Cities and Mental Health

Abstract

Background: More than half of the global population
currently lives in cities, with an increasing trend for further
urbanization. Living in cities is associated with increased
population density, traffic noise and pollution, but also
with better access to health care and other commodities.
Methods: This review is based on a selective literature
search, providing an overview of the risk factors for
mental illness in urban centers.
Results: Studies have shown that the risk for serious
mental illness is generally higher in cities compared to
rural areas. Epidemiological studies have associated
growing up and living in cities with a considerably higher
risk for schizophrenia. However, correlation is not
causation and living in poverty can both contribute to and
result from impairments associated with poor mental
health. Social isolation and discrimination as well as
poverty in the neighborhood contribute to the mental
health burden while little is known about specific inter -
actions between such factors and the built environment.
Conclusion: Further insights on the interaction between
spatial heterogeneity of neighborhood resources and
socio-ecological factors is warranted and requires interdisciplinary
research.

Full text

MEDICINE
REVIEW ARTICLE
Cities and Mental Health
Oliver Gruebner, Michael A. Rapp, Mazda Adli, Ulrike Kluge,
Sandro Galea, Andreas Heinz
SUMMARY
Background: More than half of the global population
currently lives in cities, with an increasing trend for further
urbanization. Living in cities is associated with increased
population density, traffic noise and pollution, but also
with better access to health care and other commodities.
Methods: This review is based on a selective literature
search, providing an overview of the risk factors for
mental illness in urban centers.
Results: Studies have shown that the risk for serious
mental illness is generally higher in cities compared to
rural areas. Epidemiological studies have associated
growing up and living in cities with a considerably higher
risk for schizophrenia. However, correlation is not
causation and living in poverty can both contribute to and
result from impairments associated with poor mental
health. Social isolation and discrimination as well as
poverty in the neighborhood contribute to the mental
health burden while little is known about specific inter -
actions between such factors and the built environment.
Conclusion: Further insights on the interaction between
spatial heterogeneity of neighborhood resources and
socio-ecological factors is warranted and requires inter-
disciplinary research.
►Cite this as:
Gruebner O, Rapp MA, Adli M, Kluge U, Galea S, Heinz A:
Cities and mental health. Dtsch Arztebl Int 2017; 114:
121–7. DOI: 10.3238/arztebl.2017.0121
U
rbanization is one of the main health-relevant
changes humanity is facing in our time, and will
be facing in the coming decades (1). Today more than
50 percent of the global population is living in cities; by
2050, this rate will increase to nearly 70 percent with
more than 50 percent of the urban population living in
cities of over 500 000 inhabitants (2). With growing
urbanization, more and more people are exposed to risk
factors originating from the urban social (e.g. poverty)
or physical environment (e.g. traffic noise), con -
tributing to increased stress, which in turn is negatively
associated with mental health. By contrast, cities
provide better access to health care, employment, and
education. The balance between those factors that are
deleterious and those that are protective for mental
health calls for a better understanding of the interaction
between city living and mental health.
Methods
We performed a selective literature review that
synthesizes the current evidence for urban population
mental health. We mainly included meta-analyses and
quantitative studies presenting evidence from
rural-urban or inner-urban differences in mental
disorders. Qualitative studies were excluded as well as
studies in which mental health was used to predict other
outcomes. Results are interpreted based on the theories
by Stokols (3), Galea et al. (4), and Gruebner et al. (5)
with particular consideration of socio-ecological
environments and their associations with mental health.
Results
Rural-urban differences in mental health
The risk for some major mental illnesses (e.g. anxiety,
psychotic, mood, or addictive disorders) is generally
higher in cities (e.g. 6). Studies on anxiety disorders
(including posttraumatic stress disorder, distress, anger,
and paranoia) found higher rates in urban versus rural
areas in several Latin American and Asian countries
(7–10). The same was true for psychotic disorders (e.g.
schizophrenia) in China (11) and in large urban areas in
Germany (12, 13). In a Danish study, the risk for
schizophrenia was more than twofold for individuals
who had spent their first 15 years in a major city versus
those who had grown up in rural areas (14) (see the
Table for a selective summary). Epidemiological
studies further confirmed that the risk for schizophrenia
was higher in people who grew up in cities (versus rural
areas), thereby exhibiting a dose-response relationship:
Department of Epidemiology and Health Monitoring of the Robert Koch Insti-
tute, Berlin: Dr. rer. nat . Gruebner
Social and Preventive Medicine, Universität Potsdam: Prof. Dr. med. Dr. phil.
