Alcohol use among conflict-affected persons in Ukraine: risk factors, coping and access to mental health services

Explanatory models and coping with alcohol misuse among conflict-affected men in Ukraine

Affecting nearly 10% of men globally, alcohol use disorders (AUDs) represent a significant public health burden. Existing work, including from Ukraine, suggests that living in conflict settings may exacerbate the risk of AUDs. However, there is a dearth of evidence regarding alcohol misuse, as well as knowledge of factors associated with alcohol misuse patterns, in conflict settings. The aim of this qualitative study was to investigate explanatory models of alcohol misuse among conflict-affected men in Ukraine. Purposive and snowball sampling were used to recruit 66 conflict-affected men with alcohol misuse, family members of men who misuse alcohol, community health workers, and mental health and psychosocial support providers from locations across Ukraine. In the group of men who misuse alcohol (n=25), we recruited individuals with diverse experiences of adversity: 1) internally displaced persons from eastern Ukraine and Crimea displaced after 2014; 2) Ukrainian military veterans or territorial defense volunteers from various regions; and 3) men living 5-15 kilometers from the frontline. Semi-structured interviews were conducted in Ukrainian or Russian, and analysed using deductive and inductive analysis. Qualitative data received from each subgroup were analysed separately. The resulting explanatory model represents how Ukrainian conflict-affected men describe causes of alcohol misuse. Participants identified that alcohol misuse among Ukrainian men is often used as "self-treatment" to address mental health symptoms and feelings of demoralization that are exacerbated by a lack of supportive social environments and socio-economic problems; these behaviours also occur in an environment that deems alcohol misuse to be culturally appropriate. Family members and service providers offered a similar understanding of alcohol misuse as the men themselves. Strategies suggested by conflict-affected men to protect against alcohol misuse included engaging in alternative activities, finding supportive social environments, fear of negative consequences from alcohol misuse and increasing self-awareness and self-control. These findings indicate possible implications for interventions that target alcohol misuse among conflict-affected men, as well as demonstrate a need for developing culturally sensitive interventions that can address this unaddressed public health need.

The challenges experienced by Ukrainian refugees accessing General Practice: a descriptive cross-sectional study

BACKGROUND

The war in Ukraine has led to an influx of Ukrainian refugees across Europe. Internationally, there is limited research into refugees' experiences of accessing Primary Care. Furthermore, few studies have explored the experience of one homogenous refugee group. No study has explored the specific experience of Ukrainian refugees. To improve the care provided to this marginalized group it is important to understand the challenges they experience. The aim of this research is to identify the barriers Ukrainian refugees experience when accessing General Practice in Ireland.

METHODS

A 63-item questionnaire was distributed via Ukraine Action Ireland, a registered charitable organization, to Ukrainian refugees in Ireland. Qualitive comments were collected through free-text responses and were analysed using thematic analysis.

RESULTS

A total of 368 questionnaires were completed. About 75.4% of respondents reported that they were not asked about their mental health during consultations with their GP. About 25% of respondents could not attend GP due to transport difficulties. About 55% of respondents reported that a translator was needed but only one-third of respondents reported that one was offered. Self-reported health was relatively poor when compared with refugees in other countries and with Irish citizens. Three themes were developed; disparity in patient autonomy, perceived disregard for the refugee experience, and challenges in health care access.

CONCLUSION

At a time of significant capacity challenges in General Practice it is paramount that resources are provided at a national level to address the challenges Ukrainian refuges currently experience.

Mental Health Assessment of the Population: Study Protocol of the MAP Research Program in Ukraine (MAP-U) and in Zurich (MAP-Z)

Objectives

To conduct mental health surveillance in adults in Ukraine and Ukrainian refugees (Canton of Zurich, Switzerland) as an actionable scientific foundation for public mental health and mental healthcare.

