The cost of commotion: an analysis of the psychiatric sequelae of the 1969 Belfast riots

Mental health during and after protests, riots and revolutions: A systematic review

OBJECTIVES

Protests, riots and revolutions have long been a part of human history and are increasing globally, yet their impact on mental health remains largely unknown. We therefore systematically reviewed studies on collective actions and mental health.

METHOD

We searched PubMed, Web of Science, PsycINFO and CINAHL Plus for published studies from their inception until 1 January 2018. Study quality was rated using the Newcastle-Ottawa Scale.

RESULTS

We identified 52 studies (n = 57,487 participants) from 20 countries/regions. The prevalence of post-traumatic stress disorder ranged from 4% to 41% in riot-affected areas. Following a major protest, the prevalence of probable major depression increased by 7%, regardless of personal involvement in the protests, suggestive of community spillover effects. 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. Nevertheless, two studies suggested that collective actions may reduce depression and suicide, possibly due to a collective cathartic experience and greater social cohesion within subpopulations.

CONCLUSION

We present the first systematic review of collective actions and mental health, showing compelling evidence that protests even when nonviolent can be associated with adverse mental health outcomes. Health care professionals therefore need to be vigilant to the mental and psychological sequelae of protests, riots and revolutions. Further research on this emerging sociopolitical determinant of mental health is warranted.

Terrorism and post-traumatic stress disorder: a historical review

Terror is a psychological state. Historically, most studies of terrorism focused on its societal purpose and structural consequences rather than mental health effects. That emphasis began to change shortly before the Sept 11, 2001, terrorist attacks. A vast expansion of research into post-traumatic stress disorder accompanied revisions to the classification of mental health disorders. The effect of terrorist incidents on those people now deemed vulnerable, both directly and indirectly, was actively sought. However, a review of more than 400 research articles (mostly published after Sept 11) on the association between terrorism and mental health reached the largely overlooked conclusion that terrorism is not terrorising-at least not in a way that causes a greater than expected frequency of post-traumatic stress disorder than other traumatic events. This conclusion is surprising given the emphasis on the psychological effects of terrorism in political discourse, media commentary, contemporary culture, and academic inquiry. Authorities might prefer to encourage an interpretation of terrorist incidents that highlights fortitude and courage rather than psychological vulnerability.

Patterns in drug utilization--national and international aspects: psychoactive drugs 1966-80

Although the press claimed there were dramatic increases in the use of tranquillizers in Northern Ireland after the outbreak of civil unrest in 1969, our data, based on the computerised pricing system for drugs prescribed in the province, showed average annual increases of about 20% from 1966 to 1969, and 10% from 1970 to 1975, thereafter tranquillizer prescribing levels reached a plateau and declined between 1979 and 1980. Total psychotropic drug use also reached a peak in 1975, when about 12.5% of the adult population were estimated to have been receiving such a drug, and declined in the following 5 years. Benzodiazepines accounted for three-quarters of all psychotropic drugs and 98% of tranquillizers prescribed in 1980. Benzodiazepine tranquillizer prescribing has consistently been 20-30% higher than the rest of the United Kingdom, in contrast to hypnotic and antidepressant prescribing which has been consistently lower. The rate of increase in benzodiazepine tranquillizer prescribing over the decade from 1966 was greater than in other European countries, overtaking the level in Norway in 1972 and has since remained third to Iceland and Denmark. Some possible demographic and socioeconomic determinants of these trends are discussed. The prescribing of benzodiazepine hypnotics was almost entirely explained by these variables.

Residential segregation and health in Northern Ireland

Patterns of residential segregation in Northern Ireland reflect historic sectarian conflict as well as current animosities. A number of indices of segregation are examined in this paper and their relative merits in capturing localised societal divisions are discussed. The implications of such divisions on health as mediated through conflict-related stress are then considered. Costed datasets of hospital, community and anxiety/depression prescribing data have been assembled and attributed to local geographies. The association between geographical variations in these costs and levels of segregation was modelled using regression analysis. It was found that the level of segregation does not help to explain variations in costed utilisation of acute and elderly services but does explain variations in the costs of prescribing for anxiety and depression with controls for socio-economic deprivation included. Results in this paper would indicate that strategies to promote good relations in Northern Ireland have positive implications for mental health.

