On a busy road, when the traffic rushes like water breaking through a dam and the lights refuse to turn red, the decision you may make to run across when there is a small break between cars, is a conscious one. Our ability to make informed decisions is what allows us to take responsibility for our actions. Every choice we make, every action we take is a result of neuronal pathways firing in a particular sequence in various areas of the brain. An area called the pre-frontal cortex is particularly associated with decision-making and planning. But what if the very organ that makes those choices, our brain, becomes damaged? How ethical is it to expect compensation or retribution for actions taken following damage to this decision-making organ? During my year as a PsychStar - a scheme run by the Royal College of Psychiatrists, awarded to medical students who have shown a commitment and interest in psychiatry - I was fortunate enough to attend the annual NeuroPsychiatry conference held by the Royal College of Psychiatrists. While attending, one particular lecture stood out to me in which the speaker discussed the impact of brain injuries on behaviour, and the association between acquired brain injuries and crime. An acquired brain injury (ABI) refers to any damage to the brain post-birth. This can include traumatic or medical causes, such as strokes and seizures, in the absence of congenital (present from birth) or genetic disease to the brain. In 2018, approximately 1.3 million individuals in the UK were living with an ABI. Importantly, the damage caused by an ABI can lead to dysfunction in various physical and mental processes including memory and personality. Additionally, research has shown there is an association between ABI and crime. Approximately 24.7% of individuals in prison have been hospitalised for an ABI, which is significantly more prevalent than in the general population, where 18.2% of people have been hospitalised for ABI's. Additionally, those with ABI's are 2.5 times more likely to be incarcerated than those without. Photo by rawpixel.com from FreePik What could account for these statistics? ABI’s are associated with a number of factors which may increase the likelihood of criminal behaviour. For example, individuals with ABIs are at greater risk of substance misuse, and antisocial behaviours (behaviours and actions that cause distress, alarm, or harassment to others). Importantly, both substance misuse and antisocial behaviours are also associated with higher levels of criminal behaviours. Additionally, ABIs can lead to emotional dysregulation, which can impact one’s ability to control impulses and override strong urges or temptations. Difficulty in regulating impulsivity and control has been associated with higher rates of violence, resulting in increases in offensive behaviour. Whilst we can see an association between the characteristics of patients post-ABI and criminal behaviour, it is important to consider other contributing factors to criminal behaviour which may influence this association. The personality traits of someone before an ABI, their socioeconomic status and familial relationships, have all been shown to impact rates of criminal behaviour. Additionally, if we look at socioeconomic status, there is a complex bi-directional relationship between head injury and socioeconomic status. Individuals with lower socioeconomic status are more likely to experience a head injury, and individuals with head injuries are more likely to have a lower socioeconomic status following their injury. Such complicated associations between these factors therefore make it difficult to conclude the exact extent ABIs, as an independent factor, have on an individual’s likelihood to offend. Nevertheless, given that individuals with traumatic head injuries are 2.5 times more likely to be incarcerated compared to those without, the link between ABIs and crime cannot be ignored. So where do we go from here? Just as with any medical condition that has a significant impact on a patient's life, it is important for healthcare professionals to consider a preventative approach in the management of offensive behaviour in relation to ABIs. This starts with recognising the impact of brain injuries on patients. Once a patient has experienced a brain injury, it is important for them to have a formal assessment of not just the physical, but also the mental impact of their injury. Additionally, educating patients regarding possible long-term effects of their condition, and provision of a point of contact to aid in recovery, is also important in providing appropriate patient care. If such approaches are adopted at a wider level and earlier on during the diagnostic process, patients will feel better supported. This support may have a knock-on effect, and potentially reduce first-offence and consequent criminal behaviours. Mindsource, a charity in Colorado, USA, works with individuals in the criminal justice system who have had ABIs using neuropsychological screening to establish personalised tools to help reduce reincarceration rates. For example, they advocate for the use of written notes during court hearings. This allows individuals to focus on the information being delivered at the time, and have material to take away to review and plan, such as dates of next court hearings and rules of bail. Photo by RaCool Studio from FreePik In England, there is no current national protocol which dictates the follow-up of patients suffering from ABIs. However, there is a sub-speciality of healthcare workers, forensic psychiatrists, who see patients suffering from brain injuries within the prison population. Forensic psychiatrists work closely with individuals in the justice system to aid their recovery and transition. Medical questionnaire’s for measuring the impact of an ABI on physical and emotional disability are now being used by forensic psychiatrists and neuro-psychiatrists for distinct patient groups, such as prisoners with ABIs. However, with approximately 333 consultant forensic psychiatrists in England and 87,900 individuals in prison, it is clear that the doctor-to-client ratio is unbalanced. Training staff within the healthcare and judicial systems on the management of individuals with ABIs, and developing national guidelines on how to manage patients with ABIs would aid in the delivery of equitable treatment and follow-up for those affected. Albeit, due to current staffing and financial restraints on the NHS and the global healthcare system in general, this type of intensive care and follow-up is not always feasible. However, further research and education into the association between ABIs and crime is imperative to further our understanding, and develop a better criminal justice system that works to support rehabilitation from the ground-up. How far Can we go? How far Should we go? As research moves forward, it is our duty as clinicians to understand the consequences of pathology on the lives of patients and their environment. Part of this includes further research into the consequences of brain damage on behaviour and personality, acknowledging the impact brain damage can have. Thereby, facilitating improved personalised support and care. Furthermore, it is not only enough to consider the psychological and biological impact of ABIs. The ethics of potential change in treatment and legislation must also be considered. How do we accurately measure the extent of changes in personality and behaviour following an ABI? And how fair on the victims is it to attribute crime to a brain pathology? Hopefully, with future research, the development of systems better supporting those living with ABIs (in and outside the criminal justice system) and those impacted by them, will emerge.

It is ADHD Awareness Month, and I often find myself reflecting on my own diagnosis of attention deficit hyperactivity disorder (ADHD), and the challenges and strengths it's brought to my life. However, what I have frequently found is ADHD is often discussed in terms of its impairments. Struggling to concentrate. Forgetfulness. Emotional dysregulation, and a predisposition to depression. Problems with sleep. Difficulties meeting potential at school, work and beyond. The list goes on and on, and when I was diagnosed with ADHD in my second year of medical school, I quickly found that we rarely balance it with anything positive. I am now in my seventh and final year of medical school and will graduate next year. However, at the time of my diagnosis in my second year, I was on academic probation and already very aware of my weaknesses. Although I now have a diagnosis that explains some of my difficulties, the D for “deficit” in ADHD overshadowed all the other letters for me. Image from Pexels by Tara Winstead Before my diagnosis, I was already worried I wasn’t suited for a medical career. However, reading online about ADHD after my diagnosis made me feel like I had been officially labelled as unsuitable. Most importantly, I struggled to find examples of doctors who succeeded with ADHD. Some people with ADHD do make statements online such as “ADHD is my superpower”, but that has always felt a bit unbalanced and too far in the other direction for me. I had heard that some people with ADHD claimed it made them more creative or spontaneous, and I wondered if there were any strengths of having ADHD as a doctor. I figured that ADHD must have some strengths – otherwise, why would it still be genetically pervasive, if it was 100% disadvantageous? I’m now coming to the end of my time at medical school, and going into my seventh and final year, I think I’ve finally found some of those elusive positives to having a neurodevelopmental condition. My impulsivity has got me into trouble at times - rushed work at school, booking flights to Paris on a whim, and once famously catching a hot iron with an outstretched palm. However, ADHD traits of impulsivity and distractability are thought to be partially due to novelty-seeking and exploratory behaviours also seen in ADHD. To highlight the positives of these features, novel, stimulating experiences can help those with ADHD learn and increase memory. As medicine is an ever-evolving field, with a clinical environment that is constantly changing, this experience is beneficial for my ADHD brain. A medical career involves constant learning, and this abundance of new experiences and knowledge keeps me engaged. For example, the variety of moving between different patients and performing different tasks on a ward shift is appealing to me, particularly as I dislike being stuck on one task at a time. Image from Pexels by RDNE Stock project On the other hand, ADHD makes learning things that don’t relate to my interests, such as anatomy, much harder, as I frequently lose concentration and find it hard to focus. However, I find studying things that relate to my interests, such as psychiatry, much easier to study and thus often spend hours engaging in this. Whilst it is true for all people that it is easier to focus on things you are interested in, those with ADHD can sometimes feel this to a much stronger effect. This experience is called hyperfocus, ‘a phenomenon that reflects one’s complete absorption in a task, to a point where a person appears to completely ignore or ‘tune out’ everything else’. For example, I can hyperfocus on an area of interest for hours at a time, often forgetting to do things like eat or drink. Looking at the positive side of this experience, ADHD can help me learn about things I’m interested in deeply, and this can translate into better competency for my future career. Another strength I have found is having insight into the lived experience of neurodivergent patients, which can lead to increased understanding and improved care. Neurodiversity is a model which originally arose from the autistic community, with the term neurodivergent serving as an identity for those who considered themselves as neurologically “different”, often due to conditions like ADHD, dyslexia and autism. Doctors with lived experience of neurodivergence could have an understanding and empathy for their neurodivergent patients, which is different to those without this experience. For example, some parts of accessing healthcare, such as phoning to make an appointment or sitting in a waiting room, can seem straightforward to neurotypical doctors. However, these seemingly straightforward tasks might be overwhelming and create barriers for a patient who is neurodivergent. I have spoken to several patients with ADHD who have been discharged from a service after forgetting one appointment, something I too can relate to. Recognising barriers is important for implementing change to better serve this patient group. Doctors with lived experience have unique insights and, therefore, may feel more motivated to make changes that improve care for neurodivergent patients. So, how many doctors could potentially be bringing these neurodivergent strengths to the medical profession? Whilst there isn’t any reliable data on the prevalence of neurodivergence in doctors, 3-4% of adults are estimated to have ADHD, and this number is likely to be an underestimation due to difficulties in accurately identifying ADHD in some populations, such as women. Additionally, some studies have suggested that neurodivergent people might actually be overrepresented in STEM fields, including medicine, precisely because of these skill sets. Image from Pexels by Jeswin Thomas However, stigma is unfortunately also likely to prevent doctors from sharing that they have ADHD. In a 2020 survey by the BMA, only 36% of respondents felt comfortable disclosing their disability at work, whilst a troubling 77% were fearful of discrimination. A recent review found that over half of medical literature on ADHD contained stigmatising language, and in the UK Doctors subreddit, I have sadly read disparaging comments about neurodivergence. Would you feel comfortable disclosing that you had ADHD, if there was a chance your colleague next to you had stated “ADHD is a fake diagnosis” online? I have had to learn to be resilient to comments on placement like “Why would you want to scrub in? You’re always distracted in teaching, so you probably won’t concentrate on the operation.” Comments such as these indicate a lack of understanding about ADHD. Whilst there are strengths of having ADHD in medicine, I have experienced two main barriers to these strengths being more widely recognised. The first barrier is recognition and understanding of ADHD in the workplace. Greater recognition and staff knowledge of ADHD is something we all would benefit from - whether you have ADHD or not. The second barrier is recognising ADHD in ourselves, and understanding what this means in terms of the positive traits it brings, and the areas where one might struggle. In a positive step forward, it was announced in March this year that the NHS is launching a cross-sector ADHD task force to boost care for patients living with ADHD. The new taskforce will bring experts together from a wide range of sectors, including the NHS, education and justice, to “better understand the challenges affecting those with ADHD, and help provide a joined up approach in response to concerns around rising demand”. I greatly look forward to seeing the outcome of this new taskforce.

