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Review

High‐Rise Apartments and Urban Mental Health—

Historical and Contemporary Views
Danica‐Lea Larcombe 1,2,*, Eddie van Etten 1, Alan Logan 2, Susan L. Prescott 2,3,4
and Pierre Horwitz 1
1 Centre for Ecosystem Management, School of Science, Edith Cowan University, 270 Joondalup Drive,
Joondalup, WA 6027, Australia
2 inVIVO Planetary Health, Research Group of the Worldwide Universities Network (WUN), 6010 Park Ave,

Suite #4081, West New York, NJ 07093, USA

3 School of Medicine, University of Western Australia, Nedlands, WA 6009, Australia

4 The ORIGINS Project, Telethon Kids Institute, Perth Children’s Hospital, 15 Hospital Avenue, Nedlands,

WA 6009, Australia
* Correspondence: [email protected]

Received: 20 June 2019; Accepted: 16 July 2019; Published: 31 July 2019

Abstract: High‐rise apartment buildings have long been associated with the poor mental health of
their residents. The aims of this paper are to examine whether this connection is necessarily so, by
reviewing the evidence relating to the relationships between high‐rise living and social wellbeing,
occupant’s stress levels, and the influence they have on mental health. From selected literature,
psychological stress and poor mental health outcomes of the populations that live in high‐rise
apartments are indeed apparent, and this is particularly so for apartments in poor neighbourhoods.
Yet many apartments in developed cities are in affluent areas (particularly those with views of
green/blue space), where residences on higher floors are more expensive. Either way, high‐rise
living and mental health outcomes are a social justice issue. Our review allows us to propose two
models relating to high‐rise living relevant today, based on these differences.

Keywords: high‐rise apartments; social justice; mental health; stress; wellbeing; socioeconomic
status

1. Introduction

1.1. History
High‐rise and vertical building is thought to have begun in the ancient civilizations of Egypt and
the Americas with the construction of pyramids, temples and community structures. The
architectural challenges of building multistorey residential buildings continued with the Roman
Empire [1]. Large modern high‐rise cities and suburbs began to emerge in the last century,
particularly across the United States, India, China, South East Asia and South America to house
booming populations and massive urban migration, with some of these experiencing overcrowding,
high‐crime rates and the development of slums, which has helped stigmatise the experience of living
in a high‐rise apartment as a negative one [2]. This stigmatisation was made worse by the calculated
use of high‐rise complexes to segregate disadvantaged communities. In the period between 1940 and
1980 projects—such as Pruitt‐Igoe in St. Louis, Clichy‐sous‐Bois in Paris, the Robert Moses‐
constructed projects in Harlem and the Bronx, and the Robert Taylor homes in Chicago—housed
segregated disadvantaged communities in high‐rise ‘boxes’ of poorly built, badly sited and under
landscaped residential complexes [3], with most ultimately housing far in excess of their intended

Challenges 2019, 10, 34; doi:10.3390/challe10020034 www.mdpi.com/journal/challenges

