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Urban Design and Mental Health
Layla McCay, Ingrid Bremer, Tarik Endale, Marjia Jannati, and
Jihyun Yi
Abstract
Physical and social environments can affect our mental health. With increasing
numbers of people living in cities, public mental health is now expanding beyond
the remit of psychiatrists and psychologists. Designing to support and improve
mental health has not always been an obvious priority for citymakers, even as
they begin to focus on physical health –though in fact perhaps some of the
greatest potential for their impact lies with mental health. Policymakers, urban
planners, architects, engineers, transport specialists, developers, and others
impact on mental health through their contributions to the design and delivery
of the urban built environment. This chapter discusses key opportunities for smart
urban design to help promote good mental health, prevent illness, and support
people who have mental health challenges. We focus on green space, active
space, prosocial space, and safe space across the lifespan, from ensuring safe
and local play opportunities for children to empowering older people to socialize
and safely navigate around their neighborhoods. Citymakers can consciously
seize opportunities for sustainable improvement of population mental health,
putting the research into action through policies, plans, design, development,
and management. Meanwhile, more research –and its funding –is needed to
realize the opportunities in this high impact field.
L. McCay (*)
Centre for Urban Design and Mental Health, London, UK
Department of Global Health Entrepreneurship, Tokyo Medical and Dental University, Tokyo,
Japan
Department of International Health, Georgetown University, Washington, DC, USA
e-mail: layla@urbandesignmentalhealth.com
I. Bremer •T. Endale •M. Jannati •J. Yi
Department of International Health, Georgetown University, Washington, DC, USA
e-mail: ib319@georgetown.edu;tte5@georgetown.edu;mj555@georgetown.edu;
jy447@georgetown.edu
#Springer Nature Singapore Pte Ltd. 2017
P. Munk-Jorgensen et al. (eds.), Mental Health and Illness in the City, Mental Health and
Illness Worldwide 1, DOI 10.1007/978-981-10-0752-1_12-1
1
Keywords
Mental health •Urban •City •Architecture •Urban planning •Design
Contents
Introduction ....................................................................................... 2
How Can Urban Design Improve Mental Health? ............................................... 3
Mental Health Is Often Overlooked by Citymakers . . . . ......................................... 20
Summary . . . ....................................................................................... 21
Conclusion . . . . . ................................................................................... 21
Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . 22
References . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . 22
Introduction
We are becoming a population of city dwellers. The United Nations projects that by
2050, at least two thirds of the world’s population will live in cities. This concen-
tration of people means that the question of urban public health is expanding far
beyond its traditional practitioners and becoming the remit of citymakers of all
disciplines. Policymakers, architects, designers, urban planners, public health offi-
cials, engineers, geographers, and others are increasingly finding that to meet
population needs, they need to give serious thought to how our cities can be designed
in ways that promote better public health. There are numerous, well-known exam-
ples of urban design initiatives that seek to improve physical health, such as
designing activity into city life to improve cardiovascular health and reduce obesity,
or improving air quality to reduce breathing problems. Citymakers of all disciplines
have access to a range of helpful, evidence-informed guidelines to advise them on
what they can do to actively improve population health. These are inspiring times for
synergies between public health and the city. And yet, with all the discussion and
research and guideline production and inspiring proposals, all too often the emphasis
is largely focused on just one element of health: physical health.
Improving physical health through urban design is clearly both laudable and
essential, but it is not sufficient. The World Health Organization defines health as a
state of “physical, mental and social wellbeing,”and the mental health aspect of that
definition is essential. Most of us will experience symptoms of mental health problems
in our life, and one in every four of us will have a diagnosable mental disorder. From
stress and sadness to attention deficit-hyperactivity disorder (ADHD), depression,
biopolar affective disorder, schizophrenia, addictions, and dementia, mental health
disorders directly account for about 74% of disease burden worldwide and are the
leading cause of years lived with disability. The global burden of disease attributable to
mental and substance use disorders increased by 376% between 1990 and 2010,
almost entirely due to population growth and aging (Whiteford et al. 2013). When it
comes to living in cities, these numbers may be even greater. Compared to rural
settings, city dwellers have an almost 40% increased risk of depression, over 20%
more anxiety, and risk of schizophrenia doubles (Peen et al. 2010).
2 L. McCay et al.
It would be simplistic to blame the intrinsic features of cities for the increased
associations found between city living and mental health. In fact, many of the very
challenges that predispose a person to develop mental health problems also predis-
pose that person to live in the city. In particular, people with low income, unem-
ployed people, minority groups, homeless people, those who use alcohol or illicit
drugs, and those with previous mental illness often tend to gravitate towards the city
in pursuit of better prospects, such as economic opportunities, housing, social
support, and healthcare, including mental healthcare. This trend may lead to an
elevated level of baseline risk factors for mental disorders in city populations.
Maintaining good mental health is universally important for wellbeing and
success, and its impact spreads to every part of our lives. Good mental health can
improve our enjoyment, coping skills, relationships, our educational achievement,
employment, housing and economic potential, help reduce physical health problems,
ease healthcare and social care costs, build social capital, and decrease suicides. And
while mental health problems can have complex combinations of causes, urban
design can play an important role in prevention, support, and health promotion.
Given the elevated risk of mental disorders that many city residents have, alongside
the features of cities themselves that can add to these risk factors, mental health
promotion is an important consideration for thriving, resilient, sustainable cities.
Despite the clear need and the opportunity, few policies or recommendations for
healthy urban environments currently address mental health in any depth. There is a
common adage: “no health without mental health,”and yet when it comes to city
planning, this can feel like someone else’s remit. This chapter will consider the range
of opportunities for those working in urban design to take action to improve public
and personal mental health.
How Can Urban Design Improve Mental Health?
