Mental health in the built environment

Practical physicians have always had to recognize that factors in the environment affect physical health, whether in tracing a cholera outbreak to a specific pump or in noting the contagious spread of bubonic plague. More than this, before the development of modern pharmacological treatments it was accepted that a change of scenery can be good for the health: Sir Francis Bacon (1623) noted that “nothing is more fit… than to know what be the flowers and plants that do best perfume the air.” He even suggested that people with large nostrils would live longer, as best able to absorb such scents [though one would have thought that an enhanced ability to absorb the other smells of Jacobean London would more than counterbalance this.] When there was practically nothing effective in the pharmacopeia, going away ‘to take the waters’ was often the best cure that could be found [at least, better than bleeding.]

The founders of the asylums were certainly aware. Connolly (1847) noted that “high gloomy walls, narrow or inaccessible windows… attest the prevalence of mistaken and limited views… The surroundings of the asylum should be pleasant…” This pleasantness, of course, proved very profitable when the asylums were sold off, to be replaced by ‘care in the [largely urban] community’. With the development of modern medical science interest in environmental factors shrank – it was assumed that the answer to any disorder was a pill or, more recently, a talking therapy, rather than a change of surroundings.

Most mental health researchers still largely ignore environmental effects (Lord, 2020). A search for ‘environment’ among the 193 separate editorials, papers or other items published in this journal over the two years to vol. 29[3] brought up an initially promising 36 hits. On investigation however, barely half-a-dozen really related to the topic. Very recently the pendulum has begun to swing back to a recognition of nature’s benefits (Guha, 2019), including a number of studies of the benefits of green spaces within urban areas (handily summarized for us in Callaghan et al., 2020).

However, much though we may admire nature and benefit from access to greenery, we do not live among it. An astonishing change has come over the world in the last three-quarters of a century or so: for the first time since the Neolithic the majority of humans are not involved in agriculture; most of us now live in towns, with the proportion increasing daily: Callaghan et al put the current ratio as 55% urban to 45% rural. The environment we inhabit, with all its benefits and disadvantages, is mainly man-made. Baker and Steemers (2019) estimate that, in Britain, we spend, on average, as much as 90% of our time inside buildings, 70% of it in our own homes, yet the bulk of references to ‘the environment’ in the past two years of this journal appear to relate to Mother Nature rather than to the streets and buildings we actually spend our time in.

If the built environment is the norm for people in general, it is even more so for people with mental illness. Many mental disorders in themselves induce lethargy (Fibbins et al., 2018), many pharmacological treatments have a negative effect on cardiometabolic functioning, people with mental disorders tend to be poorer than average (Anand et al., 2018) and therefore live in more restricted surroundings – their disorders may indeed further exacerbate their financial difficulties (Richardson et al., 2019), many feel socially excluded and therefore unwilling to go out (Filia et al., 2019). People with mental disorders tend to be unemployed – unemployment is both a cause and a consequence of disorder (Sveinsdottir & Bond, 2017) and, obviously, being unemployed removes one incentive to go outside. Finally, of course, some people are restrained in hospitals or, especially, care homes, and cannot get out. People with severe mental illness therefore spend nearly all their time inside buildings, and die 15–20 years earlier than their peers, chiefly from preventable and manageable physical health conditions (Stubbs & Rosenbaum 2018).

The majority of physical disorders, and many of the mental disorders presented in modern western societies are lifestyle-related: diabetes, substance abuse [especially alcohol], some cancers, coronary disorders etc. These are obviously affected by the environment – if you can comfortably and safely walk to work, shops, schools etc you are less likely to get diabetes. If kitchens are designed to be easy to use and pleasant to be in, people will be more likely to cook for themselves and therefore may be led to eating a healthier diet. If intrusive noise can be reduced then a substantial burden of disease will be lifted (WHO Regional Office for Europe, 2017). If people have access to daylight they will suffer less from sleep disorders (Boubekri et al., 2014). If a view from a window is good for you, a glimpse of a tree or a river is even better (Zelenski & Nisbet, 2014). Being a crime victim can be very traumatic. Fear of crime is a cause of stress. Both can be reduced by good urban design (Fennelly, 2013). People, and especially people with mental disorders may suffer, on the one hand, from social isolation, and, on the other, from a lack of privacy and so will benefit from planning buildings flexible enough to allow for both. The Covid-19 lockdown has forcibly demonstrated the value that humans place on casual social interaction (Kumar & Nayar, 2020). Finally, last but not necessarily least, people are happier in and around buildings that are aesthetically pleasing: depression may strike anyone anywhere, but people are more likely to feel depressed in depressing surroundings (Goldberg et al., 2012; Delos Living LLC, 2014).

