Urban living isn’t for everybody. It’s loud, it’s crowded, your upstairs neighbour has decided that Saturday at 8am is the perfect time to vacuum. That last one might just be me. The city isn’t for the faint of heart, but have you ever wondered if it’s harming your mental health?
Many researchers have. Urbanicity has long been an area of keen interest. Research shows a link between exposure to urban environments and increased rate of psychotic disorders (Kirkbride et al., 2024).
A popular explanation for this trend is social drift, the idea that individuals with psychotic disorders tend to convene in urban areas. However, recent longitudinal evidence suggests social drift can’t be the full story (March et al., 2008). City populations are increasing, and with two thirds of us projected to live in urban settings by 2050 (Ritchie et al., 2018), it makes sense that we would want to figure out what’s causing this association.
The overwhelming majority of research concerning urbanicity is conducted in the Global North (where this trend is found reliably in northern, but not southern Europe). Those studies conducted in the Global South have found conflicting results; this paper (Roberts et al., 2023) sets out to investigate this variation.
Is city living taking a toll on our mental health? Researchers are exploring how urban environments might be linked to increased rates of psychotic disorders.
Methods
This was a cross-sectional study conducted in India, Nigeria, and Trinidad, using networks of local health and community providers. It analysed how psychosis levels varied with urbanicity, classifying areas as urban or rural based on population density and the extent of built-up areas.
Researchers identified possible cases using local terms used to describe psychosis, which were gathered in an earlier qualitative pilot of the programme. Suspected cases were screened, and individuals whose cases met specified criteria were interviewed by a researcher. The case-finding period began in May of 2018, and ceased between 24, and 27 months later.
To be included in the study individuals had to be previously undiagnosed, meaning having never received a diagnosis or antipsychotic medication. Numbers of untreated psychosis were counted up, and a population estimate was used to calculate the relative rate of undiagnosed psychosis in each area.
Results
The final sample found; India: 268, Nigeria: 196, and Trinidad: 574 cases.
Trinidad
More urban areas had higher rates of psychotic disorder (IRR: 3.24, 95% CI 2.68 to 3.91). In the most urban areas rates were three-times higher than in the least urban. This trend was found with all cases, and when looking at recent onset only.
India
When all cases were included, there was no difference between more and less urban (IRR: 1.18, 95% CI 0.93–1.52). When restricted to exclude long-term untreated cases they found more urban areas had higher rates of psychosis.
Nigeria
Lower rates of psychosis were found in more urban areas (IRR: 0.68, 95% CI 0.51 to 0.91). This trend was found both with recent onset, and when including all cases.
This research suggests that urbanicity’s link to psychosis varies widely—rising in Trinidad, shifting in India, and falling in Nigeria.
Conclusions
The authors say these findings ‘tentatively’ suggest the link between urbanicity and psychotic disorder is context-specific. They found strong evidence of a link in Trinidad, which contrasts with earlier studies (Morgan et al., 2024). However, they could not rule out social drift due to the cross-sectional nature of the study.
The findings suggest the urban-psychosis link may be context-specific, though questions around social drift remain unanswered.
Strengths and Limitations
This study is the first to show a link between urbanicity and psychosis in Trinidad. The authors try to explain this finding, suggesting it’s due to an increase in risk factors (like violence) since the last study. Focusing on Nigeria, India, and Trinidad has given the authors a broad look at Global South countries. Nigeria and India are set to account for a large amount of urbanisation, making them of particular interest. Trinidad has recently been classified as a high-income country, opening possible comparisons with the effects found in Northern Europe. Another strength of the study is in its extensive limitations section, the authors show their commitment to transparency.
However, as with all studies, limitations exist. This study only included three local areas within larger countries. Particularly in India and Nigeria, these findings have limited generalisability to the countries’ wider populations. As a cross-sectional study, researchers cannot rule out social drift as no attempt was made to record childhood history and therefore exposure to urbanicity during development. Additionally, they used a two-category system for urbanicity: rural or urban. No consideration was given for areas, such as Ona Ara in Nigeria, which is a mixture of both rural and urban. Inclusion of urban areas in this rural category might have skewed the unexpected results found.
