correspondence
A joint international collaboration to address the
inevitable mental health crisis in Ukraine
To the Editor — On 24 February 2022,
Russia launched a full-scale invasion of
Ukraine, marking a major escalation in
hostilities. More than 4 million people have
fled Ukraine into neighboring countries,
causing Europe’s largest refugee crisis since
the Second World War. The mental health
problems and challenges among refugees
and other populations affected by the war
have received little attention, compared to
political boycotts and economic sanctions.
The rapid escalation of a mental health crisis
warrants urgent attention.
It is inevitable that people living in
conflict-affected areas will have short- and
long-term mental health problems. Prior
to fleeing their home countries, refugees
usually experience various traumas, such
as losing family and loved ones in conflict,
fear of being killed in war and lack of
basic necessities, all of which contribute
to an increased vulnerability to mental
health problems1. Certain risk factors,
such as pre-existing psychiatric problems,
may increase the risk of conflict-related
mental health problems among vulnerable
individuals2. During migration, ongoing
danger to personal safety and uncertainty
about the future can trigger mental
health problems3. In addition to these
short-term effects, long-term effects of
conflict-associated migration may be due
to the stress of acculturation, language and
culture barriers, and social discrimination
in the new country4.
Mental health problems will also affect
people living in the conflict zones in Ukraine.
They are exposed to a range of war traumas,
such as witnessing or experiencing war
injuries, explosions from bombs and loved
ones being killed, often repeatedly, which
can result in severe psychological traumas
and psychiatric comorbidities, including
posttraumatic stress disorder (PTSD)
and depression5. A systematic review and
meta-analysis showed that the prevalence of
psychiatric disorders (including depression,
anxiety disorder, PTSD, bipolar disorder and
schizophrenia) was 22.1% at any point in
time among conflict-affected populations,
including those who leave or stay in their
original countries6.
The war has also added to the challenges
in the prevention and control of SARS-CoV-2.
There is a low COVID-19 vaccination rate
in Ukraine of around 35.7% (ref. 7), and the
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upheaval of the public health system caused
by the war will negatively affect pandemic
control measures. The relentless conflict
combined with the COVID-19 pandemic will
put extreme pressure on the health system
in Ukraine and neighboring countries,
compromising timely delivery of mental
health services for refugees.
International psychiatric academic
associations, including the European
Psychiatric Association (EPA), American
Psychiatric Association (APA) and
World Psychiatric Association (WPA),
have released statements on how the war
will exacerbate mental health problems.
Joint international collaboration is crucial
to tackle the mental health crisis in
Ukraine and so we propose the following
actions, below.
First, health authorities in Ukraine,
as well as those in surrounding countries
hosting refugees, should provide universal
mental health services for those impacted
by the war. Online mental health surveys
and counselling services could be suitable
alternatives to face-to-face assessments and
psychological first aid; evidence for their
efficacy has come from combating mental
health problems caused by the COVID-19
pandemic8.
Second, major international psychiatric
associations, such as the WPA, APA, EPA
and the Pacific Rim College of Psychiatrists
(PRCP), should have an important role in
addressing the mental health crisis caused
by the war. The WPA has already called for
donations to supply essential medications
for mentally ill people in Ukraine9.
Collaborative efforts should include:
epidemiological surveys on the dual
mental health crises caused by the war
and COVID-19 pandemic among affected
populations; facilitating the timely
delivery of crisis intervention services; and
developing expert consensus and crisis
management guidelines to assist mental
health professionals working in the
affected countries.
Third, special attention should be given
to vulnerable populations at high risk of
mental health problems, such as the elderly
(Ukraine is one of the fastest aging countries
in the world). Finally, it is paramount
to ensure the provision of culturally
sensitive crisis interventions to all refugee
populations, including Ukrainian refugees.
