Sm. Sci. Med. Vol. 39, No. 2, pp.

233-245, 1994
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URBANIZATION AND MENTAL HEALTH IN

DEVELOPING COUNTRIES: A RESEARCH ROLE FOR
SOCIAL SCIENTISTS, PUBLIC HEALTH PROFESSIONALS
AND SOCIAL PSYCHIATRISTS
TRUDY HARPHAM
Urban Health Programme, Health Policy Unit, Department of Public Health and Policy,
London School of Hygiene and Tropical Medicine, Keppel Street, London, England, WClE 7HT.

Abstract-Urbanization in developing countries involves changes in social support and life events which
have been shown to affect mental health; mainly depression and anxiety, particularly among low income
women. Although depressive and anxiety disorders have a high prevalence and account for a large
proportion of visits to primary health services there is little international health research in this field. The
determinants, extent and outcome of the association between urbanization and mental health requires
multi-disciplinary research by social scientists, social psychiatrists and public health professionals. An
appreciation of different conceptual models and associated methods is required before effective research
can begin. Other issues such as the avoidance of environmental determinism; the separation of
macro-social and micro-social variables; the weakness of urban/rural comparisons of mental health; the
role of rural to urban migration; the debates about cross-cultural psychiatry; and the policy-relevance of
research, all need consideration in the development of research into this rapidly emerging, but relatively
neglected problem.

Key words-urbanization, mental health, psychiatry, social support, life events, depression, developing
countries

INTRODUCITON: SOCIAL CHANGE AND MENTAL
HEALTH IN DEVELOPING COUNTRIES
The great social changes which are occurring in most
developing countries involve changes in behaviour
which will undoubtedly have an impact upon health.
The role of behavioural factors in health in develop-
ing countries is a neglected research field. This paper
is concerned with one particular and important social
change-urbanization. Urbanization is associated
with many health problems [l]. It is argued here that
urbanization will have a particular impact upon
mental health and that the determinants, extent and
outcome of this association need to be examined by
a multi-disciplinary research on the part of social
scientists, public health professionals and social psy-
chiatrists. The focus of the paper is on depression and
anxiety as these common but neglected mental health
problems appear to have a particular association with
urbanization. The more specialized problems of
schizophrenia and alcohol and substance abuse are
not addressed here. The main population group
covered is adults and the paper does not review the
growing number of studies on the mental health of
children (see [2] for a review) or the elderly which
merit separate reviews. In order to enable different
academic disciplines to address the same research
problem the paper first notes differences in disci-
plinary approaches and conceptual models. For the
same reason a section on definitions and measures is
presented before documenting the extent of mental ill
health. An examination of the link between social
factors and depression leads to the development of a
conceptual model and finally research priorities and
their policy implications are identified.
As developing countries experience the epidemio-
logical transition, chronic diseases replace acute in-
fectious diseases as the major cause of morbidity and
mortality. Consequently, theories of disease aetiology
shift from ones in which a single factor (usually a
microbe) cause a single disease, to ones in which
multiple behavioural and environmental as well as
biological and genetic factors combine to produce
any single disease [3]. Mental ill health is one of the
chronic diseases which is apparently increasing in
developing countries. Mental illness is associated with
behavioural change, among other factors. Kleinman
[4] presents a stark scenario of increasing mental
ill-health and behavioural changes that is so powerful
that any precis would do injustice:
We are seeing a pandemic of disturbed behavioural con-
ditions come to occupy centre stage of the world’s health.
These behavioural conditions are shared by rich and poor
societies. They include . . urbanization with associated fam-
ily breakdown and abandonment of, and violence to spouse,
child and the elderly. and depressive and anxiety dis-
orders. Whether or not the last two disorders have actually
increased in prevalence or have merely been more accurately
reported is still a controversy. But there is suggestive
evidence from developing societies to indicate the rates are

