Climate change is one of the environmental crises caused by humans, which increases the imbalance of the Earth’s system as a whole (1). It interacts with other environmental crises caused by human influence, such as ocean acidification, air pollution, and the destruction of eco-systems. Thereby, climate change and other ecological crises are a severe threat to the basis of human livelihood (2). Mitigation and adaption efforts remain inadequate despite the accumulating knowledge about the multi-layered risks for our physical and mental health resulting from a rapidly changing climate with increasing temperatures, sea level rise, more heat waves, droughts, floods, and sand or dust storms (3).

The knowledge about human-induced environmental degradation and the anticipation of its future consequences can induce psychological distress in individuals (4, 5). This distress can express itself through a range of negative emotions, such as anxiety, sadness, guilt, despair, grief, or anger (6). It can be accompanied by cognitive indicators such as difficulty concentrating or fatigue, physiological indicators such as muscle tension or nausea, and behavioral indicators, such as poor sleep, constant alertness, or social withdrawal (7–9). While these reactions are oftentimes subsumed under the terms climate anxiety or eco-anxiety (5, 10), we will use the broader term of eco-distress to account for the fact that the concept encompasses other emotions than anxiety, as well as cognitive and physical impacts (11). With ongoing climate change, the prevalence of eco-distress is expected to rise further, especially in younger generations (8).

Although eco-distress is considered an adequate response to the threat posed by climate change and can foster pro-environmental behavior, it also shows a negative correlation with well-being and can lead to functional impairments in its extreme forms (12–16). Functional impairments can be understood as behaviors, emotions, thoughts, and physical symptoms limiting individuals in personal and occupational spheres of life, which can cause severe losses in quality of life on a personal level and substantial economic losses on a societal level (17–19). Most eco-distress questionnaires assess both negative emotional reactions, as well as different aspects of resulting functional impairments (20). Functional impairments due to eco-distress may be very similar or identical to those of depression (e.g. sleep disturbances) or anxiety (e.g. arousal), without fulfilling diagnostic requirements for depressive or anxiety disorders (21). In a previous study, patients with mental health impairments such as depression or anxiety disorders showed a heightened vulnerability for the experience of higher levels of eco-distress (22). The cause and course of the impairing consequences of eco-distress and the heightened vulnerability of persons with co-existing general mental health impairments are not yet understood and warrant further attention to minimize the functional impairments resulting from eco-distress, especially in vulnerable subgroups.

The framework of appraisal theories offers a possible explanation why the experience of eco-distress is linked to both functional impairments and pro-environmental behavior (23, 24). These theories posit that functional impairments are the result of an intense negative emotional reaction to a stimulus without the capacity to effectively regulate the response to the stimulus. In the context of the climate crisis, individuals who acknowledge the climate crisis as a threat and simultaneously do not have the capacity to effectively regulate the ensuing emotional reaction are prone to exhibit severe levels of eco-distress, accompanied by functional impairments. If, on the other hand, a person acknowledges climate change as a threat and is able to regulate the ensuing emotional response, this might foster pro-environmental behavior and motivate action (see Figure 1 ). Previous research has already addressed emotion regulation strategies and eco-distress in children (25), in relation to pro-environmental behavior (16), and in relation to worry about the future (26). Deepening our understanding of which emotion regulation strategies are relevant when faced with the threat of the climate crisis would be helpful to support people in dealing with this threat in a constructive manner. Moreover, emotion regulation strategies might represent common underlying dysfunctional processes of eco-distress and depressive and anxious symptoms, thereby explaining the heightened vulnerability of persons with mental health impairments.

Our aim was to explore the interplay of eco-distress, depressive and anxious symptoms, and emotion regulation strategies. As persons with co-existing mental health impairments are particularly vulnerable toward the experience of eco-distress, we assessed these aspects in a population of psychotherapy out-patients. No questionnaires have been evaluated regarding their psychometric properties in a clinical population before, thus our first research aim was to establish which questionnaires are suitable to assess eco-distress in a clinical sample. We hypothesized that the questionnaires which had been validated in the general population would show an acceptable fit in a clinical population, as well (H1). In a second step, we explored how elevated levels of depressive and anxious symptoms interact with eco-distress, both cross-sectionally and longitudinally. We hypothesized that psychotherapy out-patients with a pronounced anxious and depressive symptomology would show higher scores of eco-anxiety (H2). Finally, we were interested in identifying which emotion regulation strategies are associated with eco-distress and whether they mediate the relationship of depressive and anxious symptoms with eco-distress. As there was no previous literature on this relationship, this hypothesis was tested exploratory and not directed (H3).

