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Effects of ambient air pollution on psychological stress and anxiety disorder: a systematic review and meta-analysis of epidemiological evidence

Tanwi Trushna ORCID logo, Vikas Dhiman, Dharma Raj and Rajnarayan R. Tiwari



Ambient air pollution (AAP) is an important risk factor for increased mental health morbidity. Studies have highlighted the effect of AAP on psychological stress and anxiety disorder. However, existing evidence regarding this is largely equivocal. This systematic review with meta-analysis aims to synthesize published evidence to calculate the pooled estimate of the effect of AAP on psychological stress and anxiety disorder.


A systematic bibliographic search was undertaken using PubMed, JGateplus, Google Scholar, and Cochrane Library for observational human studies published in English till 31st March 2020 reporting the effect of AAP on psychological stress and anxiety disorder. Study quality was assessed using the Joanna Briggs Institute critical appraisal tools. Meta-analysis was performed adopting a random-effects model using Meta-XL. Of 412 articles retrieved, a total of 30 articles [AAP and anxiety disorders, (n=17, 57%); AAP and psychological stress, (n=9, 30%) and AAP and both psychological stress and anxiety disorders, (n=4, 13%)] fulfilled the inclusion criteria covering a total population of 973,725 individuals. The pooled estimate (OR) of the effects of PM10 on psychological stress was 1.03 [(95% CI: 1.00, 1.05) (p=0.17, I 2=41%)]. The pooled estimate of the effects of NO2 and PM10 on anxiety disorder was 0.93 [(95% CI: 0.89, 0.97) (p=0.91, I 2=0%)] and 0.88 [(95% CI: 0.78, 0.98) (p=0.01, I 2=59%)] respectively. The pooled estimate of the effects of PM2.5 on anxiety Disorder was 0.88 [(95% CI: 0.72, 1.06) (p=0.00, I 2=80%)].

Summary and Outlook

The present study provides the most updated pooled estimate of the effect of AAP on psychological stress and anxiety disorder. Future studies should focus on longitudinal studies conducted in LIC and LMIC countries using uniform and standardized criteria for exposure and outcome assessment as well as robust adjustment for confounders to minimize methodological heterogeneity resulting in reliable and comparable estimation of environmental mental health burden.

Corresponding author: Tanwi Trushna, Department of Environmental Health and Epidemiology, ICMR-National Institute for Research in Environmental Health (NIREH), Room F9-3, Bhopal Bypass Road, Bhauri, Bhopal, 462030, Madhya Pradesh, India, Email:


We thank Mrs Monali Sahu Pathange (The English and Foreign Languages University, Hyderabad) for assistance in language (English) proofreading of the manuscript.

  1. Research funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

  2. Author contributions: All authors met the authorship criteria set forth by the International Committee for Medical Journal Editors and retained full control of the manuscript content. CRediT statement: Tanwi Trushna: Conceptualization, Methodology, Investigation, Data curation, Writing- Original draft preparation; Vikas Dhiman: Methodology, Investigation, Writing - Review & Editing; Dharma Raj: Data curation, Formal analysis; Rajnarayan R. Tiwari: Writing- Reviewing and Editing, Supervision.

  3. Competing interests: The authors declare no conflict of interest.

  4. Informed consent: Informed consent is not applicable.

  5. Ethical approval: The conducted research is not related to either human or animal use.


1. World Health Organization (WHO). Ambient (outdoor) air pollution; 2018. Available from: [Accessed 17 Jun 2020].Search in Google Scholar

2. Babatola, SS. Global burden of diseases attributable to air pollution. J Publ Health Afr 2018;9:813. in Google Scholar

3. Lelieveld, J, Pozzer, A, Pöschl, U, Fnais, M, Haines, A, Münzel, T. Loss of life expectancy from air pollution compared to other risk factors: a worldwide perspective. Cardiovasc Res 2020;116:1910–7. in Google Scholar

4. Cohen, AJ, Brauer, M, Burnett, R, Anderson, HR, Frostad, J, Estep, K, et al.. Estimates and 25-year trends of the global burden of disease attributable to ambient air pollution: an analysis of data from the Global Burden of Diseases Study 2015. Lancet 2017;389:1907–18. in Google Scholar

