# Mental health burden of persons living in Ukraine and Ukrainians displaced to Switzerland: The Mental Health Assessment of the Ukrainian Population (MAP) studies

Viktoriia Yasenok, Andreas M Baumer, Viktoriia Petrashenko, Marco

Kaufmann, Anja Frei, Seraina Rüegger, Tala Ballouz, Andrii Loboda,

Vladyslav Smiianov, Erich Seifritz, et al.

► To cite this version:

Viktoriia Yasenok, Andreas M Baumer, Viktoriia Petrashenko, Marco Kaufmann, Anja Frei, et al.  
Mental health burden of persons living in Ukraine and Ukrainians displaced to Switzerland: The  
Mental Health Assessment of the Ukrainian Population (MAP) studies. 2024. hal-04853218

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# Mental health burden of persons living in Ukraine and Ukrainians displaced to Switzerland: The Mental Health Assessment of the Ukrainian Population (MAP) studies

Viktoriia Yasenok¹,²* Andreas M. Baumer¹,³* Viktoriia Petrashenko⁴ Marco Kaufmann¹,² Anja Frei¹,² Seraina Rüegger² Tala Ballouz¹,² Andrii Loboda⁴ Vladyslav Smiianov⁴ Erich Seifritz⁵ Mariya Bachmaha⁶ Orest Suvalo⁶ Susi Kriemler¹,² Viktor von Wyl¹,²,³ Andriana Kostenko³# Milo A Puhan¹,²# *Shared first authors, #shared senior authors

¹ Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, 8001 Zurich, Switzerland

²Population Research Center, University of Zurich, Hirschengraben 84, 8001 Zurich, Switzerland

³Institute for Implementation Science in Health Care, University of Zurich, Universitätstrasse 84, 8006 Zurich, Switzerland

⁴Sumy State University, Kharkivska st.116, 40007 Sumy, Ukraine.

⁵University Hospital of Psychiatry Zurich, Department of Adult Psychiatry and Psychotherapy, Lenggstrasse 31, 8008 Zurich, Switzerland

⁶Institute of Mental Health at Ukrainian Catholic University, I. Svientsitskoho Street, 17, 79011 Lviv, Ukraine

## Abstract

**Background:** The ongoing war in Ukraine is a major public health concern, likely exacerbating the prevalence and severity of mental health conditions. This study aimed to assess the burden of mental health conditions in the adult general Ukrainian population living in different regions of Ukraine and as refugees in Switzerland and to compare it to a non-war affected, general population.

**Methods:** The MAP studies are prospective, population-based cohort studies, including randomly selected Ukrainians, Ukrainian refugees in Zurich, Switzerland, and members of the general population of Zurich. We used validated and commonly used instruments to assess PTSD, anxiety, depression, health status and somatic symptom disorder and we adjusted the prevalence estimates for sensitivity and specificity of these instruments.

**Findings:** A total of 6,036 participants from Ukraine, 657 refugees in Zurich, and 766 Zurich residents were enrolled. PTSD, anxiety and depression scores were high in all regions, with higher scores in central and south-eastern Ukraine compared to the north-west. The mental health burden among refugees closely resembled that of Ukrainians living in central and south-eastern Ukraine while it was substantially lower in the Zurich control population.

**Interpretation:** This first large-scale population-based study highlights a significant mental health burden and high rates of somatic symptom disorder among adult Ukrainians across the age range, whether living in Ukraine or having fled to Zurich compared to a general population not affected by the war. These findings can inform the planning and evaluation of urgently needed public mental health and mental health care services while also aiming to destigmatize mental health disorders by highlighting the substantial impact on the civilian population.
**Funding:** Canton of Zurich (fund for cooperation and development), the University of Zurich and the Swiss Agency for Development and Cooperation.

**Keywords:** mental health burden; randomized population-based study, post-traumatic stress disorder, anxiety, depression, war-affected Ukrainian population, Refugee population, MAP-studies

**Актуальність:** Поточна війна в Україні є серйозною проблемою громадського здоров'я, через ймовірне зростання поширеності та тяжкості психічних захворювань. Метою цього дослідження було оцінити тягар психічних розладів серед дорослого загального населення різних регіонів України, та серед біженців у Швейцарії, порівнюючи ці дані з населенням, що не постраждало від війни.

**Методи:** Дослідження МАР є перспективними, популяційними когортними дослідженнями, що включають випадковим чином відібраних українців, українських біженців у Цюриху, Швейцарія, а також людей із загального населення Цюриха. Ми використовували широко вживані, валідовані інструменти для оцінки ПТСР, депресії, тривожності, стану здоров'я та соматичних розладів і скоригували оцінки поширеності з урахуванням чутливості та специфічності цих інструментів.

**Результати:** Усього було залучено 6,035 учасників з України, 657 біженців у Цюриху та 766 мешканців Цюриха. Показники ПТСР, тривожності та депресії були високими в усіх регіонах, з істотно вищими показниками в центральній та південно-східній Україні порівняно з північно-західними районами. Тягар психічних розладів серед біженців був подібним до такого серед українців, що проживають у центральній та південно-східній Україні, в той час як у контрольній групі загального населення Цюриха показники були значно нижчими.

