Heal Ukraine Trauma - Mental Health in Ukraine (April 2023)

MENTAL HEALTH IN UKRAINE
APRIL 2023
26 February 2022, Ukraine, Uzhgorod-Vyshne Nemeckoe: Refugees from Ukraine on the border
with Slovakia (checkpoint "Uzhgorod-Vyshne Nemeckoe") in the Zakarpatya regions. Photo by
Fotoreserg.
ABOUT THIS REPORT
Nick Smith, a program developer at Heal Ukraine Trauma (HUT), and
Oleh Orlov, a Kyiv-based psychologist and one of HUT’s co-founders,
developed this report. Numerous Ukrainian and non-Ukrainian academic
and news sources were used to write this report. A few key informant
interviews supported these sources to fill gaps in the evidence base.
Elise Wilson, one of HUT’s Co-founders and Director of Programs and
Operations, provided critical guidance for this project. Moreover, multiple
insightful reviews were provided by three of HUT’s other co-founders,
Elaine Klein, Elizabeth Ames, and Colin Greenstreet, alongside advisory
board member Jennifer Van Wyck. Finally, this report was edited by
Anne Wallentine and formatted by Sam Lynch.
ABOUT HEAL UKRAINE TRAUMA

HUT is the first project of Heal Traumas International, Inc., a U.S.-based
non-profit founded in April 2022 to implement conflict-related trauma
solutions in Ukraine. We work with trauma experts and strategic partners
to scale existing evidence-based programs and pilot new programs. You
can learn more about us here: https://healtraumas.org.
All donations to HUT are tax deductible to the fullest extent allowed by
law. Tax ID Number: 88-2231121.
For any inquiries, please contact our team at info@healtraumas.org.
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Table of Contents
4 Executive Summary
10 Introduction
12 The Demographics of Ukraine
14 The Mental Health Need in Ukraine
27 Mental Health Care in Ukraine
42 Conclusions
44 References
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Executive Summary
On February 24, 2022, Russia launched a full-scale invasion of Ukraine. A
recent UN survey showed that Ukrainian people believe that the most
significant impact of the war was on their mental health.1 The impact of
conflict on mental health is a widely researched phenomenon and will affect
Ukrainians for decades, yet mental health does not receive the attention or
resources it deserves.
Despite some significant developments shaping a promising future for

mental healthcare in Ukraine, the war has imposed an enormous mental
health burden on a mental healthcare system that is not equipped to deal
with this burden.2 This report aims to provide an overview of mental health
needs, mental healthcare structures, and mental health provision in Ukraine
today, together with a broader healthcare and societal context. It does not
encompass recommendations.
The Mental Health Burden in Ukraine

Before the most recent Russian invasion in 2022, Ukraine already had a high
mental health burden. Mental health disorders were Ukraine's second highest
disability burden and impacted 30% of the population before the war. Some of
the drivers for this burden include historical Soviet-era trauma, Russia’s
invasion of Ukraine in 2014, and, more recently, COVID-19.3 4
Russia's second invasion in 2022 has compounded these underlying issues.

Around nine million people will suffer from common mental health disorders
(CMDs) due to Russia’s invasion, and around two million will suffer from
severe mental health disorders.5 As a result, the Ukrainian Ministry of Health
predicts that four million people would need psychotropic medication and as
many as 15 million would need other psychosocial support.6
However, the mental health burden is not uniform across demographics.

Table 1 highlights some of the key stressors for different populations within
Ukraine emanating from the invasion.
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Table 1: Demographic breakdown of the impact of Russia’s invasion on Ukrainian mental
health
Demographic Mental Health Stressor
• Gender-based violence
Women • Traditional gender roles, including responsibility
for emotional care within the family
LGBTQIA+ • Lack of safe spaces and non-discriminatory
Gender psychological help
• Traditional gender roles in the family, including
Men providing basic needs
• Stigma towards mental health
• Conscription into the armed forces
• Lack of training and screening for civilians
Military and Veterans joining the military
• Conflict-related trauma
• Separation from families
• Family, friendship, and educational breakdown
• Vulnerability to violence, malnutrition, illness,
Children and human trafficking
• Inability to comprehend the complexity of war
• Family separation
• Intergenerational inequality over the control of
resources
• Disruption to capabilities to meet physical
needs
• Breakdown of psychosocial support, which is
People with Disabilities more critical for this group
• Targeting for killings, torture, and sexual
violence
• Existing stigma, isolation, and barriers to
community support prior to the conflict
• Non-inclusive evacuation
• Physician shortages
Healthcare Workers • High-pressure work
• A system focusing on outcomes rather than
worker well-being
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• Mental health stigma
Pre- Displacement• Conflict-related trauma and violence
• Destruction of support network

Displaced
• Bureaucratic processes
Populations
Post-displacement• Unemployment
• Discrimination
• Minimal education
• Exploitation
The geographical distribution is also heterogenous. Populations on the front

line, in areas that have experienced Russian atrocities, and in areas impacted
by weapons with wide area effects are more likely to have experienced
trauma. Furthermore, displaced populations have a significant need for
mental health support, so areas where there are high concentrations of
internally displaced people (IDPs) and where service provision for IDPs is low
will need special attention. These issues are detailed in Figure 1.
Figure 1: Top left, areas held or regained by Ukraine7 top right, sites of reported missile strikes
across Ukraine; 8 bottom left, location of IDPs in Ukraine; 9 and bottom right, percentage of
displaced survey respondents (conducted from April to early July 2022) struggling to access
basic goods and services.10
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Mental Healthcare Structure in Ukraine
Ukraine's centralized healthcare system results in relatively strong
inpatient care and weak outpatient care. While the availability of inpatient
mental healthcare is quite good, the level of outpatient care is more limited,
as it is mainly based in cities and inefficiently organized, with many services
only functioning as dispensaries focusing on one mental healthcare sphere.11
Moreover, mental healthcare is significantly underfunded. Around 2.5% (or

6.25 USD per capita) of healthcare expenditure is allocated to mental health.
This is extremely low compared to high-income countries, which have an
average spend of 58.71 USD per capita.12 Additionally, in practice up to 90% of
inpatients must pay for services themselves, and outpatients must pay for all
services, leading to high out-of-pocket expenditure.13
There is also a complex constellation of actors who provide mental