Trigger warning: This article discusses suicide. Some readers may find this distressing. Massive increases in referrals to Child and Adolescent Mental Health Services (CAMHS) over the last few years have led health professionals, including myself as a doctor, to question why. Child mental health is important to me as I have personally seen peers experience mental health problems at school, and I believe this is such a crucial time to offer support and interventions. Looking at statistics from the NHS Child and Adolescent Mental Health Services (CAMHS), the number of children currently under CAMHS care has risen from 493,434 in October 2023 to 496,897 in November 2023. Shockingly, the number of children under 18 requiring emergency mental health support has also increased by 53% since 2019. It is important to think about the contributing factors to these numbers, so professionals can better support young people and implement change that will help. As CAMHS services see a massive surge of referrals at the beginning of the school year, and a large part of life as a child and adolescent is school life, I wanted to explore factors that can occur in a school environment. Specifically, I will explore factors that may be contributing to the increased mental health referrals, and the initiatives schools can implement. So, let's break down some contributing factors. 1) Academic Pressure and Stress Photo by Andy Quezada from Unsplash Over the last several years, there has been a global decrease in school satisfaction for teenage students. This decrease in satisfaction has been linked with perceived school pressure, which is more pronounced in girls compared to boys. Additionally, this academic pressure can contribute to both physical health symptoms such as fatigue, and mental health problems such as depression, anxiety, and sadly in severe cases, death by suicide. One study looked at the causes of 595 adolescent suicide cases and found academic pressures were a recurring contributing factor. Additionally, another study found a positive association between academic pressure and timing within the school year (around the exam period), and at least one mental health outcome of anxiety, depression, self-harm, or suicidality. 2) Social Dynamics and Peer Relationships Photo by Abenezer Shewaga on Unsplash Recently, social dynamics and peer relationships have gained a lot of media attention due to the COVID-19 pandemic. The pandemic helped to understand the importance of peer relations, as it revealed a lot about the effects of restricted social interactions on school-aged children. For example, 2,160 parents of children participated in an online survey investigating the effects on mental health with school closure. In 16-17% of the children, there was an increased exposure to mental health and peer problems. In this group, mental health and peer problems were directly associated with a lack of friendship, which highlights the importance of a friendship group for mental well-being. Importantly, it has also been found that peer support is as protective in preventing low mental well-being as both school, adult support, and family support combined. 3) Bullying and Harassment Photo by RDNE Stock Project on Pexels Bullying and harassment can take place in many forms for children of school age. This includes physical, verbal, emotional, relational, and more recently cyber bullying. We know that children who experience more than one form of bullying are more predisposed to longer-term social-emotional effects. These effects can include feeling anxious or depressed, acting out or being aggressive, and having a desire to get back at others. These physical and psychological symptoms can also predispose young people to later mental health issues, with bullying consistently being associated with poor mental health. So what can schools do? The UK government recommend that a whole school multifaceted approach is needed to achieve "a safe, calm and supportive learning environment”. This approach can include promoting inclusivity and respect, enabling student voice, and providing curriculum teaching to support emotional learning. In addition, schools can offer targeted support to those that need it, and work together with parents and carers to support their children. The Department of Education also emphasises the importance of peer relationships, and recommends school peer mentoring schemes designed to increase self-esteem, emotional health, and wellbeing across the student population. What about other schemes? In 2017, the Government outlined plans in the "Green Paper for Transforming children and young people’s mental health", with a goal to enhance mental health access, including establishing community-based mental health support teams (MHSTs), training senior mental health leads and reducing CAMHS waiting times. The program introduced significant changes, such as establishing MHSTs in educational settings to link with local CAMHS services, with direct NHS supervision. Additionally, the program aimed to train senior mental health leads in all eligible state-funded schools and colleges by 2025. In addition, individual NHS trusts also have strategies to combat the increasing demand for CAMHS services. An example of this is the CUES program (South London and Maudsley NHS Foundation Trust), designed to equip primary-aged school children with therapy techniques to prevent later mental health problems, with promising outcomes. Are these schemes adequate? Despite government initiatives, schools are still struggling to deal with the increasing mental health problems at school. In a survey of nearly 18,000 members of the National Education Union, educators were questioned about student mental health. Results revealed insufficient access to specialised support services, such as CAMHS, learning support assistants, councillors, nurses, trained mental health first aiders, senior mental health leads. Many teachers cited excessive workload, lack of staff and inadequate government priorities as key barriers to student support. Teachers also expressed concerns over lengthy CAMHS waiting lists, with some children not qualifying for services despite evident need. Whilst more work is needed, the schemes discussed are a step in the right direction. The government has made a commitment to young people's mental health, with educational settings being a focus of service provision. Additionally, there is evidence that school-based mental health services overcome some of the barriers that prevent access to mental health services for children and youths, such as shortage of medical or psychological mental health professionals, mental health stigma, or the lack of transportation opportunities. Therefore, I look forward to seeing future progress and the outcomes of the government initiatives!

In my second year of medical school, I had the opportunity to choose my student-selected component of the course. There were several interesting options, ranging from short language courses to exploring case studies in medical law. However, one option stood out: ‘Cultural psychiatry.’ As a woman of colour, I'd always been fascinated with how culture shapes our understanding of mental health. In my Nigerian community, for instance, mental illness is often shrouded in stigma, with many attributing it to evil spirits' possession or drug use. The course promised to explore the role of cultural and transcultural factors in the world of psychiatry. This meant exploring how a patient's background could influence everything from how they experience symptoms to their ultimate prognosis. We'd also be looking at fascinating concepts like ‘culturally bound psychiatric syndromes.’ Culturally bound psychiatric syndromes are experiences which are recognisable as illnesses and thought to only exist within a specific culture. An example of a culturally bound psychiatric syndrome is susto, a term used in Latino cultures. 'Susto' can occur when someone experiences a frightening event and feels their soul has left their body, causing symptoms like listlessness and poor appetite. Another example is brain fag syndrome found in West Africa, which is associated with mental strain, and manifests as confusion and tiredness. The interaction between different cultures poses unique challenges in the field of psychiatry, which has led to the development of cultural psychiatry. The General Medical Council acknowledges the importance of doctors endeavouring to understand the impact of culture and personal experiences on the care that they provide to patients. Indeed, it is not enough for clinicians to just be accepting of other cultures; everyone should endeavour to learn about other cultures beyond the stereotypes. I am British. I am Black British. I am Nigerian. When thinking about culture, the first thought is often about a person’s ethnicity, nationality, or race. For example, I am black. That is a cultural identity for me, but even within that seemingly defined group, there are several different cultural groups that I belong to. There is, for example, a different cultural experience for Black British people and African Americans. Even within the Black British label, there are different cultural experiences. Whilst a small example, there is an ongoing discussion between people of African and Caribbean descent about pronouncing the food plantain - those of African descent commonly pronounce it plantAYNE, whilst those of Caribbean descent commonly pronounce it planTIN. Even within the seemingly specific label of Black-British-African, there are several ethnic divisions. We can look to the frequent discussion amongst West African nations regarding ownership and execution of the best jollof rice. Photo of British and Nigerian flags by Joe Darams on UnSplash What is culture? “Culture” was adapted from "cultura animi" (cultivation of the soul), a term coined by the Roman speaker Cicero. At this time, it referred to how humans moved towards developing an understanding of philosophy. Edward Taylor proposed an anthropological definition of culture which “includes knowledge, belief, art, morals, law, custom, and any other capabilities and habits acquired by man as a member of society”, this showed culture to be a collaboration. The current Cambridge dictionary definition of culture is “the way of life, especially the general customs and beliefs, of a particular group of people at a particular time.” Looking at these three definitions, we can see that culture is more than race or ethnicity. Culture is created, learned and shared. Culture is dynamic and open to interpretation. It is important to stress that culture can change, especially with evolving technology and cross-cultural interaction. Beyond race, nationality, and ethnicity, cultural identity is a vast spectrum. It is important to understand that different cultural identities can intersect. For example, I am Black British, but I am also a woman and a medical student. All of which are important aspects of