Social Unrest and Mental Health World Association of Social Psychiatry (WASP) Symposium at the American Psychiatric Association Annual Meeting 2021 Vincenzo Di Nicola, MPhil, MD, PhD, DFAPA, FCPA President, CASP; President-Elect, WASP Professor of Psychiatry, University of Montreal, QC Learning objectives To understand the association between social unrest and mental health … Specifically, to: Identify the social determinants of unrest Offer case examples of social unrest Review WHO prevalence estimates and overall mental health impacts of social unrest Discuss special considerations for children, youth & families Plan for presentation Social unrest and mental health: 30-45 minutes – V Di Nicola Social determinants: Triggers, aggravators & attenuators, circularity Case examples (evidence-based studies) Hong Kong Protests Black Lives Matter WHO Prevalence Estimates (data) Protests, Riots & Revolutions: A systematic review Children, Youth & Families: Special considerations

1. © 2021 American Psychiatric Association. All rights reserved.
SOCIAL UNREST AND MENTAL HEALTH
World Association of Social Psychiatry (WASP) Symposium
Vincenzo Di Nicola, MPhil, MD, PhD, DFAPA, FCPA
President, CASP; President-Elect, WASP
Professor of Psychiatry, University of Montreal, QC
vincenzodinicola@gmail.com

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DECLARATION OF INTERESTS
Professor of Psychiatry
• University of Montreal (academic salary), The George Washington University
• Harvard Program in Refugee Trauma, Harvard Medical School (stipend)
Offices
• AACAP, Diversity & Culture Committee
• APA, GMH & Hispanic Caucuses, Assembly Rep, Assembly Awards Cmte.
• CASP, President; WASP, President-Elect (stipend)
• SSPC, Board Member
Publishing: Aeon, Atropos, Durango, Fordham, Oxford, Springer, WW Norton & Co.

3. © 2021 American Psychiatric Association. All rights reserved.
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LEARNING OBJECTIVES
To understand the association between social unrest and
mental health …
Specifically, to:
• Identify the social determinants of unrest
• Offer case examples of social unrest
• Review WHO prevalence estimates and overall mental health
impacts of social unrest
• Discuss special considerations for children, youth & families

4. © 2021 American Psychiatric Association. All rights reserved.
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PLAN FOR PRESENTATION
Social unrest and mental health: 30-45 minutes – V Di Nicola
• Social determinants: Triggers, aggravators & attenuators, circularity
• Case examples (evidence-based studies)
• Hong Kong Protests
• Black Lives Matter
• WHO Prevalence Estimates (data)
• Protests, Riots & Revolutions: A systematic review
• Children, Youth & Families: Special considerations

5. INTRODUCTION
SOCIAL DETERMINANTS OF UNREST

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SOCIAL DETERMINANTS OF UNREST: POTENTIAL MODELS
• Social unrest: General dissatisfaction of a population group and the ways the
group brings attention to its problems
• Triggers (versus causes)
• Linear model of causality
• Aggravators & attenuators
• Amplifiers, perpetuating factors
• Dampers, protective factors
• Circularity (association)
• Associated effects, reciprocal factors, cascade model
• Circular causality

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SOCIAL DETERMINANTS OF UNREST: POTENTIAL MODELS
• Social unrest: General dissatisfaction of a population group and the ways
the group brings attention to its problems
• Social unrest can be studied via the social determinants of health research
platform (CSDH, 2008), or
• The related trauma model (Mollica, 2011; Di Nicola, 2018)
CSDH. Closing the Gap in a Generation: Health Equity Through Action On the Social Determinants of Health. Final Report of the
Commission on Social Determinants of Health. Geneva, Switzerland: World Health Organization; 2008.
Mollica RH (Ed), Textbook of Global Mental Health: Trauma and Recovery. Cambridge, MA: Harvard Program in Refugee
Trauma; 2011.
Di Nicola V. Two trauma communities: A philosophical archaeology of cultural and clinical trauma theories. In: PT Capretto & E
Boynton (Eds), Trauma and Transcendence: Limits in Theory and Prospects in Thinking. New York: Fordham University Press;
2018, pp. 17-52.

