Addressing the mental health needs of civilian combatants in Ukraine

War trauma impacts in Ukrainian combat and civilian populations: Moral injury and associated mental health symptoms

This is the first study to compare active-duty soldiers and student civilian samples during the first three months of the Ukrainian-Russian war in relation to moral injury and its association with PTSD, anxiety and depression. A total of 350 participants, including 191 active-duty soldiers of the Ukrainian Armed Force (UAF), who were on the frontline during the full-scale invasion of Russian troops in February 2022, and 159 students from different HEIs in Volyn oblast, were recruited into the study through their attendance at the Ukrainian Psychotrauma Center. Prior to the in-person group-intervention program of psychosocial support for military and civil populations at the Ukrainian Psychotrauma Center, moral injury, PTSD, depression, and anxiety were assessed. Results showed significantly higher moral injury, PTSD, depression, and anxiety scores in civilian students, with a two-way ANOVA indicating a significant impact of female gender in civilians only. A hierarchical regression indicated that moral injury is a predictor of PTSD symptoms in both active-duty and civilian student groups. However, previous family trauma of genocide is associated with PTSD symptoms in active soldiers only. The findings of the current study could contribute insights for clinical practice for combatants and civilians during the current war.

The mediating effect of post-traumatic growth on the relationship between personality traits and resilience among a sample of Lebanese adults

BACKGROUND

Resilience plays a crucial role in mental health promotion and prevention, and was shown to be more represented in individuals who exhibit high levels of extraversion, openness, agreeableness, and conscientiousness. However, there is a lack of studies that comprehensively investigate the association between personality traits and resilience in Lebanon and Arab countries more broadly. The purpose of the present study was to complement the literature by investigating the direct and indirect effects between the five personality traits and resilience among a sample of Lebanese adults through the intermediary role of posttraumatic growth.

METHODOLOGY

A cross-sectional study was carried out between May and July 2022, and enrolled 387 participants, all aged above 18 years old and recruited from all Lebanon governorates. The questionnaire used included socio-demographic questions, and the following scales: Connor-Davidson Resilience Scale (CD-RISC) to assess resilience, post traumatic growth (PTG), and Big Five Inventory (BFI-2). The SPSS software v.25 was used for the statistical analysis.

RESULTS

Post-traumatic growth mediated the association between extraversion / agreeableness / conscientiousness and resilience. Higher extraversion / agreeableness / conscientiousness was significantly associated with more post-traumatic growth. Higher post-traumatic growth was significantly associated with more resilience. Extraversion, but not agreeableness and conscientiousness, was significantly and directly associated with more resilience.

CONCLUSION

Findings suggest that fostering PTG in individuals who experience adversity can help promote their resilience. Hence, it could be beneficial to design and apply programs aiming at supporting PTG among people who experience stressful and traumatizing situations, to consequently help them increase their sense of resilience.

Children Fleeing War-Exploring the Mental Health of Refugee Children Arriving in Israel after the Ukraine 2022 Conflict

BACKGROUND

In February 2022, Ukraine suffered a devastating assault by Russia, leading to destruction, casualties, and mass displacement. Among those displaced were over 1.5 million children. Forced displacement exposes children to a heightened risk of mental health issues.

OBJECTIVE

This study investigated the prevalence of Post-traumatic stress disorder (PTSD) and other mental health issues among child refugees shortly after their displacement from Ukraine to Israel. It aimed to identify factors influencing PTSD development and explore their associations.

METHODS

The study included 59 child refugees who had arrived in Israel after fleeing the war in Ukraine. Parents completed self-report questionnaires to assess their children's mental health.

RESULTS

Only three children met the DSM diagnostic criteria for PTSD, with higher scores in the negative cognition and re-experiencing clusters. Over half of the children exhibited general mental health problems, with approximately 40 % showing internalizing problems, and 30 % showing externalizing problems. The study also found a significant comorbidity between PTSD symptoms and internalizing problems. Additionally, internalizing problems emerged as the sole significant predictor of PTSD levels when considering factors such as age, gender, economic status, parents' work status, internalizing problems, and externalizing problems.

CONCLUSIONS

Child refugees frequently experience psychological distress, even if they do not meet the formal diagnostic criteria for PTSD. They often exhibit other distress symptoms, primarily internalizing problems, which can be challenging to detect. A deeper understanding of the challenges faced by refugee children can inform the development of targeted assistance programs and the recruitment and training of personnel in host countries.

