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How do neighborhoods affect depression outcomes? A realist review and a call

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Soc Psychiatry Psychiatr Epidemiol (2014) 49:873–887
DOI 10.1007/s00127-013-0810-z
ORIGINAL PAPER
How do neighborhoods affect depression outcomes? A realist
review and a call for the examination of causal pathways
Alexandra Blair • Nancy A. Ross • Geneviève Gariepy
Norbert Schmitz
Received: 22 April 2013 / Accepted: 16 December 2013 / Published online: 11 January 2014
Ó Springer-Verlag Berlin Heidelberg 2014
Abstract
Purpose This realist review seeks to elucidate the modi-
fiable causal pathways through which neighborhoods affect
depressive symptoms in adult populations.
Methods Studies were identified using Medline, PubMed,
PsycInfo, Geobase, and Web of Science databases, and
chosen using reproducible selection criteria and systematic
critical appraisal.
Results A total of 14 longitudinal studies, published
between 2003 and 2011, were included. Eleven of the
articles observed a significant relationship between
depression and at least one of the following neighbor-
hood-level variables: neighborhood deprivation, disorder,
instability, and social ties. Proposed modifiable pathways
linking neighborhood characteristics and depression
include: (1) the level of neighborhood-based stress that is
placed on individuals, (2) the formation and strength of
protective and supportive social networks, (3) the level of
resiliency to negative affectivity and stress, (4) the per-
ceptions of the esthetic and form of residential space, and
(5) the sense of control and agency in place of residence.
A. Blair (&)
G. Gariepy
N. Schmitz
Douglas Hospital Research Centre, 6875 LaSalle, FBC Pavilion,
Rm. F-2116, Montreal, QC H4H 1R3, Canada
e-mail: alexandra.blair@douglas.mcgill.ca
A. Blair
N. Schmitz
Department of Psychiatry, McGill University, Montreal, Canada
N. A. Ross
Department of Geography, McGill University, Montreal, Canada
N. A. Ross
G. Gariepy
N. Schmitz
Department of Epidemiology, Biostatistics, and Occupational
Health, McGill University, Montreal, Canada
•
These pathways represent potential areas for future
research and intervention.
Conclusions Further research requires a more systematic
use of longitudinal design and a diversity of physical and
social environmental measures. Interventions aimed at
improving affective resiliency need to be tested.
Keywords Depression
Neighborhood
Review
Public
health
Epidemiology
Introduction and background
Depression is a serious public health problem and one of
the leading causes of disease burden worldwide [1]. Not
only is depression known to reduce the quality of life of
individuals, their families, and communities, it is also
associated with functional disability, cardiovascular, met-
abolic and lung diseases, as well as early mortality [2–5].
Individual risk factors for depression include childhood
developmental factors, affective personality traits, as well
as biological, cognitive, and psychosocial factors [6, 7]. On
a population scale, a socioeconomic gradient in the health
burden of depression exists [8], and has been attributed to
environmental exposure [9, 10]. It is hypothesized that the
social and material settings of one’s neighborhood of res-
idence—an area of chronic exposure to both socioeco-
nomic stressors and protective social ties [10]—can affect
depressive symptoms [9, 10]. Researchers have shown that
even after controlling for individual-level risk factors,
exposure to neighborhood social deficits or material
deprivation is associated with depression outcomes [9].
The two existing theories explaining this relationship are
that neighborhood characteristics can either act as stressors
that trigger or worsen depressive symptoms [11] or that
123
874 Soc Psychiatry Psychiatr Epidemiol (2014) 49:873–887

neighborhood environments mediate the social connections 251 publications identified through Medline (45),
that are so necessary for ensuring resiliency against nega- Scopus (64), PubMed (16), PsycInfo (51), Web of
Science (61), and Geobase (14).
tive affectivity [9]. The causal mechanisms driving the
relationships between neighborhood factors and depression 168 duplicate articles
have yet to be fully understood or summarized in a sys- excluded.
83 titles
tematic review. reviewed 3 articles eliminated due to
Four reviews have been published on the relationship irrelevance.

between neighborhoods and depression [11–14]. These 80 abstracts 36 excluded due to cross-
reviewed
reviews provide important summaries of current research, sectional study design.

