The association between daily concentrations of air pollution and visits to a psychiatric emergency unit: a case-crossover study

A stronger association of mental disorders with smaller particulate matter and a modifying effect of air temperature

Mental disorders (MDs) can be triggered by adverse weather conditions and particulate matter (PM) such as PM2.5 and PM10 (aerodynamic diameter ≤2.5 μm and ≤10 μm). However, there is a dearth of evidence on the role of smaller PM (e.g. PM1, aerodynamic diameter ≤1 μm) and the potential modifying effects of weather conditions. We aimed to collect daily data on emergency department visits and hospitalisations for schizophrenia-, mood-, and stress-related disorders in a densely populated Chinese city (Hefei) between 2016 and 2019. A time-stratified case-crossover analysis was used to examine the short-term association of MDs with PM1, PM2.5, and PM10. The potential modifying effects of air temperature conditions (cold and warm days) were also explored. The three size-fractioned PMs were all associated with an increased risk of MDs; however, the association differed between emergency department visit and hospitalisation. Specifically, PM1 was primarily associated with an increased risk of emergency department visit, whereas PM2.5 was primarily associated with an increased risk of hospitalisation, and PM10 was associated with an increased risk of both emergency department visit and hospitalisation. The PM-MD association appeared to be greatest (although not significant) for PM1 (odds ratio range: 1.014-1.055), followed by PM2.5 (odds ratio range: 1.001-1.009) and PM10 (odds ratio range: 1.001-1.006). Furthermore, the PM-MD association was observed on cold days; notably, the association between PM and schizophrenia-related disorders was significant on both cold and warm days. Our results suggest that the smaller the PM, the greater the risk of MDs, and that the PM-MD association could be determined by air temperature conditions.

Effects of ambient air pollution on the hospitalization risk and economic burden of mental disorders in Qingdao, China

OBJECTIVE

The aim of this study was to examine the impacts of short-term exposure to air pollutants on hospitalizations for mental disorders (MDs) in Qingdao, a Chinese coastal city, and to assess the corresponding hospitalization risk and economic cost.

METHODS

Daily data on MD hospitalizations and environmental variables were collected from January 1, 2015, to December 31, 2019. An overdispersed generalized additive model was used to estimate the association between air pollution and MD hospitalizations. The cost of illness method was applied to calculate the corresponding economic burden.

RESULTS

With each 10 μg/m3 increase in the concentration of fine particulate matter (PM2.5) at lag05, inhalable particulate matter (PM10) at lag0, sulfur dioxide (SO2) at lag06 and ozone (O3) at lag0, the corresponding relative risks (RRs) and 95% confidence intervals (CIs) were 1.0182 (1.0035-1.0332), 1.0063 (1.0001-1.0126), 1.0997 (1.0200-1.1885) and 1.0099 (1.0005-1.0194), respectively. However, no significant effects of nitrogen dioxide (NO2) or carbon monoxide (CO) were found. Stratified analysis showed that males were susceptible to SO2 and O3, while females were susceptible to PM2.5. Older individuals (≥ 45 years) were more vulnerable to air pollutants (PM2.5, PM10, SO2 and O3) than younger individuals (< 45 years). Taking the Global Air Quality Guidelines 2021 as a reference, 8.71% (2,168 cases) of MD hospitalizations were attributable to air pollutant exposure, with a total economic burden of 154.36 million RMB.

CONCLUSION

Short-term exposure to air pollution was associated with an increased risk of hospitalization for MDs. The economic advantages of further reducing air pollution are enormous.

Increase in sick leave episodes from short-term fine particulate matter exposure: A case-crossover study in Stockholm, Sweden

Air pollution's short-term effects on a wide range of health outcomes have been studied extensively, primarily focused on vulnerable groups (e.g., children and the elderly). However, the air pollution effects on the adult working population through sick leave have received little attention. This study aims to 1) estimate the associations between particulate matter ≤2.5 μm3 (PM2.5) and sick leave episodes and 2) calculate the attributable number of sick leave days and the consequential productivity loss in the City of Stockholm, Sweden. Individual level daily sick leave data was obtained from Statistics Sweden for the years 2011-2019. Daily average concentrations of PM2.5 were obtained from the main urban background monitoring station in Stockholm. A case-crossover study design was applied to estimate the association between short-term PM2.5 and onset of sick leave episodes. Conditional logistic regression was used to estimate the relative increase in odds of onset per 10 μg/m3 of PM2.5, adjusting for temperature, season, and pollen. A human capital method was applied to estimate the PM2.5 attributable productivity loss. In total, 1.5 million (M) individual sick leave occurrences were studied. The measured daily mean PM2.5 concentration was 4.2 μg/m3 (IQR 3.7 μg/m3). The odds of a sick leave episode was estimated to increase by 8.5% (95% CI: 7.8-9.3) per 10 μg/m3 average exposure 2-4 days before. Sub-group analysis showed that private sector and individuals 15-24 years old had a lower increase in odds of sick leave episodes in relation to PM2.5 exposure. In Stockholm, 4% of the sick leave episodes were attributable to PM2.5 exposure, corresponding to €17 M per year in productivity loss. Our study suggests a positive association between PM2.5 and sick leave episodes in a low exposure area.

Significant association between increased risk of emergency department visits for psychiatric disorders and air pollutants in South Korea

BACKGROUND

The association between air pollutants and psychiatric disorders has been investigated in many countries. However, results for the association between air pollutants and emergency room (ER) visits for psychiatric disorders are inconsistent. Further, systematic large-scale studies relating to the same are lacking, especially in South Korea.

OBJECTIVE

We aimed to investigate the acute and short-term cumulative effect of air pollutants on ER visits for psychiatric disorders in South Korea.

METHODS

The data on nitrogen dioxide (NO2) and particulate matter (PM2.5 and PM10) and ER visits due to nine representative psychiatric disorders were collected from eight major cities in South Korea for three years. We estimated the relative risk (RR) at lag 0 and a cumulative 11-day RR by increasing a 10-unit for PM and 0.01-unit for NO2 using the Distributed Lag Nonlinear Model.

RESULTS

During the study period, a total of 79,092 ER visits for psychiatric disorders were identified and tested for association with NO2, PM2.5, and PM10. The RR at lag 0 of depression per 0.01-unit increase in NO2 was the highest (3.127; 95% confidence interval [CI] 2.933 to 3.332) among the psychiatric disorders. The RRs at lag 0 of anxiety disorders per 10-unit increase in PM2.5 (1.709; 95% CI 1.424 to 2.053) and PM10 (2.168; 95% CI 1.957 to 2.403) were the highest among the psychiatric disorders.

SIGNIFICANCE

Air pollutants increased ER visits for psychiatric disorders with the highest RR of depression due to NO2 and anxiety disorder due to PM2.5 and PM10. These results contribute evidence to the positive association between ambient exposure to air pollution and aggravation of psychiatric disorders, indicating air pollution may be a modifiable risk factor in mental health management.

IMPACT STATEMENT

We investigated the effect of air pollution on emergency room visits caused by major psychiatric disorders in prominent cities in South Korea. Using the Distributed Lag Nonlinear Model, an advanced analysis method, we calculated the acute effect and short-term cumulative effect. Air pollutants increased ER visits for psychiatric disorders with the highest relative risk of depression due to NO2 and anxiety disorder due to PM2.5 and PM10. These results reveal an association between ambient exposure to air pollution and aggravation of psychiatric disorders and suggest that air pollution may be a modifiable risk factor in mental health management.

Health risk assessment of PM2.5 and PM2.5-bound trace elements in Pretoria, South Africa

Exposure to outdoor air pollutants poses a risk for both non-carcinogenic and carcinogenic respiratory disease outcomes. A standardized health risk assessment (US EPA) utilizes air quality data, body mass and breathing rates to determine potential risk. This health risk assessment study assesses the hazard quotient (HQ) for total PM_2.5 and trace elemental constituents (Br, Cl, K, Ni, S, Si, Ti and U) exposure in Pretoria, South Africa. The World Health Organization (WHO) air quality guideline (5 µg m^-3) and the yearly South African National Ambient Air Quality Standard (NAAQS) (20 µg m^-3) were the references dosages for total PM_2.5. A total of 350 days was sampled in Pretoria, South Africa. The mean total PM_2.5 concentration during the 34-month study period was 23.2 µg m^-3 (0.7-139 µg m^-3). The HQ for total PM_2.5 was 1.17, 3.47 and 3.78 for adults, children and infants. Non-carcinogenic risks for trace elements K, Cl, S and Si were above 1 for adults. Seasonally, Si was the highest during autumn for adults (1.9) and during spring for S (5.5). The HQ values for K and Cl were highest during winter. The exposure to Ni posed a risk for cancer throughout the year and for As during winters.

The association of air pollutants with hospital outpatient visits for child and adolescence psychiatry in Shenzhen, China

BACKGROUND

Although exposure to ambient air pollution has been associated with mental disorder, little is known about its potential effects on children and adolescents, especially in Chinese population. We aimed to reveal the relationship of air pollutants with hospital outpatient visits for child and adolescence psychiatry (HOVCAP) in Shenzhen.

METHODS

A case-crossover study based on time-series data was applied, and a distributed lag non-linear model (DLNM) was used to evaluate the non-linear and delayed effects of 4 major air pollutants (NO₂, PM_2.5, SO₂ and O₃) on HOVCAP. Least absolute shrinkage and selection operator (LASSO) regression was used to control the multicollinearity between covariates and to filter variables.