Due to the case-finding method, there are several accuracy concerns. For one, they couldn’t account for factors such as family history of psychosis, because of limited data. Additionally, they state case-finding was challenging in urban areas. In contrast however, they note that services are likely more accessible in urban areas, this might be driving a portion of the differences seen. These methodological weaknesses are particularly apparent in the Nigerian data.
Psychiatric diagnosis, especially psychosis needs to be carefully considered within its cultural and historical context. Psychosis is over diagnosed in Black populations, because of institutionalised racism which psychiatry historically and presently upholds (van der Ven and Susser, 2023).
I think the authors missed an opportunity to explicitly acknowledge how structural inequalities perpetuate exposure to urban living. Our environments are constructed by those in power, meaning infrastructure, pollution, green-spaces, all of these factors aren’t decided by those they affect. Whether urban living poses risks or rural living provides protection, having the freedom to change something about your environment is a privilege. Exposure to health risks are rarely determined arbitrarily and will disproportionately affect marginalised groups in society.
The findings offers insights into urbanicity and psychosis in the Global South, but also highlight how structural inequalities and power imbalances shape exposure and outcomes.
Implications for practice
This paper indicates above all else the necessity for investing in research from the Global South. The relationship between urbanicity and psychosis does not neatly translate to countries outside the Global North. This is a reminder that mental health is in constant dialogue with the cultural, political, and environmental landscape.
The authors rightfully point out that urbanicity is complex and work is needed to understand how, not just whether it affects psychosis. Identification of such factors will allow for development of effective prevention strategies. In turn this can help to improve mental and physical health by making our environments work for us.
This study underscores the urgent need for Global South research, reminding us that mental health is shaped by place, context, and complexity.
Statement of interests
As a founder of a LGBTQ+ NGO my views align with my experiences of the power of community for wellbeing. I think that community care is infinitely valuable and this has undoubtedly influenced my interpretation of the paper above. Additionally, as someone from the North of Ireland I see mental health as inextricably tied up in the effects of history, specifically oppression, violence, and systematic destabilisation from global powerhouses. Research cannot and should not shy away from naming these perpetrators. Finally, as someone who was raised in a Global North country, I want to acknowledge that my ability to understand conceptualisations of mental health across the globe is limited. My gracious colleagues and peers should be credited for continuing to broaden my understanding through sharing their knowledge, perspectives, and experiences.
Links
Primary paper
Roberts, T., Susser, E., Lee Pow, J., Donald, C., John, S., Raghavan, V., … Morgan, C. (2023). Urbanicity and rates of untreated psychotic disorders in three diverse settings in the Global South. Psychological Medicine, 53(14), 6459–6467. doi:10.1017/S0033291722003749
Other references
Abi-Dargham, A., Moeller, S.J., Ali, F., DeLorenzo, C., Domschke, K., Horga, G., Jutla, A., Kotov, R., Paulus, M.P., Rubio, J.M., Sanacora, G., Veenstra-VanderWeele, J. and Krystal, J.H. (2023), Candidate biomarkers in psychiatric disorders: state of the field. World Psychiatry, 22: 236-262.
https://doi.org/10.1002/wps.21078
Ritchie, R., Samborska, V., Roser, M., (2024, February). Urbanization. https://ourworldindata.org/urbanization
Kirkbride, J. B., Anglin, D. M., Colman, I., Dykxhoorn, J., Jones, P. B., Patalay, P., Pitman, A., Soneson, E., Steare, T., Wright, T., & Griffiths, S. L. (2024). The social determinants of mental health and disorder: evidence, prevention and recommendations. World psychiatry : official journal of the World Psychiatric Association (WPA), 23(1), 58–90.
https://doi.org/10.1002/wps.21160
March, D., Hatch, S. L., Morgan, C., Kirkbride, J. B., Bresnahan, M., Fearon, P., & Susser, E. (2008). Psychosis and place. Epidemiologic reviews, 30, 84–100. https://doi.org/10.1093/epirev/mxn006
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https://doi.org/10.1146/annurev-clinpsy-081219-120307
Morgan, C., Cohen, A., & Roberts, T. (2024). Psychosis: Global Perspectives. Oxford University Press.
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van der Ven, E., & Susser, E. (2023). Structural Racism and Risk of Schizophrenia. American Journal of Psychiatry, 180(11), 782–784. https://doi.org/10.1176/appi.ajp.20230733