Mental Health and well-being During the COVID-19 Pandemic and After the Russian Invasion of Ukraine

The study compared the mental health of university students during the COVID-19 pandemic and the Russian invasion of Ukraine. A repeated online cross-sectional study was performed twice among university students in Ukraine: in November 2020 (Pre-war sample, n = 752) and September-October 2022 (During-war sample, n = 862). The survey measured life satisfaction (SWLS), perceived stress (PSS-10), anxiety (GAD-7), and depression (PHQ-9). Stress, anxiety, and life satisfaction levels were similar during the war and pandemic, while symptoms of depression decreased during the war, compared to the pandemic. Network analysis showed that anxiety has a crucial effect on depression and stress, and stress is most closely related to life satisfaction. The association of life satisfaction with anxiety and depression disappeared in wartime, in contrast to the pandemic. The priority of prevention and intervention programs in wartime Ukraine should focus on anxiety as the most influential factor in other mental health and well-being problems. The results showed high resistance and adaptation to war conditions among university students in Ukraine.

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.

Trauma-related and risk factors associated with perceived exacerbation in psychological distress due to the Russo-Ukrainian war

This study examined trauma-related and other potential risk factors associated with perceived exacerbation in psychological distress among Israelis due to the Russo-Ukrainian War. Specifically, we assessed how vulnerability factors such as previous traumatic exposure, having relatives and friends affected by the war, media exposure, having a Holocaust familial background, lower levels of resilience, and probable posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) are associated with perceived exacerbation in psychological distress. A random sample of 845 Israeli Jews aged 18-75 who reported exposure to at least one traumatic event participated in the study. Univariate logistic regression showed that Holocaust familial background, previous exposure to trauma, media exposure to the Russo-Ukrainian War, and probable diagnosis of PTSD or CPTSD are the main factors associated with perceived exacerbation in psychological distress. These results suggest that various traumatic factors associate with perceived higher psychological vulnerability to international conflicts, even when there is no direct personal threat. Practitioners should be aware of these factors among individuals exposed to trauma.

Post-traumatic Stress Disorder and Moral Injury Among Ukrainian Civilians During the Ongoing War

While severity of post-traumatic stress disorder (PTSD) symptoms and moral injury among civilians affected by armed conflicts is generally understudied, even less research exists on civilian populations during an active war. This paper reports a large-scale study that administered standard assessments of PTSD and moral injury severity, as well as rich demographic questionnaires, to nearly 1300 Ukrainian civilians during the ongoing Russian invasion. Analyses revealed an extremely high prevalence of severe PTSD symptoms and moral injury, relative to both proposed clinical cut-offs and to earlier measurements from a similar population. Further regression analyses identified risk factors and protective factors. Greater severity of PTSD symptoms was observed among women, older and forcibly displaced individuals, and individuals from geographic regions under Russian occupation. Higher education correlated with milder PTSD symptoms. Moral injury was particularly strong in younger individuals. The present study is one of the first to report a large scale set of psychological data collected from the civilian population of Ukraine during the ongoing Russian invasion. It is obvious from the scope and long-term nature of the atrocities that psychological treatment of the civilian population will be required both presently, while the hostilities are ongoing, and in the future. This data contributes to a detailed understanding of the psychological response to traumatic stress, including its overall prevalence and presence in specific demographically and geographically defined civilian groups.

Potential impacts of Russo-Ukraine conflict and its psychological consequences among Ukrainian adults: the post-COVID-19 era

Background

Since February 2022, the nation of Ukraine has become entangled in an escalating conflict that erupted after coronavirus outbreak fostering a situation of indeterminacy and precariousness, which adversely affected several facets, especially psychological well-being. However, there is a lack of empirical evidence on the psychological well-being of Ukrainians during the Russo-Ukraine war, as well as their coping strategies in response to the war's repercussions. Consequently, this investigation endeavors to explore the prevalence of symptoms associated with depression, anxiety, stress, and insomnia and to correlate these symptoms with Ukrainians' effective coping mechanisms during the ongoing war.

Methods

An online survey was administered in Ukraine from June to August 2022 due to the ongoing Russo-Ukraine conflict. The survey employed a quota sampling technique, targeting 2,664 individuals (≥18 years). Out of the total sample, 1,833 valid responses were obtained, yielding a response rate of 68. 81%. Depression, anxiety, and stress were measured using the depression, anxiety, and stress scale-21 (DASS-21), while the Pittsburgh sleep quality index (PSQI) was utilized to evaluate insomnia symptoms. In addition, Brief-COPE was adopted to evaluate the coping mechanisms of the selected study participants.

