In the United States, an estimated 68 percent of adults with a mental health affliction have at least one concurrent medical condition and 29 percent of people with medical conditions have a behavioral mental health disorder, according to a 2011 health policy brief by the Robert Wood Johnson Foundation. With the general population’s access to services often limited by availability, financial constraint, or stigma, these totals may be understated.
This medical and behavioral health comorbidity, which is the simultaneous presence of two or more diseases that encompass both mental health and medical conditions, can be due to causality, environmental risks factors, or even to chance. A 2008 report in the American Journal of Medicine by Dr. Wayne Katon addressed comorbidity of type 2 diabetes and depression, indicating that each condition can influence the other.
For example, depression has a direct negative effect on glucose metabolism and may increase insulin resistance thereby increasing the risk of developing type 2 diabetes. Equally, the constant demand of caring for one’s type 2 diabetes, including monitoring symptoms and maintaining dietary and exercise regimens, can lead to depressive states.
For many, medical and behavioral health comorbidity is not a single episode, but an affliction that lasts a lifetime. As people live longer and the stigma of mental health eases, there will only be more instances of patients seeking out care for mental health with an underlying medical condition, or vice versa.
Successful healthcare organizations will be those that care for the whole person with facilities designed to support patients, their families, and staff, while being mindful of the populations they serve. For example, a space for veterans coping with post-traumatic stress disorder (PTSD) and cardiovascular health may be different than one for a family caring for their autistic child with feeding issues. While some with PTSD may benefit from calming spaces with cool colors and natural ambient sounds, others with hypo-sensitive autism may prefer bright colors and strange noises.
With the wide range of patient populations and conditions possible, the best opportunity for healthcare design is to create spaces that are safe for as many people as possible. This begins with understanding and mitigating the potential risks of a population and preparing the environment to accommodate the best level of care with flexibility and adaptation. It also includes addressing staff needs so that they can protect their own health, safety, and welfare as they care for others.
In an inpatient setting, dedicated units for the care of those who need the highest level of medical care—called medical-psychiatric units (MPU)—ensure that patients’ psychiatric care is not delayed while their acute medical needs are being treated. These facilities are designed like behavioral health units with ligature-resistant fixtures and tamper-resistant finishes. Unlike typical medical units they also consider programmatic spaces like group rooms and areas for staff and patients to interact and are staffed with specialized clinicians or multidisciplinary teams of medical and mental health providers who can provide the right care for each patient.
For both inpatient and outpatient settings, implementation of universal design strategies, such as access to fresh air, views, and daylight, can be beneficial to many. These architectural components, including skylights, windows, or doors, can be detailed and built in a way to prevent patient concealment or reduce ligature risk or escape while still benefitting the occupants.
Additional strategies include the use of onstage/offstage configurations that conceal support functions from patients, which can help to reduce anxiety or distress of patients and protect staff. However, it should be noted that this solution may also increase the overall footprint of a unit. Wayfinding symbols in lieu of words can help those with dyslexia as well as those with language barriers, while becoming part of an organization’s graphic branding.
Institutions have an incentive to address mental health comorbidity across the continuum of care as it directly impacts their bottom line. A 2020 report from the Center for Health Information and Analysis found that inpatient stays for this population are on average a one-and-a-half days longer and readmission rates are nearly twice as high as those without diagnosed behavioral health comorbidity. Pediatric readmission rates are three times higher.
Successful design for medical and behavioral health comorbidity comes down to humanizing space in a way that respects the dignity of every person seeking care. As designers we can help by advocating for design that embraces humanity, enhances safety, and helps destigmatize mental health while creating spaces that are thoughtful and beautiful.
Jenny Cestnik, AIA, ACHA, EDAC, NCARB, is a medical planner, designer, and architect at ZGF Architects (Portland, Oregon). She can be reached at firstname.lastname@example.org.