More than six or seven million Ukrainians have been subjected to bombing and violence on their territory since February 2022, forcing them to leave their homes. This invasion has created Europe's biggest recent humanitarian crisis, claiming more victims’ day by day and causing widespread displacement in and out of the country. Europe has been on the warpath ever since, trying to avoid any escalation in the ongoing conflict and avoid the use of nuclear weapons. So what about the mental health of all these displaced people? What is the impact of such a large-scale situation on the movement of refugees in Europe? What psychological impact can it have on Ukrainian refugees (stress factor, mental illness)? What psychological impact can there be on the long-term hosts of the refugees? At present, we are not aware of any French or English articles already published on the medico-socio-psychological aspects linked to the problems of displacement of Ukrainian families and the reactions of the hosts over the long term. In this article, we will try to address the medico-socio-psychological issue of careers and the psychological impact of deported Ukrainian refugees.

Keywords: refugees, migrants, immigration, war, Ukraine, Ukrainians, hosts, humanitarian crisis, displacement, nuclear weapons, Europe, psychiatry, post-traumatic stress disorder infection disease, global health, medical ethics

More than six million Ukrainians have been subjected to bombing and violence on their territory since March 2022, forcing them to leave their homes in a brutal manner. This invasion has created Europe's biggest recent humanitarian crisis, claiming more victims every day and causing widespread displacement within and outside the country. Europe has been on the warpath ever since, trying to avoid any escalation in the ongoing conflict and avoid the use of nuclear weapons. So what about the mental health of all those people who have to flee their country? What can such a large-scale situation mean for the movement of these refugees to Europe? What psychological consequences might there be for Ukrainian refugees (stress factor, reactionary mental illness)?  From another point of view, what psychological impact can there be, especially for the people who receive the refugees in the long term? At the moment, we are not aware of any French or English articles that have been published on the medical, social and psychological aspects of the displacement of Ukrainian families and the long-term reactions of the hosts. Therefore, in this article, we will try to address the medico-socio-psychological issue of careers and the psychological impact of deported Ukrainian refugees. Finally, how can we intervene with victims of forced migration in the prevention of mental disorders and the mobilization of therapeutic intervention with people living in situations of forced migration?

The devastation of health and mental health and human rights

The war in Ukraine has prompted a massive humanitarian response, but Russia's onslaught has intensified and is also bringing quite significant collateral damage. According to the New England Journal of Medicine,¹ recent brutal conflicts and wars have given rise to important discussions on the epidemiology of conflict-related mortality and morbidity, civilian suffering, the capacity of health care in the midst of conflict, immediate violent population displacement, and the parameters of humanitarian response, as well as legal and normative debates regarding human rights and the international dimensions of armed conflict. In Ukraine, as in other phases of other wars around the world, lack of security, inaccurate or incorrect reporting and non-functional data systems, displacement of civilians, and indirect, distant and delayed health and mental health consequences have made it almost impossible to collect accurate morbidity and mortality data. However, the United Nations, as of 20 June 2022, has counted more than 10,000 Ukrainian civilians impacted by missiles, heavy artillery and bombs: 4,569 deaths and 5,691 non-fatal injuries. But the real number of deaths and injuries is certainly higher. In addition, collateral damage from Russian attack strategies against health care facilities and health personnel are adverse consequences of reduced availability of health care and mental health. A significant proportion of the morbidity and mortality of Ukrainian civilians is likely to be attributable to illnesses resulting from forced displacement and damage to food and water supplies, health care and public health facilities and other precarious public infrastructure. Diseases are more easily transmitted due to the crowding of civilians in shelters, reduced access to clean water and food, poor hygiene and inadequate medical care. Another risk is malnutrition. Indeed, this is a particular concern for infants and young children, which can have adverse consequences for physical and cognitive development as well as increased morbidity later in life. It should also be remembered that as part of this deliberate Russian war strategy in agricultural areas, food storage and distribution systems have been damaged, restricting access to food and leading to indirect consequences for civilian nutrition with the risk of this spreading beyond Ukraine. Other consequences include increased rates of pregnancy complications, maternal deaths, prematurity, low birth weight, and neonatal deaths due to reduced access to maternal and child care. In addition, the incidence of certain non-communicable diseases is also likely to increase, and pre-existing cases are likely to be exacerbated, due to limited access to medical care and essential medicines. Rates of depression, post-traumatic stress disorder, neurosis, psychosis and other mental and behavioural disorders - with both short and long-term consequences - will increase as a result of the trauma, separation of families, death of loved ones, loss of employment and education, forced displacement and atrocities that we as Europeans are currently witnessing. In addition, the loss of male combatants and the massive displacement of women and their change in status to single parents may significantly affect the age and gender distribution of the Ukrainian population for decades to come. For those refugees who have decided to move to the safety of the rest of Europe, rates of depression, post-traumatic stress disorder and other mental health issues are likely to emerge in the coming months, if they have not already.