**Інтерпретація:** Це перше велике популяційне дослідження виявило значний тягар психічних розладів та високі рівні соматичного стресового розладу серед українців, які проживають як в Україні так і в Цюриху, порівняно з населенням, не постраждалого від війни. Ці дані є важливою основою для планування та оцінки нагально необхідних послуг та служб психічного здоров'я, а також, сподіваємось, допоможуть зменшити стигматизацію психічних розладів, підкреслюючи, що значна частина цивільного населення є постраждалою.

**Фінансування:** кантон Цюрих (фонд співробітництва та розвитку), Цюрихський університет та Швейцарське агентство розвитку та співробітництва.

**Ключові слова:** тягар психічних розладів; рандомізоване популяційне дослідження, посттравматичний стресовий розлад, депресія, тривога, постраждале від війни населення України, населення Цюриху, МАР-дослідження

## Review

Evidence before this study
We conducted an advanced PubMed Central search for recent and relevant publications, focusing on articles published between February 24, 2022, when the full-scale invasion began, and September 2024. We used the search terms “depression”, “post-traumatic”, “alcohol”, “anxiety”, “distress”, and “Ukraine”. We additionally searched for studies using the ‘Similar Articles’ function of PubMed for each included study. Studies were included if they were English-language publications that contained a quantitative analysis investigating the symptom burden and/or prevalence of post-traumatic stress disorder (PTSD), anxiety, depression, alcohol use disorder, and other mental health outcomes in Ukrainians during the Russian-Ukrainian war. Out of the 36 identified studies, eight fulfilled our criteria. There were no population-based studies using random sampling from Ukraine. All studies reported raw prevalence estimates without adjustment for sensitivity and specificity of instruments commonly used for screening. The total sample sizes of these studies ranged from 43 to 39,769. The studies showed the prevalence of symptoms of PTSD (14% - 33%),¹,² anxiety (23 - 54%),¹⁻⁴ depression (42 - 47%),²⁻⁴ and stress disorders (53 - 90%)¹,³,⁴ among the Ukrainian population. A study targeting all Ukrainian refugees in Denmark reported that close to one third of responders showed markedly elevated PTSD symptoms and their associations to war-related exposures.⁵ Only one study found that during the war, depression, anxiety, and loneliness were associated with a lower quality of life among Ukrainians in comparison to the general Ukrainian population before the war.² All studies indicated significantly higher levels of mental health conditions among internally displaced persons and refugees compared to non-displaced individuals.¹,³,⁶⁻⁸ To date, there are no population-based studies of persons living in Ukraine and Ukrainian refugees that include relevant comparisons across regions, age groups, or to a non-war-affected population.

## Added value of this study

The MAP (Mental Health Assessment of the Population) studies are the first population-based study based on random sampling of the general Ukrainian population and refugees and a control population not affected by the war. The findings reveal that the mental health symptom burden is very high and similar among Ukrainians who stayed in Ukraine and those who fled to Switzerland during the Russian-Ukrainian war. Notably, we also found a substantially poorer general health status compared to a non-war-affected population. Additionally, the differences in mental health burden across age groups were less pronounced than those typically observed in populations not affected by war.

## Impact of all available evidence

This study provides an urgently needed foundation for projecting the public mental health and healthcare needs of different age groups, both within Ukraine and among those living abroad. It also serves as a basis for planning the required personnel and infrastructure. The MAP studies mark the beginning of ongoing monitoring of mental health over time, offering insights into long-term trends and enabling the assessment of efforts to address the mental health challenges that will persist for years and decades to come.

## Introduction

Armed conflicts and wars lead to widespread mental health disorders in war-affected populations, significantly impacting individuals' overall well-being and functionality. Conflict-related mental disorders amongst soldiers were first recognized at the beginning of the 20th
century.⁹ However, it was only in the second half of the 20th century, particularly after the Vietnam War, that studies began to systematically examine the mental health impacts of conflict on civilians as well. Massive shelling and destruction, violence, family separations, displacement, loss of loved ones, and uncertainty have placed an enormous burden on Ukrainians during the Russian-Ukrainian war.¹⁰⁻¹²

Our review (box) revealed that high-quality, population-based estimates of the mental health burden on the Ukrainian population are lacking. Assessing the burden of mental disorders is essential for understanding the broad impact of mental health disorders on individuals and communities during the war and in the long term. Evidence on the prevalence and severity of common conditions such as depression, anxiety, and PTSD, helps policymakers, healthcare and social systems to prioritize health needs, identify at-risk groups (e.g. across the age spectrum) that need more attention, and allocate resources for prevention, healthcare and social services. Valid data on the mental health burden helps to set targets for improvements and serve as starting points for evaluating public health interventions and adaptations to the healthcare system. In Ukraine, it is increasingly recognized that specific and scalable health and social care community-based services and initiatives are required to support the needs of the war affected population. This is exactly why the Lancet Commission on mental health in Ukraine recently pointed out areas of mental health care and community-based services that require significant development.¹³ To adapt and refine such efforts and ultimately enhance the overall effectiveness of the health system ¹⁴,¹⁵ it is also important to monitor mental health over time. Such burden of disease studies can help reduce stigma by highlighting the seriousness of mental health issues, encourage individuals to seek help, and prepare healthcare and social care professionals to recognize the needs.