healthcare. Ukraine has a relatively high number of psychiatrists at 9.8 per
100,000 people; however, there is significant heterogeneity in the supply of
psychiatrists across regions.14 On the other hand, there is a relatively low
number of psychologists at one per 100,000, and social workers are virtually
absent at 0.3 per 100,000 people.15 All physicians are trained in basic
psychiatry during pre-service training.16 However, this training is inadequate
to provide mental healthcare to patients and the system of supporting the
training of mental health practitioners suffers from multiple deficiencies and
a lack of evidence-based practice.17 18 19 On top of this, civil society
organizations and volunteers have proliferated to address Ukraine’s
increased mental health burden since Russia first invaded Ukraine in 2014.
However, nonprofits (NPOs) and non-governmental organizations (NGOs)
have also caused some significant issues, including a lack of coordination,
accountability, and engagement of local partners in long-term programs.20
Finally, most mental health services are provided by private
psychologists/therapists who are often not officially registered.21
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Alongside the centralization of mental healthcare in Ukraine, there are
three other factors that drive the gap in access to mental healthcare:
stigma, affordability, and quality. First, stigma and discrimination are the
primary barriers to accessing mental healthcare in Ukraine. Many
communities see mental health disorders as trivial and blame the people
suffering, labelling them weak, while older generations distrust the psychiatric
system because the Soviets used it as a suppressive tool before 1991 by
diagnosing dissidents with mental illness and incarcerating them in the
country's psychiatric hospitals.22 Compounding this is the unaffordability of
mental healthcare, resulting in approximately 92% of the population worrying
about the financial burden of becoming ill.23 Thirdly, the low quality resulting
from structural issues and the community’s poor ratings of mental healthcare
fuel the community's low trust in mental healthcare professionals, further
preventing people from seeking mental health assistance.
Finally, the war has had a significant impact on the structures of mental
healthcare in Ukraine. Figure 2 is a diagram provided by the World Health
Organization (WHO) that outlines the optimal mix of mental healthcare in a
country. There is a mixed picture for Ukraine's informal services. Informal
services were lacking before the invasion, and the invasion has created
stressful material and social conditions that are increasing the pressure on
these services.24 However, the Ukrainian population have developed various
coping mechanisms that bolster informal services, including volunteering,
managing media consumption, outdoor activity, and spirituality. Ten months
of war has left Ukraine's formal services battered, with more than 600 attacks
on healthcare facilities since February 24, 2022. Those left un-attacked face
supply chain issues and are inundated by patients seeking treatment for
trauma and injuries resulting directly from the conflict.25 26
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Figure 2: WHO Service Organization Pyramid for an Optimal Mix of Services for Mental
Health.27
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Introduction
As of April 2023, the US estimates that 124,500-131,000 Ukrainian and 189,500-
223,000 Russian combatants have been killed or injured since Russia’s second
invasion of Ukraine in February 2022.28 On top of this, the invasion has
displaced over 16 million Ukrainians, and the UNHCR has confirmed 21,293
civilian casualties and expects the actual number to be much higher.29
Furthermore, Ukraine’s economy contracted by 30% in 2022.30 Poverty
reduction goals were set back by 15 years, with eight million additional
Ukrainians living in poverty by the end of 2022, and according to the Kyiv
School of Economics, the damage inflicted by Russian forces on Ukrainian
infrastructure was $127 billion as of September 2022.31 32 Finally, a report by the
World Bank, Ukrainian government, and European Commission showed that
by June 2022, Ukraine had lost $252 billion through disruptions to economic
flows and production and extra expenses linked to the war.33
However, a recent UN survey showed that Ukrainian people believe that the
most significant impact of the war was on their mental health.34 The impact of
conflict on mental health is widely researched, yet it still does not receive the
attention it deserves. Direct exposure to conflict, stressful material and social
conditions caused by conflict, and factors unrelated to conflict can lead to a
high prevalence of Post-Traumatic Stress Disorder (PTSD), depression, anxiety,
and suicidal ideation in conflict-affected communities.35 This mental health
burden can have long-term detrimental impacts on these populations
through human suffering and reduced physical health, human capital, and
economic productivity.
This report outlines three key complexities that all organizations planning to
address mental healthcare in Ukraine should consider. First, Ukraine already
had one of the highest mental health burdens in the world due to historical
trauma, Russia’s first invasion of Ukraine, and COVID-19. Second, the impact
distribution across demography and geographies is not uniform.36 37 Third, the
centralization, low funding, complex constellation of providers, low
affordability, and low quality of the Ukrainian mental healthcare system,
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alongside stigma towards mental health and the impact of war on mental
healthcare structures, drives a sizeable mental healthcare gap in the country.
Despite these complexities, Ukraine has started to build a solid base which the
government, the private sector, and civil society can use to develop the
current system into a high-quality mental healthcare system when the
current acute humanitarian phase is over. For example, Ukraine has joined the
Pan-European Mental Health Coalition, set up 126 community mental health
teams with the World Health Organization (WHO), and participated in the
Mental Health Gap Action Program (mhGAP) initiative to help scale the
management of CMDs in primary healthcare.38 HUT is excited to contribute to
this development alongside our Ukrainian and international partners.
The report is organized into four sections. First, it will present the
demographics of Ukraine. Then, it will outline the mental health need in
Ukraine, followed by the mental healthcare structure in Ukraine. Finally, it will
present conclusions.
The Demographics of Ukraine
Ukraine’s population decreased from 44 million in 2021 to around 36 million in
2023 as a result of Russia’s second invasion, and had already experienced
several decades of decline since 1990.39 This historical decline is a result of
high emigration rates due to Russia’s first invasion, high rates of poverty and
corruption, low birth rates (9.2 births per 1000 people), and high death rates
(15.2 per 1000 people).40 Moreover, Ukraine’s population is aging, with only 12%
of people between 15 and 24, 57% between 25 and 64, and 15% over 65.41
Ukraine also has a relatively low life expectancy of 71.2 (76.7 for women and
66.7 for men), which is lower than the global average of 72.8 (75.1 for women
and 70.6 for men).42
These pressures have been exacerbated by Russia’s invasion of Ukraine in

2022, decreasing the rate of population growth to -7.45% in 2022 from -0.6% in
2021, and making it the lowest in the world by around 5%.43 44 This decrease is
likely to continue, but estimating the post-war population trend is difficult.
Ukraine has four cities with populations over one million, with Kyiv having the
largest population at roughly three million people. The main ethnic groups are
Ukrainian (77.8%) and Russian (17%), with Belarusian, Bulgarian, and
Hungarian minorities making up most of the remainder. 45
The country’s spoken languages tell a similar story, with 67% of people
speaking Ukrainian and 28% speaking Russian before Russia’s second
invasion.46 However, since then, Ukrainians are rapidly repudiating the Russian
language, with friendship groups, poets, academics, and companies
conversing entirely in Ukrainian, showing an increasing cultural divide
between Russia and Ukraine.47
The predominant religious groups are the Kiev Patriarchy Orthodox Church
and the Moscow Patriarchate Orthodox Church, with a diverse mix of other
minority religions.48 The autonomy achieved by the Kyiv Patriarchy Orthodox
Church in 2019 shows further cultural divisions between Ukraine and Russia as
the Moscow Patriarchate Orthodox Church and its leader, Patriarch Kiril, has
become increasingly unpopular in Ukraine.49
The Mental Health Need in Ukraine
Overview
Before the most recent Russian invasion, Ukraine already had a high mental
health burden. Mental health disorders were Ukraine's second highest
disability burden and impacted 30% of the population, with depression being
particularly acute alongside other common mental health disorders like
anxiety, substance abuse, and alcohol abuse.50 Moreover, suicide was the
leading cause of adolescent deaths in European Low- and Middle-Income
Countries (LMICs), and in Ukraine, the prevalence for suicidal ideation for this
group was as high as 30%. 51
There is a particularly high mental health burden in Eastern Ukraine and

within displaced populations from the first invasion. A study by the Turku Child
Psychiatry Research Centre examined the impact of the 2014 Russo-Ukrainian
war on adolescent mental health.52 They found that adolescents in Donetsk
were four times more likely to develop PTSD than in Kirovograd, just over three
times more likely to have severe anxiety, and nearly three times more likely to
have moderate to severe depression.53 However, the study also found
increased levels of anxiety and depression in areas unaffected by the war,
emblematic of the impact of conflict on the mental health of communities
that are not experiencing first hand violence. 54
COVID-19 also exacerbated Ukraine's mental health burden as closures of

