Trauma, distress, and resilience among Ukrainian migrants: mental health and cultural contexts in Europe

Abstract

The full-scale Russian invasion of Ukraine has caused unprecedented displacement across Europe, yet evidence on the psychological adaptation of Ukrainian migrants in different institutional contexts remains limited. This study examines how traumatic exposure, resilience, and cultural trauma symptoms, and perceived social support interact to shape mental health outcomes among Ukrainian migrants residing in eight countries: Slovenia, Poland, Cyprus, Spain, Germany, Portugal, Serbia, and Ukraine. Using validated psychometric instruments (RHS-15, HSCL-25, DSM-5 trauma clusters, Cultural Symptoms of Trauma, RS-25), the study employs a cross-sectional design to analyze individual and contextual determinants of psychological distress. The traumatic exposure is consistently associated with higher levels of anxiety, depression, and PTSD symptoms, while resilience serves as a robust protective factor across all mental health indicators. Cultural trauma symptoms emerged as a key mediator linking trauma exposure to distress, whereas perceived social support neither mediated nor moderated this relationship. These findings highlight the multidimensional nature of refugee mental health, underscoring the need for long-term, trauma-informed, and culturally sensitive psychosocial support, alongside improvements in integration infrastructures and service accessibility. The study advances theoretical understanding of forced migration by demonstrating how cultural meaning-making and institutional structures jointly shape mental health trajectories among displaced populations.

Introduction

The full-scale Russian invasion of Ukraine in February 2022 triggered the largest humanitarian and displacement crisis in Europe since the Second World War. By the end of 2024, more than 123 million people were forcibly displaced worldwide, including over six million Ukrainian refugees and 3.7 million internally displaced persons [1, 2]. This prolonged emergency has profoundly affected the mental health and social well-being of displaced populations, while testing the resilience and capacity of European host societies to provide sustained psychosocial and health support.

Large-scale epidemiological research demonstrates the extent of this impact. A recent national study reported that 68%–80% of Ukrainians experienced moderate to high stress, 45%–50% reported anxiety symptoms, and up to 63% met DSM-5 criteria for post-traumatic stress disorder one year after the escalation of war [3].

Importantly, available pre-February 2022 evidence suggests markedly lower prevalence estimates prior to the full-scale invasion. In the nationally representative Ukraine World Mental Health (WMH) survey conducted in 2002 (N = 4725), 17.6% of adults met criteria for any DSM-IV disorder in the past 12 months, and lifetime prevalence across assessed disorders ranged up to 14.6% for major depressive disorder [4].

Beyond prevalence estimates, research across diverse refugee and forced-displacement settings shows that trauma-related suffering is often shaped and communicated through culturally embedded meaning systems (“idioms of distress”), which may not fully align with standard diagnostic categories yet remain clinically significant. This comparative evidence supports treating culturally shaped trauma expressions as a key pathway linking exposure to psychological outcomes and reinforces the need for culturally informed assessment and service design in displacement contexts [5, 6].

Comparable findings across European host countries further show that mental distress is shaped not only by exposure to war-related trauma but also by ongoing post-migration stressors, including uncertainty, social isolation, and barriers to integration [7–9]. These results confirm that the psychological burden of displacement extends across pre-, peri-, and post-migration stages [10, 11].

Scholarly debates increasingly emphasize the need to move beyond symptom-oriented approaches toward models that conceptualize mental health as a dynamic process of adjustment shaped by individual, social, cultural, and structural factors [12–14]. Strength-based perspectives have begun to illuminate this complexity: Pertek [15] demonstrates the empowering function of adaptive religious coping among displaced women, while Kiriscioglu and Van Heelsum [16] and Song et al. [17] highlight the mediating roles of social connectedness and hope in reducing psychological distress. However, the integration of psychological, cultural, and institutional dimensions remains underdeveloped, particularly in comparative analyses.

The present study addresses this gap by examining how traumatic exposure and resilience interact to influence mental health outcomes among Ukrainian migrants in eight countries: Slovenia, Poland, Cyprus, Spain, Germany, Portugal, Serbia, and Ukraine (internally displaced persons). Using validated psychometric instruments (RHS-15, HSCL-25, Cultural Symptoms of Trauma, DSM-V Trauma Symptoms, RS-25), the study situates individual psychological mechanisms within a socio-ecological framework that incorporates institutional and cultural determinants. This integrated perspective is essential for informing context-sensitive psychosocial interventions and evidence-based integration policies capable of strengthening institutional trust, social cohesion, and long-term well-being.

