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Debate on Social changes & Mental health - FOR

Social Changes in the 21st Century have Differentially Affected the Mental
Health Scenario in the Developing World

Abstract Harischandra
The effects of social development in the 21st century have affected different countries and different Gambheera
social groups differently. Although social development upgraded life standards of a sector of National Institute of Mental Health,
population, it has affected adversely on poor socioeconomic groups in different parts of the world. Angoda, Sri Lanka
Even though the economic status of urban cities in developing countries has gone up, standards of
living have not risen parallely. The social structure has changed and risk factors for common mental
illness have increased whereas poorly developed mental health services remain unchanged. Resource
allocation for the development of mental health services in developing countries still appears to be
minimal.

Key Words: Developing countries, mental health, social change, 21st century,

Introduction century. Other social changes in the fields of technology,

economy, and cultural transformation have come together
In the evolution of society, several distinct stages have
to give rise to a new form of society, the network society.
been recognized depending on the physical structure,
According to Manuel Castells, the drastic changes in
sociocultural, and economic characteristics. Preindustrial
information and communication technologies have a
(before 1700), industrial (modern: 1700–1950), and
powerful effect on transformation of labor markets and of
postmodern period are distinct stages of the society visible
the work process. Accordingly, two distinguishable work
in history. Manuel Castells argues that postmodern society
forces, self-programmable (educated knowledge) labor and
has evolved and become the current “network society”
generic labor appeared in the labor market. The “educated
since 1980.[1] Social characteristics of the various stages
knowledge” workers, who are also referred to as talents,
have affected different societies differentially depending
became more valuable assets for their companies and their
on the different sociocultural, political and economic
decision making power increased gradually over time. At
structures, and largely determined by geographical
the same time, generic workers as executors of instructions
demarcation. The effects have been visible on many
have continued to proliferate as many menial tasks can
aspects of the lives of people in those societies such as
hardly be automated and many workers particularly youth,
life standards, education, and health. This paper attempts
women, and immigrants are ready to accept whatever
to analyze ways in which recent social changes affects the
conditions are necessary to get a job. This dual structure of
mental health of developing countries. It analyses effects of
the labor market is related to the structural conditions of a
several characteristics such as revolution in communication,
knowledge economy growing within the context of a large
evolution of family, upsurge of global terrorism, rapid
economy of low-skilled services and it is at the source of
urbanization, and migration.
the growing inequality observed in most societies.[1]
Evolution of Communication Even though the key feature of the network society is
The radical changes in the realm of communication derived the network connection between the local and global,
from the revolution in communication technologies has the global architecture of the global network connects
become one of the major developments in the twenty-first places selectively according to their relative value. Thus,
networking has concentrated on populated metropolitan
regions globally, increasing disparity in socioeconomic
Address for correspondence:
Prof. Harischandra Gambheera
changes of developed and developing world as well as
National Institute of Mental Health, Angoda, Sri Lanka.
E-mail: hgambheera@gmail.com This is an open access article distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix,
Access this article online tweak, and build upon the work non‑commercially, as long as the author is credited and
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DOI: 10.4103/0971-9962.193198
How to cite this article: Gambheera H. Social changes in the 21st century
have differentially affected the mental health scenario in the developing
world. Indian J Soc Psychiatry 2016;32:238-42.

238 © 2016 Indian Journal of Social Psychiatry | Published by Wolters Kluwer - Medknow
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Gambheera: Social changes in the 21st century
rural and urban regions. Together with these changes, the
economy of the 21st century has taken a new trend which
focuses mainly on processes rather than new products.[2]
The new industries dominating would be microelectronics,
biotechnology, the materials industries, civilian aviation,
telecommunications, robots plus machine tools, and
computers plus software. The knowledge power–based
industries will take precedence over generic labor–
based industries producing products. The invention of
new products, therefore, no longer leads to sustainable
profits because these products can always be copied and
reproduced less expensively elsewhere. This shift will
invariably lead to increase the disparity between poor and
rich as well as rural and urban.
Although there are many great advantages in advanced
communication, many disadvantages that affect mental
health adversely also have been recognized. One major
adverse impact of changes in communication age is
the disruption of social capital and social cohesion.