Challenges 2019, 10, 34 2 of 14

capacity. For example, America’s largest public housing project, the now demolished Robert Taylor
homes, was originally designed for 11,000 people, but at one point housed over 27,000 people, of
whom 95% were unemployed [4]. The escalating level of crime was such that in one weekend 300
separate shooting incidences were reported [5].
More recently, due to inner‐city land shortages and compact city policies to reduce urban sprawl,
a secondary high‐rise boom is occurring in many developed countries, with a greater focus on more
lucrative luxury apartment developments in inner cities and more established wealthier suburbs
[6,7]. Perhaps to avoid the stigma still attached to housing commission flats, developers have
fashionably adopted the term ‘apartment’ for these modern high‐rise blocks [8]. However, while
luxury buildings feature elaborate landscaping, spacious living areas and two or more bedrooms [9],
there is a continuing socioeconomic divide with large numbers of ‘budget’ high‐rises still found in
disadvantaged areas and/or near transport hubs [10]. These are typically more cramped and crowded
with lack of family privacy and significantly smaller in floor area than detached houses [11–13].
Today, people choosing to buy or rent high‐rise apartments are attracted by a number of
extrinsic and intrinsic qualities, although location and cost are usually the deciding factors [14].
Extrinsic factors include perceptions about neighbourhood and other residents [15], as well as
proximity to public transport, education facilities and workplaces. For some, this also includes social
facilities and nightlife [16]. Not having to maintain a house or garden may also be an extrinsic benefit.
Desirable intrinsic qualities that may increase a resident’s quality of life include the design of the
building, the layout, orientation and size of the apartment [15], views of the surrounding area and
safety features such as a security person employed in a lobby.
The majority of high‐rise apartment complexes are also less expensive for developers to build
than detached homes, so apartments cost less to purchase, even once common land attached to the
apartment building and maintained for an annual fee by an apartment owners corporation, is taken
into account [7]. In general, this also translates to cheaper accommodation for rental tenants. For this
reason, high‐rise apartments are increasingly preferred by government agencies providing housing
for socially disadvantaged people.
Although there are considerable regional variations, the majority of people living in apartments
in developed countries are singles or couples [17,18]. In Australia, only 12.5% of high‐rise apartment
dwellers are two‐parent families [19]. Apartment living is less appealing to families, because
children’s activity levels are restricted [1,20], and parents are reluctant to let young children play
unsupervised in common areas [18]. Apartment dwellers are typically younger people seeking
proximity to central locations or older generations no longer wanting to maintain a house and garden
or seeking a change in lifestyle [6,7].
The future shows a forward trend in the development of high‐rise apartment buildings, and in
the number of levels incorporated into each building [14,21], both to accommodate more people and
to reduce the individual carbon footprint. The sustainability and quality of life in these buildings
underscores the growing need for liveable high‐density cities [22] to better manage urban sprawl,
traffic congestion and infrastructure demands [16].

1.2. Living Conditions

High‐rise apartments of four stories and above [20] have been typically constructed to solve
housing and land shortages, and create affordable residential spaces. While this might provide
cheaper housing, it can also produce adverse living conditions: apartments can be isolated, difficult
to access, hard to ventilate, more elevated from the earth (the soil), and more quarantined from a
diversity of microbes, plants and animals than traditional housing [1,23]. This burden of adversity is
often greatest in socio‐economic disadvantaged communities in high‐density areas whose
circumstances also restrict access to parks, sporting complexes, gardens or other natural spaces, with
consequences for both physical and mental well‐being, as well as opportunities to meet and socialise
with others. Astell‐Burt and Feng [24] found that residents of poor socioeconomic areas were much
less likely to exercise—a known predictor of positive mental wellbeing. Many apartment buildings
Challenges 2019, 10, 34 3 of 14

also discourage or disallow pets, another factor increasing wellbeing. Dogs, for example, encourage
physical and social activity (including visits to green spaces) and meeting other dog owners [25–27].
While socioeconomic disadvantage and environmental stress are associated with higher
predisposition for mental health issues and drug and/or alcohol dependency, it is unclear whether
the ‘high‐rise environment’ is creating the living conditions that lead to mental ill health or whether
these environments attract residents that already have mental issues. And if the latter, do these
buildings make matters worse? The location, vista, floor level and size of the apartment determine
the purchase price or rental yield, and therefore the social demographic that will live there. For
example, apartments that were built with luxury in mind in a green interesting environment will
attract an older demographic that is seeking a low maintenance property in comparison with an
apartment built next to a freeway or railway station that has been built for a housing agency [10].
High‐rise buildings can have direct and indirect effects on health. Polluted air quality, unsafe
heating systems, the presence of toxic substances, pests, and overcrowding cause direct biological,
chemical or physical effects and are easier to address than indirect effects such as individual
characteristics and socio‐economic circumstances [28]. This paper focuses on the indirect effects on
health. We summarise the evidence for links between stress and social wellbeing in city settings,
specifically the relationships between high‐rise living and social wellbeing and occupant’s stress
levels, and their influence on mental health. We then formally review the literature on high‐rise living
and mental health and explore how exacerbation of mental health issues of high‐rise dwellers in poor
socio‐economic areas could be reversed with a number of strategies.

