Nature and Mental Health An Ecosystem Service Pers

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SOCIAL SCIENCES Copyright © 2019

The Authors, some
Nature and mental health: An ecosystem rights reserved;
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service perspective American Association
for the Advancement
of Science. No claim to
Gregory N. Bratman1,2,3,4*, Christopher B. Anderson3,5, Marc G. Berman6,7, Bobby Cochran8, original U.S. Government
Sjerp de Vries9, Jon Flanders10,11, Carl Folke12,13,14, Howard Frumkin15,16, James J. Gross17, Works. Distributed
Terry Hartig18,19, Peter H. Kahn Jr.1,20, Ming Kuo21, Joshua J. Lawler1,2, Phillip S. Levin1,2,22, under a Creative
Therese Lindahl14, Andreas Meyer-Lindenberg23, Richard Mitchell24, Zhiyun Ouyang25, Commons Attribution
Jenny Roe26, Lynn Scarlett27, Jeffrey R. Smith3,5, Matilda van den Bosch28,29, NonCommercial
License 4.0 (CC BY-NC).
Benedict W. Wheeler30, Mathew P. White30, Hua Zheng25, Gretchen C. Daily3,4,5,31*
A growing body of empirical evidence is revealing the value of nature experience for mental health. With rapid
urbanization and declines in human contact with nature globally, crucial decisions must be made about how to
preserve and enhance opportunities for nature experience. Here, we first provide points of consensus across the
natural, social, and health sciences on the impacts of nature experience on cognitive functioning, emotional
well-being, and other dimensions of mental health. We then show how ecosystem service assessments can be
expanded to include mental health, and provide a heuristic, conceptual model for doing so.
Downloaded from http://advances.sciencemag.org/ on July 24, 2019

INTRODUCTION These efforts rely increasingly upon models that relate scenarios
Human well-being is linked to the natural environment in myriad of change in ecosystems to change in the provision of services (7),
ways, and actionable understanding of these links is deepening in and they have been adopted on an international scale. For example,
diverse disciplines (1–3). Many of the contributions of living nature the Natural Capital Project’s InVEST models (for Integrated Valuation
(diversity of organisms, ecosystems, and their processes) to people’s of Ecosystem Services and Tradeoffs) are being used in 185 countries
quality of life can be referred to as “ecosystem services.” They in- around the world (6). The InVEST models are based on production
clude water purification, provision of food, stabilization of climate, functions that define how changes in an ecosystem’s composition,
protection from flooding, and many others (2). Worldwide, major configuration, and function are likely to affect the flows and values
efforts are underway to bring ecosystem services and their values of ecosystem services across a landscape or seascape. They are open
into policy, finance, and management (4–6). source and are being tested and adapted through a broad network.
In some areas, such as in hydrology, this modeling is advanced and
1 builds upon decades of work, although challenging frontiers remain
School of Environmental and Forest Sciences, University of Washington, Seattle, WA
98195, USA. 2Center for Creative Conservation, University of Washington, Seattle, WA (8). In other areas, such as pollination services for agriculture and
98195, USA. 3Center for Conservation Biology, Stanford University, Stanford, CA human nutrition (9), the modeling and its empirical basis are in com-
94305, USA. 4The Natural Capital Project, Stanford, CA 94305, USA. 5Department of paratively early stages of development. These models are designed
Biology, Stanford University, Stanford, CA 94305, USA. 6Department of Psychology,
University of Chicago, Chicago, IL 60637, USA. 7Grossman Institute for Neurosci-
to be used in an ensemble to estimate change in multiple ecosystem
ence, Quantitative Biology, and Human Behavior, University of Chicago, Chicago, IL services.
60637, USA. 8Willamette Partnership, Portland, OR 97239, USA. 9Wageningen Environ- To date, these modeling and decision-making efforts have focused
mental Research, Wageningen University and Research, Wageningen, Netherlands. predominantly on services tied to biophysical dimensions of Earth’s
10
School of Biological Sciences, University of Bristol, Bristol, UK. 11Bat Conservation
International, Austin, TX 78746, USA. 12Global Economic Dynamics and the Biosphere, life-support systems and more recently on cultural services (10).
Royal Swedish Academy of Sciences, Stockholm, Sweden. 13Stockholm Resilience However, relatively little attention has been given in the field of eco-
Centre, Stockholm University, Stockholm, Sweden. 14Beijer Institute, Royal Swedish system services to the ways in which nature experience directly af-
Academy of Sciences, Stockholm, Sweden. 15Wellcome Trust, London, UK. 16School
of Public Health, University of Washington, Seattle, WA 98195, USA. 17Department fects human mental health (see Box 1 for our definitions of “nature”
of Psychology, Stanford University, Stanford, CA 94305, USA. 18Institute for Housing and “nature experience”), with a few important exceptions (11). This
and Urban Research, Uppsala University, Uppsala, Sweden. 19Department of Psy- omission is particularly concerning in light of indications that mental
chology, Uppsala University, Uppsala, Sweden. 20Department of Psychology, Uni-
versity of Washington, Seattle, WA 98195, USA. 21Landscape and Human Health
illness accounts for a substantial proportion of suffering in all re-
Laboratory, Department of Natural Resources and Environmental Sciences, Univer- gions of the world (12). The fraction of the total global burden of
sity of Illinois, Urbana, IL 61801, USA. 22The Nature Conservancy, Seattle, WA 98121, disease (GBD) attributable to mental illness has recently been estimated
USA. 23Central Institute of Mental Health, Medical Faculty Mannheim/University of to be as high as 32% of total years lived with disability (YLD) (13)
Heidelberg, Mannheim, Germany. 24Centre for Research on Environment, Society
and Health, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK. and 13% of disability-adjusted life-years (DALYs), on par with car-
25
State Key Laboratory of Urban and Regional Ecology, Research Center for Eco- diovascular and circulatory diseases (13). It is important, therefore, to
Environmental Sciences, Chinese Academy of Sciences, Beijing, China. 26Center for determine the degree to which nature experience might lessen this burden—
Design and Health, University of Virginia, Charlottesville, VA 22904, USA. 27The
Nature Conservancy, Fairfax, VA 22203, USA. 28School of Population and Public
and to integrate these effects into ecosystem service assessments.
Health, University of British Columbia, Vancouver, British Columbia, Canada.
29
Department of Forest and Conservation Sciences, University of British Columbia,
Vancouver, British Columbia, Canada. 30College of Medicine and Health, University NATURE EXPERIENCE AS A DETERMINANT OF MENTAL HEALTH
of Exeter Medical School, Exeter, UK. 31Stanford Woods Institute, Stanford University,
Stanford, CA 94305, USA. A variety of interacting factors can affect mental health, including
*Corresponding author. Email: [email protected] (G.N.B.); [email protected] (G.C.D.) social, economic, psychological, physiological, behavioral, environmental,
Bratman et al., Sci. Adv. 2019; 5 : eaax0903 24 July 2019 1 of 14