but lack a systematic synthesis of causal processes and

context-specific factors that determine how and why neigh- 16 excluded due to focus
on children/adolescents
borhoods affect depression outcomes. This information is
essential in designing future community-level interventions
10 excluded because they
targeted at improving community mental health outcomes. were not journal articles.
Indeed, in their seminal review, Diez Roux and Mair [9]
identify that ‘‘developing theory around the processes 2 excluded due to lack of
through which specific area features may affect mental peer-review or publication
status.
health’’ is one of the most important research directions for
this field of research. A first step is to summarize the litera- 8 full texts
4 excluded due to setting in
ture surrounding the proposed modifiable pathways linking reviewed
developing or non-western
neighborhood exposures to depression outcomes. The areas.
objective of this paper is to employ systematic review
4 excluded because they
methods, informed by a realist philosophy, to fill this gap in were reviews.
the literature, and elucidate the causal pathways and mech-
anisms through which neighborhoods may affect depression 7 additional 7 additional records
outcomes in adult populations. records identified through reference
identified checks of existing reviews
through
reference
Methods checks and
snowballing 8 excluded using selection
criteria
A realist review draws from but is different than a purely
systematic literature review [15]. The realist approach 14 texts
included in final
shares the systematic review’s use of reproducible and
review
explicit methodologies to identify, appraise, and analyze
relevant studies [16]. However, its underlying theoretical Fig. 1 Article selection process
framework is different. A realist review is specifically
designed to understand the contexts and causes of phe-
nomena [15]; it recognizes that causal processes are con- Search strategy
tingent upon the contexts in which they occur [17], and
intentionally seeks to understand how and why relation- Medline, PubMed, PsycInfo, Geobase, and Web of Science
ships exist rather than simply whether or not they occur— were the cross-disciplinary databases searched for pub-
which has been the traditional or ‘‘black box’’ approach to lished, peer-reviewed English language articles (Fig. 1).
conducting reviews [18]. A realist synthesis is useful for An initial search was conducted using the terms ‘‘depres-
answering the questions of how certain exposures affect sion’’ or ‘‘depressive symptom*’’, and ‘‘neighborhood*’’ or
health outcomes, who they affect, and in what circum- ‘‘neighbourhood*’’, as found in the titles of publications.
stances [15]. Though originally designed to assess health Of the 251 publications identified, 168 duplicate articles
care and policy interventions, a realist approach can also be and 3 irrelevant publications were eliminated. Once
applied to synthesize observational studies [18]. Here, a the predetermined exclusion criteria were applied to the
realist approach will take the field of neighborhood-level remaining 80 abstracts, 8 articles were identified. A
research forward by explicitly identifying the pathways and snowball search based on the reference lists of these
conditions necessary for neighborhoods to affect depres- remaining articles and those of the four existing literature
sion outcomes and proposing the first summary of causal reviews [11–14] yielded 14 additional records, 6 of which
theory on the topic. met the selection criteria and were included in the final

123
 Table 1 Summary of longitudinal studies included in the realist review
Reference Sample size, Follow-up Follow- Location, Neighborhood- Depression Adjustment for Statistical Key findings Proposed causal Future policy/
age period up rate neighborhood level variable measure covariates methods mechanisms interventions?
(%) Unit measured

Beard et al. 1,325 (aged 2005–2007 62 New York City, Socioeconomic Past 2 weeks Models adjusted Multilevel Neighborhood Affluence increases Structural
[26] 50?) (2 years USA: census tracts status: % high depression for: baseline models; affluence resiliency to interventions
follow-up) school assessed using depression, age, bivariate and remained stressors targeted toward
graduates, % PHQ-9: 10 cut- race, gender, multivariate strongly improving
with off score marital status, regressions protective health of older
undergraduate education, against persons
degrees, annual income, worsening of
income, employment, depression
occupation, % physical symptoms;
unemployed, % activity, BMI, borderline
Latino/black, % social support evidence also
living in poverty, shows that
% owner- disadvantage
occupied increases risk of
dwellings, % worsening
living in same depression
Soc Psychiatry Psychiatr Epidemiol (2014) 49:873–887

house for
5 years, density,
% foreign born
Buu et al. 273 white 1980–2000 60 Michigan, USA: (1) Socioeconomic Past-week Models adjusted Linear mixed (1) Baseline Instability hiders the Improve social
[29] women; (12 years census tracts disadvantage: % assessment for: baseline modeling depression and formation of social support
caregiver follow-up) adult using the past-year, low-SES cohesion, and systems,
or mother unemployment, Hamilton current and predicted future weakens the educational or
(average % poverty; (2) Rating Scale lifetime depression. willingness of professional
age 31) residential for depression: depression, age, Depression individuals to training
instability: % 20? score marital status, increased with intervene for the opportunities,
residents living indicates alcohol use, age; (2) common good; the accessibility
in different moderately social support, neighborhood collective efficacy of family
residence severe antisocial instability mediates alcohol counseling, and
5 years ago, % depression behavior, associated with problems and the
vacant family SES, higher depression neighbourhood
households, % family stress depression, environment by
rented housing controlling for providing
units individual support
factors; networks,
neighborhood building
disadvantage community
did not have a institutions
statistically
significant
effect
875

123
 Table 1 continued
876

Reference Sample size, Follow-up Follow- Location, Neighborhood- Depression Adjustment for Statistical Key findings Proposed causal Future policy/
age period up rate neighborhood level variable measure covariates methods mechanisms interventions?