Together with an interdisciplinary and international team of Ukrainian and Swiss scientists, mental health and public health specialists, public health officials from both Ukraine and Switzerland, and representatives from international organizations such as the International Red Cross, we launched the Mental Health Assessment of the Population (MAP) studies. The MAP studies conduct mental health surveillance of adults living in ten regions of Ukraine, Ukrainian refugees living in the Canton of Zurich, Switzerland, and residents of the Canton of Zurich not affected by war as controls. The specific objectives are to determine the burden of mental health conditions in the first half of 2024, to examine short- and long-term temporal developments of mental health, to evaluate how mental health impacts general health and healthcare-seeking behaviour, and to assess the needs, preferences, barriers, and facilitators for mental health care services among the Ukrainian general population and its subgroups. In this paper, we present the comprehensive baseline assessment that provides a detailed analysis of mental health among Ukrainians living in Ukraine, those who fled to Switzerland, and the Zurich general population.

## Methods

### Study design, participants and setting

The MAP studies are prospective, population-based, observational cohort studies that include people from the general population of Ukraine (MAP-U), people from Ukraine with refugee status S residing in the canton of Zurich, Switzerland (MAP-Z (UA)), and people from the Zurich general population (MAP-Z (ZH)). A detailed study protocol has been published, ¹⁶ the study is pre-registered (ISRCTN17240415), and we followed the STROBE Statement for reporting.
Eligibility criteria for MAP-U were people aged 18 years of age or older, residing in ten oblasts of Ukraine (Zhytomyr, Rivne, Sumy, Kharkiv, Mykolaiv, Kherson, Lviv, Chernivtsi, Kyiv, Dnipropetrovsk), providing informed consent and the ability to complete the survey; for MAP-Z (UA) - being Ukrainian, aged 18 or older, registered with refugee status S in the canton of Zurich, providing informed consent and the ability to complete the survey online; and for MAP-Z (ZH) - being aged 18 or older, residing in the Canton of Zurich with either Swiss citizenship or residence permit B or C, providing informed consent and the ability to complete the survey online.

Ukrainians living in Ukraine were randomly selected by the Center for Social Research of Sumy State University. Ukrainians living in the canton of Zurich with protection status S as well as the people living permanently in the canton of Zurich, were randomly selected by the Swiss Federal Statistical Office. Random selection was age-stratified (18–24 years, 25–44 years, 45–64 years and ≥65 years). Randomly selected persons were invited for study participation between 25 March and 9 August 2024.

Randomly selected individuals in Ukraine (MAP-U) received an email with a personalized link to the assessment via a secure digital platform (REDCap),¹⁷,¹⁸ including two reminders. If there was no response, the interviewers from our local teams in Ukraine approached them via Telegram (until May 2024 when Ukrainians were recommended to stop using it), Viber (from May 2024) or phone calls. Follow-up assessments are planned every three months for at least two years, with invitations sent by email, Telegram, or Viber.¹⁶ For MAP-Z, initial contact was made by postal mail, which has proven effective in other population-based studies in Switzerland. This design mirrors that of the digital cohort in Corona Immunitas, the COVID-19 Social Monitor, and the Swiss MS Registry.¹⁹,²⁰

To compare the state of mental health of the population within Ukraine, we focused on three regional clusters formed from ten selected oblasts across different parts of the country, which are affected differently by the war: The North-West cluster (Rivne, Lviv, Chernivtsi oblasts) is distant from the war zone and has comparatively low security risks, the Central cluster (Zhytomyr, Kyiv, Dnipropetrovsk oblasts) is situated closer to the border with the aggressor and has medium security risks, while the South-East cluster (Sumy, Kharkiv, Mykolaiv, Kherson oblasts): is near the war zone and has high security risks due to its proximity to the border with Russia.

The study was approved by the responsible ethics committee of the canton of Zurich, Switzerland (BASEC-Nr. 2023-02247) as well as by the Commission on Bioethics of Sumy State University, Ukraine (ref-Nr. 60-0274), and electronic consent was obtained from all participants.

## Data sources and outcome measurement

All data were collected directly from participants. We collected data through the electronic database REDCap using electronic questionnaires. At baseline we collected data on sociodemographic information along with the primary endpoints which included the prevalence of symptoms of PTSD (measured by PCL-5), anxiety (GAD-7), depression (PHQ-9), as well as secondary endpoints such as experiences of somatic symptom disorder (PHQ-15) and participants’ health-related quality of life (visual analogue scale of EuroQol; EQ-VAS).

## Bias

To minimize selection bias, we used stratified random sampling based on population registries and made a great effort to increase participation rates despite the very challenging situation in Ukraine. Because the gold standard approach of expert administered semi-structured interviews cannot feasibly be employed in this context, we rely on commonly used, standardized questionnaires which we chose in a systematic selection process. For the three
mental health conditions of interest, we identified potential instruments and compared them against our selection criteria: (a) strong psychometric properties; (b) applicable estimates of sensitivity and specificity for statistical correction; (c) digitally implementable; (d) available in Ukrainian; (e) appropriate in the context of war; (f) established cut-offs for likely presence of disorder; (g) established use in population studies; (h) short duration or low completion burden; (i) Previously used in Ukraine. Through this careful selection process, we made sure that the data from the MAP studies could inform the Global Burden of Disease studies of the Institute for Health Metrics and Evaluation (Seattle, USA). The final decisions were made at an international working group meeting held in Zurich in Spring 2023.

