REVIEW PAPER

International Journal of Occupational Medicine and Environmental Health 2018;31(6):711 – 721 [Link]

IMPACT OF AIR POLLUTION ​ON

DEPRESSION AND SUICIDE

ANNA GŁADKA​1​, JOANNA RYMASZEWSKA​1​, and TOMASZ ZATOŃSKI​2
Wroclaw Medical University, Wrocław, Poland ​1 ​Department of Psychiatry 2​ ​Department and Clinic of

Otolaryngology Head and Neck Surgery

Abstract ​Air pollution is one of the greatest public health threats worldwide. All substances appearing in excessive quantities in
the atmosphere, such as particulate matter, nitrogen oxides or sulphur oxides may be its ingredients. Depending on their size and
nature, these compounds may cause greater risk of suffering from respiratory or cardiovascular diseases for exposed people as
well as exacerbation and increased mortality due to these illnesses. Smaller particles may penetrate the brain’s blood barrier and
thus affect the central nervous system. In many studies, they have been shown to have negative effects on brain structure, like
diminishing white matter or neuronal degeneration, leading to the earlier onset of Alzheimer or Parkinson disease. Nev- ertheless,
there are reports of association of air pollution with mood disorders, depression, and even suicide. There are many risk factors for
these conditions, most important of which are the social situation or chronic diseases. However, it has also been confirmed that
the environment may affect mental health. This article will present experimental, clinical and epidemiological studies on
exposure to air pollution and its impact on depressive disorders and suicide. Our goal is to determine the relation- ship between
air pollution and incidence of depression and suicides. Int J Occup Med Environ Health 2018;31(6):711 – 721
Key words: Depression, Suicide, Mental health, Air pollution, Air quality, Mood disorders
INTRODUCTION ​Poor air quality is now one of the most important envi- ronmental problems in the
world. Substances occurring in excessive concentrations in the air and causing air pollu- tion include:
carbon (CO, CO​2​), nitrogen (NO​x​) and sul- fur oxides (SO​2​, SO​3​), fluorine (F), ozone (O​3​), hydrocar-
bons, phenols or particular matter (PM). Depending on the average aerodynamic particle size, PM​10​, PM​2.5
and ultrafine particulate matter (UFPM) of < 0.1 μm are distinguished. Polluted air affects health,
increases morbidity and mor- tality due to cardiovascular and respiratory diseases [1]. According to the
European Environment Agency (EEA)
Received: September 30, 2017. Accepted: January 31, 2018. Corresponding author: Anna Gładka, Wroclaw Medical University, Department of
Psychiatry, Wybrzeże L. Pasteura 10, 50-367 Wrocław, Poland (e-mail: agladka@[Link]).
report, in Europe, 467 000 people die
Nofer Institute of Occupational Medicine, Łódź, Poland ​
prematurely due to air pollution. In Poland for instance, only one com- ponent of air pollution, particulate
matter, with a mean aerodynamic particle below 2.5 m (PM​2.5​) causes more than 48 000 premature deaths
per year [2]. This is most often associated with respiratory and cardiovascular dis- eases [3]. Nevertheless,
more and more evidence is emerg- ing that these harmful compounds may reach every organ, even
beyond the cerebral blood barrier. What happens with them when they reach brain is a subject of a numer-
ous of investigations that may explain their impact on mental health. It is known, mostly from
epidemiological data, that there is an association between poor quality of
711
REVIEW PAPER ​A. GŁADKA ET AL.
 31(6) ​air
712 ​IJOMEH 2018;​ and psychiatric conditions, including neurodegenera- tive diseases,
depression and suicide attempts. Of course, there is a variety of risk factors, nevertheless air pollution
may be one of them. Suicide, as the most serious consequence of mental dis- eases, may result from many
variables such as alcohol abuse, difficult life situations or social isolation. However, the most important
risk factor is mental disorder. It is es- timated that around 60–80% of all suicide victims suffer from
depression, while 15% of patients with severe de- pression eventually commit suicide [4]. The influence
of environmental factors such as meteorological variables (air temperature, humidity, atmospheric
pressure) [5] is also proven, but little is known about the possible effects of air pollution on mental health.