Methods

Mental Health Assessment of the Population (MAP) is a research program including prospective, population-based, digital cohort studies focused on mental health monitoring. The study aims to include 17,400 people from the general population of Ukraine, 1,220 Ukrainians with refugee status S residing in the canton of Zurich, and 1,740 people from the Zurich general population. The primary endpoints are prevalence and incidence of symptoms of: posttraumatic stress disorder (measured by PCL-5), depression (PHQ-9), anxiety (GAD-7), and alcohol use disorder (AUDIT). Secondary endpoints include participants' health-related quality of life (EQ-5D-5L and EQ-VAS), experiences of somatic distress syndrome (PHQ-15), social isolation, social integration, and mental wellbeing (SWEMWBS).

Results

Baseline assessment starts in March 2024 with follow-ups occurring every 3 months for at least 2 years.

Conclusion

MAP will generate reliable, comparable, and high-quality epidemiological data to inform public mental health and healthcare policies in the Ukrainian population.

ISRCTN Registry

https://www.isrctn.com/ISRCTN17240415.

The Ukrainian version of the Perceived Injustice Questionnaire: A psychometric evaluation

Introduction

Perceived injustice is increasingly recognized as a key factor influencing mental health in war survivors. This cross-sectional study aimed to evaluate the psychometric properties of the Ukrainian translation of the Perceived Injustice Questionnaire (PIQ) among individuals directly exposed to the war in Ukraine.

Methods

170 war-exposed Ukrainians completed the Ukrainian PIQ and measures of post-traumatic tress disorder (PCL-5), depression (PHQ-9), generalized anxiety disorder (GAD-7), and potentially traumatic life events (LEC-5). Internal consistency, factor structure, and criterion validity were assessed.

Results

While the factor structure of the English version could not be reproduced, indicating an issue with factor validity in the Ukrainian version, the Ukrainian PIQ demonstrated strong correlations with post-traumatic stress disorder (PTSD) symptoms (r = .71, p <.01), moderate associations with depression (r = .62, p <.01) and generalized anxiety disorder (r = .61, p <.01), and a weaker link with potentially traumatic life events (PTLEs, r = .35, p <.01). It significantly predicted PTSD, depression, and generalized anxiety disorder (GAD) symptoms beyond PTLE exposure, explaining 33% of variance in depression, 31% in GAD, and 45% in PTSD These findings provide evidence supporting the construct validity of the PIQ in terms of its relationships with mental health outcomes. The Ukrainian PIQ also demonstrated excellent overall reliability (α = .90), with factor reliabilities ranging from α = .74 to α = .81.

Conclusions

The Ukrainian version of the PIQ demonstrates promising psychometric properties and emerges as a highly significant correlate of mental health outcomes. This underscores its potential utility in clinical practice for assessing the treatment needs of Ukrainians affected by the consequences of war. Moreover, the findings highlight the importance of developing therapy modules specifically tailored to address perceived injustice. Further research is warranted to investigate the cross-cultural adaptability and comparability of the PIQ.

A Systematic Literature Review of Substance-Use Prevention Programs Amongst Refugee Youth

This paper aims at exploring existing literature on substance use prevention programs, focusing on refugee youth. A comprehensive search for relevant articles was conducted on Scopus, PubMed, and EBSCOhost Megafile databases including Academic Search Ultimate, APA PsycArticles, APA PsycInfo, CINAHL with Full Text, E-Journals, Humanities Source Ultimate, Psychology and Behavioural Sciences Collection, and Sociology Source Ultimate. Initially, a total of 485 studies were retrieved; nine papers were retained for quality assessment after removing duplicates. Of the nine studies that met the inclusion criteria, only three are found to partially addressed substance use prevention programs. The two substance use prevention programs that emerge from the study are Adelante Social and Marketing Campaign (ASMC), and Screening and Brief Intervention (SBI). Six others explored protective factors and strategies for preventing substance use. The study findings show that refugee youth held negative attitudes toward institutions that provide substance use prevention programs. This review concluded that refugee youth often experience persistent substance use as they are not aware of prevention programs that may reduce the prevalence and/or severity of such misuse.

Adverse Childhood Experiences, Coping and Resilience in Persons with Alcohol Use Disorder and Their Non-drinking Siblings in High-density Families: A Case-control Study

Background

Adverse childhood experiences (ACEs) increase the odds of alcohol use disorder (AUD).

