From the Editor
Floods. Hurricanes. Fire. Extreme weather seems to be more common these days – resulting in some experiencing PTSD and other mental disorders. In an age of climate change, what can mental health services offer? Is it possible to prevent major mental illness with interventions like CBT?
Ahlke Kip (of the University of Münster) and her co-authors attempt to answer these questions in a new meta-analysis and systematic review which assesses the efficacy of psychological and psychosocial interventions after exposure to natural hazards. In the BMJ Mental Health paper, they looked at 10 RCT studies involving more than 5 000 participants, including both civilians and disaster responders, focusing on symptoms of PTSD, depression, and anxiety. They didn’t find superiority to passive control conditions. “The current evidence does not allow for any recommendations regarding prevention programmes in the aftermath of natural hazards.” We consider the paper and its implications.
In the second selection, Joseph Firth (of the University of Manchester) and his co-authors weigh in on youth and digital device usage. In a paper for World Psychiatry, they sought “directly actionable advice” for parents and youth and then drew on the literature to create tips for teenagers. “We sought to produce a set of best-practice approaches, on the basis of available evidence and guidelines, for adolescents and their parents looking to improve their device usage patterns.”
And in this week’s third selection, Dr. Zheala Qayyum (of Harvard University) writes about guilt and time in a paper for Academic Psychiatry. The child and adolescent psychiatrist describes an unkind act in her youth – and an opportunity to make amends decades later. She also notes the tie to training and education. “Only by sharing and reflecting on our own moments, successes, failures, and vulnerabilities, can our trainees recognize and respond to such instances in their own experience.”
DG
Selection 1: “Prevention of mental disorders after exposure to natural hazards: a meta-analysis”
Ahlke Kip, Luca Weigand, Silvia Valencia, et al.
BMJ Mental Health, 28 March 2025
The frequency and intensity of extreme weather events such as floods, storms or wildfires are on the rise due to human-induced climate change. Natural hazards not only have severe consequences on economies or infrastructure but also have a negative impact on mental health of affected civilians and emergency service personnel working during or in the aftermath of disasters. In light of the severe impairment induced by mental disorders, their likeliness to take a chronic course and high treatment costs, prevention programmes for mental health are crucial in disaster management plans.
Previous research has shown that individuals exposed to natural hazards are at higher risk of developing mental disorders compared with non-exposed individuals. In studies of both adult and youth survivors of natural hazards, it has been found that more than 20% score above cut-offs for PTSD, depression and anxiety… Preventive interventions may target the general population (universal prevention), subgroups with higher risk for developing mental health complaints (selective prevention) or individuals who already present subclinical symptoms (indicated prevention). Successful prevention increases quality of life and functioning of people affected and thus reduces societal costs. Preventive interventions in general have been shown to be effective in reducing the incidence of depression and anxiety, whereas findings on PTSD appear mixed. A systematic review of preventive interventions for responders of humanitarian crises found a positive pre–post effect in most studies. Yet, mental healthcare in the aftermath of natural disasters faces several challenges, including damaged infrastructure, precedence of rescue efforts, a shortage of trained mental health professionals, a large number of affected individuals and ongoing stressors (eg, due to loss of job or house).
So begins a paper by Kip et al.
Here’s what they did:
- They searched Web of Science, PsycINFO and MEDLINE for “peer-reviewed randomised controlled trials evaluating preventive interventions targeting symptoms of post-traumatic stress disorder, depression and anxiety.”
- They included trials conducted in both civilians and disaster responders.
- “At least 70% of participants were required to have experienced the natural hazard or participants were first responders in the aftermath of the hazard.”
- They conducted a random-effect meta-analyses “to assess the efficacy of interventions relative to active and passive control conditions.”
Here’s what they found:
- They included 10 trials with a total of 5 068 independent participants.
- Demographics and geography. The mean age was 21.8 years. Seven studies included adults, and three studies, youth samples. 67.8% of the participants identified as female. Most studies were conducted in the US; the remaining studies were conducted in Canada, China, Nepal, New Zealand, Sri Lanka, and Turkey.
- Disasters and interventions. The majority of studies were conducted in the aftermath of earthquakes (4) and hurricanes (3). Most of the included studies evaluated interventions with psychotherapeutic content, mainly cognitive-behavioural therapy.