schools, restaurants, gyms, and entertainment venues along with border
closures in Eastern Ukraine separated families, friendship groups, and other
support networks for long periods of time.55 Furthermore, the economic strain
imposed by COVID-19 added to the pressures that drive the mental health
burden.
In addition to these stressors, gaps in mental health treatment ensured the

prevalence of mental health issues remained high. Only 4% of the country's
population received mental healthcare in 2018, meaning that 26% of Ukraine's
population had mental health issues that were not treated. 56 A further 75% of
people lost access to mental healthcare in 2020 due to the pandemic, so only
1% of Ukraine's population received mental healthcare while 29% were left
untreated.57
Russia's invasion has compounded these underlying issues.58 The invasion

has stripped civilians of their sense of identity. Their world was turned upside
down overnight, allowing for little preparation and increasing cases of
depression, anxiety, and PTSD.59 These issues are rooted in all-encompassing
trauma that hits sequentially, including a fear of death, loss of freedom, grief,
separation of families, social dislocation, social disruption, forced migration
and more.60 These drivers often have devasting consequences, and evidence
is starting to show that they can cause epigenetic alterations by leaving
chemical marks on people's genomes which changes the way genes are
expressed. These changes can then be passed on to future generations.61 62
A WHO study estimated that the prevalence of CMDs—including depression,

anxiety, PTSD, bipolar disorder, and schizophrenia—in a conflict-affected
population is around 22%.63 Moreover, they estimated the prevalence of
severe mental health disorders was around 5%. Therefore, around nine million
people will suffer from CMDs due to Russia’s invasion, and around two million
will suffer from severe mental health disorders. 64 As a result, the Ukrainian
Ministry of Health predicts that four million people would need mental health
drugs and as many as 15 million would need other psychosocial support.65
Demographic Breakdown
The following section elucidates the impact of Russia’s invasion on the mental
health of different demographic groups in Ukrainian society. While not
comprehensive, this section touches on some of the most important
differences between different demographic groups. It is also important to
note that people often fall into multiple demographic categories and
therefore face multiple pressures at any one time.
Gender
Different genders face different pressures because of Russia’s invasion of

Ukraine. Women and girls are subject to increased instances of gender-
based violence, including rape, gang rape, sexual torture, and forced nudity.
At the same time, the war has weakened the structures that are supposed to
prevent gender-based violence.66 Furthermore, as the news of increased
gender-based violence has spread, women feel less comfortable spending
time outdoors, which is a critical coping strategy for mental health. 67 While the
extent of this problem is not yet clear, the impacts of increased gender-based
violence will be widespread and long-term.68 These issues will be especially
difficult to deal with considering the Ukrainian legal system already views
gender-based violence as a private matter that should be dealt with by the
victim.69
Women also take more responsibility for emotional care within the family.70 A
2020 rapid assessment of the situation and the needs of women in Ukraine in
the context of COVID-19 showed that over 53% of women devoted more time
to emotional care, compared to 39% of men.71 When families are displaced,
the lack of appropriate support means that women focus more of their
attention on the emotional well-being of their children and partners and less
attention on their own well-being, despite suffering their own conflict-related
trauma.72 Women are also more likely to become IDPs or refugees, which
comes with a host of drivers for mental health issues (as discussed below).
Men also face an increasing mental health burden for several reasons. While
the loss of income generating activities fuels stress about meeting families'
basic needs for both men and women, traditional gender roles place more
emphasis on the role of men in providing for the family. 73 Similarly, though all
genders are impacted by stigma towards mental healthcare, this is mostly
felt by men, who are more reluctant to speak about their emotional state or to
seek help.74 Furthermore, the majority of military and veterans are men, and
this also comes with a host of drivers for mental health issues (as discussed
below).
Finally, lesbian, gay, bisexual, transgender, queer, questioning, intersex,
asexual, and agender (LBGTQIA+) people struggle to find safe spaces during
peacetime, and this is amplified during war. For example, when families have
had to move in together, LGBTQIA+ people may face situations in which they
live with people who do not accept their identity or choices.75 They also note
that they require psychological help that is safe and not discriminatory.76
Military and Veterans
A particularly vulnerable group in Ukraine is those suffering from military

trauma.77 Civilians have enlisted into the army with little or no training and no
screening for suitability. This lack of training and screening makes these
combatants vulnerable to feelings of unpreparedness, leading to stress and
decreasing self-efficacy, which can make them more vulnerable to
substance abuse.78 79
Moreover, enlisting in the military will separate these combatants from family
and social networks, which they rely on to self-medicate mental health issues.
This driver might be amplified in these combatants, as they will be worried
about their families who face the stressful conditions that come with
displacement. Connecting the combatants with their families might be
challenging, but technology could overcome these barriers. For example, a
new app allows Ukrainian soldiers to remotely read their children stories.80
These stressors often translate into mental health disorders. For example,
data in Ukraine from 2012-2021 shows that military hospital admissions for
mental health increased 6.97 times during periods of active hostility. Most of
these cases were related to anxiety, stress, and other nonpsychotic
disorders.81 Another study that found 57% of Ukrainian veterans needed
psychological support. More specifically, 54% needed support due to family
conflicts; 24% due to sleep, appetite, and anxiety disorders; 12% due to
uncontrollable aggression; 6% due to suicidal behaviour; and 4% due to
substance abuse.82 While there are military psychologists deployed, their
main role is keeping fighting forces functional rather than long-term
therapeutic treatment.83
Notably, most combatants are distracted by the fighting, while their
adrenaline prevents a deterioration in mental health. The end of the war
could mean the end of this barrier to deteriorating mental health among
combatants, leading to a wave of severe mental health disorders in a large
part of the Ukrainian population.
Children
Children in Ukraine are also vulnerable to mental health disorders. Children

face isolation and family, friendship, and educational breakdown alongside
vulnerability to sexual violence, malnutrition, and illness.84 Exposure to
different types of violence, conflict duration, and the nature of trauma either
witnessed or experienced can also lead to increased susceptibility to mental
illness in later in life.85 The same study by Turku University showed that of
adolescents living in war zones, 60% had witnessed armed attacks, 14% were
victims of violence, and 30% were forced to leave their homes.86 The global
gap in access to mental health for children exacerbates this vulnerability.87
Young children are particularly vulnerable because the invasion rapidly

removed their safety. They cannot comprehend the complexities of war, they
cannot rely on their parents who are also confused and insecure, they cannot
rely on broken friendship networks, and taking refuge brings new challenges
(discussed below).88 Moreover, more than 2,400 education facilities have
been damaged or destroyed, reducing the number of child-friendly spaces
used for socialization.89
Additionally, many children have been separated from their families.90 While
the number of children separated from their families is unclear, the number is
"distressingly" high.91 92 This group requires specific care because they cannot
look after themselves, and there is intergenerational inequality over the
control of resources. These children are also at serious risk of human
trafficking and abuse.
As a result, the 2014 invasion played a critical role in approximately one in