The presentation of our analysis is structured according to the STROBE guidelines for cross-sectional studies (27). The study was approved by the ethics committee of the Medical Faculty of the University of Heidelberg (S-249/2023) and is in line with the Declaration of Helsinki. The design was pre-registered at Open Science Framework (https://osf.io/zgrqe/?view_only=d75a73f2e1b547aa8d1eeff00fc5323f).

To explore the relationship of eco-distress with depressive and anxious symptoms and emotion regulation strategies in psychotherapy patients, we initially established the factorial validity of three eco-distress mental health questionnaires, namely the EAQ-22, the GAD-7-C, and the CC-MMDS, in a clinical population. While the EAQ-22 and GAD-7-C showed an acceptable fit, the factorial structure of the CC-MMDS could not be replicated, and we conducted an exploratory factor analysis to determine an adapted factorial structure with adequate model fit. For all questionnaires assessing eco-distress, participants who screened positive for a depressive disorder or both a depressive and a generalized anxiety disorder showed significantly higher values than participants who screened negative for both disorders. However, change in anxious or depressive symptoms did not predict a change in eco-distress when re-assessed after five months. Moreover, while several emotion regulation strategies significantly predicted the level of eco-distress experienced by participants, none significantly mediated the relationship of depressive and anxious symptoms with eco-distress.

The results of the model tests in our sample indicate that the EAQ-22, as well as the GAD-7-C, are well suited to evaluate eco-distress in a sample of psychotherapy out-patients. While the EAQ-22 offers the advantage of dividing symptoms of eco-distress into negative emotional reactions (Habitual Ecological Worry) and functional impairments (Negative Consequences of Eco-Anxiety), the GAD-7-C offers the possibility to compare the severity of symptomology with established cut-offs for generalized anxiety disorder. However, symptoms pertaining to a generalized anxiety disorder certainly only represent one component of eco-distress (6). For the CC-MMDS, future research would have to determine the psychometric quality of our adapted version in other samples. Item 10, “The extent of climate change has shaken my worldview”, seems to fit better with the factor Change of Existing Belief Systems, which it belongs to in our adapted version. Of note, it also pertained to this factor in the MMDS, the questionnaire assessing reactions to man-made disasters in general that the CC-MMDS is based on (34). Moreover, the assessment of changes in existing beliefs due to climate change is a unique feature among eco-distress questionnaires (46) and may be worth pursuing further.

We could replicate the moderate correlations of depressive and anxious symptoms with eco-distress reported for the general population (4, 14, 15). It is noteworthy that twelve participants (6%) screened positive for eco-distress which is equivalent in severity to the symptom load of a generalized anxiety disorder. In comparison, a representative survey of n = 1031 adults (> 18 years) from the US used the items of the PHQ-4 to assess eco-distress. The PHQ-4 is a shortened screener for depression and anxiety, employing the first two items of the GAD-7 and the PHQ-9 (47). In this survey, 1% of the sample indicated “nearly every day” and 2% “more than half of the days” for all PHQ-4 items, which equals a positive screening for depressive or anxious symptoms of significant severity (21). This underlines a heightened vulnerability toward the experience of eco-distress in persons with co-existing mental health impairments.

To further explore this heightened vulnerability, we tested whether the severity of eco-distress differed depending and anxious and depressive symptom severity. For all three questionnaires EAQ-22, GAD-7-C, and CC-MMDS, eco-distress was higher if participants screened positive for both a generalized anxiety disorder and a depressive disorder (ANX + DEP > NONE). There were no statistically significant differences between the two groups (ANX + DEP ≈ DEP). However, our results can only provide information about the correlation at the level of symptom severity assessed with self-report questionnaires, as the psychiatric diagnoses of the participants determined by clinicians were not part of our data set. While there seems to be a tendency for individuals with pronounced mental health impairments to report elevated levels of eco-distress, no association with a specific subset of depressive or anxious symptoms could be determined. This finding points toward trans-diagnostic factors, such as dysfunctional cognitive processes, which may cause elevated levels of distress in reaction to climate change as well as to other stimuli as a possible explanation for the heightened vulnerability of persons with mental health impairments (48, 49).

