On Saturday 8th October I was sitting in the Royal Festival Hall in London, excitedly waiting for the UK premier of Hayao Miyazaki’s last film, The Boy and the Heron, to begin. Introducing the show, the BFI London Film Festival newly appointed director, Kirsty Matheson, was revealing to a clapping audience how deeply emotional the film was, and how energised she felt after watching it. I thought she chose the right words, as “energy” is exactly what I had felt every time I sat in front of one of Miyazaki’s masterpieces: that strong, even primal, rush of life force the Japanese director has always infused in his works since his 1979 directorial debut The Castle of Cagliostro. I am a Miyazaki fan, even if a recent one. Like most people of my generation, I discovered his work through the 2001 success of Spirited Away. I was sixteen back then. I liked the film, but it was not love at first sight, probably because I was too snobbish in my teenage years to admit I could truly enjoy animation (I was into really serious stuff: Ingmar Bergman was my favourite director at that time; no wonder I didn’t have many friends). In the following years, I watched and liked Howl's Moving Castle (2004) and Ponyo (2008), but never felt the urge to go digging for his earlier films. That was until a few years ago, when I found myself bedridden by a terrible cold and couldn’t find anything to watch that I could tolerate in my feverish state. Netflix’s algorithm suggested Nausicaä of the Valley of the Wind (1984), presumably knowing me better than I did, or do. I clicked on it. And something clicked in my mind: in the following weeks, months, and years I watched the entire Miyazaki’s filmography and watched it again. And again. And again. Without even realising it, I became an adept member of Studio Ghibli’s cult, and I have been ever since. The story of an angry boy I could spend the rest of the article telling you how great The Boy and the Heron is, with its sense of ineluctability and yet hope, its cosmic apocalypse that is also a vision of cosmic rebirth. The Boy and the Heron is probably the most “psychological” of Miyazaki’s films, and I mean the word in the Western, psychoanalytical sense: it could be read as a deep dive into a personal and collective unconscious, or as a journey to an archetypal underworld not so different from the one described by depth psychologists like Carl Jung or James Hillman. It is also a film which features a rich symbolist and surrealist aesthetic, with its references to Arnold Böcklin 1880’s Island of the Dead and René Magritte 1959’s The Castle of the Pyrenees. It is, ostensibly, a film about death, about the end of things, and why the end of things is not a bad thing in itself. I could tell you this and more, but I don’t want to spoil the experience. So, I’ll stick to something that becomes immediately clear from the film’s very initial scene: first and foremost, The Boy and the Heron is a film about an angry boy. A boy who is angry because he has lost his mum. A boy who following that anger, finds a way to cure his wound, and the wound of the world he inhabits. This takes me back to the first time I watched Nausicaä of the Valley of the Wind, and what really struck me about the film. In the initial scene, Nausicaa is chased by an Ohm, a huge trilobite-like insect driven into a berserk rage by the destruction of its natural environment. The Ohmu’s blind fury (which reminded me of Achilles' wrath) is an important theme in Nausicaä, and from many points of view the real engine that moves the plot. Nausicaa’s world is a world of trauma, and Nausicaa’s power is the ability to heal this trauma through her empathy. But – and this is what I really liked, even in my feverish altered state of consciousness, or maybe because of it – Nausicaa’s sympathy for all living things is not simply a cure to the Ohmu’s rage: it’s just a different, and arguably healthier, response to the underlying problem, that is to say, the trauma itself, the toxic wasteland that both Nausicaa and the Ohmu are forced to live in. In contrast to Homer’s Iliad, then, wrath isn’t seen simply as a destructive force. Anger in all of its forms is an imperfect answer to an even more imperfect situation. Anger destroys, but can also create if properly channelled. A world at war This theme (anger as a destructive force vs. anger as a creative principle) can be seen in many of Miyazaki’s films: in Princess Mononoke (1997), arguably the peak of Miyazaki’s art before the 2001 success in the West, the young heroine San identifies with a pack of wild white wolves, and is every bit as feral as them: no love she may feel for Ashitaka can tame her, or extinguish her fury for the devastation of her forest. In Howl’s Moving Castle, Howl is consumed by an apparently inexplicable rage, but it is this rage, metaphorically embodied by the fire demon Calcifer, which keeps the Castle moving. Iin Spirited Away, the river spirit is portrayed as a dragon/wolf, and his god nature hides beneath the revolting appearance of a stinky pile of mud which wreaks havoc when it arrives at the thermal baths. At the same time, though, rage is also a destructive, annihilating force. And this can be seen in the omnipresent war which serves as a backdrop for almost all of Miyazaki’s films. War is a constant presence in Miyazaki’s worlds. Nausicaä of the Valley of the Wind (1984) depicts a universe deeply lost in a fratricide war between neighbouring kingdoms; in Castle in the Sky (1986), dark powers seek to control the floating island of Laputa to rule the world; Porco Rosso (1992) is Miyazaki’s take on the WWI epic of early military aviation; Princess Mononoke (1997) is deeply rooted in the environmentalist view of an eternal war of men against nature, and of men against men; in Spirited Away (2001) the thermal baths are ruled as an authoritarian military state; in Howl’s Moving Castle (2004) a despotic power uses magic to maintain its grip on power; The Wind Rises (2013) revolves around the construction of military planes in the period between the two world wars; and in The Boy and the Heron (2023), our angry boy Mahito loses his mum in a fire during WWII, and the ghosts of the war never stop hunting him. With the exception of three films (My Neighbour Totoro, Kiki’s Delivery Service, and Ponyo) this comprises Miyazaki’s full filmography. In Miyazaki’s universe, anger is a powerful and somewhat inescapable force, one that can be used to destroy or can be transmuted into a deeper, healthier energy. A difficult emotion We need to be careful when we read the work of a Japanese artist through Western eyes: the history of the East-West relationship is the history of a misunderstanding, and it’s all too easy to mistranslate ideas and symbols to fit our Weltanschauung. And yet, all the Japanese authors who managed to become mainstream in the West consciously mixed Western and Eastern references (think about Banana Yoshimoto or Murakami Haruki in literature, for example), and Miyazaki is no exception. Broadly speaking, though, and at the risk of some generalisation, we can say that Eastern philosophies tend to be much less dualistic than the Western Platonic-Christian thought, and somewhat unburdened by our idea of Christian guilt. As I mentioned before, the archetypal image of anger in the West is Achilles’ wrath, one that morphed into the Christian idea of divine retribution. In the classic and Medieval sources rage can be justified or not, can sometimes be cathartic, but very rarely can become a force of creation: like Achilles blinded by its own fury, or like God punishing humankind for its sins with the deluge, anger destroys. This is probably why we find it so hard, in the West, to come to terms with our angry feelings. In Miyazaki, just like in the alchemical tradition or in-depth psychology, things are different. Anger isn’t good or bad per se: anger is a fire within, a form of raw energy, a tool that can be used to support the forces of good or the forces of evil (and, because things in Miyazaki are seldom as black and white as they seem at first sight, it’s not always easy to say what is good and what is evil). In Miyazaki, probably influenced here by the idea of Buddhist Samsara, war is the natural state of life: aggressiveness, ignorance, and bestiality are states that cannot be escaped. But they can be transformed, their energy can be channelled into something far more luminous, and positive. Without anger, there would be no war, but there wouldn’t be a response to the war either. Nausicaa’s empathy would be meaningless, as it would be San’s fight for the natural world. Howl would be suffering much less without the anger that consumes him, but there would be no moving castle either, with all the magical universes it brings along. Creation and destruction are part of a single, entangled whole. Mahito's apocalypse And Mahito, of course, wouldn’t have a reason to follow the heron into the underworld: it is his anger, and not only the sorrow for the death of his mother, that pushes him towards the heron. In fact, Mahito follows the heron because he wants to kill it – that is the level of rage he brings with him. The Boy and the Heron, as I said, is a film about death and the end of things. It’s the final film of a great master of human emotions if there can be one. As such, it is also a film that looks retrospectively at Miyazaki’s career and quotes more or less explicitly many of his films, from Spirited Away to Castle in the Sky and Princess Mononoke. It is also a film about the personal and collective apocalypse, the mass-death of millions of beings and the rebirth of other millions, all caught in this endless, painful, joyous, desperate and yet hopeful cycle of birth and death. It is a film, then, that celebrates the positive power of destruction, as nothing new can be born before the old is extinguished, blown up in a huge, catastrophic explosion. This is the energy Kirsty Matheson was talking about introducing the film to the BFI London Film Festival audience: this faith that human life, and life in general, is worth living even in the face of grief, sorrow, and personal and collective disaster. This is the fire within that destroys so that it can create anew.