contributing to a decrease in nature contact include perceived bar-

Box 1. Definitions. riers (such as fear) (18), increased time spent indoors and on screens,
Mental health. Mental health is defined by the World Health Organization and decreased outdoor recreation activities (see the Supplementary
as “a state of well-being in which [an] individual realizes his or her own Materials for references). In recent decades, investigators in public
potential, can cope with the normal stresses of life, can work productively health and health economics have intensified empirical research on
and fruitfully, and is able to make a contribution to her or his community” the role of nature contact and the environment as a general health
(101). Conceived in this way, mental health encompasses (i) the absence promoter, including mental health (11, 19–22). Excluded from
of mental illness and (ii) the presence of psychological well-being.
our considerations here are the clear ways in which nature contact
Mental illness entails the occurrence of disorders of cognition, affect,
and behavior, typically defined through The Diagnostic and Statistical
may be harmful to health, such as wildfires, wildlife attacks, and
Manual of Mental Disorders (102) or the International Classification of allergies.
Diseases (103). These include highly prevalent conditions such as
depression, anxiety, dementia, and substance use disorders, as well as less
common but often severe illnesses such as schizophrenia, autism, and PUTTING SCIENCE INTO PRACTICE
bipolar disorder. There is a clear demand from practitioners and decision makers to
Psychological well-being comprises multiple affective and cognitive incorporate the emerging evidence regarding the mental health ef-
components, including happiness—both hedonic (enjoyment and fects of nature experience into ecosystem service assessments and
pleasure) and eudaimonic (purpose, meaning, and fulfillment)—self- policy. Here, we frame the positive mental health values of engaging
actualization (accomplishments, optimism, and wisdom), resilience
with nature as “psychological ecosystem services.” We begin with
(capacity to cope, adaptive emotion regulation, and lack of maladaptive
an overview of the evidence base, culminating in statements of con-

