Mental health impact of war in Ukraine

The neuropsychiatric impact on survivors of war is multi-layered. The Ukrainian population are exposed to ongoing life-threatening attacks, witnessing death of friends and loved ones, torture and sexual violence, separation from family members, and destruction of homes and communities. Additionally, their displacement and readjustment to new environments creates major public mental health needs among evacuees and their new host countries. Though the resilience and altruism we are witnessing is exceptional, there will be a full range of mental health consequences including grief, anxiety, depression, sleep disorders, somatization, and post-traumatic stress disorder. Beyond war-related syndromes, we need to recognize the psychological and behavioral impacts of the use, and even threatened use, of WMD, and historical events offer important lessons learned.

Psychological and behavioral impacts of WMD events: lessons from Japan

Japan was the site of the atomic bombings of Hiroshima and Nagasaki in World War II in 1945, sarin gas attacks in Matsumoto and Tokyo in 1994 and 1995, respectively, by the cult group Aum Shinrikyo, and one of the world's worst known NPP explosions during the triple disaster in Fukushima Prefecture in 2011. The recent global COVID-19 pandemic revealed that anxiety levels have been increased in otherwise healthy people, with those with mental health disorders, prior exposure to trauma, first responders, and healthcare workers being particularly susceptible (Shigemura & Kurosawa, Reference Shigemura and Kurosawa2020). Health studies of these events give us a wealth of knowledge in understanding the substantial and enduring effect of a WMD event.

A unique issue is that precise exposure during these environmental adversities is difficult to observe or quantify. In addition, distrust of agencies responsible for public health contributed to the widespread belief that one was exposed. That personal perception is an essential factor in determining psychological and behavioral response and once embraced, becomes enduring and leads to a range of mental ill-health conditions. A study of Nagasaki survivors found anxiety and somatization persisted more than 50 years regardless of actual radiation exposure (Kim et al., Reference Kim, Tsutsumi, Izutsu, Kawamura, Miyazaki and Kikkawa2011). Atomic bomb survivors were exposed to widespread fear, discrimination, and stigmatization from the general population, exacerbating their worries about health and longevity. In turn, they experienced a decline in well-being and fear about future health effects for themselves and their families (e.g. cancer and transgenerational genetic effects) (Shigemura et al., Reference Shigemura, Harada, Tanichi, Nagamine, Shimizu, Yoshino, Ursano, Fullerton, Weisaeth and Raphael2017).

After the Tokyo subway sarin attacks, large numbers of unexposed people rushed to receive medical care, overwhelming local healthcare facilities. Among the injured, physical and ophthalmic symptoms became persistent and were associated with posttraumatic stress symptoms two decades after the attack (Nakamine, Kobayashi, Fujita, Takahashi, & Matsui, Reference Nakamine, Kobayashi, Fujita, Takahashi and Matsui2018). Just like in Chornobyl, mothers of young children and nuclear plant workers were particularly affected in Fukushima (Havenaar et al., Reference Havenaar, Bromet and Gluzman2016; Shigemura et al., Reference Shigemura, Terayama, Kurosawa, Kobayashi, Toda, Nagamine and Yoshino2021). In Fukushima, rates for adverse mental health remained high, even 8 years post-disaster (nonspecific psychological distress, 8.3–65.1%; depressive symptoms, 12–52.0%; and posttraumatic stress symptoms, 10.5–62.6%) (Shigemura et al., Reference Shigemura, Terayama, Kurosawa, Kobayashi, Toda, Nagamine and Yoshino2021). Medical tests to evaluate radiation effects were associated with both worsening and mitigating anxiety and subjective well-being, underscoring the importance of appropriate health risk communications between healthcare workers and affected communities (Murakami et al., Reference Murakami, Takebayashi, Takeda, Sato, Igarashi, Sano and Tanigawa2018).

How should healthcare professions prepare for WMD events?

When WMD events take place, it is often unclear when one has been exposed. Regardless of actual exposure, this uncertainty leads to increased distress and surges in healthcare demand. When people present for healthcare, it is frequently to emergency and primary care with concerns for physical symptoms. To address lowered health perceptions, somatization, and medical-psychiatric comorbidities, it will be essential to enhance collaborations between physical and mental health services through increased communication, education, and embedding mental health personnel within these other services (Gouweloos, Dückers, te Brake, Kleber, & Drogendijk, Reference Gouweloos, Dückers, te Brake, Kleber and Drogendijk2014). Since the Fukushima disaster, the World Health Organization and other organizations developed mental health and psychosocial support guidelines to address post-nuclear disaster challenges (World Health Organization, 2020). In addition, Psychological First Aid offers practical interventions to protect community mental health through actions that enhance the five essential elements of safety, calming, social connectedness, efficacy, and hope (Hobfoll et al., Reference Hobfoll, Watson, Bell, Bryant, Brymer, Friedman and Ursano2007). Conceivably these and other resources provided by the Red Cross, the International Medical Corps, and non-governmental organizations might serve as backbones for WMD disaster preparedness strategies.

Previous WMD disasters revealed that assessment of risk and protective factors before, during, and after the event are crucial in providing optimal care for affected people (Shigemura et al., Reference Shigemura, Harada, Tanichi, Nagamine, Shimizu, Yoshino, Ursano, Fullerton, Weisaeth and Raphael2017). These factors include, but are not limited to, prior and current mental health and trauma exposure, physical health conditions, socioeconomic conditions, social support, risk and health perceptions, and stigma. It is important for healthcare workers to respect and acknowledge patient concerns about exposure to invisible WMD agents while also providing timely medical evaluation. Healthcare workers can build trust and enhance protective health behaviors within communities through empathic listening as well as clear and understandable messages. It is also crucial that the compound effects of war and WMD trauma be anticipated and evaluated. For instance, victims of physical or sexual violence in war may have enhanced fear response to perceived WMD exposure. In humanitarian or emergency settings, utilization of brief, simple fact sheets with specific actions to protect health might be useful to enhance communication with patients who are under extreme stress and may be unable to assimilate complex health information (Center for the Study of Traumatic Stress, 2022). It is important for healthcare workers to remember that while these exposures might have occurred suddenly and quickly, the care many people will need could be very long-lasting.

Healthcare workers also experience unique challenges during WMD events likely to be complicated by stress on global healthcare systems from the COVID-19 pandemic, which itself offers lessons learned to protect the health of workers (Morganstein & Flynn, Reference Morganstein and Flynn2021). Fear for personal and family safety from exposure or contamination following work activities are common, and best addressed through ensuring adequate supplies and training in personal protective equipment use and procedures, such as decontamination. Organizational factors within healthcare systems, such as timely, updated crisis communication messaging, as well as clear and consistently applied policies and procedures reduce distress and enhance functioning for healthcare workers (Brooks, Dunn, Amlôt, Rubin, & Greenberg, Reference Brooks, Dunn, Amlôt, Rubin and Greenberg2018). Peer support during the stress of WMD events can foster a sense of safety and connectedness to bridge isolation that results from ongoing uncertainty and required use of protective barrier equipment. Leadership actions, such as role modeling of self-help and stress management, as well as being present with personnel in their workspace to address concerns and remind them of the value of their work are actions that protect health and enhance operational sustainment (Geerts et al., Reference Geerts, Kinnair, Taheri, Abraham, Ahn, Atun and Bilodeau2021).