International Journal of Environmental Research and Public Health Article Current War in Ukraine: Lessons from the Impact of War on Combatants’ Mental Health during the Last Decade Andriy Haydabrus 1, * , Mikel Santana-Santana 2,3 , Yuriy Lazarenko 4 and Lydia Giménez-Llort 2,3, * 1 Department of Neurology, Psychiatry, Narcology and Medical Psychology, School of Medicine, V.N. Karazin Kharkiv National University, 61022 Kharkiv, Ukraine 2 Department of Psychiatry and Forensic Medicine, School of Medicine, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain 3 Institut de Neurociències, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain 4 Military Medical Clinical Center of the Northern Region, 61000 Kharkiv, Ukraine * Correspondence: kpdkharkiv@gmail.com (A.H.); lidia.gimenez@uab.cat (L.G.-L.) Abstract: Ukrainian Military Hospital retrospective analysis during a decade of conflicts (3995 records) unveils specific mental health ICD-10-CM distribution per rank and the long-lasting impact of active conflict or trench warfare. Most hospitalizations in all years of observation were among soldiers. Anxiety-related disorders have been present since ‘peacetime’, mainly among professional soldiers and high ranks, pointing to the need for rank-tailored psychological training in skills to reduce the anxiety burden. High frequency of psychoactive substance use emerged with acute conflicts and in nonprofessional soldiers during wartime. This dictates the need to strengthen the selection of military personnel, considering the tendency to addiction. Military operations multiply the hospitalizations in psychiatric hospitals. The data warn about a ‘need for free beds effect’, which is worse for soldiers. This is relevant to estimating and planning the need for hospital resources for the current situation Citation: Haydabrus, A.; where the general population has been recruited for defense. In the current war, tightening the rules of Santana-Santana, M.; Lazarenko, Y.; sobriety in units and up to a ban on the sale of alcoholic beverages in areas where hostilities are taking Giménez-Llort, L. Current War in place is recommended. The specific impact on nonprofessional soldiers is relevant to the current war, Ukraine: Lessons from the Impact of with the general population of Ukraine recruited for defense and combat. War on Combatants’ Mental Health during the Last Decade. Int. J. Keywords: mental health; war; stress; Ukraine; soldiers; ICD-10; anxiety; psychoactive drug use; Environ. Res. Public Health 2022, 19, military rank 10536. https://doi.org/10.3390/ ijerph191710536 Academic Editor: Paul B. Tchounwou 1. Introduction Received: 6 July 2022 Accepted: 22 August 2022 Since 24 February 2022, the Russian war in Ukraine has become the most critical Published: 24 August 2022 international geopolitical crisis, with high human costs, including civilian casualties, mass migration, and ripple effects having a global impact [1–6]. However, the threat and preser- Publisher’s Note: MDPI stays neutral vation of the territorial integrity of Ukraine are not new issues. During the last decade, with regard to jurisdictional claims in peacetime (Peace, until 2013) was disrupted by active hostility (AH, 2014–2015) and trench published maps and institutional affil- warfare (TW, 2016–2021) [1]. iations. War and/or severe armed conflicts exert acute and chronic impacts on mental health, but they are challenging to measure during battle [1,7,8]. In the current scenario, the war may be a substrate for mental health disorders, especially worrisome since, today, the Copyright: © 2022 by the authors. large-scale conflict has demanded the recruitment of adult civilians to defend and fight Licensee MDPI, Basel, Switzerland. alongside armed forces troops. One of the first studies just reported the impact of the war This article is an open access article on the mental and emotional well-being of Ukrainian civilians—university students and distributed under the terms and personnel of four heavily bombed universities [9]. Active hostility exerts a severe impact conditions of the Creative Commons not just on the population of sides of the conflict. A wave of mental health consequences Attribution (CC BY) license (https:// of the current Russian war in Ukraine in non-directly exposed populations has also been creativecommons.org/licenses/by/ reported in other countries [10,11]. 