233
 234 TRUDYHARPHAM

actually rising. In the event, depressive and anxiety disorders of a city. “The big mystery is: wherein lies the
constitute between 10 and 20% of all patient visits to
outpatient health care services in the developing world. In
usefulness of this approach?’ [9, p. 2681.
Africa and Asia and Latin America, these conditions to- In the late ’50s a ‘sociocultural disintegration hy-
gether have a higher prevalence in primary care settings than pothesis’ was advanced by Leighton which argued
do infectious disease. Yet for all its high prevalence and that family and marital disintegration, limited social
equally high cost, mood disorder is virtually ignored in networks, high levels of hostility and similar traits
international health. In most Third World primary care
settings it is neither diagnosed nor treated. Hardly any disrupted psychological homeostasis thereby increas-
monies are devoted to mood disorder--the most common ing the risk of mental disorders. “Leighton went on
primary health problem-by ministries of health in the to note that these conditions are most likely to occur
developing world.. By far most patients with mood dis- in communities in which there is extensive poverty,
orders reside in the developing world, where they receive
cultural confusion, widespread secularization, exten-
neither effectivetreatment nor significant research attention.
Surely it is the responsibility of researchers and clinicians in sive migration and rapid social change. While these
the richer societies to do something about this tragedy [4, qualities are not limited to urban areas, it was
p. xvii]. obvious that urban areas were most likely to be the
socio-environmental context in which they occurred”
Another finding which points to the growing im- 17, P. 121.
portance of mental health in developing countries is In the 1970s Marsella and his colleagues advanced
the analysis of the ‘global burden of disease’ recently the “social stress, resources and psychopathology
undertaken in the World Bank’s [5] world develop- hypothesis” and argued that a conceptual framework
ment report which had the theme of ‘investing in which considered the stress associated with problems
health’. The analysis used ‘disability adjusted life related to housing, work, marriage, child rearing,
years’ to measure the burden of a wide range of security and other urban problems, in interaction
morbidities. In the female adult population in devel- with the resources available for their resolution or
oping countries, depressive disorders were the fifth attenuation, could explain the determinants of ‘psy-
most important contributor to the disease burden chopathology’ among urban populations. Marsella
after maternal and selected communicable diseases. acknowledges that this early work failed to examine
Despite the extent and urgency of the problem, the dynamics and mechanisms by which urbanization
mental illness continues to be assigned low priority. affected the frequency, severity and distribution of
Sugar et al. [6] explain how the dominance of public mental disorders. However, the Marsella hypothesis
health physicians in the field of international health was the broadest in terms of including a host of social
has been associated with a focus on infectious dis- factors. This in itself can cause a problem in that “if
eases and that only recently have the effects of social research on . . . urbanization and mental disorders is
and behavioural change received attention. approached all inclusively, it would be impossible to
summarize because of its extent and complexity”
[7, p. 151. Marsella’s recent work [7] proposes a
hierarchical model of research variables in an attempt
HISTORICAL INTEREST IN URBANIZATIONAND
MENTAL HEALTH to unravel the complexity, for example, urbanization
and homelessness are categorized as macrosocial vari-
There has been an interest in urbanization and ables, family structure and vandalism as microsocial,
mental health for many years. In an excellent review values and substance abuse as psychosocial, and
of early studies of urbanization and mental disorder, depression as biosocial.
Marsella [7] summarizes the Chicago urban sociology Current models and theories which attempt to
movement’s contribution to this field. For example, causally link urbanization and related social prob-
Louis Wirth in the ’40s contended that urbanization lems to mental disorders are limited in number and
led to extensive differentiation and separation among conceptual power. The following sections lead
occupational, familial, recreational and institutional towards the presentation of a new conceptual model.
aspects of life, thus preventing a normative consensus
at the community level. The result was poor social
integration with consequent alienation, aberrant be- DISCIPLINARYAPPROACHES AND CONCEPTUAL
MODELS
haviour and social withdrawal. In the ‘5Os, as com-
munity psychiatric studies were conducted, it became The analysis of social pressures, mental health
clear that the spatial distribution of mental disorders outcomes and the development of appropriate inter-
in large urban areas was a function of the concen- national and national mental health policy requires
tration of poverty in city centres rather than the multidisciplinary research. The skills of social scien-
influence of a specific geographic location. There was tists, social psychiatrists and public health pro-
thus a move away from the environmental determin- fessionals are required. While there is a great deal of
ism and ecological fallacy [8] of the Chicago school experience of social scientists and public health pro-
although some modern literature still tends towards fessionals collaborating in international health re-
these theories. There seems to be no fading away of search there is, to the author’s knowledge, little
studies which describe rates of mental health by areas involvement of social psychiatrists. Similarly, “few
 Urbanization and mental health in developing countries
experts in international public health know about the
improved reliability of diagnostic instruments in psy-
chiatry or about effective treatment of major classes
of mental illness. The result is unjustified pessimism
about the prevention and treatment of psychiatric
conditions” [6, p. 3581. For these reasons it is necess-
ary to consider the position of social psychiatry in
relation to public health and social science.
Social psychiatry is characterized by emphasis on
the environmental and social group influences on the
individual. In an interesting historical overview of the
subject, Jablensky [lo] argues that social psychiatry is
in crisis and summarizes some of its shortcomings.
The subject has been criticized from the ‘left’ for
adherence to the ‘medical model’ and for emphasis on
the adjustment of the individual to the norms of
society rather than promoting changes in the socio-
economic conditions that cause mental ill-health.
Indeed, some critics suggest that social psychiatric
programmes and research in developing countries
represent the medical legitimation of social problems
wrought by economic development (quoted in Ref.
[6]). On the other hand, the ‘right’ argues that social
psychiatry is intrusive social control, violating the
rights of individuals to personal autonomy. More
significantly, a main shortcoming of social psychiatry
is the lack of success of the psychosocial approach in
the area of prevention. Jablensky [lo] partly explains
this failure by the underdevelopment of methods to
evaluate the effect of interventions. However, from
the public health viewpoint it appears that the prob-
lem is more to do with the inability to identify and
communicate appropriate interventions. Although
authors such as Platt et al. [l l] state that the an-
tecedents of mental ill-health are largely social and
the ‘treatments’ should therefore incorporate a sig-
nificant social component, such advocated social
action is rarely elaborated upon. Perhaps because of
these failures, the current predilection in psychiatry is
to turn inward in its search for causes-to personality
traits and biological factors [12]. Modernists believe
that the biological focus in contemporary psychiatry
is ‘more scientific’ and more mainstream in terms of
medicine. This in turn enhances the status of psychi-
