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An interview with the head of a destroyed psychiatric facility in eastern Ukraine

Dr Yuriy Smal is the head of a major psychiatric centre that was bombed in the war.

The bombed-out psychiatric hospital in Sloviansk stands out like a scar, a bleak testimony to a war set against a slate sky. Eleven buildings that once housed a wide range of psychiatric patients now stand empty, their windows burnt out, their roofs collapsed.  Five years ago, fierce fighting ripped through this quiet community, forcing patients and medical staff to flee, dispersing them far across the region to safer wards. Explosive violence left destruction in its wake.

Almost overnight, Dr Yuriy Smal saw the labours of his life reduced to rubble. In 2014 –  when the conflict between the Ukrainian army and pro-Russian separatists was at its fiercest – he had been the head-doctor of this facility for thirty years. At 65, he was thinking of retiring.  He had 450 beds, 48 doctors, 180 nurses – some 480 staff in total. It was the biggest psychiatric hospital in the region and he had much to be proud off.

Today, he has had to take over a smaller building in the nearby city of Semenivka.  And while he retained his staffing levels, the number of his patients has dropped – today he only has space for 275 beds.  Some of the damaged buildings have been renovated, but three had to be totally demolished and the remaining are still under repair. In January, they hope to open the main hospital once again, but when he says that he doesn’t look optimistic.

His patients before the war had mental health issues that you might expect from a large psychiatric unit: mood disorders (such as depression or bipolar disorder); anxiety disorders; personality disorders; psychotic disorders (such as schizophrenia); eating disorders; and substance abuse disorders.  Now, though, a large portion of his work involves treating those with trauma-related disorders, especially post-traumatic stress (PTSD).  And while he personally has not done research into the prevalence of PTSD in his region, such a shift in focus comes as little surprise.

Dr Yuriy Smal is the head of a major psychiatric centre that was bombed in the war.

In the conflict-affected areas of Ukraine, 40% are said to have experienced stress, depression, anxiety, and PTSD. Among Ukraine’s IDPs, 20% are thought to suffer with moderately severe to severe anxiety, compared to 12% of Ukraine’s general population. Reportedly, 25% of IDPs suffer with moderately severe to severe depression, compared with 15% of the general population.

Perhaps of most concern, only 23% of IDPs suffering anxiety or depression are said to have received professional help. Here, in Sloviansk, they place people with PTSD away from the other patients, as these have special needs. But even Dr Smal acknowledges it might be the tip of an iceberg.

These new challenges have not come with extra funding. In total, the running costs of the hospital are about 70 million UAH a year, or $2.8 million USD.  Their budgets were not increased to cater for the impact of the war, he claims, though he was given more funding from the regional budget for construction and repair.  In addition, they have had funding from the ICRC and the German government. With such help, they hope to return to their old, now repaired hospital, in two to three years, but the war has strained much.

There have been other costs, of course.  Some doctors left and never returned.  Training for existing doctors was disrupted. Patients suffered in terrible and often hidden ways. But the aid they have been given from overseas has helped alleviate some of the burdens.  He has had paid training trips to Germany and Lithuania and, most helpfully, to Israel.  There the government helped him and his team learn how to address widespread civilian PTSD, born from their own citizens’ controversial conflict.  23 psychiatrists were trained in identifying and treating PTSD in this way, up to what he describes as ‘European standards.’

“Such training has helped our doctors change their approach and mentality,” he says, “training abroad has opened their eyes to EU standards of care.  We have begun to make interventions into the community, which means our trauma-affected patients don’t always have to be admitted to hospital long-term.  They can be treated at home with both medical and talking therapy.”

Today, the mobile mental health teams that they run are based on the same model as the Israeli governments’. The approach to treating those suffering from such trauma has changed accordingly.  Fifty years ago, when he was learning to be a psychiatrist, there was a pharmacological-centric approach towards mental health treatment.  Now they aim for both a psychotherapeutic and social rehabilitative approach, with units comprised of nurses, psychologists, social workers and rehabilitation specialists.  It is a radical shift, he says. And even though pharmacological interventions are still deployed, it is often just a first-line offering that is then backed up by a more holistic approach, in line with EU rules and guidelines.

He is keen to stress how Ukraine has such standards, and there is a sense, perhaps, that the proxy war with Russia has turned him more towards the West for medical inspiration.  After all, his life’s work was – as he himself says – reduced to rubble by Russian weapon systems.

“How much energy has been expended on that war?” he asks.  “How much has been lost?” He pauses. Does he himself suffer from PTSD?

“Of course,” he replies. “When your life’s work is destroyed, it goes deep.”