Why better conversations may matter more than blanket restrictions Image Source: Shutter Speed on Unsplash As a Senior Research Fellow in Digital Health at King's College London, I've spent the past few years speaking with young adults about social media and mental health. As the UK moves towards restrictions on social media use for under-16s, alongside other countries taking a similar approach, public discussion often comes down to a simple question: is social media good or bad for young people's mental health? To explore this topic, my colleagues and I interviewed 28 young adults aged 18 to 25 from across England who were experiencing anxiety or depression. We used these interviews to explore two related questions. First, we explored how young adults used social media, how their experiences varied with their mood, and how they tried to manage their use. Second, we explored what made it easier or harder for them to seek support from primary care when they felt social media was affecting their mental health. Their experiences suggested that asking whether social media is simply “good” or “bad” is the wrong question. Their accounts were rarely positive or entirely negative. Social media helped them stay connected, find support and access information, but it could also fuel social comparison, increase anxiety and insecurity, and expose them to upsetting content. Many felt social media affected their wellbeing, yet few discussed it with a healthcare professional, despite wanting support to manage its impact. Looking Beyond Screen Time Image Source: Getty Images on Unsplash+ When social media and mental health are discussed, the focus is often on screen time. How many hours are young people spending online? Are they using their phones too much? Should they spend less time scrolling? These questions are understandable, but they may not tell us much about how social media affects mental health. Researchers increasingly argue that we need to move beyond screen time and pay closer attention to what young people are doing online, why they use social media, and how different people experience it. In an analysis of our interviews that we are currently preparing for publication, we explored how social media use varied with mood and how young adults tried to manage it. The young adults described social media as woven into everyday life. It was where they stayed in touch with friends, organised plans, found entertainment, followed hobbies and connected with people who had similar experiences. For some, it even helped them better understand their own mental health. At the same time, participants talked about social comparison, pressure to present a perfect life, distressing content, and the feeling that social media could consume far more time than intended. Social media was not one single experience. The same platform could provide support and connection one day, while contributing to stress or self-doubt the next. Simply measuring screen time risks missing the bigger picture. Why Mood Matters Image Source: Getty Images on Unsplash+ One of the strongest themes in our analysis of everyday social media use was that social media felt very different depending on a person's mood. This mattered especially because the young adults we spoke to were experiencing anxiety or depression, meaning social media was often used when they already felt emotionally vulnerable. Many participants described turning to social media during low mood. Sometimes they wanted distraction. Sometimes they wanted reassurance. Sometimes they simply wanted to feel less alone. For some, this helped. Funny videos, messaging friends, or finding content from people with similar experiences could provide comfort and connection, particularly when seeing people face-to-face felt too difficult. However, low mood could also make social media harder to manage. This was not simply about willpower; algorithms and platform features played an important role. Young adults described becoming trapped in cycles of endless scrolling, encountering upsetting content, or being drawn into comparisons that reinforced feelings of inadequacy. Several spoke about algorithms repeatedly showing them similar content once they had engaged with it, making negative patterns harder to break. One other study exploring how adolescents experienced algorithmically curated feeds also found that repeated exposure to recommended content could shape mental health and wellbeing. Content that captures attention, whether comforting, upsetting or difficult to look away from, can become part of a cycle that keeps similar material appearing. In contrast, social media often felt different when participants were in a more positive frame of mind. They tended to use platforms more intentionally, messaging friends, sharing experiences, or seeking content that matched their interests. Some spent less time online because they were busy with work, studies, hobbies or offline social activities. These experiences highlight an important point. Instead of asking, “How much time are you spending on social media?”, we might learn more by asking, “What are you doing online, what is being shown to you, and how does it make you feel?” The Missing Conversation in Mental Health Care Image Source: Vitaly Gariev on Pexels Primary care is often the first place young adults seek help for mental health concerns, but little is known about whether they feel able to discuss the impact of social media there, or what support they need. In our interview study, we also explored young adults' views on discussing social media with primary care and other healthcare professionals. Although many felt social media affected their mental health, only a small minority had raised it with a clinician. Yet many said they would welcome the opportunity. So why were these conversations not happening? Some participants worried they would be judged. Others feared being told to spend less time on their phones, when the issue felt much more complex. Several described a generational gap, worrying that older professionals might not fully understand growing up in a digital world. Many also worried that social media would either be blamed for all their difficulties or dismissed as unimportant. Neither response felt helpful. Healthcare professionals may also struggle to know what support to offer, partly because there is still limited evidence-based guidance on how to discuss social media in mental health care, or what practical advice is most likely to help. What participants wanted was practical, non-judgemental support. They wanted help identifying triggers, understanding how social media affected their mood, and finding strategies that worked for them. They wanted professionals to be curious about their experiences rather than assume they already knew the answers. This matters because restrictions are unlikely to remove social media from young people’s lives entirely. Early evidence from Australia suggests many teenagers continued to use social media after under-16 restrictions came into effect. Age restrictions also do little to address the design of social media platforms, including algorithms and features that encourage prolonged engagement or repeated exposure to distressing content. These features can affect users of all ages, not only those under 16. If social media is to remain part of young people’s worlds, support should focus not only on whether they use it, but on how they can navigate it in more positive ways. We Need Better Conversations My research suggests that the conversation needs to move beyond whether social media is simply “good” or “bad”. A more useful question is how we can help young people maximise its benefits while reducing its risks. For parents, this might mean asking what a young person is seeing online rather than focusing solely on how many hours they spend there. For healthcare professionals, it may mean creating space for routine, non-judgemental conversations about social media during mental health consultations. For policymakers, it means recognising that protecting young people's mental health requires more than debates about access alone. It also requires attention to platform design, digital literacy, mental health services, community support, and the wider social environments in which young people live. Young people are already thinking about the role social media plays in their lives. They're already having these conversations. Perhaps it's time the rest of us started listening.

We need to talk about sex in mental health settings. In recent years, it has become widely recognised that people living with psychiatric disorders experience a disproportionate burden of preventable physical illness. Research suggests that people with Severe Mental Illness (SMI) die 15-20 years earlier than the general population, with physical health conditions contributing substantially to this mortality gap. Growing recognition of this inequality has driven efforts to improve the prevention and treatment of cardiovascular disease, diabetes, obesity, and smoking-related illness in psychiatric populations. But one important area of physical health remains significantly neglected: sexual and reproductive health. People with SMI have a two- to four-fold increased risk of sexually transmitted infections (STIs) compared with the general population. Uptake of cervical screening (which tests for high-risk strains of HPV that can lead to cervical cancer) is lower among people with SMI, while cervical cancer mortality is higher. Yet research suggests that only around 54% of people with SMI access sexual and reproductive healthcare services. There is therefore a clear disparity in need vs provision. As a PhD researcher working at the intersection of women’s mental, sexual, and reproductive health, this disparity stood out to me. In response, I developed ACcess to CErvical and Sexual health Screening in Mental Health settings (ACCESS-MH), bringing together a multidisciplinary team of clinicians, nurses, and researchers alongside gynaecological health technology company Daye to explore a different approach to sexual healthcare within mental health services. But before I explain what we are doing, it is important to understand why this gap in care exists in the first place. The Gap in Sexual Healthcare There is no single explanation for these inequalities: the barriers to accessing adequate sexual healthcare are multiple and interconnected. At an individual level, mental health symptoms can make it harder to recognise a health need, arrange an appointment, or attend screening. Stigma, shame, and fear surrounding sex and sexual healthcare can create further barriers, particularly when procedures are intimate or invasive. Sexual health is also still surrounded by stigma and embarrassment, meaning patients may feel uncomfortable raising concerns themselves, while clinicians may feel equally uncomfortable asking. This is especially important given that people with SMI are at greater risk of experiencing sexual violence than the general population, with women disproportionately affected. Cultural and religious factors may also influence how comfortable someone feels discussing sexual health or accessing existing services. These barriers may be particularly pronounced for some groups. Trans and gender-diverse people can face additional barriers to sexual and reproductive healthcare, including stigma and discrimination, services that are not designed around their needs, and assumptions about their bodies, sexual practices, or screening requirements. For trans people who also experience SMI, these barriers may intersect, creating additional challenges in accessing appropriate and affirming care. But these barriers do not sit solely with patients. In my conversations with clinical staff, discomfort around sexual health has at times been palpable, with many describing a lack of training, knowledge, and confidence in discussing sexual health and sexual healthcare with patients. And perhaps this reflects a much wider problem. As a society, we are still uncomfortable talking openly about sex. When that discomfort follows us into healthcare, sexual health needs can go unspoken, unasked about and ultimately unmet. Our collective discomfort with talking about sex could be costing our patients their health, and, in some cases, their lives. There are also significant barriers within services. When someone is acutely mentally unwell, other aspects of their health can understandably fall down the list of immediate clinical priorities. In inpatient mental health settings, sexual health is not routinely assessed, meaning that identifying a potential infection can depend on either the patient raising it or staff recognising symptoms. Even when a need is identified, screening and treatment are generally provided outside the mental health service, requiring already stretched staff to arrange and coordinate chaperoned appointments at external sexual health clinics. For patients experiencing fluctuating or severe symptoms, and staff working in busy, under-resourced, and often short-staffed services, ensuring timely access to care can be challenging. As