A lot has been changed by the COVID-19 pandemic in the last 6 months. For those of us familiar with the inside of clinic rooms, one of the starkest changes may be the sudden reliance upon providing health care electronically. As a medical student, I spend a lot of time shadowing doctors in the clinic, and since returning to medical school for Year 5, my peers and I have increasingly noticed that consultations are taking place over the phone or on a video call. Over the past 5 weeks, I have been on my paediatrics placement, and because of COVID-19, a large proportion of the clinics have been conducted via telephone consultation. Where this was once a futuristic rarity, it has very rapidly become commonplace in all specialties within medicine, psychiatry included. Over the summer, and throughout the last year, I have been working at the University of Edinburgh as part of their Learning Technology team. Our reliance as a society upon video-conferencing and other technologies to teach, learn and have meetings has increased a thousandfold since the beginning of the pandemic, and my job means that I have been working at the forefront of this. The university has adapted so many teaching exercises to enable online learning, and here at Edinburgh Medical School, we are now having practical exams teleconferencing, fully online, with mock patients. I personally have my first set of these exams in November (wish me luck) and am looking forward to learning more about the techniques and best practices for conducting consultations online. Photo by Chris Montgomery on Unsplash My interest and experience in the learning technology sector, alongside my long-standing fascination with psychiatry, prompted me to think about the possibilities that exist when combining these. I have always been particularly interested in psychiatry because of its position as a very patient-centred and holistic speciality. It involves being observant and listening well in order to build a strong therapeutic relationship with each individual patient. I began to wonder — how does one establish such a rapport and display empathy like that online? Therefore, now more than ever, I felt it is crucial to discuss developments in telepsychiatry and what its future holds. Technically defined as ‘a subspecialty of telemedicine which includes psychiatric assessments or follow-up interviews conducted using telephone calls, audio and video digital platforms’, telepsychiatry can be taken to mean the use of technology in delivering psychiatric care. Though the COVID-19 pandemic may have accelerated the adoption of telepsychiatric techniques, the first use of videoconferencing in psychiatry was reported as far back as the 1950s, when the Nebraska Psychiatric Institute first used video-calling for group therapy, liaison psychiatry and teaching at the state hospital. In Europe, telepsychiatry was used in 1998 to bring specialist psychiatric services to the population of the 3 Aran Islands off the west coast of Ireland. Interestingly, at the time, the authors of the case study recounted that “each link-up costs nine times the price of an ordinary telephone call for an equivalent length of time”. Just over 20 years later, the practice of telepsychiatry is probably almost nine times cheaper than an in-person session, when the costs of transport and consultation room hire are taken into account. Yet, we must remain mindful that not everyone has the technology and quiet space available in order to engage with telepsychiatric methods. There is also the wider question of whether seeing patients online can ever enable the same insight as a physical consultation. One can think of many reasons why this can cause issues for the delivery of mental health care specifically. The nature of psychiatry means that it relies upon a therapeutic relationship and an understanding between the patient and their psychiatrist. We all know how hard it is to make friends over Zoom (think about all the awkward conference icebreaker sessions you’ve been to over the last few months), let alone to establish and develop an effective therapeutic relationship with a patient. Not being able to see someone face-to-face may cause difficulties in interpreting body language. Especially now everyone is online more often, we have the added obstacle of unstable WiFi signals causing glitches and delays. This can mean that personal and intimate discussions (as are often required in psychiatry) are much more challenging and less productive. Photo by National Cancer Institute on Unsplash These potential weaknesses of telepsychiatric care are perhaps more obvious, but we should consider that still there is promise in the concept, at least in some contexts. For example, there is data to show that being able to consult with your psychiatrist from the comfort of your own home improves the likelihood of a patient attending an appointment. The American Psychiatric Association has conducted some preliminary work into the use of telepsychiatry methods during the COVID-19 pandemic, and the percentage of psychiatrists who reported that all their patients kept their appointments increased from 9% before, to 32% since the pandemic was declared an emergency. This is particularly important in psychiatry, where many patients have complex health and social circumstances acting as a barrier to them accessing regular healthcare (due to the cost of commuting to the hospital, for example). For these patients, telepsychiatry can alleviate a significant burden. In fact, there are some patient groups for which telepsychiatry may actually be preferable to face-to-face consultations. The Oxford Precision Psychiatry Lab suggest that, for children and adolescents on the autistic spectrum, or for adults with severe social anxiety, telepsychiatry may be preferred (and can be well-coupled with emailing as an option too). It is easy to see how this might help these specific patient groups, who often struggle in physical social situations. One of the additional clinical benefits of telepsychiatry might be that mental health professionals can get a valuable glimpse inside a patient’s home. In the same way that home visits in general practice can give GPs insight into how a patient is coping (or not), videoconference appointments may afford psychiatrists the same insight. Although in psychiatry some outpatients do get home visits, the vast majority of patients are seen in clinic. Perhaps we should consider the value of the extra information gained by seeing the patient’s home environment via telepsychiatric methods. Photo by Zach Vessels on Unsplash In some ways, psychiatry may be one of the specialties best suited to use of video technology, as many of the therapeutic modalities used in psychiatry are talking-based, e.g. cognitive behavioural therapy, or rely on medication rather than clinical devices or surgical techniques. Furthermore, in other aspects of mental health care, technological solutions are being heralded as an exciting development. Mood-tracking algorithms coupled with features like messaging an online therapist are just some of the ways in which apps like BetterHelp are beginning to make their mark. Just a few months ago, InSPIre the Mind published a blog about these apps, which I would highly recommend for a more in-depth discussion of these tools. There is vast potential for these two related but distinct technologies to work together to enhance psychiatric care, and I look forward to watching this unfold in my future career. It is impressive that since telepsychiatry has become a necessity due to the pandemic, many toolkits have been created or rapidly repurposed to allow clinicians to adapt to the change. In March, shortly after the COVID-19 restrictions came into place, a webinar was held suggesting ways to glean key information through an online neurological examination, and many of the common cognitive examinations now have online video versions, like the Montreal Cognitive Assessment. Photo by Ceibos on Wikimedia Commons As a community, psychiatry has responded well to the challenge COVID-19 has presented, and there have been innovative solutions aiding the transition across to online services. For example, a visual step-by-step guide for clinicians to use video consultations in mental health services was published rapidly in May, detailing the ethical and logistical considerations required to deliver safe, effective care. Additionally, it is exciting to see the Royal College of Psychiatrists starting to explore technological tools too — they are organising a conference discussing novel but meaningful ways of practicing psychiatry online. Now that there are so many tools that exist to allow clinicians to practice telepsychiatry, how effective is it? Numerous studies have been done each looking at very specific patient groups, e.g., adult transplant recipients with depression; children with depression; elderly patients with mild cognitive impairment, to name just a few. Using all of these studies, in widely different settings and patient demographic groups, a strong evidence base has been built supporting the view that telepsychiatric consultations are equally as effective as face-to-face consultations, if not more. This means that patients had the same diagnostic outcomes as from an in-person consultation and that the patients found the consultations to be just as helpful. For example, one study in the USA looked at the reliability of diagnosis via telepsychiatry by comparing psychiatrists’ evaluations of patients presenting to the emergency department. Patients were evaluated by a psychiatrist using videoconferencing, and another psychiatrist, who was physically present in the room, also completed an assessment of the patient. It was found that there was no significant difference in the psychiatrists’ evaluation of the patient’s mental state, or in their treatment recommendations. Additionally, another study compared patient satisfaction levels between face-to-face and video consultations using a validated tool called a Client Satisfaction Questionnaire. They found that patients found the two modalities of consultation to be equally satisfactory. Additionally, when looking at providing long-term treatment over videoconferencing, there is good evidence that this is also equally effective compared to face-to-face treatment. A study in Australia compared whether Cognitive Behavioural Therapy (a type of talking therapy used for mood and anxiety disorders) administered via videoconference produces comparable clinical outcomes to in-person treatment, ultimately finding that they the two methods are equally effective. Some research has even gone a step further and trialled asynchronous telepsychiatric care — i.e., the patient and psychiatrist are not having a live online conversation, but rather a video of a consultation with a primary care provider (such as a general practitioner), along with email correspondence between the patient and the primary care provider are sent to a psychiatrist who then consults all the sources of information at a different time. They are then able to report back to the primary care provider who can implement their recommendations in the community. Though the study is still ongoing and the full results of this work are unpublished, in theory, this model could improve access to psychiatric care, especially for patients who may have otherwise had to travel far or wait a long period of time for a direct consultation with a psychiatrist. It was also calculated to be more cost-effective than both synchronous (i.e. real-time) telepsychiatry, and in-person psychiatric consultations. Photo by Anna Shvets from Pexels In summary, though prompted by such global devastation, the recent advances in telepsychiatry show promise in a multitude of ways. Patients may get access to services quicker. Psychiatrists can get an illuminating glimpse into a patient’s home life. The cost and barriers to attending appointments may lower. Most importantly, they are proving to be of equal effectiveness to face-to-face consultations. However, we must keep being mindful that, as with all things in psychiatry, this is a nuanced discussion — ultimately, psychiatric care should be delivered in whatever manner is most effective and beneficial for the patient, something which may vary significantly between individuals and their circumstances. Personally, I look forward to seeing the evidence base for telepsychiatry develop in a range of settings and demographics as it has the potential to greatly improve access to services and remove many of the barriers patients face when seeking treatment. Special note from the editors: This is the eighth 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 Anushka, 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, and neuropsychiatry. Header image source: Bongkarn Thanyakij from Pexels

Psychiatry, like many other specialties within medicine, has a range of sub-specialties from which one can choose during higher training, which lead to further development of expertise in a certain area of psychiatry and a particular subset of patients. Neuropsychiatry is one of those sub-specialties. Simply defined, neuropsychiatry is the practice of managing mental illness in the context of an organic, neurological cause or associated lesion — depression in Parkinson’s disease, organic causes of psychosis and schizophrenia, and the psychological components of dementia are some examples of presentations that would typically be attended to by a neuropsychiatrist. It brings together the fields of neurology and psychiatry to further our understanding and facilitate the most appropriate management of presentations that are neither purely psychiatric nor purely neurological in nature — a masterful blend of mind and matter. Photo by Robina Weermeijer on Unsplash My interest in neuropsychiatry first came about after my second year of medical school whilst completing a six-week lab-based summer research project on Parkinson’s disease with one of the research groups at my university. I have always been fascinated by the brain, even before commencing my degree, and by that point was quite certain that the specialty I ended up pursuing would be one of the ones related to the nervous system. Whilst contemplating a career in neurology, I was also simultaneously exploring psychiatry, attending the annual one-week psychiatry summer school at the Institute of Psychiatry, Psychology and Neuroscience (IoPPN) at King’s College London. The outcomes of these events during that summer were: 1) a change in career plans and my decision to pursue psychiatry, and 2) an infatuation with the possibility of training in both psychiatry and neurology. This infatuation led me to discover that there, in fact, exists a neuropsychiatry sub-specialty through the psychiatry specialty training route. However, it is relatively less well-established compared to the other sub-specialties. I also explored other, equally interesting psychiatry sub-specialties: child and adolescent, perinatal, addictions, forensic… My interest in neuropsychiatry has recently re-emerged, and I am, once again, considering it as my sub-specialty of choice. Thus, I have carried out internet searches seeking to understand more about the training pathway and how neuropsychiatry as a discipline came to exist. In this blog article, I will explore the origins of neuropsychiatry, dating back to ancient history, and its place now in modern medicine. I will then discuss the current training pathway for becoming a neuropsychiatrist in the United Kingdom (UK), followed by laying down my argument for why the future of neuropsychiatry training should be its evolution into dual training in both neurology and psychiatry. “BY THE SAME ORGAN COMES JOYS, DELIGHTS…AND FEARS AND TERRORS…” — THE ORIGINS OF NEUROPSYCHIATRY Photo by David Matos on Unsplash Modern neuropsychiatry is often labelled as a relatively new practice within medicine, however, this is not strictly true. The history of neuropsychiatry can be traced back to ancient Greece, though it is slightly vague and elusive. Hippocrates, the ancient Greek physician and ‘father of medicine’, postulated his theory on the origin of epilepsy, proclaiming that: “by the same organ (from which comes) joys, delights, laughter and sports, and sorrows, griefs, despondency and lamentations…we become mad and delirious...” — HIPPOCRATES During the Renaissance and Romantic periods, neuroscience went through a number of developments. For example, neuroanatomy underwent further exploration by the likes of Andreas Vesalius and Thomas Willis. René Descartes approached questions about mind and body and existence from a philosophical and mathematical perspective. From Descartes’ musings came his famous conclusion, “cogito ergo sum”, and his contributions to ‘substance dualism’ (‘Cartesian dualism’) — the idea that the mind and body are essentially distinct entities. These ideas stemmed from a larger ‘mind-body problem’ discourse that a number of Enlightenment philosophers engaged with at the time, including Descartes. What relation do the mind and body have? Immanuel Kant, a German philosopher and one of the most influential Enlightenment thinkers, formed a model of the mind that has played a central role in the development of cognitive science. Romantic poets challenged the passive brain theory of empiricists, which had dominated theoretical neuroscience for hundreds of years — the idea that the brain solely received sensations as a receptor, which