INTRODUCTION
Poland has grappled with a significant refugee crisis, sparked by the commencement of military operations in Ukraine in 2022. With millions of individuals uprooted from their homes, the quest for safety became paramount. Since the onset of the conflict, Krakow has been at the forefront of assistance provision to refugees. The report “Urban Hospitality: Unprecedented Growth, Challenges, and Opportunities – Assessing Ukrainian Refugee Dynamics in Major Polish Cities” highlights that in April 2022, Krakow’s population surged from 779,966 to 957,531, with 19% comprised of individuals from Ukraine. Also, Krakow shares a strong bond with the Ukrainian cities, especially with Lviv, marked by a longstanding partnership dating back to 1992. This collaboration was formalized through an agreement inked on October 23, 1995, ensuring joint efforts across multiple spheres including culture, support for Polish communities in Ukraine, healthcare, promotion, economic ties, and public administration. The enduring connection with Lviv is bolstered by factors like geographical proximity, historical affinities, and the strategic importance derived from the Eastern Partnership initiative [1-3].
Literature data suggest that a crisis akin to the emergence or exacerbation of psychopathological symptoms occurs among refugees [4]. Consequently, with the onset of the crisis and the influx of Ukrainian refugees, the imperative to provide psychiatric and psychotherapeutic support became evident from day one.
Considering the harrowing realities of war, it is imperative to acknowledge the profound trauma endured by individuals. Post-traumatic stress disorder (PTSD) and acute stress reaction (ASR) are pivotal issues that demand attention in this context. Experiencing the consequences of warfare often triggers mental distress, with PTSD being the prevalent outcome. Many people commonly associate PTSD symptoms with a condition experienced by soldiers. However, literature data reveals a broader scope of its impact. For instance, among over 100 Gaza children surveyed, aged between 11 and 17, 53.5% exhibited symptoms of PTSD. Notably, risk factors extend beyond war-related trauma to include heightened incidents of violence within domestic, school and peer environments [5]. PTSD stems from profound traumatic events like violence or sudden bereavement, leading to symptoms such as recurrent memories, flashbacks, and avoidance behaviors. Physiological reactions like increased heart rate and gastrointestinal issues may also occur, alongside distorted self-perception and guilt. In children, symptom manifestation varies, potentially affecting cognitive and language development [6]. After years of extensive research, the diagnosis of this disorder has been refined, leading to the establishment of multiple diagnostic guidelines. Among the most widely used are those based on ICD-11 and DSM-5. Notably, according to the DSM-5 and ICD-11, these guidelines underscore the significance of evaluating exposure to traumatic events and their duration, thereby differentiating PTSD from other disorders that may share similar symptoms. Furthermore, the ICD-11 introduces the concept of Complex PTSD, which encompasses symptoms characteristic of PTSD alongside disturbances in self-organization. While recent studies have advanced the understanding of PTSD’s etiology, further research is required. For some individuals, exposure to wartime experiences may provoke such symptoms, for others, it could stem from feelings of profound shame and guilt. The precise mechanisms underlying the development of PTSD are still incompletely understood. Emerging research indicates that both the neuroendocrine and immune systems play integral roles in the initiation and progression of PTSD [7, 8].
ASR may also emerge in response to intense trauma, presenting symptoms similar to PTSD but manifesting immediately and lasting up to one month. Symptoms include intrusive thoughts, flashbacks, and heightened arousal. Diagnosis involves exhibiting specific symptoms across categories like intrusion and dissociation, necessitating timely intervention like cognitive-behavioral therapy to prevent the development of chronic PTSD [9].
It is essential to recognize that the experience of being a refugee can impact not only PTSD but also another mental disease i.e. depression, anxiety, and psychosis. Additionally, it exacerbates existing mental health conditions and the severity of their symptoms. In summary, this presents a multifaceted challenge of assisting individuals who cope with the aftermath of war trauma alongside those who attempt to manage their pre-existing mental disorders, potentially facing additional stressors due to their refugee status [4, 10, 11].
Shortly after the war crisis erupted, a dedicated team of 9 members was assembled at the clinic. The volunteers were fluent in Ukrainian and Russian, some of them hailing from Ukraine and Belarus. Among them were specialists in psychiatry, child and adolescent psychiatry and also residents. Addressing the mental health needs of the displaced emerged as crucial amidst this crisis. A designated phone line was established for the team.