a result, important opportunities for screening, treatment, and prevention can be missed. The consequences can be substantial. Many sexually transmitted infections cause few or no symptoms initially, yet if left undiagnosed and untreated can result in chronic pain, infertility, and other serious health complications such as cancers. Delayed diagnosis also creates opportunities for ongoing transmission. However, mental health services may also offer a unique opportunity to address these inequalities. For many people with SMI, mental health professionals are among their most consistent points of contact with the healthcare system. Rather than expecting people to navigate another disconnected service, could we make sexual healthcare more accessible within the services they already use? This is the question that led me to develop ACCESS-MH. What is ACCESS-MH? ACCESS-MH is an ongoing, co-developed, multidisciplinary implementation study investigating how Daye’s diagnostic tampon could be used within psychiatric services, allowing women and people with a cervix to self-collect a sample that can be tested for HPV and sexually transmitted infections. Importantly, we are not testing whether the tampon works as a method of collecting samples. The technology has already been developed and demonstrated to effectively collect diagnostic samples. Instead, our question is: how can we implement this technology acceptably, safely, and feasibly within mental healthcare settings? Self-sampling could remove some of the barriers associated with traditional sexual health screening by giving people greater privacy, autonomy, and control. But an effective technology will only improve healthcare if it can work for the people using it and within the services delivering it. ACCESS-MH will therefore aim to work across a combination of inpatient and outpatient mental health settings to understand how this approach can be incorporated into real-world psychiatric care. Where Are We Now? ACCESS-MH is currently in its protocol-development phase, with co-production guiding every stage of the process. Central to this is our group of 10 Lived Experience Contributors (LECs), who bring diverse perspectives across age, ethnicity, gender, socioeconomic circumstances, and cultural backgrounds. Through a series of co-production workshops, they are involved in protocol development from start to finish, shaping every major study decision – from which patient groups and clinical settings we prioritise, to recruitment and consent, study procedures, how the diagnostic tampon is introduced, and how results and follow-up care are managed. Alongside this, I am consulting with up to 30 clinical staff across both inpatient and outpatient mental health services, including nurses, support workers, occupational therapists, psychologists, and psychiatrists. These consultations will allow us to understand the practical realities of delivering the study: what would work within existing clinical pathways, where additional demands might fall on staff, and what barriers need to be addressed before implementation. Together, these perspectives give us a 360-degree view of implementation, combining the expertise of people who use mental health services with those who deliver them. Our aim is to develop a protocol that is trauma-informed, inclusive, accessible, and scientifically robust, while also being genuinely feasible within busy mental health services. By identifying and addressing barriers before implementation, we hope to develop an approach that works for both patients and clinical teams, and therefore has the potential to create meaningful, sustainable change in access to sexual healthcare. Illustration by Masantocreative on Unsplash Looking Beyond ACCESS-MH More broadly, ACCESS-MH forms part of a bigger question about how we address physical health inequalities in psychiatry. Identifying inequalities is only the first step. We need to understand the barriers that sustain them, use implementation science to determine what actually works in real-world services, and embrace innovations that can make healthcare easier to access. Crucially, we need to design solutions alongside the people who will use and deliver them, not for them. For sexual health, this also means normalising conversations about sex. Patients need to feel able to raise sexual health concerns, and clinicians need the confidence to ask about them without embarrassment or shame. Better access will only go so far if we remain uncomfortable having the conversations that enable it. Achieving genuine, real-world change also requires working across traditional boundaries, bringing together researchers, clinicians, frontline staff, people with lived experience and industry innovators. Each brings a different form of expertise, and none is sufficient in isolation. The ambition therefore extends beyond ACCESS-MH or any single diagnostic technology. ACCESS-MH is one attempt to demonstrate what can happen when lived experience, clinical expertise, research and innovation come together to design healthcare differently; making sexual healthcare a more accessible, routine and stigma-free part of mental healthcare. Illustration by Alghozy on Unsplash

Image Source: Alex Shuper on Unsplash+ I have always wanted to understand how the brain works. When I was 6, my grandfather had a serious stroke. This always witty, happy, active man became quiet, sad, and unable to move the left side of his body. He stopped eating to try to end his life several times but was kept alive with feeding tubes until he passed 5 years later. Soon after, I came across the author Oliver Sacks. His books taught me that the brain doesn't just support who we are; it is who we are. Everything from how we move, to our behaviours, can be explained by brain processes. My grandfather's left-sided weakness was due to a blood clot stopping a blood vessel feeding the right side of his brain, but the mechanism underlying his personality change and depression was unknown. This is what inspired me to investigate the processes underlying mental illness. I went to medical school with the intention of becoming a neurologist, but I was consistently drawn to the mental aspects of conditions. Although I enjoyed lectures on psychopathology, it was during my time on psychiatric wards that I really learned about the impact of mental illness. I underwent my psychiatry training at the South London and Maudsley and East London NHS Foundation Trusts, splitting my time between treating people with schizophrenia and using brain scans to investigate mechanisms underlying the disorder. I am honoured that this research, which I present below, was recently awarded the Alfred Meyer Prize from the Psychiatry Research Trust for work on the relationship between brain mechanisms and mental illness. My passion drew me to researching schizophrenia, the mental illness that carries the greatest burden and whose symptoms are among the hardest to understand. People with schizophrenia often believe that others are trying to harm them or hear the voices of people who aren't there. As if that weren't hard enough, the condition also affects memory, motivation, and thinking. As a psychiatrist, I find it hard that our current treatments don't work well for many people with schizophrenia and often cause intolerable side effects. If we can understand the brain differences underlying the condition, we may be able to develop better treatments. The living brain is difficult to study as samples cannot be taken to analyse whilst people are alive. Much of what was first learned about mental illness came from examining the brains of people once they die (postmortem). However, this cannot tell you what is happening when the person is unwell. Brain scanning has allowed exploration of brain mechanisms during mental illness. My colleagues and I used novel scanning techniques in the hope of discovering new factors that contribute to schizophrenia. Our findings suggest that low brain iron may underlie aspects of the illness. This sounds surprising at first, as we associate low iron with tiredness and anaemia, not hearing voices and losing touch with reality. Why Iron Matters Iron is a mineral found in red blood cells which allows them to carry oxygen around the body. Iron deficiency can lead to anaemia, which leaves people tired and weak. Iron is also essential for many brain functions. When brain iron levels are low, this can impair how brain cells fire and is linked to fatigue and memory problems. Iron deficiency is the most common nutritional deficiency worldwide, affecting 1 billion people. Therefore, if low brain iron levels do contribute to schizophrenia, this could theoretically affect many people. However, the majority of people with an iron deficiency do not develop schizophrenia, pointing out that low iron alone is not a cause of the disease. It is more likely that low iron levels interact with other mechanisms to increase vulnerability to developing schizophrenia. Furthermore, iron supplements can effectively increase blood and brain iron levels, indicating that the abnormality may be remedied using existing treatments. Findings from a study my colleagues and I published in Molecular Psychiatry in 2025 suggest that iron levels in the dopamine brain centres are lower in people with schizophrenia than in people without the condition. Dopamine is a chemical messenger in the brain which regulates aspects of response to rewards, motivation, attention, and mood. In schizophrenia, altered brain dopamine levels are linked to worse symptoms. For this reason, and because iron is needed for adequate dopamine function, low iron levels in dopamine brain centres may contribute to symptoms of schizophrenia. What Earlier Studies Missed Low brain iron levels in schizophrenia had never been robustly demonstrated before. The earliest attempts measured iron in brain tissue after death and found no consistent differences. This is probably because death alters brain iron levels, making it difficult to know what iron levels are during active illness. My study instead used magnetic resonance imaging (MRI), which uses powerful magnets to produce detailed images of the living brain. Because iron is magnetic, MRI can be used to estimate the amount of iron present. Earlier studies using this approach had linked schizophrenia to both higher and lower brain iron levels. However, they hadn't accounted for materials that oppose iron’s magnetic field, such as myelin. Untangling Iron From Myelin Image Source: Allison Saeng on Unsplash+ Iron and myelin push the MRI signal in opposite directions, meaning that the scan reflects a balance between both measures. A gain of myelin can therefore look like a loss of iron, and a loss of myelin like a gain of iron. Not separating the two may explain why earlier studies contradicted one another. Myelin is the white fatty coating that insulates nerve fibres and speeds up signalling between brain cells. Its abundance is why nearly 50% of the brain, known as white matter, is white! To resolve this issue in our study, we used two MRI techniques: one sensitive to iron and another sensitive to myelin. Our results indicate that both iron and myelin concentrations were lower in patients with schizophrenia. Pinpointing the Cause of Our Findings To help identify the underlying pathological process, we compared our map of iron loss with maps showing the distribution of cell types. The largest losses were concentrated in regions rich in oligodendrocytes. Intriguingly, these cells store large amounts of iron and produce myelin. This could mean that when oligodendrocytes lack sufficient iron, they may be unable to form myelin properly. Our findings suggest that schizophrenia may involve a loss of both iron and myelin, tied together through the dysfunction of these cells. Why This Matters Our results suggest that patients with schizophrenia have low iron levels in the dopamine brain centres. Dopamine is a chemical that brain cells use to communicate with each other, and people with schizophrenia have been shown to have too much dopamine—a hallmark of the disorder. We recently showed in our 2025 paper, published in The American Journal of Psychiatry, that low iron levels in the dopamine centres were related to excess dopamine production in those with schizophrenia. Given the finding that increasing brain iron levels in rats decreases dopamine production, we hypothesise that increasing brain iron levels in people with schizophrenia may be a potential treatment mechanism. There is a long way to go before any of this reaches the clinic. But the possibility that something as fundamental (and as fixable) as iron could play a part in schizophrenia is exactly the kind of answer that made me fall for this field in the first place. Luke Vano is a recipient of the Psychiatry Research Trust’s Alfred Meyer Prize, which recognises outstanding research into the relationship between brain mechanisms and mental illness. If you would like to support the next generation of researchers working to advance our understanding of mental health, please consider supporting the Psychiatry Research Trust.