Medical Management of the Traumatic Consequences of Civil Unrest Incidents

In the context of this review, civil unrest is defined as disharmony, expressive dissatisfaction and/or disagreement between members of a community, which leads to a situation of competitive aggression that may find expression as disruption of organisation, conflicts, damage to property and injuries. Such a breakdown of harmonious relationships, which may result in property damage and human injuries that may be threatening to life, varies in magnitude from participation of a very few individuals up to the involvement of large crowds of people, which may evolve into a full-scale riot. It is the latter situation often involving demonstrators, opposing groups and law enforcement personnel that can result in multiple casualties and present a very significant challenge to the resources of local healthcare institutions. The causation of civil unrest incidents is multifactorial and has generic, specific and potentiating elements. With the current national and international societal, political and discriminatory problems, it is likely that civil unrest incidents on both small and large scales will continue to occur at a high and possibly increasing rate on a worldwide basis, and for these not infrequent incidents, the medical community should be in a state of informed preparation. The circumstances of civil unrest incidents are very variable with respect to causation, overall magnitude, frequency, timing, geographical location, numbers of persons involved, demographics of participants, influence of extremists, confrontation with opposing groups and control measures used by law enforcement agencies. Methods used by police and security forces for the control of civil unrest incidents, if advanced negotiations with organisers and verbal warnings have failed, fall basically into two categories: physical and chemical measures. Physical methods include restraint holds, truncheons, batons, mounted horses, projectiles (such as bean bags, plastic and rubber bullets), water cannons, tasers and (rarely) live ammunition. All of these physical measures are associated with pain and immobilisation, and there is a high potential for soft tissue and bone injuries. Some of the more severe physical methods, including plastic and rubber bullets, may cause lethal injuries. The basis for using chemicals in civil unrest incidents is that they cause distraction, transient harassment and incapacitation, temporary impairment of the conduct of coordinated tasks and cause a desire to vacate the area of unrest. Although screening smokes and malodors have sometimes been employed, the major group of chemicals used are peripheral chemosensory irritants (PCSIs), which reversibly interact with sensory nerve receptors in exposed skin and mucosal surfaces, resulting in the production of local uncomfortable sensations and associated reflexes. Major effects are on the eye, respiratory tract and (to a lesser degree) skin. Thus, the induced transient pain and discomfort in the eye, respiratory tract and skin, together with associated lacrimation, blepharospasm, rhinorrhoea, sialorrhoea, cough and breathing difficulties, produce temporary incapacitation and interference with the conduct of coordinated tasks, and form the basis for harassment of malefactors. Currently used peripheral chemosensory irritants are 1-chloroacetophenone, 2-chlorobenzylidene malononitrile, dibenz(b.f)-1,4-oxazepine, oleoresin capsicum and pelargonic acid vanillylamide. Depending on operational circumstances, irritants may be dispersed as a smoke, powder cloud, aerosol, vapour, or in solution; the mode of generation and dispersion of irritant can influence hazard. Brief acute exposure to chemosensory irritants produces effects that generally resolve within an hour, leaving no long-term sequelae. However, sustained exposure to high concentrations may produce tissue injury, notably to the eye, respiratory tract and skin. With solutions of sensory irritants, other formulation constituents may enhance PCSI toxicity or introduce additional local and/or systemic toxicity. By the very circumstances of civil unrest incidents, injuries are inevitable, particularly when emotions are heightened and police and security forces have to resort to various chemical and/or physical means of control. Trauma may include slight to severe physical and/or chemical injuries, psychological problems and occasional deaths. Hospitals should be prepared for a wide range of casualties, and the fact that those seeking help will constitute a heterogeneous group, including wide age range, male, female, and individuals with pre-existing ill health. A major civil unrest incident necessitates that the local receiving hospital should be prepared and equipped for decontamination and triage processes. It is necessary to reassure patients who have been exposed to sensory irritants that the signs and symptoms are rapidly reversible, and do not result in long-term sequelae. With respect to chemical exposures, detailed evaluation should be given to possible ocular, cutaneous, respiratory and gastrointestinal effects. Also, exposure to chemosensory irritants results in transient increases in blood pressure, bradycardia and increased intraocular pressure. This indicates that those with cardiovascular diseases and glaucoma may be at increased risk for the development of complications. This article details the pharmacological, toxicological and clinical effects of chemicals used in civil disturbance control and discusses the management of contaminated individuals. Additionally, the potential for adverse effects from delivery systems and other physical restraint procedures is summarised. Due to the emergency and specialised circumstances and conditions of a civil unrest incident, there is a clear need for advanced planning by healthcare institutions in the event that such an incident occurs in their catchment area. This should include ensuring a good information base, preparations for medical and support staff readiness, and availability of required equipment and medications. Ideally, planning, administration and coordination should be undertaken at both local (regional) and central (governmental) centres. Regional centres should have responsibilities for education, training, ensuring facilities and staffing are appropriate, and that adequate equipment and medicines are available. There should be cooperative interactions and communications with local police and other emergency services. Centrally directed functions should include ensuring adequacy of the information base, coordinating activities and agreeing approaches between the regional centres, and periodic audits of regional centres with respect to the staffing, facility, equipment and training needs. Also, there is a need for most countries to introduce detailed guidelines and formal (regulatory) schemes for the assessment of the safety-in-use of chemicals and the delivery systems that are to be used against heterogeneous human populations for the control of civil unrest incidents. Such regulatory approval schemes should also cover advisory functions for safe use and any required restrictions.

