Wildfires are associated with increased emergency department visits for anxiety disorders in the western united states

ABSTRACT As wildfires increasingly impact the global economy and public health, understanding their effects is crucial. Particularly, the relationship between wildfires and anxiety disorders

remains unclear. In this study, we explore this association by analyzing 1,897,865 emergency department visits for anxiety disorders in the western United States. We examined records from

2007 to 2018, using a case-crossover design and conditional logistic regression to assess the impact of wildfire-related exposures on these visits. Here we show that exposure to wildfire

smoke PM2.5 is positively linked with emergency department visits for anxiety disorders. This effect is more pronounced in women and girls and in older adults, highlighting their

vulnerability. Notably, major smoke events (smoke PM2.5 contributed ≥75% of the total PM2.5) significantly amplify this risk. These findings underscore the psychological impacts of wildfires

and their smoke, suggesting a need for targeted disaster risk reduction and climate risk management strategies, especially for vulnerable groups such as older adults and women. Our results

call for increased climate awareness and tailored risk communication to mitigate these emerging health challenges. Access through your institution Buy or subscribe This is a preview of

subscription content, access via your institution ACCESS OPTIONS Access through your institution Subscribe to this journal Receive 12 digital issues and online access to articles $79.00 per

year only $6.58 per issue Learn more Buy this article * Purchase on SpringerLink * Instant access to full article PDF Buy now Prices may be subject to local taxes which are calculated during

checkout ADDITIONAL ACCESS OPTIONS: * Log in * Learn about institutional subscriptions * Read our FAQs * Contact customer support SIMILAR CONTENT BEING VIEWED BY OTHERS A SYSTEMATIC REVIEW

OF THE EFFECTS OF CHRONIC, SLOW-ONSET CLIMATE CHANGE ON MENTAL HEALTH Article 15 January 2024 LONGITUDINAL PATTERNS OF NATURAL HAZARD EXPOSURES AND ANXIETY AND DEPRESSION SYMPTOMS AMONG

YOUNG ADULTS IN FOUR LOW- AND MIDDLE-INCOME COUNTRIES Article Open access 08 May 2024 NATURAL HAZARDS AND MENTAL HEALTH AMONG US GULF COAST RESIDENTS Article 18 February 2021 DATA

AVAILABILITY As part of the data use agreement with individual states, we are prohibited from sharing the ED visits data to protect identifiable health information. However, similar data

used in this analysis can be directly requested from the corresponding health departments or hospital association. The Daymet daily 1 km meteorological data are publicly available in the Oak

Ridge National Laboratory data archive (https://doi.org/10.3334/ORNLDAAC/2129). The active-fire-point data are publicly available in the FIRMS database

(https://firms.modaps.eosdis.nasa.gov/active_fire/). The zip code level wildfire smoke PM2.5 data used for this study can be found on Figshare (https://doi.org/10.6084/m9.figshare.25016510).

The original 1 km wildfire smoke PM2.5 data are available on reasonable request from the corresponding author. Source data are provided with this paper. CODE AVAILABILITY The raw ED visits

data were processed with SAS (version 9.4). The FIRMS active-fire data, Daymet meteorological data, and wildfire smoke PM2.5 data were collected and processed with R (version 4.0.5). All the

statistical analyses and plotting were done with R (version 4.0.5). The package survival (version 3.2-10) was used to perform the conditional logistic regression analysis and is publicly

available at https://cran.r-project.org/web/packages/survival/index.html. This study does not involve any custom algorithms/software that are relevant to the core analyses. The R code is

available in the GitHub repository (https://github.com/qingyang-remote-sensing/NMH_anxiety_paper/), or on reasonable request from the corresponding author and Q.Z. ([email protected]).