Image Source: Cup of Couple on Pexels “ADHD is not a knowledge or a willpower problem—it's an execution problem. Most people with ADHD already know exactly what they need to do. The challenge is getting started and consistent follow-through. Effective ADHD management isn't about trying harder, but adapting your environment to work with your ADHD, not against it.” ADHD diagnoses in England have risen sharply since 2020, though diagnosis still lags behind estimated prevalence. But for many, diagnosis is just the beginning. While finally having an explanation for years of challenges can bring relief, a new question follows: What now? Understanding you have ADHD is one thing; learning how to manage it is another. I’m a therapist for ADHD, with ADHD. Before specialising in ADHD therapy, I experienced many of the challenges I now help clients overcome: overwhelm, procrastination, emotional intensity, difficulty prioritising, and the constant feeling that 'I should be coping better'. My diagnosis was validating and made sense of these experiences, but understanding why I struggled didn't automatically teach me how to manage day-to-day. ADHD services often stopped at diagnosis and medication, while therapy felt rigid and rarely understood the realities of ADHD. That gap between diagnosis and practical support led me to specialise in ADHD therapy. Drawing on clinical practice and lived experience, I now help adults build systems that work with their ADHD, rather than against it. Here are some evidence-based strategies that can help you do the same. What Actually Works One of the biggest challenges I see in adults with ADHD, and one I understand personally, is task initiation. Knowing what needs to be done is rarely the problem—it’s turning intentions into actions. One way to reduce this is through behavioural priming — using environmental cues or actions to signal to our brain that it's time to get started. Small, concrete actions like opening your laptop, picking up your gym bag or opening the document you've been avoiding reduces the mental effort needed to begin. This shifts the task from abstract to physical, transitioning you from thinking about the task to actively doing it. Another strategy I frequently recommend is body doubling — physically working alongside another person, completing tasks while on the phone to someone, working in a cafe, or joining a virtual co-working session. Having another person present can reduce the executive-functioning demands associated with getting started, making task initiation feel more manageable. While research is still emerging, many report improved focus, accountability, and follow-through. Motivation Follows Action However, knowing what strategies to use is only part of the process. An important skill is taking action, even when motivation isn't present. Many people with ADHD experience emotions intensely, making uncomfortable feelings such as boredom, frustration, anxiety, or rejection difficult to tolerate. This can create a pattern of waiting to feel motivated, confident, or "in the mood" before starting. However, motivation often follows action, rather than the other way around. Effective ADHD management involves learning that uncomfortable emotions don't have to determine your behaviour. Feeling bored does not mean you should stop, and feeling anxious does not mean you cannot begin. The goal is not to eliminate discomfort, but to build the ability to take meaningful action while those feelings are present. This might mean continuing a project despite low motivation, exercising when you’re not in the mood, or returning to a difficult task after challenging feedback. Readiness is not a prerequisite for action; learning to tolerate discomfort helps you stay committed, even when difficult emotions are present. Externalise Everything A common mistake many adults with ADHD make is relying on our brains to remember everything and stay organised without systems in place. ADHD significantly affects executive functioning abilities — the mental processes responsible for planning, organisation, working memory, and time awareness. Rather than relying on memory alone, externalising everything shifts information out of your head and into your environment, which reduces cognitive load. This might mean making information visible by using calendars, whiteboards, sticky notes, reminders, or written plans, rather than trying to keep everything in your head. It also means placing reminders where the behaviour happens. For example, keeping medication beside your toothbrush, sticky note reminders on your laptop, or leaving items you need by the front door. Allow your environment to prompt the action, instead of relying solely on memory. Time can also be externalised. Because adults with ADHD experience time-blindness, visual timers, hourglasses, and analogue clocks can help make the passage of time feel more concrete. Similarly, scripts and checklists for repetitive or cognitively demanding tasks, such as getting ready for work or doing the weekly grocery shop, can reduce the number of decisions you have to make in the moment, making it easier to follow through. The less your brain has to hold onto, the more mental energy it has available for taking action. Image Source: cottonbro studio on Pexels Progress Over Perfection One of the biggest barriers I see, both in myself and in clients, is perfectionism. Perfectionism is a common thinking pattern in ADHD and can derail progress. This often sounds like “I’ll do it when I’m in the mood” or “I’ll start once I know I can do it properly.” The problem is that waiting for the perfect moment often means never starting at all. For many people with ADHD, perfectionism can become another form of avoidance, creating such high expectations that beginning the task feels completely overwhelming. Two techniques can help with perfectionism: time-bounding and task-bounding. Time-bounding might involve committing to working for a set amount of time rather than focusing on completing the entire task. For example, planning to clean for 15 minutes rather than cleaning your entire bedroom. Alternatively, task-bounding involves setting a specific endpoint within the task, such as working until one section is complete, rather than trying to finish the entire task. This reduces the cognitive load of the task by shifting focus from the end goal to a smaller, more achievable step, making action feel more manageable. Image Source: Tara Winstead on Pexels Quieting the Inner Critic ADHD perfectionism is frequently accompanied by a strong inner critic. Many adults with ADHD have spent years being criticised and often told they are lazy, failures, or not trying hard enough. Over time, these external messages can accumulate and become internalised, shaping the way they speak to themselves. Learning to notice these thoughts and label them, rather than automatically believing them, can be a powerful first step. The aim isn't to eliminate all self-critical thoughts, but to change how you respond to them. Instead of being pulled into the "I'm a failure" thought, you might practise noticing, “I’m having the thought that I'm lazy” or "I'm noticing my inner critic telling me I'm a failure." This small shift creates distance from the thought, making it easier to decide how to respond rather than automatically believing the inner critic. This approach, known as cognitive defusion, comes from Acceptance and Commitment Therapy (ACT), an approach with emerging evidence for ADHD. This creates space to choose actions based on your values and goals, rather than being guided by self-criticism. Effective ADHD management isn’t about trying harder or fundamentally changing yourself; it’s about adapting your environment and implementing systems that help you work with your brain, not against it. This article has been sponsored by the Psychiatry Research Trust, who are dedicated to supporting young scientists in their groundbreaking research efforts within the field of mental health. If you wish to support their work, please consider donating.