how I experience and navigate the world. A statue of Cicero, Photo from the National Geographic Cultural concepts of distress The concept of culturally bound syndromes has now been replaced with ‘cultural concepts of distress’ in the DSM-5, a book used to classify mental health disorders. This has been a positive change, as the term now acknowledges that all mental disorders can be culturally shaped. Understanding cultural concepts of distress is crucial for dismantling barriers to mental health care. An individual's cultural background shapes their perception of mental illness, coping mechanisms, and even help-seeking behaviour. Cultural concepts of distress encompass three key areas: cultural syndromes, cultural idioms of distress, and cultural explanations. Cultural syndromes are unique clusters of symptoms specific to certain cultures. They include many of the same conditions as the former ‘culturally-bound psychiatric syndromes’ in the DSM-5. However, whilst these cultural syndromes may be more common in certain cultures, they may not be solely unique to that culture. For example, hikikomori is a cultural syndrome characterized by extreme social withdrawal and originated in Japan. However, recent international studies have found the phenomena of hikikomori has been observed outside of Japan. Secondly, we have cultural idioms of distress. Cultural idioms are ways of expressing emotional suffering, often through culturally specific terms that may not directly translate to Western diagnoses. For example, the Punjabi term, “sinking heart”, might be used instead of "depression" or "anxiety." Mental health professionals should be aware of these idioms to assess a patient's condition accurately. When a patient expresses distress through an unfamiliar phrase, like "feeling a sinking heart", asking "What does that mean to you?" can encourage the patient to share context, ultimately facilitating a better understanding of culturally specific idioms of distress, and informing a more accurate assessment. Lastly, cultural explanations view mental distress through the values, beliefs, and norms of a person's culture. The cause of distress for that person may be explained as the result of spiritual imbalances or social disharmony within that person's culture. Therefore, by recognizing these cultural concepts, one can acknowledge the vast variation in how people experience and express mental health concerns. Photo of various emoticons by Alex Shuper on UnSplash Where to go from here? Intrigued by the world of culture in psychiatry? Here are some places to learn more: The Royal College of Psychiatrists offers a dedicated course on cultural psychiatry. Check out their website. The Royal College of Psychiatrists also has a Transcultural Psychiatry Special Interest Group. Consider joining to network with and learn more from like-minded individuals. The most important thing is to keep cultivating genuine curiosity about other cultures. Remember that culture is dynamic, and cultural nuances are constantly evolving. Try to continuously engage with other cultures through books, documentaries, or even conversations with people from diverse backgrounds. Try to avoid making assumptions regarding a person’s cultural identity based on appearance. Instead, ask open-ended questions to understand their unique experience within their cultural context. Everyone, but clinicians in particular, should strive to pay attention not just to the words, but also to the emotions and body language of the others. Colourful paper doll chain, Image from the Transcultural Special Interest Group

Photo by Mathurin NAPOLY / matnapo on Unsplash “If you’ve spoken to me for even 5 minutes, you know I stammer. What you don’t know, unless you stammer too, is what I’ve undergone in the 5 decades I’ve been a stammerer”. This was how I started the message I sent to friends and family when sharing my recent ITM article, Stammering: An Invisible Handicap. In the piece, I shared my lifelong experience as a stammerer and spoke about ways in which those who stammer can be treated with more acceptance and compassion. I shared it with my family and friends as well as on my social media and the response took me by surprise. I never thought the article would resonate with the number of people it did, including many I didn’t know. I’d like to share some of the impact the piece had, not to show off but to show that even one person sharing their experiences can help many others to unlearn unhelpful interaction patterns and re-learn new ones. A for Awareness Sometimes, we assume that those close to us share our level of awareness on matters important to us. As the responses of some of my oldest friends showed me, that might not always be the case. I shared the article on a WhatsApp group with my classmates from school who have been a source of comfort for nearly 40 years. The response was immediate. Ameez, the first friend I made in school, was the first to respond. He wrote, “Being vulnerable is hard. Love how you changed that narrative. Kudos to your mum and dad”. While Rujuta said, “Thanks for those 5 tips… so good to have it out there in clear words. For this and other disabilities”. Samar, a gynaecological oncologist, wrote to say, “Except for some paediatricians, audiologists, speech therapists, and a handful of mental health professionals, 99% of doctors would not know this”, before going on to share it in his medical networks. But perhaps the biggest surprise came when I shared this with neighbours from my apartment complex. One surprised me by sharing she too had been on a journey with her own stammer and even went to the same hospital as me. Regarding stammering, she said it “needs to be talked about for empathy to develop in people around us.” Discovering that she also stammered and that we had shared another deeply personal physical space outside of our homes made me feel a newfound kinship with her. Photo by Herlambang Tinasih Gusti on Unsplash A Is for Advocacy, Too We think of advocacy as something active, forceful almost. But sometimes, it comes through in surprisingly subtle ways. Like when Kunal, a classmate from school, shared the article with his friends, most of whom I don’t know. A mother in that group took my number from him and reached out to discuss getting a speech therapist for her nearly adult son. She had been trying alternative treatments for him, and the fact that my article made her consider speech therapy was very gratifying. Prashant, another classmate from school, commented when I shared the piece on Facebook to say, “I’m also really glad that your parents got the tip when they did so you could have the confidence. I have cousins who have stammered, and I don’t think they have that kind of help and it’s been rough on them.” before going on to repost it on his wall. The tip? My paediatrician telling my parents to let me speak without correcting me or finishing my sentences. Shashank, an ex-colleague and dear friend, shared the piece on his Facebook saying, “It's important to share it, because it's just the sort of ready reckoner for sensitisation that our graceless, inconsiderate society needs a lot more of.” Seeing the message spread so quickly on a platform that I am barely active on was a testament to the power of a support system that shows up even when you’re absent. C for Change I’ve always wanted to change public perceptions around stammering, but I never actively campaigned for it. And so, I was happy when people wrote back to say the piece had changed how they viewed stammering and how they would approach a stammerer. Chriselle, a communications consultant I share a networking group with but have never met, wrote to say, “I definitely think of stammering as something to work on or change, and this really gives a different perspective!” A childhood buddy said, “I have a person in the office who is extremely competent and stammers a lot. This will help me enormously”, while another wrote to share, “I work with an amazing engineer who stammers a lot (mostly when giving presentations). I always hope that doesn’t hold him back. I’ll definitely share this”. Hearing this was particularly pleasing because, in the offices I’ve worked in as well as client spaces, I’ve been approached by so many about how they could be more vocal, and hence more visible, at work. They had all been mocked or pitied for their stammer their whole lives and, to avoid that in the workplace, stayed quiet unless pushed. Photo by Andrew Moca on Unsplash But perhaps what touched me most was when Ashok, a friend and fellow writer, said, “It takes courage to voice it and not come across as angry or frustrated. I am sorry to have corrected you and occasionally still do. I shall be more careful about this going ahead.” I’ve spent decades telling people not to complete or correct a stammerer and to just be a bit patient, so to hear it being acknowledged by a friend I’d made fairly recently made the struggle feel worthwhile. E for Empathy They say empathy begins at home, which is something Nikhubhai, my older cousin, showed us all on our family WhatsApp group. After I shared the piece, he wrote on the group to say, “We could all take a leaf out of your introspection methods and be better with dealing with our own impediments. Especially at looking at the glass as half full... I am sure that it will trigger some hidden sentiments in your readers, as it did for me.” In my experience, in India (where I am from), society can be uncomfortable and awkward about impediments and often tries to deny or mask them in their children. In that context, the impact of an elder addressing impediments on a multi-generational family group cannot be understated. Photo by Fotos on Unsplash I for Impact Let me confess – I’ve longed to share my experiences with stammering all my life. I’ve wanted to show how stammering isn’t the end of the world and also tell the world how they could help us. And so, when an ex-colleague reached out to discuss her son’s stammering with me, I was hopeful. When she hung up asking me for a speech therapist’s number, I was elated. And validated. But perhaps the biggest “reward” came almost two months after the piece went live. Janvi, a young mother from Mumbai, reached out on Instagram. She found the piece via an online search and was struck by how positive it was, unlike most of the doom-and-gloom articles on stammering she’d read. Her young son stammers and, while she was very concerned for his wellbeing, she was unsure of where and whom to turn to. We spoke. We shared. And we cried. By the end, we both felt lighter. She, because she was reassured that a “normal” life was possible for her son and that she was clear on the role she had to play for him to achieve it. And me, because for the first time in 25 years of writing, I felt that something I had written had made an impact that my parents had a big part in. And that it was something they would be proud of. 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.