problem-solving), and healthy relationships (104). For the purpose of this
framework, we also include aspects of cognitive functioning (e.g., sensus reflecting our collective knowledge. From this foundation,
attention and working memory) and a lack of mental distress (e.g., stress we then propose a conceptual model for the mental health effects
and loneliness). derived from nature experience.
Nature encompasses elements and phenomena of Earth’s lands,
waters, and biodiversity, across spatial scales and degrees of human
influence, from a potted plant or a small urban creek or park to expansive, THE BODY OF EVIDENCE
“pristine” wilderness with its dynamics of fire, weather, geology, and other Research has shown that various types of nature experience are as-
forces (105). sociated with mental health benefits in many ways (23–28). For
Nature experience includes individuals’ perceptions and/or
instance, controlled laboratory studies have demonstrated benefi-
interactions with stimuli from the natural world (from potted plants and
private gardens to more expansive public green space and wilderness,
cial psychological and stress/physiological impacts of nature images
weather, and the movements of the sun) through a variety of sensory and sounds (29). Experimental fieldwork has also shown the bene-
modalities (sight, hearing, taste, touch, and smell) (22). These experiences fits of nature experience by contrasting within-group change across
can occur through conditions of “real” (in situ) contact, window views, affective, cognitive, and physiological dimensions in participants who
representations (e.g., landscape photographs), or simulations (e.g., virtual walked in natural versus urban environments (30–32). Cross-sectional
reality). They may be deliberate or incidental, will ordinarily be colored by and longitudinal research has found that the psychological well-being
personal associations and sociocultural meanings, and can occur in the of a population can be associated, in part, with its proximity to green
context of diverse activities (e.g., park visits and passive viewing). Within space, blue space (i.e., aquatic and marine environments), and street
this broad range of types of experiences, our primary focus in this paper is trees or private gardens in both urban (33–37) and rural settings
on the benefits received from interactions with nature in situ, as this is
(38). Some cross-sectional studies suffer from the presence of con-
most relevant to the ecosystem service framework.
founders (e.g., neighborhood-level socioeconomic characteristics),
while other experimental and longitudinal work addresses and illu-
minates causal mechanisms (21).
genetic, and epigenetic influences (14). It is important to note that, Although many of these findings are correlational, the confluence
in many cases, these social and environmental determinants of health of results from experimental and correlational studies is encouraging.
may outweigh the effects of nature contact on specific outcomes. In particular, there is now a mounting body of evidence from experi-
Contextual factors determining global levels of mental illness and mental studies that nature exposure plays a causal role in improving
health include, but are not limited to (see the Supplementary Materials affect in the short term. What is currently less well established is
for references), marked demographic shifts in the world’s popula- whether these affective changes play a causal role in influencing
tion (such as aging), social shifts involving increased stress and lone- longer-term mental health.
liness, physical shifts to more sedentary lifestyles, and the factor upon Mental health benefits may vary by socioeconomic status, pref-
which we focus here—certain aspects of urbanization and a loss of erences, residential location, occupation, personality traits, culture,
many avenues for experiencing nature on a regular basis for some gender, and age (39). Effects may also differ according to the type of
people (15). interaction with nature (described below) (40), and the form of
Several aspects of contemporary lifestyles are associated with re- sensory input (e.g., visual, olfactory, auditory, or tactile). In addi-
duced routine nature contact. One is urban living (15). Cities are tion, little is known about the duration of these effects, although
centers of prosperity, employment opportunities, access to education, some studies have found that some benefits last for substantial
health and human services, and cultural advancement, all aspects of periods of time (see the Supplementary Materials for references).
life that may promote mental health (16). However, they can also be This is an important aspect to consider when framing nature exposure
associated with decreased access to nature, especially for individuals as a benefit to long-term mental health. It also bears noting that much
living within economically deprived urban areas (17). Other factors of this work is situated in urban contexts within the Global North

(41). Diversification to other locales and sociocultural perspectives sively unavailable to new generations, this creates an ever-narrowing
would greatly extend understanding. spectrum of nature experiences (65). An “environmental genera-
tional amnesia” and “extinction of experience” (66) may stem from
each generation’s reduced experience of “wildness” (or increased
CONSENSUS STATEMENT #1: EVIDENCE SUPPORTS experience of environmental pollution)—shifting the baseline of
AN ASSOCIATION BETWEEN COMMON TYPES OF NATURE reference points for the acceptable quality, richness, and variation
EXPERIENCE AND INCREASED PSYCHOLOGICAL WELL-BEING in nature experiences (67).
A wealth of studies has demonstrated that nature experience is
associated with psychological well-being. These include investiga-
tions of single as well as cumulative occasions of nature contact, and MOVING FORWARD: SUPPORTING MENTAL HEALTH
range from experimental to observational designs. The forms of AS AN ECOSYSTEM SERVICE
association include evidence that links nature experience with in- These consensus statements underpin our conceptual model. The
creased positive affect (26, 30, 32); happiness and subjective well- evidence in this arena is building to a point at which we may soon
being (42); positive social interactions, cohesion, and engagement be enabled to make meaningful (even if not extremely precise) pre-
(43, 44); a sense of meaning and purpose in life (45); improved dictions regarding the impacts of environmental change on mental
manageability of life tasks (46); and decreases in mental distress, health. Here, we propose a way forward that harnesses existing
such as negative affect (32, 47). In addition, with longitudinal stud- knowledge to eventually incorporate it into ecosystem service
ies, as well as natural and controlled experiments, nature experience assessments. Psychological and social processes differ from bio-
has been shown to positively affect various aspects of cognitive func- and geophysical processes. They exist in changing historical and