## Study size

For MAP-U, we aimed for a precision of ±5% for 95% confidence intervals around prevalence estimates. We considered a specific age group in a specific regional cluster (e.g., participants aged 25–44 in the Central cluster) as the unit for which we needed the ±5% for 95% confidence intervals. Based on the available prevalence data in Ukraine and data from other conflict areas, we expected a prevalence of 25% for anxiety and depression, and 40% for PTSD in the Ukrainian population. Sample size requirements are highest for a prevalence of 40%, on which we thus based sample size calculations. To provide a precision of ±5% in estimating prevalence with 95% confidence intervals for a specific age group in a specific cluster, the required sample size was 369 survey respondents per combination of age group and cluster. Assuming a potential attrition of 15% among those who consent to participate, the required sample size for enrolment was 435 per age and cluster stratum. The size of the target sample for MAP-U was thus 5'220 persons (net sample; given 4 age and 3 cluster of oblasts strata). Expecting a participation rate of 6-7% for MAP-U, reflecting the difficult situation in Ukraine (i.e. inability to reach randomly selected persons, concerns to participate, power outages, and other reasons), the final number randomly drawn from the population registry in Ukraine was 6'715 per stratum and 80'579 for the total sample.

For the MAP-Z study, we assumed a participation rate of 25%, based on experiences with previous population-based studies in the canton of Zurich (e.g., Corona Immunitas studies).²⁰ For the age groups 25-44 and 45-64 years among people living with protection status S, as well as for all four age groups in the general population of the canton of Zurich, we initially aimed for 435 participants per age group, totaling 1'740 people to be invited. However, there were fewer than 1'740 people with protection status S in the youngest (18-24 years) and oldest (65+ years) age groups with protection status S in Zurich. Therefore, we randomly selected 684 people in those two age groups to achieve a sample of 171 (25%). In these age groups, the precision was expected to be lower, with 95% CI expected at ±8%. The total sample sizes for people living with protection status S and for the general population living in the canton of Zurich were 1'220 and 1'740, respectively. Sample size calculations were performed using the Scalex SP calculator.²¹

## Quantitative variables

Scores for the questionnaires were summed according to guidance from the developers of the respective instruments. If less than 20% of items were missing for any single survey, we used mean imputation to calculate the sum scores. If more than 20% of items were missing, we excluded these surveys.

## Statistical methods

We used means with standard deviations, medians and interquartile ranges, or absolute numbers and percentages for the descriptive analyses of the study population as well as war related
experiences. Symptom sum scores, reflecting symptom burden, were also shown descriptively for PTSD, anxiety and depression, as well as for somatic symptom disorder.

We conducted prevalence estimations for PTSD, anxiety, and depression for subgroups defined by the cluster of oblasts (see above), age group and sex. Because the questionnaires used were primarily designed as screening tools, they prioritize sensitivity, which creates a serious risk of overestimation if prevalence is calculated based on the established cut-offs. A recent systematic review indicated that prevalence estimates based solely on standardized instruments are approximately twice as high as those prevalence estimates based on standardized diagnostic interviews.²² We addressed this challenge by estimating prevalence and 95% credible intervals using a Bayesian logistic regression model stratified by age-group, sex and cluster of oblasts and adjusted for sensitivity and specificity of the instruments based on available literature.²³ To obtain the most accurate available estimates of sensitivity and specificity for the involved instruments and our situation, when available, source studies included a population-based sample, used structured diagnostic interviews as reference standard, had a sample size of >100 and >50 positive cases. Additionally, we preferred studies with mean symptom scores that were comparable to those in our population (based on participants included up to June 30, 2024), and where we deemed the study population similar to our study population. We favoured primary studies over meta-analyses because we were better able to assess similarity between our population and a single well-characterized sample than to compare our population with the heterogeneous aggregate of samples that underlie a meta-analysis. We conducted sensitivity analyses to ensure that our results were robust by using alternative studies as sources of diagnostic accuracy metrics for adjustment of prevalence estimates.

For the PCL-5 we chose a cut-point of >=31 with a sensitivity of 0.94 and a specificity of 0.94.²⁴ The cut-point for the GAD-7 was >=10, the assumed sensitivity 0.89 and specificity 0.82.²⁵ For the PHQ-9, we chose a cut-point of >=10 and assumed a sensitivity of 0.88 and specificity of 0.88.²⁶

We conducted all analyses in R 4.4.2 https://www.r-project.org/

## Role of the funding source

The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

## Results

We recruited 6'036 participants for MAP-U, 657 participants for MAP-Z (UA) and 766 participants for MAP-Z (ZH). For the analyses, we used data from 5'286 MAP-U, 646 MAP-Z (UA) and 746 MAP-Z (ZH) participants. Characteristics of the recruitment process are detailed in Figure 1. For MAP-U it was, as expected, very challenging to reach randomly selected individuals due to the war and the numerous protective measures in place in the digital space in Ukraine, which are difficult to anticipate and not publicly disclosed due to security concerns. Initially, the vast majority of emails ended up in spam, personal survey links were inactive (e.g. links were cut off), or emails were not delivered at all. Through numerous phone calls by the local study teams to randomly selected individuals, as well as messages sent via the SendPulse email service, Telegram, and Viber, we were able to enroll 6'035 participants from Ukraine. Unfortunately, it was not possible to exactly determine how many invitees either refused to participate or did not receive the study invitation at all (a total of 74'543 but Supplementary Figure 1 shows the best possible basis for estimating recruitment rates.
<figure><img src="image_2.png" /><figcaption>Figure 1. CONSORT diagram of participant enrolment and inclusion in the study.</figcaption></figure>