then led to a muscular response (S -> R). The theory did not explain the creativity of the mind, manifested through the arts and great literary works, which required active thinking and shaping of human experiences and the world around us. Photo by Joyce McCown on Unsplash Phrenology, now a refuted concept and dismissed as pseudoscience, was conceived by Franz Gall and Johann Spurzheim and proposed that the role of different regions of the cerebral cortex of the brain in the make-up of the mind corresponded with the size of the skull encasing the region. Further evolutions within neuropsychiatry occurred until its split into two distinctly different specialisms, neurology and psychiatry, later in the 19th century. Growing, singular interest in mental states and the mind, including memory and dreams and the influence of individuals such as Sigmund Feud and his founding of psychoanalysis, led to the development of psychiatry, which focussed less on neuroscience and more on the psychological processes. This left neurology and its focus on the brain and organic disorders and lesions to develop separately into what it is recognised as today. It was not until the late 20th century that efforts were made to revive the practice of neuropsychiatry once again. Formal neuropsychiatry organisations within the medical community were formed, such as the British Neuropsychiatric Association in 1987, the American Neuropsychiatric Association in 1988, and the International Neuropsychiatric Association in 1996. Other developments included the discovery of the electroencephalogram (EEG) by Hans Berger and its use to extensively study the electrical discharge of seizures and its link to psychiatric presentations in patients. Photo by Robina Weermeijer on Unsplash NEUROPSYCHIATRY AND 21ST-CENTURY MEDICINE Neuropsychiatry has now returned to what it once was: an equally weighted practice of both neurological and psychiatric explorations of presentations that fall into the remit of the discipline — or has it? As previously mentioned, neuropsychiatry is a sub-specialty within psychiatry. Therefore, doctors going down the neurology training route with an interest in the psychiatric aspect of presentations they might encounter may not come across neuropsychiatry as a career option or may find themselves having to retrain to pursue that path. To add to the complexity of the situation, neuropsychiatry higher training is not as straightforward as the others. It is not a sub-specialty that is formally recognised by the General Medical Council (GMC), the regulatory body of medical training and practice in the UK. Therefore, aspiring neuropsychiatrists tend to have to carve out their own training pathways to meet the competency requirements to become a consultant. CV-building activities, such as completing a master’s in Clinical Neuropsychiatry, are useful pursuits in the training process. Currently, there are plans by the Faculty of Neuropsychiatry of the Royal College of Psychiatrists (RCPsych) to make training in the sub-specialty more structured by providing a curriculum and syllabus, which will hopefully lead to its formal endorsement by the GMC. But could we go one step further? After thinking about the dilemma the current situation poses for doctors keen on both specialties, I believe the best next step for the evolution and future of the discipline is the implementation of dual training in both neurology and psychiatry. THE BEST OF BOTH WORLDS Dual training in neurology and psychiatry is not a new concept. For example, it already exists in the United States (US), such as the programme offered by New York University. Residents (registrars) dual train in neurology and psychiatry for six years, an extra two years than the four-year singular neurology and psychiatry residencies. The curriculum is created by the American Board of Psychiatry and Neurology (ABPN), which oversees neurology, psychiatry, and dual neurology and psychiatry training in the US. The fact that the curriculum and certification of the individual neurology and psychiatry residencies is provided by the same board sets an example in emphasising that neurology and psychiatry are not dichotomous disciplines and should be housed by the same training body. To put things into perspective, having separate specialty boards represent neurology and psychiatry would be analogous to having obstetrics and gynaecology represented by two separate boards. It sounds absurd and goes against the norm we have accepted for obstetrics and gynaecology training to be joint — after all, they are both related to the female reproductive system. Yet that absurd situation is exactly what exists for neurology and psychiatry training in the UK: neurology is overseen by the Royal College of Physicians (RCP) as a ‘medical’ specialty and psychiatry by the RCPsych. But why? After all, they are both related to the nervous system. Photo by meo from Pexels Psychiatrists and neurologists should be trained in both specialties to achieve the higher level of competence and holistic training their patients deserve. You wouldn’t expect an obstetrician to not have the sound understanding and knowledge of gynaecological conditions required to enable them to manage gynaecological presentations, and vice versa. This is even most likely virtually impossible because of the design of their training programme. Therefore, we should expect the same when it comes to neurologists’ and psychiatrists’ understanding of the other specialty. Even if a doctor decides not to pursue neuropsychiatry as a career by the end of the dual training and chooses either neurology or psychiatry instead, they are knowledgeable in both areas and would be equipped to spot and manage presentations that fall into either category, or both, were a patient requiring this care to walk into their consultation room. The neuropsychiatric complications studied in patients who have had the coronavirus disease 19 (COVID-19) have recently highlighted the necessity for neurologists and psychiatrists to be competent in both disciplines. Dual training would mean patients would no longer need to see their neurologist for their Parkinson’s disease and have a separate appointment with a psychiatrist for their associated depression. This would allow for better continuity of care and a deeper doctor-patient rapport to be built, more efficient healthcare provision and resource management, and fewer appointments for patients to keep track of. In medicine, we are spoiled for choice — sometimes both a blessing and a curse. For those interested in neurology and psychiatry, dual training eliminates the need to choose between them early in the specialty training stage. It would open the doors to three potential career paths: neurology; psychiatry; and neuropsychiatry. Since ancient civilisation, neurology and psychiatry have been studied together, explored and attempted to be mastered as one unified discipline. To focus on one without the other is to only see half of the full picture. Moving forward, we must have a greater appreciation of their shared organ system and strive to achieve a clearer vision of all that sits within the frames of neuropsychiatric disorders. Special note from the editors: This is the seventh blog of our new 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 Bibire, be sure to head over to 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, and male mental health. Header Image Source — Behance

Source: Iz zy on Unsplash Content Warning  — This blog deals with the topic of suicide and may be distressing to some readers. If any of the topics raised resonate with you or someone you know, at the end of this blog I have signposted charities and helplines that can provide a listening ear. About me Male mental health has always been at the forefront of my mind growing up with a brother with Asperger’s. I noticed how he really struggled his whole life with getting the right support for his crippling anxiety and opening up about his mental health. Then, throughout my late teens to early twenties, the rise of social media brought to my attention fundraising and awareness campaigns such as Movember and Men’s Minds Matter, which aim to get men talking about their mental health. This made me realise that maybe I am not the only one worrying about my brother doing the unthinkable and ending his life, or my inability to reach out to him in a way that he responds to… …maybe this a societal thing. As they say, women are from Venus and men are from Mars, how on earth can I understand how he would want help with his mental health, I do not have a male brain! Why are girls seemingly much better at talking about our emotions and providing support to each other? Then, on the other hand, is this changing? Are men getting better at opening up? I am currently a final year medical student at the University of Sheffield and my passion lies with Psychiatry. My early exposure to mental health, from living with my brother, sparked my initial interest in the speciality by showing me the impact it can have on daily life. However, at medical school, I went on to join the Psychiatry Early Experience Programme, PsychSoc and completed my self-selected placement at Rampton (a high-secure forensic hospital), which collectively lead me to want to be an ambassador for and pursue a career in Psychiatry. Me and my brother Societal factors of suicide Globally, on average one man dies from suicide every minute of every day, making them on average three times more likely than women to kill themselves. This really does not sit well with me and I am sure it doesn’t with most of you reading this, so why aren’t we rushing to change it? When researching for this blog, it became clear to me that this is a complex matter, but in my opinion, one of the main influences on this disparity is society, rather than the individual. It’s the male-side of the feminist argument (never thought I would say that!); toxic masculinity is programmed into men, which provides entirely unhealthy standards for men to ‘live up to’. Obviously, there are other factors aside from ‘society’ that can contribute to someone taking their own life. Someone’s genetic lottery, past or current trauma, alcohol, and drug habits are among a few factors that can contribute, and these cannot be ignored. However, societal contributors to male suicides are the things we can have some level of control over as a community and can work to minimise to hopefully, in turn, create an environment where males feel comfortable to seek help or speak to love ones before crisis point. The charity Samaritans completed a systematic review of the current literature to find the potential societal factors of male life that can lead to suicide. However, it is important to note that this report did not take into consideration the role of intersectionality (i.e. ethnicity, the role of transgender identity, sexual orientation) on suicidality — more information on rational and focus population can be found in the report linked above. Mind map of factors This review found that when the men passed the age of 30 they seemed to lose their peers, whereas women tend to maintain these connections lifelong. This means they lost their support systems outside of their immediate family at an early stage of life. However, this difference may not matter as much as it may seem as the research also showed that male friendships tended to centre around activities, rather than divulging their recent struggles and anxieties, which was commonly shown in female peers. This lack of emotional relationships between males was linked to the men throughout their childhood being taught to be ‘manly’ and not social or emotional. Allowing men to build up distress, which only rears its head when reaching crisis point. Explaining why the men included in the review suffered greater when they go through a ‘relationship breakdown’, as their only outsource of emotional turmoil tended to be their partners. To add, it was shown this happens the most when the men hit middle age. Typically, by this point a lot of time has been invested into work and relationships, meaning they can feel trapped by their current life. Not only this, but ‘the boomers’ are trapped between their parents, who traditionally were silent and austere, and their children who are more progressive and open, leaving them not knowing which one to follow. The next two factors were masculinity and low socioeconomic status. The concept of a ‘masculine dream’ which centres around power, control and invincibility was discussed in the report. ‘Being a man’, as in providing for your family, was shown to be an important factor in the participating males mental health. Therefore, if they did not meet these standards, they felt shame and defeat. (Which I am sure admitting mental health problems would have similar affects to this ‘dream ideal’ as castration!). Low socioeconomic status was also shown to cause a feeling of powerlessness, stigma and disrespect, but also added poor education, housing and income. Which meant that the report found that the further down the social ladder you climb, the higher the rates of suicide you got. What the report states is that all of these factors boil down to certain ‘mind sets’ that have been placed upon the male gender. This idea that they feel the need to always meet the high expectations of others. I guess being at the top of the privilege tree in terms of gender has its pressures too. On reflection, what I think would be an interesting future research topic would be investigating why these men were affected by these factors leading them to commit suicide and why some men are not. Source: Dorrell Tibbs on Unsplash Why men and not women? What this information suggests to me is that men might be more likely to consider suicide at times of serious mental struggles, whereas women have more barriers they utilise first, such as simply confiding in close friends or admitting to themselves that they have a problem. However, what is interesting is that in the US women are 1.2 times more likely to attempt suicide and women generally have higher rates of depression. This is also reflecting the fact that men are tending to use more violent methods of suicide, such as firearms or jumping, rather than self-poisoning or exsanguination. Source: Tom Pumford on Unsplash This is congruent with what is seen, yet exaggerated, in prisons: men make up almost 96% of the prison population in the UK and are 3.7 times more likely to commit suicide there than in the public, thus increasing the rate of male suicide significantly. Not only this, but men are more likely to turn to alcohol and drugs, which is a factor that increases the risk of suicide, as represented by the specific section on the SAD PERSONS clinical suicide risk score. What is clear is that societal pressure could be a major player in these differences. I guess in a capitalist world where the only way is up, we have become comfortable telling women that they can be surgeons, pilots and engineers, much quicker and more easily than we have been telling men that it is great if they want to be nurses, secretaries and shopkeepers. To the future In the writing of this blog, I sadly had the sobering realisation that in my life I too can only think of males that have taken their lives. Maybe this is just me, or maybe that is the same for you as readers, but it made me realise how terribly personal it makes this issue. I am sure I am not the only one. On a more positive note and looking to the future, change and progress is happening. There is a drive and push for change that has mainly come from the community, charities, and social media. From people who have had close relatives take their life and are saying enough is enough. For example, male social media influencers such as Dr Alex and Chris Hughes from reality show Love Island, have recently been having open talks about their mental health to their large young male following. To add, movements such as the Campaign Against Living Miserably (CALM) are actively working and successfully to tackle male suicide. However, what I feel is missing is a big public health movement coming from central government, looking for major societal change in the way we view men and how they access mental health support. This change needs to happen right from day one, in schools and at home, talking to boys and men more about their mental health. We need to stop treating the individual and focus on societies pitfalls, treating the cause, not the symptom. This is when I believe we will start to see a major change in suicide rates in men. I have a feeling that day is nearly on the horizon. To get a different perspective on this topic, a previous blog post looks at this topic from an adolescent boy’s perspective and is an interesting read on comparison. Note from the author: If this topic has resonated with you about yourself or someone in your life, please see below charities that can provide a listening ear… and don’t forget help can be found from your GP! Samaritans — 116 123 (free 24-hour helpline) CALM is the Campaign Against Living Miserably — for men aged 15 to 35. Phone: 0800 58 58 58 (daily, 5pm to midnight) Men’s health forum — 24/7 stress support for men by text, chat and email. Website: www.menshealthforum.org.uk Special note from the editors: This is the sixth blog of our new 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 Bethany, 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, and global health.