The SAS code is available on reasonable request from H.H.C. ([email protected]) and R.R.D. ([email protected]). REFERENCES * Ellis, T. M. et al. Global increase in wildfire risk

due to climate-driven declines in fuel moisture. _Glob. Change Biol._ 28, 1544–1559 (2022). Article  Google Scholar  * Jones, M. W. et al. Global and regional trends and drivers of fire

under climate change. _Rev. Geophys._ 60, e2020RG000726 (2022). Article  Google Scholar  * Amrutha, K. et al. Demarcation of forest fire risk zones in Silent Valley National Park and the

effectiveness of forest management regime. _J. Geovis. Spat. Anal._ 6, 8 (2022). Article  Google Scholar  * Jolly, W. M. et al. Climate-induced variations in global wildfire danger from 1979

to 2013. _Nat. Commun._ 6, 7537 (2015). Article  PubMed  Google Scholar  * Richardson, D. et al. Global increase in wildfire potential from compound fire weather and drought. _NPJ Clim.

Atmos. Sci._ 5, 23 (2022). Article  Google Scholar  * Gannon, C. S. & Steinberg, N. C. A global assessment of wildfire potential under climate change utilizing Keetch–Byram drought index

and land cover classifications. _Environ. Res. Commun._ 3, 035002 (2021). Article  Google Scholar  * Zhang, L. et al. Large wildfires in the western United States exacerbated by

tropospheric drying linked to a multi-decadal trend in the expansion of the Hadley Circulation. _Geophys. Res. Lett._ 47, e2020GL087911 (2020). Article  Google Scholar  * Burke, M. et al.

The changing risk and burden of wildfire in the United States. _Proc. Natl Acad. Sci. USA_ 118, e2011048118 (2021). Article  PubMed  PubMed Central  Google Scholar  * Elser, H. et al.

Wildfire smoke exposure and emergency department visits for headache: A case-crossover analysis in California, 2006–2020. _Headache_ 63, 94–103 (2023). Article  PubMed  PubMed Central 

Google Scholar  * Reid, C. E. et al. Critical review of health impacts of wildfire smoke exposure. _Environ. Health Perspect._ 124, 1334–1343 (2016). Article  PubMed  PubMed Central  Google

Scholar  * Wu, J., Snell, G. & Samji, H. Climate anxiety in young people: a call to action. _Lancet Planet. Health_ 4, e435–e436 (2020). Article  PubMed  Google Scholar  * GBD 2019

Mental Disorders Collaborators. Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of

Disease Study 2019. _Lancet Psychiatry_ 9, 137–150 (2022). * Vos, T. et al. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for

the Global Burden of Disease Study 2019. _Lancet_ 396, 1204–1222 (2020). Article  Google Scholar  * Yang, X. et al. Global, regional and national burden of anxiety disorders from 1990 to

2019: results from the Global Burden of Disease Study 2019. _Epidemiol. Psychiatr. Sci._ 30, e36 (2021). Article  PubMed  PubMed Central  Google Scholar  * Clayton, S. Climate anxiety:

psychological responses to climate change. _J. Anxiety Disord._ 74, 102263 (2020). Article  PubMed  Google Scholar  * To, P., Eboreime, E. & Agyapong, V. I. O. The impact of wildfires on

mental health: a scoping review. _Behav. Sci._ 11, 126 (2021). Article  PubMed  PubMed Central  Google Scholar  * Pun, V. C., Manjourides, J. & Suh, H. Association of ambient air

pollution with depressive and anxiety symptoms in older adults: results from the NSHAP study. _Environ. Health Perspect._ 125, 342–348 (2017). Article  PubMed  Google Scholar  * Power, M. C.

et al. The relation between past exposure to fine particulate air pollution and prevalent anxiety: observational cohort study. _Br. Med. J._ 350, h1111 (2015). Article  Google Scholar  *

Shi, W. et al. Depression and anxiety associated with exposure to fine particulate matter constituents: a cross-sectional study in North China. _Environ. Sci. Technol._ 54, 16006–16016

(2020). Article  PubMed  Google Scholar  * Zhao, W. et al. PM2.5 exposure associated with prenatal anxiety and depression in pregnant women. _Ecotoxicol. Environ. Saf._ 248, 114284 (2022).

