Mental health affects our emotions, behaviour, communication, thinking, decision-making and social well-being, so it has a comprehensive impact on everyday life.

In addition to the obvious examples, insufficient attention to it can lead to worsening in physical health issues. For instance, depression increases the risk of developing or worsening a number of chronic conditions, such as diabetes, cardiovascular disease, asthma, stroke and heart attack. In 2008 The Canadian Institute for Health Information found that people with symptoms of depression experience three times as many chronic physical illnesses as the general population. Meanwhile, people suffering from such conditions are twice as likely to experience mood or anxiety disorders compared to non-depressed people.

Ukrainians have been experiencing the long-term effects of war-related stress for almost 10 years. In 2017–2019 the World Health Organization and the World Bank Group in their documents on the transformation of the mental health system in Ukraine noted that 20 to 30% of Ukrainians who had traumatic experiences related to the war already have existing signs of poor mental health, such as depression, sleep disorders, and post-traumatic stress disorder. A study of the mental state of Ukrainians conducted in the spring of 2023 revealed that the last 16 months of the war have led to traumatic experiences for more than 90% of the population.

Based on this data, we can conclude that one in three Ukrainians already has a mental health disorder. Such a large-scale traumatic experience without the most accessible, timely and close psychological support will have socio-economic consequences for decades, taking away years of full life for both civilians and the military. Currently, Ukrainians' self-assessment of their psychological state remains at a relatively high level, which is a completely natural reaction to stress. According to a study conducted in the Czech Republic among Ukrainian refugees,

• 51 per cent of Ukrainian refugees have depressive conditions, but only 14 per cent admit it by self-assessment;
• 23 per cent of Ukrainian refugees have high and very high levels of anxiety, compared to 4 per cent of Czech residents.

The authors of the study on the capacity of the mental health care market in Ukraine suggest that next year, the situation with a relatively high level of self-assessment of their psychological state by Ukrainians will change for the worse and by 2028, the level of anxiety disorders will potentially triple and the level of depression will double compared to 2016.

It is also important to note that the state of mental health has a direct impact on economic performance. The World Bank Group estimates the economic value of restored productivity (the economic value of productivity restoration in the context of mental health includes the costs of psychotherapy, medical treatment and other mental health services, as well as economic benefits such as increased productivity, reduced human resource losses, reduced disability and marginalisation as a result of improving mental health) with the treatment of common mental disorders in the period from 2017 to 2030 of over USD 800 million for depression and USD 350 million for anxiety disorders. In practical terms, for timely mental health care services, each dollar invested in expanding treatment for common mental disorders in Ukraine will result in USD 2 in restored productivity and added economic value.

According to the World Bank, the mental health system in Ukraine is 90% centralised. Mental health facilities are mostly located in large cities and are primarily represented by Soviet-style inpatient and outpatient clinics with outdated approaches to providing services that are out of step with the challenges faced by modern Ukrainians. In 2020 the Ministry of Health launched a reform of the mental health system, trying to bring services closer to patients at the primary healthcare level. Also, various volunteer and donor projects are quite active in this field, trying to overcome the most acute challenges, but they cannot cover the full range of needs. mhGAP community toolkit: field test version. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO.

mhGAP community toolkit: field test version. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO.

What exactly is there to do at the municipal level to improve the mental health situation? First of all, we need to consider the following three steps:

      I. Determine responsibility for mental health organization, development and education in your municipality.

     II. Identify groups of people in your municipality according to age and social factors. For example,

• children of school age,
• internally displaced children,
• children who lost loved ones in the war,
• children whose relatives were injured,
• children whose relatives were/are involved in active hostilities,
• children who survived the occupation,
• children who have previously sought help for mental health issues

A significant number of cases will be complex and require greater attention!

It is advisable to carry out such an analysis for all identified categories of residents, but in case of a lack of resources, it is better to focus on certain categories: children, military personnel, bereaved families, IDPs, etc.

    III. Identify those who help to support the mental health of different categories of residents within your municipality: volunteer organizations, healthcare professionals, self-support groups, spiritual institutions, etc.

• What percentage of the medical staff of the primary healthcare facility have been trained in managing common mental disorders at the primary level of care?
• What percentage of residents have undergone a mental health assessment?

As with any healthcare intervention, efforts to improve access to mental health services start with a needs assessment. Aware of the high stigma attached to mental health among most Ukrainians, a multi-stage survey is a method of determining the relevance and scope of mental health services needed:

1. Mental health self-assessment. The issues are tailored to the groups and their needs in cooperation with doctors and psychologists.
2. Determining the level of mental health awareness, such as: sleep disorders, post-traumatic stress disorder, anxiety, eating disorders, etc. Are the residents of your community aware of the existence of such conditions and their main symptoms at the household level?
3. The residents' awareness of the services available and their readiness to receive such services. For example, are people aware that they can get a mental health consultation from their family doctor or that the municipality provides access to online counselling with psychologists?

The issues can be grouped according to age and social factors in the municipality, and the survey can be conducted both online and in paper form. The following conclusions can be drawn from the results of such surveys:

• What percentage of the residents of the municipality self-assess that they have sleep disorders, high and ultra-high anxiety, feel lonely and isolated, have decision-making difficulties, mood swings, etc;
• What percentage of residents are unsure whether they need help and where to find it;
• The number of residents who do not seek help due to financial and/or logistical barriers, long queues;
• The number of residents who do not seek help due to high stigma and reluctance to let anyone know they sought help.

After conducting such a study, the following step is to create a mental health map of the municipality and identify steps to develop this system, using the support of national, international and volunteer projects.

So what can be achieved today?

1. Ensure maximum privacy at family doctor's appointments. Patients are more likely to open up if they have the opportunity to visit a doctor in private.
2. Conduct mental health assessments for residents who visit family doctors. If possible, provide additional financial incentives for medical professionals involved in such assessments.
3. Collect information on mental health services available in the region, both free and fee-based, and post this information in accessible places and online.
4. Print out “mental health red flags for different age groups” and actively distribute them.
5. Determine who can assist in finding appropriate care and making appointments with maximum privacy, without leaving the person to deal with these issues alone.
6. Whenever technically possible, provide access to online consultations in publicly accessible places (libraries, ASCs, schools, cultural centres) with the maximum possible privacy.
7. Identify municipality residents who are ready to be educated in various aspects of mental health.

Mental health is an integral part of a person's full life. The mental health status of the residents of municipalities is closely related to the potential for development and restoration of the municipality, the level and life expectancy of its residents, so it is crucial for every municipality in Ukraine to raise awareness of the impact of mental disorders on people's everyday lives, reduce the stigma of seeking mental health care and realise that the task is not a sprint, but rather a marathon for several years, but at the same time, every minute and hryvnia invested in mental health will contribute to the restoration of our country.

1. Stories of change in four countries: building capacity for integrating mental health care within health services across humanitarian settings. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO.
2. Voice of Ukrainians: Mental health / Research among refugees. Research authors
3. Martina Kavanová, Daniel Prokop, Michael Škvrÿák, Matyáš Levinsky (PAQ Research) Zoe Guerrero, Petr Winkler (National Institute of Mental Health)
4. https://ontario.cmha.ca/documents/the-relationship-between-mental-health-mental-illness-and-chronic-physical-conditions/
5. Assessment and Guidance for Strengthening Integration of Mental Health into Primary Health Care and Community-Based Service Platforms in Ukraine World Bank Group, 2019
6. https://www.statista.com/outlook/hmo/mental-health/ukraine
7. mhGAP community toolkit: field test version. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO.
8. https://academy.nszu.gov.ua/