By Janice R. Bray, MD MBA, CPE, FAPA
Psychiatry Department of Veteran’s Affairs
Norfolk
Abstract
This article, written by a practicing psychiatrist in Virginia, examines the impact of extreme heat on mental health, physical safety, and the efficacy of medication. It draws on personal observation, public health data, and clinical experience to provide practical guidance on prevention, early recognition, and management of heat-related illness. Special emphasis is placed on vulnerable populations, psychiatric medication interactions, and strategies for community and individual resilience.
As our current President Karl Northwall, MD said in our Virginia News Summer 2025 issue, “…we are living in unprecedented times”, to which I agree, requires empowering personal responsibility for survival of the fittest.
I am Janice Bray, MD, a practicing psychiatrist in Virginia. The following is shared as recent exposure and experience-driven awareness and knowledge.
On July 26, 2025, I received a text message “Excessive Heat Conditions” from my clinic’s area regional medical office, reporting that my geographical area was experiencing excessive heat. All strenuous nonessential outdoor activity is restricted for personal safety. The Virginia Department of Health (VDH) reported that heat-related illnesses spiked up to 85% on some days that week compared to past years. A text message alert read, “stay hydrated and observe proper safety precautions, especially when working outside, today.” The heat index was 106 degrees Fahrenheit. The opportunity to work remotely that day was much appreciated.
As the morning hours passed, I looked up from my office to see my husband cutting the lawn. However, the sweat-drenched shirt, with a drawn, reddened face, was alarming. Alarm escalated to panic as he slumped behind the mower to his knees.
Monitoring a perspiring family member’s collapse, I remained confident in the fact that our bodies are enduring and wonderfully designed. Our bodies adjust in many ways to soaring temperatures of climate change. They can calibrate the amount and saltiness of sweat. A mechanism in your brain can trigger a sensation of thirst, prompting you to drink enough water to create enough sweat. The vascular system shunts more blood toward the skin, where it can be cooled by a breeze or evaporating sweat.
Under some conditions, when temperatures soar however, sweating just isn’t enough.
My awareness, perception, and knowledge of urban heat have increased after witnessing this impact of prolonged exposure to heat. Understanding heat-related weather terminology may assist many of our patients in being prepared for hot weather.
Table 1 – Heat-Related Weather Terminology
| Heat Index is a measure of how hot it feels when relative humidity is added to the air temperature. |
| Excessive Heat Outlooks: Issued when the potential exists for an excessive heat event in the next 3-7 days. |
| Excessive Heat Watches: Issued when conditions are favorable for an excessive heat in the next 24 to 72 hours. |
| Excessive Heat Warning/Advisories: Issued when an excessive heat is expected in the next 36 hours. All strenuous nonessential outdoor activity is restricted for personal safety. |
https://www.vdh.virginia.gov/news/extreme-heat-and-heat-related-illnesses/
Table 2 – Heat Exhaustion Symptoms
| Heat exhaustion symptoms include: |
| Cool, moist skin with goose bumps when in the heat |
| Heavy sweating |
| Faintness |
| Dizziness |
| Fatigue |
| Weak, rapid pulse |
| Low blood pressure after standing up |
| Muscle cramps |
| Nausea or vomiting |
| Headache |
| Extreme thirst |
| Mild confusion |
| Decreased urine output |
Treatment
Untreated, heat exhaustion can lead to heatstroke, which is a life-threatening condition. If you suspect heat exhaustion, take these steps immediately:
| Move the person out of the heat and into a shady or air-conditioned place. |
| Lay the person down and raise the legs and feet slightly. |
| Remove tight or heavy clothing. |
| Have the person sip chilled water, a sports drink containing electrolytes or another nonalcoholic beverage without caffeine. |
| Cool the person by spraying or sponging with cool water and fanning. |
| Monitor the person carefully. |
It is important to empower personal responsibility for survival during this climate crisis.
A brief overview of the effects of extreme temperatures on prescribed medications is as follows:
Heat and Psychiatric Medications
Medications used for mental health for illnesses, such as schizophrenia or bipolar illness, can change your regulation of heat, your ability to sense that you’re too hot, and your ability to sweat. I’ve seen people walk around with heavy mink coats when it’s 100 and 105 degrees outside because of their lack of thermo regulation or ability to regulate their body temperature.
Dehydration can affect levels of some medications, such as lithium, which can become more concentrated in the body and potentially lead to toxicity. If you get dehydrated, your lithium level can rise significantly. Lithium has a very narrow therapeutic range. You can become toxic with lithium, which can be quite serious with heart arrhythmias, coma, seizures, and even death, if it gets severe enough.
