At various times, anxiety has been regarded either as a natural state worth embracing or as a central dimension of mental suffering.
Anxiety disorders, such as panic disorder, generalized anxiety disorder, social anxiety disorder and specific phobia, represent an especially common way to think about anxiety in the 21st century as something that is often pathological and worthy of treatment.
The emotions that make up anxiety disorders are more elemental and more widely experienced: fear (an emotional response to an imminent threat) and, of course, anxiety (an emotion related to the expectation of a threat). There is a long-standing tension between the familiarity of anxiety as an emotion and the idea that such a common and even valuable emotion can be the basis of a pathology.
Though anxiety disorders are now considered the most common type of psychiatric disorders in the United States and Canada – affecting up to 35% of adults at some point in their lifetime – anxiety hasn’t always stood out as a well-recognized mental health problem. In the US and elsewhere, the concept of anxiety has evolved over time in ways that have better allowed it to be seen as a major clinical concern.Historically, anxiety has often been mixed with other symptoms in a way that has masked its significance. For example, in American Nervousness (1881), the American neurologist George Miller Beard outlined the causes of what he regarded as an epidemic level of fear in US culture. His specific diagnosis was ‘neurasthenia’. A significant part of the diagnosis included anxiety, but it also featured a variety of other psychological and physical symptoms, catalogued over long lists, including insomnia, heart palpitations and back pain.
In the following decades, Sigmund Freud did much to renew the profile of anxiety, starting with an attempt to cleave it from the remnants of neurasthenia. He saw promise in the study of fear and anxiety, casting fear (and, by extension, anxiety) as the problem whose solution would throw a floodlight on mental life writ large.
His followers took up this mantle, too, describing, among other things, some of the social circumstances that increase anxiety. In the middle of the 20th century, anxiety would again re-emerge as a significant concern and a cultural idiom of unease, the lens artists and authors used to talk about change.
Anxiety also fit well within an emerging medical ecology. Milltown, an anxiolytic drug, was launched in the 1950s, ushering in a new era of seriously treating ‘nerve problems’, including the ‘nervous breakdown’ (of which anxiety was thought to be a key symptom). As a minor tranquillizer, Milltown was fast-acting and effective in calming nerves in a way that could seem miraculous. Advertisements focused on its ability to treat stress and anxiety, encouraging consumers to see their everyday unease in a new way – as a treatable condition.
The creation of psychiatric disorder categories in manuals like the DSM is not merely an academic matter. The concepts that psychiatrists create tend to assume a life of their own once they are enshrined in diagnostic instruments and articulated as scientific tools. Due in part to the criteria provided in the DSM, the late 20th century could rightly be regarded as the age of depression.
With the ascent of selective serotonin reuptake inhibitors (SSRIs) such as Prozac starting in the late 1980s, major depressive disorder assumed a special significance. By the DSM’s criteria, many people met the threshold for a major depressive disorder. And SSRIs seemed especially well suited to treating it. Around the time Prozac came on the market, the total number of doctors’ office-based visits per year for depression increased significantly, going from 10.99 million in 1985 to an average of 20.43 million in 1993 and 1994.
It’s not that instances of depression suddenly multiplied. Instead in an echo of the advent of early anti-anxiety drugs – depression was suddenly regarded and talked about by more people as a treatable medical condition, rather than as an everyday trouble that could be ignored.
Of course, anxiety never went away. Depression might have seemed ubiquitous, but people in the late 20th century hardly had less to be anxious about or more to be depressed about.
Indeed, anxiety disorders frequently co-occur with major depression. Therapists have certainly recognized the importance of anxiety as a dimension of suffering in their patients: alleviating a patient’s fear and anxiety is the better part of making them well, even if targeting depression with SSRIs is the focus of much treatment. Furthermore, reported anxiety, as a basic emotional experience, began rising across birth cohorts during the 20th century.
Some of the long-standing uncertainty about whether anxiety is worthy of treatment has been resolved as well. It is increasingly clear that even though a degree of anxiety might be natural and perhaps even essential to a well-adapted species, anxiety also has negative consequences with respect to role performance and wellbeing. Anxiety can undermine school performance in children and adolescents. Anxious workers are often less productive. Anxious athletes might not perform up to their own expectations. Over time, anxiety could led to worse physical health, too.
Although there remains considerable stigma attached to most psychiatric disorders, for anxiety, it is different and shifting. It is possible to regard anxiety as both treatable and not at all unusual. Much of the enduring stigma surrounding psychiatric disorders centers on a fear of violence. But in the mind of the public, anxiety is less associated with violence than, for instance , schizophrenia is.
The lingering stigma related to anxiety is partly due to the idea that it reflects weakness. An old theme that has fed into the ambivalence over treating anxiety as a clinical problem is that people can overcome it with the right mindset and might even learn from it. Yet there is growing acceptance that psychiatric disorders are largely genetic in origin, diminishing the stigma once attached to disorders that were previously regarded as a matter of weak character. It is likely easier now to admit to others that one is anxious.
