City design and planning can enhance many aspects of people’s lives, but what about sleep? Sleep is easy to forget because it’s a biological necessity that cannot be avoided. However, adequate sleep impacts physical, emotional, and mental health and urban planning can contribute to the sleep health of an entire community.

Design, nature and sleep

The effects of an urban environment on the mind and body revolve around green space and its impact on overall health. In as early as 1984, physicians began to notice that patients who either had a view of or spent time in a garden area recovered faster. That led to a review published in Science, wherein hospital records from 1972 through 1981 were thoroughly examined to see if patients healed faster in rooms with a view. It was concluded that a view of nature rather than a brick wall consistently shortened recovery times.
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At the time, it was considered groundbreaking research. Roger Ulrich, who conducted this first review, continued his research and found several key components that contributed to improved patient outcomes. Today, these findings are regularly incorporated into modern hospital design. However, the value of his findings goes well beyond a medical setting into daily use for those not recovering from medical procedures.

Three of Ulrich’s components that led to shorter recovery times can also be applied to sleep-enhancing environments.

• Noise levels: It’s easy to understand how noise levels interfere with sleep. Residential areas with green space create distance between people and noise pollution. Trees, grass, and bushes absorb noise, creating a barrier between people and urban sounds. Whether spending time in the green space or homes and apartments built around the green space will have some protection from sleep-disrupting noise.
• Sun exposure: Sun exposure is critical to the sleep-wake cycle. The human eye has photoreceptors that absorb the blue light that results when sunlight passes through the earth’s atmosphere. A signal travels directly from these photoreceptors to the circadian region of the brain. This region of the brain controls the circadian rhythms, which regulate everything from hormone release to metabolism. Natural light helps the body sync the sleep-wake cycle to the day/night schedule. Access to natural sunlight is absolutely necessary to keep the circadian rhythms in check. In fact, many of the sleep disorders associated with old age occur because dimming eyes don’t absorb enough light to regulate the circadian rhythms. Urban design that maximizes exposure to sunlight helps the human body stay on a regular sleep schedule.
• Access to windows with a view of nature: A 2015 study published in the Proceedings of the National Academy of Sciences found that taking a 90-minute walk in a natural environment versus an urban one improved mental health. After spending time in nature, participants reported thinking less negatively about themselves and their situations. The results also showed lower activity in the region of the brain associated with depression and anxiety. While the effects may not be as strong as taking a walk in nature, a window view of nature can have a similar effect on mental health. Patients in Ulrich’s reviews and studies may not have been able to go outside, but even a window with a view improved their recovery times.

Nature restores mental wellbeing

The research begs the question as to why natural environments stimulate the brain differently than built-up urban environments. One answer lies in the different forms of human attention. When reading a book, driving, or writing, the brain pays direct attention to the task at hand. Urban settings require decision-making from navigating traffic to acknowledging strangers. It requires mental effort and discipline that can fatigue the mind.

On the other hand, involuntary attention happens without concentrated effort. The rustle of leaves, a bird flying by, or bright flowers involuntarily capture the mind’s attention without concentration. The restorative nature of involuntary attention is encapsulated in attention restoration theory. When boiled down to the basics, this theory implies that nature requires very little of the human brain to keep its attention. That in and of itself restores mental energy just like food and water restore physical energy. It entertains while requiring nothing of the brain, creating the right conditions for relaxation and, eventually, sleep.

The average adult needs a full seven to nine hours of sleep for complete restoration. Environments that can reduce stress and anxiety will naturally contribute to better sleep. Healthy sleep contributes to immune system health, appetite regulation, diet, and a reduced risk of diseases and illnesses such as diabetes, high blood pressure, and heart disease.  

While hospitals may have been the first to realize the value of green space, we now know it can improve more than recovery times, and this is a design factor no longer just for hospitals. In an increasingly urban society, it creates an environment that improves, sustains, and actively contributes to the mental and physical health of those who live in it. 

Designing for better sleep

Design that enhances sleep tends to both reduce noise and increase access to green space. Plans may require a combination of design techniques to achieve optimal conditions. For example, planning major roadways away from residential areas while using earth bunds and sound barriers to reduce the sound waves that reach residential areas. Noise-tolerant buildings and sound-proofing insulation can reduce noise even further.

Good planning for restorative sleep also makes room for green space. Planners must also consider the kind of green space people want to use. In general, large, open spaces that use the natural landscape attract more users than small parks. However, it might be necessary to get creative when finding green space. Transforming rooftops into gardens and old railways into trails are two common examples. Looking for unused or forgotten areas that can be used as green spaces can increase access and better utilize what’s already available. Residential areas with communal green space and walking access to parks creates a sense of community and can promote the mental health of residents. The key is to make them accessible and usable. Trail networks along with pedestrian-only walkways and bridges provide safer access.