The team at the Department of Adult, Child and Adolescent Psychiatry has encountered significant challenges in providing free of charge psychiatric care to refugees from Ukraine. Information regarding the clinic’s activities was disseminated through the university hospital’s website and shared with teams of medical volunteers and psychologists engaged in refugee assistance efforts. Teenage migrants have distinct healthcare requirements and are often susceptible to healthcare disparities arising from various factors, including language and cultural barriers or limited awareness of available educational and vocational support. It is crucial for healthcare providers to understand the medical procedures for this population [12]. The Department of Adult, Child and Adolescent Psychiatry in Krakow remains actively engaged in offering essential diagnostics and psychiatric care to Ukrainian refugees.
The study aimed to consolidate the efforts of our crisis center at the University Hospital’s Department of Adult, Child, and Adolescent Psychiatry in Krakow. The research emphasized disease presentation, age demographics among our patients and evaluated the center’s effectiveness in managing language and cultural barriers. Additionally, we sought to present refugees mental health care practices in other countries, to identify systemic challenges and opportunities for improvement within the Polish healthcare context. Considering Europe’s reemergence into military conflict, enhancing our understanding of this realm could prove invaluable for the foreseeable future.
METHODS
The research has examined the operations of the refugee crisis center, which was an integral part of the Clinical Department of Psychiatry for Adults, Children and Adolescents at the University Hospital in Krakow. The study presents medical data from all patients seeking specialized care at refugee crisis center (107 visits). Each patient was diagnosed by a psychiatrist in a standardized interview, medical examination, and review of medical records, based on ICD-10 classification. Visits were conducted individually for adults, while for children and adolescents, a legal guardian was present. Additionally, with the guardian’s consent, the visits with younger patients were also held individually. All data was gathered and recorded in the Hospital Information System routinely employed at the University Hospital in Krakow. The majority of interactions proceeded smoothly in Ukrainian or Russian, with only one doctor requiring translation assistance. This effective communication was facilitated by the diverse linguistic backgrounds of the clinic’s staff, who hailed from Ukraine, Belarus, and the regions bordering Poland and Ukraine. Additionally, some staff members had received their education in Ukraine, which helped with the provision of linguistic assistance. Initially, there were concerns that the use of Russian might trigger negative associations with the language of the invaders. However, our observations was that it did not cause additional retraumatization. Instead, it became apparent that for many refugees, linguistic identity coexisted comfortably with their sense of belonging to the Ukrainian nation. The crisis center was staffed by six adult psychiatrists, child and adolescent psychiatrists, and psychiatry residents proficient in Ukrainian and Russian. Three team members were also qualified in psychology or psychotherapy. Notably, two team members came from conflict- affected regions, providing a unique perspective that facilitated connections with refugees but also introduced additional stress for the doctors involved. What’s more, at the onset of the crisis, the clinic staff faced an unexpected situation. While locating a doctor or psychologist proficient in Ukrainian or Russian posed little difficulty, finding someone to manage patient registration and initial medical document reviews proved to be problematic. Consequently, doctors found themselves juggling multiple responsibilities, leaving them with additional non-medical challenges and tasks that added considerable strain to their workload.
The outpatient clinic operated from the onset of the war until June 2022, after which care transitioned to regularly operating structures. Despite this transition, team members continued to encounter refugees with limited knowledge of the Polish language. Early in the conflict, we forged a partnership with Prof. Nathaniel Laor’s team from the Cohen and Harris Resilience Center in Tel Aviv, Israel, who provided multifaceted support for addressing war trauma and its prevention. Prof. Laor and his team offered direct training sessions in Krakow within the conflict’s first months. Additionally, we received assistance from the psychiatrists affiliated with “The Children and War Foundation”.
Our staff also collaborated with another team from the Jagiellonian University Medical College, which together with Doctors Charity Center Foundation created Emergency Response Teams with a primary focus on somatic diseases as part of the Doctors Ukraine project [13]. Their primary objective was to provide essential medical assistance, including consultations and medications as required.
Throughout the provision of assistance, no formal scientific research was conducted and contact with refugees in need of psychiatric care occurred on an ad hoc basis. This research is drawn from the data obtained from general medical documents.