My interest in mental health grew considerably when I started medical school. I remember being spellbound by a lecture in the first term of my first year on the interface between public health and child mental health, and wondering whether this might be something I’d like to do as a career. Quickly realising that psychiatry comprised such a small part of our curriculum, I began dedicating my evenings to attending extracurricular talks run by my medical school’s Psychiatry Society. Hearing from clinicians who were so passionate about making a difference to people with mental illness really made me contemplate a career in psychiatry. I am now a fourth-year medical student, and during the first lockdown last year, I was looking into ways to use my additional free time productively to further my knowledge and experience in psychiatry. I received an email inviting applications to the Psych Star scheme, so I decided to take the plunge and apply. The Psych Star scheme is a year-long scheme run by the Royal College of Psychiatrists, designed to support medical students with an interest in psychiatry to increase their knowledge and awareness of what the career entails. Students are awarded a bursary and given a mentor to assist them in their career development, as well as being expected to act as an ambassador for psychiatry in return. I had the privilege of being appointed as one of only 12 Psych Stars in the UK following a competitive application process and interview. The networks I have built and the learning I have accessed as a result of the scheme have been absolutely outstanding, as well as the support I have received from so many inspirational people working in psychiatry. As my time in post is now sadly drawing to a close, I wanted to reflect on what a phenomenal experience it has been and highlight some of my favourite parts of the year. Connecting with like-minded people A big highlight of the Psych Star scheme has been the amazing people I have met and worked with. I was very lucky to be assigned a great mentor, Dr Richard Laugharne, who has been an incredible help and supported me to achieve my aims. Richard put me in touch with lots of local psychiatrists who were able to assist me with different requests, such as extra placement opportunities, discussions around mental health first aid training for students, and speakers for university careers events. I couldn’t have made the most of this year without my fellow Psych Stars. It was fantastic to be part of such a diverse group of like-minded students from all over the UK. Due to the pandemic, we were unfortunately unable to travel to London to meet at the Royal College in person for our welcome and induction evening. We thankfully managed to have meetings online so we could get to know each other, the scheme leads at the College, and the Careers team. Keeping in touch through our regular meetings was really motivating as we got to learn about the different activities that each Psych Star was accessing through the scheme and reflect on our experiences. All of us thoroughly enjoyed the opportunity to write a blog for the InSPIre The Mind Psych Star blog series last year, headed by a reflection from Dr Adrian James, President of the Royal College of Psychiatrists. You can read our musings on the future of psychiatry here. Image source: Clare Wynn-Mackenzie Promoting a career in psychiatry I think the most important part of my role as a Psych Star has been acting as an ambassador for psychiatry. Although recruitment to psychiatry has improved dramatically over the past few years (67.3% of core training posts were filled in 2017, compared to 99.4% in 2020), we still have a long way to go in attracting people to the specialty. I have also helped to organise events for our Psychiatry Society, as well as running some teaching sessions myself. Our ‘Divergent Psychiatry’ events series covered a wide variety of topics relating to different disciplines that inform psychiatric practice. Notable events included ‘The Neurobiology of Addiction’ with Professor Anne Lingford-Hughes; ‘Delusion and Spiritual Experience’ with Professor Bill Fulford; and ‘Apps Focused on Epilepsy’ with Dr Rohit Shankar MBE. Our pre- and post-event surveys showed that these events had a positive impact on students’ opinions of psychiatry and their interest in this career path. The ‘Choose Psychiatry’ campaign run by the Royal College of Psychiatrists has been very successful in promoting a career in psychiatry to students and doctors at varying stages in their training, so I was thrilled to be part of this campaign locally. The Exeter, Plymouth, and Bristol Psychiatry Societies worked with the Choose Psychiatry Peninsula Network to organise an event for medical students and foundation doctors within the South West division. ‘The History of Psychiatry: Told Through the Arts’ aimed to explore the evolution of psychiatry through various art forms such as films and paintings, as well as demonstrate the benefits of art-based therapies for patients with mental illness. Attendees remarked on how insightful the event was, and how interesting it was to learn about psychiatry through a broader, less medical lens. Image source: Isabelle Wood Attending conferences and the International Congress As a student from a widening participation (under-represented in higher education) background, the financial aid afforded to me by the Psych Star scheme was invaluable. I had planned to use the majority of my funding to cover conference fees and travel expenses, though the latter didn’t end up being necessary. Being able to attend whichever conferences I liked was instrumental in allowing me to learn more about areas of psychiatry that I’d never even heard of. The Adolescent Forensic Psychiatry Special Interest Group conference was a prime example of this. Initially believing that this was a very niche area, I registered for the conference purely to find out more about what the specialty actually entailed. I was immediately fascinated by the complexity of the medicolegal issues in this field and the neuroscience underpinning decision making in adolescence, especially in the context of ‘Minimum Age of Criminal Responsibility’. I was also able to further my knowledge in areas I knew I was interested in; I have worked with many individuals with autism in my part-time job and also done a research internship in neurodevelopmental disorders, so I was very excited to attend the Autism Spectrum Disorders Continuing Professional Development (CPD) Update. It was great to explore the research underpinning sex differences in neurodevelopmental disorders, and learn about the assessment and treatment of mental health problems in people with autism spectrum disorders. Free registration for the International Congress was an enormous benefit of the Psych Star scheme, and attending the virtual 4-day event was definitely a highlight of my year. There was a massive variety of lectures, workshops, and interactive sessions on every specialty and underpinning science in psychiatry. It would be impossible to pick my favourite part of the Congress but some serious contenders would be the sessions on social determinants of health; the genetics of eating disorders; the neurobiology of obsessive-compulsive disorder (OCD); the relationship between adverse childhood experiences and neurodevelopmental disorders; and suicide, mental capacity, and the law. Image source: rcpsych.ac.uk CPD Resources The Psych Star scheme also provides subscriptions to the CPD Online and Trainees Online e-learning platforms. With over 200 learning modules and 150 podcasts on CPD Online, I have been spoiled for choice with such a diverse assortment of resources on all aspects of psychiatry. Reviewing the content available on Trainees Online has been excellent revision, as well as introducing me to new concepts. Receiving free copies of the British Journal of Psychiatry and its sister journals has been a great source of ongoing education for me. Having access to the latest research and advances in psychiatry has really inspired me, as well as improved my scientific reading skills. I particularly enjoyed reading the publications on self-harm and suicide prevention in the most recent edition of the British Journal of Psychiatry. As someone who has undertaken Applied Suicide Intervention Skills Training (ASIST), it was intriguing to read about the evidence for safety planning-type interventions for suicide prevention. Image source: Emily Jones Overall, I have had the most exceptional experience throughout my past year as a Psych Star, and I would wholeheartedly recommend any interested student to apply for the scheme. I thought it would be fitting to end this reflection with some career advice we received from our scheme leads at our final Psych Star virtual meeting: “Look after your patients and your career will look after itself” “If you’re up all night worrying about a patient, that’s your sign to talk to a senior about it” “It’s a marathon, not a sprint — enjoy the journey” “Eat well and invest in some comfy shoes!” Feeling inspired? Visit the Royal College of Psychiatrists Psych Star page to find out more about the scheme, and sign up for a free Student Associate membership here. Header Image source: Robina Weermeijer on Unsplash

Special note from the editors: This is the fifth blog of our new 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. Global mental health is a term that describes the practices, research and policies delivered and enacted worldwide to improve the mental health of the world's citizens. I have chosen today to discuss global mental health because it is a topic I feel most passionately about. I am of Ugandan heritage, a low-income country in East Africa, and it was my learning of the stark contrast in the services and unique experiences and challenges faced by patients and mental health professionals, in comparison to our services here in the United Kingdom, that first led me to become interested in transcultural psychiatry and global mental health. Although it is not perfect, the United Kingdom benefits from an incredible National Healthcare Service, including brilliant mental health services, and this is in part why I decided to study medicine and it has inspired me to pursue psychiatry as a career. However, this also means for many of us it can be easy to forget to consider the lived realities and struggles of those at home and that of others in what can feel like half a world away. Photo by Kyle Glenn on Unsplash Mental illness and substance misuse are leading causes of disability globally and account for just under 15% of annual deaths worldwide. By 2030 it is projected that mental health problems, particularly depression, will be the single leading cause of mortality and morbidity universally. The presence of a worldwide treatment gap in mental health services has been described wherein people in need are not receiving care. This division is large and is described across many mental health conditions including depression, anxiety disorders and schizophrenia, whilst being the greatest in those experiencing alcohol abuse and dependence. These inequalities vary throughout the globe and are most pronounced in less economically developed nations where services are scarcer and less accessible, with up to an estimated 76–85% of mental disorders going untreated in less developed nations, in comparison to 35–50% in more developed nations. This failure to implement public mental health interventions leads to largely preventable suffering at a population level. Photo by Tim Mossholder on Unsplash What issues is Global Mental Health facing? It is increasingly recognised that the conditions in which individuals are born, grow, live and work, impacts both their physical and mental health. These circumstances are heavily influenced by the division of power, finances and resources from the local to the global level, creating health disparities between communities. A number of structural barriers within countries contribute to the global treatment gaps observed including a lack of human resources, fragmented service delivery models and poor service funding. Compounding these difficulties is a lack of knowledge in identifying mental illness features within communities, coupled with stigma and fear towards mental illnesses and their treatment. A great number of factors influence the mental health of individuals worldwide. It is felt some of the most prominent changes to global mental health in the coming years will come to head in the face of heightening political instability, increasing war and conflict, rising urbanicity and migration, the mounting effects of climate change, and most recently, the COVID-19 global pandemic. Image by Porapak Apichodilok via Pexels In 2019, 79.5 million people were forcibly displaced globally. Most people remain displaced within their home country but 26 million people worldwide have fled to other countries as refugees. In 2018 there were over 125,000 refugees and 45,000 pending asylum applications in the UK alone. It is known that asylum seekers and refugees face unique and complex mental health challenges and are more likely to experience mental distress, including higher rates of depression, PTSD and anxiety disorders. Despite this, refugees are less likely to receive the appropriate support than the general population. Recent history has borne witness to individuals crossing borders to flee their homes and countries in situations of political instability and war, and it is these often harrowing pre-migration experiences that contribute to this vulnerability, alongside issues faced later such as poor housing, family separation and difficult asylum processes. Climate change is set to be the largest cause of mass migration and displacement of all time and with it bringing untold difficulties for affected citizens globally. Loss of land, homes, livelihoods and worsening food and water insecurity and poverty due to extreme weather is thought to be driving disease burden, including worsening of mental health concerns, particularly an increase in depression, substance abuse and PTSD. The effects of climate change pose an extreme threat to the wellbeing and mental health of the worlds citizens, disproportionately affecting the worlds least economically developed nations. Global action and collaboration to tackle both the immediate and long-term outcomes is urgently needed. Photo by Julie Ricard on Unsplash The emergence of the COVID-19 pandemic has had an overwhelming impact on individuals mental health and has disrupted the delivery of mental health services globally, particularly impacting low and middle-income countries, where services are already fragile. Those in need are finding it harder to get the support they need in an age where it was already difficult to receive the support they needed even prior to the pandemic, and even in more developed countries. The long-term psychosocial manifestations of COVID-19 are still unclear but the impact of physical distancing, loneliness, death of friends and family members, and job