Samantha Kent is a researcher for SleepHelp.org. Her favorite writing topic is how getting enough sleep can improve your life. Currently residing in Boise, Idaho, she sleeps in a California King bed, often with a cat on her face.  ​

Published in the prestigious Journal of the American Medical Association last week at long last those of us interested in green space and mental health have a city-wide experimental study, and it’s good news! (South, Hohl, Kondo, MacDonald, & Branas, 2018)

KEY FINDINGS

• Creating urban green spaces reduced feelings of depression and worthlessness
• The effect was most pronounced in people with low income
• The effect did not involve active use of the green spaces
• The effect of simply tidying but not greening the spaces had minimal impact
• The effect was achieved with small-scale greening interventions

Until now, green spaces in one’s urban environment have been shown to confer a range of mental health benefits to their local populations only in observational epidemiological studies. In the most common type of these studies, snapshots of a populations’ access to green space and their mental health are measured at the same moment in time. These methodologies are of course hindered by problems for inferring causality.

The relationship between green spaces and mental health is a hugely complex one. There are a long list of ways in which the benefits are explained. The most well-evidenced mechanisms to date are: promoting exercise and socialisation, reducing exposure to air and noise pollution, reducing stress and restoring attention, and building senses of community and place attachment . These mechanisms, among many others, are hugely complex and very difficult to adjust for in observational studies despite best efforts. A common criticism which therefore arises from observational studies is whether the effect could be caused by any one of a thousand factors associated with green spaces, which could be good for mental health. Furthermore, the observational studies so far have reported widely variable results. Some have demonstrated impressive reductions in anxiety (de Vries et al., 2016) and depressive symptomatology (Triguero-Mas et al., 2015). While others have shown virtually zero impact at all (Houlden, Weich, & Jarvis, 2017). These variable results are likely in a large part due to the many confounding factors. In response, study after study, commentary after commentary, has been crying out for experimental style studies - natural experiments or randomized control trials (RCTs) – the benefits of which allow for the single issue of interest to be studied in isolation from the disruptive noise of the complex co-factors in the relationship. In RCTs of sound methodology we can be quite confident that the results we see are due to the factor we are interested in.

Step forward Eugenia South and her colleagues from the University of Pennsylvania and their RCT set in Philadelphia.
 
Green fingered Philly
 
Initially concerned with the high burden of mental health conditions, and in light of the then fledgling evidence for green space benefit, researchers extended their work which had previously shown reductions in crime rates following neighbourhood improvement projects to consider mental health outcomes (Kondo, Hohl, Han, & Branas, 2016). By early 2013 city officials in Philadelphia had identified nearly 45,000 lots of unused vacant, often derelict brownfield land across the city. Given such an opportunity authors designed their methodology to include three study arms into which randomly selected plots, grouped together into local clusters of a 0.25 mile radius, would be allocated. The first arm would be left as they were at present. The vacant plots in the second arm would be tidied up, and the third would be “greened”. The researchers would then be able to differentiate whether the “greenness” of the spruced-up space itself contributed anything to outcomes.

Random plots were selected from the master list, and random plots also from the list and within a 0.25 mile radius were included in the cluster. To be eligible for the study, lots were to be less than 5500sqft, deemed to be abandoned, and stricken with ‘blight’, for example that there was evidence of fly-tipping (dumping), abandoned cars, or numerous police reports concerning crimes associated with the lot. In total 110 clusters were formed, containing 541 lots. Over a period of two months gardeners from the Pennsylvania Horticultural Society transformed the third of these vacant plots allocated to the “greening” arm, and tidied the third in the second arm, they will continue to maintain these lots monthly for the foreseeable future.

Gardeners were instructed to follow a strict, replicable, modification process of grading the land, cleaning debris, planting grass and a small number of trees, and enclosing the space with a wooden fence with openings, in the aim of avoiding future dumping.
 
What impact on locals’ mental health?
 
In their study researchers randomly selected individuals living within the catchment areas of clusters and administered questionnaires before the intervention, and again after the intervention. There was a 77.4% success rate at interviewing the same people post-intervention at 18 months, achieving a final sample size of 342 subjects used in analysis. Questionnaires primarily consisted of key demographic information, financial status and a measure for mental health status. The short form “Kessler-6 scale” is a quick screening tool widely used for assessing poor mental health. Each question concerns a key symptom of psychological distress: nervousness, hopelessness, restlessness, depressive feelings, worthlessness, the feeling that everything is an effort, and a summary result which gives a good approximation of overall mental health and psychological distress. An annoying limitation of the short form Kessler scale is that we cannot make clinical judgments about the results: we can only identify the presence of depressive symptomatology, rather than making a diagnosis of clinical depression. However the two are of course highly related.

On to the results. Between individuals living in clusters which were greened versus those which were not, authors demonstrated significant reductions in two of the sub-categories of the K-6: depressive feelings were reduced by 41.5% and feelings of worthlessness by 50.9%(!) All other components had major drops in prevalence too. The combined figure showed impressive community wide reductions of psychological distress by 62.8% (95% CI, −86.2 to 0.4; P = 0.051). In the second arm of the study, tidying up the lots compared to no intervention produced weaker result than greening did, and while the prevalence of all psychological categories decreased, non came close to a real significance (a strong likelihood of true difference); overall psychological distress for example was reduced by 30.1% (95% CI, −74.7 to 93.2; P = 0.49).