Rapp
Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin,
Berlin: Prof. D r. med. Adli, Dr. phil. Kluge , Prof. Dr. med. Dr. phil. Heinz
School of Pub lic Health, Boston Un iversity, MA, USA: Ga lea, MD, DrPH
Berlin Institute for Integration and Migration Research (BIM), Humboldt Univer-
sity of Berli n: Dr. phil. K luge, Prof. Dr. me d. Dr. phil. Heinz
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The more time spent in an urban environment as a
child, the higher the risk for schizophrenia as an adult
(15–23).
Likewise, mood disorders were observed more fre-
quently among residents of large cities in Germany
(12). In contrast, rural residents in China were more
likely to have depressive disorders (8, 24). This was
also true in a study on common perinatal mental
disorders (depression and substance use) in women in
Vietnam (25). Addictive disorders (for instance exces -
sive use of massive multiplayer online role-playing
games [MMORPG]) was mainly found among young
adult university graduates living alone in urban France
(26). In contrast, rural residents were more likely to
have alcohol dependence than were urban residents, as
shown in a study in China (8).
Inner-urban differences and mental health
Urban social environments:
Social risk factors for mental health in cities include
●
concentrations of low socio-economic status
(SES) (e.g. education levels, income),
●
low social capital (e.g. social support, efficacy),
●
or social segregation (e.g. perceived minority
status, ethnic group membership) (27–34).
SES is by far the most studied risk factor and has
been consistent in its association with mental health.
For example, living in poor or deprived neighborhoods
is associated with greater risk of poor mental health
(e.g. depression, schizophrenia) versus living in richer
neighborhoods (27, 29, 33, 35–40, e1–e4). The associ-
ation between familial liability and mental illness was
stronger in more deprived neighborhoods, with
neighborhood variables mediating urbanicity effects in
Turkey (38). In another study, adverse conditions as-
sociated with very poor neighborhoods in slums were
associated with mental health disorders in India (39).
Persons within disadvantaged areas may have more
difficulties building and sustaining supportive social
relationships and may have increasing susceptibility to
mental illness. Evidence also exists for socially
disorganized neighborhoods in which people feel inse-
cure and frequently experience violence (e1, e2), con-
tributing to increased trauma exposure with related
consequences for mental health (40, e3, e4).
However, it is important to keep in mind that corre-
lation is not causation. Selective migration may lead to
worse population health in those neighborhoods that
movers leave behind and to better health at the desti-
nation, as movers often have better health status (e5,
e6).
Research also indicated a reciprocal effect, that is,
people who had poor health or who experienced diffi-
cult life events (e.g. relationship breakdown, job loss)
were more likely to move to more deprived areas
versus others (e7, e8), e.g., due to low, affordable rents.
For example, increased schizophrenia risk was reported
for living in an urban environment five years after
disease onset (14). However, this effect did not fully
explain increased schizophrenia rates in inner cities,
because numerically, effects of urbanization early in
life were somewhat larger, suggesting at least two
mechanisms: First, growing up in cities has an effect on
illness risk, and second, higher amounts of people with
health problems move to urban areas (17).
Living in socially deprived neighborhoods itself may
have a heritable component (ranging from a 65%
elevated variance in a sibling study to 41% in a twin
study) (e9). The authors assume that genetic suscep -
tibility for schizophrenia predicts subsequent residence
in individuals with schizophrenia. They found that
effects of population density on schizophrenia risk
disappeared when known familial risk factors were
accounted for, and assumed that in relatives of schizo-
phrenia subjects, familial or specifically genetic risk
factors are associated with cognitive functions, which
causally contribute to living in poverty (e9). However,
such familial and even genetic risk factors may be inde-
pendent of cognitive style and rather include visible
minority status.
Indeed, schizophrenia risk is substantially increased
in migrants, not only in the first generation exposed to
transitional stressors, but also in subsequent gener-
ations (e10). Moreover, psychosis rates are particularly
high when patients belong to a visible minority (e.g.,
people from West Africa and the Caribbean in London,
Moroccans in Den Haag) (34) and when the ethnic
density in the neighborhood is low. These findings
suggest that social exclusion and discrimination play an
important role in the development of schizophrenia
(e11).