123
(%) Unit measured

Cutrona 897 black 1997–1999 88 Non-inner city or (1) Disadvantage: Past-year Models adjusted Hierarchical Neighborhood Having few economic None
et al. [23] mothers or (2 years metropolitan areas average per assessment for baseline and multilevel disadvantage opportunities and
caregivers follow-up) of the US: census capita income, % using Michigan lifetime logistic and social few role models for
of 10- to bureau block female-headed University depression, regressions disorder economic success
12-year- group areas households, % Composite education, age, predicted onset undermines
old child on public International reception of of major optimism and
(aged assistance, % Diagnostic government depression, belief in personal
24–80) households Instrument assistance, even when mastery,
below poverty (UM-CIDI) number of controlling for undermines
level, % children, individual recovery from
unemployed employment, variables; the negative events,
men. (2) Social income, number latter and affects family
disorder of past-year relationship was dynamics; disorder
(perceived): negative life only marginally inhibits supportive
delinquency, use events, significant relationships,
of drugs, personality when prevents
garbage, public traits controlling for predictability, and
drinking, gang negative life threatens physical
violence events safety
Curry et al. 786 (mean 1997–2002 87 Baltimore, USA: (1) Objective Past-week Models adjusted Correlation Not a direct path Less available social Community-wide
[34] age 39) (3 years census bureau disorder: city depression for gender, analysis; between support and social violence
follow-up) block group areas police crime data assessed using education, Path model neighborhood- resources affects prevention
on violent, or 20-item CES-D employment, analysis level of violent health. Violence is interventions:
person-to-person scale: 16? cut- age, partner crime and associated with stricter
crimes (assaults, off score; was status, injected depression; lower social enforcement
murders, rapes, measured at drug use, crime was capital; fear of laws, increased
robberies); (2) follow-up personal associated with crime and violence police presence,
subjective experience with CES-D through leads to few neighborhood
disorder: crime and (1) perceptions between-people watch groups,
perceived violence in the of interactions and surveillance
vandalism, litter, past year neighborhood disorganization, cameras, and
vacant housing, disorder and (2) which impede street cleaning
loitering through social capital
experiences of
violence in the
neighborhood.
Correlation
between
perception of
disorder and
violent crime
Soc Psychiatry Psychiatr Epidemiol (2014) 49:873–887
 Table 1 continued
Reference Sample size, Follow-up Follow- Location, Neighborhood- Depression Adjustment for Statistical Key findings Proposed causal Future policy/
age period up rate neighborhood level variable measure covariates methods mechanisms interventions?
(%) Unit measured

Galea et al. 1,020 (aged 2002–2003 (6 81 New York City, Socioeconomic Lifetime, past Models adjusted Multilevel Respondents In low-SES If the relation
[35] 18?) and USA: New York status: 6 months MD for past multivariate residing in neighborhoods between urban
18 months City community dichotomized assessed using 6 months, models; Cox lower SES there are more neighborhood
follow-up) districts along median Modified current and proportional neighborhoods stressors, less poverty and
split of median Structured lifetime hazards had more than material and social depression is
household Clinical depression, age, analysis two times of resources; people mediated by
income Interview sex, race developing are more likely to signs of
(DSM-III): cut- education, depression experience trauma, physical
off of 5? income, marital during follow- and are more disorder,
symptoms for status, social up relative to vulnerable. Limited interventions
two straight support, those living in social cohesion could address
weeks directly high-SES areas; diminishes capacity vandalism and
affected by women had to control disorder; trash in urban
09/11, PTSD greater risk for exposure to areas
incident disorder may result
depression than in psychological
Soc Psychiatry Psychiatr Epidemiol (2014) 49:873–887

men stress
Glymour 4,000 (aged 1992–2006 90 US: census tracts Disadvantage: % Past-week Models adjusted Logistic Residence in a No relationship None
et al. [27] 55–65) (10 years high school depression for baseline regression disadvantaged observed
follow-up) graduates, % using 8-item depression, neighborhood
male CES-D scale: race, sex, did not predict
unemployment, 3? cut-off education, onset of
% poor score. household elevated
households, % wealth, marital depressive
female heads of status, symptoms
household, employment
median
household
income
Kim [31] 2,482 (aged 1995–1998 54 Illinois, USA: census (1) Perceived Past-week Models adjusted Structural Residents living (1) Neighborhood None
18–92) (3 years tract disorder: social depression for baseline equation in disadvantage
follow-up) relationships, assessed using depression, age, modeling disadvantaged increased
neighborhood 20-item CES-D race, education, neighborhoods depression directly,
social ties, social scale: 16? cut- household are more likely (2) neighborhood
support, (2) off score income, marital to be more disadvantage
disadvantage: % status, urban/ depressed; increased
female-headed rural residence disorder depression by way
households, % mediates the of neighborhood
poverty latter disorder, and (3)
households relationship; neighborhood
social ties disadvantage
reduce feelings decreased
of depression, depression by way
but do not of enhanced social
completely relationships
mediate the
relationship
between
disadvantage
and depression
877

123
 Table 1 continued
878

Reference Sample size, Follow-up Follow- Location, Neighborhood- Depression Adjustment for Statistical Key findings Proposed causal Future policy/
age period up rate neighborhood level variable measure covariates methods mechanisms interventions?