tion (48), memory and attention (30, 32, 49), impulse inhibition (50), cultural contexts, and even short-term changes are susceptible to
and children’s school performance (51), as well as imagination and multiple determinants. Given current knowledge, the model can
creativity (52). only address average, population-level impacts, with the aim of
eventually being able to distinguish and specify effects as they occur
at the individual, subgroup (e.g., gender and age categories), or at-
CONSENSUS STATEMENT #2: EVIDENCE SUPPORTS risk subpopulation (e.g., people with depression and ADHD) levels.
AN ASSOCIATION BETWEEN COMMON TYPES OF NATURE Nonetheless, our approach is broadly guided by other ecosystem
EXPERIENCE AND A REDUCTION OF RISK FACTORS AND BURDEN service models, insofar as we trace a pathway from environment to
OF SOME TYPES OF MENTAL ILLNESS mental health (Fig. 1).
Nature experience has been associated with improved sleep (53) and In step 1, we characterize and define “natural features” (includ-
reductions in stress, as assessed by self-report and various physio- ing size, type, composition and spatial configuration, biodiversity,
logical measures and biomarkers of acute and chronic stress (32, 35). and other attributes of land covers/uses). In step 2, we characterize
These impacts on sleep and stress may entail decreased risk for “exposure” of people to nature (and/or type of “use”) through an
mental illness, as sleep problems and stress are major risk factors for accounting/estimation of the proximity of this nature to people. In
mental illness, especially depression (54). In addition, there is grow- step 3, we illustrate some of the crucial specifics of nature exposure
ing evidence that nature experience is associated with a decreased (i.e., nature experience) through the approaches captured in the no-
incidence of other disorders [see (28, 55, 56) for reviews on the ef- tions of “interaction pattern” and “dose.” In step 4, we account for
fects of green space on specific psychopathologies, including anxiety the mental health effects of nature experience via the translation of
disorders (57), attention deficit and hyperactivity disorder (ADHD) this nature experience into specific mental health benefits. Separately
(58, 59), and depression (60, 61)]. Several of these associations are (see Box 2), we discuss what may be involved in placing a value on
moderated by various contextual and individual factors, such as these benefits, in monetary or other terms.
socioeconomic status, gender, and age (62).
In both consensus statements above, we include studies that have Step 1: Natural features
demonstrated significant associations, with a range of certainty re- This step characterizes the elements of nature potentially influencing
garding correlation versus causation. It is essential that future re- mental health and includes size (total area), composition (propor-
search continues to specify and investigate underlying pathways tions of different types of natural elements), and spatial configura-
and causal mechanisms to refine understanding of the relationships tion (e.g., degrees of fragmentation and connectivity with other
between the environment and human well-being. green space) of natural landscapes. Other relevant natural attributes
may include tree canopy density, vegetation structure, species com-
position, or biodiversity (68, 69). Data can be gathered from a variety
CONSENSUS STATEMENT #3: EVIDENCE SUGGESTS THAT of sources (e.g., remote sensing and fieldwork) and can be opera-
OPPORTUNITIES FOR SOME TYPES OF NATURE EXPERIENCE ARE tionalized in different ways (e.g., land-use classification maps and
DECREASING IN QUANTITY AND QUALITY FOR MANY PEOPLE databases).
AROUND THE GLOBE Determining which aspects of natural features are relevant to
Over the past century, people have been increasingly concentrated mental health—and should therefore be considered in this step—is
in urban areas. In many instances, modern living habits involve re- a key research frontier and will be informed through an iterative
duced regular contact with outdoor nature and increased time spent process via an evolution of insights and evidence regarding effects
indoors, on screens, and performing sedentary activities (63, 64). (see step 3). For example, are some tree species more beneficial than
This disengagement from nature may be partially driven by a nega- others (70)? Is a diversity of tree species in a forest more beneficial
tive feedback loop. As direct nature experiences become progres- than a monoculture stand (71)? It is also important to note that little

Box 2. Valuation and decision-making contexts.

There is a considerable literature describing the monetary valuation of
mental health. Analyses have focused on the avoided costs of mental
illness and on the economic benefits of happiness, well-being, and
thriving. A range of methods has been used in these cases, including
direct market valuation, indirect market valuation (avoided cost, factor
income, hedonic pricing, etc.), and contingent valuation (106). In general,
mental distress and mental illness account for considerable costs, and
relief of such suffering yields large benefits for society and the individuals
affected (107, 108). Improved learning and work productivity resultant
from nature contact may also have positive economic impacts (109).
However, monetary value is only one of many ways to quantify the
mental health benefits produced by nature exposure. Many noneconomic
measures of quality of life, well-being, and happiness have been
developed (110), both in clinical settings and in sustainability science, and
these may have a role in valuing mental health as an ecosystem service.
One example is the DALY, now a standard currency in quantifying burden
of disease and potentially suitable in ecosystem services calculations.
Another form of valuation includes a ranking approach (rather than