RESULT

A total of 94,660 cases aged 3-18 were collected from 2014 to 2019 in the Mental Health Center of Shenzhen. Results of pollutants at mode value (M₀) showed that in the single lag effect result, when the average daily concentration of NO₂ at 24 μg/m³, there was a significant effect on HOVCAP over lag 1, lag 4 and lag 5, respectively. The cumulative RR of NO₂ M₀ value to the outpatient visits were 1.438 (1.137-1.818) over lag 0-2, 1.454 (1.120-1.887) over lag 0-3, 1.466 (1.084-1.982) over lag 0-4, 1.680 (1.199-2.354) over lag 0-5, 1.993 (1.369-2.903) over lag 0-6, and 2.069 (1.372-3.119) over lag 0-7. However, PM_2.5, SO₂, O₃ were not associated with HOVCAP over neither single lag effects nor cumulative effects. The RR values both shown an increase either when NO₂ increases by 10 units or when the maximum concentration of NO₂ is reached.

CONCLUSION

Our study suggests that exposure to the normal air quality of NO2 in Shenzhen may associated with the risk of HOVCAP. However, PM2.5, SO2, O3 were not associated with HOVCAP.

Are there joint effects of different air pollutants and meteorological factors on mental disorders? A machine learning approach

Exposure to air pollutants is considered to be associated with mental disorders (MD). Few studies have addressed joint effect of multiple air pollutants and meteorological factors on admissions of MD. We examined the association between multiple air pollutants (PM_2.5, PM₁₀, O₃, SO₂, and NO₂), meteorological factors (temperature, precipitation, relative humidity, and sunshine time), and MD risk in Yancheng, China. Associations were estimated by a generalized linear regression model (GLM) adjusting for time trend, day of the week, and patients' average age. Empirical weights of environmental exposures were judged by a weighted quantile sum (WQS) model. A machine learning approach, Bayesian kernel machine regression (BKMR), was used to assess the overall effect of mixed exposures. We calculated excess risk (ER) and 95% confidence interval (CI) for each exposure. According to the effect of temperature on MD, we divided the exposure of all factors into different temperature groups. In the high temperature group, GLM found that for every 10 μg/m³ increase in O₃, PM_2.5 and PM₁₀ exposure, the ERs were 1.926 (95%CI 0.345, 3.531), 1.038 (95%CI 0.024, 2.062), and 0.780 (95% CI 0.052, 1.512) after adjusting for covariates. Temperature, relative humidity, and sunshine time also reported significant results. The WQS identified O₃ and temperature (above the threshold) had the highest weights among air pollutants and meteorological factors. BKMR found a significant positive association between mixed exposure and MD risks. In the low temperature group, only O₃ and temperature (below the threshold) showed significant results. These findings provide policymakers and practitioners with important scientific evidence for possible interventions. The association between different exposures and MD risk warrants further study.

Explainable Gated Recurrent Unit to explore the effect of co-exposure to multiple air pollutants and meteorological conditions on mental health outcomes

Mental health conditions have the potential to be worsened by air pollution or other climate-sensitive factors. Few studies have empirically examined those associations when we faced to co-exposures, as well as interaction effects. There would be an urgent need to use deep learning to handle complex co-exposures that might interact in multiple ways, and the model performance reinforced by SHapely Additive exPlanations (SHAP) enabled our predictions interpretable and hence actionable. Here, to evaluate the mixed effect of short-term co-exposure, we conducted a time-series analysis using approximately 1.47 million hospital outpatient visits of mental disorders (i.e., depressive disorder-DD, Schizophrenia-SP, Anxiety Disorder-AD, Bipolar Disorder-BD, Attention Deficit and Hyperactivity Disorder-ADHD, Autism Spectrum Disorder-ASD), with matched meteorological observations from 2015 through 2019 in Nanjing, China. The global insights of gated recurrent unit model revealed that most of input features with similar effect size caused the illness risk of SP and ASD increase, and most markedly, 73% of relative humidity, 44.6 µg/m³ of NO₂, and 14.1 µg/m³ of SO₂ at 5-year average level associated with 2.27, 1.14, and 1.29 visits increase for DD, SP, and AD, respectively. Both synergic and antagonistic effect among informative paired-features were distinguished from local feature dependence. Interestingly, variation tendencies of excessive visits of bipolar disorder when atmospheric pressure, PM_2.5, and O₃ interacted with one another were inconsistent. Our results provided added qualitative and quantitative support for the conclusion that short-term co-exposure to ambient air pollutants and meteorological conditions posed threats to human mental health.

The Effect of Sustained Poor Air Quality on EMS Call Volume and Characteristics: A Time-Stratified Case-Crossover Study

OBJECTIVES

As wildfires and air pollution become more common across the United States, it is increasingly important to understand the burden they place on public health. Previous studies have noted relationships between air quality and use of Emergency Medical Services (EMS), but until now, these studies have focused on day-to-day air quality. The goal of this study is to investigate the effect of sustained periods of poor air quality on EMS call characteristics and volume.

METHODS

Using a time-stratified case-crossover design, the effect of exposure to periods of poor air quality on number and type of EMS calls in California, USA from 2014-2019 was observed. Poor air quality periods greater than three days were identified at the United States Environmental Protection Agency's (EPA's) Air Quality Index (AQI) levels of Unhealthy for Sensitive Groups (AQI 100) and Unhealthy (AQI 150). Periods less than three days apart were combined. Each poor air quality period was matched with two one-week controls, the first being the closest preceding week that did not intersect a different case. The second control was the closest week at least three days after the case and not intersecting with a different case. Due to seasonal variation in EMS usage, from the initial cases, cases were used only if it was possible to identify controls within 28 days of the case. A conditional Poisson regression calculated risk ratios for EMS call volume.

RESULTS

Comparing the case periods to the controls, significant increases were found at AQI >100 for total number of calls, and the primary impressions categories of emotional state or behavior, level of consciousness, no patient complaint, other, respiratory, and abdominal. At an AQI >150, significance was found for the primary impressions categories of other, pain, respiratory, and digestive.

CONCLUSION

These data demonstrate increased EMS calls during sustained poor air quality, and that several EMS primary impression categories are disproportionately affected. This study is limited by the imprecision of the primary impression's classification provided by the EMS clinician responding to the EMS call. More research is needed to understand the effects of periods of poor air quality on the EMS system for more efficient deployment of resources.

Pediatric anxiety and daily fine particulate matter: A longitudinal study

Daily variations in ambient fine particulate matter (PM_2.5) could contribute to the morbidity of anxiety disorders in children and adolescents, but has not yet been studied longitudinally at a daily level. We tested this association using repeated weekly measures of anxiety symptom severity in a group of 23 adolescents with generalized anxiety disorder. After estimating ambient PM_2.5 concentrations using a validated model, we found that increased concentrations were significantly associated with increased anxiety symptom severity and frequency two, three, and four days later. PM_2.5 may be a novel, modifiable exposure that could inform population level interventions to decrease psychiatric morbidity.

Ambient ozone exposure and hospitalization for substance abuse: A time-stratified case-crossover study in Taipei

A number of studies investigating the possibility that air pollutant exposures increases the risk of adverse effects on mental health including frequency of suicide and depression, is a major growing public health concern. Human data demonstrated that exposure to various ambient air contaminants including ozone (O₃) adversely affected nervous system functions. It is also well-established that substance abuse produces central nervous system dysfunctions with resultant increase in suicide rates. However, the role of substance abuse in combination with O₃ exposure on mental health remained to be determined. The aim of this investigation was to conduct a time-stratified case-crossover study to examine the possible correlation between short-term ambient O₃ exposure and daily hospital admissions for substance abuse, including alcohol dependence syndrome and non-dependent abuse of drugs, in Taipei from 2009 to 2013. In our single pollutant model, a 35% rise in interquartile (IQR) O₃ levels on cool days and a 12% elevation on warm days was associated with increase in mental health hospitalizations. In our two-pollutant models, O₃ remained significantly associated with elevated number of hospitalizations after adding any one of possible air pollutants, PM₁₀, PM_2.5, SO₂, NO₂, and CO, to our model on cool and warm days. Data suggested that temperature may affect the association between outdoor ambient air O₃ exposure and enhanced risk of hospitalization for substance abuse. Further study is needed to better understand these findings.

An Evaluation of Risk Ratios on Physical and Mental Health Correlations due to Increases in Ambient Nitrogen Oxide (NOx) Concentrations

Nitrogen oxides (NOx) are gaseous pollutants contributing to pollution in their primary form and are also involved in reactions forming ground-level ozone and fine particulate matter. Thus, NOx is of great interest for targeted pollution reduction because of this cascade effect. Primary emissions originate from fossil fuel combustion making NOx a common outdoor and indoor air pollutant. Numerous studies documenting the observed physical health impacts of NOx were reviewed and, where available, were summarized using risk ratios. More recently, the literature has shifted to focus on the mental health implications of NOx exposure, and a review of the current literature found five main categories of mental health-related conditions with respect to NOx exposure: common mental health disorders, sleep, anxiety, depression, and suicide. All the physical and mental health effects with available risk ratios were organized in order of increasing risk. Mental health concerns emerged as those most influenced by NOx exposure, with physical health impacts, such as asthma, only beginning to surface as the fourth highest risk. Mental health conditions occupied seven of the top ten highest risk health ailments. The results summarized in this narrative review show that there are clear positive correlations between NOx and negative physical and mental health manifestations, thus strengthening the argument in support of the reduction in ambient NOx levels.

