Journal of Urban Health: Bulletin of the New York Academy of Medicine 2003 The New York Academy of Medicine Vol. 80, No. 4, December 2003 The Built Environment and Mental Health Gary W. Evans ABSTRACT The built environment has direct and indirect effects on mental health.High- rise housing is inimical to the psychological well-being of women with young children. Poor-quality housing appears to increase psychological distress, but methodological issues make it difficult to draw clear conclusions. Mental health of psychiatric patients has been linked to design elements that affect their ability to regulate social interaction (e.g., furniture configuration, privacy). Alzheimer’s patients adjust better to small-scale, homier facilities that also have lower levels of stimulation. They are also better adjusted in buildings that accommodate physical wandering. Residential crowding (number of people per room) and loud exterior noise sources (e.g., airports) elevate psychological distress but do not produce serious mental illness. Malodorous air pollutants heighten negative affect, and some toxins (e.g., lead, solvents) cause behavioral disturbances (e.g., self-regulatory ability, aggression). Insufficient daylight is reliably associated with increased depressive symptoms. Indirectly, the physical environment may influence mental health by altering psychosocial processes with known mental health sequelae. Personal control, socially supportive relationships, and restoration from stress and fatigue are all affected by properties of the built environment. More prospective, longitudinal studies and, where feasible, randomized experiments are needed to examine the potential role of the physical environment in mental health. Even more challenging is the task of developing underlying models of how the built environment can affect mental health. It is also likely that some individuals may be more vulnerable to mental health impacts of the built environment. Because exposure to poor environmental conditions is not randomly distributed and tends to concentrate among the poor and ethnic minorities, we also need to focus more attention on the health implications of multiple environmental risk exposure. Human beings spend more than 90% of their lives indoors,1 yet we know much more about ambient environmental conditions and health than we do about the built environment and health. This article critically analyzes what is known about the built environment and mental health. The built environment affects mental health in two major ways. Characteristics of the built environment can directly influence mental health. Environmental characteristics with direct effects on mental health include housing, crowding, noise, indoor air quality, and light. In addition to direct effects, the built environment can indirectly impact mental health by altering psychosocial processes with known mental health consequences. For example, higher residential density interferes with the development of socially supportive relationships within the household. Diminished social support increases Dr. Evans is with the Departments of Design and Environmental Analysis and Human Development, Cornell University. Correspondence: Gary Evans, Department of Design and Environmental Analysis and Department of Human Development, Cornell University, Ithaca, NY 14853-4401. (E-mail:
[email protected]) 536 THE BUILT ENVIRONMENT AND MENTAL HEALTH 537 psychological distress. The indirect pathways I examine are personal control, social support, and restoration. Following discussion of indirect mental health correlates of the built environment, conceptual challenges and future research needs are outlined. DIRECT MENTAL HEALTH CORRELATES OF THE BUILT ENVIRONMENT Housing Most research on housing and health has focused on physical health.2,3 Nonetheless, house type (e.g., high-rise), floor level, and housing quality (e.g., structural problems) have all been linked to mental health. House Type Studies on house type converge on the conclusion that high-rise, multiple dwelling units are inimical to the psychological well-being of mothers with young children and possibly that of young children themselves.4–6 These effects seem particularly pronounced among low-income families. Nearly all of these studies employ cross-sectional designs with statistical controls for socioeconomic status (SES). They tend to rely on self-report measures of psychological distress that incorporate subclinical symptoms of anxiety and depression. A small number of studies have taken advantage of natural experiments in which tenants were randomly assigned to dwellings.7–9 Suspected reasons for the link between high-rise housing and psychological distress are social isolation of mothers and restricted play opportunities for children. In many high-rise buildings, particularly for low-income families, insufficient resources are allotted to spaces that afford the development and maintenance of social networks. Lobbies, lounges, and other small-group spaces are absent or located too far from residences or in public areas that