2. The Contribution of Stress and Social Well‐Being to Mental Health Problems

2.1. Stress and Mental Health

Mental health is essentially a measure of resilience, and has been defined as “the ability to adapt
personally and collectively to a given environment…to mature and fulfil potentials…living in
homeostatic balance” despite the changing environment [20]. However, there is every indication that
factors in the modern environment are eroding resilience and capacity to buffer stress. This is
reflected in the staggering increase in mental health disorders, especially anxiety and depression,
predicted by the World Health Organisation to become one of the major threats to human health by
2020 [29,30]. This also has implications for economic prosperity, as stress, depression and anxiety are
the second major cause (13.7%) of work‐related issues in Europe [31].
Stress, described in 1915 by Walter Cannon as ’an acute threat to the homeostasis of an
organism’, contributes to physical and psychological well‐being [32,33]. While humans can readily
adapt to acute stress, chronic stress can negatively affect brain structure and function [33]. This can
affect long term resilience and predisposition to a range of psychiatric diseases, including
schizophrenia, depression, and anxiety [34,35]. Susceptibility to stress is a reflection of complex
individual, community, social, and environmental factors, of which neighbourhood factors are
clearly important. Mental health disorders are more prevalent in urban areas, although the influence
of urban structure is not well known [36].
Living in high‐rise flats or apartments has been associated with higher rates of psychological
distress [37]. This is multifactorial and may relate to concerns about housing, feeling trapped in
deprived social environments [37], fears of falling from windows or balconies, being trapped by fire,
earthquake, or terror attacks [1,38], and fears of acquiring a communicable disease through sharing
elevator buttons, door handles and hallway air [1].
Of particular concern to public health are high‐rise buildings that were constructed during the
post‐war boom of the 1950–1970s of which many are in poor condition, house disadvantaged
communities and are located in low socioeconomic suburbs [28]. Architects in the 1970s raised
concerns that “there is abundant evidence to show that high buildings make people crazy” [39]. Even
today, there is a prevailing reputation of high‐rise housing as socially isolating living environments,
drug and crime havens and generally unhealthy places [28,40].
Challenges 2019, 10, 34 4 of 14

2.2. Mental Health and High‐Rise Living

2.2.1. Floor Level

First, we examined the role of floor level on mental health outcomes. One of the most
comprehensive studies on this relationship was examined by Evans et al. [12] who conducted a
critical review of the evidence on mental health and housing (including type, floor level and housing
quality). They found that six out of eight studies reported residents of higher floor levels to have
poorer mental health compared to residents of lower floors. Another study in Germany randomly
allocated the wives of British and Canadian servicemen to floors in three to four level blocks of flats.
The women on the fourth floor reported twice the levels of psychological distress as those living on
the ground floor [41]. In a study of 964 adults living in high‐rise flats in Scotland residents from the
fifth floor upwards experienced twice the number of symptoms of poor mental health as those on
lower floors and detached houses [42]. Similarly, a study found women on higher floors to have
greater levels of emotional strain in a study of 442 public housing residents [43].
Evans et al. [12] surmised that more mental health problems are experienced by families living
on upper floor levels. Panczak et al. [28] used data of 1.5 million people from the Swiss National
Cohort in a more recent study that looked at whether floor level was linked to cardiovascular disease
and found instead that people living on the eighth floor and above had a substantially increased
chance of suicide by jumping. It may be argued that this was because of easy access to a place of great
height but those people living above the eighth floor may have been socially isolated which
contributed to their mental health issues. From the fifth floor and upwards residents become
disconnected with what is going on in the world around them as they cannot see what is happening
on the ground [22,28,44].
In regards to floor level, it is not known whether people with existing mental health conditions
choose to live on higher floors, or whether this contributes to their condition via isolation factors;
although Moore [45] found that neurotic personalities living in flats were more likely to experience
psychiatric illness compared to stable personalities.