losses is likely to be tremendous. In addition, it is becoming more apparent that those having endured significant illness are experiencing new onset chronic disease and disability bringing with it mental distress. It is also recognised that intensive care hospitalisation can lead to the development of anxiety disorders, depression and PTSD. There is substantial evidence that ethnic minorities are being disproportionately affected by the COVID-19 virus. This is in addition to the fact that in the UK, those of African and Caribbean backgrounds are already consistently over-represented within mental health service admissions whilst also experiencing disproportionate cases of compulsory detention, coercive treatment and adverse care incidents. Structural racism, economic disadvantage, social exclusion, barriers to service accessibility and misdiagnosis are some of the major factors that contribute to the poor experience of services reported by some minority populations. Image by RF._.studio via Pexels How is global mental health moving forward? Governments are the most commonly cited source of mental health service funding worldwide, followed by non-governmental and non-profit organisations and finally employers and private expenditure. A growing interest in global mental health issues over the last decade has seen funding opportunities for global health activities increase, echoed by a growth in research initiatives, such as the UK’s £1.5 billion Global Challenges Research Fund to support cutting-edge research that addresses the challenges faced by developing countries. Year by year this field expands, and it is precisely this developing awareness and interest from academics, clinicians, activists, citizens and alike that will encourage further funding from government and non-governmental bodies, greater opportunities for healthcare professionals and researchers and a wealth of real global change. Researchers have considered possibilities for the future of global mental health, most pertinently calling for worldwide co-ordination of research and a universal consensus concerning the minimum standards of care for patients with mental disorders. In response to shortages in service delivery, the 2018 Lancet Commission on global mental health and sustainable development recognised mental health as a fundamental element of universal health coverage. The Commission stressed the need to scale up services and highlighted the promising capacity of digital health solutions in improving accessibility of services globally. For example, the widespread adoption of mobile phones in low-income countries has led to their increasing use for health interventions given their potential for increasing access and coverage in hard-to-reach areas. Photo by Brian McGowan on Unsplash Global concern regarding the psychosocial effects of COVID-19 has led major funding bodies and governments to increasingly appeal for proposals and solutions to tackle these outcomes. In addition to this, it is understood that treatment interventions alone are insufficient to reduce the burden of mental illness and a call for research to further understand the social determinants of global mental health is being made. The development of public health strategies for the prevention of mental illness in global communities will be hugely impactful and will reduce the need for mental health services utilisation, increasingly vital in nations for whom services are scarce and fragile. Photo by Vladislav Klapin on Unsplash Final thoughts Although the picture I have painted today is perhaps a difficult one, improving the quality and accessibility of care is ongoing, particularly in low-resource settings. The future of global mental health is rapidly evolving under challenging circumstances, particularly in light of the COVID-19 pandemic. We are all global citizens sharing the same planet and I believe the provision of equitable, accessible mental health services for all those who may need it, regardless of location or personal characteristics, alongside the implementation of supportive health policies, should be of paramount importance in addressing what is a largely preventable global disability and mortality issue. I consider it extremely important for all healthcare professionals to be knowledgeable about global mental health issues and the inequalities that divide our societies, regardless of whether they work in mental health services, as these issues permeate all areas of medicine, life and beyond. It reminds me of the poignant words of Dr Brock Chisholm, the first Director-General of the WHO: “Without mental health there can be no true physical health” In the next few decades, I hope to see the much-needed changes come to fruition, ultimately leading to fewer people suffering unnecessarily and definitively receiving the care they deserve. I am optimistic that I will see this brighter future in my lifetime and hope to be a part of this incredibly important global change. NOTE FROM THE EDITORS: If you enjoyed today’s blog by Cecilia, 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, and gender inequality in psychiatry.

Special note from the editors: This is the fourth blog of our new 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. Psychiatry, like most scientific and medical fields, has historically not been kind to women. Freud himself, still heralded by some as the father of modern psychiatry, considered women to “oppose change, receive passively, and add nothing of their own”, a perception that half the population has not necessarily been able to shake since. While in some respects Freud’s acknowledgement of women’s sexuality were remarkably progressive for the era, his somewhat obsessional emphasis on labelling these desires as hysterical and rooted in a woman’s aspirations to be more like her male counterpart were less welcoming, and was coupled with fashion of the time for lobotomy, incarceration and sterilisation to manage “perverse sexual misbehaviour”. Underlying these views, however, was a desire to understand what Freud considered unfathomable — untangling the “riddle of femininity” and women, who were notably absent from the medical profession until the late 1800s — something Freud declared beyond even the power of his superior male brain. Drawings of inpatients of British Asylums diagnosed with mania, hysteria and nymphomania. Images: Royal College of Physicians of Edinburgh, Asylum Patients in Art As a student at Edinburgh Medical School, the first UK institution to accept female students, I am exceptionally proud of the university’s legacy and contribution to the empowerment of women, particularly in medicine. However, my own experiences of sexism and those of my peers, both in a clinical and teaching environment, have exemplified to me the need to continue to strive and campaign for equality. It was only more recently that I began to explore how the underlying sexism in medical literature and the education and treatment of women students might also be affecting patient care, which is described extensively in Caroline Criado Perez’s 2019 book, Invisible Women. Organisations such as the Medical Women’s Federation and the Women in Healthcare Leadership project have created vital platforms and communities for women doctors to share experiences and support a new generation of medical graduates, whom may be better prepared to tackle prejudices and reshape future practice to overcome some pitfalls discussed here. The Edinburgh Seven: the first women to attend a British University at Edinburgh Medical School in 1869, but were ultimately not permitted to graduate from the university and all completed their medical degrees elsewhere. Image: The Edinburgh Seven, Edinburgh Museums By the 21st century, the medical field has managed to debunk some of Freud’s more divisive theories on women. Modern Psychiatry boasts an impressive proportion of women physicians, academics and allied health professionals, when compared with most surgical and internal medical specialties. Currently, women make up the majority of medical students, the majority of junior doctors and the majority of psychiatry trainees. Notable leadership and management roles in Psychiatry are or have recently been occupied by women, including past College Presidents. Therefore, one could be forgiven for presuming that the patriarchy has been thoroughly dismantled in some, if not all, fields of medicine. ormer Presidents of the Royal College of Psychiatrists. Images: Royal College of Psychiatrists, Past Presidents and Chairmen But how does this relate to patient care? Representation, within doctors and other healthcare staff, is crucial to delivering person-centred care as it increases the diversity of opinion and insight into a patient’s wellbeing. To match the diversity of patients within psychiatry requires the same level of diversity of ethnicity, religion, disability, and sexual orientation as well as gender in order to understand similarities between lived experience. From a patient perspective, however, it might not quite be time to pat ourselves on the back for a jolly good job well done. The evidence suggests that, in many respects, psychiatry, much like other fields of medicine, is still failing women. Incarceration and lobotomy aside, our inherent biases shaped by gender stereotypes insidiously invade aspects of medical practice and may contribute to a gender care gap. Women, as the quintessentially more “emotional sex”, are diagnosed with depression or anxiety nearly twice as often as men, and are twice as likely to be on an anti-depressant, even when they have not reported depression in the consultation. This is often attributed to health-seeking behaviours, with more women than men consulting their GP, and the assumption that women are generally more comfortable discussing their mental health. However, there are studies of note which have actually found lower rates of depression in women and yet still higher rates of anti-depressant prescribing. More sinister, however, are the number of testimonies from women whose physical symptoms indicative of an underlying organic health condition were disregarded as psychosomatic (physical manifestations of psychological upset) or stress-related — the equivalent of sending your male patient with abdominal pain for a CT scan whilst reassuring your female patient that she probably needs to relax more and ‘it’s all in her head anyway’. This mimics studies which previously found that, in response to pain, men were more likely to be offered painkillers and women, antidepressants or sedatives drugs such as diazepam. Our implicit biases, carried by both men and women physicians, which may still consider the behaviours of women to be more irrational and hyperbolised, demonstrate that the sole presence of women within a professional field is not enough to grant equal representation and, moreover, representation is not enough to power definitive change of attitude. Alternatively, we may just not account for the possibility that men and women experience pain and ill-health differently. Looking forward, as we teeter on the precipice of an impending COVID-related global mental health crisis, we are granted a unique opportunity to assess our circumstance and determine the direction we take from here. Feminism is able to monopolise on large waves of change, from the success of the #metoo movement, the everyday sexism project and acceptance of intersectional feminism into youth culture, thanks to role models and advocates like Michelle Obama, and as such, the political unrest in the aftermath of the coronavirus pandemic should be no exception. The Everyday Sexism Project is an international platform developed by Laura Bates to document and anonymously share incidents of sexism and discrimination, aiming to demonstrate the extent of the patriarchy. Image: Everyday Sexism By Laura Bates There are several key areas than warrant address with regards to medical feminism. Firstly, there is need to tackle the major data gaps in psychiatric research, including within drug manufacture and trials, all of which historically forget women: the vast majority of pre-clinical in vitro and animal studies use only male test subjects, and, those that do, rarely sex-disaggregate data, even in female-prevalent conditions, such as the development of novel anti-depressants. In addition, we need to reassess how our epidemiological data, looking at the distribution of illness, considers gender, as an independent risk factor determined by chromosomal composition or as one determined by societal influence and behavioural norms. On a patient level, we must avoid teaching our students and trainees to stigmatise and label based on gendered ideas of normalcy and debunk gender stereotypes in healthcare — for example, that the archetypal patient with an eating disorder must be adolescent, female and fixated on calorie-cutting with a BMI lower than her age, and equally, that it is normal for women to experience significant pain and psychological upheaval due to menstruation. To champion these initiatives requires further support for more women in clinical academia, research posts and department leads, to translate representation into change. This approach, despite popular villainisation of the so-called “man-hating feminist”, does not and should not exclude men. In fact, in direct opposition to this criticism, true feminism benefits everyone, men and women alike, because it is not just women that fall victim to stereotypes and inequity. For example, erasing the stigma associated with men’s mental health and vulnerability, even in small circles, is essential to reducing the frequency of male suicides, which are particularly abhorrent in the LGBT+ and BAME communities. Equally, our female-orientated perception of mood and eating disorders further alienates male patients and creates additional barriers to accessing appropriate support. Social media posts highlighting gender stigmatisms that may negatively impact men’s mental health. Images: @themind_doc Instagram This complex interaction between biological, social and cultural components that increases risk in these groups is equally reflected in the feminist movement, which seeks to include, understand and recognise the heterogeneity of individuals and their experience. To alter societal expectations of masculinity requires a reciprocal shift to normalise women stepping into more traditionally male-dominated positions of bread-winning, leadership and self-reliance. By addressing these, it is my hope that psychiatry will remain and develop as a field covered by a diverse and representative array of doctors, who understand and are able to interpret the emotional, psychological and sociological impact of disease on the individual. Therefore, the future of psychiatry should at every opportunity, be routed in the mantra that the future not be female but be feminist in its thinking. NOTE FROM THE EDITORS: If you enjoyed today’s blog by Rebecca, 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, and the future of child & adolescent psychiatry.