afford insufficient residential control and feelings of ownership (e.g., public lobby upon entrance). Women in large, high-rise housing developments report more loneliness and diminished territorial control in comparison to women of similar backgrounds living in other types of housing.4,6 Parents of young children in large multiple-dwelling units often cope with the paucity of nearby play spaces by keeping children inside their apartments. Such restrictions heighten intrafamilial conflict, minimize play opportunities with others, and remove a primary avenue for parents to get to know their neighbors.10,11 Floor Level Some of the adverse mental health consequences of high-rise housing may be caused by floor level itself. Families living on higher floors have more mental health problems. However, all of the studies showing this, save one,7 are crosssectional.4,6 Thus, the potential methodological problem of self-selection bias is a plausible rival explanation. People with greater preexisting mental health problems may wind up living on higher floor levels. Housing Quality Housing quality, which typically incorporates some aspects of structural quality, maintenance and upkeep, amenities (e.g., private bath, central heat), and physical hazards, is positively associated with mental health. Although there is near consensus on an inverse relationship between housing quality and psychological distress,4–6,12 a host of methodological problems plagues this literature. 29. none of these studies specifies physical qualities of neighborhoods.538 EVANS Most housing quality and mental health study designs are cross-sectional. and too many rely on respondent reports of housing quality. some of which are dichotomous (e.17. In addition. college dorms) populations. A few explanations for the positive link between housing quality and mental health have been offered. and a greater number of housing code violations. The occupants of poor-quality housing are often low-income renters who are concerned about housing tenure.26. demonstrating significant increments in explained variance (8% to 19%) by improving the reliability of housing quality measurement instruments.. Variability in housing quality for such populations is truncated.g.27 It is difficult to disentangle the quality of the residential unit from the neighborhood context in which the housing is situated. present/absent). housing quality assessment instruments often contain few items. many housing quality studies have focused on low-income or institutional (e. independent of household SES. instead defining neighborhood quality as a bundled index of multiple social (e. On the other hand. People living in poor-quality housing experience stigma and may attribute some of their predicament to themselves. other “third” variables could be operating that are not adequately captured by SES controls. smoke detectors..22–25 Neighborhood Quality When people change houses.g. military.. people who are depressed might rate their housing quality lower than others not suffering psychological distress.12. Although many investigators have employed statistical controls for SES.28. Frequent relocations.18 Involuntary relocation negatively affects psychological adjustment among older19 and middle-aged adults20 as well.g. multiple-family dwellings are more likely to be proximate to busy streets. which occur more often among people living in poor-quality housing. their mental health improves in comparison to those who do not move. close proximity to higher volume street traffic..24 Poor-quality housing is more likely to be located in neighborhoods with multiple indicators of urban decay. Furthermore..29 There is growing literature demonstrating that neighborhood quality has mental health impacts on children and their families. they often move to new neighborhoods as well.30 Unfortunately. hot water temperature regulators). There are constant difficulties with repairs and unresponsive landlords. some authors12–15 have shown that when people move into better housing. since psychological well-being can affect one’s judgment about environmental quality. For example. For example. including one with random assignment. Evaluations of three recent experiments with housing voucher programs for low-income families in the United States.21 Parents in poor housing are more apt to contend with safety hazards including insufficient safety protection (e. show that relocating from low-income neighborhoods to middleincome areas is associated with enhanced mental health for both adults and children. Insecurity often accompanies poor-quality housing. number of abandoned build- .g. Christenson et al. thus downwardly biasing estimates of covariation with health outcomes. some of the apparent correlation between housing quality and well-being may be spurious. all of which contribute to childhood injury rates.g. For example. and rarely incorporate reliability estimates. percentage unemployed) and physical attributes (e. causing underestimation of housing–mental health relationships. Some methodological problems may lead to the opposite bias.16 compared associations between indices of housing quality and residential satisfaction. are a risk factor for socioemotional problems in children. 