2.2.2. Street and Surroundings

Next, we examined whether poor socioeconomic ‘streets’ similarly contain socially
disadvantaged residents as has been shown for high‐rise buildings. According to McCarthy et al. [37]
symptoms of mental disorders are less likely to be found in streets of similar householders than in
high‐rise flats located within ‘inner‐city problem’ estates. Rates of psychological distress were
compared for different dwelling types located in ‘easy to let’ and ‘difficult to let’ council areas and
those who lived in ‘difficult to let’ high‐rise housing were shown to be particularly vulnerable. One
of the issues with unsatisfactory housing is that when residents get better opportunities and have the
resources to move out, they leave the more disadvantaged residents, thereby creating social ghettos
[37]. These people may not have a choice in their housing arrangements compared to residents of
high‐rise buildings in more affluent areas. From the above literature, it appears to be that the types
of areas people inhabit are more closely associated with mental illness. For example, Ellaway [46]
reported that residents’ negative perceptions of their surroundings were associated with poor mental
health. A study of four disadvantaged sites in Melbourne, Australia (two high‐rise and two detached
homes) found that high‐rise dwellers had greater negative perceptions of the neighbourhood that led
to poor health and well‐being than did residents in detached homes, thus leading to the conclusion
that a concentration of disadvantaged people in a high‐rise building not only increases crime and
insecurity for the surrounding area but decreases mental health for the residents [47].

2.3. Thematic Review

The literature was searched for articles assessing the relationship between high‐rise housing and
mental health and overall 25 relevant journal articles were found, including those already mentioned.
Synthesis of key themes, study focus and health outcomes of the 25 journal articles are presented in
Challenges 2019, 10, 34 5 of 14

Table 1. The method and full findings can be found in Appendix A. The majority of studies were
conducted by surveys, either self‐reported or by interview. The limitations of the searched literature
were that not all studies could be retrieved in full detail, and it was not clear how many floor levels
were in some of the earlier studies of flats.

Table 1. Summary of key themes, mental health study focus, high‐rise health outcome (in comparison
to low‐rise/detached houses) for 25 found articles from 1967 onwards assessing the relationship
between high‐rise housing and mental health across a broad spectrum of mental health categories (<
less, >greater).

Key Theme Mental Health Study Focus High‐Rise Health Outcome References
>social isolation Fanning [41]
<social support and involvement Wilcox and Holahan [48]
<social interaction Zalot and Webber [49]
<social networks McCarthy and Saegert [50]
Social isolation/less social
Social wellbeing Churchman and Ginsberg
interaction <social support
[51]
<social contact Levi, et al. [52]
>poor social outcomes Kearns, et al. [18]
>social isolation Chile, et al. [40]
Social wellbeing Alienation >feelings of alienation Amick and Kviz [53]
Psychological
Nervous disorders >neurotic scores Bagley [54]
health
>depression Moore [55]
>depression Richman [56]
>emotional strain Gillis [43]
>psychological distress McCarthy and Saegert [50]
Psychological Psychological problems i.e., <depression after moving out Littlewood and Tinker [13]
health depression >psychological distress McCarthy, et al. [37]
>psychological distress Husaini, et al. [57]
< stress coping skills Dasgupta, et al. [58]
>mental symptoms Hannay [42]
>worse psychosocial outcomes Kearns, et al. [18]
Psychological >suicide by jumping on higher
Suicide Panczak, et al. [28]
health floors
Psychological
Self‐rated health <self‐rated health Verhaeghe, et al. [44]
health
Psychiatric >neurotic personalities likely to Moore [45]
Psychiatric problems
health experience psychiatric illness Edwards, et al. [59]
Perceptions of
Sense of place neighbourhood factors that >perceived negative influence Warr, et al. [47]
influence health
Sense of control Sense of efficacy (control) >sense of efficacy after moving out Rosenbaum, et al. [60]

The studies in Table 1 clearly show an exacerbation of mental health problems in high‐rise
buildings in comparison to low‐rise or detached houses. Psychological problems (58%) and social
isolation (35%) featured prominently in the literature as areas of difficulty for apartment dwellers,
and contributing to this are socio‐economic factors and building design. Chile et al. [40] found
consistent experience and expression of social isolation across all age groups. Although there are
many factors that contribute to social isolation in high‐rise apartment living, social isolation in itself
is shown to be an important factor that contributes to mental health problems of high‐rise dwellers
[18,40]. It may be harder to form a community in high‐rise apartments as it feels as if one is living
with many strangers [18,50].
Many of the early study subjects of high‐rise apartments were women, and Richman [56] found
that complaints of depression were common. Gillis [43] found that higher floor levels predicted
higher levels of emotion strain, and Littlewood and Tinker [13] found that women showed fewer
symptoms of depression after moving out of high‐rise apartments.
Challenges 2019, 10, 34 6 of 14