Special note from the editors: This is the third blog of our new 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. As a medical student soon to be beginning my clinical years of study, the world is still very much my oyster in terms of choosing a career path. I am certain, however, that my passion for child mental health will influence my journey in some shape or form. I have worked with many children and young people with mental health difficulties in my part-time job, both before and during medical school. What has really struck me when working with these children and their families is their vastly different experiences of getting support from child and adolescent mental health services (CAMHS). Some families have had relatively straightforward interactions with CAMHS, whereas others felt that they couldn’t get appropriate support with their child’s condition and had no choice but to turn to private services. Equalising disparities in accessing and experiencing help from CAMHS is something I really feel strongly about; children with mental health difficulties should not face a postcode lottery when they need help. Having recently been appointed as one of the Royal College of Psychiatrists’ ‘Psych Stars’ for this academic year, I am keen to take full advantage of the mentorship, learning and funding opportunities offered by this scheme in order to further explore a career in child and adolescent psychiatry. For now, as a potential child and adolescent psychiatrist of the future, I share my thoughts on what I believe child and adolescent mental health and service provision will look like in the years to come. Children and the coronavirus — a match made in hell? At present, there is one thing on every healthcare professional’s mind: the coronavirus pandemic. In addition to the physical symptoms, which are still not fully understood, there is emerging evidence describing COVID-related neuropsychiatric symptoms. This means that people are experiencing new symptoms of a mental health disorder as a result of the brain being infected with the virus. In children, it appears that encephalitis (inflammation of the brain) and seizures can occur as a result of being infected with the coronavirus. Although COVID-encephalitis cases seem to be rare, encephalitis can cause serious damage to the brain, resulting in complications such as personality and behavioural changes. This draws parallels with a similar group of pathologies, Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infection (PANDAS). PANDAS is suspected when children suddenly develop obsessive-compulsive disorder (OCD) or tic disorder following a streptococcal infection (a type of bacterial infection) such as scarlet fever. It is not yet known whether encephalitis related to coronavirus could trigger an autoimmune attack on the brain, and replicate symptoms of PANDAS. Concern has also been expressed that coronavirus infection in children with pre-existing PANDAS could severely worsen tics and symptoms of OCD. The complexity of these issues is further confounded by the fact that there is debate within the scientific and medical community as to whether PANDAS actually exists. PANDAS onset, symptoms, and their responses to treatment can be extremely varied, and so some clinicians are uncomfortable with accepting PANDAS as a formal diagnosis. This could prevent some children from getting the help they need. It is therefore critical that investigating coronavirus-related neuropsychiatric conditions in children becomes a research priority, especially when planning for future service provision. Child and adolescent psychiatrists should be upskilled in accordance with the outcomes of this research, in preparation for a potential influx of new neuropsychiatric presentations in children following the pandemic. Source: MIT News As well as the physiological effects of the coronavirus, the accompanying lockdown has thrown the psychological wellbeing of children and young people wildly off balance. Closure of schools has meant that routine has been disrupted, and children have been isolated from their peers and teachers. Loneliness and social isolation have been shown to negatively impact children’s mental health, with the correlation between duration of loneliness and worse outcomes being particularly alarming, given the nature of the lockdown. For some children, school is also unfortunately their only escape from unstable home environments. Decreased contact with teachers and support services during the pandemic means it is much more difficult to monitor the wellbeing of children, especially those who have already been identified to be at risk. Lockdown will also have put a strain on relationships within families that weren’t previously at risk. It is unfortunately very likely that some children will have suffered abuse during the lockdown, and it is therefore imperative that these children are identified and supported as soon as possible. The Royal College of Psychiatrists recently expressed concern regarding widespread and inappropriate media coverage of people gaining weight during the lockdown. Such reports have led to young people with eating disorders relapsing and rapidly losing weight, and presenting to hospital having become very unwell as a result. Recent initiatives to combat obesity are hot in conversation at the moment, but have also been argued to be a potential risk to young people’s relationships with food. Eating disorder support charities such as BeatED have criticised proposed actions such as presenting calorie counts on menus, as it could harm people suffering from eating disorders by encouraging them to eat less. Not everyone is critical of such efforts, others argue that these actions are important for many. Referrals to CAMHS have also decreased considerably during the pandemic, meaning children and young people might not be accessing the help they need. Identifying and supporting those who have slipped between the cracks during the pandemic should be absolutely paramount. It is likely that children and young people will be reeling from the effects of lockdown for quite some time when things return to ‘normal’, so picking up the pieces will be a key role for child and adolescent psychiatrists in the near future. Image source Public Domain Pictures But there are positive lessons from the pandemic It’s not all bad news, though. Entirely to the contrary, there are children and families who have thrived during the lockdown, proving that there are lessons to be learned from the positive experiences as well as the negative ones. Enforced infection control strategies such as social distancing and travel restrictions have assisted a drastic improvement in health for children with immunodeficiencies. This reduced contact with the ‘outside world’ has meant less opportunity for contracting infections, meaning that these children are spending more time in good health. This has in turn boosted mental wellbeing within this group, which could mean that there is scope for mental health professionals to advocate for alternative learning arrangements for some young people (e.g., more learning from home where appropriate) in order to promote their physical health, and in turn, their mental health. With a large proportion of the working population furloughed or working from home due to the pandemic, parents and caregivers are also spending considerably more time at home with their children. This has been a lifeline for some children with conditions such as autism or learning disabilities. Some parents have had more time to dedicate to helping their children with learning and activities to support their development, which in many cases is helping these children progress considerably. Reaching these educational and socioemotional milestones is bound to have a positive impact on the mental health of not only the children themselves, but their parents too. This again shows that child and adolescent psychiatrists could play a role in ensuring that these children receive appropriate support within school, but also with their wider development. This could be done in many ways such as 1:1 support with learning, a modified school day, and increased parental support with activities where possible. Image source Peeple The negative impact of social media on the mental health of children and young people is already widely documented and has been explored in an earlier InSPIre the Mind blog. Whilst it is easy to criticise social media, lockdown has allowed us to see the potential benefits of the interconnectedness it brings. Social media platforms of all kinds have allowed young people to keep in touch with each other and their families during the lockdown, thus easing loneliness in otherwise incredibly isolating circumstances. Young people are being kinder to each other on social media, with anecdotal reports of less cyberbullying. It is disappointing that it has taken a pandemic to drive this change, but encouraging nonetheless to see that young people are viewing life through a different lens. The merits of technology have also been harnessed and used in service delivery. Running appointments over the telephone or via video call software has proven to be, in some cases, acceptable alternatives to face-to-face appointments during the pandemic. The flexibility and improved accessibility afforded by these methods could mean that virtual appointments are here to stay, especially for people who have conditions that make leaving their homes difficult, or for those who have to travel a significant distance. Despite these benefits, many people will still prefer face-to-face appointments and so these should still form a large part of service delivery where possible. Moving forward from the coronavirus pandemic will inevitably form a major part of the future of child and adolescent psychiatry, with meticulous planning needed in order to ensure that service provision meets the changing needs of children and young people. The realities of resourcing CAMHS When considering the future of child and adolescent mental health services, it is important to not only consider the population that needs serving, but also the resources available to provide this service. CAMHS is chronically underfunded, and psychiatry training posts across the board are undersubscribed. There’s an old adage in medicine that ‘prevention is better than a cure’, which is absolutely true, until you realise you physically do not have the resources to provide preventative services. CAMHS funding has decreased by almost £50 million since 2010, and currently only comprises 6.7% of all mental health spending. This has led CAMHS to take a largely reactive approach to child mental health crises and treat them as they occur, rather than being proactive and able to prevent these crises to begin with. This means that children and young people with severe mental health difficulties are understandably prioritised, but it leaves hordes of young people with emerging mental health difficulties without the help they need. It would be naive to think that the ‘magic funding fairy’ will solve all of the problems faced by CAMHS, but more funding would certainly go a long way in helping to turn current service provision on its head and put the emphasis on prevention. More funding would hopefully also allow more local mental health beds to be secured, so children and young people won’t have to travel so far from home for specialist inpatient care. Photo by Michael Longmire on Unsplash Traditionally, psychiatry has been one of the least popular choices of medical specialty for trainees. This could be for a number of reasons, such as the perception that psychiatry ‘isn’t medical’, or the fact that our understanding of mental health has been historically poor when compared with physical health. Whilst perceptions are currently changing in the right direction, we still have a long way to go in order to raise the profile of a career in psychiatry and mental health. Changing the psychiatry training pathway is showing great potential to attract more trainees to the profession. ‘Run-through’ posts allow trainees to spend the entirety of their psychiatry training in their subspeciality of choice (like child and adolescent psychiatry), rather than spending three years in core psychiatry training and then picking a subspecialty later on. Applications to train in child and adolescent psychiatry through these newer run-through posts were significantly higher than applications to train via the traditional route in 2019. This could mean that increasing run through training places both for child and adolescent psychiatry and other psychiatric subspecialties could go some way in increasing recruitment. Initiatives such as less-than-full-time (LTFT) training, or out-of-programme opportunities, are also making psychiatry a more desirable specialty. LTFT training does what it says on the tin, and affords trainees greater flexibility with having children or other responsibilities outside of clinical work. Out-of-programme opportunities allows trainees to take time out of training and pursue other interests such as research, working abroad, or teaching. These opportunities should be advertised more heavily to prospective trainees. The Royal College of Psychiatrists’ ‘Choose Psychiatry’ campaign recently celebrated an incredible success, with 99.4% of core psychiatry training posts being filled for 2020 intake. As current PsychStars and future psychiatrists, we in turn need to engage with and inspire the next generation of budding psychiatrists in order to support them and attract them to the profession. Into the unknown: child mental health research Finally, a crucial part of planning for the future is evaluating