40 Unfortunately.g. accommodation of wandering.38 Patients with their own rooms are better adjusted and more socially engaged. chairs facing one another at a comfortable distance. reduction in noise levels. Among the design features best documented with positive mental health outcomes including less depression. The above institutional studies focused on psychiatric facilities. often lacking appropriate controls. chairs arranged around a table).. and isolated.g. Institutional Settings Vulnerable members of society who cannot live on their own may reside in institutional environments. There is a small body of research on design and mental health among residents of psychiatric facilities and residences for Alzheimer’s patients. and reductions in behavioral disturbances are the following: smaller (9–20 residents) versus larger units. and open sleeping wards that had modular.41.42 Furthermore. These walkways are rather public.31 found that housing areas with deck access had higher rates of depression. Psychiatric Facilities When furniture is rearranged to promote social interaction (e. and psychological distress. respectively. number of people per room. Improvements (e. Recently. use of simple geometric floor plans.32–35 Timko36 showed that better physical amenities in psychiatric facilities (e. there is evidence that design can make a difference in the well-being of Alzheimer’s patients.. whereas little change occurred in the partitioned open sleeping ward. and provision of noninstitutional. Indices of crowding measured in the aggregate such as people per census tract bear little relationship to mental health outcomes. weather protection at entryways) were significantly related to multiple indicators of psychological adjustment. Zimring et al. mental alertness) were found pre. it is important to exclude people living alone.to postconstruction for those living in the suites and corridors.THE BUILT ENVIRONMENT AND MENTAL HEALTH 539 ings). the greater the amount of social withdrawal. landmarks and good signage. Weich et al. small corridors. Crowding Examination of the literature reveals a positive relationship between one index of crowding. Large open sleeping wards that typically accommodated 15 to 20 severely retarded adults were renovated into three different residential designs: suites. passive behaviors decrease. emerging area of research. social interaction among hospitalized patients increases.. less disorientation.37 had the opportunity to evaluate architectural renovations in a hospital for the developmentally disabled. Zimring’s data are consistent with prior work showing that the more individuals a psychiatric patient shares a bedroom with. anonymous spaces with little evidence of residential social control or ownership. nearly all of these studies suffer from weak research designs. Alzheimer’s Facilities Although a new. more homelike features. hallway decorations. The open wards resembled in many respects an open office design. The data on number of people per room and psychological distress are consis- . Deck access residences are multifamily units in which individual apartments open directly onto open walkways connected to a central staircase. in measuring number of people per room. since single residence is a welldocumented correlate of mental illness.g. social interaction.39 The latter may be particularly effective if design elements from the historical period matching the individual’s middle adulthood are incorporated. partially (half height) partitioned spaces. lead. One prospective study with children indicated that 8. and heating and cooking systems affect indoor air quality.g.g. pesticides).. with changes in prison cell density coinciding with fluctuations in well-being. most of these studies on psychological distress are cross-sectional.41. Ozone levels.49 There is evidence.g. with early studies supporting a positive association between aircraft noise exposure and elevated psychiatric admissions.57.54–56 Indoor Air Quality Epidemiologists and physicians studying air pollution and health were among the first to appreciate that environmental problems in the built environment were not equivalent to outdoor ambient conditions..53 On the other hand.49 A study of children exposed to traffic noise from roads and trains in small towns in Austria generated a dose-response function between noise and psychological distress.52. ventilation..42.43 Tripling up of college students also reveals similar trends.50 These investigators also uncovered greater adverse impact among children at higher biological risk (e.540 EVANS tent with the few insignificant findings likely due to truncated range in density and/ or poor measurement of mental health.42 Noise Most research on noise and mental health has examined airport noise exposure. longitudinal study revealed that although residential density was not related to psychological distress at initial occupancy. Unfortunately. Chemical properties of building materials themselves can be toxic.58 The evidence includes large crosssectional comparisons and longitudinal studies. Subsequent work with better controls for socioeconomic status has largely refuted this earlier literature.58–60 Negative be- . 