Is Rural Living Better for Mental Health?

Key points

• In the past, social psychiatrists were interested in mental health in rural settings.

• Studies found that rates of mental illness in rural settings were similar to those in urban settings.

• Although researchers found that social problems contributed to mental illness, they failed to call for action.

If you’re not a psychiatric epidemiologist or a mental health historian, it is doubtful that you’ve heard of Stirling County, Nova Scotia. And for good reason. Stirling Country, Nova Scotia, doesn’t exist, at least in the sense that you’ll never find it named on a map. But it is a real place, and a place that played an enormous role in shaping our understanding of the social factors that contribute to mental health and illness. Why haven’t you heard of it?

The answer is simple. Stirling County is a pseudonym. It stands in for a county in Nova Scotia that hosted one of the world’s longest and most important epidemiological studies, in this case focusing on mental health. Why the pseudonym? When the study began in 1948, mental illness was deeply stigmatized, even more than today. Unlike the Framingham Heart Study, which focuses on risk factors related to cardiovascular health and began in the same year (and is based in Framingham, Massachusetts), many people in “Stirling County” didn’t want to be associated with mental illness. And even though it is quite easy to identify the real name of the host county (I’ll leave you to figure that out for yourself), researchers were still keeping it a secret very recently.

You might ask another question: Why situate a study about mental health in a rural setting? As my last post suggested, most people during the middle of the twentieth century were much more concerned with the threat cities posed to mental health. In a way, there’s your answer. Psychiatrists and social scientists interested in social psychiatry, or the social determinants of mental health, wondered about whether rural settings were better for mental health. Stirling County helped to provide some of the answers.

The Stirling County Study was the brainchild of two prototypical social psychiatrists: husband and wife team Dorothea Cross Leighton (1908-1992) and Alexander Leighton (1908-2007). The Leightons met at Johns Hopkins, where they both earned medical degrees, specializing in psychiatry. But they were both intrigued by the social sciences and took advantage of opportunities to do field work in indigenous communities in Alaska, New Mexico, and Arizona. Their time in such places, along with their experiences in World War II, convinced both of them to switch their attention to studying mental health using methods from the social sciences.

Following the Second World War, which catalysed psychiatric interest in the impact of social factors on mental health, the Leightons looked for opportunities to lead their epidemiological study. They opted for Nova Scotia in part because Alexander Leighton had spent his summers there ever since he was a boy. The Leightons received one of the first grants from the newly founded National Institute of Mental Health, which, along with other funders, paid for a team of 100 researchers, including psychiatrists, social scientists, historians, and even a photographer.

As with other pioneering social psychiatry studies, including those in Manhattan and New Haven, the Leightons delved deeply into the history and social structure of Stirling County. One of the three books the study published, People of Cove and Woodlot (1960), focused exclusively on Stirling County’s historical and social context. Although Stirling County was a rural setting, it was remarkably mixed in terms of geography, ethnicity, and economy. The county was primarily made up of English Canadians, who tended to be Protestant, and French Canadians (Acadians), who were Roman Catholic, along with indigenous people, Black Canadians, and a few other ethnic minorities. It was on the sea and many people worked in the fishery, but others worked in the lumber industry or farming. People’s economic situation also varied considerably, ranging from the comfortably well-off to those living in abject poverty.

Did Stirling County’s residents have better mental health than people living in cities? The short answer, to the surprise of many, was no. Statistics revealed that the rates of mental illness in Stirling County were very similar to those found in the Midtown Manhattan Study, which Leighton also ended up running in the late 1950s. Moreover, many of the risk factors in both places were similar: poverty, inequality, social isolation, and community disintegration. Simply being in a crowded city, it seemed, wasn’t problematic in itself.

Interestingly, when the Leightons reassessed rates of mental illness in one of the most deprived communities, “The Road,” a decade later, they found that residents’ mental health had improved. While Alexander Leighton argued that this was due to an adult education program and more mixing with wealthier people due to the consolidation of two schools, it is also notable that new employment opportunities had come to the area.

I would imagine that these new jobs lifted people out of poverty, gave their lives new meaning, and fomented new social relationships was probably more of a factor. But Alexander Leighton, much like most social psychiatrists of the period and, indeed, just like the architects of Lyndon Johnson’s “War on Poverty,” was not minded to lift people out of poverty by giving them more material resources. Rather, they believed there was something inherently wrong with the poor, that could be taught out of them (thus explaining the adult education programs). Such thinking was one of the greatest shortcomings of social psychiatry and Johnson’s Great Society policy initiative.

By the 1970s and 1980s, psychiatry shifted away from social explanations for mental illness and onto neurological and genetic ones, along with psychopharmaceutical treatments. Although the Stirling County Study kept trundling on, most psychiatrists moved on from social psychiatry. These days, as we try to contend with ever-rising rates of mental illness, it is important to reassess such studies and to determine what their real lessons are.

Note: This article originally appeared on Psychology Today.