atry in medical society’s hierarchy [13]. Nuckolls
suggests that “psychiatry is attempting to remedical-
ize itself, so that it can return to the medical family
of origin” [14, p. 11.
While many psychiatrists are ignoring social fac-
tors, anthropologists are increasingly becoming inter-
ested in social factors and mental health. A
development which has brought anthropologists and
psychiatrists together (sometimes in conflict) is the
evolution of transcultural psychiatry into the ‘new
cross-cultural psychiatry’ [ 151.The ‘old’ transcultural
psychiatrists assessed the abnormality of behaviour
against the yardstick of Western psychiatric diagnos-
tic characteristics. The term itself implied that culture
can be transcended. Where the behaviour did not
readily fit these categories it was claimed that the
235
culture had influenced the overt content of the illness,
but that the underlying form was the same. More
attention was paid to behaviour than beliefs [16]. The
‘Russian dolls’ model suggests that if the outer layers
are removed, hidden within lies a core of illness which
is common to all people. According to Kleinman “the
chief failing of the ‘old transcultural psychiatry’ is its
total reliance on Western psychiatric categories which
are applied by clinicians and epidemiologists as if
they were independent of cultural bias, but which in
fact are culture-specific categories” [15]. The ‘new’
cross-cultural psychiatry by contrast offers an
anthropological investigation of indigenous disease
categories. Skultans [16] suggests that this anthro-
pological move in the direction of psychiatry is
encouraged by the need to find new pastures for
anthropological investigation: “the drying up of
‘exemplary elsewheres’ as Geertz [17] calls the SO-
cieties studied by anthropologists has led to a search
for the strange or alien within, namely psychiatric
theory and practice” [16, p. 211. Skultans also
suggests that the anthropologist’s or cross-cultural
psychiatrist’s own conceptual framework is brought
to bear upon alien medical systems and that the new
approach is still not culturally unbiased. Littlewood
[18] and Bracken [19] consider the usefulness of
cross-cultural psychiatry and examine the tensions
between psychiatry and anthropology.
One source of the division between psychiatry and
anthropology and of the anthropologist’s distrust of
psychology (and by implication psychiatry) derives
from Durkheim [16]. Although Durkheim did not
specifically address the subject of mental illness it is
generally acknowledged that he had an enormous
influence on cross-cultural psychiatry. Skultans [16]
suggests that the Durkheimian stance is best summar-
ized in the edict: “Every time a social phenomenon is
directly explained by a psychological phenomenon we
may be sure that the explanation is false” [20, p. 1041.
Thus, the argument goes, mental health and illness
should be examined in terms of culturally grounded
categories with social roots rather than behaviour.
If one steps back and asks why comparisons of
rates of psychiatric disorders across diverse popu-
lations are desirable the answer is not so clear. What
do such differences mean? A partial list of possible
causes for differences includes the following: demo-
graphic differences in the general population; differ-
ences in mortality of the psychiatrically ill; different
genetic composition; differences in effectiveness of
prevention/treatment services; differences in patho-
genic factors within the society or culture; and differ-
ences in social factors which permit recovery or
coping despite psychiatric disorder (e.g. employment,
stable residence) [21]. Much of the debate between the
disciplines has not addressed explanations of differ-
ences but focusses on the measurement of differences.
In the next section selected measurement and defini-
tional issues which are relevant to this paper, are
discussed.
236 TRUDY HARPHAM
DEFIYmIONS AND MEASURES
This section considers the problems of definitions
of depression and anxiety and briefly comments upon
the most common methods used to measure these
phenomena. Sartorius [22] suggests that confusion
and vagueness about the concept of mental health
have been a reason for the low status given to mental
health programmes. While it could equally be argued
that lack of knowledge of determinants of mental
ill-health and therefore appropriate action to prevent
and treat the problem are the reasons for limited
attention, there is no doubt that the lack of clear
definitions in this field is off-putting.
Problems of definitions do not disappear when one
focuses on particular conditions of mental health.
Definitions of depression, the interest of this paper
and the most prevalent disorder in psychiatry, are
fraught with difficulties. For example, many psychia-
trists claim that the findings which are reviewed in the
following sections are not concerned with depression
in a true clinical sense. Brown [12] responds by
agreeing that this may well be so if one has in mind
patients suffering from manic-depression or severe
melancholic forms with psychotic features but that
such severely depressed patients are not typical of
out-patient clinic attenders.
Another problem arises is differentiating between
depression and anxiety. The view that anxiety
(usually encompassing phobias and obses-
sive-compulsive disorders) and depression can be
subsumed within a category of mood (affective) dis-
orders originated over 50 years ago and still seems
useful considering the difficulty of separating the
conditions. In a helpful review of the issues Clark and
Watson [23] conclude that the correlation commonly
found between measures of depression and anxiety is
not a superficial one due to methodological con-
straints but that the overlap is “pervasive and deeply
rooted” [23, p. 471. A further complication hinders
comparison in that, while many researchers recognize
at least two major subtypes of depression (e.g. psy-
chotic vs neurotic, endogenous (unrelated to environ-
mental stressors) versus reactive, primary versus
secondary), the majority of research studies that have
contrasted anxious with depressed patients have
focused on only one of these depressive subtypes [23].
The arguably inseparable nature of depression and
anxiety is reflected in instruments in most common
use in population-based surveys. The respondent-
based General Health Questionnaire (GHQ) devel-
oped by Goldberg [24] (and the derived Self
Reporting Questionnaire-20 items, SRQZO) is a
successful screening instrument (identifying probable
cases and non-cases) but cannot, and does not claim,
to differentiate between depression and anxiety. Such
self-rating scales are useful in distinguishing ‘high-
symptom’ from ‘low symptom’ persons and correlate
well with impairment [21]. They are often said to
measure ‘conspicuous psychiatric morbidity’ (CPM).
..
Alternative, ‘investigator-based’, psychiatric inter-
view type instruments such as the Present State
Examination (PSE) aim at symptom identification
rather than screening and have to therefore move
closer to separating out depression from anxiety.
After symptoms have been measured these investi-
gator-based type instruments rely on formal rules to
reach a decision about diagnosis or ‘caseness’. These
rules (usually computer-based algorithms) allow sep-
arate diagnoses of depression and anxiety as well as
identification of subtypes within these categories. The
validity of these diagnoses is still hotly debated but
will not be examined here.
Another scheme for diagnosis, which frequently
appears in the literature is the influential third edition
of the American Psychiatric Association’s Diagnostic
and Statistical Manual of Mental Disorders (DSM-
III) and the revised version (DSM-III-R) [25]. The
scheme is for researchers and clinicians and enables
the formation of diagnoses such as major depression
disorder (MDD) and generalized anxiety disorder
(GAD). This is a national diagnostic system which is
being used internationally [21] despite the fact that it
is U.S. culture-based and that there is little universal
validity of many of the disorders in the DSM [13].
For a critique of the DSM-III-R see Brown [26]. For
the purposes of definitions, an alternative to the
DSM-III-R is the international classification of dis-