Results

Of 1,833 Ukrainian adults, 60.5% had symptoms of stress; 62.4% of them reported symptoms of anxiety; and 58.2% reported symptoms of depression. Symptom criteria for insomnia were found in about 21.8% of the study sample. The factors of sex, living area, area occupied by Russian forces, and having older adults and children in the house were statistically significant with symptoms of depression, anxiety, stress, and insomnia. The productive coping strategies of self-distraction, using instrumental support, planning, and behavioral disengagement, were observed as statistically significant with four psychological constructs.

Conclusion

The study outcomes highlight a substantial prevalence of symptoms related to depression, anxiety, stress, and insomnia attributed to the accumulated consequences of ongoing conflict and the COVID-19 outbreak. The aforementioned findings emphasize the imperative of providing healthcare services and facilitating effective coping strategies among Ukrainians amid the ongoing war.

Postpartum depression: The prevalence and associated factors among women attending postnatal clinics in the Bawku municipality, Upper East Region of Ghana

Introduction

This study examined postpartum depression (PPD) among mothers in the Bawku municipality of Ghana, aiming to assess its prevalence and associated risk factors.

Methods

A total of 242 women, 2-12 weeks postpartum, were randomly recruited for this cross-sectional analytical study. The Edinburgh Postnatal Depression Scale was used for depression screening, and multivariate logistic regression analysis was employed to assess the factors associated with PPD.

Results

The study showed that 34.7% of the postpartum mothers were within the age range of 25-29, with a mean age of 27.9 (standard deviation [SD] ± 6.33). The prevalence of PPD was 50.4% (95% confidence interval [CI] 43.9-56.9). Several significant risk factors were identified, including inadequate prenatal visits (adjusted odds ratio [aOR] = 13.44, 95% CI 3.66-49.37, P < 0.001), obstetric complications (aOR = 3.39, 95% CI 1.23-11.19, P = 0.019), less than 3 weeks postpartum (aOR = 8.14, 95% CI 1.95, 33.94, P = 0.004), 6-8 weeks postpartum (aOR = 7.72, 95% CI 1.71-34.80, P = 0.008), and stressful life events (aOR = 3.30, 95% CI 1.23-8.89, P = 0.018).

Conclusion

The study concluded that the prevalence of PPD in the Bawku municipality is higher than previously reported in Ghana, emphasizing the need for early identification of pregnant women at risk for PPD.

The mental health impact of the ongoing Russian-Ukrainian war 6 months after the Russian invasion of Ukraine

Objective

This study aimed to investigate the impact of the ongoing war in Ukraine on the mental health of Ukrainians, focusing on war-induced trauma, disturbances in self-organization, post-traumatic stress disorder, complex post-traumatic stress disorder, anxiety, stress, and depression.

Methods

Data was collected from 703 participants 6 months after the full-scale invasion using a structured questionnaire that included sections on socio-demographic information, trauma-related issues, and mental health.

Results

The study found that levels of depression and anxiety were relatively low, while stress and resilience were relatively high among Ukrainians affected by the war. However, those who were directly exposed to military actions, physical violence, or severe human suffering had higher levels of anxiety, depression, stress, and trauma-related symptoms. The war experience varied by gender, age, and living conditions. Participants who stayed in Ukraine had significantly lower anxiety, depression, stress, and trauma-related symptoms compared to those who moved abroad. Anxiety, depression, stress, low resilience, and subjective satisfaction with living conditions were predictors of trauma-related symptoms, including PTSD and CPTSD.

Conclusion

These findings suggest that the mental health of Ukrainians affected by the war was impacted differently depending on their level of exposure to violence and their living conditions. Additionally, the study identified several predictors of trauma-related symptoms, including PTSD and CPTSD, such as anxiety, depression, stress, low resilience, and subjective satisfaction with living conditions. Future research should further explore the relationships between trauma type, sociodemographic factors, resilience, stress, anxiety, depression, and PTSD and CPTSD to better understand the mediation mechanisms underlying these relationships and to develop effective interventions to support the well-being of Ukrainians during this difficult time.

