Mental Health After a Wildfire: My Spokane Fire Experience and What Physicians Need to Do

Physicians are increasingly familiar with climate change’s physical manifestations on health. Less consistently integrated into clinical practice is the mental health burden. As I was drafting a more general article on climate change and mental health, I became one of the over 65,000 people in Spokane, Washington evacuated for three separate wildfires. (Over 900 people lost their homes but mine was spared when the fire was stopped 1.5 miles away. Evacuation time was prolonged).

Wildfires are not only environmental and respiratory emergencies; they are behavioral health events. Physicians are often the first trusted professionals to recognize these effects when patients present for smoke exposure, medication refills, chronic disease management, injury care, or documentation related to evacuation, displacement, and loss.

Why Wildfires Affect Mental Health

Wildfire exposure combines immediate threat, sudden evacuation, loss of home, livelihood, smoke-related illness, separation from routines, financial uncertainty, community disruption, and prolonged uncertainty about return or rebuilding. These stressors can produce acute stress reactions and contribute to longer-term posttraumatic stress symptoms, depression, generalized anxiety, complicated grief, sleep disorders, and increased substance use.

Patients may also experience secondary wildfire stress without direct property loss, including repeated smoke days, school closures, work interruptions, isolation, fears about loved ones, and concerns about future fire seasons. Psychological burden may be amplified for patients with asthma, chronic obstructive pulmonary disease, cardiovascular disease, pregnancy, disability, limited transportation, unstable housing, prior trauma, or preexisting psychiatric disorders.

Long-Term Psychological Impacts

• Post-traumatic stress and depression (PTSD): elevated rates of PTSD, severe depression, and generalized anxiety persist years after the flames subside, affecting both survivors and evacuees.
• Environmental distress: survivors often experience solastalgia, the deep existential distress of seeing local landscapes, homes, and community networks destroyed.
• Compound stressors: post-fire displacement, insurance battles, housing insecurity, and unemployment act as chronic, recurring triggers for mental strain.
• Smoke and neuroinflammation: fine particulate matter from prolonged wildfire smoke exposure is increasingly linked to biological inflammation that worsens mood disorders and spikes psychiatric emergency visits.

Common Presentations in Medical Settings

• Sleep disturbance: insomnia, nightmares, early awakening, fatigue, or increased use of alcohol or sedatives to sleep.
• Anxiety and hyperarousal: persistent worry, irritability, panic symptoms, exaggerated startle, difficulty concentrating, or avoidance of reminders such as the smell of smoke or the sound of sirens.
• Depressive symptoms: low mood, loss of interest, guilt, hopelessness, withdrawal, appetite change, or impaired functioning.
• Trauma-related symptoms: intrusive memories, nightmares, avoidance, emotional numbing, hypervigilance, and functional impairment lasting beyond the acute period.
• Somatic symptoms: headaches, chest tightness, gastrointestinal symptoms, pain flares, palpitations, and fatigue that may overlap with smoke exposure or chronic disease.
• Substance use changes: increased alcohol, cannabis, stimulant, opioid, benzodiazepine, or tobacco use; relapse after prior recovery; or medication misuse.
• Family and occupational strain: conflict, caregiving stress, missed work, school disruption, housing instability, and difficulty managing paperwork or benefits.

The clinical task is to distinguish patients who are recovering with support from those who are deteriorating or need urgent intervention. Effective care is practical, trauma-informed, culturally responsive, and integrated into routine medical encounters.

Screening: Brief Questions That Fit into Routine Care

Physicians can normalize screening by linking mental health to the patient’s wildfire exposure.  As an example, you could say, “Many people notice changes in sleep, mood, or concentration after evacuating or breathing smoke for days. Has anything like that been happening for you?” A brief approach can include questions about safety, sleep, functioning, trauma symptoms, substance use, medication access, and social needs.  Some helpful questions may include:

• “Where are you staying now, and do you feel safe there?”
• “How are you sleeping?”
• “Are memories, images, or worries about the fire intruding when you do not want them to?”
• “Are you avoiding anything because it reminds you of the fire?”
• “How has this affected work, caregiving, school, or daily routines?”
• “Have you been using alcohol, cannabis, tobacco, or other substances more than usual?”
• “Have you had thoughts that life is not worth living, or thoughts of harming yourself?"
• “Do you have access to your usual medications, medical equipment, transportation, food, and reliable communication?”

Clinical Management Over Time

First days to two weeks: Focus on safety, stabilization, sleep, medication continuity, respiratory and cardiovascular needs, family reunification, and concrete resources. Normalize common reactions while explaining when to seek help. Schedule follow-up for patients with high exposure, prior mental illness, bereavement, major loss, limited supports, or concerning symptoms. When symptoms are significant, use PHQ-9 for depression, GAD-7 for anxiety, PCL-5 or PC-PTSD-5 for trauma symptoms, AUDIT-C for alcohol use, and brief substance use screening. Repeat screenings can be more informative than a single early assessment, because some patients appear highly functional during the immediate response and worsen during the recovery phase.