Aim

To study the ACEs, coping, and resilience in persons with AUD and their non-drinking siblings from high-density families.

Methods

The study used a case-control study design. Using purposive sampling, 135 participants were selected; the sample consists of persons with AUD (n = 45), non-drinking siblings (n = 45), and healthy controls (n = 45), selected from out-patient and in-patient services from a government-run de-addiction centre in Bengaluru. Individuals were administered an ACEs questionnaire, Brief-COPE, and Connor-Davison Resilience scale. Descriptive statistics, Friedman's test, and Bonferroni's post-hoc test, Binary Logistic Regression were used for analysis.

Results

ACEs, coping, and resilience significantly differ across the three groups. Persons with AUD and their non-drinking siblings are comparable in terms of ACEs and having dysfunctional family members. Non-drinking siblings and healthy controls have similar coping and resilience. None of the healthy controls had dysfunctional family members.

Conclusion

ACEs are more prevalent and more frequent in persons with AUD. Individuals with AUD showed higher avoidant coping and lower resilience than their non-drinking siblings and healthy controls. Early identification of ACEs and interventions to build resilience and coping strategies could prevent individuals from developing AUD in high-density families.

The effect of conflict-related violence intensity and alcohol use on mental health: The case of Colombia

We investigated the causal impact of conflict-related violence on individual mental health and its potential pathways in Colombia. Using data from before and after the 2016 peace accord between the Colombian government and the Revolutionary Armed Forces of Colombia (FARC), we adopted a difference-in-differences empirical design combined with instrumental variables estimation. We also used formal mediation analysis to investigate a possible mediating role of alcohol consumption in the relationship between conflict exposure and mental health. Our results did not support the hypothesis that changes in exposure to conflict violence after the peace accord causally led to any changes in individual mental health. We were unable to identify a statistically significant mediating effect of alcohol consumption in the relationship between exposure to conflict violence and mental health.

Prevalence of stress, anxiety, and symptoms of post-traumatic stress disorder among Ukrainians after the first year of Russian invasion: a nationwide cross-sectional study

Background

In February 2022 the Russian federation started a new invasion of Ukraine as an escalation of the ongoing war since 2014. After nine years of war and the COVID-19 pandemic, the mental health state of Ukrainians requires systematic monitoring and relevant action. The aim of present study was to investigate the state of mental health among Ukrainians assessing the levels of stress, anxiety, and post-traumatic stress disorder (PTSD) prevalence in not displaced persons (NDPs), internally displaced persons (IDPs), and refugees abroad.

Methods

This study was designed as an online survey arranged in the 9-12 months after the start of the new invasion of Ukraine and includes sociodemographic data collection, evaluation of stress intensity by Perceived Stress Scale (PSS-10), anxiety with General Anxiety Disorder (GAD-7), and symptoms of post-traumatic stress disorder with PTSD Check List (PCL-5).

Findings

The sample size of 3173 Ukrainians consisted of 1954 (61.6%) respondents that were not displaced persons (NDPs), 505 (15.9%) internally displaced persons within Ukraine (IDPs), and 714 (22.5%) refugees that left Ukraine. Moderate and high stress was prevalent among 68.2% (1333/1954) and 15.5% (302/1954) of NDPs, 64.4% (325/505) and 21.6% (109/505) of IDPs, and 64.7% (462/714) and 25.2% (180/714) of refugees, respectively. Moderate and severe anxiety was prevalent among 25.6% (500/1954) and 19.0% (371/1954) of NDPs, 25.7% (130/505) and 23.4% (118/505) of IDPs, and 26.2% (187/714) and 25.8% (184/714) of refugees. High levels of PTSD (33 and higher) were prevalent among 32.9% (642/1954) of NDPs, 39.4% (199/1954) of IDPs, and 47.2% (337/714) of refugees. DSM-V criteria for PTSD diagnosis was met by 50.8% (992/1954) of NDPs, 55.4% (280/505) of IDPs, and 62.2% (444/714) of refugees. Only 7.2% of the respondents reported no or mild stress, anxiety, and PTSD levels within the sample.

