Extreme weather events and disasters

Climate change is leading to an increase in extreme weather and disasters [Reference Romanello, Napoli, Drummond, Green, Kennard and Lampard5]. Extreme weather events include floods, storms, fires, and droughts [Reference Romanello, Napoli, Drummond, Green, Kennard and Lampard5]. Extreme weather events can reach the scale of disasters, threatening physical integrity and destroying livelihoods and critical infrastructure [3, Reference Romanello, Napoli, Drummond, Green, Kennard and Lampard5].

Extreme weather events and disasters can result in significant mental distress via different pathways [Reference Cianconi, Betrò and Janiri4, Reference Vins, Bell, Saha and Hess11, Reference Lane, Charles-Guzman, Wheeler, Abid, Graber and Matte12]. 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 [Reference Cianconi, Betrò and Janiri4, Reference Vins, Bell, Saha and Hess11]. The mental symptom severity depends on the extent to which the person is affected by the environmental event [Reference Vins, Bell, Saha and Hess11, Reference Lane, Charles-Guzman, Wheeler, Abid, Graber and Matte12] and the symptoms can last for years [Reference Mulchandani, Armstrong, Beck, Waite, Amlôt and Kovats13]. 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 [Reference Patwary, Bardhan, Haque, Moniruzzaman, Gustavsson and Khan14].

The prevalence of post-traumatic stress disorder (PTSD) increases after disasters [Reference Fernandez, Black, Jones, Wilson, Salvador-Carulla and Astell-Burt15, Reference Galea, Brewin, Gruber, Jones, King and King16]. After Hurricane Katrina, one in three residents of New Orleans showed symptoms of PTSD [Reference Galea, Brewin, Gruber, Jones, King and King16]. Symptoms of anxiety, psychosis, and depression including suicidal thoughts may increase following extreme weather and disasters [Reference Lane, Charles-Guzman, Wheeler, Abid, Graber and Matte12, Reference Rodney, Swaminathan, Calear, Christensen, Lal and Lane17, Reference Silveira, Kornbluh, Withers, Grennan, Ramanathan and Mishra18]. 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 [Reference Waite, Chaintarli, Beck, Bone, Amlôt and Kovats20]. In follow-up studies, the persistence of symptoms in those affected by the floods was demonstrated even after several years [Reference Mulchandani, Armstrong, Beck, Waite, Amlôt and Kovats13]. 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 [Reference Paranjothy, Gallacher, Amlôt, Rubin, Page and Baxter21]. 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 [Reference Galea, Brewin, Gruber, Jones, King and King16].

There is also an increased prevalence of affective disorders following droughts, bushfires, and forest fires [Reference Cianconi, Betrò and Janiri4, Reference Rodney, Swaminathan, Calear, Christensen, Lal and Lane17, Reference Silveira, Kornbluh, Withers, Grennan, Ramanathan and Mishra18]. Droughts are increasing in severity and frequency due to climate change [7] and droughts are a major driver of climate-associated migration [Reference Thalheimer, Choquette-Levy and Garip22]. 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 [Reference Cianconi, Betrò and Janiri4]. There are also indications of increases in alcohol and other substance use and domestic violence following disasters [Reference Cianconi, Betrò and Janiri4].

Increases in ambient temperature

Since the end of the nineteenth century, the average global surface temperature has increased according to data since 1850 [Reference Brohan, Kennedy, Harris, Tett and Jones23]. 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 [Reference Romanello, Napoli, Drummond, Green, Kennard and Lampard5]. In the general population, periods of heat are associated with increases in mental health problems, such as stress and negative emotions [Reference Obradovich, Migliorini, Paulus and Rahwan25]. Heat leads to increased mortality [Reference Liu, Varghese, Hansen, Xiang, Zhang and Dear26] and psychiatric disorders are a leading risk factor for heat-related deaths [Reference Bouchama, Dehbi, Mohamed, Matthies, Shoukri and Menne27, Reference Lee, McLean, Kuo, Richardson and Henderson28]. An increased mortality risk was identified for organic mental illnesses such as dementia [Reference Liu, Varghese, Hansen, Xiang, Zhang and Dear26]. 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 [Reference Lee, McLean, Kuo, Richardson and Henderson28, Reference Lõhmus29].

