Natural surroundings in childhood are associated with lower schizophrenia rates.

High exposure to green space and natural environments has previously been associated with lower schizophrenia rates possibly through low air pollution and improved psychological restoration. Exposure to natural environments could explain the negative urban-rural gradient of schizophrenia, but it is unclear if all natural environments are associated with schizophrenia rates. We investigated the association between schizophrenia and growing up surrounded by environments classified as mainly urban, agricultural, near-natural green space, and blue space. Vegetation density and air pollution were assessed as potential pathways. We used the Danish population (943 027 people) and remotely-sensed environmental data to determine land cover exposure and vegetation density around each individual's residence. Effect sizes were estimated using Cox regression and adjusted for air pollution, socioeconomic status, and urbanization. Our results show that growing up surrounded by non-urban environments is associated with lower schizophrenia rates. Firstly, growing up surrounded by non-built-up areas (agricultural areas, near-natural green and blue space) is associated with lower schizophrenia rates compared to urban areas. Secondly, rates decrease with vegetation density in a dose-response relationship for urban and agricultural areas. Air pollution mitigation more strongly explained the protective association in near-natural green spaces, implying that restorative pathways together with air pollution mitigation may explain lower rates in natural environments. This study suggests that ensuring access to natural environments during childhood may be important for schizophrenia prevention, whilst being the first study to show that natural environments may influence schizophrenia rates through multiple pathways.