In turn, neighborhoods characterized by higher
social support and collective efficacy may buffer per-
ceived stress through support networks promoting
mental health (e12, e13). In addition, neighborhood
social support networks may also contribute to social
norms and practices that have been found to be protec-
tive for substance use disorders or suicide attempts
(30–32).
Living in neighborhoods characterized by residential
ethnic segregation is associated with greater risk of de-
pression and anxiety, versus living in less segregated
neighborhoods (29, e3, e14). Our research group
investigated the differential contribution of poverty and
minority status at the community level on individual-
level mental health, controlled by individual-level
differences in SES and migration in an inner city popu-
lation in Berlin, Germany (27) (Figure).
We found that individual-level mental distress in
migrants was associated with community-level poverty,
independent of individual-level SES, in that, roughly, a
10% increase in the percentage of residents receiving
public welfare in the neighborhood corresponded to an
increase of 8 points on the GHQ-28 (General Health
Questionnaire).
We noted that the effect of poverty was more pro-
nounced in migrants versus native citizens, in that a
10% increase in the proportion of residents with a
migration background accounted for an additional 5
points on the GHQ-28. Our observations suggest that
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the high level of mental distress in migrants was largely
driven by community-level SES, beyond the effects of
individual resources, emphasizing the need for targeted
interventions (27).
There is also cumulative evidence that urban resi-
dents belonging to a minority group including those
with a migration background carry an increased risk for
depression and psychosis (e15–e18). Remarkably,
social support among minorities appears to be an im-
portant protective factor, while having visible minority
status as a resident in neighborhoods with low numbers
of ethnic minorities (“lower ethnic density”) was
associated with increased rates of e.g. schizophrenia
(34). Such effects may well be due to increased
discrimination in segregated neighborhoods and are
supported by neurobiological studies emphasizing the
role of social isolation stress in the development of
mental disorders (e11, e19).
Urban physical environments: Similar patterns can
be found for the urban physical environment that
compared to rural areas may contain
TABLE
Studies on the effect of urban exposure on mental health*
1
*
1
Selective summary results of studies using meta analyses (6, 15 ,e10) or large population sizes (>1.75 million) (14, 23);
Provincial cities had more than 100 000 inhabitants and provincial towns more than 10 000 inhabitants (14, 23).
We also included one study that looked at psychotic disorders among immigrants in The Hague, Netherlands (34), to cover inner urban differences in mental health.
*
2
Unadjusted; *
3
adjusted;
CI, confidence interval; IRR=Incidence rate ratio; OR= Odds ratio; RR=Risk ratio
Reference
Peen et al.
(2010) (6)
Vassos et al.
(2012) (15)
Pedersen
& Mortensen
(2001) (14)
Mortensen et al.
(1999) (23)
Cantor-Graae
& Selten
(2005) (e10)
Veling et al.
(2008) (34)
Exposure factor
Urban vs. rural
Urban vs. rural
Urban vs. rural
Urban vs. rural
Continuous urbanicity index
Per 15 years lived in capital city vs. rural area
Per 15 years lived in capital suburb vs. rural area
Per 15 years lived in provincial city vs. rural area
Per 15 years lived in provincial town vs. rural area
Place of birth: Capital vs. rural area
Place of birth: Capital suburb vs. rural area
Place of birth: Provincial city vs. rural area
Place of birth: Provincial town vs. rural area
First generation migrants vs. natives
Second generation migrants vs. natives
First and second generation migrants vs. natives
Immigrant vs. Dutch in urban area of low ethnic
density
Outcome
Any disorder*
2
Mood disorder*
2
Anxiety disorder*
2
Substance use disorder*
2
Schizophrenia
Schizophrenia*
3
Schizophrenia*
3
Schizophrenia*
3
Schizophrenia*
3
Schizophrenia*
3
Schizophrenia*
3
Schizophrenia*
3
Schizophrenia*
3
Schizophrenia
Schizophrenia
Schizophrenia
Psychotic disorder*
3
Effect size
1.38 (OR)
1.39 (OR)
1.21 (OR)
1.31 (OR)
2.38 (OR)
2.75 (RR)
1.69 (RR)
1.71 (RR)
1.32 (RR)
2.40 (RR)
1.62 (RR)
1.57 (RR)
1.24 (RR)
2.7 (RR)