In our article we will briefly explain how air pollution impacts on nervous system, then we will present
experi- mental, clinical and epidemiological studies related to an exposure to air pollution and its impact
on depression and suicide. The aim of this article, in addition to determin- ing the impact of air pollution
on depression and suicide, is to provide sufficient evidence to support intervention strategies aimed to
protect human health against further adverse effects caused by bad air quality.
MATERIAL AND METHODS ​The study was conducted in the electronic databases MEDLINE and
Scopus. The relevant articles were searched by keywords and medical topics (medical subject headings,
MeSH): air pollution, air pollutants, suicide, suicide, depression, mood disorders, affective disorders. We
followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
Peer- reviewed and academically published observational or ex- perimental articles in English were
included. We excluded papers concerning indoor air pollution and tobacco smok- ing. The 558
publications were collected, 406 of which did not meet our criteria or were duplicated. The 39 articles
were excluded during full text screen. We qualified 12 ar- ticles concerning depression, 9 – suicides.
AIR POLLUTION’S EFFECT ON NERVOUS SYSTEM ​There are many mechanisms by means of
which air pol- lutants may cause pathologies of the nervous system. Ex- perimental studies have
confirmed that one of the main components of air pollution, PM​2.5​, as well as compounds adsorbed on its
surface, causes cell cycle arrest and apop- tosis of neurons. This action, together with the oxidative stress
and gene damage induced by these particles, may lead to degenerative changes in the brain [6]. Moreover,
substances occurring in smog may also cause systemic infection. In response to the exposed organ- ism,
an increased number of immune cells produces cy- tokines that pass through the blood-brain barrier via
ac- tive transport. In response, there is an increased migra- tion of monocytes to the central nervous
system [7]. This phenomenon was confirmed in the brain tissue analysis of people who lived in highly
polluted areas. Increased CD-68, CD-163 and HLA-DR cells (indicating infectious monocytes or
increased microglial activity in the patient), elevated inflammatory markers (interleukin-1β, IL-1), en-
dothelial cell activation, prefrontal brain damage, increase in Aβ42 protein (Alzheimer’s protein) and
damage to the blood – brain barrier were detected [8]. Hippocampus is most susceptible to inflammatory
damage due to multiple receptors for proinflammatory cytokines such as interleu- kin (IL) 1 p, IL-6 and
tumor necrosis factor α (TNFα) [9]. In research on the etiology of affective and cognitive dis- orders,
attention is increasingly focused on the general- ized inflammatory state [10]. In addition, it has been
confirmed that ozone and par- ticulate matter interfere with cerebral blood vessels by modulating the
expression of genes involved in key vaso- reactive pathways in the brain [11]. This is consistent with
increased prevalence of cerebral stroke in populations ex- posed to increased air pollution [12].
with poor air quality. It has been shown, that air pollu-
tion induces a decrease in white matter volume in older
Also, neurodegenerative diseases may be associated
adults [13] and may be a risk factor for Alzheimer dis-
ease. It represents 60–80% of dementia [14], and one of air within households may cause depressive mood in
its causes is deposition of amyloid plaques in the brain. vulner- able individuals [21,22]. Scientists proposed
In studies of animals exposed to contaminated environ- many possible mechanisms to explain this
ment, symptoms of increased oxidative stress, phenomenon. Experimentally it has been shown that
premature appearance of amyloid plaques and a particulate matter may be transported through the
significant increase in the number of DNA lesions in blood- stream [23] and directly through the olfactory
the olfactory bulb, fron- tal cortex and hippocampus pathway [24] to the brain. This has been confirmed by
were observed [15]. Other publications also show that finding particles in olfactory neurons, intracellular
heavy metal particles (nickel and vanadium) get erythrocytes in the frontal lobe [15]. It is possible due
through the nose and the olfactory tract reaches the to its small size, which allows some particles to
frontal cortex. This may indicate that the early penetrate through lungs and blood-brain barrier to reach
symptoms of Parkinson’s and Alzheimer’s dis- ease neurons [25]. Consequently, those com- pounds may
due to damage to the olfactory tract may be caused by stimulate innate immunity. It has been con- firmed that
air pollution [16]. Additionally, air pollution’s particular matter induces proinflammatory cy- tokines
compounds may have a spe- cific impact on a cell (IL1-β, TNFα and INFγ) in olfactory neurons [26].