Based on these theoretical foundations, the study formulates three hypotheses:

(H1) a higher number of traumatic experiences will be associated with higher levels of psychological distress (RHS-15, HSCL-25, DSM-5);

(H2) higher resilience (RS-25) will be negatively associated with depression, anxiety, and trauma symptoms;

(H3) cultural symptoms of trauma and perceived social support will mediate the relationship between traumatic exposure and mental health outcomes.

Theoretical background

Understanding the mental health of forcibly displaced populations requires an integrative theoretical approach that considers the interaction of trauma exposure, individual adaptive capacities, cultural meaning systems, and institutional environments. Contemporary refugee research has moved beyond linear stress–response models toward frameworks that conceptualize adaptation as an ongoing, transactional process shaped by multiple ecological layers [12–14]. These models emphasize that psychological outcomes cannot be reduced to trauma histories alone but must be situated within broader contexts of uncertainty, mobility, social embeddedness, and structural constraint.

Trauma exposure and post-migration stressors

Classic trauma theory posits that cumulative exposure to adverse events increases vulnerability to psychological distress, particularly when traumatic experiences occur under ongoing threat or instability [11]. In forced migration contexts, trauma is not limited to wartime events but extends throughout the displacement trajectory, including experiences of loss, dislocation, ambiguity, legal precarity, and disrupted social roles. Li et al. [10] argue that post-migration stressors may have effects as strong as, or even stronger than, pre-migration trauma, particularly when individuals have limited control over their environment. This theoretical perspective supports the expectation that traumatic exposure is likely to be associated with elevated levels of depression, anxiety, and trauma-related symptoms (H1).

Resilience as a dynamic process of adaptation

Resilience theory conceptualizes positive adaptation in the face of adversity as a dynamic, relational, and context-dependent process, rather than a fixed trait [12]. In refugee research, resilience is increasingly understood as arising from the interplay of psychological strengths, social resources, and environmental opportunities [13]. Adaptive capacities such as emotional regulation, self-efficacy, future orientation, and meaningful goal pursuit have been shown to mitigate the negative psychological effects of displacement. Empirical studies demonstrate that resilience is particularly protective in contexts of prolonged uncertainty, where immediate resolution is unlikely and individuals must develop forward-oriented strategies despite instability [14]. This theoretical foundation supports the hypothesis that higher resilience is associated with lower levels of distress (H2).

Cultural meaning-making and mediating mechanisms

Anthropological and cultural-psychological theories highlight that distress among displaced populations is expressed not only through universal symptoms but also through culturally embedded idioms of suffering, memory, and meaning [11]. Cultural symptoms of trauma encompass embodied, cognitive, and social manifestations of distress that reflect collective narratives, cultural models of adversity, and symbolic interpretations of harm. Such culturally shaped meaning-making processes influence how individuals appraise traumatic events, attribute causality, and regulate emotional responses. They may therefore mediate the relationship between traumatic exposure and psychological outcomes by filtering traumatic experiences through shared cultural frameworks.

At the same time, theories of social and institutional support emphasize that perceived support—including interpersonal connectedness, community embeddedness, and the responsiveness of formal institutions—acts as a regulatory mechanism that can buffer distress, facilitate coping, and promote psychological recovery [17]. In the context of forced migration, perceived support gains particular importance, because migrants’ evaluations of safety, belonging, and resource accessibility are often shaped by both informal networks and institutional environments.

European integration frameworks further underscore this institutional dimension. Ager and Strang’s [18] influential model conceptualizes integration as shaped by “markers and means” (e.g. rights, services, employment), “social connections” (bridging, bonding, linking capital), and “foundations” such as safety and stability. Each of these domains is directly relevant to mental health: limited access to services may exacerbate distress, while strong social connections and institutional responsiveness can enhance resilience and perceived coherence. For Ukrainian migrants navigating new social and institutional landscapes, perceived social support is therefore not merely an interpersonal resource but an indicator of broader structural conditions that shape well-being.

