Behavioral and mental health (BMH) conditions affect one in five adults in the United States each year, and are even more common among patients receiving care for medical conditions. According to the National Institute of Mental Health, the spectrum of BMH conditions includes anxiety, attention deficit disorders, autism spectrum disorders, bipolar disorders, depression, obsessive-compulsive disorders, post-traumatic stress disorder (PTSD), substance abuse, and suicide, among others. Up to 45% of patients admitted to the hospital for a medical condition or presenting to the emergency department with a minor injury also have a concurrent BMH condition. These BMH comorbidities increase the risk of psychological harm associated with care.
Safety and “therapeutic” design are equally important in settings that are not specifically intended for BMH conditions, because BMH patients often have physical health problems, too.
The implications of these statistics are two-fold: (1) BMH patients may be found anywhere within the facility, even if BMH concerns are not the primary diagnosis for admission, and (2) those being treated for BMH conditions are likely also in need of treatment for other conditions. In fact, they are more likely than the general population to require medical care (Druss & Walker, 2011). The widespread shortage of beds to handle BMH conditions, in conjunction with the reality of comorbidities, is being addressed with the design of new unit types, such as the medical behavior unit at the Children’s Hospital of Philadelphia (Dinardo, 2017) or Stabilization Units (Pinkerton & Johnson, 2017).
In this complex context of comorbidities, safety and “therapeutic” design (i.e., designing an environment that promotes psychological wellness and healing) are both important. This is not only true in settings that are “purpose-fit” for BMH, but also in health facilities of all kinds that serve patients with BMH comorbidities.
1. An estimated 8.1% of people 12 and older had a substance use disorder within the past year.
2. 17.9% of adults had experienced a mental health issue (not counting developmental disorders) within the past year.
3. 3.3% of adults experienced both a substance use disorder and a mental health issue during that timeframe.(Center for Behavioral Health Statistics and Quality, 2016)
Most design teams acknowledge that providing BMH patients with a healing, therapeutic environment should be an important goal for health design, but the evidence base for designing for BMH in medically -oriented healthcare facilities has focused almost exclusively on physical safety. While safety is obviously the right place for the healthcare design community to start when designing for BMH, it is clearly not the right place to stop. Similarly, “normative” approaches have been criticized as oversimplifying the complexity of designing for BMH (Chrysikou, 2012). However, emerging evidence and expert opinion suggest that certain design features are important for BMH treatment facilities/units (Karlin & Zeiss, 2006; Shepley et al., 2016; Shepley & Pasha, 2013):
Many of these design features have also proven beneficial in other patient populations and may contribute to the comfort of staff members and visitors. For this reason, design interventions aimed at improving the psychological well-being of patients with BMH comorbidities may be more cost-effective than they initially appear if design teams leverage a universal approach to support improved well-being for all populations.
When behavioral and mental health patients receive care for their physical health conditions, it is important that this care is delivered in a safe and therapeutic environment (i.e., an environment that promotes psychological wellness and healing). Adding to the complex picture of behavioral and mental health (BMH) conditions is the variety of spaces in which care can be delivered: inpatient, outpatient, residential, or emergency departments. The design of the environment can either enable recovery, health, and wellness, or act as a barrier to restoration.
Between 25–45% of patients admitted to the hospital for medical care have one or more BMH comorbidities.
Most research on designing for patients with BMH conditions has focused on psychiatric units or specialized BMH care facilities. However, it is equally important to consider settings that are not purpose-built for BMH conditions. In fact, patients with BMH conditions are more likely than the general population to require medical care(Druss & Walker, 2011)
Behavioral and mental health conditions are a common source of poor health in the U.S. (Center for Behavioral Health Statistics and Quality, 2016; National Institutes of Health, 2007). Each year, one out of every five adults experiences one or more BMH conditions, but many do not receive the care they need. Fifty-six percent of U.S. adults with a mental illness go without treatment, along with 80% of adolescents with depression (Mental Health America, 2016).
1. 68% of people with BMH conditions also have at least one concurrent medical condition (comorbidity).
