Mental health burden among people remaining in Ukraine

The prolonged war in Ukraine has precipitated a major public health emergency, and mental health needs have escalated dramatically. Civilians who have remained in the country, including older adults and those with limited mobility, experience constant exposure to threat, uncertainty and social disruption. Daily stressors such as displacement within local communities, destruction of infrastructure and separation from family members compound the psychological toll of living under chronic insecurity.

A systematic review and meta-analysis found that about 22% of people exposed to conflict were likely to develop a mental health condition; ^{Reference Charlson, van Ommeren, Flaxman, Cornett, Whiteford and Saxena1} this would account for 9.6 million people in the Ukrainian context. A recent study of adolescents in Ukraine found that 32% screened positive for moderate or severe depression, 18% for moderate or severe anxiety and 35% for clinically relevant trauma. ^{Reference Goto, Pinchuk, Kolodezhny, Pimenova, Kano and Skokauskas2} These figures indicate the scale of the challenge faced by mental healthcare services in Ukraine.

However, mental health provision remains fragmented and under-resourced. Whereas international humanitarian efforts have focused primarily on physical safety, shelter and basic healthcare, mental health recovery has received less attention and funding. Despite notable progress in training of primary-care clinicians and scaling of low-intensity psychological support, capacity remains insufficient relative to population need. The European mental health community has an ethical responsibility to identify innovative, evidence-informed strategies that can be implemented even under unstable conditions to complement conventional psychiatric care.

Current responses and persisting service gaps

In Ukraine, psychosocial support initiatives such as emergency counselling hotlines, tele-psychiatry services and non-governmental organisation (NGO)-led therapy groups, have offered crucial assistance. ³ However, these initiatives face considerable logistical and systemic barriers. Unreliable internet connectivity can interrupt or prevent access to online counselling, tele-psychiatry and other forms of remote mental health support. In addition, trained mental healthcare staff are in short supply, and face-to-face interventions are restricted by safety risks and displacement.

Moreover, many services rely on short-term external funding or international partnerships. When humanitarian organisations withdraw, continuity of care becomes uncertain. Standard therapeutic formats, such as cognitive–behavioural therapy or trauma-focused group work, require consistent attendance and privacy, both of which are difficult to maintain for individuals in temporary or overcrowded housing. Consequently, there is a pressing need for psychosocial approaches that are low-cost, easy to deliver and adaptable to collective or mobile settings.

European psychiatry increasingly recognises the value of public mental health strategies that integrate lifestyle and environmental dimensions of well-being. ^{Reference Furst, Bagheri and Salvador-Carulla4,Reference Firth, Solmi, Wootton, Vancampfort, Schuch and Hoare5} Within this framework, interventions grounded in nature exposure, mindfulness and relaxation training could offer sustainable support that is aligned with cultural values and available infrastructure.

Nature exposure, lifestyle psychiatry and virtual reality interventions

Exposure to natural environments has long been associated with improved psychological well-being. Forest bathing exemplifies a structured approach to mindful immersion in nature. Empirical studies have consistently reported reductions in cortisol levels, blood pressure and self-reported anxiety following forest-bathing sessions. In a recent meta-analysis, forest bathing was found to be effective in reducing all included mental health outcomes including anxiety, depression and stress, with the largest effect observed for anxiety. ^{Reference Kotera, Richardson and Sheffield6} These findings complement broader evidence that nature contact enhances positive affect and reduces depressive symptoms across populations, with studies finding benefits of forest bathing not only in Asia, where the practice originated, but also across Europe, demonstrating its adaptability across cultures. Ukraine’s relationship with nature is deeply embedded in its cultural identity, as symbolised by the red viburnum (kalyna), willow (verba) and the expansive steppe and river landscapes celebrated in national folklore and poetry. These natural symbols are often associated with home, continuity, endurance and collective belonging. In this sense, nature may carry also relational and cultural meaning as well as restorative sensory qualities. This may be especially relevant in wartime, when familiar landscapes can evoke memories of safety, identity and connection. At the same time, such imagery may also evoke grief or loss for some individuals whose homes or local environments have been damaged by war. For this reason, technology-assisted nature sessions in Ukraine should be culturally sensitive, optional and adaptable in content, allowing participants to engage with calming natural environments without requiring exposure to personally distressing imagery. Integration of familiar landscapes and sounds into digital interventions may enhance emotional engagement and perceived authenticity when used carefully and collaboratively. Although forest bathing originated in Japan, studies included in the meta-analysis have shown beneficial effects in several European countries, ^{Reference Kotera, Richardson and Sheffield6} indicating that its principles (mindful attention and sensory immersion) are meaningful beyond their original cultural setting.

Within the framework of lifestyle medicine, nature interaction has been recognised alongside nutrition, exercise and sleep as a core pillar of mental health. ^{Reference Marx, Manger, Blencowe, Murray, Ho and Lawn7} However, direct access to restorative environments is not always possible, especially for individuals in conflict zones or institutional settings. This gap has prompted interest in technology-assisted nature interaction (e.g. use of a virtual reality headset or virtual nature on screen) as a tool to simulate natural experiences safely.