5. Newell, K, Kartsonaki, C, Lam, KBH, Kurmi, OP. Cardiorespiratory health effects of particulate ambient air pollution exposure in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Planet Health 2017;1:e368-80. in Google Scholar

6. Rajak, R, Chattopadhyay, A. Short and long-term exposure to ambient air pollution and impact on health in India: a systematic review. Int J Environ Health Res 2019;30:593–17. in Google Scholar PubMed

7. Rodriguez-Villamizar, LA, Magico, A, Osornio-Vargas, A, Rowe, BH. The effects of outdoor air pollution on the respiratory health of Canadian children: a systematic review of epidemiological studies. Can Respir J 2015;22:282–92. in Google Scholar PubMed PubMed Central

8. Fan, SJ, Heinrich, J, Bloom, MS, Zhao, TY, Shi, TX, Feng, WR, et al.. Ambient air pollution and depression: a systematic review with meta-analysis up to 2019. Sci Total Environ 2020;701:134721. in Google Scholar PubMed

9. Braithwaite, I, Zhang, S, Kirkbride, JB, Osborn, DPJ, Hayes, JF. Air pollution (particulate matter) exposure and associations with depression, anxiety, bipolar, psychosis and suicide risk: a systematic review and meta-analysis. Environ Health Perspect 2019;127:126002. in Google Scholar PubMed PubMed Central

10. Chen, S, Oliva, P, Zhang, P. Air pollution and mental health: evidence from China; National Bureau of Economic Research, Inc; 2018:24686 p. [Online]. Available from: [Accessed 17 Jun 2020].10.3386/w24686Search in Google Scholar

11. Kodavanti, UP. Stretching the stress boundary: linking air pollution health effects to a neurohormonal stress response. Biochim Biophys Acta 2016;1860:2880–90. in Google Scholar PubMed

12. van den Bosch, M, Meyer-Lindenberg, A. Environmental exposures and depression: biological mechanisms and epidemiological evidence. Annu Rev Public Health 2019;40:239–59. in Google Scholar PubMed

13. Power, MC, Kioumourtzoglou, MA, Hart, JE, Okereke, OI, Laden, F, Weisskopf, MG. The relation between past exposure to fine particulate air pollution and prevalent anxiety: observational cohort study. BMJ 2015;350:h1111. in Google Scholar PubMed PubMed Central

14. Jung, M, Cho, D, Shin, K. The impact of particulate matter on outdoor activity and mental health: a matching approach. Int J Environ Res Publ Health 2019;16:2983. in Google Scholar PubMed PubMed Central

15. Klompmaker, J, Hoek, G, Bloemsma, LD, Wijga, AH, van den Brink, C, Brunekreef, B, et al.. Associations of combined exposures to surrounding green, air pollution and traffic noise on mental health. Environ Int 2019;129:525–37. in Google Scholar PubMed

16. Mehta, AJ, Kubzansky, LD, Coull, BA, Kloog, I, Koutrakis, P, Sparrow, D, et al.. Associations between air pollution and perceived stress: the veterans administration normative aging study. Environ Health 2015;14:10. in Google Scholar PubMed PubMed Central

17. Sass, V, Kravitz-Wirtz, N, Karceski, SM, Hajat, A, Crowder, K, Takeuchi, D. The effects of air pollution on individual psychological distress. Health Place 2017;48:72–9. in Google Scholar PubMed PubMed Central

18. Nuyts, V, Nawrot, TS, Scheers, H, Nemery, B, Casas, L. Air pollution and self-perceived stress and mood: a one-year panel study of healthy elderly persons. Environ Res 2019;177:108644. in Google Scholar PubMed

19. Hajat, A, Hazlehurst, MF, Golden, SH, Merkin, SS, Seeman, T, Szpiro, AA, et al.. The cross-sectional and longitudinal association between air pollution and salivary cortisol: evidence from the Multi-Ethnic Study of Atherosclerosis. Environ Int 2019;131:105062. in Google Scholar PubMed PubMed Central

