A Need for Coordinated Mental Health and Psychosocial Care for Addressing Consequences of the Brutal War in Ukraine

Commentary

The war in Ukraine has resulted in unimaginable human suffering. More than 7 million refugees have been recorded in Europe alone (UNHCR) [1] and 7.1 million people have been internally displaced, representing one-third of the pre-war Ukrainian population [2]. Towns and cities are systematically razed to the ground; schools and hospitals are bombed and destroyed, among them psychiatric hospitals and social care homes [3]. The coming winter is bound to add to the human misery because of lack of social infrastructure e.g. heating and electricity. Despite the ongoing war, the generally unsafe situation and the increasing lack of resources, already 2.5 million persons returned to Ukraine [4]. What we are observing while working in and with Ukrainians since 2014 is the strong resilience, social cohesion and steady volunteerism. Despite these strengths-considering the ongoing severe mass experience of the war-mental health experts see the onset of deep disturbances in psychic equilibrium at individual, family and societal levels.

As Ryunosuke G, et al. [5] state, War has both immediate and long-term public health consequences: people can be killed or injured from violence itself, or can develop health problems stemming from the traumatic experience of war and the scarcity of access to adequate health care“ [5]. We could not precisely predict the trajectories of mental ill Commentary health conditions, but experiences and studies document the short- and longer-term sequel of such massive trauma. Here we are joining colleagues that call for prioritising mental health and psychosocial support (MHPSS) services in relief and recovery efforts in Ukraine [6]. It is evident that international professional communities should be mobilized to support the Ukrainian population, with a special attention to the needs of children and adolescents, ex-combatants, first respondents and victims of torture and rape. Mental health recovery should be an integral part of all support programs to the country and also central in all policies developed by Ukraine.

There are strong groups that already reach out to people-both within the country and in countries with refugee communities. For instance, UN IASC collected and translated all available publications on humanitarian mental health and psychosocial aid; European Society of Traumatic Stress Study (ESTSS) is conducting webinars for Ukrainian colleagues; Traumatic Stress Network of the European College of Neuropsychopharmacology coordinates meetings to address emerging hot topics [7]; European trauma specialists created the Mental Health Resources for Clinicians and Researchers [8] with available Ukrainian - language measures; etc.

The Federation Global Initiative on Psychiatry (FGIP), together with GIP-Tbilisi (Georgia) and the Czech National Institute of Mental Health, and with support from Cardiff University/UK and the Ukrainian Association of Psychiatrists, has developed a platform to provide guidance to both mental health professionals and the general population how to deal with the psychological consequences of the war. The platform operates on basis of a Ukrainian-language website  www. samopomi.ch  (initiated in late February 2022), and other social media channels (telegram, Instagram and Facebook that within the first six months had more than 40 million views) where short and concrete advise is provided on a daily basis. Capacity building courses for Ukrainian mental health specialists are also ongoing, improving quality of delivered services to various target groups, including first respondents.

Still there is a lack of external coordinating mechanism for mainstreaming offered help, identifying gaps and effectively complementing resources. International collaboration might indeed help to alleviate the impact of this unprecedented humanitarian crisis on mental wellbeing of Ukrainian people [9]. The external mental health aid could help local authorities in addressing extensive needs of their population in more efficient manner if these links could be systematically maintained and strengthened.

At this stage we could envisage 4 main types of strategies to help the affected people and also prevent the further deterioration of mental wellbeing for Ukrainian people:

• Providing evidence-based mental health and psychosocial support, adapted to the local context, considering ongoing trauma. Multi-layered, multi- disciplinary support system should be developed and be operational for coming years.
• Lowering barriers for accessing care for those who acknowledge their conditions, but do not seek help due to some reasons (i.e. the ill-health is„ normalised “as an expected outcome of the situation; or there is not easily available services nearby, etc.). The COVID-19 era boosted the development of the tele-mental health that proved to be effective [10, 11], thus online counselling and therapy could indeed play a vital role here.
• Devising outreach tactics/schemes to engage those who have mental health problems, but do not acknowledge them, therefore do not seek help (i.e. awareness rising, psychoeducational campaigning). This is one of the key public mental health problem-for example, Georgian IDPs, after 20 years of exposure to war trauma and uprooting, still exhibiting high rates of mental ill health conditions, but almost 30% of them did not report problems or seek care [12].
• Engaging those who are resilient or found inner strength and purpose to serve as focal points in communities (i.e. providing peer-support).

In all these policies and programs local mental health specialists should play a central role and be engaged in the processes with carefully and sensitively devised outside support. Even after the beginning of the war in 2014, resulting in the occupation of Crimea and parts of the Donbas, a national wide study demonstrated a large treatment gap for displaced persons, with 74% of respondents who likely required MHPSS care over the past 12 months not receiving it [13]. Over the past years Ukraine embarked on a much criticized and partially failed mental health reform program [14]. The risk of the current situation is that in the post-war period much emphasis will be placed on building back the old rather than moving forward with a carefully designed deinstitutionalization program that leads to a balanced mental health care system.