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SOCIAL DETERMINANTS OF UNREST
• Social unrest: General dissatisfaction of a population group and the ways
the group brings attention to its problems
• “Despite social unrest, protests, and violence being a global phenomenon
with an established history, it is indeed surprising that mental health issues
have not been assessed systematically” (Bhargava & Gupta, 2020)
• Stress the need for definitions and multi-displinary approach
Bhargava R, Gupta N. Social unrest and its impact on mental health. Indian J Soc Psychiatry 2020;36:3-4.
[serial online] 2020 [cited 2021 Feb 4];36:3-4. Available from: https://www.indjsp.org/text.asp?2020/36/1/3/280832

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SOCIAL DETERMINANTS OF UNREST
• Social, political, economic and environmental factors often in background
• “Causes” (cf. triggers, aggravators & attenuators, circularity) may include:
• Racial and ethnic conflicts
• examples: South Africa, Cambodia, Rwanda, Sri Lanka, Black
Lives Matter
• Political and language tensions
• examples: Quebec, Belgium, The Arab Spring, Hong Kong unrest
• Health crises, pandemics
• examples: AIDS, SARS, Ebola, Covid-19

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SOCIAL UNREST AND MENTAL HEALTH: CONSEQUENCES
• High prevalence in probable depression and suspected PTSD could result
in functional impairment for parenting and work, and substantial economic
costs
• This will have an impact on children and other dependents of affected adults
• This must be added to the direct impacts on children and youth themselves
• Impacts are potentially long-term and multi-generational
Di Nicola V. Family, psychosocial, and cultural determinants of health. In: E Sorel (Ed), 21st Century Global Mental Health.
Burlington, MA: Jones & Bartlett Learning; 2012, pp. 119-150.

11. SOCIAL UNREST AND MENTAL HEALTH
EVIDENCE-BASED CASE EXAMPLES

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PROTESTERS IN HONG KONG RALLYING AGAINST A NEW NATIONAL
SECURITY LAW ON JULY 1, 2020. PHOTO: AFP

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SOCIAL UNREST AND MENTAL HEALTH: CASE EXAMPLE – HONG KONG
• Major Social Unrest in Hong Kong: Prospective Cohort Study
• Heavy social media use (≥2 h per day) associated with depression risk
(aggravator)
• Political neutrality halved the risk of suspected PTSD (attenuator, damper)
• Family support mitigated against probable depression (attenuator, damper)
• Mental health burden increased service requirements by 12%
Ni MY, et al. Depression and post-traumatic stress during major social unrest in Hong Kong: a 10-year prospective cohort
study. The Lancet 2020, Volume 395, Issue 10220, 273 – 284. DOI:https://doi.org/10.1016/S0140-6736(19)33160-5

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SOCIAL UNREST AND MENTAL HEALTH: CASE EXAMPLE – HONG KONG
• Major Social Unrest in Hong Kong: Prospective Cohort Study
• Major mental health burden during the social unrest in Hong Kong
• Requires substantial increases in service surge capacity
(capacity building)
• Vigilance in recognizing possible mental health sequelae (prevention)
• Implications for service planning to better protect population mental
health globally (policy implications)
Ni MY, et al. Depression and post-traumatic stress during major social unrest in Hong Kong: a 10-year prospective cohort
study. The Lancet 2020, Volume 395, Issue 10220, 273 – 284. DOI:https://doi.org/10.1016/S0140-6736(19)33160-5

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PROTESTERS IN MINNEAPOLIS WHERE GEORGE FLOYD WAS KILLED AND
THE UNREST BEGAN SOURCE MONS.WIKIMEDIA.ORG/W/INDEX.PHP?CURID=90776413

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SOCIAL UNREST AND MENTAL HEALTH: CASE EXAMPLE – USA
• Social unrest impact on Black Americans’ mental health
• Black Americans are 20% more likely to experience "serious mental health
problems" than the general population (amplifier)
• Black youths who are exposed to violence are 25% more likely to experience
PTSD (aggravator, cascade of factors)
• After the video of George Floyd’s death in Minneapolis, US Census Bureau
data found that anxiety among Black Americans had increased by 26% and
depression increased by 22% (aggravator, cascade model)
ABC News, Sept 8, 2020

17. WHO PREVALENCE ESTIMATES
EPIDEMIOLOGICAL DATA

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SOCIAL UNREST AND MENTAL HEALTH: CONSEQUENCES
• WHO prevalence estimates of mental disorders in conflict settings
• Estimated prevalence of mental disorders: 22.1%
(depression, anxiety, post-traumatic stress disorder, bipolar disorder, and
schizophrenia) at any time in the conflict-affected populations assessed
• The burden of mental disorders is high in conflict-affected populations
• Given the large numbers of people in need and the humanitarian imperative to
reduce suffering, there is an urgent need to implement scalable mental health
interventions to address this burden
Charlson F, van Ommeren M, Flaxman A, Cornett J, Whiteford H, Saxena S. New WHO prevalence estimates of mental
disorders in conflict settings: a systematic review and meta-analysis. Lancet 2019; 394: 240–48.

