Russia’s war against Ukraine is being fought not only with missiles and artillery, but also in the cognitive and psychological domains, where fear, exhaustion and social fragmentation can be weaponised deliberately.
In this context, mental health and psychosocial support (MHPSS) are not secondary humanitarian concerns, but core components of national resilience, civil defence, and long-term recovery. Drawing on the experience of Ukraine, the Baltic states, and the wider global community in responding to crises, we explore how investment in mental health can act as a form of ‘armour’ in cognitive warfare, sustaining social cohesion, preserving human capital, and enabling societies to endure prolonged emergencies while resisting coercion and manipulation.
Dmitri Teperik: When you first arrived in Ukraine ten years ago, what was your first impression of the scope of work needed to be done? And now, after all this time, what are some of the most significant changes in society that you notice?
Dr Fahmy Hanna: I focus on the area of mental health and psychosocial support (MHPSS) and emergencies, including interagency coordination between NGOs, governments, and UN agencies. In Ukraine, I was requested to support coordination in the east of the country after the establishment of the first MHPSS mechanism in 2015, and my mission came one year later to provide support and capacity building.
Ukraine is a good example that investing in MHPSS and preparedness pays off. Taking international resources and not only translating them to Ukrainian but also adapting them to the local context, and training local experts—all of it had been done in the years that preceded the full-scale invasion. When the full-scale invasion happened, one day later, Ukraine was already publishing 20 resources to make sure that every relevant expert is equipped with the standardised guidelines to make sure that we promote good practice in MHPSS. That foundation helped to scale up afterwards, with higher quality and in line with international guidance. The Ukrainian government took this issue very seriously, establishing the Coordinating Centre for Mental Health, an inter-ministerial council, through an initiative by the first lady of Ukraine, which put MHPSS as a national priority. Yet, it was the local-level preparedness and investment that enabled readiness.
Oksana Zbitneva: The realisation that MHPSS was critical to rehabilitation and capacity building, as well as to resistance and resilience, came already in 2015. With time, the Ministry of Health developed a national concept. However, the understanding of how essential mental health was to retaining human capital was still lacking. It wasn’t until May 2022 that the First Lady started her “How are U?” initiative as an attempt to meet the massive challenges of stress, disorientation, and radical upheaval of life routines and interactions.
An important achievement in Ukraine’s public discourse is that mental health is no longer limited to psychiatric disorders. We have understood that it concerns everyone and, building upon the First Lady’s initiative, have begun to take the first, yet systemic steps. Such ginormous social transformations, unfortunately, do not happen overnight. They require changes to the cultural paradigm, as well as one’s treatment of self as a resource, on the one hand. On the other hand, it requires restructuring of how the government operates. The authorities had to be persuaded that MHPSS was integral not only to healthcare but also to defence and security, to veterans’ affairs, to the economy, to education, youth and social policies, etc. It touches every sector where people interact with the state. When an individual applies for any public service, an official providing it must also be trained to offer first, basic, crisis MHPSS.
For the last three years, Ukraine has been building an MHPSS network from scratch: we did not have a national programme on mental health, and now, we do. Previously, MHPSS was confined to hospitals, usually psychiatric clinics, and the general public had little faith in psychotherapy. That notwithstanding, our goal is not to match every person with a psychologist or a psychiatrist. Most people can cope by themselves: experts and research suggest that 80% can, in fact. However, people need to know how to cope. For example, how to keep calm in a bomb shelter or how to calm down a child. People need to know where to look for resources, including the resources within oneself. It puzzles me how we are able to carry on amidst the blackouts and winter cold, and yet, we still go to work every day.
On the governmental level, it is vital to be able to assess and predict such mental conditions and how they present themselves in society—e.g., via aggression, rage, or apathy. To take care of oneself is to resist. The enemy is trying to crush our will to resist, for instance, through fear and exhaustion in order to coerce us to a ‘peace at any cost.’
DT: If 80% of the population can cope on their own, then the remaining 20% belong to the vulnerable groups. Who is considered vulnerable?
OZ: No one knows where to draw this line. There is no mental health tumbler. Some groups have a higher risk of a disorder due to a set of indicators. It applies to every individual who has experienced war: in occupation or in trenches, having been displaced or at home but without power. Everyone has a different ‘war experience,’ even within one family.