You think your twenties are going to follow the shape of New Girl or Sex and the City. You forget most of these characters are in their thirties because that doesn’t fit the narrative, and your twenties are all about the narrative. You’re expecting an eclectic gut-punch of a decade, but there’s probably still a worrying amount of quiet. Give yourself a little more time because, well, 2020 happened, and more worldly events seem to keep happening on top of it. Until you realise the quiet moments are your twenties: quietly anxious, quietly hopeful, quietly despondent. It’s no wonder that this period is associated with having a mental breakdown. It can be kind of lonely, huh? Image Source: Priscilla Du Preez on Unsplash I’m Chloe Johnson, and as a writer in my twenties living with an anxiety disorder, I can see why the image of the scared, confused, somewhat jubilant young person coming-of-age is particularly captivating. There’s a dichotomy in your twenties. An air of mystique that it’s for messing up alongside a crippling pressure that it’s a defining decade where you have to actually be something, not just dream it. You can feel the carefully placed weight of time, the creeping sense of dread that you’re falling behind. It can be difficult not to sacrifice your well-being on the quest to ‘have it all’. All of this is quite well-documented. This won’t be the first article you’ve read on the subject of the perilous twenties; they'll tell you it makes sense to feel behind, immature, lost. After all, suddenly, life is no longer highly structured and typical adult milestones that might have once applied feel harder to reach. For those with a uterus, add to that societal pressure to start thinking about the biological aspect of the future, and you have a cocktail for anxious existentialism. But what happens when you add an anxiety disorder on top? In your twenties, everyone you know is biting the bullet on something (starting a business, travelling, having kids, rewatching their comfort show for the tenth time). But for the (a little over) 1 in 10 of us living with an anxiety disorder in the UK, the indecision about biting the bullet or sending the bullet in the opposite direction is the task. And it can be paralysing. Your twenties are meant to be a decade of making messy mistakes – but when you have an anxiety disorder, especially conditions such as obsessive-compulsive disorder (OCD), which involves recurring unwanted thoughts or repetitive behaviours; post-traumatic stress disorder (PTSD), which can develop after experiencing or witnessing trauma; or agoraphobia, an intense fear of situations where escape may feel difficult (or symptoms closely related), you might struggle to cope with anything short of perfect. To even get out there and experience those ‘mistakes’ in the first place. Diana Oliver wrote about this in her feature exploring agoraphobia - ‘the true definition of agoraphobia falls short of the literal meaning that usually accompanies the word. This is because far from implying a fear of open spaces, it’s actually a fear of fear itself.’ Gen-Z and young millennials, in particular, are noted to be struggling when it comes to issues of self-esteem and anxiety that consume them. It’s easy enough to dismiss these feelings and just blame the damn phones, but there's a huge cultural shift at play. The creep of all things digital has not only allowed us to live increasingly online lives, but also to know more and more about our mental health and each other than ever before. Image Source: Pawel Janiak on Unsplash This is obviously extremely helpful. More of us than ever know what to look for as markers of struggling mental health. But it can also be a bit of a trap, especially for those predisposed to self-examination. Gen Z are increasingly plugged in politically, rejecting the expectation of emotional labour and advancing causes around mental health, so we’re more self-informed than generations before. But when people spend a lot of time analysing every uncomfortable feeling, practically, it can make you feel stuck: as if there are no good options. We’re also more likely to keep an eye on the world at large, as well as to self-examine. Digital overload can have us feeling like the world is in crisis; some we are largely at a loss to help, others we feel uniquely responsible for. According to a survey by Extra Gum, 28 per cent of Gen Z describe themselves as 'chronic overthinkers', with 32 per cent reporting that overthinking happens every single day. Indeed, as we enter the era of ‘maxxing’, where everything can be optimised, we can see that a predisposition to ‘fix’ things can sometimes even make things worse. There’s a reason that incredibly successful artists such as Olivia Rodrigo and Noah Kahan are listened to so widely, especially as they articulate the feelings of extreme anxiety, perfectionism and obsession. While it can seem simple to add two and two together and say that if young people went out more and got off their phones, the ‘anxious’ generation would get a lot better, it ignores a lot of the changes to modern society. Third spaces which by definition are informal places outside home and work or school where people can socialise - on the whole have decreased, and half of adults now spend less than three hours a week in natural settings such as gardens, parks, fields or woods, according to a survey by the Wildlife Trusts. With fewer third spaces, there’s less emphasis on just ‘hanging out’. Connection then turns into something deliberate: added pressure to do stuff in the best way. There is also pressure to be on social media to create a ‘brand’, which is a subtle hum beneath everything as job security continues to feel more mythical – and for those who struggle with chronic illness or other disabilities, connecting online can be a meaningful way of connecting and seeking community. Of course, offline groups and hobbies not connected to our phones can definitely be helpful, but it’s the blame (and the pressure) put on the individual that can make anxiety disorders such a lonely condition in your twenties. For those of us struggling to make the same ‘mistakes’ as our peers in our twenties due to anxiety disorders or, conversely, feeling like we’re making too many of them, connecting online can help us realise that you can’t actually ‘waste’ your twenties. In fact, many women in their thirties and beyond, especially those diagnosed with mental health or neurodivergent conditions, are sharing about how life only gets better as you learn more about yourself and find your own coping mechanisms, knowing the boundary between self-care and pushing yourself is definitely one that needs to be tried and tested first. Image Source: CHUTTERSNAP on Unsplash And you’re likely doing that, even when you think you’re making no progress. Jackie Adedeji said it best in her Substack on 30: “So, on reflection 30 feels like…we have plenty of time to sometimes live a little slower, fall, make mistakes, enter adversity, create stuff that makes no sense to anyone, fail, cry, have numerous breakdowns, dust ourselves off and then eventually come back to who you are because guess what? I’m back.” There’s a prevailing 24-hour clock analogy that suggests that at 30 years of age, it's just after 9.00 am in the morning. No wonder you’re anxious; you might not have even had your coffee yet. The fear of making mistakes might be amplified with an anxiety disorder, and the milestones might look smaller from the outside, but the tiny, subtle shifts that shape who you’re growing to be? They’re still happening, even on the worst of days. This article has been sponsored by the Psychiatry Research Trust, who are dedicated to supporting young scientists in their groundbreaking research efforts within the field of mental health. If you wish to support their work, please consider donating.

A culturally sensitive family intervention for young people on the edge of care or custody I am Simone, a consultant clinical and forensic psychologist employed by South London & Maudsley NHS Foundation Trust. I am both a researcher and a clinician. I work within a National Specialist team that oversees the delivery of an evidence-based intervention to young people and their families, where there are high concerns around the young person’s behaviour. The intervention is called Multisystemic Therapy or MST. The aim of treatment is to prevent the young person from going into care or custody and to remain safely at home with their family. Image Source: Mart Production on Pexels What Is MST and Who Is It For? MST is a family intervention for young people (age 10-17) with significant behavioural concerns where they are at risk of going into care of the local authority or custody. Their behaviours might include physical aggression in the home, truancy or school exclusion, substance misuse and antisocial behaviour in the community. Referrals usually come from social care or via the criminal justice system. MST is recommended in the NICE guidelines for conduct disorder and there is a very strong evidence base, with over 110 published outcome studies. The family will be allocated a therapist who will meet them at times that are convenient for them, usually in their home and will work intensively (several times a week) for 3 to 5 months. There is also a 24/7 on-call system available for families during crises. The therapist will also work with various systems around the young person, such as the school, other professionals involved (including social workers, youth justice workers and the police) and the peer group. The therapist’s goal is to empower and skill up the carers so that they can better understand and support their child once the intervention is finished. Image Source: Cottonbro Studio on Pexels Working with Diverse Communities MST started in the US and has grown internationally. It is now delivered in over 15 countries worldwide. We have 30 teams working across the UK and Ireland. Although MST uses a model and therapists are guided by a set of treatment principles, each intervention is very much tailored to the specific needs of the family. MST therapists work with a diverse range of families, many of whom may be from racially marginalised communities. Young people from minority backgrounds are disproportionately represented across many stages of the care and criminal justice system. Many of the families we work with have had previous poor experiences of services, including social care, education and the police. Teams are skilled at working with interpreters and attending to issues of discrimination and racism. This is so vital in building good relationships with the young person and their carers. Trust and engagement often take time and the therapist is sometimes a bridge between the family and the wider professional systems, which may include advocating for them in meetings. Image Source: Gustavo Fring on Pexels Research on MST Working with Culturally Diverse Families I have been involved in several research projects that have looked at understanding the experiences of families from diverse communities, and the practitioners who are working with them. By listening to carers, young people and practitioners, we hope to learn and improve the service we provide to ensure it best responds to the needs of everyone we work with. Research with Carers: Research with Carers highlighted the therapist skills that help build good engagement. These include taking time to learn about the family’s culture, being culturally sensitive, asking questions and respecting differences. For second-generation young people, carers highlighted how differences between dual cultures can cause conflict in the home and the therapist may act as a cultural broker, helping them and their child to see things from each other’s perspectives. Research with Young People: Young people also talked about the importance of the therapist exploring the family culture and increasing their knowledge and understanding. They said that their parents might disengage if this was not done well. It was also important for therapists to explore the young person’s cultural identity which might include how both their parents’ culture and that of their friends impacts them. They also spoke about the therapist helping them to see things from their parents’ perspective and vice versa. Research with MST Therapists: Therapists talked about how experiences of systemic racism affect engagement, reluctance to share information and willingness to involve other systems in plans which could help them. For example, fear around contacting the police if their child is missing. Families often feel disempowered by the systems around them including education, social care and the criminal justice system. Therapists spent time helping families to understand how different systems work, preparing them for meetings and supporting them to have more of a voice. They would sometimes need to directly address oppressive practices and overt racism. Language barriers led to further power imbalance and there were challenges around using interpreters especially around the 24-7 on call system. Image Source: August de Richelieu on Pexels Impact The team I work for is responsible for the recruitment, oversight and training of the therapists and supervisors who work directly with the families. We have a Diversity and Inclusion Group where we are continuously reviewing our support to the teams. This includes developing resources and guidance to improve recruitment of a diverse workforce, career development for racially marginalised staff and training for teams. We take the voices of the young people, carers and therapists into account in shaping the work that we do. To conclude, MST is a systemic intervention that supports families from diverse communities. We are continually learning and adapting our practice based on findings from the research and the feedback that we get from families and the teams that we work alongside.