Antipsychotics can make it harder for people to sense their temperature, so they can’t tell when they’re overheating. Examples: Haldol (haloperidol), clozapine
Antidepressants can cause heat intolerance, can affect the way people’s bodies react to, or perceive heat, and heighten the risk of heat-related issues from a psychiatric and medical perspective. Examples: Prozac (fluoxetine), Lexapro (escitalopram).
Antihistamines / Anticholinergic medications — including some over-the-counter antihistamines, like Benadryl — can reduce sweating.
ACE inhibitors, or ARBs, are used to manage high blood pressure and make it harder to realize you’re thirsty. Examples: lisinopril, losartan, metoprolol, aspirin
Beta blockers, such as propranolol, decrease sweating, making it harder to cool off.
Diuretics, commonly prescribed for kidney problems, may contribute to dehydration. Used to increase or balance urine output, leading to dehydration, mental status changes, and confusion. Examples: Lasix (furosemide), metolazone.
Diabetes medication: Heat can degrade or damage some medications, such as decreasing the potency of Insulin and injectables. Storing medications in a cool, dry place is an important reminder for patients during extreme temperatures.
Certain medications can also cause the skin to be super sensitive to sunlight and UV light. Called photosensitivity, it causes skin to burn easily, which can produce a rash or sunburn that can be painful, itchy, blistered, and lead to peeling. Example: Antibiotics – doxycycline, tetracycline.
| Antifungals (examples: Ancobon, VFEND) |
| Antihistamines (examples: Benadryl, Claritin) |
| Cholesterol-Lowering Drugs (examples: Zocor, Lipitor) |
| Nonsteroidal Anti-inflammatory Drugs (NSAIDs) (examples: Advil, Aleve) |
| Oral Contraceptives and Estrogens |
| Retinoids (examples: Soriatane, Acutane) |
Summer temperatures in Virginia normally climb into the upper 90s and even reach higher than 100 degrees at times. The hot temperatures and high heat indexes can cause ill health effects. Associations between high ambient temperatures and heat waves with mental health outcomes have been identified by the U.S Department of Public Health in published reviews of 2018. During the Summer of 2025, as witnesses to our weeks of life under the ‘heat dome,’ the influence of temperature on various aspects of daily life is increasingly clear. Although the idea that climate change affects mental health is not widely recognized, understanding and addressing the relationship between temperature and mental well‐being is crucial to our practice and patients in the context of rising global temperatures.
At its core, the association between high temperatures and mental health rests upon a complex interplay of biological and psychological responses.
Chronic heat can lead to increased stress, anxiety, and cognitive impairment. Vulnerable populations include the very young, the elderly, and individuals with pre‐existing mental health conditions.
Prolonged exposure to elevated temperatures triggers a cascade of physiological reactions, ranging from accelerated heart rates and increased sweating leading to dehydration. These responses, while crucial for maintaining thermal equilibrium, can exert subtle yet important effects on those with pre-existing cognitive impairments, mobility issues, and through some medications’ mechanism of action.
Understanding and recognizing heat stress is critical for managing its effects on mental health. Heat stress occurs when the body cannot adequately cool itself and typically results from prolonged exposure to high temperatures.
A common side effect of extreme heat is irritability, which can arise from physical discomfort and disrupted sleep patterns, the fatigue from sweating, working in the heat, and lack of quality sleep. People feeling stressed and on edge are at risk of further psychological distress, including reduced motivation, decreased mood, and agitation. Behaviorally, extreme heat can lead to tempers flaring or even road rage.
“A study of over 2 million people found an increased visit rate or incidence of people going to the emergency department with psychiatric and mental health-related concerns during periods of high heat,” says Dr. Robert Bright of the Mayo Clinic.
“It showed a higher level of visits for substance abuse, anxiety, mood disorders, and even people with schizophrenia had an increased incidence of distress or issues with their illness, bringing them to the emergency department.”
Self-care behavior and environmental adaptations are great for keeping yourself safe.
What to do?
- Take the risks from heat seriously and develop a plan to keep cool.
- Drinking plenty of water and staying cool can help mitigate these risks.
- Staying hydrated with electrolytes, using electrolyte drinks, powders, and tablets.