20. Sirivelu, MP, Mohan Kumar, SMJ, Wagner, JG, Harkema, JR, Mohan Kumar, PS. Activation of the stress axis and neurochemical alterations in specific brain areas by concentrated ambient particle exposure with concomitant allergic airway disease. Environ Health Perspect 2006;114:870–4. in Google Scholar PubMed PubMed Central

21. Generaal, E, Timmermans, EJ, Dekkers, JEC, Smit, JH, Penninx, BWJH. Not urbanization level but socioeconomic, physical and social neighbourhood characteristics are associated with presence and severity of depressive and anxiety disorders. Psychol Med 2019;49:149–61. in Google Scholar PubMed PubMed Central

22. Pun, VC, Manjourides, J, Suh, HH. Close proximity to roadway and urbanicity associated with mental ill-health in older adults. Sci Total Environ 2019;658:854–60. in Google Scholar

23. Vert, C, Sánchez-Benavides, G, Martínez, D, Gotsens, X, Gramunt, N, Cirach, M, et al.. Effect of long-term exposure to air pollution on anxiety and depression in adults: a cross-sectional study. Int J Hyg Environ Health 2017;220:1074–80. in Google Scholar

24. Roberts, S, Arseneault, L, Barratt, B, Beevers, S, Danese, A, Odgers, CL, et al.. Exploration of NO2 and PM2.5 air pollution and mental health problems using high-resolution data in London-based children from a UK longitudinal cohort study. Psychiatry Res 2019;272:8–17. in Google Scholar

25. Evans, G, Campbell, JM. Psychological perspectives on air pollution and health. Basic Appl Soc Psychol 1983;4:137–69. in Google Scholar

26. Gong, Y, Palmer, S, Gallacher, J, Marsden, T, Fone, D. A systematic review of the relationship between objective measurements of the urban environment and psychological distress. Environ Int 2016;96:48–57. in Google Scholar

27. O’Donnell, RR. Green and blue wellness: a model for improving physical and mental health. J Nurs Health Sci 2017;3:18–26. [Online]. Available from: [Accessed 07 Dec 2020].Search in Google Scholar

28. Thomson, EM. Air pollution, stress, and allostatic load: linking systemic and central nervous system impacts. J Alzheimers Dis 2019;69:597–614. in Google Scholar

29. Tzivian, L, Winkler, A, Dlugaj, M, Schikowski, T, Vossoughi, M, Fuks, K, et al.. Effect of long-term outdoor air pollution and noise on cognitive and psychological functions in adults. Int J Hyg Environ Health 2015;218:1–11. in Google Scholar

30. World Health Organization (WHO). Air pollution levels rising in many of the world’s poorest cities; 2016. Available from: [Accessed 28 Oct 2020].Search in Google Scholar

31. Liu, Q, He, H, Yang, J, Feng, X, Zhao, F, Lyu, J. Changes in the global burden of depression from 1990 to 2017: findings from the Global Burden of Disease study. J Psychiatr Res 2020;126:134–40. in Google Scholar

32. Sagar, R, Dandona, R, Gururaj, G, Dhaliwal, RS, Singh, A, Ferrari, A, et al.. The burden of mental disorders across the states of India: the Global Burden of Disease Study 1990–2017. Lancet Psychiatr 2020;7:148–61. in Google Scholar

33. García-Iglesias, JJ, Gómez-Salgado, J, Martín-Pereira, J, Fagundo-Rivera, J, Ayuso-Murillo, D, Martínez-Riera, JR, et al.. Impact of SARS-CoV-2 (Covid-19) on the mental health of healthcare professionals: a systematic review. Rev Esp Salud Publica 2020;94:e202007088. [Online]. Available from: [Accessed 15 Nov 2020].Search in Google Scholar

34. Tyerman, J, Luctkar-Flude, M, Graham, L, Coffey, S, Olsen-Lynch, E. A systematic review of health care presimulation preparation and briefing effectiveness. Clin Simul Nurs 2019;27:12–25. in Google Scholar

35. Dixon, KE. A comparison of case-crossover and case-control designs in a study of risk factors for hemorrhagic fever with renal syndrome. Epidemiology 1997;8:243–6. in Google Scholar