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 [Reference Liu, Varghese, Hansen, Xiang, Zhang and Dear26]. 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 [Reference Meadows, Mansour, Gatto, Li, Howard and Bentley30]. In addition, both global warming and heat waves are associated with increases in acute admissions to psychiatric clinics and emergency departments [Reference Liu, Varghese, Hansen, Xiang, Zhang and Dear26, Reference Thompson, Hornigold, Page and Waite31, Reference Basu, Gavin, Pearson, Ebisu and Malig32].

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 [Reference Aguglia, Serafini, Escelsior, Amore and Maina33, Reference Rizavas, Gournellis, Pantazis, Chatzinikolaou, Douzenis and Efstathiou34]. 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 [Reference Clayton35, Reference Eisele, Flammer, Steinert and Knoblauch36]. A dose-response relationship was found between increasing heat and increasing aggressive incidents in inpatient settings [Reference Eisele, Flammer, Steinert and Knoblauch36]. 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 [Reference Clayton35, Reference Eisele, Flammer, Steinert and Knoblauch36].

The effects of heat on suicide rates have also been examined [Reference Thompson, Hornigold, Page and Waite31, Reference Burke, González, Baylis, Heft-Neal, Baysan and Basu37, Reference Gao, Cheng, Duan, Xu, Bai and Zhang38]. 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 [Reference Burke, González, Baylis, Heft-Neal, Baysan and Basu37]. 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 [Reference Burke, González, Baylis, Heft-Neal, Baysan and Basu37].

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 [Reference Romanello, Napoli, Drummond, Green, Kennard and Lampard5, 7, Reference Heinz, Meyer-Lindenberg, Adli, Bornheimer, Brandt and Hurlemann10]. Air pollution may have a negative impact on cognitive functioning, including attention, memory, reading comprehension, verbal intelligence, and non-verbal intelligence [Reference Lu39].

In addition, studies suggested an increased risk of mental illness, that is, affective disorders such as depression, with air pollution [Reference Khan, Plana-Ripoll, Antonsen, Brandt, Geels and Landecker40–Reference Braithwaite, Zhang, Kirkbride, Osborn and Hayes43]. A recent meta-analysis found that the exposure to air pollutants such as PM_2.5 and NO₂ may be associated with the onset of depression [Reference Cao, Tian, Hu, Yu, You and Yang44].

Recent publications discuss neuroinflammatory activation by pollutants as a possible mechanism for the link between air pollution and mental illness [Reference Khan, Plana-Ripoll, Antonsen, Brandt, Geels and Landecker40]. This possible neuroinflammatory mechanism in humans is supported by findings from animal models in which depression-like phenotypes were immunologically induced by pollutants [Reference Khan, Plana-Ripoll, Antonsen, Brandt, Geels and Landecker40, Reference Fonken, Xu, Weil, Chen, Sun and Rajagopalan45]. However, research is needed to better understand the causal links between air pollution and mental illness [Reference Cuijpers, Miguel, Ciharova, Kumar, Brander and Kumar46].

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 [Reference Gruebner, Rapp, Adli, Kluge, Galea and Heinz47, Reference Rapp, Kluge, Penka, Vardar, Aichberger and Mundt48] and that poverty in the neighbourhood is also related to the extent of environmental pollution and reduced green spaces [Reference Darabi, Kluge, Penka, Mundt, Schouler-Ocak and Butler49].

Mental distress due to climate change

Climate change can cause individual’s fears about the future, which can be associated with considerable distress [Reference Clayton, Manning, Krygsman and Speiser50, Reference Ojala51]. ‘Eco-distress’ refers to negative emotions such as sadness, anger, fear, and hopelessness in relation to climate change and the loss of biodiversity [Reference Walinski, Sander, Gerlinger, Clemens, Meyer-Lindenberg and Heinz8, Reference Clayton, Manning, Krygsman and Speiser50]. ‘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 [Reference Heinz, Meyer-Lindenberg, Adli, Bornheimer, Brandt and Hurlemann10, Reference Strife52–Reference Clayton and Karazsia54]. In this context, a survey was conducted in 2021 among 10,000 adolescents and young adults aged 16 to 25 years from ten countries [Reference Hickman, Marks, Pihkala, Clayton, Lewandowski and Mayall55]. 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 [Reference Bhullar, Davis, Kumar, Nunn and Rickwood56].