- Planning ahead: “The car is a pressure cooker, especially if it’s been sitting out in the sun. If you know you’re going to be driving somewhere, start the car ahead of time and turn on the air conditioner”
Mindfulness and stress management techniques can be effective in mitigating the mental health impact of heat stress. Mindfulness involves staying present and calmly acknowledging one’s feelings, thoughts, and bodily sensations. This approach can help individuals manage their reactions to heat, thus reducing psychological distress. Techniques may include mindful breathing exercises, guided meditations, or progressive muscle relaxation. Stress management strategies such as maintaining a regular sleep schedule, eating a balanced diet, staying hydrated, and taking breaks from heat exposure can also be beneficial.
During times such as this, it’s important for people to protect themselves and respect other people. Everybody’s struggling. Each individual experiences stress in their own way. Recognize that and that you are not alone.
If you need help, seek help.
If you’re feeling really overwhelmed and as though you truly can’t cope, then it’s time to reach out for help! Whether that is calling a Crisis Line, walking into an emergency room asking for assistance, or contacting a therapist or counselor.
In general, high temperatures can exacerbate symptoms of preexisting mental health conditions. Individuals with anxiety, depression, bipolar disorder, and schizophrenia may experience intensified symptoms, be insensitive to impact, and have pharmacological and physiological alterations unique to mental health treatments. As psychiatrists, these truly are unprecedented times, and in times like these we need to lean into the impact of climate change on mental health.
On a broader scope, timely interventions to support mental health during heat‐related crises could be facilitated through early warning systems for extreme heat events.
Integrate mental health considerations into climate adaptation strategies and ensure that mental health services remain accessible and well‐prepared to address the increased stressors associated with escalating temperatures.
References
- Robert Bright, M.D., (Journalists: Broadcast-quality sound bites with Dr. Bright are available in the downloads at the end of the post. Please, courtesy: Mayo Clinic News Network. Name super/CG: Robert Bright, M.D. / Psychiatry / Mayo Clinic.)
- Mark Morocco, MD, clinical professor of emergency medicine at the David Geffen School of Medicine at UCLA,
- https://www.mayoclinic.org/first-aid/first-aid-heat-exhaustion/basics/art-20056651#:~:text=Faints.,Celsius)%2C%20which%20indicates%20heatstroke.
- Haynes A, Nathan A, Maitland C, et al. Prevalence and correlates of observed sun protection behaviors across different public outdoor settings in Melbourne, Australia. Health Educ Behav. 2022;49:405‐414. 10.1177/10901981211026535
- Nayak SG, Shrestha S, Sheridan SC, et al. Accessibility of cooling centers to heat‐vulnerable populations in New York State. J Transp Health. 2019;14:100563. 10.1016/j.jth.2019.05.002
- Heracleous C, Michael A. Experimental assessment of the impact of natural ventilation on indoor air quality and thermal comfort conditions of educational buildings in the Eastern Mediterranean region during the heating period. J Build Eng. 2019;26:100917. 10.1016/j.jobe.2019.100917
- Eady A, Dreyer B, Hey B, Riemer M, Wilson A. Reducing the risks of extreme heat for seniors: communicating risks and building resilience. Health Promot Chronic Dis Prev Canada. 2020;40:215‐224. 10.24095/hpcdp.40.7/8.01
- Vander Molen K, Kimutis N, Hatchett BJ. Recommendations for increasing the reach and effectiveness of heat risk education and warning messaging. Int J Disaster Risk Reduct. 2022;82:103288. 10.1016/j.ijdrr.2022.103288
- Sather EW, Svindseth MF, Crawford P, Iversen VC. Care pathways in the transition of patients between district psychiatric hospital centres (DPCs) and community mental health services. Health Sci Rep. 2018;1(5):e37. 10.1002/hsr2.37
- Climate-change-induced extreme weather events increase heat-related mortality and health risks for urbanites, which may also affect urbanites’ expressed happiness (EH) and well.
- Climate-change-induced extreme weather events increase heat-related mortality and health risks for urbanites, which may also affect urbanites’ expressed happiness (EH) and well-being.
- https://www.uclahealth.org/news/article/some-medications-can-increase-risk-heat-related-illness-2 (accessed Aug 2025)
- National Institutes of Health (NIH) | (.gov) https://pmc.ncbi.nlm.nih.gov › articles › PMC10696165
- Obradovich N, Minor K. Identifying and preparing for the mental health burden of climate change. JAMA Psychiatry. 2022; 79:285. 10.1001/jamapsychiatry.2021.4280 [DOI] [PubMed] [Google Scholar]8, 9
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Thompson R, Hornigold R, Page L, Waite T (2018) Associations between high ambient temperatures and heat waves with mental health outcomes: a systematic review. Public Health 161:1710191 (https://doi.org/10.1016/j.puhe.2018.06.008)
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