ease (ICD). Two sub-categories of this classification
are pertinent to the current paper: mood disorders
and ‘neurotic, stress-related and somato-form dis-
orders’. Mood disorders include disorders in which
there is a change in affect or mood to depression or
elation. There are several sub-categories of ‘neurotic,
stress-related and somato-form disorder’ but the two
most relevant here are generalized anxiety disorder
and adjustment disorders. The dominant symptoms
of GAD are variable but include complaints of
persistent nervousness, trembling, muscular tensions,
sweating, light headedness, palpitations, dizziness
and epigastric discomfort. Fears that the patient or a
relative will shortly become ill or have an accident are
often expressed. This disorder is often related to
chronic environmental stress [27]. Adjustment dis-
orders involve distress and emotional disturbance,
usually interfering with social functioning and per-
formance, arising in the period of adaption to a
significant life change or stressful life event. The
stressor may have affected the integrity of an individ-
ual’s social network (bereavement, separation experi-
ences) or the wider system of social supports and
values (migration, refugee status), or represented a
major developmental transition or crisis (going to
school, becoming a parent, failure to attain a cher-
ished goal, retirement). In more lay terms these two
sub-categories can be taken to represent depressions,
neuroses and anxieties.
Some studies reviewed below are better than others
in clearly defining their concept of depression. For
example, in most of Brown’s work a person is
 Urbanization and mental health in developing countries
required to have depressed mood and at least four
other core symptoms of depression such as hopeless-
ness, suicidal plans or actions, neglect due to brood-
ing and delayed sleep (this definition is based on the
PSE). Others use broader concepts, for example, as a
psychological phenomenon, depression “is a lived
experience-‘to feel depressed-that is the result of
physiological processes interacting with meaning sys-
tems and social relationships” [28, p. xv].
Another concept which has suffered from loose,
conflicting and changing definitions is ‘stress’. Stress
has been described variously as pressure, strain,
tension, turmoil or conflict. The currency and popu-
larity of the concept of ‘stress’ derives from the work
of Selye [29, 301 who was among the first to draw
attention to the fact that all manner of illnesses
manifest themselves in somewhat similar symptoms
of ill-health or ‘distress’. Selye defined stress as “the
nonspecific response of the body to any demand
made upon it”. If this is too broad a definition Bertan
[31] suggests that the concept has now evolved into a
general term applied to all sorts of stimuli or insults
or impacts on the human body and mind, so much so
that it is in danger of losing its meaning. In reviewing
definitions of stress, Monroe and Depue find that
terms mostly “connote some form of tension between
the individual and his or her life’s challenges, often
also incorporating some notion of subjective discom-
fort” [32, p. 1051. While many authorities argue that
stress is a central determinant of depression, others
relegate it to a more peripheral role. Even with the
best measures available, it seems that the majority of
individuals under severe stress do not develop a
depressive disorder (for example Brown reports that
only 1 in 5 women experiencing a severe event go on
to develop a depressive disorder). Social support is
the most widely acknowledged moderator of the
impact of stress. This buffering effect is considered
below in the section on social support.
EXTENT OF THE PROBLEM
When considering the extent of the problem of
mental ill-health associated with urbanization in
developing countries, several groups of literature
need to be highlighted. These can be categorized into
studies which address: rural-urban comparisons;
rural-urban migration; urbanization over time; and
depression/anxiety in urban-based populations.
Rural-urban comparisons
When reviewing the literature on rural/urban
differences and mental health one finds several con-
tradictory studies. Cheng [33] points out that the
notion that urbanization has adverse effects on men-
tal health has been held by many medical and social
scientists. In contrast, the supportive traditional rural
life pattern is believed to be beneficial to mental
health [34-381. Dohrenwend and Dohrenwend [39]
reviewing and summarizing data concluded that eight
231
out of ten studies reported a higher frequency of
mental disorder in urban populations than in rural
ones, the increase being mainly in neuroses and
personality disorders. However, Cheng [33] found no
rural/urban difference in overall minor psychiatric
morbidity in Taiwan and pointed out that this was in
agreement with surveys in developed countries in-
cluding the U.S.A. [40], Australia [41] and Great
Britain [42]. Ekblad [43] notes that culture might
exert a strong influence on the relationship between
urbanization and health and highlights Shen et al.‘s
[44] study in China which also found lowest rates of
psychiatric morbidity in urban areas. Inkeles and
Smith [45] and Cheng [33] suggest that the notion of
an adverse effect of urbanization on psychological
well-being is probably misleading and stress that
social risk factors may be specific to a particular
community. Burvill [46] suggests that every society
may produce its own specific stresses, and these
stresses are no more frequent in industrialized, urban-
ized society but merely different in type.
Although some discussion of rural-urban differ-
ences is inevitable in a paper focussing on urbaniz-
ation and mental health, caution should be exerted in
interpreting the results of such comparative studies.
Webb’s [47] review of rural-urban differences in
mental disorder failed to show any consistency and
comparison was, in any case, difficult due to: use of
different types of data, definitions and methods; the
confounding by migrants; and different age, sex,
education, income, occupation, mobility and ethnic-
ity-factors which may affect mental health more
than place of residence. A weakness of many studies
which compare settings is that compositional differ-
ences between urban and rural areas are not taken
into account: if urban/rural residence is a risk factor
for psychiatric morbidity, that relationship should be
observed once compositional differences (e.g. age,
sex, socio-economic status) between urban and rural
areas are statistically controlled [38]. As Marsella [7]
notes, instead of comparisons of rural-urban differ-
ences, what is needed are studies which focus on
specific sub-populations, specific disorders and
specific dynamics.
Rural-urban migration
The ‘social change’ associated with urbanization in
developing countries which has received most atten-
tion in the mental health literature is internal
rural-urban migration (see Refs [48] and [49] for
reviews of selected literature). Gaviria et al. [50]
present a model to explain the relationships between
migration and mental health. The assumption is that
particular social, political and economic contexts give
rise to an internal migratory process which encom-
passes stressors and coping resources which have an
impact upon mental health. In addition, acculturative
adaptation (integration, assimilation or rejection)
after migrating can affect mental health. This last
factor has been studied in the developing country
238 TRUDY HARPHAM
context by Brody [51] who examined Brazilian
rural-urban migration in the context of industrializ-
ation, rapid social change and acculturation. He
concluded that illiteracy was a major factor in mental
illness because it limited capacity to understand and
manipulate symbols, to receive and integrate infor-
mation, and to form reciprocal relationships with the
more dominant members of society. There are several
problems associated with many of the studies of
internal migration. These include the assumption that
change per se is pathogenic, which is not inevitable
[52] and neglecting to measure the degree to which
mentally healthy individuals self-select themselves
into either migratory or non-migratory patterns
based upon their internal resources prior to mi-