Furthermore, and importantly, in line with other studies of green spaces in local communities and mental health outcomes (Roe, Aspinall, & Ward Thompson, 2016), evidence from this study suggests that these benefits are even more pronounced for those individuals with low incomes (in this study judged to be household income under $25,000 pa). Notably, feelings of depression dropped in this sub-group by 68.7%, (−86.5 to −27.5; P < 0.01). All other aspects dropped by large amounts, but with wide confidence intervals and without strong evidence of a true difference.

In short, authors, and readers, can conclude from this presented data, that the greening interventions conducted by these gardeners notably reduced the overall number of citizens with poor mental health, and has been especially good for reducing the number of people with depressed feelings, particularly for those with low incomes.

A call to arms for communities

The evidence presented by South and her colleagues marks an important point for green space / mental health research. For the first time, this is large scale, experimental data, which provides key, and long-needed reassurance that the work of observational studies to date is replicable when the complex web of confounding factors are evaporated away.

Furthermore this study offers much to the way in which to think about green space within urban design. Especially in conjunction with this team’s previous work on the reductions in crime rates in ‘greened’ neighbourhoods, this paper adds to the conversation about the mechanisms of action of the now-undeniable benefits of green neighbourhoods to the mental health of their residents. Recent emphasis in the debate had been placed on active use of green spaces, but this study may now shift thought back towards passive or indirect observable functions of green spaces (such as attention restoration, stress reduction and protection from nuisance environmental exposures), and promotes greenery as a key facet of improving the quality of neighbourhoods, given tidying the area alone produced only marginal benefit.

Next, we must ask environmental psychologists to consider why South’s interventions delivered improvement to rather specific facets of psychiatric symptomatology (depressive feelings and worthlessness specifically: the authors propose a renewed sense of local authorities caring about their communities as a possible explanation). Hence whether specific mechanisms of green space produce specific mental health symptom benefits? In this sense, facilitating other mechanisms with other flavours of green space interventions, perhaps larger green spaces for promoting recreation, and as community foci, other facets of psychiatric symptomatology will be addressed for an overall multifaceted tackling of community psychiatric burden.

Other important areas for consideration now should be the replication of these results across other cities, with larger sample sizes, and more rigorous, clinically validated assessments.

More than ever, we should feel renewed in a community focused approach to urban (re)design. That efforts in renewing small scale (and very small scale) blighted vacant lots in our communities (some clusters only renovating 5 lots to produce such improvements in mental health) is to be of benefit. It is highly likely that these small projects are achievable for many communities. Authors further report that these initiatives are  affordable too: in their previous work, greening improvements of this kind cost on average US$1,597, plus US$180 in yearly maintenance. Local government structures can now add “improving the mental health of my community” to the long list of reasons for revitalising derelict land that is perhaps too small and financially unappealing to property developers. Otherwise, in the spirit of work which has suggested community involvement and directorship of a community’s spaces is of multifaceted benefit through building a sense of community, of place, and of stewardship, councils might look to devolve authority of these small projects to community groups themselves. When all is said and done improving mental health is not the only outcome of improving the quality of local communities, but it is a major player in an interconnected web of community, environment and health, which the work presented here by South and colleagues could more reliably inform and encourage local and national decision makers to take a little more seriously.

de Vries, S., ten Have, M., van Dorsselaer, S., van Wezep, M., Hermans, T., & de Graaf, R. (2016). Local availability of green and blue space and prevalence of common mental disorders in the Netherlands. British Journal of Psychiatry Open, 2(6), 366-372. doi:10.1192/bjpo.bp.115.002469

Houlden, V., Weich, S., & Jarvis, S. (2017). A cross-sectional analysis of green space prevalence and mental wellbeing in England. BMC Public Health, 17(1), 460. doi:10.1186/s12889-017-4401-x

Kondo, M., Hohl, B., Han, S., & Branas, C. (2016). Effects of greening and community reuse of vacant lots on crime. Urban Stud, 53(15), 3279-3295. doi:10.1177/0042098015608058

Roe, J., Aspinall, P. A., & Ward Thompson, C. (2016). Understanding Relationships between Health, Ethnicity, Place and the Role of Urban Green Space in Deprived Urban Communities. Int J Environ Res Public Health, 13(7). doi:10.3390/ijerph13070681

South, E. C., Hohl, B. C., Kondo, M. C., MacDonald, J. M., & Branas, C. C. (2018). Effect of greening vacant land on mental health of community-dwelling adults: A cluster randomized trial. JAMA Network Open, 1(3), e180298. doi:10.1001/jamanetworkopen.2018.0298

Triguero-Mas, M., ., Dadvand, P., Cirach, M., Martínez, D., Medina, A., Mompart, A., . . . Nieuwenhuijsen, M. J. (2015). Natural outdoor environments and mental and physical health: Relationships and mechanisms. Environment International, 77, 35-41. doi:http://dx.doi.org/10.1016/j.envint.2015.01.012

Jacob King is a UD/MH Associate and junior doctor practising in UK. His main interest concerns the association between green space exposure and mental health, and how we can design interventions to promote this relationship.

