Mental health and the city: Intra-urban mobility among individuals with schizophrenia
Introduction
In their landmark study on the geographic variability of mental illness in the city, Faris and Dunham (1939) observed an association between high rates of certain severe and enduring mental illness, particularly schizophrenia (less so for bipolar and affective disorders), and residence in disadvantaged and socially disorganized inner-city neighbourhoods in Chicago. An extensive literature on “psychiatric geographies” (Giggs, 1973; Lapouse et al., 1956; Dear and Wolch, 1987; Wolch and Philo, 2000; Silver et al., 2002; Almog et al., 2004) has largely confirmed the pattern Faris and Dunham first identified—that individuals with schizophrenia continue to cluster in disadvantaged inner-city areas. There are two well-established theories for the over-representation of individuals with schizophrenia in the inner city and their under-representation in suburban areas: the social selection and social causation hypotheses. The social selection hypothesis focuses on whether individuals with schizophrenia drift into deprived, service-rich inner-city areas, while the social causation hypothesis focuses on the disproportionate development of the disease in socially disorganized and residual neighbourhoods (Dear et al., 1980; Dohrenwend et al., 1992; Timms, 1998; Wolch and Philo, 2000; Silver et al., 2002).
Despite the well-established findings on the geographic distribution of individuals with schizophrenia, there has been limited study about their residential mobility (DeVerteuil, 2003; Bhugra, 2004; Lix et al., 2006). Understanding residential mobility patterns—including the degree to which individuals with schizophrenia move, where they move from and to, and whether these patterns differ from the general population—is important for several reasons. First, in a post-asylum, post-mental health reform era, it is more important than ever to have an accurate “big picture” of the dominant flows of individuals with schizophrenia, in order to provide the most equitable distribution of services (Wolch and Philo, 2000). From the perspective of individuals with schizophrenia, there are equity concerns involving the social and built environments in which they must live and cope with—in particular, the degree to which mobility patterns are intersecting with stigmatized and disadvantaged neighbourhoods. This can possibly lead to spatial entrapment which in turn can worsen mental health problems and even facilitate additional disorders, such as substance abuse. From the perspective of neighbourhoods, there are equity concerns over why so few are obliged to support the majority of individuals with schizophrenia, and why most neighbourhoods are not similarly obliged. Second, moving can be a stressful life event, negatively affecting both physical and mental health (Torrey et al., 1992; DeVerteuil, 2003; Bhugra, 2004; Larson et al., 2004). High levels of mobility, particularly homelessness, can create discontinuities in the receipt of health care and disrupt employment, education and social support networks, as well as precipitate a relapse (Bastide, 1972; Bachrach, 1987; Abood et al., 2002; Harkness et al., 2004). Alternatively, moving may be positive when it involves a reduction in the distance to health care and/or family supports (Dear and Wolch, 1987; Milligan, 1996; Breslow et al., 1998).
A more systematic understanding of the variations in the likelihood of mobility (i.e. the likelihood of making at least one permanent residential move in a designated time period) as well as the overall direction of mobility (i.e. the direction of permanent residential moves across different environments, such as rural to urban, suburbs to inner city, etc.) among individuals with schizophrenia would help to clarify these issues. In terms of the likelihood of mobility, previous research is inconsistent about whether individuals with schizophrenia are more mobile than the general population. This inconsistency partly stems from limited samples that make the detection of mobility differences between different populations difficult to detect. In addition, studies of the direction of mobility have been limited by coarse levels of geography, such as counties, which may not provide a sufficiently sensitive scale to detect differences among groups. Systematic studies of mobility at an intra-urban, neighbourhood scale have rarely been undertaken.
This paper re-examines, with the advantage of population-based administrative health data, both the likelihood and direction of intra-urban mobility among individuals with schizophrenia, a numerically important subgroup of the severely mentally ill. Using population-based data enables us to identify all individuals with a diagnosed mental illness in a specified period of time, as well as an appropriate non-mentally ill comparison group, and to track the movement of both groups over time at a fine level of geographic scale. The goals of this study were to: (1) examine the geographic variability of a cohort diagnosed with schizophrenia in a particular city; (2) examine and compare the socio-demographic characteristics of the schizophrenia cohort and a matched control cohort; and (3) compare the likelihood and direction of residential mobility of these cohorts and examine the variables associated with residential mobility within a particular city. To address these goals, we first review the literature, identify gaps and propose two research questions. Second, we present the methods and data, followed by the results. Finally, we discuss the results and its implications, suggesting future lines of research to better understand the complex and dynamic geographies of schizophrenia in the city.
Section snippets
Literature review
Research findings on the likelihood of residential mobility among individuals with schizophrenia remain inconclusive. On one hand, there is evidence suggesting that the likelihood of moving for individuals with schizophrenia is greater than for the general population (Lix et al., 2006). Dembling et al. (2002) found that one-third of individuals with three or more inpatient admissions to Virginia state psychiatric facilities had changed their county of residence between their first and last
Research questions
Given these methodological and data limitations in previous research on the mobility of individuals with schizophrenia, it seems appropriate to examine two key questions within mental health geography:
- 1.
Is the likelihood of moving higher among a cohort of individuals with schizophrenia than among an age–sex matched cohort?
- 2.
Is a cohort of individuals with schizophrenia more likely to move to lower income, inner-city neighbourhoods and less likely to move to suburban, higher-income neighbourhoods
Data sources
The data are from the Winnipeg Regional Health Authority (WRHA), which encompasses the City of Winnipeg (the provincial capital of Manitoba, Canada) and several exurban areas. As of June 1, 2002, the population of the WRHA was approximately 650,000, or 60% of the province's entire population (WRHA, 2004). A regional health authority in Manitoba has “the responsibility for providing for the delivery and administration of health services in specified geographic areas” (Manitoba Health, 2004). As
Results
A total of 2443 individuals continuously resident in the WRHA during the entire study period were identified with a diagnosis of schizophrenia in the definition period (April 1, 1996 to March 31, 2000). There were 12,135 individuals in the matched cohort. Socio-demographically, the schizophrenia cohort and matched cohort differed in several respects, as shown in Table 2.
The majority of the schizophrenia cohort was in the youngest age group (50.4%) and was more likely to be male (54.2%). Similar
Discussion
The comparative residential mobility results clarified several key issues within the field of mental health geography, as well as confirmed previous findings in a more systematic way. Consistent with the larger literature, the schizophrenia cohort is spatially concentrated in the inner-core area surrounding the Central Business District. As previously noted, the inner core is defined by its lower socio-economic status (lower-income quintiles), while the suburbs are generally associated with
Conclusions: schizophrenia and the city
This paper has contributed to a more systematic understanding of the dynamic and complex movements of individuals with schizophrenia and, critically, how they compared to the general population. By using (1) a systematic, large-scale and longitudinal administrative database, (2) a more sensitive geographical scale, in the form of three intra-urban neighbourhood areas, and (3) a matched control cohort, we were able to overcome certain key methodological and data limitations inherent in previous
Acknowledgements
This research was supported by Canadian Institutes of Health Research (CIHR) Grant (#HSM-62336) and a Social Sciences and Humanities Research Council of Canada (SSHRC) Canada Graduate Scholarship to the second author. Comments by Jennifer Wolch were much appreciated. Thanks to Okechukwu Ekuma for assistance with data extraction and cohort selection. The authors are indebted to Health Information Management of Manitoba Health for providing the data used in this study. The results and conclusions
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