Innovations in Behavioural Health Architecture

Stephen Verderber

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351819862
• Edition: 1
• Topic: Architecture
• Subtopic: Architecture General

***WINNER OF A NAUTILUS 2018 SILVER MEDAL BOOK AWARD***

Innovations in Behavioural Health Architecture is the most comprehensive book written on this topic in more than 40 years. It examines the ways in which healthcare architecture can contribute, as a highly valued informational and reference source, to the provision of psychiatric and addictive disorder treatment in communities around the world. It provides an overview of the need for a new generation of progressively planned and designed treatment centres – both inpatient and outpatient care environments – and the advantages, challenges, and opportunities associated with meeting the burgeoning need for treatment settings of this type. Additional chapters address the specifics of geriatric psychiatry and its architectural ramifications in light of the rapid aging of societies globally and provide a comprehensive compendium of planning and design considerations for these places in both inpatient and outpatient care contexts. Finally, the book presents an expansive and fully illustrated set of international case studies that express state-of-the-art advancements in architecture for behavioural healthcare.

Part 1

Background

Chapter 1 Introduction

Dramatic events are transforming the global mental health landscape. In developing regions, where four fifths of the world’s population reside, noncommunicable diseases (NCDs) are supplanting traditional diseases as leading causes of disability and premature death. By the year 2020, NCDs are expected to account for 7 out of every 10 deaths in developing regions, due in large part to an aging global population, combined with declining birth rates. The rate of change combined with the absolute numbers impacted will pose serious challenges to healthcare systems, requiring difficult decisions. Worse, many governments lack basic health status population data, so necessary in effective policy making.¹ Recent reports in the Lancet and the Lancet Psychiatry have underscored the gravity of this situation, concluding the growing burden of untreated mental disorders in the world’s two most populous countries, China and India alone, cannot be adequately addressed without fundamental changes to their internal healthcare systems.² In these two countries, less than 10% of those who suffer from a mental disorder ever receive treatment, and the burden of disability is higher in these places than in all Western nations combined. These two countries, accounting for one third of the world’s entire population, are in the midst of major economic transformations, and will need to invest significantly more than the less than 1% they currently devote to mental health care services.

China is especially ill prepared for the coming tsunami of need as its population ages. Its central government started a program in 2004 that, to date, has trained 10,000 psychiatrists and built hundreds of outpatient community mental health centers, representing an unprecedented national investment in psychiatric care.³ In addition, folk medicine is an integral if unorthodox component of the healthcare system in numerous countries: this includes the work of traditional faith healers, herbalists, and spiritualists who have practiced their traditions for centuries. In China, many doctors receive some exposure to the traditional healing arts (i.e., herbal treatments, acupuncture, and qigong). In India, similarly, many physicians incorporate yoga and Ayurveda traditions in their practices, and medical doctors and folk healers are just now beginning to collaborate in some places. In Nigeria, folk tribal healers are becoming ever-slightly willing to treat conventional diagnoses such as depression and anxiety, although not schizophrenia or bipolar disorder, both traditionally considered demonic afflictions.⁴

The rate of occurrence of depression, alcohol dependency, and schizophrenia tend to be underestimated by researchers who take account of only a nation’s death rate and not the occurrence of mental disability. The reasons for this bias are many, but one reason has been an overarching focus on infectious disease; this has accounted for historically blasé attitudes toward the study of mental health in many parts of the world.⁵ While psychiatric illnesses are responsible for little more than 1% of all deaths worldwide, annually, they account for nearly 11% of the total global disease burden. Adults under the age of 70 in sub-Saharan Africa now face a higher probability of death from an NCD than adults of the same age in highly developed societies.⁶ How are various disease burdens comparatively measured? Research in the past two decades has identified a set of metrics for documenting health outcomes associated with disease and disability. This research has yielded a metric widely known as the Disability-Adjusted Life Year (DALY) index. The DALY index documents the total years of life lost due to premature death as a fraction of the total years lived with a disability. One DALY is therefore the equivalent of one lost year of a healthy life. A premature death is defined as one that occurs before the age a dying person could have been expected to live if she or he were a member of a standardized population with a life expectancy at birth equivalent to that of the world’s longest-surviving population (Japan).⁷

The unseen burdens of psychiatric illness are both timeless and omnipresent, and epidemiological research on the quantification of the disease burden index has until recently been rather undependable. Of the 10 leading causes of disability worldwide in 1990 – as measured in years lived with a disability – 5 were psychiatric conditions: unipolar depression, alcohol and substance abuse, bipolar affective disorders (manic depression), schizophrenia, and obsessive compulsive disorders. Unipolar depression alone is responsible for more than 1 in every 10 years of life lived with a disability worldwide. Altogether, psychiatric and neurological conditions account for 28% of all years of living with a disease, compared with only 1.4% of all deaths globally. Alcohol abuse is a leading cause of male disability in advanced developed societies and fifth highest in less-developed societies.⁸ That said, mental illness and other NCDs are rapidly emerging as dominant causes of ill health worldwide and this trend shows no signs of diminishing.⁹ In 2010, mental and substance abuse disorders accounted for 183.9 million aggregate DALYs, translating into 7.4% of all DALYs worldwide. Overall, these disorders are the fifth leading disease category of all global DALYs, with such disorders having increased by 37.6% in a 20-year period between 1990 and 2010.¹⁰ What is the function of the physical environment and the effects of human mistreatment of planet Earth in predicting the occurrence of mental illness and substance addiction?