what we know and where the gaps in our knowledge lie. Research in child psychiatry is rapidly developing as we continue to explore the complex interplay of neuroscience, psychology and sociology in shaping the mental health of young people. Adverse childhood experiences (ACEs) and their strong correlation with poor mental health in later life is an area of research that has gained increasing traction since the 1990s. There are ten recognised ACEs and they are broadly categorised into abuse, neglect, and household dysfunction (see image below). Source: Centres for Disease Control and Prevention; Credit: Robert Wood Johnson Foundation This previous InSPIre the Mind blog explores ACEs in more detail. Whilst it is too late to prevent mental health problems in the now-adults that were studied in past research on ACEs, a better understanding of ACEs will allow for the development of preventative strategies to be implemented for children in the future. Professionals like teachers, who have lots of contact with children, already have a role in safeguarding children, but they could be trained specifically in recognising and referring children that may be at risk of ACEs. Child and adolescent psychiatrists, with the help of other teams such as social services, can then provide an early and sustained intervention in order to mitigate effects of the ACEs and give the children the best possible chance of a ‘normal’ life. The processes and criteria for diagnosing for mental health disorders in children need to be scrutinised and reviewed more regularly in order to ensure that diagnoses are made in a timely and appropriate manner. This will help children with mental health difficulties receive early intervention and support tailored to their needs, but also ensure that we are not pathologising what are essentially just variants of ‘normal’ childhood behaviour. Child and adolescent psychiatrists will have a role in auditing services, so that the diagnostic processes are accurate and lead to good patient outcomes, rather than over-diagnosing children and potentially causing them harm as a result. Despite their general effectiveness, more research into the use of mental-state altering (psychotropic) medications in children with mental health difficulties is also needed; they are often a last resort due to their side effect profiles. The issues surrounding these medications need to be further explored in order to support a change in the system, for example by developing new and hopefully safer medications for future use, or through more robust education for caregivers on the risk and benefits for their children. Overall, the future of child and adolescent psychiatry looks to be very dynamic and rapidly evolving, and I am very much excited to be a part of it. It is clear that mental health services will face many challenges in the years to come, especially in the wake of the coronavirus pandemic, but I am confident that the future of psychiatry lies in safe hands. NOTE FROM THE EDITORS: If you enjoyed today’s blog by Emily, 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 and the mind-body interaction. header image source Hey Sigmund

Special note from the editors: This is the second blog of our new 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. As a final year medical student, I have been exposed to a wide range of medical and surgical specialities. I have noticed, in almost every placement I have attended, that patients with long-standing acute and chronic conditions often face a barrage of mental health issues on top of their physical ill-health. This often seemed to be unrecognised by both the patient and the treating physician. Mental health services are organised into mental health trusts which are managerially separate from general hospitals even if they are on the same geographical site. This has meant that psychiatrists tend not to work closely with other specialities and Liaison psychiatry services — which specialises in the interface between general medicine and psychiatry — are not always able to fill this void. Source: https://www.youtube.com/watch?v=O-OK365II34 Patients with chronic health conditions are more likely to suffer from mental health issues and patients with mental health problems are more likely to experience physical ill-health. Recognising this and addressing it openly would lead to benefits for patients whose health concerns would be addressed in a more holistic way (an approach that sees the person as a whole). There would also be benefits for the physicians, who often experience frustration that their patients’ physical health is not improving as much as expected, often because of their poor mental health. Finally, for a parsimonious healthcare system, the benefit of treating patients holistically means that costs of repeated attendance at hospital outpatient clinics would be reduced. In this blog, I will discuss how joint working between physicians and psychiatrists can improve patient treatment through the discussion of two examples of mind-body interaction: the mind-gut connection and psychodermatology. I have chosen these two areas specifically because of my experience of them from clinical placements. I was fascinated to see the impact of holistic treatment for patients with dermatological (skin) or gastroenterological (digestive system) issues. However, many other specialities such as cardiovascular (heart) and rheumatology (joints) also have equivalent areas of mind-body interaction. Recognition of the importance of the mind-body relationship should be part of the armamentarium of all clinicians. The mind-gut connection The enteric (gastrointestinal) nervous system has long been recognised as the body’s “second brain”, with colloquial phrases such as ‘going with your gut’ or feeling ‘butterflies in your stomach’ being common parlance. Scientific evidence has legitimised these expressions, and accumulating evidence supports the critical importance of the mind-gut interface. Some conditions such as irritable bowel syndrome (IBS) are known to have an important psychological component. This leads many clinicians to simply dismiss their patients as having medically unexplained symptoms. Their patients, who are suffering with painful and debilitating symptoms, are often left feeling frustrated and abandoned. On the other hand, inflammatory bowel disease (IBD), which has an established cause, is often treated aggressively with medication by physicians. However, clinicians often fail to address the psychological sequelae of this group of diseases. Learning to live with a chronic condition, managing to live well, and controlling the stress accompanying IBD, must not be overlooked, and is a crucial supplement to pharmacological (medicinal) and surgical treatment. Source: https://www.fodmapeveryday.com/wp-content/uploads/2018/07/gut-brain-axis.png The increasing awareness of the mind-gut connection has led to the development of specialist holistic professionals. For example, as part of my clinical placement, I shadowed an IBS hypnotherapist, where talking therapy and cognitive behavioural therapy (CBT) are integrated into the treatment plan to address the psychological aspects of IBS. This involved performing relaxation hypnotherapy exercises, as well as addressing underlying anxieties, making significant improvements in what could be a painful and incapacitating illness. I found the impact that this therapy had on patients astounding. Patients who had reported of debilitating chronic pain and embarrassment were able to have normal lives as a result of this therapy after only a few months. Patients who had refused to leave the house for fear of not reaching the toilet in time felt significantly less anxious with almost no symptoms after a few months of hypnotherapy. Peter Whorwell, Professor of Medicine and Gastroenterology at the University of Manchester, has been exploring the use of hypnotherapy in IBS for forty years. His research has highlighted that more than 60% of IBS patients who have hypnotherapy are able to see significant and maintainable long-term improvements in their symptoms. The National Institute for Clinical and Care Excellence now lists hypnotherapy as one of the treatments for IBS. However, this is not widely available on the National Health Service. Greater awareness of its possible applications in improving the quality of life patients with IBS and IBD is warranted. Other psychological therapies include psychotherapy, CBT, interpersonal therapy, relaxation therapy and stress management. Systematic reviews have found that CBT, multicomponent psychological therapy, dynamic psychotherapy and interpersonal therapy may be particularly useful for these patients. Higher-quality studies are required to support the use of these treatments. Source: https://healthylifeessex.co.uk/2020/06/mental-health-gut-brain-connection/ Psychodermatology In this second experience, the psychiatric component was also made abundantly clear to me. In my dermatology placement, I was astounded to learn that 30 to 60 percent of patients with common, chronic skin conditions, such as psoriasis or eczema, also suffer from significant mental health problems. This shocking statistic has resulted in the development of much-needed psychodermatology clinics. Various models for these clinics have been set up. In the clinic I attended during my psychiatry placement, patients were seen by a consultant dermatologist and either a psychologist or a psychiatrist together in the clinic, and then separately by a psychologist when appropriate. Patients who had suffered from lifelong eczema or psoriasis spoke of their reluctance and anxiety at leaving the house, and the depression and suicidal thoughts with which they were plagued. The hour-long appointments provided patients with the opportunity to seek treatment beyond pharmacological therapy for their skin condition, something impossible in a rushed ten-minute slot in an overbooked dermatology clinic. Source: https://www.canadianliving.com/health/prevention-and-recovery/article/how-psychodermatology-can-help-combat-both-your-skin-issues-and-mental-health Patients received CBT with the psychologist to help manage their symptoms and their anxiety, and medications, such as anti-depressants, where indicated. These kinds of treatments could lead to improvement in the patients’ skin conditions as well as their mental health and wellbeing. I also saw patients presenting at the psychodermatology clinic who had severe psychiatric disorders relating to beliefs about their skin. Several patients I saw suffered from delusional parasitosis (Ekbom’s syndrome) in which they held the unshakable belief that their bodies were infested with lice and fleas. The following patients described are compilations of stories and not real patients, so that they are not identifiable. One patient had excoriations all over his body and refused to leave the house for fear of what people might think of him. The dermatologist listened and acknowledged the patient’s concerns whilst the psychiatrist was able to find the medical cause of this itching. This was due to an underactive thyroid, meaning that he had low levels of thyroid hormone responsible for regulating his metabolism. This can lead to reduced sweating and subsequent itching as in this example. This is an example of a collaborative working relationship to develop to ensure the best possible outcome for the patient. An elderly patient believed that pigeons were inhabiting his house and causing fleas to infest his body. He demanded investigations and spent hours on internet chat rooms discussing his symptoms. He even presented a “photo” of one of the supposed fleas. His main fears were about infecting other people with whom he lived or worked. The psychiatrist was able to prescribe risperidone, an antipsychotic medication, for this patient, whilst the dermatologist reassured the patient that there was no infestation. By working together in this way, the patient accepted prescription of an anti-psychotic medication when it would have been highly unlikely that the patient would have agreed to see a psychiatrist in the normal way. Psychodermatology clinics are currently only available in three centres in the United Kingdom; further development of these services are urgently needed across the country to treat patients such as these. I found this placement so interesting that I arranged my elective placement at a psychodermatology clinic abroad, but unfortunately, this was cancelled due to COVID-19. I hope I can rearrange this placement at a future time. Source: Psychodermatology Whilst psychodermatology is a very niche subspeciality, it exemplifies the immense value of psychiatrists working with other healthcare professionals across all medical specialities. I have discussed two examples briefly from my own experiences, yet many other fields have similar interfaces. For example, rheumatologists face difficulties treating patients with fibromyalgia, whilst ear nose and throat consultants struggle to treat patients with chronic tinnitus. In conclusion, clinicians must work together to acknowledge the mind-body relationship. This is fundamental for improving both the psychological and medical treatment of all patients. In the future, psychiatrists must find creative ways to reach out to this subgroup of patients who otherwise might be difficult to engage. Psychiatry must become a more integrated part of patients’ holistic journey. NOTE FROM THE EDITORS: If you enjoyed today’s blog by Rebecca, be sure to head over to InSPIre the Mind and check out the previous and first blog in our Psych Star series all about compassion. Stay tuned for more from these fantastic medical students every Friday!