Cherry blossom season is upon us in Japan. The national news is filled with cherry blossom reports: it feels like everybody is invested in the specific day that the flowers will bloom in their town. There is good reason for this interest, and not just the national appreciation of beauty, flowers and the ephemeral nature of life. Cherry blossom behavior is part of Japan’s national psyche. In a unique moment of nationwide celebration, the country’s usual work-focused culture presses pause, and a different priority is embraced: cherry blossoms viewing, known as hanami. People walk amongst cherry blossoms, admire them, photograph them… Admiring cherry blossoms is part of the pulse of Japan.
 
As the flowers fleetingly blossom, so too does another fleeting pleasure: leisurely outdoor social interaction. Everyone dashes to their nearest cherry blossom location to enjoy raucous, convivial, drunken hanami parties, crowded on blue tarpaulin sheets spread under the trees. Offices, universities, friends, and just about anyone else organises hanami parties, characterised by picnicking (with copious alcohol usually involved). Office workers are even sent to the park early in the morning to secure a good spot.

But as the blossoms start to fade, so too does this particular form of social interaction. At the end of cherry blossom season, Japanese people pack up their picnic blankets and store them til next spring. This seems a missed opportunity: many people live in very small homes, particularly those in large cities like Tokyo, which inhibits their inviting others to their homes for socialising. Picnics should be an ideal solution. And yet they are not. Part of the reason may be lack of venue. Tokyo has only 5.4 m2 of green space per person; this compares to 11.8m2 in Paris, 26.9m2 in London and 29.1 m2 in New York. While picnicking takes over many public spaces during hanami season, for the rest of the time this is not appropriate, and many parks are designed to be admired, not as appropriate social dining spots for adults. But finding the right venue is not the only hurdle. Picnics do not tend to be part of Japanese culture. According to many Japanese people, picnicking outside at any non-hanami time of the year is generally considered 'bizarre', 'childish', and even 'suspicious'.
 
Hiroshi Ota, an architect, and Kaori Ito, an urban designer, helped establish the Tokyo Picnic Club in 2002. Its mission: to tempt Tokyoites to picnic outside of hanami season, socialising in natural settings year-round. They claim: ‘to picnic is the urban culture to utilize the public spaces, to make up for the deficiencies of our city life.’ The appreciation of parks is a cultural norm, but the idea of picnics is unusual. Yet they offer many benefits, not least the opportunity to promote good mental health in the city. Picnicking offers exposure to natural green spaces, encourages physical activity (at least walking to the picnic spot), and facilitates pro-social interaction, which are all urban factors associated with good mental health.

The connections between picnics in the park and good mental health tends to be underappreciated. “Japanese people don’t feel the direct connection between spending time in nature and health,” Ota explains. “However, if parks are used for community activities, that can lead to improved mental health.”

The Tokyo Picnic Club helps people make that all-important but unappreciated connection between urban design and mental health by linking picnics to more commonly accepted health promotion ideas. “In Japan, people tend to think about food when it comes to health. Since the idea of the picnic is based on food, this helps with the idea that going to the park for a picnic can help enhance health.” Ito adds that in Japan, expressing creativity is another important facet of mental health, and this can be achieved by preparing elaborate picnics. “When Japanese people enjoy creativity, they tend to feel happy. Therefore, we believe that writing a poem, making food, and wearing creative costumes during the picnic may also make people feel happy.”
 
There are further benefits to socialising in the park, Ito proposes: “If you go to a shopping centre, you will notice the lack of diversity. However, parks are open for anyone. You can see all the generations, including rich, poor, elderly and young people.”

But their enthusiasm for picnics is not shared by everyone. The Tokyo Picnic Club described setting up picnics in various patches of green space around Tokyo – and measuring how long it took before their party caught the attention of the police and were reprimanded for their subversive attitude to picnicking outside the social boundaries of hanami season. It rarely takes long before they are questioned - and often asked to move on.
 
“We just want the places to have our picnic. We need neither benches nor waterworks. We simply want a spacious lawn. If Green Fields such as beautiful parks are open to us, the picnic becomes the art of encounter in our urban lifestyles. If Brown Fields such as ex-industrial sites or abandoned harbors are open to our picnic, we can develop meals, tools, manners and conversations to fit in the new atmosphere of the modern cityscape.”
 
The Tokyo Picnic Club hopes that by raising awareness, the value of year-round picnicking will be better understood and appreciated in Japan. Their efforts have included portable lawns, and Grass on Vacation, an art show where they remove aeroplane-shaped pieces of turf from locations where people do not sit on the grass, and take them on ‘vacation’ to other locations where the grass can 'enjoy' its intended use: people are encouraged to sit, lie, socialise, eat and generally enjoy the experience of nature in the city.

The Tokyo Picnic Club smilingly insist that the "Right to Picnic" should be a basic human right for urban dwellers. Given the normality of picnicking in other cities all over the world, in Tokyo, this is a surprisingly subversive demand.

