a sense of despair. In addition, respondents supported efforts to educate parents, caregivers, teachers, and educational leaders to identify early signs of climate-related distress among youth. Through partnerships with educational institutions and local communities, young people should be supported and encouraged to play a leading role in climate action and mitigation.
Commenters encouraged SAMHSA to expand and develop behavioral health collaborations with other natural areas of youth activities such as organizations and agencies sponsoring youth sports and recreation programs and childcare centers. SAMHSA also could expand and develop collaborations with professional organizations and groups as well as allied organizations working in this area to support translational research, education, and programs.
Many respondents mentioned that with the effects of climate change, climate migration within the nation will likely increase. As well, they discussed that the psychological consequences and footprint of emergencies and disasters are much longer and wider than previous decades and that these emergency events are often overlapping in time. Within these contexts, respondents emphasized that there are links between multigenerational trauma, Adverse Childhood Experiences (ACEs), and acute stress reactions. Screening and assessment are needed as the grief and trauma associated with weather related disasters may have been normalized and/or larger mental health conditions may go undiagnosed and treated. There is a need for screening and assessment tools for individuals experiencing intergenerational trauma due to climate change, natural disasters, and/or forced migration. Other countries are facing these issues at the same time as the United States and thus it is important to look for opportunities to learn with and from best practices in other nations.
Respondents suggested that a wide variety of resources be developed for community leaders to create programs that increase resilience. Ensure that resources are available through multiple sources and readily available. It is also important to have region-specific preparedness materials which cover the critical areas of preparedness and learning, including substance use disorders, which may be exacerbated by climate-change and disaster-related trauma.
Within the topic of trauma, respondents discussed that there is a need to understand the increasing complexity and cascading sequelae of repeated disasters, climate change, poverty, grief, and the pandemic. Commenters also noted continuing impacts from the COVID-19 public health emergency and its overlap with climate change-related challenges. Respondents also emphasized that tribal nation communities and communities that have experienced repetitive traumas, especially those in low resource areas, are especially likely to experience trauma.
Respondents emphasized that there should be increase access to and awareness of SAMHSA programs. SAMHSA should emphasize the use of the National Child Traumatic Stress Network and other resources to support building consistent, trauma-informed systems and care across communities. SAMHSA should implement trauma-informed approaches in keeping with the National Strategy for Trauma-Informed Care Operating Plan led by the Interagency Task Force on Trauma-Informed Care.
Evidence suggests that individuals with substance use disorders and serious mental illness disproportionately experience adverse impacts associated with heat waves, extreme heat events, and wildfires. Respondents proposed that SAMHSA invest in creating the resources to collect, maintain, and disseminate data that informs and drives decision making at the individual, community, and regional level in hot, arid environments by establishing a baseline and tracking changes over time. Commenters strongly recommended that programs provide the necessary education, training, and interventions for heat and substance use.
Respondents also emphasized that:
- More study is needed on the side effects of mental health medications with extreme heat and regulation of body temperature. Substance use as well as certain psychotropic medications can make individuals more susceptible to extreme temperatures.
- Attention should also be given to unhoused populations who may be using substances that make them vulnerable to extreme heat and regulation of body temperature, such as those taking certain psychotropic medications.
- Focus should be on interventions prioritizing those at greatest risk of heat waves, such as people with substance use disorders and serious mental illness.
Understanding broader population behavioral health in prolonged heat events is a burgeoning area of research. Multi-country climate behavioral health research has demonstrated that both human sleep and subclinical psychosocial outcomes are sensitive to extreme heat, in the US and globally. Although the mechanisms are still being explored, a substantial body of research has shown that high temperatures are associated with increased psychiatric hospitalizations and risk of suicide, as well as increases in aggression. Sleep is an important protective factor against harmful substance use, as well as increased injury risk, decreased learning and academic performance, altered physical activity, increased hostile language and violent conflict, and depressed emotional sentiment.
Weather-related disasters have the potential to damage and disrupt communities through physical destruction; however, they can also significantly impact mental health. The long tail effects of disasters must be factored into the planning, operations, and logistics of emergency and disaster response. More research is needed (including long-term, longitudinal studies), as well as treatments for communities that have been struck multiple times. There is need for a more integrated model of care after a disaster (behavioral health and physical medicine).
Important behavioral health services are often disrupted by disasters, leaving patients without access to continuity of care. Behavioral health, including disaster behavioral health, longer-term behavioral health supports for communities, and behavioral health supports for at-risk populations must fully be integrated into disaster and emergency management planning, tabletop exercises and services at all stages of disaster and emergency management in state, local, tribal nation, and territory jurisdictions. In addition, the United States needs universality across the nation for its disaster behavioral health response. It is imperative that all communities develop a disaster behavioral health plan that integrates with the existing emergency/disaster medical plan. SAMHSA should advocate for inclusion of mental health and wellness providers in ongoing federal mass casualty event tabletop exercises. As well, psychiatric medications should be considered essential and on par with other essential medications such as those for cancer, diabetes, and other health conditions.
