(Not) PTSD: The Ukrainian experience

In late September, headlines around the world carried a striking claim: "Nearly one in three Ukrainian civilians has PTSD or complex PTSD." It came from a new study by British and Ukrainian researchers, published in the European Journal of Psychotraumatology.

We treat war trauma in soldiers and civilians, in Ukraine and in the United States. We have no doubt that this war is causing enormous psychological harm. But I disagree with how that number has been presented. A natural response to a real and ongoing threat is not, by itself, a mental disorder. Calling a normal reaction to abnormal circumstances an illness does harm. So does downplaying what war does to people. Both mistakes get in the way of what matters most: understanding what each person actually needs, and making sure they get that kind of help.

The researchers surveyed more than 2,500 adults by phone in May 2024. By their count, 25% showed signs of probable PTSD, and another 6% of probable complex PTSD. It is careful work, done under difficult conditions. The problem lies in a single word: "post."

Post-traumatic stress disorder describes what happens after. The danger has passed, yet the body and mind keep reacting as if it were still close. Memories break into the present. The body stays braced for an attack that is no longer coming. The fire is long out, and the alarm keeps ringing.

The questionnaire the researchers used is built on that logic. It asks people to pick one event from the past and rate how it still affects them. That works for a veteran who has come home, or for a survivor years after a disaster. It works far less well for someone who will hear an air-raid siren again tonight.

Ukrainians are living inside a trauma that is still unfolding, day after day. Drones and missiles reach cities hundreds of miles from the front line. In those conditions, sleeping lightly, flinching at loud noises and staying on guard mean the alarm system is doing its job, because the danger is real. A woman in Kharkiv who wakes at every siren is reading her surroundings correctly.

Psychologists have a name for this: continuous traumatic stress. It was first described in places where the threat never went away. In Sderot, an Israeli town that lived under rocket fire for years, researchers found that residents' anxiety was tied to daily danger, not to a single past event, and that it eased when people moved out of range. An alarm that switches off once the danger is gone is an alarm that works.

The study's authors acknowledge this themselves. They write that in today's Ukraine, hyperarousal should be seen as an accurate signal of real threat rather than a "false alarm." They also warn that a tool designed for life after trauma may overcount PTSD among people who are still in danger. The lead author, Dr. Emma Facer-Irwin, noted that people's responses to an ongoing war do not always fit models developed for post-conflict settings. I agree. And when the tool does not fit the situation, the number it produces should not become the headline.

A phone survey is also no substitute for a conversation with a clinician. Questionnaires deliberately cast a wide net so that no one is missed, which is why they usually find more cases than a clinical assessment later confirms.

Read past the headline, and the study tells a different story about Ukrainians. More than 70% of respondents had lived through shelling near their homes. Half have a loved one on the front line. A third were forced to leave home. Yet only 6% showed signs of complex PTSD, the more severe form that can develop after prolonged trauma. That is lower than some earlier studies found. Among the possible reasons, the authors point to a strong sense of national identity, close community ties and mutual support.

Anyone who has spent time in Ukraine has seen this up close. It is the neighbor who sweeps up broken glass the morning after a strike and opens her shop on time. It is the teacher who holds class in a bomb shelter. It is the volunteers who arrive with tea and a generator before the smoke has cleared. These people live and work every day in conditions that are hard to imagine for anyone who has not been through them.

Labels matter. Tell a third of a country that it is sick, and those words can start to come true. People who believe they are broken begin to act broken, and normal reactions to danger start to look like illness.

At the same time, many Ukrainians still find it hard to see a psychologist or psychiatrist because of stigma. So the other half of the message matters just as much. If someone does come in for help, they are genuinely struggling, and that deserves to be taken seriously. Some people will do well after a few sessions; others, soldiers and civilians alike, will need long and intensive therapy. That call belongs to a trained professional who has actually talked with the person, not to a questionnaire or a headline. According to the WHO Mental Health Atlas, Ukraine has about 34 mental health workers per 100,000 people, compared with a European median of 53. That makes it all the more important for each person to get the kind of help they actually need.

None of this means ordinary reactions should simply be endured. A normal reaction can still be exhausting. Scientists call this cost allostatic load: the wear and tear the body pays for months and years in survival mode. Poor sleep, tension, irritability and fatigue are part of that price. When constant alertness keeps you from sleeping, working or simply being present with your family, it deserves attention. And you do not need a diagnosis to get help.

The good news is that an overworked alarm can be turned down, and much of what helps is simple. Slow breathing with long exhales calms the body. Insomnia is treatable, and even apps based on cognitive behavioral therapy help people sleep better. Regular physical activity reduces anxiety. Short group programs, led by trained people without a psychology degree, help those who have lived through war and displacement.

Psychologists who work after mass disasters name five things that help people recover: a sense of safety, calm, belief in one's own and the community's ability to cope, connection with others, and hope. While the war goes on, full safety is out of reach. That makes the other four matter even more, and they are built in kitchens, classrooms and bomb shelters as much as in doctors' offices.

For people whose alarm gets "stuck" and will not switch off, treatments that act directly on the nervous system are also being studied. One of them, stellate ganglion block, an injection that calms a cluster of nerves in the neck, reduced PTSD symptoms more than a placebo procedure in a trial with U.S. soldiers. The Weatherman Foundation offers this treatment to Ukrainian service members.

The study's own conclusions point the way forward. For most people, the authors recommend strengthening community and group support. For those whose symptoms persist, early treatment should target the sense of threat, avoidance and an alarm that will not shut off. That kind of care works, in Ukraine too: in a trial with Ukrainian veterans and displaced people, a structured form of psychotherapy significantly reduced PTSD symptoms. Finding the people who need specialist care will take conversations with clinicians, follow-up over time and tools built for a war that is still being fought.

Ukrainians are not broken. They fall asleep to sirens and get up the next morning to go to work, to school, to the volunteer center. There is strength in that worth recognizing, and exhaustion worth helping with. The way we measure their pain should respect both.

I sincerely thank my colleagues at the Weatherman Foundation for their help in preparing this material:

Meaghan Mobbs, PhD, CEO and President of the Weatherman Foundation. A former U.S. Army officer with a doctorate in clinical psychology from Columbia University, where she specialized in trauma.

Valerii Androsov, Director of the Psychophysiological Rehabilitation Program for the National Police at the Weatherman Foundation. A psychologist in Kyiv since 2017, postgraduate researcher and lecturer at NTU "KhPI".

Lauren Guillaume, Director of the Weatherman Foundation in Ukraine. Holds a Master's degree in Global Policy Studies from the LBJ School of Public Affairs (University of Texas at Austin).