Urban Mental Health in the Twenty-First Century

  • Norman Sartorius
  • Naotaka Shinfuku
  • Heok Eee Kua
  • Takahiro A. Kato
  • Alan R. Teo
  • Masaru Tateno
  • Tae Young Choi
  • Yatan Pal Singh Balhara
  • Shigenobu Kanba


  • N. Sartorius

The contribution of the WPA Section on Urban Mental Health to the volume describing the work of the WPA sections describes three facets of the work on the promotion of mental health in urban settings. The first, that of Professor Shinfuku, deals with the consequences of a disaster on people living in towns; the second, that by Professor Kua, describes the issues related to getting old in an urban setting; and the third describes hikikomori, a syndrome of isolation and withdrawal from social contacts—apparently growing in parallel with urbanization—that has recently gained prominence. All three contributions are placed in the setting of Asia, in two of the most urbanized countries in the world, Japan and Singapore.

The selection of these examples among many others could be criticized as being restricted to a small section of the whole world currently reeling under the impact of urbanization which has never been so rapid and massive as it is now; yet, such a...



This review paper is mainly based on our recently published papers (Kato et al. SPPE 2012; Teo et al. Int J Soc Psychiatry 2015; and Teo et al. Psychiatry Res 2015). The introduced studies in this review paper were supported by Grant-in-Aid for Scientific Research on (1) the Japan Agency for Medical Research and Development (AMED) (Yugo-Nou to TAK); (2) the Japan Society for the Promotion of Science-KAKENHI (to TAK (26713039 & 15 K15431)); (3) Innovative Areas “Will Dynamics” (16H06403 to TAK) of the Ministry of Education, Culture, Sports, Science, and Technology, Japan; (4) Young Principal Investigators’ Research Grant of Innovation Center for Medical Redox Navigation, Kyushu University (to TAK); and (5) SENSHIN Medical Research Foundation (to TAK). The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Dr. Teo is supported by the Department of Veterans Affairs. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Conflict of Interests

In this review paper, all the authors report no financial relationships with commercial interests.