Respondents also commented that SAMHSA should place special emphasis on funding to support treatment infrastructure, particularly bricks and mortar. Even when one provider is impacted by a natural disaster, the costs associated with renovation and rebuilding can be high. Most severely impacted by disasters are providers of residential treatment services and their patients because services cannot be provided without adequate physical facilities. Rebuilding and ensuring that behavioral health systems can come back “online” to provide services after a disaster has been a challenge for behavioral health providers in disaster-prone geographic settings.
Concerns were raised that emphasis on normalizing in the response to the impact of climate change can lead to underdiagnosing and need for behavioral health supports may not be appropriately addressed. Screening tools need to be adapted to include climate change considerations and potential long-term implications. Social workers who are licensed and trained to provide these services should be included in programs created to address climate change along with peers, psychologists, psychiatrists, and other professionals.
Respondents emphasized the need for universality across the nation for disaster behavioral health response and recovery systems. Included in this was the importance of giving ongoing attention to the mental health needs of the responder workforce, especially first responders and essential workers. Responders also expressed that it is imperative that all communities develop a specific disaster behavioral health plan that integrates with their existing emergency/disaster medical plan. Commenters suggested SAMHSA expand the breadth and capacity of resources offered through the 988 Suicide and Crisis Lifeline, the Crisis Text Line, and the Disaster Distress Helpline. They also suggested that the SAMHSA Disaster Distress Helpline’s staff and other relevant disaster behavioral health responders receive training related to eco- anxiety and solastalgia.
Respondents also mentioned the importance of social cohesion and connectedness in community recovery as a lesson learned. Building on this, they discussed that SAMHSA should support addressing climate-related behavioral health impacts now by using immediate interventions as a foundation for long-term solutions and proactive mitigation of health disparities. SAMHSA can support efforts to create locally developed, community-based neighborhood resiliency projects, such as climate resilience hubs that serve as centers for neighborhood-level community preparedness, response, and recovery activities.
Enhance Collaboration with Government and Non-Governmental Partners
Climate change is affecting the physical and social infrastructures that support health and well-being in the United States. Addressing these challenges requires a sustained commitment to multilevel, collaborative, transdisciplinary approaches among government agencies. According to commenters, a unified effort must be taken to address the effects of and mitigate climate change, similar to how the U.S. addressed the pandemic or mobilized during World War II.
Respondents also recognized that many of the disciplines that need to work together in this coordinated approach have distinct theoretical frameworks, approaches, statistical techniques, and vocabularies, making it difficult to synthesize the contributions of each discipline to address the complex challenges posed by climate change. Along with recommendations for participation in a variety of federal interagency working groups (many in which SAMHSA does currently participate). Respondents suggested that SAMHSA should leverage existing relationships with Federal partners including agencies within the U.S. Department of Health and Human Services and the Federal Emergency Management Agency (FEMA) to improve access to behavioral health services, ensuring compliance with the Mental Health Parity and Addiction Equity Act, and providing services to marginalized populations.
Other suggestions for collaboration included:
- Introduce the topic of climate change to behavioral health programs as SAMHSA's initial priority.
- Convene annual conferences on this topic and publish policy statements or white papers.
- Support heath care organizations, particularly small ones, in reducing their carbon footprint.
- Extend collaborations and coordination to a wide range of community organizations, faith-based groups, National Alliance on Mental Illness (NAMI), and other groups where people have natural engagements.
- Collaborate with housing, urban planning, and political decision makers for communication with communities in geographically vulnerable areas while also recognizing that disproportionate numbers of historically marginalized communities are often residing in communities that are more geographically vulnerable due to historical policies and practices that were racially biased.
- Review, analyze, and develop recommendations internally to reduce SAMHSA’s carbon footprint.
Conclusion
The ideas expressed in reply to this request for information were robust, informative and will assist SAMHSA and federal agency partners in considering multiple ways that federal resources can support climate-informed mental health and substance use wellness across the nation. In August 2023, SAMHSA published a 2023-2026 Strategic Plan. This four-year plan emphasizes a more person-centered approach and introduces a new mission and vision, key priorities, and guiding principles.
SAMHSA is grateful for the ideas received through replies to this request for information because they have provided us with clear concepts and operational ideas that are critical to SAMHSA’s mission is to lead public health and service delivery efforts that promote mental health, prevent substance misuse, and provide treatments and supports to foster recovery while ensuring equitable access and better outcomes.
SAMHSA will use the recommendation in response to this RFI at its discretion.