Emotion regulation strategies were evaluated as a possible dysfunctional cognitive process contributing to the level of eco-distress experienced by individuals. Indeed, Rumination and Catastrophizing explained a significant share of the variance for all three eco-distress questionnaires, Putting into Perspective for EAQ-22 and CC-MMDS, Positive Reappraisal for GAD-7-C, and Self-Blame and Planning for CC-MMDS. Putting into Perspective was the only emotion regulation strategy predicting lower scores of eco-distress. This result is in line with previous research showing that denial or shift of guilt, relativizing, and trusting that powerful others are in control can induce distancing effects which can mitigate distress (50–52). Perhaps counterintuitively, higher scores for Positive Reappraisal and for Refocusing on Planning predicted higher scores of eco-distress, as well. This finding suggests that the more time a person with mental health impairments thinks about climate change, the more prone that person is to experience higher levels of eco-distress. This might be linked to the fact that climate change is a problem which is unsolvable on the individual level, and therefore even typically proactive strategies might eventually lead to feelings of hopelessness and helplessness.

Overall, our results suggest that individuals with mental health impairments experience higher levels of eco-distress, even if they tend to employ adaptive emotion regulation strategies, while the only strategy correlated with lower eco-distress scores aims at emotional distancing from the climate crisis and its consequences. At a first glance, these findings might suggest that practitioners should indeed support individuals with mental health impairments in their efforts to distance themselves from their thoughts and feelings regarding the climate crisis. However, this assumption does not hold when considering its implications. For one, previous research shows that avoidance and eco-distress are positively correlated, as well (53, 54). Thus, if a person experiences eco-distress, ignoring these feelings might help to reduce them on a short-term basis – however, psychotherapy research clearly shows that avoiding or suppressing negative emotions are no viable long-term strategies (55). Secondly, in addition to the individual level, the implications of clinical decisions for the societal level have to be taken into account, as well. Eco-distress is strongly related to pro-environmental behavior (15, 56), and the emotions in itself are considered an adaptive response to a real threat (57). Therefore, the aim of interventions for individuals experiencing eco-distress cannot be to reduce these feelings to a minimum. Rather, individuals should be enabled to act on their feelings by reducing the functional impairments resulting from eco-distress which might hinder people from action and which present the main mental health burden. Indeed, a recent experimental study showed that moderate levels of eco-distress are associated with the highest level of pro-environmental behavior, while not being correlated with elevated levels of general anxiety and death anxiety (58). Developing a feeling of agency might be one possibility to support individuals in dealing with feelings of eco-distress in such an adaptive way: in an experimental study with young people, agency when faced with the climate crisis led to more meaning-focused coping and less anxiety (59).

Lastly, we tested whether emotion regulation strategies mediate the relationship of depressive and anxious symptoms with eco-distress. No mediation showed to be significant. Thus, while emotion regulation strategies explain a significant share of the variance in eco-distress, they do not offer an explanation for the heightened vulnerability of persons with co-existing mental health impairments. Moreover, the only significant direct effect in the mediation analyses was the prediction of GAD-7-C scores by GAD-7 scores, which could be expected due to the high similarity of the items. Therefore, our data shows a heightened vulnerability of individuals with co-existing mental health impairments; simultaneously, it shows that eco-distress is not a mere reflection of depressive and anxious symptoms. This finding is supported by our analysis of a re-assessment after five months, showing that none of the change scores for eco-distress were significantly predicted by change scores for anxious or depressive symptoms. Moreover, it is in line with a recent longitudinal study which showed that over time, climate change-related anger, fear, and sadness are distinct from general anger, fear, and sadness (60). However, as none of the emotion regulation strategies assessed in our study showed to be a significant mediator, it remains unknown which factors are causing the positive correlation of depressive and anxious symptoms with eco-distress and the heightened vulnerability of persons with mental health impairments.

Of note, emotion regulation strategies explained a large share of the overall variance in all three eco-distress questionnaires, ranging from 33% - 68%. Thus, emotion regulation strategies seem integral to the understanding of eco-distress, and a valuable target for interventions. In the treatment of depressive and anxiety disorders, targeted interventions to improve emotion regulation are well established and have been shown to be effective in reducing symptom severity (50, 61). Based on our results, an intervention targeted at building resilience against eco-distress would have to address the dysfunctional emotion regulation strategies of Catastrophizing and Rumination. One possibility would be to adapt successful interventions to the specificities of eco-distress. A recent randomized controlled trial employed a similar approach and adapted a trans-diagnostic treatment manual to eco-distress, with several modules addressing emotion regulation (62). Participants reported lower scores of eco-distress and of depressive symptoms. This further supports the hypothesis of shared dysfunctional cognitive processes which lead both to elevated levels of eco-distress and of general mental health impairments.