Psychiatry has been a highlight of my medical school experience. Every psychiatrist I’ve met, every talk and lecture I’ve attended, and every topic I have studied, nothing has grabbed my attention more than psychiatry. So, when the opportunity presented itself to meet MORE psychiatrists, attend MORE talks and conferences, and gain MORE experience, it was a no-brainer that I had to apply to the Psych Star Scheme. I therefore applied to and was accepted into the scheme, specifically in Intellectual Disability. Intellectual Disability psychiatry involves working with people with learning disabilities, who are much more likely than the general population to experience mental health conditions. A learning disability affects the way someone learns new things throughout their life, and is different for everyone. For example, a person with a learning disability might have some difficulty understanding complicated information, learning some skills, or looking after themselves. Additionally, people with learning disabilities' physical and mental health needs are often overlooked or misattributed to their learning disabilities. This results in unnecessary consequences, which could be prevented by access to the right care and support. This is where Intellectual Disability psychiatry comes in: to try to prevent and provide the right care to people with these disabilities. Importantly, it focuses on how we can adapt situations to the needs of those with differences, so they can still enjoy and get the most out of the experiences life offers. I am grateful to have been able to explore this area of Psychiatry through the scheme. What Have I Done on the Scheme? The first and most important aspect of this scheme is the mentoring. Without my mentor, Dr Niraj Singh, I would not have received any of the opportunities I have had. He was so understanding of what I wanted and took the time to introduce me to other psychiatrists in my area, point out books he felt were important that I read, and mention experiences I did not consider. For example, my mentor suggested a course in Makaton, a language that uses a combination of signs, symbols, and speech to help people communicate. Makaton is the UK’s leading programme for adults and children with intellectual disabilities and/or communication difficulties. As someone who has already learnt British Sign Language (BSL) during a phase of craving learning over lockdown, and has a 828 day streak on Duo Lingo learning both Turkish and Spanish, I adore languages. Therefore, learning a language which is used so greatly in those with intellectual disabilities will significantly help in my time as a doctor, when I will come across new people every day. Photo by author - Megs Grainger Following on from my talks with my mentor, I attended the intellectual disability conference in Leeds, which was the first non-university ran conference I attended. This was a phenomenal experience, despite the storm getting me stranded in Leeds for an additional night! The talks were incredibly interesting, and despite there being few students, I did not feel as if I was an imposter, or too young to be there. Everyone I spoke to made me feel included and as though I was an equal. One specific talk stood out to me. This talk discussed how there is an increased likelihood of those with autism spectrum disorder (ASD) experiencing gender dysphoria whilst also having an increased difficulty in handling these emotions. Following this talk, I read more about the topic as it was something I was not aware of prior. Whilst more research is needed, a systematic review, which is research that summarizes multiple studies, found a higher prevalence of gender dysphoria amongst people with autism. Over time, clinical guidance has started to be developed for patients with co-occurring autism spectrum disorders and gender dysphoria, to improve clinical care. The National Autistic Society have also interviewed people with autism about their gender identity, and provided personal stories surrounding this topic. Taken directly from their website, Dr Wenn Lawson, autistic advocate, researcher, and psychologist, said: "The non-autistic world is governed by social and traditional expectations, but we may not notice these or fail to see them as important. This frees us up to connect more readily with our true gender." Another project I have been involved in is with the Child and Adolescent Mental Health Service (CAMHS) department, where I have been talking to those who work in the educational areas of CAMHS. From my time as a medical student, experience in psychiatry as a whole has been difficult to come by. I have therefore used my own experiences to liase with the CAHMS team, through online and in person mediums, to help increase CAHMS awareness for medical students. What Do I Have Lined Up? So, it is only June as I write this, and I have had to take a step back from all of the exciting opportunities as a Psych Star to focus on my exams. However, I do have so many more exciting experiences set up for the Summer! Firstly, my mentor has helped me find clinical experience over the summer in Intellectual Disability. This will allow me to see and get a feel for a day in the life of a Psychiatrist. I would otherwise not have been exposed to this for another two years of university. Therefore, being able to do this sooner is a great opportunity! As I have mentioned, but truly want to emphasize, it is difficult as an early-year medical student to get experience in any area of psychiatry except for a few lectures on the basics of depression. This is something that scares me as, as much as I love the field of psychiatry, I’ve had no real hands-on experience. Photo from Unsplash by Emily Underworld If it wasn’t for the Psych Star programme, it would take me until 5th year of University to truly discover if Psychiatry is what I wanted to do. This is why I’m so thankful for all the people who have taken me through this experience, from the team who run the Psych Stars, to my mentor, and the Psychiatrist giving me the opportunity to shadow him. Finally, I have not one, but two, conferences lined up for the rest of this year. The first one is the Royal College of Psychiatrists International Congress in Edinburgh, which we are automatically given tickets to through the Scheme. I haven’t ever been to Edinburgh before, so it is all a new experience for me. I am also attending the 2024 annual Intellectual Disability conference to do a talk on my time as an Intellectual Disability Psych Star, which is the first time I will have done public speaking on such a big scale! I typically have a fear of public speaking, so starting my public speaking journey with a personal presentation on my amazing time as a Psych Star, will be an amazing step in helping out these anxieties! My Conclusions Overall, being a Psych Star has been an unforgettable experience, and there is still so much more to come. While it has been stressful around exams and placement, I am happy for the understanding of all of those involved to be able to still make the most out of it. I could not thank the Royal College of Psychiatrists more!

Perusing the Royal College of Psychiatrists website, I stumbled upon the faculty page for 'Rehabilitation and Social Psychiatry'. I had never heard of this subspecialty before but quickly became excited when I realised it sounded right up my alley. As a medical student with a background in anthropology and psychology, I have a particular interest in the broader social, economic, political, and cultural factors that influence mental well-being. 'Rehabilitation and Social Psychiatry' closely aligns with this; encompassing a holistic approach to mental health care, with emphasis on the importance of social support systems, community integration, and recovery-oriented practices. Rehabilitation and social psychiatry focuses on aiding individuals with severe mental health issues, such as treatment-resistant psychotic disorders like schizophrenia and bipolar disorder. Often, the symptoms and co-morbidities/co-existence of multiple of these disorders can make daily activities and social interactions harder, leading to isolation. However, this is where mental health rehabilitation services come in. Rehabilitation services are delivered by multidisciplinary teams and provide a range of interventions. These include medication management, psychological and occupational therapy, family support, and educational, leisure, and vocational opportunities. These services aim to provide hope to these individuals by equipping them with the skills, support, and confidence needed for successful community participation. Despite high ongoing support needs, research shows these services facilitate successful hospital discharge and community progression, reducing inpatient service use and care costs. To learn more about my interest in rehabilitation psychiatry, I applied to the Royal College of Psychiatry’s ‘Psych Star’ scheme, which provides mentorship, funding, and resources to medical students interested in psychiatry. I was chuffed to learn that my application was successful and that I was attached specifically to the Faculty of Rehabilitation and Social Psychiatry. For the rest of this article, I will discuss what I have been doing during my time as a Psych Star. I am writing this on the flight back from a trip to Budapest with four of my Psych Star peers. Using our funding, we decided to attend the European Psychiatric Association’s annual congress. This was a fantastic opportunity to hear about current research, and psychiatrists from across the world shared insights into their successes and challenges. I was particularly interested to hear about how different countries are approaching suicide prevention, refugee mental health, unemployment, and childhood trauma. Lauren at the European Congress of Psychiatry Conference Spending time with my fellow Psych Stars was one of the best parts of attending the conference. We spent most of the day crying from laughter at our feeble attempts to navigate the realms of ‘networking.’ Pumped on the delicious free coffee, we got involved in heated debates and fangirled over our psychiatry heroes. It was particularly exciting to meet with Dr Lade Smith, the current president of the Royal College of Psychiatrists. She reminded us that we are each other’s future professional networks and that we should stay true to our ideals throughout our careers. Aside from the European Psychiatric Association’s annual congress, the Psych Star scheme has also allowed me to attend other brilliant events. Notably, I was funded to go to the Rehabilitation and Social Faculty Conference in Leeds. Additionally, as part of the scheme, I was assigned two mentors from the faculty who I meet with virtually every month. They have provided invaluable support and have given me an insight into the everyday life of a consultant in rehabilitation psychiatry. Lauren at the UCL Reimagining Psychiatry Conference At the Leeds conference, I was able to meet my mentors in person, which was a very welcome change from Microsoft Teams. One of my mentors kindly let me co-lead a workshop at the conference, focusing on what rehabilitation psychiatrists need to know about sustainability. The conference gave me a helpful overview of the current approaches to rehabilitation in the UK, as well as future challenges for the speciality. For example, I learned about areas of psychiatric research that I am less familiar with, including the role of peer support and the significance of environmental factors, such as noise and light, in creating a rehabilitative environment that is conducive to recovery. Some of the conference speakers were service users themselves. Their insight was invaluable and served as a pertinent reminder of the complexities of mental health and the importance of rehabilitation. The conference also provided a fantastic chance to meet with leading professionals in the field. This initial meeting has led to meaningful connections. As Co-Chair of University College London’s Psychiatry Society, I was able to use this network to host my university’s first student psychiatry conference. I have also started working with some of the conference speakers on a research project focused on the current state of community rehabilitation service provision. In June, my Psych Star cohort will attend the Royal College of Psychiatry’s International Congress in Edinburgh. As part of the Psych Star programme, I have been researching homeless health and medical education. Having worked for years with people experiencing homelessness, I am extremely passionate about this topic and will present some of my research at the International Congress. I am also excited to hear more about the other Psych Stars’ projects and how they have found the scheme. A group of Psych Stars at the European Congress of Psychiatry Overall, the Psych Star programme has been an incomparable and invaluable opportunity, and I would highly recommend applying if you are a medical student interested in psychiatry. The scheme allowed me to meet like-minded individuals, talk to service users, receive mentorship, and learn about national and international best practices and future challenges. Spending time with rehabilitation psychiatrists has reminded me of the importance of treating each service user as a whole person, paying attention to the wider context in which they exist, and working to create an inclusive and safe environment that supports recovery. My time as a Psych Star will undoubtedly shape my future practice and has solidified my passion for mental health and social inclusion.

