Introduction
In recent years, the world has been confronted with many humanitarian crises – events or series of events representing a critical threat to the health, safety, security, or wellbeing of a community, usually over a wide area (Bloxham 2022; World Health Organization 2007). Natural hazards (floods, hurricanes, earthquakes), pandemics and man-made disasters (mass violence, armed conflicts) can lead to psychological harm (Lotzin et al. 2023). The COVID-19 pandemic and war in Ukraine are mentioned among the main 21st century concerns (Barchielli et al. 2022). They were referred to as a twofold emergency severely compromising physical and mental health (Kalaitzaki et al. 2023). It is important to assess the impact of a crisis on mental health, as this can provide a basis for developing interventions in subsequent disasters (Hobfoll et al. 2007).
The outbreak of war in Ukraine in February 2022 had profound psychological effects on the people of that country (Chudzicka-Czupała et al. 2023a, 2023b; Pavlova et al. 2022; Xu et al. 2023). Negative psychological sequelae also affected communities in many countries, including Poland (Chudzicka-Czupała et al. 2023a, 2023b; Gottschick et al. 2023; Kasierska et al. 2023; Maftei et al. 2022; Mottola et al. 2023; Predoiu et al. 2024; Riad et al. 2022; Scharbert et al. 2024).
The indirect exposure theory assumes that people who are not directly exposed to the threat of loss of life and violence may also experience the negative impact of war on mental health. This includes residents of countries neighboring the conflict area and countries hosting refugees (Chudzicka-Czupała et al. 2023b). Exposure to war can occur as a result of viewing images of fighting on social media and on television (Anjum et al. 2023; Chudzicka-Czupała et al. 2023b; Rizzi et al. 2023). The war in Ukraine is an example of an information war, in which presentation on television programs and social media produces symptoms of anxiety, depression and uncertainty about the future (Rozanov et al. 2019). The results of several studies (Gottschick et al. 2023; Kasierska et al. 2023; Surzykiewicz et al. 2022) have confirmed that exposure to news concerning the Russo-Ukrainian war was associated with a risk of mental health deterioration.
Of those who have experienced exposure to traumatic events, many do not exhibit mental health problems, some present only mild or moderate psychological symptoms, and some develop trauma-related mental disorders such as posttraumatic stress disorder (PTSD) and depression (Southwick and Charney 2012). This group of individuals requires short or long-term clinical and community support after living through traumatic war-related experiences (Anjum et al. 2023).
Individual variability in how humans respond to stress and trauma depends on numerous genetic, developmental, cognitive, psychological, and neurobiological factors (Southwick and Charney 2012). An important role in overcoming the adverse effects of stressful situations is played by resilience, which is a dynamic and person-situation-defined process (Métais et al. 2022). Resilience is defined as the ability to adapt successfully to adversity, stressful life events, significant threats, or trauma (Feder et al. 2019). A core feature of resilience is the ability to confront diverse challenges and return to normal functioning (bounce back) once the situation has ended (Métais et al. 2022). In the resilience process, people use resources within themselves and in the environment by active outreach or support (Anjum et al. 2023). Resilience varies widely from person to person and depends on environmental as well as personal factors (Southwick and Charney 2012). People with high resilience levels who experience serious threats and crises have more positive mental health outcomes and are described as being more flexible and more adaptive upon responding to crises (Rutter 2006). Research has shown that people with higher mental resilience cope better with stressful situations and are less likely to develop mental disorders, while those with lower resilience are more likely to experience negative emotions, stress, and trauma (Su et al. 2023).
Protective factors of resilience include active coping, social support, habitual cognitive reappraisal, executive functions, and optimism, among others (Feder et al. 2019). Coping strategies are closely linked to resilience (Campbell-Sills et al. 2006). Coping is defined as a variety of cognitive and behavioral strategies individuals use to manage their stress (Folkman and Moskowitz 2004). The literature distinguishes between problem-focused coping (dealing with the source of stress), emotion-focused coping (handling thoughts and feelings associated with the stressor) (Folkman and Moskowitz 2004) and avoidance coping, which involves avoiding the stressor or one’s reaction to it (Snyder and Pulvers 2001). Avoidance strategies may reduce distress in the short term. They are conceptualized as being maladaptive if an individual persists on relying on them (Snyder and Pulvers 2001).