What about the medical-psychological aspect?

Psychological impact on Ukrainian refugees: stressors

The psychological traumas suffered, the grief caused by sudden and violent deaths, the permanent stress leading refugees to be in a cognitive mode of shock, alertness and/or mental hypervigilance can deteriorate the mental health of refugees and be at the origin of psychological suffering requiring care from health and mental health professionals.  Refugees arriving in France and Belgium (or in other European countries) have a different history, culture and reference points from our own. These differences can be difficult to understand, particularly because of the language barrier. These refugees may also have experienced traumatic events, such as the death of relatives, and be deeply shocked and upset. Even in the safety of "host" countries, these upheavals can cause difficulties in their day-to-day functioning in a variety of ways. In their own countries, or on the way to "host" countries, refugees have been confronted with extreme stressors. Even once they have arrived in the safety of host families, many sources of stress persist, and coping with them can be disruptive and exhausting. The psychological traumas experienced (the terror of war, nuclear threats as a feeling of insecurity, grief caused by sudden and violent deaths, shock and shocking feelings, psychological collapse, the anxiety of missiles exploding nearby, lack of sleep, nightmares, lack of food, access to medical care and unfavorable living conditions.), permanent stress can deteriorate the mental health of refugees and be the cause of mental suffering requiring care. In addition, this suffering may be the cause of manifestations, attitudes or behaviour that are difficult to interpret. Despite the loss, devastation and destruction experienced, refugees remain capable of self-determination and autonomy. Maintaining some control over their daily lives, and more broadly, their lives, is essential to their mental health. Despite all the protective bulwarks that may have been put in place, resilience to remain functional, children and adolescents are in turn just as exposed as adults to the psychological consequences of the events they have experienced. Moments of anxiety, sadness, anger, stress and strong emotions can arise and persist.² According to Christina Greeneway,³ in a recent analysis she highlights the urgent need to improve health and mental health care and social services for people fleeing traumatic situations. Indeed, as these refugees face socio-economic stresses soon after arrival, they are at greater risk of transitioning to poor health than other migrants. She notes that among Ukrainian refugees there is a high prevalence of chronic diseases, including cardiovascular disease and diabetes, smoking is common, and rates of mental illness are high. Even before the current conflict, it was estimated that about 33% of the Ukrainian population suffered from mental illness. Risks of vaccine-preventable diseases, such as measles, polio and COVID-19, may be high due to the lack of access to vaccines in Ukraine and the reluctance to vaccinate.  Rates of tuberculosis, viral hepatitis and HIV may be high, particularly among certain risk groups. The prevalence of alcohol-related disorders among men is reportedly higher in Ukraine than in the rest of the world (6.0% vs. 1.5%), and the prevalence of drug use disorders is estimated at 0.7%. According to a 2020 World Health Organization (WHO) report.⁴ Ukraine has one of the highest suicide rates in the world, with 30.6 deaths per 100,000 people, compared to a global average of 10.4 deaths per 100,000 people. It is expected that people fleeing the current conflict and arriving in France and Belgium will have experienced significant trauma, which in turn may increase the risk of mental health disorders. Current evidence-based guidelines recommend a trauma- and violence-informed approach to care that can reduce the risk of disabling mental illness, which involves resisting the immediate evocation of traumatic stories.  Keeping families and close friends together can promote a sense of physical and emotional safetý in individuals on the move, allowing for collaborative choice and decision-making, focusing on refugees' hope and strengths, and providing space for personal and social identities, which can improve outcomes.^5,6  

