Policy, Mental Health, and Ukrainian Refugees

Co-authored by Amir Afkhami, Renee Mao, M.D., and Varun S. Mehta

The ongoing war in Ukraine has resulted in thousands of civilian deaths and millions displaced.^i,ii The antagonists, particularly the Armed Forces of the Russian Federation, have often ignored the international conventions for protecting civilians in armed conflicts, most prominently documented in the abuse and deaths of Ukrainian noncombatants in the town of Bucha.ⁱⁱⁱ

As these horrors continue to unfold, so too are mental health crises among survivors as they attempt to cope with the myriad physical and psychological traumas endured. Though the direct physical impact of this armed conflict on civilians has dominated the global consciousness, medical literature suggests that the traumas of migration and settlement may have an even greater impact on their long-term psychiatric well-being while also exacerbating the impact of pre-migration trauma.^{iv,v,vi,vii,viii}

Psychosocial risk factors and policies that address these vulnerabilities can reduce the severity of post-migration trauma and associated behavioral health complications and can therefore be a critical area of intervention for Ukrainian refugees.

It is well-established that the number of traumatic events and their chronicity can mediate long-term psychiatric conditions, including depression, anxiety, PTSD, and psychosis. Many Ukrainian refugees have already experienced traumatic violence and assaults, including death, rape, bombardment, and inhumane living conditions in areas of Russian occupation.

However, these refugees now face many potential additional psychosocial traumas stemming from separation from loved ones, loss of social networks, fear for the safety of family members, unstable housing, and barriers to employment, education, and medical care. Making matters worse, they must grapple with the stressors of the asylum-seeking process, including marginalization and discrimination, acculturating to a new environment, adopting a new language, and changes in gender roles and social status. These factors have all been recognized as social determinants of health which can negatively impact the mental health of refugee populations, especially when they accumulate and persist.

As of this writing, approximately six million Ukrainians have fled, mostly to neighboring Western countries, while eight million have been displaced within Ukraine.^ix Women and children comprise 90 percent of these refugees, as military-aged men have been barred from leaving. These women and children must cope with the uncertain fate of their husbands and fathers while they themselves remain vulnerable to gender-based violence, exploitation, and abuse.^x

Poland, which has absorbed the greatest share of Ukrainians, demonstrates many of the long-term challenges with resettlement and integration for countries now hosting this influx. Challenges with housing, education, and integration into the Polish job market are just some of the challenges the Polish government faces.

Poland’s healthcare system, which had been strained even before this most recent conflict. A huge volume of children must be integrated into schools, despite not knowing the language and often suffering from the sequelae of wartime trauma, which is known to impact their cognitive and emotional development.^xi

Historically, integration in Poland has also been fraught with racism, as Poland has recently refused asylum to refugees from Syria, Yemen, Iraq, and Afghanistan.^xii

These are enormous long-term challenges all host countries face, as witnessed in other migration crises, such as that of Syrian refugees in the past decade. These challenges require a sustained, coherent political will from both the host government and citizens to address. Unfortunately, as time passes and the conflict endures, there is a greater risk that this will fade while refugees become more vulnerable to the chronicity and accumulation of their stressors.

Refugees are estimated to have rates of depression and PTSD of up to 15-30 percent. They are also at elevated risk of adjustment, anxiety, and psychotic disorders. Refugees may experience difficult emotions, including grief, mourning, and distress, which may not meet the criteria for a formal psychiatric disorder but nonetheless can be distressing and debilitating.^xiii,xiv

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As Ukrainian refugees face difficulties from multiple angles, host countries must also take a comprehensive approach to mitigate these challenges. Starting from the psychosocial perspective, countries must address refugees’ needs for safe and stable housing, healthcare, employment, and education, as the failure to address these needs heavily predisposes refugees to mental illness while constraining the potential benefit of mental health interventions.

Regarding education, in particular, early childhood education programs have been instrumental for both children and parents to identify and mitigate developmental delays.^xv

As refugees attempt to settle, countries must reduce practices in the asylum process, which prolong separation, uncertainty, and instability, including limiting processing times and increasing visa/residency permit lengths. Community-based interventions that build collective identities and support networks have the potential to mitigate the risks of social isolation while providing a means for refugees to advocate for themselves and increase their sense of agency.

Direct medical interventions must also be comprehensive and exceed trauma-focused treatments. Providers must maintain cultural awareness while screening refugee patients for the immediate aftereffects of trauma and mental illness, as well as screening for other health conditions which may have arisen during forced displacement, such as malnutrition and infectious disease.

Similar to government actors, healthcare provision for these refugees should also incorporate local community participation and feedback and seek to adapt therapeutic measures and interventions in a way that incorporates the Ukrainian cultural context. This should include training mid-level providers and other behavioral health paraprofessionals to utilize the Ukrainian language when possible, have ready access to translators, and select treatment locations that are easily accessible and perceived as “safe” by refugees, such as their homes, schools, and places of faith.^xvi

As the war in Ukraine has disrupted the global order, so too has it dislocated the lives of millions of individuals. Only a comprehensive, multidisciplinary approach that addresses the myriad social determinants of health, both physical and psychological, can truly reassemble a life torn apart by war.