The aim of this study was to assess the role of psychological resilience and different coping strategies of Polish residents in the context of anxiety and depression triggered by the crisis situation of war in a neighboring country.
Material and methods
Study procedure
The study group and methodology are described in detail in another paper (Kasierska et al. 2023). Briefly, the study was conducted among Polish residents as a longitudinal online survey using Google Forms at three time points – in the first month of the conflict, after one month, and after six months of the conflict.
The study was approved by the Bioethics Committee of the Poznan University of Medical Sciences and was not classified as a medical experiment.
Participants
Seventy-two adults living in Wielkopolska Province were included in the survey: 12 men and 60 women. Fifty-five people were aged ≤ 39 years, 17 people > 39 years, 51 people had a university education, and the rest had no education or had primary or secondary education. Twenty-eight persons lived in rural areas or small towns, 44 in large cities. Thirty-five people were single, 37 in a relationship, 7 living alone, 65 with other people.
Research tools
Generalized Anxiety Disorder Questionnaire (GAD-7) (Spitzer et al. 2006) – a self-report scale used to assess the severity of anxiety and the risk of generalized anxiety disorder (GAD). The scale contains 7 items, and the scoring range is 0-21 points. Scores of 5, 10, and 15 are defined as cut-off values for the presence of mild, moderate, and severe intensity of anxiety, respectively.
Beck Depression Inventory (BDI) – a screening tool used to assess the presence and severity of depressive symptoms. It consists of 21 statements scored from 0 to 3 points. The following cut-off points are used: 0-9 no depression, 10-18 mild to moderate symptom severity, 19-29 moderate to severe, and 30-63 severe depression (Beck et al. 1988; Parnowski and Jernajczyk 1977).
State-Trait Anxiety Inventory (STAI X-1) – an instrument used to measure anxiety understood as a transient and situationally conditioned state of the individual. The X-1 inventory consists of 20 questions (Spielberger et al. 1970; Wrześniewski et al. 2011).
A survey questionnaire developed by the authors, including demographic data, questions on relationships with close people, diet, physical activity, sleep, history of psychiatric treatment, alcohol consumption, time spent by respondents watching the news and conducting conversations about Russia’s war with Ukraine, fear of an armed attack on Poland, impact of war on the sense of security and concerns about the deterioration of their financial situation due to war.
Mini-COPE – an abbreviated version of the Coping Orientations to Problems Experienced (COPE) questionnaire (Carver 1997; Carver et al. 1989). It includes 28 statements and allows identification of 14 coping orientations to stress and general strategies: problem-focused, emotion-focused, or avoidance-focused. Each statement is rated on a scale of 0-3, with higher scores indicating more frequent use of a particular coping strategy (Carver 1997; Cooper et al. 2008; Ogińska-Bulik and Juczyński 2009).
Resilience Measure Questionnaire (KOP-26) – a questionnaire assessing the construct of resilience, defined by personal, family, and social competence (Gąsior et al. 2016). It consists of 26 items allowing individual competencies and the overall resilience of the subject to be determined. For personal competence (PC), a score below 33 points indicates a low level of resilience, a score between 33 and 39 points is a medium level of resilience, and a score above 39 points indicates a high level of resilience. For family relationship (FR), a score below 44 points is a low level of resilience, 44-51 points is a medium level of resilience, and a score above 51 points indicates a high level of resilience. Social competence (SC) is low with a score below 18 points, medium between 18 and 22 points, and high with a score above 22 points. A score below 98 points is a low level of resilience, 98-109 points is a medium level of resilience, and more than 109 points indicates a high level of resilience (Gąsior et al. 2016).
Statistical analysis
Due to the non-normality of the distribution of some variables, confirmed by the Shapiro-Wilk test, statistical methods that do not require normality of distributions were used. The Kruskal-Wallis test was used to assess differences between groups at different time points, and Spearman’s rank correlation test was used to examine relationships between variables. Statistical significance was set at p < 0.05. The Statistica 10 PL package was used to perform the analyses.
Results
Severity of depression and anxiety symptoms in the study group in the first month, in the second month and after six months of the war in Ukraine
The severity of depression and anxiety symptoms is shown in Table 1.
The intensity of depressive symptoms increased nonsignificantly in the second month and significantly decreased thereafter. Symptoms of generalized anxiety disorder (GAD-7) were significantly lower in the second month of the war and after six months of the conflict than in the first survey. The intensity of state anxiety (STAI X-1) was significantly lower at the third time point as compared to the first two surveys.