36. Lugtig, P, Smith, PA. The choice between a panel and cohort study design. Utrecht University, Netherlands & University of Southampton, UK; 2019. [Online]. Available from: [Accessed 18 Jun 2020].Search in Google Scholar

37. Cohen, AJ, Anderson, HR, Ostro, B, Pandey, KD, Krzyzanowski, M, Künzli, N, et al.. Urban air pollution (Chapter 17). Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva, Switzerland: World Health Organization; 2004, 2:1353–433 p.Search in Google Scholar

38. DerSimonian, R, Laird, N. Meta-analysis in clinical trials. Contr Clin Trials 1986;7:177–88. in Google Scholar

39. DerSimonian, R, Laird, N. Meta-analysis in clinical trials revisited. Contemp Clin Trials 2015;26343745(Pt A):139–45. in Google Scholar PubMed PubMed Central

40. Furuya-Kanamori, L, Barendregt, JJ, Doi, SAR. A new improved graphical and quantitative method for detecting bias in meta-analysis. Int J Evid Based Healthc 2018;16:195–203. in Google Scholar PubMed

41. Jin, X, Antony, B, Wang, X, Persson, MS, McAlindon, T, Arden, NK, et al.. Effect of vitamin D supplementation on pain and physical function in patients with knee osteoarthritis (OA): an OA Trial Bank protocol for a systematic review and individual patient data (IPD) meta-analysis. BMJ Open 2020;10:e035302. in Google Scholar PubMed PubMed Central

42. Niedzwiecki, MM, Rosa, MJ, Solano-González, M, Kloog, I, Just, AC, Martínez-Medina, S, et al.. Particulate air pollution exposure during pregnancy and postpartum depression symptoms in women in Mexico City. Environ Int 2020;134:105325. in Google Scholar PubMed PubMed Central

43. Cho, J, Choi, YJ, Sohn, J, Suh, M, Cho, SK, Ha, KH, et al.. Ambient ozone concentration and emergency department visits for panic attacks. J Psychiatr Res 2015;62:130–5. in Google Scholar PubMed

44. Hwang, MJ, Cheong, HK, Kim, JH, Koo, YS, Yun, HY. Ambient air quality and subjective stress level using Community Health Survey data in Korea. Epidemiol Health 2018;40:e2018028. in Google Scholar PubMed PubMed Central

45. Kim, J, Kim, H. Demographic and environmental factors associated with mental health: a cross-sectional study. Int J Environ Res Public Health 2017;14:431. in Google Scholar PubMed PubMed Central

46. Shin, J, Park, JY, Choi, J. Long-term exposure to ambient air pollutants and mental health status: a nationwide population-based cross-sectional study. PloS One 2018;13:e0195607. in Google Scholar PubMed PubMed Central

47. Chen, S, Kong, J, Yu, F, Peng, K. Psychopathological symptoms under smog: the role of emotion regulation. Front Psychol 2018;8:2274. in Google Scholar PubMed PubMed Central

48. Lin, Y, Zhou, L, Xu, J, Luo, Z, Kan, H, Zhang, J, et al.. The impacts of air pollution on maternal stress during pregnancy. Sci Rep 2017;7:40956. in Google Scholar PubMed PubMed Central

49. Yue, J-L, Liu, H, Li, H, Liu, JJ, Hu, YH, Wang, J, et al.. Association between ambient particulate matter and hospitalization for anxiety in China: a multicity case-crossover study. Int J Hyg Environ Health 2020;223:171–8. in Google Scholar PubMed

50. Jorcano, A, Lubczyńska, MJ, Pierotti, L, Altug, H, Ballester, F, Cesaroni, G, et al.. Prenatal and postnatal exposure to air pollution and emotional and aggressive symptoms in children from 8 European birth cohorts. Environ Int 2019;131:104927. in Google Scholar PubMed

51. Kooijman, MN, Kruithof, CJ, van Duijn, CM, Duijts, L, Franco, OH, van IJzendoorn, MH, et al.. The generation R study: design and cohort update 2017. Eur J Epidemiol 2016;31:1243–64. in Google Scholar PubMed PubMed Central