three children showing signs of depression and PTSD prior to the recent
invasion.93 The recent invasion is compounding this by putting over 1.5 million
Ukrainian children at risk of developing mental health disorders like
depression, anxiety, and PTSD.94 People are also noticing that children are
creating war-associated drawings in classrooms, playing more aggressively,
and are in more need of attention.95
People with Disabilities
There have been relatively few studies on the impact of war on the mental
health of people with disabilities. However, some of the studies have
documented more worry, avoidant behaviour, and post-traumatic stress
reactivity in this population.96
War can be more detrimental towards the physical needs of people with
disabilities, like disruptions to protected spaces, toilets, showers, and the
supply of appropriate food and medicine. Additionally, people with disabilities
are often more reliant on certain psychosocial needs like family bonds, social
connections, mental health support, and a sense of belonging that can be
disrupted by war.97 People with disabilities can even be targeted for killings,
torture, sexual violence, and may be used as human shields.98
In Ukraine, people with disabilities have experienced challenges since the first
invasion, as shown by a United Nations Office for the Coordination of
Humanitarian Affairs (OCHA) report that estimated that people with
disabilities made up 13% of the population requiring humanitarian
assistance.99 This percentage is disproportionate, as only 6% of the total
population in Ukraine has a disability.100 Since Russia's invasion in 2022, the
entire population of 2.7 million people with disabilities across Ukraine are at
risk of developing mental health issues as a result of their physical and
psychosocial needs being disrupted.101
Moreover, even before the invasion, people with disabilities faced stigma,
isolation, and barriers to accessing community support.102 Stigma towards
people with intellectual disabilities persists and even worsens during conflict.
These issues are particularly acute for the tens of thousands of people
segregated from communities in residential institutions, with footage of
children with disabilities living in inhumane conditions often tied up and
restrained alongside powerless staff.103 104
Some of the issues people with disabilities face in Ukraine also stem from
evacuation. For example, the communication of information on evacuation,
location of shelters, and assistance is not inclusive. This lack of inclusivity
means that people with disabilities find it difficult to access humanitarian
assistance and are often left behind, facing separation from critical support
networks.105 Furthermore, people with intellectual disabilities may be unable to
understand the war and evacuation, with any changes to their everyday life
having a massive impact on their mental health.106
Healthcare Workers and First Responders
Healthcare workers and first responders are vulnerable due to physician

shortages, the stress associated with their profession, and a system focusing
on efficiency and outcomes rather than worker well-being. These stressors
lead to burnout, depression, and alcohol and substance use.107 Moreover,
there is a stigma towards mental health within the profession, as healthcare
workers do not want to become patients. The Russian invasion of Ukraine is
increasing pressure on healthcare workers and first responders and, in turn,
worsening the burden of mental health already faced by this population.
Displaced Populations
At least 15 million Ukrainians have been forced to flee their homes since
February 2022.108 Displaced populations face stressors both before and after
displacement. Pre-displacement stressors include conflict-related trauma
and violence. In contrast, post-displacement stressors include bureaucratic
processes, unemployment, discrimination, minimal education, and
exploitation, and are often more significant drivers of mental health disorders
than pre-displacement stressors.109
One of the most important impacts of displacement is the destruction of

support networks through family and friendship separation. Most of those
displaced are women and children, as men must stay behind as combatants.
Moreover, many people who are older or disabled are unable to flee the
conflict, so have had to stay behind. This family separation has a severe
impact in Ukraine, as people rely on these networks to address mental health
needs instead of seeking professional help due to the high levels of stigma
towards mental health discussed below.
There are four distinct populations of displaced people to consider – IDPs,

Ukrainian refugees and asylum seekers outside of Ukraine, refugees and
asylum seekers within Ukraine, and stateless persons.110
a. Internally Displaced People (IDP)
IDPs are "persons or groups of persons who have been forced or obliged to
flee or to leave their homes or places of habitual residence, in particular as
a result of or in order to avoid the effects of armed conflict, situations of
generalized violence, violations of human rights or natural or human-
made disasters, and who have not crossed an internationally recognized
state border."111
In 2021, Ukraine had the 9th largest IDP population in the world—1.5 million—
due to Russia’s invasion of Donbas and Crimea in 2014. The most recent
Russian invasion has significantly increased this number to eight million
people, which amounts to 20% of the total population, including more than
2.5 million children.112 113 114
Rates of mental health disorders among IDPs are very high, especially
among women. A 2016 study of IDPs who were displaced due to the war in
Eastern Ukraine suggests the prevalence of mental health disorders may
be as high as 32% for PTSD (22% men and 36% women), 22% for depression
(16% for men and 25% for women), and 18% for anxiety (13% for men and
20% for women).115
Despite the prevalence of mental health disorders in these populations,

the evidence since the start of the Eastern Ukrainian conflict shows that
74% of IDPs are not seeking mental health services. The reasons why IDPs
were not seeking care included a preference for self-medication,
affordability, stigma, lack of awareness, lack of understanding by
healthcare providers, and poor quality.116
b. Ukrainian Refugees and Asylum Seekers Outside of Ukraine
Many Ukrainians have left the country since the invasion in February to
seek shelter in other countries, primarily in Europe. European countries
have recorded about 7.8 million Ukrainian refugees and registered 4.8
million for temporary protection.117 Ninety-four percent of refugees
registering for temporary protection are women and children and Poland
hosts the most refugees at 1.4 million, with the majority being children,
women, and the elderly.118
The gap in access to mental healthcare for refugees is like that for IDP
populations in Ukraine, and similar factors drive this gap. 119 An additional
driver behind the gap in access to mental healthcare in foreign countries
comes from the language barrier, which can stop refugees from seeking
help or make it difficult to describe what they are feeling. Financial barriers,
including the costs of transportation, services, or medication, as well as
cultural stigma from their country of origin, can also stop them from
seeking help.120
Evidence from past crises shows that if mental healthcare facilities

targeting refugees are not scaled up, then refugees will struggle to
integrate into their host countries.121 As part of this scale-up, there needs to
be a mental health outreach strategy led by host communities that
includes comprehensive communication plans.122 In Poland, there is a
department for “integration” and Caritas Poland is also leading many
integration programs, including language classes, employment
assistance, basic psychosocial support services, and in some cases
advanced mental health services.123
Refugee populations also have a higher risk of suicide than the general
population, especially from areas with already elevated mental health
risks.124 As countries receiving Ukrainian refugees such as Lithuania,
Slovenia, and Hungary, have some of the highest rates of suicide in Europe,
the rate of suicide in refugee populations is likely to be significant.125
c. Refugees and Asylum Seekers in Ukraine
The third group is refugees and asylum seekers in Ukraine. Refugees are
“unable or unwilling to return to their country of origin owing to a well-
founded fear of being persecuted for reasons of race, religion, nationality,
membership of a particular social group, or political opinion.”126 As of 2021,
Ukraine hosted approximately 2,200 refugees.127
Alternatively, an asylum seeker is "a person who is unable or unwilling to

return to their country who has not yet been legally recognized as a
refugee and is waiting to receive a decision on their asylum claim.”128 As of
2021, there were approximately 2,700 asylum seekers in Ukraine, mainly
from Afghanistan, Syria, Bangladesh, Commonwealth Nations, and
Russia.129
These populations were already facing similar stressors to those faced by

Ukrainian IDPs and refugees. Russia’s invasion of Ukraine has exacerbated
their vulnerability.
d. Stateless Persons
A stateless person is "a person who is not considered as a national by any