3. Proposed Causal Sequences

The factors examined in this review are stress, social wellbeing and mental health, and how or
whether living in high‐rise buildings might be related to them. There are clearly a number of
confounding factors—such as the design of the buildings (although no studies have been found on
the link between building design and mental health), the place in which they are situated and the
type of person living in them—which may be modifying these relationships. Furthermore, the design
of many studies does not include prior status of health, and greater than 80% are correlative only.
Drawing from the early research conducted in the 1970s and 1980s, (mostly studied on non‐
affluent areas), and the construction of modern high‐rise apartments in western developed countries,
a divide exists today between ‘rich and poor’, particularly in the area of public housing [61]. We use
the flow diagrams below (Figures 1 and 2) to represent both sides of this divide and form the
beginnings of a hypothesis on the causal pathways and compounding effects of high‐rise apartment
living that could be inferred by social justice and affluence [24].
Figures 1 and 2 explain the difference between where a high‐rise apartment is situated (low
socioeconomic or affluent area) as to what type of demographic might live in an apartment in that
area. For example a high‐rise in a low socioeconomic area may have environmental health concerns,
limited green space, a higher likelihood of renters rather than owners, and occupant dissatisfaction
with living space and neighbourhood. This is in contrast to a high‐rise in an affluent area that may
have interesting views, generous living space, social amenities and nearby green space. From the type
of person living in the apartment in combination with the features and landscape of the apartment
building, this may then determine whether a person develops a mental health disorder.

High Rise in poor

socioeconomic area
(disadvantaged
residents)

Small spaces, crowding, noise

disturbances, dissatisfaction and
Near polluted areas, poor upkeep of building
limited amount of green
space, lack of incentive
to exercise High likelihood of
renting, less incentive to
improve property

Fears of crime, security issues,

social isolation

Psychological stress and poor

mental health

Figure 1. A possible causal sequence of high‐rise apartments in poor socioeconomic areas where
environmental health problems, dissatisfaction of living space, limited green space and a higher
likelihood of renting may lead to social isolation, security fears and declining mental health status.
Challenges 2019, 10, 34 7 of 14

Less stress and

good mental
Social health
amenities
nearby and
Sound social
attenuation, areas/activities
air within building
conditioning,
Generous quality fittings
space in and fixtures,
apartment, security
views of systems,
water or satisfaction
High Rise
green with building,
in affluent
space, higher rates of
neighbour
greening ownership
-hood
strategies,
(well-off
incentive to
residents)
exercise

Figure 2. A possible causal sequence of high‐rise apartments in affluent areas where good
environmental health, satisfaction of living space, access to green space and social amenities that lead
to higher ownership, may lead to less stress and good mental health.

4. Housing Interventions to Increase Wellbeing

4.1. Relocation
The demographic concepts described above has lead Gifford [1] to question whether moving
people from high‐rise apartments in a poor socio‐economic area into luxury apartments would
improve their mental health. To some degree, the high‐rise residents could escape at least some
negative effects on mental wellbeing, however if mental disorders/drug and alcohol problems are
already established, the benefits may be more limited. In other words, the outcomes of living in a
high‐rise apartment are moderated to some extent by the ‘characteristics and qualities of the residents
themselves’ [1]. However, two studies have found that residents of high‐rise public housing who
relocated to detached (stand‐alone) homes as opposed to other high‐rise buildings showed improved
mental health [13,60]. Using 267,000 responses to the Kessler 10 Psychological Distress Scale, Astell‐
Burt and Feng [24] also found that people on low incomes living in affluent areas were less likely to
experience psychological distress than those living in low socioeconomic areas. Collectively these
findings suggest that extrinsic living factors remain an important determinant in mental well‐being.
The Gautreaux Program in Chicago in the United States saw over 3500 families randomly moved
from high‐rise deprived areas to either other high‐rises or suburbs and followed up over a
longitudinal study. It was found during telephone interviews of 100 mothers and children who
moved to the suburbs, that they felt the high‐rise buildings were like ‘a restrictive prison
environment’, and once they moved they gained a new sense of efficacy due to freedom from fear
[60]. The reverse is also possible, with depression emerging after being moved from an affluent
neighbourhood to one of poor socioeconomic status.

