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Mental health in water scarce cities: an unrecognized climate change pressure point

Water unavailability is one of many linked stressors increasingly likely to affect mental health in some city populations. Azar M Abadi and colleagues consider the evidence and propose steps forward to protect vulnerable residents

Several megatrends, including climate change, urbanization, and water stress, are converging to put additional strain on global mental health. The impact of water scarcity on mental health has been well characterized for rural populations;1 the nexus at the intersection of water scarcity and mental health for urban dwellers deserves closer examination. 

Mechanisms may include stress and insecurity felt due to water scarcity; displacement of families to urban areas; effects of dehydration on effectiveness of psychoactive medications; heat-related aggression, violence, and suicide; and high mental burden on women for their efforts to find and procure clean water. 

Water scarcity also contributes to mental health through myriad indirect pathways including land degradation, famine, malnutrition, spread of disease, heat waves, and reduced air quality. Highly correlated stressors associated with water insecurity in urban settings mean that water stress is unlikely to be identified as a principal cause for mental illness.

Pathways linking water stress and mental health disorders

Urban migration is a common coping strategy for rural people exposed to drought. In this context, depression and anxiety resulting from the rupture of community and place bonds is a likely causal pathway.1 Migration, particularly early in the life cycle, is a significant risk factor for several mental disorders.2

The impact of migration on mental health is greater among women, youth, elderly people, and people with disabilities.3 Compromised mental health in caregivers or parents is likely to directly influence not only concurrent child wellbeing but also developmental trajectories of child mental health thereafter. 

Several studies link poor water access and quality to adverse mental health in urban settings, including in Iran;4 Bolivia;5 and the United States.6 Women are at particular risk, studies in Bolivia,7 urban Nepal,8 and Odisha, India,9 have concluded. 

Climate change is increasing the frequency of compound hazards, wherein heat and water stress overlap.10 Myriad studies have found high ambient temperatures associated with mental and behavioural disorders. Older people are more vulnerable to extreme heat.11 Existing mental health issues like schizophrenia, schizotypal disorders, neurotic disorders, and disorders related to substance misuse are associated with increased morbidity and mortality at higher temperatures.3,12 Lower socioeconomic status, homelessness, and living in slums were associated with adverse mental health outcomes in hot cities.13

Evidence informed solutions

Optimum management is likely to include strategies to manage water insecurity in urban settings,21 increased mental health surveillance and service delivery, and protecting the most vulnerable people from the combined stressors that can exacerbate mental health concerns. 

Focusing on interventions that are likely to benefit mental health is particularly important. Limited access to green and blue space can compromise mental health. Diminished active spaces exacerbates physical and mental health conditions.14 Management of urban green spaces in wealthy and poor neighbourhoods is central,15 as is maintenance of and access to urban waterways.16

Sustained access to clean water is a key health determinant. Like other determinants, access tends to vary across familiar inequity gradients. Recognition of the impact of upstream drivers, such as neighbourhood conditions or household financial status, and the differential impact on marginalized populations, is key.17

Some water and sanitation management strategies could exacerbate mental health threats. Recognizing the many hydro-social contracts that affect health between water managers and urban residents can help reduce harms. Recognizing the human right to clean, safe water has important implications for reducing harms.18 Water management strategies need to be flexible and responsive. For example, a study in Australia reported that permanent water restrictions are not viable long-term policy.19 In addition, indiscriminate use of water pricing strategies to restrict demand, without consideration of impacts on economically vulnerable populations, is likely to worsen stresses and undermine mental health.20

Education, in health and water sectors and of the general population, is important. For example, health counselling about extreme temperatures can be included in the outpatient care program for patients with mental disorders. 

Existing global mental health priorities highlight the need for a life-cycle approach and early interventions. Existing priorities also emphasize approaches that integrate family members and communities, and wrap-around services should incorporate water insecurity into mental health programming.

More research needed

Evaluation and research are crucial to identify vulnerable populations and risks. More research, data collection, and mental health surveys are needed to create larger databases in real time and to identify vulnerable populations and allocate more funding to make these populations more resistant to water insecurity. 

Climate change, urbanization, and water stress present challenges to livelihoods and services, from mental health surveillance and treatment provision to water sourcing to sanitation, that are already under significant strain. Climate change has the potential to amplify trends and conditions that already strain systems to monitor and tackle population health challenges. These systems need to be updated to respond to looming additional burdens. 

Thoughtful, proactive investments could blunt many of the worst effects. As with many other climate change impacts, however, there is worrisome potential for the world’s most vulnerable to suffer most.

Azar M. Abadi, PhD, University of Nebraska Medical Center, USA

Ann Vander Stoep, PhD, MS, University of Washington, USA

Katherine T. Foster, PhD, University of Washington, USA

Susan Clayton, PhD, College of Wooster, USA

Jesse E. Bell, PhD, Omaha, USA

Jeremy Hess, MD, MPH, University of Washington, USA

This article is part of a series commissioned by The BMJ for the World Innovation Summit for Health (WISH) 2020. The BMJ peer reviewed, edited, and made the decisions to publish. The series, including open access fees, is funded by WISH.

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