52. Berg, AV, Krämer, U, Link, E, Bollrath, C, Heinrich, J, Brockow, I, et al.. The GINIplus study group. Impact of early feeding on childhood eczema: development after nutritional intervention compared with the natural course - the GINIplus study up to the age of 6 years. Clin Exp Allergy 2010;40:627–36. in Google Scholar PubMed

53. Heinrich, J, Bolte, G, Hölscher, B, Douwes, J, Lehmann, I, Fahlbusch, B, et al.. Allergens and endotoxin on mothers’ mattresses and total immunoglobulin E in cord blood of neonates. Eur Respir J 2002;20:617–23. in Google Scholar PubMed

54. Polańska, K, Hanke, W, Jurewicz, J, Sobala, W, Madsen, C, Nafstad, P, et al.. Polish mother and child cohort study (REPRO_PL)–methodology of follow-up of the children. Int J Occup Med Environ Health 2011;24:391–8. in Google Scholar PubMed

55. Porta, D, Forastiere, F, Di Lallo, D, Perucci, CA, Grupo Collaborativo, GASPII. Enrolment and follow-up of a birth cohort in Rome. Epidemiol Prev 2007;31:303–8. [Online]. Available from: [Accessed 18 Jun 2020].Search in Google Scholar

56. Guxens, M, Ballester, F, Espada, M, Fernández, MF, Grimalt, JO, Ibarluzea, J, et al.. Cohort profile: the INMA–INfancia y medio ambiente–(environment and childhood) project. Int J Epidemiol 2012;41:930–40. in Google Scholar PubMed

57. Marques, S, Lima, MLP. Living in grey areas: industrial activity and psychological health. J Environ Psychol 2011;31:314–22. in Google Scholar

58. Szyszkowicz, M, Colman, I, Wickham, M, Rowe, BH. Ambient sulphur dioxide and emergency department visits for migraine and depression. Int Neuropsychiatr Dis J 2013;1:77–88. [Online]. Available from: [Accessed 18 Jun 2020].10.9734/INDJ/2013/5245Search in Google Scholar

59. Yolton, K, Khoury, JC, Burkle, J, LeMasters, G, Cecil, K, Ryan, P. Lifetime exposure to traffic-related air pollution and symptoms of depression and anxiety at age 12 years. Environ Res 2019;173:199–206. in Google Scholar

60. Bullinger, M. Psychological effects of air pollution on healthy residents—a time-series approach. J Environ Psychol 1989;9:103–18. in Google Scholar

61. Beecher, ME, Eggett, D, Erekson, D, Rees, LB, Bingham, J, Klundt, J, et al.. Sunshine on my shoulders: weather, pollution, and emotional distress. J Affect Disord 2016;205:234–8. in Google Scholar

62. Evans, G, Colome, SD, Shearer, DF. Psychological reactions to air pollution. Environ Res 1988;45:1–15. in Google Scholar

63. Chattopadhyay, P, Som, B, Mukhopadhyay, P. Air pollution and health hazards in human subjects: physiological and self-report indices. J Environ Psychol 1995;15:327–31. in Google Scholar

64. Tameh, M, Allipor, BR, Pouraram, H. Interaction between air pollution and total antioxidant capacity (DTAC) on the managers and teachers’ anxiety and memory in two polluted and less polluted areas of Tehran province. Iran 2019;1. [Online]. Available from: [Accessed 18 Jun 2020].Search in Google Scholar

65. Zeidner, M, Shechter, M. Psychological responses to air pollution: some personality and demographic correlates. J Environ Psychol 1988;8:191–208. in Google Scholar

66. Sheffield, PE, Speranza, R, Chiu, YH, Hsu, HH, Curtin, PC, Renzetti, S, et al.. Association between particulate air pollution exposure during pregnancy and postpartum maternal psychological functioning. PloS One 2018;13:e0195267. in Google Scholar PubMed PubMed Central

67. Buoli, M, Grassi, S, Caldiroli, A, Carnevali, GS, Mucci, F, Iodice, S, et al.. Is there a link between air pollution and mental disorders? Environ Int 2018;118:154–68. in Google Scholar PubMed