There’s a very common misconception held by many who do not suffer from mental health issues that they are a very recent, new type of affliction. This is an incorrect and harmful assumption, as it can further stigmatise those who suffer from mental illness, and can lead to people dismissing their issues as something that has been recently "invented". In fact, there are records of mental health symptoms from thousands of years ago, including a recording of what is contested to be a case of PTSD from ancient Greece. As someone who is very interested in ancient history, alongside other time periods, I decided to write this article to illuminate a topic that has existed for as long as we have, but which has historically received very little attention until recently. Namely, the study and investigation of mental health. The oldest documented case? Herodotus was a Greek historian and geographer, who is thought to have travelled extensively around the Greek World, the Persian Empire, and Pharaonic Egypt. He wrote the book "Histories", which is widely considered the first history book in Western literature. The entire work is split into nine books, and in the sixth, during his description of the famous battle of Marathon, Herodotus mentions a soldier called Epizelus, who was struck blind by fear upon seeing an enormous enemy soldier kill the man fighting next to him. Translated into English, this intriguing passage reads as follows: “- an Athenian, Epizelos the son of Cuphagoras, while fighting in the close combat and proving himself a good man, was deprived of the sight of his eyes, neither having received a blow in any part of his body nor having been hit by a missile, and for the rest of his life from this time he continued to be blind; and I was informed that he used to tell about that which had happened to him a tale of this kind, namely that it seemed to him that a tall man in full armour stood against him, whose beard overshadowed his entire shield; and this apparition passed him by, but killed his comrade who stood next to him. Thus, as I was informed, Epizelos told the tale”. While Herodotus is often doubted for the truthfulness of his sources, and is often suspected of embellishing details, we can see from this excerpt possible evidence of several symptoms of PTSD, and even neurological symptoms brought on by psychological trauma. Since the term PTSD was coined, the case of Epizelus was often pointed to as the first documented case. However tempting this diagnosis is, due to its similarity in being caused by a traumatic event, there is considerable pushback against this idea, as many say that he actually suffered from what is known as "Conversion Disorder". Like PTSD, Conversion Disorder is a rare phenomenon in which stressful events and trauma can cause periodic or lasting symptoms such as paralysis, slurred speech, and issues with vision, among others. In this case, it is speculated that Epizelus was suffering from a form of Conversion Disorder which caused him to become blind as a response to the trauma of seeing such violence around him. Presumably, this was the body’s way of blocking out the possibility of seeing even more horrific events. Also, like many cases of PTSD, the trauma was not caused by physical violence committed on the sufferer, but instead is caused by witnessing it. However, there is an even earlier case of suspected PTSD, which this time can’t easily be mistaken for something different. This time it comes from ancient Mesopotamia (modern day Iraq), from the time of the Assyrian Dynasty, which lasted from 1300-609 BC. The people of Mesopotamia were the first in the world to develop writing, with the oldest discovered text being from the ancient city of Uruk and dated from 3200 BC. Because of the thousands of years writing has existed in this region, many of their records have survived to this day, often in the form of clay tablets. Many of these take the form of medical texts, which attempt to help Ašipus (people who practiced Assyrian medicine, typically in armies) diagnose and treat different illnesses. For example, they talk of soldiers words being "unintelligible for three days", or "depression keeps falling on him for three consecutive days", and even an individual who "sees either a living person or a dead person (...) and becomes afraid". This last example is theorised by the authors of this paper, Walid Khalid Abdul-Hamid and Jamie Hacker Hughes, to be a reference to hallucinations caused by PTSD. In fact, it is very likely that similar afflictions were common during this time, as all villages and towns were obliged to supply a certain number of volunteers to fight on a three year cycle, due to the ever-present nature of war during this period. The ancient Mesopotamians believed that these symptoms were punishments from the Gods. Specifically, they believed the Gods would allow the spirits of those a soldier had killed in battle to attack them, causing the symptoms seen above. Nowadays of course, we can use modern science and the benefit of hindsight to be more sure of what caused this. Although the term was only coined in 1980, the actual disorder of PTSD has existed as long as violence has existed. So, what can we learn from this discovery? Well, sufferers of PTSD and other traumas may feel reassured to learn that people have always suffered from mental health problems, and may also be glad we live in an age when they are better understood and more easily treated. It’s also a good distinction to make that PTSD is not only caused by involvement in war. It can equally be caused by accidents, assault, and exposure to traumatic events, and it is always useful to contact a professional if you suspect you may be affected by it.

I like to think I have a good memory. I rarely forget a birthday. I can remember random facts I learned while studying for my GCSEs almost a decade ago. Things my friends tell me about their hobbies and interests stick to my brain like it's made of honey. But there are huge swathes of time that I have no recollection of. They're just... gone. I spent much of my childhood in my own little world. I've always had a very vivid imagination, and I would happily play for hours by myself. I was labelled a "dolly daydreamer" by teachers, who saw my mental disappearing acts as nothing more than a — albeit slightly odd — personality quirk. I learned to hide it better as I got older, learned how to make my body look like it was paying attention when my mind had drifted off to one of the make-believe lands I'd built for myself. Soon, though, I was doing a different kind of disappearing act. The connection between my mind and body would sever altogether for short bursts of time. It wasn't daydreaming anymore. It was detachment. I would be in class, and it would be like like I was watching a film where the person living in my body was the main character. Only that person wasn't me. Imagine looking down at your body with a virtual reality headset on. That's what it felt like. I had no idea what this feeling was called. My best friend has type one diabetes, and she can sometimes become disorientated if her blood sugar is too high or too low. I assumed something similarly physical was happening to me. This went on for years. Sometimes I would feel detached for hours, other times, it would be days or weeks. In August 2017, I was mugged on my way home from a friend's house. Not only did I completely detach when it happened, but I found myself detaching more and more frequently in the weeks and months that followed. Finally, in 2019, I saw a video on YouTube that mentioned dissociation. I googled it, and as I read through the various definitions and explanations, it was like a lightbulb went off in my head. "If you dissociate, you may feel disconnected from yourself and the world around you. For example, you may feel detached from your body or feel as though the world around you is unreal," Mind UK said. "Dissociation may be something that you experience for a short time while something traumatic is happening. But you also may have learned to dissociate as a way of coping with stressful experiences. This may be something that you've done since you were young." That was it. That. Was. It. I finally had a word for the thing I'd been experiencing for well over a decade. I'd heard of dissociation before, I just didn't understand it and had never connected it to what I was feeling. I'd only ever heard of dissociation in relation to Dissociative Identity Disorder (DID). I didn't know that people who didn't have DID could also dissociate and that this dissociation looked very different. I also didn't know that anxiety wasn't always panic attacks (which I also experienced). According to the NHS, DID is just one type of dissociative disorder. People can also have dissociative amnesia, where they have "periods where they cannot remember information about themselves or events", or depersonalisation-derealisation disorder. Depersonalisation is where a person feels like they are outside themselves. Derealisation is where the world around them doesn't feel real. I experience depersonalisation and derealisation together. Some people might experience one or both at different times. There is also some overlap between the three different types. People who have depersonalisation-derealisation disorder can experience memory loss, for example. As I started learning more about dissociation, I started to understand how it related to my anxiety and how to manage it. I dissociate when my anxiety reaches a certain level. My brain decides it can't cope with it, and it "checks out". It's hard for even me to detect sometimes. It can just feel like I'm calming down, and I don't realise until I'm observing my emotions rather than feeling them that I've dissociated. I once experienced this for two weeks straight, but it's more common for me to experience short bursts that sometimes last even less than an hour. I try to prevent it from occurring. I work really hard to keep my anxiety under control: I take medication and keep a journal. I talk to my friends and family as soon as I start to feel anxious about something. I generally just do my best to create a stress-free environment and life for myself. Obviously, that isn't always possible. Sometimes, things are out of my control. When I've dissociated, tracking my thoughts is no longer helpful. I have to do something physical to bring me back to my body. Running is my go-to, but I also take cold showers or do breathwork. Thankfully, the changes I've made and the work that I've done mean that I no longer dissociate as frequently. I can go months without having an episode of what I consider "unhelpful dissociation" — that detached, film-like feeling. I still have vivid daydreams, but now I have them when I'm doing something creative — like planning my writing — rather than when I can't cope with my feelings. I can enjoy my imagination because I know I'm in control of it. My experience with dissociation taught me the single most valuable lesson I've learned on my mental health journey: everyone experiences symptoms differently. They don't have to align perfectly with someone else's to be valid. Everyone has a unique combination of symptoms. My experience with dissociation is my own. My anxiety doesn't always look how others, or even I, expect it to, and that's okay. It won't stop me from seeking out support. And it shouldn't stop you, either.