Application of Fluorescent Probes in Reactive Oxygen Species Disease Model

Reactive oxygen species (ROS) play an important role in living activities as signaling molecules that regulate the living activities of organisms. There are many types of ROS, mainly including hydrogen peroxide (H2O2), hypochlorous acid (HOCl), hydroxyl radical (•OH), peroxyl radical (ROO•), singlet oxygen (1O2), peroxynitrite (ONOO-) and superoxide anion radical (O2-•) etc. Existing studies have shown that changes in ROS levels are closely associated with the development of many diseases, such as inflammation, cancer, cardiovascular disease, and neurodegenerative damage. Small molecule fluorescent probes have been widely used in biology, pathology and medical diagnosis due to their advantages of noninvasive, high sensitivity and in vivo real-time detection. It is extremely important to better apply small-molecule fluorescent probes to detect ROS levels in organisms to achieve early diagnosis of diseases and assessment of therapeutic conditions. This work focuses on summarizing the representative applications of some fluorescent probes in ROS disease models in recent years. This article focuses on summarizing the construction methods of various ROS-related disease models, and classifying and analyzing the basic ideas and methods of fluorescent probes applied to disease models according to the characteristics of various diseases.

Air pollution and individuals' mental well-being in the adult population in United Kingdom: A spatial-temporal longitudinal study and the moderating effect of ethnicity

BACKGROUND

Recent studies suggest an association between ambient air pollution and mental well-being, though evidence is mostly fragmented and inconclusive. Research also suffers from methodological limitations related to study design and moderating effect of key demographics (e.g., ethnicity). This study examines the effect of air pollution on reported mental well-being in United Kingdom (UK) using spatial-temporal (between-within) longitudinal design and assesses the moderating effect of ethnicity.

METHODS

Data for 60,146 adult individuals (age:16+) with 349,748 repeated responses across 10-data collection waves (2009-2019) from "Understanding-Society: The-UK-Household-Longitudinal-Study" were linked to annual concentrations of NO2, SO2, PM10, and PM2.5 pollutants using the individuals' place of residence, given at the local-authority and at the finer Lower-Super-Output-Areas (LSOAs) levels; allowing for analysis at two geographical scales across time. The association between air pollution and mental well-being (assessed through general-health-questionnaire-GHQ12) and its modification by ethnicity and being non-UK born was assessed using multilevel mixed-effect logit models.

RESULTS

Higher odds of poor mental well-being was observed with every 10μg/m3 increase in NO2, SO2, PM10 and PM2.5 pollutants at both LSOAs and local-authority levels. Decomposing air pollution into spatial-temporal (between-within) effects showed significant between, but not within effects; thus, residing in more polluted local-authorities/LSOAs have higher impact on poor mental well-being than the air pollution variation across time within each geographical area. Analysis by ethnicity revealed higher odds of poor mental well-being with increasing concentrations of SO2, PM10, and PM2.5 only for Pakistani/Bangladeshi, other-ethnicities and non-UK born individuals compared to British-white and natives, but not for other ethnic groups.

CONCLUSION

Using longitudinal individual-level and contextual-linked data, this study highlights the negative effect of air pollution on individuals' mental well-being. Environmental policies to reduce air pollution emissions can eventually improve the mental well-being of people in UK. However, there is inconclusive evidence on the moderating effect of ethnicity.

Air pollution and increased number of psychiatric emergency room visits: A case-crossover study for identifying susceptible groups

BACKGROUND

Ambient particulate matter is a leading risk factor for disease globally. Particulate matter 10 (PM₁₀) and particulate matter 2.5 (PM_2.5) are derived from different sources, including operating motor vehicles as well as from industrial activities. In this study we investigate the association between increased concentrations of PM and total daily visits to the psychiatric emergency unit (PEV). Further, the aim is to identify specific risk groups who are more susceptible to the effects of air pollution exposure by studying sex, age, ongoing psychiatric follow-up and diagnoses of depression/anxiety or substance use.

MATERIAL AND METHODS

The sample was comprised of data from 2740 days to 81 548 PEVs at Sahlgrenska University Hospital in Gothenburg and daily mean concentrations of PM₁₀ and PM_2.5. A time-stratified case-crossover design was used to analyse associations between air pollution and PEVs.

RESULTS

Mean number of daily PEVs were 35 and sex distribution was even. PM exposure was associated with total PEV at lag 0 (the same day), by RR 1.016 (95% confidence interval [CI] 1.004-1.028) and RR 1.020 (95%CI 1.003-1.038) per 10 μg/m³ increase in PM₁₀ and PM_2.5, respectively. In females, PEV were increased at lag 0 and lag 1, and in males at lag 1 and lag 2. In the age-stratified analysis, PEVs significantly increased following PM exposure amongst individuals aged 35-65 years by lag 0-2 and in individuals who had contact with outpatient care at lag 0 to lag 1. There were no associations between air pollution and PEVs for any specific diagnostic group evaluated (amongst depression, anxiety and substance use disorder).

CONCLUSIONS

The results indicate that acute exposure to PM₁₀ and PM_2.5 may trigger acute worsening in mental health in both males and females, especially among 35-65 year old individuals. However, in subgroups of the most common psychiatric diagnoses, we did not observe statistically significant associations with PM exposure.

Gaseous air pollutants and hospitalizations for mental disorders in 17 Chinese cities: Association, morbidity burden and economic costs

The short-term morbidity effects of gaseous air pollutants on mental disorders (MDs), and the corresponding morbidity and economic burdens have not been well studied. We aimed to explore the associations of ambient sulfur dioxide (SO₂), nitrogen dioxide (NO₂), ozone (O₃) and carbon monoxide (CO) with MDs hospitalizations in 17 Chinese cities during 2015-2018, and estimate the attributable risk and economic costs of MDs hospitalizations associated with gaseous pollutants. City-specific relationships between gaseous pollutants and MDs hospitalizations were evaluated using over-dispersed generalized additive models, then combined to obtain the pooled effect. Concentration-response (C-R) curves of gaseous pollutants with MDs from each city were pooled to allow regional estimates to be derived. The morbidity and economic burdens of MDs hospitalizations attributable to gaseous pollutants were further assessed. A total of 171,939 MDs hospitalizations were included. We observed insignificant association of O₃ with MDs. An interquartile range increase in SO₂ at lag0 (9.1 μg/m³), NO₂ at lag0 (16.7 μg/m³) and CO at lag2 (0.4 mg/m³) corresponded to a 3.02% (95%CI: 0.72%, 5.38%), 5.03% (95%CI: 1.84%, 8.32%) and 2.18% (95%CI: 0.40%, 4.00%) increase in daily MDs hospitalizations, respectively. These effects were modified by sex, season and cause-specific MDs. The C-R curves of SO₂ and NO₂ with MDs indicated nonlinearity and the slops were steeper at lower concentrations. Overall, using current standards as reference concentrations, 0.27% (95%CI: 0.07%, 0.48%) and 0.06% (95%CI: 0.02%, 0.10%) of MDs hospitalizations could be attributable to extra SO₂ and NO₂ exposures, and the corresponding economic costs accounted for 0.34% (95%CI: 0.08%, 0.60%) and 0.07% (95%CI: 0.03%, 0.11%) of hospitalization expenses, respectively. Moreover, using threshold values detected from C-R curves as reference concentrations, the above mentioned morbidity and economic burdens increased a lot. These findings suggest more strict emission control regulations are needed to protect mental health from gaseous pollutants.

TUBE Project: Transport-Derived Ultrafines and the Brain Effects

The adverse effects of air pollutants on the respiratory and cardiovascular systems are unquestionable. However, in recent years, indications of effects beyond these organ systems have become more evident. Traffic-related air pollution has been linked with neurological diseases, exacerbated cognitive dysfunction, and Alzheimer's disease. However, the exact air pollutant compositions and exposure scenarios leading to these adverse health effects are not known. Although several components of air pollution may be at play, recent experimental studies point to a key role of ultrafine particles (UFPs). While the importance of UFPs has been recognized, almost nothing is known about the smallest fraction of UFPs, and only >23 nm emissions are regulated in the EU. Moreover, the role of the semivolatile fraction of the emissions has been neglected. The Transport-Derived Ultrafines and the Brain Effects (TUBE) project will increase knowledge on harmful ultrafine air pollutants, as well as semivolatile compounds related to adverse health effects. By including all the major current combustion and emission control technologies, the TUBE project aims to provide new information on the adverse health effects of current traffic, as well as information for decision makers to develop more effective emission legislation. Most importantly, the TUBE project will include adverse health effects beyond the respiratory system; TUBE will assess how air pollution affects the brain and how air pollution particles might be removed from the brain. The purpose of this report is to describe the TUBE project, its background, and its goals.

Examining air pollution (PM10), mental health and well-being in a representative German sample

There is a growing debate on the role of the physical environment and what constitute risk and protective factors for mental health. Various forms of air pollution have shown links to physical and mental health concerns and considering that Germany does not meet the WHO air quality standards-poor air quality affects a large proportion of Germans and is more important now than ever. This study investigates the physical environmental factor, air pollution, measured by particulate matter of particles with an aerodynamic diameter smaller than 10 µm (PM10) and effects on determinants of mental health and well-being (life satisfaction, stress resilience, anxiety, depression, and self-esteem). A representative sample of N = 3020 German adults with 54% females (46% males) and an age range between 18 and 92 years (M = 49.04, S.D. ± 17.27) was used. Multivariate linear regression analyses show that higher life satisfaction, more self-esteem and higher stress resilience are predicted by less air pollution (PM10). Individual income, age, and gender were taken into account for each regression model. Gender specific sub-analyses revealed similar predictions for PM10 and stress resilience whereas PM10 and self-esteem were only significantly associated for females. Associations between mental health or well-being determinants and air pollution (PM10) are found in the representative German sample.