While in many cases, there is a need for more research to help define and explore this
promising field, there is already substantial evidence that identifies a wide range of
opportunities with good potential to promote good mental health, help prevent
mental illness, and support people who have mental health problems through good
urban design. These opportunities are important to consider during any urban design
project. However, many architects and urban planners report that they encounter
challenges when trying to think about how to integrate mental health into urban
design.
Mind the GAPS: A Thematic Framework to Conceptualize Key
Opportunities to Improve Mental Health Through Urban Design
The Centre for Urban Design and Mental Health has given particular thought to an
approach that helps focus policy thinking and practical planning to support
policymakers, planners, designers, and developers to improve mental health in
Urban Design and Mental Health 3
their projects. We are developing a framework through which to consider any urban
project using the lenses of four key opportunity themes for good mental health,
summarized by the acronym GAPS: Green places, Active places, Prosocial places,
and Safe places.
While these themes are by no means fully inclusive, they aim to provide a
framework that urban planning, design, and development professionals can apply
to any project to help identify diverse opportunities to promote and support good
mental health. The themes can be defined as follows:
Green space –There are important relationships between accessible green spaces
and mental health and wellbeing. Access to natural settings in neighborhoods and
in the course of people’s daily routines seems to help improve and maintain
mental health and wellbeing.
Active space –Exercise and mental health are closely correlated. Regular activity
improves mood, wellbeing, and many mental health outcomes. There are almost
limitless opportunities to design cities in ways that integrate physical activity into
daily life. From facilitating accessible, convenient, safe active transport to placing
outdoor gyms, action can be taken to help integrate exercise, social interactions,
and a sense of agency into people’s daily routines to promote good mental health.
Prosocial space –Urban design should facilitate positive, safe, and natural interac-
tions among people and promote a sense of community, integration, and belong-
ing. This includes potentially vulnerable groups like refugees, migrants, young,
and older people, with multifaceted engagement from passive observation to
active participation. Interesting, flexible, and accessible public places are impor-
tant, and their creation should involve citizens at each stage of design and
development.
Safe space –A sense of safety and security is integral to people’s mental health and
wellbeing. People benefit from feeling safe and comfortable moving around their
neighborhoods, and urban design has a great deal to contribute. Urban dangers
include traffic, getting lost, environmental pollutants, and risks posed by other
people. Appropriate street lighting and surveillance, distinct landmarks that help
4 L. McCay et al.
people with dementia navigate their neighborhoods, and people-centric design of
residential, commercial, and industry routes are good examples of important
urban design interventions. However, a balanced approach is necessary: a safe
environment may improve accessibility and comfort, but risk-averse city design
can reduce action opportunities and people’s sense of agency and choice.
These four themes are clearly interrelated and can be applied to different types of
projects in the built environment, whether focused on particular settings (for exam-
ple, public open spaces, parks and gardens, transportation, sidewalks, and so on) or
on target populations, such as the young or the old. Specific interventions that might
be applied to these projects will be considered in the following pages.
First, it can be helpful to consider specific settings where research indicates
particular interventions can have positive impact on mental health.
Green Space and Mental Health
Perhaps the most frequently researched correlation between the built environment
and mental health is access to green space. Green space is the vegetated land or water
that exists within the urban environment, including parks, gardens, playing fields,
woods, green corridors, rivers, and canals. Functionally, they can be described as
breathing spaces, health spaces, play spaces, wild spaces, and growing spaces.
Sometimes people refer to “green and blue spaces,”which includes water features.
We consider these together (Fig. 1).
What Are the Effects of Green Space on Mental Health?
Research consistently finds links between green spaces and mental health and
wellbeing. A survey of 10,000 people in the UK found that communities living in
greener urban areas were more likely to report lower mental distress and higher
levels of wellbeing after adjusting for socioeconomic variation at the individual and
regional level (White et al. 2013). Another study found a possible association
between more trees per kilometer of street and a decrease of 1.18 antidepressant
prescriptions per thousand population (Taylor et al. 2015). Other effects of green
spaces include the positive impact on stress reduction (Grahn and Stigsdotter 2003),
improved social and cognitive functioning (including for those with attention deficit
disorder), reductions in depression, including mood symptoms associated with
dementia, and a reduction in violence (Dannenberg et al. 2003).
Part of the positive impact of green spaces for mental health is delivered through
synergies with physical health. Green spaces promote and facilitate physical activity,
which can have substantial benefits for mental health. Exercise has positive effects
on people’s general self-esteem and sense of wellbeing. Exercise can be moderately
effective for reducing the symptoms of stress and anxiety. Studies have also dem-
onstrated regular exercise helps alleviate symptoms of depression and can be just as
effective as taking antidepressants for the treatment of mild to moderate depression
(Stathopoulou et al. 2006). Exercise seems to be particularly helpful for depression
Urban Design and Mental Health 5
that is associated with chronic physical illnesses. Exercise can also help alleviate
some symptoms associated with attention deficit disorder, dementia, and even
schizophrenia (blunted emotions, loss of drive, and thinking difficulties). Also
important is the role of physical activity in counteracting the side effect of weight
gain that is associated with taking certain common antipsychotic medications –
through weight management and increasing fitness, exercise can help reduce these
people’s risk of diabetes and cardiovascular disease (Morgan et al. 2013).
Providing spaces that promote social interaction and social cohesion for all ages is
another important aspect of green spaces, and indeed may be one of the key
mechanisms by which mental health gains are achieved. Again, the key impacts
are on reducing symptoms of stress and depression. However, it is important to be
aware that green spaces can also have negative effects on people’s mental health and
social cohesion. For example, if the environment feels threatening to people’s safety,
such as a park known to be frequented by drug dealers, others may experience
anxiety and avoidance of these places. Achieving balance between nature access and
safety for good mental health is an important objective in urban design.
