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|Year : 2000
: 2 | Issue : 8 | Page
|A review of environmental noise and mental health
SA Stansfeld1, MM Haines1, M Burr2, B Berry3, P Lercher4
1 Department of Psychiatry, St Bartholomew's and the Royal London School of Medicine and Dentistry, London, United Kingdom
2 Centre for Applied Public Health Medicine, Cardiff, United Kingdom
3 National Physical Laboratory, Teddington, United Kingdom
4 Institute for Social Medicine, University of Innsbruck, Innsbruck, Austria
Click here for correspondence address
The question of whether environmental noise exposure causes mental ill-health is still largely unanswered. This paper reviews the studies of environmental and industrial noise and mental ill-health published between 1993 and 1998 and suggests possibilities for future research. Recent community based studies suggest high levels of environmental noise are associated with mental health symptoms such as depression and anxiety but not with impaired psychological functioning. Several studies find that self-reported noise sensitivity does not interact with noise exposure to lead to increased vulnerability to mental ill-health. Chronic aircraft noise exposure in children impairs quality of life but does not lead to depression or anxiety. Further research on environmental noise and mental health should be accompanied by more accurate and detailed measurement of noise exposure and consideration of the impact of other environmental stressors and careful measurement of confounding factors such as social class. Target study populations exposed to noise should be chosen to avoid those where noise exposure is likely to have led to noise sensitive individuals moving away from the area. There should also be greater use of standardised instruments to measure a wider range of mental health outcomes. Also other physiological outcomes such as hormonal measures could with benefit be measured simultaneously.
Keywords: Noise, Mental health, Depression, Environment
|How to cite this article:|
Stansfeld S A, Haines M M, Burr M, Berry B, Lercher P. A review of environmental noise and mental health. Noise Health 2000;2:1-8
| Introduction|| |
This five year review describes new studies relating noise and mental ill-health reported since the last reviews of this field [Schwarze & Thompson, 1993; Job, 1993; Stansfeld et al, 1993]. After a short summary of previous research, current research will be reviewed, methodological limitations in the field will be outlined, and suggestions made for directions for further research. The review is based on a MEDLINE and PSYCHLIT search, the proceedings of the 7th International Congress on Noise as a Public Health Problem in Sydney (November 1998) and a search of relevant environmental health journals not included in these two databases.
Summary of Noise and Mental Health Studies before 1993
Many different mental health outcomes have been examined in relation to environmental noise, largely involving noise from aircraft and road traffic. There have been few consistent results across studies. However, there have been some consistent results for less severe outcomes, namely psychological symptoms.
High levels of aircraft noise have been related to reports of 'headaches', 'restless nights', 'irritability' and being 'tense and edgy' [OPCS,1971; Kokokusha, 1973; Finke, 1974]. The explicit link between noise and symptoms in these cross-sectional surveys may have led to response bias [Barker & Tarnopolsky, 1978]. Grandjean's study around 3 Swiss airports, which made no explicit links between aircraft noise and health, found no association between noise and symptoms [Grandjean et al, 1973]. In the West London Survey, 'depression', 'irritability', 'waking at night' and 'difficulty getting to sleep' were more common as acute symptoms (within the last two weeks) in high aircraft noise exposed areas, but as chronic symptoms in low noise areas [Tarnopolsky et al, 1980]. This apparent contradiction may be explained by poorer pre-existing ill-health, probably related to high levels of social disadvantage rather than specifically to noise, in the low noise areas, leading to more chronic symptoms.
Use of health services by noise exposure shows similarly mixed results: noise level has been associated with general practitioner contact rates and use of prescription drugs in some studies [Grandjean et al, 1973; Knipschild & Oudshoorn, 1977] but not in others [Watkins et al, 1981]. Turning to indices of more severe psychiatric disturbance, early studies found associations between aircraft noise exposure and admission to psychiatric hospitals [AbeyWickrama et al, 1969; Meecham & Smith, 1977; Meecham & Shaw, 1979]. These studies have been criticised in relation to the definition of noise areas, population denominators and adjustment for confounding factors [Chowns, 1970; Frerichs et al, 1980]. Further comprehensive studies have found at most a moderating, rather than a causal role for noise on psychiatric hospital admission rates [Jenkins et al, 1979; Jenkins et al, 1981]. However, Kryter did find an association between aircraft noise and psychiatric hospital admission rates after taking into account further sociodemographic indices in a re-analysis of earlier data from hospitals accepting admissions from around Heathrow Airport [Kryter, 1990].