Mental health in Northern Ireland: have "the Troubles" made it worse?

OBJECTIVES

To measure the effects of the civil unrest (the Troubles) on the mental health of the general population of Northern Ireland.

DESIGN

A secondary analysis of a nationally representative population survey conducted in 1997.

SETTING

Northern Ireland.

METHODS

This is an analysis of the 1694 respondents (aged 16-64) who had their mental health assessed using the 12 question version of the General Health Questionnaire (GHQ). The effects of the Troubles was based on the responses to two survey questions; one asking about the impact on respondent's area; the second about the impact on the life of the respondent or their family. To model simultaneous effects, multiple logistic regression models were constructed with GHQ case as the dependent variable, the impact of the Troubles questions as independent variables, and the demographic, socioeconomic, and health related factors as covariates.

RESULTS

21.3% (361) of respondents said that the Troubles had either "quite a bit" or "a lot" of impact on their lives or the lives of their families and 25.1% (418) reported a similar impact on their area of residence. The likelihood of psychological morbidity increased the greater the extent to which the Troubles affected the respondent's area or life, the association being stronger for the second factor. Neither demographic nor socioeconomic factors significantly diminished this relation although adjusting for health related factors did attenuate the magnitude of the odd ratios especially for the effects of the Troubles on area of residence.

CONCLUSION

It is probable that mental health of the population of Northern Ireland has been significantly affected by the Troubles. Whether this is attributable to the violence in itself or to other aspects of the Troubles is unclear and whether any additional inputs from psychiatric services are needed requires further study.

Ideological commitment, experience of conflict and adjustment in Northern Irish adolescents

This study aims to assess young people's overall experience of political conflict, as well as the extent of these experiences in relation to gender, religious affiliation and residential location (high or low conflict). Second, this study assesses the impact that young people's ideological commitment and experiences of the conflict have on their self-esteem and mental health. A sample of 96 Protestant and Catholic young people (mean age 15.2), drawn from four schools in two areas of Northern Ireland, completed self-report measures of self-esteem, mental health, ideological commitment and experience of conflict. The areas differed substantially in the amount of violence they had experienced. The results indicated that young people's experience of violence varied in relation to the town in which they lived. Boys' experience of violence appeared to be related to their religious affiliation. Experience of conflict and ideological commitment, two attributes that were positively related, interacted to predict both mental health and self-esteem. The importance of ideological commitment to our understanding of the impact of political conflict on young people is discussed.

Gender trends in occupancy rates in mental health beds in Northern Ireland

Based on census material from 1926 to 1991, this study focuses on gender differences in occupancy rates in mental health beds in Northern Ireland. More specifically, using two sets of research literature--the relationships between war and mental health and gender and mental health respectively--it explores changing patterns in bed occupancy in terms of both gender and age differences within this society. The results suggest that, although men and women no longer vary in terms of their overall occupancy rates within mental health facilities in Northern Ireland, within their respective male and female sub-populations, however, some notable age-specific differences have now emerged. Since 1981, whereas increases in mental health bed occupancy among women have been exclusively confined to the old (65 years or older), among males, it is the very young, specifically men aged 15-24 years, who have demonstrated the most dramatic rise in bed usage. It is important to note, however, that these age-specific gender increases cannot be accounted for by demographic changes in the general population. The authors suggest that, at least as far as men are concerned, the increasing pattern of vulnerability among the young may be attributed to the impact of changing definitions of mental disorder rather than to the effect of political violence on mental health. It is to this group of individuals--the cohort of men born since the outbreak of civil unrest in Northern Ireland in 1969--that future research should be directed.

