EHJ October 2004, pages 302-304
Public health campaigners are recognising the role mental health plays in wellbeing. Tina Bexson considers noise nuisance and hoarding and asks if it's time for EHPs to include mental illness in their public health remit

Historically, public health has primarily concentrated on the physical effects of the environment, with the thornier subject of mental health being largely uncharted territory, and outside its remit. Issues such as air quality, food safety, housing, and odour pollution, and their consequences for health, have dominated the agenda.

But there now appears to be a sea change in the focus of public health, with environmental and public health organisations and campaign groups starting to at least address mental health issues, and how they are related to the environment and different forms of environmental stress, and most of all, how environmental health departments can effectively deal with them.

In their joint response to the government's white paper on public health, the CIEH and the Royal Society for the Promotion of Health recently said they would like to see a "strong emphasis and clear policy focus on the role of the built environment in promoting mental wellbeing".

They also acknowledge that the "lack of adequate housing, overcrowding in rented accommodation, and the number of people in temporary accommodation, all create mental health burdens and help reinforce inequalities".

So does noise. In fact, noise is a powerful and useful example of how the environment can impact on mental health and influence levels of stress and annoyance, as well as triggering depression and anxiety.

As we know, public health has always included noise in its remit but it has rarely addressed its differing mental health effects, especially on people with existing mental health problems. Noise can exacerbate their condition and induce relapse. People with mental health problems can also affect the environment themselves by causing noise and, as we shall see later, other housing-related problems such as hoarding.

Mary Stevens from the National Society for Clean Air and Environmental Protection (NSCA) says that noise has in the past "been bandied around by the former environment minister Michael Meacher as the Cinderella pollutant, and so it hasn't always been taken into consideration in the areas of health".

It should be. World Health Organisation (WHO) guidelines say that noise can adversely affect performance, for example in reading, attentiveness, problem solving and memory. They also say that a "link between community noise and mental health problems is suggested by the demand for tranquillisers and sleeping pills, the incidence of psychiatric symptoms and the number of admissions to mental hospitals".

But noise assessment is problematic, and the real effects of noise are largely unknown. As leading noise expert, Prof Stansfeld, has pointed out in A review of environmental noise and mental health, the question of whether environmental noise exposure causes mental ill-health is still largely unanswered.

However, at the CIEH conference on the Local environment, housing, and mental health in May this year, he did outline that noise disturbs activities and communication, causing annoyance and that, in some cases, annoyance may lead to stress responses, then symptoms and possibly illness. Also the response to noise may depend on characteristics of the sound, including intensity, frequency, duration and meaning of the noise.

He also warned that action plans to deal with noise should be evidence-based and focused on what works. But evidence-based research is lacking. The results of what research has been done has been woolly. As Ms Stevens points out: "Because there are so many different factors involved in the effects of noise on health and mental health, it makes it difficult to quantify. So, the reason the government has been so slow to conduct research in the past is because it has said there is no proof of a direct cause and effect as there is with, say, air pollution and negative health effects."

There have, though, been some developments. The Department of Health has recently set up an ad hoc advisory group on the health effects of noise and, over the next 12 months, it will be looking into whether there is a need for a longer term standing group on noise and health.

Also, the Department for the Environment, Food and Rural Affairs' (Defra) ongoing noise research programme, which includes the much publicised noise mapping, seeks to provide evidence-based advice to support policy and the development of statutory and voluntary controls for neighbour, neighbourhood and environmental noise in the UK and Europe.

What is more, Defra acknowledges that the factors influencing human reactions to noise and the options for dealing with the problems are many and complex and that, although noise is an inevitable consequence of human activity, much more needs to be done to minimise the nuisance it causes, and the potential adverse effects on health.

Neighbourhood noise is one of the biggest stressors for people. It has also become somewhat of a bete noir for local authority noise teams too, despite their recent successes in some areas.

A report by NSCA Wales, Noise interventions and health: a silent scream, found that people find neighbourhood noise more annoying and disturbing than any other types of noise, including traffic and noise from louder sources, because of its general irregularity. "If noises are regular you can ignore them."

The Mori Social Research Institute conducted public opinion research in 2003 to assess the nature, extent, and significance of noise. One-in-seven (14 per cent) identified neighbour noise as a problem affecting quality of life. Among certain groups, such as residents in high density flats, it became one of the most significant quality of life issues.

Mori's research gives two main reasons as to why noise from neighbours is most disturbing. First, people appear to develop a certain degree of immunity to noises from traffic and trains, but this doesn't apply to the irregularity and lack of utility from neighbour noise. Second, it says that neighbour noise is "considered synonymous with a lack of consideration".

"This is critical to understanding the dynamics of disputes and shows the importance of the social context of noise as opposed to its purely physical attributes," it adds.

Mori's priorities for noise services include ensuring housing policy is central to the resolution of noise complaints, and ensuring there is an "impact assessment of any new legislation to ensure it is practicable, resourced and enforceable on the ground".