General anaesthesia-related complications of gut motility with a focus on cholinergic mechanisms, TRP channels and visceral pain

General anesthesia produces multiple side effects. Notably, it temporarily impairs gastrointestinal motility following surgery and causes the so-called postoperative ileus (POI), a multifactorial and complex condition that develops secondary to neuromuscular failure and mainly affects the small intestine. There are currently limited medication options for POI, reflecting a lack of comprehensive understanding of the mechanisms involved in this complex condition. Notably, although acetylcholine is one of the major neurotransmitters initiating excitation-contraction coupling in the gut, cholinergic stimulation by prokinetic drugs is not very efficient in case of POI. Acetylcholine when released from excitatory motoneurones of the enteric nervous system binds to and activates M2 and M3 types of muscarinic receptors in smooth muscle myocytes. Downstream of these G protein-coupled receptors, muscarinic cation TRPC4 channels act as the major focal point of receptor-mediated signal integration, causing membrane depolarisation accompanied by action potential discharge and calcium influx via L-type Ca²⁺ channels for myocyte contraction. We have recently found that both inhalation (isoflurane) and intravenous (ketamine) anesthetics significantly inhibit this muscarinic cation current (termed mI _CAT) in ileal myocytes, even when G proteins are activated directly by intracellular GTPγS, i.e., bypassing muscarinic receptors. Here we aim to summarize Transient Receptor Potential channels and calcium signalling-related aspects of the cholinergic mechanisms in the gut and visceral pain, discuss exactly how these may be negatively impacted by general anaesthetics, while proposing the receptor-operated TRPC4 channel as a novel molecular target for the treatment of POI.

Nuclear Anxiety Amid the Russian-Ukrainian War 2022 (RUW-22): Descriptive Cross-Sectional Study

Nuclear anxiety, which refers to the fear of nuclear war and its consequences, is expected to increase amid the Russian-Ukrainian War of 2022 (RUW-22). This study aimed to evaluate the prevalence of nuclear anxiety and its associated variables among university students in the Czech Republic during the first weeks of RUW-22. A cross-sectional survey-based study was carried out from March-April 2022, utilizing a digital self-administered questionnaire (SAQ) to collect data from the target population. The SAQ consisted of multiple-choice items inquiring about demographic characteristics; generalized anxiety symptoms using generalized anxiety disorder-7 (GAD-7); depressive symptoms using patient health questionnaire-9 (PHQ-9); and attitudes towards civilian uses of nuclear power, and nuclear war-related anxiety. Of the 591 participating students, 67.7% were females, 68.2% were Czech nationals, and 61.8% followed the RUW-22 news at least once daily. The mean GAD-7 score of our participants was 7.86 ± 5.32 (0-21); and their mean PHQ-9 score was 8.66 ± 6.29 (0-27). Regarding the civilian uses of nuclear power, most participants agreed that nuclear power was safe (64.5%), denied being afraid that civilian use of nuclear power might deteriorate their health (79.7%), and thought that public acceptance was important for building new nuclear power plants (56.9%). About 42.1% and 45.5% of the participants reported feeling depressed at the possibility of nuclear war and agreed that the chances that there would be a nuclear war in their lifetime were very high, respectively. When asked about their preparedness measures during the previous four weeks, less than one quarter (23.9%) reported looking for recommendations for protection against nuclear accidents, and less than one-fifth (19.3%) were looking for the nearest bomb shelter. The depression about nuclear war possibility was positively and relatively strongly correlated with the level of "feeling concerned about the RUW-22" (rs = 0.401), and it was moderately correlated with GAD-7 (rs = 0.377) and PHQ-9 (rs = 0.274) scores and weakly correlated with RUW-2-related news-following frequency (rs = 0.196). Within the limitations of the present study, nuclear anxiety was common among Czech university students. Its associated factors may include but are not limited to the female gender; common psychological disorders such as generalized anxiety and depression; RUW-22-related news following-frequency; and the level of "feeling concerned".

The Effects of Art Therapy on Anxiety and Distress for Korean-Ukrainian Refugee: Quasi-Experimental Design Study

Since Russia invaded Ukraine in February 2022, there has been an urgent need to provide mental healthcare and share various practices for Ukrainian war refugees. This study urgently focuses on the need for art therapy to support the mental health of Ukrainian refugees, Koryo-saram, who are staying in the Republic of Korea due to the wartime emergency. It also examines the impact of art therapy intervention on anxiety and subjective stress. The single-session art therapy with the 54 Koryo-saram refugees aged 13-68 showed the effectiveness of the art therapy intervention. The results indicate that GAD-7 (t = 3.092, p = 0.003) and SUDs (t = 3.335, p = 0.002) were statistically significant within the intervention group. In addition, satisfaction assessments of the qualitatively analyzed participants showed that Ukrainian Koryo-saram had a positive experience of art therapy. Therefore single-session art therapy in this study demonstrated the efficacy of art therapy for the anxiety and subjective distress of Ukrainian Koryo-saram refugees. This result suggests that the intervention of art therapy as immediate mental healthcare for refugees facing war could benefit the mental health of Koryo-saram refugees.

