Mental Health and the Built Environment
Title Text Here
Bart Sheehan
Scott Weich
Health Services Research Institute
Neighbourhood & Mental Disorder
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Many studies on place effects in past decade
Impressive designs but largely negative findings
Often based on secondary analysis
Context v composition
Built environment v social environment
Opportunistic outcomes (usually symptoms)
Little attention to specific design features
Dearth of contextual data
Few hypotheses, and lack of attention to mechanisms
Static rather than dynamic conceptualisation of place
Limited integration of quantitative and qualitative methods
Limited enthusiasm for models based on interactions
Untapped potential for studying neurobiological mediators
Gospel Oak, North London
Example – care homes
• Around 16000 care homes in the UK
• 410 000 residents, around 450 000 places (5% of all older people)
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Mean size 30 places
80% private, under 10% local authority
50% are single stand alone businesses
25% offer specialist dementia care
Sources Laing & Buisson 2004, OFT 2005
Mental health in care homes –
depression prevalence
Prevalence
UK samples
• Mann et al 1984 40%
• Schneider et al 1997 40%
• Godlove Mozley et al 2000 45%
• Jongenelis et al 2004 – Holland – 22% DSM IV depression
• Llewellyn Jones et al 1999 Australia 27% GDS depression
Mental Health in care homes –
depression incidence
Parmelee et al 1992 US
• 6% incidence among non depressed at 12 months
Payne et al 2002
• US dementia care homes – 20% depressed at baseline
– incident depression at 12/12 6%
Mental health in care homes –
depression outcomes - UK
Sutcliffe et al 2007 Am J Geriat. Psychiatry
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308 NW England Care home residents
38% depressed at baseline
19% of those depressed receiving treatment
43% still depressed at 9 months
Depression independently increased mortality
‘It’s so depressing there’
• No prospective studies thus far really recruit
people before they move into care homes
• Very difficult to randomize people to care
home v community care
• Important to understand what about life in a
care home may be depressing, including built
environment
Designing to optimise mental health in
care homes for older people
• 1 year study 2004-5
• Funded by NHS Estates (now
DoH)
• Warwick Medical School
Bart Sheehan (PI)
Eleanor Gilbert
• Oxford Brookes
Elizabeth Burton (PI)
Kristina Stockdale-Juhlberg
Aims
• To identify built environment features in care homes
associated with mood
• To produce guidance on design of care homes which
may minimize feelings of depression
The sample
20 care homes
• Mean 32 places (range 9-60)
• 4 victorian, 16 built 1960s on
• 5 provide specialist dementia care
81 residents
• Mean age 85 (range 65 to 99)
• 59 (73%) female
• Significantly disabled
Three key data sources
• Semi-structured interview with resident covering
Care, built environment, effect of environment on mood,
liked/disliked areas, reasons for feelings
• Independent architectural checklist – validation
exercise embedded in study
Records detail re building, individual spaces within it
• Matched photographic choices
Bathroom photographs – traditional
v assisted
Garden – hard v soft landscaping
Semi structured interview findings
• Satisfaction with care homes very high
• Most rated built environments highly
Very positive for mood
• Bedroom, garden if accessible
Moderately positive
• Communal rooms – lounges, dining rooms
Least positive
• Entrance areas
Reasons
• privacy, personalization, accessibility
Independent architectural checklist Influences on mood
Univariate analyses show trends towards better mood
if
• Warm, welcoming design
• Group living arrangements (smaller subunits)
• Open transparent design
Design preferences
Strongest preferences for
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Soft landscaping of gardens, with variety of planting
Accessible design of garden
Single storey buildings
Assisted bathroom style
Grouped seating spaces
Multifunctional spaces
Open transparent design of communal spaces
Conclusions
Study deficiencies include
• Convenience sample, may be unrepresentative
• Unvalidated mental health measures
But
Built environment may affect mood in care homes
• Research can identify what features of built environment
are important
• Multiple methods appropriate in new territory
• New tool developed to objectively describe built
environment
OLDER PEOPLE’S EXERCISE IN RESIDENTIAL ACCOMMODATION
PI Martin Underwood Warwick Medical School
OPERA
Co-investigators
OLDER PEOPLE’S EXERCISE IN RESIDENTIAL ACCOMMODATION
WMS
QMUL
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Sallie Lamb
Bart Sheehan
Scott Weich
Margaret Thorogood
Anne-Marie Slowther
Sandra Eldridge
Suzanne Parsons
Anne Spencer
Stephanie Taylor
Objective
Within Residential and Nursing Homes (RNHs)
• To evaluate the impact on depression of a 'whole home'
intervention, consisting of;
– training for residential and nursing home staff
– backed up with a twice-weekly physiotherapist-led
exercise class
OPERA
OLDER PEOPLE’S EXERCISE IN RESIDENTIAL ACCOMMODATION
Outcomes
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Depression (Geriatric Depression Scale – 15¹)
Collect data on
• Age
• Dependency
• Cognition
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Medical illness
OPERA
OLDER PEOPLE’S EXERCISE IN RESIDENTIAL ACCOMMODATION
¹Yesavage et al 1983
The interventions
• Control
– Depression awareness training
• Intervention
– Depression awareness training
– Physical activation programme
• Build into normal routine
– Walking aids & footwear
– Twice weekly group-based exercise based on best
evidence
OPERA
OLDER PEOPLE’S EXERCISE IN RESIDENTIAL ACCOMMODATION
The sample
• 77 care homes in
Warwickshire/London
• 1124 older residents in
these care homes
OPERA
OLDER PEOPLE’S EXERCISE IN RESIDENTIAL ACCOMMODATION
OPERA – current situation (Mar
2009)
• Pilot intervention in 3
Coventry homes
completed late 2008
• 2 received full
intervention, 1 control
home
• Recruitment of full set of
homes started Jan 2009
• 77 homes by Dec 2009
OPERA
OLDER PEOPLE’S EXERCISE IN RESIDENTIAL ACCOMMODATION
An opportunity
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Large cohort of older people in care homes
High quality depression outcome measure
Prospective data
Easy to capture built environment
No ethical barriers to conducting study
• Excellent PhD candidate – Rachel Potter
Research questions – PhD
study 2009-2012
• How can design features of care home
environment be measured?
• What is relationship between design
features and depressive symptoms
among care home residents?
OPERA
OLDER PEOPLE’S EXERCISE IN RESIDENTIAL ACCOMMODATION
Conclusions
• ‘Bespoke’ research into built
environment is possible but challenging
• Large scale research projects can
provide an opportunity to address built
environment questions.