4.0/). Int. J. Environ. Res. Public Health 2022, 19, 10536. https://doi.org/10.3390/ijerph191710536 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2022, 19, 10536 2 of 9 This communication presents a retrospective cross-sectional analysis of 3995 admis- sions and mental health reports ([variables: military rank, days of hospitalization, and mental health disorders according to ICD-10-CM [12]) in a Ukrainian Military Hospital Mental Health inpatient setting during the last decade of conflicts. The analysis aimed to (1) unveil the impact of those conflicts on the mental health of the army and (2) help us to anticipate risk factors (ranks, time period) and need for resources (admissions and days of hospitalization per time period, rank and disease) as well as estimate the current impact on mental health, particularly on civilians mobilized in combat, to hamper the effects and tailor interventions. 2. Materials and Methods 2.1. Database and Study Design A retrospective cross-sectional analysis of an anonymized part of the internal database of the Military Medical Center of the Northern Region, Kharkiv, Ukraine, that can be used for scientific purposes was performed. The database set of the last decade (2012–2021) included 3995 anonymized records, year of admission, military rank, days of hospitalization recorded on a regular basis, as well as the mental health disorders as assessed by first and third authors after admissions and according to ICD-10-CM (F01–F99, Mental, Behavioral, and Neurodevelopmental disorders) [12]. According to the chronology of the events in the eastern part of Ukraine during the last decade [1], the timeline was divided into three time periods: Peacetime (2012–2013), Active Hostility (AH, Donbas conflict: April to September 2014; January–February 2015; since February 2015, positional battles went on) and Trench Warfare (TW; TW1, 2016–2017; TW2, 2018–2019; TW3, 2019–2021). 2.2. Statistical Analysis Data are expressed as the frequency (%), fold-increase, or mean ± SEM. Chi-square analysis and ANOVA with Bonferroni post hoc correction were performed with Jamovi (Sidney, Australia) [13]. In a secondary analysis per rank and war period, TW3 was excluded since, during the COVID-19 outbreak, the data on ranks were incomplete, and the results showed convergence on TW2. For particular Chi-square comparisons, GraphPad QuickCalcs Web site: https://www.graphpad.com/quickcalcs/contingency1/ San Diego, CA, USA (accessed on 25 June 2022) by Dotmatics was used. Figures were generated with GraphPad and edited in PowerPoint. Chi-square, in all cases, p < 0.05 was considered statistically significant. 3. Results 3.1. Anxiety Disorders Were Already Present in Peacetime, While a High Frequency of Psychoactive Substance Use Emerged with Acute Conflicts During the last decade, the temporal distribution of admissions (Figure 1A) showed a 6.97 (AH) and 3.62 (TW) [5.02 (TW1, 2016–2017), 3.91 (TW2, 2018–2019), and 1.95 (TW3, 2020–2021)] fold increase per year compared to peacetime. The most frequent mental health problems (Figure 1B), accounting for 76.1% of cases, were ‘anxiety, dissociative, stress-related, somatoform and other nonpsychotic disorders’ (F40-F48, ANXd, 40.1%, 1602/3995) and ‘mental and behavioral disorders due to psychoactive substance use’ (F10–F19, PSUd, 36.0%, 1439/3995). ‘Reaction to severe stress and adjustment disorders (F43, 76.5%, 1225/1602) and ‘Alcohol-related disorders (F10, 89.3%, 1285/1439) were the predominant mental health disorders, respectively (Figure 1C). Less than 10% of cases were diagnosed with ‘schizophrenia, schizotypal, delusional, and other nonmood psychotic dis- orders’ (F20–F29, 7.7%, 306/3995) or ‘disorders of adult personality and behavior’ (F60–F69, 6.8%, 273/3995). Int. J. Environ. Res. Public Health 2022, 19, x FOR PEER REVIEW 3 of 9 Int. J. Environ. Res. Public Health 2022, 19, 10536 3 of 9 Mental Figure 1.1.Mental Figure health health distribution distribution in ainUkrainian a Ukrainian Military Military Hospital Hospital during during the decade. the last last decade. (A) (A) Temporal Temporal distribution distribution of admissions of admissions in a mental in a mental healthhealth (MH) (MH) inpatient inpatient unit. unit. (B) (B) Frequency Frequency (%) of (%) of disorders disorders per year,per waryear, war and period, period, and (C) decade. decade. (C) Frequencies Frequencies of disorders of disorders in the twoinmost the two most frequent categories. ANXd: Anxiety, frequent categories. ANXd: dissociative, stress-related, Anxiety, dissociative, somatoform somatoform stress-related, and other nonpsychotic mental and other nonpsy- disorders; PSUd; chotic mental Mental and disorders; PSUd;behavioral disorders Mental and due to behavioral psychoactive disorders due tosubstance use. substance psychoactive Statistics (see use. depicted in the insets): Frequencies (%), Chi-square. Statistics (see depicted in the insets): Frequencies (%), Chi-square. 