The Mental Health Costs of Armed Conflicts-A Review of Systematic Reviews Conducted on Refugees, Asylum-Seekers and People Living in War Zones

AIMS

Armed conflicts produce a wide series of distressing consequences, including death, all of which impact negatively on the lives of survivors. This paper focuses specifically on the mental health consequences of war on adults and child/adolescent refugees or those living in war zones through a review of all systematic reviews and/or meta-analyses published from 2005 up until the current time.

RESULTS

Fifteen systematic reviews and/or meta-analyses conducted in adult populations, and seven relating to children and adolescents, were selected for the purpose of this review. Prevalence rates of anxiety, depression and post-traumatic stress disorder (PTSD) were two- to three-fold higher amongst people exposed to armed conflict compared to those who had not been exposed, with women and children being the most vulnerable to the outcome of armed conflicts. A series of war-related, migratory and post-migratory stressors contribute to short- and long-term mental health issues in the internally displaced, asylum seekers and refugees.

CONCLUSION

It should be a required social responsibility for all psychiatrists and psychiatric associations to commit to raising awareness amongst political decision-makers as to the mental health consequences caused by armed conflicts, as part of their duty of care for people experiencing the consequences of war.

Relation between resilience and personality traits: The role of hopelessness and age

Resilience refers to the process by which individuals use the ability to cope with challenges to successfully adapt to adverse situations, inclining towards the future and hope. The main aim of this study was to analyze the relation between resilience, personality traits, and hopelessness. Furthermore, we conducted comparisons between two age groups: young and older adults. The sample comprised 439 Spanish participants (66.7% women; M = 43.73, SD = 26.41; age range = 18-98 years). The Connor-Davidson Resilience Scale, NEO-Five Factor Inventory, and Beck Hopelessness Scale were used to measure the main study variables. The results revealed a negative relation between resilience and neuroticism, and a positive association with the other personality traits. Additionally, levels of resilience were found to be negatively related to hopelessness. The group of older adults showed significantly lower resilience levels than the young adults, although age was not a significant predictor of resilience. Neuroticism, extraversion, openness, and hopelessness were the only predictors of resilience for the current study. This work contributes to the study of resilience and related factors, by attempting to understand the role of resilience and resistance to risk and how individuals tackle challenges over time, with important implications for mental health.

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.

Traumatic brain injury: progress and challenges in prevention, clinical care, and research

Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research.

In LMICs, the occurrence of TBI is driven by road traffic incidents, often involving vulnerable road users such as motorcyclists and pedestrians. In HICs, most TBI is caused by falls, particularly in older people (aged ≥65 years), who often have comorbidities. Risk factors such as frailty and alcohol misuse provide opportunities for targeted prevention actions. Little evidence exists to inform treatment of older patients, who have been commonly excluded from past clinical trials—consequently, appropriate evidence is urgently required. Although increasing age is associated with worse outcomes from TBI, age should not dictate limitations in therapy. However, patients injured by low-energy falls (who are mostly older people) are about 50% less likely to receive critical care or emergency interventions, compared with those injured by high-energy mechanisms, such as road traffic incidents.

Mild TBI, defined as a Glasgow Coma sum score of 13–15, comprises most of the TBI cases (over 90%) presenting to hospital. Around 50% of adult patients with mild TBI presenting to hospital do not recover to pre-TBI levels of health by 6 months after their injury. Fewer than 10% of patients discharged after presenting to an emergency department for TBI in Europe currently receive follow-up. Structured follow-up after mild TBI should be considered good practice, and urgent research is needed to identify which patients with mild TBI are at risk for incomplete recovery.

The selection of patients for CT is an important triage decision in mild TBI since it allows early identification of lesions that can trigger hospital admission or life-saving surgery. Current decision making for deciding on CT is inefficient, with 90–95% of scanned patients showing no intracranial injury but being subjected to radiation risks. InTBIR studies have shown that measurement of blood-based biomarkers adds value to previously proposed clinical decision rules, holding the potential to improve efficiency while reducing radiation exposure. Increased concentrations of biomarkers in the blood of patients with a normal presentation CT scan suggest structural brain damage, which is seen on MR scanning in up to 30% of patients with mild TBI. Advanced MRI, including diffusion tensor imaging and volumetric analyses, can identify additional injuries not detectable by visual inspection of standard clinical MR images. Thus, the absence of CT abnormalities does not exclude structural damage—an observation relevant to litigation procedures, to management of mild TBI, and when CT scans are insufficient to explain the severity of the clinical condition.