In the UK, roughly 1 in 5 people suffer from depression; while many find that they have some degree of response to antidepressant treatment methods, up to one-third of people living with depression are considered to be resistant to treatment. This means that, despite the use of traditional treatments, these medications appear to have no measurable effect on their depression. Unsurprisingly, those with treatment-resistant depression (TRD) often find that they have fewer options — especially pharmaceutically — available to them for managing their mental wellbeing. Though treatment-resistant, this doesn’t mean that they are untreatable, as Dr Etta Nettis explains perfectly in an earlier blog. With this in mind, mental health research has shown increasing interest in finding ways that medicine can support those who are otherwise unsupported by conventional treatment strategies. There are quite a few approaches and angles that researchers have looked at over the years. One such approach is to look at the body’s chemical responses to stress, and in particular at the activation of the inflammatory system. On the path to personalised treatments New research from our laboratory, and other collaborators in the UK and Italy, has found that measuring levels of inflammation and stress-response in the blood may provide useful information to show which patients with depression will or will not respond to treatment with antidepressants. As previously discussed in another of our blogs, identifying subgroups of depressed patients based on how their bodies and immune systems respond to stress can help developing personalised treatment plans for patients, in turn allowing patients to bypass the delay in getting the most helpful treatment for them. This may reduce time spent trying different antidepressants with little to no response. Published in the scientific journal, Translational Psychiatry, our new study examines blood from 130 patients with major depressive disorder (MDD) and 40 healthy controls to understand how gene expression it the blood — the process which signals the production of new molecules such as those responsible for managing the immune system and stress response — could be used to distinguish those patients with TRD from those who are responsive to medication. The participants are part of the Biomarkers in Depression (BIODEP) Study, funded by the Wellcome Trust. “While there is overwhelming evidence of increased inflammation in depression it is still unclear how exactly this occurs and what it looks like at the level of chemistry within the body.”” — DR ANNAMARIA CATTANEO, LEAD AUTHOR ON THE PAPER. As also discussed in our blog, inflammation and stress-related responses in depression have been an area of great intrigue for quite some time now. Indeed, previous research has shown that high levels of C-reactive protein (CRP) in the blood indicate some degree of inflammation in the body. Building on this framework, our research, led by Dr Cattaneo, finds higher levels of blood CRP in both patients that were resistant to treatment and medication-free patients, compared with patients with depression who are responsive to medication, as well as healthy controls. Sixteen inflammation and stress-related genes have been measured in this study, some of which have never before been measured in human blood. As with CRP, researchers also reported that the expression of several inflammation-related genes (including IL-1-beta, IL-6, TNF-alpha, and P2RX7) was also increased in both treatment-resistant and medication-free patients. So, what do these findings mean for patients with depression? While inflammation is well-established as being linked to stress and MDD, it is also not a standard abnormality: not every person with depression will exhibit heightened inflammation. The findings of this new research support the growing evidence that patients that do not respond to antidepressants or have untreated depression have heightened inflammation compared with controls. Considering this link and the findings of this study, targeting inflammation appears to be a viable avenue for future clinical trials to examine the usefulness of anti-inflammatory medications to treat those with TRD. We also examined idicators of stress and found that both the treatment-resistant and drug-free patients have reduced numbers of glucocorticoid receptors, which are involved in the body’s stress response. With reduced numbers of these receptors, the body’s ability to buffer stress through hormones such as cortisol is diminished, which increases the risk of more severe forms of depression. “Our study has provided important insight into the mechanisms that can explain the link between inflammation and depression which will especially impact the future of personalised psychiatry.” — PROFESSOR CARMINE PARIANTE, SENIOR AUTHOR OF THE PAPER. As far as antidepressant treatments have come in the last 50 years, they still have quite a way to go. While much of the medication-based interventions for depression currently rely on a ‘trial and error’ approach, studies such as this highlight the importance of getting a more thorough and complex understanding of the individual patient so that they may be guided directly to treatment strategies which work best for them, through a personalised medicine based approach. Yes, we still have a long road ahead of us, with unpredictable turns and bothersome bumps — but our group and other researchers in this field have, and continue to make fantastic strides, so that the future of mental health treatments can make the promise of effective medical support to all those who need it. NOTE FROM THE EDITORS: The study was led by King’s College London and involved researchers from IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli (Brescia, Italy), University of Milan (Italy), University of Cambridge, University of Oxford, University of Glasgow, Cardiff University, and Janssen Pharmaceutica. The sources of funding of the study, and any conflicts of interests, are detailed in the original paper.

