At the age of 14, Elena Briongos left Peñalba de Castro, a small town in the province of Burgos, to go to Barcelona to study. “When she was 18, she was studying and working as a secretary, living what might have been a late adolescence, looking for myself,” says Briongos, who is now 61 years old. “Then I went to a week-long meeting where there was a workshop on mindfulness, alternative therapies, yoga, dance, a series of things that helped me find myself,” she remembers. “But then I mightn’t control the return to normal life and that’s where it all started.” She had a first diagnosis of schizophrenia, which years later was changed to bipolar disorder, and she began a pilgrimage to specialists in Madrid and Barcelona. “I returned to the town with my parents, farmers.”
Briongos believes that the city offers many possibilities, but “you find yourself in the town.” After seven admissions, the last one in 2003, she feels strong and now, as president of the Castilla y León Mental Health Federation, she helps other people with problems similar to hers. In Aranda de Duero they already have three psychiatrists and have created a headquarters in Huerta del Rey, a larger town in the area, where they bring together people from smaller towns to carry out activities together. “When you go with a person to have coffee and they know you, distance and stigma are removed, it is an advantage of the towns. And if something happens to you, someone is going to come to your house,” she points out. “But it’s also harder to break the stigma of a diagnosis, because everyone knows who you are,” she acknowledges.
But the charm of the cities is great and does not seem to be in decline. Albert Einstein revolutionized physics from Bern, Aretha Franklin was discovered for music in a church in Detroit and the Spanish Constitution was negotiated in Madrid. The world of the future and the interpretation of the past is created in cities, and it is created by people who adapt well to them. Urbanization represents a global increase in wealth and inventions that continue to transform the planet, and the stories of those who succeed in cities add momentum to these human agglomerations. It is estimated that, in the next decade, the population of cities of more than 10 million inhabitants will multiply by four and in 2050, 68% of humanity will live in cities. The strong and the smart and the millions of supporting actors of their dreams gather there.
The benefits of cities do not reach everyone equally. A recent study concluded that the same elite that generates the innovations and wealth that gives cities their good numbers is also the one that concentrates the benefits, with the majority of urbanites partially excluded from that prosperity. Added to this inequality is another risk of these engines of progress: mental health.
Epidemiological studies generally show that mental health is worse in cities than in rural areas. “There are more affective disorders, anxiety disorders, but above all serious disorders, such as schizophrenia,” says Jordi Alonso, director of the Epidemiology and Public Health Program at the Hospital del Mar, in Barcelona. “We found no differences in the use of alcohol or other substances and, in general, when adjusted for socioeconomic factors, there are no differences,” he adds. To explain this urban toxicity, we usually point to inequality, marginalization, stress and violence, which are more frequent in cities. In the rural environment, social cohesion, which in some cases can be oppressive for those who are different, is a protective factor, just like the proximity of the countryside or less atmospheric or noise pollution.
There are more affective disorders, anxiety disorders, but above all serious disorders, such as schizophrenia”
Jordi Alonso, Barcelona Sea Hospital
In a 2020 analysis, led by Lydia Krabbendam, from the Free University of Amsterdam, an evolutionary hypothesis was proposed. Humans, following hundreds of thousands of years of evolution in communion with nature, feel out of place in artificial environments where there are only animals of their species. The need for directed attention wears down cognitive abilities, which need contact with the natural environment to recover, and, compared to the past, when our ancestors lived in egalitarian groups where everyone was close, the city is full of people with whom we collide. on the street, but we don’t know anything regarding it.
Interacting factors
In Tarragona, Ángel Urbina (57 years old), who was diagnosed with a serious mental illness when he was at university, sees drawbacks to the city, but also advantages. As president of La Muralla, an association that is part of the Federació Salut Mental Catalunya, he organizes meetings that are also attended by people from nearby towns. “They have to take a bus and I can walk, and the same thing happens with health services,” he points out. However, at times when you are at your worst, crowds and noise can become a problem. “When I have problems, I need peace, I look for a park or go to the beach. Contact with people makes me feel bad and that happens to many people, you become very sensitive to contact with people and stress,” he adds. His opinion on the value of less social cohesion in cities is also ambivalent. “In a city, if you are very unwell, it is possible that no one will find out and you may even die alone at home, but we also do not suffer from the stigma that old mentalities can impose in places where everyone knows you. Here you can walk into a bar and no one will think that you are the crazy person in town,” he exemplifies.