State under the operation of its law.”130 As of 2021, Ukraine had 40,000
stateless people, including marginalized groups like Roma and older
generations who still hold Soviet passports. Furthermore, 60,000 people
born in Donetsk and Luhansk since 2014 are at risk of becoming stateless
as they have no birth certificate, a number that is likely to increase due to
the invasion.131
Geographic Breakdown
The geographical distribution of the mental health burden and the drivers
behind this burden are heterogeneous. Populations in regions most impacted
by violence will likely need the most mental healthcare. Approximately 67% of
IDPs have come from Eastern Ukraine and this number has increased by 77%
from March to August 2022, reflecting the increasing concentration of the war
in this region. On the other hand, the internal displacement of people from
Northern and Central Ukraine has steadily decreased across this period,
showing the decreasing concentration of conflict in these regions.132
Multiple sources of trauma exist in

Figure 3: Areas held or regained by Ukraine.134
occupied regions, including Russian
authorities blocking access to
critical care, aggressive stop and
searches, Russian military police
raids in people's homes,
incarceration, torture, and a lack of
basic services like water and
electricity.133 Therefore, as Ukraine is
regaining areas in Eastern Ukraine
as shown in Figure 3, liberated
populations will desperately need
access to mental health
assistance.134
Populations in areas that have experienced Russian atrocities are particularly

susceptible to conflict-related trauma. For example, areas of Kyiv (including
Bucha and Irpin), Kharkiv, and Chernihiv have experienced civilian executions,
rape, unlawful violence, and looting.135 Evidence of mass graves in Izium shows
that the Ukrainian military will continue to uncover evidence of atrocities and
hardship as they liberate more land from Russian control.
Additionally, populations in
Figure 4: Sites of reported missile strikes across Ukraine.137
areas impacted by
weapons with wide area
effects shown in Figure 4
are more likely to have
experienced trauma.
Russia has targeted
populated areas including
main cities like Kyiv and
Kharkiv with heavy
shelling, making civilians
more prone to mental
health disorders in these
areas.136 While there may
be an increased incidence
of mental health disorders in these regions, it is important not to confuse
natural reactions to traumatic
Figure 5: Location of IDPs in Ukraine.138
events with the onset of a
mental health disorder.137
As discussed, displaced
populations have a significant
need for mental health support.
Most of the IDP population is
concentrated in Eastern and
Western Ukraine as shown in
Figure 5.138
The intensity of post-displacement stressors for IDP populations is a
significant driver in the onset of mental health disorders. Figure 6 shows
that IDPs in Eastern Ukraine have the lowest access to goods and
services, which is one of the key post-displacement stressors, while IDPs
in Western Ukraine have relatively higher access.139140
Figure 6: Percentage of displaced respondents to a survey conducted from

April to early July 2022 struggling to access basic goods and services.140
It is worth noting that some IDPs are sheltering in public places like air raid
shelters, metro stations, and collective shelters like schools, churches, gyms,
or concert halls. However, most IDPs are sheltering with family and friends or
in rented private accommodations, making them more challenging to
identify.141
Mental Healthcare in Ukraine
The Ukrainian Healthcare System
Healthcare Statistics
The Ukrainian government spends less on healthcare than its European

neighbors. In 2019, expenditure on healthcare in Ukraine was 7% of GDP
compared to 10% in the European Union (EU).142 Per capita, the difference is
even greater at 250 USD in Ukraine and 3500 USD in the EU. 143
Ukraine also has an exceptionally high level of out-of-pocket healthcare

spending at 51% compared to 16% in the EU, despite the constitutional right to
a package of healthcare services free at the point of use.144 The high rates of
out-of-pocket expenditure are mainly due to the high cost of
pharmaceuticals and informal payments for services that are supposed to be
free.145 146 Most government expenditure goes to inpatient services (52% in
2012) and a small amount to outpatient services (4.3%), while both in- and
outpatients pay for most pharmaceuticals.147
Ukraine currently has 76 doctors, 569 nurses, and one pharmacist per 100,000
people and is facing an emigration crisis of healthcare workers.148
Healthcare Reform
The Ukrainian healthcare system is transitioning to a system based on

western standards but maintains vestiges from the soviet era. It is highly
centralized, with the Ministry of Health (MoH) coordinating healthcare while
regional authorities implement the MoH’s policy.149 The system is also highly
fragmented, making it difficult to transfer funds between different levels of the
system.150
Healthcare reform accelerated in Ukraine after the 2014 Euromaidan

Revolution. In 2015, the MoH acted to root out corruption in procuring
medicines and vaccines by outsourcing procurement to international
organizations, including UNICEF, the United Nations Development Program,
and Crown Agents.151 By outsourcing procurement, the MoH increased
transparency and reduced the prices for vaccines and drugs.152
Then, in 2016, the MoH, under a new reformist Minister of Health, Ulana Suprun,
started to completely overhaul the healthcare system with the twin goals of
reducing corruption further and improving the health outcomes of the
Ukrainian population. Reforms included:153
• Reconfiguring the system of primary care financing from one that

provided lump sum payments to healthcare facilities regardless of the
number of patients or quality of care to one that paid healthcare
facilities per patient treated. In this new “money follows the patient”
system, patients could switch to a new healthcare provider if they were
dissatisfied with the service they received, thus putting pressure on
healthcare providers to improve the quality of care they provided.
• Increasing the wage of healthcare providers to reduce out-of-pocket
expenditure for informal payments.
• Reforms focused on reducing corruption in medical university
admissions and the appointment processes for Senior Healthcare
Managers.
• The digitization of the healthcare system by Transparency International
to improve the management of healthcare spending and to reduce
corruption.
These reforms were starting to produce positive results. By 2020, 97% of

primary healthcare providers had signed on to the new financing system,
rates of bribery when accessing primary healthcare fell from 20% in 2017 to 7%
in 2018, and 29 million patients, 24,500 doctors, and 11,000 pharmacists had
joined the new electronic healthcare system. 154 Additionally, there was a
consistent satisfaction rate with primary healthcare doctors at over 70%. 155 As
a result, corruption and the cost of healthcare for Ukrainians decreased, whilst
the efficiency of the healthcare system increased. 156
However, Suprun’s reforms stalled in 2019. Her efforts to overhaul the corrupt
and inefficient pre-2014 health care system left her open to attacks from anti-
reformist political factions.157 158 Despite support from President Poroshenko
and Prime Minister Groisman, Suprun was eventually forced out of office in
August 2019 after Kyiv’s Regional Administrative Court moved to suspend her
authority as acting Minister of Health.159
The risks to reforms deepened when President Zelensky entered office and
quickly cycled through three Ministers of Health, including Maksym Stepanov,
a vocal critic of reforms who stepped down after accusations of corruption.160
Healthcare reform in Ukraine has been challenging and vulnerable to reversal

due to its politically charged nature and the powerful vested interests in the
pre-2014 system. Despite this, the reforms made from 2014-2019 laid the
foundations for a more effective healthcare system and have shown that
positive change is possible.
Mental Healthcare Structure in Ukraine

