| Batterham, Mark, Deering, Kris and Singleton, Aled Mark 2023. Urban influences on the development, perpetuation and mitigation of psychosis. Mental Health Practice 10.7748/mhp.2023.e1653 |
Abstract
Background A wealth of research dating back to the 1930s suggests that in certain societies, including the UK, urban living is associated with an increased risk of experiencing non-affective psychosis (Vassos et al 2012), meaning a psychotic condition without a significant mood element. This association has become known as ‘the urbanicity effect’, with ‘urbanicity’ describing the effect of living in urban environments on individuals’ mental health (Vlahov and Galea 2002). Childhood has been identified as a critical period for the risk-increasing effect of urbanicity on the development of non-affective psychosis (Marcelis et al 1999). However, no geographical concentration in terms of the urbanicity effect has been found consistently for the development of affective psychosis (March et al 2008). Research on the urbanicity effect on the development of psychosis has expanded beyond studies of population density (Pedersen and Mortensen 2001) to take account of numerous social, economic and environmental factors. Examples of such factors include economic deprivation, ethnic density and exposure or proximity to green spaces (outdoor environments that feature natural vegetation, for example public parks) and/or blue spaces (outdoor environments that feature water) (Fett et al 2019). Although the urbanicity effect is believed to operate across multiple domains, the social geography of localities appears to be particularly influential in the development of psychosis. In particular, low social cohesion (where communities struggle to coexist and cooperate) and ethnic fragmentation (where minority groups exist in small numbers and are exposed to exclusion and discrimination) are cited as neighbourhood-level risk factors (March et al 2008). Public Health England (2016) has reported higher rates of psychosis in urban areas and lower rates in rural and sparsely populated areas, which indicates that city living remains a risk factor for the development of psychosis. However, as well as contemplating the hazards of urban living, it is important to recognise the potential of urban areas in supporting mental health recovery. Kogstad et al (2011) suggested that recovery ‘is not only an internal process; it also requires external conditions that facilitate a positive culture of healing’. Meanwhile, the Community Mental Health Framework for England (NHS England 2019) emphasises the importance of community places and resources in addressing mental health issues. Since most mental health service users are generally supported in community rather than institutional settings (Parr 2008), there is a need and opportunity to expand and strengthen practice to achieve the recovery aspirations of connection, active engagement and social belonging (Neil et al 2009, Leamy et al 2011). Recovery can be aided by developing an understanding of service users’ experiences of urban environments and the effects of such environments on their well-being and experiences of psychosis. However, research investigating urban influences on the lives of people experiencing or recovering from psychosis is relatively scarce (Ünal et al 2019). The authors decided to undertake a scoping review to explore this area further. Aim To summarise the evidence from participatory studies investigating urban factors that affect the lives of people experiencing or recovering from psychosis. The findings can be used to inform future research and develop clinical practice. Method This scoping review was based on the approach proposed by Arksey and O’Malley (2005). A preliminary evaluation of prominent and recent urbanicity reviews led to the development of the following review questions: •Which urban elements are identified by service users as harmful or distressing? •Which urban elements are identified by service users as supportive, restorative or therapeutic? •What participatory methods have been used in studies that seek to answer the first two questions? To ensure the reporting of research was robust and coherent, the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist (Tricco et al 2018) was used. Eligibility criteria The review was concerned with primary studies exploring the experiences of individuals living with or recovering from non-affective psychosis. No age limits were applied, reflecting the drive for ageless early intervention in psychosis services in England (National Institute for Health and Care Excellence 2014). Participatory research is characterised by direct collaboration between researchers and those affected by the issue being investigated (Vaughn and Jacquez 2020). Therefore, the inclusion criteria required participants to have contributed to the data collection process and to have understood the aim of the research being undertaken. This awareness was either stated or implicit in the studies reviewed. A broad definition of ‘urban’ as large population settlements was used. No date limits were set. Studies were required to be peer-reviewed and published in English to ensure high-quality research that could be readily understood and appraised. Search strategy Searches of the PsycINFO, Medline and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were undertaken in September 2021 and October 2021. In the first search (September 2021), the following terms were used to identify relevant literature: urban AND psychosis OR psychoses OR ‘psychotic disorder’ OR schizophrenia OR ‘schizophrenia spectrum disorder’ OR delusion* OR hallucination* OR paranoia AND ‘lived experience’ OR ‘qualitative study’ OR participants OR patients OR ‘service users’ OR clients. In the second search (October 2021), urban was replaced with neighbourhood OR neighborhood OR city OR cities. Study selection and analysis Rayyan software for systematic reviews facilitated the screening process by storing, displaying and labelling articles and identifying potential duplicates. The duplicates were checked and removed by the first author (MB), then the titles and abstracts of the remaining articles were screened for relevance to the review questions. Literature reviews, commentaries and pilot or feasibility studies were also excluded by the first author at this stage. Where there was uncertainty, this was discussed and resolved with the second author (KD). Thereafter, the first two authors independently screened the articles against the eligibility criteria. Conflicts were discussed before agreeing on the final studies for review. The database searches returned 1,195 articles after removal of duplicates. A further eight articles were identified through scanning the reference lists of key texts. Twenty-one articles remained following the initial screening process. As this was a relatively small number of articles, the authors relaxed the inclusion criteria to accommodate studies with weaker participant involvement. Nevertheless, a further nine articles were excluded at the full text screening stage, leaving 12 studies for inclusion in the review. The first author re-read the eligible studies and colour coded pertinent findings. Relevant data were tabulated, and the study methodologies were reviewed by the second author for the extraction table. The main findings were categorised to answer the review questions. The first two authors then discussed each thematic category to summarise and interpret the data.
| Item Type: | Article |
|---|---|
| Date Type: | Published Online |
| Status: | Published |
| Schools: | Schools > Business (Including Economics) |
| Publisher: | RCN Publishing (RCNi) |
| ISSN: | 1465-8720 |
| Date of Acceptance: | 28 February 2023 |
| Last Modified: | 12 Jun 2025 15:00 |
| URI: | https://orca.cardiff.ac.uk/id/eprint/177641 |
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