In time, the Picnic Club hope for proper observation of one of the 15 rules of Tokyo Picnic Club: every day is a picnic day. By encouraging people’s access to green space and positive, natural social interaction, this is also an apt mantra for mental health promotion in the city.

Trees present an excellent opportunity for planners to help enhance urban mental health and wellbeing. But choosing the wrong trees can be more detrimental to urban communities than having none at all. To make the most of urban green spaces, both tree characteristics and spatial thinking need be considered early on in the planning process. In this article, we will explore common challenges in choosing trees in urban design and how five tools can better support planning and build more vibrant, healthy urban communities.

The ‘wrong trees’ can do more harm than good

These tools are important because despite the best of intentions, implementation problems often occur at the neighborhood scale when the ‘wrong trees’,  or trees unsuitable for a place’s specific urban variables, are brought into the built environment. For example, city planners plant beautiful Ginko bilboa trees along local roads to contribute to the city’s beautification project. The intention is to increase shade, safety, health and happiness across the local community - all laudable aims. However, over time the trees grow too large for the city’s infrastructure and budget. The branches begin to destroy electrical lines, crack underground water pipes, fall onto cars during winter storms, and litter pounds of smelly fruit every spring. The city  becomes frustrated and cut down the trees... only to replace them with smaller, younger Ginko trees. So where did they go wrong?

How to choose the ‘right tree’ for mental health, wellbeing… and for tax dollars

In the US, the Arbor Day Foundation advocates The Right Tree in the Right Place framework, emphasizing that proper planning is vital to achieve the outcome of healthy urban green spaces. They describe trees that will “cool your home in summer and tame the winter winds… grow well in the soil and moisture of your neighborhood… be properly placed to avoid collisions with powerlines and buildings.” Furthermore, thousands of city tax dollars can be prevented in sidewalk and electrical repairs if planners match trees to the urban locations in which they will be planted.

Tree characteristics to consider for sustainable urban design:

• Height, canopy spread, form, and shape
• Growth rate
• Soil, sun, and moisture
• Fruit
• Temperature extremes in your region - hardiness zone
• Urban variables (soil compact, road salt, contained space, toxicity to pets, etc.)
  

Tool 1: Tree Finder Wizard (for the US)

But how to identify the right tree for a particular location? For instance, a local coffee shop in New York City wants to plant a few trees above the front patio to give customers shade. But there are electrical lines 50 feet above ground, there’s limited planting space for roots, partial shade, and the northeast winters are harsh. So what should they do?

One helpful tool they can use is the Tree Finder Wizard tool, developed by the American Arbor Day Foundation. This tool identifies the right tree species for any community in the US based on the variables of zip-code, soil, height, growth rate, spread, and aesthetics desired (fruit, evergreen, deciduous, etc.) | website

Tool 2: National Tree Benefit Calculator (for the US)

The Right Tree Right Place framework is an important first step towards using trees to help achieve healthier communities and more impactful outcomes. However, getting the information and facts to the right people is another challenge. Evidence of economic improvement can form a persuasive argument that helps turn ideas into action. Whether it’s city officials, policy makers, neighborhood HOAs, or school principals who need to be persuaded, the free National Tree Benefit Calculator is an effective tool to communicate specific economic benefits of urban trees and diversity of tree populations. While it does not yet consider health benefits, it calculates the monetary benefit of trees based on tree species, age, and size based on potential improvements in stormwater, property value, energy usage, and air quality |  website

Tool 3: Google’s SketchUp

However, city planning doesn’t only mean city effort. Local non-profits, businesses, and homeowners can too create designs for public spaces, backyards, and community gardens using the right tree right place framework and free 3D spatial design tools.

SketchUp is Google's free design software. It incorporates a few landscape templates to help get a project started. In SketchUp, one can upload a photo and create objects from scratch easily on a laptop to help plan tree design within a given landscape. | website

Tool 4: Garden Visualizer

The Marshalls Garden Visualizer lets a beginner user design a garden or small public space with stunning 3D quality. Photos of community structures and buildings can also be uploaded and displayed in the backdrop | website

Tool 5: Mappler K2

Predicting future trends and integrating community input early on into the design process are challenges that city and regional planners encounter regularly. Where do community members want more trees? In what areas do we need more trees to improve safety, mental health, and healing? How can a city streamline input and provide effective solutions? Mappler is a free crowdsource mapping tool and a mobile data collector app to easily conduct assessments and identify community needs across a city scale. It is a tried and true tool to collect diverse inputs on a large scale to help identify community issues, needs, and successes. | website | community asset mapping

A prime example of the use of Mappler was in New Jersey where local residents entered the location of road potholes. Local officials then used this input to prioritize areas of operation and improve road conditions. When each road was fixed, they were able to input a comment to notify the public that the issue they identified had been fixed.

This same process can be used for identifying other community needs, for instance the tracking and maintaining of urban forests as demonstrated by Casey Trees in Washington DC (online map).

These tools can contribute to smarter urban planning that will achieve the wide range of positive impacts - and help avoid the unintended pitfalls - of planting trees to improve community life.