Research is increasingly finding that the positive effects of urban green space on
mental health and wellbeing extend beyond the benefits of physical exercise and
social interaction (Crouche et al. 2007). After adjusting for socioeconomic variables,
perceived “neighborhood greenness”has been found to be strongly associated with
Fig. 1 A busy street in Tokyo, Japan prioritizes pedestrians and green space, with places to sit that
encourage relaxation and social behavior (Photograph by Layla McCay)
6 L. McCay et al.
mental health, an effect only partially explained by physical activity and increased
social interaction (Sugiyama et al. 2008; de Vries et al. 2013). Even simply seeing
green space on a regular basis may benefit mental health.
How Does Green Space Exert Its Effects on Mental Health?
While there is growing evidence that the very nature of being both in and around
green space is associated with better mental health and wellbeing, the mechanisms
of this effect are less well understood. There are three primary theories for how
this association may work, all of which evolved in the 1980s (Crouche et al.
2007). The first is Edward Wilson’s biophilia theory (Sugiyama et al. 2008).
Wilson’s theory argues that humans have a close relationship with the natural
world and as such, a predetermined biological need has evolved that drives
humans to subconsciously seek contact with other species. Around the same
time, Roger Ulrich proposed his stress reduction theory. Ulrich’s theory maintains
that natural environments promote recovery from stress by through a range of
physiological and psychological responses to exposure (de Vries et al. 2013),
including distance from everyday demands, possibilities for aesthetic apprecia-
tion, and activity driven by interest (Wilson 1984). Thirdly, Rachel and Stephen
Kaplan proposed the attention restoration theory (Ulrich 1983). The Kaplans’
theory argues that nature environments exert benefits by relieving “attention
fatigue”through distancing people from performing tasks that require prolonged
maintenance of attention and instead facilitating the use of attention without the
need for concentration.
Is There a “Dose”of Green Space?
Given the numerous potential benefits of green space for mental health, the question
of a “dose”or “prescription”for access to green space is often discussed, both as a
strategy to prevent mental health problems and to address their symptoms. It is clear
that quality and quantity of urban greenery are both connected to mental health
(Hartig 2008) and parks and other green spaces that are walkable and have oppor-
tunities for physical activity and socializing are likely to reap greater benefits than
green features in the streetscape or in buildings (Kaplan and Kaplan 1989). That said,
there is a risk of limiting people’s exposure to green spaces to places they need to
travel to, rather than ensuring they encounter these spaces naturally in their course of
their day. The more time people spend in outdoor green spaces, the less stressed they
seem to feel, regardless of age, gender, and socioeconomic status (Fan et al. 2011).
Both visual and physical access to green space seem to be beneficial, opening the
possibility of exploring landscaping and vegetation options inside and around places
of work and study, including urban parks, walkways, and incorporation into building
design. Specific location is also important: distance from a person’s home to green
space is an independent predictor of stress (Nielson and Hanson 2007). And when
people move from a green to a less green neighborhood, measures of mental health
have been found to deteriorate (Alcock et al. 2014). However, the optimal location,
qualities, or duration of access to parks and other green space with the specific
objective of benefiting mental health are not yet fully understood. Still, green space
Urban Design and Mental Health 7
represents an important opportunity in urban design to promote good mental health,
and there are many exciting projects in this area.
Public Spaces, Streetscapes, and Mental Health
A key opportunity for urban designers to improve community mental health is
through streetscapes. A streetscape refers to a street’s appearance and how it is
designed (particularly how the paved or pedestrian area of the street is laid out and
treated). This includes faces of the buildings visible from the street, the street surface,
and street-furniture and fittings from bus shelters to benches to planters. With most
urban dwellers being exposed to streetscapes on a daily basis, the potential for their
impact on public mental health is important (Fig. 2).
Land Use to Promote Mental Health
Land use in urban environments has become a matter of much debate, as many cities
evolve from the traditional “town square”model to a more dispersed, sometimes
less-cohesive layout. Mixed land use with streets that contain a diversity of lively
neighborhood shops, cafes, and housing can help create a sense of community,
positive perceptions of a neighborhood, and facilitate social interactions; these
benefits can be lost when land use is segregated, so that driving between isolated
locations becomes necessary, turning potential social trips into town into discrete,
often solitary activities.
Boring Streetscapes
Another important evolution in the cityscape is the transition from smaller occupied
facades that give personality and diversity to the street view to often long, monot-
onous walls that often lack features such as windows or entrances for whole city
blocks at a time. If we are not busy processing varied information that we perceive in
the external world, people are more likely to dwell and ruminate on pessimistic
internal thoughts and to become bored. Boredom is associated with stress and risky
behaviors, particularly addiction. Urbanists such as Jan Gehl (2011) recommend that
to engage people’s minds and prevent rumination and boredom, the average walker,
moving at a rate of about 5 km per hour, should see an interesting new site about
once every 5 s. Long, unchanging facades such as office blocks or the walls of
monolithic shops that extend, unchanging, for many meters may have negative
effects on mental wellbeing in that they may create boredom and support negative
ruminations, limit social opportunities, and reduce people’s interest and ability in
interacting with their environment. While more research will improve our under-
standing, many urbanists consider these factors highly relevant for people’s positive
interactions in their environment (Fig. 3).
Nature Exposure
In terms of green space provision, urban parks seem to be one of the most effective
interventions for positive impact on mental health promotion. Tree and flower
8 L. McCay et al.
planting has perhaps become the most common way to incorporate nature into urban
environments. As a result, street-based trees have become an abundant and accessi-
ble form of urban nature, with the associated mental health benefits. There is much
that can be achieved within the streetscape, though design can be complex, meeting
the needs of both pedestrians and road users (Ichihashi et al. 2000).