Descriptive data

Demographic and educational characteristics of enrolled participants are detailed in Table 1. Both Ukrainian samples exhibited a sex imbalance, with 71% (n=3755) of participants identifying as female in the MAP-U sample and 72% (n=398) in the MAP-Z (UA) sample. In contrast, MAP-Z (ZH) demonstrated a nearly even sex distribution (53% women). The age of respondents at enrolment ranged between 18 and 96 years.

<table><caption>Table 1. Demographic characteristics of MAP-U, MAP-Z (UA) and MAP-Z (ZH) samples.</caption><thead><tr><th></th><th>MAP-U<br>Ukraine<br>(N=5286)</th><th>MAP-Z (UA)<br>Refugees<br>(N=646)</th><th>MAP-Z (ZH)<br>Zurich<br>(N=746)</th></tr></thead><tbody><tr><td><strong>Sex</strong></td><td></td><td></td><td></td></tr><tr><td>Female</td><td>3755 (71.1%)</td><td>468 (72.4%)</td><td>398 (53.4%)</td></tr><tr><td>Male</td><td>1316 (24.9%)</td><td>152 (23.5%)</td><td>331 (44.4%)</td></tr><tr><td>Missing</td><td>214 (4.0%)</td><td>26 (4.0%)</td><td>17 (2.3%)</td></tr><tr><td><strong>Age Group</strong></td><td></td><td></td><td></td></tr><tr><td>18-24</td><td>1263 (23.9%)</td><td>107 (16.6%)</td><td>144 (19.3%)</td></tr><tr><td>25-44</td><td>2195 (41.5%)</td><td>273 (42.3%)</td><td>207 (27.7%)</td></tr><tr><td>45-64</td><td>1413 (26.7%)</td><td>200 (31.0%)</td><td>216 (29.0%)</td></tr></tbody></table>
<table><tbody><tr><td>65+</td><td>414 (7.8%)</td><td>66 (10.2%)</td><td>179 (24.0%)</td></tr><tr><td><strong>Highest Educational Attainment</strong></td><td></td><td></td><td></td></tr><tr><td>Less than Secondary Education</td><td>8 (0.2%)</td><td>0 (0%)</td><td>6 (0.8%)</td></tr><tr><td>Completed Secondary Education</td><td>627 (11.9%)</td><td>53 (8.2%)</td><td>36 (4.8%)</td></tr><tr><td>Professional Education</td><td>868 (16.4%)</td><td>96 (14.9%)</td><td>193 (25.9%)</td></tr><tr><td>Baccalaureate or higher professional education*</td><td>NA<sup>†</sup></td><td>NA<sup>†</sup></td><td>243 (32.6%)</td></tr><tr><td>University Degree</td><td>3565 (67.5%)</td><td>470 (72.8%)</td><td>256 (34.3%)</td></tr><tr><td>Missing</td><td>217 (4.1%)</td><td>27 (4.2%)</td><td>12 (1.6%)</td></tr></tbody></table>

*Because education systems differ greatly, no direct equivalent exists in all cases. †Not Applicable

The educational systems in Ukraine and Switzerland differ strongly and direct comparisons between the samples should be avoided. In terms of educational attainment, the samples are largely representative of the underlying population.

Table 2 details some of the war-related experiences reported by MAP-U and MAP-Z (UA) participants. Direct experiences of war-related events were less common than relatives being affected. Notably in both samples 1 in 10 experienced the death of a relative since February 2022.

<table><caption>**Table 2.** Selected war-related experiences reported by MAP-U and MAP-Z (UA) participants.</caption><thead><tr><th></th><th>MAP-U<br>Ukraine<br>(N=5285)</th><th>MAP-Z (UA)<br>Refugees<br>(N=646)</th></tr></thead><tbody><tr><td><strong>Displacement</strong></td><td>1173 (22.2%)</td><td>581 (89.9%)</td></tr><tr><td><strong>Residence Damaged</strong></td><td>477 (9.0%)</td><td>97 (15.0%)</td></tr><tr><td><strong>Relatives Mobilized</strong></td><td>1195 (22.6%)</td><td>77 (11.9%)</td></tr><tr><td><strong>Injuries or Trauma from Hostilities</strong></td><td>69 (1.3%)</td><td>5 (0.8%)</td></tr><tr><td><strong>Gender-based violence</strong></td><td>57 (1.1%)</td><td>5 (0.8%)</td></tr><tr><td><strong>Death of a Relative</strong></td><td>499 (9.4%)</td><td>67 (10.4%)</td></tr><tr><td><strong>Separation from Family Members</strong></td><td>1800 (34.1%)</td><td>498 (77.1%)</td></tr></tbody></table>
## Outcome data

Figure 2 shows the distribution of symptom scores for PTSD, anxiety, and depression, as well as for somatic symptom disorder and general health status (EQ-VAS). The results are stratified for cluster, age group and sex. We observed a high symptom burden across the three clusters in MAP-U for PTSD, anxiety, and depression. Scores in MAP-Z (UA) were largely comparable to MAP-U. The MAP-Z (ZH) comparator group reported a much lower symptom burden.