6 months later it was positively related to elevated psychological distress.45–47 Furthermore. Experimental studies with random assignment to short-term crowding in the laboratory reveal significant impacts on negative affect as well as physiological stress.to 10-year-olds’ psychological health was adversely impacted by the opening of a new airport.48 Children also evidence adverse mental health correlates of residential crowding. however. studies around Heathrow Airport have found more equivocal data on noise and children’s mental health. Building properties (e. prisoners) evidence associations between crowding and psychological distress. for example. that community noise exposure from airports may be associated with less catastrophic indices of psychological well-being than psychiatric admissions. As an illustration. are usually lower indoors than outside. solvents.51 There are also data indicating dose-response functions between airport noise and use of psychotropic drugs in adults. including some time series analyses. an unvented gas stove raises indoor nitrogen dioxide concentrations above typical outdoor levels. Initial research focused on psychiatric admissions. construction materials) can also alter exposure to ambient pollutants..44 Several residential density studies also reveal evidence of a dose-response relationship. prematurity). It is worth brief mention that outdoor ambient pollutants have been associated with mental health outcomes. Malodorous Pollutants Research on indoor pollutants and mental health has focused on malodorous substances and various behavioral toxins (e. although many incorporate statistical controls for SES. There is consistent evidence of elevated negative affect under well-controlled laboratory experiments and in field studies of malodorous pollutants.42 Investigations of institutionalized populations (e.g.42 One of the prison studies included longitudinal data. a prospective. 62. Seasonal affective disorder (SAD) is a form of depression that occurs in relation to the amount of exposure to daylight. Lead. impedes self-regulatory behavior in children (e.61 Studies of cognitive deficits associated with early childhood lead exposure are a prime example.59 Behavioral Toxins Most research on behavioral toxins such as heavy metals. and. however.65 Exposure to heavy metals has also been linked to criminal behavior in adults. Animal toxicological models also reveal evidence of aggression and deficient maternal behavior. Patients hospitalized for severe depression recover more quickly in sunny versus dimly lit rooms.g. fighting.64 Several other hazardous materials (mercury. but emotional reactions to color are idiosyncratic and transitory. fatigue. Three psychosocial processes affected by the built environment .72 Insufficient exposure to daylight from windows in a Swedish study disrupted normal circadian rhythms of cortisol in school children. there is no clear evidence that color affects mood.73 Summary Table 1 provides an overview of the direct effects of the physical environment on mental health... pessimism and fatalism (particularly with respect to future health). or psychological well-being in any systematic manner. Community members who discover they have been exposed to hazardous materials reveal multiple indices of psychological distress including fear and panic. including lead.71 Level of illumination and not spectral frequency is the critical element in SAD. There is consistent evidence on color preferences. frustration tolerance). for example. focused attention. sleep disturbance. and concentration difficulties. and in some cases posttraumatic stress disorder. pesticides. organic solvents) produce neuropsychiatric symptoms including anxiety.70 Individuals chronically exposed to shorter hours of daylight suffer more sadness. which in turn is related to behavioral conduct disorders such as yelling. impact psychological well-being. INDIRECT MENTAL HEALTH CORRELATES OF THE BUILT ENVIRONMENT There are indirect pathways that may account for how the built environment influences mental health.58.63 It is less well appreciated that several of the behavioral toxins. and solvents has focused on neurological and cognitive impacts. Distractibility and cooperative social behavior in the classroom were also adversely affected. and other forms of aggression. emotions.68.69 Heightened family conflicts are also common.THE BUILT ENVIRONMENT AND MENTAL HEALTH 541 havioral reactions (e. irritability. also impact psychological well-being.g. clinical depression. Levels of illumination.62.67 Psychological Trauma From Hazardous Exposure Some behavioral reactions to toxins are caused by the psychological trauma associated with threats to personal health. particularly the amount of daylight exposure. depression. feelings of loss of control and helplessness.66 but the evidence comes from only a few correlational studies. for some. aggression) to pollutants also occur under certain conditions. manganese. Light Despite widespread belief. heat.g. poor maintenance. Small number of studies. Consistent and includes intervention studies. Consistent and includes data from randomized field studies. hazards. although most have SES controls. 