4.5 (RR)
2.9 (RR)
2.36 (IRR)
95% CI
[Lower level;
upper level]
[1.17; 1.64]
[1.23; 1.58]
[1.02; 1.42]
[0.97; 1.78]
[2.01; 2.81]
[2.31; 3.28]
[1.43; 1.99]
[1.41; 2.06]
[1.13; 1.54]
[2.13; 2.70]
[1.37; 1.90]
[1.36; 1.81]
[1.10; 1.41]
[2.3; 3.2]
[1.5; 13.1]
[2.5; 3.49]
[1.89; 2.95]
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●
higher rates of pollution (e.g., air, water),
●
noise pollution (e.g., traffic)
●
specific urban designs (e.g. tall buildings that may
be perceived as oppressive),
●
or more physical threats (e.g., accidents,
violence),
thereby likely increasing stress levels with negative
effects on mental health (5, e20–e25). Research indi-
cates that urban air, water, and noise pollution can have
substantial effects on the mental health of urban
populations. For example, living close to major streets
or airports increases exposure to traffic noise and
pollution and is associated with higher levels of stress
and aggression (e20, e26–e28).
Adjusted by SES, age, and type of residential area,
one study in Germany found that those who were
highly annoyed by road traffic, had a 1.8-fold (women)
and 2.5-fold (men) increased risk for impaired mental
health (e29). Urban light exposure may further
influence the circadian rhythm and change sleeping
patterns with known consequences for mental well-
being (e30).
Urban design exhibits associations with population
mental health (4, e22, e23, e31–e41). For example,
greater access to green space and better walkability was
FIGURE
Mental distress (mean GHQ-28 scores) as a function of local poverty levels (beyond individual SES), as defined by the percentage of
residents receiving public welfare, in 11 local neighborhoods in the inner city borough of Berlin (Mitte).
The percentage of residents receiving public welfare is depicted in yellow (low) to red (high) color-coding (range: 18% to 45%), and mean
levels of mental distress (Mean GHQ-28 scores = 18.53, standard deviation = 4.79, range 10.7 to 26.3) are shown as column heights in each
local neighborhood.
GHQ, General Health Questionnaire; SES, socio-economic status
Reinickendorf
Park
Rehberge
Pankow
Charlottenburg
Mitte
Alexanderplatz
Prenzlauer
Berg
TV Tower
Brandenburg
Gate
Park
Tiergarten
West
Wedding
Moabit
East
Wedding
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associated with less depression and enhanced physical
activity that may promote health (e32–e34). Fur-
thermore, the recreational aspects of well-maintained
urban green and blue spaces are apparently associated
with the mental well-being of urban populations (e33,
e42, e43). Urban green and blue features additionally
have the capability to buffer urban heat island effects
and to reduce heat stress (e44). Moreover, urban street
canopy can reduce the “oppressive” effects of tall
buildings (e22, e23).
In addition, urban density (as opposed to sprawl) has
been associated with better mental health as it
comprises better access to resources (e.g. parks, play-
grounds, health-, and social care) (e45).
In contrast, less green space may indicate more traf-
fic noise and worse access to neighborhood resources,
which may lead to low housing rents attracting low
SES groups. Work in the field of environmental justice
may offer more insights into these relationships and
may help further promote mental health in urban areas.
Future challenges
Urban neighborhoods play a particular role in shaping
urban population health due to their unique socio-
ecological environments constituting both risk and
health promoting factors (6, 12, 36, e46). Six key
challenges and opportunities for future research direc-
tions need to be addressed:
First: there remains much we need to know about
the functional relationships between city living or up-
bringing and mental health problems in urban popu-
lations (19–22, 37, e47–e49). Research would benefit
from more longitudinal studies facilitating the analysis
of causal relationships between the duration of expo-
sure to inner-urban socio-ecological factors and mental
health.
Second: we do not know much about the associ-
ations of neighborhood resources (e.g. green spaces)
with different dimensions of mental health. Although
studies have looked into different mental health out-
comes, they have not been systematically assessed
within the same contexts, that is, whether e.g. green
spaces are associated with similar effects across mental
health dimensions.
