The Lancet Psychiatry Commission on mental health in Ukraine

Executive summary: The Russian invasion and annexation of eastern Ukraine and Crimea in 2014, along with the ongoing war since February, 2022, have inflicted incalculable damage to Ukraine with many deaths and injuries, massive population displacement, and extensive physical and emotional trauma. These events put an immense strain on the general health-care and mental health-care systems. For many years the mental health-care system in Ukraine was dominated by large psychiatric hospitals and residential institutions focusing on biological therapies; it was a system known for neglect, abuse, and human rights violations. While coping with current stressors, Ukraine is looking to the future with recovery initiatives and reforms to bring its health and social infrastructures to meet the needs of the Ukrainian people and international standards. This Lancet Psychiatry Commission was convened to identify the current mental health needs in Ukraine, and to outline a plan for a future, in which Ukrainians receive evidence-based care through a system that values human rights and lived experiences of people with mental illness. The Commission included five workgroups, each examining specific opportunities for change, development, and modernisation of the Ukrainian mental health-care system, along with requirements for success in clinical services, clinical training, research, forensics and legal advocacy, and finance. Workgroups built upon Ukraine’s pre-war efforts to create a modern mental health-care system, while simultaneously looking at a 5–10-year horizon for bringing Ukrainian mental health care, training, research, and legal practices in line with international standards, which the country must meet in preparation for its expected European Union (EU) membership. 40 experts in mental health, health economics, law, science, and epidemiology, along with people with lived experience of mental illness, from 12 countries, joined to create this Commission.

Part 1: Community-based mental health care and a vision for a new network of Ukrainian mental healthcare services. The current high prevalence of depression and anxiety in Ukraine requires the application of rapidly implementable and scalable solutions that can also be provided by properly trained non-specialists in primary care settings that are readily accessible to all Ukrainians. To achieve this transformation and ensure optimal service coverage, the Commission recommends using a steppedcare approach. The provision of some low-intensity services and interventions should be shifted from specialised mental health workers to non-specialised personnel within the health sector and beyond, while ensuring appropriate training and supervision and use of emerging digital solutions. This approach will allow for a scaling-up of the management of common mental disorders in primary health care, while establishing a referral system with standardised assessment tools for more complex disorders. Most importantly, this strategy will facilitate the transition of people currently in institutions into the new community-based services as they become available.

Part 2: Training and education of the mental health workforce. Ukraine requires a large, skilled, multidisciplinary mental health workforce. Workforce expansion will be made possible only by implementing substantial revisions of undergraduate medical education curricula, as well as clinical training. Reform of training and education of the mental health workforce should begin with an assessment of the national training needs that considers current and future requirements of mental health-care services. This assessment will allow formulation of a national mental health workforce plan, or a similar overarching guiding document, which will outline the resources and structures necessary for longer psychiatric training experiences for medical students and residents. These recommendations will be aligned with European standards and quality assurance, as well as the necessary steps for adopting the European Union of Medical Specialists’ psychiatry frameworks for training and continuing medical education.

Part 3: Rebuilding mental health research capacity and infrastructure. Rebuilding and reforming mental health-care services will require revitalised research infrastructure. Mental health research funding should be consistent with the prevalence and effects of mental disorders within the entire Ukrainian health-care system. More Ukrainian research funds should be allocated to mental health, for both applied research and implementation science. The Government and funding bodies should initiate funding targets for key topics, such as post-traumatic stress disorder (PTSD) and the impact of war on veterans and families who have been affected by violence or separation. The research should take place across multiple settings (hospital, community, and primary care) and be done by multi-disciplinary mental health research teams. Research on the social and economic effects of deinstitutionalisation should guide the development of community services. Ukrainian researchers should be invited to visit programmes, within and outside Ukraine, that offer mental health support for people living with trauma or in conflict zones. The purpose of such initiatives is to develop skills of Ukrainian researchers and to establish collaborations to facilitate the implementation and evaluation of innovative services in Ukraine.

Part 4: Reform of advocacy and legal principles regarding mental health. Ukraine should make every attempt to revise its mental health laws to best reflect international standards with respect to autonomy, capacity, competence, guardianship, coercive treatment, advocacy, and other related issues. The laws must be fundamentally amended to be human rights-based and person-oriented, and should include the assumption of capacity and prioritise consent. Strict limitations and legal oversight should be implemented regarding restricting individual liberty, including a procedure for appeals with requisite legal aid. Involuntary intervention should be restricted to situations in which it is absolutely necessary, with explicit time limits, strong multi-disciplinary oversight, and effective legal remedies. Human rights principles should be integrated into legal dispositions, including addressing the risk of harm to self and others, based on multi-disciplinary assessments and rehabilitation possibilities, and with peer support. Finally, mental health conditions should be decriminalised.

Part 5: Resourcing the future of mental health. Not only is the total financial support for Ukrainian mental health care disproportionately low relative to the needs of the population, but a major share of resources is allocated to institutional care rather than evidence-based community services. Financial investments and a gradual shift in resource allocations to meet the needs of patients in their communities will be more effective and sustainable than current practice. To reach more people with mental health conditions in need of care and support, the Ukrainian Government should increase investment in mental health (from 3% to 4·5% of total health spending); at least 5% of the budget for mental health should be allocated to preventive measures. In view of the current macroeconomic conditions and security priorities, implementation of the proposed measures in the short term is likely to require external donor assistance; however, a community-based approach to care and an evidence-based focus will reap the benefits of effectiveness and efficiency.

Conclusion: Ukraine has faced extraordinary adversities in the past 10 years. However, among the incredible stresses, the country has remained focused on working towards a better future, including improving its health-care and mental health-care systems. Recognising the perilous road ahead, the Lancet Psychiatry Commission shares the Ukrainians’ powerful sense of hope and unequivocally supports Ukraine’s bid to join the community of nations and meet international standards for clinical care, medical education, research, legal protection, and funding.