gration. The few studies which try to tease out the
relationship between migration and mental health
tend either to undertake rural-urban comparisons
(see criticisms of rural-urban comparisons above) or
to compare migrants in the city to ‘indigenous’ city
dwellers.
Urbanization over time
Few studies examine urbanization over time in a
particular city and associated mental health. Notable
are a range of studies from Taiwan [53-551 which
demonstrate that rapid urbanization, industrializ-
ation and related social changes from the 1940s to the
1980s were accompanied by escalating rates of de-
pression and anxiety disorders. The behavioural
effects of urbanization on children in Khartoum have
been studied by Rahim and Cederblad [56] where
mothers reported more symptoms for more children
in 1980 than they did in 1975, using the same instru-
ment. In examining patterns of mental illness in the
early stages of urbanization in Swaziland, Guiness
[57] suggests that adolescents and young adults are at
the forefront of change and that they will be particu-
larly vulnerable to the effects of rapid social change.
Depression /anxiety in urban -based populations
What is the prevalence of depression and anxiety in
developing countries and, in particular, in urban
populations? Where standard definitions of de-
pression are used (e.g. DSM-III-R) the prevalence of
depression varies greatly across cultures. Jenkins
et al. [58] have summarized this variation and note
that among the highest rates in the world are those
reported for Africa: 14.3% for men and 22.6% for
women in Orley et al’s [59] Uganda research. Sugar
et al. [60] point out that anxiety disorders, like
depression, present a substantial burden of morbidity
in parts of the developing world. Globally, the com-
munity prevalence of all anxiety disorders seems to
range from 3-8% and the cross-cultural similarities in
the prevalence of anxiety disorders as a whole are
more impressive than the differences [61].
The number of population-based and health-facil-
ity based studies of depression/anxiety in urban
populations of developing countries is growing and it
is not intended to review such studies here. However,
some of the more useful published studies of psychi-
atric morbidity, representing a range of developing
country urban settings include:
Health -facility based:
Alam [62] found a 39% prevalence of psychi-
atric morbidity in his general practice survey in
Dhaka, Bangladesh.
Sen et al. [63] used a two-stage design (SRQ20)
and the clinical Interview Schedule (CIS) and
found a prevalence of minor psychiatric mor-
bidity of 46% in a study of primary medical
care settings in Calcutta.
Mari [64] used the PSE and CIS with primary
care attenders in Sao Paulo, Brazil and found
a prevalence of minor psychiatric morbidity of
45-63% in three clinics.
Population -based:
Rahim and Cederblad’s [65] survey of 204
adults in Khartoum, Sudan in which a wide
range of methods were used including the SRQ,
found that 40% had at least one psychiatric
symptom, in 23.7% this was mild but in the
remaining 16.6% it was moderate to severe.
Chakraborty [66] used a ‘Household Survey
Questionnaire and Interview’ method in Cal-
cutta with 13,335 persons and found 13.8%
with a ‘broad category of mental disorder.’
Reichenheim and Harpham [49] used the
SRQ20 with mothers of children under 5 years
in a squatter settlement in Rio de Janeiro,
Brazil and found that 36% of respondents were
probable cases of mental ill-health and that
poverty was a more important risk factor than
migration.
Bahar et al. [67] used the 30 item GHQ on a
community-based sample of 1670 adults in
Palembang, a city in Sumatra, Indonesia and
found a GHQ case rate of 20% and a PSE case
rate of 12%. There was a strong association
between symptoms and poverty and migration.
Interestingly, when a government measure of
the level of development of the neighbourhood
was used, persons belonging to communities
which had ‘progressed’ had fewer symptoms.
As this paper is limited to ‘minor’ psychiatric
diseases, the prevalence of severe psychiatric disease,
such as schizophrenia, in urban areas of developing
countries is not covered but see Carstairs [68] and
Sethi [69] for reviews.
It is clear that many urban populations are experi-
encing high rates of depression/anxiety. Women and
persons of low socio-economic status are more prone
to depression. There is clear evidence from Western
studies that women have approximately twice the rate
of depression compared to men [70,71]. This is
regardless of whether studies are population-based or
health facility-based. After reviewing cross-cultural
 Urbanization and mental health in developing countries
studies of women’s depression, Jenkins et al. [58]
hypothesize that studies in developing countries will
reveal a similar disparity between female and male
rates of depression. They add that overall rates are
likely to vary for women relative to local factors such
as control over resources, marriage patterns and
cultural ideology. Similarly, Western research has
demonstrated that rates of depression are signifi-
cantly higher in persons of lower socio-economic
status (SES) than in persons of higher SES [72].
Although beset with the problems of valid measures
of SES, Jenkins et al. [58] present a small number of
studies in developing countries which replicate this
finding. Putting the two risk factors of female gender
and low SES together, it comes as no surprise that
working class women are most at risk of depression.
Brown and Harris [73] found that working class
women had a rate of depression four times higher
than middle class women. The reasons for these
phenomena are considered in the next section.
THE LINK BETWEEN SOCIAL FACTORS AND DEPRESSION
What evidence exists to demonstrate the role of
social factors in depression? The answer to this
question varies according to which author one reads.
Becker and Kleinman [28] suggest that social vari-
ables “such as life events and social support which
had initially appeared to significantly influence
. . . depressive disorders have not proven to be as
consistently replicable or predictive as expected” [28,
p. vii]. They acknowledge that this might be due to
the methodological problem of different definitions,
or diagnoses, of depression being used (see section
above on definitions). However, most authors accept
the significant role of social factors in depression.
L$e events
Threatening or unpleasant life events play a crucial
role in the development of depression [74,75]. Life
events refer to a change in the external environment
which occurs sufficiently rapidly to be approximately
dated [76]. Differential exposure to stressful life
events appears to explain, in part, gender and social
class differences in the prevalence of depression [74].
Platt et al. [1 1] provide a useful summary of Brown
and Harris’ [73] work: “Although working class
women experienced a greater number of severe life
events overall, the differences in life event experience
between them and middle class women were limited
to four particular domains-housing, their partner’s
job, finance and marriage. Working class women,
moreover, appeared to be particularly vulnerable in
that they were more likely to break down after a crisis
event. This, in turn, was found to be related to the
quality of their emotional relationships, the number
of young children in the home and whether the
woman was in paid employment outside the
home. . . life events are often the end result or focus
of long-term difficulties or problems rather than
239
discrete occurrences” [73, p. 1251. The effects of
long-term difficulties (chronic stressors) on mental
health has often been found to be greater than the
effect of acute stressors (life events) (for example,
[771).
The results of Brown’s original population survey
in Camberwell, London, concerning severe life events
have been replicated on at least ten occasions [12].
Brown argues that “when such events and difficulties
are taken into account, their impact is considerable.
Expressed in terms of an epidemiological measure,
the population attributable risk, which gives the
proportion of onsets of depression related to prior
event or difficulty. . . the average percentage is 73%”
[12, p. 231. Although most of Brown’s work has con-
centrated on women, studies of men indicate that the
