Mending Minds… Meeting the mental health needs of service veterans in Ukraine

Much of the (mostly US and UK) research conducted on service veterans is irrelevant to the current Russian-Ukrainian war, which is an existential conflict and a fight for national identity. Unlike US and UK veterans, Ukrainian veterans are returning to a devastated country, still in the midst of an existential fight for its survival, and to a  home where many family and loved ones have been equally traumatised by the impact of war.

More than one million men and women of working age are service veterans and their sheer numbers make any special provision for them impossible, especially given the massive burden of war trauma related mental health problems within the population overall (World Economic Forum, 2022). What might be done to mitigate their suffering when the country finally has an opportunity to rebuild? Bricks and mortar are easily replaced, broken minds less so.

Preventative measures should begin with serving personnel: apart from those with a clear history of mental illness, recruit screening to try and identify individuals likely to break down doesn’t work, as the Americans discovered in WWII (see Jones et al (2010), Killgore et al (2008)). Reducing or eliminating alcohol consumption amongst combatants, does however, and has been shown to be effective in reducing mental breakdown in service. Commanders should receive training on mental health problems amongst combatants. For, regardless of any medical advice, it is ultimately their decision whether a soldier is “ill”, deserving of treatment (and if necessary evacuation from the battlefield), or “cowardly”, deserving punishment. 

When I attended a UK Army course for future Commanding Officers, I spent three days learning how to discipline and punish soldiers, but nothing about their mental health. Such training is not time consuming and could easily be included in existing courses designed for senior officers about to be given their first command. They need to learn that keeping mentally ill soldiers (whose performance can be worse than useless) on the battlefield can not only reduce overall combat efficiency of a unit creating an administrative, medical, and often legal burden distracting commanders from the task at hand.

Mental illness and suicide are more likely in young, single male servicemen, who also happen to be the individuals least likely to seek help (Crawford et al., 2009). Stigma and reluctance of men to admit mental health problems remains a common barrier to treatment. The displacement of suffering and anger into alcohol, drugs and domestic and sexual violence is commonplace on return from operations, as well as so called ‘risky’ behaviour such as reckless driving, gambling, fighting, sexual promiscuity, all of which are of course fuelled by excessive alcohol use (Thomson et al 2011).

The warning signs of a significant mental health emergency amongst military veterans in Ukraine are already evident. A 2020 study by the Ukrainian Foundation for Public Health found that 57% of veterans needed psychological support. In 2021 the Deputy Minister for Veterans Affairs, Inna Drahanchuk, estimated that 700 Ukrainian Veterans had committed suicide since 2014, and admitted that tracking former military personnel was difficult and that the number of suicides. . . ‘might be a gross underestimate’. The psychological toll of the war extends well beyond the immediate protagonists. Thus, many US and UK Veterans, including older veterans from previous conflicts, have experienced an exacerbation of symptoms watching images of the Ukrainian conflict reported in the media.

Once the war is over, therapy for damaged veterans is likely to be very limited given the large veteran population. Therefore, efforts to provide therapy, particularly by NGOs and humanitarian organisations, need to be coordinated to avoid duplication of effort as well as try to promote equity of access according to need (although coordinating their efforts can be a challenge for authorities). Such resources are scarce and should be used wisely and efficiently. For example, local self-help support groups for veterans and families coordinated and overseen by mental health professionals is a more effective use of resources than efforts to provide individual therapy for a few. The provision of practical support such as food, warmth, shelter, safety and security are prerequisites and need to be in place for any psychological support to be effective.

Mental health professionals have an important coordinating and supervisory role to play, advising on policy, training and making themselves available to the most complex cases. On a national level, efforts to reduce stigma and facilitate help seeking should be promoted using the media to reach as many people as possible. Raising awareness and promoting openness and discussion of mental health issues is half the battle and encourages veterans to seek help. Although health education is an obvious platform for this, the use of drama and fiction to address real world situations, and key opinion leaders to share their own mental health problems, thereby legitimising the suffering of others, are potentially powerful tools to influence the behaviour of large numbers of people. Politicians (including the President) and key opinion leaders in the country should show leadership in this regard, they are role models and could do much to reduce stigma and encourage an open discussion of mental health issues. Film and TV programme makers should be encouraged to address the mental health issues facing returning veterans in movies, TV dramas and popular TV soap operas. Everyone can help the veteran population, not just doctors and psychologists.

Servicemen and women face far more stress and strain than bombs and bullets. Understanding this can make any therapy or mental health intervention much more effective. Ukraine has many broken buildings to repair, but repairing the broken minds of much of the veteran population will be a task immeasurably more challenging. Thus, civilians, politicians and professionals of all stripes need to try to understand the issues faced by those who risked their lives to protect and preserve the way of life of their fellow countrymen.

References

1. Thomson J et al. (2011) Effects of combat deployment on risky and self-destructive behaviour among active duty military personnel. J. Psychiatric research. Oct, 45(10): 1321-1231. doi: 10.1016/j.psychires.2011.04.003. Epub 2011 May 6.
2. Chen, A. & Melwani M. (2022). Battle against the Mind: The mental health of Ukraine’s soldiers. BMJ: British Medical Journal (online), 378, o1921.
3. Crawford, M. J., Sharpe, D., Rutter, D., & Weaver, T. (2009). Prevention of suicidal behaviour among army personnel: A qualitative study. Journal of the Royal Army Medical Corps, 155(3), 203–207.
4. Jones, N., Fear, N. T., Jones, M., Wessely, S., & Greenberg, N. (2010). Long-term military work outcomes in soldiers who become mental health casualties when deployed on operations. Psychiatry, 73(4), 352–364. doi.org/10.1521/ psyc.2010.73.4.352
5. Killgore, W. D., Cotting, D. I., Thomas, J. L., Cox, A. L., McGurk, D., Vo, A. H., Castro, C. A., & Hoge, C. W. (2008). Post-combat invincibility: Violent combat experiences are associated with increased risk-taking propensity following deployment. Journal of Psychiatric Research, 42(13), 1112–1121.
6. Richard Gabriel (1987). No more Heroes. Madness and psychiatry in war.