Urbanization is probably the world's single most important demographic shift over the past century. In the early nineteenth century a mere 5% of the world's population was urban. In 1996, 46% of the world's population lived in urban areas. It is expected that in 2007 half of the world's population will be living in urban areas, and by 2030 the urban population will double and reach 5.1 billion. This massive growth is particularly evident in developing countries, especially in Africa and Asia (Figure). In Asia, the urban population currently constitutes 37% of the total population.1
Megacities—cities with over 10 million inhabitants—are rapidly increasing in number. Currently, 15 cities of this size exist but more are expected to proliferate over the next 3 decades, especially on the Asian continent. Although population growth is found in cities of all sizes, the fastest growth is in cities with populations in the 1 to 5 million range.1
The urban explosion affects mostly poor populations because growing cities fail to match the population expansion with proper infrastructure, housing, services, job opportunities, and economic expansion. This demographic change is significantly affecting both cities and rural areas. Today's cities are studies in contrast. They are agents of change—centers of finance, entertainment, and culture—offering opportunities for recreation, employment, and access to services; however, they are also reservoirs of crime, violence, poverty, and inequality.
Mostly because of increased speed and decreased costs of communication and transportation, cities are growing increasingly diverse in their population. Consequently, cultural factors have taken center stage in the understanding of urban mental health. This article will focus on the main approaches to urban mental health and briefly summarize the 3 lines of research in this area. It will then discuss the main themes of a vast body of literature on the cultural aspects of urban mental health.
Approaches to urban
The 4 most frequently cited methods of conceptualizing urban health and mental health are the urban health penalty, urban sprawl, urban living conditions, and urban health advantage.2
- Urban health penalty concentrates on unhealthy environments of inner cities, particularly in the United States where, over the past 50 years, the departure of the middle class and jobs to suburbs has left behind impoverished and increasingly segregated populations.
- Urban sprawl concentrates on the
adverse effects of growth on health. A rise in obesity, sedentary lifestyle, and social isolation have been associated with urban sprawl.3
- Urban living conditions focuses on physical and mental health as shaped by a variety of contexts. This is an integrated model that sees urban health as a function of individual factors affected by local, social, and physical environments.
- Urban health advantage views urban living as an advantage when it comes to health. Some health indicators are better in urban than rural areas, especially in developing countries. In essence, the urban poor often fare better than the rural poor. In a demographic and health survey, infant mortality in poor populations was found to be lower in the urban setting than in the rural.4
The literature on urban mental health can be divided into 3 main categories, comparisons of urban versus rural, comparisons between cities, and features of urbanization and mental health.5 The urban-rural comparisons that were popular in the 1960s and 1970s, have recently become less frequent, in part because of conflicting results—some investigators found differences in prevalence of psychopathology while others did not—and also because they can only provide a snapshot of cities whose realities often change over time. For example, higher rates of mental illness have been described in urban compared with rural areas in the United Kingdom,6 while no differences were found in a similar study in Canada.7
The between-the-cities approach attempts to identify features that may have an impact on mental health, but by and large, findings may be hard to generalize to other cities or even to the rest of the city's populations.8
The third and currently in-vogue approach is to study discrete spatial units (neighborhoods or communities) to identify specific characteristics in small areas that are associated with specific physical and mental health problems. Because this approach is also context-specific, findings from this type of research are also not easy to generalize. Yet, this model, compared with the other 2, has the advantage of looking at discrete features of urban living; this approach leads to the ability to identify health outcomes and allows for a more focused, and therefore more likely to succeed, plan for intervention.
Cultural patterns in
The increased opportunities for geographic mobility have produced an unprecedented multiethnic influx to cities. In New York, first-generation immigrants compose almost 10% of the population (50% of them from the Americas). In the borough of Queens, with its 250,000 inhabitants, there are 80 different languages spoken from 123 different countries. The United States' cultural and ethnic composition is rapidly changing. Demographers project that by the year 2050, 1 of 4 US inhabitants will be of Spanish decent.9
The complexities of cultural aspects that impact psychopathology and mental health are producing both challenging and beneficial changes in the way psychiatry is practiced. The negative aspects of such multiethnic migration, however, may include lack of familiarity with illness presentation, culturally specific belief systems, and reluctance to rely on medical systems—all of which may significantly delay proper assessment and treatment. The multiculturalism of today's cities contributes to increased tolerance, better quality of life, and sociocultural stimulation; at
the same time, it often contributes to heightened social tensions, interethnic striving, and cultural conflicts—all of which undoubtedly carry mental health ramifications.