Article  PubMed  Google Scholar  * Hao, G. et al. Associations of PM2.5 and road traffic noise with mental health: evidence from UK Biobank. _Environ. Res._ 207, 112221 (2022). Article 

PubMed  Google Scholar  * Eisenman, D. P. & Galway, L. P. The mental health and well-being effects of wildfire smoke: a scoping review. _BMC Public Health_ 22, 2274 (2022). Article 

PubMed  PubMed Central  Google Scholar  * Mirabelli, M. C. et al. Wildfire smoke and symptoms affecting mental health among adults in the US state of Oregon. _Prev. Med._ 164, 107333 (2022).

Article  PubMed  PubMed Central  Google Scholar  * Humphreys, A. et al. What can we do when the smoke rolls in? An exploratory qualitative analysis of the impacts of rural wildfire smoke on

mental health and wellbeing, and opportunities for adaptation. _BMC Public Health_ 22, 41 (2022). Article  PubMed  PubMed Central  Google Scholar  * Agyapong, V. I. O. et al. Prevalence

rates and predictors of generalized anxiety disorder symptoms in residents of Fort McMurray six months after a wildfire. _Front. Psychiatry_ 9, 345 (2018). Article  PubMed  PubMed Central 

Google Scholar  * Li, S. H. & Graham, B. M. Why are women so vulnerable to anxiety, trauma-related and stress-related disorders? The potential role of sex hormones. _Lancet Psychiatry_

4, 73–82 (2017). Article  PubMed  Google Scholar  * Lachlan, K. A. et al. The 2018 California wildfires: examining sex differences in response to crisis communication and underlying

processes. _Atl. J. Commun._ 31, 85–96 (2023). Article  Google Scholar  * Hong, J. et al. Significant association between increased risk of emergency department visits for psychiatric

disorders and air pollutants in South Korea. _J. Expo. Sci. Environ. Epidemiol._ 33, 490–499 (2023). Article  PubMed  Google Scholar  * Szyszkowicz, M. et al. Air pollution and emergency

department visits for mental disorders among youth. _Int. J. Environ. Res. Public Health_ 17, 4190 (2020). Article  PubMed  PubMed Central  Google Scholar  * Ferreira, A. P. S. et al.

Experimental rodent models exposed to fine particulate matter (PM2.5) highlighting the injuries in the central nervous system: a systematic review. _Atmos. Pollut. Res._ 13, 101407 (2022).

Article  Google Scholar  * Chu, C. et al. Ambient PM2.5 caused depressive-like responses through Nrf2/NLRP3 signaling pathway modulating inflammation. _J. Hazard. Mater._ 369, 180–190

(2019). Article  PubMed  Google Scholar  * Hong, J. S. et al. Mental health effects of the Gangwon wildfires. _BMC Public Health_ 22, 1183 (2022). Article  PubMed  PubMed Central  Google

Scholar  * Andréen, L. et al. Sex steroid induced negative mood may be explained by the paradoxical effect mediated by GABAA modulators. _Psychoneuroendocrinology_ 34, 1121–1132 (2009).

Article  PubMed  Google Scholar  * Kondo, M. C. et al. Meta-analysis of heterogeneity in the effects of wildfire smoke exposure on respiratory health in North America. _Intl J. Environ. Res.

Public Health_ 16, 960 (2019). Article  Google Scholar  * Masri, S. et al. Disproportionate impacts of wildfires among elderly and low-income communities in California from 2000–2020. _Intl

J Environ. Res. Public Health_ 18, 3921 (2021). Article  Google Scholar  * Wibbenmeyer, M. & Robertson, M. The distributional incidence of wildfire hazard in the western United States.