Social Susceptibility to Multiple Air Pollutants in Cardiovascular Disease

INTRODUCTION

Cardiovascular disease (CVD) is the leading cause of death in the United States, and substantial research has linked ambient air pollution to elevated rates of CVD etiology and events. Much of this research identified increased effects of air pollution in lower socioeconomic position (SEP) communities, where pollution exposures are also often higher. The complex spatial confounding between air pollution and SEP makes it very challenging, however, to disentangle the impacts of these very different exposure types and to accurately assess their interactions. The specific causal components (i.e., specific social stressors) underlying this SEP-related susceptibility remain unknown, because there are myriad pathways through which poverty and/or lower-SEP conditions may influence pollution susceptibility - including diet, smoking, coexposures in the home and occupational environments, health behaviors, and healthcare access. Growing evidence suggests that a substantial portion of SEP-related susceptibility may be due to chronic psychosocial stress - given the known wide-ranging impacts of chronic stress on immune, endocrine, and metabolic function - and to a higher prevalence of unpredictable chronic stressors in many lower-SEP communities, including violence, job insecurity, and housing instability. As such, elucidating susceptibility to pollution in the etiology of CVD, and in the risk of CVD events, has been identified as a research priority. This interplay among social and environmental conditions may be particularly relevant for CVD, because pollution and chronic stress both impact inflammation, metabolic function, oxidative stress, hypertension, atherosclerosis, and other processes relevant to CVD etiology. Because pollution exposures are often spatially patterned by SEP, disentangling their effects - and quantifying any interplay - is especially challenging. Doing so, however, would help to improve our ability to identify and characterize susceptible populations and to improve our understanding of how community stressors may alter responses to multiple air pollutants. More clearly characterizing susceptible populations will improve our ability to design and target interventions more effectively (and cost-effectively) and may reveal greater benefits of pollution reduction in susceptible communities, strengthening cost-benefit and accountability analyses, ultimately reducing the disproportionate burden of CVD and reducing health disparities.

METHODS

In the current study, we aimed to quantify combined effects of multiple pollutants and stressor exposures on CVD events, using a number of unique datasets we have compiled and verified, including the following. 1. Poverty metrics, violent crime rates, a composite socioeconomic deprivation index (SDI), an index of racial and economic segregation, noise disturbance metrics, and three composite spatial factors produced from a factor analysis of 27 community stressors. All indicators have citywide coverage and were verified against individual reports of stress and stressor exposure, in citywide focus groups and surveys. 2. Spatial surfaces for multiple pollutants from the New York City (NYC) Community Air Survey (NYCCAS), which monitored multiple pollutants year-round at 150 sites and used land use regression (LUR) modeling to estimate fine-scale (100-m) intra-urban spatial variance in fine particles (PM2.5), nitrogen dioxide (NO2), sulfur dioxide (SO2), and ozone (O3). 3. Daily data and time-trends derived from all U.S. Environmental Protection Agency (EPA) Air Quality System (AQS) monitors in NYC for 2005-2011, which we combined with NYCCAS surfaces to create residence- and day-specific spatiotemporal exposure estimates. 4. Complete data on in- and out-patient unscheduled CVD events presented in NYC hospitals for 2005-2011 (n = 1,113,185) from the New York State (NYS) Department of Health's Statewide Planning and Research Cooperative System (SPARCS). In the study, we quantified relationships between multiple pollutant exposures and both community CVD event rates and individual risk of CVD events in NYC and tested whether pollution-CVD associations varied by community SEP and social stressor exposures. We hypothesized (1) that greater chronic community-level SEP, stressor, and pollution exposures would be associated with higher community CVD rates; (2) that spatiotemporal variations in multiple pollutants would be associated with excess risk of CVD events; and (3) that pollution-CVD associations would be stronger in communities of lower SEP or higher stressor exposures.

RESULTS

To first understand the separate and combined associations with CVD for both stressors and pollutants measured at the same spatial and temporal scale of resolution, we used ecological cross-sectional models to examine spatial relationships between multiple chronic pollutant and stressor exposures and age-adjusted community CVD rates. Using census-tract-level annual averages (n = 2,167), we compared associations with CVD rates for multiple pollutant concentrations and social stressors. We found that associations with community CVD rates were consistently stronger for social stressors than for pollutants, in terms of both magnitude and significance. We note, however, that this result may be driven by the relatively greater variation (on a proportional basis) for stressors than for pollutants in NYC. We also tested effect modification of pollutant-CVD associations by each social stressor and found evidence of stronger associations for NO2, PM2.5, and wintertime SO2 with CVD rates, particularly across quintiles of increasing community violence or assault rates (P trend < 0.0001). To examine individual-level associations between spatiotemporal exposures to multiple pollutants and the risk of CVD events, across multiple lag days, we examined the combined effects of multiple pollutant exposures, using spatiotemporal (day- and residence-specific) pollution exposure estimates and hospital data on individual CVD events in case-crossover models, which inherently adjust for nontime-varying individual confounders (e.g., sex and race) and comorbidities. We found consistent significant relationships only for same-day pollutant exposures and the risk of CVD events, suggesting very acute impacts of pollution on CVD risk. Associations with CVD were positive for NO2, PM2.5, and SO2, as hypothesized, and we found inverse associations for O3 (a secondary pollutant chemically decreased ["scavenged"] by fresh emissions that, in NYC, displays spatial and temporal patterns opposite those of NO2). Finally, to test effect modification by chronic community social stressors on the relationships between spatiotemporal pollution measures and the risk of CVD events, we used individual-level case-crossover models, adding interaction terms with categorical versions of each social stressor. We found that associations between NO2 and the risk of CVD events were significantly elevated only in communities with the highest exposures to social stressors (i.e., in the highest quintiles of poverty, socioeconomic deprivation, violence, or assault). The largest positive associations for PM2.5 and winter SO2 were generally found in the highest-stressor communities but were not significant in any quintile. We again found inverse associations for O3, which were likewise stronger for individuals living in communities with greater stressor exposures.

CONCLUSIONS

In ecological models, we found stronger relationships with community CVD rates for social stressors than for pollutant exposures. In case-crossover analyses, higher exposures to NO2, PM2.5, and SO2 were associated with greater excess risk of CVD events but only on the case day (there were no consistent significant lagged-day effects). In effect-modification analyses at both the community and individual level, we found evidence of stronger pollution-CVD associations in communities with higher stressor exposures. Given substantial spatial confounding across multiple social stressors, further research is needed to disentangle these effects in order to identify the predominant social stressors driving this observed differential susceptibility.

Climate change, environment pollution, COVID-19 pandemic and mental health

Converging data would indicate the existence of possible relationships between climate change, environmental pollution and epidemics/pandemics, such as the current one due to SARS-CoV-2 virus. Each of these phenomena has been supposed to provoke detrimental effects on mental health. Therefore, the purpose of this paper was to review the available scientific literature on these variables in order to suggest and comment on their eventual synergistic effects on mental health. The available literature report that climate change, air pollution and COVID-19 pandemic might influence mental health, with disturbances ranging from mild negative emotional responses to full-blown psychiatric conditions, specifically, anxiety and depression, stress/trauma-related disorders, and substance abuse. The most vulnerable groups include elderly, children, women, people with pre-existing health problems especially mental illnesses, subjects taking some types of medication including psychotropic drugs, individuals with low socio-economic status, and immigrants. It is evident that COVID-19 pandemic uncovers all the fragility and weakness of our ecosystem, and inability to protect ourselves from pollutants. Again, it underlines our faults and neglect towards disasters deriving from climate change or pollution, or the consequences of human activities irrespective of natural habitats and constantly increasing the probability of spillover of viruses from animals to humans. In conclusion, the psychological/psychiatric consequences of COVID-19 pandemic, that currently seem unavoidable, represent a sharp cue of our misconception and indifference towards the links between our behaviour and their influence on the "health" of our planet and of ourselves. It is time to move towards a deeper understanding of these relationships, not only for our survival, but for the maintenance of that balance among man, animals and environment at the basis of life in earth, otherwise there will be no future.

Energy Consumption and Health Insurance Premiums in China's Provinces: Evidence From Asymmetric Panel Causality Test

This article employs asymmetric panel causality test to address the causal nexus between energy consumption (EC) and healthcare insurance premiums (IP) for China's different provinces. The empirical results indicate that there exist asymmetric causality runs from positive EC shocks to positive healthcare IPs in Beijing, Hebei, Tianjin, Shanxi, Inner Mongolia, Shaanxi, Gansu, Qinghai, Ningxia, Shandong, Henan, and Anhui. There is no significant link in southern and northeastern provinces mainly because of their industrial structure, high economic development level, strong insurance consciousness, and climate conditions. Therefore, governments should encourage technological innovation and further improve energy efficiency. Meanwhile, we need to optimize EC structure and raise the proportion of renewable energies. The authorities should carry out stricter environmental protection policies and protect people from pollution that comes from fossil fuel burn. The commercial health insurance should be included in the health system and become an important supplement to public health insurance.