Although blood-based protein biomarkers have been shown to have important roles in the evaluation of TBI, most available assays are for research use only. To date, there is only one vendor of such assays with regulatory clearance in Europe and the USA with an indication to rule out the need for CT imaging for patients with suspected TBI. Regulatory clearance is provided for a combination of biomarkers, although evidence is accumulating that a single biomarker can perform as well as a combination. Additional biomarkers and more clinical-use platforms are on the horizon, but cross-platform harmonisation of results is needed. Health-care efficiency would benefit from diversity in providers.

In the intensive care setting, automated analysis of blood pressure and intracranial pressure with calculation of derived parameters can help individualise management of TBI. Interest in the identification of subgroups of patients who might benefit more from some specific therapeutic approaches than others represents a welcome shift towards precision medicine. Comparative-effectiveness research to identify best practice has delivered on expectations for providing evidence in support of best practices, both in adult and paediatric patients with TBI.

Progress has also been made in improving outcome assessment after TBI. Key instruments have been translated into up to 20 languages and linguistically validated, and are now internationally available for clinical and research use. TBI affects multiple domains of functioning, and outcomes are affected by personal characteristics and life-course events, consistent with a multifactorial bio-psycho-socio-ecological model of TBI, as presented in the US National Academies of Sciences, Engineering, and Medicine (NASEM) 2022 report. Multidimensional assessment is desirable and might be best based on measurement of global functional impairment. More work is required to develop and implement recommendations for multidimensional assessment. Prediction of outcome is relevant to patients and their families, and can facilitate the benchmarking of quality of care. InTBIR studies have identified new building blocks (eg, blood biomarkers and quantitative CT analysis) to refine existing prognostic models. Further improvement in prognostication could come from MRI, genetics, and the integration of dynamic changes in patient status after presentation.

Neurotrauma researchers traditionally seek translation of their research findings through publications, clinical guidelines, and industry collaborations. However, to effectively impact clinical care and outcome, interactions are also needed with research funders, regulators, and policy makers, and partnership with patient organisations. Such interactions are increasingly taking place, with exemplars including interactions with the All Party Parliamentary Group on Acquired Brain Injury in the UK, the production of the NASEM report in the USA, and interactions with the US Food and Drug Administration. More interactions should be encouraged, and future discussions with regulators should include debates around consent from patients with acute mental incapacity and data sharing. Data sharing is strongly advocated by funding agencies. From January 2023, the US National Institutes of Health will require upload of research data into public repositories, but the EU requires data controllers to safeguard data security and privacy regulation. The tension between open data-sharing and adherence to privacy regulation could be resolved by cross-dataset analyses on federated platforms, with the data remaining at their original safe location. Tools already exist for conventional statistical analyses on federated platforms, however federated machine learning requires further development. Support for further development of federated platforms, and neuroinformatics more generally, should be a priority.

This update to the 2017 Commission presents new insights and challenges across a range of topics around TBI: epidemiology and prevention (section 1 ); system of care (section 2 ); clinical management (section 3 ); characterisation of TBI (section 4 ); outcome assessment (section 5 ); prognosis (Section 6 ); and new directions for acquiring and implementing evidence (section 7 ). Table 1 summarises key messages from this Commission and proposes recommendations for the way forward to advance research and clinical management of TBI.

Anxiety Assessment in Polish Students during the Russian-Ukrainian War

Anxiety is described as a feeling of fear that appears in stressful or threatening situations. A terrorist attack is one such situation. The aim of this study was to assess anxiety levels among students using the STAI questionnaire. The study group consisted of 510 participants. Statistical analysis was performed using Statistica software. Anxiety levels, correlations between STAI scores, and individual variables were assessed. Logit models were performed for the study variables. Higher levels of anxiety were found in females compared to males (p = 0.0000). The highest level of anxiety overall was found in year 1 students, the lowest in year 5 students (p = 0.0005). The highest level of anxiety overall was found in pharmacy students, the lowest in midwifery students. We concluded that there was a relatively strong relationship between anxiety and gender. Gender and fear of an armed attack on Poland had a significant impact on anxiety.

Disease burden in older Ukrainian refugees of war: a synthetic reanalysis of public records data

BACKGROUND

Since the Russian invasion of Ukraine on Feb 24, 2022, more than 6 million Ukrainians, including hundreds of thousands of older people, have sought safety abroad. Older people generally have a higher burden of disease than younger people and the aim of our study was to estimate this burden in older Ukrainian refugees, given the potential financial and logistical impacts on the health-care systems of receiving countries.