Third: we also do not know much about socio-
demographic differences in the relationship between
access to neighborhood resources and mental health
(19). Socio-demographic groups may not have similar
access to these resources and may be disproportionately
distributed benefiting e.g. more affluent populations,
which is increasingly recognized as an environmental
justice issue (e50). Including these issues in the context
of urban mental health may help for more sustainable
distributions of balanced resources.
F o u r t h : our understanding of moderators (e.g. social
or ethnic segregation) to help explain differences be-
tween groups in mental health is also limited (27, 28,
30). In this context, breaking up social and ethnic
segregation and discrimination appears to be warranted
to improve living conditions and reduce social
isolation. Furthermore, both heterogeneous and homo-
geneous neighborhoods (e.g. low SES) may have
negative associations with individual level mental
health such that respective effects can only be assessed
in multilevel-adjusted research studies. In addition, we
do not know whether the risk of mental health problems
is reduced in people if they think they have the option
to move away.
We also do not know much about the spatial
heterogeneity in the association of neighborhood re-
sources with mental health across urban neighbor-
hoods. High unemployment rates in one neighborhood
may have an effect also on adjacent neighborhoods
(30). For example, high unemployment rates are associ-
ated with higher substance abuse (e51) and may affect
drug use in neighboring parks or facilities, even though
unemployment (or substance use) rates are low there.
Fifth: our knowledge on synergies between inter-
ventions is limited, so that we do not know much about
the mental health effects of policies that were not
specifically designed for improving mental health of
urban populations (e.g. introducing street trees,
reduced-traffic areas). Systematic evaluations of inter-
ventions that have worked in other settings and their
effects on urban mental health are still scarce in the
literature, especially in developing cities of resource
poor countries (e52, e53).
Sixth: interdisciplinary research between architec-
ture, city planning, epidemiology, geography, neuro -
sciences, and sociology are crucial to better under-
stand to which extent urban socio-ecological environ-
ments affect population mental health. Such an ap-
proach may also identify populations who lack the
“urban advantage” and who are at risk for psycho-
pathology.
Conclusions
A series of studies exhibit interaction between
urbanici ty, the socio-ecological environment, and
mental health (19, 27). Research would benefit from
more longitudinal studies focusing on both rural-
urban and inner-urban causes and distributions of
mental health.
More in-depth knowledge about different dimen-
sions of mental health disorders across diverse socio-
demographic groups might shed light on the distribu-
tions of these disorders and guide us in better devel-
oping health promoting urban designs. Knowledge
on moderators from the socio-ecological environ-
ment, on the spatial heterogeneity of neighborhood
resources, and their associations with mental health
within and across neighborhoods will help to eluci-
date the mechanisms linking urban environments to
mental health.
Acknowledgement
We would like to thank Mr. Werner of the Audiovisual Center at the University
of Potsdam for his support in creating the Figure.
This study was funded by the German Research Foundation (DFG, GR
4302/1–1, GR 4302/2–1 to OG).
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Conflict of interest statement
Prof. Rapp has received consultancy fees from Eli Lilly. He has received reim-
bursement of travel and accommodation expenses from Servier Germany. He
has received lecture fees from Merz, GlaxoSmithKline and Johnson &
Johnson, as well as study support (third-party funds) from Willmar Schwabe.
PD Dr. Adli has received author’s royalties from Random House. He has
received lecture and consultancy fees from Deutsche Bank, ViiV, Gilead
Sciences, MSD, Servier, aristo, Janssen-Cilag, Merz, mytomorrows and Lund-
beck. He has received study support (third-party funds) from Servier and
aristo, as well as reimbursement of travel and accommodation expenses from
Lundbeck and Servier.
The other authors declare that no conflict of interest exists.
Manuscript received on 19 July 2016, revised version accepted on
11 January 2017
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Corresponding author
Prof. Dr. med. Dr. phil. Michael A. Rap p
Sozial- und Präventivmedizin
Universität Potsdam, 14469 Potsdam, Germany
michael.rapp@uni-potsdam.de
Supplementary material
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Cities and Mental Health
by Oliver Gruebner, Michael A. Rapp, Mazda Adli, Ulrike Kluge, Sandro Galea, and Andreas Heinz
Dtsch Arztebl Int 2017; 114: 121–7. DOI: 10.3238/arztebl.2017.0121

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