19. PROTESTS, RIOTS & REVOLUTIONS
A SYSTEMATIC REVIEW

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PROTESTS, RIOTS & REVOLUTIONS: A SYSTEMATIC REVIEW
• 52 studies (n = 57,487 participants) from 20 countries/regions
• Prevalence of post-traumatic stress disorder: 4% to 41% in riot-affected areas (impacts)
• After major protests, the prevalence of probable major depression increased by 7%,
regardless of personal involvement in the protests, suggestive of community spillover effects
(cascade model, vicarious influences)
• Risk factors for poorer mental health included female sex, lower socioeconomic status,
exposure to violence, interpersonal conflicts, frequent social media use and lower resilience
and social support (amplifiers)
• Two studies suggested that collective actions may reduce depression and suicide, possibly
due to a collective cathartic experience and greater social cohesion within subpopulations
(attenuators, dampers)
Ni MY, Kim Y, McDowell I, Wong S, Qiu H, Wong IO, Galea S, Leung GM. Mental health during and after protests, riots and
revolutions: A systematic review. Aust N Z J Psychiatry. 2020 Mar;54(3):232-243. doi: 10.1177/0004867419899165. Epub
2020 Jan 28. PMID: 31989834.

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PROTESTS, RIOTS & REVOLUTIONS: A SYSTEMATIC REVIEW
Take away message – like a good news/bad news joke:
• First, the bad news: Vicarious (indirect) experiences just as likely to make an
impact (cascade model)
• Now, the good news: Collective/community action may have a positive impact
on mental health (attenuator, damper)*
* Cf. Barreto, et al.’s “Integrative Community Therapy”
Ni MY, Kim Y, McDowell I, Wong S, Qiu H, Wong IO, Galea S, Leung GM. Mental health during and after protests, riots and
revolutions: A systematic review. Aust N Z J Psychiatry. 2020 Mar;54(3):232-243. doi: 10.1177/0004867419899165. Epub
2020 Jan 28. PMID: 31989834.
Barreto AP, Filha MO, Silva MZ, Di Nicola V. Integrative Community Therapy in the Time of the New Coronavirus Pandemic
in Brazil and Latin America. Special Theme Issue: COVID-19 Pandemic and Social Psychiatry. World Social Psychiatry,
2020, 2(2): 103-5

22. CHILDREN, YOUTH & FAMILIES
SPECIAL CONSIDERATIONS

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DEVELOPMENTAL MODEL OF TRAUMA RISKS
• Age of the child
• Characteristics of neighbourhood
• Degree of community resources
• Amount and quality of support
• Experience of previous abuse
• Proximity to violent event
• Familiarity with victim or perpetrator

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DEVELOPMENTAL FACTORS THAT INFLUENCE A CHILD’S REACTION
• Appraisal of the threat
• Intra-psychic meaning attributed to event
• Emotional and cognitive means of coping
• Capacity to tolerate strong affects
• Ability to adjust to other’s life changes
• Ability to deal with loss and grieving

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EARLY ADVERSE EXPERIENCES
• “Derail” a child’s developmental trajectory
• Compromise a child’s ability to regulate affects
• Compromise early and future relationship problems
Felitti VJ, Anda RF. The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders and
sexual behavior: implications for health care. In: Lanius RA, et al. (Eds), The Impact of Early Trauma on Health and Disease:
The Hidden Epidemic. Cambridge: Cambridge Univ Press; 2010:77-87.

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EXPOSURE TO VIOLENCE
• Affects the way children think about themselves and the world
around them
• Affects the extent to which they view relationships as trustworthy and
dependable

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EFFECTS OF EXPOSURE TO VIOLENCE DEPEND ON:
• Characteristics of the violence itself
• Developmental phase of the child
• Family, community, and social context
• Response to violence exposure by family, school, community, and social
institutions

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MEANING OF VIOLENCE FOR THE CHILD INFLUENCED BY:
• The nature of the threat and the damage
• The child’s relationship with the victim or perpetrator
• Severity and duration of violence
• Proximity of violence to child
• Direct and vicariously-experienced violence and unrest are salient

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PROTECTIVE FACTORS FOR CHILDREN EXPOSED TO VIOLENCE
• A safe place
(home, safe haven in the neighbourhood)
• A supportive person (parent, relative, friend, teacher):
caregivers who can mediate a dangerous environment and
help regulate adverse experiences
• Support systems in the environment
• Resources to find alternative ways of coping
(adaptive temperament, intelligence)