People whom we consider to be ‘high risk’ and our ‘target groups’ have survived unimaginable pressure on their psyche—combat veterans, first and foremost. They have to re-adapt to civilian life. Second, parents of children under six years old. Ukraine now has a generation of ‘children of war’ who have been born since 2014 and are being born now, under missiles. All of those are inhumane trials. Third, the elderly. They are commonly overlooked. In many cases, their children and grandchildren have left, while they have stayed behind, refusing to abandon their lifetime homes and possessions. However, loneliness in the elderly may lead to early dementia, among other ills. Loneliness is as dangerous an enemy as stress, an invisible killer that undermines our ability to live. Fourth, people with disabilities. And fifth, minors and especially teenagers. Children under six usually have an able adult who takes care of them and their emotional needs, whereas teenagers usually lack such an ‘authority’ figure at home or at school, and age characteristics compound their torments.
Now, sociological surveys point to a new group in the ‘red’, high-risk zone—i.e., “women who wait.” This category comprises mothers, spouses, partners, sisters, etc. They are exhausted by the ‘waiting’ as well as by the fear of what may come after. This is to say nothing of people who have lost their loved ones, whose loved ones are missing, and a separate group among them—those who lost their brothers and sisters in arms. Such losses take our pillars of strength, one by one. So, a person ends up standing as a heron on one leg, and anything can become the last straw that breaks them. In order not to break, we must learn new survival skills for this new reality, to learn to take care of one’s mental health so that it becomes as natural as a morning routine.
DT: What approaches and practises are the most critical? What lessons can Estonia or other countries that are on the borderline and under continuous stress learn?
FH:The World Health Organisation (WHO) is the United Nations’ lead agency on health, and since its establishment, mental health has been part of its definition of health. MHPSS is any intervention from inside or outside the community that protects and promotes psychosocial well-being, as well as prevents and treats mental health conditions. The 194 member states, including Estonia and Ukraine, have endorsed a resolution on integration of MHPSS before, during, and after emergencies.
To respond during emergencies, we promote a framework called the Minimum Service Package. The key message is that there are evidence-based tools that can help reduce suffering and improve mental health and psychosocial well-being, which underpins a more resilient system that functions during the emergency and in recovery. It is a whole-of-society and multi-sector approach where the ministry of education, civil protection agencies, and water and sanitation services have a role. It starts with coordination. The Minimum Service Package synchronises not only the language but also uniform activities that make the response predictable and help us avoid doing harm.
In 2023, Estonia hosted a global, field-based simulation exercise, where member states agreed to establish a monitoring indicator for MHPSS integration in preparedness and disaster risk management. When we measured it in 2025, after the COVID pandemic and after the full-scale invasion of Ukraine, 48% of countries in the world, including Estonia, had already integrated MHPSS in their preparedness plans. But we’re still far from reaching the global targets—i.e., 80% by 2030. I think every country is unique in its strengths and challenges. Estonia has played a leadership and pioneering role, but has also been learning from examples from others. Ukraine has a lot to learn from Estonia: for example, its decentralised, community-based mental health services. Organisations like the WHO facilitate this knowledge exchange.
Many years ago, the WHO launched a flagship publication titled Build Back Better: Sustainable Mental Health Care after Emergencies. It is now being updated to include some of the recent case studies and success stories, such as Ukraine, the Syrian refugee crisis in Türkiye, and Jordan during the War in Iraq. And it will be retitled as Build Back Better Sustainable Social Care and Mental Health Services During and After Emergencies. Because many examples show countries building systems during emergencies against all the odds, using policymakers’ interests and populations’ needs as catalysts to attract international attention and motivate local champions. We need to use every emergency—whether in the country affected or in a neighbouring country experiencing, for example, a refugee influx—as an opportunity to build a sustainable mental health care system.
As long as there is political will and prioritisation (as we see in Estonia), human and financial resources, and a desire to improve the system to make it more resilient, recovery is possible during as well as after an emergency. In fact, some of the biggest leaps forward in the mental health system around the world during the last couple of decades have actually happened this way.
DT: We should be thinking not just about preparedness and response during an emergency, but also about early recovery. But our resources are limited, and political will may not always be there. So, decision makers face a dilemma of where and how to invest: in restoring physical infrastructure or the social tissue of society. How do we solve this challenge?
FH: Funding cuts have affected us all, including humanitarian organisations. But when I say resources, I mean both human and financial resources. One of the remarkable ways Ukraine has developed its system is by investing in capacity building, by investing in people. Estonia has human resources: my Estonian colleagues were motivated to prioritise preparedness, even when a very small number of countries were talking about it. They are the real assets.