<figure><img src="image_3.png" /></figure>

**Figure 2.** Symptom burden in MAP-U (by cluster), MAP-Z (UA) and MAP-Z (ZH), stratified by age group and sex. Pictured are sum-scores of the PCL-5, GAD-7, PHQ-9, PHQ-15 and the EQ-VAS. Dotted horizontal lines indicate cut-offs used to indicate the (very) likely presence of a specific mental health condition.

While symptom scores were high in all Ukrainian clusters, they were higher in central and south-eastern Ukraine compared to the north-west. This holds true for all three assessed mental health dimensions. The mental health burden of the MAP-Z (UA) population closely resembles that of clusters Central and South-east. The MAP-Z (ZH) population had consistently lower mental health and somatic symptoms burden, as well as higher EQ-VAS scores.

Beyond mental health, physical health was also affected with MAP-U and MAP-Z (UA) participants reporting high somatic symptom burden and low EQ-VAS scores as shown in Figure 2. In the MAP-Z (ZH), an apparent age-related pattern emerged, with the 18-24-year-
old respondents reporting the highest symptom scores and lowest EQ-VAS values across
measures.

Main results

<figure><img src="image_4.png" /></figure>

Figure 3. Adjusted prevalence estimates in percent of moderate or severe symptoms of PTSD, anxiety, and depression, measured using the PCL-5, GAD-7, and PHQ-9 respectively. Points indicate the mean estimate and vertical bars the 95% credible interval.

Figure 3 displays the estimated prevalences of PTSD, anxiety, and depression after adjusting for sensitivity and specificity. In line with the high symptom scores, prevalence estimates were elevated across clusters in MAP-U and MAP-Z (UA). Differences by sex are particularly stark in Anxiety.

Other analyses

We conducted sensitivity analyses to ensure that our results were robust by using alternative studies as sources of diagnostic validity metrics for adjustment of prevalence estimates.

While estimates were affected to some degree, trends in the data remained stable. This is detailed in the appendix.

Discussion

Key results

In this first population-based study, post-traumatic stress, anxiety, and depression were greatly elevated among Ukrainians and Ukrainian refugees compared to a non-war-affected population living in Zurich, Switzerland. Within Ukraine, symptom scores were higher in south-eastern and central regions, where more intense fighting had taken place, than in north-western Ukraine. Ukrainian refugees in Zurich were most comparable to those in the central and south-
eastern cluster and reported a higher burden than those in north-western Ukraine. Notably, symptom burden and estimates of prevalence were relatively similar across age groups in Ukrainians living in Ukraine or Switzerland. In contrast, data from the general population of Zurich, Switzerland showed lower estimates in older adults compared to younger ones, as commonly reported in the literature on populations not affected by armed conflicts.

Beyond purely mental health burden, somatic syndrome disorder scores followed similar patterns.

## Main findings

A study from 2016 estimated a prevalence of 32% for PTSD, 17% for anxiety, 22% for depression, and a high risk for developing somatic symptom disorder in internally displaced persons.²⁷ There are also other estimates from before the war, however, due to differences in sampling approaches, instruments, and the lack of adjustment for sensitivity and specificity against the reference standard of standardized clinical interviews, it is difficult to compare our results with those from before the war. Our study serves as an important starting point for mental health surveillance in Ukraine and helps anchor the burden of mental health of Ukrainians living in Ukraine and in Switzerland compared to a general population not affected by war, but where PTSD, and in particular anxiety, depression and somatic symptom disorder are also prevalent. Our data show that the symptom burden and estimates of PTSD, anxiety, and depression are significantly higher in Ukrainians affected by the war compared to a population not affected by the war. Also, somatic symptom disorder is substantially more prevalent. It is important to understand these findings in the context of the characteristics of our participants. Based on the reported experiences of war (Table 2), 1.3% of Ukrainians in Ukraine, and 0.8% of Ukrainians in Switzerland, respectively, were directly physically injured or traumatized by the hostilities. Despite this relatively low level of direct exposure to hostilities and violence, and our focus on civilians who were not directly involved in the conflict, the impact on mental health is substantial across the general population.

A recent study, conducted online in a non-randomly selected population also found increased prevalence of stress, anxiety, and PTSD among Ukrainian adults with more symptom burden among refugees and internally displaced persons compared to non-displaced persons. However, there was no control group from a non-war affected population and results were not presented stratified by age. While our study is not directly comparable to this one, the results are largely consistent with WHO global estimates. They suggest that one in five people living in an area affected by conflict at any time during the previous 10 years has some form of mental health condition, and nearly one in 10 is expected to live with a moderate or severe mental health condition.¹,²⁸

## Implications

Our data help plan and evaluate urgently needed public mental health and mental health care services as outlined by the Lancet Commission on mental health in Ukraine.¹³ A number of bottom-up projects to modernize mental health care and move towards community-based care, such as Mental Health for Ukraine, had already started before the full-scale invasion. Our project lays the basis for estimating the number of persons who need support, determining the capacity for social and health personnel and infrastructure, and highlights the need for a planning framework across the age spectrum, including older people. Additionally, prevention, health promotion, and destigmatization are key to strengthening resilience of the population and the social and health care workforce. They also help address the significant mental health challenge in Ukraine from a multisectoral perspective and relieve some of the pressure from the healthcare system. Longitudinal surveillance of mental health, as conducted in the MAP studies, will be crucial for evaluating whether targets are met and for ensuring that important
developments over time are not overlooked. We hope that our results help destigmatize mental health disorders by highlighting that a substantial proportion of the civilian population is affected. Only a concerted, scalable effort that reaches all segments of society will reduce the high mental health burden of the Ukrainian population.