METHODS

On May 20, 2022, we searched the official websites of the Polish Ministry of Digitisation for data on Ukrainian refugees who had applied between Feb 24, 2022, and May 19, 2022 for a Polish personal identification number (PESEL). We extracted the number of older people (ie, of pension age, which in Ukraine is 60 years or older for men, and 55 years or older for women). We calculated the percentage of older people among these PESEL applicants then extrapolated this percentage to two groups, for which population data had been extracted from UN, WHO, and Polish Border Guards websites: refugees who had crossed into Poland but had not applied for a PESEL and refugees who had fled to neighbouring countries other than Poland. Between April 4 and May 19, 2022, we searched the Ukrainian Ministry of Health official website for data on the prevalence and incidence of various diseases in the Ukrainian population of older people. We asked the Ukrainian Ministry of Health to confirm and expand on the website data, and thereby obtained annual data for 2010-17. The ministry did not supply tuberculosis statistics, so on May 21, 2022, we searched the Ukrainian Ministry of Health website and extracted the most recent tuberculosis data, which were for 2020. We then calculated the absolute prevalence and incidence of diseases in older refugees.

FINDINGS

As of May 19, 2022, 6·3 million Ukrainians had fled their country, including 3·5 million (56%) who had entered Poland. 1 114 418 people applied for a PESEL, including 109 985 older people (91 349 Ukrainian women aged 55 years or older and 18 636 Ukrainian men aged 60 or older). We estimated that the overall number of older Ukrainian refugees was 624 690. We estimated that these older refugees have a mean of 2·5 diseases each, the most frequent of which are cardiovascular diseases, followed by gastrointestinal, respiratory, musculoskeletal, and genitourinary diseases. We estimated that the expected absolute incidence is greatest for pulmonary disorders (71 689 diagnoses), followed by cardiovascular (49 327), ocular (24 100), musculoskeletal (20 367), and genitourinary (16 836) disorders. The estimated number of new diagnoses per year was 4578 for tuberculosis and 7827 for cancer.

INTERPRETATION

Our data indicate that the disease burden of older Ukrainian refugees is considerable. Although our estimates are only approximations, they provide a basis for predicting which areas of health care will most need to be reinforced to meet the challenge of the potential financial and logistical impacts on receiving countries.

FUNDING

There was no funding source for this study.

Mental Health Burden of the Russian-Ukrainian War 2022 (RUW-22): Anxiety and Depression Levels among Young Adults in Central Europe

Armed conflicts are public health emergencies that affect human lives at multiple levels. The mental health of adolescents and young adults is at high risk during crisis settings; therefore, this cross-sectional survey-based study aimed to evaluate anxiety and depressive symptoms among university students in the Czech Republic following the Russian-Ukrainian war of 2022 (RUW-22). The study used standardized screening instruments; the Generalized Anxiety Disorder (GAD-7) for anxiety and the Patient Health Questionnaire (PHQ-9) for depression. Of 591 students who participated in this study, 67.7% were females, 68.2% held Czech citizenship, and 63.8% were enrolled in medical or healthcare programs. The participants were highly concerned about the RUW-22 news, with a mean score of 7.17 ± 2.50 (0–10). While 34% and 40.7% of the participants in this study manifested moderate to severe levels of anxiety and depression, respectively, the mental health burden of the RUW-22 was confirmed by the positive correlation between “feeling concerned”, GAD-7 (ρ = 0.454), and PHQ-9 (ρ = 0.326). Female gender, higher frequency of news following, and social media use were associated with higher levels of anxiety and depressive symptoms; thus, proposing them to be risk factors for psychological disorders following the RUW-22.

Ukraine - Russia crisis and its impacts on the mental health of Ukrainian young people during the COVID-19 pandemic

The Russia-Ukraine crisis has been at the center of international talks since early 2022. This conflict, bursting after the sanitary crisis of the covid 19 pandemic, creates an atmosphere of uncertainty and instability, which negatively impacts many aspects, including mental health. Young Ukrainians have been suffering from socio-political instability for decades, and the current war, together with the Covid 19 pandemic, shatters hopes of brighter days. This commentary covers the challenges facing the younger generation in Ukraine and the impact of this situation on their mental health.

A Public Health Perspective of Post-Traumatic Stress Disorder

Trauma exposure is one of the most important and prevalent risk factors for mental and physical ill-health. Prolonged or excessive stress exposure increases the risk of a wide variety of mental and physical symptoms, resulting in a condition known as post-traumatic stress disorder (PTSD). The diagnosis might be challenging due to the complex pathophysiology and co-existence with other mental disorders. The prime factor for PTSD development is exposure to a stressor, which variably, along with peritraumatic conditions, affects disease progression and severity. Additionally, many factors are thought to influence the response to the stressor, and hence reshape the natural history and course of the disease. With sufficient knowledge about the disease, preventive and intervenient methods can be implemented to improve the quality of life of the patients and to limit both the medical and economic burden of the disease. This literature review provides a highlight of up-to-date literature on traumatic stress, with a focus on causes or triggers of stress, factors that influence response to stress, disease burden, and the application of the social-ecological public health model of disease prevention. In addition, it addresses therapeutic aspects, ethnic differences in traumatic stress, and future perspectives, including potential biomarkers.