3.2.An 3.2. AnIncrease IncreaseininPsychological Psychological Stress Stress Symptoms Symptoms Could Be a Confounding Factor in Admissions Diagnosed as Admissions ‘Healthy’as ‘Healthy’ Diagnosed Interestingly, 2.3% Interestingly, 2.3% (90/3995) (90/3995) ofofcases casesadmitted admittedto tothe thepsychiatric psychiatricinpatient inpatientunit unitwere were diagnosed as ‘mentally healthy’. When analyzed per period [peace, 3.8% (4/212); diagnosed as ‘mentally healthy’. When analyzed per period [peace, 3.8% (4/212); active active hostility, 12.4% (83/1478); hostility, trench warfare, 12.4% (83/1478); trench 0.001% warfare,(3/2305)], the resultsthe 0.001% (3/2305)], suggested that an increase results suggested that anin psychological increase stress symptoms in psychological stresscould work could symptoms as a confounding factor. This false-positive work as a confounding effect factor. This false- could also explain the higher increase in active hostility. Military personnel suffers positive effect could also explain the higher increase in active hostility. Military personnel from a set of disorders and psychological consequences caused by extreme trauma, which suffers from a set of disorders and psychological consequences caused by extreme trauma, impacts the individuals leading to a general feeling of instability and promoting more which impacts the individuals leading to a general feeling of instability and promotinganxiety [14]. These stress response symptoms could be misdiagnosed as symptoms of a disease. more anxiety [14]. These stress response symptoms could be misdiagnosed as symptoms of a disease. 3.3. The ICD-10 Category Depended on the War Period A secondary 3.3. The analysis ICD-10 Category indicated Depended on that the Period the War ICD-10 category depended on the war period (Figure 1B), with peacetime to TW2 accounting for 90% (3582/3995) of cases. ‘ANXd’ were A secondary the main analysis mental health indicated problem thatperiod, in any the ICD-10withcategory depended 61.8% (131/212) of on theoccurring cases war period in (Figure 1B), with peacetime to TW2 accounting for 90% (3582/3995) of cases. peacetime. Their frequency decreased in active hostility (32.9%, 486/1478) and TW1 (39.3%, ‘ANXd’ were the main mental 417/1064) health problem and increased in TW2in(51.2%, any period, withThis 424/828). 61.8% (131/212) was not dueoftocases feweroccurring admissionsin peacetime. Their frequency decreased in active hostility (32.9%, 486/1478) with ANXd but an increased number with other pathologies (mainly PSUd). PSUd, residual and TW1 (39.3%, 417/1064) in peacetime [6.1%,and increased (13/212)], in TW2 reached (51.2%, their peak 424/828). This was(47.4%, in active hostility not due to fewer with 700/1478), ad- missions with ANXd but an increased number with other pathologies 97.9% (685/700) of ‘Alcohol-related disorders’ as the cause of these admissions (Figure 1C),(mainly PSUd). PSUd, which residual in peacetime could agree [6.1%, with the use (13/212)], of alcohol reached serving as a their copingpeak in activein mechanism hostility (47.4%, front traumatic 700/1478), with 97.9% (685/700) of ‘Alcohol-related disorders’ as the events [15]. We can also speculate that people that use alcohol might be those with cause of these admis-an sions (Figure 1C), which could agree with the use of alcohol serving as addiction. Thus, alcohol consumption may not only be related to dealing with stress and a coping mecha- nism in front symptoms traumatic events of psychological trauma[15].but Wealso cantoalso speculate addiction. that people Military service inthat use zone a war alcohol has might be those with an addiction. Thus, alcohol consumption may not only be related to TW2, 25.1%, 208/828) but still occupied a large proportion, with a decrease more remark- able than that caused by the decrease in the sample. ‘Schizotypical disorders’ experienced a gradual increase to their peak at TW2 (8.6%, 71/828), being twice as frequent as in peacetime (4.2%, 9/212). ‘Mood (affective) disorders’ (Peace, 4.2%, 9/212) reduced their frequency during conflicts (range: 0.8–1.3%). Despite the19, Int. J. Environ. Res. Public Health 2022, other 10536categories being very residual, some showed conspicuous changes. ‘Personality 4 of 9 disorders’ peaked in peacetime (16.3%, 34/212) and decreased afterward. ‘Mental health disorders due to known physiological conditions’ (F01-F09, 2.8%, 111/3995), relatively sta- blea and with modest relatively a peak in TW1 (4.8%, long-term effect51/1064), showed on the alcohol a 7- (AH), drinking 12.75-of(TW1), patterns and 4.75- male veterans [16]. (TW2) fold increase compared to peacetime (4/212). ‘Behavioral syndromes In trench warfare, PSUd decreased (TW1, 39.2%, 417/1064; TW2, 25.1%, 208/828) but still associated with physiological occupied a large disturbances proportion, with and physical a decreasefactors’, more ‘Pervasive’, remarkable and than‘Childhood that causeddisor- by the ders’ were stable decrease and residual. ‘Intellectual disabilities’ were relatively stable (range: 0.7– in the sample. 