4–7 Housing quality (structural defects. more homelike. Consistent but largely based upon cross-sectional evidence. climatic problems (e. 12 Neighborhood quality (aggregate bundle of social and physical attributes) Greater psychological distress and poorer cognitive development in children. 26.. Consistent but small number of studies. isolated behaviors in psychiatric patients. Direct mental health effects of the physical environment Environmental characteristics Mental health impacts Assessment of the evidence References High-rise housing Elevated psychological distress. 39 . 4–6 Residential floor level Adults living on higher floors have more psychological distress. fewer behavioral problems. humidity) Greater psychological distress in housing of poorer quality. some without control groups. single rooms) Severely retarded adults and psychiatric patients reveal better functioning with more ability to regulate social interaction. including less disorientation. around tables) Increased social interaction and reduced passive. 29–31 Furniture placement (at social distances. Inconsistent and all cross-sectional. 32–25 Privacy (architecture. 27. Consistent and mainly cross-sectional. less noise. especially among low-income mothers. A few studies control for SES. A few longitudinal studies show similar patterns. accommodation of wandering) Improved functioning. Recent randomized experiment relocating low-income families into better quality neighborhoods reveals similar effects. 38 Alzheimer’s facilities (smaller scale units. Some but not all studies control for SES. 37. 4–6.542 TABLE 1. Areal indices such as people per census tract unrelated to mental health. Mixed data. 543 . cross-sectional data.Residential density (people/room) More negative affect. Many incorporate SES controls. and dose-response functions. primarily case study designs. greater psychological distress. Most statistically control for SES. 70–73 SES. Behavioral toxins related to acting out. 57–69 Light No reliable impacts of color. Consistent data for malodorous air but only small number of behavioral toxicology studies. but one prospective study and some dose-response data for children’s psychological distress. Consistent clinical and experimental data for illumination level impacts. and one prospective field study. socioeconomic status. 49–56 Indoor air quality Malodorous pollutants linked to negative affect. 41–48 Noise (aircraft) Unrelated to psychiatric disorder. Elevated psychological distress in children. Psychiatric disorder not related to crowding. Consistent and includes lab studies. Levels of illumination but not spectrum effect depression. aggression. Several analyses of trauma in contaminated communities. Community contamination reliably related to trauma. Hormonal pathways reasonably well characterized. Tall. College students in dormitories with long corridor designs manifest multiple indices of helplessness in comparison to those living in suite arrangements. noise) while performing a task and then presenting them with opportunities to avoid a noxious stimulus by performance on either the same or a different task.83 for example. in turn. Collective efficacy is related to actual crime as well as fear of crime.77–79 crowding.95. Personal Control People feel better and have better mental health when they can control their surroundings.83–85 reveals the same patterns of results among elementary school children.103 When public housing residents relocate to middle-class suburban neighborhoods. has well-characterized mental health sequelae. Acoustical improvements in a noisy preschool building led to greater task persistence. Chronic exposure to community noise42. large structures. through small group spaces. Bullinger et al. is related to the physical environment. and permeability of interior rooms influence the degree of social control afforded to residents. The provision of a range of social interaction spaces from small intimate spaces for solitude. individuals are exposed to an uncontrollable stimulus. Laboratory exposure to acute noise.89 manifest greater helplessness in task persistence.51 replicated these effects in a prospective.. the ability to monitor and regulate use of space. longitudinal study using the opening of a new airport. In another learned helplessness paradigm. and are associated with both actual crime levels and fear of crime. Cohen et al.98 Territoriality.88. long interior corridors..g.97. Uncontrollable social interaction appears to explain these design effects. greater helplessness is indicated by reduced persistence (giving up) on the subsequent task.104 . and restoration. more public interaction opportunities is associated with