absolute values) that projects the expected relative benefits of alternative
scenarios of change in a specific location.
These valuation approaches can help reveal the contribution of
ecosystems to mental health in decision-making. With a more complete
picture, decision makers can more fully consider the repercussions of
losing or enhancing access to nature, in the context of urban design,
including the spatial layout of built and natural environments, and
proximity to workplaces and homes. Valuation can help inform judgments
of whether to invest in nature and how to do so while also considering
other pressing needs. Our knowledge regarding the magnitude of mental
health benefits on their own may not be enough to justify the costs
associated with increasing nature within cities, but together with benefits
such as water quality, flood security, urban cooling, and recreation, we can
obtain a more complete picture of the impact of these types of decisions.
Fig. 1. A conceptual model for mental health as an ecosystem service. (1) Nat-
ural features include the characteristics (size, type, and qualities such as configura-
tion) of the nature under consideration. (2) Exposure is estimated through methods Step 2: Exposure
that take proximity, likelihood, and duration of nature contact into account. (3)
Exposure is a broad term, here referring to the amount of contact
Experience characterizes the types, forms, and intensity of experience that expo-
sure instantiates. (4) Effects (i.e., mental health impacts) will vary according to the
that an individual or population has with nature. Because data on
moderating influences of individual differences and sociocultural context, which actual exposure are usually not available, especially in cases in which
may affect the impact experienced by people [here represented conceptually by we are concerned with hypothetical scenarios, actual exposure is often
groups A to D (e.g., different age groups)], members of which may receive different estimated by access/availability metrics based on the presence of the
benefits from nature experience, given these moderators. It is also possible that a types of natural features identified in step 1.
group will receive a net negative effect due to individuals’ aversion to urban green The proximity of people to nature is likely to be a large determi-
spaces or the negative repercussion of green gentrification in their area, for example nant of exposure. A watershed located 50 km outside a city might
(represented conceptually by group B). Photographs are from the public domain generate considerable ecosystem services in provision of clean wa-
and free for public use. ter to the city but not much opportunity for everyday interaction
with the landscape. Conversely, the presence of a small city park
is known about relationships between ecological integrity or com- may result in extensive nature exposure for neighborhood residents
plexity and mental health benefits. It may be that places intermediate and commuters.
on the wild-anthropogenic spectrum, tuned to some common At present, there is a limited repertoire of methods for estimat-
evolutionary-based human preferences, are associated with better ing nature exposure based on geography. Ekkel and de Vries (73)
mental health (72). Our lack of certainty with respect to these and have identified two principal approaches: cumulative opportunity
other questions regarding the relationship between nature and mental and proximity measures.
health underscores the need for future research. It is also a reminder Cumulative opportunity is based on the proportion of nature within
that the purpose of this endeavor is to create a conceptual model a spatial unit that incorporates individuals’ location (typically a res-
with which to integrate the best available evidence, wherever that idence). Using sources such as satellite images or land-use databases,
may stand, as the field evolves. We must also consider how aspects this proportion is generally calculated as the percentage of an area
of natural features result in various amounts of exposure, given the of interest (a zip code area, census block, etc.) that comprises natu-
different opportunities for direct and indirect nature contact they ral elements (e.g., street trees, green space, and blue space). A cu-
afford. This is addressed in the next step. mulative exposure metric for a population can then be derived for a

given spatial unit based on this composition score (e.g., percentage

of green space) (73). Proximity measures typically estimate use and
exposure to nature as a function of direct physical distance to the
nearest nature area of a certain size, usually from a place of resi-
dence. Walking time from residence to nature has also been used as
a proximity measure.
These and other approaches, based primarily on estimations of
average exposures, show mixed levels of reliability in their associa-
tions with health outcomes (74). As metrics are further developed,
frequency and duration of exposure should be considered, as well as
aspects of the natural features themselves (from step 1). For exam-
ple, the composition, spatial configuration, and other features of
nature will influence the amount of exposure that a population will
experience (intentionally or otherwise) due to resultant differences
in accessibility (Fig. 2). Other characteristics of these natural spaces
(e.g., amenities, upkeep, and perceived safety), as well as park pro-
gramming that is effectively tailored to neighborhood populations,
may moderate the relationship between natural features and expo-
sure through encouraging or discouraging visitation or affording