Author’s Note: My name is Kanika Phillip, and I am a big lover of music and carnival. Calypso and soca have always been genres that uplift me when I'm feeling low. This is a short story for anyone struggling to find their light again, particularly after grief — and how music and carnival can provide aid and comfort through those low moments. Carnival originates from our ancestors, yet we don’t always get the chance to truly honour them. Image Source: Glodi Miessi on Unsplash Since losing her Uncle Easton, Cara hadn't felt like herself — until she played mas again, dancing to groovy soca in the sun at Notting Hill Carnival. Cara has always been someone who keeps to herself. You could call her a lone wolf by nature — she keeps her emotions close, but is the kind of person who is always there to lend a listening ear and a smile to those on their heaviest days. Having first experienced depression at 15, Cara would wander into her dad's room and lie on his bed when he came home from work. She didn't say anything, but just having him there gave her the comfort she needed. Years went on, and Cara was better, just a few low moods here and there. That was until she lost her Uncle Easton, and her emotions came crashing in. He was a true West Indian from the emerald island of Montserrat, a permanent presence in her life since childhood and the reason she fell in love with her West Indian roots: from cognac to calypso, dancing, dominoes, and persistent laughter. After his passing, the weight of everyday life became harder and more confusing. For a while, calypso — the genre he first introduced her to — made her sad. But playing mas at Notting Hill Carnival in 2025 was a turning point. The celebration helped her fall in love with calypso again, seeing the genre as a form of light, not sadness. For those lucky enough to have met Uncle Easton, it was always a pleasure. A firm but kind man who was always laughing, always smiling. Cara once noticed an invitation to a christening on Uncle Easton's table. It was from a woman he had befriended at the local Irish pub. She asked him whose baby it was. Uncle Easton grinned and said, “Me nuh know, some pickney from a lady at the pub,” before they both burst out laughing. That pretty much sums up the person he was, always full of laughter and a story to tell. It was Uncle Easton who first played calypso for Cara on his stereo. She remembers Byron Lee and the Dragonaires blasting through the speakers, the groovy soca remake of Tarrus Riley’s ‘So Royal’ filling the room with electrifying beats, riffs, and steel pan. From that moment, she was hooked. Every week, she would sit with him and her Auntie Katie, listening to his stories — the same ones told again and again — but Cara never minded. She would smile and laugh as though she were hearing them for the first time, listening to her uncle reminisce about playing in a steel pan band in Montserrat and taking part in carnival parades. Together, Cara and her uncle would pore over old photos of beautiful women in elaborate costumes, dancing and smiling in the Montserrat carnival parade. When the chance to play mas at Notting Hill Carnival came around again, Cara was hesitant, but her big brother Joe convinced her to take part. Together, they looked through Uncle Easton’s old carnival photos, laughing as they remembered how he would joke that he could chip from Little Bay all the way to Antigua. Cara noticed a beautiful white costume her uncle once wore, covered in sparkling gems. While scrolling online, she came across a similar costume and instantly felt it was a sign to play mas again. On costume collection day, holding the costume in her hands brought a huge smile to her face. But on carnival morning, as she carefully put it on, tears filled her eyes as it reminded her of her uncle and the joy carnival brought him. Image Source: Rahimat Onize Shaibu on Pexels On Carnival morning, Cara stood in front of the mirror admiring the beautiful white gems sparkling across her costume. The crown sat perfectly on her head, making her feel elegant and powerful all at once. The costume hugged her figure in a way that filled her with confidence, while her glittering shoes completed the look. As she finished her makeup, highlighting her eyes and glossing her lips, Cara finally smiled at her reflection, feeling beautiful and ready for the road ahead. Taking one last look at herself before leaving, Cara grabbed her bag and headed out the door, the nervous excitement in her chest growing stronger with every step towards the road. “Joe, take a picture of me; I feel so beautiful,” Cara joyfully expressed. By 10:50 am, Cara and Joe were hurrying down Latimer Road, weaving through the crowds as they tried to catch their band before the 11 am set-off. “Joe, you’re always running on West Indian timing — we’re going to miss the band!” Cara shouted. Joe laughed and pointed ahead. “I think I see our band. See, Cara, they haven’t even left yet. I told you we were good.” They made it with just enough time to grab some leftover breakfast from the food truck: Johnny cakes and saltfish. The smell instantly took Cara back to carnival mornings with her uncle, who would make the same breakfast for her before the road. It made her feel at ease and ready for the day ahead. Joe points towards the sea of flags ahead. “Look, Cara, I spot Grenada, Curaçao, and Antigua. I recognise our beautiful sun on the flag anywhere, and the sun is actually shining too. Jheez, I can already sense good vibes." “You’re right, Joe. And look, I see three big Anguilla flags too! I’d recognise our dolphin pendant any day. Anguilla stay representing — I have to take a picture and send it to Mumzy.” Cara replied. Joe smiled as another flag caught both his and Cara’s eyes. They looked at each other and said in unison, “There’s Montserrat’s flag too.” “And the costume looks identical to Uncle Easton’s back in the day,” Joe added. For a moment, surrounded by music, laughter, and the colours of the Caribbean, Cara felt her uncle’s presence with her again. The band starts taking off, and Joe and Cara began dancing, the sun shining on their skin as smiles from random strangers in the band appeared while they sang together. The smell of Caribbean food drifted through the road as Cara and Joe passed stall after stall. Vendors sold steamed fish and callaloo while rum punch flowed into plastic cups. They spotted doubles, buss up shut and pilau from Trinidad, alongside ackee and saltfish, fried plantain and sweet festivals. Further along, Martinique and Guadeloupe stalls served fresh bokits stuffed with spicy fillings. Everywhere they looked, people were smiling — spectators waving whistles, babies perched on their parents’ shoulders, elderly couples dancing slowly together, and young people jumping to the music. For a moment, the whole road felt like the Caribbean gathered in one place. In the middle of the day, ‘Savannah Grass’ by Kes the Band starts playing. A beautiful song about the singer’s ancestors. Image Source: Jorge Bagnuoli on Pexels When Cara hears the song during carnival, she feels as though her ancestors are present with her in the moment — a sense of connection — like they are sharing the space with her. That moment gives Cara hope, a belief that wherever she is, her ancestors are with her, supporting and cheering her on. Cara starts to get lost in the moment as the day goes on, dancing alongside Joe and strangers in the band. “This takes me back, Cara, to younger days attending carnival with our family”, Joe said. Cara smiled. Full Blown’s “Good Spirits” starts playing, followed by Yung Bredda’s “The Greatest Bend Over”. Joe gives Cara a side-eye as she moves closer to a man in the band, ready to take a sweet wine. “Face yuh front, Joe,” Cara smirked. Joe bursts out laughing. As the judging point approaches and they prepare to cross the stage, ’DNA’ by Mical Teja comes on. Joe and Cara wrap their arms around one another, embracing as the carnival begins to come to an end. As Cara crossed the stage with her brother, she realised this day had been for Uncle Easton too. Every dance, every laugh, and every song along the road had become a way of honouring him and keeping his spirit close. “I’m so glad we did this, Joe. Thanks for convincing me,” Cara smiled. As the sky turned orange over Ladbroke Grove, the music still echoed through the streets long after the band had passed. Feathers brushed against strangers, whistles blew in the distance, and the scent of jerk smoke lingered in the evening air. Cara stood beside Joe, watching the final trucks roll by her, glitter catching the last of the sunlight. She thought about Uncle Easton — his laughter, his stories; the old carnival photos spread across the table. For the first time since losing him, the memories no longer felt painful to hold onto. Cara smiled softly and looked at Joe. “I think Uncle would’ve loved seeing us out here today.” This article has been sponsored by the Psychiatry Research Trust, who are dedicated to supporting young scientists in their groundbreaking research efforts within the field of mental health. If you wish to support their work, please consider donating.