Resilience (KOP-26) and coping with stress (Mini-COPE) in the first month, in the second month, and after six months of war in Ukraine
The results of the resilience and coping survey at each time point are shown in Table 2.
Respondents had an average level of resilience as measured by the KOP-26 questionnaire, and the competencies remained at a similar level across the survey points.
As time went on, respondents were more likely to use coping strategies such as active coping, positive reframing, humor, and general problem-focused strategies, and less likely to use self-blame strategies.
The relationship of resilience and coping strategies with symptoms of anxiety and depression
The relationship of resilience and coping strategies with mental health in the studied group is shown in Table 3.
Relationship of generalized anxiety symptoms with coping competencies and strategies
The intensity of generalized anxiety symptoms (GAD-7) decreased with higher social competence (KOP-26). It increased with the use of stress coping strategies (Mini-COPE) such as: distraction, denial, venting of emotions, behavioral disengagement, self-blame, avoidance strategies.
Relationship of depressive symptoms with coping strategies and resilience
The intensity of depressive symptoms (assessed using BDI) decreased with: higher social, personal, and family competence and general resilience (KOP-26); more frequent use of active coping strategies and positive reframing.
The intensity of depression increased with more frequent use of stress coping strategies (Mini-COPE), such as: denial, venting of emotions, behavioral disengagement, self-blame, avoidance strategies.
Relationship of resilience and coping strategies with symptoms of state anxiety
The state anxiety intensity (measured by STAI X1) decreased with: higher social and personal competence and general resilience (KOP-26); more frequent use of strategies of positive reframing.
The intensity of anxiety as a trait grew with increased use of stress coping strategies such as: distraction, denial, venting of emotions, behavioral disengagement, self-blame, avoidance strategies.
Discussion
Resilience in the context of mental health
The results of our study revealed a relationship between resilience and the severity of anxiety and depressive symptoms in the study group. This is consistent with the results of a study by Kask and Murnikov (2024) conducted among Estonian residents one month after the outbreak of war in Ukraine. They found that resilience was negatively correlated with perceived stress, post-traumatic stress disorder, depression, and anxiety. Our results are in line with data from the literature showing that resilience is important in coping with stress and can protect against negative emotional outcomes (Bonanno and Mancini 2008; Helmreich et al. 2017; Su et al. 2023). Mechanisms that contribute to resilience include better coping strategies, a larger social support network, and positive beliefs about one’s ability to manage difficulties (VanMeter and Cicchetti 2020).
Effective and ineffective coping strategies
Coping methods are the main factors that create resilience in war-affected people (Rizzi et al. 2023). In studies on the relationship between traumatic war events and psychiatric disorders, relatively little attention has been paid to coping strategies (Rizzi et al. 2023). Ours is among the few studies addressing the relevance of resilience and coping strategies to the mental health of people indirectly affected by war in Ukraine. In the Polish population, a study of coping strategies was conducted by Chudzicka-Czupała et al. (2023b), finding that avoidant coping strategies had a stronger association with psychological distress than problem- and emotion-focused strategies. The latter two categories of coping strategies had comparable associations with psychological distress among the people of Ukraine, Poland, and Taiwan.
In the literature, coping strategies are often divided into adaptive and maladaptive strategies (Carver et al. 1993). Eight scales (active coping, planning, use of emotional support, use of instrumental support, positive reframing, acceptance, religion, and humor) can be regarded as adaptive, whereas the remaining ones (venting, denial, behavioral disengagement, self-distraction, substance use, and self-blame) are presumably maladaptive (Carver et al. 1993; Meyer 2001).
Adaptive coping scales tend to be linked with desirable outcome, whereas maladaptive coping scales tend to be associated with undesirable outcomes (Meyer 2001).