cycle. It is shown, that simultane- ous exposure to Studies have shown that exposure to PM​2.5 in ​ mice
PM​2.5​, SO​2 and
​ NO​2 results
​ in impaired apoptosis gene causes, in addition to neuropathic inflammation,
expression (p53, bax and bcl-2), which may lead to changed morpholo- gy of hippocampal neurons which
neuropathic changes, memory disorders and spa- tial may lead to altered affec- tive behaviors and
orientation [17]. Overall, the complexity of the impairment of cognitive abilities [27].
interaction of air pollu- tion on the nervous system may
be due to the multitude of inhaled compounds
Particulate matter ​Numerous studies have
coexisting. However, to better un- derstand the effect
documented that exposure to particular matter may be
of smog, clinical and epidemiological aspects should
associated with more frequent incidences of depression
also be considered.
(Table 1). This association was specified in the Kim
study, where it was found that the risk of a depressive
AIR POLLUTION AND DEPRESSION ​Depressive episode rises with increasing con- centration of PM​2.5
disorders are one of the most common prob- lem by 10 μg/m​3​, especially in people who suffer from
affecting approximately 350 million people world- concomitant chronic diseases [28]. An- other study has
wide, which accounts for about 5–6% of the popula- shown, that the increase in PM​10 as​ well as NO​2 and
​ O​3
tion [18]. It may lead, among others, to a significantly may lead to the onset of depressive symp- toms among
reduced quality of life [19], an increased risk of the elderly, which is most strongly associated with
morbidity and mortality from cardiovascular diseases emotional symptoms [29]. Pathogenesis is probably
[20] and even a rise in suicides. There are many related to particular matter induced oxidative stress and
environmental factors that may cause its higher risk, generalized inflammation. Experimental studies suggest
including ambient air pollu- that both pathomechanisms have been associated with
vascular IMPACT
lesionsOFand
AIR POLLUTION ON DEPRESSION AND SUICIDE
neurodegenerative disorders [30].
REVIEW PAPER
As a result, these processes may cause or exacerbate the
symptoms of depression [31].

tion. Although, it has been confirmed that also polluted

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Table 1. ​General characteristics of studies concerning relationship between depression and air pollution
Author Study design Exposure assessment Main outcome Perera et al. (2006) [45] prospective
cohort study
714 ​IJOMEH 2018;​ 31(6) ​high prenatal exposure positively associated with anxious/depressed symptoms and
attention problems Fonken et al. (2011) [27] experimental
study
polycyclic aromatic hydrocarbons (PAH) particulate matter long-term exposure to particulate air pollution levels
alter affective responses and impair cognition Lim et al. (2012) [30] cross-sectional
study
increases depressive in symptoms PM​10​, NOamong 2​​ , and Othe 3​ ​levels elderly
may increase
Davis al. (2013) [44] experimental
study
PMozone
10​, nitrogen dioxide,
nPM increased depression-like responses after prenatal
exposure to nPM Cho et al. (2014) [22] time-stratified case-crossover study
SOof ED 2​​ , PMvisits 10​​ , NOfor 2​​ , depressive and CO significantly episode, especially increase among
the risk
individuals with cardiovascular disease, diabetes mellitus, or asthma Wang et al. (2014) [47] prospective
cohort study
sulphur nitrogen dioxide, dioxide, PMcarbon
10​,
monoxide
no evidence of a positive association between depressive symptoms and mean pollutant levels in the preceding 2
weeks Mokoena et al. (2015) [41] experimental
study
PMcarbon, 2.5​​ , sulfates, ultrafine
black
particles ozone ozone inhalation induces memory impairment,
anxiety and depression-like effects Zijlema et al. (2016) [42] cross-sectional
cohort study
PM​10​, nitrogen dioxide heterogeneous results of associations pollutants and depressed mood
of the air
Szyszkowicz et al. (2016) [35] case-crossover
study
positive association between exposure to air pollution and visits for depression Kioumourtzoglou et al.