Social cohesion refers to the extent of connectedness
and solidarity among groups in society. According to
Durkheim, “a cohesive society is one that is marked by
the abundance of mutual moral support, which instead of
throwing the individual on his own resources leads him to
share in the collective energy and supports his own when
exhausted.” Social capital is defined as those features of
social structures such as interpersonal trust and norms
of reciprocity and mutual aid which act as resources for
individuals and facilitate collective action.[3] The shift from
industrial urban era to the communication age causes great
disruption of social values, characterized by increasing
levels of crime and social disorder, the decline of kinship
as a source of social cohesion, and decreasing levels of
trust.[4] These changes will have a great impact on mental
health in different degrees depending on the advancement
of communication.
Migration and Urbanization
Migration and urbanization are worldwide phenomena and
migration from developing countries to developed countries
as well as from rural areas to urban cities has increased
dramatically over the past few decades. The effects of
migration have a more negative impact in developing
countries compared to developed countries. The poorly
developed infrastructures in cities in low-income countries
face enormous difficulties due to socioeconomic and
cultural problems in finding homes for a large population.
Migration to cities has increased dramatically over the
past few decades. Most migrants come from rural areas,
bringing values, beliefs, and expectations about mental
health that are often very different from the ones they
encounter in their new location. In many instances, people
coming from rural areas have endured years of isolation,
lack of technologic connection, poor health, poverty,
unemployment, and inadequate housing. They need to
Indian Journal of Social Psychiatry | July-September 2016 | Volume 32 | Issue 3
acculturate and adapt not only to a new challenging urban
environment, but also to alternative systems of symbols,
meanings, and traditions.
Increased population in an unstructured city will indeed
lead to overcrowding and insufficient infrastructure. The
life of the migrants will be substandard with unemployment
and poverty. The increase in shanty dwellings lead to
environments with overcrowding, poor upkeep, and
garbage, destroying the esthetic appearance of the city.
The cultural changes will disintegrate families that might
lead to child employment and exploitation of women
labor. Increases in conflicts, estrangement, and isolation
are also seen. In addition to the increase in crime, there
will be an increase in traffic problems, overcrowding, and
industrialization leading to environmental pollution. The
future of city dwellers will be uncertain.
Poverty, drastic cultural changes, and poor sanitation will
obviously carry mental health ramifications. The range of
disorders and deviancies associated with urbanization are
many and include psychoses, depression, sociopathy, drug
and alcohol use, crime, delinquency, vandalism, family
disintegration, and alienation.[5] The negative effects on
mental health will be more in developing countries with
poorly developed unstructured cities and the inability to
deal with a large number of new immigrants.
Despite recent rapid urbanization, more than 70% of people
in developing countries are still living in rural areas and
there are advantages in living in traditional communities.
The international pilot study on schizophrenia compared
1200 patients in nine countries. The investigators found
that patients with schizophrenia in developing countries
tended to have a less severe course and better outcomes
than those in developed countries and those outcomes
may be more favorable in rural settings. Favorable
outcome was associated with vertical mobility, extended
families, psychiatric services that included active
family participation, and absence of specific community
stereotypes of mentally ill persons. These findings point to
the importance of cultural expectations, support systems,
and stigma. High tolerance for mental illness appears
to have a significantly positive impact on patients with
schizophrenia in developing countries.[6]
Evolution of Family Structure
The physical, psychological, and economic structure of
the family has undergone various changes over many
thousands of years in its journey of evolution. In early
hunter-gatherer societies it was small hierarchically
organized communities rather than composites of organized
families. Hunter-gatherer societies evolved toward agrarian
societies and accumulation of agricultural surplus with
the transition of land ownership from communal to
private from 4,000 to 5,000 years ago changed the form
and the structure of the family significantly.[7] The family
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Gambheera: Social changes in the 21st century
organized around agricultural productions, traditional
crafts, or other family business ventures. These families
were employers, producers, and also were consumers. They
were called institutional families and the highest value was
responsibility.[8]
Family and social structures evolved, adapting to the
physical and social conditions of production, heavily
influencing family dynamics and child rearing practices.[9]
The structure of the modern family has been observed
in the west with the beginning of the modern industrial
era. There are three basic sentiments that can be seen in
modern nuclear families; romantic love between spouses,
maternal love and firmer relationships within the family.[10]
The principal value of the modern family which is also
termed as the psychological family is satisfaction.[8]
Although the relationship within the family became so
stronger and neighbors were strangers; the modern family
became a “haven in a heartless world.”[11]
Modernization has commercialized many aspects of life
leading to erosion of family values leading to independent
individualism. The development of consumer market erodes
even the values of the nuclear family, eventually leading
to autonomous and irresponsible individualism.[12] Thus,
advanced commercialization has influenced child rearing
practices so much that preparing children for autonomy
tends to make them precocious, unruly, and independent
individuals eroding the traditional familism.
