Hong Kong has been host to escalating social unrest since 2014; however, tensions peaked in June 2019, when legislators introduced proposal to allow criminal suspects in Hong Kong to be extradited to mainland China. Though physical injuries resulting from the ensuing protests have been documented, researchers found that there was also a substantial increase in rates of depressive symptoms, probable depression, and suspected post-traumatic stress disorder over a 10-year period among civilians in Hong Kong, according to study results published in The Lancet.

The population sample used in the study was drawn from the FAMILY Cohort, comprising adults from Hong Kong who were assessed for physical, mental, and social wellbeing at the household, neighborhood, and individual levels at 9 timepoints starting in 2009. The Patient Health Questionnaire-9 (score ≥10) and PTSD Checklist-Civilian Version (score ≥14) were used to measure probable depression and suspected PTSD, respectively. Direct exposure to traumatic events associated with social unrest since 2014 was also evaluated.

Assessments were conducted at baseline (waves 1 and 2), during the 2014 Occupy Central Movement (waves 3 and 4), post-Occupy Central (waves 5-7), and during the social unrest between 2019 and 2020 (waves 8 and 9). In analyses adjusted for pre-unrest physician-diagnosed anxiety and depression disorders, researchers examined the associations between probable depression and suspected PTSD. A random subset of 1213 to 1736 participants from waves 3 and 4 were followed after the 2 baseline surveys and included in the analysis. There were an estimated 0.9 million (95% CI, 0.8-1.0) participants in the rally held June 8, 2019. This number rose to 1.2 million (95% CI, 1.1-1.3) for the June 16, 2019, rally.

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In 2019, approximately 11.2% (95% CI, 9.8-12.7) of participants reported probable depression. This rate was substantially higher than the 1.9% (95% CI, 1.6-2.1) of participants between 2009 and 2014 and 6.5% (95% CI, 5.3-7.6) of participants in 2017 following the Occupy Central Movement and prior to the current unrest. An estimated 12.8% (95% CI, 11.2-14.4) of participants had suspected PTSD during wave 9. Overall, the combined prevalence of either probable depression or suspected PTSD was 21.8% (95% CI, 19.9-23.7). Additionally, the prevalence of depression and suspected PTSD comorbidity was 2.5% (95% CI, 1.8-3.3).

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There was a strong association between probable depression and suspected PTSD with spending ≥2 hours per day engaged in sociopolitical news via social media (adjusted odds ratio [aOR], 2·82; 95% CI, 1.30-6.15). Probable depression and suspected PTSD were not associated with age, sex, educational attainment, or household income. Lower PTSD scores were more often found in participants who were neutral or had no comment toward the extradition bill (aOR, 0.39; 95% CI, 0.19-0.80). Additionally, family support was associated with less probable depression (high: aOR, 0.14; 95% CI, 0.08-0.26).

Limitations of the study included the omission of participants <18 years of age and the lack of assessment for causal factors for suspected PTSD and probable depression.

According to the investigators, increases in probable depression and suspected PTSD among residents of Hong Kong may add an estimated 12% extra service requirement to the public sector queue. “It is a challenge for the government and service providers to see beyond clinical services as piecemeal solutions to population mental health concerns and take a multipronged and sustainable approach to tackle citizens’ needs on all fronts,” they wrote.

Disclosure: A study author declared affiliations. Please see the original reference for a full list of authors’ disclosures.


Ni MY, Yao XI, Leung KSM, et al. Depression and post-traumatic stress during major social unrest in Hong Kong: a 10-year prospective cohort study [published online January 9, 2020]. Lancet. doi: 10.1016/S0140-6736(19)33160-5.