Psychological impact on hosts: stressors

According to Carine Duray-Parmentier,⁷ “the arrival of Ukrainian refugees requires security and a stable environment. They need medium and long-term perspectives. They are mostly women and children who arrive from Ukraine in France and Belgium or from other parts of Europe (Poland, Hungary, Romania, etc.). They are particularly vulnerable. Their accommodation requires the full attention of the host. It is important to be aware of the challenges that the hosts will face and the psychological impact this will have. Hosting will create a co-location from the outset. This can be accompanied by particular challenges. Initially, it is a question of the "chemistry" between the host and the host (the refugee). A crucial factor is the freedom of choice of all concerned, as there is no guarantee of mutual sympathy. It is important to take into account that Ukrainian refugees have different expectations and are not primarily looking for a new home and a new family. Many want to return to Ukraine as soon as possible and return to their former life and environment. In particular, this can be seen in the patriotism exercised by the men who stayed in. Ukraine to fight Russia. This may mean that these refugees do not easily accept and/or adapt to the new living conditions. It is imperative for the host to bear in mind that the children and their careers have a strong need for safe, secure shelter and that they are not primarily looking for a flat share with strangers. Refugees may want to be grateful for the help offered. They may feel guilty for needing help without being able to provide compensation. They need privacy and the environment provided is important: room, sanitary facilities and kitchen, whether shared with the host or not. The need for the refugee to create his or her own secure and intimate temporary cocoon is often encountered. Moreover, the length of time spent in accommodation has a considerable impact on the host's psyche and, until now, no study has addressed this issue. Beyond the benevolent idea, the host will be confronted with various factors that they have not taken into account: although they are aware of what is happening in Ukraine, they are not really aware of the reality on the ground and the difficult journey their hosts have to make to arrive in the host country. Many Ukrainian refugees have adjustment and mental health problems such as alcoholism or personality disorders or post-traumatic stress disorder, they have a different history and culture, the notion of freedom differs between Eastern and Western Europe, gender roles are not the same everywhere. They arrive and have expectations imposed on them that are specific to Western European countries and must immediately adapt to them (forced adaptation, finding a job, enrolling their children in school, registering with a health insurance company, ....). The policy of the receiving countries requires them to integrate into other codes and laws as soon as they arrive, without allowing them to really breathe and digest what has just happened to them. From one trauma (fleeing war), they move on to a second trauma (adapting). From then on, the question arises as to whether our infatuation with reception and the way of proceeding is healthy for everyone, whether they are the host or the looked after? This can have an impact on the career who is faced with difficulties in understanding a guest who does not seem to meet the expectations of the reception. Many hosts mention the fact that Ukrainian refugees stay in their rooms, do not share family life, have alcohol problems, do not inform their hosts of important information (outings, trips to another country in the Schengen area because they are authorized), some refuse to learn the language of the host country. A gap is created and frustrations emerge for both parties. A key element is also highlighted: the duration of the reception. Usually, when the host hosts a guest, they know the entry and exit dates, i.e. the duration of the stay. For many host families, the uncertainty about the duration of the reception of Ukrainian refugees is paramount. Politicians caught off guard by the war in Ukraine have put in place certain arrangements for the mass reception of people fleeing the Russian invasion of Ukraine. Emergency responses that leave some people uncertain about the reception of refugees. Social welfare centers are caught off guard as the demand for social housing is saturated. This uncertainty regarding the end date of the reception leads to considerable stress for the host.⁸ Both the foster career and the host feel helpless and the situation is uncertain and unclear. The feeling of guilt can also be felt by the host. Indeed, the longer the hosting period lasts, the more the host is confronted with a new reality: he/she is no longer alone in his/her private home and the desire to return to his/her old habits and homeostasis becomes more and more felt. He or she may then be caught in an inner conflict of welcoming and wanting the host to leave. So how can we improve contact and exchanges, especially when language is a barrier, when codes are different, when values are different and when there are difficulties in adapting to each other? This is, of course, an analysis that consists of the beginning of an in-depth reflection based on a certain number of experiences and felt testimonies. Ideally, it would be appropriate to direct some studies in the coming months. It is a matter of preliminary analysis.

