If city-makers are to address mental health through urban design, where should they start? Layla McCay, the Director of Centre for Urban Design and Mental health, explains the reasons that city-dwellers are at greater risk of mental health problems and shows how urban design can support better mental health.

This article is part of our Creating Healthy Places programme which sets out to tackle preventable diseases shaping the built environment so that healthy activities and experiences are integral to people’s everyday lives.

Urban planners and designers might be forgiven for covertly reminiscing about how things were simpler in the good old days. Back then, health was almost synonymous with safety: would the design bear people’s weight, could someone fall over the barrier, might construction materials contain toxins? But for today’s planners and designers, the question has become more complex: no longer simply how design might cause injury, but how design might cause health.

The question brings an important opportunity for urban design to deliver substantial value to public health. Good population health is essential for thriving, resilient, urban cities, and it has become increasingly clear that urban design plays a role in achieving this. The realisation has unleashed a proliferation of health-themed planning and design guidelines, case studies, recommendations, and recognition for innovation in this space. And yet amidst the flurry to understand and integrate health promotion into urban design projects, one key question is often missing: what about mental health? 

Part of achieving thriving, resilient, sustainable cities is ensuring that citizens can realise their potential, cope with the normal stresses of life...

Mental health: the orphan in urban design for health

Hans Wirz from the urban planning office in Basel, Switzerland is famously quoted as saying: “It took decades to integrate knowledge about the biomedical effects of the cityscape into (my) profession. But when it comes to mental health, we haven’t a clue.” Indeed, planners and designers are only just starting to understand their huge potential value and impact in mental health promotion. As such, mental health is still often neglected in discussions. Some planners and designers feel they lack the expertise to integrate mental health into their projects, some say that mental health is too complex, or not the remit of planners and designers whereas some consider the issue to be lower priority than physical health - and others say nothing, fearing that they will experience stigma if they talk about mental health beyond a general nod to the concept of happiness. 

And yet, mental illness is no minor issue to be overlooked, dismissed or avoided. Part of achieving thriving, resilient, sustainable cities is ensuring that citizens can realise their potential, cope with the normal stresses of life, work productively and fruitfully, and make a contribution to their community. In addition to being a recipe for a successful city, this is the precise World Health Organisation definition of mental health. Clearly the two are intertwined. As such, mental health should already be a priority for citymakers.

City dwellers have an almost 40% increased risk of depression, over 20% more of anxiety, and double the risk of developing schizophrenia compared to people who live in the countryside

Mental disorders are responsible for about 14% of the entire world’s disease burden, and they cause more disability than any other non-communicable disease. This is particularly relevant in the urban context. City dwellers have an almost 40% increased risk of depression, over 20% more of anxiety, and double the risk of developing schizophrenia compared to people who live in the countryside. Certainly the causes of mental disorders can be complex, but this is equally true of many physical disorders. And it is no longer acceptable for planners and designers to shy away from the topic for fear of stigma – particularly given the a key role urban designers can play in helping to reduce mental distress and achieve happier, healthier cities.  

Why urban living is associated with mental distress

So if planners and designers are to address mental health in urban design, where should they start? Part of the answer may come from a better understanding of the reasons that people who live in cities are at greater risk of various mental health problems.

There are four main contributing factors:  pre-existing risk factors, disparities, overload and loss of protective factors – each of which I explain below.

Pre-existing risk factors 

Many vulnerable people who have an elevated risk of having mental health problems tend to gravitate to the city. For example, those with financial problems may move in search of housing, employment or other economic opportunities; people with mental disorders or drug addictions may move in search of peers, or health and social support; people who have experienced traumatic life changes, from divorce to bereavement to immigration or asylum seeking may seek (or be placed) in cities. 