Do you have a great tool to suggest? Please add a link and description in the comments section.

by Tracy A Marciano

Urban Planning as a means to organize people, places, concepts and practices has an interesting history. As civilization progressed, urban planning followed a parallel trajectory,  reacting to practices that outlived their usefulness. With each era, large scale redesign was at the forefront of change with small pockets of improvement on the periphery.

Contemporary discourse about urban health is primarily focused on green spaces and walkability. While both are important in the urban fabric, they are not absolute measures of ideal public health and their results are hard to quantify against the variations in symptoms and treatments for mental disorders. Introducing concepts from other fields and recalibrating them into plausible urban design initiatives is a potentially interesting approach to improve mental health in cities. In particular, as urban areas gain momentum, exploring concepts from eastern medicine such as acupuncture, aromatherapy (or horticulture therapy), directional alignment with the sun and the moon, nocturnal gardens, botanical soundscapes and energy balancing might be applied to exert a positive impact on mental health in modern cities.

As populations migrate towards urban centers at an accelerated rate, advancing improved health strategies - rather than utopia - is often being achieved through incremental improvements.

A recent movement is New Urbanism, or tactile urbanism, which seeks to align with sustainability, preservation of existing buildings and walkability.  However, as with past attempts at planning perfect cities, such as The Garden City movement, individual experience, public mental health and most importantly, the causation and impact of mental health problems have been largely excluded from the dialog.

Jamie Lerner, who served three terms as the mayor of Curitiba, Brazil uses urban acupuncture as the philosophy behind his successful initiatives.  Urban acupuncture is the mature cousin to tactical urbanism, which has suffered a bit of backlash lately as a trendy, high-concept practice of questionable long-term impact. Lerner writes in his book “Industrious mediocrity is gaining ground, along with merchants of complexity: the bean-counters and the inconclusive, never-ending researchers. But sometimes, just one stroke of creativity is acupuncture powerful enough to make progress.”

In 2007 University of Minnesota published a paper about their collaboration with Blue Cross and Blue Shield of Minnesota. This paper highlighted key findings about how to increase accessibility to nature to address mental health problems. Their research also found that social networks are important and that mental health is connected to fundamental public health issues but did not offer developed solutions with measurable results.

In most cities, areas that create tension and erratic energy and areas that can exacerbate anxiety, depression and isolation are evident. If cities are viewed as a biological system and receptive to holistic wellness plans, the philosophy of urban acupuncture may be an ideal platform to improve heath. For example, if obstructed walkways and clogged streets create tension and anxiety, a small area, such as an acupressure point along a vertical meridian line, could be addressed rather than attempting a complete urban redesign.  

Green space is prevalent in urban planning. However, an actual plan for the green space is often missing. Green space can mean a small strip of grass, or a few trees added as an afterthought. Applying other eastern principles, such as aromatherapy would be a progressive addition to the design phase. For example, if there is a lack of people using a public space where there is ample seating, adding a vertical garden with aromatic herbs may draw people to the area. Aromatherapy, or a fragrance garden, on a large scale could enhance individual experiences while reducing stress and anxiety. It also gives purpose to a vertical garden aside from aesthetics.

Incorporating vespertine gardens (night blooming) would help understand that urban areas have enormous potential after sunset; and would also align with solar and lunar lighting during the design phase. Nocturnal plants are more fragrant and assist visually impaired individuals when combined with other sensory plantings. Using balance between day/night, light/dark can create enough stability to reduce tension and anxiety.

Urban acupuncture is an intriguing starting point to reconsider conventional urban planning and design. It highlights that we are at a critical moment in time when all stakeholders can think about long term plans and how those plans will have a positive impact on mental and public health in urban centers.

Biophila, our innate love of nature, is an obvious way to enhance our cities into environments promoting mental health. The word was first coined by the social psychologist Eric Fromm to describe the positive feelings we obtain from interaction with natural systems and species. This describes everything from the joy we experience in seeing a family of ducklings swimming in a pond, to the beauty of an old growth forest, and the harmonious sound of crickets on a summer night.

Biophila was originally explored as a niche area of psychology and neuroscience research.  Books such as The Biophila Hypothesis, The Last Child in the Woods, and Healing Spaces have done much to spread the concept of biophilia to other fields, and it is now beginning to gain traction in design circles, influencing architecture, interior design and urbanism.

When one thinks of nature and cities, the first thought that comes to mind is likely a tree-lined street with a beautiful canopy. Trees are one of the best ways to start with enhancing the natural environment in a city because of their myriad of benefits, from creating summer shade havens to ecosystems for birds that calm us with their song.  Much work is already being done to green our cities; planting more trees is a top priority for stormwater management, reducing the heat island effect, and the health benefits they bring for urban dwellers.  Organizations such as the Sustainable Urban Forests Coalition and Million Trees NYC are non-profits that have grown recently, dedicated to planting and maintaining our urban forests. Washington DC, for instance, has proudly made tree planting and protection a priority by having an Urban Forestry Administration as part of the District's Department of Transportation. 