2. 29% of people with a medical condition also have a BMH comorbidity.
(Druss & Walker, 2011)
In fact, access to BMH care is so poor that adults with severe mental illness are three times more likely to be found in a jail or prison cell than in a psychiatric hospital bed, leading Torrey et al. (2010) to conclude, “America’s jails and prisons have become our new mental hospitals” (p. 1).
Not only do BMH conditions increase the risk of medical conditions, but medical conditions (and treatments) can also increase the risk of BMH conditions. And both share common risk factors (Druss & Walker, 2011).
BMH comorbidities are especially common among those who require hospital care. Between 25–45% of patients admitted to the hospital for medical care have one or more BMH comorbidities (Doupnik, Feudtner, & Marcus, 2017; Fulop, Strain, Fahs, Schmeidler, & Snyder, 1998; Levenson, Hamer, Silverman, & Rossiter, 1986), and as many as 45% of patients who present to the emergency department with a minor physical injury may meet the diagnostic criteria for a positive BMH history or current BMH condition (Richmond et al., 2007).
These BMH comorbidities often go unreported by patients and undetected by clinicians (Mayou, Hawton, Feldman, & Ardern, 1991; Richmond et al., 2007). This means that reactive interventions that are implemented only in response to a diagnosis cannot succeed in providing a safe and therapeutic environment for patients with BMH comorbidities. Instead, these design interventions must operate for all patients, at all times, in all areas of the hospital.
Historically, efforts to improve design for people with BMH conditions have focused mostly on specialized BMH facilities or units, and mostly on safety. This work has informed the development of widely-adopted guidelines and regulations to support best practice in mitigating the risk of self-harm and harm to others (Hunt & Sine, 2016; New York State Office of Mental Health & architecture +, 2012).
As knowledge in this field has grown, it has become increasingly apparent that proactive, hospital-wide solutions are required to promote physical safety. As mentioned above, patients with (often unrecognized) BMH comorbidities are treated in all areas of the hospital. Moreover, even the best available techniques for suicide risk assessment and violence risk assessment are not reliable predictors of patient outcomes (Fazel, Singh, Doll, & Grann, 2012; Large et al., 2016). As a result, recent Joint Commission guidance clarifies that ligature points and other “self-harm environmental risks” must be identified and removed from all areas of the hospital unless they are necessary for the treatment of the patient (The Joint Commission, n.d.).
Avoidable patient suffering is “the affective experience of pain or emotional harm (anxiety, fear, distress, etc.)” that is not “an inherent part of [a] patient’s diagnosis or treatment.” (Card & Klein, 2016, p. 32)
But protecting patients with BMH conditions from physical harm is not enough. Providing a safe and healing environment requires a “whole hospital” design strategy to protect patients against both physical and psychological harm, and to promote healing and health-related quality of life.
Psychological well-being is a core component of health (Card, 2017; Engel, 1977). So when the hospital environment impairs psychological well-being and contributes to avoidable patient suffering, it is causing real patient harm, and undermining the mission of the healthcare organization (Card & Klein, 2016). In short, designing the hospital to promote the psychological well-being of those with behavioral and mental health conditions is the right thing to do.
A major barrier to this kind of design improvement is that the proportion of patients with behavioral and mental health comorbidities is perceived as small, which makes the business case look poor. Despite evidence that 25–45% of hospital patients have BMH comorbidities, this misperception can be difficult to change.
However, while those with BMH conditions are the most vulnerable to environmentally-mediated psychological harm, all are susceptible. So the kinds of design interventions that might improve psychological well-being for patients with BMH comorbidities may also benefit other users of the facility (e.g., other patients, staff, and visitors). Considering design interventions in this broader context can help to make a stronger business case for improvements to support those with BMH comorbidities.
Healthcare is a complex adaptive system(Wieman & Wieman, 2004)
, which means (among other things) that changes made at one point in the system, and aimed at one specific goal, will usually have other consequences elsewhere in the system. While these consequences are often unintended, they are not necessarily problematic. They can be positive, negative, or—perhaps more often—both.