In the villages and towns of Indian-administered Kashmir, mental illness often arrives disguised as something else. People complain of racing heartbeats, chest pain, breathlessness, dizziness, stomach discomfort, and fear. Many spend months, and sometimes years, visiting hospitals convinced they are suffering from heart disease or another physical illness. They undergo repeated tests, collect folders full of prescriptions, and move from one doctor to another in search of answers. What many eventually discover is that the illness they have been treating is not cardiac or gastrointestinal at all. It is anxiety, depression, trauma, or another mental health condition that remained undiagnosed because specialist care was unavailable. As a journalist, I have spent years reporting from Kashmir, a region where mental distress has become one of the most significant yet least discussed public health challenges. In district and sub-district hospitals, crowded psychiatric wards, and remote mountain villages, I encountered people whose journey to a diagnosis was often longer and more painful than the treatment itself. Their stories reveal how the dearth of psychiatrists, combined with geography, political violence, and stigma, continues to shape mental healthcare across the region. Patients queue for consultation at a government hospital in Srinagar. Photo by Irfan Amin Malik A Flutter, Then Fear As dusk settles over Kuchmullah, a village of orchards and rice fields in Kashmir, some 44 kilometres from the capital city of Srinagar, Sameena Akhtar (name changed) begins to worry. The 45-year-old has come to recognise the feeling. It starts with a flutter in her chest before her heart begins racing uncontrollably. Breathing becomes difficult. Sometimes she feels as though she is about to collapse. Wrong Diagnosis For nearly two years, Sameena believed she had a serious heart condition. Repeated visits to the nearby sub-district hospital brought electrocardiograms, medicines, and reassurances that nothing appeared seriously wrong. Yet the attacks kept returning. “My heart would beat so fast that I thought I was suffering from a serious cardiac problem,” she says. “I would become breathless and restless. Sometimes I thought I would die. The doctors kept telling me my heart was normal, but I knew something was wrong. I spent years moving from one doctor to another before somebody finally explained what was happening to me.” The answer came only after she travelled 44 kilometres to the capital city, Srinagar, and consulted a psychiatrist. The diagnosis was anxiety disorder. For Sameena, the discovery brought relief. It also brought frustration. Years had passed before anyone identified what she was experiencing. During that time, her husband, who works in a flour mill on a modest salary, spent thousands of rupees on consultations, medicines, tests, and travel. The family was searching for an illness they believed was affecting her heart, while the real problem remained untreated. No Specialist in Sight Every day, patients arrive at hilly sub-district hospital Tral complaining of racing heartbeats, insomnia, chest discomfort, unexplained fear, dizziness, and anxiety. Few suspect they are suffering from a mental health condition. Most arrive believing they have a cardiac or neurological problem. Yet there is no psychiatrist posted at the hospital, despite serving around 150,000 people. Most patients are seen by general physicians who do what they can with the resources available. ECGs are ordered, medicines are prescribed, and symptoms are managed. While the treatment may provide temporary relief, the underlying condition frequently remains undiagnosed. Dr Junaid Ahmad, a Bachelor of Unani Medicine and Surgery physician posted at the hospital, says the shortage of specialists has forced doctors to take on responsibilities far beyond their training. “Such is the dearth of doctors in government hospitals that BUMS doctors are asked to handle outpatient departments and manage the rush of patients irrespective of the disease,” he says. “We see patients with all kinds of complaints and the rush increases every evening. Many come with symptoms that later turn out to be related to anxiety or depression.” Patients wait to collect OPD tickets before their doctor consultations at the Sub-District Hospital, Tral. Photo by Irfan Amin Malik. Staggering Shortfall Dr Majid Shafi, a leading consultant psychiatrist in Srinagar and Nodal Officer for Mental Health and Addiction Treatment under the Directorate of Health Services Kashmir, puts the shortfall plainly. "There is a clear shortage of psychiatrists in Kashmir. As per WHO guidelines, one psychiatrist should be available for every 100,000 people. What we have instead is one specialist for half a million people." He estimates the region needs at least 140 psychiatrists. It has around 40 to 50. That gap is made worse by a fact the national figures alone do not capture: Kashmir's mental health burden is four times higher than the national average. A 2015 study found that 45% of the population in J&K was experiencing immense psychological distress. Studies estimate that nearly 45% of adults show signs of mental distress, depression affects 41%, anxiety disorders 26%, and PTSD 19%. Childhood mental health disorders affect up to 27% of children between eight and fourteen. Figures presented before the J&K Assembly this year confirmed that eleven districts are operating without a single psychiatrist. Roads Close, Patients Wait In Poonch, a mountainous and border district near the Line of Control, specialist mental healthcare is virtually absent. Zareena Banoo, 43 (name changed), struggled with severe anxiety and insomnia for years, repeatedly told by doctors that anaemia was the cause. In August 2023, she made the 170-kilometre journey to Srinagar with her son. "Doctors kept telling me it was because of weakness and low blood levels. I took the medicines, but my condition did not improve." A psychiatrist identified the problem almost immediately. Today medication helps, but she must return every two months. During winter, the Mughal Road connecting Poonch to the Kashmir Valley closes due to snow. "Sometimes my anxiety becomes worse and I want to consult the doctor, but travelling is not possible. Then I have to wait until the roads reopen." Fifty kilometres away in Pulwama, Kasim Jan, a 50-year-old tribal woman living in a tent with her family and livestock, has had severe anxiety for eight years. "Every time we migrate with our livestock, some animals die, the stress becomes unbearable, and my blood pressure rises. I have never found a psychiatrist who could help me.” Photo by Lalit Regar on Unsplash 200,000 Visits, One Facility For those who reach Srinagar, there is IMHANS, the Institute of Mental Health and Neurosciences, a 140-bed facility that recorded nearly 200,000 patient visits in 2025. Inside the jam-packed hospital, the families arrive carrying years of unanswered questions, having already spent months being treated for conditions they never had. At JLNM Hospital in Srinagar’s Rainawari, Dr Majid Shafi sees 120 patients from morning to evening. "One doctor cannot handle a huge clinic for hours together. The patient does not get adequate time, and that compromises quality care." His prescription is direct: one psychiatrist at every sub-district hospital, at minimum. Dr. Shafi estimates that 90% of mental health patients in Kashmir are currently being seen by neurologists and cardiologists rather than psychiatrists. Without a psychiatrist, each condition is treated as whatever it most closely resembles. The government has expanded access through Tele-MANAS, a 24-hour mental health helpline launched in 2022. It has helped primarily women experiencing anxiety, stress, and concerns about drug addiction. For more information, you can read my previous article here. However, mental health experts have cautioned that, while it is helpful, technology cannot replace psychiatrists and counsellors working on the ground. This article has been sponsored by the Psychiatry Research Trust, who are dedicated to supporting young scientists in their groundbreaking research efforts within the field of mental health. If you wish to support their work, please consider donating.

What I learnt from my wife’s experience, and why we do ourselves a disservice when we reinforce a mind-body divide Most of us will know that nausea and vomiting are common in pregnancy, affecting up to 70% of pregnant women. Less well known is hyperemesis gravidarum, or HG, in which nausea and vomiting reach a severity such that women struggle to eat or drink, often losing weight or becoming dehydrated, sometimes to the extent that they require intravenous fluids. As a neuropsychiatric doctor and researcher at King’s College London, I have a particular interest in the overlap of physical and mental health. Whilst I had a general awareness of HG from my medical training, it’s safe to say that I had never truly grasped just how debilitating and difficult to treat this disorder could be. Without going into detail, in late 2024 my wife Yasmeen developed HG while pregnant with our first child. She spent the next seven-to-eight months struggling with almost relentless nausea and retching, regularly calling in sick to work, and trialling first, second, and third-line treatments with little effect. At the time, I was reminded of a lecture in medical school during which an ENT professor emphatically informed us that persistent nausea can be just as debilitating as chronic pain. Last year, thanks to my good colleague and friend Dr Tom Pollak, I was given the opportunity to access TriNetX, an international database of anonymised health records. Perhaps in an act of sublimation, I decided to focus on the issue at the forefront of my mind, and attempt to answer the question, what happens to the mental health of women with HG? Image Source: Annie Spratt on Unsplash What Causes HG and How Might It Affect Mental Health? If you speak with anyone who has been affected, or cared for someone with HG, then you’ll know that it would be an understatement to describe the illness as “morning sickness”. HG can often leave women unable to care for themselves, work, or take part in family life, and this can sometimes persist beyond the first trimester through to delivery. Despite its severity, HG has long been underrecognised and inadequately treated, with patients reporting disbelief and difficulty accessing care. For much of the twentieth century, the underlying cause of HG remained the subject of inquiry, with proposed mechanisms ranging from hormonal sensitivity and gastrointestinal motility to metabolic and psychological drivers. Today we have compelling evidence for a causal pathway. Research led by Dr Marlena Fejzo and colleagues has shown that GDF15, a hormone produced largely by the fetus and placenta, and the mother's sensitivity to it, both contribute substantially to HG. As a clinician working in neuropsychiatry, it is easy to appreciate the enormity of identifying a putative biological marker of disease, not least as it may open the door to novel methods of diagnosis, monitoring, and targeted treatments. That it should require the discovery of a biomarker for an individual’s illness and suffering to be seen as valid by wider society or be considered treatable is perhaps a separate issue, one which I am certain many colleagues in mental health services can empathise with. There have now been several articles in the general media regarding tragic outcomes in women with HG linked with mental health. Similarly, important work by colleague Melanie Nana has served to shine a light on the psychological impacts of HG, finding that a quarter of women with HG had thoughts about suicide. Other studies have found increased rates of depression, anxiety and PTSD in women with HG, though the largest studies to date numbered in the hundreds to thousands of participants. Image Source: MART PRODUCTION on Pexels What Did Our Study Find? In our study, we identified 476,857 pregnant women with HG across 18 countries. We matched each of them with a pregnant woman without HG who was similar on factors including age and previous physical and mental health diagnoses. We then examined new diagnoses recorded during pregnancy and roughly three months following delivery. We found that women with HG had an increased risk of various mental health conditions. A new diagnosis of depression was recorded in almost 8% of women with HG, compared with about 4% of matched pregnant women. Postpartum depression was nearly three times as common, and anxiety disorders were almost twice as common. We also found higher risks of PTSD, eating disorders, suicidal thoughts and, although still rare in absolute terms, puerperal psychosis. One finding initially came as a surprise. Women whose HG was coded as involving metabolic disturbance, such as dehydration or electrolyte imbalance, had lower recorded rates of depression than women whose HG was labelled "mild". Initially, not knowing what to make of this, I asked Yasmeen for her thoughts, to which she suggested that perhaps women with metabolic disturbance were more likely to be admitted to hospital, and that this might in turn impact their experience of care and validation. We were able to check and confirm the former suggestion, that women with metabolic disturbance were indeed more likely to be admitted to hospital, and we saw that the latter postulation was in line with previous qualitative findings regarding the importance of recognition and validation from health-care professionals. What can we take from this? Perhaps that absence of metabolic disturbance is not absence of need, and that everyone with HG deserves to have both their physical and mental health taken seriously. Image Source: DΛVΞ GΛRCIΛ on Pexels Moving Beyond Mind Versus Body Earlier this year, I was invited to present our findings at the International Conference for Hyperemesis Gravidarum in Bergen where I also led a discussion on priorities for mental health research. Around the table were healthcare professionals, researchers, lived experience representatives, and many who occupied more than one of those roles. A recurring theme in the discussion was that of difficulty in accessing mental health care. Whilst many individuals found support groups helpful, a number shared how they had been told, often by healthcare professionals, that as their distress and low mood were linked to a physical condition, there was little that could be done to support them psychologically. Sadly, this picture is perhaps not uncommon. Despite guidance from the Royal College of Obstetricians that all women with HG should undergo routine assessment of their mental health, we know that screening is happening in less than half of UK maternity services. Arguably, this speaks to a need for services to move beyond the historical Cartesian division of mind and body, and to implement integrated care which recognises the psychosocial burden of HG. Reasons for Hope Bergen was also full of reasons for optimism. We heard about research into metformin (a medication used to treat type 2 diabetes and gestational diabetes) before pregnancy as a possible way of reducing recurrence of HG, and novel treatments designed to block GFRAL, the brain receptor through which GDF15 signals and causes nausea and vomiting. I was equally inspired by talks from clinicians, including Dr Andrew Housholder, who presented emerging evidence that mirtazapine and olanzapine may help some women with treatment-resistant HG. Whilst these are off-label approaches that require further study, they serve as an exemplar of what might be possible when we overcome traditional boundaries between psychiatric and medical. Last year, Yasmeen and I saw The Hidden Mothers, Clare Hughes's participatory exhibition about HG, at Science Gallery London. Drawing on the Victorian practice of concealing mothers behind fabric while their children were photographed, the exhibition gave poignant visual form to how women with HG, and their struggles, often go unseen. Whilst public conversations and research developments are helping to bring HG into the light, only time will tell whether this will translate into the provision of integrated services and pathways for holistic care. Image Source: Clare Hughes Photography Afternote: If anyone reading this article is, or cares for somebody affected by HG, there are charities such as Pregnancy Sickness Support and the HER Foundation which have dedicated resources and support groups.