The mental health crisis caused by the
war in Ukraine is driving an unprecedented
humanitarian crisis both for refugees and
for war survivors living in Ukraine. We call
for a cohesive and timely collaboration,
nationally and internationally, to address
and minimize the mental health suffering of
conflict-affected populations. ❐
Wei Bai   1,2,3,10, Hong Cai1,2,3,10, Sha Sha4,10,
Chee H. Ng5 ✉, Afzal Javed6, Jair Mari7,
Zhaohui Su   8, Naotaka Shinfuku9 and
Yu-Tao Xiang1,2,3 ✉
1
Unit of Psychiatry, Department of Public Health
and Medicinal Administration, and Institute of
Translational Medicine, Faculty of Health Sciences,
University of Macau, Macao SAR, China. 2Centre for
Cognitive and Brain Sciences, University of Macau,
Macao SAR, China. 3Institute of Advanced Studies
in Humanities and Social Sciences, University of
Macau, Macao SAR, China. 4The National Clinical
Research Center for Mental Disorders, and Beijing
Key Laboratory of Mental Disorders, Beijing Anding
Hospital, and the Advanced Innovation Center
for Human Brain Protection, Capital Medical
University, Beijing, China. 5Department of Psychiatry,
The Melbourne Clinic and St Vincent’s Hospital,
University of Melbourne, Richmond, Victoria,
Australia. 6Pakistan Psychiatric Research Centre,
Fontain House, Lahore, Pakistan. 7Department of
Psychiatry, Federal University of São Paulo, São
Paulo, Brazil. 8School of Public Health, Southeast
University, Nanjing, China. 9Graduate School of
Medicine, International Center for Medical Research,
Kobe University, Kobe, Japan. 10These authors
contributed equally: Wei Bai, Hong Cai, Sha Sha.
✉e-mail: cng@unimelb.edu.au; xyutly@gmail.com
Published online: 13 May 2022
https://doi.org/10.1038/s41591-022-01828-w
References
1. Silove, D. et al. World Psychiatry 16, 130–139 (2017).
2. Nielsen, M. B. et al. Lancet Public Health 4, e353–e359 (2019).
3. Chase, E. et al. Lancet 394, 1305–1307 (2019).
4. Hassan, G. et al. Epidemiol. Psychiatric Sci. 25, 129–141 (2016).
5. Farhood, L. F. et al. Eur. J. Psychotraumatology 7, 31509 (2016).
6. Charlson, F. et al. Lancet 394, 240–248 (2019).
7. Park, A. Why Ukraine’s COVID-19 problem is
everyone’s problem. TIME https://time.com/6153254/
ukraine-russia-war-covid-19 (2022).
8. Liu, S. et al. Lancet Psychiatry 7, e17–e18 (2020).
9. Javed, A. Call for donations to supply medications for mentally ill
patients in Ukraine. World Psychiatric Association https://www.
wpanet.org/post/call-for-donations-to-supply-medications-for-
mentally-ill-patients-in-ukraine (2022).
Author contributions
W.B., H.C., S.S., C.H.N. and Y.-T.X. conceptualized this
Correspondence and its format; W.B. and Y.-T.X. drafted
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correspondence
the text; A.J., J.M., Z.S., N.S. and C.H.N. made critical
revisions of the manuscript. All authors approved the
final version.
China can prepare to end its zero-COVID policy
To the Editor — To date, mainland
China has promptly blocked hundreds of
COVID-19 outbreaks that are associated
with imported cases, enabling it to maintain
the zero-COVID policy for more than
20 months1. Although tremendously costly,
this zero-case policy could have saved an
estimated one million lives, compared with
the global average mortality of COVID-19
(as of 16 February 2022)1. Many people
in China and around the world are
wondering if and when mainland China
will change its zero-case policy to one of
living with SARS-CoV-2. We believe that
this change will happen sooner or later,
as SARS-CoV-2 will probably become a
seasonal infection in 2022 and circulate in
humans indefinitely2,3.
There are several reasons why this
change could be feasible in 2022 (Table 1).