_Environ. Res. Lett._ 17, 064031 (2022). Article  Google Scholar  * Vasiliadis, H. M. et al. The excess healthcare costs associated with depression and anxiety in elderly living in the

community. _Am. J. Geriatr. Psychiatry_ 21, 536–548 (2013). Article  PubMed  Google Scholar  * Zhang, D. et al. A machine learning model to estimate ambient PM2.5 concentrations in

industrialized highveld region of South Africa. _Remote Sens. Environ._ 266, 112713 (2021). Article  PubMed  PubMed Central  Google Scholar  * Zhu, Q. et al. Satellite-based long-term

spatiotemporal patterns of surface ozone concentrations in China: 2005–2019. _Environ. Health Perspect._ 130, 027004 (2022). Article  PubMed  PubMed Central  Google Scholar  * Filonchyk, M.,

Peterson, M. P. & Sun, D. Deterioration of air quality associated with the 2020 US wildfires. _Sci. Total Environ._ 826, 154103 (2022). Article  PubMed  Google Scholar  * Levin, N.

& Heimowitz, A. Mapping spatial and temporal patterns of Mediterranean wildfires from MODIS. _Remote Sens. Environ._ 126, 12–26 (2012). Article  Google Scholar  * Klotzbach, P. J. et al.

Trends in global tropical cyclone activity: 1990–2021. _Geophys. Res. Lett._ 49, e2021GL095774 (2022). Article  Google Scholar  * Sibolla, B. H., Van Zyl, T. & Coetzee, S. Determining

real-time patterns of lightning strikes from sensor observations. _J. Geovis. Spat. Anal._ 5, 4 (2021). Article  Google Scholar  * Zhang, D. et al. Wildland fires worsened population

exposure to PM2.5 pollution in the contiguous united states. _Environ. Sci. Tech._ 57, 19990–19998 (2023). Article  Google Scholar  * NASA Earthdata MODIS Collection 6 Hotspot/Active Fire

Detections MCD14ML. _NASA FIRMS_ https://firms.modaps.eosdis.nasa.gov/download/ (2019). * Thornton, M. M. _et al_. Daymet: daily surface weather data on a 1-km grid for North America,

version 4 R1, _ORNL Distributed Active Archive Center_, https://doi.org/10.3334/ORNLDAAC/2129 (2022). * Lawrence, M. G. The relationship between relative humidity and the dewpoint

temperature in moist air: a simple conversion and applications. _Bull. Am. Meteorol. Soc._ 86, 225–234 (2005). Article  Google Scholar  Download references ACKNOWLEDGMENTS This work was

supported by the National Institute of Environmental Health Sciences of the National Institutes of Health (NIH; awards R01ES034175 (Y.L.) and R01ES027892 (H.H.C.), P30ES019776 (C. Marsit)).

The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH. We are grateful for the support of the health data sources listed in the

following sentence and their contributing hospitals. The ED visits data used to produce this publication were acquired from the Arizona Department of Health Services; California Office of

Statewide Planning and Development, now California Department of Health Care Access and Information; Nevada Division of Health Care Financing and Policy (DJCFP), released through the Center

for Health Information Analysis (CHIA) of the University of Nevada, Las Vegas; Oregon Healthcare Enterprises, Inc., Apprise Health Insights, a subsidiary of the Oregon Association of

Hospitals & Health Systems; and Utah Department of Health, Office of Health Care Statistics (OHCS). The contents of this publication, including data analysis, interpretation, conclusions

derived, and the views expressed herein, are solely those of the authors and do not represent the conclusions or official views of listed data sources. Authorization to release this

information does not imply endorsement of this study or its findings by any of these data sources. The data sources, their employees, officers, and agents make no representation, warranty,

or guarantee as to the accuracy, completeness, currency, or suitability of the information provided here. AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Gangarosa Department of Environmental

Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA Qingyang Zhu, Wenhao Wang, Haisu Zhang, Binyu Yang, Kyle Steenland, Noah Scovronick, Stefanie Ebelt & Yang Liu

* Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA Danlu Zhang, Rohan Richard D’Souza & Howard H. Chang Authors *

Qingyang Zhu View author publications You can also search for this author inPubMed Google Scholar * Danlu Zhang View author publications You can also search for this author inPubMed Google

Scholar * Wenhao Wang View author publications You can also search for this author inPubMed Google Scholar * Rohan Richard D’Souza View author publications You can also search for this

author inPubMed Google Scholar * Haisu Zhang View author publications You can also search for this author inPubMed Google Scholar * Binyu Yang View author publications You can also search

for this author inPubMed Google Scholar * Kyle Steenland View author publications You can also search for this author inPubMed Google Scholar * Noah Scovronick View author publications You

can also search for this author inPubMed Google Scholar * Stefanie Ebelt View author publications You can also search for this author inPubMed Google Scholar * Howard H. Chang View author

publications You can also search for this author inPubMed Google Scholar * Yang Liu View author publications You can also search for this author inPubMed Google Scholar CONTRIBUTIONS Q.Z.,

Y.L., and H.H.C. conceptualized the study and designed the analysis. D.Z. and W.W. produced the wildfire data. R.R.D. processed the ED visits data. H.Z. and Q.Z. collected the Daymet

meteorological data. Q.Z. performed the main analyses in consultation with K.S., N.S., S.E., H.H.C., and Y.L. The data visualization was completed by Q.Z. and B.Y. Q.Z. wrote the initial

paper in collaboration with D.Z., W.W., R.R.D., and H.Z. The paper was reviewed and edited by B.Y., K.S., N.S., S.E., H.H.C., and Y.L. The supporting fundings were acquired by S.E., H.H.C.,

and Y.L. All collaborators of this study that have fulfilled the criteria for authorship required by Nature Portfolio journals have been included as co-authors of this paper. The roles and

responsibilities were agreed among collaborators ahead of the research. CORRESPONDING AUTHOR Correspondence to Yang Liu. ETHICS DECLARATIONS COMPETING INTERESTS The authors declare no

competing interests. PEER REVIEW PEER REVIEW INFORMATION _Nature Mental Health_ thanks Amy Lykins, Manzhu Yu and the other, anonymous, reviewer(s) for their contribution to the peer review

of this work. ADDITIONAL INFORMATION PUBLISHER’S NOTE Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. SUPPLEMENTARY

INFORMATION SUPPLEMENTARY INFORMATION Supplementary Figs. 1–5 and Table 1. REPORTING SUMMARY SUPPLEMENTARY DATA 1 Source data for Supplementary Fig. 1. SUPPLEMENTARY DATA 2 Source data for

Supplementary Fig. 2. SUPPLEMENTARY DATA 3 Source data for Supplementary Fig. 3. SUPPLEMENTARY DATA 4 Source data for Supplementary Fig. 4. SUPPLEMENTARY DATA 5 Source data for Supplementary

Fig. 5. SOURCE DATA SOURCE DATA FIG. 1 Statistical source data. SOURCE DATA FIG. 2 Statistical source data. SOURCE DATA FIG. 3 Statistical source data. RIGHTS AND PERMISSIONS Springer

Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author

self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. Reprints and permissions ABOUT THIS ARTICLE

CITE THIS ARTICLE Zhu, Q., Zhang, D., Wang, W. _et al._ Wildfires are associated with increased emergency department visits for anxiety disorders in the western United States. _Nat. Mental

Health_ 2, 379–387 (2024). https://doi.org/10.1038/s44220-024-00210-8 Download citation * Received: 23 June 2023 * Accepted: 23 January 2024 * Published: 15 February 2024 * Issue Date: April

2024 * DOI: https://doi.org/10.1038/s44220-024-00210-8 SHARE THIS ARTICLE Anyone you share the following link with will be able to read this content: Get shareable link Sorry, a shareable

link is not currently available for this article. Copy to clipboard Provided by the Springer Nature SharedIt content-sharing initiative