Special Note from the Editors: Welcome to our brand-new series written by the 2023 Psych Stars! Chosen by the Royal College of Psychiatrists, Psych Stars are medical students awarded a place in the scheme for their interest and commitment to psychiatry. To celebrate their work and success, we have invited several Psych Stars to write fortnightly articles on their visions for the future of mental health research and care, each choosing an area in which they are especially passionate. After you read today's article, be sure to check out the excellent collection by the 2020 Psych Stars! As a medical student, I know that medicine can be full of stereotypes. Orthopaedic surgeons are apparently all "gym bros" like Todd from the TV show Scrubs. Neurosurgeons supposedly all have type A personalities with egos to match, and pathologists allegedly reclusive introverts. One of my favourite videos is "Med Student’s First Day" by Dr Glaucomflecken. In these videos, a medical student experiences first-hand stereotyped caricatures of different specialities, such as a gym-loving orthopaedic surgeon or an exhausted overrun family doctor. Upon meeting the resident psychiatrist, the medical student is asked, "Do you have any tweed? Corduroy? Anything with elbow patches?". Dr Glaucomflecken’s dressed as the stereotype of a psychiatrist. Photo from Eye News. Although I do enjoy self-deprecating humour, I couldn’t help but notice that psychiatrists seem to be stereotyped in a negative light. In 2018, the Cambridge Medical Journal published a study which looked at the speciality stereotypes held by students. In this study, students were asked to describe various specialities using single adjectives. The description of psychiatrists by students in this study included: talkative, crazy, mad, detached, woolly, odd, unhinged, nosy, and hairy. These stereotypes aren’t a new phenomenon. In an older study from 1986, students described psychiatrists as "fuzzy thinkers", and as doctors who "talked a lot but did little". Quite interestingly, psychiatry as a speciality was described as having the lowest status in medicine, with psychiatric treatment being "basically fraudulent" and psychiatry being a "waste of medical education" and "the least important area of medicine". I mean — OUCH!! This is coming from aspiring doctors, yet to choose their field. This had me thinking about my own introduction to psychiatry & psychiatrists. 'Sex-Obsessed Trickcyclists' My introduction to psychiatry was watching the TV show Fawlty Towers with my parents as a child. In one episode, Basil (the proprietor of the hotel) becomes anxious when he discovers that a pair of psychiatrists are amongst the guests. He believes that psychiatrists are obsessed with the sexual activities of others and instructs his wife to avoid talking to them at all costs. Due to his paranoia that his behaviour will be critiqued and judged, he exhibits increasingly bizarre behaviours including imitating a primate, wrapping his blazer around his head, and jumping like a frog. Why did the mere presence of psychiatrists cause Basil to have a complete breakdown? My "real life" introduction to psychiatrists was through the whisperings of my father. I heard him refer to someone we had just met as a "trickcyclist" (unbeknownst to me, an archaic slang term for psychiatrist) in a hushed tone so as not to be overheard. I very much got the impression that I shouldn’t interact with this person. There was a paranoid stigma — almost a fear. Many years later when I told my father of my ambition to specialise in psychiatry, I could see that he looked uncomfortable and quite perturbed. I got the feeling that he thought it was a bizarre choice of career. I wouldn’t say that I have received disapproval for my choice, but I am certain that if I championed myself as a future ophthalmologist, cardiologist, or neurosurgeon, he would have responded with far more enthusiasm. I had to question, what on earth is going on? Psychiatrists are doctors. They practice evidence-based medicine. Do we have history to blame? The origin of psychiatry in the UK can be traced back to the mid-14th century, when Bethlem Hospital in London was used to house patients with "mente capti" (latin for "caught in the mind"). In fact, it is this bastardisation of the hospital name that led to the word Bedlam entering the English language to refer to uproar, chaos, or confusion. Despite the lack of understanding of psychiatric conditions, let alone treatment, the hospital became a specialist asylum by the end of the century. Bethlem Hospital. Photo from BBC News By the late 16th century, Bethlem Hospital had relocated to a purpose-built facility in Moorfields, and to raise hospital funds, public visitation was encouraged. In other words, much like we would pay admission to visit animals in a zoo, the gentry of the time could pay admission to observe the unusual behaviours of the patients. Unfortunately, by the 18th century, an entire trade had been established with public "lunatic asylums" springing up all over the UK. It was not until the Lunacy Act of 1845 that the psychiatrically ill were recognised as patients requiring treatment. This act was revised in 1890 in response to wrongful confinements and profiteering from private asylums which resulted in a psychiatry crisis in the UK. As we move into the 20th century, despite early recognition and categorisation of psychiatric diseases, treatments were still in their infancy. Electroconvulsive therapy was introduced in the 1940s to treat schizophrenia and depression, whilst lobotomy was championed as a successful psychosurgical method (even securing a Nobel Prize for its’ pioneer). Talk about a chequered history! For centuries, psychiatry was essentially turned into a circus with the mentally ill imprisoned for the entertainment of others, with the earliest attempts at treatment consisting of electrocution and removing part of a patient’s brain. This is an oversimplification, but that is some reputation to overcome. Mind Reading and "Not Really Doctors" I recently found myself reading an interesting article published in the BMJ discussing misunderstandings of the psychiatrist's role. In this short article, two statistics jumped out at me: first, 47% of patients reported they would be uncomfortable sitting next to a psychiatrist at a party, and second, 60% believed that psychiatrists could effectively read minds. In 2008 Professor Rob Howard (then RCPsych Dean) is quoted as saying "Lots of other doctors don’t think that we’re real doctors". Most interestingly, in his 1987 RCPsych Presidential Lecture, Dr Thomas Bewley discussed the public perception of psychiatrists and acknowledged that only 50% of patients believed psychiatrists to be medically trained, and 75% thought that hypnotists were psychiatrists. Photo from The Royal College of Psychiatrists So What Now? Given what I have discussed above, it would be easy for there to be despondency in changing the perception of an entire profession with a less-than-stellar history. However, in the 21st century, there have been some promising signs that psychiatry is shedding the stigma and rising in status. In 2015, the European Psychiatric Association published guidance on how to improve the perception of psychiatry and psychiatrists. This guidance included celebrating evidence-based research and clinical successes and improving engagement with policymakers, medical students, and the general public. A meta-analysis published in 2017 concluded that "there is no indication that psychiatry as a medical discipline is stigmatised." and highlighted that the public readiness to seek help from a psychiatrist has increased over the past 25 years. Within the profession, we have seen the number of applicants for Core Psychiatry Training increase from 754 in 2018 to 2610 in 2023. From my experience as a medical student, psychiatry has lost its stigma massively and we have received excellent exposure to clinical teaching and learning opportunities in this speciality. From a personal perspective, I have thoroughly enjoyed being involved with the RCPsych Psych Star scheme through which I have met talented and driven medical students with a shared passion for psychiatry. I am optimistic that over the course of our careers that psychiatry can shed the stigma, move past its history and be universally respected as a highly skilled evidence field equalling that of any other speciality. A group of the 2023-2024 Psych Stars. Authors own image.

Reflections from the President of the Royal College of Psychiatrists on the latest series of PsychStar blogs I was glad to be invited to write this blog to conclude this fantastic series of work from our PsychStar participants. I’ve read the blogs with interest, and have found the topics thought-provoking and forward-thinking. I’ve worked as a psychiatrist for many years, and I specialise in Forensic psychiatry. I became the President of the Royal College of Psychiatrists in July of this year. The College is the professional and educational body for psychiatrists in the United Kingdom. We work to secure the best outcomes for people with mental illness, learning difficulties and developmental disorders by promoting excellent mental health services, training outstanding psychiatrists, promoting quality and research, setting standards and being the voice of psychiatry. I want to highlight how important it is to develop support and encourage the leaders of the future, and I think the PsychStar initiative should be commended for doing just that. The students that have been involved to date are incredibly talented, and I hope we can continue to support many more students in the future through this programme. My thanks also go to all of our colleagues who manage the blog and make it possible, and in particular to Professor Carmine Pariante. When I have psychiatry trainees who work with me, I generally ask them to imagine what people in fifty years will think about our current practices. I ask them to think ahead and try and use this perspective to understand what we should be doing more of and what we should be doing less of, as we have sometimes not been so good at reflecting on our practice. This series of blogs was indeed reflective, and covered diverse and wide-ranging topics. As I read them, I also reflected on my own four priorities (parity for mental health, equality and diversity, sustainability, and workforce wellbeing) as the president of the College, and thought about how we can move forward in developing our practice and driving changes which will result in better care for people with mental illness. I also reflected on our need, no matter what the topic or specific illness we’re working with, to involve people with lived experience of mental illness every step of the way, and to continue to make strides in achieving genuine collaboration with people with lived experience to help make services better. I much enjoyed reading the blog about neurology and psychiatry working together, and it was fascinating to reflect on the history of neuropsychiatry and to think about the importance of understanding of both neurology and psychiatry for practitioners of either specialty. It made me think about integration, parity, and the need for those with physical and mental health expertise to work closely together. There is also the need for integrated specialist care for both physical and mental illness, especially for those with severe mental illness (SMI), who sadly have a 15–20 years shorter life expectancy than the general population, partially due to higher rates of comorbidities such as cardiovascular disease or chronic respiratory illness. If mental and physical health were valued equally, the person-centred care needed would be easier to achieve, and people with SMI would have a more integrated package of support, something the College I lead is currently pressing for. I have also been working recently on equality issues in mental health, both concerning people with mental illness, and the mental health workforce. 2020 has been an important year for equality issues, with the pandemic and action on racial inequality highlighting the need for change. Equality, diversity and inclusion is one of my four presidential priorities, and the College is working hard to develop a strategy on this, this year. We are looking at inequalities broadly, how they can impact on mental health, and how they can affect people’s access to, experience of, and outcomes from mental health care across the UK. Image source: Daily Mail I was interested to read the two blogs in the series that had a perspective on gender, and outlined how gender stereotypes can impact mental health. One refers both to disparities in how women are cared for when they have mental illness, and how women have experienced challenges in efforts to achieve equality within the healthcare workforce. The other looks at high rates of male suicide, and explores possible contributing factors, including toxic masculinity. It also highlights why we must continue to work hard to tackle stigma around mental health because, although we’ve come a long way, there is still much further to go. We know that big disparities also still exist for those with intellectual disability and autism, and so I was glad to see that intellectual disability was also highlighted through another of the blogs, which explored the history of care for people with intellectual disability, and highlighted the important role of specialist community services, as well as specialist psychiatrists and the need for medical professionals across the board to have understanding and knowledge of intellectual disability. I enjoyed reading the two articles that focused on children and young people’s mental health, one focusing on how we can improve child and adolescent mental health services (CAMHS) — both in regard to the variable service provision across the country and also with regard to what will undoubtedly be the huge impact of the Covid-19 pandemic on young people’s mental health. The second article spoke to the need to bridge the generation gap between young people and their elders, especially in turbulent times, and focus on the need to encourage fostering a compassionate approach, which is incredibly important in these difficult circumstances. It made me think about one issue I know many of us, and particularly young people of today are worried about, and that’s the climate. Sustainability is another of my four