RESULTS
The infirmary has held a total of 107 visits, 83 with females aged 8 to 75 years old and 24 with males aged 2.5 to 65 years old. The median age for females was 33.4 ± 17.7 years, whereas for males it was 15.3 ± 18 years. The visits mostly took place at the crisis center within the University Hospital’s Psychiatric Clinic for Adults, Children and Adolescents in Krakow. Psychiatrists also made several visits to refugee centers to provide psychiatric care. Among female patients, the most common diagnosis was acute stress reaction, affecting 45.45% of cases, followed by autism spectrum disorder and depressive disorders, each accounting for 14.29% of cases. Anxiety disorders and paranoid schizophrenia were also diagnosed, with each making up for 10.39% of all diagnoses. For male patients, the distribution was slightly different, with acute stress reaction and autism spectrum disorder being equally common – each present in 35% of cases. Attention deficit hyperactivity disorder (ADHD) was the next most frequent diagnosis, affecting 20% of male patients, and depressive disorder followed at 15%, while still fewer refugees were diagnosed with mental retardation (10%) and paranoid schizophrenia (5%). While acute stress reaction was a leading diagnosis in both groups, notable differences were found in the prevalence of other conditions between male and female patients. The differences in the prevalence of neurodevelopmental disorder observed in our study aligned with the findings reported in the literature [14, 15]. The characteristics of patients are presented in Tables 1 and 2.
Table 1
Female patients characteristics (n = 83)
Table 2
Male patients characteristics (n = 24)
The largest group of patients at the crisis center comprised teenagers and adults who were refugees and had previously received psychiatric treatment. The main complaints included suicidal ideation, sleep disorders, and self-mutilation, particularly prevalent among adolescents and patients with psychotic disorders. Most psychotic themes centered around war and its aftermath. Some symptoms arose back in Ukraine, when families had to take refuge in basements for safety, while others emerged during the journey that was often long and arduous. Moreover, the overwhelming information about casualties and destruction induced chronic stress, potentially triggering the onset or exacerbation of mental disorders. Many people were caught off guard by the sudden onset of war and were unprepared to cope with it. Many concerns expressed by patients during interviews with examining psychiatrists revolved around their future and the future of their families, as well as worrying about those left behind in Ukraine and the future of the country affected by the conflict. It is noteworthy that the military conflict also resurfaced other traumatic experiences, such as domestic violence or other traumas. Many patients sought guidance on discussing the war or the loss of loved ones with their children. They recounted the terrifying experiences of the war’s onset, including the fear induced by falling bombs and the sound of approaching planes, which instilled a pervasive sense of danger. It is crucial to stress that in such circumstances, people often struggle to establish clear causal relationships and are burdened by feelings of guilt, particularly in cases where the loved ones, including parents or children, perished. It was observed that loud sounds, especially for children, triggered aggressive or self-destructive behaviors, such as fighting. Additionally, some individuals have developed symptoms of depression, including sadness, apathy, or social withdrawal. Another challenging and traumatic aspect of their experience was the stay in refugee centers, where the deterioration of mental health was notable.
We found that we were unprepared for the variety of patients seeking our assistance. While we expected to work primarily with individuals who experienced the conditions mentioned in the previous sections, our main tasks involved answering phones, registering patients, helping referrals to refugee support services, explaining the workings of the Polish healthcare system, extending prescriptions for people on long-term medication, and issuing medical certificates for various purposes, such as disability assessments and disability pension applications to the Social Insurance Institution, detailing health status and medication regimens.
DISCUSSION
Since the 1960s, the Clinical Department of Adult, Child and Adolescent Psychiatry in Krakow has not addressed war trauma. Our prior post-war trauma research experience focused on examining approaches and publications. The early 1950s research concentrated on former concentration camp inmates (KZ syndrome). Led by Prof. Antoni Kępiński, the clinic extensively studied the disease, yielding insights into psychopathology, reaction dynamics, post-camp adaptation, hypermnesia, and somatic changes. This research influenced PTSD classification and ethical patient treatment [16]. Additionally, another research in our clinic, i.e., “Holocaust Narratives – Between Impossibility and Obligation” involved transgenerational trauma in families of former camp inmates [17].
For several decades since World War II, the clinic has not been in direct contact with war victims, which left us unprepared. This may suggest a denial of risk of war, even though the current conflict has persisted since 2014, with Poland being a frontline country for almost a decade. Due to its geographical position, Poland found itself among the first countries forced to cope with the challenges posed by the refugee crisis. Complicating matters further was Poland’s lack of prior experience in dealing with such circumstances at a state level. As a result, certain measures were adopted based on strategies employed in other countries, while some challenges were addressed through intuitive, ad hoc problem-solving methods.