Public Open Spaces
Public open spaces can provide an opportunity to facilitate nature exposure and
prosocial interaction. High quality public open spaces are venues for cooperative
community activities that create feelings of social integration and belonging and
provide opportunities for people to volunteer for positive activities; altruistic dona-
tion of time and skills to others is associated with mental wellbeing. An Australian
study showed that residents in neighborhoods with high quality public open spaces
had a lower risk of psychological distress –and that quality was more important than
quantity in generating both positive social interactions and community activities but
also a place in which to relax (Francis et al. 2012). However, care must be taken in
the design and management of public open spaces to avoid them becoming settings
for crime, intimidation, or abuse, which would limit their use and conversely have
negative effects on people’s mental wellbeing.
Fig. 2 A public space in La Mariscal in Quito, Ecuador, welcomes people to a safe pedestrian
space with seats and greenery in the city, alongside welcoming food establishments and separation
from traffic, facilitating relaxation and social interactions (Photograph by Jaime Izurieta-Varea)
Urban Design and Mental Health 9
Transportation and Mental Health
Automobile infrastructure is increasingly taking over space in neighborhoods, mar-
ginalizing pedestrians into narrow sidewalks, reducing opportunities for social
interaction, and disconnecting different parts of the neighborhood.
The realm of transportation is therefore another exciting opportunity for urban
design to improve communities and positively impact mental health. The majority of
people interact with transportation, and for many, transport use is an integral part of
their daily routines, making transportation an important aspect of urban design to
promote and improve mental health, though this is an area where further research
would be helpful.
Transport plays an essential, largely positive role in urban mental health by
moving people efficiently and affordably, linking communities, facilitating move-
ment around the city, and by doing so, increasing opportunities for education,
employment, housing, leisure, social interaction, and access to nature, all of which
are important for mental health. Living near public transit connections is positively
associated with good mental health, particularly for older people, who may be less
likely to be able to drive. Bike lanes, pavements, and other infrastructure can also
promote active transport options that can help improve people’s mental health
through physical activity, access to nature, and sometimes even social interactions.
Fig. 3 Another street in Quito, Ecuador, where an almost-featureless perimeter wall renders the
street less engaging for users (Photograph by Jaime Izurieta-Varea)
10 L. McCay et al.
However, transportation can also have negative impacts on people’s mental
health. A great deal of land is increasingly used for roadways, intersections, and
car parking spaces. In many countries, roads split communities, reduce walkability,
and create noise, pollution, and danger, all of which can create mental health
challenges. A key challenge here is the growing global dominance of the car. The
amount of time people spend in their cars is increasing across the world, with
growing traffic density, and people commuting substantial distances from their
home to their job every day. This trend has important consequences for mental
health, particularly impacting on stress, social capital, and access to green spaces and
positive streetscapes.
Commuting
The act of commuting, especially long distance commuting, can have a range of
negative impacts on mental health, particularly when commutes last for over 30 min.
Exposure to noise, crowds, unpredictable traffic, and traffic congestion during
commutes across town can each contribute to stress, anxiety, hostility, aggression,
and negative feelings (Fong et al. 2001), and this is exacerbated when people have
slept poorly (Sygna et al. 2014). Commuting problems can create tardiness at work,
which can contribute to work-related stress, and spending long times in transit each
day means less time for social engagement with friends and family. Indeed, spending
extended commuting can have substantial impact on people’s social capital, with
transit time coming at the expense of the very social interactions that are supportive
of good mental health. A study looking at automobile duration and the quantity of
time spent with friends and family found that when daily commuting surpassed 1 h
per day, it decreased the amount of time men were able to spend with their spouses
and children and decreased the time women spent with their friends (Christian 2012).
Long-distance commuting in particular can also impact on sleep and physical
activity, essential for mental health maintenance. In one Swedish study, commuters,
whether traveling by car or public transport, experienced increases in everyday
levels of stress, poor sleep quality, and feelings of exhaustion (Hansson et al.
2011). On the other hand, when infrastructure is in place to ensure safety, commuting
by walking or bicycle can have positive mental health benefits, particularly through
exercise and often access to nature.
Interventions to improve mental health through transportation should therefore
aim to improve the quality of people’s commute, increase leisure and social time,
increase use of active modes of transportation, reduce stress, and aim to support
improved quality of sleep. Specific interventions may include protected bikeways
and networks, bikeshares, bus-only routes, and pedestrian plazas to enhance active
commuting and opportunities for social interaction.
Lessons from the Mental Healthcare Facility Setting
Looking beyond the cityscape to identify relevant lessons from other settings, there
is a wide body of research that concentrates on the interaction between people with
Urban Design and Mental Health 11
mental health problems and their environment in the context of mental healthcare.
This research has been driven largely by architects and interior designers seeking to
create high-quality mental healthcare facilities that are sensitive to the particular
needs of their users and offers lessons relevant to design in the wider built
environment.
Quality of Setting
In the mental healthcare context, the quality of a person’s accommodation has been
linked to their levels of psychological distress. Clean, comfortable, safe, and high-
quality settings can help promote self-worth and reduce stress levels (Evans 2003),
while residential crowding may increase psychological distress (though this has not
been linked to the development of serious mental illnesses).
Balancing Privacy and Social Interaction
The need to balance privacy and social interaction is another important opportunity
for design in the built environment. In particular, people appreciate the opportunity
for solitary time and the ability to exert personal control to regulate their social
interactions with others in their environments. In the healthcare setting, this has
been achieved, for example, through the configuration of spaces, furnishing,
windows, welcoming entry features on a building’s exterior such as porches
(Szapocznik et al. 2009), and balancing opportunities for socializing and privacy
(Evans 2003).