Disparities

Secondly, people who do have these pre-existing risk factors often encounter enormous disparities in the city. This can lead to physical and psychological segregation in the city, affecting people’s self-esteem, feelings of belonging and mental health. Researchers have studied at this effect, particularly in terms of economic status. They found that poorer people’s mental health is at risk both when they live in physically separate locations from richer people, but also when they live in mixed-income communities (known as the ‘poor door effect’).

The mechanisms by which this disparity affects mental health are still not fully understood, but are most likely driven by exposure to comparisons, which can lead to feelings of injustice, social inferiority, hopelessness, and experiences of prejudice and discrimination; research suggests the negative impact on mental health may be greatest for young boys. 

Overload

Thirdly, the city can provide overwhelming stimuli. The density, crowding, noise, smells, sights, disarray, pollution and intensity of other factors may combine to make people feel overloaded. This can have the result of increasing stress, it can also encourage people to retreat into their private spaces and reject the social connections that can promote good mental health.

City living can decrease access to nature, reduce regular exercise, and separate people who move to the city from their social networks of friends and family without building new, strong networks.

Loss of protective factors

Lastly, and perhaps most interestingly in terms of urban design opportunities, the city strips its citizens of the protective factors that help people maintain good mental health. City living can decrease access to nature, reduce regular exercise, and separate people who move to the city from their social networks of friends and family without building new, strong networks. 

Cities can reduce leisure time, privacy and security, and through a combination of crowding, light and noise can even impact sleep. The cumulative effect can be an increased risk of mental health problems, many of which could be partially addressed by smarter urban design.

Urban design opportunities to improve mental health

An increasing body of research is accumulating to explore how urban planning and design can help mitigate risk factors and contribute to better mental health and happiness in the city. There are four key areas of opportunity for urban planners and designers. These can be conceptualised and applied using a framework called ‘Mind the GAPS’: green place, active place, pro-social place and safe place. These four design principles facilitate innovative thinking, yet there is no one city that fully embodies them. Rather, an increasing number of developments within the wider city are incorporating these principles to promote better mental health and wellbeing.

1. Accessibility to green places in the course of people’s daily routines

Research consistently finds links between urban green spaces (vegetated land and water) and mental health and wellbeing, even after adjusting for socioeconomic variation. Green space has been associated with reduction of depression and stress, and improved social and cognitive functioning (including for attention deficit hyperactivity disorder, or ADHD).


Green spaces are associated with the reduction of depression.

However, it is not enough to simply incorporate a bit of green space into a design and then move on. Green space’s potential to improve our mental health is not fully understood by scientists, but there are several theories. Certainly green space encourages exercise and social interactions that both promote good mental health.

Three principal theories compete and combine to help explain the positive impact. Edward Wilson’s Biophilia Theory maintains that humans have a biological need that is sated when we are in contact with other species. Whereas Roger Ulrich’s Stress Reduction Theory proposes that being able to appreciate the aesthetics of a natural setting while experiencing some distance from one’s daily demands is how green spaces have their effect. Finally, Rachel and Stephen Kaplan’s Attention Restoration Theory proposes that natural settings capture people’s attention without the concurrent need for concentration that typifies non-natural settings. In reality, these theories likely all play a role in the mental health benefits people derive from access to green space.  

Inaccessible or poorly managed green space that feels inconvenient or threatening can deter its use and thus its benefits.

However, it is not enough to simply add some green space into a design and assume it will improve mental health. Inaccessible or poorly managed green space that feels inconvenient or threatening can deter its use and thus its benefits. Similarly, green spaces must be designed to feel inclusive and welcoming to the full diversity of the city’s population, rather than being monopolized by certain groups.

Indeed, if appropriate care is not taken, green spaces have the potential to become places of fear, where dark corners, poor sightlines and concealed entrances might help encourage anti-social behaviour and engender intimidation that deters potential users of the green space, particularly when people who may make others feel unsafe, such as drug users, commandeer the space. 