opportunities for different activities (75). In future iterations of the
model, we can look to methods used by recreation and cultural eco-
system service models for ways to isolate predictors of visitation to
areas in a landscape (e.g., participatory Geographic Information
Systems (GIS), interviews, social media data mining, and other methods)
(10). Where available, primary data on actual nature exposure (versus
potential or opportunity for exposure) can also be incorporated.
With respect to characteristics of beneficiaries, the model should
eventually account for the sociodemographic, cultural, perceptual,
attitudinal, and behavioral differences that influence the tendency
for seeking out nature exposure (76, 77). Measurement approaches
based on location alone can fail to account for differences in expo-
sure that are due to factors such as access to transportation corri-
dors, time demands, income disparities, and perceived safety. They
can also fail to take into account the specifics of the exposure itself—
an aspect that can be measured in a variety of ways, including eco-
logical momentary assessment techniques, designed to understand Fig. 2. Configuration and composition of urban green space. Along with other
peoples’ psychological states in given geographical contexts (78). This factors, spatial configuration and composition should be considered when esti-
consideration brings us to step 3. mating nature exposure. Different shades of green here represent different types
of nature [e.g., clusters of open lawns (A to C) versus trees (D to F)], which are em-
Step 3: Experience bedded within urban surroundings. Despite these differences, all panels have the
The third step in the model accounts for the experiential character- same total amount of nature (34 street blocks). Vertical contrasts illustrate differ-
ences in configuration of this nature [e.g., (A) versus (B) versus (C)]; horizontal con-
istics of nature exposure—what we term nature experience. In moving
trasts illustrate differences in its composition (i.e., type of nature) [e.g., (A) versus
from nature exposure to mental health effects, we need to consider
(D)]. Images (A) to (F), ©2017 Google; images (A)–(C) and (D)–(F) are photographs
these specifics. Though attuned to pragmatic considerations regard- from the public domain and free for public use.
ing data availability, neither cumulative opportunity nor proximity
measures account for some relevant aspects of nature experience,
including, for example, the sensory qualities of the exposure. Al- One way of modeling this human-nature interaction is in terms of
though much of the research literature defaults to eyesight as the “interaction patterns”—a description of the meaningful ways in which
primary modality for nature contact (79), the auditory, tactile, and human beings interact with nature, characterized at a level of ab-
olfactory modalities are also important to consider (80). Effective straction such that it can be applied across different forms of nature.
park programming can also have a substantial impact on the ways in For example, walking along the edge of water and land can occur at
which users interact with natural spaces, and thereby help deter- the ocean or alongside a lake or river. To date, around 150 human-
mine how these sensory pathways are engaged (21). Two approach- nature interaction patterns, with photos and descriptions for many
es suggest ways to classify nature exposure and characterize nature of them, have been generated and catalogued (40, 81). Future stud-
experience: ies can look at specific health outcomes of people who engage not
Interaction only in specific forms of interaction but also in constellations of them.
The specific ways in which people interact with nature may account Dose
for differential impacts of nature exposure on mental health (40). Toxicologists distinguish between “exposure,” the amount or intensity
Looking at water is different from swimming in water, for example. of a physical, chemical, or other environmental agent that reaches

the target population or organism, and “absorbed (or internal) dose,” ronmental change (e.g., planting of urban trees for heat or pollution
the amount taken up by an organism and/or delivered to the target mitigation).
organ (82). Exposure and dose can vary considerably in toxicology, Consider a decision-making context in which practitioners would
if, for example, two people exposed to the same concentration of an like to estimate the impacts of planting residential street trees on the
air pollutant breathe at very different rates. A similar phenomenon prevalence of mental illness. Using our model, they would initially
may operate with respect to nature contact (83) via different levels gather information regarding the natural features of the relevant
of attention, preference, and feelings of personal connection with region (step 1). In this particular case, available data might consist
nature (84). People have different levels of awareness and percep- of information on existing and proposed tree distribution, the spe-
tions of natural environments (85) in their attitudes and receptivity cies of trees, and perhaps some information on tree structure, likely
toward nature, childhood experiences, and sense of connectedness gathered from city databases and natural history accounts. Practi-
to nature—factors that probably affect the delivered dose that re- tioners could also deduce planned composition and configuration
sults from a given exposure. The transition from dose to effects cor- of the trees from consulting the planning proposals from the city.
responds to what economists call a production function, and what However, other aspects of the natural features (e.g., bird song, height
toxicologists and epidemiologists quantify using a dose-response of trees, care, and maintenance) may not be available.
curve. We discuss more on the multiple potential causal mecha- As the body of empirical research grows, practitioners could consult
nisms below in step 4. a central data repository containing multiple studies or meta-analyses
with effect sizes documented at the relevant scale for given outcomes
Step 4: Effects of interest. This would be necessary to make a prediction with any
The fourth and final step of our conceptual model involves a char- degree of certainty or scientific rigor. Continuing with the concep-