123
(%) Unit measured

Latkin and 818 mostly 1997–1999 72 Baltimore, USA: Perceived disorder: Past-week Models were Spearman Higher frequency Chronic, ambient Allowing
Curry [30] low-SES (9 months Baltimore City perceived depression adjusted for correlation of church stressors (e.g., individuals to
adults, pop follow-up) block problems of assessed using baseline matrix; attendance, social regain social
with high vandalism, litter, 20-item CES-D depression, Linear high education disorganization) control through
levels of trash, vacant scale: 16? cut- social support, regression and male affect sense of community
substance housing, off score social Models gender all controllability (of organizations;
abuse teenagers integration associated with litter, crime); even provide training
(mean age hanging out, (having partner lower with high levels of and
39) burglary, drug attending depression social support, the employment
selling, and church), gender, scores; worse networks are so opportunities
robbery marital status, perceptions of impoverished that outside of the
housing status, neighborhood they cannot reduce drug economy,
income, drug significantly neighborhood reduce the
use, criminal associated with stressors physical decay
history, higher and destruction,
education depression at and provide
follow-up, even adequate
after controlling housing and
for individual social services
factors
Lofors and 4.5 million 1997–1999 97 Sweden: small area (1) Linking social First Models were Multilevel Depression rates Poor social networks Decision makers
Sundquist (aged (2 years market statistics capital: mean hospitalization adjusted for logistic increased when result in a lack of should take into
[20] 25–64) follow-up) voting due to age, gender, regression linking social social support, account the
Swedes participation. (2) depression housing tenure, capital isolation, and evidence of
followed Deprivation: % classified employment, decreased and political and social neighborhood
from 1997 with low- according to education, neighborhood powerlessness, effect on mental
until first educational the marital status, deprivation which in turn health in
hospital status, % international country of birth increased; the increases decisions
admission unemployment, classification association vulnerability to regarding sites
due to % elderly people of diseases between social depression of psychiatric
depression living alone, (ICD9 and capital and clinics and
number children ICD10) by a depression no community
under age 5, clinical longer support services
single parents, psychologist significant after for psychiatric
mobility, % adjusting for patients
foreign born neighborhood
people deprivation
Soc Psychiatry Psychiatr Epidemiol (2014) 49:873–887
 Table 1 continued
Reference Sample size, Follow-up Follow- Location, Neighborhood- Depression Adjustment for Statistical Key findings Proposed causal Future policy/
age period up rate neighborhood level variable measure covariates methods mechanisms interventions?
(%) Unit measured

Santiago 136 parents 2002–2004 70 Denver, colorado: Structural Past 6 months Models were Hierarchical Disadvantage Residential mobility Consider
et al. [24] or (2 years zip code disadvantage: assessment adjusted for linear mode predicts and high poverty childcare,
guardians follow-up) levels of using baseline psychological rates reduce a employment,
(mean age poverty, Achenbach depression, syndromes; community’s family
34) unemployment, System of occupation, instability is ability to exercise resources;
educational Empirically education, age, harmful for social control advocate for
attainment, Based sex, race, adults. Poverty through strong area
residential Assessment family poverty- predicted more social ties; They improvement
mobility Adult Self- related stress, social problems also reduce initiatives,
Report and both and affected interconnectedness programs that
Questionnaire affective, and psychological within and encourage
behavioral functioning; commitment to the cohesion and
characteristics unemployment community investment, and
related to fewer more resources
social problems for low-income
and fewer families
Soc Psychiatry Psychiatr Epidemiol (2014) 49:873–887

depressive
symptoms
Schootman 998 African- 2000–2004 90 St-Louis County, Deprivation index: Past-week Models adjusted Two-level No association No relationship None
et al. [28] Americans (3 years MO, USA: census (1) disadvantage: assessment for baseline logistic between any observed
(aged 50?) follow-up) tracts % below poverty using 11-item depression, regression observed
line, % on public CES-D scale: gender, income, models attribute of
assistance, % 9? cut-off inadequacy, subject location
age 25? with score limits in vision, and
less than high underweight or development of
school, % obesity, past- depression
housing units year
lacking hospitalization,
plumbing, % social support,
black, % medical
unemployed. (2) conditions, use
Residential of health
stability: % services, use of
residing over anti-depressant
5 years, %
owner-occupied
housing. (3)
Social
disorganization:
% female-
headed
households, %
aged 64?
879

123
 Table 1 continued
880

Reference Sample size, Follow-up Follow- Location, Neighborhood- Depression Adjustment for Statistical Key findings Proposed causal Future policy/
age period up rate neighborhood level variable measure covariates methods mechanisms interventions?

123
(%) Unit measured

Stafford 8,780 (aged 2002–2005 82 England: English (1) Social Past-week Models adjusted Structural Greater Social cohesion Interventions that
et al. [21] 50?) (2 years Longitudinal cohesion: sense assessment for baseline equation neighborhood mediates potential foster
follow-up). Study of Aging of belonging, using 8-item depression, age, modeling social cohesion negative impacts of neighborhood
primary study perception of CES-D scale: gender, sense of associated with friendships and social cohesion
cluster units trust, perception 3? cut-off friendship, fewer enhances personal
of solidarity and score sense of depressive sense of control;
friendliness, control, total symptoms at environments with
perception of wealth, follow-up low cohesion also
reciprocity, (2) occupation and likely to be
safety: problems marital status multiply
with vandalism disadvantaged;
and graffiti, socially cohesive
perceived safety environments are
while outside thought to be more
after dark, sense conducive to
of helpfulness of supportive social
neighbors relations
Weich et al. 7,659 adults 1991–1992 80 UK: electoral wards Socioeconomic Last few week Models adjusted Multilevel Maintenance, but No relationship None
[22] (aged (12 months deprivation: assessment for baseline models; not episode observed
16–74) follow-up) (using the using 12-item depression, age, Bivariate onset, was
Carstairs Index) General Health gender, marital and significantly
% male Questionnaire: status, financial multivariate increased
unemployment, score of 3? strain, health regressions among those
households with problems, living in most
no car, % household deprived areas;
overcrowding, overcrowding these results did
head of and type, not reach
household in tenure, and statistical
lower social problems. significance
class Occupational after adjustment
social class, for individual
household and household
income, car characteristics;
access household
variables did
not have an
effect on
depression
outcomes
Soc Psychiatry Psychiatr Epidemiol (2014) 49:873–887
 Table 1 continued
Reference Sample size, Follow-up Follow- Location, Neighborhood- Depression Adjustment for Statistical Key findings Proposed causal Future policy/
age period up rate neighborhood level variable measure covariates methods mechanisms interventions?
(%) Unit measured