But beyond greening our urban landscape, biophilia has a wider focus: to bring more of the natural world in contact with our day to day lives. The Biophilic Cities Project and Partnership for Sustainable Communities are two non-profits working to bring biophila to urban environments. Terrapin Bright Green, a sustainable research & development consultant based in New York, has published several recent white papers on the topic of special interest to the built environment. The 14 Patterns of Biophilic Design and the Economics of Biophilia make the case for incorporating natural systems into our built environment for both financial reasons and to support our wellbeing. Design strategies such as incorporating natural patterns and analogues, creating a visual connection with nature, stochastic sensory stimuli, dynamic lighting, complexity, and the concepts of spatial prospect and refuge explain that creating a biophilic environment is the next step beyond planting trees.  

Research on the physiological effects of natural environments has revealed tangible benefits in stress reduction, concentration, memory, creativity, comfort, healing, and emotion and mood regulation. A few empirical results specific to mental health include:

• Spatial forms evoking mystery and risk result in a strong dopamine or pleasure response
• Prospect, or long range views, result in improved comfort, perceived safety and reduced boredom and fatigue
• Presence of water results in improved concentration, memory, enhanced perception and psychological responsiveness
  

This is the first in a series of posts where I will explore specific examples of biophilia in urban environments and its relation to mental health, which can be seen as a reflection of our strength and fragility as a species. As humans, we are highly sensitive to our environment. Surrounding ourselves with nature reaffirms that we live in a connected world.

Have you ever heard of green building? According to the US Green Building Council, green building is defined as ‘a holistic concept that starts with the understanding that the built environment can have profound effects, both positive and negative, on the natural environment, as well as the people who inhabit buildings every day’ and ‘an effort to amplify the positive and mitigate the negative of these effects throughout the entire life cycle of a building’ (Kriss, J., 2014). Green building, which is also called ‘sustainable building,’ is ‘the practice of creating and using healthier and more resource-efficient models of construction, renovation, operation, maintenance and demolition’ (US EPA: Green Building, 2014). Its aims are to reduce the adverse effects of the built environment which impacts on both human and the nature by maximizing the efficiency of energy, water and other resources, minimizing waste and environmental pollution, and improving health and productivity (US EPA: Green Building, 2014). 

The USGBC created Leadership in Energy and Environmental Design (LEED) certification, a rating system to assess how the built environment meets the requirements of green building (Concrete Thinking, 2015). Nationals Park in Washington, D.C. is the first Major League Baseball stadium with LEED certification (USGBC, 2014). It uses energy-efficient field lighting, which anticipates savings of $440,000 over 25 years (USGBC, 2014). The ballpark does not only encourage visitors to use public transportation but also provides parking areas and valet services for bicycles, promoting environmentally friendly transportation without using fossil fuel (USGBC, 2014). The USGB reported that the stadium could save over 4 million gallons of water a year thanks to low-flow faucets and dual-flush toilets as well as air-cooled chillers instead of water-cooled chillers (USGBC, 2014). 

But how about the impact on human health? A literature review article identified that green buildings can benefit both physical and mental health (Allen et al., 2015). For instance, green buildings designed to improve indoor air quality can reduce the incidence of workers’ asthma and allergies, which in turn, can enhance their productivity (Allen et al., 2015). Compared to a conventional hospital, a LEED-certified green hospital indicated a reduced mortality rate of patients, higher satisfaction of employees, and improved quality of care indicating a lower rate of blood stream infections (Allen et al., 2015). According to the Indian Green Building Council, green hospitals designed to maximize daylight and optimize the artificial light can reduce seasonal affective disorder, sometimes referred to as 'winter depression' (Indian Green Building Council, 2015). They found that green hospitals with more gardens and landscape are associated with positive feelings such as pleasantness and calmness for both patients and employees (Indian Green Building Council, 2015). In particular, environmental noise can lead to cognitive dysfunction as well as psychological distress for both adults and children (Stansfeld & Matheson, 2003; Weitzman et al., 2013). Green space can provide buffer to block or reduce environmental noise. 

Living in an environment that incorporates green space is certainly better for our mental health. However, it can be a challenge to create large open spaces or green spaces in highly populated and small land areas such as New York City in the US, Tokyo in Japan, or Seoul in South Korea. Using innovative solutions like green roofs or rooftop gardens are one way not only to reduce environmental noises but also to make it easier to access the natural environment. The initial cost of installing a green roof may be more costly than a conventional roof, but tangible and intangible benefits of a green roof can soon offset the expenses (US EPA: Green Roofs, 2013). These roofs can reduce energy use of cooling and heating; reduce air pollution and greenhouse gas emission; slow storm-water runoff; and improve the quality of life and human health (US EPA: Green Roofs, 2013). 
​Green building is a fascinating and rapidly emerging concept, but its relationship with mental health, especially for specific mental illnesses, is not well documented yet. Interdisciplinary studies to find out the impacts of green buildings on mental health and multi-sectoral interventions to make our environment greener and healthier are needed for the better future.