No wonder why the majority of paranormal incidents took place in the 1950 to 1985 as many of those incidents can be linked to a psychological problem such as psychosis, schizophrenia, depression etc.
Cities are bastions of opportunity. They are filled with vast numbers of people meeting friends and family, visiting restaurants, museums, concert halls and sporting events, and travelling to and from jobs. Yet many of us who live in cities have occasionally been overwhelmed by the activity. At other times, we might feel ‘alone in the crowd’. For decades, the conflicting experiences of city living have led urbanites and scholars to ask: are cities bad for mental health?
Lower rates of depression in larger cities seem to be a consequence of how cities are built and can be explained by a new scientific view of cities called urban scaling theory. Urban scaling theory has helped us understand why some experiences are common to all urbanites and provides us with new perspectives on how these collective experiences influence innovation, crime, economic productivity and, now, mental health. The infrastructure networks of cities are similar to the human circulatory system, and the branching patterns of trees
How is it possible that we can make such precise predictions given all the factors that make each city and neighborhood unique? At its core, urban scaling theory is a collection of mathematical models explaining how cities are organized. These models, to borrow a phrase from Plato, ‘bring together in one idea the scattered particulars’ of modern city living, and explain and contextualize some of the experiences that city dwellers have every day.
One key insight is that the physical layouts of cities follow simple rules. Cities have layered infrastructure networks – made up of electrical lines, streets, railway lines, etc – with larger components branching off into smaller ones that serve smaller groups of people. In this sense, the infrastructure networks of cities are similar to the human circulatory system’s network of branching arteries, veins and capillaries, and the branching patterns of trees. To add to this, people’s semirandom movement through cities is constrained by these infrastructure networks. This means that we can borrow some mathematical tools from physics to construct equations that descried how people move through cities.
With regard to depression, the most important insight is that larger cities facilitate more social interactions. And yes, this too follows the 12 per cent rule. To ground this in some hypothetical numbers, if residents of a city of 1 million people averaged 43 social contacts within the same city, then residents of a city of 10 million people would be expected to average 63 social contacts.
Why is this important for depression? For about 10 years, we have known that the number of social contacts people have is strongly associated with the risk for depression: the more people you interact with, the lower your risk of experiencing depressive symptoms. Given this, it makes sense that we have found that depression rates are lower in larger cities, and that this reduction in depression rates follows the 12 per cent rule.
Thats why also is very important to have your social media contacts in Facebook, what’s up, messenger an other form of social net working , but it is more important that you keep face to face conversation and get out of the house and your cellar phone to meet people to decrease the risk of depression.
This observation has profound implications for how we think about depression. In the context of an ongoing global pandemic, a notable one is that depression within cities can be partly understood as a collective ecological phenomenon. Individual factors are of course important for any one person’s experience with depression, but so is the larger social network in which people are embedded.
Unfortunately, we still do not fully understand the exact dynamics that connect social interactions to depression. However, my research suggests that the effect of social interactions is cumulative: close, supportive friendships and family relationships might be more important than passing interactions with strangers, but it is likely that there is more of both (and every other type of social interaction) in bigger cities.
Importantly, the physical environment of the city its roads, train and bus lines, sidewalks and bike paths shapes these social networks. Specifically, at the level of entire cities, infrastructure facilitates the delivery of goods, services and information, which help support all of the opportunities that cities have to offer. At the same time, these infrastructure networks allow people to move throughout the city to access these opportunities and, as a result, they also facilitate opportunities for a greater diversity and number of social interactions.
In this sense, it is true that the character of a city, the collective influence of its inhabitants, hangs in the air, ready to have an effect on whoever is around to breathe it in. That is also true about the work place, school, and parks . We must improve the design of those areas to reduce stress, anxiety and depression , in term of size, lighting, fresh ear, green, the flow of entry and exit points etc.
This analogy takes on a more concrete meaning with respect to COVID-19 which, unsurprisingly (since social contact facilitates airborne transmission), follows the same 12 per cent rule in the speed at which it spreads through cities. As is the case with infectious diseases such as COVID-19, there is a strong rationale for frequent, local measurements of depression rates.
Cities have historically had a bad reputation for mental and physical health. However, in a fast-urbanizing world, the higher social connectivity of larger cities could have positive influences on city dwellers’ mental health. While more social contacts make containing epidemics such as COVID-19 harder, they also lead to greater economic opportunity, more political and technological innovation, and, apparently, lower rates of depression.
As more people live in cities every year, it is important that we acknowledge, measure and internalize how the physical places we inhabit –and the people we share those spaces with – influence our wellbeing in ways we might not expect.
Steve Ramsey, PhD.