Although mental illness has been linked to well-being and economic losses, it is one of the most neglected areas of public health, writes 2017 AsiaGlobal Fellow Layla McCay, director of the Centre for Urban Design and Mental Health and co-author of Restorative Cities: Urban Design for Mental Health and Wellbeing. In the post-Covid-19 future, she argues, resilient cities will be those that invest in the prevention of mental ill health by taking advantage of the built environment.
Stress in the city: Urban life comes with an almost 40 percent higher risk of mood disorders such as depression, over 20 percent more anxiety, and double the risk of schizophrenia compared to living in the countryside (Credit: Phonix_a Pk. sarote / Shutterstock.com)
Mental ill health is one of the world’s biggest causes of disability, with direct and indirect costs accounting for 4 percent of world GDP. Depression and anxiety alone are estimated to cost the global economy US$ 1 trillion a year in lost productivity. Taking into account health and economic losses, this cost is predicted to reach around US$6 trillion a year by 2030. According to pre-pandemic estimates, mental ill-health will likely cost US$16 trillion in lost economic output worldwide between 2011 and 2030. The mental health crisis, coupled with Covid-19, would only increase these predicted costs, and have lasting impact.
Given the costs involved, and the clear impact of mental health on urban sustainability, resilience and economic productivity, city leaders should give priority to the issue as they make their investment decisions, not least because living in a city is itself a risk factor for mental ill health. Research tells us that urban life comes with an almost 40 percent higher risk of mood disorders such as depression, over 20 percent more anxiety, and double the risk of schizophrenia, in addition to more loneliness, isolation and stress, compared to living in the countryside. Reducing people’s risk of developing these disorders would have a significant impact on productivity, and thus on urban economies.
Economic analyses predict that for every US$1 invested in scaled-up treatment for depression and anxiety, there is a US$4 return in better health and productivity. Mental illness accounts for around a third of the global burden of disease. Yet, globally, countries spend on average just 2 percent of their health budgets on mental well-being, making it one of the most neglected areas of public health. So, why are city leaders not investing more?
My analysis of available research suggests a combination of stigma, lack of awareness, and lack of knowledge. Around the world, outdated and inaccurate concepts of mental illness as a source of shame continue to affect people’s willingness to speak openly about the issue, recognize its parity with physical health, and prioritize or invest in it. This has led to a lack of awareness about what mental health and mental illness involve, and the extent of their impact on the population and economy. In turn, many city leaders are unaware of what can be done to promote good mental health among to citizens. But, none of these reasons justifies the loss of productivity associated with inaction.
Investing in convenient access to diagnosis and high quality, evidence-based healthcare services for any person with a mental illness is key to reducing the effects of mental ill health on a population and an economy. Enabling innovation is another. One area with exciting potential for innovation and impact is making best use of the built environment to boost mental health resilience, help prevent mental ill health and support recovery from mental illnesses.
A growing body of research is emerging on how to design and plan cities that promote and support good mental health and well-being, and this knowledge is being integrated more and more into healthy, resilient, and sustainable city strategies. Taking advantage of the built environment to benefit public health is a well-known approach to support a population’s physical health, but the question of how to select interventions that will most benefit mental health has not always had a clear answer.
My book, Restorative Cities: Urban Design for Mental Health and Wellbeing, which I co-authored with environmental psychologist Jenny Roe, brings together current research from across different academic specialties, from public health, psychiatry, neuroscience and environmental psychology, to architecture, planning, design, geography and engineering, to explain how and why certain aspects of urban design affect mental health – and to define practical approaches to implementation. We have distilled urban design opportunities for public spaces into seven chapters that make up a new Restorative Cities framework. The principles of this framework can be practically applied to any city at the municipal level, the neighborhood level, or within individual developments.