Two weeks to three months: Reassess mood, anxiety, sleep, substance use, trauma symptoms, functioning, and caregiver strain. Consider brief behavioral interventions, collaborative care, therapy referral, and treatment for depression, anxiety, PTSD, or substance use disorders when diagnostic criteria and impairment are present.

Beyond three months: Continue to monitor patients with persistent symptoms, unresolved housing or financial stress, disability, chronic illness, bereavement, or repeated smoke exposure. Recovery can be nonlinear; anniversaries, new fires, insurance delays, rebuilding decisions, and respiratory flares can reactivate distress. Emerging research suggests that anxiety, depression, and suicidal ideation may remain elevated long after evacuation or frontline response.

Patients at increased risk include older adults, people with disabilities, those with underlying psychiatric disorders, first responders (50% of wildland firefighters have suicidal ideation in the first year), clinicians, and essential workers. Screen for cumulative trauma, moral distress, sleep deprivation, irritability, substance use, and avoidance. Encourage peer support, rest cycles, confidential care pathways, and leadership attention to workload and recovery time.

Referral and Crisis Resources

Maintain an updated local referral list that includes behavioral health clinics, crisis lines, mobile crisis teams, substance use treatment, domestic violence services, family supports, school-based resources, tribal and culturally specific services, social work contacts, housing assistance, and disaster case management. For immediate behavioral health crisis support in the United States, patients can call or text 988. People experiencing disaster-related emotional distress can also contact the Disaster Distress Helpline at 1-800-985-5990. The American Osteopathic Foundation can help if your office is damaged or destroyed (https://aof.org/impact-initiatives/disaster-relief).

Additional Physician Actions

Adapt prescribing and monitoring. Fires are often associated with extreme heat. During extreme heat, assess renal function, hydration status, and toxicity risk for psychiatric medications; review anticholinergic burden; counsel patients on heat precautions; and consider whether dose adjustments or closer monitoring are needed. For patients on long-acting injectable antipsychotics, methadone, buprenorphine, clozapine, or complex medication regimens, develop continuity plans before predictable seasonal hazards. In regions with recurrent wildfire smoke, missed appointments may reflect transportation barriers, school closures, respiratory symptoms, or fear rather than nonadherence.

Include osteopathic manipulative treatment when appropriate. During the acute phase of disaster, chronic care and musculoskeletal complaints are common, especially when standard medications are unavailable. OMT may provide symptom relief and aligns with the osteopathic emphasis on treating mind, body, and spirit. Emerging evidence also suggests OMT may reduce stress, anxiety, depression, and PTSD-related symptoms in both patients and providers during and after disaster response.

Build clinic and health-system preparedness. Practices should identify high-risk patients before heat and smoke seasons, create outreach registries, prepare staff scripts, coordinate with pharmacies and community organizations, and ensure emergency messaging is accessible to patients with limited literacy, limited English proficiency, disability, or unstable housing. Telehealth can preserve continuity during disasters only when patients have devices, connectivity, privacy, and a backup plan. Mental health should be a core component of emergency operations, and patients should be encouraged to enroll in local evacuation notification systems.

Teach climate-related mental health across the continuum. Students, residents, and practicing clinicians need practical competencies in recognizing psychiatric sequelae of disasters, managing heat-sensitive medications, screening for climate-related social needs, communicating risk, and collaborating with public health and community partners. Research priorities include better risk quantification, evaluation of scalable interventions, health services planning, implementation strategies for under-resourced communities, and further study of OMT for acute and chronic disaster-related concerns.

Before I had to evacuate, I had already prepared my “to go bag.”  The bag included hard copies and a thumb drive (can get a secure one) of all paperwork that might be destroyed, including insurance info, driver’s license, passports, medical license, checkbook and credit cards, important contacts including utility info etc. I also include extra clothing.  The recommendation is for seven days of clothing, but you very well might need more if the evacuation is prolonged as was mine.  Finally, I included an online inventory of household items. Most insurance companies will provide a list for you to fill in ahead of the emergency.  I used an app called “UnderMyRoof” to assist. You should also have an inventory for your office.

Conclusion

Wildfires present is a clinical, environmental, and social emergency. Physicians can reduce harm by anticipating predictable risks, asking targeted exposure questions, protecting vulnerable patients, maintaining continuity of chronic disease care, recognizing delayed complications, and reinforcing clear safety messages. The most effective medical response begins before the fires start and continues long after devastation occurs.

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AOA Disaster relief for your practice - https://aof.org/impact-initiatives/disaster-relief

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