same aetiological ideas are broadly applicable to
them, despite their lower prevalence of depression
(e.g. ]781).
Although the importance of social factors has been
established for many years, until recently, there has
still been debate about the causal route i.e. depression
may exist prior to, rather than be a consequence of,
adverse socio-economic circumstances. Platt et al.
[ll] and Warr [79] argue that the reasonably firm
conclusion from a vast literature is that the causal
link goes from adverse socio-economic circumstances
to poor mental health, and not vice versa.
It can be hypothesized that long term difficulties
and life events will increase with urbanization in
developing countries. Long term-difficulties might
include poor over-crowded physical environment, the
need for acculturation in the case of migration, a
change from subsistence to cash economy in the case
of migrants, high levels of violence, accidents and
insecure residential tenure. Life events will include
increased separations from partner, loss of employ-
ment and migration. Some life events, such as child-
birth, have potentially both negative and positive
impacts on mental health [80]. The social and be-
havioural changes associated with urbanization may
exacerbate the negative impact and thereby diminish
the positive impact. For example, the two social
factors which have been shown to be associated with
increased postnatal depression are poor quality of
marital relationship and inadequate social support.
In low-income urban environments it is possible that
the rituals and customs which have been commonly
observed across rural areas of developing countries
such as isolation/seclusion of the mother, provision
of help and prescribed rest and release from normal
social roles and previous demands [80] will be eroded
due to the necessary early resumption of economic
activity and reduced social support (which is dis-
cussed in the section below). This whole area of
reproductive psychiatry is relatively under-re-
searched. Similarly, although the number of sexual
partners may increase with urbanization the author
could find no literature on the effect of this on mental
health.
240 TRUDY HARPHAM
Social support
The above debate relates to life events. The other
social factor which has an important link with de-
pression is social support. Research attention fo-
cussed on social support in the mid-‘70s and the
concept was first used in the mental health literature.
Social support can be defined as the degree to which
a person’s basic social needs are gratified through
interaction with others ([81], after Kaplan). Support
may be emotional or instrumental. The literature
[3, 82-841 suggests that social support enhances
physical and, particularly, mental health. Social sup-
port generally accounts for about 5-10% of the
variance in anxiety and depression [85]. Becker and
Schmaling [86] explain that social support tends to
reduce feelings of helplessness and of low self-regard,
while lack of social support tends to increase anxiety
and depression leading to physical and mental ill-
health. These consequences may occur even in the
absence of severe life events (stressors). If severe life
events are present, social support is purported to (a)
enable the events to be regarded as non-threatening
(i.e. copable with), or (b) reduce (buffer) the impact
of the event. Franks et al. [87] have pointed out that
there is very little accepted theory in this field (quot-
ing debates in [SS-911). Numerous articles have been
published which essentially criticize the conceptualiz-
ation and operationalization of social support and
which, interestingly often do not cross refer to each
other (e.g. [81] and [89]). Connell and D’Augelli
suggest that the problems are so numerous that
“research on social support has arrived at a concep-
tual impasse” [88, p. 1061. Coyne and Bolger [91]
suggest that the social support literature rests on
untenable assumptions and Pearlin [92] argues that
because the study of social support is separated from
the institutional and network contexts in which it
exists, the concept lacks ‘sociological substance’. De-
spite this, “during the last two decades, the concept
of social stress has enjoyed the attention of social and
behavioural scientists to a greater extent than any
other psychosocial variable. It has been heralded as
a magic bullet and attacked as a myth” [93, p. 12491.
Apart from problems of poor or absent definitions
there is the problem of the confounding of social
support and life events. Life events may alter the
support available to individuals and support may
decrease the likelihood of event occurrences. Can
changes in the social support system account for the
overall effect of life events? Thoits [81] suggests we
may be able to dispense with life events as an
aetiological factor of importance. The outcome of
mental ill-health may be simply a function of initial
support level and change in support over time. In
terms of action, it seems more feasible to attempt to
improve and strengthen social supports rather than
reduce exposure to stressors (life events) [81]. Simi-
larly, House et al. [3] and Ganster and Victor [85]
argue that social support may become unimportant in
aetiological terms if the determinants of social sup-
port (e.g. exogenous biological, psychological or
social variables) turn out to be determinants of health
also. Almost no attention has been paid to social
support as a dependent variable.
Another problem is the confusion of social net-
work (the structure of linkages) with the social sup-
port (behaviour). Networks have a variety of
functions of which the provision of social support is
but one [89]. The validity and reliability of instru-
ments measuring social support is rarely tested
and/or reported [94,89]. O’Reilly suggests that “as
long as conceptual and operational confusion re-
mains, the predictive utility of the concepts will not
progress to the stage where logical and meaningful
interventions can be developed” [89, p. 8721.
The theories which have been used to explain
mechanisms through which social support affects
health include behavioural, psychological and
physiological theories 1851.For example, persons with
viable social support networks may be encouraged to
engage in healthful behaviour. Or, social support
might enhance health by reducing or preventing the
negative consequences of stress, for example, the
perception that others will provide aid leads to a
better psychological state, which in turn leads to
better physical and mental health. The physiological
mechanism through which social support affects
health works either to relax the ‘fight or flight’
response or to strengthen the immune system
response [85].
Although there are debates about which theory to
accept, most social support theorists agree that any
amount of social support is a ‘good thing’. In con-
trast, social exchange theorists argue that social
interaction does not equal social support [95] and that
there is a cost to social relationships as well as
rewards [96]. A growing literature demonstrates the
negative side of social interaction and its effect on
health (summarized in [87] and [97]).
It is ironic that “just as we discover the importance
of social relationships for health, and see an increas-
ing need for them, their prevalence and availability
may be declining” [3, p. 5441. It can be hypothesized
that social support is declining with urbanization in
developing countries due to reduction of extended
families, increase in single parent households, re-
duced fertility, age-specific rural-urban migration,
women’s labour force participation, and under- or
unemployment. If these aspects of social support are
put together with the earlier discussion of long-term
difficulties and life events it is possible to construct a
conceptual model (Fig. 1) which identifies particular
conditions and processes which are likely to occur in
(particularly low-income) urban populations in devel-
oping countries which, in turn, may be associated
with increased mental ill-health (mainly depression
and anxiety). The model is not comprehensive. For
example, some potential stressors related to the
physical environment, for instance traffic and
 Urbanization and mental health in developing countries 241