In our study, the use of active coping was associated with lower severity of depressive symptoms and positive reframing with lower severity of depression and anxiety. Active coping strategies that focus on proactive action to reduce or eliminate stressors are positively associated with greater psychological well-being. According to Carver et al. (1989), problem-focused strategies, such as active coping, are effective, whereas avoidant strategies, such as denial or avoidance, provide only temporary relief. Positive reframing is the process of changing the perception of a situation by finding more adaptive aspects in it. Similarly, Crișan et al. (2023) found that positive reframing is the main coping strategy that predicted less anxiety and higher levels of well-being in Romanians indirectly affected by the war in Ukraine. There is scientific evidence that this strategy can positively affect psychological well-being (Stoeber and Janssen 2011) and reduce depressive symptoms (Lambert et al. 2012) and may be associated with post-traumatic growth (Munroe et al. 2022). Individuals who use positive reframing often experience fewer negative psychological outcomes resulting from difficult life situations (Calhoun and Tedeschi 2013).
In our study, avoidant coping strategies (self-distraction, denial, and behavioral disengagement) and two emotion-focused strategies (venting and self-blame) showed adverse effects on the severity of depression and anxiety symptoms. The use of behavioral disengagement and denial was associated with worsening of depressive and anxiety symptoms, while self-distraction was associated with worsening of anxiety symptoms (GAD-7 and STAI X-1). Venting and self-blame showed adverse effects on depression severity and anxiety severity (GAD-7 and STAI).
Our results are consistent with those of the study by Crișan et al. (2023), in which venting emotions and behavioral disengagement were the coping strategies that had the strongest negative impact on the anxiety and well-being of the Romanian population in the context of the war in Ukraine. Our results are also consistent with those of Aldao et al. (2010), who found that avoidant coping strategies may contribute to increased psychopathological symptoms, including anxiety and depression, by impeding effective emotional processing. Also, in our study the strategy of self-blame was associated with higher intensity of symptoms of anxiety and depression. Similarly, in a study of the relationship between stress coping strategies and depression in adolescents, behavioral disengagement and self-blame were associated with higher severity of depression (Horwitz et al. 2011).
Changes in applied strategies
In our study, we observed an improvement in the mental health of the study group in the six months following the outbreak of war – a significant reduction in the severity of depression and anxiety symptoms. These results correspond with those of Scharbert et al. (2024), where, in weeks after the outbreak of war, the subjects showed a trend towards recovery in their well-being. It can be hypothesized that, similar to the study by Scharbert et al. (2024), the reduction in depression and anxiety symptoms we observed is in line with set-point models of well-being (Diener et al. 2006), which assume that events both good and bad have an impact on well-being, but that people return to initial well-being after a short period of time; however, people differ in their adaptation to events, their set-points may change, and some people show no change in well-being in response to the event (Diener et al. 2006).
Over time, we have seen an increase in the use of the problem-focused strategy (higher order strategy) and its two constituent strategies – active coping and positive reframing. In a stressful situation, people usually use more than one coping strategy and change them when the ones used so far do not have the desired effect (Folkman 2013). Emotion-focused coping is often used initially, which may be highly effective at first (Breznitz 1983; Hobfoll et al. 1991), but in the next stage, problem-focused coping should dominate, and if this is delayed too long, problems can accumulate and escalate, making coping more difficult (Hobfoll et al. 1991).
An important result of our study is the observation of changes in the strategies used within the emotion-focused strategy. The use of this higher order category did not change over time, but the use of self-blame decreased and the use of humor increased. Both of them belong to the emotion-focused strategies.
Self-blame often leads to negative outcomes. People who respond to stress with self-blame feel responsible for everything bad that happens to them. Consequently, they feel that their actions may bring further problems for them and their loved ones and this prevents them from coping adequately (Hobfoll et al. 1991). In contrast, humor can provide emotional relief, enhance social connections, and foster resilience in the face of adversity (Rodrigues et al. 2023).
There is divergence in the literature as to the role of emotion-focused strategies. Some authors believe that the adaptiveness of individual strategies depends on the controllability of the situation. Problem-focused strategies are more adaptive in controllable situations, and emotion-focused strategies in uncontrollable ones, in situations which have to be accepted (Folkman and Moskowitz 2004). This approach emphasizes the ‘adjustment’ between the stressor and coping strategy used (Littleton et al. 2007). According to other researchers, emotion-focused strategies are less adaptive than problem-focused ones because the latter focus on actively addressing the problem (Masel et al. 1996). However, it is important to remember that the category of emotion-focused strategies includes diverse strategies – some of them encourage avoidance, whereas others encourage approach (Roth and Cohen 1986) – and these distinct aspects of emotion-focused coping are aggregated (Stanton et al. 2000). Thus, the effectiveness of emotion-focused coping depends on the particular form of emotion-focused strategy employed (Carver et al. 1989). The results of our study therefore confirm the need to assess a diverse range of coping strategies (Carver et al. 1993).