Although children from most traditional societies were more
altruistic, children from modern complex societies were
more egoistic. Depending on the degree of modernization
children became more and more egoistic. This phenomenon
has been observed only in a part of society, especially in
the middle class. The postmodern family is also called
pluralistic and it consists of many small free-flowing
groupings that include modern nuclear families; a few
traditional families; single parents; blended, co-parent,
adopted, test-tube, surrogate mother, and gay and lesbian
families, with or without formal marriage contracts.[8,10]
There is always a disparity and cultural difference between
generations. Superimposition of new technology, new
media, and value related to these has widened the cultural
distance between generations and such disparity is more
visible in developing countries than in developed countries.
Wide cultural differences affect negatively on traditional
family structures in developing countries.
The effects of the family on mental health are diverse and
they differentially influence the etiology and management
of long-term mental illness. However, a cohesive family
structure is a good social support system that could
protect from common mental illness and facilitate the
management of mental illness. This is especially true for
long-term major mental illness where a persistent social
support system is necessary. The strength of cohesiveness
depends on the degree of modernization and the traditional
240 Indian Journal of Social Psychiatry | July-September 2016 | Volume 32 | Issue 3
family structure still remains intact to a greater extent in
developing countries. Having an extended family structure
has also been found to have positive effects on prognosis.[6]
Effects of Terrorism
Terrorism is the premeditated use or threat of use of
violence by individuals or subnational groups to obtain
a political or social objective through the intimidation of
a large audience, beyond that of the immediate victim.
Terrorists’ attacks are intended to apply pressure on
governments to achieve their objectives and usually use
extraordinary methods of violence. Terrorism has increased
not only from its intensity but also from its breadth.
Since 2000 there has been over a five-fold increase in
the number of deaths from terrorism rising from 3,361
in 2000 to 17,958 in 2013. Over the same period, the
number of countries that experienced more than 50 deaths
rose from 15 to 24. Although it is highly concentrated in
some countries, it is distributed throughout the world. It
is recorded that more than 80% of deaths due to terrorist
activity in 2013 occurred in five countries, namely Iraq,
Afghanistan, Pakistan, Nigeria, and Syria. Terrorism
is driven by many reasons such as religious, political,
nationalistic, and separatist movements.[13]
Terrorist incidents have major impact on politics,
economics, health, and finally society at large. Among
economic consequences, diverting foreign direct
investment, destroying infrastructure, redirecting public
investment to security, and limitation of trade are important
aspects. The economic downturn can create grievances that
can lead to terrorism and then the poor economic conditions
can be both the root cause and consequence of terrorism.[14]
There is a vast difference in the socioeconomic impact
of terrorism in developing countries when compared with
developed countries. Developed countries possess more
capable government institutions that can apply monetary,
fiscal, and other policies to recover from either a large scale
attack or a prolonged campaign. In addition, developed
countries can take decisive and effective security measures
to restore the confidence of the people. The impact of
terrorism on health services is significant and these effects
affect developing and developed countries differently. Apart
from immediate physical damage, the long-term psychiatric
sequelae following terrorist attacks have a great impact on
mental health services.
Compared to developed countries, mental health services
are poorly developed in developing countries. Poorly
developed mental health services in developing countries
in turn affects mental health literacy.[15] Therefore, any
economic downturn due to terrorism will affect already
compromised mental health services, and low mental health
literacy indirectly increases the suffering of the afflicted
people who by not realizing the nature of the illness do not
seek appropriate help.
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Gambheera: Social changes in the 21st century
Psychiatric sequelae following a terrorist attack is diverse
and affects even geographically distant location from the
attacks. Studies indicate that posttraumatic stress disorder
(PTSD) is the most common disorder experienced by the
direct victims of the attack and depression, traumatic grief,
panic, phobias, generalized anxiety disorders, somatization
disorders, and substance misuse disorders are other
disorders found among the victims.[16]
Although 30–40% of those directly affected by terrorist
attacks develop PTSD, a minority of those not directly
involved experience clinical or subclinical levels of
symptoms often accompanied by functional impairment.