Within this framework, cultural trauma symptoms represent how experiences of threat, displacement, and collective memory are internalized and expressed, while perceived social support reflects migrants’ sense of embeddedness within both community networks and host-country institutions. Together, these constructs capture key pathways through which trauma may translate into psychological distress. Consequently, it is theoretically expected that cultural trauma symptoms and perceived social support mediate the effects of traumatic exposure on mental health outcomes (H3).

In parallel, systematic review evidence indicates that resilience is consistently associated with better mental health outcomes in forcibly displaced populations (lower depression, anxiety, and PTSD symptoms). Together, findings from other displacement contexts support an integrated view in which culturally shaped trauma expressions and resilience processes help explain heterogeneity in post-displacement trajectories [5, 19].

Methodology

Study design

This study used a cross-sectional, comparative survey design to examine the relationships between traumatic exposure, resilience, cultural trauma symptoms, perceived social support, and psychological distress among Ukrainian migrants living in eight countries (Slovenia, Poland, Cyprus, Spain, Germany, Portugal, Serbia, and Ukraine—internally displaced persons).

Participants and procedure

Participants were Ukrainian adults aged 18 years and older who had left Ukraine after the escalation of hostilities in February 2022 or who were internally displaced within Ukraine. Recruitment took place between March and June 2025 through refugee support organizations, Ukrainian community networks, NGOs, and social media platforms in each participating country. Respondents completed an online questionnaire available in Ukrainian, designed to ensure accessibility and linguistic accuracy.

A total of 1631 respondents participated (Slovenia n = 104; Poland n = 715; Spain n = 92; Cyprus n = 94; Ukraine n = 232; Germany n = 101; Portugal n = 103; Serbia n = 190). The sample was predominantly female (78.6%), reflecting gender patterns in the displacement context (UNHCR 2025a). Participants’ ages ranged from 18 to 65 years (M = 38.82, SD = 13.911). Most respondents were currently employed (67.8%), followed by students (13.5%), professionally inactive individuals (9.6%), retirees (6.0%), and those selecting “other” (3.1%).

This diverse sample captures variation in both institutional regimes and migration trajectories, providing a unique basis for comparative analysis of adaptation mechanisms.

Data collection and instruments

The study used standardized, validated psychometric instruments to ensure reliability and comparability across contexts. All instruments were administered in Ukrainian using the forward–backward translation procedure recommended by the World Health Organization to ensure linguistic and conceptual equivalence.

The Refugee Health Screener (RHS-15) and the DSM-V Trauma Symptoms Checklist [20] assessed traumatic exposure and post-traumatic symptoms, capturing both somatic and affective dimensions. The Hopkins Symptom Checklist (HSCL-25) [21, 22] measured anxiety and depression symptoms on a 4-point Likert scale, providing an index of general psychological distress.

Resilience was measured using the Resilience Scale (RS-25) [23], capturing Personal Competence and Acceptance of Self and Life.

Cultural congruence—the alignment between individual coping preferences and culturally sanctioned forms of support—was assessed using a modified version of the Cultural Symptoms of Trauma Scale (CSTS) [11].

Pilot testing with 25 Ukrainian participants in Slovenia confirmed linguistic clarity and cultural sensitivity. Minor adjustments were made to ensure that terms describing emotional and somatic distress aligned with Ukrainian idioms.

Analytic strategy

Analyses were conducted using SPSS/AMOS. Data screening included checks for normality, multicollinearity, and missing data. Descriptive statistics and bivariate correlations were calculated for all variables.

To test the hypotheses: H1–H2: Multiple regression analyses examined associations between trauma, resilience, and distress indicators, H3: Mediation analyses using bootstrap procedures (5000 resamples) evaluated indirect effects of cultural trauma symptoms and perceived social support on the relationship between trauma and distress. Significance was set at P < .05, with 95% confidence intervals reported where relevant.

Ethical considerations

The study was conducted in accordance with the Declaration of Helsinki and approved by the Bioethics Committee of Pomeranian Medical University in Szczecin, Poland (KB.006.41.2024). Participation was voluntary, and informed consent was obtained electronically before survey completion. Respondents received information about psychological support hotlines in each country. No personally identifiable data were collected.

