A new request to the social psychiatry in Ukraine : stress-related disorders and PTSD , are we ready ?

In early 2014 resulted by the outbreak of con lict in eastern Ukraine 823,000 people became internally displaced, according to the Ukrainian State Emergency Service. All of the above requires a new assessment of the state of people in a situation of chronic stress and distress taking into account their mentality, psychological amortization properties and social situation. We need systematic training of specialists in the ield of acute stress and PTSD, with following consistent professional development. It is necessary to develop a national protocol for PTSD management and to implement an appropriate modernization of the Ukrainian health care system. Ключові слова: PTSD, conflict, Ukraine, refugees, soldiers


Background
By end 2014, 59.5 million individuals were forcibly displaced worldwide as a result of persecution, con lict, generalized violence, or human rights violations.This is 8.3 million persons more than the previous year (51.2 million) and the highest annual increase on record.During 2014, con lict and persecution forced an average of 42,500 individuals per day to leave their home and seek protection elsewhere, either within the borders of their own country or in other countries.This compares to 32,200 per day in 2013, 23,400 in 2012, 14,200 in 2011, and 10,900 in 2010.
The global igure included 38.2 million internally displaced persons.The Ukraine was the single largest country of origin for asylum-seekers in 2014, with 288,600 new applications submitted by its nationals during the year -on average, every ifth claim.The outbreak of con lict in eastern Ukraine had a major impact on the 2014 displacement ig-ures, with more than 271,000 or close to 99 per cent of the asylum claims in the Russian Federation or to seek refuge in European countries lodged by Ukrainians.The last time a country registered a comparable igure was in 2009, when South Africa reported that 222,300 persons had lodged individual asylum requests, many of them from Zimbabwe.

Stress-related disorders in Ukraine
Large-scale armed con lict, the ighting that broke out in eastern Ukraine and outbreak of violence forced hundreds of thousands to leave their homes and to become internally displaced persons.In early 2014 resulted in 823,000 people becoming internally displaced by the end of the year, according to the Ukrainian State Emergency Service [1].
Psychologists, psychotherapists and psychiatrists faced a new serious problem in Ukraine.They were unprepared for a massive social request for psychological and psychiatric help from the patients who were exposed to powerful stress and faced distress in the situation of war and radical social changes within the country.
We identi ied possible problems and prospects for specialists who provide psychological, psychotherapeutic and psychiatric care for patients with stress related disorders.We analyzed the data from open sources on the Internet in Ukraine and the United Nations.
As a result, there are currently 60,000 soldiers in the region of the armed con lict in eastern Ukraine (their families remain in a waiting situation and a profound anxiety for their lives -about 200,000 people).As well, about 6,000 volunteers participate there.6,000 people have already been killed, including 1,500 military personnel.1 500 000 people -2 000 000 people were internally displaced within Ukraine, including 200 000 children and 120 000 disabled or elderly people (internal migration).About 2 million civilians still remain in the con lict zone.
We modeled the probability of developing stress-related disorders in Ukraine in the next 5-10 years on the example of other countries that participated in military con licts (United States, Israel, Balkans countries, Russia, Georgia, Armenia).According to the most optimistic outcomes, we expect that about 500,000 people will have social dysfunction, delinquent behavior, PTSD or psychosomatic disorders (mainly cardiovascular pathology, gastrointestinal problems, lung disease).Now in Ukraine, from our personal experience, the following problem arises: • from one hand excessive enthusiasm and volunteerism, and lack of professional experience from the other hand; • social and clinical psychologists were not trained enough to work with stress-related disorders; • personnel in general hospitals and somatic network, clinical psychologists and psychotherapists basically, were not ready to identify and cope with effects of acute stress; • absence of national protocols and guidelines for management of PTSD (diagnostic, treatment and rehabilitation); • lack of permanent training system in prevention and treatment of PTSD for clinical psychologists, psychotherapists and psychiatrists; • lack of social services outside of health facilities or hospitals that provide suf icient concomitant psychological and psychotherapeutic support; • absence of effective multidisciplinary professional teams, specialized in psychological trauma management; • lack of available scienti ic and psychoeducational literature on PTSD and psychosomatic disorders.
As a conclusion: we need systematic training of specialists in the ield of acute stress and PTSD, with following consistent professional development.It is necessary to develop a national protocol for PTSD management and to implement an appropriate modernization of the Ukrainian health care system.
Moreover, the situation with stress related disorders in Ukraine has acquired its speci ic features, due to a number of new factors related to the war and previously not described.In our opinion, these include: • the presence of insuf icient support as a background feeling, loss of basic trust due to the elements of nihilism, which causes a special sense of guilt towards those "who stayed at war"; • low level of social capital; • complete trust only for those who were near ("tested by war"); • mistrust and, quite often, resentment on the inhabitants of the peaceful territory of Ukraine; • exaggerated resentment for those who remain at war and ight in comparison with others; • aggression against injustice or incorrect statements towards the military; • fatigue and depression after a long stay in the zone of military operation; • the tendency to seek "traditional relaxations" -especially alcohol (faster intoxication), risky sexual behavior; • the situation of ambivalent space illing by mass media, especially television.After negative information about the war, next content can be entertainment TV-shows, including jokes about the war, which stimulates cognitive dissonance at the micro -and macrosocial level; • confusion with the de inition of what is happening (from terminological and to the ideological point of view): "hybrid war", "trade with the aggressor", "business in the country of aggressor", "brotherly nations in past", "traficking in war zone" and others; • the idea that someone from "big" countries negotiates and decides the fate of Ukraine behind the peoples back ("USA, the EU and Russian Federation will decide the fate of the country"); • numerous family ties with the aggressor's country; • everyday use of the cultural heritage of the aggressor's country (language, books, ilms, songs, music, etc.); • there are many joint religious traditions and rituals with the country of the aggressor.they appeal to the same syncretic igures, with a frequent loss of con idence in the primacy of theological ideas; • there is a loss of lexibility and amortization properties of the individual in opposition to the massive information in luence with double standards.
The war that continues in Ukraine increasingly acquired traits of Conscientia (understanding, consciousness, conscience), that is, the war with the primary goal of changing consciousness, rethinking what is happening, destroying national self-awareness, spreading nihilistic and pessimistic ideas, which decreases the level of social capital.Such a war is directed at the same time to the whole society, causing the loss of national identity, and to each individual separatelythe loss of self-identi ication, the refusal or reduction of individual amortization capacities due to the rejection of cultural and mnestic subconscious protection mechanisms, and the loss of con idence in the basal protective functions of the state at the microsocial level.
Particular characteristics of a conscientinal war are some forms of cognitive biases and cognitive distortion due to the loss of suf icient insight of the powerful informational impact in the situation of uncertainty and constant expectation of troubles ahead, the destruction of the spiritual values of previous generations with the rapture of continuity with these generations.

Conclusion
All of the above requires a new assessment of the state of people in a situation of chronic stress and distress taking into account their mentality, psychological amortization properties and social situation.