The Commodification of Pride & its Impact on LGBTQ+ Mental Health It’s the last day of Pride 2021. For the last thirty days, brands have plastered their social media accounts with rainbow logos, pride flags, and hashtags to show their undying support for the LGBTQ+ community. Well, undying until July 1st. What? You didn’t really expect these big-name brands to keep up the rainbow profile picture, the “love is love! buy this shirt!” pinned tweet, and matching header image forever, did you? June is over, and along with it, the rainbow-clad attempts by brands to appear supportive of LGBTQ+ lives. In June 2019, I wrote a piece for InSPIre the Mind called “Is Mental Health Awareness the New Marketing Strategy Trend?” — I also spoke about this on BBC Radio 4's Beyond Today podcast last year, which you should definitely check out! Funnily enough, this was a piece initially inspired by conversations that friends and I had had surrounding rainbow capitalism and brands profiting off of Pride celebrations. As I began writing, however, the piece grew into a much wider commentary on how big-name brands were (and still are) taking advantage of the increasing popularity of mental health discussions to, essentially, make a profit. In the blog, I said: “Brands will plaster a general statement on a rainbow logo, and maybe a promotional video that goes viral, and then the other 11 months of the year is radio silence.” As with most issues, this isn’t as simple as “brands marketing Pride is bad” — it’s a lot more nuanced than that. All of what I’ve said above is true, but so is the fact that brands getting involved in Pride Month is incredibly important. Generally speaking, brands involving Pride and LGBTQ+ conversation in their advertisements and social media campaigns are, for example, a fantastic way to gain visibility. In a survey on 2000 gay and bisexual men, it was found that 52% of respondents felt “invisible” in advertising, meanwhile, 54% felt that greater exposure to LGBTQ+ representation in advertising would have helped them come out sooner, thanks in part to normalisation efforts. It’s no surprise that a great number of brands have faced backlash and had their motivations brought into question by LGBTQ+ individuals and their allies (those who stand with and unconditionally support LGBTQ+ people though don’t identify as part of the LGBTQ+ community themselves). Year after year, we’ve seen brands flaunt their support of the LGBTQ+ community in the form of limited-edition product lines and discounted subscriptions. Yet come July 1st, the same brands go back to business as usual with little to no input where it matters to LGBTQ+ lives, at least from what we can see. In other words, their support — or allyship — can appear conditional. It’s tough to see this as genuine rather than just a marketing team noticing an advertising opportunity in the ever-growing popularity of Pride Month. This a global community spanning race, gender, ethnicity, class and politics which has long been marginalised and discriminated against, not just a market to profit off the struggles of. I want to emphasise that this isn’t to discredit the earnest work being done by a huge number of people. I simply want to talk about patterns I’ve noticed over the years regarding brands and the ways that they engage with Pride month. With this blog, I want to talk about how brands have commodified Pride and the impacts this has had on the community both generally and in regard to mental health. As much as we might hate it, the world of politics is hugely influential on our everyday lives, and this is only more so the case for marginalised groups still advocating for equality. Unsurprisingly, businesses play a huge part in these systems as well. To the outside world, these brands and corporations get to play the role of a supportive ally while doing little to none of the work. In fact, a US study investigating the involvement of brands in funding lawmakers supporting anti-LGBTQ+ legislation found that several powerhouses of corporations were contradicting their own public statements of allyship by directly funding millions of dollars to lawmakers opposing the 2019 Equality Act — a bill with incredibly harmful implications to the LGBTQ+ community. It may very well be the case that these corporations are financially supporting candidates on “both sides” since this would guarantee them influence and allies in congress regardless of who wins. However, I think it’s fair to say that they yield that neutrality the moment they decide to take advantage of social outcry to sell a product. Once these brands caught on that morals sell, they quickly made being seen as socially aware their top priority, over the wellbeing, mental health, and livelihood of real LGBTQ+ folks. Rainbow Capitalism, TV and Cinema Disney, one of the world’s largest companies and media kingpin, has also joined the fun this June with its Rainbow Disney Collection and a non-profit online show “This is Me”. Disney has… a complicated past (and present) with its commitment to LGBTQ+ representation and allyship however it’d be unfair to ignore the good work they’ve done to only focus on the negative (which I’ll still be doing, don’t worry). Though they haven’t specified the portion of funds raised from the Collection that’ll be donated, the LGBTQ+ charities they’re supporting are listed. Nevertheless, considering how much Disney makes a year and a staggering reported $54 billion in retail sales worldwide of licensed and direct-to-consumer products, I would hope that all proceeds from this would go directly to the LGBTQ+ community. It really feels like every few months there’s yet another round of “Disney introduces first-ever openly gay character!” and almost every time, it’s at best disappointing and at worst insulting. The blink-and-you’ll-miss-it “exclusively gay moment” with LeFou in Beauty and the Beast, for example, was a moment that social media and practically every news outlet had a lot of fun with. Despite the directors attempts to lower the audience’s expectations, buzz around the movie was at an all-time high, with some praising Disney for its bravery and others expressing their frustration at yet another example of a company or studio doing the bare minimum to profit off of LGBTQ+ individuals’ need to be properly represented. Four years on, and what was lauded (though briefly) as a historic moment in Disney cinematic history, is now just part of a meme. To generate even more excitement for the final instalment of the Star Wars sequels, director JJ Abrams teased the reveal of an LGBTQ+ character. Despite enthusiasm from both the actors and audiences to see one of the main three leads — Rey, Finn and Poe — be not straight, it was actually two very minor characters who, once again, share a blink-and-you’ll-miss-it moment together, right at the end of the film. Frustratingly, these are by no means the only examples of Disney and their marketing teams using the deep need of LGBTQ+ audiences to be seen and honestly represented in the stories they love just as their heterosexual peers always have been. This also very nicely ties into a discussion of queerbaiting (a marketing technique in which TV & film creatives purposefully hint at a character or a pairing being not straight without any intention of actually making those characters anything other than straight to attract, in particular, queer audiences.) and how harmful that can be for, particularly younger, LGBTQ+ audiences. What message are gay audiences being sent here? That they’re an afterthought? That they can exist, sure, just never as the hero of a story? Across the Marvel Cinematic Universe’s 23 films, not a single hero — or even minor character — is a lesbian, gay, bisexual or trans. Of course, the character of Loki is canonically genderfluid and bisexual; however, this was only in his own TV show last week. Though the big screen is yet to see any diversity in terms of gender or sexuality, Disney’s slate of TV shows have been doing far better. A wonderful example was Disney Channel’s original series Andi Mack which had one of its main characters say, out loud, the words “I’m gay” and allowed this young boy to get a happy ending with the boy he likes at the end of the show. Television reflects the real life world and today that includes LGBTQ youth who deserve to see their lives depicted on their favorite shows. Disney has been a leader in LGBTQ inclusion and there are so many young people who will be excited to see Cyrus’ story unfold. – Sarah Kate Ellis, President and CEO of GLAAD There’s an indescribable comfort that comes with being seen and feeling understood and media, which acts as a reflection of who we are as people and as a society, has long been the medium people have turned to find this. We’re all very familiar with relating to characters and for most cisgender and straight people, it’s pretty damn easy to find one or 20 characters you can point out and say “they're like me!”