Association Between Ambient Heat and Risk of Emergency Department Visits for Mental Health Among US Adults, 2010 to 2019

Abstract

Importance: The implications of extreme heat for physical health outcomes have been well documented. However, the association between elevated ambient temperature and specific mental health conditions remains poorly understood.

Objective: To investigate the association between ambient heat and mental health-related emergency department (ED) visits in the contiguous US among adults overall and among potentially sensitive subgroups.

Design, setting, and participants: This case-crossover study used medical claims data obtained from OptumLabs Data Warehouse (OLDW) to identify claims for ED visits with a primary or secondary discharge psychiatric diagnosis during warm-season months (May to September) from 2010 through 2019. Claims for adults aged 18 years or older with commercial or Medicare Advantage health insurance who were living in 2775 US counties were included in the analysis. Emergency department visits were excluded if the Clinical Classifications Software code indicated that the visits were for screening for mental health outcomes and impulse control disorders.

Exposures: County-specific daily maximum ambient temperature on a continuous scale was estimated using the Parameter-Elevation Relationships on Independent Slopes model. Extreme heat was defined as the 95th percentile of the county-specific warm-season temperature distribution.

Main outcomes and measures: The daily incidence rate of cause-specific mental health diagnoses and a composite end point of any mental health diagnosis were assessed by identifying ED visit claims using primary and secondary discharge diagnosis International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. Conditional logistic regression models were used to estimate the incidence rate ratio (IRR) and 95% CIs for the association between daily temperature and incidence rates of ED visits.

Results: Data from 3 496 762 ED visits among 2 243 395 unique individuals were identified (56.8% [1 274 456] women; mean [SD] age, 51.0 [18.8] years); of these individuals, 14.3% were aged 18 to 26 years, 25.6% were aged 27 to 44 years, 33.3% were aged 45 to 64 years, and 26.8% were aged 65 years or older. Days of extreme heat were associated with an IRR of 1.08 (95% CI, 1.07-1.09) for ED visits for any mental health condition. Associations between extreme heat and ED visits were found for specific mental health conditions, including substance use disorders (IRR, 1.08; 95% CI, 1.07-1.10); anxiety, stress-related, and somatoform disorders (IRR, 1.07; 95% CI, 1.05-1.09); mood disorders (IRR, 1.07; 95% CI, 1.05-1.09); schizophrenia, schizotypal, and delusional disorders (IRR, 1.05; 95% CI, 1.03-1.07); self-harm (IRR, 1.06; 95% CI, 1.01-1.12); and childhood-onset behavioral disorders (IRR, 1.11; 95% CI, 1.05-1.18). In addition, associations were higher among men (IRR, 1.10; 95% CI, 1.08-1.12) and in the US Northeast (IRR, 1.10; 95% CI, 1.07-1.13), Midwest (IRR, 1.11; 95% CI, 1.09-1.13), and Northwest (IRR, 1.12; 95% CI, 1.03-1.21) regions.

Conclusions and relevance: In this case-crossover study of a large population of US adults with health insurance, days of extreme heat were associated with higher rates of mental health-related ED visits. This finding may be informative for clinicians providing mental health services during periods of extreme heat to prepare for increases in health service needs when times of extreme heat are anticipated.

Figure 1.. Maps of Contiguous US Showing County-Level Data on Number of Emergency Department (ED) Visits and Warm-Season Temperatures

NCA4 indicates Fourth National Climate Assessment.

Figure 2.. Cumulative Exposure-Response Curve of the Association Between Warm-Season Temperatures and Emergency Department Visits for Any Mental Health Condition

Incidence rate ratio of emergency department visits with increasing temperature compared with optimal temperature. Main model adjusted for relative humidity and day of the week. Shading represents the 95% CI. The optimal temperature is the first percentile of the county-specific temperature distribution, at which minimum morbidity occurs. The additional temperatures shown on the x-axis represent the 25th, 50th, 75th, and 100th percentiles of the county-specific temperature distribution, converted to the equivalent actual temperature across all counties in the study area.

Figure 3.. Cumulative Exposure-Response Curve of the Association Between Warm-Season Temperatures and Emergency Department Visits for Specific Mental Health Conditions

Incidence rate ratio of emergency department visits with increasing temperature compared with optimal temperature. Main model adjusted for relative humidity and day of the week. Shading indicates the 95% CI. The optimal temperature is the first percentile of the county-specific temperature distribution, at which minimum morbidity occurs. The additional temperatures shown on the x-axis represent the 25th, 50th, 75th, and 100th percentiles of the county-specific temperature distribution, converted to the equivalent actual temperature across all counties in the study area.