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Original Investigation
July 2018

Association of Urbanicity With Psychosis in Low- and Middle-Income Countries

Author Affiliations
  • 1Graduate School of Social Service, Fordham University, New York, New York
  • 2Department of Psychiatry, Royal College of Surgeons, Dublin, Ireland
  • 3School of Social Work, University of Southern California, Los Angeles
  • 4Department of Sociology, University of California, Riverside
  • 5Department of Public Policy, University of California, Riverside
  • 6Research and Development Unit, Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, Fundació Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain
  • 7Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental, Madrid, Spain
JAMA Psychiatry. 2018;75(7):678-686. doi:10.1001/jamapsychiatry.2018.0577
Key Points

Question  Is urban living associated with elevated odds for psychotic experiences or psychotic disorder in low- and middle-income countries?

Findings  In this cross-sectional epidemiological study of 42 countries and 215 682 participants, urban residence was not associated with increased odds of psychotic experiences or psychotic disorders.

Meaning  The association between urban living and psychosis, widely replicated in high-income countries, may not generalize to low- and middle-income countries, where 80% of the world’s population resides.


Importance  Urban residence is one of the most well-established risk factors for psychotic disorder, but most evidence comes from a small group of high-income countries.

Objective  To determine whether urban living is associated with greater odds for psychosis in low- and middle-income countries (LMICs).

Design, Setting, and Participants  This international population-based study used cross-sectional survey data collected as part of the World Health Organization (WHO) World Health Survey from May 2, 2002, through December 31, 2004. Participants included nationally representative general population probability samples of adults (≥18 years) residing in 42 LMICs (N = 215 682). Data were analyzed from November 20 through December 5, 2017.

Exposures  Urban vs nonurban residence, determined by the WHO based on national data.

Main Outcomes and Measures  Psychotic experiences, assessed using the WHO Composite International Diagnostic Interview psychosis screen, and self-reported lifetime history of a diagnosis of a psychotic disorder.

Results  Among the 215 682 participants (50.8% women and 49.2% men; mean [SD] age, 37.9 [15.7] years), urban residence was not associated with psychotic experiences (odds ratio [OR], 0.99; 95% CI, 0.89-1.11) or psychotic disorder (OR, 0.89; 95% CI, 0.76-1.06). Results of all pooled analyses and meta-analyses of within-country effects approached a null effect, with an overall OR of 0.97 (95% CI, 0.87-1.07), OR for low-income countries of 0.98 (95% CI, 0.82-1.15), and OR for middle-income countries of 0.96 (95% CI, 0.84-1.09) for psychotic experiences and an overall OR of 0.92 (95% CI, 0.73-1.16), OR for low-income countries of 0.92 (95% CI, 0.66-1.27), and OR for middle-income countries of 0.92 (95% CI, 0.67-1.27) for psychotic disorder.

Conclusions and Relevance  Our results provide evidence that urbanicity, a well-established risk factor for psychosis, may not be associated with elevated odds for psychosis in developing countries. This finding may provide better understanding of the mechanisms by which urban living may contribute to psychosis risk in high-income countries, because urban-rural patterns of cannabis use, racial discrimination, and socioeconomic disparities may vary between developing and developed nations.