. As a series directed at a younger audience, Andi Mack and shows alike provide LGBTQ+ children and teens the chance to find that same comfort. According to the 2019 GLSEN National School Climate Survey, 86% of LGBTQ+ youth report being harassed or assaulted at school, which can significantly impact their mental health. With rejection and victimisation being leading risk factors for mental ill-health in LGBTQ+ youth, it's vital for adolescents of all gender identities and sexual orientations to be exposed to positive representations of LGBTQ+ characters in the shows and characters they love. Children should see that queerness is a perfectly normal and common thing, and that you can have friends and family in your life whose love is not conditional. Stronger and more frequent representations of LGBTQ+ people in media can help diminish the stigma which fuels the homophobia and bullying so prevalent in our schools. Compared to their heterosexual and cisgender peers, studies have shown that LGBTQ+ people are at greater risk of suicidal ideation and self-harm, with 1 in 8 young adults aged 18–24 years reporting attempting suicide in the last year. Furthermore, according to the 2017 Stonewall report, 52% of LGBT people reported experiencing depression in the last year. What does this mean for brands and how they get involved in pride? Fear is a powerful and dangerous thing, we know this. It’s why 1 in 7 LGBTQ+ individuals admit to avoiding healthcare treatment due to fear of discrimination; not surprising given that almost a quarter of participants reported receiving discriminatory remarks from healthcare professionals. This fear of reaching out, of opening up about yourself, is by no means uncommon to a lot of LGBTQ+ individuals and stems from a wide range of core issues, a large one of which is stigma. If brands genuinely want to be a part of the conversation, they need to be putting in the work behind the scenes in June as well as every other month of the year. LGBTQ+ activism and gay Pride are not social media fads to participate in when it’s convenient. As with the Black Lives Matter movement, these causes are not opportunities to make fast money — they are extremely important fights for justice and equality for groups who have and continue to be discriminated against. And they should be respected as such. So, today is the last day of Pride 2021. What are you and the brands you engage with doing to effectively support your LGBTQ+ friends, family, and peers all year round? I’d encourage everyone who can to get involved and below are some great resources to help you get started: Stonewall.org — covers all kinds of ways that you can support the LGBTQ+ community including donating, campaigning, volunteering, and researching. MindOut — great mental health support (online and phone) and advice resource. Also includes volunteering and fundraising opportunities. Mind— find out more about LGBTQ+ mental health and how you can support those in need — you can call the Mind Infoline on 0300 123 3393 / info@mind.org.uk, the Mind Legal Advice service on 0300 466 6463 / legal@mind.org.uk Talk to the Samaritans — they offer 24-hour emotional support in full confidence. You can call them for free on 116 123 Albert Kennedy Trust — Supports LGBTQ people aged 16–25 who are homeless or living in a hostile environment. Galop — Provides helplines and other support for LGBTIQ+ adults and young people who have experienced hate crime, sexual violence or domestic abuse / 0207 704 2040 (hate crime helpline)/ 0800 999 5428 (National LGBT+ domestic abuse helpline)

What Can We Learn from Blood & the Brain? Since their introduction to medicine in the 1950s, antipsychotics have been the first line of treatment for people struggling with psychosis. Of course, their utility for so many is undeniable, and yet, it’s equally difficult to ignore that a great number of people with psychosis don’t find such treatments helpful to them at all. Naturally, the first question we ask ourselves here is: well, why not? Why don’t all people with psychotic disorders find improvement on the medicines made specifically for them? That’s a great question — and one that researchers have spent years searching for the answers for. And what exactly has all this research found so far? This is exactly what I wanted to understand and so, we decided to conduct a review of all the research on this topic to date. Alongside my role for InSPIre the Mind, I’m also a research assistant the SPI Lab at King’s College London and, though I have written about inflammation research from our group before (in the context of depression), with this blog, I’ll be discussing the findings of my own review on inflammation and psychosis, and what we can learn from the brain and from the blood. Before I get too ahead of myself, let me first set the scene: What is Psychosis & Psychotic Disorder? Psychotic disorders are mental health conditions that cause atypical thinking and behaviour. For example, someone experiencing a psychotic episode may hear things that aren’t actually there — hallucinations — or believe things that aren’t necessarily based in reality — delusions. Though the severity of these hallucinations and delusions, as well as other behavioural changes like difficulties with emotional balance and trouble with sleep, will vary between people, most people will experience some degree of disruption to their usual behaviour. As you can expect, people living with something like schizophrenia without effective management can struggle daily with things such as decision-making, concentration, emotional regulation, and other psychiatric disorders such as depression and anxiety, for example. Though talk therapies are also used, antipsychotic medications are the first-line treatments for psychotic disorders and so finding the best way to predict which patients will and which won’t respond to antipsychotic treatment is essential so that the necessary adjustments to healthcare plans can be made. This way, we can eventually ensure that all individuals with psychosis are getting the most effective treatment possible. Though we do still have some way to go, researchers have identified a promising avenue: inflammation. The Role of the Immune System in Psychosis In the last few decades, there’s been ever-growing interest into how the immune system plays a role in disorders such as ADHD and depression; indeed, depression alone has been a huge area of curiosity; how the immune system interacts with our genes and environment, its interplay with sex hormones, how we can target inflammation as a treatment strategy, and the potential efficacy of anti-inflammatory drugs in depression. Inflammation is the biological process by which your immune system responds to injury or infection (such as bacteria or viruses). This is a typical and perfectly natural response by your body and, more often than not, it’s a temporary one. However, there are instances where the body’s immune system kicks off this inflammatory response despite the lack of any external threat or injury. We see this quite often in disorders such as depression and ADHD, among others, as discussed regularly on InSPIre the Mind. The main inflammatory markers studied in patients with psychotic disorders include C-reactive protein (CRP) and cytokines analysed from blood samples. CRP plays a role in innate immunity as an early defence system against infections and its levels increase following the body coming into contact with infective agents or internal damage leading to immune activation. Cytokines are small proteins produced by immune cells (e.g., macrophages, lymphocytes, mast cells) and represent important signalling molecules for the regulation of the immune response. What’s interesting in the context of psychosis, is that despite being otherwise healthy (i.e., no flu, no cold, no infection nor physical injury) people with schizophrenia appear to show increased levels of inflammation compared to their no-psychosis-experiencing counterparts. What does this mean for patients with schizophrenia, though? As we similarly see in depression, research has shown that atypical levels of inflammation can potentially affect brain structure by disturbing neurogenesis (forming new brain cells), neuroplasticity (the brain's natural ability to adapt), and the functioning of neurotransmitters (chemical messengers of the brain). From this, it has been suggested that the brain changes seen in schizophrenia may be in some way interacting with the inflammatory response to contribute to the development of psychosis and treatment resistance in patients with psychosis. Where to Next? So, we decided to conduct what is known as a systematic review — essentially a very thorough search of all existing research on the specific topic we want to learn more about. With this, key literature is selected, in accordance with previously specified criteria, and studied as a collection. This way, we’re able to identify the patterns, similarities, and differences between all the research in a given topic are to then draw conclusions. Through our search, we wanted to identify all research covering two key concepts. First, studies investigating the efficacy of inflammatory biomarkers (like CRP and various cytokines) in predicting clinical outcome in psychosis. Second and in parallel, we searched for studies that investigated neuroimaging (scans of patients’ brains) findings in relation to inflammation in psychosis. After a lengthy process of filtering, reading, more filtering, and even more reading, we managed to identify a grand total of 31 papers covering our two aims: 17 for inflammatory biomarkers, and 14 for neuroimaging. What Did the Systematic Review Reveal? With this, we provided the first comprehensive systematic review of the literature investigating the potential role of inflammatory biomarkers as predictors of clinical outcome, and their association with neuroimaging markers, in patients with psychosis. You can read the full paper on Frontiers in Psychiatry. First, we found that in the literature, CRP and cytokines like IL-6 (interleukin-6) and IL-10 (interleukin-10) were most consistently correlated with clinical outcome (such as how well their psychotic symptoms improved over time), both as predictors of treatment response and associated with changes in symptoms severity over time. This meant that the patients with irregular inflammatory profiles were more often not responding well to their antipsychotic medication, unlike those who had typical levels of inflammation who appeared to be responding relatively well to their antipsychotic medications. When we looked at what the research suggested regarding the power of CRP as a predictor of clinical outcome and treatment response, we made an interesting discovery. While an individual’s CRP levels prior to/early on in the antipsychotic treatment can potentially be used to predict how well they may respond to said treatment, this marker appears to only be helpful in the long term. For example, CRP may help clinicians understand how well patients will respond to antipsychotic medications from only as early as 6 months into treatment. But what about before then? Are patients just supposed to push through those 6 months in the hopes that they do eventually respond well to their medication? Not necessarily! Promisingly, other inflammatory markers such as IL-6 seem to be better suited for this shorter-term follow-up (1–3 months). As with CRP, higher IL-6 levels were also associated with