(2017) [34]
PMsulphur 2.5​ ​ , nitrogen dioxide
dioxide,
prospective ozone, cohort study
PM​2.5​, PM​10 association
​ ​exposure and between
​ ​depression both
​ ​onset, long-term
​ ​specifically ozone
​ and ​stronger
PM​2.5 ​with antidepressant use Lin et al. (2017) [43] cross-sectional
 study
dose-dependent association between air pollution and emotional stress during pregnancy Tallon et al. (2017) [28]
observational,
longitudinal, population- based study
sulphur dioxide, sarticulate matter PM​2.5 positive
​ associations between recent long-term ambient depression PMand
2.5 ​levels stress
and erectile dysfunction,
PMNO​2.5 2 –​ – particulate matter, particles with a nitrogen dioxide; O​3 –​ ozone; SO​2 –​ sulphur diameter dioxide; of 2.5 CO μm –
carbon or less; monoxide; PM​10 ​– particulate nPM – nanoparticulate matter, particles matter; with ED a – diameter emergency of
department.
10 μm or less;
Ozone
to ozone and depressive episodes. In the case of women, The influence of ozone exposure on the
incidence of de-
exposure to ozone was associated with an increased risk of pression [32,33] has also been confirmed.
Kioumourtzo-
medical visits due to this condition from 1 to 7 days after glou et al. [34] in prospective cohort studies
among a large
exposure, while in men between 1 and 8 days [35]. Also, group of women have demonstrated an
association be-
the study of Tallon et al. [32] proved relationship between tween prolonged exposure to this allotropic
variant of oxy-
exposure to increased concentrations of PM​2.5​, NO​2​, gen and PM​2.5 ​and depression. It was particularly
strong
and O​3​, depressive episodes and erectile dysfunction in people taking antidepressants [34]. Another article
among older men. However, statistical significance has not has shown a positive association of short-term
exposure
been demonstrated [32].
Moreover, Thomson found that exposure to ozone
induced a twofold increase in serum cortisol levels,
To understand an impact of ozone on mental health, it
which is elevated in de- pressive states without
is crucial to explain ways it may distort processes in
affecting adrenaline levels [40]. Other data indicates
human body. It has been shown, that ozone may affect
that chronic ozone inhalation results in cortical and
the immune system, irritate mucous membranes, alter
hippocampal changes that involve reduced oxygen
neurotransmit- ters concentrations such as serotonin,
suppression and catalase activity, as well as low- ered
which play a major role in impulse responses, and
central monoamine levels similar to those observed in
thereby increase the risk of suicide [36]. Moreover,
depression. What is more, it was found that effects of
exposure to ozone may lead to brain lipid peroxidation,
melatonin, desipramine and escitalopram are
neuronal death in the substantia nigra [37] and thereby
significantly impaired in the presence of ozone [41].
to motor disorders [38] and memo- ry impairment [39].
In animal studies, it has been observed that ozone
exposure results in the production of cytokines in the Nitrogen dioxide ​Furthermore, numerous publications
brain such as IL-6 and TNFα, as well as vascular suggest, that expo- sure to NO​2 ​and NO​x ​increase the
endothelial growth factor, which, however, may be likelihood of depres- sion [27,29,35]. On the other
con- sidered a beneficial compensatory response. hand, a cohort study con- ducted in several European
countries showed inconsistent results, indicating a years [45]. Air pollution also affects cogni- tive
positive correlation between long- term exposure to disorders and abnormalities in the architecture of the
NO​2 ​in subjects in the Netherlands and negative in white matter in later childhood [46]. Nevertheless, there
Norway [42]. are reports that contradict air pollu- tion influence on
the prevalence of depression. Wang did not find
evidence of the relationship between depressive
Sulphur dioxide ​Another compound of air pollution,
symptoms in persons over 65 years of age and
sulphur diox- ide, among others, may have a
long-term or short-term exposure to pollution levels
detrimental impact on mood [23,35]. Interestingly, in
[24].