When we say investing in mental health requires resources, we need to keep in mind that these are cost-effective resources. According to the UN Office for Disaster Risk Reduction (UNDRR), every dollar invested in preparedness is $10 saved in response. Prevention and treatment of depression and anxiety have a $4 return on investment for the economy and the community, according to the World Bank and the WHO.
Some of the biggest success stories I have seen were building on existing resources rather than building a completely new service. It’s about enhancement, about fine-tuning, about alignment and adaptation of international guidance rather than investing in building big structures.
DT: There are many success stories, but there are also stories of failure. Yet, all have to be studied. What do they teach us?
OZ: Now is the right time for Estonia to develop MHPSS programmes for first responders; not only healthcare providers and educators, but anyone who interacts with people, from bank clerks and supermarket cashiers to ticket inspectors. Ukraine is playing catch-up in many areas, but thankfully, with some solid groundwork.
We must think of human capital and human resources. We must learn to count properly in economic terms. If we calculate the economic impact of mental health and stress-induced disorders—such as heart attacks and strokes, diabetes and cancers—in terms of sick days and disabilities, productivity and efficiency, it turns out that MHPSS is a much cheaper, long-term investment for a state budget.
Both our countries share a Soviet legacy of oppression, whereby anything with a ‘psyche-‘ element to it is automatically rejected by the public. This stigma and bias affect decision makers, too.
When we began introducing the WHO Mental Health Gap Action Programme (mhGAP) at the primary care level, we realised that medical schools in Ukraine fail to teach one basic skill—i.e., communication. Future family doctors only have 8 hours of psychiatry in their curriculum. Family doctors must learn to see mental and physical health as a whole, because an ulcer or heart pain may be triggered by stress. So, we decided to start integrating mhGAP already at the university level. By now, we have trained over 150 thousand healthcare professionals: doctors, paramedics, nurses, and even social workers.
Professionals are key, because care services are not about state-of-the art facilities but about providers.
Today, medical corps within the Armed Forces of Ukraine and the Ministry of Internal Affairs undergo mhGAP as well. The next challenge will be building out a continuous MHPSS in the military: from recruitment and training to demobilisation. It is a work in progress. The country is also confronting post-traumatic stress disorder (PTSD) in military and civilians alike, which can manifest in addictions and suicides. We can see it already and forecast many more cases in the future. Now, we are ‘in tonus’, but the breaking point will come eventually. It is something we must prepare for but can never be fully prepared.
Mental health is one’s armour in cognitive warfare. Whenever Russia cannot kill us physically, it tries to kill us mentally. Estonia has developed a psychological defence doctrine to resist and counter disinformation, which is important. But equally important is to nourish one’s psychological resources, one’s resilience. One has to train it as a muscle every day.
We are designing a new service infrastructure: in addition to a network of over 100 outpatient clinics and multidisciplinary teams of professionals, we have “resilience centres” (центри життєстійкості), a priority project under the Ministry of Social Policy, Family, and Unity and First Lady’s “How are U?” initiative. It has a unique philosophy wherein MHSSP are the focus of social services. People are in dire need of in-person contact, group activities, and collective action: be it singing or weaving camouflage nets, something to do with their hands to help restore cognitive functions. It is beneficial for the government to invest in such collective initiatives because when a crisis arrives, these personal networks are more effective than orders from the state.
We are used to talking about mental health in terms of severe disorders, such as depression or schizophrenia, which have very narrow definitions. So, people tend to think that it does not apply to them. Instead, we should be talking about conditions such as sleeping or eating disorders, anxiety or hyperfixation. We should be promoting simple, evidence-based coping mechanisms such as breathing techniques, finding objects, counting, etc. In Ukraine, we put up banners with such advice everywhere—in train cars, in subway stations, in bomb shelters. Not everyone will use these tips, but they must be accessible to everyone. They must be available in different forms, such as textbooks and guidelines for teachers and parents, tales and comic books for children, podcasts, etc.
Our next innovation is the Lessons of Happiness (уроки щастя) for school children. Our US partners shared their “well-being courses” with us, while we, together with the Ukrainian Catholic University, adapted them to our realia. Interestingly enough, we had a rather heated debate on what to call it. Well-being is not high on people’s agenda in wartime; well-being is an illusory concept to begin with. Moreover, our research and interviews reveal that the Ukrainian people have …. ‘a ban on happiness.’ I believe that we should normalise a narrative that even in such horrific conditions as war, people must prioritise joy to survive. This ban on happiness might be a hidden pattern that dates back to our shared Soviet past, or even earlier—when it used to be socially unacceptable and ‘boastful’ to laugh or demonstrate one’s delight in public, for example. This dictates the way we think, and then, the way we act and condition ourselves. During the war, to dream is to resist. By dreaming, you refuse to succumb to fear, which is exactly what the enemy wants.