worse clinical outcome or deterioration in symptoms over time. With this in mind, researchers have taken the logical next step: targeting this inflammation with the aim of improving the associated psychotic symptoms. And the findings to date are encouraging. For example, one study testing the effect of add-on (meaning it was taken in addition to participant’s usual medication) anti-inflammatory treatment called Minocycline reported that the reduction in IL-6 levels induced by the minocycline treatment was associated with an improvement in negative symptoms. If we can therefore identify patients with psychosis who also have elevated IL-6 levels, using anti-inflammatory medications alongside their prescribed antipsychotic medications may be a promising way forward in helping these patients’ psychotic symptoms. The mechanisms through which peripheral (outside of the central nervous system (CNS)) inflammation could contribute to worse clinical outcome are still partly unclear. However, it has been suggested that peripheral inflammation could potentially lead to an atypical immune response in the CNS (the brain and the spinal cord) too, in turn affecting the brain's ability to repair and renew itself as well as how well various areas of the brain are able to communicate. We found that increased inflammatory markers were mainly associated with neural changes in patients with psychosis. This meant that patients with higher levels of inflammation were also more likely to have smaller hippocampal volumes and reduced cortical thickness, which can be problematic due to the associations these have with vital processes like learning and memory. Conversely, higher IL-6 levels were also associated with larger choroid plexus volume — a region of the brain where the blood-brain barrier is usually less tight and therefore, potentially, a main structure involved in the communication between the inflammation in the body and the brain. Final Thoughts Though we still don’t have definitive answers to the question I started this blog with — “why don’t all people with psychotic disorders respond the same way to the medicine made specifically for them?” — I still consider this systematic review a great success. Clinically, our findings can be used as guidance for future research aiming to identify the most promising inflammatory and neuroimaging markers when investigating the prediction of clinical outcomes in psychosis. These studies should also look into whether using a combination of these inflammatory and neuroimaging markers could further improve our ability to predict clinical outcome in patients with psychosis. (And this was a personal success for me too, with it being my first-ever systematic review and published paper!) Just as each person, their history, their environment, and, in this case, their symptoms, are individual, their medication and care should reflect this. The “one-size-fits-all” approach in treatments for disorders like psychosis have been problematic for decades now and research is at the stage where developing personalised treatment plans for patients in disorders like psychosis and depression are becoming more and more feasible. I for one am excited to see where we go next with this field of research and how we reach a point where we’re able to provide effective psychosis treatments for all, with a little help from blood and the brain. If you enjoyed this blog and would like to learn more about the research discussed, I’d recommend reading the full paper in Frontiers in Psychiatry.

Once again, the consequences of prioritising financial gain above real human wellbeing and mental health are being broadcasted, clear as day, to studio executives and companies. The question is: are they finally going to listen this time? Between talks of "crunch culture" in the gaming industry, the exposing of toxic workplace practices for animators and developers, and now the ongoing writers' strike in America, it sometimes feels like we're stuck in a time loop, having the same discussions, writing the same think-pieces, and calling out the same problems over and over again to no end. As many of you will have heard, the Writers Guild of America (WGA), a trade union representing film and television writers, is on strike. Currently on its 28th day, the ongoing WGA strike has been the largest disruption to production within the entertainment industry since the last WGA strike of 2007, which lasted 100 days. Many US-produced shows of the time had their 2007-2008 seasons cut short as writers scrambled to wrap up what they could before the strike began. Though its impact was most obvious in television, cinema certainly felt a hit from the strike too. Famously, for the James Bond film, Quantum of Solace, widely criticised for its messy plot and seemingly abrupt ending, actors didn't have a script to follow at times, with lead actor Daniel Craig improvising lines on the day of filming. To say that the 2007 strike had an impact on the film and television industry would be a tremendous understatement; aside from causing $3bn of economic damage in Los Angeles alone, in the years to come, the industry would undergo an extraordinary shift in how we consume the films and television we do today, namely with the widespread popularity of streaming services. Interestingly, it also resulted in a surge in the popularity of reality TV shows, which were substantially cheaper to produce and required, notably, no writers. Discussed in further detail on their website, the Guild has five key demands: Improved pay, accounting for inflation — According to the WGA, over the last decade, writer-producer pay has decreased by 23%, while the proportion of writers making the minimum rate has increased from 33% to 49%. Improved staffing — The widely despised practice of “mini rooms”, where only a small team of 2 or 3 writers will be made to pen scripts for a whole season of a show, has been a key issue the guild demands be addressed. Understaffing projects not only puts tremendous strain on the small teams to deliver projects within often short timeframes, but also shuts out newer writers as studios are less likely to take the risk of hiring those with less experience. Furthermore, while traditionally writers would remain involved in the entire production process, from writing the scripts to filming on set and consulting during editing, this has become less common practice over the last decade, resulting in a clear-even-to-audiences disconnect between writers and their own work. Refusing to allow writers to see how their scripts come to life on set takes away an incredibly valuable opportunity to improve their skill as writers, but also leaves writers stuck with little to no room for career progression. Better residuals — With traditional television, writers get small (typically only a few dollars) residual payments every time an episode they've worked on has a re-run. However, with the rise of streaming platforms, residual pay has all but ceased to exist despite those streaming services continuing to profit off those very shows that wouldn’t exist without said writers. Shorter exclusivity deals — This refers to the amount of time that must pass following the completion of work on a project before a writer can work on a new one. Current exclusivity rules are outdated, appropriate for the time of the 22-episode year-long season of television but not so much the 8-episodes-every-2-years season format we’re seeing more regularly. Safeguards on the use of AI in writing — Discussion on the danger of AI to art and entertainment is one we’re likely only going to be having more often. Within television and film production it’s no different; sustainable pay is dubious enough as it is, and introducing AI is only going to complicate things further. In solidarity, here in the UK, the Writers’ Guild of Great Britain (WGGB) has stated "The WGGB support the WGA in their ongoing negotiations. If a strike cannot be avoided, we will advise our membership not to work on projects within the jurisdiction of the WGA for the duration of the strike in line with our IAWG agreements". The strain that practices like "mini rooms" and reduced opportunities for pay, thanks to shorter seasons with fewer episodes, on writers' mental health and wellbeing is undeniable. When writers, particularly younger writers, attempting to establish themselves in their field, are made to get second side-jobs to make ends meet and survive — sadly, something we’re only hearing more about across various industries too, including teaching and nursing — little time is left to properly care for themselves. Not only are increased incidences of mental health difficulties apparent, but the continuous stress over unsustainable pay and working conditions is also detrimental to the quality of their work. Again, this isn't in any way an issue that only writers in the entertainment industry have to deal with — in fact, you can hear about this very problem and how it impacts the lives of NHS workers on a recent episode of At the Back of Your Mind, with guest Professor Dame Anne-Marie Rafferty. Also, YouTuber Drew Gooden in his recent video, "The Future of TV is Bleak", also talks about the ongoing WGA strike and its impacts on both writer wellbeing and the industry as a whole, so I’d recommend giving it a watch if you’re interested in hearing more. Though not explicitly addressed in the WGA's demands, one recurring issue that workers across the entertainment industry face is "crunch culture". What is "crunch culture"? "Crunch" and "crunch time" simply refer to the period before a major deadline where employees will work extremely exhausting long hours, often unpaid overtime, to ensure that the product is delivered on time. While "crunch" itself isn’t necessarily an issue or uncommon in everyday life, "crunch culture" within workplaces can become extremely dangerous extremely quickly. Unsurprisingly, high incidences of burnout and elevated stress and anxiety are frequently seen. Only a few months ago, online content production company Rooster Teeth came under fire for inappropriate conduct towards several ex-employees, including unpaid overtime, underpaid salaries, dismissal of mental and physical health concerns, and harassment. Though