presidential priorities, and we’ve been doing a lot of work at the College to look at sustainability and mental health, including trying to understand how best we can support those who are worried — and particularly young people — about the climate, both now and in the future. The problem of climate change highlights the need for us to think globally, and reminds us just how interconnected our small planet really is. I was glad to see that the series included a piece looking at mental health care across the globe. It was a stark reminder of the fact that mental illness is a leading cause of disability globally, and that yet, many who would benefit from treatment have no access to the right support. The College has recently developed an international strategy to enable us to work better with our colleagues in other countries, and to work to try to tackle some of these issues as an international community. We also need to think about innovative new ways of treating patients, and I was intrigued to read the thought-provoking article on using psychedelics to treat drug-resistant depression. This has been a topic that has been on the agenda recently through colleagues who are working hard to research the potential benefits of these new treatments, and I follow the progress with interest. An example of our recent work on pharmacology and depression was our patient-facing leaflet on stopping antidepressants. The Covid-19 pandemic has also fast-tracked our use of digital and tech to help support patients, and so the article about advancing telepsychiatry comes at a time when this is especially important. It is generally acknowledged that these services are really the future of our healthcare system, and so considering how we can harness their impact and ensure services stay accessible to everyone is very important. Of course, we as a profession also have our role to play in public health, both specifically and broadly. I agreed with the points set out in the blog that explored the role of a psychiatrist in prevention, and highlighted the need for parity when it comes to prevention as well as care. Reflecting on how we may be able to mobilise better tools to help us identify those who could be at risk of mental illness and act to prevent illness from developing was very thought-provoking and is something we should continue to explore and prioritise. These blogs delve into some fascinating and specific areas, which of course link to the wider picture. We must also view these issues in light of the broader landscape for psychiatry in the UK and beyond. We have done so much work in recent years to drive mental health up the agenda, and increase the public and political will to help make change happen. Although huge steps forward have been made in the UK — for example with substantial moves to further integrate physical and mental healthcare — we still have a long way to go before parity of esteem, and ultimately care, is achieved. That is why parity of esteem — treating mental health with the same value and importance as physical health — is another of my top four priorities. Finally, I’d like to highlight the importance of our workforce, my final presidential priority, the silver thread running through all these blogs, and the core of psychiatry and mental healthcare as a whole. Without dedicated and committed mental health workers to care for and support our fellow human beings, we have no health service. We need to advocate for better training and opportunities to enable new generations of psychiatrists and other mental health professionals to develop in their professional practice and continue to move our healthcare system forward, just like those who have written the considered and intelligent pieces featured on this website. And we need to make sure we support them to realise their potential so they can best care for their patients, and ultimately to be happy and fulfilled themselves. The College will continue to work to support whatever progress is needed to make this happen. NOTE FROM THE EDITORS: We would like to take a moment to say a massive ‘thank you’ to Dr Adrian James for taking the time to share his thoughts on the successful Psych Star series, and highlighting the continual need to improve existing systems to get psychiatry to the best place it can be to support every patient effectively — we’re all incredibly proud of the hard work these fantastic students and future leaders in mental health, and looking forward to seeing what they do next. Well done and thank you, Dr James and the brilliant Psych Stars.

My experiences working as a support worker for adults with intellectual disability, before starting medical school and alongside my studies, has given me valuable insight into the lives and experiences of the people that I supported. In this role, I gained an appreciation of some of the challenges faced by people with intellectual disability, including the impact of stigma and healthcare inequalities. I also was able to appreciate the vital role that specialist community teams play in supporting people with intellectual disability to access mainstream services and in providing specialist support regarding issues such as challenging behaviour, communication difficulties and the management of physical health issues. Before I continue, I would like to first define what an intellectual disability is. An intellectual disability, also known as learning disability, is where a person has reduced intellectual ability (normally an IQ of less than 70) alongside experiencing difficulty with day-to-day life skills such as socialising, personal care and household tasks. Many different factors can impact on the development of the brain before birth or during early childhood, causing an intellectual disability. These include genetic disorders such as Down syndrome, complications during pregnancy and birth such as oxygen deprivation, and serious illness or brain injury during childhood. Image source Mencap In this blog, I would like to raise awareness of the stigma and inequalities faced by people with intellectual disability and highlight the vital importance of specialist services, including the role of intellectual disability psychiatrists. I will first look at how attitudes towards people with intellectual disability and the services provided have changed throughout history in the UK. I will then focus on how people with intellectual disability are supported in the today and how this can move forward in the future. Back in the Middle Ages, people with intellectual disability were supported in a way that was similar to today. The courts would offer support to the families if they were struggling to support their loved one due to financial problems, a family crisis or due to challenging or disruptive behaviour. They also provided support for people with intellectual disability to live more independently. The industrial revolution triggered significant changes in how people with intellectual disability were viewed and treated in society. Before this, people with intellectual disability often worked alongside others in group cooperatives. However, during the industrial revolution there was a move towards individual wages and salaries. This change led people with intellectual disability to be perceived as a financial burden both on their families and on society in general. At the beginning of the 1800s, small institutions were set up and run by volunteers where people with intellectual disability were trained to become ‘productive members of society’, with the aim of reintegration. Later on in the 19th century, larger government funded institutions were set up with the aim of containing and segregating people with intellectual disability. It was believed at the time that people with intellectual disability needed to be sheltered from society to keep them safe, since they were viewed as being vulnerable. Since at the time intellectual disability was believed to be heritable, it was also argued that people with intellectual disability should be segregated from wider society to prevent intellectual disability from the condition becoming more prevalent. The photograph below was taken at Pennhurst State School in Philadelphia, which was an institution for people with intellectual disability. Image source Future Learn At the beginning of the 20th century, the government formally recommended the segregation of people with intellectual disabilities in institutions, with the Mental Deficiency Act 1913 making it a legal requirement for local authorities to offer institutional care. During the 1950s and 1960s, there were growing doubts about the appropriateness of institutional care, which triggered the gradual transition towards community-based care. A number of sociological studies considered the impact of institutions on child development. One of the most famous of which was the Brooklands Experiment, led by Professor Jack Tizard at the Maudsley Hospital in London where it was shown that children with intellectual disability living in a smaller home-like environment showed improved development of their social, emotional and verbal skills compared to children living in long-stay hospitals over a period of 2 years. These doubts were compounded by a series of reports exposing poor conditions in institutions, the most famous of which was the enquiry into the poor conditions and treatment of patients at Ely Hospital in Wales, a long-stay institution for people with intellectual disability and mental illness. The photograph below is from an exhibition about Ely Hospital, organised by Mencap Cymru. Image source Wales Online In 1971, the parliamentary white paper, ‘Better Services for the Mentally Handicapped’, recommended deinstitutionalisation in the UK, with an increase in community-based services. These were further reinforced in the 1979 Jay Report, which highlighted the need for community-based services led by local authorities which were in line with the principle of normalisation. Normalisation was a concept first defined by Wolf Wolfensberger (shown in the photograph below) in 1972 which promoted the idea that people with intellectual disability should have the same rights as the general population. Wolfensberger argued that the ‘devaluing characteristics’ of disadvantaged groups were a result of being rejected by society and devalued. Wolfensberger later redefined this as ‘social role valorisation’ which included the idea that increasing integration of people with intellectual disability in the community and therefore allowing people to have direct experiences with them would challenge negative stereotypes and lead attitudes towards people with intellectual disability to become more positive. Wolfensberger’s ideas contributed to the development of the social model of disability which is widely accepted today. Image source Walker-web Over the last 50 years, deinstitutionalisation has led to the closure of long-stay hospitals and the development of specialist community services. ‘Valuing People: A new strategy for learning disability in the 21st century’, published in 2001, outlined the main principles of inclusion, choice, rights and independence for people with intellectual disability. This was later updated in 2009 with ‘Valuing people now: a new three-year strategy for people with learning disabilities’. Key legislation has been developed in the last 20 years to protect the rights and liberty of people with intellectual disability and safeguard them from abuse and discrimination, including the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards, The Equality Act 2010 and the Care Act 2014. Specialist intellectual disability services are offered by a multidisciplinary team of health and social care professionals, including intellectual disability psychiatrists and nurses, clinical psychologists, and allied health professionals. Specialist services are there to provide support in a wide range of areas including mental health, communication, behavioural support, postural care and neurological disorders, including epilepsy and dementia. Due to a range of biopsychosocial risk factors, mental illness is more common amongst people with intellectual disability compared to the general population and can have a profound impact on individuals with intellectual disability and their families. People with intellectual disability may present with mental illness in a non-specific way, for example by becoming withdrawn; it is an interesting diagnostic challenge for intellectual disability psychiatrists to elicit whether a change in behaviour may be due to mental illness, a physical health problem or a change in that individual’s environment or routine. The roles of intellectual disability psychiatrists include improving access to mainstream services by providing specialist advice regarding clinical management of physical and mental health conditions in people with intellectual disability, providing training for staff on intellectual disability, and by influencing service provision in management and leadership roles. Intellectual disability psychiatrists also work closely with specialists in collaborative care networks, for example, with neurologists to support patients with intellectual disability and complex epilepsy or with old age psychiatrists to support patients with intellectual disability and dementia. Photo by Nathan Anderson on Unsplash Although there have been dramatic improvements in the quality of care and support provided for people with intellectual disability over recent decades, stigma regarding intellectual disability and autism is unfortunately still present in society today. This stigma continues to be reflected in healthcare inequalities faced by people with intellectual disability, inequities in the provision and funding of specialist intellectual disability services and shortages of staff providing specialist care for people with intellectual disability and autism, including intellectual disability psychiatrists and nurses. The Transforming Care Programme, implemented in 2015, aims to ensure that people with intellectual disability are not inappropriately placed in long-stay hospitals and are instead supported in community settings. Although this programme has a very important goal, the decreases in inpatient beds available for people with intellectual disability have unfortunately not yet been met by sufficient increased availability of appropriate community-based alternatives or wider support packages to allow