A Need for Compassion when Encouraging Young People to Engage in Mental Health Special note from the editors: Please enjoy reading the first blog of our brand-new 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 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. It has been well established that there is inevitably a clash between generations when it comes to how one should behave, think or even live in society. This has become continuously more fragmented between ‘baby boomers’ and ‘generation X’ versus the incoming ‘millennials’ and ‘gen z’. The former often accuse the latter of being ‘snowflakes’ whilst in reverse there have been emotionally fuelled claims of destroying hopes and dreams. It needs to be understood that concerns differ between generations and that, through compassion, we can understand each other better to improve mental health. Figure source: American Psychological Association. Despite this continuous back and forth debate, we must all remember that we’re only human. To forget this could be devastating for our mental health. Why am I presenting a debate as to why ‘boomers’ and ‘snowflakes’ should take time to listen and understand each other? Because I believe it follows one of the essential rules which has both saved my life and lives of others: compassion. By being compassionate and truly going one step ahead of a ‘them versus us’ philosophy, we are able to grow as individuals and delve into the root of issues. Therefore, intergenerational understanding and compassion are topics which need to be understood in the psychiatric world and beyond. At the risk of sounding condescending: we were all born on the same planet with the same foundational DNA. However, what is different, are the challenges we face today; particularly in an era where uncertainty is greater than ever. The fact that challenges faced by incoming generations today are different largely invalidates the excuses older adults give for not listening to those who are younger. These excuses can range from distrusting a lack of experience, to the desire for creating a hierarchical society of fear. On the flip side, it also likely exposes a vulnerability the young tend to fail to consider: as everything is different and unknown, it is likely it is unfamiliar to us all. By criticising older generations for dealing with issues differently due to the unique challenges of the past and the (often contradictory) life lessons gained from this, young people fail to empathise as to why this may cause older individuals to struggle. These struggles can stem from the simple concept of having extensive experiences to refer to, to tangible, societal issues facing older people today. Both sides therefore become more divided and disillusioned despite the irony that we are often foundationally very similar and working towards aligned goals. Hence the need for a new ‘generation game’ (I have not watched the show, but I am sure my mother would be proud of the reference). For those who are unaware, the Generation Game was a 1970's television show hosted by the late Bruce Forsyth, where teams of two, containing different generations, would put against each other. At the time, it was unique as it encouraged intergenerational conversation and cooperation. Interestingly, the 70's were also a pivotal time for changing attitudes towards mental health. Although the original show has long past, the lessons and concept behind it should not be forgotten about. From taking on a new ‘generation game’, we can be encouraged to work with all ages in a symbiotic and productive manner. This is particularly important when it comes down to our own mental health and wellbeing. The Original ‘Generation Game’. Image source: BBC Mental health is something we all have, yet it is all too often that a limited age-group of individuals shape its treatment during illness. Keeping mentally healthy is something so important yet unique to us all, so it is vital that different generations and experiences are able to work together in both how we respond to our mental health and how it is treated once it becomes illness. This will not only mean the incoming generations can make their voices heard; but also ensures we can treat our parents, grandparents, uncles, and aunts in a way that is meaningful and effective to them. Compassion is about working alongside an individual, to understand, reason with, and support them in solving a problem (not to be confused with empathy, which does not include the additional step of helping others). This can apply to many areas of life. With mental health, it means working cohesively with others to ensure it is maintained whilst being non-judgmental if their reactions or thought processes are different to our own. I can understand that, to many, this may appear like a theoretical enlightenment which fails to come to practice in reality. I thought this too. As a medical student, we are often encouraged to use compassion and its synonyms to show that we really understand what our patients are going through. Videos of actors display how the correct posture and occasional concerned nods should be enough to do the trick. It simply did not add up to me: how could acting a certain way translate to how I felt and cared for that other person? Was it just to make the patient feel more at ease? How did it actually ensure I was compassionate and treated the patient in such a way that really reflected their needs? From my first few years as a medic, followed by being a patient first-hand due to mental illness, I quickly learned that this was unfortunately an institutional misunderstanding. Just because you look like you care, does not necessarily mean this translates into acting compassionately. However, there is hope. Following a period of leave due to my own mental illness, I unfortunately felt disillusioned by my fellow medics. Despite constant reassurances that ‘it will get better’ and they ‘understood’ my explicit difficulties, I became hospitalised and relied heavily on my personal support network to recover. WellMed Peer Support has encouraged young people to engage in mental health whilst successfully becoming integrated into student support services — an area which was formerly only led by older adults. Through this, I was inspired to publicly write about my mental health journey. In total, this led to one hundred public reflections through a challenge called ‘100 days of Happiness’. Not only was this an incredibly cathartic experience, the feedback was simultaneously inspiring and heart-breaking. Every day, I received feedback from individuals, often at the same stage of their careers as myself, stating they felt so relieved to finally hear (or read) that somebody else had similar thought processes, struggles, questions and reflections to themselves, as shown in the blog. Although not all had experience of mental illness personally or with loved ones, what was appreciated was the openness of discussion; the balance and understanding of how others reacted to my situation and how I constantly reassessed my recovery. The feedback taught me more than my reflections: that there was more to compassion and supporting others than just the behavioural adjustments taught in medical school. The experience inspired me to launch a mental health peer support group for my fellow medics, which I named a WellMed (a conjunction of, you guessed it: Wellbeing for Medics). Not only to provide a safe space for individuals to openly talk and question mental health and illness - destigmatising its occurrence in such a competitive discipline — but to share information and experiences on how to engage with such issues. A year later, and we have become the university’s largest peer support group (with an award thrown in). Even more significantly, our most well attended event has been established into a reoccurring series called ‘A Blether at Black Medicine’. It involves the ‘boomers’ (often experienced consultants) and ‘millennials’ (often timid medical students) meeting at a coffee shop (called Black Medicine) one evening to discuss (blether) anonymised questions around mental health. Left: A WellMed peer support session encouraging group discussion around mindfulness, facilitated by Dr Avinash Bansode. Right: a reflective doodle made by a student after openly an intergenerational discussion of mental health among medics in differing stages in their career. This has completely changed the dynamic of how we speak to each other, and how we want to be spoken to, alongside what this means for our behaviour as clinicians. Students are no longer scared to speak up when their feelings are excluded, as it is done at an approachable level, rather than relying on decisions made by their seniors. The playing field is leveled to expose the simple fact I discussed at the beginning: we are all humans with new challenges reacting in different ways. Consultants are able to listen to raw feelings to honest questions, and in turn give realistic and effective responses. Now, I realise (and have been reminded continuously), that medics are perhaps not the most ‘normal’ breed. As a future physician, I wanted such compassionate support to expand beyond the medical sphere. This led to me conducting a thesis as part of my intercalated degree in Global Health Policy. I looked into the challenges of involving young people in mental health policy nationally. By involving individuals in health policy, governments, and therefore health systems and their physicians, are able to completely reform how they react to patients and their treatment. It hereby follows that this has the potential to completely transform how doctor-patient relations and patients themselves are viewed. For the small group trialed by the government and analysed for my study, the young people finally felt empowered and understood. The biggest challenge? After the trial, when the communication lessened from Scottish government, the young people started feeling that their ideas were no longer being translated in the manner intended. It meant that, although their ideas were taken on, they were potentially being interpreted by policymakers in a manner different to the young people. This strongly suggested that for different age groups to effectively interact and engage in each other’s thoughts, work and ultimately mental health, the listening and understanding is something which must go beyond the use of a trial group or initial consultation. Compassion is part of the Patient Rights (Scotland) Act 2011 and as such is taken as a core value in health boards across the country (source: NHS Scotland Careers). Although WellMed and the group analysed as part of my study are relatively small groups representing young people wanting to change mental health in a society often governed by older adults, they show that young people are keen to be engaged in change. However, it is so important that this is done in a manner which is accessible, a manner which truly understands what their thought processes are and a manner which can work alongside older age groups. This can also allow for mutual peer support between generations as it allows it allows all individuals the opportunity to discuss their personal challenges in a sensitive way. Such a working mechanism creates a refreshing dynamic which can allow all groups involved to be enthusiastic in creating and understanding mental health as a concept for all. The best bit? Compassion is a practice which everyone can take on board. Looking forward, I truly am enthusiastic that the generational divide is changing and, slowly, closing. We all have our differences but we also all have mental health. So, no matter who you are, your background or experience, it is something that can be discussed over an activity as simple as going to a coffee shop. I think that everyone does, to some extent, care about others: they just may react and rationalise their reactions in a different manner. By showing compassion, we can acknowledge this whilst also supporting the most vulnerable in the way which is the most adaptive and engaging for them.

Key takeaways from organising a science communication workshop series When we think about research, we often imagine a clean laboratory with people in white coats who work with fancy equipment. While some research might actually look like this, research in the field of mental health is sometimes harder to picture and more complicated to explain. There are many ways we can collect information and engage with the topic we are studying, and we are continuously trying to improve the ways in which we conduct our research and report what we have found. I myself am a postdoctoral researcher (which is what we call researchers after completing their PhD) for the EDIFY project (EDIFY - shaping a fresh approach to eating disorders), one of the seven research programmes that are currently funded by the UK Research and Innovation (UKRI) ‘Adolescents Mental Health and Developing Mind’ initiative. This means the UKRI is financially supporting our research project, so that we can look into different ways of improving the lives of young people, in our case specifically young people with eating disorders. Across the different projects funded by this initiative, we have a vast amount of expertise spanning areas of digital mental health, adverse childhood experiences, and neurodivergence. To get the most out of our combined expertise, the UKRI decided to provide additional funding for smaller projects that would help us build connections and share knowledge across the programmes. As a result, four groups of postdoctoral researchers were granted the opportunity to organise a variety of events to build a sense of community amongst Early Career Researchers (ECRs, including postdoctoral researchers, research assistants, and PhD students) and the young people who work with the project teams as experts by experience (youth advisors). This new series is one of the outcomes of a project organised by EDIFY ECRs to develop researchers’ and youth advisors’ skills in ‘science communication’ - the ways in which we engage with, discuss, and share our research with other researchers, the media, and relevant audiences. As part of our events, we organised a two-day London-based science communication workshop, as well as an online showcase to reflect on how best to communicate research experiences and outcomes to different audiences. This was achieved through research-focused media training provided by HawkEye Media in London, guided group discussions, networking activities (Bingo and speed networking), and many opportunities to share knowledge and experiences. Taking our science communication to the next step, we are now excited to share what we have learned with a wider audience to shed more light on our research practices and the lessons learnt. In the following weeks, this series will provide interesting insights into the ways our researchers and youth advisors experience the research process, including challenges and opportunities we have encountered - all from the perspective of those still finding their feet in the research world. As the main organiser of the science communication events, I wanted to kick off the series by reflecting on three key learnings that I am taking away from planning a project series where I was both the lead organiser and the target audience. Event organisation might not be the first thing one thinks of when picturing the tasks of a researcher, but more often than not it is a skill we have to learn to bring people together for training, data collection, or conferences. Events should always benefit the people you consider your “target audience” This first point might be an obvious one, but sometimes the costs of attending an event (not just financially) can outweigh the benefits of what is being offered. For example, to attend an event some people will need to travel, they might need to make up the time they spent at the event, or they might need to plan around other responsibilities. Equally, if attending the event is associated with many additional commitments (additional work), people might experience the event as more of a burden than a benefit. This is the reason why we wanted to organise a variety of activities, including training that did not require any preparation and would be both fun and useful to attend. We also organised our second “showcase” event online, to give people who cannot or do not want to travel an opportunity to participate. Most importantly, we financially supported travel and accommodation costs and made sure to adequately compensate youth advisors for their time. There is no one-size-fits-all approach, however! Although we received primarily positive feedback, some of our attendees would have preferred fewer interactive activities. If you are organising an event, think about your main goals, not just in terms of visible outcomes, but also the overall experience. You will never make everyone happy, but that should be the goal you are striving for! Communication is key – be creative! To organise our events, I had to send many emails. I almost felt like apologising every time I sent another reminder. However, it is important to communicate all relevant details to all interested parties. This does not only involve key details about the event (the “W questions” – who, where, when, why), but also visuals on how to find the event location, summary reports, thank you emails, and updates on future events and opportunities. I personally loved using software like Canva to help with this and used it as much as I could to create pretty posters, flyers, and reports. I find that it just helps with getting your message across, especially if you organise a science communication event. Whatever you are trying to achieve, if your audience does not receive the information they need, people will either not attend or miss out on important learnings. Ask for help, especially from others with more expertise and wider networks Organising a series of events was a challenge for our ECR team, as we had to balance our usual work responsibilities with time-consuming additional tasks (the emails alone were a full-time job!). We could have never done this without some help from our project leads (the “more senior” academics) and we distributed tasks whenever possible. Realistically, there will always need to be one person in charge who oversees the events and makes sure that all bases are covered (catering, travel, advertisements, planning content, communications, etc.). However, to grow we first need to learn and be able to make some mistakes, and that requires us to reach out when we struggle or when we could benefit from additional support. At the same time, people often don’t expect you to do everything – our showcase consisted mostly of attendees presenting their own science communication strategies. Recognising everyone’s expertise (including ECRs’ and youth advisors’) means that you can truly learn from each other. I am very grateful to be part of an academic community that is moving towards more collaborative working and acknowledges that we need to first build the expertise that we expect to see in research outputs. For this reason, I am looking forward to all the inspiring and instructive articles that will follow this introductory piece. This series is meant to celebrate ideas and reflections on research processes while we are building our community and move towards better research practices.

