City life takes its toll on São Paulo's residents

Abstract

Brazil's largest city, São Paulo, has a high prevalence of mental health disorders that some experts are linking to the stressful lives that most residents live. Carlos Henrique Fioravanti investigates. The locals in Greater São Paulo—one of the largest conurbations in the world, with around 20 million inhabitants or 10% of the Brazilian population—have good reasons to feel highly stressed. Residents live daily with the frustration of severe traffic congestion and its related noise and pollution, as well as high levels of urban violence. In a recently published survey coordinated by WHO, around 30% of the 5037 adults interviewed reported having had a disorder in the past 12 months at various levels of severity. This prevalence, which represents nearly 7 million people with a mental disorder, was the highest in the survey of 25 countries, followed by the USA, where 26% of the population has some kind of mental disorder. The lowest prevalence (6%) was found in Nigeria. The figures concerning treatment, though, are low. Only 8·7% of people interviewed with an active disorder had received treatment for mental health problems and just 30·2% of the severe cases were being assisted by health services. “It is much less than in the USA, where 25% of all people suffering mental disorders are treated”, says Laura Andrade, professor at University of São Paulo Medical School and coordinator of the survey in Brazil. The difficulty in recognising mental disorders as a health problem and the stigma surrounding them remain barriers to treatment. Even when they are solved, the path to treatment is hard. “The public health system is disarticulated and general physicians are not well trained to identify mental disorders”, Andrade affirms. “A medical appointment with a psychiatrist can take a month to be scheduled.” She told The Lancet that, from all people interviewed, she invited about 700 to do a more accurate diagnosis and start treatment at the university hospital. Many of them had an active disorder, but only a few had been treated. The most common conditions were anxiety in its various forms (19·9%); mood disorders (11·0%), including depression, disthymia, and bipolar disorder; impulse-control (4·3%); and substance abuse (3·6%). Experts have argued that nurses and community health agents should be trained to identify common disorders like these and provide medical treatment. “We need to translate our findings into better public health services”, urges Jair Mari, professor at Federal University of São Paulo and visiting professor from Kings College, London, UK. “Mental health should be in the public agenda in any city.” Urban violence is associated with depression and other mental disorders. Half of the people interviewed (52%) had experienced at least one of the seven crime-related traumatic events examined, such as witnessing someone being injured or killed, being mugged, or seeing a relative or friend kidnapped, tortured, or raped. The figures concerning violence in Greater São Paulo, concluded Andrade's team, were higher than war-related events reported by the civil population who survived recent civil wars in countries like Lebanon. The high prevalence of mental disorders may be down to the stressful lives lived in a third world metropolis. “The less green space in the cities, the higher risk of having depression and other mental disorders”, commented Sandro Galea, from Columbia University, NY, USA, at a meeting on mental health in São Paulo earlier this year. He warned that exposure to the highest level of traffic has been shown to increase the risk of disorders like schizophrenia. “We need to rethink the effect of urban environment on mental health and to identify people at low and high risks.” The experts agreed that they cannot simply link the prevalence of mental disorders with badly planned urban environments. “To better understand the causes of mental disorders, we need to listen to the patients’ personal stories”, Mari highlights. Coming from another region and living in social deprivation could increase the feeling of loneliness and worsen mental disorder, but may have no effect when people maintain social links with the community. “People have different levels of resilience to their problems”, he argues. “Real or alleged mental disorders can express social dramas”, warns Denise Martin, from Catholic University of Santos, after doing in-depth interviews with 16 women living in Embu, a town on the outskirts of Greater São Paulo with high rates of homicides and underemployment. All women had been diagnosed with depression, which, Martin concluded, was rooted in their oppressive daily life. All of them had experienced episodes of violence, such as having a son murdered or being beaten by their husbands. “The social links were nearly non-existent”, she observed. “Just a few women had friends or knew the neighbour, who could be criminal. For these women, the police didn't exist as an institutional reference.” Shaping cities for health: a UCL/Lancet CommissionCities are bustling, vibrant, built-up places where millions of people reside, often in close proximity to each other. Most, whether in high-income or low-income countries, exist with vast, and very visible, social and health inequalities between inhabitants. But the provision of health services cannot reduce these inequalities alone; the physical fabric and design of a city also have parts to play. In today's Lancet, we publish a joint Commission with University College London (UCL) that sets out how policy makers can develop urban areas to foster the health of citizens so that they become healthy cities. Full-Text PDF Shaping cities for health: complexity and the planning of urban environments in the 21st centuryThe Healthy Cities movement has been in process for almost 30 years, and the features needed to transform a city into a healthy one are becoming increasingly understood. What is less well understood, however, is how to deliver the potential health benefits and how to ensure that they reach all citizens in urban areas across the world. This task is becoming increasingly important because most of the world's population already live in cities, and, with high rates of urbanisation, many millions more will soon do so in the coming decades. Full-Text PDF