3.7%). ‘Schizotypical disorders’ experienced a gradual increase to their peak at TW2 (8.6%, 71/828), being twice as frequent as in peacetime (4.2%, 9/212). ‘Mood (affective) disorders’ 3.4. The Dramatic (Peace, Increase 4.2%, 9/212) in Admissions reduced and the Specific their frequency duringMental Health conflicts Profiles (range: per RankDespite 0.8–1.3%). Put thethe Hospital’s Efficiency at Risk other categories being very residual, some showed conspicuous changes. ‘Personality disorders’ If we couldpeaked in peacetime protect (16.3%, hospitals from the34/212) wagingand decreased of war afterward. [17], their efficiency ‘Mental wouldhealth still disorders due to known physiological conditions’ (F01-F09, be compromised by the dramatic increase in admissions and restrictions on human and2.8%, 111/3995), relatively stable resources. medical and with a peak in TW1 (4.8%, 51/1064), showed a 7- (AH), 12.75- (TW1), and 4.75- (TW2) fold increase The admissions (Figurecompared 2) of highto peacetime (4/212). ranks (Major, ‘Behavioral Lieutenant syndromes Colonel, associated and Colonel) with physiological disturbances and physical factors’, ‘Pervasive’, were relatively stable over time. ANXd were the most frequent mental health disorders and ‘Childhood disorders’ were and stable and increased withresidual. ‘Intellectual rank [Major disabilities’ (63%, 46/73), wereColonel Lieutenant relatively stable24/33), (72.7%, (range:and 0.7–3.7%). Colo- nel (100%, 2/2)]. Despite their small sample size, the analysis of high ranks is of interest 3.4. The Dramatic Increase in Admissions and the Specific Mental Health Profiles per Rank Put the due to theirEfficiency Hospital’s military roles. at Risk In contrast, admissions of low ranks (Soldiers; professional Soldiers: Contract Service If we could protect hospitals from the waging of war [17], their efficiency would still Soldiers; and Sergeant-Ensign) depended on the war period. Soldiers showed a peak in be compromised by the dramatic increase in admissions and restrictions on human and peacetime (50.5%, 107/212) and active hostility (55.2%, 816/1478) and decreased in trench medical resources. warfare (TW1 24.4%, 260/1064; TW2, 7.4%, 61/828). In contrast, professional soldiers The admissions (Figure 2) of high ranks (Major, Lieutenant Colonel, and Colonel) were (Peace, 15.1%, 32/212; AH, 8.3%, 122/1478) peaked at trench warfare (TW1, 44.7%, relatively stable over time. ANXd were the most frequent mental health disorders and 476/1064; increased TW2, with66.3%, 549/828). rank [Major (63%,With lower 46/73), frequency, Lieutenant Sergeant-Ensign Colonel (Peace, (72.7%, 24/33), and13.2%, Colonel 28/212) peaked in active hostility (24.4%, 360/1478) and trench warfare (100%, 2/2)]. Despite their small sample size, the analysis of high ranks is of interest (TW1, 19.5%, due to 208/1064; TW2, 10.4%, their military roles. 86/828). Figure Figure 2. Admissions 2. Admissions perper Military Military ranks. ranks. Admissions Admissions perper rank, rank, warwar period period andand total total ANXd: ANXd: Anxiety, Anxiety, dissociative, dissociative, stress-related, stress-related, somatoform somatoform andand other other nonpsychotic nonpsychotic mental mental disorders; disorders; PSUd; PSUd; Mental Mental and behavioral disorders due to psychoactive substance use. Statistics (see depicted in the inset): and behavioral disorders due to psychoactive substance use. Statistics (see depicted in the inset): Frequencies Frequencies (%), Chi-square. (%), Chi-square. In contrast, admissions of low ranks (Soldiers; professional Soldiers: Contract Service Soldiers; and Sergeant-Ensign) depended on the war period. Soldiers showed a peak in peacetime (50.5%, 107/212) and active hostility (55.2%, 816/1478) and decreased in trench warfare (TW1 24.4%, 260/1064; TW2, 7.4%, 61/828). In contrast, professional soldiers (Peace, 15.1%, 32/212; AH, 8.3%, 122/1478) peaked at trench warfare (TW1, 44.7%, 476/1064; TW2, 66.3%, 549/828). With lower frequency, Sergeant-Ensign (Peace, 13.2%, 28/212) peaked in active hostility (24.4%, 360/1478) and trench warfare (TW1, 19.5%, 208/1064; TW2, 10.4%, 86/828). Int. J. Environ. Res. Public Health 2022, 19, x FOR PEER REVIEW 5 of 9 Int. J. Environ. Res. Public Health 2022, 19, 10536 5 of 9 3.5. The Specific Impact on PSUd in Nonprofessional Soldiers Is Relevant to the Current War, 3.5. withThe the Specific GeneralImpact on PSUd Population in Nonprofessional of Ukraine Recruited forSoldiers DefenseIsand Relevant Combatto the