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Texas Standard

Feature: War takes a toll on mental health, but getting psychiatric medications to conflict zones is a work in progress

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Illustration by Wells Dunbar
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Texas Standard

When pharmacies closed early on in the war in Ukraine, aid groups had to navigate local norms and laws to deliver crucial medicine.

From Texas Standard:

When Russia invaded Ukraine, the international humanitarian group Doctors Without Borders sent an alert to donors. It called the war a “humanitarian race against time.” And workers on the ground at the time described a dire situation.

The group needed money to ramp up its emergency response. That included training hospital staff to handle mass casualties, as well as delivering medical supplies and medicines. But it wasn’t clear how the organization was caring for people with mental health issues.

Were people with bipolar disorder, depression or schizophrenia getting the medication they needed? That matters because psychiatric drugs change the way the brain works. Some drugs can cause serious withdrawal symptoms if a person stops taking them abruptly. This can even be life-threatening. For example, suicidal thoughts could return. Or someone experiencing psychosis may not understand an armed soldier’s instructions.

Natalie Roberts
Remi Decoster
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For MSF
Dr. Natalie Roberts.

Dr. Natalie Roberts, the director of studies at Doctors Without Borders in France – known internationally as Médecins Sans Frontières, or MSF – says people who go without needed medication can go into into catatonic states or become “floridly, psychotically unwell,” making it hard for them to be stabilized by health care workers.

But psychiatric care hasn’t always been seen as essential during humanitarian crises. Back in 1990, the World Health Organization and other groups developed Interagency Emergency Health Kits containing essential medicines and supplies. But only recently did the kit begin to include psychiatric medication. Roberts says adding them has been a game-changer.

“I’ve been working for MSF for 10 years, and the first place I went to was the Philippines. I used the health kits; they had no psychiatric medicines in them. It’s only really [been] in the last few years,” she said about the medications being available.

The drugs in the kit are the basics – ones that stabilize people experiencing severe anxiety, depression or psychosis.

But getting the kits to people living in a war zone can be challenge.

Since the war in Ukraine started, MSF has been shipping its kits there, but the psychiatric medications had to be shipped separately. Roberts says Ukraine still has a highly centralized, Soviet-era health care system that scrutinizes the use of psychiatric drugs. Mental health disorders are also stigmatized, and community mental health care isn’t common. Instead, only people with the most severe conditions get treatment, and it’s usually in the hospital.

And despite MSF’s best efforts, Roberts still worries about the people the group hasn’t been able to reach, especially those in Kharkiv, where she worked.

“Kharkiv is a very difficult place to work because we can only work in areas like the metro stations, which is seen as safe,” she said. “And so there’s some people we know … that are probably stuck in their apartments or stuck in these institutions, these nursing homes for people with psychiatric illness or disabled people, elderly people, some of those we can’t access because they’re just in very, very dangerous locations.”

Emergency mental health aid isn’t a one-size-fits-all situation. Roberts has worked in Yemen, Pakistan and Syria, and each location has required aid groups to adjust their approach.

The Syrian American Medical Society took a piecemeal approach to getting psychiatric drugs to Syrian refugees and people living in Syria, where war has been raging for over 11 years. The group bought drugs from Turkey, Lebanon and Jordan – whatever it could manage. But Mohammad Hamza, a Texas-based psychologist who used to work with the group, says getting the drugs was often prohibitively expensive.  

“If you buy a month’s supply of Zoloft or Abilify … in the United States, it will cost you 12 or 15 bucks a month. Over there, it’s about 50 to 100 Dinars, which is close to $100- $140, multiplied by the thousands that we are putting on medication,” he said.

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Courtesy Kaleemullah Ghazi
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Kaleemullah Ghazi, who worked for the U.S. government in Afghanistan, says many people in his home country live with “mental issues” because of war trauma.

Kaleemullah Ghazi says that ever since the United States pulled out of his home country of Afghanistan, people are just trying to survive. Mental health care isn’t even on most peoples’ radars. But he says that doesn’t mean that their mental health hasn’t suffered. Ghazi worked with the U.S. government in Afghanistan and recently resettled in Austin. He said, at a recent Ramadan event, that he believes every single person in Afghanistan has what he called “mental issues.”

“Because of the the bomb blasting, because of the suicide attackers, because of the targeted killings and all these incidents, which was everyday happening in Afghanistan,” Ghazi said.

In places where war is normal and mental health disorders are stigmatized, Dr. Roberts with Doctors Without Borders says her approach is to work within the local norms.

“You can’t just come in and start throwing psychiatric drugs around willy nilly, because that’s not really how it’s happened before,” she said.

When she worked in Syria, her organization didn’t have a separate psychiatric clinic, so she incorporated psychiatric care during visits for other medical conditions.

“We had people who suffered from extreme injuries, amputations and other things like that,” she said. “And … we would always make sure that we had, at the very least, a psychologist available and the possibility to prescribe psychiatric medicines for people who who did require them.”

MSF Mobile Clinics in Kharkiv Metro
Adrienne Surprenant/MYOP
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For MSF
Elena, 35 years old, and her son Kirill, 6 years old, wait to see a Doctors Without Borders doctor in Kharkiv, Ukraine, on April 11, 2022. She was living near the metro station where she took refuge with her son, husband, mother and stepfather on the first day of the war.

Back in Ukraine, where most of the Western world is focused right now, a war is still raging. And Ukrainians will need solutions beyond emergency aid for mental health as the war goes on. Roberts says she wants Doctors Without Borders to move toward a humanitarian aid model that plans for the long term.

But until then, some Ukrainians are trying to fill the gap. One of them is Liki24, an online prescription delivery service that’s been helping Ukrainians locate hard-to-find medications since the war started. Early on in the war when most deliveries had stopped, it created a map of every open pharmacy in the country. Mykola Solomiichuk, Liki24’s chief financial officer, says almost 2 million Ukrainians have used the map.

“We updated this map every day and it helps to go up, to find open pharmacy nearby and go there to buy something that they have,” he said. “Nobody delivers and drives in that moment; it was super critical.”

Solomiichuk says Liki24 moved its headquarters to western Ukraine, farther from the front line, and has resumed deliveries. Prescription shipments that took five to seven days earlier in the war now take two to three days.

The war effort has even motivated Liki24 to expand its business. Solomiichuk says the company is creating a separate nonprofit organization to help Ukrainians access free humanitarian medicine.

“Our platform has huge coverage of people here, and we can efficiently distribute this medication to the people,” he said.

He believes Ukraine will win the war, and giving people the ability to take care of their health will help its cause.

“We want Ukraine to survive, and to help people as we can,” he said.

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