Prevalence of depression, anxiety and post-traumatic stress in war- and conflict-afflicted areas: A meta-analysis

BACKGROUND

With the rise of fragility, conflict and violence (FCV), understanding the prevalence and risk factors associated with mental disorders is beneficial to direct aid to vulnerable groups. To better understand mental disorders depending on the population and the timeframe, we performed a systematic review to investigate the aggregate prevalence of depression, anxiety and post-traumatic stress symptoms among both civilian and military population exposed to war.

METHODS

We used MEDLINE (PubMed), Web of Science, PsycINFO, and Embase to identify studies published from inception or 1-Jan, 1945 (whichever earlier), to 31-May, 2022, to reporting on the prevalence of depression, anxiety and post-traumatic stress symptoms using structured clinical interviews and validated questionnaires as well as variables known to be associated with prevalence to perform meta-regression. We then used random-effects bivariate meta-analysis models to estimate the aggregate prevalence rate.

RESULTS

The aggregate prevalence of depression, anxiety and post-traumatic stress during times of conflict or war were 28.9, 30.7, and 23.5%, respectively. Our results indicate a significant difference in the levels of depression and anxiety, but not post-traumatic stress, between the civilian group and the military group respectively (depression 34.7 vs 21.1%, p < 0.001; anxiety 38.6 vs 16.2%, p < 0.001; post-traumatic stress: 25.7 vs 21.3%, p = 0.256). The aggregate prevalence of depression during the wars was 38.7% (95% CI: 30.0-48.3, I ² = 98.1%), while the aggregate prevalence of depression post-wars was 29.1% (95% CI: 24.7-33.9, I ² = 99.2%). The aggregate prevalence of anxiety during the wars was 43.4% (95% CI: 27.5-60.7, I ² = 98.6%), while the aggregate prevalence of anxiety post-wars was 30.3% (95% CI: 24.5-36.9, I ² = 99.2%). The subgroup analysis showed significant difference in prevalence of depression, and anxiety between the civilians and military group (p < 0.001).

CONCLUSION

The aggregate prevalence of depression, anxiety and post-traumatic stress in populations experiencing FCV are 28.9, 30.7, and 23.5%, respectively. There is a significant difference in prevalence of depression and anxiety between civilians and the military personnels. Our results show that there is a significant difference in the prevalence of depression and anxiety among individuals in areas affected by FCV during the wars compared to after the wars. Overall, these results highlight that mental health in times of conflict is a public health issue that cannot be ignored, and that appropriate aid made available to at risk populations can reduce the prevalence of psychiatric symptoms during time of FCV.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=337486, Identifier 337486.

Early evidence on the mental health of Ukrainian civilian and professional combatants during the Russian invasion

Background

The ongoing Russian invasion of Ukraine has led many Ukrainians to fight for their country, either in the regular army or as civilian members of voluntary territorial defense forces. There is, however, a dearth of knowledge on the mental health of combatants in this conflict. Prior research on the mental health of combatants is unlikely to translate to the situation at hand because such research is focused on combatants fighting abroad and neglects civilian combatants.

Methods

This study provides the first attempt to investigate the mental health of Ukrainian combatants in the regular army and voluntary territorial defense forces by analyzing the prevalence rates of common mental health issues, as well as their demographic and socioeconomic predictors.

Results

Between March 19 and 31, 2022, the initial period of Russia’s invasion of Ukraine, a sample of 178 Ukrainian combatants (104 in the regular army and 74 civilian combatants) participated in a survey on symptoms of anxiety (GAD-2), depression (PHQ-2), and insomnia (ISI).

Conclusions

A sizable portion of Ukrainian combatants reached cut-off levels for clinical symptoms of anxiety (44·4%), depression (43·3%), and insomnia (12·4%). Importantly, the mental health of Ukrainian combatants varied between professional soldiers and civilian combatants, as well as by gender, marital status, by whether or not they were located in Russian-occupied/active-combat areas, and dependent on whether they were personally involved in combat. This study provides early evidence on the mental health of Ukrainian combatants, pointing to their urgent need for mental health assistance in the ongoing war.