this was the most recent incident for the company, concerns about the poor management and crunch culture at Rooster Teeth had actually been raised a few years prior as well, by a number of ex-employees including animators, voice actors, and show creators. Those familiar with the group - for me, I loved watching their gaming YouTube videos and podcasts as a teen - will be very familiar with the company's history with "crunch time". For years, on podcasts and in YouTube videos, we'd hear comments, laughed off as jokes, about how they (most often writers and animators) were exhausted and had to spend the night at the office again because they didn't have time to go home with the tight production deadlines they were working under. With how they'd laugh it off themselves, and how Rooster Teeth for years prided themselves as being a big family of sorts, a group of friends goofing off and making content they love, audiences decided this must be normal. Quickly following the media attention that the recent incident gained, however, Rooster Teeth this time apologised for the past actions of their management staff, promising to listen and implement the necessary changes to ensure healthier work environments and appropriate pay for all staff. I can't say how it's been for employees since, but I am glad that this time Rooster Teeth are acknowledging the harm caused and actively making attempts to improve working conditions and worker wellbeing are certainly steps in the right direction. Beyond television and film One of the other moments that inspired me to eventually write this article was the conversation surrounding the wellbeing of developers during the production of the then highly anticipated 2020 video game, Cyberpunk 2077. Following almost a decade of waiting and ever-escalating expectations for a game that, very early on, was anticipated to be the "game of the decade", the actual launch ended up being… rough, to say the least, and certainly not what audiences had been dreaming of. Its now infamous "tumultuous, bug-ridden release", combined with the repeated release delays, and controversy surrounding "crunch culture", left audiences extremely disappointed, and finding positive commentary on the game was near impossible. To this day, I still haven’t even played the game myself, but at the time, if you were remotely interested in video games and the gaming industry, it was difficult to avoid seeing the endless stream of criticism towards the game and its creators. That’s not to say some of it wasn’t deserved, but I’ll get into that in a moment. Now, over two years since its release and many bug-fixing patches later, players appear content with where the product is at, with many explaining that the game is finally the "finished product" that it should have been on launch day. Nevertheless, audiences have moved on to other games and Cyberpunk 2077 will likely remain, for many, as simply the Keanu Reeves game with the incredibly cool trailer but completely botched release. So, what went wrong? With this game, and many others, key reasons as to why the released product failed to meet the expectations of both audiences and studio alike, were unrealistic timelines resulting in unhealthy work environments and in turn strained employee mental and physical wellbeing. This is where, yet again, "crunch culture" comes in. Earlier I mentioned that some of the criticism towards the handling of Cyberpunk 2077 was necessary. Audiences (and individuals working within the videogame production industry) rightfully calling out the toxicity of "crunch culture" is what I was referring to. With Cyberpunk, while employees were not forced to work 100+ hour weeks and forego rest and self-care – an argument made regularly by individuals defending the studio over concerned workers – it’s often made clear to employees that their employment is very much contingent on them putting in that extra time and pushing themselves to demonstrate their "loyalty". But this isn’t what writers, artists, and developers sign up for when they follow their passion to work in this industry. Research expectedly shows that the high incidence of burnout syndrome among workers, as well as the poor employee retention, in the video games industry, is attributed to "crunch time". As Assistant Professor and video games researcher Professor Amanda Cote states perfectly in a recent paper, "Months of overtime, 100-hour workweeks, and 12+ hour days do not sound like the characteristics of a "dream job"; they sound like red flags that should leave anyone with an alternative heading in the opposite direction". Ultimately, "crunch culture" is a predatory and manipulative practice to ensure that employees play their crucial yet undervalued role in producing a product. Studios might make a loss when the game or show inevitability takes a hit in quality, but the ones really paying are the artists and creatives pushed to their limit for weeks, months, and sometimes even years at a time. What does the future hold? As I said, the 2007 right to strike had tremendous impacts on the entertainment industry; impacts we’re still seeing the ramifications, for better or worse, today. Though it doesn’t seem like an agreement will be reached soon, I have to say that I’m incredibly curious to see where today’s strike will take the film and television industry and how what effects we’ll be seeing ten years from now. And I am hopeful, though perhaps naively, that the value of these workers will be recognised, even if it once again takes months for executives to wake up and realise the reality of the matter is: we need writers, we need creators, and we need artists.

This is the fourth and final article in a series inspired by EU-PEARL (EUropean-Patient-cEntric clinicAl tRial pLatforms). The EU-PEARL project aims to shape the future of clinical trials, creating a framework for platform trials. Psychiatric medications are a critical part of the treatment plan for many living with mental health disorders. In fact, data on prescribing trends across GP practices in England show that, between 2020 to 2021, a total of 79.4 million antidepressant drug items were prescribed to 7.87 million identified patients. For many, the necessity of these antidepressants is undeniable, and with such high numbers of people receiving them, one important consideration for researchers, patients, and doctors alike is: how exactly are these medications being administered to patients? The route of administration can have a significant effect on how well a given drug treats symptoms, as well as affecting its safety, comfort, and convenience for the patient, each route coming with its own benefits and downsides. This article will explore the various routes of administration for psychiatric medications and the research that has been conducted on their acceptability in patient populations. Alongside my role for Inspire the Mind, I’m also a research assistant at the SPI Lab at King’s College London and, although the project launched back in 2018, I began my work within EU-PEARL mid-last year. As you may remember from this introductory article, the EU-PEARL project’s mission is to ultimately create a novel, adaptive, and efficacious clinical trial platform via collaboration between research centres, non-profit organisations, hospitals, pharmaceutical companies, and the very patients that the trialled medications may one day help treat. Thanks to the use of a ‘master protocol’, the introduction of the ‘platform trial’ paves the way to changing the way drug research and development takes place, allowing multiple potential drugs to be tested simultaneously and flexibly (i.e., if one drug is deemed unsuccessful, it can easily be removed from and replaced in the trial). Expectedly, platform trials are also a great way to trial established and already approved medications, only this time for different purposes (e.g., an antibiotic or ketamine to treat inflammation and major depressive disorder) and via different routes of administration (e.g., an injection instead of a tablet). What is ‘the route of administration’? When it comes to treating psychiatric conditions, there are several ways we can approach them. While medications and psychotherapy are commonly used, understanding which route of administration — the way in which a treatment is given — is best suited for a patient is key and as such, requires careful consideration. The delivery of the chosen psychotherapeutic care — whether it be as an oral tablet, intravenous (IV) injection, inhaler, nasal spray, or any other form — can impact a patient’s level of success. A patient’s success with an intervention refers to how well the invention (e.g., a medication) addresses the condition; for example, for a patient with depression, “success” would be measured by how well a chosen antidepressant reduces the depressive symptoms the individual otherwise experiences. Though a range of other factors also play a role in how helpful a medication will be for a patient, such as when and how regularly it’s taken, whether it’s taken with another medication, or whether the patient has any other illness or any other mental health condition, for the purposes of this article, I will be focussing on the influence of the route of administration. Orally administered medications The most commonly used antidepressants globally all come in orally administered (any medication taken through the mouth) forms, including tablets, capsules, liquids, and oral drops. Ease of administration is a big part of the reason oral medications are so widely produced and used; being able to carry a pill bottle around with you in your bag, taking your medication in the comfort of your own home, and not needing to speak to a healthcare professional before every dose are conveniences that we all certainly can appreciate. Likewise, with relatively low manufacturing costs, less time spent in hospitals, clinics, or at the GP with healthcare staff, and absence of specialist equipment to administer your next dose, oral medications are generally far less expensive overall than, for example, IV infusions and inhalers. However, although the convenience of taking tablets allows us to adapt our treatments to our own lives, this independence