4.2. Green Space

Another potential intervention relates to the amount of green space surrounding residential
buildings. If greening strategies were employed around the high‐rise buildings so that residents
could be exposed to green space, studies have shown that they would report fewer symptoms of
Challenges 2019, 10, 34 8 of 14

psychological distress [29]. An explanation for the better mental health of residents of high‐rise
buildings in more affluent areas (with generally more environmental biodiversity) is the
psychophysiological stress reduction theory. The theory proposes that contact with nature can shift
highly stressed people to a more positive emotional state [62,63]. Van den Berg et al. [64] suggest that
the general health of populations in lower socio‐economic areas would benefit the most from having
green spaces in their living environment.
No research to support the positive impact of access to green space interventions for high‐rise
dwellers could be found.

5. Further Research
Relocation, as discussed above, warrants a longitudinal study to determine if residents would
still experience social isolation and psychological stress after the apparently positive social transition.
For green space interventions, carefully controlled comparative studies would need to take into
account the likelihood that wealthier high‐rise dwellers may be more able to access help for mental
health issues, and have access to private transport to visit green spaces and other community
facilities. With cross‐sectional designs, because of the ‘moment in time’ aspect of these type of studies
there is the classical debate that residents who have poor mental health may choose to live in high‐
rise apartments and upper floors due to the causality of associations [11,12,44], however this debate
may have unfounded claims. Gifford [1] ascertains that no causal conclusions between high‐rise
apartment living and mental health can be drawn because of the uncertainty over whether any study
of high rise apartments meets standard criteria for scientific hypothesis testing, which is often because
researchers have been forced to use research designs that are sub‐optimal. The majority of studies
used self‐reported surveys that are still being used in valid research today. Verhaeghe et al. [44] state
that most architectural studies claiming that ‘high buildings make people crazy’ are old and do not
take into account socioeconomic position however most high‐rise buildings of the post‐war
construction boom were built in more deprived areas and therefore comparative socioeconomic
studies were not considered. Although observational or longitudinal design would be beneficial, the
weight of replication of the cross‐sectional studies with similar conclusions means that those results
should still be taken into account, particularly when informing socioeconomic policy. Additional
studies involving floor level and comparisons between high‐rise apartment locations (while
controlling for socioeconomic status) would be useful to investigate possible interventions and to add
to the literature for a more definitive conclusion.

6. Conclusions
Inequitable approaches to urban design have a powerful influence in perpetuating social
disadvantage and mental adversity. The socioeconomic status of intended residents remains a
dominant undercurrent in divergent approaches to high‐rise building design in high‐density urban
cities. With increasing urban migration, this will amplify health inequities, stress, crime and poverty,
making cities increasingly “unhealthy” unless new approaches are mandated. Our investigation of
the relationships between high‐rise living and social and mental wellbeing revealed clear evidence
that location plays a key role in the socioeconomic structure of the building. Poorly thought‐out
placement of high‐rise buildings can have an adverse socioeconomic effect on city areas with a flow‐
on effect to the people living in those areas. In addition, a concentration of disadvantaged residents
in one high‐rise building increases the risk of adverse mental health outcomes.
We suggest a series of feasible strategies that may be considered—ideally with urban planners
working closely with the communities they serve to co‐create healthier environments. Preferably
these strategies, wherever applied, should be evaluated for their impact on mental health outcomes.
One strategy is to encourage a mixed tenancy of affluent and disadvantaged residents or a mix of
privately owned and rented apartments with a view to maintaining this mixed quota. Another is
using relocation of residents of high‐rise buildings in poor socioeconomic areas to either detached
homes or perhaps other high‐rise buildings in more affluent areas. A strategy that encourages
exposures to environmental biodiversity (natural environment consisting of trees, plants, grass and
Challenges 2019, 10, 34 9 of 14

