Addressing war trauma in Ukrainian refugees before it is too late

ABSTRACT

Russian invasion of Ukraine has led to one of the largest refugee crises in recent history. Many internally displaced Ukrainians and refugees will need care for PTSD, anxiety, and depression. Here I will suggest practical steps to reduce long-term impact of trauma and stress on refugees’ mental and physical health, and functioning. These include mental health first aid in acute phase of arrival, education of mental health and navigating healthcare system in the host countries. As well, training of manualized trauma-focused therapy and intervention methods in the host countries, focused education for physicians on psychopharmacological interventions for common mental health issues among refugees (PTSD, depression, anxiety), and utilization of videoconferencing for treatment, and consultation and supervision for providers.

Highlights

• Many internally displaced Ukrainians and refugees will need care for PTSD, anxiety, and depression to prevent long-term disability and health consequences.

• There are challenges in receiving the needed care including stigma, lack of awareness by patients and providers, lack of resources, and lack of skills in trauma-focused treatments.

• In this article, suggestions are made on how to overcome these obstacles, that include mental health first aid upon arrival, education for refugees and those serving them, training providers at different layers, and remote treatment and counselling/supervision services.

Russian invasion of Ukraine has led to devastating death, injuries, and one of the largest refugee crises in the modern history. One in four Ukrainians have been displaced and near four million have left their country. Per United Nations Children's Fund (UNICEF), near five million, more than half of the Ukraine's children have left their homes (UNICEF 2022).

I write this Editorial as a psychiatrist expert in treatment and research of posttraumatic stress disorder (PTSD) and other consequences of trauma in civilians, specifically refugees, survivors of torture, and first responders. I will reflect on the foreseeable mental health impact of war trauma on Ukrainian refugees and suggest practical solutions for addressing their needs.

Per United Nations High Commissioner for Refugees (UNHCR), ‘Refugees are people who have fled war, violence, conflict or persecution and have crossed an international border to find safety in another country.’ While important historical, cultural, political, geographic, and socioeconomic factors differentiate experiences of refugees across the globe, refugees also share unique experiences as they: (a) are civilians without self-protection resources, exposed to military and war trauma, (b) have repeated cumulative exposure to such trauma, (c) endure immense personal, material, psychosocial, literal and symbolic losses, including of family members and loved ones, homes, socioeconomic standing, and memories among others, (d) sustain cumulative psychosocial stress, economic hardship, and lack of resources during the flight, and years after displacement. War-related stress itself often continue via exposure to the news, and worries about, or loss of family members who still reside in the conflict area. These all can cause high levels of psychological impact.

1. Mental health impact of war trauma exposure and displacement

While PTSD is often known as the main outcome, depression and anxiety are other very common disabling consequences. Depending on the context, prevalence ranges largely across studies (Mesa-Vieira et al., 2022). However, average estimates suggest about a third of refugees pass the diagnostic threshold for posttraumatic stress disorder (PTSD), depression, and anxiety (Mesa-Vieira et al., 2022). While data specific to the current conflict are missing, one previous large study of internally displaced Ukrainians suggests similar impact among them (Shevlin et al., 2018). It is important to note that none of these are dichotomous disorders (like COVID is), and a person who misses the DSM or ICD diagnostic threshold for PTSD on a questionnaire by one, two or three symptoms, might still have majority of the symptoms, leading to disability and dysfunction, with need for intervention. As a result, a larger number of people than the above numbers would potentially need clinical care to different degrees.

Children are often forgotten in refugee trauma research. Despite parents’ efforts to protect them, children often share the same adverse experiences with their parents, and are able to understand the direness of the situation in the adults’ behaviour. Limited available studies, including from our group among Syrian refugee children resettled in the United States find elevated level of PTSD, and anxiety in as many as half of the children (Javanbakht et al., 2018).

While some might assume that removal from the war context will automatically relieve the invisible wounds of refugees, research suggests otherwise. For example, our study of Syrian refugees who had left their country an average of two years before, still showed PTSD rates of 30% among adults. This and other studies show that for many refugees, consequences of trauma do not remit if left unaddressed, and can continue on to impact the brain and mental health, and exacerbate a range of physical illnesses. A multitude of postmigration environmental stressors such as poverty, un/underemployment, social and cultural disconnect, and prejudices also play important role in the course of the symptoms.

2. What can be done

While mandatory or recommended health screenings in the host countries often do not focus on mental health, the above-mentioned numbers, as well as the high level of disability caused by PTSD, anxiety and depression suggest these conditions are the largest disabling health problems in refugees needing attention. Lack of focus on mental health could be due to lack of knowledge about these conditions by providers, the invisibility of mental illness, stigma on the side of the refugees, their families, and the providers, and lack of resources and skills for handling them if diagnosed. There are ways however to help overcome such barriers.