The association between ozone and fine particles and mental health-related emergency department visits in California, 2005-2013

Recent studies suggest that air pollutant exposure may increase the incidence of mental health conditions, however research is limited. We examined the association between ozone (O3) and fine particles (PM2.5) and emergency department (ED) visits related to mental health outcomes, including psychosis, neurosis, neurotic/stress, substance use, mood/affective, depression, bipolar, schizotypal/delusional, schizophrenia, self-harm/suicide, and homicide/inflicted injury, from 2005 through 2013 in California. Air monitoring data were provided by the U.S. EPA's Air Quality System Data Mart and ED data were provided by the California Office of Statewide Health Planning and Development. We used the time-series method with a quasi-Poisson regression, controlling for apparent temperature, day of the week, holidays, and seasonal/long-term trends. Per 10 parts per billion increase, we observed significant cumulative 7-day associations between O3 and all mental health [0.64%, 95% confidence interval (CI): 0.21, 1.07], depression [1.87%, 95% CI: 0.62, 3.15], self-harm/suicide [1.43%, 95% CI: 0.35, 2.51], and bipolar [2.83%, 95% CI: 1.53, 4.15]. We observed 30-day lag associations between O3 and neurotic disorder [1.22%, 95% CI: 0.48, 1.97] and homicide/inflicted injury [2.01%, 95% CI: 1.00, 3.02]. Same-day mean PM2.5 was associated with a 0.42% [95% CI: 0.14, 0.70] increase in all mental health, 1.15% [95% CI: 0.62, 1.69] increase in homicide/inflicted injury, and a 0.57% [95% CI: 0.22, 0.92] increase in neurotic disorders per 10 μg/m3 increase. Other outcomes not listed here were not statistically significant for O3 or PM2.5. Risk varied by age group and was generally greater for females, Asians, and Hispanics. We also observed seasonal variation for outcomes including but not limited to depression, bipolar, schizophrenia, self-harm/suicide, and homicide/inflicted injury. Ambient O3 or PM2.5 may increase the risk of mental health illness, though underlying biological mechanisms remain poorly understood. Findings warrant further investigation to better understand the impacts of air pollutant exposure among vulnerable groups.

Air Pollutants and Daily Hospital Admissions for Psychiatric Care: A Review

OBJECTIVE

Air pollution is a major environmental risk to health. Ambient (outdoor) air pollution in both cities and rural areas was estimated to cause 4.2 million premature deaths worldwide in 2016. In this review, the authors sought to briefly summarize original research investigating the short-term effects of air pollution exposure on mental health.

METHODS

A systematic search of the electronic databases PubMed, Scopus, and Web of Science was conducted (from any time until March 4, 2019) to identify research studies reporting associations between daily levels of air pollutants and daily admissions to hospitals or emergency departments (EDs) for psychiatric disorders and symptoms. A final set of 19 articles was reviewed.

RESULTS

The results of all selected studies showed statistically significant associations between daily hospital admissions and ED visits for mental disorders and daily levels of some or all air pollutants considered, including particulate matter (PM) of variable sizes (in micrometers given in subscripts; PM_2.5 and PM₁₀), sulfur dioxide, carbon monoxide, nitrogen oxide, and ozone. The strongest and more consistent evidence across studies was found for PM_2.5 and PM_10.

CONCLUSIONS

The results summarized in this review extend the evidence that air pollution may contribute either to worsening of psychiatric symptoms or to the decision to seek treatment for a large group of mental diseases and conditions, including severe psychiatric disorders such as schizophrenia and depression.

Attributable risks associated with hospital outpatient visits for mental disorders due to air pollution: A multi-city study in China

AIM

To determine the associations between outdoor air pollution and hospital outpatient visits for mental disorders in China.

METHODS

We obtained data of 111,842 hospital outpatient visits for mental disorders from the largest hospitals of 13 cities, China, between January 01, 2013 and December 31, 2015. We collected air pollutant data including particulate matter ≤2.5 µm in diameter (PM_2.5), particulate matter ≤10 µm in diameter (PM₁₀), nitrogen dioxide (NO₂), ozone (O₃) and sulphur dioxide (SO₂) from China National Environmental Monitoring Centre during the same period. We conducted a time-stratified case-crossover design with conditional logistic regression models to determine the associations.

RESULTS

A 10 µg/m³ increase in PM_2.5, PM₁₀, NO₂ and SO₂ was associated with a significant increase in hospital outpatient visits for mental disorders on the current day. When stratified by age, sex and season, the effects of PM_2.5 and NO₂ were robust among different subgroups at lag05 days. PM₁₀ showed positive associations in males, in cold season, and in depression patients. SO₂ showed positive associations in males, in cold season, and in anxiety patients. O₃ showed positive associations in females, in warm season, and in depression patients. Nearly one sixth hospital outpatient visits for mental disorders can be attributable to NO₂.

CONCLUSIONS

Short-term increase in PM_2.5, PM₁₀, NO₂, SO₂ and O₃ concentrations was significantly associated with exacerbation of mental disorders in China as indicated by increases in hospital outpatient visits. NO₂ had more serious health threat than other pollutants in terms of mental disorders. Our findings strongly suggest a need for more strict emission control regulations to protect mental health from air pollution.

Size-fractionated particulate air pollution and myocardial infarction emergency hospitalization in Shanghai, China

BACKGROUND

Fine particulate matter (PM_2.5) air pollution has been associated with increased risks of acute myocardial infarction (AMI), but it remains unknown about the potentially differentiated effects of size-fractionated particulate matter on AMI risk.

OBJECTIVE

To identify the specific size ranges that dominate the effects of particulate matter on AMI onset.

METHODS

We conducted a time-series study in Shanghai, China from January 2014 to December 2018. We evaluated particle size distribution of 0.01 μm to 2.5 μm from an environmental supersite and AMI emergency hospitalizations from the largest cardiovascular hospital in Shanghai. We used over-dispersed generalized additive models to estimate the associations of size-fractionated particle number concentrations (PNC) with AMI and its types.

RESULTS

We identified a total of 4720 AMI emergency hospitalizations. PM_2.5 was significantly associated with increased AMI risk on the concurrent day. The associations were significant only for PNC < 0.3 μm. For an IQR increase of PNCs for size ranges 0.01-0.03 μm, 0.03-0.05 μm, 0.05-0.10 μm and 0.10-0.30 μm, AMI hospitalizations increased by 6.68% (95% CI: 2.77%, 10.74%), 6.53% (95% CI: 2.08%, 11.17%), 5.78% (95% CI: 0.92%, 10.88%) and 5.92% (95% CI: 1.31%, 10.74%), respectively. The associations of PNC < 0.05 μm remained significant when adjusting for other air pollutants. There were consistently much stronger associations of particles with ST-segment elevation AMI than those with non-ST-segment elevation AMI.

CONCLUSIONS

This epidemiological investigation suggested that ultrafine particles, especially those <0.05 μm, may be mainly responsible for the acute AMI risk induced by PM_2.5.

Health and economic impacts of particulate matter pollution on hospital admissions for mental disorders in Chengdu, Southwestern China

The evidence for adverse effects of ambient particulate matter (PM) pollution on mental disorders (MDs) is limited, especially in developing countries. This study aimed to quantify both PM related health impacts and corresponding economic loses for overall and specific MDs in southwestern China. Data regarding 134,292 hospital admissions for MDs were collected from local Compulsory Medical Insurance Database in 2013-2017. A generalized additive model (GAM) was applied to estimate the exposure-response effects of PM pollution on hospital admissions for MDs. And the cost of illness method (COI) was adopted to further assess corresponding hospitalization costs and productivity loses. It was showed that PM pollution was significantly related to hospital admissions for overall and specific MDs. Each 10 μg/m³ increase in concentrations of PM₁₀ (particles with an aerodynamic diameters ≤10 μm), PM_2.5 (≤ 2.5 μm) and PMc (2.5 μm < c < 10 μm) at the cumulative lag03 day would be responsible for 3.25% (95%CI: 2.34-4.16%), 6.38% (95%CI: 4.79-7.97%), and 3.81% (95%CI: 2.13-5.50%) increments in daily hospital admissions for MDs, respectively. Stronger associations were observed in males, cool season and people over 45 years. During the study period, PM pollution brought 1453.18 million Yuan economic losses for overall MDs, accounting for 0.026% of local GDP. This study suggested that short-term exposure to PM pollution, especially to PM_2.5, was associated with increased hospital admissions for MDs in southwestern China. In addition, potential benefits of lowering PM concentrations are considerable.

Short-term effects of air pollutants on daily mortality in the Stockholm county - A spatiotemporal analysis

Short-term exposure to air pollutants has been extensively related to daily mortality, however most of the evidence comes from studies conducted in major cities, and little is known on the extent of the spatial heterogeneity in the effects within areas including both urban and non-urban settings. We aimed to investigate the short-term association of air pollutants with daily cause-specific mortality in the Stockholm county, and to test whether an association exists also outside the metropolitan area. We used a spatiotemporal random forest model to predict daily concentrations of fine and inhalable particulate matter (PM_2.5 and PM₁₀), nitrogen dioxide (NO₂) and ozone (O₃) at 1-km spatial resolution over Sweden for 2005-2016. We collected data on daily mortality for each small area for market statistics (SAMS) of the Stockholm county, to which we matched daily exposures to air pollutants and air temperature. We applied a case-crossover design to investigate the short-term association between the four pollutants and mortality from non-accidental, cardiovascular and respiratory causes. We compared the associations in and out the Stockholm urban area, by SAMS population density and across the 26 municipalities of the county. We found weak effects of most air pollutants on cause-specific mortality in the full year analysis, with estimates much larger and significant only during the warmer months (April to September): non-accidental mortality increased by 4.58% (95% confidence interval - 95% CI: 0.89%, 8.41%) and by 2.21% (95% CI: 0.71%, 3.73%) per 10 μg/m³ increase in lag 0-1 PM_2.5 and O₃, respectively. Associations were in general higher in the Stockholm city and in SAMS with high population density. When comparing the 26 municipalities, we didn't detect a significant heterogeneity in the short-term associations with air pollutants. In conclusion, we found a suggestion of a harmful role of air pollution also in non-urban areas, but the study was underpowered to draw firm conclusions. We consider this study as a pilot to investigate the spatial heterogeneity of the association between daily air pollution and mortality at the national level in Sweden.