Autonomy to Regulate One’s Own Environment
Another important component of design to support mental health in the healthcare
setting is the opportunity to understand one’s environment and exert autonomous
decision-making, as opposed to having only one option of where, when, and how to
interact with a place. In the hospital, this could mean having more than one route to
the common area or flexible spaces where furniture can be moved to suit different
needs. Being invited to make decisions engages people and supports their cognitive
functioning. The importance of autonomy, choice, and personal agency can be
extrapolated to the city setting: having options supports people’s development of
attention, problem solving, and conscious engagement with the places they are in,
engaging their brains in active decision-making.
Safety and the Urban Environment
Improving safety in the urban environment is not always thought of as a specific
intervention to improve mental health, but in fact a feeling of security in one’s daily
life is an important contributor to mental health and wellbeing in any urban setting.
People who have their property stolen or experience or witness violent crime are
more likely to demonstrate poorer mental health, and these effects tend to persist for
over a year after an incident (Clark et al. 2006). Crime prevention through urban
design has been extensively discussed, and a full description of methods to reduce
12 L. McCay et al.
crime through urban design is beyond the scope of this chapter. However, some key
principles apply.
First, taking opportunities to leverage natural surveillance is important. Crime
often occurs where people feel there are no witnesses to their activity. Since the
feeling of being seen is a deterrent for criminal activity, the built environment can be
designed to increase public visibility of people’s activity in public places. Classic
examples include designing windows into the walls of buildings that overlook
pedestrian areas, creating supportive infrastructure that increases pedestrian and
cycling traffic, avoiding sight-limiting walls, and ensuring potentially risky areas
are well-lit, with lighting particularly angled to show faces, while avoiding too-
bright security lighting that cast glare and shadows.
Another opportunity is natural access control and territorial marking. This means
ensuring that the difference between public and private space is well demarcated to
dissuade public space users from encroaching on private space for the purpose of
criminal activity. Classic examples include minimizing the number of entry points to
private spaces, using impediments to access vulnerable access points such as posi-
tioning thorny bushes under windows, avoiding design features that allow access to
upper levels or roofs, and using lighting, signage, and other design features to make
clear what is public space and what is not.
Next is the question of maintenance. The “broken windows theory”uses a broken
window as a metaphor for all types of neighborhood disorder in the built environ-
ment. This theory proposes that the presence of features such as broken windows
create a neighborhood feeling that the area is not safe. Further, a dilapidated,
deteriorating space implies a tolerance of disorder and less likelihood of oversight
and therefore increases vulnerability to criminal behavior. On the other hand, a clean,
well-maintained space implies oversight and engenders pride in an area.
Senses on the Street
Another opportunity that has recently gained much interest is how to leverage the
senses for good mental health in the urban built environment. A study looking at the
design of sound and visual components in urban soundscapes evaluated the effect of
natural sounds in conjunction with road traffic noise and visual components in urban
streets. The study found that “the perceptual dimensions of the environment were
different from the noise levels (Hong and Jeon 2013).
Noise is defined as “unwanted, uncontrollable, and unpredictable”sound, and
urban noise can impact people’s mental wellbeing. A particularly important aspect of
noise is nocturnal noise: sleep plays a key role in people’s mental health and
wellbeing, and disturbed sleep can exacerbate many mental health problems.
Noise can also impair task performance and aggravate mood symptoms such as
anxiety and anger.
The specific impact of sound on mental health has been studied, but the results are
inconclusive. Loud outdoor noises, such as those associated with airports or traffic,
have been reported to increase psychological distress, but links have not been found
Urban Design and Mental Health 13
with serious mental illness (Evans 2003; Clark et al. 2006). Moderate but persistent
traffic noise has been associated with symptoms of depression (Orban et al. 2015).
Sudden loud sounds, such as the beeping of horns in heavy traffic, may trigger
auditory reflexes that put people in a state of sound-driven high alert and potentially
increase stress over time (Pheasant et al. 2010). However, a quiet street is not
necessarily an optimal street for mental wellbeing; a more helpful aim is to achieve
a balance of sounds. In particular, nature sounds such as birdsong have been
associated with wellbeing –though urban designers need to approach this opportu-
nity with caution: research has also found that the sound of falling water was
considered to degrade the quality of the soundscape if there was concurrent traffic
noise (Hong and Jeon 2013).
Smell should also be taken into account by urban designers. In the past, attempts
were made to keep smells from abattoirs and tanneries and the like far from
residential areas; with increasing mixed land use, smell can impact on people’s
experience and perceptions of their environment (Orban et al. 2015); smells can
contribute to wellbeing though as yet there is no conclusive evidence about the
association of smell with serious mental illness.
Target Population Groups and Urban Design
In addition to generally designing urban environments to promote good mental
health, there are often occasions where planners, designers, and developers seek to
understand specific opportunities for target population groups. Three of the most
interesting opportunities lie with people who have addictions, the young, and the old.
Urban Design and Addiction
The built environment can have significant impact on alcohol and illicit drug
consumption that interact with the other risk factors of developing addictions.
Condition of the Built Environment
People living in neighborhoods with buildings that are in a dilapidated and
deteriorating condition have been found to be 150% more likely to report heavy
drinking than those who live in neighborhoods in better condition (Bernstein et al.
2007). A wide range of research has also demonstrated the links between dilapi-
dated, deteriorating built environments and urban drug use, including an associa-
tion with an increased likelihood of fatal accidental drug overdose, even after
taking individual factors into account. This research demonstrates the importance
of good upkeep of the built environment (Jackson 2003; Hembree et al. 2005). A
dilapidated environment is also conducive to the use of intravenous drug use,
creating a vicious circle; certain cities have created safe injecting spaces, which
may reduce fatal overdose, as well as the spread of infectious diseases (Epstein et
al. 2014) as well as making the outdoor environment more welcoming to the
general public.