species richness) may enhance urban design to benefit the mental health of high‐rise dwellers in low
socioeconomic areas. This is particularly important in cities with land and resource scarcity that
inhibit designing new green spaces or new lower density suburban hubs. It would also help to bridge
the gap between wealthy and low socioeconomic areas of a high‐density city and can be achieved
retrospectively by utilising greening strategies such as streetscaping, redesigning unused grey
spaces, living walls, or communal rooftop gardens. For high‐rise apartments without balconies, it is
advised to develop communal green space around the apartment building and encourage indoor
plants. Finally education for strata corporations is also suggested to allow residents to keep pets and
grow plants themselves.
Overall, our review shows that social justice has a part to play in redefining equitable high‐rise
apartment living for better mental health outcomes.
Author Contributions: Conceptualization, D.L. and P.H.; writing—original draft preparation, D.L.; writing—
review and editing, D.L., E.V., P.H., SP.; visualization, D.L.; supervision, P.H., E.V., S.P., A.L.

Funding: This research received no external funding.

Acknowledgments: The corresponding author was the recipient of an Australian Postgraduate Award.

Conflicts of Interest: The authors declare no conflict of interest.

Appendix A: Investigation of Literature

Methods
The literature was searched using the Web of Science and Pubmed databases. A Google Scholar
search was also conducted to help identify any ‘grey’ literature or papers not in major journals. Key
literature was also hand searched for relevant supporting literature not previously identified. Papers
were included if they were in English and peer‐reviewed journal articles. A time limit was not set as
there were a limited number of articles in recent years, and for this reason, reviews were included.
Search terms used were ‘apartment’, ‘high‐rise’, ‘condominium’ ‘high density’, ‘multi‐family’,
‘urban’, ‘housing’, and ‘wellbeing’, ‘mental health’, ‘stress’ using a variety of combinations to target
key references. Identification of areas for future exploration is discussed. Key papers for floor level
and mental health were graded according to the criteria in Table A2.

Table A1. Key paper grading criteria of high‐rise apartment studies.

A GRADE B GRADE C GRADE D GRADE

contains a comparison contains a comparison contains a comparison
contains high‐
between high‐rise and low‐ between high‐rise and mid‐ between high‐rise floor
rise data only
rise rise levels
Challenges 2019, 10, 34 10 of 14

Table A2. Summary of findings for articles assessing the relationship between high‐rise housing and mental health (n = 25).

Reference and Sampling Subject’s Age, Gender and Number of

Grade Type of Housing Health Specialty Findings of Note
Study Design Method Ethnicity People
[41] Women with medical issues
Random A Doctor’s Records Flats vs. houses (first consults) from the 1500 Mental/Psychoneurotic Social isolation of women in flats
Assignment United Kingdom/Canada
[53] High‐rise vs. low‐ Public housing residents Significantly higher levels of alienation
A Survey 915 Alienation
Cross‐sectional rise (United States) in high rise buildings
High‐rise vs. two Neuroticism and House dwellers had fewer neurotic
[54]
A Survey stories with a Women (United Kingdom) 69/43 Medical Doctor (MD) scores and fewer visits to MD with
Cross‐sectional
garden visits nervous disorders
[56] High‐rise vs. low‐ Psychological More loneliness and depression
A Survey Women (United Kingdom) 75
Cross‐sectional rise v. houses problems complaints from women in high‐rises
[55] British and Canadian Women living in houses had less
A Survey Flats vs. houses 169 Depression
Cross‐sectional servicemen’s wives depression than those living in flats
Neurotic personalities living in flats
[45] British and Canadian more likely to experience psychiatric
A Survey Flats vs. houses 167/167 Psychiatric illness
Cross‐sectional servicemen’s wives illness than stable personalities in flats.
No similar difference in house dwellers
People on the 5th floor or above had
High‐rise Floor 5+ Random adults from a
[42] Psychiatric twice the number of mental symptoms
A, C v. Floors 1–4 vs. health centre (Glasgow, 964 Mental symptoms
Cross‐sectional Screening Survey as those on lower floors (or in other
detached homes Scotland)
types of housing)
Students (2nd‐year High rise dwellers found to have less
[48] High‐rise vs. low‐ Social interaction/
A Survey freshmen) in the United 110 social support and less socially
Cross‐sectional rise dormitories social support
States involved
Eight types of
[43] Public housing residents, Floor level predicts higher levels of
A, C Survey public housing Inc. 442 Psychological strain
Cross‐sectional Canada emotional strain for women
high‐rise
[49] High‐rise vs. Residents of detached homes had more
A Survey Canada 87 Social interaction
Cross‐sectional detached homes contact with neighbours
[50] High‐rise (14 Adults, mostly of Puerto Greater social overload, less social
Psychological distress,
Random A Survey stories) vs. low‐rise Rican or African American 60 networks, less attachment to the
social support
assignment (three stories) descent community
[13] High‐rise vs. Fewer symptoms of depression after
A Survey Women Unknown Depression
Longitudinal detached homes moving out of high‐rise
Multi‐family More psychiatric problems amongst
[59]
A Survey dwellings vs. single Canadian families 560 Psychiatric problems men in multi‐family housing, no
Cross‐sectional
family dwellings. difference in women
[37] Self‐reported Eight types of Adults, local authority 674 Symptoms most prevalent in ‘difficult to
D Psychological distress
Cross‐sectional survey housing area housing, United Kingdom (383 households) let’ housing—location rather than type
Challenges 2019, 10, 34 11 of 14