A restorative environment helps regulate our emotions and promotes recovery from mental fatigue, stress and the demands of everyday life. Perhaps the most well-recognized urban design intervention that can deliver a restorative environment is the effect of nature. The Restorative Cities framework examines how and why the Green City (an urban environment with various types of greenery) and the Blue City (a city with water-based features) promote mental wellbeing. From offices that offer views of nature and full immersion in an urban forest to delivering urban cooling effects and attractive open spaces for recreation and social activities, natural settings offer myriad direct and indirect benefits to mental health.
Natural settings provide a key element of the sensory stimulation that is explored in research on the concept of the Sensory City – the science of how to employ sight, sound, smell, touch and even taste in urban environments to maximize benefits for mental wellbeing. Current urban design tends to favor the sense of sight over the others, but the urban experience should involve full sensory immersion. The Restorative Cities framework provides evidence-based insights on how these opportunities can be unlocked to benefit mental health.
The Active City expands on well-established research that tells us that regular physical activity can be as beneficial for mild to moderate depression as anti-depression medication. Emerging research shows that this can be expanded to a fuller range of benefits. Approaches such as increasing the walkability and bikeability of cities and strategically making use of infrastructure such as public transit can help achieve mental health benefits, often alongside the physical health benefits of integrating exercise into people’s daily routines. This is linked but separate to a newly emerging concept of the Playable City, which seeks to access the mental health benefits of integrating interaction, participation, fun, wonder and awe into people’s experiences.
An intrinsic part of mental health and well-being is positive social interaction. Loneliness and social isolation are key risk factors for developing mental health problems and for struggling to recover. They can also be a part of life in the city, as many migrate to urban areas, leaving behind their social support systems and then finding themselves surrounded by people with whom they have no meaningful relationship. The Restorative Cities framework defines the Neighborly City in terms of how to use urban planning and design to help create social cohesion, conviviality and meaningful social support within the sprawling density of the urban environment. Linked to this are opportunities offered by the Inclusive City, which focuses on how to create a sense of belonging for every person within the complex diversity and density of a city.
During the Covid-19 pandemic, people have become more aware of the impact on not just their physical but also their mental health of features in their local environment such as the proximity to their home of a high-quality park, the ability to practice social distancing while walking along the street or commuting, or the solidarity experienced with neighbors through community singing and the public expression of appreciation for health workers. Investments in temporary changes in cities across the world – sidewalk widening, bike lanes and pop-up parks, for example – have shown city leaders and populations alike that change is possible and can be beneficial.
Post-pandemic, cities are reinventing themselves. By 2050, two-thirds of the global population will live in cities whose economic success is predicated on their productivity. Cities that seek to be resilient in the post-Covid-19 future will have to recognize and invest in the important relationship between the urban economy and urban mental health. And while investing in healthcare services is essential, any good strategy for population mental health must include the prevention of mental ill health. Taking account and making use of the built environment is an innovative, yet largely underused, solution. In the aftermath of the pandemic, it will be a necessity.
Dietrich, Uta; Chu, Jean; Li, Yeoh, Hui Li; and Kumar, Aish. (October 2020) “Urban design and mental health in George Town, Malaysia: a city case study”, Journal of Urban Design and Mental Health, edition 6, Centre for Urban Design and Mental Health, London, UK.
McCay, Layla; and Lai, Larissa. (February 2018) “Urban design and mental health in Hong Kong: a city case study”, Journal of Urban Design and Mental Health, edition 4, Centre for Urban Design and Mental Health, London, UK.
McCay, Layla; Suzuki, Emily; and Chang, Anna. (August 2017) “Urban design and mental health in Tokyo: a city case study”, Journal of Urban Design and Mental Health, edition 3, Centre for Urban Design and Mental Health, London, UK.
Roe, Jenny; and McCay, Layla. (August 12, 2021) Restorative Cities: Urban Design for Mental Health and Wellbeing, Bloomsbury Publishing, London, UK
2017 AsiaGlobal Fellow, Asia Global Institute, The University of Hong Kong