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 [Reference Brubacher, Peach, Chen, Longboat, Dodd and Elliott57]. 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 [Reference Brubacher, Peach, Chen, Longboat, Dodd and Elliott57].

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 [Reference Lawrance, Thompson, Fontana and Jennings6]. 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 [Reference Lawrance, Thompson, Fontana and Jennings6, Reference Tschakert, Tutu and Alcaro58]. 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.

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 [Reference Fusar‐Poli, Correll, Arango, Berk, Patel and Ioannidis60]. 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 [Reference Fusar‐Poli, Correll, Arango, Berk, Patel and Ioannidis60]. Furthermore, access to primary care, such as regular consultations with general practitioners, may support physical health as well as mental health [Reference Fusar‐Poli, Correll, Arango, Berk, Patel and Ioannidis60, Reference Tzartzas, Oberhauser, Marion-Veyron and Saillant61]. Taken together, a public mental health approach is key to achieve prevention of mental disorders, promotion of mental resilience, and more sustainable healthcare [Reference Campion62].

Second, optimising guideline development processes is advisable (e.g. “living guidelines” that are characterised by frequent guideline updates based on the most current evidence) [Reference Akl, Meerpohl, Elliott, Kahale, Schünemann and Network63]. 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, Reference Clayton, Manning, Krygsman and Speiser50]. 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 [Reference Stanley, Leviston and Tseung-Wong64]. 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 [Reference Cuijpers, Miguel, Ciharova, Kumar, Brander and Kumar46, Reference Henssler, Brandt, Müller, Liu, Montag and Sterzer65, Reference Brandt, Henssler, Müller, Wall, Gabel and Heinz66].

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 [Reference Cuijpers, Miguel, Ciharova, Kumar, Brander and Kumar46]. 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 [Reference Luque-García, Muxika-Legorburu, Mendia-Berasategui, Lertxundi, García-Baquero and Ibarluzea67, Reference Paredes-Céspedes, Vélez, Parada-López, Toloza-Pérez, Téllez and Portilla68].

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 [Reference Romanello, Napoli, Drummond, Green, Kennard and Lampard5]. 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 [Reference Romanello, Napoli, Drummond, Green, Kennard and Lampard5]. These findings illustrate the potential of high-quality health care with lower emissions [Reference Romanello, Napoli, Drummond, Green, Kennard and Lampard5]. 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, Reference Leucht, Bauer, Siafis, Hamza, Wu and Schneider-Thoma70–Reference Corvalan, Prats, Sena, Campbell-Lendrum, Karliner and Risso74]). 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 [Reference Lawrance, Thompson, Fontana and Jennings6, 69, Reference Corvalan, Prats, Sena, Campbell-Lendrum, Karliner and Risso74]. 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 [Reference Cianconi, Betrò and Janiri4, Reference Romanello, Napoli, Drummond, Green, Kennard and Lampard5]. 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, Reference Clayton, Manning, Krygsman and Speiser50].

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

Research

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 [Reference Luykx, Vinkers and Tijdink75] 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 [Reference Darabi, Kluge, Penka, Mundt, Schouler-Ocak and Butler49, Reference Meyer-Lindenberg, Falkai, Fallgatter, Hannig, Lipinski and Schneider76].

On an intervention level, climate mitigation and adaptation actions can simultaneously benefit mental health and mental healthcare [Reference Jennings, Fecht and Matteis77]. 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 [Reference Nguyen, Astell-Burt, Rahimi-Ardabili and Feng78]. 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 [Reference Nguyen, Astell-Burt, Rahimi-Ardabili and Feng78], 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 [Reference Zagel, Helgenberger, Pawloff, Kirchhoff, Röthler and Schmitz79–Reference Ligozat, Névéol, Daly and Frenoux81].

Teaching

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 [Reference Lawrance, Thompson, Fontana and Jennings6, 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 [Reference Horton and Lo82]. 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 [Reference Horton and Lo82]. 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].