greater perceived control and comfort in residential settings. Helplessness is operationalized by exposing subjects to an uncontrollable stimulus (e.51.g.99–102 Social cohesion among neighbors along with willingness to exert social control over the behaviors of others constitute collective efficacy.74–76 When opportunities for control over the environment are thwarted. location. Architecture may impact helplessness as well. followed by a different task wherein the aversive stimulus is no longer present. and poor visual surveillance capability (e.90–92 Students were randomly assigned to living units and the greater the duration of residence. found cross-sectional and longitudinal evidence of diminished task persistence on a challenging jigsaw puzzle among third through fifth graders attending schools in areas affected by airport noise in comparison to children in similar schools located in quiet neighborhoods. lack of small group spaces. to larger.544 EVANS are personal control. High-rise housing and poor-quality housing have also been associated with more uncontrollable social interaction. inability to monitor entrances. Each of these processes.. feelings of mastery increase relative to other public housing residents who relocate to low-income neighborhoods.93. Extensive SES controls were incorporated in Cohen and colleagues’ work. helplessness can occur.80–82 and malodorous pollutants59 cause learned helplessness in people. the stronger the impact. places for concealment) interfere with territorial control and feelings of ownership.96 The size. In each case. Several studies have directly linked the built environment to helplessness.94 Other design features may influence the regulation of social interaction. social support.86 Adults who live in more crowded neighborhoods87 and children in more crowded housing42. 125.THE BUILT ENVIRONMENT AND MENTAL HEALTH 545 Social Support A second indirect pathway potentially linking the built environment to mental health is social support.124 Noise interferes with communication. and furniture arrangements that encourage social interaction. one can see what is happening in the space prior to making a behavioral commitment to the space). which is undoubtedly a component of social support.105–108 Cross-sectional. aggression.e.129 .131 and several studies reveal correlations between rates of illness and room views of natural landscapes among institutional populations (e. views of nature125 and landscape paintings. No data directly address the relationship between either noise or pollution exposure and social support. Restoration A third indirect pathway through which the built environment might influence mental health is restoration. Pollutants increase negative affect. and people exposed to noise are significantly less likely to help others in need of assistance.42. prisoners). Irritability and negative affect are increased by exposure to noise both at home and at work. prospective.116 More crowded residential settings (i. face one another.129 In addition.g. higher number of people per room) cause social withdrawal and impair the development and maintenance of socially supportive relationships. Successful focal points include neutral territory.121–123 Noise can potentiate the expression of aggression.128.114 Many of these same design features also facilitate positive social interaction in outdoor plazas and social spaces.93. are more socially withdrawn and less likely to know their neighbors. and. irritability.119 Residents on busy streets.111.g.... A multitude of empirical studies reflect positive relationships between social support and mental health. There are multiple ways in which the built environment can influence the development and maintenance of socially supportive networks.117 There are also several studies of parent-child interaction indicating more conflict and less responsive parenting in more crowded homes.118.. and natural landscapes replenishes cognitive energy. Recovery from surgery in a randomized trial was accelerated by hospital window views of nature.. Evidence includes cross-sectional and prospective longitudinal field studies as well as experimental studies in the laboratory. water. and longitudinal studies and intervention experiments all converge on this conclusion. Several properties of the physical environment have been directly linked to recovery from cognitive fatigue and stress. Laboratory and field studies have demonstrated that exposure to natural elements such as trees.8. but such pathways are plausible. visual prospect (i.120 All of these studies incorporated controls for SES.130 are all associated with increased positive affect and comfort. nearby offices)111–113 and by creating focal points.115.129 as well as indoor plants. compared to those living on streets with lower traffic volume. Self-report and cognitive performance data converge on this conclusion.110 Social interaction is also promoted inside buildings by proximity (e. The probability of social interaction is greater when entrances to residential units are proximate.109.e. or are directly connected to major pedestrian paths or meeting areas. inclusion of activity generators (e. under some circumstances.125–127 Psychophysiological recovery from experimental and naturalistic stressor exposure is also facilitated by exposure to natural elements.g.42 Analogous findings have also been uncovered in high-rise housing developments in comparison to low-rise units or detached homes. food). 