Ukraine's Semashko-style (publicly owned and controlled) centralized mental
healthcare structure is also in transition. The MoH oversees psychiatric and
narcological departments in hospitals and specialty psychiatric and
narcological hospitals. Overall, the availability of inpatient mental health
services is quite good.161
However, the level of outpatient care is more limited. There are networks of
outpatient clinics, polyclinics with mental healthcare providers on staff, and
psychiatric agencies that work under other departments.162 However, these
networks are mainly based in cities and are inefficiently organized, with many
services only functioning as dispensaries focusing on one mental healthcare
sphere.163
Moreover, psychologists and psychotherapists working in outpatient care

cannot diagnose people but still provide psychotherapeutic interventions,
and there is little communication between different clinics and roles. For
example, psychiatrists will diagnose patients but do not communicate with
psychologists about interventions and patient care.164
Underlying these inefficiencies is the low funding and out-of-pocket payment
required for outpatient care discussed below. As a result of these issues with
community care, the interventions are not well targeted and the level of
community care for mental health is extremely low.
Funding and Payment for Mental Healthcare in Ukraine

Around 2.5% (or 6.25 USD per capita) of healthcare expenditure is allocated to
mental health. This is comparable to other upper-middle-income countries
but extremely low compared to high-income countries, which have an
average spend of 58.71 USD per capita. Moreover, 89% of this budget is
allocated to inpatient psychiatric care, which is higher than in many other
countries.165 As a result, funding for outpatient and community-based services
is limited.
People suffering from mental disorders have the right to inpatient care in
psychiatric hospitals and psychoneurological hospitals and can get free or
discounted drugs.166 Additionally, some groups are entitled to specific
benefits, including war veterans suffering from severe mental illness.167
However, in practice, up to 90% of inpatients must pay for services
themselves, while outpatients must pay for all services.168
Practitioners Working in Mental Healthcare in Ukraine

In 2015, there were 89 psychiatric and narcological hospitals in Ukraine, with
98 beds per 100,000 people.169 This number is similar to Russia's, and much
higher than other countries with decentralized care. Ukraine also has a
relatively high number of psychiatrists at 9.8 per 100,000 people; however,
there is significant heterogeneity in the supply of psychiatrists across
regions.170 About 25.7 nurses per 100,000 people are working in mental
healthcare in Ukraine, but the government does not classify them as
psychiatric nurses.171
On the other hand, there is a relatively low number of psychologists at 1 per

100,000 and social workers are virtually absent at 0.3 per 100,000 people.172
Additionally, there is a shortage of mental healthcare for children, as there are
only 339 child psychiatrists and only 8.5% of Ukrainians receiving mental
healthcare as of 2021 were aged between 0 and 17. 173
The MoH has developed new protocols for the integration of mental
healthcare and primary healthcare to expand access to mental healthcare,
consistent with globally recommended practices. These protocols say that
primary healthcare doctors should identify mental health disorders using
specified screening instruments such as the Patient Health Questionnaire-9
(PHQ-9), provide psychoeducation and basic psychological interventions,
and prescribe psychiatric medications like antidepressants and
benzodiazepines to the best of their ability.174
All physicians are trained in basic psychiatry during pre-service training.175

However, this training is inadequate to provide mental healthcare to patients
and the system of supporting the training of mental health practitioners
suffers from multiple deficiencies and a lack of evidence-based practice.176 177
178
Moreover, according to law, only medical institutions and doctors with
licenses can prescribe psychiatric medication. As a result, district
psychiatrists based in outpatient services assess most people with mental
health complaints.179 These psychiatrists cover a particular catchment area,
determine the intervention needed, and either provide the treatment or make
a referral.
Mental Health Organizations and Providers in Ukraine 180
Ministry of Health
Within the MoH, the Public Health Directorate, the Directorate and the
Department of Medical Services, and the Center for Mental Health and
Monitoring of Drugs and Alcohol share responsibility for mental health.180
The MoH has formed a group of specialists who are tasked with the
development of protocols for mental health treatment.181 This group has
already developed protocols for depression and PTSD as discussed above.
Within the MoH, numerous specialists are responsible for mental health
including:182
• Two mental health advisors to the Minister of Health.
• A mental health consultant to the MoH who is an associate professor

and advises on psychotherapy, psychological rehabilitation, and
rehabilitation of veterans.
• A director and deputy director of the Ukrainian Research Institute of

Social and Forensic Psychiatry and Narcology.
The MoH has outlined a few key proposals for mental health reform looking to
deinstitutionalize the mental healthcare system and increase the provision of
mental healthcare in the community.
181 182 183 184 185 186 187 188 189 190 191 192 193 194 195
Military Psychiatry & Psychological Services
Most military hospitals are overcrowded with patients that have extreme
trauma, but there are not enough specialists to deal with this trauma. In
fact, there are no physical or rehabilitative medicine specialists in military
hospitals, and there are only 5-6 high-quality rehabilitation centers in Kyiv
that can offer intensive care.183 The other centers can only deal with already
stabilized patients, and the situation outside Kyiv is even worse.184
To improve rehabilitative care, military hospitals need equipment, but more

importantly they need psychologists, physical therapists, and assistants. 185
Ukrainian Association for Stroke Prevention has been building a
rehabilitation system in Ukraine since 2014 and says that military doctors
are willing to cooperate by incorporating this service into military hospitals.
However, there has not been much progress on this goal yet. 186
Private Practice Therapists

On paper, the private sector is small and mainly operates within the realms
of pharmacies, diagnostic facilities, and private physicians. 187 Most private
expenditure is due to out-of-pocket payments, which mainly go towards
pharmaceuticals. No mental health services are covered by insurance and
insurance generally only covers 1% of healthcare expenditure. 188
In reality, most mental health services are provided by private

psychologists/therapists who are often not officially registered. As a result,
they officially work in public institutions while providing mental healthcare
to patients privately.189
NPOs and NGOs in Ukraine
Civil society organizations and volunteers have proliferated to address
Ukraine’s increased mental health burden since the second invasion. Since
February 2022, more than 200 new professional and voluntary
organizations have started operations in Ukraine, on top of the 50
organizations that have been present since first invasion in 2014. 190 There
are some clear benefits of this proliferation, including increased attention
on mental health, strengthening of international cooperation, and
increased civilian engagement.191 Funding NPOs and NGOs is crucial as it
can help to fill the gap in community care. 192
A World Bank report mapped the community organizations present in two

oblasts (administrative divisions) before the second invasion: Lviv and
Zaporizhzhia.193 The results showed that community organizations are
primarily present in areas with the most IDPs, and that they generally target
IDPs, veterans, and family members of veterans, while services are not
available to the general population. Moreover, the report outlined that most
organizations offered psychosocial support while few offered psychological
interventions for CMDs.194
NPOs and NGOs have also caused some significant issues. These issues
include:195
• Insufficient coordination between government-run mental
healthcare and NGOs.
• Lack of coordination among NGOs themselves.
• No accountability or mechanism to ensure quality care.
• Engagement of local partners in short-term training that simply
translates western methods without follow-up, supervision, or
mentoring.
• A focus on single mental health issues without using a needs-
based assessment or public mental health principles to guide a
broader approach.
• Insufficient financing for local NGOs.
• An unstable supply of volunteers.
Coordination Mechanisms
The above discussion points towards a need for coordination mechanisms
between the different prongs of mental healthcare support at the local,
national, and global level to ensure that different actors can work together
and to avoid duplication. The WHO started this by establishing an EU-wide
mental health working group to bring together different mental health and
psychosocial support (MHPSS) actors.196 Moreover, the MHPSS group under the
Inter Agency Standing Committee (IASC) has developed some coordination
in the context of emergency responses.197 In addition to these coordinating
bodies, the Interagency Coordination Council for Mental Health and
Psychological Assistance to Victims of the Armed Aggression of the Russian
Federation Against Ukraine, established by Olena Zalenska, the First Lady of
Ukraine, works to bring together efforts within the Ukrainian government to
address the mental health needs emanating from the invasion.198
How Stigma, Affordability, and Quality Affect Access to

