Declining mental health: An aftermath of fast-paced urbanization

The United Nations estimated in 2020 that over 56.2% of the global population resides in urban areas of settlement.[1] In India, however, only 35.87% of the population resided in urban settlements in 2022, as per World Bank estimates.[2] Urbanization plays a critical role in the social and economic development of a nation and impacts overall global development. It has been a transformative force in terms of global development and humanitarian welfare, advancing society by leaps and bounds over a span of a few decades. Opportunities for education, employment, healthcare, transport, and social and cultural progression are all better in urban areas of settlements and undoubtedly attractive to those who are not born into such areas.[1,3]

However, not all that glitters is gold, and this fast-paced urbanization has rendered individuals vulnerable to mental illnesses, has caused a decline in overall mental health at a community level, and has worsened the outcome and course of mental illnesses as well.[1,3] Poor housing standards, overcrowding, pollution of air, water, sound, scarcity of potable water, poor food standards, poor standards of sanitation and waste disposal, excessive road-traffic, poverty, unemployment, high rates of crime and violence are only some of the vices which can cast a shadow on the mental health of the urban dwellers.[4]

Mental illnesses are now being labeled as an urban phenomenon as the instability and insecurity progressively skew the dynamics of a healthy lifestyle in today’s time and age. Major mental illnesses such as mood disorders, anxiety, psychotic disorders, and substance use disorders are seeing an uprising trend in urban communities, at rates that may be as high as two-fold, when compared to rural communities.[4]

A typical day in an urban area is characterized by incessant exposure to high-frequency audios or sounds of machinery, tedious daily commutes across large distances, flashing and glaring lights, excessive crowding in areas of public utility; over and above the seemingly impossible task of balancing work, family, and self-care. Most urban dwellers deem themselves incapable of enduring the simultaneous exposure to so many stressors at once, and can even quantify a progressive deterioration of their mental faculties. It is not unusual for us to hear someone, or even ourselves, let out an “I just cannot.” time and again.[3,5]

The overbearing competition, which inevitably arises as a result of a stark imbalance between scanty opportunities and overwhelming aspirants, now occupies a prominent role in urban living. Running the gauntlet to acquire nearly anything: no matter how trivial or inconsequential, is now a routine activity for an urban dweller. Needless to say, a quest can only have so many winners, leaving multitudes to deal with the anguish of failure, rejection, and disappointment. Moreover, resilience is a subjective property, and some may take a larger hit at a loss, than others. Daily struggles of such sort insinuate a sense of inferiority in people, which takes them only further down the ladder of achievements and acquisitions.[3]

An urban settlement provides an array of cultures and traditions, religions and allegiances, attitudes and outlooks, interests and hobbies. Large neighborhoods, workspaces, educational institutions, and various other areas in a city mandate interaction among people with varied belief systems, which provide a conjectural potential to give rise to conflicts and misunderstandings. This is an often-overlooked area of mental distress, as people are advised to treat it as insignificant even when it invariably affects their daily functioning and efficiency. Many times, conflicting beliefs are blown out of proportion and may create havoc and confusion on a more widespread basis, as is seen in religious and political debaucheries.[3,4]

Loneliness has now acquired the tag of an epidemic in modern urban society. It can be defined as a discrepancy between one’s expectations and the realities of interpersonal relations. Cities in the developed west have citizens reporting rates of loneliness, which go as high as 76% today. The sudden and exponential rise in loneliness can be largely attributed to the widespread incorporation of technology, the World Wide Web, and social media in the life of an average urbanite. While, on the one hand, easy access to the internet has provided facile solutions to daily life, it has also unequivocally tousled the fabric of healthy social survival. Overexposure and continuous exposure to unwanted information, guileful and superficial relations through smartphone applications, the pressure to keep up with the waxing and waning trends on social media, and a marked reduction in pursuit of activities that require physical and mental presence are certain vices that have markedly influenced the increased sense of perceived isolation in individuals, which they term “loneliness.”[6,7]

The relationship between substance abuse and urbanization is well-established, with many theorists claiming it to be a social illness, rather than an individual illness. The stressful living environments generated by urbanization have also resulted in an increased reliance on substance use as a faulty coping mechanism. Alcohol, tobacco, and other illicit substances have found an exponentially advancing market for themselves in urban cities.