- PTSD and depression. They didn’t find preventive interventions to be superior to active or passive control conditions regarding symptoms of post-traumatic stress disorder (g=0.08 and g=0.05) and depression (g=0.13 and g=0.32, respectively).
- Anxiety. Effects on anxiety symptoms were unclear.
- Quality. The overall study quality was low.
A few thoughts:
1. This is a timely and relevant paper, published in a solid journal.
2. The main finding in a sentence: “We found no evidence of the overall efficacy of preventive interventions in reducing post-traumatic stress disorder (PTSD), depression or anxiety symptoms at postintervention compared with passive control conditions.”
3. Ouch.
4. The clinical implications? The authors write: “Our results are a call for action to develop and test more effective interventions to prevent mental disorders in the aftermath of natural hazards. In this context, more high-quality randomised controlled trials are needed.”
5. The idea of preventing illness is compelling. But is the goal too ambitious? Since we aren’t quite sure why someone develops, say, PTSD, is targeting the population simply too broad (as opposed to focusing on at at-risk sub-populations)? And a note of caution: we have seen this sort of enthusiasm but middling results before: that is, debriefing exercises after major events. Good will, alas, isn’t enough.
6. Like all studies, there are limitations. The authors note several, including: “A limitation of this meta-analysis is the focus on PTSD, depression and anxiety, whereas exposure to natural hazards may also promote the development of additional mental health complaints such as insomnia, suicidality or substance use.”
The full BMJ Mental Health paper can be found here:
https://mentalhealth.bmj.com/content/28/1/e301357
Selection 2: “Promoting healthy digital device usage: recommendations for youth and parents”
Joseph Firth, Marco Solmi, Johanna Löchner, et al.
World Psychiatry, February 2025
Young people’s usage of digital devices is currently a central topic of interest for researchers, clinicians and the general public, particularly with regards to the impact of social media on adolescents’ mental health. Notably, the duration of screen time is not the primary determinant of mental health outcomes. Rather, the ‘quality’ of an individual’s device usage patterns, experiences and interactions online, and how they correlate with other lifestyle variables (e.g., sedentary time and sleep) appear to matter most.
Other than avoiding the more clear-cut ‘online harms’ (e.g., addictive behaviors, cyberbullying, and online blackmail or exploitation), there is a lack of consensus on how youth can improve the ‘quality’ of their online time. This is in part because the details of what constitutes ‘healthy’ device usage are unclear, and likely differ with regards to sociodemographic factors. Here we sought to produce a simplified set of recommended actions to promote adolescents’ healthy digital device usage.
So begins a paper by Firth et al.
They offer three tips:
Out of sight, out of mind.
“The implementation of tech-free zones and times is featured consistently across existing guidelines/recommendations, empirical studies, and youth feedback. The most common recommendation is aiming for at least one hour of tech-free time before bed, to mentally disconnect from the online world and promote adequate, restful sleep. Designating bedrooms as tech-free zones at night and setting up device charging stations in other locations may help youngsters build these habits.”
Use device features to control usage.
“Digital devices, particularly smartphones, increasingly offer a range of technological features for tracking and managing one’s usage. There are specialist apps through which the user can customize restrictions around content access and usage durations. The default features in iOS and Android systems now readily enable screen time tracking, timing (with reminders), notification blocking, and privacy controls.”
Replace rather than restrict.
“One of the primary downsides of digital device usage is the extent to which online time can detract from healthy behaviors, such as regular physical activity, adequate sleep, and real-world socialization. Efforts to reduce the use of devices during the day will be more acceptable, enjoyable and effective when the user focuses on replacing screen time with engaging, healthy activities, ideally performed with friends and/or family members to also enhance socio-emotional skill acquisition. Alongside this, the physical and mental health outcomes of device usage can be improved by replacing some of the time spent passively consuming social media with intentional engagement in ‘healthier’ online activities.”
They also make suggestions for parents. Here, we highlight two:
Agree on a plan.