Mental Healthcare
Alongside the centralization of mental healthcare in Ukraine, there are three
main factors that drive the gap in access to mental healthcare: stigma,
affordability, and quality.
Stigma
Stigma and discrimination are the primary barriers to accessing mental

healthcare in Ukraine.199 Older generations distrust the psychiatric system
because the Soviets used it as a suppressive tool before 1991 by diagnosing
dissidents with mental illness and incarcerating them in the country's
psychiatric hospitals. Moreover, trust in health services remains low due to
unfavorable stories told by patients. Additionally, individuals are worried
about having mental health issues on their medical records if it prevents
them from getting employment.200
Furthermore, communities often blame mental health illnesses on the people
suffering. For example, people view CMDs as trivial, attribute CMD
susceptibility to character flaws and weakness, see seeking help as a
weakness, and have exclusionary attitudes towards those with mental health
issues.201 These exclusionary attitudes are more intense for individuals that
suffer from alcohol and substance abuse.202
Due to the stigma discussed above, Ukrainians suffering from mental health
issues access less information from social services and health professionals
than from other sources. Instead, they cope through reading self-help books
and praying or going to church. As a result, people lack a proper
understanding of mental health and how to treat it.203
Stigma about seeking help with mental illness is especially acute in the
healthcare industry. Healthcare work environments do not tolerate mental
health issues, so doctors are worried about losing their medical licenses due
to mental health disorders. In addition, healthcare workers do not want to
become patients, so they tend to self-medicate with alcohol or other
substances, which can exacerbate the issue.204
Affordability
A further driving force behind the gap in access to mental healthcare in

Ukraine is affordability. A therapeutic session costs approximately 800-1,400
Ukrainian hryvnia (UAH; 22-38 USD), and the average length of therapy is
about ten sessions, making a course of therapeutic treatment approximately
8,000-14,000 UAH (217–379 USD).205 This is incredibly expensive relative to the
average salary in Ukraine, which was 16500 UAH (521 USD) per month in
January 2022.206 Furthermore, pharmaceuticals are typically more expensive
in Ukraine when compared to international standards.207
There is also heterogeneity in the affordability of mental healthcare across

mental health disorders, with one study finding that those suffering with PTSD
were paying four times as much for care and around double as much for
medication as those suffering from anxiety and depression.208
Due to unaffordable mental healthcare, around 92% of the population is
worried about the financial burden of becoming ill, and this acts as a barrier
to seeking help.209
Quality
A long-term deficit in healthcare spending has created inadequate

healthcare infrastructure and poor quality services. This has led to increases
in deaths from noncommunicable diseases like cardiovascular disease,
which rose from 12 to 21 deaths per 100,000 people between 1994 and 2015.210
Similarly, mental health services have been rated as poor, with some people
reporting that not all interventions are evidence-based.211
The quality of mental healthcare for IDP populations is particularly low. In 2017,
a study found that only 6% found the care helped a lot, 19% found it helped
somewhat, 57% found that it helped only a little, and 18% felt it didn’t help at
all. Moreover, only 36% of respondents were satisfied with the mental
healthcare they received.212
Furthermore, the institutions in place are not prepared to deal with the
complexities of trauma that will emanate from the current crisis. For example,
it is necessary to treat combatant PTSD and civilian PTSD separately, but no
psychiatric service is adapted to this level of trauma.213
Healthcare professionals say they urgently need appropriate training. This

training should include topics on treatment methods, protocols, and choosing
from a wide variety of treatment options. However, an influx of training and
workshops by NGOs adds confusion, as it is sometimes poorly coordinated
and often does not match global standards. As a result, medical staff often
experience burnout because they are burdened by emotionally supporting
people without the right tools.214
Positive Developments in Ukraine’s Mental Healthcare
System
Before Russia’s second invasion, the Ukrainian government, international
organizations, and local NGOs had taken significant steps to improve mental
healthcare provision in Ukraine. Some of these developments are listed
below:215
• mhGAP: An initiative started in 2019 to scale up the provision of mental

healthcare at the primary care level, led by the MoH and WHO, with
other international organizations, including Médecins du Monde (MdM)
and Médecins Sans Frontières (MSF).
• Community Mental Health Teams: 126 teams across Ukraine were set
up under the Program of State Medical Guarantees in 2021, which
include a nurse, social worker, psychologist, and psychiatrist to support
people with severe mental health conditions.
• The Pan-European Mental Health Coalition: The MoH and Ukrainian
NGOs joined the Pan-European Mental Health Coalition, whose goal is to
help countries transform their mental healthcare systems, governance,
and leadership.
• MHPSS Minimum Services Package (MSP): Ukraine is one of the
demonstration countries for the MSP project.
• The WHO Special Initiative for Mental Health (SIMH): Since its initiation
in 2019, SIMH has attracted investment in providing mental healthcare in
Ukraine, focused explicitly on community mental health teams.
• MH4U Project: A project funded by the Swiss Agency for Development
and Cooperation which focuses on self-assessment, care, and support
for mental healthcare.
• Common Elements Treatment Approach: A mental healthcare
intervention for IDPs, veterans, and their families supported by USAID.
• The coordination mechanisms mentioned above.
Impact of the Invasion on Mental Health Structures
The conflict since 2014 and the pandemic had already created a shortage of
mental healthcare professionals, especially in conflict-affected areas where
services are limited and often unavailable.216 217
The WHO recommends that mental health services should be based on a

pyramid structure as outlined in Figure 7. The base of the pyramid shows that
informal services including self-care and informal community care are
needed the most. Formal services are needed with a lower frequency, with
primary care needed more than psychiatric services in general hospitals and
community mental health services. Long stay facilities are needed least often.
Figure 7: WHO Service Organisation Pyramid for an Optimal Mix of Services for Mental
Health.218
First, it is important to consider the strengths and capabilities of the informal
services in Ukraine, so that interventions can empower people to deal with
mental health issues by building on these capacities. Within families, some of
the most common coping strategies involve communication, especially when
people do not live with each other. This communication is a particularly
important coping strategy for the elderly. People also manage their own
media consumption by being selective of what to watch, go walking, spend
time outdoors, exercise, work in the garden, and engage in daily routines to
distract themselves from the invasion. People also turn to spirituality and
religion as a coping strategy.219
Perhaps the most widespread coping strategy amongst the Ukrainian