However, the epidemiology of different diagnostic
categories following trauma may be different in various
cultures. The directly affected victims experience symptoms
much longer term and the indirect victims usually suffer
for short periods.[17] Psychological effects of trauma on
children depend on the child’s developmental stage and
the extent of the trauma. Although the studies are fewer,
it has been observed that the children are more likely to
experience PTSD.[18]
In developing countries, the poorly developed mental health
services have no disaster preparedness, infrastructure,
or adequate human resources to deal with any disaster
including terrorist attacks. Therefore, psychiatric services
in developing countries are not adequately prepared to
intervene early to minimize the post psychiatric sequelae
or continue to treat the affected people who need the help
of psychiatric services. Affected people themselves are
ignorant about their needs due to their poor mental health
literacy and do not seek appropriate help.
Effects of Stigma
Mental illness suffers immensely from the stigma attached
to it. Stigma is defined as a mark of shame, disgrace, or
disapproval, which results in an individual being rejected,
discriminated against, and excluded from his/her society.[19]
Stigma prevents persons with mental illness seeking
treatment early, worsening their disability, and thereby
increasing stigma further. Stigma affects negatively not
only at the level of the individual but also at family and
administrative levels. Mental health services also suffer from
stigma and discrimination due to attitudes and the behaviors
of health administrators and political authorities.[20]
They do not believe that mental illness can be treated and
mentally ill persons can be reintegrated in the community.
Stigma attached to mental illness prevails widely in
developing countries than in developed countries.[21]
Their concept of mental illness is also vastly different
and the causation of mental illness is attributed mainly to
supernatural powers and seeks remedies accordingly. The
pathways to care are predominantly determined by the
belief system toward causation of mental illnesses and their
remedial measures. The community mental health services
Indian Journal of Social Psychiatry | July-September 2016 | Volume 32 | Issue 3
in developing countries are also not developed adequately.[22]
Because of a multitude of factors, the duration of untreated
psychoses is most often longer in developing countries than
in developed countries.[23] Social changes in 21st century
have made little change in attitudes and behaviors toward
mental illness in low-income countries. Mental health
services remain scanty and localized around cities and
mental health literacy remains poor.
Variations in Global Disease Burden
New sociocultural and economic developments in the
network age have widened the disparity between developed
and developing countries as well as rural and urban
areas. Poverty levels have increased, cultural differences
even among generations have been widened, and risk for
common mental illness among lower socioeconomic groups
has increased.
New changes in sociocultural development have affected
epidemiology of common mental disorder worldwide.
Mental and substance use disorders have been the leading
cause of years lived with disability (YLDs) throughout the
world and major depressive disorders have been predicted
to become the leading cause of global burden of disease in
the future.[24] The prevalence of unipolar depression varies
not only across cultures but also across time.[25] Depression,
which was the fourth leading cause of the global disease
burden in 2000, will be the second leading cause in 2020.
Sociocultural factors rather than hereditary factors may
be responsible for such an increase in the prevalence of
unipolar depression. Sociocultural and economic changes
secondary to rapid urbanization such as overcrowding,
unemployment, and poverty; increased crime and pollution;
cultural changes leading to conflicts, estrangement, and
isolation; child employment; and disintegration of families
may be a playing a significant role in the changing
epidemiology of common mental disorders.
Adverse sociocultural factors experienced in the urbanized
network society may be influencing epigenetic mechanisms
to make such changes in epidemiology of mental and
behavioral disorders. Epigenetic mechanisms are molecular
events that govern the way the environment regulates
the genomes of organisms. Epigenetic processes lead to
individual differences in appearance, physiology, cognition,
and behavior—the group of traits known as the phenotype.[26]
It has been observed that there is a close association
between poverty and common mental illness. Even though
it has not been possible to establish a causal relationship,
many studies have shown an association between indicators
of poverty and risk of developing mental disorders. Factors
commonly and closely linked with poverty such as poor
education, unemployment, homelessness, and low-income
levels have been recognized as risk factors for common
mental illness.[27] The direct and indirect costs of mental
ill-health worsen the economic condition, setting up a
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Gambheera: Social changes in the 21st century
vicious cycle of poverty and mental disorder. Illnesses
that have been recognized as common mental disorders
are depressive and anxiety, somatoform, and stress-related
disorders.
Conclusion
The effects of social development in the 21st century have
affected different countries and different social groups
differently. Although social development upgraded life
standards of a sector of population, it has affected adversely
on poor socioeconomic groups in different parts of the
world. Even though the economic status of urban cities
in developing countries has gone up, standards of living
have not risen parallely. The social structure has changed
and risk factors for common mental illness have increased
whereas poorly developed mental health services remain
unchanged. Resource allocation for the development of
mental health services in developing countries still appears
to be minimal.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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