• What are the most effective ways of achieving exposure to the natural environment in different settings?
• What is the minimum 'dose' of natural environment exposure needed to achieve mental health benefits? 
• Do particular countries/cultures build nature into their urban environment in ways that offer lessons for others?

If you have research or ideas about these questions or any others pertaining to the question of green building and mental health, please send us an op-ed to be considered for publication in Sanity and Urbanity. 

References 

1. Allen, J.G., MacNaughton, P., Laurent, J.G.C., Flanigan, S.S., Eitland, E.S. & Spengler, J.D. (2015). Green buildings and health. Current Environmental Health Reports, 2(3), 250-258. 

2. Concrete Thinking. (2015). Benefits > LEED. Retrieved from http://www.concretethinker.com/solutions/LEED-Certification.aspx 

3. Indian Green Building Council. Green Hospitals. (2014). Technical Bulletin. Retrieved from https://igbc.in/igbc/html_pdfs/technical/Green%20Hospitals.pdf 

4. Kriss, J. (2014). What is green building? The US Green Building Council (USGBC). Retrieved from http://www.usgbc.org/articles/what-green-building 

5. Stansfeld, S.A. & Matheson, M.P. (2003). Noise pollution: non-auditory effects on health. British Medical Bulletin, 68, 243-257. 

6. The US Green Building Council (USGBC). (2014). Nationals Stadium. Retrieved from http://www.usgbc.org/projects/nationals-stadium 

7. US Environmental Protection Agency (EPA). (2013). Green Roofs. Retrieved from http://www.epa.gov/heatisld/mitigation/greenroofs.htm 

8. US Environmental Protection Agency (EPA). (2014). Green Building. Retrieved from http://archive.epa.gov/greenbuilding/web/html/ 

9. Weitzman, M., Baten, A., Rosenthal, D.G., Hoshino, R., Tohn, E. & Jacobs, D.E. (2013). Housing and child health. Current Problems in Pediatric and Adolescent Health Care, 43(8), 187-224.

What are your research interests, Greg?

I work in the nexus of biology and psychology, studying the impacts of nature experience on human cognitive function, mood, and emotion regulation.
 
You've just published a research study that looks at the links between nature and mental health. What got you interested in this subject?

My interest in this area comes from a desire to investigate the value that natural landscapes may provide for people with respect to mental health.  Following in the footsteps of the compelling work before me in environmental psychology, I set out to determine whether I would obtain empirical evidence for the impact of nature experience on cognitive function, mood, and emotion regulation, using the tools of psychology.   I also want to explore ways of incorporating this evidence into urban design and decision making.

Briefly, can you describe what your study involved?

38 people came into the lab and filled out a questionnaire on their current levels of rumination (repetitive thought focused on negative aspects of the self). They also underwent a brain scan. They were randomly assigned to a 90-min walk in either a natural setting (a park near Stanford) or an urban setting (beside a busy street in Palo Alto).  Upon completion of the walk, participants filled out the rumination questionnaire again, and underwent a second, follow-up scan.  We analyzed whether there was a differential change in nature vs. urban walkers in both self-reported rumination (the questionnaire) and in a part of the brain that has been shown to be active during rumination (the subgenual prefrontal cortex). 

What did your study find?

Participants who went on a 90-min walk through a natural environment reported lower levels of rumination and showed reduced neural activity in an area of the brain linked to risk for mental illness compared with those who walked through an urban environment.

How do you believe that exposure to nature achieves this impact on people's mental health?

This is an active area of exploration for us — and we hope to publish some findings on this soon.

Given that your study involved healthy participants, do you think the nature exposure is more likely to help prevent depression, or could it also be helpful for people who are already depressed?

We do not know the answer to how nature experience will impact rumination in depressed individuals, as our study focused on healthy participants.

What are the practical implications of your study's findings for urban planners, designers and developers?

More work needs to be done in this arena, but our work, along with the work of others, is helping to contribute to an overall body of evidence that nature experience provides benefits to human cognitive function and mood.  This knowledge can inform the ways in which urban planners incorporate nature into cities, and provide accessible natural landscapes for urban and suburban residents.  It can also provide support for conservation of open space and wilderness areas in policy design.

What's next for you in your research? (And what would you like to see other researchers address on this topic?)

We are exploring our hypothesis that emotion regulation shifts are a possible causal mechanism for the cognitive function and mood benefits that we have observed to be resultant from nature vs. urban experience.  I hope that other researchers continue to explore both the characteristics of the impacts of nature experience, possible causal mechanisms, and how these impacts may or may not be moderated by individual differences.

For people who want to learn more about the links between nature, urban design, and impact on mental health, what other research studies or other resources do you recommend they might like to read?

There is more to list here than room allows, but I would start with a great textbook which was recently published entitled Environmental Psychology by Linda Steg (Editor), Agnes E. van den Berg (Editor), Judith I. M. de Groot (Editor)— it includes a great overview of theory and some of the classic studies in this area.

Learn more about Greg Bratman's study:

Read the original research paper in the Proceedings of the National Academy of Sciences of the United States of America.

Read about the research in the New York Times. 

Watch Greg talk about his research in this video: