The 2019 Hong Kong protests, also known as the Anti-Extradition Law Amendment Bill (or Anti-ELAB) movement, are an ongoing series of demonstrations in Hong Kong that were triggered by the introduction of the Fugitives Offenders amendment bill by the Hong Kong Government. If enacted, the bill would allow local authorities to detain and extradite criminal fugitives who are wanted in territories with which Hong Kong does not currently have extradition agreements, including Taiwan and Mainland China.

This aroused concern and suspicion that the bill would subject Hong Kong residents and visitors to the Mainland Chinese jurisdiction and legal systems, undermining Hong Kong’s autonomy and its civil liberties. At the time of this writing, there continue to be serious confrontations between the police and protesters, so much so that many major highways linking key areas of Hong Kong are blocked by barricades and the city’s Mass Transit Railway ceases regular service after 10 pm daily.

Negative impact of social unrest on mental health

This unprecedented political crisis affects everyone in Hong Kong. There has been a deterioration in mental health among the people to its worst level in 8 years, 41% of survey respondents said that their mental health is being negatively affected by social unrest.1 Although the exact causes need to be elucidated by additional research studies, there are several possible reasons that explain how and why people are affected adversely by the recent social unrest.

1) Both protesters and the police are directly involved in repeated and major violent conflicts.

2) People working in areas where major confrontations between police and protesters happen are exposed to violent scenes or subjected to physical violence.

3) Families and friends disintegrate because of different political views, which results in shrunken social roles and support network.

4) Because of the socioeconomic downturn associated with traffic chaos and uncertainty among investors, many people who work in the service and tourist industries are facing salary cuts and unemployment.

Financial difficulties understandably lead to detrimental effects on housing, education, and social problems. These socioeconomic adversities are exacerbating factors for a variety of mental health problems. Moreover, there has been a negative impact on mental health caused by exposure to vivid traumatic scenes depicted in television and social media.2 A preference for visual processing may be positively related to intrusion frequency of traumatic images even when only hearing about a traumatic event.3 Therefore, the negative effect of regular and intensive exposure to vivid videos and news of street violence can affect the mental health of people even when not directly exposed to the traumatic event.

Major impact on existing mental health problems

Anecdotal accounts from various mental health facilities indicate an increase of self-reports of acute stress-disorder–like symptoms. Patients with established mental health problems report traumatic flashbacks, hypervigilance, and dissociative experiences as a consequence of regular exposure to newsfeeds and online videos of street violence.

In response to these common complaints among patients, the Hong Kong College of Psychiatrists released a set of mental wellbeing tips for dissemination to schools, social welfare agencies, community centers, health clinics, and hospitals. These tips include advice on restrictions of social media use, better sleep hygiene, balancing different roles and commitments, maintaining normal routines as much as possible, and sustaining existing social networks. With an aim of encouraging news media outlets to provide precise news reports, the College has held workshops with journalists to educate them on the symptoms of stress-related disorders and the negative impact of excessive exposure to news and videos.

A mental health tsunami in Hong Kong

Preliminary territory-wide service statistics data show no obvious surge in the number of people presenting to public mental health services for new onset mental health issues. Although stigma toward mental health and lack of mental health literacy about stress-related disorders may explain this lack of a major surge in service demand, there may be other causes.

The trajectory of stress response is highly complex. An Australian study showed that of those with PTSD onset 12 months after trauma, only 37% had symptoms at 3 months with worsening of symptoms with time.4 This phenomenon is more common among military personnel than civilian trauma survivors.5 The confrontation between protestors and police officers, as well as other responders such as journalists, emergency medical staff, firefighters, and other volunteers and counselors are not unlike military personnel being deployed to a frontline war zone. Thus, the mental health tsunami might only hit the shore weeks or months after social unrest has died down.

Apart from the possible delay in onset of stress-related disorders, there may be a delay in presentation to public mental health systems for political reasons. In past months, there have been rumors among social media and e-news that public health care workers deliberately disclosed personal information of injured protesters seeking help in public hospitals to the police force. Such personal information could be used by the police to facilitate immediate arrest and removal of individuals from hospitals to criminal detention centers.

Conversely, there have been sit-in protests among health professionals in major public hospitals in Hong Kong condemning the use of excessive violence toward the protestors by police officers. As such, many police officers are skeptical about whether they will receive proper care from health professionals. There have been sporadic news reports of confrontations between health care workers and police officers in the emergency departments of public hospitals.

Protestors and police officers also have disclosed to their trusted health care providers that they are concerned that their mental health records will be accessed by legal authorities to their disadvantage. Under the Hong Kong Personal Data Privacy Ordinance, personal data will be released to law courts upon receipt of court orders by the public health authority, even in the absence of informed patient consent. If the speculations are true, the mental health problems experienced by protestors and police will have a delay in illness presentation and wil not be obvious until mental health emergencies set in.

Because of the high costs associated with private mental health care, only a small proportion of vulnerable groups will be able to receive care in a timely manner. The results are dire with a likely increase of acute presentations of mental health emergency crises-including suicide.

Implementing mental health relief actions

Formal and informal mental health care support is available to people affected by current social unrest. Volunteer social workers, counselors, psychologists, and doctors are providing acute psychological support to protestors.

As of the writing of this article, there are no data either on the number of or the expertise and professional background of these underground mental health care workers. Nor is there an official number of persons with mental health problems. One report indicates that more than 35% have symptoms suggestive of PTSD. (Hong Kong Economic Journal, November 1, 2019).

Apart from this informal care network, the Federation of Social Services launched a program in October 2019 whereby people with mental health problems are referred to free psychosocial intervention sessions. The available therapies range from traditional Chinese medicine to clinical psychological services. Workshops and talks have been organized to educate relevant stakeholders in managing conflicts arising from political differences in schools, at workplaces, and within families.

In response to the unmet mental health needs among people from different walks of life, the Hong Kong College of Psychiatrists launched a systematic and multi-level mental health intiative, the Care4ALL Programme. Its goal is to promote mental health resilience; knowledge posters, videos, and pamphlets have been created. The objective is to increase knowledge and skills among relevant community stakeholders in early identification and referral of people with mental health problems.

The College has more than 80 volunteer psychiatric fellows who provide psychiatric care at low cost for a limited number of sessions. Through a collaboration with the Division of Clinical Psychology, the Hong Kong Psychological Society and New Life Psychiatric Association, eligible patients receive a number of protocol-driven psychological interventions in parallel with the care offered by the volunteer psychiatrists.

This program provides a new model of mental health care that addresses the usual cost barrier associated with private psychiatric care and concerns of privacy breaches and perceived discrimination by public mental health workers. The program has received widespread media coverage and has been highly regarded by the Food and Health Bureau and Hospital Authority of Hong Kong.

Every cloud has a silver lining

Although there is ongoing political crisis in Hong Kong, many people are confident that the crisis will resolve eventually and bring about fundamental changes in the political and social landscapes. However, the mental health crisis may last for decades and affect the next two generations.

Although severe trauma can lead to stress-related disorders, the course and outcome of stress symptoms are highly variable and largely depend on posttrauma support and care.4 The College will continue to take an active role in mobilizing mental health capacities in Hong Kong. It will also endeavor to assume an advocacy role to help the government develop social policies and rebuild a strong social network in schools, within families, and in workplaces. The goal is a tolerant and compassionate society that respects and values diversities in all aspects of life.