an article by Lin et al. it
IMPACT OF AIR POLLUTION ON DEPRESSION AND SUICIDE
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SUICIDES AND SUICIDE ATTEMPTS ​Suicide,
which may be a consequence of untreated affec- tive
disorders, accounts for nearly one million deaths per
was found that women living in areas with higher year worldwide, with a frequency of 10.1/100 000
levels of NO​2​, PM​10 and
​ SO​2 in
​ addition to increased inhabit- ants [47]. In Poland, this indicator is nearly
levels of stress during pregnancy have a higher risk of twice as high (18.5/100 000 inhabitants; 32.7 for males,
depressive episodes [43]. 4.9 for females). The etiology of this phenomenon is
extremely complex, but mental disorders are the most
Impact on children ​It is important to mention about air important risk factor. It is estimated that 7–15% of
pollution’s possible effect on affective disorders in patients with depressive disor- ders commits suicide
children. Experimen- tal studies have demonstrated the [48]. In the case of bipolar disorder, the percentage is
influence of ultrafine particulate matter (UFPM < 100 15%. Suicide is the result of a complicated interaction
nm) on prenatal de- velopment of the central nervous of many variables, including psychological features
system and the result- ing increased risk of depression (i.e., personal- ity traits, emotional responses),
[44]. Furthermore, other dangerous compounds, biological (genetic predis- positions, drugs,
polycyclic aromatic hydrocarbons, have been found to co-occurring diseases) and environmen-
cause anxiety and depression in chil- dren aged 7–8

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Table 2. ​General characteristics of studies concerning relationship between suicides and air pollution
Author Study design Exposure assessment Main outcome
Biermann et al. (2008) [36] population
study
716 ​IJOMEH 2018;​ 31(6) ​ozone ozone might even be a causative agent in the multifactorial genesis of a suicide
Szyszkowicz et al. (2010) [50] case-crossover
study
positive association between air pollution and emergency department visits for suicide attempts
Yang et al. (2011) [56] case-crossover
study
carbon monoxide, nitrogen dioxide, sulphur dioxide, PM​10 sulfur
​ dioxide, ozone positive associations between
suicide and air
pollution, weather and unemployment data Kim et al. (2015) [51] nationwide
study
ozone and atmospheric particulate matter increased concentrations related to suicide rate, no significant associations
for nitrogen dioxide, carbon monoxide and sulfur dioxide Bakian et al. (2015) [57] case-crossover
study
ozone, particular matter, nitrogen dioxide, carbon monoxide, sulfur dioxide
positive associations between air pollution and suicide across study locations with vastly different meteorological,
geographical, and cultural characteristics Lin et al. (2016) [52] case-crossover
study
nitrogen dioxide, particulate matter, sulfur dioxide
suicide risk positively associated with ambient air pollution level Ng et al. (2016) [54] time-stratified case-crossover
study
PMnitrogen ​10​, sulphur dioxide
dioxide,
​ , NOpopulation 2​ ​and SO​2 ​linked subgroups
PMin certain 2.5​
to suicide mortality
Stickley et al. (2017) [53] time-stratified case-crossover study
PMsulphur ​2.5​, nitrogen dioxide
dioxide,
airborne pollen airborne pollen linked to suicide mortality among
females
Casas et al. (2017) [55] time-stratified case-crossover study
PM​10​, ozone PMwarm elderly 10 ​ ​or periods; population
O​3 may
​ PMtrigger ​ 10 ​ especially suicide, among particularly children during and
Abbreviations as in Table 1.
tal factors (support, demography). However, there are
ic ≤ 10 μm) have the highest influence 0–2 days before also reports that air pollution may play a
significant role
suicide and PM​2.5 particles
​ 1 day before suicide. Addi- in suicides (Table 2).
tionally, other study concerning co-morbidity found that people with cardiovascular diseases are more
susceptible ​Particular matter
to PM​10 [50].
​ In a study conducted in Guangzhou, China, It has been shown that the number of suicide
attempts
it has been shown that particulate matter contributes to is increasing during the period of the highest
concentra-
more frequent suicide, but at different seasons of the tions of particulate matter in the atmosphere [49].