Professor Laor’s established intervention model proved unfeasible in our refugee crisis center, primarily due to challenges in engaging the state not only in aiding refugees but also in preparing Polish citizens, including both children and adults, for similar crises. It should be mentioned that just as we were not ready for addressing the refugee crisis, we are also unprepared for the potential trauma for Polish population. However, a solution developed in Israel is readily available and applicable. Prioritizing resilience and coping strategies for challenging circumstances should be among the core subjects taught in Polish schools [18].
Since the beginning of conflict, it became apparent that the number of people seeking help in the clinic exceeded initial expectations. In our clinical practice, we have observed that Ukrainian children with special needs, especially those with autism spectrum disorders, often required psychiatric consultations upon arriving in Poland. However, navigating Poland’s educational and legal systems posed challenges in accessing appropriate support. It was also noticed that children with autism spectrum disorders were particularly vulnerable to secondary traumatization and PTSD symptoms due to displacement, reacting strongly to changes in their environment and routines. Individuals with autism spectrum disorder may construe a range of stressful situations, such as intense sensory stimuli or disruptions to routine, as traumatic. The unique sensory, perceptual, social, and cognitive characteristics of patients with autism spectrum disorder may affect their perception of events as traumatic. Integrating PTSD diagnosis and therapy into their care is important yet challenging [19]. Similarly, a review exploring trauma and PTSD among adults with intellectual impairments highlighted the challenge of distinguishing between stressful life events and traumatic ones. It advocated for expanding the examination of various events and experiences that could potentially be perceived as traumatic. It is crucial to acknowledge that some individuals may perceive trauma or stressors differently from the society at large [20].
Eventually, it took us some time to comprehend the reasons why trauma victims reported fewer cases than anticipated. Notably, the number of Ukrainian teenagers with anxiety, depression, or PTSD symptoms seeking psychiatric help was low. It was essential to understand whether this was due to gaps in the support system or reluctance from their families to seek help. Finally, we concluded that this discrepancy likely stemmed from a broader societal perception of psychiatric care and the associated stigma surrounding mental health disorders, leading to underreporting to psychiatric facilities. Despite recognizing the need for a more proactive approach in reaching out to those in need, our capacity to implement such a system has been stretched, and has to be yet integrated into the systemic solutions. Subsequent experiences, including those of Maciej Pilecki MD PhD, who supervised psychological support in one of the refugee centers, highlighted that the issue extended beyond mere distrust of psychiatrists and involved the fundamental reluctance to engage with mental health matters. The most effective model identified was one where psychologists built trust through regular interactions with children and adults, facilitating referrals for specialized care during informal conversations. It was also observed that significant number of refugee children are currently outside of the Polish education system, instead participating in remote learning programs based in Ukraine. Consequently, Polish services are unaware of their educational needs and challenges. All of this highlights the need for improved accessibility and awareness of mental health services for Ukrainian refugees in Poland.
In addition to these foreseeable challenges, we encountered various barriers, characterized by the use of medications not applied in Poland, such as CDP – choline and glycine, Noobut – phenibut-phenolic derivative of GABA, Pantogam – hopantenic acid, Ceraxon – citicoline, nootropic effect, Nota – homeopathic medicine, Tenoten – homeopathic with sedative effect, Cogitum – acetylaminosuccinic acid, Gidazepam – benzodiazepine, Fluphenazine or Perphenazine – antipsychotic medications. Also, in case of medications applied in Poland but under different trade name, including Monsetin – atomoxetine, Truxal – chlorprothixenum, Eridon – risperidon. Clozapine, while used in Poland, was found to be applied differently and administered in small doses for treating insomnia, without blood morphology testing.
Considering all these challenges, preparing for refugee crisis should be integrated into civil protection strategies. This includes essential specialized training in trauma- informed care and crisis intervention for medical personnel. Additionally, collaboration between mental health services and educational and legal systems is crucial to support young refugees with special needs. Public awareness campaigns should promote resilience and our understanding of refugee mental health challenges, while adopting proven models from other countries that could strengthen our approach. Finally, a centralized database for refugee mental health data would improve care coordination and enable informed policy-making for future crises.
In order to compare various experiences, we collected insights from other countries in receiving refugees, allowing us to explore and discuss different challenges and needs, as outlined below.