14 L. McCay et al.
Alcohol Outlet Density
Residential exposure to alcohol outlets is associated with harmful consumption of
alcohol (Jozaghi 2012). An Australian study (Murphy et al. 2014) found that “each
additional liquor store in the neighborhood was associated with an increase by 1% in
the mean number of standard drinks of alcohol consumed per drinking day and by
6% in the mean number of days of harmful consumption of alcohol.”. In the USA,
alcohol outlet density, particularly bunching of outlets, has been found to have a
negative effect on binge drinking and alcohol related injuries and violence (Pereira et
al. 2013).
Locations for Drug Dealing
Research has examined the design attributes of locations that make antisocial
behavior such as drug dealing more likely, particularly in urban parks. Dealers and
addicts were found to favor entrances where there is disorganization, confusion, and
chaos and areas where furniture is old and worn out. In terms of lighting, they favor
locations where plants have created dark and shady areas, where the trees have low
and vast crowns, and where the view is limited. Areas where food is served and
minor routes that end at the main entrance are also vulnerable, though unsurprisingly
the more a space attracts public behavior, the less likely that space will be used for
purposes such as dealing drugs (Livingston et al. 2007).
Children, Urban Design, and Mental Health
The experience of childhood is becoming increasingly urban, which can have a
range of important implications for their mental health. Much of the researched
impact of the urban environment on children’s mental health and wellbeing is
characterized by limitations in the opportunity for self-discovery and play in natural
environments.
Places for Play
Part of the restriction in play opportunities that many children experience in the
urban environment can be attributed to the design of housing and surrounding areas.
In particular, high-rise multiple dwelling units with lack of nearby play spaces result
in children being confined to apartments, diminishing these children’s opportunities
for nature exposure, play, and socializing with other children; this effect is more
marked with children who live on higher floors (Evans 2003).
Quality of Housing
However, housing can also contribute to a child’s mental health and development in
other ways. Children who live in a situation of residential crowding have been found
to manifest more behavioral problems in day care centers compared to their peers
from uncrowded homes, and girls living in crowded homes are particularly likely to
experience helplessness in task persistence (Evans 2003). A further factor is toxins
Urban Design and Mental Health 15
such as lead in building materials or house paint; in particular, lead can negatively
affect self-regulatory behavior such as focused attention and frustration tolerance,
which can contribute to conduct disorders and aggression (Aminzadeh and Afshar
2004). Finally, poor quality of housing, such as structural quality, maintenance, or
upkeep, can help create stigma that can result in social exclusion and frequent
relocations, both risk factors for socioemotional problems for children (Evans 2003).
Children, Attention, and the Built Environment
In studies in day care and residential settings, children with greater access to nature
and to natural light have been found to be less impulsive and have better concentra-
tion (Evans 2003) to the extent that studies have found children with attention deficit
hyperactivity disorder (ADHD) undertaking outdoor activities in nature settings
have shown 30% improvement in their symptoms compared to those undertaking
outdoor activities in non-nature settings, and three-fold compared to those under-
taking the activities indoors (Kuo and Taylor 2004). Some physicians are now
“prescribing”time playing in parks as prevention or as an adjunct to medication
for children with symptoms of ADHD. While it is not known what an optimal “dose”
of outdoor play in natural environments may be, it is becoming increasingly clear
that this practice delivers significant benefits for children’s mental health and
wellbeing. Another environmental factor impacting on children’s concentration
and task persistence is the presence of external noise when, for instance, they are
undertaking schoolwork.
Children, Stress, and the Built Environment
There is some evidence that contact with nature also helps children to deal with
stress. There seems to be an association between nature exposure, higher self- worth,
and lower levels of stress. This exposure has been found to be particularly effective
for children who have been bullied, punished, have recently relocated, or are
experiencing family strife (Evans 2003).
Adolescents, Mental Health, and the Built Environment
Studies have shown links between adolescents’perceptions of their environment
and their mental health (Mair et al. 2008). Components of the built environment
that may be best leveraged to support good mental health for adolescents build
opportunities for physical activity and for positive social interactions. Age-
appropriate public spaces where adolescents can safely spend time with their
friends, including exercising, can help foster social capital, social support, and
so-called “peer competence”and may have a corresponding positive mood
impact and have a protective impact on adolescent mental health (Aneshensel
and Sucoff 1996).
Conversely, a perceived threatening environment has been associated with symp-
toms of depression, anxiety, oppositional defiant disorder, and conduct disorder in
adolescents, while environments that are run down and attract crime in particular
tend to support antisocial behavior (Mair et al. 2008).
16 L. McCay et al.
Older People, Urban Design, and Mental Health
Another subset of the population whose built environment often receives special
focus is older people. The close relationship between older people, mental health,
and urban design is well-encapsulated by Garin et al. (Garin et al. 2014): “In the
elderly, the immediate urban environment becomes an important issue. People tend
to spend more time in this environment because of physical decline, retirement,
decreased access to transport and shrinking in social networks.”
A positive built environment is linked to older people’s independence, autonomy,
self-esteem, and physical and mental wellbeing. Given the increased importance of
the local built environment to impact older people, and its potential to both positively
and negatively impact on their mental health, it is disappointing to identify compar-
atively few academic studies addressing this matter; of existing studies, the majority
are cross-sectional, which means that it is difficult to ascribe specific cause and
effect. However, they demonstrate clear links between urban design and mental
health. There are two key areas of focus for older people in urban design: preventing
depression and supporting good psychosocial health for people who have dementia.