Still,
year and to other social groups. There was an increased the mechanism of this phenomenon is still
tentative. In
risk, especially in brutal ways, during the winter, while investigations where authors were looking for a
relation-
less drastic during the summer. Authors of this publica- ship between timing of exposure and suicides, it
has been
tion also explicit a risk groups by revealing, that this rela- revealed, that PM​10 particles
​ (with average
aerodynam-
tionship was stronger for men and for those with higher
education [51]. On the other hand, in the paper from
To- kyo, particular matter was associated with a 50% concentration was correlated with a rise in suicides.
higher risk of suicide among women compared to days Au- thors precise, that adjusted suicide rate was
where there was practically no increased level of increased by approximately 7.8% during months of the
particular mat- ter [52]. Among the same population, it highest contam- ination of ozone [50].
was also found that PM​2.5 and
​ SO​2 increase
​ the
proportion of suicide among widows and widowers Nitrogen dioxide ​Nitrogen dioxide was also
[53]. Finally, the latest article from Belgium on more investigated for its effects on suicide. In study based on
than 20 000 cases of suicides has also confirmed that nearly 30 000 cases, high levels of NO​2 have
​ been
short-term incre- ases in PM​10 and
​ O​3​, even below associated with a higher risk of suicide in people under
European levels, may in- crease the risk of suicide. In the age of 30 [53]. A simi- lar relationship was
addition, PM​10 ​may have a strong impact on the deaths confirmed by Szyszkowicz, who published evidence of
of children and older people [54]. the link between admissions to emergency departments
due to suicide attempts and increased PM​10​, CO and
Sulfur dioxide ​Sulfur dioxide may be also associated NO​2 ​concentrations [49]. Bakian’s article has shown
with an increased risk of suicide. The study conducted that the risk of suicide increas- es in people between
in Taiwan indicated sulfur dioxide and ozone as factors 36–64 years who are exposed to high levels of nitrogen
that increased the probability of this event [55]. dioxide and PM​2.5​, and this is particu- larly visible two
days after an exposure. In addition, in case of high
levels of PM​2.5 during
​ spring and autumn, the risk
Ozone ​Numerous of studies show, that ozone is one of increases on the second day, while for nitrogen dioxide
the main contributing factors for suicides. Biologically, after 3 days. Finally, after 3 days of exposure to both
it can affect the distribution of serotonin, which plays a pol- lutants, the risk of violent suicide rises [56].
major role in impulsivity, aggression, depression, and
thus may affect suicide. In addition, the highest
concentration of this sub- stance coincides with the DISCUSSION ​Air pollution may affect the central
peak of suicide death in summer. Alternatively, it may nervous system in many ways, among others through a
be caused by the influence of higher ambient neuropathic inflam- mation, an oxidative stress or a
temperatures leading to more violent behavior, which damage to blood vessels. Its components pass through
may result in suicide [36]. Nevertheless, the blood-brain barrier, where not only the particles
epidemiological data shows a relationship between themselves, but also various toxic compounds adsorbed
ozone and number of suicides. Yang et al. [55] found on their surface may cause pathological changes.
that both sulfur dioxide and ozone increased the risk of Taking into account the complexity of the body’s
this way of death among people who were exposed to it response to air pollution, central nervous sys- tem
for a long time. This study showed significant corre- pathology is probably caused by the synergistic inter-
lations between suicide and air pollution, while also action of many pathways and mechanisms. Numerous
tak- ing into account data on weather and articles suggest the relationship between air pollution
unemployment [55]. These reports have been and higher prevalence of depressive disorders and
corroborated in the analysis of South Korea’s data, suicides. As we have learned, their etiology is ex-
where a 4-week period of high ozone tremely complex, as does the health effects of many
sub- IMPACT OF AIR POLLUTION ON DEPRESSION AND SUICIDE
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31(6) ​stances present in the air. While epidemiology indicates an increased risk of
718 ​IJOMEH 2018;​
depression and suicides in exposed to contaminated air individuals, further research is still required to
fully explain these findings. Epidemiological data may show a particular dependence, but more clini- cal
and experimental studies are needed for better under- standing the impact of air pollution on mental
health. Limitations in the current study include the fact, that it was not conducted by two independent
researchers and the lack of many long-term exposure studies for air pol- lution. Articles were also limited
in diversity, according to air pollutants. Additionally, inconsistent results of in- cluded studies should
require further metaanalysis to settle final conclusions. Future directions should include exploring
depression morbidity and suicide statistics and compare areas with high average concentrations of pollut-
ants to those with low pollution.
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