“Many professional bodies and independent think tanks recommend that families discuss the best ways to manage digital device usage and put the results ‘in writing’ as some form of agreement or plan. Ideally, this text should encompass agreed tech-free times/zones, screen time replacement activities, boundaries on app/website usage, and plans for raising concerns or discussing experiences regarding adverse interactions or content in the online world.”
Communicate often and openly.
“Maintaining a non-judgemental frame and encouraging a two-way conversation about the content and quantity of online time is essential for: a) supporting the adoption of healthy device usage in young people, and b) creating well-functioning pathways for identifying and managing more serious threats that may arise, such as cyberbullying or online exploitation.”
A few thoughts:
1. This is a practical and thoughtful paper published in a major journal.
2. There is much to like here.
3. For the record, “replace not restrict” is particularly good advice.
The full World Psychiatry paper can be found here:
https://onlinelibrary.wiley.com/doi/10.1002/wps.21261
Selection 3: “The Red Pencil Sharpener”
Zheala Qayyum
Academic Psychiatry, April 2025
I was new to this school in Pakistan, joining toward the end of second grade. The school supplied notebooks, stationery pencils, and pencil sharpeners. Most were green and blue. I was over the moon to end up getting a red one, then devastated when I lost it in class.
That’s when I spied a red sharpener on a fellow student’s desk and demanded that he give it back. He picked it up and clutched it tightly. I marched to the front of the class to ask the teacher to intervene. The boy was summoned and questioned, struggling, despite his hearing impairment and associated speech impediment, to explain that the red sharpener was indeed his.
Perhaps it was because I was more confident. Or perhaps because I was not the child with the hearing aids. But I left with the sharpener firmly in hand as he still stood there, crying, trying desperately to explain.
It was a week later, somewhere in the lowest recesses of my school bag, that I found another red sharpener – the one that actually was mine. However, I said nothing. I just didn’t have the courage.
So begins a paper by Dr. Qayyum.
Years later, she is doing work in Pakistan – and recognizes a face. “On one of these visits, I was asked to consult on the case of a certain youth. After the Pakistani resident presented the case, the patient came in for an interview with their family. The grandfather introduced the patient and gave a brief history of the illness, development, and family. Both parents had hearing impairment. The grandfather then pointed to the father to introduce him. As I looked squarely at his face, my head spun. It was the face of the boy I had pictured in my mind all these years, older, but still the same.”
“This time, however, I found the courage to speak. With their psychiatrist’s support, I sent a note of apology to the young patient’s father. And I enclosed a red sharpener.”
She notes the challenges faced by those with disabilities. “Perhaps we would better understand the challenges of people with disabilities if we heard their voices more regularly as part of our training. Incorporating patient voices requires deliberate effort and attention on our part as educators. Finding opportunities to highlight how situations might be different for those with disabilities, in various clinical circumstances, and sharing our experiences can be really meaningful.”
She ties her experience to her work as an educator. “This incident also jolted me from the inertia of my weariness. As I watch my colleagues, trainees, and myself get overwhelmed by burnout and discussions of moral injury, this moment reminded me about my – and our – ‘why.’ In the chaos and demands of everyday clinical work, it is too easy to forget the purpose behind who we are, what we do, and why we do it.”
She closes by reminding us of our role and purpose as clinicians. “Each day, we save lives. As I helped the child of the student I had tormented, I realized yet again that this willingness to help others is the most profound antidote to the exhaustion permeating and rippling through our profession. Yes, boundaries and balance are important. But doing a little extra sometimes can be surprisingly rewarding in its own right.”
A few thoughts:
1. This is beautifully written essay.
2. Anyone who has a childhood regret – which is to say, everyone – can relate to Dr. Qayyum’s story.
3. This line is worth repeating: “Only by sharing and reflecting on our own moments, successes, failures, and vulnerabilities, can our trainees recognize and respond to such instances in their own experience.”
4. Dr. Qayyum’s writing has been considered in past Readings. Back in 2020, she wrote about her experiences as an army reservist posted to NYC during the early days of COVID-19. It begins hauntingly: “Lately I’ve found myself giving people directions to the hospital morgue.” The full essay – which is a must read – can be found here:
The full Academic Psychiatry paper can be found here:
https://link.springer.com/article/10.1007/s40596-024-02044-z
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.\
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