Effect modification of the short-term effects of air pollution on morbidity by season: A systematic review and meta-analysis

Studies of the health effects of air pollution have traditionally controlled for ambient temperature as a confounder, and vice versa. However, season might be an important factor contributing to adverse health effects of air pollution. Given the current inconsistencies in results of previous studies on the effect modification of air pollution on morbidity by season, a systematic review and meta-analysis was conducted to synthesize the current evidence on effects of season on air pollution and morbidity. The electronic databases including PubMed, Web of Science, Embase, CNKI, and Wanfang were used to identify papers published up to the 30st of November in 2019. We identified 4284 articles, after screening, eighty papers met the inclusion criteria. Significant effect modification of CO, O₃, SO₂ and NO₂ on morbidity by season was observed, with corresponding ratio of relative risk of 1.0009 (95% CI: 1.0001-1.0018), 1.0080 (95% CI: 1.0021-1.0138), 0.9828 (95% CI: 0.9697-0.9962) and 0.9896 (95% CI: 0.9824-0.9968), respectively. Season significantly modified the effect of CO on pneumonia, the effect of SO₂ on cardiovascular disease, the effect of PM₁₀ on stroke, and the effect of O₃ on stroke, asthma and pneumonia. The effect modifications of air pollution by season were similar among males and females, while the effect estimates seem to be higher among children under 18 years old and the elderly aged 75 or over. Further research is needed to better understand the mechanisms underlying the seasonal variance of the effect of air pollutants on morbidity.

Air pollutants and daily number of admissions to psychiatric emergency services: evidence for detrimental mental health effects of ozone

AIMS

Aim of the current study is to investigate the associations between daily levels of air pollutants (particulate matter, ozone, carbon monoxide, nitrogen dioxide) and daily admissions for mental disorders to the emergency department of two general hospitals in Umbria region (Italy).

METHODS

We collected data about daily admissions to psychiatric emergency services of two general hospitals, air pollutants' levels and meteorological data for the time period 1 January 2015 until 31 December 2016. We assessed the impact of an increase in air pollutants on the number of daily admissions using a time-series econometric framework.

RESULTS

A total of 1860 emergency department admissions for mental disorders were identified. We observed a statistically significant impact of ozone levels on daily admissions. The estimated coefficient of O3 is statistically significant at the 1% level. All other pollutants were not significantly associated with the number of daily admissions.

CONCLUSIONS

Short-term exposure to ozone may be associated with increased psychiatric emergency services admissions. Findings add to previous literature on existing evidence for air pollution to have an impact on mental health. Ozone may be considered a potential environmental risk factor for impaired mental health.

Do cognitive and non-cognitive abilities mediate the relationship between air pollution exposure and mental health?

Considered as a key component of human capital, mental health has drawn substantial scholarly attention for its effect on people’s health status and economic outcome. When facing the challenge of stress, people’s heterogeneity in cognitive ability and non-cognitive ability causes difference in patterns of coping, resulting in different manifestations in mental health. Previous researches have shown that cognitive and non-cognitive abilities have positively direct or indirect effects on mental health, but few studies research their role of coping with air pollution. We used the China Family Panel Survey (CFPS) and matched individual data with county or district level PM_2.5 information from NASA. The study found that air pollution has negative effect on mental health with every increase of 1μg/m³ in PM_2.5 deteriorating mental health by 0.038 standard deviation, which is the total effect of air pollution. However, the direct effect of air pollution on mental health will decrease to 0.028 in absolute value when considering mediating effects. By employing different approaches, we found positive mediating effects via cognitive ability and non-cognitive ability. Individuals with high cognitive and non-cognitive abilities are able to accurately diagnose problems and select the optimal coping strategies, thus restoring positive mental health.

Ambient fine particulate matter is associated with increased emergency ambulance dispatches for psychiatric emergencies

AIMS

As a top ambient pollutant in urban area, fine particulate matter (PM_2.5) has been associated with the occurrence and deterioration of many medical conditions, while limited studies have observed the association with psychiatric conditions. This study aimed to investigate the association between short-term PM_2.5 exposure and psychiatric emergency events, and further explored the variation by age, sex and seasonal patterns, which have been suggested to be associated with both psychiatric risk and pollutant toxicity.

METHODS

We used time-series analysis to investigate the association between short-term exposure of PM_2.5 and emergency ambulance dispatches for psychiatric emergencies (EPE) (n = 158634) in Beijing, one of the top polluted cities in China during the study period between 2008 and 2014. Stratified analyses were conducted to examine the effects of age, sex and seasonal pattern.

RESULTS

Every 10 μg/m³ increase of the PM_2.5 concentration was associated with a 0.12% increase of the same-day overall EPE (95% CI: 0.03-0.22%, p = 0.013) and a 0.12% increase of the suicide-related EPE at lag 2 (95%CI: 0.01-0.24%, p = 0.041). The associations remained when adjusted for sunlight duration. An age effect was observed where children (age <18) showed a higher risk of suicide-related EPE after PM_2.5 exposure compared to adults (18 ≤ age≤64). We did not observe evidence of effect modification by sex and season based on the results of stratified analysis.

CONCLUSIONS

We found a positive association between acute PM_2.5 exposure and increased psychiatric emergency presentations indicated by emergency ambulance dispatches data. Children were more vulnerable and might develop psychiatric problems including those leading to suicide. Public awareness of the health risks of PM_2.5 is important to strengthen current efforts to reduce emissions.

Pediatric Psychiatric Emergency Department Utilization and Fine Particulate Matter: A Case-Crossover Study

BACKGROUND

Acute exposure to ambient particulate matter < 2.5 μ m in aerodynamic diameter (PM 2.5 ) has been associated with adult psychiatric exacerbations but has not been studied in children.

OBJECTIVES

Our objectives were to estimate the association between acute exposures to ambient PM 2.5 and psychiatric emergency department (ED) utilization and to determine if it is modified by community deprivation.

METHODS

We used a time-stratified case-crossover design to analyze all pediatric, psychiatric ED encounters at Cincinnati Children's Hospital Medical Center in Cincinnati, Ohio, from 2011 to 2015 (n = 13,176 ). Conditional logistic regression models adjusted for temperature, humidity, and holiday effects were used to estimate the odds ratio (OR) for a psychiatric ED visit 0-3 d after ambient PM 2.5 exposures, estimated at residential addresses using a spatiotemporal model.

RESULTS

A 10 - μ g / m 3 increase in PM 2.5 was associated with a significant increase in any psychiatric ED utilization 1 [OR = 1.07 (95% CI: 1.02, 1.12)] and 2 [OR = 1.05 (95% CI: 1.00, 1.10)] d later. When stratified by visit reason, associations were significant for ED visits related to adjustment disorder {e.g., 1-d lag [OR = 1.24 (95% CI: 1.02, 1.52)] and suicidality 1-d lag [OR = 1.44 (95% CI: 1.03, 2.02)]}. There were significant differences according to community deprivation, with some lags showing stronger associations among children in high versus low deprivation areas for ED visits for anxiety {1-d lag [OR = 1.39 (95% CI: 0.96, 2.01) vs. 0.85 (95% CI: 0.62, 1.17)] and suicidality same day [OR = 1.98 (95% CI: 1.22, 3.23) vs. 0.93 (95% CI: 0.60, 1.45)]}. In contrast, for some lags, associations with ED visits for adjustment disorder were weaker for children in high-deprivation areas {1-d lag [OR = 1.00 (95% CI: 0.76, 1.33) vs. 1.50 (95% CI: 1.16, 1.93)]}.

DISCUSSION

These findings warrant additional research to confirm the associations in other populations. https://doi.org/10.1289/EHP4815.

Association of Extreme Heat Events With Hospital Admission or Mortality Among Patients With End-Stage Renal Disease

Importance

Extreme heat events (EHEs) are increasing in frequency, duration, and intensity, and this trend is projected to continue as part of ongoing climate change. There is a paucity of data regarding how EHEs may affect highly vulnerable populations, such as patients with end-stage renal disease (ESRD). Such data are needed to inform ESRD patient management guidelines in a changing climate.

Objectives

To investigate the association between EHEs and the risk of hospital admission or mortality among patients with ESRD and further characterize how this risk may vary among races/ethnicities or patients with preexisting comorbidities.

Design, Setting, and Participants

This study used hospital admission and mortality records of patients with ESRD who underwent hemodialysis treatment at Fresenius Kidney Care clinics in Boston, Massachusetts; Philadelphia, Pennsylvania; or New York, New York, from January 1, 2001, to December 31, 2012. Data were analyzed using a time-stratified case-crossover design with conditional Poisson regression to investigate associations between EHEs and risk of hospital admission or mortality among patients with ESRD. Data were analyzed from July 1, 2017, to March 31, 2019.

Exposures

Calendar day- and location-specific 95th-percentile maximum temperature thresholds were calculated using daily meteorological data from 1960 to 1989. These thresholds were used to identify EHEs in each of the 3 cities during the study.

Main Outcomes and Measures

Daily all-cause hospital admission and all-cause mortality among patients with ESRD.