Results

Traumatic exposure and psychological distress

To test H1, which predicted that a greater number of traumatic experiences would be associated with higher levels of psychological distress, Pearson’s correlation coefficients were calculated between traumatic exposure and all distress indicators (RHS-15, HSCL-25 anxiety and depression, and DSM-5 clusters) (Table 1).

Table 1.

Correlations between migration variables and psychological distress

Distress indicator	Trauma exposure	Emigration duration	Stage of leaving Ukraine
RHS-15 Average score	0.093***	0.032	–0.045
HSCL-25 Anxiety symptoms	0.106***	–0.046	0.041
HSCL-25 Depression symptoms	0.112***	–0.053*	0.037
DSM-V Intrusion	0.153***	–0.042	0.081***
DSM-V Avoidance	0.156***	–0.043	0.032
DSM-V Negative cognition/mood	0.149***	–0.069**	0.073**
DSM-V Arousal/Reactivity	0.144***	–0.062**	0.079**
DSM-V Total score	0.168***	–0.059*	0.072**

^*** P < .001,

^** P < .01,

^* P < .05.

DSM-V, Trauma Symptoms Checklist; HSCL-25, Hopkins Symptom Checklist; RHS-15, Refugee Health Screener.

Trauma exposure showed a consistent positive association with all indicators of psychological distress. Greater exposure to war-related events was associated with greater general distress (RHS-15), increased anxiety and depressive symptoms (HSCL-25), and greater PTSD symptom severity across DSM-V clusters. The strongest correlation was observed for the DSM-V total symptom score (r = 0.168, P < .001), with similar effects across intrusion, avoidance, negative cognition/mood, and arousal/reactivity (r ≈ 0.14–0.16). These findings support H1, indicating that greater traumatic exposure is consistently associated with higher levels of psychological distress.

Resilience as a protective factor

To evaluate H2, which hypothesized that resilience would be negatively associated with depression, anxiety, and trauma symptoms, correlations were calculated between RS-25 scores and multiple distress indicators (Table 2).

Table 2.

Associations between RS-25 and psychological distress

Variable	RS-25 (resilience)
HSCL-25 Anxiety symptoms	–0.240***
HSCL-25 Depression symptoms	–0.271***
DSM-5 Intrusion	–0.252***
DSM-5 Avoidance	–0.178***
DSM-5 Negative cognition and mood	–0.254***
DSM-5 Arousal and reactivity	–0.251***
DSM-5 Total score	–0.257***
RHS-15 Psychological distress	–0.170***

^*** P < .001.

DSM-V, Trauma Symptoms Checklist; HSCL-25, Hopkins Symptom Checklist; RHS-15, Refugee Health Screener.

Across all measures, resilience showed significant negative correlations with anxiety, depression, and trauma-related symptoms. The strongest associations were observed for depressive symptoms (r = 0.271, P < .001) and negative cognition/mood (r = –0.254, P < .001). These results clearly support H2, confirming that resilience functions as a robust protective factor across multiple dimensions of psychological distress.

Mediation and moderation by cultural trauma symptoms and social support

Finally, H3 predicted that cultural trauma symptoms and perceived social support would mediate the relationship between trauma exposure and psychological distress. These pathways were tested using PROCESS Model 4 and Model 1.

Mediation analysis

Trauma exposure had a significant total effect on distress, but the direct effect was no longer significant when mediators were included. The total indirect effect was significant and was driven almost entirely by cultural trauma symptoms (Table 3). Perceived social support did not contribute a significant indirect pathway. Thus, cultural trauma symptoms mediate the trauma–distress relationship, whereas perceived social support does not.

Table 3.

Indirect effects of trauma exposure on psychological distress

Effect	b	Boot SE	95% Bootstrap CI	P
Total effect (c)	0.0557	0.0157	0.0249 to 0.0865]	.0004
Direct effect (c′)	0.0189	0.0145	–0.0096 to 0.0474	.193
Total indirect effect	0.0368	0.0076	0.0225 to 0.0521	—
Via cultural trauma symptoms	0.0359	0.0075	0.0217 to 0.0511	—
Via perceived social support	0.0009	0.0009	–0.0007 to 0.0030	—

Moderation analysis

To examine whether social support moderated the trauma–distress association, PROCESS Model 1 was used (Table 4).