  1. 1.
    Shinfuku N. Mental health in the city of Kobe, Japan. In: Goldberg D, Thornicroft G, editors. Mental health in our future cities, Maudsley Monograph number forty-two. London: Psychology Press; 1997.Google Scholar
  2. 2.
    Ueno Y, Nishimura A, Tatsuno Y, et al. Analysis of the result of inquests in the Great Hanshin Earthquake. In: Comprehensive medical studies on the earthquake victims. Kobe: Kobe University School of Medicine; 1998. p. 27–34.Google Scholar
  3. 3.
    Shinfuku N. To be a victim and a survivor of the Great Hanshin-Awaji Earthquake. J Psychosomat Res. 1999;46:541–8.CrossRefGoogle Scholar
  4. 4.
    Shinfuku N. Psychological consequences of the Great Hanshin Earthquake. Stress Sci. 1996;10:25–30.Google Scholar
  5. 5.
    Kokai M, Shinfuku N. PTSD in Asian society (in Japanese). Encycl Clin Psychiatry. 2000;S6:309–18.Google Scholar
  6. 6.
    Kato H, Asukai N, Miyake Y, Minakawa K, Nishiyama A. Post-traumatic symptoms among younger and elderly evacuees in the early stages following the 1995 Hanshin-Awaji earthquake in Japan. Acta Psychiatr Scand. 1996;93:471–7.CrossRefGoogle Scholar
  7. 7.
    Kokai M, Fujii S, Shinfuku N, Edwards G. Natural disaster and mental health in Asia. Psychiatr Clin Neurosci. 2004;58(2):110–6.CrossRefGoogle Scholar
  8. 8.
    Wang X, Gao L, Shinfuku N, Zhang H, Zhao C, Shen Y. Longitudinal study of earthquake-related PTSD in a randomly selected community sample in north China. Am J Psychiatry. 2000;157:1260–6.CrossRefPubMedGoogle Scholar
  9. 9.
    Chen CC, Yeh TL, Yang YK, et al. Psychiatric morbidity and post-traumatic symptoms among survivors in the early stage following the 1999 earthquake in Taiwan. Psychiatry Res. 2001;15:13–22.CrossRefGoogle Scholar
  10. 10.
    Shinfuku N. Disaster mental health: lessons learned from the Hanshin Awaji Earthquake. World Psychiatry. 2002;1:158–9.PubMedPubMedCentralGoogle Scholar
  11. 11.
    World Health Organization. World urbanization prospects. Geneva: World Health Organization; 2014.Google Scholar
  12. 12.
    Lim LL, Ng TP. Living alone, lack of a confidant and psychological well-being of elderly women in Singapore: the mediating role of loneliness. Asia Pac Psychiatr J. 2010;2:33–40.CrossRefGoogle Scholar
  13. 13.
    Ferri CP, Prince M, Brayne C, et al. Global prevalence of dementia: a Delphi consensus study. Lancet. 2005;366:2112–7.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Soh KC, Kumar R, Niti M, et al. Subsyndromal depression in old age: clinical significance and impact in a multi-ethnic community sample of elderly Singaporeans. Int Psychogeriatr. 2008;1:188–200.Google Scholar
  15. 15.
    Kua EH, Mahendran R, Feng L, Tian X, Ng TP. Preventive psychiatry in late life: studies on depression and dementia from the Singapore Gerontological Research Program. Taiwan J Psychaitry. 2013;27:267–75.Google Scholar
  16. 16.
    Rawtaer I, Mahendran R, Yu J, Fam J, Feng L, Kua EH. Psychosocial interventions with art, music, tai-chi and mindfulness for subsyndromal depression and anxiety in older adults: a naturalistic study in Singapore. Asia Pac Psychiatry. 2015;7:240–50.CrossRefPubMedGoogle Scholar
  17. 17.
    Wu DX, Feng L, Yao SQ, Xian FT, Mahendran R, Kua EH. The early dementia prevention programme in Singapore. Lancet Psychiatry. 2013;1:9–11.CrossRefGoogle Scholar
  18. 18.
    Kua EH. Colours of ageing. Singapore: Write Editions; 2017.Google Scholar
  19. 19.
    Humpel N, Owen N, Leslie E. Environmental factors associated with adults’ participation in physical activity: a review. Am J Prev Med. 2002;22:188–99.CrossRefPubMedGoogle Scholar
  20. 20.
    Pretty J, Peacok J, Sellens M, Griffin M. The mental and physical health outcomes of green exercise. Int J Environ Health Res. 2005;15:319–37.CrossRefPubMedGoogle Scholar
  21. 21.
    Son KC, Um SJ, Kim SY, Song JE, Kwack HR. Effect of horticultural therapy on the changes of self-esteem and sociality of individuals with chronic schizophrenia. Acta Hortic. 2004;639:185–91.CrossRefGoogle Scholar
  22. 22.
    Ho R, Ng KH, Chan HY, Ng M, Sia A, Mahendran R. Gardening and mental health of the elderly. Presented at the annual scientific conference on ageing, Singapore, 5 May 2016.Google Scholar
  23. 23.
    Zung WWK. A self-rating depression scale. Arch Gen Psychiatry. 1965;12:63–70.CrossRefPubMedGoogle Scholar
  24. 24.