125. curiosity.g. self-selection) may cause overestimation of the association between the built environment and mental health.135 Design elements other than nature have the potential to enhance restorative processes within settings. aquariums. underlying mechanisms: control. Note that only in a few cases (e..139.134 Low-income housing areas in London with less access to private gardens have higher prevalence of depression. inadequate exposure estimation) would bias the results in the opposite direction. these different methodological shortcomings do not sum to a readily discernible bias. nonlinear relationships between environmental quality and well-being.140 Instead. These challenges include self-selection (drift) of people into settings. and animals (e.. or involuntary attention ought to enhance recovery from mental fatigue. Clearly.136. more thought and analyses are necessary on why and how the physical environment might affect mental health. CONCEPTUAL OVERVIEW AND RESEARCH AGENDA Several methodological challenges face research on the built environment and mental health. I summarize in Table 2 evidence for the initial link in the indirect pathway. Views of nature. Architectural features that support fascination. an aviary) as well as paintings of landscapes and other coherent. fireplaces. that is. tranquil scenes are among the design elements with the potential to afford restoration. and have more positive affect than others from the same housing development living near outdoor spaces devoid of nature.126. what exists is evidence for the initial link between the physical environment and the psychosocial mediator on the one hand. and between the psychosocial process and a mental health outcome on the other.. suggesting that control. social support.137 Spaces where people can briefly get away and be alone may buffer some of the harmful effects of residential crowding. and restoration.g. higher density → lower social support → increased psychological distress) has full mediation been tested.g.546 EVANS Children in day care settings with greater access to nature are less impulsive and concentrate better.31 and public housing residents living adjacent to natural outdoor areas report better adjustment to their living environment.138 Summary Table 2 summarizes indirect connections between the built environment and mental health.132 Wells133 found similar results for residential access to nature in a longitudinal study comparing children who relocated. I have offered three hypothetical.g. Some of the problems (e. overreliance on self-report indicators rather than objective markers of environmental quality.g. poor exposure estimation. On balance.g. Children with attentional disorders (e. and restoration may intercede between the physical environment and mental health. independent of SES. social support.. inadequate environmental measurement. fountains.. feel safer. housing within neighborhood). Perhaps the most difficult intellectual challenge facing scholars and policymakers interested in the potential role of the built environment in mental health is the issue of underlying mechanisms or explanatory models. whereas other problems (e. and the embeddedness of different settings within one another (e. restricted variance in environmental quality. . attention-deficit/hyperactivity disorder) have fewer behavioral problems when they spend more time in natural settings. correlations between the physical environment and each of these three hypothetical psychosocial mediators.. Numerous cross-sectional and a couple of intervention studies show 93–94. 117 higher density causes social withdrawal and the deterioration of socially supportive relationships. 51. intervention. Laboratory and field (cross-sectional and prospective) data reveal that 42. and coherent. 83–86 Children living in higher density homes (people/room) have greater 42. study) show uncontrollable noise can induce helplessness. 547 Design elements other than nature may have similar capabilities. corridor Spatial hierarchy Territoriality Social support Distance Crowding Housing Restoration and recovery from cognitive fatigue and stress Natural elements Architecture References Laboratory and field (including one prospective and one intervention 42.. quiet and solitude. Theoretical but little empirical evidence for claim that providing a 95–96 range of social interaction spaces (i.TABLE 2. and have few semiprivate spaces (e. 125. 77–79. field. 136–138 . Physical proximity increases unplanned social interaction. doorway opening.e. High-rise housing and residence on high-traffic volume streets is associ8. 118–120 ated with less interaction with neighbors. 