1. United Nations Department of Economic and Social Affairs, Population Division. World Urbanization Prospects: The 2001 Revision. Available at: http://www.un.org/esa/population/publications/wup2001/
WUP2001report.htm. Accessed October 31, 2006.
2. Vlahov D, Gale S, Gibble E, Freudenberg N. Perspectives on urban conditions and population health. Cad Saude Publica. 2005;21:949-957.
3. Frumkin H. Urban sprawl and public health. Public Health Rep. 2002;117:201-217.
4. Montgomery MR, Stren R, Cohen B, Reed HE, eds. Cities Transformed: Demographic Change and Its Implications in the Developing World. Washington, DC: The National Academies Press; 2003.
5. Galea S, Vlahov D. Urban health: evidence, challenges and directions. Annu Rev Public Health. 2005;26:341-365.
6. Paykel R, Abbott R, Jenkins TS, et al. Urban-rural mental health differences in Great Britain: findings from the National Morbidity Survey. Int Rev Psychiatry. 2003;15:97-107.
7. Parikh SV, Wasylenski D, Goering P, Wong J. Mood disorders: rural/urban differences in prevalence, health care utilization, and disability in Ontario. J Affect Disord. 1996;38:57-65.
8. Rodwin VG, Gusmano MK. The World Cities Project: rationale, organization, and design for comparison of megacity health systems. J Urban Health. 2002;79:445-463.
9. Mezzich JE, Caracci G. Epidemiogical perspectives on the health of New York City. The city and mental health: Interdisciplinary and International perspectives. Int J Mental Health. 1999-2000;8:41-47.
10. World Health Organization. The world health report 2001. Mental Health: New Understanding, New Hope. Geneva: World Health Organization; 2001. Available at: http://www.who.int/whr/2001/en/. Accessed October 31, 2006.
11. Khoa LX, Van Deusen J. Social and cultural customs: their contributions to resettlement. J Refug Resett. 1981;
12. Westermeyer J. Paranoid symptoms and disorders among 100 Hmong refugees: a longitudinal study. Acta Psychiatr Scand. 1989;80:47-59.
13. Kirmayer LJ. Confusion of the senses: implications of ethnocultural variations in somatoform and dissociative disorders in PTSD. In: Marsella AJ, Friedman MJ, Gerrity ET, et al, eds. Ethno-Cultural Aspects of Post Traumatic Stress Disorder; Issues, Research and Clinical Implications. Washington, DC: American Psychological Association; 1996:75-84.
14. Moser C. Confronting crisis: a comparative study of household responses to poverty and vulnerability in four poor communities. Environmentally Sustainable Studies and Monograph Series. Washington, DC: World Bank; 1996.
15. Baron L, Straus MA. Cultural and economic sources of homicide in the United States. Social Q. 1988;29:371-390.
16. Huesmann LR, Guerra NG. Children's normative beliefs about aggression and aggressive behavior. J Pers Soc Psychol. 1997;72:408-419.
17. Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52:1048-1060.
18. Blue I, Ducci ME, Jashwal A, et al. The mental health of low-income urban women: case studies from Bombay, India, Olinda, Brazil, and Santiago, Chile. In: Harpham T, Blues I, eds. Urbanization and Mental Health in Developing Countries. Brookfield, Vt: Ashgate; 1995:75-102.
19. Harnois G, Gabriel P. Mental Health and Work: Impact, Issues and Good Practices. Geneva: World Health Organization; 2000. Available at: http://www.who.int/mental_health/media/en/73.pdf. Accessed October 26, 2006.
20. WHO International Consortium on Psychiatric Epidemiology. Cross-national comparisons of the prevalence and correlates of mental disorders. Bull World Health Organ. 2000;78:413-426.
21. Dohrenwend BP. Socioeconomic status (SES) and psychiatric disorders: are the issues still compelling? Soc Psychiatry and Psychiatr Epidemiol. 1990;25:41-47.
22. Gilbert AC, Allen S. The role of defeat and entrapment (arrested flight) in depression: an exploration of an evolutionary view. Psychol Med. 1998;28:585-598.
23. Strauss JS, Carpenter WT Jr. The prediction of outcome in schizophrenia. II. Relationships between predictor and outcome variables: a report from the WHO international pilot study of schizophrenia. Arch Gen Psychiatry. 1974;31:37-42.
24. Jablensky A, Sartorious N, Ernberg G, et al. Schizophrenia: manifestations, incidence and course in different cultures: a World Health Organization ten-country study. Psychol Med Monogr Suppl. 1992;20:1-97.