Wight et al. 3,442 (aged 1993–1998 55 US: census tracts (1) Socioeconomic Past-week Models adjusted Hierarchical Change in With extended aging, None
[25] 70?) (5 years disadvantage: % assessment for baseline linear depressive neighborhood
follow-up) residents aged using 8-item depression, models symptoms conditions are so
25? without CES-D scale: education, significantly distal to the
high school 3? cut-off household associated with individual’s own
degree. % score income, gender, neighborhood; health
households age, ethnicity, socioeconomic circumstances that
receiving marital status, disadvantage the environmental
assistance, % religions, and ethnic ‘‘press’’ may reach
residents living assistance with composition in a plateau in late
below poverty activities of unadjusted life; neighborhood
line, % residents daily living, models, but not disadvantage may
aged 16? heart problems, in models that affect well-being
unemployed, % stroke, count of control for only for those who
residents 65?, other major individual-level are most weighed
(2) affluence: % medical characteristics; down by poverty
Soc Psychiatry Psychiatr Epidemiol (2014) 49:873–887

households with conditions, there is a

$50,000 cognitive statistically
incomes, (3) function significant
racial/ethnic protective
composition: % effect for
residents who Hispanics living
are black, % in high-density
residents who and deprived
are Latino Hispanic
neighborhoods
881

123
882 Soc Psychiatry Psychiatr Epidemiol (2014) 49:873–887

review. Snowballing has been shown to identify a greater Pathways/Mediators

number of relevant sources than database or hand search-
ing, and is a key component of the purposive sampling Neighborhood exposures
method of realist review [15]. Social disadvantage
Instability
Disorder
Inclusion and exclusion criteria Social ties
Exposure to stress
Formation of supportive and/or mobilized
social networks
Resiliency to negative affectivity
Perceptions of aesthetics
Sense of control or powerlessness
Sense of fear and anxiety

Most neighborhood-level research of health outcomes has

been conducted in the past 15 years [9], and so the search Outcome
Confounders Depressive symptoms
was limited to works published since 1995. Publications Education
selected were empirically based longitudinal studies; cross- Income
Employment
sectional studies, experimental studies, and literature Occupation
Effect modifiers
reviews were excluded. The findings of previously pub- Race
Personality traits
lished reviews, however, are incorporated into the discus- Migration history
Partner health
Number of children
sion section to contextualize findings. Publications needed Family troubles
Social support
to include a clinically validated outcome measure of Negative life events
depression or depressive symptoms, as well as a validated Anti-depressant use
Education
neighborhood-level exposure variable. Neighborhoods are
Income
defined geographical units that are smaller than, and exist Employment
within, a larger city or area unit (e.g., city blocks, census Occupation
Number of children
tracts, or enumeration areas). Community-based studies Household crowding
without adequate geographic coding or linking to place
were excluded due to their lack of reproducibility. All
Fig. 2 Summary of proposed pathways, confounding variables, and
articles discussed at least one causal pathway or mecha- effect modifiers in the relationship between neighborhood variables
nism linking neighborhoods to depression outcomes. and depression outcomes in included studies

Data extraction
Articles were critically appraised using Heller et al.’s [19]
checklist for public health research. In addition, we applied
the checklist (Table 1) to assess the quality of the studies’
neighborhood and depression measures, as well as their focus
on proposed causal mechanisms. Data from each paper were
extracted and classified in a table format in Table 1.
Results
neighborhoods on specific sub-populations, which is valu-
able within a realist review framework [15]. Finally, all 14
studies discussed the risk of bias surrounding rates of fol-
low-up. The interview follow-up rates were above 70 %
and satisfactory for ten of the reviewed articles. In the four
studies that yielded lower rates, whiter, older, wealthier,
urban-dwelling, and less depressed participants at baseline
were more likely to respond at follow-up [25, 26, 29, 31].
Sample characteristics, and study settings and methods are
described in further detail in Table 1.