Current War, with the General Population of Ukraine Recruited for Defense and Combat In addition, a rank × disorder effect (Figure 3) indicated that soldiers showed more In addition, a rank × disorder effect (Figure 3) indicated that soldiers showed more PSUd (44.7%, 556/1244) than ANXd (31.5%, 392/1244) and professional soldiers (PSUd, PSUd (44.7%, 556/1244) than ANXd (31.5%, 392/1244) and professional soldiers (PSUd, 26.1%, 308/1179). In contrast, professional soldiers showed more ANXd (47.5%, 560/1179) 26.1%, 308/1179). In contrast, professional soldiers showed more ANXd (47.5%, 560/1179) than PSUd and compared to soldiers. These results suggest different vulnerability and than PSUd and compared to soldiers. These results suggest different vulnerability and coping strategies among ranks with implications for designing tailored interventions and coping strategies among ranks with implications for designing tailored interventions and managing hospital resources. Additionally, they warn of the impact of the current war on managing hospital resources. Additionally, they warn of the impact of the current war on civilians recruited or volunteering as soldiers. civilians recruited or volunteering as soldiers. Figure 3. Figure 3. Mental Mental health health disorders disorders per per military military ranks. ranks. Left Left axis: axis: ICD-10-CM categories. Right axis: Military ranks. Military ranks. Statistics: Statistics: Frequencies Frequencies (%), (%), Chi-square Chi-square (see (see depicted depicted using using colors, colors, in in the the inset). inset). 3.6. 3.6. A A ‘Need ‘Need for for Free Free Beds BedsEffect’ Effect’Could CouldExplain ExplainShorter ShorterHospital HospitalStays Staysduring duringActive ActiveConflict Conflictand Anticipate Similar Phenomena in the Current War and Anticipate Similar Phenomena in the Current War Hospital stays for people with ANXd or PSUd lasted at least one month in peacetime Hospital stays for people with ANXd or PSUd lasted at least one month in peacetime but significantly decreased in war periods (Figure 4). This could be explained by a ‘need for but significantly decreased in war periods (Figure 4). This could be explained by a ‘need free beds effect’ (Figure 4A) and the distribution of admissions by ranks (Figures 2 and 4B). for free beds effect’ (Figure 4A) and the distribution of admissions by ranks (Figures 2 and In addition, in active hostility and trench warfare TW1, people with PSUd spent fewer days 4B). In addition, in active hostility and trench warfare TW1, people with PSUd spent fewer than those with ANXd, probably due to a high frequency of ‘acute alcohol-related disorders’ days than those with ANXd, probably due to a high frequency of ‘acute alcohol-related among PSUd in these periods (97.9% and 84.5%, respectively). After active hostility, PSUd disorders’ among PSUd in these periods (97.9% and 84.5%, respectively). After active hos- increased while ANXd decreased. tility, PSUd increased while ANXd decreased. Sergeant-Ensigns had shorter hospitalization than nonprofessional and professional soldiers. Hospitalization was also analyzed in the three lowest ranks since they were the most significant part of the sample size (Figure 4B). The mean showed no differ- ences between the two soldier categories, but both had longer hospitalization times than Sergeants-Ensigns. Significant effects of the war period, rank, and interaction were also found, with a drastic reduction after peacetime that was more substantial in soldiers. The temporal curves mimicked those per disorder (Figure 4A) and would agree with a higher frequency of PSUd in soldiers and ANXd in the other two professionalized ranks. This may indicate that the need for empty beds has contributed to a reduction in the length of treatment, as well as an increase in the number of military personnel with anxiety and intoxications who did not require long-term treatment. Int. J. Environ. Res. Public Health 2022, 19, x FOR PEER REVIEW 6 of 9 Int. J. Environ. Res. Public Health 2022, 19, 10536 6 of 9 Figure 4. Days of hospitalization. (A) Days of hospitalization per disorder, and (B) per military rank. ANXd: Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders; Figure 4. Days of hospitalization. (A) Days of hospitalization per disorder, and (B) per PSUd; Mental and behavioral disorders due to psychoactive substance use. Statistics (see depicted in military rank. ANXd: Anxiety, dissociative, stress-related, somatoform and other the insets): Frequencies (%), Chi-square; and Mean ± SEM, ANOVA with post hoc Bonferroni. nonpsychotic mental disorders; PSUd; Mental and behavioral disorders due to psycho- active substance use. Statistics (see depicted in the insets): Frequencies (%), Chi-square; 4. Discussion and Mean In ±the SEM, ANOVA previous withsubheadings section, post hoc Bonferroni. have highlighted the main findings, and specific discussion has beenhad Sergeant-Ensigns added to each shorter of the results. than hospitalization Further aspects to discuss nonprofessional andare presented here: professional soldiers. Hospitalization was also analyzed in the three lowest ranks since they wereonly War to defend the state has its own characteristics. In the literature, we have the seen studies in the professional military. The most common disorders most significant part of the sample size (Figure 4B). The mean showed no differences be- among active military tweenpersonnel the twoare depression soldier and PTSD categories, but both[18].had In contrast, in our work, wetimes longer hospitalization have than also observed Ser- geants-Ensigns. Significant effects of the war period, rank, and interaction wereofalso mental health disorders among professional military data. Two categories mental disorders, namely the PSUd and ANXd, were the most prevalent found, with a drastic reduction after peacetime that was more substantial in soldiers. Theand were mainly found among soldiers. temporal curves mimicked those per disorder (Figure 4A) and would agree with a higher It is important to note that, similarly to the current situation, during the last decade frequency of PSUd in soldiers and ANXd in the other two professionalized ranks. This in Ukraine, many civilian populations were recruited for defense and combat. Therefore, may indicate that the need for empty beds has contributed to a reduction in the length of the hospital units received two distinct categories of soldiers, nonprofessional soldiers, treatment, as well as an increase in the number of military personnel with anxiety and and contract service (professional) soldiers. The retrospective analysis unveiled that in intoxications who did not require long-term treatment. each group of soldiers (nonprofessional and professional), the proportions of the most prevalent disorders, PSUd and ANXd differed. Our study is supported by current data 4. Discussion from survey results; the study in the four Ukrainian universities—with a 1:6 male:female In the previousimportant ratio—reports section, subheadings have highlighted psycho-emotional alterationsthe main of in most findings, and specific the participants (97.85), discussion has been added to each of the results. Further aspects shown as exhaustion (86.7%), depression (84.3%), nervousness (84.4%), anger to discuss are presented (76.9%) and here:loneliness (51.8%), with age/status (students more than personnel) and gender (females War to more thandefend males)theeffects. state has Theits useown characteristics. of substances In more (males the literature, we have than females) (i.e.,only tobacco, seenalcohol, studies pain in therelievers, professional military. The and sedatives) and most common unhealthy fooddisorders has increasedamong active as well mili- as loneliness tary associated personnel are withdepression fear, burnoutand and PTSD [18].resilience. lower In contrast,Furthermore, in our work,civil we have statusalso ob- influenced served mental health loneliness, disorders participants with unmarried among professional military feeling more lonelydata. thanTwo categories unmarried. Asofwe men- can see, tal disorders, namely the PSUd and ANXd, were the most prevalent the symptoms of mental disorders were associated with the use of drugs among civilians. and were mainly found among soldiers. Int. J. Environ. Res. Public Health 2022, 19, 10536 7 of 9 Alcohol addiction is common among military personnel, but this is due to the presence of anxiety disorders, symptoms of stress, and the presence of symptoms of PTSD. In the category of nonprofessional soldiers, PSUd and, in particular, alcohol dependence occurred as an independent disorder. Thus, the retrospective analysis indicated the predisposition of the nonprofessional soldier to alcohol dependence. This may be a consequence of insufficient military service screening during hostilities outbreaks [19]. Given the substantial cost of alcohol misuse, it is imperative to examine factors that may contribute to problematic drinking so that interventions can be employed to address this issue within the military. Military-related traumatic stress seems to elevate the risk of individuals misusing alcohol. The co-occurrence of posttraumatic psychiatric disorders seems to play a major explanatory role in the association between military stress and alcohol misuse. Screening and intervention for alcohol misuse, particularly following exposure to military-related trauma, are clearly needed, as are integrated