Studies have established the correlation between urbanization and alcohol use disorder, as well as other psychiatric and medical concerns secondary to alcohol abuse.[8]

A rural background and upbringing have been considered a protective factor from the subsequent development of a substance use disorder in adults. The average urban adult has a higher rate of consumption of substances when compared to his counterpart from rural areas. Studies trying to explain this relationship have suggested the following features to make an urban adult, irrespective of gender, more liable to substance use and abuse: (i) cultural acceptance of substance use and abuse, (ii) earlier age of initiation of substance use, (iii) higher educational levels help normalize substance use, and (iv) stronger influence of peer groups and social circuits on an individual. The last factor is the most commonly quoted reason by individuals for initiating, continuing, or restarting substance use. The age of onset of initiation of substance use is particularly important, and that is significantly lesser in urban areas, with some individuals even starting in their late childhood or early adolescence.[9]

Various studies have also found that urban adults, especially men, justify the use of substances with greater stress levels. Consuming alcohol and other such drugs to relieve stress and anxiety, and feel a sense of detachment from the continuous triggers that urban life provides, is being increasingly reported.[10]

Studies evaluating the stress that an individual undergoes for the same job in urban areas and rural areas conclude negatively for the latter. Urban individuals are more liable to poor functioning as a result of anxiety and depression than their rural counterparts. Studies have found definitively higher prevalence rates of depressive disorders in urban areas, but comparable rates of anxiety disorders. Rural settlements are grounds for closer-knit communities and better social support than the large and lonely terrains of an urban city. The discrepant reports of higher suicide rates in rural areas, however, could be due to the mental health interventions being primarily focused in urban cities and the relative difficulty encountered in accessing mental health services by those living in rural areas. A poorer understanding of mental illnesses amongst individuals from a rural setting could also have a role to play.[11]

More recently, the urban neurosis can be explained neurobiologically as well. Using functional magnetic resonance imaging (MRI), studies have reported increased amygdala activity in dwellers. They have also concurred that an urban upbringing affected the pregenual anterior cingulate cortex in a way that resulted in stress and anxiety via its control over the amygdala.[9,10]

Slums are houses or neighborhoods in urban cities, which are informal settlements in a condition that is unsafe and improper for residence. Although not a hard-ruled dictum, most of the slums comprise rural natives in search of better economic avenues, immigrants, or social outcasts. Formation and expansion of slums in a city is an inevitable consequence of rapid urbanization, and it is estimated that nearly 40% of India’s urban population resides in slums.[12] There is a stark disparity in the standard of life in the urban slum, as demonstrated by poor education and employment opportunities, child labor, income inequalities, poor access to clean food and water, poor housing and sanitation, lack of easy access to healthcare, increased vulnerability to conflicts and disasters, and high rates of crime. Such factors have a negative effect on the mental stability of urban slum dwellers, as evidenced by higher rates of mental illnesses, accidents, suicides and homicides, substance abuse, and antisocial activities.[3,4]

India has always been a primarily agrarian society; in fact, agriculture remains the mainstay industry. So, when the winds of urbanization hit the country, it clashed with some of its fundamental tenets, causing an ideological conflict. The disruption of some of the traditional morals and beliefs is regarded widely to be the precipitant of criminal activities. The entrenchment of capitalist orders in Indian societies served further to widen the societal disparities. Various theories regard crime to occur from the disadvantaged sects of societies, as a form of “revolt.” Socio-psychological accounts explain this to stem from anger resulting from inequity, but this also unjustly serves to stereotype certain sects and communities by attributing misdeeds to them without much afterthought. The socially privileged are not devoid of crimes either, although the socio-psychological construct behind these societies may differ. Cybercrimes are also an increasingly prevalent urban phenomenon that cannot now be demarcated between the socially advantaged and disadvantaged due to the ease of availability of the internet and its resultant abuse, especially amongst the youth.[13]

Urbanization has been given the status of the single underlying factor behind the increasing rates of delinquency in all countries. This relies on the social learning theory, which suggests that children acquire behaviors by learning and imitating those with whom they stay in close contact. Extrapolating this, we can assert that children who grow up in societies that are morally grounded and have a positively influencing role model exhibit responsible and socially correct behaviors, whereas those who may not have the same or are exposed to societal vices are more likely to exhibit delinquent behaviors. The latter environment is more likely to be seen in urban societies, where families are fragmented and fraught due to the rising pressures and competition. The lack of formal control and familial cohesion, combined with easy access to amenities, renders these children and adolescents susceptible to committing unacceptable acts and likely to be influenced by deviant peer connections. There is an unrestrained use of modern technology in these youngsters who are not yet able to draw a line between what is good and bad. Violent behaviors, stabbing or shooting, sexual assaults, robbery, and drug and human trafficking are now more common than ever amongst the urban youth. The adverse childhood experiences of witnessing violence between parents, parental separation or divorce, emotional neglect, or the absence of a trustworthy guardian are also instrumental in children resorting to violence, drug abuse, or homicidal activities.[14]

Effectively tackling the mental health hazards arising from urbanization requires the development of policies and schemes which can be applied at both the individual level as well as the community level. The relevant factors that need urgent addressing have been highlighted above. Mental Healthcare Act 2017 has granted mental illnesses the same footing as physical illnesses in terms of attention and treatment and healthcare workers should ensure its effective implementation. Attention is also needed from local authorities and governing bodies to ensure safe and sanitary living conditions, access to clean water and food, and equity in terms of education and employment. Last but not least, camaraderie should be encouraged in neighborhoods and institutions; as the father of our nation once said, “Man becomes great exactly in the degree in which he works for the welfare of his fellow men.”