For instance, adopting shock-absorbent flooring materials to reduce harm from patient falls might also have the positive consequence of reducing foot and leg pain in nurses, and the negative consequence of increasing back pain among patient transport workers who push wheelchairs, gurneys, and beds all day.
There are often benefits to other users when applying solutions that may be specifically intended to support one group. For example, pictograms for wayfinding that are intended to serve those with language barriers may also help those with dyslexia or visual impairment, or those who are simply dealing with a high cognitive load (e.g., an agency nurse, parents visiting a sick child, etc.). Hallway benches intended to assist older adults with mobility problems might also provide a space for families to gather and talk without waking a sleeping patient.
Universal design is the design of products and environments to be usable by all people, at every changing level of need, to the greatest extent possible, without the need for adaptation or specialized design. (Piatkowski & Taylor, 2016)
The classic example of this is the way mobility ramps or curb cutouts designed to meet ADA requirements not only help wheelchair users, but also parents with strollers, people with wheeled luggage, workers pushing handcarts, etc. Proactively making accommodations to enable accessibility for one group also lowers barriers for many others. Because of these broader impacts, the mobility ramp is far more cost-effective at the systems level than it appears when only wheelchair users are considered. Contrast this with a reactive approach in which accommodations are put in place only when a wheelchair user arrives. It is clear that relying on a reactive approach fails to support all the other populations who might benefit from a ramp.
These examples highlight the benefits of universal design. An extension of Story’s definition of universal design (1997), proposed in an earlier brief (Piatkowski & Taylor, 2016), also serves as the premise for the present approach: “Universal design is the design of products and environments to be usable by all people, at every changing level of need, to the greatest extent possible, without the need for adaptation or specialized design.”
Current practice in health facility design often equates universal design with ADA compliance. But as this definition makes clear, its scope is much broader than simply designing for physical accessibility.
By taking a system-wide view from the start of a project and evaluating design proposals through the lens of universal design, it is possible to predict some of the broader consequences of a design intervention. This allows design teams to accentuate the positive consequences and eliminate (or at least mitigate) the negative. This approach, in which these broader impacts are treated as an intentional component of a design intervention, can enable much more sophisticated assessments of cost and benefit.
The goal of this approach is to design healthcare settings that provide a therapeutic environment for patients with BMH comorbidities, while proactively maximizing “spillover benefits” for patients without BMH comorbidities, staff, and visitors.
While there is little existing evidence focused specifically on designing for medical patients with BMH comorbidities, emerging evidence and expert opinion suggest that certain design features are important for BMH treatment facilities/units (Karlin & Zeiss, 2006; Shepley et al., 2016; Shepley & Pasha, 2013). Many of these may also be applicable to universal design for psychological well-being in hospitals. Examples include:
Some of these design features may be more applicable to certain patient populations than others. For instance, patients who spend longer in the hospital might benefit more from designs that support social interaction outside of patient rooms, or from a homelike environment that promotes autonomy, than patients with a very short length of stay.
Identify the unmet needs of patients with BMH comorbidities
Consider other populations that might benefit from (or be harmed by) design features that address these needs
Select and implement design features that meet the needs of patients with BMH comorbidities, while maximizing benefits/minimizing harms for other users of the facility
Evaluate outcomes and share learning to help advance the evidence base.
Other design features are likely to help everyone. Noise control, for instance, will reduce stress and other noise-induced health impacts for all building users. Similarly, exposure to sunlight has a host of benefits across different categories of hospital users. And both of these design features may improve sleep, which plays a crucial role in both physical and psychological healing.
There are several ways a benefit analysis for a more universal approach might be considered. With each, the goal would be to balance the benefits with both first and long-term costs/cost avoidance. Three possible approaches are listed below.
Start Big. The first approach would identify a design consideration widely used for most populations in healthcare (e.g., access to daylight/sunlight, access to outdoors) and consider the benefit for an “unknown” BMH population (the 25–45% of inpatients suffering from comorbid conditions of BMH). This would also require thought for any mediation that might be required for patients with BMH comorbidities (e.g., restricted window opening or control of window shade devices).
