The psychological consequences of the Ukraine war: What we know, and what we have to learn

On 24th February 2022, Russian troops invaded Ukraine and launched an unprovoked and illegal war, which independent experts have concluded represents an intended genocide.1 The people of Ukraine will surely have experienced horror at the real and immediate threat to their lives, the lives of their loved ones, and to the existence of their nation. In a country of 44 million people, more than 7 million people have been forced to move to another country and another 8 million people have been internally displaced.2 This occurred in the context of nearly 2 million Ukrainians having already been internally displaced by Russian aggression in the Donbas in eastern Ukraine since 2014.3 The international community is becoming aware of the human toll the Russian war on Ukraine, but the level of psychological trauma that Ukrainians are, and have been, living with, and the damage this will have on their mental health remains to be determined. We must expect it will be significant. Following the Russian invasion of Crimea and Donbas in 2014, the Internally Displaced Persons Mental Health Survey in Ukraine was launched, which surveyed more than 2000 people who had been internally displaced.4 This study found a very high burden of mental health problems among these people. The number of people who exceeded clinically accepted thresholds for posttraumatic stress disorder (21%), depression (22%), anxiety (18%), somatization (55%), and hazardous alcohol use (14.3% of men and 1.7% of women) was high. Furthermore, nearly three-quarters of people with mental health problems were not receiving any mental health or psychosocial support.5 It is highly probable, therefore, that many Ukrainians, living inside and outside of Ukraine, will be experiencing mental health problems as a direct result of this war. Just as the political and economic consequences of the war will be felt by people far outside the borders of Ukraine (e.g., increases in national defence spending that means less money spent on other national services, rapid increases in inflation, food shortages, disruption to supply chains), the mental health consequences of this war will ripple out of Ukraine and affect people in near and far destinations. In a new study in this journal entitled ‘Deterioration of patients with mental disorders in Denmark coinciding with the invasion of Ukraine’, Østergaard and colleagues6 raise our attention to this fact. They analysed data from the Danish Electronic Patient Record System by searching electronic medical records of 16,000 patients for indications of patients having mentioned ‘Ukraine’. There was a sharp rise in the frequency of such clinical notes almost immediately after the invasion, and indications of associated worsening mental health symptoms. The authors concluded that this could serve ‘…as an early warning sign of the potential width of the negative mental health impact from the war’. The ‘width’ of the negative mental health impact of this war can hardly be underestimated. There are likely to be effects that are immediate, others that will emerge over a longer period, and then across generations for decades to come. In Northern Ireland, another European country that was affected by ongoing violence and conflict until recently, there is evidence of intergenerational and familial transmission of psychological trauma.7 Indeed, the temporal cascading of the effects of trauma are now well documented and the mechanisms are increasingly well understood.8 As the mental health community begins to respond to this crisis, both in terms of documenting the mental health consequences of the war and working to heal the trauma of those affected by it, we must be aware of the many and varied ways that psychological distress related to this war can manifest. Here we highlight two disorders worthy of attention. With the recent release and implementation of the 11th version of the International Classification of Diseases, the psychiatric community has ‘officially’ recognised two new disorders that may be especially pertinent to the people of Ukraine: Complex posttraumatic stress disorder (CPTSD) and prolonged grief disorder (PGD). CPTSD is a disorder that can follow an extremely threatening or horrific event, or series of events, particularly those that are prolonged in nature, ongoing, and from which escape is difficult or impossible. Should the war in Ukraine continue over the longer term, and the people of Ukraine remain subjected to an ongoing threat of war and destruction from Russia, it is likely that many people will be vulnerable to developing this disorder. There is evidence that CPTSD is a persistent disorder with long term consequences. A prospective study of Israeli Army prisoners of war who were subjected to intense isolation and systematic torture during the 1973 Yom Kippur War found that over 40% experienced symptoms consistent with CPTSD 20 years later, and a further 7 years later this group reported poorer physical health, higher levels of functional impairment, lower cognitive performance, and higher levels of dissociation and loneliness.9 PGD can occur following the death of a loved one and is characterised by persistent and pervasive longing for the deceased and preoccupation with the deceased that is accompanied by intense emotional pain. Accurate estimates of the number of Ukrainians that have been killed during the war, and since the 2014 invasion, are hard to come by but they are surely already in the thousands, if not tens of thousands. It is likely that traumatic and prolonged grief will be commonplace among the Ukrainian population for years to come as a direct result of this war. Given that these are relatively newly recognised and studied disorders, the scientific community does not know a lot about who is most likely to develop these disorders within ongoing conflict settings, or how effective and acceptable our existing interventions are likely to be. It is important that the scientific community makes an effort to answer these questions. We may feel that there is little we can do at this time to help, but we can follow the lead of Østergaard et al. and explore and document the mental health impact of this war on the people of Ukraine, Europe, and the world using the most appropriate methods for adults, children and young people10, 11 to understand who is most likely to require help; and to develop and deliver effective and efficient interventions to heal the psychological wounds of those affected. The authors have no conflict of interests. N/A.