transport problems, high noise and pollution levels
are excluded. This is not because these factors are
believed to have no association with mental health
(although no literature demonstrating any indepen-
dent effect was found) but because these factors are
not easily conceptualized as long-term difficulties or
life events, the areas which have clear links with
mental health as demonstrated by the literature.
THE POLICY-RELEVANCE OF RESEARCH ON
URBANIZATION AND MENTAL HEALTH
In addition to generating knowledge for its own
sake, research on urbanization and mental health is
important in relation to the extent health services are
used by people suffering from anxiety and/or de-
pression and in terms of guiding social support action
to reduce vulnerability to mental ill-health. The
global burden of depression and anxiety creates a
heavy demand on primary health services [98]. Mixed
anxiety-depression is the most common presenting
problem in primary care wherever this has been
examined in the Americas, Europe, Asia and Africa,
accounting for a sixth to a third of all attenders [61].
There is increasing evidence to suggest this is true for
developing countries. The well-known WHO collabo-
rative study on strategies for extending mental health
care (in Colombia, the Philippines, Itldi? and Sudan)
found that lO-20% of 1642 primary care attenders
suffered depression and/or anxiety [99]. Forty-eight
percent of primary care attenders- in a study in
Lesotho suffered from depressiori- or anxiety (as
defined by DSM III criteria) (Hollifeld 1989, a per-
sonal communication quoted in [60]). Using the SRQ
and PSE in a Soweto clinic in South Africa, Zwi and
Thorn [loo] found 10.3% of 301 attenders had con-
spicuous psychiatric morbidity (CPM). Giel and Van
Luijk [loll found that 18.5% of those attending an
urban clinic and 19.5% of those presenting to a rural
clinic in Ethiopia were primarily suffering from a
psychiatric disorder. In a Kenyan rural clinic
(n = 140) the figure was 20% [102]. In an urban
hospital outpatient department in Zimbabwe, Hall
and Williams [103] found 10.5% CPM using the SRQ