126. Primarily theoretical arguments with little data. solitude to small group) fosters better ability to regulate social interaction..g. lead to feelings of lack of control and are associated with crime. 87–89 learned helplessness. 80–82.g. large.. Students in long-corridor dormitories show greater learned helplessness 90–92 than those living in suite designs. Longitudinal. tranquil stimuli. and cross-sectional evidence. group territory). Cross-sectional data only. 99–102 that multifamily residences that are tall. Laboratory. Functional op109–113 portunities for interaction (e. 93. Salient qualities include fascination. Indirect mental health effects of the physical environment Indirect pathway Environmental characteristic Assessment of the evidence Personal control Noise Crowding Suite vs. Similar findings among crowded adults in the laboratory. and intervention studies converge on nature reducing 125–135 stress and diminishing cognitive fatigue. proximity to pedestrian pathway) also afford greater social interaction. 6 The link between residential crowding and helplessness appears to be stronger in female than male children.147 The negative association between residential crowding and mental health appears stronger among those residing in multifamily dwellings relative to single family or row houses. the harmful impacts of poverty on health may be conveyed by cumulative environmental risk exposure. Traditionally. the most pressing need is . Nearly all of the empirical data reviewed report overall effects of a particular characteristic of the built environment (e. may be more vulnerable to adverse psychological consequences of housing.152 Finally. attend work or school. SES has been treated as a confounding variable. and recreate in suboptimal environments relative to their more affluent counterparts. Individuals already facing psychosocial stressors are more psychologically vulnerable to suboptimal environmental conditions.4. Yet we know that in many cases there is likely to be variability in individual reactions to the built environment.. ideally over time.548 EVANS Another challenge is moderator effects. adults living in crowded residences in high-density neighborhoods manifest more psychological distress than adults living in crowded residences situated in low-density neighborhoods. and rely on appropriate indicators of psychological well-being.143 noise.149.142.141 residential crowding. The negative effects of housing quality. Women. I briefly noted that lowquality housing is frequently embedded within distressed neighborhoods and thus presents methodological challenges to disentangle the source of mental health impacts.154 Second.156 Moreover. the natural ecology of environmental risk is strongly affected by SES.144 and air quality145 on psychological health are all exacerbated by the presence of other social stressors such as family turmoil or interpersonal loss. Psychological distress in relation to inadequate housing is exacerbated among those living in more distressed neighborhoods. requiring control in order to pinpoint the role of environmental risks in health. However. Another important conceptual and analytic challenge in studying mental health and the built environment is socioeconomic status.155. at this nascent stage of scholarship on the built environment and mental health.151 Children from more crowded homes manifest more behavioral problems in crowded day care centers than children in crowded day care centers who live in uncrowded homes.g. particularly low-income women with young children.150 The well-documented relationship between crowding and negative emotional reactions is exacerbated by high temperatures. First. There is abundant evidence of environmental injustice showing that the poor and ethnic minorities are disproportionately likely to reside.42 Qualities of the physical environment can also interact with the social environment as they influence mental health. cumulative social and environmental risk factors have substantially greater impact on health than singular risk factors. Obviously. There is a dearth of information on this topic. This view can be challenged in at least two respects. light) on some indicator of mental health.146.148 Crowded families living on higher floors of multifamily dwellings do worse than crowded families residing on lower floors. In my discussion of housing quality and mental health.153 Each of these studies demonstrates that exposure to multiple adverse physical and social conditions can combine to yield more negative mental health outcomes compared to exposure to individual environmental stressors.28. Some aspects of this issue have been addressed by studies examining the interaction of housing quality and neighborhood quality on mental health.157 Thus the assessment of singular environmental risk factors is both nonrepresentative and likely underestimates the health consequences of poor environmental quality. researchers need more investigation with stronger research designs that incorporate good exposure measurement. Moch A. 6. 11. 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