Table 4.

Moderation analysis (PROCESS model 1): social support as moderator of the trauma–distress relationship

Predictor	b	SE (HC3)	t	P	95% CI
Constant	1.4516	0.0210	69.11	<.001	1.4104 to 1.4928
Trauma exposure	0.0520	0.0158	3.29	.001	0.0210 to 0.0830
Social support	–0.1153	0.0255	–4.53	<.001	–0.1653 to –0.0654
Trauma × social support	–0.0278	0.0194	–1.43	.153	–0.0659 to 0.0103

Trauma exposure significantly predicted distress, and social support was inversely associated with distress. However, the interaction term was not significant (P = .153), indicating that perceived social support does not moderate the association between trauma and distress. Thus, H5 was not supported: cultural trauma symptoms act as a mediator, while perceived social support does not mediate or moderate the trauma–distress link.

Discussion

The findings of this study provide an integrated understanding of the psychological adaptation of Ukrainian migrants across diverse European institutional contexts. Overall, the results support theoretical assumptions regarding the multifactorial determinants of mental health following forced displacement and offer new insights into how individual, cultural, and structural factors interact to shape psychological outcomes.

Consistent with H1, traumatic exposure emerged as a significant—though modest—predictor of psychological distress among Ukrainian migrants. Individuals who reported a greater number of war-related traumatic experiences exhibited higher levels of anxiety, depression, general distress, and PTSD symptoms. These findings are coherent across all applied instruments, reinforcing cumulative stress models suggesting that pre-, peri-, and post-migration adversities jointly heighten vulnerability to psychological strain [10, 11]. The pattern is further reflected in the observation that individuals who left Ukraine later during the escalation phase showed slightly elevated intrusion and arousal symptoms, which may indicate that prolonged exposure to acute threat sustains heightened physiological and psychological reactivity [7]. Taken together, these results confirm that traumatic exposure constitutes a robust risk factor shaping mental health outcomes in displaced populations, even when its effects are relatively small in magnitude—likely due to the diversity of post-migration environments and individual resilience processes.

Strong support was also found for H2, which predicted a protective role for resilience. Resilience demonstrated a consistent and robust negative association with all indicators of psychological distress, reinforcing contemporary perspectives that conceptualize resilience as a dynamic, context-sensitive process of psychological adaptation [12, 13]. The most pronounced effects were observed for depressive symptoms and negative alterations in cognition and mood, indicating that resilience may buffer against maladaptive cognitive–emotional patterns such as hopelessness, negative self-evaluation, and disruptions in meaning-making. This interpretation aligns with emerging research on Ukrainian refugees, which highlights resilience as a key mechanism mitigating the psychological consequences of displacement [24]. Collectively, these findings underscore that resilience operates as an important individual resource that supports emotional regulation and adaptive functioning in the face of sustained adversity.

The analysis of mediating mechanisms provides partial support for H3. Cultural trauma symptoms emerged as a significant mediator of the relationship between trauma exposure and psychological distress, highlighting the role of culturally embedded idioms of distress, collective memory, and meaning-making processes in shaping psychological responses to adversity. This finding aligns with anthropological and transcultural perspectives, which emphasize that trauma among displaced populations must be interpreted within culturally and historically grounded frameworks [8]. In contrast, perceived social support—although directly associated with lower distress—did not mediate or moderate the trauma–distress relationship. This suggests that while social support contributes to psychological well-being, it may be insufficient to counteract severe trauma, particularly in settings where formal service provision remains inconsistent and social networks are unstable or fragmented [17].

Overall, the study makes several key contributions to scientific knowledge. By simultaneously examining trauma exposure, resilience, cultural trauma symptoms, and perceived social support within a comparative multi-country design, this study advances theoretical understanding of refugee mental health as a multidimensional and context-dependent process. The cross-national evidence clearly demonstrates that psychological outcomes are shaped by the institutional and welfare environments in which migrants rebuild their lives. Rather than reflecting individual factors alone, variations across countries underscore the relevance of broader structural conditions. Identifying cultural trauma symptoms as a mediator enriches existing models by demonstrating that culturally grounded ways of interpreting and expressing distress constitute an important pathway linking traumatic exposure with mental health outcomes.