people with intellectual disability who have more complex needs to live in the community. This is on a background of historical inequities where the provision of specialist services to meet the needs of people with intellectual disability have not been given the same priority as mainstream physical and mental health services. The shortfalls in the provision of specialist services for people with intellectual disability as well as training for staff in mainstream services on supporting and making reasonable adjustments for people with intellectual disability mean that people with an intellectual disability still face significant healthcare inequalities. People with intellectual disability are more likely to experience poor mental health and more likely to die at an earlier age and from a preventable cause. The ongoing COVID-19 pandemic has brought the healthcare inequalities faced by people with intellectual disability into stark focus. Data reported by the Care Quality Commission has shown a significant increase in the number of deaths of people with intellectual disability during the peak of the pandemic, with 386 deaths reported between the 10th of April and the 15th of May 2020 compared to 165 deaths in the same period last year. This is an increase of 134%. Out of the 386 deaths reported, 206 were a result of either suspected or confirmed COVID-19. In addition to this, findings reported by the Office for National Statistics indicate that compared to those without a disability, individuals who have a disability are more worried about the impact of the pandemic on their wellbeing and daily life, and are more frequently reporting that the pandemic is causing their mental health to be worse, is causing them to feel lonely and a burden on other people. The stigma against intellectual disability may potentially be contributing to difficulties in attracting staff to work in specialist intellectual disability and autism services, with shortages present in the numbers of specialist intellectual disability nurses, psychiatrists and allied health professionals. Tackling stigma against people with intellectual disability and increasing the awareness of the importance of providing specialist health and social care services to meet the needs of this patient group is essential to keep making progress in how society supports and values people with intellectual disability. As a medical student and support worker, I believe that good quality training for medical students and doctors on intellectual disability, including how to make reasonable adjustments, is essential in ensuring the provision of good quality care for patients with intellectual disability. I also feel that awareness needs to be raised regarding how rewarding, interesting and fulfilling a career specialising in intellectual disability can be to encourage recruitment into specialist services. Special note from the editors: This is the eleventh (+ FINAL) blog of our series, The future of mental health as seen by the future leaders in mental health, written by the 2020 ‘Psych Stars.’ Selected by The Royal College of Psychiatrists, Psych Star ambassadors are a group of final year medical students awarded for their particular interest and commitment to psychiatry. During the year-long scheme as Psych Stars, students are nurtured in their interest in psychiatry through the assignment of mentors, by gaining access to learning resources and events, and by becoming part of a network of like-minded students. More information on the Psych Stars scheme can be read here. We have decided to invite each of the Psych Stars to write a blog on how they envision the future of mental health by choosing an area in which they are passionate. We have decided to run the series as a celebration of these student’s success and to provide an outlook for each of the awardees to share their passion. With a new blog published each Friday, the series will run over the next few months. If you enjoyed today’s blog by Lucy, be sure to head over to InSPIre the Mind and check out the previous blogs in our Psych Star series covering topics such as compassion, the mind-body interaction, the future of child & adolescent psychiatry, gender inequality, global health, male mental health, neuropsychiatry, telepsychiatry, psychedelics, and primary prevention.

Mental health stigma and discrimination is slowly decreasing, as shown in the report ‘Time to Change’ in 2015. Given the current effects of the COVID-19 pandemic and associated social distancing/quarantining, the incidence of mental health problems is anticipated to rise. As a final year medical student on a placement in GP at the moment, I have witnessed first-hand the mental distress induced by the pandemic. Many people fear of contracting the virus while others have had their support structures break down to maintain social. The support that is available is predominantly virtual which doesn’t suit everyone (see the blog from my fellow Psych Star Anushka on a balanced review of the future of telepsychiatry). It is a difficult time to be living in, but I remain hopeful that mental health services will continue to do their best to serve those who most need it. As we pass world mental health day, now is a good time to reflect and take the opportunity to think about how our efforts might be best focused to help peoples’ mental health in future. Taken from IStock Mental health is slowly becoming recognised as something we all struggle with to varying degrees at some time in our lives, just as we do with our physical health. As a young British Pakistani man, I myself am very grateful for the way prominent men have spoken about their struggle with mental illness; most recently Freddie Flintoff discussing his struggle with Bulimia comes to mind. More broadly I am very happy to see that more culturally tailored mental health services exist, such as the Muslim Youth Helpline, who have been doing great work at supporting young people with mental health problems in a culturally sensitive way. Even within healthcare itself, the taboo of being a healthcare provider with mental health issues is being broken down, and individuals such as Dr Ahmed Hankir, a psychiatrist with lived experience of mental distress (who has also written a blog on InSPIre the Mind), are being rightfully celebrated. All this progress even within my relatively short life-span is astonishing; it has made me feel so much more comfortable and open discussing my own mental health with family, friends and colleagues. The perception of Psychiatry has come a long way and people have been getting better at recognising common and serious mental health problems, from depression to psychosis. Although stigma still remains and needs to be tackled, the discussion shifts towards what other responsibilities psychiatry has. My fellow Psych stars have already done a great job at discussing various aspects about the future of Psychiatry. As we reach a point where we are advocating for equal care for both mental health and physical health, the question that arises for me is: shouldn’t we have pathways in place to prevent mental health problems, as well as we do for physical health? Taken from Talalay A helpful example in general medicine is the QRISK-3 score, a well-established algorithm which predicts the risk of heart attack or stroke over the next ten years, putting together a range of risk factors such as age, gender, ethnicity, blood pressure, cholesterol and family history. The risk can’t tell us with guarantee whether an individual will have a heart attack in the future but, regardless, it is used widely by doctors Using the tool. A 45-year-old Indian man who has a diagnosis of diabetes and high blood pressure but with no family history, would have greater than a 10% chance of a heart attack and stroke in the next 10 years. Based on this calculation, this man would be started on statins (a medication to reduce cholesterol) to prevent them from getting a heart attack, even though it may never have happened anyway. In the same way, why are prediction tools for various mental health problems not being more widely used to prevent mental illness? In doing so we could help reduce the pressure on an overstretched mental health service, reduce complications, and overall improve patients’ lives by reducing the potentially devastating effect of mental illness. The exact algorithms/tools to use to predict mental illness are being developed by continuing research. The question for Psychiatry remains how to implement the use of these tools in a meaningful way. A particularly pertinent issue within mental health is the issue of “over-medicalising”. We all have mental health and mental wellbeing, yes, but that doesn’t mean we all have mental illness (see figure below). Classically, a mental health problem is diagnosed as a disorder once it fulfils specific clinical crieria and is causing “clinically significant distress or impairment in social, occupational, or other important areas of functioning”. However, as we move into primary prevention of mental illness, where do we draw the line? By intervening too early we risk over pathologizing and medicalising normal human phenomenon. Taken from Student Christian Movement One area that has illustrated the blurry line between mental illness and benign human experience is in the realm of psychosis. Psychosis is the experience of either having hallucinations (experiencing a sensation in the absence of anything causing it, such as hearing voices) or having delusions (fixed beliefs that are not in keeping with reality). Over the last few decades, there has been a shift to recognising that treating psychosis earlier is linked to improved outcomes and this has led to the integration of core “early intervention services” to assess, investigate and treat individuals with first episode psychosis (the first time someone experiences psychosis symptoms). This takes a whole-person approach (both medical and psychological) to treat individuals with psychosis before a formal diagnosis (e.g., schizophrenia, schizoaffective disorder) is given. Research has taken this even further with the identification of those in an “At-Risk Mental State” (ARMS) — individuals with a 20–30% chance of developing psychosis in the next 2–3 years. However, an even earlier stage of the “psychosis spectrum” (see figure ) are Psychotic-like experiences (PLEs). The majority of people will have psychotic-like experiences at some point in their lives, such as feeling like people around you are saying things with double meaning or thinking you are destined to be someone who is very important. For the majority of people though, these experiences don’t last and are ultimately harmless, never developing into mental health problems. However, a small group of people with distressing and persistent experiences have a greater likelihood of future mental health illness, especially psychotic disorders. Even with this increased risk, many will never transition to psychosis. Therefore, if we are hoping to implement interventions to prevent transition to psychosis, we have to ensure that the risk of interventions doesn’t out-weigh the relatively low risk of psychosis, and that the interventions are cost-effective. Figure by Danish Hafeez One such answer is the “Clinical staging model” which originates and is already widely used to stage cancers; it’s a simple way to classify how severe someone’s disease is, and treatment is targeted to their stage. It helps provide a universal language, giving both patients and doctors information about severity, chance of complications and how to measure progression. Similarly, in mental health it might be useful to move away from whether a particular mental health disorder is present or not, but towards a staging model on which to target care. By having such a framework, it also allows for less severe conditions between normal behaviour and mental illness to be targeted, allowing individuals to be caught before they develop a mental disorder and be given appropriately targeted treatments. This could in the long run reduce mental healthcare costs and maximise the resources available to those who need it the most. The question does arise: what is the role of a psychiatrist in all of this? Should psychiatrists simply stick to treating mental illness once it arises? Although that will always stay a significant part of clinical duties as a psychiatrist —  and is an important use of their skill set — I think there is scope and opportunity for psychiatrists to get involved more broadly and larger scale using their training. We need greater Psychiatrist representation: within public health, to promote mental wellbeing; to implement targeted interventions for those at risk of mental illness, and conduct the studies to assess them in at risk individuals; and finally, to run and oversee clinical services targeted towards high-risk groups, such as Oasis. Working in collaboration with the multi-disciplinary team and GP’s may help to treat common mental health problems at an earlier stage. Taken from Source Special note from the editors: This is the tenth blog of our series, The future of mental health as seen by the future leaders in mental health, written by the 2020 ‘Psych Stars.’ Selected by The Royal College of Psychiatrists, Psych Star ambassadors are a group of final year medical students awarded for their particular interest and commitment to psychiatry. During the year-long scheme as Psych Stars, students are nurtured in their interest in psychiatry through the assignment of mentors, by gaining access to learning resources and events, and by becoming part of a network of like-minded students. More information on the Psych Stars scheme can be read here. We have decided to invite each of the Psych Stars to write a blog on how they envision the future of mental health by choosing an area in which they are passionate. We have decided to run the series as a celebration of these student’s success and to provide an outlook for each of the awardees to share their passion. With a new blog published each Friday, the series will run over the next few months. If you enjoyed today’s blog by Danish, be sure to head over to InSPIre the Mind and check out the previous blogs in our Psych Star series covering topics such as compassion, the mind-body interaction, the future of child & adolescent psychiatry, gender inequality, global health, male mental health, neuropsychiatry, telepsychiatry, and psychedelics.