In a comprehensive cross-sectional epidemiological study, the West London Survey, no overall association was found between aircraft noise exposure, measured by the Noise and Number Index, and psychiatric disorder measured by a standardised screening instrument, the General Health Questionnaire, except in two sub-groups: those who 'finished full-time education >19 years' and 'professionals' [Tarnopolsky & Morton Williams, 1980]. This raised the question that some people may be more vulnerable to the effects of noise than others. Further examination of a subsample of highly noise sensitive women from the West London Survey compared to a less sensitive sample found that noise sensitivity was associated with psychiatric disorder, namely depression and phobic disorders [Stansfeld et al, 1985]. However, there was no evidence that noise exposure predicted psychiatric disorder in noise sensitive women. Research which pursued this association in a sample of depressed psychiatric patients indicated that noise sensitivity levels fell on recovery from depression but noise sensitive individuals tended to have high levels of noise sensitivity irrespective of illness [Stansfeld, 1992]. Evidence from the West London Survey suggested that noise sensitivity tends to be a stable aspect of personality [Stansfeld, 1988]. The association between noise sensitivity has continued to be investigated recently and this is further discussed in the section on new research below.
Recent Literature on Noise and Mental Health
There have been several recent studies examining the effects of environmental noise in the community. A questionnaire study of 1053 residents around the busy Kadena military airport in Japan used the Todai Health Index, based on the Cornell Medical Index to assess health symptoms (Ito et al, 1994; Hiramatsu et al, 1997). Mental health subscales included depressiveness, nervousness, neurosis, and mental instability. Noise level was expressed as WECPNL (the power average of the maximum perceived noise exposure level in dB(A) ) from 75-79, 80-84, 85-89, 90-94 and over 95. In unadjusted analyses statistically significant differences were found in scores of depressiveness, nervousness and neurosis subscales between the non-noise exposed control group and the pooled group exposed to 75-95 WECPNL. In multivariate analysis adjusting for age, sex, marital status, type of house and the length of residence, noise exposure greater than 95 WECPNL was associated with higher scores on depressiveness and neurosis (Hiramatsu et al, 1997). Clear dose-response relationships were not found between scale scores and noise exposure as expressed in five unit steps. However, using more broadly defined groups a dose-response association was evident - this highlighted differences between the highest noise exposure group and lower noise exposure groups and may indicate a threshold effect- that health effects are more likely to be found at higher noise levels. In general, psychological rather than somatic symptoms were more related to noise in this study. A further survey using similar methodology on 6,486 respondents found dose-response relationships between aircraft noise exposure, nervousness, and mental health (Miyakita et al, 1998). These studies are an important contribution to the literature because of the opportunity to examine the effect of high noise exposure levels and the probability that out-migration of vulnerable persons from noisy areas biasing the sample was small. They can be criticised because no adjustment was included for social class. Although in the absence of selective outmigration by social class, adjustment for social class in analyses associating noise and mental ill-health could be considered 'overadjustment.' This might be the case if social class were a better indicator of objective noise exposure than noise exposure based on contours. It is not clear whether these depression and nervousness questions are measuring symptoms where associations have been shown between noise and symptoms in the past, or clinical conditions, where associations with noise have not previously been shown.