The findings also have important implications for policy and public health practice. The strong association between trauma and distress highlights the necessity of sustained, trauma-informed mental health services that extend beyond short-term emergency responses. Enhancing access, continuity, and coordination of care is essential, particularly in welfare systems where service fragmentation inhibits long-term recovery. The protective role of resilience emphasizes the value of interventions that strengthen adaptive capacities such as emotional regulation, problem-solving, and meaning making [25, 26]. Moreover, the mediating role of cultural trauma symptoms indicates that clinical and psychosocial services must incorporate culturally sensitive approaches that recognize Ukrainian idioms of distress, collective memories, and culturally grounded expressions of suffering. Finally, improving integration infrastructures and social protection systems would help ensure that migrants can mobilize both institutional and interpersonal resources needed for psychological adaptation.

For decision-makers, evidence from displaced populations supports a stepped-care approach combining scalable and specialized options. Low-intensity WHO programs have randomized-trial evidence for feasibility and improvements in distress in refugee settings, while trauma-focused treatments (e.g. Narrative Exposure Therapy) show efficacy for PTSD symptoms in refugees. Adaptation-focused models (e.g. Integrative Adapt Therapy) also demonstrate benefits in randomized trials. These options can be aligned with local capacity and culturally informed formulations of distress [27–31].

Limitations

Despite its contributions, the study has limitations. Its cross-sectional design precludes causal inference, making longitudinal research necessary to capture how psychological responses change over time. Reliance on self-report measures may introduce biases related to recall, social desirability, or cultural differences in symptom expression, highlighting the value of incorporating qualitative methods or clinician-administered measures in future research. Although the sample includes participants from multiple countries, it is not nationally representative, and recruitment through assistance networks may underrepresent more socially isolated or marginalized individuals. The focus on individual psychological factors also limits insights into community-level and collective resilience processes, which should be explored in future work. Finally, the dynamic geopolitical and migration landscape suggests that psychological responses may shift over time, underscoring the need for ongoing monitoring and contextually adaptive research.

Conclusion

This study offers a comprehensive comparative analysis of the psychological adaptation of Ukrainian migrants across various contexts. By integrating trauma exposure, resilience, cultural trauma symptoms, and perceived social support into a single analytical framework, the findings show that mental health outcomes after forced displacement are shaped by the interplay of individual psychological resources, culturally embedded meaning-making processes, and the structural characteristics of host-country systems. Traumatic exposure was consistently associated with increased distress, while resilience emerged as a strong protective factor across all dimensions of mental health.

Taken together, these findings underscore the need for long-term, trauma-informed, and culturally sensitive mental health interventions, along with improvements in integration infrastructure and service accessibility. Strengthening institutional predictability and social protection systems is essential to enable migrants to mobilize internal and external adaptive resources. Future research should adopt longitudinal and mixed-method approaches to better capture the evolving psychological needs of displaced populations and further elucidate the multilevel mechanisms through which institutional, cultural, and individual factors intersect to shape well-being over time.

Conflict of interest: None declared.

Funding

Subsidized by EU funds under the project: “MultiCultiMed—modern multicultural education for medical and health science students,” contract number: 2024-1-PL01-KA220-HED-000251323.

Data availability

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Key points.

• Higher levels of traumatic exposure among Ukrainian migrants are consistently associated with increased anxiety, depression, and PTSD symptoms, underscoring the cumulative psychological burden of forced displacement.

• Resilience functions as a strong protective factor, showing robust negative associations with all indicators of psychological distress across eight national contexts.

• Cultural trauma symptoms significantly mediate the relationship between traumatic exposure and distress, highlighting the critical role of culturally embedded meaning-making in psychological adaptation.

• Perceived social support improves overall well-being but does not mediate or moderate the trauma–distress link, suggesting limited buffering effects under conditions of prolonged instability.

• Findings call for long-term, trauma-informed and culturally sensitive mental health policies as well as improved integration infrastructures to ensure sustained accessibility and predictability of psychosocial support for displaced populations.