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Urbanisation and incidence of psychosis and depression: Follow-up study of 4.4 million women and men in Sweden

  • Kristina Sundquist (a1), Gölin Frank (a1) and Jan Sundquist (a1)
Extract
Background

Previous studies of differences in mental health between urban and rural populations are inconsistent.

Aims

To examine whether a high level of urbanisation is associated with increased incidence rates of psychosis and depression, after adjustment for age, marital status, education and immigrant status.

Method

Follow-up study of the total Swedish population aged 25–64 years with respect to first hospital admission for psychosis or depression. Level of urbanisation was defined by population density and divided into quintiles.

Results

With increasing levels of urbanisation the incidence rates of psychosis and depression rose. In the full models, those living in the most densely populated areas (quintile 5) had 68–77% more risk of developing psychosis and 12–20% more risk of developing depression than the reference group (quintile 1).

Conclusions

A high level of urbanisation is associated with increased risk of psychosis and depression for both women and men.

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Copyright
Corresponding author
Correspondence: Dr Kristina Sundquist, Family Medicine Stockholm, Karolinska Institutet, Alfred Nobels allé 12, SE-141 83 Huddinge, Sweden. Tel: +46 8 524 887 08; fax: +46 8 524 887 06; e-mail: Kristina.Sundquist@klinvet.ki.se
Footnotes
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See editorial, pp. 287–288, this issue.

Declaration of interest

None. Funding detailed in Acknowledgements.

Footnotes
References
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  • EISSN: 1472-1465
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Urbanisation and incidence of psychosis and depression: Follow-up study of 4.4 million women and men in Sweden

  • Kristina Sundquist (a1), Gölin Frank (a1) and Jan Sundquist (a1)
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eLetters

Destigmatizing campaigns, urbanisation and psychosis!

Dr.Naseem A. Qureshi
19 April 2004

Dear Sir:I read with interest an article by Sundquist and her colleagues. First, this study is highly impressive in the sense that it fulfills almost all statistical requirements for estimating accurately the incidence and prevalence of a complex mental disorders such as psychosis and depressive disorder. Secondly, the findings of this study can be generalized to at least all European countries and other developed nations.

Notably, by and large the etiology of complex psychiatric disorders such as schizophrenia and mood disorders until now is speculative and moreoften an array of biological, psychological and sociocultural factors havebeen evoked in the etiopathogenesis of these disorders [Qureshi, 1981]. Urbanisation,i.e destroying rural quality of a district as an environmental factor has a long history of its association with increased incidence of psychosis and depression, though some studies have reported inconsistent results. Furthermore, a selective review of literature of thepast five decades suggests that incidence of psychosis is rather low in rural areas. Moreover, the WHO International Pilot Studies on Outcome of Schizophrenia have attested this fact and have also reported that the outcome of psychosis is relatively better in developing countries where urbanisation is a slow process, which is not coupled with greater stressors. We have also reported the similar results [Qureshi,Prakash & Sethi,1990].

Besides many other factors which explain the increased incidence of psychosis and depression in urban areas, mental disorder destigmatising campaigns, mental disorder awareness programs, and early screening programs for mental diseases have definite impact on the incidence of psychosis and depression. Obviously, these programs are more often directed at urban population. The other relevant factor which could explain this epidemiological trend is the revealed pattern of rather benign symptomatology of psychosis and depression among rural patients in particular female gender and most importantly unaffected family members and also people living in rural areas are reported to have a high index oftolerability of their kith and kin with mental disorders including psychosis and depression.

Declaration of interest:none

Reference:

Sundquist K, Frank G, & Sundquist J.Urbanisation and incidence ofpsychosis and depression: Follow-up study of 4.4 million women and men in Sweden. Br J Psychiatry 2004; 184: 293-298

Qureshi NA. Etiology of schizophrenia. J Comm Psychiatry(Mumbay)1981;Jan-March: 25-32.

Qureshi NA, Prakash R, Sethi BB. A follow-up study of schizophrenia. Arab J Psychiatry 1990; 1: 190-200.

Address: POBox.2292, Buraidah Mental Health Hospital,Kingdom of Saudi Arabia.

Mobile:+96654283547
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Conflict of interest: None Declared

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Increased testosterone may be the cause...

James M. Howard, biologist
09 April 2004

Increased testosterone may be the cause of the findings of Sundquist,et al., that is, that “A high level of urbanisation is associated with increased risk of psychosis and depression for both women and men.” Two hypotheses are required to explain this.It is my hypothesis that human evolution is driven by testosterone ("Androgens in Human Evolution," Rivista di Biologia / Biology Forum 2001;94: 345-362). Based on this, I suggest the "secular trend," the increase in size and earlier puberty of children, is actually an increase in the percentage of individuals of higher testosterone. The “trend” may actually be a change in percentage of individuals within our populations and their “characteristics” may also be increasing. This phenomenon occurs when a "feed and breed" environment occurs. In these situations, individuals of higher testosterone, men and women, will increase more rapidly than those of lower testosterone over time. (Individuals of higher testosterone are more aggressive and sexual; they will increase in percentage with time.) Urban areas are "feed and breed" centers. I suggest urban centers are areas of higher testosterone.

It is my hypothesis that dehydroepiandrosterone (DHEA) is directly involved in growth and development, and subsequent maintenance, of all tissues, especially the brain. (The large brain of mammals may have resulted from an evolutionary increase in DHEA (“Hormones in Mammalian Evolution,” Rivista di Biologia / Biology Forum 2001; 94: 177-184). Numerous reports of beneficial effects of DHEA on neurons and tissue-levelstructures of the brain exist in the literature. I have suggested in the past that depression and schizophrenia, among other mental diseases, result from low DHEA during growth and development, subsequently exposed by adverse circumstances during maintenance. DHEA is low in depression and schizophrenia. Two other hormones may adversely affect the function or availability of DHEA: cortisol and testosterone. Over the past few years the connection of low DHEA, along with increased cortisol, have beendemonstrated regarding depression. It is known that schizophrenia is often characterized as resulting from a non-causal, but significant, stressful event (cortisol) usually beginning in the late teens or early twenties (testosterone of puberty, in men and women, along with the natural decline of DHEA which begins around age twenty). In individuals of low DHEA, increased cortisol and testosterone may expose underlying, silent pathology.

Therefore, I suggest that increased rates of psychoses and depressionin urban areas may be the product of increased stress and testosterone in both men and women. As suggested above, the secular trend may be due to increasing numbers of individuals of higher testosterone. This increase in these individuals of higher testosterone, along with increasing stress of urbanization, may account for the findings of Sundquist, et al., as well as reports of current increases of these mental disorders.
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