Fourteen articles were systematically reviewed. The pub-
lication dates of these papers ranged from 2003 to 2011.
One study was set in Sweden [20], two were set in England
[21, 22], and the other 12 were set in the US—in both non-
urban areas [23] and cities. The sample populations studied
in these works varied greatly in size and characteristics.
Sample sizes ranged from 136 individuals [24], to several
hundreds or thousands, to 4.5 million [20]. All papers
demonstrated satisfactory statistical power. Five publica-
tions were specifically limited to middle-aged or elderly
populations [21, 25–28], and certain samples were limited
to African-American mothers [23], white mothers [29], or
in the case of one study, limited to a population with high
levels of substance abuse [30]. Despite the lack of gener-
alizability, these studies offer insights into the effects of
Neighborhood contexts and measurements
A wide range of spatial units were used to study the neigh-
borhood area, most of which were census-based neighbor-
hood units that have been widely studied and validated in the
literature [13, 32, 33]. Neighborhood-level variables included
neighborhood disadvantage and deprivation, affluence,
deterioration, safety, disorder and criminality, residential
instability, socioeconomic status, social capital, social sup-
port, social cohesion, and racial and ethnic composition.
Depression measurement and control for confounding
Depression outcomes were assessed using several different
diagnostic tests, all of which are clinically validated.

123
Soc Psychiatry Psychiatr Epidemiol (2014) 49:873–887
However, depression assessment methods were highly
heterogeneous in terms of timeframes of assessment (e.g.,
symptoms in past week, past two weeks, or over lifetime)
and diagnostic tools; some studies utilized symptoms
scales, while others used clinical interviews or self-report
data. Baseline and follow-up measurements of depressive
symptomatology were taken in 13 of the 14 studies; only
one study examined depression solely at follow-up [34]. In
studying the etiology of depression it is crucial to control
for baseline symptoms, and ideally lifetime symptoms as
well. This allows researchers to begin to address the issue
of reverse causality or ‘‘social drift’’ wherein depressed
people are thought to move to more deprived neighbor-
hoods [9]. Other principle confounders were age, gender,
education, income, employment, race, and marital status.
Table 1 includes a summary of the confounding variables
that models were adjusted for in each of the studies, and a
visual summary of confounding variables and effect mod-
ifiers described in included studies is found in Fig. 2.
Neighborhood characteristics and proposed causal
pathways
Three of the 14 articles reported no significant prospective
relationship between any neighborhood-level variables and
depression outcomes [22, 27, 28]. The other eleven articles
reported statistically significant relationships between at
least one neighborhood-level variable and depression out-
comes. Only two articles specifically tested the significance
of causal pathways linking neighborhood characteristics to
depression [31, 34], while the others made claims based on
either existing literature or empirical observations of their
data. This discrepancy in methodology will be discussed
throughout the following sections, as the proposed linking
pathways between depression and neighborhood-level
measures are described and explained. Evidence is sum-
marized in Table 2.
Socioeconomic disadvantage, deprivation,
and deterioration
Neighborhood disadvantage, deprivation, and deterioration
were measured in 10 of the 14 articles. These variables
were derived from proxies such as rates of adult unem-
ployment, household poverty, female-headed households,
high school graduation, as well as income distribution and
family composition. In two of the studies, the statistical
significance of the relationship between neighborhood
disadvantage and depression outcomes was lost after con-
trolling for individual sociodemographic, economic, and
health characteristics [22, 25]. In the remaining four stud-
ies, the relationship between neighborhood disadvantage,
deprivation, and deterioration and depression outcomes
883
was significant, even in unadjusted models [24, 27–29].
These four articles discuss three potential modifiable
pathways through which neighborhoods affect depression
outcomes. First, disadvantaged neighborhoods are likely
the sites of exposure to multiple, negative, and concurrent
stressors, which can interact to worsen depressive symp-
toms [35]. Second, neighborhood deprivation or affluence
may affect individuals’ resiliency or vulnerability to
stressors and negative life events, which can put them at
greater risk of experiencing depressive symptoms [23, 26].
Third, living in a deprived neighborhood makes individuals
more likely to perceive disorder, and feel a sense of
powerlessness therein [31]. Feeling powerless worsens
depressive symptoms. Few studies have tested these
pathways.
Instability and mobility
Instability, or the movement in and out of neighborhoods
through time, was seen to affect depression outcomes in
two of the studies reviewed [24, 29]. It was proposed that
neighborhood instability can affect depression outcomes
through three potential mechanisms. First, it can shape the
amount of personal and community-level social, economic,
and political investment into the neighborhood, which can
have repercussions on the mental health of residents [24].
Secondly, it can affect the potential of social organization,
which is needed to garner the political clout to advocate for
health promoting services and resources [24, 29]. Finally, it
can impact the support networks needed to protect indi-
viduals from worsening depressive symptoms [29].
Disorder, crime, and perceived safety
Neighborhood disorder, which was measured in six of the
reviewed papers, was mostly derived from aggregate per-
ceptions of youth delinquency, litter, public drinking and
drug use, vandalism and graffiti, gang violence, and crime.
The only objective measure of disorder was police-reported
crime rates [34]. Though perception-based measures can
create a problem of same-source bias, there is often a
strong statistical correlation between perceived and
objective markers of disorder [34]—making perceptions of
crime, delinquency, and disorder strong proxies for actual
measures. Two papers observed no statistically significant
relationship between neighborhood disorder and depression
outcomes in their respective populations of adults living in
England [21] and older adults living in St-Louis, MO, USA
[28], while four did observed a statistically significant
relationship between these variables. In these four papers,
two main pathways were proposed to explain the causal
relationship between disorder and depression. First,
neighborhood disorder affects the level of predictability
123
884 Soc Psychiatry Psychiatr Epidemiol (2014) 49:873–887