Interpretation

The lowest stress, anxiety, and PTSD severity was observed among NDPs, with significantly higher levels among IDPs and the highest among refugees. Being forcibly displaced from the previous living area and, especially, entering a new cultural environment significantly contributes to the mental health issues caused by war exposure and witnessing.

Funding

Ministry of Education and Science of Ukraine.

The development of compulsive coping behavior depends on dorsolateral striatum dopamine-dependent mechanisms

Humans greatly differ in how they cope with stress, a natural behavior learnt through negative reinforcement. Some individuals engage in displacement activities, others in exercise or comfort eating, and others still in alcohol use. Across species, adjunctive behaviors, such as polydipsic drinking, are used as a form of displacement activity that reduces stress. Some individuals, in particular those that use alcohol to self-medicate, tend to lose control over such coping behaviors, which become excessive and compulsive. However, the psychological and neural mechanisms underlying this individual vulnerability have not been elucidated. Here we tested the hypothesis that the development of compulsive adjunctive behaviors stems from the functional engagement of the dorsolateral striatum (DLS) dopamine-dependent habit system after a prolonged history of adjunctive responding. We measured in longitudinal studies in male Sprague Dawley rats the sensitivity of early established vs compulsive polydipsic water or alcohol drinking to a bilateral infusion into the anterior DLS (aDLS) of the dopamine receptor antagonist α-flupentixol. While most rats acquired a polydipsic drinking response with water, others only did so with alcohol. Whether drinking water or alcohol, the acquisition of this coping response was insensitive to aDLS dopamine receptor blockade. In contrast, after prolonged experience, adjunctive drinking became dependent on aDLS dopamine at a time when it was compulsive in vulnerable individuals. These data suggest that habits may develop out of negative reinforcement and that the engagement of their underlying striatal system is necessary for the manifestation of compulsive adjunctive behaviors.

Mental health and stress level of Ukrainians seeking psychological help online

Due to the Russian invasion of Ukraine on February 24th, 2022, more than 8 million Ukrainians have been displaced from their homes. Ukrainians exposed to armed conflict and migration are likely to have low levels of mental health status and seek help. We provide a uniform quantitative assessment of the mental health conditions of Ukrainians seeking help soon after the invasion and resettlement. We screen the mental well-being and psychological distress of 1165 refugees, migrants, internally displaced, and non-displaced individuals from Ukraine who seek psychological help online in Ukraine and across 24 countries of the European Union. We surveyed participants in the study as a part of our online program for adult Ukrainians from June 22nd to July 6th, 2022. We report descriptive results of mental-health status for the aggregate sample and the sub-groups. More than half of the respondents exhibit low levels of mental well-being and high psychological distress, with 81 % being at risk of depression; 57 % having severe psychological distress. Refugees and internally displaced participants show a particularly high risk of depression and severe psychological distress in our sample. Many Ukrainians seeking psychological help work, study, or volunteer, and those who engage in these activities have relatively alleviated mental well-being. Our results indicate a considerable psychological burden on Ukrainians. Although our analysis focuses on Ukrainians seeking help, it shows that the displaced soon after resettlement require particular attention and can be reached in a short time across borders, irrespective of their (officially documented) migration status.

Will the Russian war in Ukraine unleash larger epidemics of HIV, TB and associated conditions and diseases in Ukraine?

The Russian war in Ukraine poses many risks for the spread of HIV, TB and associated conditions, including possible increases in the numbers of people who inject drugs or engage in sex work in the years ahead. Ukrainian civil society and volunteer efforts have been able to maintain and at times expand services for HIV Key Populations. The extent of mutual-aid and volunteer efforts as well as the continued strength and vitality of harm reduction organizations such as the Alliance for Public Health and the rest of civil society will be crucial resources for postwar efforts to assist Key Populations and prevent the spread of HIV, TB and other diseases. The postwar period will pose great economic and political difficulties for Ukrainians, including large populations of people physically and/or psychically damaged and in pain who might become people who inject drugs. Local and international support for public health and for harm reduction will be needed to prevent potentially large-scale increases in infectious disease and related mortality.