Results

The study included 7445 patients with ESRD (mean [SD] age, 61.1 [14.1] years; 4283 [57.5%] men), among whom 2953 deaths (39.7%) and 44 941 hospital admissions (mean [SD], 6.0 [7.5] per patient) were recorded. Extreme heat events were associated with increased risk of same-day hospital admission (rate ratio [RR], 1.27; 95% CI, 1.13-1.43) and same-day mortality (RR, 1.31; 95% CI, 1.01-1.70) among patients with ESRD. There was some heterogeneity in risk, with patients in Boston showing statistically significant increased risk for hospital admission (RR, 1.15; 95% CI, 1.00-1.31) and mortality (RR, 1.45; 95% CI, 1.04-2.02) associated with cumulative exposure to EHEs, while such risk was absent among patients with ESRD in Philadelphia. While increases in risks were similar among non-Hispanic black and non-Hispanic white patients, findings among Hispanic and Asian patients were less clear. After stratifying by preexisting comorbidities, cumulative lag exposure to EHEs was associated with increased risk of mortality among patients with ESRD living with congestive heart failure (RR, 1.55; 95% CI, 1.27-1.89), chronic obstructive pulmonary disease (RR, 1.60; 95% CI, 1.24-2.06), or diabetes (RR, 1.83; 95% CI, 1.51-2.21).

Conclusions and Relevance

In this study, extreme heat events were associated with increased risk of hospital admission or mortality among patients with ESRD, and the association was potentially affected by geographic region and race/ethnicity. Future studies with larger populations and broader geographic coverage are needed to better characterize this variability in risk and inform ESRD management guidelines and differential risk variables, given the projected increases in the frequency, duration, and intensity of EHEs.

Assessment of Spatial Variability across Multiple Pollutants in Auckland, New Zealand

Spatial saturation studies using source-specific chemical tracers are commonly used to examine intra-urban variation in exposures and source impacts, for epidemiology and policy purposes. Most such studies, however, has been performed in North America and Europe, with substantial regional combustion-source contributions. In contrast, Auckland, New Zealand, a large western city, is relatively isolated in the south Pacific, with minimal impact from long-range combustion sources. However, fluctuating wind patterns, complex terrain, and an adjacent major port complicate pollution patterns within the central business district (CBD). We monitored multiple pollutants (fine particulate matter (PM_2.5), black carbon (BC), elemental composition, organic diesel tracers (polycyclic aromatic hydrocarbons (PAHs), hopanes, steranes), and nitrogen dioxide (NO₂)) at 12 sites across the ~5 km² CBD during autumn 2014, to capture spatial variation in traffic, diesel, and proximity to the port. PM_2.5 concentrations varied 2.5-fold and NO₂ concentrations 2.9-fold across the CBD, though constituents varied more dramatically. The highest-concentration constituent was sodium (Na), a distinct non-combustion-related tracer for sea salt (µ = 197.8 ng/m³ (SD = 163.1 ng/m³)). BC, often used as a diesel-emissions tracer, varied more than five-fold across sites. Vanadium (V), higher near the ports, varied more than 40-fold across sites. Concentrations of most combustion-related constituents were higher near heavy traffic, truck, or bus activity, and near the port. Wind speed modified absolute concentrations, and wind direction modified spatial patterns in concentrations (i.e., ports impacts were more notable with winds from the northeast).

Short-term PM2.5 exposure and emergency hospital admissions for mental disease

Epidemiologic studies regarding the relationship between short-term exposure to particulate matter with a median aerodynamic diameter < 2.5 µm (PM_2.5) and mental disease are limited. This study examined the effects of short-term exposure to PM_2.5 on emergency admissions to the hospital for mental disease in Seoul, Korea. Data regarding 80,634 emergency admissions for mental diseases were collected from a nationally centralized healthcare claims database in Seoul during 2003-2013. Generalized linear models with climate variables were used to examine associations between short-term PM_2.5 exposure and mental disease admissions. To comprehensively assess PM_2.5 effects, we used single- and two-pollutant models, which considered other pollutants in combination with PM_2.5. The relative risk (RR) of emergency admissions for mental disease was 1.008 (95% confidence interval, 1.001-1.015) for each 10 μg/m³ increase in 2-day average PM_2.5 concentration. This effect persisted or became slightly stronger in the two-pollutant models that included carbon monoxide, nitrogen dioxide, ozone, or sulfur dioxide (RR, 1.01-1.021), but association appeared to be limited to individuals < 65 years of age. Significant association was estimated only during the warm season (RR, 1.021-1.023) in the two-pollutant models. The exposure-response curve was steeper at lower concentrations, suggesting that the risk of mental disease at lower concentrations of pm2.5 (0-30 µg/m³). PM_2.5 was associated with increased admissions even when it was below the World Health Organization's Air Quality Guidelines (25 μg/m³), but the association was not statistically significant. Thus, based on the data from a large database, exposure to PM_2.5 was associated with increases in emergency admissions for mental diseases, and this association was significant during the warm season. PM_2.5 may even affect mental disease at levels below the current air quality guidelines. These results provide substantial insight regarding the effects of air pollutants and have important implications for policy makers.

Attributable risk of hospital admissions for overall and specific mental disorders due to particulate matter pollution: A time-series study in Chengdu, China

The associations of particulate matter (PM) pollution with the morbidity of overall and subtypes of mental disorders (MDs), as well as the corresponding morbidity burden, remain understudied, especially in developing countries. This study aimed to evaluate the short-term effects of PM_2.5 (diameters ≤ 2.5 µm), PM₁₀ (diameters ≤ 10 µm) and PM_C (diameters between 2.5 and 10 µm) on hospital admissions (HAs) for MDs in Chengdu, China, during 2015-2016, and calculate corresponding attributable risks. A generalized additive model (GAM) with controlling for time trend, meteorological conditions, holidays and day of the week was used to estimate the associations. Stratified analyses were also performed by age, gender and season. We further estimated the burden of HAs for MDs attributable to PM exposure. During the study period, a total of 10,947 HAs for MDs were collected. PM_2.5, PM₁₀ and PM_C were significantly associated with elevated risks of MDs hospitalizations. Each 10 μg/m³ increase in PM_2.5, PM₁₀ and PM_C at lag06 corresponded to an increase of 2.89% (95% CI: 0.75-5.08%), 1.91% (95% CI: 0.57-3.28%) and 3.95% (95% CI: 0.84-7.15%) in daily HAs for MDs, respectively. The risk estimates of PM on MDs hospitalizations were generally robust after adjustment for gaseous pollutants in two-pollutant models. We found stronger associations between PM pollution and MDs in males and in cool seasons than in females and in warm seasons. For specific subtypes of MDs, significant associations of PM pollution with dementia,schizophrenia and depression were observed. Using WHO's air quality guidelines as the reference concentrations, 9.53% (95% CI: 2.67-15.58%), 9.17% (95% CI: 2.91-14.70%) and 6.10% (95% CI: 1.40-10.32%) of HAs for MDs could be attributable to PM_2.5, PM₁₀ and PM_C, respectively. Our results suggested that PM exposure might be an important trigger of hospitalizations for MDs in Chengdu, China, and account for substantial morbidity burden.

Association between ambient air pollution and hospital admission for epilepsy in Eastern China

BACKGROUND

We aimed to study the short-term association between air pollutants and hospitalization for epilepsy in 47 hospitals from 10 cities in eastern China.

METHOD

We identified hospital epilepsy admissions in 2014 and 2015. A conditional Poisson regression model was used to examine the association between air pollutants and hospital admission, with temperature and relative humidity adjusted using the natural spline (ns) function. Pollutants included sulfur dioxide (SO₂), nitrogen dioxide (NO₂), carbon monoxide (CO), and particulate matter (PM). The association was stratified by sex, age, and geographic region in single-pollutant and two-pollutant models.

RESULTS

An interquartile (IQR) increase of NO₂ and CO on the concurrent day is correlated with an increased admission of 2.0% (0.5%, 3.6%) and 1.1% (0.1%, 2.1%), respectively. The association is stronger in children (≤18 years) and in northern China, but did not vary with sex. A positive association was also observed on the previous day for CO [1.5%, 95% confidence interval (CI): 0.3%, 2.6%], NO₂ (2.5%, 95% CI: 0.6%, 4.3%), and PM_2.5 (1.32%, 95% CI: 0.16%, 2.48%). Moving average concentration of 7 days for all pollutants was associated with decreased admission (CO: -1.29%, NO₂: -0.4.69%, SO₂:-2.12%, PM_2.5:-0.98%, PM₁₀:-1.70%).

CONCLUSION

Exposures to NO₂ and CO on concurrent days, and PM_2.5 on the previous day, are associated with increased epilepsy hospitalization, whereas cumulative exposure appeared protective.

Ambient Temperature and Associations with Daily Visits to a Psychiatric Emergency Unit in Sweden

High or low ambient temperatures pose a risk factor for the worsening or onset of psychiatric disorders. The aim of this study was to investigate the association between ambient temperature and psychiatric emergency visits in an urban region in a temperate climate. The daily number of visits to a psychiatric emergency room (PEVs) at Sahlgrenska University Hospital, Gothenburg, Sweden and the daily mean temperature were extracted for the study period 1 July 2012 to 31 December 2017. Case-crossover analysis with distributed lag non-linear models was used to analyse the data by season. The warm season was defined as May to August and the cold season as November to February. Shorter lags periods were used for the warm season than the cold season. In the analysis, temperatures at the 95th percentile was associated with 14% (95% confidence interval (CI): 2%, 28%) increase in PEVs at lag 0⁻3 and 22% (95%CI: 6%, 40%) for lags 0⁻14 during the warm season, relative to the seasonal minimum effect temperature (MET). During the cold season temperatures at the 5th percentile were associated with 25% (95% CI: -8%, 13%) and 18% (95% CI: -30%, 98%) increase in PEVs at lags 0⁻14 and 0⁻21 respectively. We observed an increased number of PEVs at high and low temperatures; however, not to a statistically significant extent for low temperatures. Our findings are similar to what has been found for somatic diseases and in studies of other mental health outcomes in regions with more extreme climates. This merits the inclusion of individuals with psychiatric disorders in awareness planning for climate warning systems.

