Over the past 12 months the people of Ukraine have lived through a full-blown Russian invasion, with all the horrors you might expect. Those who lived in conflict zones, have had to flee or witness death and destruction on a massive scale. Many have either witnessed or experienced war crimes – including sexual violence. Millions have lost their homes and possessions, while thousands are mourning lost loved ones.
Academic researchers in Ukraine have looked into the prevalence of post traumatic stress disorder (PTSD), which suggests the scale of this problem – particularly the case for young women. Worryingly sexual assault and associated trauma may be playing a role.
At the beginning of October 2022, a paper was published by an international research group suggesting that that 25.9% of those that completed the survey had “probable PTSD”. The researchers also showed that of this broadly representative sample the respondents had witnessed an average of nine stressors associated with conflict – including air raids, fire fights, seeing people killed and dead bodies, among other horrific experiences associated with modern conflict. Compare this with the UK, where a general adult population sample found that 3.7% of men and 5.1% of women screened positive for PTSD.
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It’s important to note that the term “probable PTSD” is used because the research described in this article is based on self-reporting. This is where the respondents complete clinical checklists to see if they meet the criteria for PTSD. They are not diagnostic tools and there are no clinical interviews with psychologists or psychiatrists to qualify the results.
So there may be errors whereby people either under or over-report symptoms. This may skew results slightly but the larger the sample the less significant this effect.
Since the mid-1990s, Kharkiv National University of Internal Affairs has been undertaking annual surveys to better understand the behaviour and some aspects of the mental health of the population. Since the invasion, the researchers – of whom co-author Alexey is one – have included measures to look specifically at PTSD. They have good response rates with nearly 3,500 adults aged 18-65 and over 3,800 younger people (age 15-25) completing the Kharkiv University surveys.
So far, the results from these unpublished surveys which we have been allowed to see confirms the earlier estimates for probable PTSD – with 30% of adult and 23% of the youth sample meeting the threshold. But in both of both of these surveys there were some significant differences between men and women, with about twice as many women reporting PTSD symptoms in both.
This is important because of the numbers of these respondents also reporting unwanted sexual advances (13%), domestic violence (8%) and forced sexual experiences (5%). Given the ongoing and brutal conflict in Ukraine, this may not be completely surprising. But, further to the earlier observation on self-reporting errors and bias, it is possible that people are less likely to report sexual assault, because of shame or guilt, so there is a considerable chance that sexual violence estimates may be a lot higher.
Fixing the system
The first lady of Ukraine, Olena Zelenska, has championed mental health treatment as a priority for her country. But to get this right, capacity needs to be built across the whole of the system. This will require extensive investment – and above all – cultural change: possibly the most difficult thing to achieve.
It means that even given the difficult circumstances and the scarcity of resources for the treatment of mental health, efforts must be made to ensure that the most unwell are treated first. Treatment must be on the basis of the most urgently needed rather than first come, first served. This will require a regime of triage and screening, evidence-based interventions and treatments, alongside a commitment to change and improve outdated psychiatric practices.
But treatment will also need to address the horrific repercussions of the use of sexual violence. This will inevitably require additional investment.
Unfortunately Ukraine is saddled with one of the most underfunded and resourced mental health services in Europe, attracting only 3% of the country’s health budget compared to 13% in the UK and 18% in Denmark. Mental health service provision in Ukraine continues to be affected by the legacy of a post-Soviet system of under-investment and containment in poorly staffed and run institutions, rather than a more progressive regime. There are serious concerns about systematic corruption within Ukraine’s health system with evidence of collusion with pharmaceutical companies and malpractice.
Broken system
The understandable focus of media reporting and mental health research in Ukraine are on the direct impacts of the Russian war on citizens, especially PTSD. And that’s hardly surprising when you consider that one survey of adolescents and young adults from the Kharkiv region, where fighting had been particularly heavy, reported that 30% have seen someone beaten, shot, or killed and 38% reported they had seen a corpse (not including at a funeral).
But we need to be very mindful that while it is vital to address the challenges that the war is creating, they must be seen within the context of the whole of the Ukrainian mental health system.
While it is important to focus on the impact and legacy of war on the mental health of the whole population, many already have had a severe mental illness. Using very conservative estimates for the numbers of people expected to have severe mental illness (1%) and common mental health problems like depression or anxiety disorders (20-25%), for a county the size of Ukraine, this equates to approximately 690,000 and 17 million people respectively, of which at least 200,000 will require ongoing specialist interventions.
So, whilst the world continues to look on with horror after 12 months of relentless and brutal war, the focus for immediate provision will be on those directly affected by the conflict, with early results suggesting a focus on younger female population. But this must be done within the context of investment, systemic reform and a complete overhaul of the post-Soviet legacy of inadequate, underfunded and outdated psychiatric practice.
The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.