## Limitations

While this study provides valuable insights, there are several limitations. First, the sample of men in MAP-U and MAP-Z (UA) is likely not fully representing the general population but this could not be avoided given the mandatory duty of men to serve in the army. While we believe that the results are likely generalizable for women, this is less certain for men in our sample. Yet, the lower symptom burden and prevalences observed for men compared to women is comparable to many studies conducted in other populations around the globe. Second, the response rate was low to moderate in both MAP-Z studies but comparable to response rates in longitudinal, population-based studies. We made a substantial effort with multiple reminders, incentive programs, and individual phone calls to reach as many randomly selected Ukrainians living in Ukraine or who fled to Switzerland as possible. However, potential selection effects remain a concern, as individuals who chose to participate in the study may systematically differ from those who did not. For the MAP-U study, it was not possible to determine the exact response rate because it is unclear how many persons have actually been reached. We believe the response rate may be substantially higher than the reported 7.5%, if only those who were actually reached were counted in the denominator. Third, the baseline assessment was conducted during a time of war, when Ukraine was enduring ongoing missile and drone attacks, along with prolonged power and internet outages in almost all oblasts of the country, which also represented a major challenge. These disruptions contributed to non-response among MAP-U participants, which could have introduced bias if the characteristics, feelings, or opinions of non-respondents differed significantly from those of the participants. Nevertheless, the sample size was sufficiently large, and responders represent all geographical regions of Ukraine (North-Western, Central and South-Eastern).

## Generalisability

The limitations of sex imbalance and response rate need to be kept in mind when considering the findings' generalizability. Nevertheless, the random population-based sampling approach and our extended effort to reach selected persons is a clear strength in this regard. The consistency of the observed trends across age groups, geographic regions, sex and mental health dimensions also enhance confidence in their robustness.

## Conclusions

This study showed a high symptom and mental health burden experienced by the Ukrainian population with higher levels of PTSD, anxiety and depression compared to a general population not affected by the war. Within Ukraine, we observed a pronounced regional gradient, with higher symptom burden in persons living in central and south-eastern Ukraine and being more exposed to war-related activities, compared to those living in north-western Ukraine. No apparent differences were found between different age groups, indicating that the psychological impact of war affects Ukrainians of all ages. The refugee population also showed a high symptom burden of PTSD, anxiety, and depression, with symptom levels closely resembling those of individuals from the central and south-eastern regions of Ukraine. Continued monitoring is crucial for understanding both the short-term and long-term mental health outcomes in the Ukrainian general population, guiding future interventions, and supporting recovery efforts in the aftermath of the war.
**Other information**

Authors' contribution

VY, VvW, TB, SK, MK, AF, AK, AL, ES, VP, SR, and MAP contributed to the conceptualization and methodology of the study. MK curated the data and provided support for the software. MK and AB conducted the formal analysis and validation of the data. VY, VP, VS, AL, AF, and AK contributed to the investigation. VY, AF, and AK administered the project. VY, AF, and AK contributed to the provision of resources. AMB, MK, and VY worked on the data visualization. MK and AMB had full access to the raw data of the study. VY, AMB, and MAP prepared the original draft. All authors contributed to reviewing and editing the manuscript. MAP handled the funding acquisition and supervision of the study. All authors have read and agreed to the published version of the manuscript.

Declaration of interests

The authors have no competing interest to declare.

Funding

This study is funded by the Canton of Zurich (fund for cooperation and development, decision 817/2023 of government of Zurich, June 28, 2023), the University of Zurich and the Mental Health for Ukraine (MH4U) project funded by the Swiss Agency for Development and Cooperation (project number 7F09385).

References

1 Lushchak O, Velykodna M, Bolman S, Strilbytska O, Berezovskyi V, Storey KB. Prevalence of stress, anxiety, and symptoms of post-traumatic stress disorder among Ukrainians after the first year of Russian invasion: a nationwide cross-sectional study. *The Lancet Regional Health - Europe* 2024; **36**: 100773.

2 Wang S, Barrett E, Hicks MH-R, et al. Associations between mental health symptoms, trauma, quality of life and coping in adults living in Ukraine: A cross-sectional study a year after the 2022 Russian invasion. *Psychiatry Res* 2024; **339**: 116056.

3 Kurapov A, Danyliuk I, Loboda A, et al. Six months into the war: a first-wave study of stress, anxiety, and depression among in Ukraine. *Front Psychiatry* 2023; **14**. DOI:10.3389/fpsyt.2023.1190465.