Consideration therefore needs to be given to the built environments within which most of us, sick or well, spend most of our time. Urban development sometimes seems to be focused on maximizing productivity or profitability: “For too long what… developers have offered has paid scant regard for people’s wellbeing” (Ashton, 2020). Watson (2020) found that only 4% of the architectural practices sampled always do post-occupancy evaluations, and only a further 22% frequently did so: “a large proportion of architects don’t seem to care what people think or feel about their buildings.”

Planning on the assumption that the aim is to maximize health and happiness requires a radical change in attitude (Guha, 2018). It is therefore gratifying to note that there are an increasing number of architects who are trying to design for health (a sample of them reviewed in Guha, 2020), and especially trying to collate research on the impact of buildings on mental health: one of us [BC] is, as far as we are aware, the first ‘Mental Health Ambassador’ designated by an architectural practice (Channon, 2019). These are matched by an increasing number of therapists who are becoming aware of the effects of the environment on health.

Consultation

In both cases, the need for consultation needs to be mentioned. The caricatures of, on the one hand, the pompous, dominant hospital consultant – the Expert Physician who knows best and sees no need for any input from the patient, and, on the other hand, the creative consulting architect whose sensitive artistic visions are so cruelly trammelled by the interference of the ignorant client, are, perhaps, out-of-date and were never really true to life. Nevertheless it is important to emphasise that people benefit from feeling that their opinions carry weight. This includes both clinical staff and patients. Singha (2020) mentions the risk of hospital buildings being commissioned by administrators without the views of the staff who will work in them being canvassed. If service providers are at risk of being ignored, then service users are even more likely to be left out.

In their study of what helps and what hinders recovery, Agrest et al. (2018) noted that “Users mentioned that physical space was an important facilitator, and had positive remarks about the physical environment at the day hospital.” One participant said “Space is crucial: paintings and colours in the walls… when my family comes, they come with joy and they like the place where I spend part of my day.” This is what designers and architects should be aiming for.

The Tyrer (2019) have indeed based an entire therapeutic method – nidotherapy [from the Latin ‘nido’ – a nest] on a move away from the authoritative professional deciding what treatment will best ‘cure’ a mental disorder, towards becoming a facilitator helping to create an environment – physical, social or even horticultural, that accords with the consumer’s expressed views on what will make them feel comfortable with themselves.

This emphasis on the service user’s expressed views – giving them the freedom to choose, is important. Piat et al. (2020) in a useful study of the large contribution which being able to make personal choices made towards mental health recovery in the context of social housing, found that tenants valued three domains of choice: choosing to be responsible for one’s own life; choosing how to organise one’s social life; and, choices that made them feel at home. Perceived control affects the happiness and wellbeing of all of us (Larson, 1989).

Designing for health and happiness

A problem with all new building is the desire of the people commissioning them for the ‘WOW’ effect: if building, say, a new hospital block, they want to be able to have a duchess or a governor come to open it, be impressed enough to say ‘wow’ and then go away again, rather than trying out occupying a bed in it. Sir Francis Bacon again: “Houses are built to live in, and not to look on; therefore let use be preferred… Leave the goodly fabrics of houses for beauty only to the enchanted palaces of the poets, who build them with small cost.” It is possible to design buildings and building interiors that are aesthetically pleasing, that allow for privacy and yet allow for social interaction, that give access to the natural world and to natural light, and which encourage people to lead healthy lifestyles (Baker & Steemers, 2019; Channon, 2019). It is possible to design buildings that are socially inclusive – bearing in mind that this means more than just a ramp up to a back entrance and a disabled toilet tucked into an odd corner – “A comprehensive system must include strategies on a continuum which ranges from pre-natal care to dementia” (Fennelly, 2013).

Few readers of this journal will ever have the opportunity to commission a whole building, but all of us have some say on the interior layout and design of the building spaces we live and work in. Opportunity has to be found for all of us – service users as well as service providers, to express our views.

Disclosure statement

No potential conflict of interest was reported by the author(s).