Start Small. Conversely, teams could evaluate specific features used in behavioral health-specific environments (e.g., anti-ligature fixtures in bathrooms) and apply the same solutions to more general environments where the behavioral health patient may not be known, but where a “traditional” design would pose risk (e.g., sink with ligature points, shower curtains).
Start by Exploring. Lastly, in purpose-built facility/unit types that address specific populations across the continuum of BMH, there should be a clear articulation of benefits, risk, and potential cost avoidance for solutions to create both a safe and healing environment.
A supplemental tool provides a suggested framework for data extraction of the evidence that can be used for prioritization and discussion.
Providing health to all patients requires a focus on both physical and psychological well-being. A very large proportion (25–45%) of hospitalized patients are especially vulnerable in terms of psychological health due to pre-existing BMH comorbidities. It is crucial that this be taken into account in the (re)design of healthcare facilities. Specifically, designers should engage stakeholders in an evidence-based design process to:
This approach will not only help designers and healthcare organizations make better decisions about how to address the needs of patients with BMH comorbidities, but also help to make the case for taking action in the first place. Design interventions aimed at improving the psychological well-being of patients with BMH comorbidities may be more cost-effective than they initially appear if a universal design approach is used to extend the benefits of these interventions to other populations (e.g., other patients, staff, and visitors).
Bayramzadeh, S. (2016). An Assessment of Levels of Safety in Psychiatric Units. HERD: Health Environments Research & Design Journal, 10(2), 66–80. https://doi.org/10.1177/1937586716656002
Card, A. J. (2017). Moving Beyond the WHO Definition of Health: A New Perspective for an Aging World and the Emerging Era of Value-Based Care. World Medical & Health Policy, 9(1), 127–137. https://doi.org/10.1002/wmh3.221
Card, A. J., & Klein, V. R. (2016). A new frontier in healthcare risk management: Working to reduce avoidable patient suffering. Journal of Healthcare Risk Management, 35(3), 31–37. https://doi.org/10.1002/jhrm.21207
Center for Behavioral Health Statistics and Quality. (2016). Key Substance Use and Mental Health Indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (No. SMA 16-4984, NSDUH Series H-51). HHS. Retrieved from https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.htm
Chrysikou, E. (2012). From Normalization theory to a “‘Fit for Purpose’” architecture for the mentally ill. World Health Design, 5(July).
Dinardo, A. (2017, September 19). Safe Haven: Children’s Hospital of Philadelphia [HCD Magazine]. Retrieved October 13, 2017, from https://www.healthcaredesignmagazine.com/projects/safe-haven/
Doupnik, S. K., Feudtner, C., & Marcus, S. C. (2017). Family Report Compared to Clinician-Documented Diagnoses for Psychiatric Conditions Among Hospitalized Children. Journal of Hospital Medicine, 12. https://doi.org/10.12788/jhm.2698
Druss, B. G., & Walker, E. R. (2011). Mental disorders and medical comorbidity (Research synthesis report No. 11) (p. 26). Princeton, NJ: Robert Wood Johnson Foundation.
Engel, G. L. (1977). The need for a new medical model: a challenge for biomedicine. Science (New York, N.Y.), 196(4286), 129–136.
Fazel, S., Singh, J. P., Doll, H., & Grann, M. (2012). Use of risk assessment instruments to predict violence and antisocial behaviour in 73 samples involving 24 827 people: systematic review and meta-analysis. BMJ (Clinical Research Ed.), 345, e4692.