4 Xu W, Pavlova I, Chen X, Petrytsa P, Graf-Vlachy L, Zhang SX. Mental health symptoms and coping strategies among Ukrainians during the Russia-Ukraine war in March 2022. *International Journal of Social Psychiatry* 2023; **69**: 957-66.
5 Karstoft K-I, Korchakova N, Koushede VJ, et al. (Complex) PTSD in Ukrainian refugees: Prevalence and association with acts of war in the Danish refugee cohort (DARECO). *J Affect Disord* 2024; **366**: 66–73.

6 Ben-Ezra M, Goodwin R, Leshem E, Hamama-Raz Y. PTSD symptoms among civilians being displaced inside and outside the Ukraine during the 2022 Russian invasion. *Psychiatry Res* 2023; **320**: 115011.

7 Preiss M, Fňašková M, Berezka S, et al. War and women: An analysis of Ukrainian refugee women staying in the Czech Republic. *Cambridge Prisms: Global Mental Health* 2024; **11**: e47.

8 Rizzi D, Ciuffo G, Sandoli G, et al. Running Away from the War in Ukraine: The Impact on Mental Health of Internally Displaced Persons (IDPs) and Refugees in Transit in Poland. *Int J Environ Res Public Health* 2022; **19**: 16439.

9 Crocq M-A, Crocq L. From shell shock and war neurosis to posttraumatic stress disorder: a history of psychotraumatology. *Dialogues Clin Neurosci* 2000; **2**: 47–55.

10 Kostyantyn Dumchev VK. The Commission on mental health in Ukraine: areas for development. *Lancet Psychiatry* 2024; **11**: 867–9.

11 Levin Y, Bachem R, Hyland P, et al. The association between daily life changes and anxiety among Ukrainians following the Russian invasion. *Psychiatry Res* 2023; **329**: 115530.

12 Mental Health in Ukraine: Displacement, Vulnerabilities and Support - Thematic Brief. Ukraine, 2024.

13 Pinchuk I, Leventhal BL, Ladyk-Bryzghalova A, et al. The Lancet Psychiatry Commission on mental health in Ukraine. *Lancet Psychiatry* 2024; **11**: 910–33.

14 Otorkpa OJ, Otorkpa CO, Emmanuel S, et al. Review of global burden of disease studies: trends, challenges, and future directions. *International Journal of Public Health Science (IJPHS)* 2024; **13**: 766.

15 Menges D, Ballouz T, Anagnostopoulos A, et al. Burden of post-COVID-19 syndrome and implications for healthcare service planning: A population-based cohort study. *PLoS One* 2021; **16**: e0254523.

16 Yasenok VPMA. Mental Health Assessment of the Population: study protocol of the MAP research program in Ukraine (MAP-U) and in Zurich (MAP-Z). 2024 www.ssph-journal.org.
17 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. *J Biomed Inform* 2009; **42**: 377–81.

18 Harris PA, Taylor R, Minor BL, et al. The REDCap consortium: Building an international community of software platform partners. *J Biomed Inform* 2019; **95**: 103208.

19 Moser A, Carlander M, Wieser S, Hämmig O, Puhan MA, Höglinger M. The COVID-19 Social Monitor longitudinal online panel: Real-time monitoring of social and public health consequences of the COVID-19 emergency in Switzerland. *PLoS One* 2020; **15**: e0242129.

20 Speierer A, Chocano-Bedoya PO, Anker D, et al. The Corona Immunitas Digital Follow-Up eCohort to Monitor Impacts of the SARS-CoV-2 Pandemic in Switzerland: Study Protocol and First Results. *Int J Public Health* 2022; **67**. DOI:10.3389/ijph.2022.1604506.

21 Naing L, Nordin R Bin, Abdul Rahman H, Naing YT. Sample size calculation for prevalence studies using Scalex and ScalaR calculators. *BMC Med Res Methodol* 2022; **22**: 209.

22 Levis B, Yan XW, He C, Sun Y, Benedetti A, Thombs BD. Comparison of depression prevalence estimates in meta-analyses based on screening tools and rating scales versus diagnostic interviews: a meta-research review. *BMC Med* 2019; **17**: 65.

23 Gelman A, Carpenter B. Bayesian Analysis of Tests with Unknown Specificity and Sensitivity. *J R Stat Soc Ser C Appl Stat* 2020; **69**: 1269–83.

24 Geier TJ, Hunt JC, Nelson LD, Brasel KJ, deRoon-Cassini TA. Detecting PTSD in a traumatically injured population: The diagnostic utility of the PTSD Checklist for DSM-5. *Depress Anxiety* 2019; **36**: 170–8.

25 Spitzer RL, Kroenke K, Williams JBW, Löwe B. A Brief Measure for Assessing Generalized Anxiety Disorder. *Arch Intern Med* 2006; **166**: 1092.

26 Kroenke K, Spitzer RL, Williams JBW. The PHQ-9. *J Gen Intern Med* 2001; **16**: 606–13.

27 Roberts B, Makhashvili N, Javakhishvili J, et al. Mental health care utilisation among internally displaced persons in Ukraine: results from a nation-wide survey. *Epidemiol Psychiatr Sci* 2019; **28**: 100–11.
28 Charlson F, van Ommeren M, Flaxman A, Cornett J, Whiteford H, Saxena S. New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysis. *The Lancet* 2019; **394**: 240–8.