Acute phase and upon arrival: through the process of transition to the host countries or within Ukraine, non-medically trained persons, whether the drivers transporting the refugees, or case workers at the border or welcoming centres, can be trained in mental health basic first aid. This would basically include providing a supportive, safe and understanding environment, and meeting refugees’ basic needs. As well, these persons can be trained in identifying common signs of mental consequences of trauma that need attention. Such training should also include what not to do, including pressing refugees to disclose details of their traumatic experiences. These are basically measures taken in medical emergency settings for survivors of trauma.

A challenge for receiving mental health services for refugees, is unfamiliarity with the healthcare system in the host countries. Providing easy to understand algorithms of receiving primary care, and ways of connecting with mental health providers via resettlement agencies and host organizations advising refugee families (including ways of access to financial support for these services when required), is pivotal. Same applies to providing basic information on symptoms of anxiety, depression and PTSD that can be help with treatment. Potential barriers in seeking help among the Ukrainian refugees (and other refugees) might include stigma, shame, lack of trust in psychiatry, and less understanding of mental illness (Romaniuk & Semigina, 2018). A problem-focused, rather than label-focused approach might help overcome the stigma. Training and supervision could be provided for peers and resettlement workers who can offer education and peer support for the refugees. These approaches should also consider contextual differences among the host countries that affect refugees’ mental health post-migration (mental healthcare model, ease of navigating healthcare system, available resources for refugees, and cultural and language familiarity). For example, currently, most of the Ukrainian refugees are in Poland, with close cultural ties and some familiarity with language.

For the healthcare system, the major challenge is inadequate access to trauma experts fluent in the culture and language of refugees. On the other hand, treatment for depression and anxiety can be provided by most psychiatrists, primary care providers, and therapists. There are ways to overcome the barriers:

1. Psychotherapies such as cognitive therapy and exposure therapy are first-line treatments for PTSD and other consequences of trauma. It might be time-consuming to train therapists in these treatments, and language and cultural barriers become more important here. However, as these treatments are manualized, they can still be learned relatively quickly. Importantly, there has been recent progress in simplifying these treatments and the ability to provide them in massed short duration. Furthermore, psychosocial interventions have been proven effective in reducing symptoms of refugees and asylum seekers (Turrini et al., 2019). Training for these interventions can be provided by experts willing to volunteer from across the globe.

2. Psychopharmacological treatment of depression, anxiety, and PTSD is almost exclusively SSRIs and SNRIs. Many primary care providers, especially those who frequently work with refugees, have training and experience in treating anxiety and depression, and sometimes PTSD. It is also feasible to train primary care providers on the frontline, how to screen and diagnose PTSD, anxiety, and depression, and basics of prescribing and dosing locally available antidepressants. Psychiatrists more skilled in trauma could be available for consultation. This is already being done in integrated mental health care models with primary care clinics in the United States and some other countries.

3. A network of Ukrainian and Russian-speaking psychiatrists (as most Ukrainians speak both of these languages), primary care providers, and therapists, who have the skills or are trained, could function at a global or regional across the European Union countries. While trauma therapies require more specialized training, treatment for anxiety and depression can be provided by most psychiatrists and therapists informed in culture and language. The pandemic has taught us that much of our services can be provided remotely with great flexibility. In the United States, the States loosened their regulations to allow providing mental health services across the stateliness, and insurances quickly moved to covering telepsychiatry. Such accommodations across the affected EU countries would allow a larger network of providers serve Ukrainian refugees via telemedicine and with more flexibility. For non-Ukrainian or Russian-speaking providers, reliable access to interpreters, especially in areas with highest numbers of refugees could be a challenge, which could in part be addressed by training volunteers, or peer refugees.

4. Creative group-based interventions can be used especially for those with subthreshold symptoms, without a need for high level of training for providers (Acarturk et al., 2022). For example, we have successfully used body-based mindful dance and movement, and art therapies for refugee children within remote group-based setting across school systems in areas with highest refugee populations (Grasser & Javanbakht, 2021). Flexibility and diversity of the methods available can help overcome logistics, knowledge, and cultural barriers and stigma in dealing with various levels of trauma impact, expectations, and needs. Furthermore, these approaches can have a transdiagnostic impact by reducing stress and improving coping skills in dealing with postmigration stress.

There is an enormous level of skills available globally and across the Western countries for treatment of trauma, and more so for other mental illnesses common among refugees. These skills can be used in a collective effort across the Western world for offering training, support, and consultation for providers in the countries accepting refugees, via in-person or remote methods.

Funding Statement

This work was supported by National Institute of Child Health and Human Development.

Disclosure statement

No potential conflict of interest was reported by the author(s).