treatments that address conjoined alcohol and PTSD problems [20]. Because the available data only detect the primary underlying disease, we cannot determine the level of relationship between PSUd (alcohol abuse) and ANXd (anxiety). However, in this respect, the recent study in four Ukrainian universities in the eye of the storm [9] has reported two significative data in this respect: the level of substance use by their students/personnel before the war (69.9%, alcohol > tobacco > pain killers > hypnosedatives)—higher in males than females—has increased during the war (10 to 19%, alcohol > hynosedatives > tobacco > pain killers) and is associated with lower resilience; higher fear, burnout, and loneliness. Therefore, given that in our retrospective study the group of nonprofessional soldiers recorded more alcohol abuse, we can offer less discipline among this contingent and a greater propensity for dependence. Therefore, the relationship between addictions and the regulation/dysregulation of emotions shown to play an important role both in war and peace times in other conflicts [21] should be considered for tailored interventions since adaptive emotional regulation strate- gies decrease the experience of negative emotions [11]. In particular, the Italian study on the role of emotion regulation on aggressive responses related to the current Russian–Ukrainian conflict has shown the negative effect of cognitive reappraisal of emotions [11]. Professional military officers suffered mainly from neurotic disorders and anxiety during their current service. If these disorders are not treated, they will be the basis for the future development of PTSD, adjustment disorders, anxiety disorders, and depressive disorders [22]. Not only treatment but also prevention of anxiety disorders is important to reduce the burden on hospital staff. Some of the limitations of this retrospective study are: The data on a masculinized military structure limit the analysis under the gender perspective needed in the current war, where female civilians have also joined the combat. The university study [9] already indicates the relevance of gender effects on mental health. The transversal design cannot provide clues on the long-term effects on an individual base, i.e., the subsequent increase in alcohol dependence and vulnerability to mental health disorders described in veterans [8,14,23]. 5. Conclusions The three main conclusions and implications for the current war can be summarized as: 1. The dominance of ANXd, mainly among professional soldiers and high ranks, points to the need for rank-tailored psychological training in skills to reduce the ANXd burden. 2. The large number of PSUd in nonprofessional soldiers during wartime dictates the need to strengthen the selection of military personnel, taking into account the tendency to addiction. In the current war, tightening the rules of sobriety in units and up to a ban on the sale of alcoholic beverages in areas where hostilities are taking place is recommended. Int. J. Environ. Res. Public Health 2022, 19, 10536 8 of 9 3. Military operations multiply the hospitalizations in psychiatric hospitals. Admissions are heterogeneous and depend on the military rank (soldiers and professional soldiers spend more time than other low ranks). This is relevant to estimating and planning the need for hospital resources for the current situation where the general population has been recruited for defence and combat. Author Contributions: For A.H. and Y.L. assessed the patients and built the database. A.H. and L.G.-L. conceived the study. L.G.-L. and M.S.-S. designed the statistical methods. M.S.-S. conducted the statistical analysis. L.G.-L. and M.S.-S. interpreted the results and wrote the draft manuscript. A.H., M.S.-S., Y.L. and L.G.-L. revised the manuscript. All authors have read and agreed to the published version of the manuscript. Funding: This research received support from Envellir bé-Saber envejecer—Healthy Aging.org Memorial Mercedes Llort Sender 2022/81/24091941/01. Institutional Review Board Statement: The study was conducted on an anonymized part of the internal database of the Military Medical Center of the Northern Region, Kharkiv, Ukraine, that can be used for scientific purposes. Informed Consent Statement: Not applicable. Data Availability Statement: The dataset is available upon request. Acknowledgments: To the Ukrainian people and all those who stand by them. Those who died will never be forgotten. Conflicts of Interest: The authors declare no conflict of interest. References 1. OHCHR. Ukraine: Civilian Casualty Update 19 May 2022. Available online: https://www.ohchr.org/en/news/2022/05/ukraine- civilian-casualty-update-19-may-2022 (accessed on 27 June 2022). 