acterization of the potential mental health impacts that follow from tual exercise, in our present example, decision makers might con-
nature experience. Epidemiologic and experimental studies have sider the outcome of antidepressant prescription rates as a crude
revealed a range of effects, as summarized above (see consensus proxy for depression prevalence. To do this, they could consult
statements), although most have omitted step 3, going straight from Taylor et al. (89) as an empirical study upon which to base a predic-
step 2 to step 4 (for exceptions, see the Supplementary Materials for tion. In this case, they would need to temper the confidence in their
references), and calculated associated effects from an exposure metric prediction with the knowledge that they were extrapolating from a
(thereby neglecting to account for “experience”). The production of single correlational study.
mental health benefits from nature experience may occur through Given the approach used in this particular study, the calculation
multiple psychological causal mechanisms and pathways, including of exposure (step 2) would be based on the change in street tree density
reduction of stress, increases in social cohesion or physical activity, in a residential neighborhood. From this exposure metric, practi-
or replenishment of cognitive capacities, to name just a few. In many tioners could then apply the association found between the density
cases, the same natural area will engage multiple mechanisms during of street trees and the rate of antidepressant prescribing, in which a
each single experience (24, 86, 87) so that the cumulative effects at- regression analysis indicated that each additional tree per kilometer
tributed to any single pathway may be misestimated. Current in- of street was associated with 1.38 fewer antidepressant prescriptions
sight into each of these mechanisms is incomplete. However, the (95% confidence interval, 0.03 to 2.72) per 1000 population per year.
evidence regarding the effects themselves is sufficient to support Critically, we note that this rough, potential exposure metric
some decision-making contexts (discussed below) that encourage (i.e., step 2) does not incorporate qualities addressed in step 3 (ex-
nature contact to promote health (24, 33, 88). perience) into its results, as the source paper itself did not take these
As with the characteristics of exposure, the effects of nature expe- details into account, and we therefore cannot properly integrate
rience will also depend on age, gender, current affective state, and these components into the calculations. Factors from other studies
other personal characteristics (e.g., preferences for nature) (35, 36, 62). that do speak to mechanisms thought to mediate the relationship
The types of mental health benefits will also vary (e.g., cognitive between the presence of street trees and the distribution and char-
function, mood, and stress reduction). Some will relate to psycho- acteristics of mental health outcomes could be integrated in future
logical well-being, and others will relate to relevant factors for the iterations of the model and will almost certainly increase the accu-
onset of disease. The range of these outcomes includes population- racy and validity of the effects on a causal level. We have also not
level indicators and clinical-level measures, assessed through self- accounted for effect modification by individual- and population-
report, physiological measures, and other approaches. level differences in potential beneficiaries. Basing predictions on
simple regression analyses lacks precision. This rough calculation thus
likely comes with a large degree of error, but can provide insight
AN EXAMPLE APPLICATION nonetheless, and inform decisions better than not taking mental
Given the degree of complexity and the need for future iteration, it health services into account at all.
is helpful to consider an example application of this conceptual To address effects (step 4), practitioners would calculate the num-
model to illustrate its potential for informing decisions regarding ber of people within the “ecoserviceshed” (i.e., the part of the land-
land use, urban planning, or environmental management (Fig. 3). scape providing these particular ecosystem services) of the street
We briefly describe a hypothetical decision-making context below trees. Controlling for other independent predictors of antidepressant
and define the steps that one might take in applying the conceptual prescription derived from Taylor et al. (89) (e.g., income), decision
model. As stated above, while many factors affect health through makers could then calculate a potential total benefit, defined as a
complex pathways, this model relates only to a subset of environ- decrease in antidepressant prescriptions (considered here as a crude
mental factors. In addition, we do not account here for the other proxy for a decrease in mental illness). It is possible then to calculate
potential impacts or benefits of scenarios involving planned envi- a value of this output using global estimates of the cost of depression.


Fig. 3. A hypothetical application of the conceptual model using a case study for which antidepressant prescription is the outcome. Information is gathered for
each of the three steps. (1) Natural features in this case are street trees (other characteristics unspecified, including spatial configuration). (2) Exposure is calculated using
a cumulative exposure approach regarding residential street tree density (spatial configuration illustrated here for conceptual purposes but not relevant to this estima-
tion metric). (3) Dose and/or interaction were not taken into account. (4) The effect of decreased antidepressant (AD) prescriptions in areas with more street trees is rep-
resented along with other potential benefits (e.g., stress and working memory) not projected specifically in this case, although they are represented conceptually. As
illustrated in Fig. 1, different nature options provide benefits that we can quantify over and above a “no nature” version of an urban plan. The model allows us to compare
net benefits (total benefits less costs) of different viable plans. Benefits will also likely vary according to the moderating influences of individual differences and sociocul-
tural context, here represented conceptually by groups A to D, as people receive different benefits from nature experience given these moderators. Photographs are from
the public domain and free for public use.
Despite the limitations of this approach, it is possible that this pre- and many more people have subclinical levels of depressive or other
diction will be a lower bound of the total mental health benefits symptoms), and assessed with regard to one period of time. We
provided, as it is context dependent (i.e., depends on the probability that emphasize again the intention behind this exercise, especially given
a depressed person will receive an antidepressant prescription—a the cross-sectional results upon which it is based: to give a hypo-
feature of physician practice patterns, the health care system, and thetical workthrough of a conceptual model, the accuracy of which
other factors), based on only one form of disorder and dimension of will be refined through successive iteration and incorporation of
association (e.g., many depressed people are not diagnosed or treated, empirical data as they are generated by the research community.