Mental health symptoms have been studied in a secondary analysis of a road traffic noise study (Halpern, 1995). Among 7540 people in this British study, the 'noise level in dB(A) exceeded for 10% of the time', a measure of peak noise level, was weakly associated with a five item mental health symptoms scale. This association remained after adjustment for age, sex, income and length of residence. Weaker associations between traffic density and the mental health symptoms scale may relate to the skewed distribution of the traffic density variable. It seems that traffic noise level was more important than traffic flow. The scale used included some clear mental health items but also some that were less obviously related to mental health. It may be questioned that the reported association between noise level and mental health symptoms was actually due to noise exposure; adjustment for the amount of 'noise heard' reduced the association very little, suggesting no causal association with noise, but it is likely that 'noise heard' was not reliably measured. However, it may be that peak noise level is a good indicator of environmental noise heard indoors and this is a crucial noise indicator for mental health. One community study in 366 Japanese women suggests that road traffic noise only has effects on depression, fatigue and irritability above a threshold of 70 dB(A) (Yoshida et al, 1997). However, these analyses were unadjusted for age or social class. A study comparing 70 steel tube factory workers exposed to industrial noise of 101 dB and 71 non-noise exposed workers in the same factory found higher scores on the Hamilton Depression Rating Scale in the noise exposed group (Bing-shuang et al, 1997).
Analysis of the results from the Caerphilly Study (Stansfeld et al, 1996) found that there was no longitudinal dose-response association between the initial level of road traffic noise and minor psychiatric disorder in this small Welsh town, even after adjustment for sociodemographic factors and baseline psychiatric disorder. However, there was a small non-linear association of noise with increased anxiety scores adjusting for age, social class, employment status, and noise sensitivity. Why was a linear association between road traffic noise and mental health found in Halpern's analyses but not in the Caerphilly Study? First, this may be related to the degree of mental illhealth - Halpern's study measured symptoms while Stansfeld measured the more severe 'psychiatric caseness'. Secondly, it may be that Halpern's study by taking measurements from many different sites managed to adjust for unmeasured sociodemographic confounding factors in a way that was not possible in the Caerphilly Study.
Both of these studies agree, however, that there was no interaction between noise exposure and self-reported noise sensitivity in determining psychiatric symptoms and caseness. This suggests that noise sensitivity does not moderate the effect of noise on psychiatric disorder. Nevertheless, it is certain that noise sensitivity does predict future psychiatric disorder independently of noise level, and is related to health complaints in general (Nivison & Endresen, 1993). After the association between noise sensitivity and psychiatric disorder was adjusted for baseline trait anxiety in the Caerphilly Study, the effect of noise sensitivity was no longer statistically significant. This suggests that the confounding association with trait anxiety may account for much of the association between noise sensitivity and psychiatric disorder. Thus constitutionally anxious people may be both more aware of their environment and more prone to future psychiatric disorder. This environmental awareness may be more general as noise sensitivity has been shown to predict perception of car fumes, dust and soot (Lercher et al, 1995). There are two other possible explanations for noise sensitivity. Either noise sensitive people may pay more attention to environmental stressors than less sensitive people but not necessarily have a lower perceptual threshold for environmental stimuli, or they may be less able to screen out unwanted environmental stimuli.
Another study which included mental health indicators was that of five rural Austrian communities exposed to road traffic noise where noise levels above 55 dB(A) were associated with increased risk of taking sleeping tablets (OR = 2.22 [CI 1.13- 4.38]) and overall prescriptions (OR = 3.65 [CI 2.13-6.26]) relative to road traffic noise exposure less than 55dB(A) (Lercher,1996). This suggests effects at fairly low noise levels. In this case mental ill-health may be secondary to sleep disturbance, which is likely to occur at lower nocturnal noise levels than mental health symptoms resulting from daytime noise exposure. As this occurred in a rural setting where road traffic noise was the predominant noise source it would be interesting to replicate these findings in other settings. Initial results from the Health Impact Assessment at Schiphol Airport suggest that there was higher sedative use in areas exposed to aircraft noise (>60 Laeq) than in quieter areas (<45 Laeq) (Franssen et al, 1998).