Psychological functioning and substance abuse before and after the 1992 Los Angeles riot in a community sample of women

An ongoing study of interventions designed to increase nontraditional social supports among women at high risk for HIV infection was in the field during the 1992 Los Angeles riot in those neighborhoods most affected by the urban unrest. Using data from structured interviews, the psychosocial characteristics, drug abuse patterns, and distress levels among the women who were recruited for the project in the six months before and after the riot were examined. While substance abuse levels among participants did not increase or decrease as a function of the riot, there were a smaller number of social supports and marginally greater levels of already high psychological distress. Women in the community specifically mentioned a lack of social supports from counselors available in affected areas after the riot. An ethnographic analysis discusses the experience of the participants in the community during the same period of time. Problems in social supports are pointed out. The results are discussed in terms of a general theory of service provision by increasing nontraditional social supports, especially immediately after a major cataclysm.

Patterns of service utilisation following the 1989 Newcastle earthquake: findings from phase 1 of the Quake Impact Study

A screening questionnaire was distributed to 5,000 adult members of the community six months after the 1989 Newcastle earthquake, with a response rate of 63 per cent (n = 3,007). The mean age of respondents was 46.7 years and 58 per cent were female. Subjects' earthquake experiences were rated in terms of weighted indices of exposure to threat and disruption. Psychological morbidity was measured using the General Health Questionnaire and the Impact of Event Scale. Subjects were asked to indicate which of a range of general and disaster-related support services they had used in dealing with the stressful effects of the earthquake. It was estimated that 21.3 per cent of the adult population used general and/or disaster-related support services. Users of these services reported greater exposure to threat and/or disruption and had higher levels of psychological distress than nonusers. However, a high level of use of general services and reliance on medical services were related more to psychological morbidity than degree of exposure to earthquake-related events. Overall, the Newcastle community's needs for assistance in the aftermath of the earthquake were effectively absorbed by the existing support services and the resources marshalled to supplement those services. Individuals and organisations mobilised following natural disasters need to be strengthened by enhancing the capacity of support service workers to identify and manage psychological distress in their clients.

Derivation and implications of MMPI cluster groups in clinically depressed inpatient females

The purpose of this study was to subclassify clinically depressed patients based on a cluster-analytic examination of the MMPI. Subjects were 79 female inpatients with major depression. A cluster analysis of the MMPI validity and clinical scales resulted in three clusters labeled psychotic (287 MMPI profile), hostile (24 MMPI profile), and histrionic (32 MMPI profile) depression. The psychotic group exhibited the greatest depression as measured by the Beck Depression Inventory (BDI). The psychotic and hostile groups, however, did not differ on other associated aspects of depression, such as negative cognitions, nonassertiveness, or personality style. The hostile group reported the fewest physical difficulties and the most excessive alcohol use. The groups, however, did not differ on other aspects of depression history or presentation such as family history of depression or previous hospitalizations. A repeated measures ANOVA for the three cluster groups on the BDI at admission, discharge, and 6 months after discharge indicated that all groups showed improvement at discharge but that only the hostile depressive group continued to show improvement at the 6-month follow-up.

Mental illness in Northern Ireland. A comparison with Scotland and England

First and all admissions to psychiatric hospitals and units during 1981 were obtained from the DHSS in England, Scotland and Northern Ireland. Age and sex standardized rates were calculated for each country. Possible reasons for observed rate differences are discussed. Whilst overall high rates of admissions in Northern Ireland are most likely attributable to provision and use of beds, these factors may not entirely account for high rates of admissions for neurotic disorder, particularly among males.

The consequences for preschool children of a parent's detention: a preliminary South African clinical study of caregivers' reports

Semi-structured interviews on the consequences for preschool children of a parent's detention were conducted with primary caregivers of 19 South African children aged 2-6 yrs. Caregivers reported emotional problems, separation anxiety and fear as well as physical problems, aggression, secondary enuresis and developmental difficulties. Adaptive mechanisms are described. Fantasies focused chiefly on children's images of the detention situation, and on plans to alter current circumstances. Children who felt secure in the environment seemed generally to adjust better to the experience, particularly in the long term.