Regular access to safe, well-managed green space should be a priority in urban planning and designing. The most effective green spaces seem to be walkable and encourage social interaction, such as parks. However, both physical and visual access to green space can have impact on people’s mental wellbeing, and frequency of exposure seems to be important. As such, equally important is a focus on smaller spaces that people will encounter naturally in the course of their daily routines, including streetscapes, workplace gardens, and even views from office windows.

2. Integration of activity in people’s daily routines

When designers and planners think about exercise, there can be a tendency to consider it a physical health intervention. However, activity is one of the most important design opportunities for mental health. Exercise can be just as effective as anti-depressant medication for mild and moderate depression. It can also reduce stress and anxiety, and help alleviate some of the symptoms associated with ADHD, dementia, and even schizophrenia. And yet many people, particularly in the urban environment, struggle to incorporate exercise into their daily routines.

A key opportunity is designing active transport options, including safe and convenient pedestrian and bike paths, which harness not just the benefits of exercise but also reduction of stressful, sedentary commutes, with the added benefit of freeing up leisure time and sleep time to further promote good mental health.
 


Activity is one of the most important design opportunities for mental health.

3. Creating pro-social places

Mental health is closely associated with strong social connections and social capital. This is increasingly understood as one of the key opportunities in mental health promotion. As such, there is extensive potential for designers to innovate, creating features within projects that facilitate positive, safe, natural interactions amongst people and foster a sense of community, integration and belonging. This means strategies such as developing public spaces for flexible use (including participation and volunteering opportunities), street furniture for resting and chatting, and orientation of entrances to promote social greetings. It also means avoiding long, unchanging facades that extend across city blocks and cause people’s minds to dwell on negative thoughts, or cities that promote individual car use over pedestrian connections. 


Mental health is closely associated with strong social connections.

4. Safety and security  

A particular feature of urban living that impacts people’s mental health is a feeling of insecurity in the course of a person’s daily life. Occasional fear can trigger the ‘fight or flight response’ where the body detects a threat and stress hormones prepare the body for survival responses. As an evolutionary function, this would save people from being eaten by a lion or such, and afterwards, the body would return to resting state.

In the city, constant low-level threats can keep the body in an unnatural habitual state of preparation, which can affect mood and stress in the long term. Relevant urban dangers can include risks posed by other people (such as being robbed), risks from traffic (such as being run over), and the risk of getting lost (particularly pertinent for those with dementia, where this risk can limit their independence and thus their quality of life). Appropriate design of roads, good street lighting, and distinct landmarks and wayfinding cues are just some of the design features that can increase perceptions of safety in a neighbourhood. 


Good street lighting is one of the design features that can increase perceptions of safety in a neighbourhood.

Towards better integration of urban design and mental health promotion

The question of how to link health and design experts to identify evidence-based design opportunities to improve people’s mental health was the main driver in founding the Centre for Urban Design and Mental Health (UD/MH) in 2015. This global think tank seeks to explore opportunities to design better mental health into cities.

Since its establishment, we have seen an increasing understanding of the opportunities, along with a rapid expansion of interest and commitment to improving mental health through urban design. Even so, the topic often remains an afterthought for many planners and designers, and rarely features explicitly in city policies; a notable exception is New York City’s Guiding Principles for Design and Construction Excellence 2.0, one example of design guidelines that meaningfully address mental health. 

To fully realise the potential and value of urban design in promoting public mental health and wellbeing, opportunities must be appreciated and seized not just by the public health experts and by urban designers, but also by the policymakers, planners, and clients.

It is essential to focus on the truth that people are the very heart of cities. To fully realise the potential and value of urban design in promoting public mental health and wellbeing, opportunities must be appreciated and seized not just by the public health experts and by urban designers, but also by the policymakers, planners, and clients involved in commissioning and approving urban design projects. This is important because mental health promotion adds value to urban design that is needed to achieve successful cities all over the worlds.

This article originally appeared in the Urban Design Journal. It has been reproduced with their permission. 

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Feature — 09/08/2017