Table 2 Summary of evidences surrounding each neighborhood-level variable and proposed causal mechanism
Neighborhood characteristic examined Studies that found significant association between baseline neighborhood Studies that found no
characteristic and depression outcomes, and the proposed mechanism significant association

Social disadvantage Cutrona et al. [23]: lack of economic opportunities and resources undermine Wight et al. [25]
sense of self-worth, affect resilience to stressors and life events Weich et al. [22]
Kim [31]: lack of protective social ties worsens depressive symptoms Buu et al. [29]
Galea et al. [35]: multiple stressors of living in a socially disadvantaged Glymour et al. [27]
neighborhood seen to affect depressive symptoms Schootman et al. [28]
Beard et al. [26]: affluence increases resiliency to negative affectivity
Instability and Buu et al. [29]: instability hinders the formation of protective social ties Schootman et al. [28]
mobility Santiago et al. [24]: mobility hinders community investment and social
mobilization for the betterment of the community
Disorder, crime, Cutrona et al. [23]: social disorder inhibits formation of supportive Stafford et al. [21]
perceived safety relationships, and decreases sense of predictability of place, which Schootman et al. [28]
increases risk of depressive symptoms
Curry et al. [34]: fear of crime limited between-people interactions and
social capital development
Latkin and Curry [30]: the lack of controllability associated with
neighborhood disorder affects depressive symptoms
Kim [31]: social disorder mediates relationship between neighborhood
disadvantage and depression; social ties reduce, but do not erase symptoms
Social ties, cohesion Lofors and Sundquist [20]: poor social participation result in reduced social
and social capital networks of support, and increased sense of powerlessness
Stafford et al. [21]: social cohesion influences sense of control in a
neighborhood setting, which has impact on depressive symptoms

and controllability in the neighborhood. A lack of pre- Ethnic composition

dictability—in terms of environmental hazards, criminal-
ity, or social interactions—will lead residents to feel a lack
of control, which can worsen depressive symptoms [23,
30]. Secondly, residents living in disorderly neighborhoods
might feel an increased sense of fear, which can stop them
from leaving their homes and forming protective social
networks [34].
Social ties, cohesion, and social capital
Social capital is defined as the amount of investment,
resources, and networks in any given locale that in turn
produces relationships of trust, mutual aid, cohesion, and
engagement [36]. Only two articles examined the rela-
tionship between social ties and networks and depression
outcomes [20, 21]. Three ways through which neighbor-
hood social ties affect depression outcomes were proposed.
First, social participation can influence the formation of
protective support networks, which in turn can improve
depression symptomatology [20]. Secondly, social partici-
pation can allow people to feel more control and agency in
affecting change to their living environments. A decrease
in sense of powerlessness can have positive impacts on
depression outcomes [20]. Finally, better social cohesion
can imbue a greater sense of trust, which can positively
impact the protective nature of friendships [21].
In three of the articles discussed above, a racial or ethnic
composition variable was used to form an aggregate
measure of neighborhood socioeconomic status or depri-
vation [20, 26, 28]. Indeed, race or neighborhood racial
composition is often measured as a proxy for socioeco-
nomic class; however, its functionality as a pathway
between neighborhood environments and depression out-
comes is poorly understood. One article specifically
observed the relationship between ethnic density and
depression outcomes [25]. The authors observed a statis-
tically significant protective effect for Hispanics living in
high-density Hispanic neighborhoods. Though Wight et al.
did not explain this observation, other authors have dis-
cussed the beneficial impacts of cultural proximity and
ethnic solidarity [37, 38].
Discussion
This realist review summarized the causal pathways link-
ing neighborhoods to depression that are currently pro-
posed in the literature. Eleven of the 14 papers found a
significant relationship between depression and at least one
aspect of neighborhood exposure. Neighborhood depriva-
tion, disadvantage, disorder, crime, and social ties

