Teaching to Our Time: a Survey Study of Current Opinions and Didactics About Climate Mental Health Training in US Psychiatry Residency and Fellowship Programs

To the Editor:

Global warming is a public health emergency that poses significant threats to mental health [1]. The need for graduate medical education about the effects of climate change on health has increasing support from organizations like the Accreditation Council for Graduate Medical Education [2], but it is unclear what is currently taught in psychiatry training about the mental health impacts of global warming.

We therefore designed an online module to assess what US psychiatry trainees currently learn about the impacts of climate change on mental health, determine the perceived importance of this topic, and test whether exposure to a brief educational video about climate mental health altered this perception. In addition, we solicited feedback about where climate mental health education could fit into existing didactics. We hypothesized that few psychiatry programs offer training on this topic and that increasing knowledge through video exposure would correlate to increased perceived importance of teaching and learning about this area.

Psychiatry residents, fellows, and training directors were recruited through an email to the American Association of Directors of Psychiatric Residency Training Listserv and the membership of the Group for the Advancement of Psychiatry and the Climate Psychiatry Alliance. Recipients were asked to forward this information to psychiatry training directors and trainees in their professional networks. Only individuals who identified as psychiatry residents, fellows, or program directors were included in the analysis.

The module included demographics, a four-question presurvey on current curricula offered on climate mental health and the perceived importance of the topic using a 6-point Likert scale (“Not at all important” to “Essential”), a six-minute video summarizing the effects of climate on mental health as illustrated through clinical vignettes [3], and a nine-question post-survey to assess the perceived importance after watching this video, how participants felt it should be included in didactics, and optional free-text responses. This study was reviewed and approved by the Research Subjects Review Board at the University of Rochester. Participants did not receive incentives for participating. A Wilcoxon signed rank test was used to assess for changes in perceived importance of this topic. All free-text responses were coded using thematic qualitative analysis.

The module was accessed 105 times: 87 participants completed the pre-survey and 82 met inclusion criteria. Of these, 73 completed the post-survey (11% attrition). The participants represented 60 unique training programs at 47 US medical institutions, included roughly equal proportions of men and women spanning the age spectrum. Only 8 of the 60 training programs (13.3%) offered didactics on climate mental health. Of these, half reported stand-alone didactics on this topic and half integrate this material into didactics on social determinants of health. Prior to watching the educational video, 48.8% (40/82) of participants thought that didactics on this topic were very important to essential, 37.1% (32/82) rated them as neutral to somewhat important, and the remaining 12.2% (10/82) reported feeling that they had little to no importance. The most common theme identified in the free-text responses was that participants felt they did not know enough about the effects of climate on mental health to have a strong opinion about its importance. Others reported having few patients with climate-related concerns or felt this material is not important enough to replace other content in space-limited curricula.

After watching the video, the percentage who identified climate mental health didactics as very to extremely important grew from 48.8% (40/82) to 68.5% (50/73) (p < 0.001), and the proportion that rated the importance as neutral to somewhat important decreased to 20.5% (15/73). Those that rated the topic as having little to no importance remained similar (10.9%, 8/73). Overall, after watching the video, 46.6% (34/73) of participants reported a one-to-two-point increase on the Likert scale for topic importance, and only one participant reported a one-point decrease. A common theme in the free-text responses was that participants found the video significantly improved their understanding of the topic. A few reported that psychiatry trainees already receive training to support patients with these issues and that didactics on this topic could be politically motivated. Stand-alone didactics, incorporation into didactics on social determinants of health, and inclusion in other didactics (e.g., discussing side effects of psychotropics during heat waves) were all considered viable options for including this material in residency curricula.

While the small convenience sample of this study limits its generalizability, in those programs sampled, a minority teach about climate mental health. It is worth noting that junior trainees in our sample might be unaware of their programs’ didactics on this topic, and recall of didactics among participants may be variable, both of which might contribute to underreporting of existing didactics. The impact of the video itself was limited to actor portrayals of clinical vignettes and could have been strengthened with inclusion of citations to the literature. We have subsequently included citations in the video description. Nevertheless, nearly 70% of our sample identified this topic as very important to essential to learn about after exposure to relevant information. A lack of content expertise to teach this material and limited space in curricula may account for this discrepancy in offered didactics and popular demand. Avoidance of the topic can be a way of managing its distressing nature, and framing this socio-scientific topic as political or no different than other content already taught can be ways of avoiding its importance.

It will be increasingly essential to educate medical students, psychiatry trainees, and psychiatry educators on the impacts of climate change on mental health and to test the effectiveness of these didactics in larger samples. Embedding these ideas into existing core competencies, establishing national learning objectives for climate mental health, and assessing these topics during certifying examinations will be necessary next steps [4]. Patients with mental illness and disadvantaged populations are among those most affected by climate change, and the current lack of education about this topic tacitly neglects our duty to serve these groups and the general population equitably. Psychiatric education has always adjusted to teach to its time, and the climate health crisis can be no different.