In situ visualization of ozone in the brains of mice with depression phenotypes by using a new near-infrared fluorescence probe

Ozone (O₃), one of the reactive oxygen species (ROS), is deeply involved in diseases including depression. However, the lack of appropriate in situ detection methods suitable for the complex biological context of brain impedes uncovering the exact relationship between depression and changes in the O₃ level. Therefore, we developed a near-infrared (NIR) fluorescent probe (ACy7) for the direct visualization of O₃ in mice brains. The specific cycloaddition reaction between O₃ and the terminal double bond of the butenyl group extends the conjugation of the "pre-" heptamethine cyanine system, which emits NIR fluorescence of heptamethine cyanine. This makes the ACy7 specific, highly sensitive and able to deeply penetrate tissue. Using ACy7, we found that under glutamate stimulation, the O₃ content in PC12 cells was significantly higher than that in control cells. By imaging analysis on the brains of mice, we revealed for the first time that the levels of O₃ in mice with depression phenotypes were markedly higher than that in control mice. Intriguingly, experimental results unravelled that excess O₃ promoted high expression of the pro-inflammatory cytokine interleukin-8 (IL-8), which ultimately induced depression phenotypes. Our work demonstrates the pivotal role of elevated O₃ in depression and provides a fresh entry point for exploring oxidative stress contributing to depression.

Is there a link between air pollution and mental disorders?

Several studies have demonstrated the association between air pollution and different medical conditions including respiratory and cardiovascular diseases. Air pollutants might have a role also in the etiology of mental disorders in the light of their toxicity on central nervous system. Purpose of the present manuscript was to review and summarize available data about an association between psychiatric disorders and air pollution. A research in the main database sources has been conducted to identify relevant papers about the topic. Different air pollutants and in particular PM and nitric oxides have been associated with poor mental health; long exposition to PM_2.5 has been associated with an increased risk of new onset of depressive symptoms (Cohen's effect size d: 0.05-0.81), while increased concentration of nitric dioxide in summer with worsening of existing depressive conditions (Cohen's effect size d: 0.05-1.77). However, the interpretation of these finding should take into account the retrospective design of most of studies, different periods of observations, confounding factors such as advanced age or medical comorbidity. Further studies with rigorous methodology are needed to confirm the results of available literature about this topic.

Ambient ozone exposure and mental health: A systematic review of epidemiological studies

BACKGROUND

An increasing number of studies have suggested adverse effects of air pollution on mental health. Given the potentially negative impacts of ozone exposure on the immune and nervous system driven from animal experiments, ozone might also affect mental health. However, no systematic synthesis of the relevant literature has been conducted yet. This paper reviews the studies that assessed the link between ozone exposure and mental health thus far.

METHODS

We followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA). PubMed, Web of Science, and EMBASE were systematically searched for epidemiological studies on ambient ozone exposure and mental or behavioral disorders according to the International Classification of Disease. The period was from January 1st, 1960 to December 14st, 2017. We evaluated the risk of bias by the Office of Health Assessment and Translation (OHAT) Approach and Navigation Guide for each included study.

RESULTS

The keyword search yielded 567 results. 31 papers met the selection criteria and were included in the review. We found only inconclusive evidence that ozone affects autism spectrum disorders, impairment of cognitive functions and dementia, depression, and suicide. The large heterogeneity of study designs, outcome definitions and study quality in general prevented us from conducting meta-analyses.

CONCLUSIONS

Current evidence for an association between ambient ozone exposure and mental health outcomes is inconclusive and further high quality studies are needed to assess any potential links given the strong biologic plausibility.

Climate Change Impacts on Disaster and Emergency Medicine Focusing on Mitigation Disruptive Effects: an International Perspective

In recent decades, climate change has been responsible for an increase in the average temperature of the troposphere and of the oceans, with consequences on the frequency and intensity of many extreme weather phenomena. Climate change’s effects on natural disasters can be expected to induce a rise in humanitarian crises. In addition, it will surely impact the population’s long-term general health, especially among the most fragile. There are foreseeable health risks that both ambulatory care organizations and hospitals will face as global temperatures rise. These risks include the geographic redistribution of infectious (particularly zoonotic) diseases, an increase in cardiac and respiratory illnesses, as well as a host of other health hazards. Some of these risks have been detailed for most developed countries as well as for some developing countries. Using these existing risk assessments as a template, organizational innovations as well as implementation strategies should be proposed to mitigate the disruptive effects of these health risks on emergency departments and by extension, reduce the negative impact of climate change on the populations they serve.

Ambient air pollution exposure and emergency department visits for substance abuse

There is growing evidence supporting the notion that exposure to air pollution can contribute to cognitive and psychiatric disorders, including depression and suicide. Given the relationship between exposure to acute stressors and substance abuse, the present study assessed the association between exposure to ambient air pollution and emergency department (ED) visits for alcohol and drug abuse. ED visit data selected according to International Classification of Disease (ICD-9) coding 303 (alcohol dependence syndromes) and 305 (non-dependent abuse of drugs) were collected in five hospitals in Edmonton, Canada. A time-stratified case crossover design was used. Conditional logistic regression was applied to calculate odds ratios (OR) and 95% confidence intervals (95% CI). Season, temperature, and relative humidity were adjusted for using natural splines.

Results are reported for an increase in pollutant concentrations equivalent to one interquartile range (IQR). Statistically significant positive associations with substance abuse were observed for CO, NO₂ and particulate matter with an aerodynamic diameter less than 10 μm (PM₁₀) and 2.5 μm (PM_2.5). The strongest results were obtained in the cold period (October–March) for 1-day lagged CO (OR = 1.03, 95% CI: 1.01, 1.05, IQR = 0.4 ppm) and NO₂ (OR = 1.04, 95% CI: 1.01, 1.07, IQR = 12.8 ppb); ORs were also significant for CO and NO₂ with lags of 2 to 6 days and 2 to 7 days, respectively. The study suggests that, even at low levels, increases in ambient CO, NO₂, and PMs are associated with increased hospital admissions for substance abuse, possibly as a result of impacts of air quality on mental health or depression.

Association between Ambient Temperatures and Mental Disorder Hospitalizations in a Subtropical City: A Time-Series Study of Hong Kong Special Administrative Region

Background: Mental disorders have been found to be positively associated with temperature in cool to cold climatic regions but the association in warmer regions is unclear. This study presented the short-term association between temperatures and mental disorder hospitalizations in a subtropical city with a mean annual temperature over 21 °C. Methods: Using Poisson-generalized additive models and distributed-lagged nonlinear models, daily mental disorder hospitalizations between 2002 and 2011 in Hong Kong were regressed on daily mean temperature, relative humidity, and air pollutants, adjusted for seasonal trend, long-term trend, day-of-week, and holiday. Analyses were stratified by disease class, gender and age-group. Results: 44,600 admissions were included in the analysis. Temperature was positively associated with overall mental-disorder hospitalizations (cumulative relative risk at 28 °C vs. 19.4 °C (interquartile range, lag 0-2 days) = 1.09 (95% confidence interval 1.03, 1.15)), with the strongest effect among the elderly (≥75 years old). Transient mental disorders due to conditions classified elsewhere and episodic mood disorders also showed strong positive associations with temperature. Conclusion: This study found a positive temperature-mental-disorder admissions association in a warm subtropical region and the association was most prominent among older people. With the dual effect of global warming and an aging population, targeted strategies should be designed to lower the disease burden.

Long-term exposure to ambient air pollutants and mental health status: A nationwide population-based cross-sectional study

There is a suspected but unproven association between long-term exposure to ambient air pollution and mental health. The aim of this study is to investigate the association between long-term exposure to ambient air pollution and subjective stress, depressive disorders, health-related quality of life (QoL) and suicide. We selected 124,205 adults from the Korean Community Health Survey in 2013 who were at least 19 years old and who had lived in their current domiciles for > five years. Based on the computer-assisted personal interviews to measure subjective stress in daily life, EuroQoL-5 dimensions, depression diagnosis by a doctor, suicidal ideation, and suicidal attempts, we evaluated the risk of mental disorders using multiple logistic regression analysis according to the quartiles of air pollutants, such as particulate matter <10μm (PM10), nitrogen dioxide (NO2), carbon monoxide (CO), and sulfur dioxide, using yearly average concentration between August 2012 and July 2013. The prevalence of high stress, poor QoL, depressiveness, diagnosis of depression, and suicide ideation was positively associated with high concentrations of PM10, NO2, and CO after adjusting for confounding factors. Men were at increased risk of stress, poor QoL, and depressiveness from air pollution exposure than were women. The risk of higher stress or poor QoL in subjects < age 65 increased with air pollution more than did that in subjects ≥ age 65. Long-term exposure to ambient air pollution may be an independent risk factor for mental health disorders ranging from subjective stress to suicide ideation.