68. Brunoni, AR, Santos, IS, Passos, IC, Goulart, AC, Koyanagi, A, Carvalho, AF, et al.. Socio-demographic and psychiatric risk factors in incident and persistent depression: an analysis in the occupational cohort of ELSA-Brasil. J Affect Disord 2020;263:252–7. in Google Scholar PubMed

69. Khan, S, Khan, RA. Chronic stress leads to anxiety and depression. Ann Psychiatry Ment Health 2017;5:1091. [Online]. Available from: [Accessed 18 Jun 2020].Search in Google Scholar

70. Post, RM, Leverich, GS. The role of psychosocial stress in the onset and progression of bipolar disorder and its comorbidities: the need for earlier and alternative modes of therapeutic intervention. Dev Psychopathol 2006;18:1181–211. in Google Scholar

71. Corcoran, C, Mujica-Parodi, L, Yale, S, Leitman, D, Malaspina, D. Could stress cause psychosis in individuals vulnerable to schizophrenia? CNS Spectr 2002;7:33–42. in Google Scholar

72. Luca, L, Nemeroff, CB. The role of the hypothalamic–pituitary–adrenal axis in anxiety disorders. In: Ressler, KJ, Pine, DS, Rothbaum, BO, editors. Anxiety disorders. Oxford, UK: Oxford University Press; 2015.10.1093/med/9780199395125.003.0028Search in Google Scholar

73. Miller, JG, Gillette, JS, Kircanski, K, LeMoult, J, Gotlib, IH. Air pollution is associated with elevated HPA-axis response to stress in anxious adolescent girls. Comprehensive Psychoneuroendocrinology 2020;4:100015. in Google Scholar

74. Kobza, J, Geremek, M. Do the pollution related to high-traffic roads in urbanised areas pose a significant threat to the local population? Environ Monit Assess 2016;189:33. in Google Scholar

75. WHO Regional Office for Europe. C: proximity to roads, NO2, other air pollutants and their mixtures. Review of evidence on health aspects of air pollution – REVIHAAP project: Technical report. Copenhagen, Denmark: WHO Regional Office for Europe; 2013.Search in Google Scholar

76. Cichowicz, R, Stelęgowski, A. Average hourly concentrations of air contaminants in selected urban, town, and rural sites. Arch Environ Contam Toxicol 2019;77:197–213. in Google Scholar

77. Litman, TA. Understanding urban mental health impacts and how to create saner, happier cities. Victoria Transport Policy Institute; 2020. [Online]. Available from: [Accessed 15 Nov 2020].Search in Google Scholar

78. Braga, AL, Saldiva, PH, Pereira, LA, Menezes, JJ, Conceição, GM, Lin, CA, et al.. Health effects of air pollution exposure on children and adolescents in São Paulo, Brazil. Pediatr Pulmonol 2001;31:106–13.;2-m.10.1002/1099-0496(200102)31:2<106::AID-PPUL1017>3.0.CO;2-MSearch in Google Scholar

79. Sly, PD, Flack, F. Susceptibility of children to environmental pollutants. Ann N Y Acad Sci 2008;1140:163–83. in Google Scholar

80. Jerrett, M, Arain, A, Kanaroglou, P, Beckerman, B, Potoglou, D, Sahsuvaroglu, T, et al.. A review and evaluation of intraurban air pollution exposure models. J Expo Sci Environ Epidemiol 2005;15:185–204. in Google Scholar

81. Wakefield, J, Shaddick, G. Health-exposure modeling and the ecological fallacy. Biostat Oxf Engl 2006;7:438–55. in Google Scholar

82. Liang, L, Gong, P, Cong, N, Li, Z, Zhao, Y, Chen, Y. Assessment of personal exposure to particulate air pollution: the first result of City Health Outlook (CHO) project. BMC Publ Health 2019;19:711. in Google Scholar PubMed PubMed Central

83. Horton, RA, Wing, S, Marshall, SW, Brownley, KA. Malodor as a trigger of stress and negative mood in neighbors of industrial hog operations. Am J Publ Health 2009;99(Suppl 3):S610–5. in Google Scholar PubMed PubMed Central

Supplementary Material

The online version of this article offers supplementary material (

Received: 2020-09-16
Accepted: 2020-11-22
Published Online: 2020-12-18
Published in Print: 2021-12-20

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