In 1939, Robert Faris and Warren Dunham published a study on the distribution of mental disorders in Chicago. That pioneering work observed that the greater the population density of the neighborhoods and the proportion of the black population, the more schizophrenia. “It was not clear which component of urban life increased the risk, but for many decades it was accepted that this was the case,” says Gonzalo Martínez Alés, a psychiatrist at the Harvard School of Public Health. “There was a moralistic interpretation, which identified the city with vice and the rural area with something more bucolic,” he explains. But then, starting in the 1990s, studies in China found that schizophrenia was more common in rural areas, and seemingly contradictory results continued to appear around the world. Maybe it wasn’t regarding the city, but regarding poverty; or there were populations more prone to these diseases that in the city were exposed to circumstances that triggered the latent disorder.
There is a direct relationship between seeing green areas and well-being”
Ester Higueras, Polytechnic University of Madrid
“We have evidence that the increased risk of schizophrenia among immigrant groups in London is inversely proportional to group size. That is, the smaller the group of immigrants, the greater the additional risk of schizophrenia,” explains Guillermo Lahera, professor of Psychiatry at the University of Alcalá. Among migrants, it has been seen that people who try to integrate into the culture to which they arrive suffer more than those who interact mainly with the people of their country, with a network of contacts that gives them the feeling of continuing to be part of a majority, despite being far from home. Lahera points out that these results “have urban planning and social organization implications,” and proposes trying “to reduce isolated ghettos of ethnic minorities, favoring multicultural social cohesion over fragmentation.”
This type of urban planning that takes mental health into account is already happening, at least on paper. Ester Higueras, a specialist in healthy urban planning at the Polytechnic University of Madrid, points out that “there is a direct relationship between the perception of greenery and well-being.” “Even people who see green spaces through their windows in hospitals recover faster,” she adds. Higueras is one of the authors of the report City, urban planning and health commissioned by the Government of Spain, which offers guidelines to create more favorable environments for health, including mental health. In addition to facilitating access to green spaces, they emphasize the need to create environments in which people can socialize or that are protected from noise. The advice coincides with the consequences of the hypothesis that associates health with environments more similar to the nature in which humans emerged and is supported by much evidence. A study in Madrid estimated that lowering traffic noise by one decibel would prevent 468 premature deaths per year. The stress associated with noise increases the risk of atherosclerosis and also psychological ailments.
Not everything shines in rural areas
Although mental health risks seem greater in cities, Higueras points out that not everything is so easy. “In the city we lack green, but in the countryside they have it and their life is not happy and perfect either. There are nuances that we have to study,” she points out. “In towns there may be a lack of spaces for coexistence; “The town bar is very important, we are social beings,” she speculates. And she remembers a particularly dramatic indicator: “In rural areas there tend to be more suicides.” Martínez Alés believes that this may be due, among other things, to the fact that suicide is usually possible during a brief crisis, and it depends a lot on whether during that period one has the means to commit it. “In rural environments there is usually more access to weapons or pesticides, and there can also be isolation factors,” he believes.
As in other areas of medicine, personalized treatments are sought in mental health. “There are people who are especially vulnerable to developing mental disorders, but not all of them develop them, and, on the other hand, we have proven risk factors, but not all people exposed to these risk factors develop the disease,” explains Lahera. To better understand these interactions between genetics and environment, there are researchers who are identifying the biological mechanisms by which pollution or poverty can increase the risk of depression or schizophrenia. In a study published in 2023 in Nature Medicineit was observed that an environment without crowding and with green spaces protects once morest anxiety symptoms.
“It’s common sense, but this data-driven result provides more specificity and implies brain areas and genetic susceptibility to this common sense observation,” says Gunter Schumann, co-author of the study and director of the Center for Population Neuroscience and Precision Medicine. Theirs is an institution dedicated to identifying these relationships between genetics and environment that can help minimize people’s individual risks, regardless of where they live. Some studies have observed that cities present risk factors for children during the first fifteen years of life, and projects such as environMENTAL, led by Schumann, aim to better understand these risks to intervene in advance and prevent them.
Although mental health is generally worse in cities than in towns, Schumann believes that it is an approach that has little interest because “many people have no choice.” It is more useful to add data that confirms, beyond the hunch, the concrete damage that pollution and noise or loneliness in the elderly can cause to the mental health of an adolescent. And with that data, convince city mayors that their decisions regarding traffic can reduce depression or schizophrenia in their neighbors.
Those affected by mental health problems know that in both rural and urban environments there is room for improvement. Briongos demands that people in the towns be given access to medical treatment “where one lives” and that, if this is not possible, transportation be subsidized. Urbina highlights the importance of facilitating socialization: “The most important thing in mental health is the community part, that people can integrate into their society. “One of the most serious mental health problems is social isolation, that people ignore you.”
