The war in Ukraine: mental health in primary care

Oleksii Korzh is head of the Department of General Practice – Family Medicine at Kharkiv National Medical University, Ukraine

The Russian invasion of Ukraine has a significant impact on the healthcare sector.^1,2 And perhaps the war’s most devastating legacy is its impact on mental health on a scale unprecedented in Europe since the end of World War II. Nearly 10 million people are now potentially at risk for mental disorders such as acute stress, anxiety, depression, substance use and post-traumatic stress disorder.³

It is hard to describe the stress, trauma and mental breakdown due to overnight displacement, separation from family, and the killing of friends and family members.⁴ Victims often require years of mental health support as they struggle with sleep problems, recurring memories, anxiety, grief and anger.⁵ The data and evidence collected by the Ministry of Health of Ukraine and the World Health Organization in recent months show that mental health, rehabilitation and the population’s access to health services are the top priorities and issues to be addressed.⁶

The gap between the need for and availability of mental health services in Ukraine is large. It is generally accepted that the best way to expand the range of services for individuals with an identified need for mental health care is to integrate this care into primary health care. The concept is that primary health care should offer the first contact, and in addition to providing comprehensive, continuous and coordinated services for people with illnesses, it should also demonstrate the possibility of rapid referral to higher levels of care.⁷

The greatest needs are in areas the most severely impacted by the war, but populations in relatively safer parts of the country are also affected by anxiety or sadness, difficulty sleeping, fatigue, anger and unexplained somatic symptoms. People with pre-existing mental illness who previously relied on public mental health and social care face additional challenges in accessing the services they need.

Despite the significant level of mental health problems among displaced persons and returnees in Ukraine, the provision of services at the level of primary health care is lacking. According to our data, this is due to many factors; increased patient workload in primary health care facilities, lack of mental health training for primary care physicians, stigmatization, lack of awareness among the public and health professionals, understaffing in health facilities, and lack of mental health guidelines/policies at the primary care level.

The medical needs of the population vary widely, according to primary care physicians.⁸ However, at the same time, they revealed common health problems in the population, regardless of the level of war impact, displaced status, age or gender. These include both physical and mental health problems. Mental disorders are dominated by somatic complaints, depression, anxiety, and symptoms of psychological distress. The number of alcohol and substance use disorders is on the rise.⁹

We must provide sufficient confidentiality and adequate trust between clinicians and patients. We can overcome this stigma affecting patients and provide them with treatment because in primary health care we don’t always diagnose mental health problems. Even if we suspect any mental health issues or medically unexplained issues, people feel stigmatized.¹⁰ Even for counseling, people want to avoid going to a psychiatrist (psychotherapist) because of the stigma.¹¹ We think they are well, judging by their appearance and their daily lives. But, the loss of family members, the loss of work lead to deeper problems in people.

There is a need to study people’s mental health needs at the first contact level, but people are not currently screening or looking for mental health at the primary health care level. Thus, doctors overlook many mental health issues and unnecessarily prescribe painkillers and other medications. The increased burden on primary health care is seen as a major barrier to the effective detection and treatment of mental disorders.

Integrating mental health care into primary health care is useful for delivering better services to people.¹² However, in Ukraine there is a significant gap in the integration of mental health into the primary health care system due to lack of human resources, training, financial constraints, political will, stakeholder involvement and lack of knowledge/awareness among policy makers.

References

1. A lmoshantaf, M. B., Swed, S., Sakkour, R., & Shoib, S. (2023). War and health crisis: humanitarian catastrophe in Ukraine. International journal of surgery (London, England), 10.1097/JS9.0000000000000051.
2. Korzh O. (2022). A letter from Ukraine: challenges for primary care. The British journal of general practice : the journal of the Royal College of General Practitioners, 72 (720), 335.
3. Roszik-Volovik, X., Brandão, A. P., Kollárovics, N., Farkas, B. F., Frank-Bozóki, E., Horváth, L. O., Kaló, Z., Nguyen Luu, L. A., & Balazs, J. (2023). Research group as helpers due to the war in Ukraine: Focus group experiences of women researchers. Frontiers in psychiatry, 14, 1139252.
4. Dean, L., Theobald, S., Nallo, G., Bettee, A., Kollie, K., & Tolhurst, R. (2022). A syndemic born of war: Combining intersectionality and structural violence to explore the biosocial interactions of neglected tropical diseases, disability and mental distress in Liberia. PLOS global public health, 2(6), e0000551.
5. Vus, V., Shipley, K., & Lühmann, T. (2023). Mapping and identifying barriers and facilitators to mental health and psychosocial support interventions for war-affected children. Polski merkuriusz lekarski : organ Polskiego Towarzystwa Lekarskiego, 51(1), 64–73.
6. War in Ukraine Taking Heavy Toll on Mental Health: WHO https://www.voanews.com/a/war-in-ukraine-taking-heavy-toll-on-mental-health-who-/6967840.html
7. Tanner, L. M., Wildman, J. M., Stoniute, A., Still, M., Bernard, K., Green, R., Eastaugh, C. H., Thomson, K. H., & Sowden, S. (2023). Non-pharmaceutical primary care interventions to improve mental health in deprived populations: a systematic review. The British journal of general practice : the journal of the Royal College of General Practitioners, 73(729), e242–e248.
8. Puschner B, Kösters M, Bouché L, Weinmann S. The epidemiology, burden, and treatment of mental disorders in primary care. In: Carvalho AF, McIntyre RS, editors. Mental Disorders in Primary Care: A Guide to Their Evaluation and Management. Oxford: Oxford University Press; 2017.
9. Olivera JN, Ford J, Sowden S, Bambra C. (2022). Conceptualisation of health inequalities by local healthcare systems: a document analysis. Health Soc Care Community, 30(6):e3977–e3984.
10. Hoppen TH, Priebe S, Vetter I, Morina N. (2021). Global burden of post-traumatic stress disorder and major depression in countries affected by war between 1989 and 2019: a systematic review and meta-analysis. BMJ Glob Health, 6(7):e006303.
11. Kessler RC, Aguilar-Gaxiola S, Alonso J, et al. (2017). Trauma and PTSD in the WHO world mental health surveys. Eur J Psychotraumatol., 8(sup5):1353383.
12. Coventry P, Lovell K, Dickens C, et al. (2015). Integrated primary care for patients with mental and physical multimorbidity: cluster randomised controlled trial of collaborative care for patients with depression comorbid with diabetes or cardiovascular disease. BMJ, 350:h638.

Featured image by Diana Vyshniakova on Unsplash