Urban Design Interventions to Prevent Depression for Older People
Older people can be subject to loneliness and depression. Various urban design
interventions may help. Older people having a positive impression of the internal
quality of their own home have been found to be associated with fewer depressive
symptoms, for instance the home being well-decorated, well-lit, clean, fully
furnished, and containing all facilities that might be expected in a dwelling in a
particular location (Stewart et al. 2002; Lai and Guo 2011). Having sufficient living
space is also important; research suggests having more than two rooms in a home has
a protective impact on depression in older people (Chan et al. 2011). Attending to the
prevention of moisture build-up, lighting, and design for easy upkeep may be further
important factors.
Outside the home, neighborhood walkability plays a role, though its impact is
mixed. Being able to get out of the house and walk about in a local neighborhood has
clear benefits through providing opportunities for nature exposure, social interaction,
autonomy, and physical exercise. Good walkability seems to be associated with
lower depressive symptoms for men, though the same effect has not been shown for
women (Berke et al. 2007). Consideration should be given to build assisted care
facilities, nursing homes, and residences for the elderly in walkable neighborhoods.
However, the picture is complex. One study showed that greater land use diversity
and retail availability seems to be associated with higher depressive symptoms in
older men, despite the association with increased walkability (Saarloos et al. 2011).
This indicates the complexity of these urban design, depression, and older people.
Urban Design Interventions to Support the Mental Health of People
with Dementia
Importantly for urban planners, increasing numbers of older people with dementia
are living in urban environments (Mitchell and Burton 2006; Forbes et al. 2006). It is
Urban Design and Mental Health 17
imperative that this rapidly growing population is considered when designing the
built environment, from the design of neighborhoods and cities to the design and
location of care facilities. In order to understand the opportunities for urban design to
support the mental health of people with dementia, it is important to understand
some of the symptoms of dementia. These symptoms can include memory loss,
difficulties with thinking, orientation, problem-solving, and/or language, and mood
or behavior changes. If older people tend to spend more time than other people in
their immediate environment, given the challenges of these symptoms, this trend is
even more marked for those with dementia. As their symptoms progress, many
people with dementia find themselves unable to drive and experiencing challenges
when trying to use public transport, meaning they can become increasingly limited
to destinations within walking distance of their home (Mitchell and Burton 2006).
Even getting around in the immediate urban environment can create particular
challenges for people with dementia, such as disorientation, fear, and difficulties in
getting safely between their home and their destinations, all of which can have
substantial negative effects on people’s health and wellbeing.
Older people who do not experience social isolation and feelings of disconnection
are half as likely to experience rapid cognitive decline in multiple functional
domains (Mitchell and Burton 2006). And yet the effects of dementia can contribute
to both. The ability of a person to undertake basic routine tasks, take a walk, have
encounters with nature, and engage socially in neighborhoods can play pivotal roles
in maintaining a person’s sense of self, wellbeing, and quality of life –in addition to
the physical health benefits of this exercise. Being unable to go out safely and
confidently withholds most of these benefits. Urban design can actively help main-
tain older people’s independence, social engagement, stimulation, exercise, and
physical wellbeing.
Two major opportunities are in design to facilitate social engagement and simple,
accessible navigation. In particular, key opportunities lie with familiarity, legibility,
distinctiveness, accessibility, comfort, and safety (Evans 2003), an approach cur-
rently being taken by the movement to create “dementia-friendly neighbourhoods.”
Improving Street Layout to Help People with Dementia Navigate
People with dementia can have difficulties both in concentration and in ability to
communicate, relying on environmental cues such as landmarks to navigate. Urban
design can inadvertently make it more difficult for these people to find their
locations, for instance, changes to the local area remove familiar landmarks and
can cause disorientation, while loud noises can create distractions and lead to
confusion.
Even when people with dementia are familiar with a neighborhood and feel
confident with navigation, many still get lost, with the greatest challenge often
being in spaces that lack clear, visible environmental cues, and at road junctions –
particularly crossroads; forks and T-junctions tend to be easier (Mitchell and Burton
2006). People with dementia report avoiding long, wide roads due to their monotony,
favoring short, narrow, gently winding streets where the ends of streets and other
18 L. McCay et al.
environmental cues can be more easily identified and help maintain interest and
concentration.
Buildings as Environmental Cues for People with Dementia
Environmental cues are a key aid for everyone’s location and direction in the built
environment, but for people with dementia, these landmarks take on extra impor-
tance. People with dementia report that the most helpful navigational cues are
distinct, easily recognizable buildings with functions that are clearly obvious from
their style, image, and details, for example, church steeples or grocery shops with
fruit displayed in front (Mitchell and Burton 2006). Varied shapes, features, colors,
and contrasts in building form and architecture can all be helpful. As such, people
with challenges navigating tend to favor routes with diverse land use, building form
and architectural feature variability, particularly routes containing landmarks with
distinct and obvious uses. Commonly cited types of helpful navigational landmarks
include: historical or civic buildings (churches, libraries, town halls), distinct struc-
tures (clock and water towers, public art), places of activity (mixed-use squares,
parks), places of personal significance, aesthetic features (gardens, trees, planters),
and practical features (telephone boxes, bus shelters). In residential neighborhoods
that lack more obvious navigational landmarks, distinctive rooflines, tiles, chimneys,
front doors, windows, and gardens can all be employed as navigational aids. A clear
hierarchy of streets including main streets, side streets, and alleyways may be
helpful, with efforts made to create streets that have distinguishing features rather
than blocks of almost identical streets. In all environments, whenever a distinctive
building or landmark is being considered for removal, the role of that structure as a
navigational cue for people with dementia should be considered.