High‐rise vs. low‐

[51] High‐rise dwellers encountered more
A Survey rise owned Women, Israel 344 Social interaction
Cross‐sectional people, and more who were strangers
apartments
[57] High‐rise vs. Elderly men and women, High rise residents in low SES areas
A Survey 600 Psychological distress
Cross‐sectional detached homes South Africa experienced more psychological distress
[52] High‐rise v. mid‐ Adults, children and More social contact with neighbours in
A, B Survey 503 Mental health
Cross‐sectional rise vs. low‐rise elderly, China low rise v. mid‐rise and high‐rise
Residents failed to cope with the stress
[58] D Survey High‐rise Elderly men, India 100 Mental health
produced by living in high‐rise buildings
Residents of high‐rise towers were
Adults in four socio‐
Perceptions of more likely than other residents to
[47] High‐rise vs. economically
A Survey 1199 neighbourhood factors nominate proximal aspects of the
Cross‐sectional detached homes disadvantaged sites in
that influence health neighbourhood as having a perceived
Melbourne, Australia
negative influence on health.
Residents who moved out of high‐rises
[60] Gautreaux Program
High‐rise vs. Sense of efficacy into detached homes reported a greater
Random A Interview —Mothers and children, 100
detached homes (control) sense of efficacy including freedom from
Assignment Chicago, United States
fear.
14 social housing Poor social outcomes in high rise flats
[18] Survey with 1392 high Residential, social,
A areas, high‐rise to Glasgow, United Kingdom (for all factors), some psychosocial
Cross‐sectional interview rise/1848 houses psychosocial
low‐rise outcomes worse in high rise flats.
High‐rise of four Mortality from all causes higher in
1,500,015
[28] floors and above, ground floor dwellers. Suicide by
A, C Survey Census data, Switzerland (160,629 high Mortality
Cross‐sectional Comparison of jumping increased on higher floors at a
rise buildings)
floors 1–15 rate of 0.41%.
The experience and expression of social
isolation was consistent across all age
Self‐reported groups, with highest correlation
429 Surveys, 30
[40] Survey. between functional social isolation and
D High‐rise Auckland, New Zealand interviews, four Social isolation
Cross‐sectional Interview, Focus “being student”, and older adults (60+
focus groups
Groups years), length of tenure in current
apartment and length of time residents
have lived in the inner‐city.
Residents’ worse self‐rated health in high‐
rise buildings can be explained by the
strong demographic and socioeconomic
[44] Self‐reported High‐rise vs. low‐ Census data and Belgium 2,998,227 Male segregation between high‐ and low‐rise
A Self‐rated health
Cross‐sectional Survey rise Register, Belgium 3,104,593 Female buildings in Belgium. A weak, but robust
positive curvilinear relationship between
floor level and self‐rated health within
high‐rise buildings.
Challenges 2019, 10, 34 12 of 14

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