Cities and the Health of the Public

13. Mental Health in the City

247 13 Mental Health in the City Sandro Galea, Michaeline Bresnahan, and Ezra Susser Mental Health: Global and Local Burden Mental and behavioral disorders affect more than 25% of people during their lifetime and are estimated to be present in 10% of the adult population at any time.1 The Global Burden of Disease report for 20002 estimates that mental health problems account for 12% of the total disability adjusted life years (DALYs) lost worldwide and for 31% of the years of life lived with a disability. The most common mental disorder, unipolar major depression, is the fourth leading cause of DALYs among all ages and both sexes, accounting for 4.4% of the total DALYs worldwide. In specific age and gender groups, mental health problems account for an even higher proportion of DALYs. For example, among women aged 15 to 44, unipolar major depression is the second leading cause of DALYs worldwide , accounting for 10.6% of DALYs. Beyond their impact on the individual, mental health and behavioral problems are frequently accompanied by social and economic impact on families and society. Mental health problems impose a substantial burden on health services, particularly primary health care. Anxiety and depression have been shown to be the most common presenting complaint in primary care settings in multiple studies conducted worldwide; it is estimated that anxiety and depression account for up to a third of all presentations in primary care settings.3, 4, 5 Despite the persuasiveness of the evidence on the high prevalence of mental health problems worldwide, public health attention on mental health disorders has long lagged behind public health attention paid to physical disorders. For example , the World Bank’s 1993 World Development Report6, 7 focused on health but barely mentioned mental health problems in the text of the report, although mental health did feature in tables in the report appendices. The suffering caused by 248 Part IV: Health Outcomes and Determinants mental illness and the relative neglect the topic has received makes it particularly important to consider how cities and urban living—rapidly becoming the norm for populations worldwide—may affect mental health. A full discussion of all the issues relevant to the study of mental health in cities can occupy several volumes and thus is beyond the scope of a single chapter. Therefore, in this chapter, we limit ourselves to three principal areas of discussion. First, we discuss key concepts that underlie the study of urban mental health. Second , we discuss the evolution of thinking about urban living conditions and health and provide an overview of the primary empiric evidence that has explored the relations between urban living and mental disorders in the past century. Third, to better explore how urban living may be associated with urban health, we consider the example of schizophrenia and synthesize the best evidence for the relation between urban living and schizophrenia. Drawing on the issues raised in these three sections, we conclude with a discussion of the potential implications of our observations and identify viable avenues for research. City Living and Mental Health Cities have long been the subject of literary and academic interest as a powerful force shaping the health of populations. Writers from several eras in Western European history considered cities as places that were detrimental to health, and in many ways, for much of history, cities were characterized by features that were unquestionably linked to poor health. Literary figures, commentators, and social theorists observed the problems endemic to these growing cities and suggested that they had a role in shaping individual well-being. The 19th-century English romantic poet Percy Bysshe Shelley8 observed, “Hell is a city much like London.” Indeed, a full collection of the writings that have denounced cites or deplored living conditions in cities would fill several volumes.9 It is worth considering why historically so many leading thinkers have considered that cities could be detrimental to health. Most of the early thought about cities and how they may unfavorably influence human health arose from the growing role played by cities in European life over much of the past millennium. As cities grew, particularly as the Industrial Revolution accelerated, population density, numbers of marginalized populations, pollution, and crime frequently increased, resulting in health in cities being worse than it was outside of cities in many countries . Literary observers and social commentators, reflecting on these observations, ascribed to city living an etiologic role in shaping health.10–13 In many ways, it was the process of rapid...