Amid chaos of war, Ukraine hopes to boost mental health system

An international group of experts has a recovery plan to help Ukraine modernise its mental health system after nearly three years of war.

While Ukrainians have found ways to continue their lives, the constant shelling, casualties, and wartime uncertainties have taken their toll.

Studies conducted shortly after Russia launched its full-scale invasion in February 2022 found that 55 per cent of Ukrainians had a significant uptick in anxiety and 26 per cent met the criteria for post-traumatic stress disorder (PTSD).

“Our fight for freedom and democracy comes at a heavy price, a price we pay not only in lives but also in the mental and emotional toll on our people,” Oksana Zbitnieva, who leads the Ukrainian government’s coordinating centre for mental health, said on Wednesday.

“This is the reality we face in the heart of 21st century Europe,” she added.

Yet restoring Ukraine’s mental health is about much more than winning the war – it also means reimagining the entire system, including patient care, workforce training, scientific research, and legal reform, according to a group of mental health experts from 12 countries who worked with Ukrainian psychiatrists to issue recommendations that were published in the Lancet Psychiatry medical journal.

Much of that work involves putting mental health on the agenda in the first place. Ukraine currently spends about 8 per cent of its gross domestic product (GDP) on health care, with about 2.5 per cent of that going toward mental health, mainly for patients in psychiatric hospitals and long-term care, the commission found.

Ukraine’s institutional approach to mental health care is a relic of the Soviet era when the state weaponised the system by holding political dissidents in psychiatric hospitals.

According to the commission report, these facilities can house about 30,000 people today.

Now, the commission says Ukraine should pivot toward a more community-based model where people with common mental health problems like depression and anxiety can get help in non-specialised settings, such as at their general practitioner’s office, while people with more serious conditions receive care through mental health centres and other partners.

These services should also be tailored toward specific patient groups, like veterans, former prisoners of war, and people displaced from their homes and communities, they said.

That work is already underway, with a mental health law under consideration by the Ukrainian government.

“The ongoing reform will replace outdated Soviet psychiatry with a modern system,” Zbitnieva said.

The commission set some targets for this transition over the next five to 10 years.

Along with a 50 per cent reduction in the number of people in hospitals and other inpatient settings, there should be a 16-fold increase in primary care capacity, a tripling of community-based mental health services – from 65 to 185 programmes – and a doubling of capacity in outpatient settings, the experts said.

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That would require a 45 per cent boost in public spending on mental health, but it could also come with a 37 per cent decline in patients’ out-of-pocket spending, according to Dan Chisholm, the World Health Organization (WHO)’s mental health lead for Europe.

In that scenario, total government spending on mental health would rise to about 4.5 per cent of the budget, Chisholm said.

Training and research

Ukraine’s health workforce should also be bolstered to meet the needs of the population, the experts said, especially given the COVID-19 pandemic and the war with Russia disrupted the education system and squeezed the pipeline of future mental health workers.

They recommend that new psychiatrists’ residency programmes be extended from two to five years, bringing them in line with European standards.

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Workforce development should also come with improvements to high-level research, they said.

Less than 0.5 per cent of the relevant government budgets currently go to mental health research, a level that will need to be increased in order to support both senior and upcoming scientists to compete on the international stage.

The commission wants Ukrainian mental health research to be shored up and integrated with the rest of the European scientific community by 2030.

It could be a long road ahead. Applications to Ukrainian medical schools dropped from 25,200 in 2019 to about 19,900 in 2023 – a 21 per cent decline, the commission found.

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And in addition to increased government funding, legal reform will likely be necessary to achieve all of these goals, the commission said.

That includes implementing mental health laws that limit involuntary inventions such as putting people in institutions, as well as overhauling Ukraine’s guardianship system, which legally handicaps people with mental health impairments.

Dr Irina Pinchuk, president of the Ukrainian Psychiatric Association and co-lead of the new commission, acknowledged that “the plan for Ukrainian mental health is ambitious”.

But the Lancet experts don’t just want Ukrainians to psychologically recover from the war, she said – they want the new system to become an example for other countries rethinking their own approaches to mental health care.

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“It is important that we build this system on the best global evidence and practices,” Zbitnieva said.