population is volunteering. There are a wide range of opportunities to
volunteer, including sharing food with a neighbour, mobilizing resources for
the community, providing psychological support for vulnerable groups,
volunteering as drivers or managers, and engaging in territorial defence.
While traditional gender roles are present in volunteering work, as men tend
to volunteer as managers, drivers, and territorial defenders, and women tend
to volunteer in mobilizing resources for the community and providing
psychological support, they are less rigid than in ordinary life.220 However,
when the war ends the need for volunteering could decrease, triggering a
wave of mental health disorders as people struggle to replace this coping
mechanism.
Ukraine’s informal services are also under strain due to the invasion. The
invasion has created stressful material and social conditions which have
increased tension and conflict within families.221 This increased tension is
particularly acute in cases where families have had to move in together and
share small spaces.222 Furthermore, these material and social conditions
decrease people’s ability for self-care. For example, people in occupied
territories or areas where the conflict is most intense may not be able to
spend time outdoors due to well-founded fears for their life.223 Finally,
displacement and conscription into the army have torn communities apart,
leaving many people separated from their support systems.
Moreover, ten months of war have left Ukraine's formal services battered, with
more than 600 attacks on healthcare facilities since February 2022. Those left
un-attacked are inundated by patients seeking treatment for trauma and
injuries resulting directly from the conflict.224 225 The healthcare system is also
facing pressure from disrupted supply chains, inflation, inaccessible
stockpiles, destroyed caches of medicine and medical supplies, and a lack of
doctors trained in battlefield medicine (most are trained to operate in sterile
hospitals).226
Conclusion
This report aimed to articulate the complex impact that Russia's invasion of
Ukraine and the subsequent war has had on the mental health of the
Ukrainian population. To do this, it explored the impact on various
demographic and geographical groups and outlined the strengths and
weaknesses of the Ukrainian healthcare system.
There is clearly a sizeable mental healthcare gap in Ukraine, fueled by the

ongoing war and impacted by structural attitudinal and funding
issues. Consequently, mental health resources delivered in the current
environment can achieve the highest impact by addressing gaps in
community mental healthcare services while navigating the challenges
posed by an active war in Ukraine.
More specifically, this report highlighted the different impact of Russia’s

second invasion on six demographic groups, with some people falling into
multiple categories. These groups include people of different genders, military
combatants and veterans, children, people with disabilities, healthcare
workers, and displaced populations. MHPSS actors will need to consider the
differences between the impact of the war on these different groups when
designing MHPSS interventions.
Concurrently, the varied geographic impact of the invasion should be

considered in programming, with a priority on populations in areas on the
frontline, areas experiencing shelling, areas experiencing atrocities, and areas
impacted by limited essential services. Programs should focus on addressing
the drivers behind the mental health burden of each group, while
understanding that a significant proportion of depressive or anxious reactions
to these drivers is completely natural.
The Ukrainian population has developed various ways to cope with the
impact of the invasion on their mental health, such as volunteering, seeking
support from friends and family, and using digital tools to support mental
health. Mental health and psychosocial support programs that can scale
evidence-based services to reach more people and new initiatives targeted
to specific underserved populations are needed to augment existing services.
Heal Ukraine Trauma is working with partners in the government, private

sector, and civil society to contribute towards this vision. This report provides
a critical foundation for Heal Ukraine Trauma’s work, helping to ensure that we
coordinate with other MHPSS actors in Ukraine, do no harm, target the right
groups, avoid duplication, and have the most significant impact. We hope it
will be of similar use to Ukrainian organizations, NGOs, and international aid
organizations.
As Ukraine moves from its current humanitarian phase to reconstruction, the

promise of the healthcare improvements initiated in the past 10 years may
come to fruition. With reconstruction support, Ukraine will have the capability
to build a highly effective mental healthcare system, and the opportunity to
restore human capital, ensuring a healthy population for its future.
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Number of people with disabilities in Ukraine/Population of Ukraine * 100 = 2.7
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Average wage January 2022 * USD->UAH exchange rate in January 2022 = 521 * 32
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Heal Ukraine Trauma - Mental Health in Ukraine (April 2023)

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Heal Ukraine Trauma - Mental Health in Ukraine (April 2023)

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MENTAL HEALTH IN UKRAINE

ABOUT HEAL UKRAINE TRAUMA

3|Hea l Ukr a i n e T r a u m a | M enta l Hea l th i n U k ra i ne

Despite some significant developments shaping a promising future for

The Mental Health Burden in Ukraine

Russia's second invasion in 2022 has compounded these underlying issues.

However, the mental health burden is not uniform across demographics.

4|Hea l Ukr a i n e T r a u m a |M enta l Hea l th i n U k ra i ne

Demographic Mental Health Stressor

5|Hea l Ukr a i n e T r a u m a | M ental Hea l th i n U k ra i ne

• Destruction of support network

The geographical distribution is also heterogenous. Populations on the front

Moreover, mental healthcare is significantly underfunded. Around 2.5% (or

There is also a complex constellation of actors who provide mental

7|Hea l Ukr a i n e T r a u m a | M enta l Hea l th i n U k ra i ne

8|Hea l Ukr a i n e T r a u m a | M ental Hea l th i n U k ra i ne

These pressures have been exacerbated by Russia’s invasion of Ukraine in

There is a particularly high mental health burden in Eastern Ukraine and

COVID-19 also exacerbated Ukraine's mental health burden as closures of

In addition to these stressors, gaps in mental health treatment ensured the

Russia's invasion has compounded these underlying issues.58 The invasion

A WHO study estimated that the prevalence of CMDs—including depression,

Different genders face different pressures because of Russia’s invasion of

Military and Veterans

A particularly vulnerable group in Ukraine is those suffering from military

Children in Ukraine are also vulnerable to mental health disorders. Children

Young children are particularly vulnerable because the invasion rapidly

As a result, the 2014 invasion played a critical role in approximately one in

People with Disabilities

Healthcare Workers and First Responders

Healthcare workers and first responders are vulnerable due to physician

One of the most important impacts of displacement is the destruction of

There are four distinct populations of displaced people to consider – IDPs,

a. Internally Displaced People (IDP)

Despite the prevalence of mental health disorders in these populations,

b. Ukrainian Refugees and Asylum Seekers Outside of Ukraine

Evidence from past crises shows that if mental healthcare facilities

c. Refugees and Asylum Seekers in Ukraine

Alternatively, an asylum seeker is "a person who is unable or unwilling to

These populations were already facing similar stressors to those faced by

A stateless person is "a person who is not considered as a national by any

Multiple sources of trauma exist in

Populations in areas that have experienced Russian atrocities are particularly

Figure 6: Percentage of displaced respondents to a survey conducted from

The Ukrainian government spends less on healthcare than its European

Ukraine also has an exceptionally high level of out-of-pocket healthcare

The Ukrainian healthcare system is transitioning to a system based on

Healthcare reform accelerated in Ukraine after the 2014 Euromaidan

• Reconfiguring the system of primary care financing from one that

These reforms were starting to produce positive results. By 2020, 97% of

Healthcare reform in Ukraine has been challenging and vulnerable to reversal

Mental Healthcare Structure in Ukraine

Moreover, psychologists and psychotherapists working in outpatient care

Funding and Payment for Mental Healthcare in Ukraine

Practitioners Working in Mental Healthcare in Ukraine

On the other hand, there is a relatively low number of psychologists at 1 per

All physicians are trained in basic psychiatry during pre-service training.175

• Two mental health advisors to the Minister of Health.

• A mental health consultant to the MoH who is an associate professor

• A director and deputy director of the Ukrainian Research Institute of

To improve rehabilitative care, military hospitals need equipment, but more

Private Practice Therapists

In reality, most mental health services are provided by private

A World Bank report mapped the community organizations present in two