Increased stressors (life events)

a. Long-term difficulties

e.g. - poor, overcrowded physical environment

- need for acculturation it migrant

* change from subsistence to cash economy

* high levels of violence. accidents

- insecure tenure

b. Life events
/
e.g. * separation from pariner

* loss of employment

* migration
/ \

URBANIZATION MENTAL HEALTH

Reduced social support

e.g. - reduction of extended families

- increase in single parent households

* reduced fertility
\ /
- age-specific rural-urban migration

- women’s labour force participation

* under- or unemployment

Fig. 1. A model of social factors of urbanization in developing countries associated with mental health.
242 TRUDY HARPHAM

Table I. The Goldberg-Huxley model of pathways to psychiatric care

Level Filter Description of filter
I. Community (total psychiatric morbidity in random samples) Illness behaviour
1st filter
2. Primary care (total psychiatric morbidity among attenders)
2nd filter Ability to detect disorder
3. Primary care (identified morbidity)
3rd filter Willingness to refer
4. Mental illness services
4th filter Factors determining admission to hospital
5. Mental illness services (admissions to hospital)

with 448 attenders. Abiodun [104] found a 22% hardiness, resourcefulness, and coping with the urban
prevalence of anxiety or depression among Nigerian context. This leads us into the issue of vulnerability.
primary care attenders (n = 214). If these are typical For example, why are some people more vulnerable
levels among general primary care attenders, the than others to depression as a result of severe life
prevalence in the community is likely to be signifi- events? In attempting to understand vulnerability we
cantly higher. This is explained in Goldberg and respond to the criticisms levelled by Holland and
Huxley’s [105] model of ‘pathways to psychiatric Fitzsimons who bemoan the fact that “studies have
care’ with filters between each level (see Table 1) not yet developed beyond the standard age/sex/social
whereby illness behaviour ‘filters out’ some of the class studies associated with mental illness, and do
cases in the community and means that only a not elaborate on the mechanism by which these
proportion of cases attend primary care services. For factors operate” [109, p. 151. As the work of Brown
example, in rural Lesotho, only 40% of those with suggests, it is the context within which life events
generalized anxiety disorder said they sought help occur than their characteristics that determine de-
[106]. pressive reactions. We therefore need an exploration
The model in Table 1 is very psychiatric. It is of local social world/systems. We need to measure life
unlikely that psychiatric resources will increase sig- events and social support within the social context in
nificantly in developing countries and much future which events are perceived, experienced and managed
action will focus on the community level and the [58]. Rook [95] suggests that much of the current
strengthening of social support for those identified as enthusiasm for work on social support derives from
particularly ‘vulnerable’. This focus on societal vul- the expectation that research will provide guidelines
nerability and action within the community has been for the design of social support interventions to
termed the “fourth revolution in the history of the enhance well-being. Any research in this direction
mental health approach” (after the innovations of needs to be linked to community level initiat-
Pinel, Freud and community mental health centres) ives/action so that research results can be acted upon.
([107] quoted in Ref. [108]). The approach consists of An examination of the cultural and social context
education on adaptive competences, reduction of calls for ethnography (description of patterns of
stress processes and the building of support groups shared cultural measuring, behaviour and experi-
and networks. There is a growing literature on these ence). In addition, epidemiological surveys are re-
approaches which will not be reviewed here. quired to test certain hypotheses. Jenkins et al., have
argued that “the complementarity of these ap-
proaches is fundamental, and no researcher attempt-
FUTURE RESEARCH PRIORITIES
ing cross-cultural studies in mental health should
Mental health and urbanization is a large and exclude an ethnographic component of research” [58,
complex issue. In identifying priorities for future p. 911. More specific understandings of vulnerability
research one has to tackle issues such as definitions of women to depression are particularly required.
of the dependent variable(s) (i.e. what aspect of “Properly conducted cross-cultural research can yield
mental health to consider) and the independent vari- results which can help to resolve the conundrum of
ables (i.e. which risk factors to consider). As Marsella depression and respond to the challenge which de-
[7] suggests, it is important to study the frequency, pression poses to the society, to public health auth-
duration, severity and situational context of psychi- orities, and to the individuals who suffer from it”
atric symptoms rather than simple diagnoses since [llO].
these may be more directly linked to specific urban Phillips suggests that “research into and service
problems via stress states and other individual vari- provision for urban mental ill-health, particularly in
ables. This implies concentrating on ‘conspicuous developing countries, may become the major chal-
psychiatric morbidity’ which can be measured by lenge of the coming decades” [ 111, p. 181. In addition
existing tools with high validity, rather than using to academic institutions calling for more research on
psychiatrist-dependent instruments to provide diag- mental health it is interesting to note that some
noses. Marsella [7] also argues that it is essential that international agencies are now beginning to recognize
more attention be directed toward the study of the importance of mental health. For example, in a
 Urbanization and mental health in developing countries
recent multi-donor evaluation of UNICEF, the latter
organization was criticized for making too few at-
tempts to “articulate and address the special needs of
women as care givers, including long working hours
and tension and stress related disorders under con-
ditions of poverty” [ 112, p. iii]. In their recent report
on “Health trends and emerging issues in the 1990s
and the twenty-first century”, WHO [113] identified
mental illness as one of the eight specific diseases and
conditions which they felt “deserved particular atten-
tion and action because of the observed
trends. . . which are likely to increase the extent or
effects of these problems”, one of the observed trends
being urbanization.
Urbanization and mental health in developing
countries requires the research attention of social
scientists, public health professionals and social psy-
chiatrists. Multi-disciplinary research will illuminate
the processes at work and direct appropriate strat-
egies to tackle this rapidly emerging, but relatively
neglected problem.
Acknowledgements--I would like to thank: Dr Dinesh
Bhugra of the Institute of Psychiatry, U.K.; Professor
Andrew Cheng of the Taiwan Institute of Biomedical
Sciences; Professor Anthony Marsella of the University of
Hawaii and Drs Glyn Lewis and Melissa Parker of the
London School of Hygiene and Tropical Medicine for their
useful comments on an earlier draft. I was unable to act on
all their advice but am deeply grateful for all of it. I am
particularly grateful to Vanessa Lavender for her efficient
word-processing and administrative support. The Urban
Health Programme is funded by a grant from the Overseas
Development Administration, U.K.
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