    Zung WWK. A rating instrument for anxiety disorders. Psychosomatics. 1971;12:371–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Kua EH, Sia A. Green environment and mental health in the city. In: Jorgensen M, Okkels N, Kristiansen CB, editors. Mental health and illness worldwide. Singapore: Springer; 2017.Google Scholar
  26. 26.
    Saito T. Social withdrawal (Shakaiteki Hikikomori). PHP Shinsho (in Japanese), Tokyo; 1998.Google Scholar
  27. 27.
    Koyama A, Miyake Y, Kawakami N, Tsuchiya M, Tachimori H, Takeshima T, World Mental Health Japan Survey, G. Lifetime prevalence, psychiatric comorbidity and demographic correlates of “hikikomori” in a community population in Japan. Psychiatry Res. 2010;176(1):69–74.CrossRefPubMedGoogle Scholar
  28. 28.
    Kato TA, Kanba S, Teo AR. A 39-year-old “adultolescent”: understanding social withdrawal in Japan. Am J Psychiatry. 2016b;173(2):112–4.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Kato TA, Shinfuku N, Sartorius N, Kanba S. Are Japan’s hikikomori and depression in young people spreading abroad? Lancet. 2011;378(9796):1070.CrossRefPubMedGoogle Scholar
  30. 30.
    Kato TA, Tateno M, Shinfuku N, Fujisawa D, Teo AR, Sartorius N, Akiyama T, Ishida T, Choi TY, Balhara YP, Matsumoto R, Umene-Nakano W, Fujimura Y, Wand A, Chang JP, Chang RY, Shadloo B, Ahmed HU, Lerthattasilp T, Kanba S. Does the ‘hikikomori’ syndrome of social withdrawal exist outside Japan? A preliminary international investigation. Soc Psychiatry Psychiatr Epidemiol. 2012;47(7):1061–75.CrossRefPubMedGoogle Scholar
  31. 31.
    Furuhashi T, Figueiredo C, Pionnie-Dax N, Fansten M, Vellut N, Castel PH. Pathology seen in French “hikikomori”. Seishin Shinkeigaku Zasshi. 2012;114(10):1173–9.PubMedGoogle Scholar
  32. 32.
    Garcia-Campayo J, Alda M, Sobradiel N, Sanz Abos B. A case report of hikikomori in Spain. Med Clin (Barc). 2007;129(8):318–9.CrossRefGoogle Scholar
  33. 33.
    Lee KM, Koo JG, Kim EJ, Lee SH. The psychosocial characteristics of Oiettolie adolescents (in Korean). Korean J Counsel Psychother. 2001;13(1):147–62.CrossRefGoogle Scholar
  34. 34.
    Lee YS, Lee JY, Choi TY, Choi JT. Home visitation program for detecting, evaluating and treating socially withdrawn youth in Korea. Psychiatry Clin Neurosci. 2013;67(4):193–202.CrossRefPubMedGoogle Scholar
  35. 35.
    Malagon-Amor A, Corcoles-Martinez D, Martin-Lopez LM, Perez-Sola V. Hikikomori in Spain: a descriptive study. Int J Soc Psychiatry. 2015;61(5):475–83.CrossRefPubMedGoogle Scholar
  36. 36.
    Sakamoto N, Martin RG, Kumano H, Kuboki T, Al-Adawi S. Hikikomori, is it a culture-reactive or culture-bound syndrome? Nidotherapy and a clinical vignette from Oman. Int J Psychiatry Med. 2005;35(2):191–8.CrossRefPubMedGoogle Scholar
  37. 37.
    Teo AR, Kato TA. The prevalence and correlates of severe social withdrawal in Hong Kong. Int J Soc Psychiatry. 2015;61(1):102.CrossRefPubMedGoogle Scholar
  38. 38.
    Wong PW, Li TM, Chan M, Law YW, Chau M, Cheng C, Fu KW, Bacon-Shone J, Yip PS. The prevalence and correlates of severe social withdrawal (hikikomori) in Hong Kong: a cross-sectional telephone-based survey study. Int J Soc Psychiatry. 2015;61(4):330–42.CrossRefPubMedGoogle Scholar
  39. 39.
    Teo AR, Fetters MD, Stufflebam K, Tateno M, Balhara Y, Choi TY, Kanba S, Mathews CA, Kato TA. Identification of the hikikomori syndrome of social withdrawal: psychosocial features and treatment preferences in four countries. Int J Soc Psychiatry. 2015a;61(1):64–72.CrossRefPubMedGoogle Scholar
  40. 40.
    Teo AR, Stufflebam K, Saha S, Fetters MD, Tateno M, Kanba S, Kato TA. Psychopathology associated with social withdrawal: idiopathic and comorbid presentations. Psychiatry Res. 2015b;228(1):182–3.CrossRefPubMedGoogle Scholar
  41. 41.
    Saito K. Hikikomori No Hyouka-Shien Ni Kansuru Gaido-Rain (Guideline of hikikomori for their evaluations and supports). Tokyo: Ministry of Health, Labour and Welfare; 2010.
  42. 42.
    Teo AR, Gaw AC. Hikikomori, a Japanese culture-bound syndrome of social withdrawal? A proposal for DSM-5. J Nerv Ment Dis. 2010;198(6):444–9.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Kudo R, Nishikawa M. A study of the feeling of loneliness (I) :the reliability and validity of the revised UCLA Loneliness Scale. Exp Soc Psychol Res. 1983;22:99–108.CrossRefGoogle Scholar
  44. 44.