Disclaimer: This blog is by no means an endorsement, nor is it advocating illegal activities. It is purely a discussion about the growing interest in psychiatric research on the potential of psychedelics in novel treatment approaches in mental health. It should be noted that the use of recreational drugs such as psychedelics is, under law, a criminal activity. Psychedelics should only be used within the legal framework of one's county and under the supervision of a clinician expert in their use. What would be the first thing to come to your mind if I were to mention psychedelics? If you’re anything like me, psychedelics probably conjure images of 1960’s trippy hippies, or rave attending teens. So, you can imagine my surprise when I learnt that these substances are seeing a resurgence, not amongst clubbers or hippies, but neuropsychiatrists hoping to find new ways of treating mental illnesses. The idea that psychedelics can be used as a psychiatric treatment is however, not a new one. Prior to the 1971 ban on these substances, over 130 clinical studies using LSD were funded in the USA. The results from these studies were promising at the time, with some even reporting the benefit of treating alcoholism with psychedelics like LSD and psilocybin (the active substance found in magic mushrooms). So what happened? Image by Mikee Atendido on Behance It is largely accepted that the growing anti-government sentiment during the Vietnam war sparked the push to ban psychedelics. With the need to find a source of this anti-war unrest intensifying, psychedelic drugs became the natural target; and so began the war on drugs. I first became aware of the use of psychedelics in psychiatry when I stumbled upon a YouTube video on the subject; a talk by the author Michael Pollan given at Google. That serendipitous moment sparked my initial interest and led me happily down the psychedelics rabbit hole. What really fascinates me about this topic is both the interaction between politics and medicine, and of course, its potential to revolutionise psychiatry. Since 1971, psychedelics have been classed as ‘Schedule 1’ substances by the UN Conventions on Drugs and the UK Misuse of Drugs Regulations 2001. This means they can only be prescribed by medics for the purpose of research, which in itself does not block their use in therapeutic clinical trials. The lack of scientific research into the effects of psychedelics on mental illness over the past 50 years instead stems from the stigma surrounding their rebranding as recreational drugs. Funding for these projects consequently ceased as many sponsors were keen to distance themselves from the public image of recreational drug use. We often talk about stigma in mental health, but I for one, never expected it would have such pervasive power. Psychedelics have been largely excluded from in the scientific community over the past 50 years. But that is all changing now. Photo by chris farr on Unsplash Psilocybin is fast becoming hailed as a wonder drug in psychiatry, seemingly with the potential to treat everything from depression to eating disorders. There are numerous phase 2 trials emerging across the world, including one at King’s College London where psilocybin is being used to treat drug resistant depression. While we may have to wait years until the results of these trials are published, the results from earlier feasibility trials (which essentially ask if it can be done) indicate that a large proportion will likely be successful. But the wait hasn’t stopped everyone, some people have reportedly been using drugs such as psilocybin to self-medicate in a phenomenon called ‘microdosing’, you can read more about this in a previous blog on InSPIre the Mind. How do psychedelics work? There is evidence that psychedelics change your brain. Not only do these substances mimic serotonin (the ‘happy’ neurotransmitter), they have actually been found to interrupt a network within the brain called the default mode network (DMN). If you are anything like me, the DMN will be one of the most active regions within your brain. That is because the DMN is responsible for daydreaming, introspection, thinking about the past and future. It is the region that is directly opposed to the task focused network; any time you are not focusing on completing a task, the DMN comes alive. However, excessive use of the DMN has been identified across a range of mental health conditions; this is where psychedelics really shine. Interrupting the DMN causes what some refer to as ‘ego dissolution’. One’s ruminations and worries melt away, allowing the brain to form new connections; unlocking new regions and therefore new ways of thinking. If you are interested in the effect of psychedelics on the DMN, this article provides a great explanation. Photo by Christopher Ott on Unsplash What does psychedelic therapy look like? The experience one has when under the influence of psychedelic substances is highly influenceable. These so-called ‘trips’ can therefore be prompted to go in a particular direction by a therapist before the session has even begun. It is this ability to guide psychedelic trips that makes them ideal for treating past trauma in PTSD, and rumination in depression. A typical guided therapy session will involve a preliminary session to establish the goals of treatment, and guidance on how to deal with any negative trips. Unlike the recreational use of psychedelics, therapists give set doses under full supervision; section 1 substances can only be sourced from highly regulated producers. The key to psilocybin therapy arguably lies in its follow-up integration session, during which the patient is helped to incorporate the psychedelic experience into their life. The pre-treatment and post-treatment integration sessions are time consuming yes, but form the framework of this therapeutic model which clinical trials are currently testing. The profound experience one has whilst on a psychedelic trip has the ability to alter mood for months, even years after the session. Compare this to antidepressants which must be taken daily to continue having effect, and you can see why I am so excited by the therapeutic potential of psychedelics. No more weight gain, sexual dysfunction or regular blood tests — common side effects of antidepressants. It all sounds too good to be true, doesn’t it? Surely these substances are addictive or harmful in some way, otherwise they wouldn’t be so tightly controlled? These were questions that I too had when delving into the available resources online. Yet it seems that the intense experience of a psilocybin trip is not actually as addictive as we may presume. The fact is that guided psychedelic therapy is incredibly safe. As noted by Imperial College London’s Professor David Nutt, LSD and ecstasy are far safer than alcohol or indeed horse riding; a position that led to his removal from the government advisory board on drugs. Photo by Marcus Loke on Unsplash The tight regulations surrounding the production and distribution of Schedule 1 drugs does however mean that patients can only access psilocybin through clinical trials. The effects of the law on research has been neatly outlined by Professor David Nutt in an article for the Lancet that you can read here. The limited number of said trials recruiting patients has led to a growing number of underground therapists to spring up all over the world, offering guided therapy sessions using psilocybin — which for now, is illegal. Read or watch the reports from patients who have participated in underground psilocybin therapy. Most will say it was a positive experience, many even say it triumphed where conventional treatments have failed. The issue with sourcing psilocybin outside of clinical trials is that the product itself is unregulated, making effective doses hard to establish. I worry that this leaves patients vulnerable to unscrupulous ‘therapists’ who themselves may be unlicensed and undertrained, and potentially dangerous substances purporting to be psilocybin. Moreover, the uncontrolled way in which psychedelics are administered outside of a research setting means that the testimonies of the patients they help cannot be considered as evidence of their efficacy. This does nothing to progress science or the future of psychiatry. I refuse to accept that forcing patients to break the law in order to seek treatment for their mental illness represents the future of psychiatry. However, with legislation currently as it is, I see this only continuing to happen. Image by Nadzeya Makeyeva on Behance So what does the future of psychedelics look like? Unlike some working in this field, I do not agree that psychedelics like psilocybin should be legalised for the general public to use. As Michael Pollan says in his fascinating book on the topic, psychedelics are not recreational drugs. They can have profound effects on one’s life and as such should only be taken under the supervision and guidance of trained professionals. I do, however, hope that the growing evidence from clinical trials will culminate in their down-regulation from Section 1 to Section 2; allowing for regulated prescription and administration in the same vein as medical marijuana. We must ask ourselves how much influence we will allow government policy to have over scientific innovation. Psilocybin and the blood thinner warfarin can both be derived from plants (mushrooms and grasses respectively), and both have therapeutic properties. Yet, only one is accepted as a medicinal treatment. By educating ourselves on where this stigma has come from, we can advocate for it to change. As future psychiatrists, we cannot be afraid to explore new ways of helping our patients, however unconventional or strange they seem. Special note from the editors: This is the ninth blog of our series, The future of mental health as seen by the future leaders in mental health, written by the 2020 ‘Psych Stars.’ Selected by The Royal College of Psychiatrists, Psych Star ambassadors are a group of final year medical students awarded for their particular interest and commitment to psychiatry. During the year-long scheme as Psych Stars, students are nurtured in their interest in psychiatry through the assignment of mentors, by gaining access to learning resources and events, and by becoming part of a network of like-minded students. More information on the Psych Stars scheme can be read here. We have decided to invite each of the Psych Stars to write a blog on how they envision the future of mental health by choosing an area in which they are passionate. We have decided to run the series as a celebration of these student’s success and to provide an outlook for each of the awardees to share their passion. With a new blog published each Friday, the series will run over the next few months. If you enjoyed today’s blog by Isabella, be sure to head over to InSPIre the Mind and check out the previous blogs in our Psych Star series covering topics such as compassion, the mind-body interaction, the future of child & adolescent psychiatry, gender inequality, global health, male mental health, neuropsychiatry, and telepsychiatry.