Technology-assisted approaches enable exposure to lifelike natural environments via visual and auditory stimulation. In a controlled study, a 5 min virtual reality forest session produced significant gains in vitality, mood and perceived restoration, with outcomes comparable to those seen after visits to physical forests. ^{Reference Mattila, Korhonen, Pöyry, Hauru, Holopainen and Parvinen8} Such interventions are feasible for people with restricted mobility and for residents in areas where access to nature is unsafe (e.g. locations contaminated by landmines or unexploded ordnance or at risk of shelling), and they can be delivered with minimal facilitation once equipment is in place.

In the European context, virtual reality relaxation has been tested within acute psychiatric services, including in-patient wards and out-patient clinics, and has shown strong feasibility and acceptability. ^{Reference Riches, Nicholson, Fialho, Little, Ahmed and McIntosh9} These findings support the idea that technology-assisted nature exposure could be integrated into humanitarian or low-resource mental health frameworks with minimal specialist input. ^{Reference Chirico, Lucidi, De Laurentiis, Milanese, Napoli and Giordano10}

Technology-assisted forest bathing for people in Ukraine

Building on converging evidence from lifestyle medicine, environmental psychology and digital health, we propose the development of technology-assisted forest-bathing sessions for individuals in Ukraine. These sessions could be delivered in several flexible formats through portable virtual reality headsets, tablets or communal large-screen projections in shelters, clinics or community centres. Such inclusivity would ensure accessibility for older adults and people with limited mobility, who may find headsets uncomfortable or unfamiliar.

Even brief daily sessions of 5–10 min may provide measurable relief from stress, anxiety and depressive symptoms. In addition to their individual benefits, shared screen-based sessions can promote a sense of connection and belonging, thereby mitigating loneliness; this is another core pillar of lifestyle medicine, ^{Reference Marx, Manger, Blencowe, Murray, Ho and Lawn7} as loneliness is a major risk factor for deterioration of mental health in prolonged crises. Group viewing can also create collective rituals of calmness and mutual support, which are important elements of community resilience.

From an implementation perspective, this approach is consistent with the development by the World Health Organization (WHO) of scalable, low-intensity psychological interventions for adversity-exposed communities; such interventions include Problem Management Plus (PM+), a brief five-session intervention that uses simplified cognitive–behavioural strategies to help adults to manage distress, depression, anxiety, stress and practical problems in settings with limited specialist mental health resources. ¹¹ Ukraine’s strong digital capacity provides an important advantage: the Diia digital ecosystem and associated e-health infrastructure could serve as a national conduit for distribution of virtual nature content and short instructions, as well as for collection of brief outcome data. Equipment requirements are modest, because sessions do not depend on a single technology: they can be delivered through existing screens or communal display systems in shelters, clinics or community centres, or through portable tablets or virtual reality headsets deployed through non-governmental organisation and municipal networks. Sessions could also be delivered in a self-guided format using preloaded content and brief instructions, and basic facilitator training in safe use and trauma-sensitive relaxation techniques would enable community workers or volunteers to provide support where needed.

Acceptability and uptake will depend partly on how the intervention is framed. In conflict settings, some individuals may be reluctant to engage with anything presented explicitly as mental healthcare, particularly when immediate threats remain present. In such contexts, technology-assisted forest bathing may be better introduced as a brief, optional self-care practice for rest, stress reduction and emotional recovery, rather than as formal psychological treatment. ^{Reference Kotera12} Embedding sessions within existing support activities in shelters, clinics or community centres may further reduce stigma and improve uptake, while preserving flexibility for those who do not wish to participate.

Safety considerations remain essential. Although virtual reality and screen-based exposures are generally well tolerated, participants should be screened for motion sickness, photosensitive seizure risk or trauma-related triggers. For some individuals, nature imagery may also evoke grief, homesickness, or painful memories of places damaged or lost during war. Content should therefore be introduced gently, with options to pause, stop or choose alternative natural scenes. Feedback loops and qualitative evaluations could guide refinement and local adaptation. Future adaptation in Ukraine should therefore involve co-design with local psychologists, artists and community organisations to ensure cultural sensitivity and maximise psychological benefit, ^{Reference Kotera, Newby, Kuzman, Gorwood, Fiorillo and Slade13} consistent with the WHO European Framework for Action on Mental Health 2021–2025, ¹⁴ which emphasises integrated, person-centred and community-based mental health support.

Through a combination of technological innovation with nature-based healing principles, technology-assisted forest bathing offers a feasible, low-cost and human-centred strategy for enhancing mental well-being in conflict-affected populations. It also exemplifies how psychiatry can integrate digital tools and natural restoration to foster resilience and recovery under the most challenging circumstances.

Policy and research implications

This proposal is aligned with recent European Psychiatric Association priorities related to digitalising mental healthcare and innovation in service delivery. ¹⁵ Integrating technology-assisted forest bathing into existing psychosocial frameworks could enable support to be extended to people who remain outside formal services owing to insecurity, mobility restrictions or workforce shortages. At a global level, the approach is consistent with the WHO Mental Health Gap Action Programme and the United Nations Sustainable Development Goal 3.4, both of which emphasise scalable mental health promotion and illness prevention.

The next research step will be to conduct feasibility and acceptability trials in collaboration with Ukrainian and European partners. Mixed-methods designs should assess both symptom change and experiential outcomes such as calmness, nature connectedness, and sense of belonging or hope. Such evidence could guide practical recommendations for integration of virtual nature within community and humanitarian mental health settings.

As the war continues to reshape Europe’s public health landscape, clinicians and researchers are challenged to think creatively. Technology-assisted forest bathing represents one such innovation that is evidence-informed and culturally adaptable.