    Russell D, Peplau LA, Cutrona CE. The revised UCLA Loneliness Scale: concurrent and discriminant validity evidence. J Pers Soc Psychol. 1980;39(3):472–80.CrossRefPubMedGoogle Scholar
  45. 45.
    Kurimoto A, Awata S, Ohkubo T, Tsubota-Utsugi M, Asayama K, Takahashi K, Suenaga K, Satoh H, Imai Y. Reliability and validity of the Japanese version of the abbreviated Lubben Social Network Scale (in Japanese). Jpn J Geriatr. 2011;48(2):149–57.CrossRefGoogle Scholar
  46. 46.
    Lubben J, Blozik E, Gillmann G, Iliffe S, von Renteln Kruse W, Beck JC, Stuck AE. Performance of an abbreviated version of the Lubben Social Network Scale among three European community-dwelling older adult populations. Gerontologist. 2006;46(4):503–13.CrossRefPubMedGoogle Scholar
  47. 47.
    Olfson M, Fireman B, Weissman MM, Leon AC, Sheehan DV, Kathol RG, Hoven C, Farber L. Mental disorders and disability among patients in a primary care group practice. Am J Psychiatry. 1997;154(12):1734–40.CrossRefPubMedGoogle Scholar
  48. 48.
    Sheehan DV. Sheehan disability scale. Washington: American Psychiatric Association; 1983.Google Scholar
  49. 49.
    Kondo N, Sakai M, Kuroda Y, Kiyota Y, Kitabata Y, Kurosawa M. General condition of hikikomori (prolonged social withdrawal) in Japan: psychiatric diagnosis and outcome in mental health welfare centres. Int J Soc Psychiatry. 2012;59:79–86.CrossRefGoogle Scholar
  50. 50.
    Tateno M, Park TW, Kato TA, Umene-Nakano W, Saito T. Hikikomori as a possible clinical term in psychiatry: a questionnaire survey. BMC Psychiatry. 2012;12:169.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Kato TA, Hashimoto R, Hayakawa K, Kubo H, Watabe M, Teo AR, Kanba S. Multidimensional anatomy of ‘modern type depression’ in Japan: a proposal for a different diagnostic approach to depression beyond the DSM-5. Psychiatry Clin Neurosci. 2016a;70(1):7–23.CrossRefPubMedGoogle Scholar
  52. 52.
    Kato TA, Watabe M, Kanba S. Neuron-glia interaction as a possible glue to translate the mind-brain gap: a novel multi-dimensional approach toward psychology and psychiatry. Front Psych. 2013;4:139.Google Scholar
  53. 53.
    Watabe M, Kato TA, Monji A, Horikawa H, Kanba S. Does minocycline, an antibiotic with inhibitory effects on microglial activation, sharpen a sense of trust in social interaction? Psychopharmacology. 2012;220(3):551–7.CrossRefPubMedGoogle Scholar
  54. 54.
    Watabe M, Kato TA, Teo AR, Horikawa H, Tateno M, Hayakawa K, Shimokawa N, Kanba S. Relationship between trusting behaviors and psychometrics associated with social network and depression among young generation: a pilot study. PLoS One. 2015;10(3):e0120183.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Watabe M, Kato TA, Tsuboi S, Ishikawa K, Hashiya K, Monji A, Utsumi H, Kanba S. Minocycline, a microglial inhibitor, reduces ‘honey trap’ risk in human economic exchange. Sci Rep. 2013;3:1685.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Norman Sartorius
    • 1
  • Naotaka Shinfuku
    • 2
    • 3
  • Heok Eee Kua
    • 4
  • Takahiro A. Kato
    • 5
    • 6
  • Alan R. Teo
    • 7
    • 8
  • Masaru Tateno
    • 9
  • Tae Young Choi
    • 10
  • Yatan Pal Singh Balhara
    • 11
    • 12
    • 13
    • 14
  • Shigenobu Kanba
    • 4
  1. 1.Association for the Improvement of Mental Health ProgrammesGenevaSwitzerland
  2. 2.Kobe University School of MedicineFukuokaJapan
  3. 3.Department of Social WelfareSchool of Human Sciences, Seinan Gakuin UniversityFukuokaJapan
  4. 4.Department of Psychological MedicineNational University of SingaporeSingaporeSingapore
  5. 5.Department of NeuropsychiatryGraduate School of Medical Sciences, Kyushu UniversityFukuokaJapan
  6. 6.Brain Research Unit, Innovation Center for Medical Redox NavigationKyushu UniversityFukuokaJapan
  7. 7.Portland VA Medical CenterPortlandUSA
  8. 8.Department of PsychiatryOregon Health & Science UniversityPortlandUSA
  9. 9.Sapporo Hana Developmental Psychiatry Clinic, Department of NeuropsychiatrySapporo Medical UniversitySapporoJapan
  10. 10.Department of PsychiatryCatholic University of Daegu School of MedicineDaeguSouth Korea
  11. 11.National Drug Dependence Treatment Centre, Department of PsychiatryAll India Institute of Medical Sciences (AIIMS)New DelhiIndia
  12. 12.King’s College LondonLondonUK
  13. 13.University of AdelaideAdelaideAustralia
  14. 14.Virginia Commonwealth UniversityRichmondUSA

Personalised recommendations