CONCLUSION researchers can run clinical trials that explicitly test the impacts of
Diverse stakeholders, including city planners, landscape architects, nature versus urban experience (or another comparison condition) on
engineers, parks departments, developers, infrastructure providers, psychological well-being and mental health. An increasing openness
health professionals, community-based organizations, and environ- to support these study designs has been demonstrated through
mental advocates, could use a tool that helps them anticipate the foundations and governmental funding institutions. Third, the use
mental health impacts of decisions they make relating to the envi- of prospective cohorts and ecological momentary assessment pro-
ronment. Although the magnitude and distributions of these im- vides a valuable context for assessing associations of within-individual
pacts are still questions requiring further research, practitioners are change in mental health with nature contact over time using large
nonetheless in need of the best available evidence to inform deci- samples of participants.
sions that may have repercussions for mental health. Reports are These and other situations provide opportunities to make and
beginning to be generated in response to this demand, including a refine predictions of the impacts of nature contact on mental health,
recent example in which the relative value of mental health benefits through a priori estimates based on emerging evidence, and a test-
was calculated to be 7% of the total economic benefits of London ing of the predictions through observations of actual change over
parks, a large fraction (amounting to ca. £6.8 billion over 30 years) time in real-world contexts. Through this iterative process, the con-
given that the major economic benefit considered was higher prop- ceptual model can evolve from its current state into an ever more
erty values (90). robust tool for pragmatic implementation and predictive value.
With respect to general health, models are already starting to be Ultimately, our evolving conceptual model can broaden current
applied within these contexts. Examples include urban tree canopy ecosystem service models by accounting for the effects of nature
restoration to improve air quality (91), the siting of new park loca- exposure on mental health, and identifying where additional green

tions to improve physical activity (92), and efforts to use environ- spaces or better access to nature may improve it, or where certain
mental investments to advance health equity (93). This last point is infrastructure, building siting, and other land-use decisions may
critical. Given the emerging evidence base for the benefits of nature negatively affect it. Given the large contribution of mental illness to
contact, greater effort should be made to increase access to nature to the global burden of disease, these are essential issues to address.
help address the significant health inequities that people from low- With respect to modeling, mental health benefits typically co-occur
opportunity neighborhoods experience, in contrast to their privi- with other ecosystem service benefits and may therefore be consid-
leged counterparts. A greater recognition of the relationship between ered “co-benefits” to other services with longer research histories.
nature exposure and mental health is also likely to highlight income- These include heat-island mitigation, flood protection, and water
related inequalities and provide one of many possible pathways to security in cities, all of which are now being incorporated into the
reduce them. Removing social and physical barriers to nature contact Natural Capital Platform (7). The development of this tool must be
is an issue of environmental justice (94–98) (see the Supplementary scrutinized critically for accuracy as it evolves. But as it continues to
Materials for additional references). be refined, incorporating its outputs into land-use and urban plan-
Throughout this paper, we have been careful to note the limita- ning decisions will enable considerations that might not otherwise
tions of the evidence base today, as well as the capacity and opportunity be made explicit. In this way, a critical aspect of environmental im-
to integrate existing evidence into predictions using a conceptual pact on human well-being may be incorporated into assessments of
model. These limitations point to important research frontiers in (i) the contributions from the natural world—and increase informed
moving beyond correlation to causal understanding of relationships efforts to conserve and manage it (100).
and (ii) filling priority gaps in predictive capacity through consider-
ation of often-confounded predictors of health. A great challenge is SUPPLEMENTARY MATERIALS
to distinguish the nature experience signal from other (in many cases Supplementary material for this article is available at http://advances.sciencemag.org/cgi/
content/full/5/7/eaax0903/DC1
stronger) social and environmental predictors of health (lack of op-
Table S1. Supplementary references.
portunity, insufficient amenities, racial prejudice, etc.). References (111–273)
Despite these limitations, we believe that there is a strong need
for this type of conceptual model. Planners and practitioners are
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Acknowledgments: This paper represents a consensus of diverse coauthors who C. Folke, H. Frumkin, J. J. Gross, T. Hartig, P. H. Kahn Jr., M. Kuo, J. J. Lawler, P. S. Levin, T. Lindahl,
developed the ideas and text together as part of a formal working group supported by the A. Meyer-Lindenberg, R. Mitchell, Z. Ouyang, J. Roe, L. Scarlett, J. R. Smith, M. van den Bosch,

Natural Capital Project, with funding from the Marianne and Marcus Wallenberg B. W. Wheeler, M. P. White, H. Zheng, G. C. Daily, Nature and mental health: An ecosystem service
Foundation and John Miller. We thank G. Young for superb research assistance. For perspective. Sci. Adv. 5, eaax0903 (2019).

Nature and mental health: An ecosystem service perspective
Gregory N. Bratman, Christopher B. Anderson, Marc G. Berman, Bobby Cochran, Sjerp de Vries, Jon Flanders, Carl Folke,
Howard Frumkin, James J. Gross, Terry Hartig, Peter H. Kahn, Jr., Ming Kuo, Joshua J. Lawler, Phillip S. Levin, Therese
Lindahl, Andreas Meyer-Lindenberg, Richard Mitchell, Zhiyun Ouyang, Jenny Roe, Lynn Scarlett, Jeffrey R. Smith, Matilda van
den Bosch, Benedict W. Wheeler, Mathew P. White, Hua Zheng and Gretchen C. Daily
Sci Adv 5 (7), eaax0903.

DOI: 10.1126/sciadv.aax0903

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contributing to a decrease in nature contact include perceived bar-

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Box 2. Valuation and decision-making contexts.

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given spatial unit based on this composition score (e.g., percentage

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