How Giving Voice to Our Primary Needs Is Vital to Physical and Mental Health Image Source: Kinocchio on Unsplash After my early studies in engineering, where I learnt how to build systems, make them work, or fix them, I returned to my books in my forties to study psychiatry, psychology, and neuroscience. I came to appreciate that, while some of these disciplines are also “technical” (an issue or illness is identified, categorised, and addressed through problem-solving), others are much closer to the human dimension: “healing a mind” requires human interaction, where nosology and medical terminology have limited relevance. Having both approaches within the same faculty (to simplify, the brain on one side and the mind on the other) allowed me to understand how they influence each other, and why the mind can ultimately shape the brain: fMRI studies show how talk therapy modifies brain activation in areas crucial to emotional balance and functioning. Combined with my personal therapeutic experience, I became increasingly convinced that personal growth begins with acknowledging the existence of the mind and taking care of it. The first step, however, is to find supportive allies, within your family or beyond, and move forward one step at a time, even if you are starting from far away. Starting With a Little User Manual My father was born in the 1930s into a modest family and, after high school, he enrolled in the navy; very good at sports and in his studies, his view was that willpower was key to success and that emotions should be contained. He worked as a pilot in highly hierarchical environments such as the navy and civil aviation, where social interactions are highly standardised. My education was based on the same principles: as an 8-year-old boy, when playing mini-basketball, he often reproached me for not being gritty enough; sport was supposed to be a school of life, where I should learn how to fight on the court in preparation for life — but this made me even more anxious, and I eventually gave up team sports. Regarding socialisation, his recommendation was that I should make myself respected and fight, if necessary, even physically: this advice became an internal imperative for me. My mother was more protective, but she was never vocal and was often silenced by my father, especially when expressing emotions or anxieties, which were labelled as nonsense or irrational. At 11, I started meeting up with peers in my neighbourhood; they were often quite verbally aggressive and mocked me. One day, I had had enough and tried to follow my father’s advice. I responded verbally to their mockery and then shoved and fought with a few of them on the road in front of my house, eventually breaking into tears of rage. I had done what I was supposed to do, but I felt ashamed of my “girlish crying” and didn’t have the courage to tell my parents about it. But I wanted to succeed, so I kept meeting up with these guys, always committing to defend myself the next time, yet never being able to do so. For many years, I felt continuously stressed, never comfortable in this group: either not having fun or being mocked, feeling I should react yet never able to, frozen by the fear of both the physical fighting and of telling the truth to my father. Image Source: Ahmed Hossam on Unsplash Frozen, and less and less self-confident, the idea that people are intrinsically willing to hurt others, and that I had no means to defend myself, spread to every social context, triggering a constant sense of alarm. Taking Off… with Some Odds Before my 18th birthday, with my high school diploma in sight, things were going better. My hope was that adults would spare me mockery and childish aggressiveness. I would consolidate my role as a brilliant student at university, maybe find a girlfriend, and so on. But a new challenge was about to strike. One morning my mother called me in tears and revealed things I would never forget – not even now that I understand it was not true. My mother told me that my father had an affair and was planning to abandon us with no home and no money; she was absolutely desperate. Image Source: pratik prasad on Pexels My father was harsh, but I trusted him, and I was petrified. Later, I was told that a major depression had hit my mother, and that delusions of betrayal were among the symptoms of psychosis. The transition to menopause was explained to me as one of the triggers of the breakdown; my father tried to reassure me, saying he would handle the situation and I would not be exposed to it any more. But with my father often away for work, I remained stuck at home for many years, during which my mother lived a life of ups and downs, taking her medication for a few months and then stopping when she felt better, quickly relapsing into psychosis. I was her only trusted person, and she would share her secrets with me, while pretending to feel well when my father — a villain in her mind — was around. During all those years, I had no understanding of the role of emotions in her condition; I could only think it was a very unfortunate situation, and no one told me that in such cases you should try to distance yourself or protect yourself rather than remain stuck. Season after season, the only thing I could do was study, becoming more and more isolated from the world, hoping my mother would take her medication. A Toll to Pay In adolescence, I survived by achieving brilliant results in my studies, but neglecting other essential aspects of life, such as friendship, affection, and love, came at the cost of physical conditions. None of these are purely psychogenic, but the fact that many of them faded when I started taking care of my emotional life is already meaningful evidence. Asthma developed during adolescence: although there were no obstructive crises, the cough was so intense — especially at night — that I was advised to undergo a bronchoscopy examination. I was diagnosed with tracheal inflammation and prescribed a break from sports for a year. Heart arrhythmia: at age 20, a routine test revealed about 30,000 extra beats per day. Although I could not feel them, I was treated with medication and underwent years of medical investigations. Image Source: David Trinks on Unsplash The arrhythmia resolved in my thirties as I became more emotionally stable. Temporomandibular disorder caused persistent pain for more than twenty years, initially mistaken for ear pain, until it was identified as muscle tension related to bruxism. Essential tremor began in my early twenties and was strongly influenced by stress, especially in social situations. The conclusion is simple: ignoring the mind comes at a cost. Eventually, after years of accumulated stress, I experienced a panic attack shortly before graduation, followed by depression. Seeking psychiatric help marked the beginning of a new phase in my life. Image Source: Artem Stoliar on Unsplash A Different Culture Throughout my adult life, my wife stood by me, and we had three daughters. Now in my fifties, I see emotional balance as a lifelong process. In our family, we express affection openly and normalise psychological support when needed. Each family will find its own ways, but fostering awareness of mental health will make a profound difference for future generations: the journey may be long, but it is never too late to start walking.