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EFFECT OF UNREST & VIOLENCE ON CAREGIVERS
• Caregiver’s ability to listen may be limited
• Caregiver may not be able to hear child’s distress
• Caregiver may need to protect herself from feelings of vulnerability and
trauma
• Parent may have more trouble tolerating child’s resultant anxiety and
aggression

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DEVELOPMENTAL OUTCOMES OF ADVERSITY: PRACTICAL IMPACTS
• Greater risk for children who have not yet attained optimal potential
development
• Knowing developmental status is crucial to understanding the
experience of infant and childhood exposure to violence and trauma

32. CONCLUSIONS

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CONCLUSIONS
• Recognize social unrest and the threat of disruption with or without violence as a major
stressor impacting mental health in many ways – directly and indirectly (vicariously)
• Develop language to express the complexity of stressors and their impacts that includes
but goes beyond linear causal models to embrace aggravating and attenuating factors
• Models of circular causality, reciprocal influences, and cascading factors are available as
“mixed methods” for theorizing, research, practice, and policy-making
• There are evidence-based case examples and population estimates of the mental health
impacts with credible and durable data and clear implications
• Vulnerable populations need to be recognized and addressed with special
considerations, notably children, the elderly, and other dependent and needy groups
• Finally, don’t forget the caregivers, frontline workers, and all mental health and
social service workers who are subject to the same stressors and to “burnout”

34. © 2021 American Psychiatric Association. All rights reserved.
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REFERENCES
• Barreto AP, Filha MO, Silva MZ, Di Nicola V. Integrative Community Therapy in the Time of the New
Coronavirus Pandemic in Brazil and Latin America. Special Theme Issue: COVID-19 Pandemic and
Social Psychiatry. World Social Psychiatry, 2020, 2(2): 103-5
• Bhargava R, Gupta N. Social unrest and its impact on mental health. Indian J Soc Psychiatry
2020;36:3-4. [serial online] 2020 [cited 2021 Feb 4];36:3-4.
Available from: https://www.indjsp.org/text.asp?2020/36/1/3/280832
• Charlson F, van Ommeren M, Flaxman A, Cornett J, Whiteford H, Saxena S. New WHO prevalence
estimates of mental disorders in conflict settings: a systematic review and meta-analysis. Lancet
2019; 394: 240–48.
• CSDH. Closing the Gap in a Generation: Health Equity Through Action On the Social Determinants
of Health. Final Report of the Commission on Social Determinants of Health. Geneva, Switzerland:
World Health Organization; 2008.
• Di Nicola V. Family, psychosocial, and cultural determinants of health. In: E Sorel (Ed), 21st Century
Global Mental Health. Burlington, MA: Jones & Bartlett Learning; 2012, pp. 119-150.

35. © 2021 American Psychiatric Association. All rights reserved.
35
REFERENCES
• Di Nicola V. Two trauma communities: A philosophical archaeology of cultural and clinical trauma
theories. In: PT Capretto & E Boynton (Eds), Trauma and Transcendence: Limits in Theory and
Prospects in Thinking. New York: Fordham University Press; 2018, pp. 17-52.
• Felitti VJ, Anda RF. The relationship of adverse childhood experiences to adult medical disease,
psychiatric disorders and sexual behavior: implications for health care. In: Lanius RA, et al. (Eds),
The Impact of Early Trauma on Health and Disease: The Hidden Epidemic. Cambridge: Cambridge
Univ Press; 2010:77-87.
• Mollica RH (Ed), Textbook of Global Mental Health: Trauma and Recovery. Cambridge, MA: Harvard
Program in Refugee Trauma; 2011.
• Ni MY, et al. Depression and post-traumatic stress during major social unrest in Hong Kong: a 10-
year prospective cohort study. The Lancet, 2020, Volume 395, Issue 10220, 273 – 284.
DOI:https://doi.org/10.1016/S0140-6736(19)33160-5
• Ni MY, Kim Y, McDowell I, Wong S, Qiu H, Wong IO, Galea S, Leung GM. Mental health during and
after protests, riots and revolutions: A systematic review. Aust N Z J Psychiatry. 2020 Mar;54(3):232-
243. doi: 10.1177/0004867419899165. Epub 2020 Jan 28. PMID: 31989834.

36. © 2021 American Psychiatric Association. All rights reserved.
36
ACKNOWLEDGEMENTS
• APA Scientific Committee
• CASP & WASP Executive Committees
• Adalberto Barreto, Brazilian Association of Social Psychiatry (BASP)
• Richard Mollica & the Global Mental Health Faculty
Harvard Program in Refugee Trauma, Harvard Medical School