Noise and Mental Ill-health in Children
Generally there are very few studies that have examined the effects of noise on child mental health. In one British study, the depression (Child Depression inventory) and anxiety (Child Manifest Anxiety Scale) scores of 169 children attending four schools exposed to high levels of aircraft noise (>66 dBA 16hr outdoor Leq) were compared with 171 children attending four matched control schools exposed to lower levels of aircraft noise (<57 dBA 16hr outdoor Leq) around Heathrow Airport in West London (Stansfeld & Haines, 1997). Mirroring the results from the adult studies, no associations were found between chronic aircraft noise exposure and anxiety and depression in school children. These results suggest that chronic aircraft noise exposure does not directly affect anxiety and depression. However, it is possible that noise might affect other more stress-related aspects of mental health such as self-reported stress, social functioning, behavioural adjustment and wellbeing in children. This possibility is supported by evidence from the Munich Airport Study where it was found that aircraft noise was associated with reduced quality of life in children aged 9 -11 years (Evans et al, 1998).
Noise Exposure and Quality of Life
As environmental noise predicts annoyance and psychological symptoms but does not seem to be associated with more severe health problems such as clinically definable psychiatric disorder, it seems advisable to examine whether environmental noise might be associated with milder conditions such as are measured by wellbeing and health functioning. We examined this as the first stage in an intervention study examining the effect of introducing a by-pass to relieve traffic congestion in a small town in North Wales. Health functioning was measured by the SF-36 General Health Survey (Ware & Sherbourne, 1992) including dimensions of general health status, physical functioning, general mental health and social functioning.
Ninety eight respondents were studied who lived on a busy high street with traffic noise levels varying between 72 and 75 dBA outdoor Leq. These respondents were compared with 239 control subjects living in adjacent quieter streets (noise level 55-63 dB(A) outdoor Leq). Although subjects were well matched on age, sex, housing insulation, car ownership and employment status, they were not so well matched on proportion of manual workers, household crowding, deprivation and home ownership. We found no evidence that respondents exposed to higher levels of road traffic noise had worse health functioning than those exposed to lower levels of traffic noise, adjusting for levels of deprivation [Table - 1]. Thus there was no major effect of noise on health functioning in this sample.
Scope for Further Research
Current evidence does seem to suggest that environmental noise exposure, especially at higher levels, is related to mental health symptoms and possibly raised anxiety and consumption of sedative medication but there is little evidence that it has more serious effects. Existing studies may be confounded either by prior selection of subjects out of (or into) noisy areas related to noise exposure, or by confounding between noise exposure, socioeconomic status/deprivation, and psychiatric disorder. It is also possible that people underestimate or minimise the effects of noise on health through optimism bias (Hatfield & Job, 1998) and that this is particularly protective for mental health.
Ideally further studies investigating the association between noise and psychiatric disorder should be carried out longitudinally, either in populations in whom there is a change to lower noise exposure or better still, where baseline measurements are carried out in low noise conditions and follow-up measurements are made at a time when noise exposure has increased. In this way the population will not be pre-selected to included only those less affected by noise, and migration of subjects out of the study sample can be followed, to assess whether noise sensitive subjects tend to move away as the noise increases. There should also be measurement of other contemporaneous environmental stressors to assess additive and multiplicative interactions with noise exposure, careful assessment of socio-economic differences between areas of high and low exposure and assessment of potential moderating factors between noise exposure and psychiatric disorder.
There is also a need for improving the measurement of noise sensitivity and annoyance. At the same time the breadth of psychiatric outcomes studied should be enlarged to include well-being, hostility, depression, anxiety, somatisation disorders, and phobias while also measuring relevant aspects of personality such as neuroticism and negative affectivity which may influence reporting of symptoms. This needs to be combined with measurement of the appraisal of noise sources and evaluation of coping mechanisms (Lercher, 1996). An assessment of perceived threat from noise should be taken into account and different ways of coping with prolonged noise exposure need to be examined in more detail. It also would be interesting to combine mental health measures and hormonal measures to assess psychological and physiological responses to stress concurrently.
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S A Stansfeld
Department of Psychiatry, St Bartholomew's and the Royal London School of Medicine and Dentistry, Mile End Road, London E1 4NS
Source of Support: None, Conflict of Interest: None
[Table - 1]