Mental health symptoms and coping strategies among Ukrainians during the Russia-Ukraine war in March 2022

CONTEXT

The Russian attack on Ukraine has been ongoing since February 24, 2022. Nevertheless, no research has documented the mental health of Ukrainians during the biggest land war in Europe after the Second World War, or how Ukrainians cope with the impact of the war.

OBJECTIVES

To provide the prevalence rates of symptoms of psychological distress, anxiety, depression, and insomnia; and to link them with Ukrainians' productive coping strategies during the war.

DESIGN, SETTING, AND PARTICIPANTS

Online survey conducted in Ukraine during the initial period of the Russian invasion (March 19-31, 2022), using a quota sampling method, of 1,400 Ukrainians aged 18 years or older, with a total of 801 valid responses for a response rate of 57.2%.

MAIN OUTCOME MEASURES

Psychological distress assessed by the Kessler Psychological Distress scale (K6); anxiety assessed by Generalized Anxiety Disorder-2 (GAD-2) scale; depression assessed by Patient Health Questionnaire-2 (PHQ-2); insomnia assessed by Insomnia Severity Index-4 (ISI-4); modes of coping assessed by Brief COPE.

RESULTS

Of 801 Ukrainian adults, 52.7% had symptoms of psychological distress (mean = 13.3 [SD = 4.9]); 54.1% of them reported symptoms of anxiety (mean = 2.9 [SD = 1.7]); 46.8% reported symptoms of depression (mean = 2.6 [SD = 1.6]). Symptom criteria for insomnia were met by 97 respondents (12.1%) (mean = 10.4 [SD = 4.2]). Demographic variables (including gender, living in an urban area, having children or elderly persons in the household, living in an area occupied by Russian forces) were associated with symptoms of distress, anxiety, depression, and insomnia. The productive coping strategies of using instrumental support, behavioral disengagement, self-distraction, and planning were significantly associated with mental health symptoms.

CONCLUSIONS

Prevalence rates of symptoms of psychological distress, anxiety, depression, and insomnia were high. These findings underscore the need for healthcare and productive coping strategies for Ukrainians during the war.

The Ukraine crisis: Mental health resources for clinicians and researchers

The mental health consequences of the war in Ukraine will be enormous. Mental health professionals who are providing care for people in Ukraine, or those resettled elsewhere, may require access to standardized and validated assessment tools. We have developed a repository of mental health measures that are available in Ukrainian, Russian and English and can be accessed at www.traumameasuresglobal.com/ukraine.

The Ukraine crisis: Mental health resources for clinicians and researchers

The mental health consequences of the war in Ukraine will be enormous. Mental health professionals who are providing care for people in Ukraine, or those resettled elsewhere, may require access to standardized and validated assessment tools. We have developed a repository of mental health measures that are available in Ukrainian, Russian, and English and can be accessed at http://www.traumameasuresglobal.com/ukraine.

Mental health care in Eastern Europe and Central Asia: An analysis of needs and a call for greater investment

Over the past decade, there has been increased attention to global mental health, which emphasizes improving access to quality mental health care in order to reduce the worldwide treatment gap. However, Eastern European and Central Asian countries and their specific mental health needs have largely been under-emphasized, evidenced by a dearth in literature and funding. Here, we provide an overview of the mental health needs in Ukraine and its challenges with quality care provision as a key example in highlighting these gaps, then broaden our discussion to include parallels with other countries in the Eastern European and Central Asian region. We describe the unique strengths relative to mental health care provision that are present in Eastern Europe and Central Asia and suggest the importance of post-graduate training, regional collaboration, and capacity building specific to research management as strategies to address the current challenges. We stress that greater investment from funders, government, and the global mental health community are needed to improve the current mental health situation in Ukraine, specifically, and Eastern Europe and Central Asia, broadly. We argue that greater attention to Eastern Europe and Central Asia is needed to fully advance the agenda of the global mental health field.