Signage to Help People with Dementia Navigate Their Environment
While landmarks are the most effective and least complicated way for people with
dementia to navigate, signs may also play a role in adding clarification at places
where confusion is most likely to occur, such as direction signs placed at junctions or
location signs on buildings whose function is unclear. Signs that people with
dementia report being most helpful are simple, have large dark lettering on light
backgrounds, convey only brief, essential information, and use highly realistic,
recognizable symbols. Direction signs can be particularly helpful at junctions,
while location signs should be perpendicular to walls. While signage can be helpful,
they can also be confusing for people with dementia and create navigational chal-
lenges rather than solving them. People with dementia have criticized signs placed
too low, too high, or parallel to walls. Signs may be too numerous, too crowded, too
hard to read, too complicated, or have nothing to do with navigation, at which point
they become a hindrance rather than an aid to navigating the environment.
Comfort and Safety for People with Dementia
Neighborhoods can be inviting or intimidating to their inhabitants in a range of ways,
but for people with dementia, open informal spaces with a lot of activity can present
a more welcoming and safe space than empty ground or imposing historical
Urban Design and Mental Health 19
architecture that can seem forbidding. A cluttered environment with lots of street
furniture such as railings, kiosks, and trashcans, or complicated patterns on the
ground, can create confusion. Persistent background noise can impact people’s
hearing, and sudden loud noises can be startling and disconcerting, leading to
confusion and anxiety. Finally, good lighting helps people with dementia to better
identify both navigational cues and obstacles, avoiding both disorientation and
injury.
Mental Health Is Often Overlooked by Citymakers
There are clear opportunities to integrate mental health promotion and support into
urban design. But with an incoming wave of competing voices, demands, needs,
funders, activists, research, and more, citymakers must prioritize. Despite the sub-
stantial benefits to health and wellbeing, mental health often features low on these
priority lists. Three important barriers to prioritizing mental health in urban design
are stigma, fear of complexity, and low prioritization becoming a self-fulfilling
prophecy.
Stigma is often associated with mental illness and that stigma can extend beyond
the individual experiences into citymaking. Policymakers and designers may lack
knowledge about how common mental illness is, have negative beliefs about it,
worry that people will make assumptions about their own mental health, or just never
happen to think about including it as a consideration in urban planning and design
for a sustainable city, even as they integrate physical health promotion. For that to
change, vocal advocacy is needed to persuade citymakers of the benefits of attention,
action, and investment for mental health in urban projects. Often advocates for other
causes are louder, or advocates are deterred for fear of experiencing stigma, and the
case for mental health goes unheard. Mental health advocates need to engage
policymakers and designers with personal stories, activate champions, and demon-
strate persuasive research and case studies –in other words, they need to build a
good, engaging, consistent, evidence-based argument for action, just as advocates
for physical health in urban design have achieved.
A second barrier seems to be the perceived complexity of mental health disorders.
Mental disorders may emerge from a complex range of factors including genetics,
early experiences, family relationships, and social settings that cannot be addressed
through urban design –but urban design can and should play a role, just as it does for
physical disorders, which have equally complex causes.
A third barrier is the self-fulfilling prophecy of low prioritization: if the health
promotion aspect of urban planning, design, and development continues to focus on
innovations around physical health, then it will be these initiatives that are show-
cased, discussed, and rewarded, while urban design for mental health will have less
visibility. This exposure creates awareness, expectations, appreciation, and demand,
erroneously implying that when it comes to integrating health into urban design, the
key opportunities lie with physical health. Without a similar movement for mental
health, citymakers are inevitably hearing much less about mental health in urban
20 L. McCay et al.
design plans, policies, and projects. This has the self-perpetuating effect of insuffi-
cient inspiration, motivation, and empowerment around mental health in urban
design, despite the need and opportunity. The time to act to advocate for mental
health integration in urban design is now.
Summary
With an increasing number of people growing up, living, working, and spending
their retirement years in cities, the mental health component of public health is not
only becoming more recognized –it is rapidly becoming the remit of those involved
in designing and building cities, from policymakers and planners to architects,
engineers, and developers. The links between the built environment and mental
health are increasingly understood, making urban design and mental health a
growing interdisciplinary field. Through considering green, active, prosocial, and
safe spaces, there is a full palette of opportunities for urban designers to improve
population mental health, and many of these opportunities are already being enacted,
whether by creating places where people feel safe and confident, reducing noise to
improve sleep, facilitating encounters with nature, promoting social interactions, or
reducing the stress associated with commuting. But there is more that can be
achieved. More investment in research will reap rewards, as will leveraging creative
research methods, such as smartphone technology, to better understand reactions to
specific places in real time. As cities strive to become “smart cities,”here too is a
place for mental health. Opportunities beyond this chapter will continue to emerge,
and the future of the emerging urban design and mental health specialty is exciting.
Conclusion
Numerous factors contribute to people’s mental health, but there is exciting untapped
potential for improving public mental health by better leveraging urban design.
Urban planners and designers can integrate mental health promotion into their
projects to help promote mental health for diverse citydwellers across their lifespans,
achieving substantial positive impact. Urban design can promote good mental health
and wellbeing for the urban population, support the mental health and wellbeing of
vulnerable people, and aid the recovery of those with mental health problems at all
phases of their lives as residents of a city.
So the time has come to move beyond the stigma that has held back progress in
this field, to clarify the opportunities, and start designing urban mental health into
plans and projects. Citymakers must seek and seize these opportunities. All of us are
at risk of mental health problems, so this matters personally to everyone on a
personal level, to cities, and to countries.
These authors envision that as awareness and research both develop, integrating
better mental health and wellbeing into urban design will become a standard
component of sustainable urban policy. Funders will further invest in this exciting,
Urban Design and Mental Health 21
high impact field, and citymakers will put research into action through policies,
plans, design, development, and management. This is a moment of great opportu-
nity, and action is needed today.
Cross-References
▶City spaces, Neighbourhoods and Mental Health
▶Green Environment and Mental Health in the City
▶Loneliness and Single Person Households
▶Urban Health (New Title: Revisiting the Virtuous City: Learning from the Past to
Improve Modern Urban Mental Health)
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