The number of fatal cases in China has been
low. Of the total 24,249 new COVID-19
cases confirmed in mainland China from
15 May 2020 to 15 February 2022, only two
people died before 15 March 2022 (case
fatality rate (CFR) of 0.008%), although
many had pneumonia1. This low CFR
can mitigate any social panic. Indeed, the
global CFR of SARS-CoV-2, which was
around 80 times higher than that of
seasonal influenza (~0.12%) in April 2020,
will be likely less than 2 times higher than
that of seasonal influenza in 2022 (ref. 3) due
to the effects of mass vaccination, immunity
from infection and the highly transmissible
but relatively low-pathogenicity Omicron
variant. Furthermore, COVID-19
vaccination coverage reached more
than 85% in mainland China, with each
person inoculated with around 2.2 doses
on average1.
The change from a zero-COVID
approach will come with many advantages,
but also great challenges (Table 1). The
change should better balance the control
of COVID-19 versus other socioeconomic
issues. The change should also better
balance the control of COVID-19 versus
other diseases, as the zero-COVID approach
has occupied vast public health resources.
Moreover, living with the virus in a
highly vaccinated population can lead
1104
Competing interests Psychiatrists. J.M. is Chair of the World Psychiatric
A.J. is President of the World Psychiatric Association. Association - Urban Mental Health Section. All other
C.H.N. is President of the Pacific Rim College of authors declare no competing interests.
Table 1 | Key factors to consider in ending China’s zero-COVID policy
Factor Rationale
Feasibility From 15 May 2020 to 15 February 2022 there were only two COVID-19 deaths in
mainland China
The global SARS-CoV-2 CFR in 2022 appears to be less than two times higher than
that of seasonal influenza
Vaccination coverage has reached more than 85% in mainland China, and each
person has been inoculated with 2.2 doses on average
Advantages A better balance between COVID-19 and other socioeconomic issues
A better balance between COVID-19 and other diseases
Generate robust herd immunity against future potential variants through repeated
mild infections
Challenges COVID-19 cases will surge rapidly and stay high for months
Healthcare systems could be overwhelmed by too many patients, which could
increase greatly the COVID-19 fatality rate
Strategies for Expand online clinical services to reduce in-person patients and nosocomial
preparedness infections
Train millions of local healthcare workers to provide better services for mild
COVID-19 cases
Stockpile antivirals, personal protective equipment, N95 masks, ventilators and
relevant traditional Chinese medications
to robust herd immunity against various services should be widely and rapidly
SARS-CoV-2 variants through repeated promoted, so that mild COVID-19 cases
natural mild infections2–4. can be seen at home. This could prevent
The greatest challenge of moving away hospitals from being overwhelmed and
from the zero-COVID approach in populous greatly reduce the risk of nosocomial
mainland China is that SARS-CoV-2 cases infections, including to healthcare
could surge rapidly, with high case numbers workers5. By June 2021, mainland China
for months after stringent control measures had constructed more than 1,600 online
are lifted. The rising cases could overwhelm hospitals with more than 239 million
healthcare systems (Table 1), which could users6, providing a solid foundation
greatly increase the COVID-19 CFR. for the rapid development of online
SARS-CoV-2 is currently circulating in healthcare services.
Japan, South Korea and Hong Kong at Local healthcare workers in community
high levels1, which should be observed clinics are critical to control the COVID-19
closely as natural pilot experiments to pandemic. By 2021, 970,036 community
evaluate the risk of the change in mainland hospitals had been established in mainland
China. It should be noted that the China, employing more than 3 million
COVID-19 vaccination rate is low in healthcare workers (around 1 community
Hong Kong, particularly in elderly hospital for every 1,400 residents)6. These
people, which may render the COVID-19 millions of local healthcare workers
outbreak there more severe than in can be trained to provide better online
mainland China. and offline healthcare services for mild
To prepare for the end of the COVID-19 cases7.
zero-COVID policy, we propose that Mainland China should also stockpile
development of online healthcare antivirals, personal protective equipment,
Nature Medicine | VOL 28 | June 2022 | 1103–1108 | www.nature.com/naturemedicine