Layla McCay is Director of the Centre for Urban Design and Mental Health, a global think tank that considers how to build better mental health into cities. A British psychiatrist and international public health and health systems specialist, she holds international health positions at Georgetown University (USA), London School of Hygiene and Tropical Medicine (UK), Tokyo Medical and Dental University (Japan), and the World Bank. She lives in Tokyo.
When John Snow pulled the handle off a London water pump in 1894, he did more than halt a deadly cholera epidemic: he helped initiate the field of urban public health. Since then, citymakers and health professionals all over the world have asked themselves: with the huge influx of people into cities (along with their substantial – and expensive – healthcare needs), how can we help make the city better for our health?
From infectious diseases to non-communicable diseases to road traffic accidents, we know all sorts of ways in which cities can be bad for our health. We also know that many of these risks can be reduced through good urban planning and design. These are inspiring times for synergies between public health and urban policymakers, planners and designers.
Over the last few years we have seen citymakers getting inspired about using urban design to help improve physical health, for instance through projects that support cardiovascular health and aim to reduce obesity. But in all the excitement, the showcasing of physical health improvement initiatives, the conferences, the awards, the new guidelines, the policy recommendations and the funding, we often forget to think about an aspect of health for which urban planning and design has particular potential: mental health.
It is not sufficient for health-focused initiatives to address only physical health: the World Health Organization (WHO) defines health as a state of not just physical, but also mental and social wellbeing – and mental health is important for us all. After all, mental health and substance use disorders affect one in four of us, and account for up to 14% of the global burden of disease – a proportion that grew by more than a third over the last decade.
This matters because good mental health is essential for a thriving population: it can improve our enjoyment, coping skills, and relationships; our educational achievement and employment; our housing and economic potential; help reduce physical health problems; ease healthcare and social care costs; build social capital, and decrease suicides. Clearly mental health promotion should be a priority for any city that seeks sustainability, economic development and a thriving, productive population.
It is clear that there is a substantial role for urban planning and design to help promote good mental health in the city, prevent mental disorders developing, and support people who have mental health problems. But despite the clear need and opportunity, few policies or recommendations for healthy urban environments currently address mental health in much depth. Perhaps policymakers, planners and designers assume that it is someone else’s remit. Perhaps stigma produces unhelpful barriers that make them reluctant to include it alongside other components of health. Or they erroneously think mental health is too complex (but of course the causes of physical disorders can be just as complex). Or simply forget that mental health is an essential component of health. Whatever the reasons, a common result is healthy city policies that omit mental health, or reduce the substantial opportunity to a cursory paragraph or two, reducing the prioritization, demand and remit of mental health design initiatives in the eyes of funders, planners, designers, developers – and the population at large.
Many urban planners and designers have responded that they simply don’t know where to start, or feel they lack a remit as their city does not appear to consider mental health a priority investment. Certainly there is a need for more funding and research to fully understand the range of opportunities. But substantial evidence is already freely available. What’s missing is clear guidelines – and with them, an expectation that citymakers should be integrating mental health into local policy and projects alongside physical health.
To help with this deficit, The Centre for Urban Design and Mental Health is developing an evidence-based framework to improve mental health through urban design. This framework, called ‘Mind the GAPS’, can be used to integrate mental health thinking into any aspect of urban policy and project development.
G stands for Green space. There are important relationships between green space and mental health, from the beneficial effects of simply having access to nature to the opportunities for individual and social exercise.
A stands for Active space. Exercise and mental health are closely correlated: we know that regular activity improves mood, wellbeing, and many mental health outcomes, and there are numerous opportunities to integrate exercise into the city, from developing active transport infrastructure to installing free outdoor gyms.
P stands for Pro-social space. An important contributor to good mental health is positive social interaction, integration, and the feeling of belonging (while still having the opportunity for privacy). Urban design should be actively integrating flexible, accessible public places that prioritize facilitating natural, positive, inclusive interactions among a city’s communities.
Finally S stands for Safe space. A sense of safety and security in a neighborhood is integral to people’s mental health and wellbeing. Urban design can contribute much in this domain, from ensuring appropriate street lighting to traffic management to ensuring distinct landmarks to help people with dementia navigate more easily.
The name Mind the GAPS is of course inspired by the London Underground’s famous catchphrase – but also by the WHO’s mental health gap action program (mhGAP). This program seeks to help scale up services for people with mental health disorders, wherever they live in the world. Currently in low-income countries, only one in four people with moderate to severe mental disorders receive basic care – and even in higher income countries, people struggle to receive the care they need. And that is without taking into account the vast numbers of people with milder problems, and of course the many millions of sad and lonely people in the city.
The challenge of improving the city’s mental health is huge. But just as mental health is not the sole concern of individual citydwellers, addressing it cannot be the sole remit of healthcare professionals. A population’s mental health affects the sustainability and success of any city, so it needs to be embedded as part of standard urban policy. It is time for citymakers to find the mental health equivalent of John Snow’s water pump – and start pulling off the handle to initiate a new era for urban public mental health.