DT: How do we communicate to the leadership that MHPSS should be a priority when building public trust and resilience?
FH: First, facts and figures matter to policymakers. Second, policymakers and the community in general need to hear more from people with lived experience. The more we talk about projects and numbers only, the more we distance ourselves from the people we wish to help. The stigma of mental health conditions is evident in all societies. The best way to address it is to engage the people affected and ask them to speak out through testimonials with their consent, of course, so that policymakers can get in touch with the real situation on the ground, associate with the person speaking, and understand why these interventions are effective. Third, this is a shared, joint responsibility for all decision makers in the ministries and various stakeholders—taking a whole-of-government and whole-of-society approach. The way you treat your neighbour if they have a mental health condition is equally important. Finally, people feel the topic is relevant when it’s close to them, closer to their heart. Policymakers also need intervention for their own mental health and psychosocial well-being. For instance, the WHO has Guidelines on mental health at work, which are directed not only at employees but also at managers.
There is a common message here: it’s okay not to be okay. However, this can be, to some extent, misleading. When you are not okay, there are ways to help you become okay. There are many ways of negative coping: smoking, alcohol, non-prescribed medication, etc. We should be promoting positive coping skills for stress management and, if a situation is affecting an individual functionally, ways to seek more advanced levels of help. It should be universally accessible without a financial burden and offer privacy and confidentiality—a universal healthcare coverage that includes MHPSS.
DT: The mental health system is human-centric, and in times of crisis, we need somebody to speak with, somebody to seek help from. Yet, in my observation, it has become more difficult to communicate with young people, and many are social media addicts. Moreover, now, we see the rapid development of AI and AI tools that offer a conversation partner of sorts. Is this behaviour a bad habit or a negative coping mechanism?
FH: Young people have very specific needs. At that age, many mental health conditions can start, but also be prevented. The general coping mechanisms apply here as well, but peer influence is significant. For example, the WHO has a tool for young teens called I Support My Friends specifically for young teens, so that when a crisis happens, they can sit down with a peer instead of negative coping, such as bullying, stressing, or phasing out someone who needs support.
The impact of social media depends on how we use it, what for, and for how long. If social media makes us distant from real interactions with people in our community, or affects us educationally and functionally, we need to approach it as we approach a negative coping mechanism. There are many positive effects that we can get from social media by educating about mental health conditions and coping mechanisms.
When it comes to AI or bot-supported digital psychological intervention, there is ongoing research about these matters. The WHO is also investing in studies and the development of AI. For example, there is an online platform, Step by Step, for supporting the treatment of depression and anxiety, backed by human specialists when needed. Furthermore, the WHO is developing an AI-enabled bot that targets adolescent mental health and psychosocial support..
The AI itself cannot, at this stage, completely negate the need for psychotherapists, especially in cases where more advanced support or immediate intervention is needed.. But AI can support psychiatrists and psychologists in limited-access areas.
OZ: We must invest in human networks. AI will never replace human interaction. AI and innovative technology are tools to assist human professionals in their daily work by automating routine tasks, such as initial screening or monitoring a patient after a consultation. But AI cannot treat a patient or supervise their recovery and rehabilitation.
TF: What is one message that you wish to convey to governments and community leaders?
FH: I can think of multiple messages. The key message is that MHPSS is not a luxury, including during or before an emergency. Humans need MHPSS as much as they need food and water, shelter and medication to be able to cope and thrive. My next message is to invest in MHPSS before emergencies happen. It saves time and funds, as well as guarantees a higher quality response. My final message: if you want to go fast, go alone, but if you want to go deep and big, go together. You cannot scale up responsible MHPSS with one sector only. This is an area that requires a whole-of-society, whole-of-government, multisectoral approach.
OZ: It bears reminding that Russia has been targeting Ukraine’s energy infrastructure not only for us to freeze and grow angry, but to become too apathetic to continue fighting. So, for us, it is not about surviving this moment but about being resilient in the long term. To be guided by values, to know not only what you are fighting against but also what you are fighting for. Estonia knows it because it remembers the Soviet occupation.
This article was written for ICDS Diplomaatia magazine. Views expressed in ICDS publications are those of the author(s).