Urbanization

The world’s population as of 2015 was 7.3 billion, a number expected to rise to 8.5 billion by the year 2030. By 2050, 66% of the world’s population is expected to live in urbanized regions.¹¹ Globalization, combined with advancements made possible by telecommunication networks, long-distance air travel, and the Internet, is fueling accelerated rates of urbanization. Rural-to-urban migratory shifts are happening with increasing frequency as people relocate to cities in unprecedented numbers. By comparison, in the mid-1970s, less than 40% of the world’s population lived in cities.¹² Back in 1950, 41 of the world’s 100 largest cities were in less-developed countries. By 1995 this statistic had risen to 64 cities and keeps arcing ever upward.¹³ Rapid urbanization warrants examining the complex interrelationships between the experience of living in increasingly dense cities and the status of their residents’ mental health and well-being. Admission rates to psychiatric institutions are often significantly higher in urban areas compared to rural areas. In one nationwide study in the Netherlands, hospital admission rates were twice as high in the most highly urbanized municipalities compared to the least urbanized municipalities in the country.¹⁴ In another study, of 4.4 million persons living in Sweden, a similar rural-versus-urban pattern was found to exist with higher incidences of psychosis occurring in the latter contexts.¹⁵ This pattern was consistent across all major psychiatric disorders and across study groups of children and adolescents, the aged, men and women, married couples, and among unmarried individuals.¹⁶

Systematic research on the incidence of mental illness among urban residents dates from the 1950s, stemming from findings showing first-time hospitalization rates for schizophrenics were higher in the densest inner urban neighborhoods of Chicago, with comparable admission rates gradually decreasing outward toward the urban periphery.¹⁷ It was concluded population density per se, combined with an inadequate social and physical infrastructural support network, is associated with a higher level of mental illness, irrespective of ethnicity, race, or income level.¹⁸ From the 1970s to the present, the work of psychiatric researchers has focused on further understanding this interrelationship. Urbanization in many less-developed countries has been linked to increasing occurrences of depression and anxiety disorders, and particularly among low-income women.¹⁹ Not until 1991 did the World Health Organization (WHO) officially acknowledge this pending crisis, and only then did it act to define eight specific diseases believed to be deserving of particular attention and policy action, reflective of clearly discernable quality-of-life risk factors in urban environments.²⁰

Often, these risk factors become magnified as the size of the city and its surrounding region intensifies, and length of residency in such places has been linked with higher probabilities for developing psychosis within one’s lifetime.²¹ In a recent meta-analysis of numerous research studies, the occurrence of schizophrenia in dense cities was found to increase by as much as 72%. It is now estimated that urbanization accounts for nearly 30% of all reported cases of schizophrenia in all Western countries.²² Effective social support infrastructures, for their part, are a necessary ingredient in order to help in early detection. By contrast, a socially fragmented urban community – that is, one with high social and income inequality; pervasive crime; and poor, ineffective neighborhood-level social supports – is in general associated with higher rates of psychosis. The concept of urban social capital has become widely known in the past 15 years in terms of how it can help explain these outcomes, for better and worse. Urban areas with relatively high levels of intrinsic, or built-in, social capital tend to report lower rates of mental illness and substance addiction, and this has been attributed to a higher overall social cohesiveness quotient as defined by their existing physical, environmental, and sociocultural infrastructures.²³

While specific definitions of social capital are many, the sociologist Robert Putnam postulates it is definable by five key characteristics, centered on the presence of (1) viable community social networks; (2) active civic engagement and participation; (3) a shared collective sense of civic identity and of belonging to something larger and more important than oneself, solidarity, and social equality; (4) reciprocity and effective, normative communication channels to achieve mutual cooperation, a shared sense of purpose, and a sense of obligation to help others in need, with the confidence this will be reciprocated if and when needed; and (5) a general presence of trust in the community and throughout its constituent social networks.²⁴ The social capital construct has been extended more recently to include the impact of urbanization on individuals’ mental health status, with higher social capital associated with lower rates of mental illness and addictive disorders. Restated, cities with more in-place ‘bridging’ social capital infrastructure will more naturally produce and sustain the types of social safety nets necessary to buffer the psychological impacts of adverse life events.²⁵

These urban communities are also better positioned to more successfully acquire and hold on to educational, health, and housing resources linked to improved mental health outcomes. Kwame McKenzie views urban social capital as relatively easy to destroy, but tediously slow to build back up, once lost. This is because it takes so much time to reestablish trust and to rebuild social structures that previously fostered positive life outcomes, before having been disrupted. He views rapid, unplanned urban sprawl as undermining the development of social cohesiveness because it destroys innumerable cognitive and structural horizontal bonds, and predictably, this results in a greater propensity for mental illness because the needed social buttresses and buffers erode and in time become completely dysfunctional. Cities with a characteristically low level of social capital tend to be associated with a characteristically high level of mistrust and the need to look out for oneself, above all else. This inadvertently results in a toxicogenic psychological environment of high stress compounded by low mutual social support. This manifests in disconnection from one’s neighbors, the people one work...