Understanding the health needs of internally displaced persons: A scoping review

We seek to strengthen understanding of the health needs of internally displaced persons (IDPs) in contexts of conflict or violence. Based upon a scoping review, our paper identified limited evidence on IDP health, but nevertheless indicates that IDPs tend to experience worse health outcomes than other conflict-affected populations across a range of health issues; and this is due to the particularly vulnerable situation of IDPs relative to these other populations, including reduced access to health services. Further research is required to better understand these needs and the interventions that can most effectively address these needs.

A randomized-controlled trial of community-based transdiagnostic psychotherapy for veterans and internally displaced persons in Ukraine

BACKGROUND

There is limited research on community-based mental health interventions in former Soviet countries despite different contextual factors from where most research has been conducted. Ongoing military conflict has resulted in many displaced persons and veterans and their families with high burdens of mental health problems. Lack of community-based services and poor uptake of existing psychiatric services led to the current trial to determine the effectiveness of the common elements treatment approach (CETA) on anxiety, depression, and posttraumatic stress symptoms (PTS) among conflict affected adults in Ukraine.

METHODS

We conducted a three-armed randomized-controlled trial of CETA delivered in its standard form (8-12 sessions), a brief form (five-sessions), and a wait-control condition. Eligible participants were displaced adults, army veterans and their adult family members with elevated depression and/or PTS and impaired functioning. Treatment was delivered by community-based providers trained in both standard and brief CETA. Outcome data were collected monthly.

RESULTS

There were 302 trial participants (n = 117 brief CETA, n = 129 standard CETA, n = 56 wait-controls). Compared with wait-controls, participants in standard and brief CETA experienced clinically and statistically significant reductions in depression, anxiety, and PTS and dysfunction (effect sizes d = 0.46-1.0-6). Comparing those who received standard CETA with brief CETA, the former reported fewer symptoms and less dysfunction with small-to-medium effect sized (d = 0.20-0.55).

CONCLUSIONS

Standard CETA is more effective than brief CETA, but brief CETA also had significant effects compared with wait-controls. Given demonstrated effectiveness, CETA could be scaled up as an effective community-based approach.

Noncommunicable disease burden among conflict-affected adults in Ukraine: A cross-sectional study of prevalence, risk factors, and effect of conflict on severity of disease and access to care

Background

There is limited research on noncommunicable diseases (NCDs) in humanitarian settings despite the overall global burden and disproportionate growth in many conflicts and disaster-prone settings. This study aimed to determine the prevalence of NCDs and assess the perceived effect of conflict on NCD severity and access to treatment among conflict-affected adults (≥ 30 years) in Ukraine.

Methods and findings

We conducted two population-representative, stratified, cross-sectional household surveys: one among adult internally displaced people (IDPs) throughout Ukraine and one among adults living in Donbas in eastern Ukraine. One randomly selected adult per household answered questions about their demographics, height and weight, diagnosed NCDs, access to medications and healthcare since the conflict began, as well as questions assessing psychological distress, trauma exposure, and posttraumatic stress disorder. More than half of participants reported having at least one NCD (55.7% Donbas; 59.8% IDPs) A higher proportion of IDPs compared to adults in Donbas experienced serious psychological distress (29.9% vs. 18.7%), interruptions in care (9.7–14.3% vs. 23.1–51.3%), and interruptions in medication than adults in Donbas (14.9–45.6% vs. 30.2–77.5%). Factors associated with perceived worsening of disease included psychological distress (p: 0.002–0.043), displacement status (IDP vs. Donbas) (p: <0.001–0.011), interruptions in medication (p: 0.002–0.004), and inability to see a doctor at some point since the start of the conflict (p: <0.001–0.008).

Conclusions

Our study found a high burden of NCDs among two conflict-affected populations in Ukraine and identified obstacles to accessing care and medication. Psychological distress, interruptions to care, and interruptions in medication were all reported by a higher proportion of IDPs than adults in Donbas. There is a need for targeted policies and programs to support the unique needs of displaced conflict-affected individuals in Ukraine that address the economic and perceived barriers to NCD treatment and care.