The approach of German mental health personnel stands out for their empathetic understanding of the needs and concerns of refugees. Following UNHCR guidelines (United Nations High Commissioner for Refugees), a qualitative study was undertaken to delve into the specific psychosocial needs of Syrian refugees in Germany. The psychological disorders, needs, and concerns reported strongly mirrored those observed among Ukrainian patients by our team. Syrian refugees exhibited symptoms suggestive of PTSD, depression, and schizophrenia. Many described persistently visualizing their homeland in their minds, accompanied by a profound sense of despair. Essential requirements for refugees included access to language courses, securing a residence permit, and safeguarding against experiences of racism [21]. Tailored interventions addressing both children’s and parents’ mental health needs are vital for refugee families, combining trauma-focused interventions for children and family-based approaches to alleviate parental stress and improve children’s well- being [22].
Within the realm of refugee mental health literature, the language barrier emerges as a prominent challenge. This difficulty was also highlighted in the study conducted in the United Kingdom. According to research conducted by Teresa Polland and Natasha Howard, for individuals in need of assistance to access it effectively, they must possess adequate language resources, either through proficiency in a foreign language or by having access to an interpreter. However, it is essential to acknowledge that the presence of a third party during medical appointment can impede the complete transfer of crucial information to the doctor. Therefore, for solutions to the language barrier to be meaningful, refugees must trust their interpreters. Another obstacle that arises is the lack of training for medical staff in conducting visits with an interpreter, particularly crucial in the context of psychiatric treatment. It is imperative to underscore the necessity for establishing a relationship of trust and mutual respect among healthcare professionals, interpreters, and patients to navigate these challenges effectively [23]. According to Paudyal et al. study [24], it is important to highlight the ongoing struggles faced by refugees as they adapt to a new society. Loss of loved ones and longing for their homeland contribute to psychological distress, compounded by difficulties in forming connections due to cultural differences and transient migrant communities. Many turn to self-care methods like faith and nature for comfort, while stigma around mental health and language barriers limit access to the necessary services.
The article “Mental Health Services for Syrian Refugees in Lebanon: Perceptions and Experiences of Professionals and Refugees” provides valuable insights into the complexities of refugee life and the provision of psychological support. The authors discuss several key themes, notably the cultural barriers that hinder mental health care provision for Syrian refugees. Professionals underscored the importance of addressing these cultural differences through awareness sessions and education initiatives. Also, establishing trust with refugees emerged as a crucial aspect, given apprehensions regarding potential deception and manipulation. Environmental stressors, such as inadequate housing and unemployment, were also reported as prominent concerns among refugees. Discrimination from the host community and fear of arrest added to their distress. Refugees described employing adaptive strategies, such as altering their appearance and behavior, to navigate the challenges they faced. Interestingly, discussions often shifted towards concerns about interaction with humanitarian agencies, overshadowing conversations about mental health support [25].
LIMITATIONS
Our study provides valuable insights into the mental health needs and challenges faced by refugees and medical staff. However, it is essential to acknowledge the limitations inherent in our research. Firstly, it was conducted as single center research. That is why, our findings may not have fully captured the diverse range of needs experienced by all refugees, as they were based on the experiences of individuals who sought assistance at our crisis center. This excluded those who did not seek help, potentially due to severe mental health deterioration or the stigma associated with psychiatric disorders.
Furthermore, the retrospective nature of our study necessitates careful interpretation of the results, as they reflect past experiences and may not fully represent the current situation. Also, during the psychiatric examination, we did not utilize any diagnostic tools, as our primary focus was on providing immediate medical help. At that time, such tools either were not available in Ukrainian or we had yet to identify their source.
CONCLUSIONS
The research sheds light on the urgent need for mental health support for refugees, not only those affected by war trauma. The influx of Ukrainian refugees into Krakow highlighted the significant challenges faced by healthcare providers in addressing the complex mental health needs of the displaced individuals.
The public institution faced significant challenges in adapting to the critical situation, such as establishing separate queuing and registration processes tailored for refugees, including independent registration in Ukrainian. The incoming calls were not limited to psychiatric assistance requests, many sought general healthcare support. Preparation for a refugee crisis should be integrated into civil protection strategies to mitigate potential challenges. As conflicts persist globally, this study provides invaluable lessons for enhancing mental health interventions and support systems for refugees worldwide.