Fulop, G., Strain, J. J., Fahs, M. C., Schmeidler, J., & Snyder, S. (1998). A prospective study of the impact of psychiatric comorbidity on length of hospital stays of elderly medical-surgical inpatients. Psychosomatics, 39(3), 273–280. https://doi.org/10.1016/S0033-3182(98)71344-1
Hunt, J., & Sine, D. (2016). Design Guide for the Built Environment of Behavioral Health Facilities: Edition 7.1. White Paper/Guidelines, Facility Guidelines Institute. Retrieved from https://www.naphs.org/Design%20Guide%205_2%20FINAL.pdf
Karlin, B. E., & Zeiss, R. A. (2006). Environmental and Therapeutic Issues in Psychiatric Hospital Design: Toward Best Practices. Psychiatric Services, 57(10), 1376–1378. https://doi.org/10.1176/ps.2006.57.10.1376
Large, M., Kaneson, M., Myles, N., Myles, H., Gunaratne, P., & Ryan, C. (2016). Meta-Analysis of Longitudinal Cohort Studies of Suicide Risk Assessment among Psychiatric Patients: Heterogeneity in Results and Lack of Improvement over Time. PloS One, 11(6), e0156322. https://doi.org/10.1371/journal.pone.0156322
Levenson, J. L., Hamer, R., Silverman, J. J., & Rossiter, L. F. (1986). Psychopathology in medical inpatients and its relationship to length of hospital stay: a pilot study. International Journal of Psychiatry in Medicine, 16(3), 231–236.
Mayou, R., Hawton, K., Feldman, E., & Ardern, M. (1991). Psychiatric problems among medical admissions. International Journal of Psychiatry in Medicine, 21(1), 71–84. https://doi.org/10.2190/NDPB-YCW9-BETA-AYJE
Mental Health America. (2016). The State of Mental Health in America 2017. Alexandria, VA. Retrieved from http://www.mentalhealthamerica.net/issues/state-mental-health-america
National Institutes of Health. (2007). Information about Mental Illness and the Brain. National Institutes of Health (US). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK20369/
New York State Office of Mental Health, & architecture +. (2012, July). Patient Safety Standards, Materials and Systems Guidelines. Design Guidelines, Albany, NY. Retrieved from http://www.omh.ny.gov/omhweb/patient_safety_standards/guide.pdf
Piatkowski, M., & Taylor, E. (2016). Universal Design: Designing for Human Needs. Issue Brief, The Center for Health Design. Retrieved from https://www.healthdesign.org/insights-solutions/universal-design-designing-human-needs
Pinkerton, P. J., & Johnson, J. L. (2017). Design practices contribute to stabilization unit safety. Behavioral Healthcare Executive, (June), online.
Richmond, T. S., Hollander, J. E., Ackerson, T. H., Robinson, K., Gracias, V., Shults, J., & Amsterdam, J. (2007). Psychiatric Disorders in Patients Presenting to the Emergency Department for Minor Injury. Nursing Research, 56(4), 275–282. https://doi.org/10.1097/01.NNR.0000280616.13566.84
Shepley, M. M., & Pasha, S. (2013). Design Research and Behavioral Health Facilities (Literature Review) (pp. 1–81). Concord, CA: The Center for Health Design. Retrieved from https://www.healthdesign.org/sites/default/files/chd428_researchreport_behavioralhealth_1013-_final_0.pdf
Shepley, M. M., Watson, A., Pitts, F., Garrity, A., Spelman, E., Kelkar, J., & Fronsman, A. (2016). Mental and Behavioral Health Environments: Critical Considerations for Facility Design. General Hospital Psychiatry, 42, 15–21. https://doi.org/10.1016/j.genhosppsych.2016.06.003
Story, M. F., Mueller, J. L., & Mace, R. L. (1997). The Universal Design File: Designing for People of All Ages and Abilities (Revised). NC State University, The Center for Universal Design. Retrieved from http://eric.ed.gov/?id=ED460554
The Joint Commission. (n.d.). Ligature risks: Assessing and mitigating risk for suicide and self-harm. Retrieved July 19, 2017, from http://www.jointcommission.org/standards_information/jcfaqdetails.aspx
Torrey, E. F., Kennard, A. D., Eslinger, D., Lamb, R., & Pavle, J. (2010). More Mentally Ill Persons Are in Jails and Prisons Than Hospitals: A Survey of the States (p. 22). The National Sheriff’s Association & The Treatment Advocacy Center.
Wieman, T. J., & Wieman, E. A. (2004). A systems approach to error prevention in medicine. Journal of Surgical Oncology, 88(3), 115–121. https://doi.org/10.1002/jso.20121