What broken pottery taught me about coming back from the bottom Image by Manuel Gomez, Phoenix Kintsugi. Cover art for the Kintsugi Justice curriculum. Kintsugi is the Japanese craft of repairing broken pottery with gold. It does not hide a break. It fills the fracture with something precious and makes the repair the most visible part of the object. This essay is about learning to do that with a life. It begins in a house where I had to be invisible to be safe, runs through the Navy, an illness, and a prison cell, and ends in the work my wife and I do now with veterans who are somewhere in the middle of the same process. The idea underneath it is simple. The break is not the end of the story, and the mend does not have to be hidden to count as recovery. I learned to live two lives before I learned much else. My mother had schizophrenia. I was a child and did not know what the word meant. What I knew was that some months she did not get out of bed, and I fed myself. My dad drank his sorrows away. I remember him coming home drunk, and my brothers and I learning to disappear. In that house, invisibility was how you stayed safe. That was the first life. The second came as I grew, when I turned the invisibility inside out and became the loudest in the room. If people could not help but see me, maybe I counted. Both lives were the same life. Both were a child asking to be enough. I joined the Navy to get out of that house. I thought I was running toward something. I was running from something. That distinction took me twenty years and a prison cell to understand. I will never forget how happy I was to walk onto the USS Peleliu. Standing on the flight deck in a uniform I had earned, I thought I had made it out. I had a berthing, a job, a name that meant something. For the first time, I was somewhere I was supposed to be. For a while it worked. Then I got sick. The disease was scrofula, tuberculosis of the lymph nodes. I spent months at Balboa Naval Hospital, and the illness was not what destroyed me. The fear did. Every uncertain conversation with a doctor carried one possibility: that this would end my time in the Navy and send me back to the house I spent my life trying to escape. I had run and run, and now my own body was handing me back to what I ran from. That fear did something to my mind I had no language for. I did not know how to ask for help. Asking would have meant letting someone see the invisible kid, and I had spent my life making sure nobody did. So I treated it as a moral failure and hid it. The Bottom After the Navy, the loud life took over. I became a yes man, because yes kept me seen. Help meant honesty about who was underneath the noise. The distance between that and losing everything is short. My health. My freedom. I went to prison. Broken is the word I would use now. At the time, I had no word. I had a bunk, a number, and a silence I had been building since I was a child. Inside, a social worker told me I could have avoided prison. If the system had asked what was happening to me before it asked what I had done, I might never have been in that room. I will never forget that sentence. There is a particular shame in being a veteran in a cell. You joined to become somebody. You became a number instead. Image Source: Sheldon Liu on Unsplash A Day in Isolation I sat in isolation, and I found myself. It is the closest I can come. No voice, no lightning. A radio, sometimes, and a man the world had written off. A quiet moment when both of my lives went silent, and underneath them was the invisible kid. Still there. Still waiting. I did not have a plan. I had a decision. If I left that cell as the same person who walked in, everything that had happened would have won. I could not accept that any of it had been for nothing. I decided to make it be for something. What Kintsugi Taught Me Years later, that decision found its name. Kintsugi is a Japanese craft. When a piece breaks, the artisan mends it with lacquer and dusts the fracture lines with powdered gold. The repair is not hidden. It is made luminous. The bowl becomes more valuable than before it broke, not despite the damage but because of how it was met. I had been trying to be a piece of pottery that had never fallen. Kintsugi told me that version did not exist and was not the goal. The goal was to be visibly, unmistakably mended, the mend itself was the point. Making it be for something took years, and it started in a classroom. I went back to school. Undergraduate. Then a master’s. Then a doctorate. I will never forget passing my defence and hearing someone say Dr. Gomez. The noise stopped. A lifetime of being the loudest in the room went quiet. I did not need the room to see me anymore. For the first time I could remember, I felt like enough. It was strange. My wife noticed it before I could put words to it. Education, for me, was gold. Every degree was a seam. The doctorate is where the healing caught up with me. I put my dark pages into the work, and the work changed them. Page by page they turned into beams. What once buried me now holds my community up. The point was never to become someone else. It was to become the person the break made possible, which cannot happen while the break is still hidden. My wife never asked me to look unbroken. She saw the seams and called them gold first. The Work The nonprofit my wife and I built, VetPhoenix, exists for veterans in the middle of the same process. Most have been through the criminal justice system. All carry things they cannot yet name. We do not sell wholeness. We teach a curriculum called Kintsugi Justice, and its premise is that the goal is not to erase what happened. The goal is to make the mend visible. Peer support does something clinical relationships often cannot. When another veteran who has been where you are sits across from you and does not flinch, the message is not verbal. The message is that the room contains someone whose seams show and whose life continued anyway. That is the intervention. Image Source: SIMON LEE on Unsplash The field is starting to say the same thing. Trauma-informed care asks what happened to you rather than what is wrong with you. Recovery frameworks increasingly treat lived experience as expertise. Moral injury now has a research literature. These are gold seams laid by people who refused to stay silent. The Mend Is Where the Light Gets In If you are reading this from somewhere near the bottom, hear this from someone who has been there. The break is not the end of the story. You do not have to look unbroken. The seams are the evidence that you survived the thing that tried to end you, and that somebody, eventually you yourself, decided you were worth the gold. Image Source: SIMON LEE on Unsplash The pottery does not go back to what it was. It becomes something the potter could not have made on purpose. The invisible boy who fed himself while his mother lay in bed is not gone. He is repaired. The gold is in. My five kids are growing up in a house where nobody needs to be invisible to be safe. And when I sit across from a veteran who has not yet found a word for what he is carrying, I get to see him the way nobody saw that boy. I tell him the break is not the end of the story, and what comes next is the mend. And the mend is where the light gets in. This article has been sponsored by the Psychiatry Research Trust, who are dedicated to supporting young scientists in their groundbreaking research efforts within the field of mental health. If you wish to support their work, please consider donating.

In November 2022, I took my first step into science as a full-time researcher. I had no idea then that the very first project I worked on would take nearly four years to reach publication. In this article, I will talk about what truly works to treat depression in pregnancy, and why I do this research. Image by Getty Images for Unsplash+ The What and the Why Depression in pregnancy, which is known as antenatal depression (AD), affects nearly 30% of pregnant women around the world. What makes AD so important to treat is the negative impacts it has on both the mum as well as her baby. These include the increased risk of preterm birth (babies born before 37 weeks of pregnancy are completed), babies having low birthweight, and additional concerns that persist well beyond infancy. For mums, antenatal depression remains one of the strongest risk factors for postnatal depression, or depression after birth. Postnatal depression is widely recognised and receives much of the attention in the public domain. However, it is just as important to take a step back and examine mental health during pregnancy, not just after birth. Despite emerging research showing that AD can have a profound and long-lasting impact for both mum and baby, it isn’t talked about enough. And this is the remit of the HappyMums consortium, which you can learn more about in this ITM piece. The research I will talk about today was done as part of this large consortium, focusing entirely on mental health during pregnancy. The How We wanted to look at the different types of treatment pathways available to treat depression in pregnancy. Our aim was to bring together the entire evidence base of interventions and quantitatively evaluate the effectiveness of each. So, we used a statistical method called a meta-analysis, which analyses and combines the overall effect sizes (quantitative estimates of how effective a treatment is for a condition), across numerous research studies. This included psychological interventions like Cognitive Behaviour Therapy (CBT), counselling, and mindfulness for example, and also non-psychological interventions like Omega-3 supplementation, yoga, and music therapy, to name a few. We decided to focus on randomised controlled trials, the ‘gold-standard’ research methodology to evaluate interventions. In a randomised controlled trial, participants are randomly allocated to either the treatment or a control group to evaluate the true effectiveness. Image by Getty Images for Unsplash+ The What Did We Find? As we were looking at any peer-reviewed (a quality control process where experts in a specific field evaluate research, scholarly work, or professional performance before it is approved for publication) studies ever published, we had over 2,000 potential studies to filter. Overall, in our analysis, we included 115 studies from all over the world, with over 12,561 participants, and a wide range of interventions. We found that all the available interventions, regardless of type or format, were effective in treating depression. Of course, given that the interventions were so varied in duration, method of delivery, and the way the outcome was measured, the studies were extremely heterogeneous. So, after accounting for any ‘outlying’ studies, we ran another analysis, which still found a modest treatment effect. This made me curious to dig deeper, and to see whether any specific intervention formats were more effective than others. For example, were interventions delivered face-to-face more effective than those which were digitally delivered, and were psychological interventions more effective than others? Short answer: no. We did what is called a subgroup analysis, which meant splitting the research data into smaller subsets, like intervention type, format, and location of delivery. Image by Andrej Lišakov for Unsplash+ Very interestingly, we did not find any significant differences between intervention type and format. This meant that non-psychological interventions were just as effective as psychological interventions. Furthermore, interventions delivered digitally (through a tablet or smartphone application) were as effective as those delivered face to face. This does not mean that non-psychological interventions should take precedence over treatments like CBT, which have decades of research and proven efficacy. This means that we have more options than we originally thought in treating AD. We have previously seen, from the SHAPER Melodies for Mums trial, how singing has proven to be effective in treating postnatal depression. Our findings do not mean that these interventions should replace current guidelines. In the UK, the official treatment guidelines for moderate to severe depression recommend antidepressant medication and high-intensity psychological intervention. And I agree, it should remain this way. What our do findings show is that when health services face such high demand, leading to long waiting lists, these adjunctive therapies can, and have been shown to be effective. This allows for more flexibility and for earlier treatment, which, in this critical period, is so important. Talking about intervention formats, I was pleasantly surprised to see that digital interventions are as effective as those delivered in-person. This allows for so much flexibility, especially if a pregnant woman faces barriers related to physical health or distance. We also found that ‘combination’ interventions, integrating these different aspects, for example psychological therapy with aerobics, and in person interventions with digital support between sessions, were most effective. We proposed that having a flexible approach also allows for intervention facilitators to engage with participants in-between physically delivered sessions and may have higher levels of participant engagement. Finally, we wanted to see whether biological improvements also align with the psychological improvements. We did another sub-analysis of studies which reported on biological components like cortisol (our primary stress hormone), cholesterol (a marker related to heart health), and other inflammation-associated components. What we found is a clear ‘stress reduction’ effect associated with these biological components. So, our findings show that these interventions not only improve physical health, but also the underlying biological mechanisms. Image by Getty Images for Unsplash+ The ‘What Next’? Our study, to our knowledge, is the most comprehensive meta-analysis which demonstrates the effectiveness of interventions in the management of AD. Hopefully, our review shows that there are more interventions that have proven effectiveness than just one, giving more flexibility in treating women earlier on. What particularly excited me was the finding that digitally delivered interventions show comparable efficacy. And this gets me thinking: if the treatment of AD can be digitalised, could the digital screening of women at risk of developing depression follow a similar pathway? And spoiler alert, this is exactly what we’re investigating in the HappyMums Smartphone App study. Stay tuned! This full-text research is now available, open access, in Archives of Women’s Mental Health