2. UN Refugee Agency. Ukraine Refugee Situation. 2022. Available online: https://data.unhcr.org/en/situations/ukraine (accessed on 1 August 2022). 3. Sidney, C. Displacement in Ukraine: Insights from Survey Data IDMC, Internal Displacement Monitoring Centre. 2022. Available online: https://www.internal-displacement.org/expert-opinion/displacement-in-ukraine-insights-from-survey-data (accessed on 1 August 2022). 4. Selyukh, A.; Hurt, A.; Jin, C.H.; Underwood, N. The Ripple Effects of Russia’s War in Ukraine are Changing the World. Available online: https://www.npr.org/2022/05/10/1093066817 (accessed on 27 June 2022). 5. Chumachenko, D.; Chumachenko, T. Ukraine war: The humanitarian crisis in Kharkiv. BMJ 2022, 376, o796. [CrossRef] [PubMed] 6. Patel, S.S.; Erickson, T.B. The new humanitarian crisis in Ukraine: Coping with the public health impact of hybrid warfare, mass migration, and mental health trauma. Disaster Med. Public Health Prep. 2022; advance online publication. [CrossRef] [PubMed] 7. Darden, J.T. In Ukraine and other conflicts, measuring the human cost is important. It’s also very difficult. The Washington Post. Available online: https://www.washingtonpost.com/politics/2022/03/11/ukraine-casualties (accessed on 27 June 2022). 8. Blakey, S.M.; Griffin, S.C.; Grove, J.L.; Peter, S.C.; Levi, R.D.; Calhoun, P.S.; Elbogen, E.B.; Beckham, J.C.; Pugh, M.J.; Kimbrel, N.A. Comparing psychosocial functioning, suicide risk, and nonsuicidal self-injury between veterans with probable posttraumatic stress disorder and alcohol use disorder. J. Affect. Disord. 2022, 308, 10–18. [CrossRef] [PubMed] 9. Kurapov, A.; Pavlenko, V.; Drozdov, A.; Bezliudna, V.; Reznik, A.; Isralowitz, R. Toward an Understanding of the Russian- Ukrainian War Impact on University Students and Personnel. J. Loss Trauma 2022, 1–8. [CrossRef] 10. Riad, A.; Drobov, A.; Krobot, M.; Antalová, N.; Alkasaby, M.A.; Peřina, A.; Koščík, M. Mental Health Burden of the Russian– Ukrainian War 2022 (RUW-22): Anxiety and Depression Levels among Young Adults in Central Europe. Int. J. Environ. Res. Public Health 2022, 19, 8418. [CrossRef] [PubMed] 11. Cricenti, C.; Mari, E.; Barchielli, B.; Quaglieri, A.; Burrai, J.; Pizzo, A.; Lausi, G. Can Emotion Regulation Affect Aggressive Responses? A Study on the Ukrainian–Russian Conflict in a Non-Directly Exposed Sample. Int. J. Environ. Res. Public Health 2022, 19, 6189. [CrossRef] [PubMed] 12. WHO. ICD-10. Available online: https://www.who.int/standards/classifications/classification-of-diseases (accessed on 25 June 2022). 13. The Jamovi Project. Jamovi (Version 1.6) [Computer Software]. 2021. Available online: https://www.jamovi.org (accessed on 1 August 2022). 14. Rozanov, V.; Frančišković, T.; Marinić, I.; Macarenco, M.; Letica-Crepulja, M.; Mužinić, L.; Jayatunge, R.; Sisask, M.; Vevera, J.; Wiederhold, B.; et al. Mental health consequences of war conflicts. In Advances in Psychiatry; Javed, A., Fountoulakis, K., Eds.; Springer: Cham, Switzerland, 2019. [CrossRef] Int. J. Environ. Res. Public Health 2022, 19, 10536 9 of 9 15. Goldberg, J.; Eisen, S.A.; True, W.R.; Henderson, W.G. A twin study of the effects of the Vietnam conflict on alcohol drinking patterns. Am. J. Public Health 1990, 80, 570–574. [CrossRef] [PubMed] 16. Schumm, J.A.; Chard, K.M. Alcohol and stress in the military. Alcohol Res. 2012, 34, 401–407. [PubMed] 17. Alnahhas, H.; Mishori, R.; Heisler, M. Hospitals and healthcare workers must be protected from the waging of war. BMJ 2022, 376, o764. [CrossRef] [PubMed] 18. Update: Mental health disorders and mental health problems, active component, U.S. Armed Forces, 2016–2020. MSMR 2021, 28, 2–9. 19. Haydabrus, A.V. Dynamics of changes in the structure of mental illness among servicemen treated in the psychiatric ward of the military medical clinical center of the northern region. Psychiatry Neurol. Med. Psychol. 2020, 15. [CrossRef] 20. Inoue, C.; Shawler, E.; Jordan, C.H.; Jackson, C.A. Veteran and military mental health issues. 2021 May 24. In StatPearls [Internet]; StatPearls Publishing: Treasure Island, FL, USA, 2022. 21. Halperin, E.; Porat, R.; Tamir, M.; Gross, J.J. Can Emotion Regulation Change Political Attitudes in Intractable Conflicts? From the Laboratory to the Field. Psychol. Sci. 2013, 24, 106–111. [CrossRef] [PubMed] 22. Jacobson, I.G.; Ryan, M.A.; Hooper, T.I.; Smith, T.C.; Amoroso, P.J.; Boyko, E.J.; Gackstetter, G.D.; Wells, T.S.; Bell, N.S. Alcohol use and alcohol-related problems before and after military combat deployment. JAMA 2008, 300, 663–675. [CrossRef] [PubMed] 23. Sharbafchi, M.R.; Heydari, M. Management of Substance Use Disorder in Military Services: A Comprehensive Approach. Adv. Biomed. Res. 2017, 6, 122. [CrossRef] [PubMed]