In the Journals

Mental health burden of Hong Kong protests highlights risks of social unrest

The ongoing social unrest in Hong Kong has led to a major mental health burden among the city’s residents, many of whom are experiencing high levels of depression and PTSD, according to study findings published in The Lancet.

“With social unrest rising around the world, including in major cities such as Barcelona, Delhi, Paris and Santiago in 2019, the issue of how social unrest impacts population mental health is of great public-health importance,” Michael Ni, MD, of the School of Public Health at The University of Hong Kong, said in a press release.

According to Ni and colleagues, the movement in Hong Kong that began in 2019 differs from the previous instance of largescale social unrest in that it has seen escalating levels of violence involving assault, arson and vandalism across 7 months. Further, the authorities have deployed live ammunition, rubber bullets and tear gas. The 2014 movement, known as Occupy Central Movement, was a largely nonviolent civil disobedience campaign lasting for 79 days.

Although direct physical injuries have been reported in the current protests, their potential impact on the population mental health has not yet been reported, the researchers noted. To determine this impact, the researchers analyzed data from individuals aged 18 years or older who were included in the FAMILY Cohort — a prospective population-based study of social, physical and mental well-being at the individual, household and neighborhood levels in Hong Kong. Participants were assessed at nine timepoints beginning in 2009. They used data from this cohort to assess the population mental health burden before, during and after major protests across 10 years and across nine successive waves of longitudinal data sets.

After analyzing data from more than 18,000 randomly sampled Hong Kong residents in two initial surveys, Ni and colleagues compared outcomes for this group with those of a representative sample of between 1,213 and 1,715 adults surveyed five times during and following the Occupy Central Movement. They also compared the outcomes between the 18,000 residents, and 1,600 to 1,736 adults surveyed two times during the 2019 social unrest.

The researchers found that 11.2% (95% CI, 9.8-12.7) of participants reported probable depression in 2019, compared with 1.9% (95% CI, 1.6-2.1) during 2009 to 2014 and 6.5% (95% CI, 5.3-7.6) following the Occupy Central Movement in 2017 and before the current unrest. The estimated prevalence of suspected PTSD in 2019 was 12.8% (95% CI, 11.2-14.4). Educational attainment, sex, age or household income were not associated with either outcome, but heavy social media use of 2 or more hours per day was associated with both. Although protest participation and political attitude were not associated with probable depression, residents who were neutral toward the extradition bill had approximately half the risk for suspected PTSD. The researchers estimated that mental health care providers should prepare for a potential 12% increase in demand for public sector services.

“Hong Kong is under-resourced to deal with this excess mental health burden,” Gabriel Leung, MD, of the School of Public Health at The University of Hong Kong, said in the release. “With only around half the per-capita psychiatry capacity of the UK, and pre-existing average public sector outpatient waiting times of up to 64 weeks, it is important that we enhance mental health and social care provision so that all those in need are able to access high-quality services.”

Study author Cynthia Yau, MSc, of the School of Public Health at The University of Hong Kong, underscored the global implications of these findings.

“We hope our study will alert health care professionals, service planners and policy makers to the need for mental health and psychosocial support during and after widespread unrest to better protect population mental health globally,” Yau said.

In a related editorial, Xue Yang, PhD, and Winnie W. S. Mak, PhD, both of The Chinese University of Hong Kong, noted the importance of ending the ongoing social unrest for lessening the mental health burden on Hong Kong residents.

“What is left unspoken are the structural and sociopolitical ways in which our society can respond to this crisis,” they wrote. “If the social situation and political climate in Hong Kong are left unchanged, the distress of citizens stemming from this social unrest cannot be completely addressed and healing cannot commence.” – by Joe Gramigna

Disclosures: Leung, Ni and Yau report no relevant financial disclosures. Mak reports a donation to The Chinese University of Hong Kong from the Jockey Club Charities Trust for a community project on an online mental health platform. Yang reports funding to her institution from the Jockey Club Charities Trust. Please see the study for all other authors’ relevant financial disclosures.

The ongoing social unrest in Hong Kong has led to a major mental health burden among the city’s residents, many of whom are experiencing high levels of depression and PTSD, according to study findings published in The Lancet.

“With social unrest rising around the world, including in major cities such as Barcelona, Delhi, Paris and Santiago in 2019, the issue of how social unrest impacts population mental health is of great public-health importance,” Michael Ni, MD, of the School of Public Health at The University of Hong Kong, said in a press release.

According to Ni and colleagues, the movement in Hong Kong that began in 2019 differs from the previous instance of largescale social unrest in that it has seen escalating levels of violence involving assault, arson and vandalism across 7 months. Further, the authorities have deployed live ammunition, rubber bullets and tear gas. The 2014 movement, known as Occupy Central Movement, was a largely nonviolent civil disobedience campaign lasting for 79 days.

Although direct physical injuries have been reported in the current protests, their potential impact on the population mental health has not yet been reported, the researchers noted. To determine this impact, the researchers analyzed data from individuals aged 18 years or older who were included in the FAMILY Cohort — a prospective population-based study of social, physical and mental well-being at the individual, household and neighborhood levels in Hong Kong. Participants were assessed at nine timepoints beginning in 2009. They used data from this cohort to assess the population mental health burden before, during and after major protests across 10 years and across nine successive waves of longitudinal data sets.

After analyzing data from more than 18,000 randomly sampled Hong Kong residents in two initial surveys, Ni and colleagues compared outcomes for this group with those of a representative sample of between 1,213 and 1,715 adults surveyed five times during and following the Occupy Central Movement. They also compared the outcomes between the 18,000 residents, and 1,600 to 1,736 adults surveyed two times during the 2019 social unrest.

The researchers found that 11.2% (95% CI, 9.8-12.7) of participants reported probable depression in 2019, compared with 1.9% (95% CI, 1.6-2.1) during 2009 to 2014 and 6.5% (95% CI, 5.3-7.6) following the Occupy Central Movement in 2017 and before the current unrest. The estimated prevalence of suspected PTSD in 2019 was 12.8% (95% CI, 11.2-14.4). Educational attainment, sex, age or household income were not associated with either outcome, but heavy social media use of 2 or more hours per day was associated with both. Although protest participation and political attitude were not associated with probable depression, residents who were neutral toward the extradition bill had approximately half the risk for suspected PTSD. The researchers estimated that mental health care providers should prepare for a potential 12% increase in demand for public sector services.

“Hong Kong is under-resourced to deal with this excess mental health burden,” Gabriel Leung, MD, of the School of Public Health at The University of Hong Kong, said in the release. “With only around half the per-capita psychiatry capacity of the UK, and pre-existing average public sector outpatient waiting times of up to 64 weeks, it is important that we enhance mental health and social care provision so that all those in need are able to access high-quality services.”

Study author Cynthia Yau, MSc, of the School of Public Health at The University of Hong Kong, underscored the global implications of these findings.

“We hope our study will alert health care professionals, service planners and policy makers to the need for mental health and psychosocial support during and after widespread unrest to better protect population mental health globally,” Yau said.

In a related editorial, Xue Yang, PhD, and Winnie W. S. Mak, PhD, both of The Chinese University of Hong Kong, noted the importance of ending the ongoing social unrest for lessening the mental health burden on Hong Kong residents.

“What is left unspoken are the structural and sociopolitical ways in which our society can respond to this crisis,” they wrote. “If the social situation and political climate in Hong Kong are left unchanged, the distress of citizens stemming from this social unrest cannot be completely addressed and healing cannot commence.” – by Joe Gramigna

Disclosures: Leung, Ni and Yau report no relevant financial disclosures. Mak reports a donation to The Chinese University of Hong Kong from the Jockey Club Charities Trust for a community project on an online mental health platform. Yang reports funding to her institution from the Jockey Club Charities Trust. Please see the study for all other authors’ relevant financial disclosures.