Updated on: January 20, 2020

EXCLUSIVE: ICD Coding and Climate-Related Psychiatry

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Original story posted on: January 13, 2020

EDITOR’S NOTE: Anyone who has viewed the wildfires in Australia knows why it has been called the “canary in the coal mine” of climate change. No wonder that Solastalgia was discovered there. As the ever-increasing carbon is being emitted from the world’s coal mines and other fossil fuel sources, life as we know it is at increased risk of being poisoned one way or another, with harmful health and mental health effects around the world that we in healthcare ethically have to address. In light of the situation being experienced in Australia, the editors are re-posting the first in an exclusive series of articles on the impact of climate change on healthcare, written by a nationally renowned psychiatrist and author H. Steve Moffic, MD. Dr. Moffic is a popular panelist on the long-running Talk Ten Tuesdays live Internet broadcast.

If you have been reading or hearing about how climate instability is adversely affecting mental health, where should you look to find out more? In the International Classification of Diseases, ICD-10? Or the American-based related psychiatric tool, Diagnostic and Statistical Manual of Mental Disorder, DSM-5?

No, you won’t find anything there, perhaps because ICD-10 was developed before it was apparent that climate-related conditions were receiving attention. However, I can’t find anything in ICD-11, either. Maybe there is some climate denial in our field, like elsewhere. You instead would have to look at other sources of professional and personal literature. You could even find such information in the cultural and musical icon, Rolling Stone!

The closest we have in ICD-10 are the Z codes, defined as “persons with potential health hazards related to socioeconomic and psychosocial circumstances.” Even here, however, the words “environment” and “climate” are not mentioned.

Regardless, what climate-related conditions might qualify for a Z64 code, and can we go from there? Since there are many to consider, we will summarize them in this column, then discuss each in more depth in follow-up articles early in the New Year. We will close with a column on interventions.

Solastalgia
In many ways, this is the most intriguing and unusual condition to consider. The term was coined not by a mental health professional, but by a philosopher in Australia. Australia has been a ground zero of sorts for climate instability, because it is a country that has always had high temperatures a good part of the year, especially in the inhospitable interior. It also has large cities only on the coasts, where rising seas are a potential problem.

As the Outback was besieged with increasingly worsening droughts, many who lived there but couldn’t leave became distraught by the changes in their environment. Since this seemed to relate to a negative sense of nostalgia, along with the blazing sun, the term “solastalgia” seemed to reflect that. In a sense, as parts of the rest of the world’s environment change with the climate, solastalgia may turn into a globally relevant classification.

Pre-Traumatic Stress Disorder
We all know by now about post-traumatic stress disorder or PTSD. This “pre” version is a different kind of condition. As many people anxiously await more frequent and worse traumatic disasters in many countries, anticipatory anxiety emerges. Then, when climate-related disasters happen anywhere, those sensitized to the disasters will often feel that they are being traumatized secondarily. This is especially applicable to children and may account for their taking a lead in protesting the climate threats to their future.

Climate-Related Anxiety
It would not be surprising that, given the increasing media coverage of climate instability, people would start to become more anxious about the future. If you live in vulnerable areas prone to flooding, wildfires, and drought, that anxiety is likely to wax and wane but could be always lurking in the background.

Climate-Related Dysphoria
Another name for this is climate-related depression, but dysphoria helps to distinguish it from clinical depression. This is a sadness that relates to what has been lost, especially people. The sadness is not present all the time or in all circumstances. People who are especially vulnerable to it are those who tend to be more empathic and compassionate.

Ecological Grief
Grief is generally more difficult to recover from when the loss is human-induced. Given our essential role in causing climate instability, many people are feeling guilty, consciously or unconsciously, about what they have contributed to the adverse changes in our environments. Guilt always makes grieving more complicated.

Climate Activists Burnout
We already know that up to half or more of workers in healthcare are burning out. What mainly causes that are systems that block what we can contribute and don’t engage us in policy discussions. Those activists who are trying every day to address climate change often encounter similar obstacles. Just consider those in the United States, where our government has been dismantling environmental protection policies and withdrawing from a comprehensive global climate accord. Frustration increases, and the burnout triad of emotional exhaustion, cynicism, and a sense of decreasing accomplishment emerges.

Climate-Related Suicide
As we know, most suicides, but not all, are a consequence of unresolved mental disorders, especially major depression or bipolar disorders. However, there are existential exceptions. One is terminal and painful illness. Another is cultural, as in the suicide terrorist bombers, though that may be better defined as “homicide” bombers. Then, occasionally, it is an expression of protest, which occurred when a lawyer in 2018 set himself on fire in a New York park in a protest over climate change. Given how climate may change the land, this has been not only linked to thousands of farmer suicides in India, but to farmer suicides in Syria, which may have helped spark the civil war there.

Other Considerations
Besides these emerging conditions, other formal diagnostic disorders also relate to climate instability. Wherever there are climate-related disasters like intense hurricanes, cyclones, wildfires, and drought, we see an increase in PTSD. When climate refugees emerge, so does an increase of full-fledged depressive and anxiety disorders. Violence also increases when temperatures rise in already hot areas.

These emerging climate-related conditions may turn into formally classified diseases and disorders, but that will take more research by experts in psychiatric classification to ensure validity, reliability, and clear criteria. Nevertheless, they need attention, because they reflect human suffering and need for intervention, right now.

As large numbers of climate scientists assert, we are in a global climate emergency. That is why we have to cover these risks expeditiously and continually. We also need a version of ICD that can adapt and respond as necessary.

Programming Note:

Listen to Dr. Moffic report this story live today during Talk Ten Tuesday, 10-10:30 a.m. EST.

H. Steven Moffic, MD

H. Steven Moffic, MD, is an award-winning author whose fifth book, “The Ethical Way: Challenges & Solutions for Managed Behavioral Health,” is considered a seminal study on healthcare ethics. Always in demand as a writer, Dr. Moffic has attracted a national audience with his three blogs: Psychiatry Times, Behavior Healthcare, and Over 65. H. Dr. Moffic, who is also a popular guest on Talk Ten Tuesdays, recently received the Administrative Psychiatry Award from the American Psychiatric Association (APA) and the American Association of Psychiatrist Administrators (AAPA).

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