My name is Sanaa, and I am an undergraduate Psychology student at King’s College London who is passionate about developmental and clinical psychology. As the youngest child and a South Asian woman, I have always found myself observing and dissecting the complex dynamics within my family. Lately, this awareness has become increasingly introspective, not only noticing fragments of my grandparents in my parents, but fragments of my parents within myself. Growing up in a three-generation South Asian household alongside my paternal grandparents, parents, and siblings, I recognise many of these fragments reflected in our interactions. Patterns of thinking, values, and behaviours: a difficulty communicating openly, discomfort with emotional expression, a reluctance to accept help during times of struggle, a desire to control the uncontrollable, and a tendency towards chronic people-pleasing. However, genuine love, care and sacrifice coexist alongside these, creating an ambiguous space where questions are raised: Why do we instinctively adopt these patterns that we disapprove of in our hearts? And why do they transfer across generations despite an intrinsic desire for change? These questions have become increasingly difficult to ignore as I grow older. I noticed recurring similarities in the way my family members and I react, interact, and navigate everyday life, despite vast differences in our personalities and experiences. The persistence of these similarities made me wonder whether they were truly individual or part of something larger that had been quietly inherited across generations. Setting the Scene In 1955, my paternal grandmother migrated from Lahore, Pakistan, to Nairobi, Kenya, after marrying to conform to her parents’ expectations, selflessly upholding their societal reputation. Ten years later, both my grandparents moved to the UK, experiencing drastic hardship and accepting overbearing responsibilities at very young ages. Image Source: Wasif Mehmood on Pexels These experiences were not directly lived again by my parents, siblings or myself, yet they appear to have silently shaped the emotional climate in which I grew up. In South Asian culture, the concepts of upholding izzat (honour) and avoiding sharam (shame) have been deeply ingrained, dominating pivotal decisions for relatives such as my grandmother. Sharam can be felt internally within oneself and externally by family, often accumulated through behaviours breaching gender norms, challenging authority, transgressing religion or even disregarding advice from elders. Such attitudes are considered culturally rebellious, and this shared feeling of sharam can lead to the loss of public izzat. Behaving within the lines may create a positive community image and protect family status, respecting conventional concepts of social hierarchy. Yet, alongside these superficial benefits exists a build-up of exhaustion from obedience, restriction and seeking validation. These sociocultural concepts remain prevalent and continue to drive the more damaging tendencies I have observed, almost out of unspoken tradition. If my grandparents and parents experienced the burden of these expectations firsthand and reflect critically upon them, why do they continue to be unintentionally reinforced within our family? Lived Experience Meets Psychological Explanation Listening to the generational stories of my family, which travel from one country to another, I noticed not only the role of culture and tradition, but survival, too. It is through this new lens that I recognised intergenerational trauma does not always refer to a specific event or circumstance being passed down. Rather, it can explain how emotional and behavioural responses shaped by previous experiences of stress, migration and instability can be carried into later generations. Reactions which once provided safety and survival are inherited by following generations, who may not require such “social armour” anymore. Viewing my family’s experiences through this perspective, I began to see our hyper-independence, discomfort with emotional vulnerability and pressure to maintain a respectable image as patterns that may have originated as ways of coping with abuse, drastic changes in lifestyle and complex attachments. I consider myself extremely fortunate to have avoided the adverse experiences my older relatives endured, but this explanation raises the prospect that my siblings and I have not escaped the longer-term consequences. Repetition compulsion also helps to explain this strange cycle, suggesting that individuals tend to repeat past emotional reactions or behaviours, even if they have no desire to. This repetition is a subconscious attempt to resolve unresolved emotional experiences or trauma, even if it continues to perpetuate the very patterns one once wished to escape. My initial instinct had been to view these persistent behaviours as products of pride and stubbornness, along with a lack of desire to learn. Through this perspective, I now come to realise why they continue to reappear, despite awareness of the emotional burden they often carry. Achieving an understanding of the mechanisms behind intergenerational responses is a critical step for preserving treasured relationships, reducing resentment or confusion and increasing personal freedom. By recognising that we automatically repeat and inherit patterns, we acquire the choice to continue or end them. Yet, changing them is often more complex, particularly when learned, reinforced and normalised throughout childhood until now. Image Source: Anik Das on Unsplash These more tenacious tendencies can be explained through social learning theory, whereby behaviours are absorbed through observation and imitation of caregivers. Over time, they become automatic, reinforced through rewards or punishments, and tied to personal and familial identity. As a result, changing them can feel emotionally unsafe, threatening a sense of belonging and identity. This has reinforced my existing knowledge that our environments play a critical role in shaping who we are, with our minds beginning as blank slates. Nevertheless, I had failed to consider the possibility that these habits may also be reinforced by viewing my elders as role models and identifying with them, subconsciously blurring the boundaries between their identities and my own. Perhaps, through this process, we may gradually lose sight of our individual values and sense of self, contributing to a generational cycle of over-identification with others and the unconscious mirroring of beliefs, behaviours, and emotional responses. In cultures like mine, where going against learned values such as izzat and sharam is often disapproved of, another layer of difficulty is added: social consequences. Fear of public disapproval surfaces when not conforming to these standards, often triggering an avoidance of change. Agency within Intergenerational Patterns It is important to recognise that culture is not a singular entity; it is made up of harmful and meaningful practices that often co-exist. Many of the behaviours we struggle with are rooted in the ways older generations learned to express care, protection and responsibility. What seems to be control or rigidity may be their love language, shaped by their own upbringing and lived experiences. The goal may not be to separate ourselves from those who came before us, who, in my case, provide us with identity, affection and belonging. Rather, it is to become more conscious and proactive in what we choose to carry with us going forward. We cannot choose the culture and environment we are born into, or the underlying mechanisms we end up adopting. But we can recognise that agency is the ability to act consciously and wisely within these influences – the concept of Stoicism. We no longer drain ourselves trying to modify the circumstances beyond our control. Instead, we find a space between an experience and our reaction where choice, and therefore change, becomes possible. Image Source: Javier Allegue Barros on Unsplash With a more nuanced perspective, I have come to realise that many of the overlapping fragments I once viewed as flaws are in fact rich in situational context. Appreciating their origins in no way excuses the harm they may cause to ourselves and others, and we should not ignore the requirement for accountability. To be human is to be shaped by paths we did not choose and still find ways to slowly reshape ourselves. Consequently, we gain the opportunity to decide which values, behaviours and ways of thinking we carry forward and prioritise in future. We begin to choose our own directions. Generations of persistent patterns do not abolish the possibility of change.

Parents’ views on raising children in an increasingly digital world. The UK Government recommends no more than one hour a day of screen time for under 5’s, but this is an unachievable standard for many modern parents. With screen usage increasing during and after the Covid-19 pandemic, for many families, screens are a part of daily life. Increasingly, educational and homework demands have also taken a virtual format since the pandemic. In March 2026, the UK government released a set of guidelines regarding screen time use for under 5s. This included avoiding all screen time for under 2s, unless the activity encourages bonding, conversation or interaction between the infant and caregiver. For the 2-5s, screens should also be avoided during mealtimes and before bed. But guidelines often fail to account for the realities of raising children in the digital age. I am a Doctoral Researcher, whose career path so far has been (trying to!) understand how the experiences of early life, from in the womb to beyond, shape our development and wellbeing. This encompasses biological effects, including brain development, genetics and viral infections before birth, to environmental effects, including parenting, pandemics and education. This means I work directly with pregnant women and their babies once they are born, toddlers, all the way up to pre-teens. I also work directly with a focus group of women who gave birth during the pandemic, which helps me to shape my research to the focus and interest of those I am studying. They also, in turn, share their experiences with me on what it was like to be a new parent when the world was changing. Photo by Kelly Sikkema on Unsplash Children Are Sponges To take a step back, why do we need to study child development? Well, children are sponges. By this I mean they are experts at soaking up information around them, making new connections, and learning new things. In fact, the average 1-2 year old has about 50% more synapses than adults do. Children’s brains are hardwired to take in information, though not all of it is useful. Anyone who has met a child before, knows that they can draw outlandish conclusions (I recently heard from a child that cheese is, in fact, made of strings). This is why we go through something called ‘Synaptic Pruning’, where our brains start to remove the unneeded connections as we get older, to strengthen the important ones. This means children are in something called a critical period for development, where the things they learn during the early stages of their lives shape the behaviours, patterns and pathways they can follow as they get older. By studying things that can both positively or negatively impact these early experiences, we can ensure that every child gets the best start in life, and shapes the world more positively for the next generation of adults. Is Screen Time Bad for Children? One such early experience a child may have is with screens. Today, it is very difficult to imagine a life without screens. Many of us can agree that screen usage has changed in recent years. The widespread use of touchscreen mobile phones, laptops and tablets differs from a single TV in the living room, as was the norm many years ago. Currently, around 97% of US homes have a TV, 83% have a tablet and 77% have smartphones. Many of these screen time increases have been driven by the pandemic. One study found that within 10–11-year-old children in the UK, screen time increased by 11% compared to pre-pandemic levels. Another study found that across 6 countries, in 3–7-year-olds, screen time has increased on average by 50 minutes a day, mostly driven by entertainment, rather than educational, content. Despite the rise of screen usage, recent research has cautioned against the use of screens with young children. A 2024 Systematic Review found that prolonged exposure to screens within the first two years of life was associated with poorer language skills and overall cognitive development. They found that toddlers who watched more than two hours of TV a day were four times more likely to have delayed cognitive development, and were 3.7 times more likely to have delayed motor development. Another study found that children with excessive screen time had poorer mental health outcomes in their teenage years. The Big However Despite increasing evidence that screen time usage increases, many studies caution against blindly accepting that screens are inherently malicious devices. Many factors can influence how negatively screens can impact children. Firstly, context. Screen time detriments are seen less when screen time is accompanied by an active parent. This study found that delayed language development was 8.47 times more likely when watching television without a parent actively engaging. Secondly, content. Passive content was associated with poorer quality of life and socio-emotional outcomes, however, educational content was the opposite and was related to positive educational outcomes and no detriment to socio-emotional development. Finally, interactive content, for example video games, led to positive educational outcomes, but poorer socio-emotional outcomes. Thirdly, type. One study found that fast-paced cartoons produced more negative associations with cognitive skills such as inhibitory control, attention and even memory. But that slower-paced content did not. Many other factors warrant further investigation, including time, age of screen time onset, device type, etc. Though demonising screen use fails to consider the bigger picture regarding its effects on development. What Do Parents Think? Back in April, the new governmental screen time recommendations in the UK had just been released. I wanted to speak with the people this advice was written for to understand their views. So, we asked them questions as part of a general discussion and used their feedback to help design some questions for our study participants regarding screen time use. This is part of my wider role within the Gen2020 Study but as part of Patient and Public Involvement and Engagement (PPIE). The consensus: parents were glad to have some kind of guidance. Parents reported that often it can be a minefield of misinformation when it comes to how to parent their children. Overzealous opinions online of all forms made it hard to know what the right thing was to do. They appreciated then that they could come to a source that they trusted for guidance regarding screens. The caveat was that parents also thought that the guidelines were often not actually attainable. Parents mentioned that often their child did slip over the 1 hour a day recommended for 2–5-year-olds. Similarly, those with under 2s, couldn’t often stick to avoiding all passive screen time. This led to feelings of guilt and shame. Often TV was the only option for parents working from home without other childcare, or parents allowed their children to watch TV when they had had a long day. Overall, they felt the guidelines were useful, but that a more realistic approach to parenting may be necessary. So, What Is the Answer? Firstly, more research is needed to understand the nuances in screen time use in children. Secondly, we should also consider the impact on maternal mental health and the secondary effects of mothers’ wellbeing on children. In my opinion, striving for the best possible upbringing for your child is always best. But also understanding that we are all human, and that the best is not always the outcome, but simply the aim.