Psychiatric aspects of terrorist violence: Northern Ireland 1969-1987

For 18 years, Northern Ireland has suffered a changing pattern of civil disorder. Early years were marked by widespread sectarian rioting, shootings, and bombings, which heightened community tension and caused much social and commercial disruption. However, in recent years, terrorist organisations have been more selective in their acts of violence. There are methodological difficulties in assessing the psychological impact of civil disorder and terrorism. But, as well as can be judged from community surveys, hospital admissions and referral data, psychotropic drug usage, suicide and attempted suicide rates, and from assessment of the actual victims of violence, society has not 'broken down' nor has the impact been judged considerable. Possible explanations are discussed.

The impact of political violence on mild psychiatric morbidity in northern Ireland

Evidence concerning the impact of the violence in Northern Ireland on psychiatric morbidity is limited to studies examining admission rates and psychotropic drug prescribing rates; their results varied from suggesting no effect to indicating that greater levels of violence are actually equated with higher levels of mental health. The present study is the first to use a community sample, in which respondents (797) from two towns, which have experienced contrasting levels of violence over the last ten years, completed the 30-item version of the General Health Questionnaire (GHQ), and also indicated their perception of the level of violence in their area and how safe they felt this was to live in. Those who lived in the more violent town scored higher on the GHQ, as did women compared to men and those who perceived that their area had experienced more violence. There was also a two-way interaction, such that the small number of people, who perceived much violence in their area and who also lived in the more violent town, scored more highly on the GHQ. It is possible that the majority of people in Northern Ireland deal effectively with stress generated by the political violence, but do so by denying the existence of this violence around them.

Psychotropic drug use in Northern Ireland 1966-80: prescribing trends, inter- and intra-regional comparisons and relationship to demographic and socioeconomic variables

A study of psychotropic drug prescribing, derived from the computerized pricing data in Northern Ireland from 1966, showed that the use of these drugs reached a peak in 1975, when about 12.5% of the adult population were estimated to have been receiving them, and declined in the following 5 years. Benzodioazepines accounted for three-quarters of all psychotropic drugs prescribed in 1980. Benzodiazepine tranquillizer prescribing was consistently 20-30% higher than in the rest of the United Kingdom, in contrast to hypnotic and antidepressant prescribing which has been consistently lower. The rate of increase in benzodiazepine tranquillizer prescribing was greater than in other European countries, but the level remains lower than in Iceland and Denmark. The influence of a number of demographic and socioeconomic variables was studied in an intra-regional analysis of the 1978 data for the 17 health districts in the province, using multivariate and multiple regression statistics. The prescribing of benzodiazepine hypnotics was almost entirely accounted for by the proportion of elderly (over 65 years) and women aged 45-59 years: neuroleptic prescribing was largely a function of factors associated with rural areas (overcrowding and unemployment) and the proportion of elderly; but neither tranquillizer, antidepressant, barbiturate hypnotic nor psychostimulant prescribing were satisfactorily explained by these variables.

Psychiatric sequelae to a civil disturbance

On 13 May 1969, intercommunal rioting broke out between the Malay and Chinese sections of the population of Kuala Lumpur and continued for a full week. Subsequently a state of emergency was proclaimed, parliamentary government was suspended and the country was placed under the rule of the National Operations Council (a council of top ministers, civil servants and the chiefs of the armed forces and police) which ruled by edict.

Depressive illness and aggression in Belfast

An inverse relation has been suggested between the incidence of depressive illness and the opportunity to externalize aggressive behaviour. The riot situation in Belfast in 1969-70 provided an opportunity to study this hypothesis. The incidences of depressive illness in the city and a neighbouring peaceful rural county were compared over a number of years. Data regarding age, sex, area of the city, and type of depression were obtained. The city was divided into areas and four of these were studied in detail. Similar data were obtained for persons showing aggressive behaviour.There was a significant decrease in depressive illness in Belfast in both sexes and all age groups. This was more pronounced in males but the decrease was confined to those in social groups IV and V. The decrease was more significant in riot areas. The suicide rate fell by almost 50% and there was a noticeable increase in the rates of homicide and crimes of violence. In contrast the rural county showed a sharp increase in male depressives.