Observations of changes in the strategies used over time are consistent with data from the literature that indicate the dynamic nature of adaptation to stress: coping mechanisms can evolve and change their effectiveness depending on the duration and context of the stress. It is emphasized that the ability to flexibly adapt coping strategies in response to changing conditions may contribute to greater effectiveness in managing stressors (Penley et al. 2002). Coping strategies that are effective in one situation may not work in another (Blum et al. 2012). According to Blum et al. (2012), rather than assessing strategies as solely adaptive or maladaptive, it is important to look at them in a broader context: their effectiveness depends on a number of factors, such as the person’s individual needs and goals, or the timing of their use, which corresponds with the results of our study. In addition, it is worth considering using different techniques simultaneously, as combining several strategies can increase the chances of better coping with challenges.
Practical implications
The results of our study and those reported by other authors (Hobfoll et al. 1991; Scharbert et al. 2024) suggest that in a crisis situation some people will exhibit dysfunctional coping with stress. At the state or regional level, interventions can be carried out as psychoeducational messages broadcast by the media and disseminated through schools, community groups, the military, and support groups (Hobfoll et al. 1991). The content of these messages should include information about what reactions can be expected, and what are favorable and unfavorable ways of coping.
At the same time, the awareness of schools, support groups, psychologists, and primary health care workers should be increased in terms of identifying people showing excessive or prolonged reactions (Hobfoll et al. 1991; Hoffmann et al. 2024). It is also important to monitor the mental health of persons exposed to humanitarian crises so that the therapeutic intervention can be timely and appropriate. It is pointed out that support should be targeted primarily at those who are actually experiencing persistent difficulties or dysfunctions as a result of the trauma, as natural resilience processes often allow recovery without external intervention (Bonanno and Mancini 2008). This highlights the importance of accurate needs assessment and referral to appropriate forms of support. Further research should include work on identifying the best methods of resilience enhancement, which is an investment in mental health but also in overall quality of life.
The launch of telephone support, web-based interventions, and the provision of social support can be beneficial (Scharbert et al. 2024). Tailoring interventions to the needs of individuals is key. Individuals with exacerbated or prolonged symptoms of a depressive episode, PTSD, or other disorders require specialist therapy conducted by a psychiatrist and psychologist. Attempts to apply interventions designed for people with mild and transient disorders to them may be ineffective or detrimental (Litz 2008; Scharbert et al. 2024).
Limitations of the study
Our study is not free of limitations. These include the small size of the group, comprising residents of a single province, which limits the possibility of generalizing the results to a wider population. A study conducted online does not allow for the inclusion of less technologically advanced people. The role of the COVID-19 pandemic, which may have been a stressor affecting participants’ mental health, was not analyzed separately. A methodology that relies on the subjective assessment of participants may lead to measurement errors, especially in the context of assessing one’s resilience or the severity of psychopathological symptoms. Additionally, focusing on a 6-month perspective may not provide a complete picture of the long-term effects of an armed conflict on mental health.
Conclusions
Based on the study on the impact of the conflict in Ukraine on the mental health of Poles, we can draw several conclusions. The results indicate a protective effect of resilience against the occurrence of depressive and anxiety symptoms in the study subjects. The use of problem-focused coping strategies, such as active coping or positive reframing, was associated with lower intensity of depression and anxiety symptoms. In contrast, coping strategies focused on avoiding problems were associated with higher intensity of anxiety and depression. This highlights the need to promote adaptive coping approaches in crisis situations. Our observations indicate that coping strategies changed over time, suggesting that interventions should be adapted to different stages of the crisis, as intervention needs after several months of a crisis may differ from those in the initial phase. Our results indicate the need for insightful interpretation of individual strategies within the emotion-focused category. These strategies and their variability over time may be related to both adaptive and maladaptive responses to stress.
The results of our study can contribute to the development of health policies and intervention programs focused on strengthening mental resilience and promoting effective coping strategies during crises.
Disclosures
This research received no external funding.
The study was conducted in accordance with the Declaration of Helsinki, and approved by the Bioethics Committee of the Poznan University of Medical Sciences, and was not classified as a medical experiment.
The authors declare no conflict of interest.
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