Are the support systems adequate?

The activation of the EU Temporary Protection Directive (to be implemented for the first time in 2021) is changing the way the reception of people fleeing war is organised in the European Union. Specifically, Ukrainian refugees are not considered as asylum seekers. Their status allows them access to the labour market, housing, and social and medical assistance. The regions therefore have a unique role in dealing with this crisis. Coordination of all levels is all the more essential. In Belgium, for example, Wallonia has set up a task force at ministerial cabinet level and an administrative coordination unit, housed in the Regional Crisis Centre. Governments have come together to define their accommodation strategy in each European country. It is based on five axes:

1. Stimulating and supervising the reception of Ukrainian nationals by citizens in private accommodation
2. The inventory of all potentially available collective accommodation or available buildings on the whole Walloon territory
3. Reception strategy: identify the public housing mechanisms that can be activated.
4. Support strategy for frontline actors, i.e. local authorities.
5. Requisition modalities, should they prove indispensable.

A platform has also been set up containing all the information relating to the reception of Ukrainian refugees and the consequences of the conflict (with a translation into Ukrainian).⁹ Despite the EU's commitment to the resettlement of Ukrainian refugees, there are some important gaps that need to be recognized and addressed: rapid access to health care is key to the successful integration and settlement of refugees and people fleeing conflict and disaster.^5,10  Ensuring accessibility to medical and paramedical care is a key safety feature for deportees. The most effective models of primary care delivery for refugees include coordination with settlement services and the community, the establishment of care corridors with other health services and the use of professional interpreters for all patient encounters.^11,12 The exhaustion of these long-term private foster care arrangements also needs to be addressed in order to better articulate between the foster care and the refugee. At present, even if we are beginning to become aware of the various shared difficulties encountered by host families and refugees, nothing is yet really in place to help Ukrainians or host people. There seems to be a lack of clarity that puts aid in a position of stagnation. While on the one hand aid is well implemented at institutional and political level, another part of the population, which has decided to help by volunteering and welcoming refugees, feels abandoned or unsupported by the European authorities.

Today, with the experience of the reception of Ukrainian refugees, we are faced with a reception in private homes that is based on two complementary expectations. For people in distress, living in a private home is an opportunity to find safety in the hope of being able to return home. The importance for refugees of being able to create sufficient intimate space for them to maintain certain points of reference that provide security to their usual way of life. Conversely, hosting a refugee in one's own home is an opportunity to help with external distress, to experience a unique human encounter, and to allow the host to share in the daily life of the inhabitant. A coordinated multilateral approach should be put in place by policy makers, health and mental health administrators not only for the protection of refugees and other migrants in order to promote their autonomy and health (which seems to be a gap at the moment), but also to take into account the psychological impact that this has on the host in the long term regarding the reception.

This research did not receive any specific funding from public, commercial or non-profit funding bodies.

The authors have nothing to declare. They all contributed equally to the writing of the manuscript.

Not applicable.

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