It also found that there is very little awareness of local noise services, concluding that this is "an area for immediate attention". Mori's results will feed in to Defra's programme of work towards a UK noise strategy.

There are still no national statutory guidelines on how local authorities should deal with noise. All we have is the CIEH's management code, which is voluntary, with only a handful of local authorities using it. Considering our European neighbours' lack of fear when it comes to imposing regulations about community living, this could be down to a very British dread of a "nannying state".

However, some legislation has recently been updated. Since the end of March this year, local authorities have had new powers to issue fixed penalty notices to those found responsible for domestic night-time noise offences, as brought in via the amendment to the Antisocial Behaviour Act 2003.

But as many EHPs have found, in reality, fixed penalty notices are not always that practical. Noise teams usually consist of only one or two people dealing with late night complaints and often having to fight for their safety or endure reprisals from noise makers. There's also the problem of how cost-effective it is to have a 24-hour noise patrol.

Another issue concerns the fact that the laws governing the effects of the environment on wellbeing and living ignore mental health considerations and tend to treat "people" as a homogeneous group.

As Val Weedon from the Noise Network points out, the nuisance law under the 1990 Environmental Protection Act is the main law which EHPs use to decide whether a nuisance occurs, but it excludes people with "sensitivities".

"It could be argued that those with mental health problems are the people with 'sensitivities'," she explains. "If so, then they are being excluded from any legal remedy. If they are complainants about noise, then the law should be rewritten to protect them."

"There are roughly five deaths a year from murder and suicide as a result of noise. Some of them already had mental health problems, some didn't. But it was the noise that pushed them over the edge," she adds. In its fact sheet on community noise, the WHO says that noise "above 80dB may increase aggressive behaviour".

Environmental Health News has recently reported cases of "noise rage", including that of a Middlesbrough man who stabbed his neighbour to death because he was fed up with the man's alleged DIY noise (EHN, 3 June, page 3), and a Littlehampton woman who stabbed her neighbour to death following a dispute about the victim's daughter playing loud music at midnight (EHN, 13 August, page 5).

We cannot comment on the exact motives of these offenders but Val Weedon argues that: "The main point of the issue is that it's noise that triggers the violence, and so it's noise that must be dealt with. WHO backs this up, saying it's far better to take a precautionary and preventative attitude towards noise."

Noise can also affect the rehabilitation of people with existing mental health problems. Paul Farmer, director of public affairs at Rethink, believes that people with a severe mental illness have the right to receive the best quality of support to help them recover a meaningful quality of life. "The right environment is crucial because the needs of people with severe mental illness cannot be met by the NHS alone," he says.

"When someone is discharged from hospital after being prescribed a medicine that helps treat their schizophrenia, the right home environment is vital for the best chance of recovery. "Our own research has found that only 1 per cent of people using mental health services are happy with their quality of life. Factors like poor housing and noisy neighbours may contribute to this poor quality of life, and increase the chances of relapse."

Most importantly, he says that given how much mental health and the environment are connected, "environmental health officers may need to find out more about mental illness".

People with mental health problems can of course, inadvertently cause environmental problems themselves. Then we have a catch 22 situation with the local environment and housing conditions of those people further deteriorating with neglect.

Howard Price, CIEH principal policy officer, recently presented a paper at CIEH conference on environment, housing, and mental health. He explains that hoarding gives an example of how mental health problems can affect the immediate environment. Hoarding generally only comes to the attention of local authorities when neighbours complain about pests or smell and unsightliness. The CIEH will be publishing an extended paper in the autumn which will include some examples of good practice guidelines. Mr Price says their aim was to look at how better to deal with problems like hoarding.

"I had a sense that the outcome of the way we [the environmental health profession] handle these problems is not very successful. They tend to return quite quickly. So, I wanted to look into whether there was a more effective and sensitive way of dealing with the people who are, by most definitions, ill. I don't think there's a magic bullet for this phenomenon, but it still deserves a closer look.

"Although a huge number of people hoard - there's a whole spectrum of it - there comes a point when the opinion that some hoarders are simply those not conforming to society's norms, doesn't hold water any more. The medical model defines that as the point when hoarding starts to impair the sufferer's function. This is when something ought to be done.

"A particular manifestation is called Diogenes syndrome, which affects elderly people. It is estimated to affect one in every 2,000 who are over 60 years old." Mr Price has asked local authorities for recent experiences of hoarding and got 77 replies from a possible 402. They collectively report on a total of 209 cases in the last calendar year.

"The dilemma, is that EHPs have little discretion and what they are driven to do by a statutory duty is not effective." Echoing Val Weedon's comments, he says that EHPs' "duty does not acknowledge any individual difference". "The laws tend to treat people as being the same," he says. "They do not give any consideration to the underlying causes [of hoarding]."

Mr Price adds that: "Although the success rate of EHP intervention is low, [they are best] when the subjects are treated as individuals and support is tailored accordingly."