123
Soc Psychiatry Psychiatr Epidemiol (2014) 49:873–887
significantly affected depression outcomes in the papers
reviewed. Our review has shown that some of the proposed
modifiable pathways linking the latter concepts to depres-
sion outcomes are the following: (1) the level of neigh-
borhood-based stress that is placed on individuals; (2) the
formation and strength of protective and supportive social
networks; (3) the level of resiliency to negative affectivity
and stress; (4) the perceptions of the esthetic and form of
residential space; and (5) the sense of control and agency in
place of residence. The first three of these proposed path-
ways fit within the existing theories that neighborhoods act
as stressors and affect protective social ties [9, 11]. These
theories suggest that stress is a negative psychological
reaction to a stressor, and in turn leads to activation of the
biological stress response [39]—a response that is associ-
ated with worsening depressive symptoms [40]. Previous
literature has described the effects of chronic exposure to
everyday realities of pollution, noise, street lighting or lack
thereof, crime, vandalism, or hate speech and discrimina-
tion [10, 41]. The chronicity and simultaneity of exposures
to potential residential stressors is thought to mediate the
relationship between neighborhood form and depressive
symptoms [11]. Juxtaposed to this potential mediator of
stress is the pathway of resiliency. Resiliency is defined as
‘‘a construct representing positive adaptation despite
adversity’’ [42]. It is a marker of an individual’s capacity to
cope with stressors. In the context of neighborhoods, it is
possible that if neighborhoods offer supportive services,
recreational spaces, or any other opportunities for self-care,
health promotion or the development of protective social
support networks, negative affective symptoms can be
alleviated [23, 26]. This proposed mechanism remains to
be tested in future longitudinal research. The third pro-
posed pathway complements the former two; supportive
networks can aid in coping with stressors by promoting
relationships of support and care. Indeed, neighborhoods
are the sites of chronic exposure to potentially protective
social connections, which can decrease feelings of social
isolation, mediate coping behavior, and alleviate depres-
sive symptoms [43].
Compared to the first three pathways noted, the last two
proposed pathways mentioned above are extraneous to
existing epidemiological theories about the relationships
between neighborhoods and depression. Perceptions of
esthetics and sense of control are both associated with
affectivity [44], but they are not discussed within existing
stress or neighborhood social network theories [9, 11].
Perceptions of ecological stressors are directly informed by
personality traits, mood, personal history, cultural norms,
and demographics such as age, and coping skills [45], and
they can mediate the stress pathway between stressors and
stress response [39]. However, to date very little research
has tested the relationship between perceptions of
885
neighborhood-based stress and affectivity, or examined
how perceptions of neighborhood environments can be
modified to improve mental health outcomes. We recom-
mend an examination of this proposed causal pathways in
future research. Furthermore, though the themes of agency
and control have been explored in other fields of epide-
miological inquiry, such as workplace mental health
research [46], they have rarely been studied in the context
of neighborhoods of residence. Yet, these themes were
evoked in several of the studies reviewed [23, 30]. The loss
of sense of control accompanied by the witnessing of dis-
orderly events or behaviors at a neighborhood-level can
impact individuals’ responses to stressors and impact their
mental health outcomes [47]. The pathway of sense of
control should also be examined in future research.
Strengths and limitations
The wide range of sample population sizes, research fol-
low-up times, and heterogeneous tests for depression
symptoms reduce comparability of studies to some degree.
In terms of neighborhood-level exposures examined, there
was a lack of studies examining the relationship between
ethnic composition and depression outcomes. It is impor-
tant to recognize that ethnic composition can have varying
effects and meanings for different populations, depending
on their demographic, socio-political, cultural, economic,
and historical contexts [48]. Future longitudinal, place-
based research is needed to test the mechanisms linking
race, ethnicity, and depression at a neighborhood level for
both minority and non-minority communities. There was,
furthermore, a large amount of heterogeneity between
studies in relation to the control of confounders. It could be
particularly important for future research to systematically
account for variables that are relevant to the specific out-
come of depression, especially baseline depression symp-
toms [6, 49].
There was agreement among the articles on the signifi-
cant associations between depression and neighborhood
deprivation, social capital, instability, and disorder. These
results are comparable to those found in other reviews on
this topic [11–14], which observed similar associations
between facets of neighborhoods and depression outcomes
in the literature they reviewed. However, none of these
reviews specifically examined the causal pathways linking
neighborhood attributes to depression outcomes in a sys-
tematic, reproducible manner. Many of them reviewed
cross-sectional studies that could not make conclusions on
the causal relationship between neighborhoods and
depression outcomes. Among the articles studied, there was
a strong amount of overlap between the proposed causal
mechanisms; perceptions and experience of stress, support
networks, resiliency, and positive affectivity were
123
886
recurring themes in the discussions of articles reviewed.
Several studies used these themes as springboards for
recommending future areas of research and intervention.
Proposed solutions include: investment in community
organizations to strengthen neighborhood-level social ties;
improvement of social service and resource provision
within deprived neighborhoods to offer support to vulner-
able individuals and families; and change of the esthetic or
physical quality of neighborhoods through community
clean-ups, vandalism control strategies, and garbage col-
lection. These strategies, and the pathways they aim to
modify, remain to be fully tested—either through an
examination of natural experiments or community-research
partnerships in intervention design. Future research also
requires a more systematic use of longitudinal design,
relevant control variables, and a diversity of neighborhood-
level measures that account both for the physical and social
environment.
Conclusion
Neighborhoods can affect depression outcomes through
environmental disorder, crime, social ties, and deprivation-
related stressors. It is hypothesized that these aspects of
neighborhoods affect depression outcomes through indi-
vidual perceptions, feelings, and emotions in both positive
and negative ways. Future research is needed to explore
these pathways further. Though several studies made brief
suggestions for future neighborhood-level interventions
aimed at improving affective resiliency, these cursory
recommendations indicate the lack of policy-readiness
within the body of the literature surveyed. It remains
unclear, for example, how to improve social ties within a
community. It will be important for future research to both
develop a more thorough explanation of the ways in which
interventions can be designed, and systematically test the
mental health effects of these neighborhood-level
interventions.
Acknowledgments Alexandra Blair receives funding through Dr.
Norbert Schmitz’s Canadian Institute for Health Research Operating
Grant MOP 106514 (Neighborhood characteristics and depression
SEC 117118), and through a Master’s Award from the Fonds de la
recherche en santé du Québec (FRSQ Dossier 28229).
Conflict of interest On behalf of all authors, the corresponding
author states that there is no conflict of interest.
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