Climate-Related Disasters and Homelessness: What Psychiatrists Can Do

This past summer brought the burning realities of climate change into full view. July was the hottest month ever recorded in human history—and by a wide margin. The related suffering and loss of life due to wildfires in Maui, flooding in Vermont, and heatwaves and droughts in the Midwest and Southern United States reinforced the growing frequency and impact of disasters. And yet—strikingly—data suggest that this may have been one of the coolest summers for the rest of our lives. Psychiatrists must therefore be informed about how to help patients prepare for and cope with climate-related disasters.

When disasters strike, all populations are at risk, though the risk is unevenly distributed. Vulnerable populations such as those experiencing homelessness are often most severely affected. Disasters and homelessness are intimately linked. The high burden of co-occurring physical, mental, and substance use disorders; absence of reliable shelter; limited access to health information and emergency messaging systems; and scarcity of financial, transportation, and nutritional resources all create unique vulnerabilities for this population. These factors restrict the ability of people experiencing homelessness to prepare before, and respond during and after, a disaster. In addition to affecting those already homeless, disasters can displace entire communities leading to newly and often hidden homeless “climate refugees,” who may spend years regaining housing.

Such vulnerabilities trigger staggering outcomes. Estimates suggest that homeless individuals are at least 200 times more likely than sheltered individuals to die from heat-related causes. During cold weather, 700 homeless people die from hypothermia each year, according to the National Coalition for the Homeless. Survivors are not unscathed, as extreme weather and related disasters leave individuals experiencing homelessness at high risk for re-traumatization, isolation, depression, anxiety, irritability, increased substance use, and worsened physical health. Evidence suggests that psychiatric illnesses themselves, such as schizophrenia, depression, and anxiety disorders affect the body’s ability to dissipate heat. Additionally, many psychiatric medications and particularly antipsychotics impair key mechanisms of heat dissipation. Moreover, sedating substances like alcohol, benzodiazepines, and opioids increase the chances of people falling asleep in extreme weather. Despite these realities, disaster planning has rarely included people experiencing homelessness or the providers and organizations that care for them.

What, then, can psychiatrists do? From a clinical perspective, psychiatrists can proactively counsel their patients experiencing or at risk for homelessness on how to stay safe from weather-related injury. Patients with severe mental illness may not realize the extent of danger from extreme weather and live in conditions that put them at risk. Thus, during hot weather, psychiatrists can be particularly mindful to provide heat education; check medication serum levels such as lithium to reduce risk of toxicity due to dehydration; and discuss approaches to stay cool, such as emergency shelters, shade, and hydration. During cold weather, psychiatrists can encourage people to go to warming centers; be aware of frostbite; and provide information on accessing hats, gloves, and handwarmers. Talking patients through a tailored disaster safety plan can help prepare them for climate emergencies.

From a systems perspective, psychiatrists can proactively plan with staff to ensure their clinics are equipped to continue providing care in the event of extreme weather or a disaster. Clinics may establish outreach methods to reach patients (including updating emergency contacts), make telehealth accessible, and distribute emergency supplies. To ensure patients continue receiving care, psychiatrists can prescribe longer scripts, provide long-acting injectable antipsychotics, and encourage vaccines prior to climate disruptions. Staff can be trained to provide psychological first aid and trauma-informed care as well as practice with cultural humility. Psychiatrists can partner with local outreach and emergency management organizations to reach those not receiving care in a clinic. During the COVID-19 pandemic, for instance, one of us worked with a team at Massachusetts General Hospital and Boston Health Care for the Homeless Program to set up a mental health disaster response at a field hospital for patients experiencing homelessness. Finally and most importantly, psychiatrists can be advocates to reduce climate change and its impact at the local, state, or national level.

The summer of 2023 is likely a harbinger for the extreme weather and disasters that will mark our society’s future. We as psychiatrists can proactively advocate, plan, and adapt our care delivery to mitigate harm to all, including the most vulnerable among us. ■

Katherine A. Koh, M.D., M.Sc., is the co-chair of the Massachusetts Psychiatric Society Disaster Readiness Committee and a member of the APA Committee on the Psychiatric Dimensions of Disaster. She is also a street psychiatrist at Massachusetts General Hospital and the Boston Health Care for the Homeless Program and an assistant professor of psychiatry at Harvard Medical School.

Andrew Alix, M.D., is a PGY-3 psychiatry resident at the University of Arizona College of Medicine-Phoenix, an APA Public Psychiatry Fellow, and a fellow member of the APA Committee on Psychiatric Dimensions of Disaster.