means that responsibility for administration lies (almost) solely with us. If a dose is missed, taken with the wrong food, not enough food, or with alcohol or recreational drugs, that’s on the patient, rather than the professional administering the dose directly within a controlled environment. Moreover, some people simply cannot tolerate oral medications for a range of reasons, whether it be due to their taste, inability to swallow pills in general, past bad experiences, or possible side effects such as nausea or vomiting. Also, compared to medications administered directly to the bloodstream or other target area, orally administered drugs can be slow in terms of absorption into the bloodstream due to digestion-related delays. This means that effects may not be felt as quickly as via other routes of administration after taking a dose and could be diminished when taken with food or other substances such as alcohol or recreational drugs. Is this delay such a huge deal though, in the context of antidepressants? Potentially. Those with experience or knowledge about how antidepressants work will know that, with most antidepressants, though time frames vary slightly depending on the type taken (i.e., SSRIs, SNRIs, TCAs, or MAOIs), typically, users only start to feel improvement to their symptoms after the first couple of weeks of consistent use, which can be understandably frustrating to some. So, what options do patients have, and are there other routes of administration for these antidepressants that could improve this delay? Alternatives to oral administration Intravenous (IV) infusion therapy involves administering drugs through a needle directly into a vein resulting in fast absorption, though requiring hospitalisation until the procedure is finished. For many of us, this technique is probably most associated with cancer-treating chemotherapy sessions, but it’s certainly not limited to it. The need for specialist staff, equipment, and facilities is associated with increased costs not usually seen with orally administered medications. The use of IV administration of antidepressant medication has long been an area of great clinical interest, with the primary rationale being the faster onset of action (i.e., how quickly the drug starts working in the body) compared to orally administered drugs. However, research suggests that this is only really the case depending on the drug. For example, ketamine has demonstrated great potential as an antidepressant, as discussed by Dr Naghmeh Nikkheslat in an article for Inspire the Mind. Research investigating the impact of the route of administration, comparing oral ketamine to IV ketamine, found that despite the typical advantages of oral administration (i.e., more convenient, and accessible), it also comes with greater risk of abuse by users due to that removal of a controlled environment. Though an oral form of ketamine for depression would be much more convenient for patients, this benefit doesn’t outweigh the fast action, high effectiveness, and high bioavailability (how much of the drug actually enters your bloodstream) of IV ketamine. Currently though, research on the practical real-world use of an antidepressant like oral ketamine over IV or intranasal (via the nose) is limited. Nevertheless, in the case of ketamine, oral is clearly not the “best” route, even though it may be with most typical antidepressants. The clinical utility of IV is definitely not something to ignore — yes, they aren’t as easy to administer as a simple tablet swallowed with water, often requiring a visit to the hospital, but at the same time, for many, injections are easily the preferred form. Likewise, alternative routes beyond oral and IV also show promise in successful administration of antidepressants and other mental health medications. Choosing the best route Multiple routes of administration are currently available for patients in the wide field of mental health, each with their upsides and drawbacks when it comes to efficacy, speed, delivery, safety, and convenience. Where ever possible, offering options between routes of administration along with all the information on their respective pros and cons to patients for whom, one route may be uncomfortable, unsuitable, or preferable compared to another could help massively improve patient drug compliance. Further research into patient preference and acceptability of various routes of administration for depression treatments is needed if we are to better understand the user’s perspective and what factors impact their choices. Ultimately, continuous communication between clinician and patient throughout the process of forming a treatment plan essential so that the most suitable personalised care is provided — and how medications are delivered to the patient is a big part of it.

We often consider mental health as a yes-or-no situation. You are either basking in the full light of well-being or you are trapped in the shadows of depression. You either see, hear, or taste things that aren’t really there (hallucinations), or you, well, just don’t. But is it really that simple? Can we neatly package mental health into distinct boxes with their own labels? And allocate each and every one of us to either one or none of these boxes…? Hello everyone! My name is Isabella Molnar, and I am a Master’s Student at King’s College London., and am currently doing an internship at Inspire the Mind. In this article, I want to talk about the shift from the categorical to the continuous view of mental health due to its enormous relevance in research, approach, and treatment. So, I am hoping to give you some insights into how mental health has been and most likely will be viewed in the future as well as encourage you to think about your ideas on this topic. The categorical approach has dominated the field of clinical psychology and psychiatry for decades, classifying mental health conditions into discrete categories, each with its own set of symptoms and diagnostic criteria. Yet, a growing body of literature has challenged this approach, emphasising the notion of a continuum approach, which assumes mental health lies on a continuum rather than being an either-or construct. The Categorical View The reason that the categorical view has dominated the field for so long is because it helps professionals identify those who need treatment (patients) and those who don’t (non-patients). Based on this approach, guidelines have been developed which state what criteria an individual has to meet in order to be diagnosed with a certain mental health condition. Without this categorical tool, it might be more difficult for professionals to exclude and/or include certain conditions in their diagnosis process. Besides being helpful for professionals, it has been suggested by research that some individuals might find it helpful to be able to "label" their experiences. It can be considered a relief, reassurance, and, importantly, a validation of their feelings and problems that goes beyond stress and adversity. A psychiatric diagnosis is not only helpful for some individuals, but also crucial in many legal, financial, and educational contexts (e.g., when seeking out disability support). Having a shared language can facilitate mutual understanding and communication in many of these contexts. You ‘have’ it, or you don’t. What’s so wrong with that? Disadvantages of the Categorical View The problem with the categorical view, widely criticised by academics, is that you can’t just neatly package mental health into distinct boxes with distinct labels. Mental health and illness are far too complex and multifactorial to be differentiated into a patient vs. non-patient model. Besides, even within the patient population, symptoms and experiences vary. Two individuals can receive the same diagnosis without sharing a single symptom. The categorical view has also been criticised by academics due to the high overlap across conditions (comorbidity). Patients often meet criteria for more than one condition, and there is even evidence to suggest that conditions even overlap genetically (for example, between panic disorder and major depressive disorder). Additionally, the patient vs. non-patient model can create stigmatisation. Individuals receiving a psychiatric diagnosis might experience negative connotations, myths, and misconceptions associated with the condition. Also, similar symptoms have been reported in non-clinical populations. 6-15% of the general population experience hallucinations — does this mean it should be considered a symptom of a conditions we have to uncover? Or does that mean we are all just on different positions on the continuum? In some cultures, hallucinations are also perceived as something positive, so maybe there should be a continuum for cultural beliefs and views? Lastly, individual symptoms are likely to change over time. Consider someone who is experiencing depressive symptoms, but then goes home for a week or so, and feels much better. Would we then say this person is not depressed anymore? Even though these diagnostics do consider time, I think it presents an issue. Individuals might think they aren’t struggling enough to seek help, or that you only need treatment, if you have been struggling for a long time. Therefore, the cut off points are not representative of the full spectrum of experiences. So, what can we do instead? The Continuum View There has been a lot of research investigating the potential shift from the categorical view to the continuum view. According to this notion, mental health conditions lie on a continuum. So, rather than either being a patient or not, experiences range from non-clinical, healthy functioning to problematic and severe mental illnesses causing distress. The position on the scale can shift as situations improve or deteriorate due to several factors (e.g., age, prognosis/progression of symptoms, treatment, formulation). What’s so good about it? The continuum view might lead to a reduction of stigmatisation, as we can appreciate that we all lie somewhere on the scale. It diminishes the idea of you are either mentally "ill" or you are "well" — which might be helpful for many people. It also might help normalising the discussion around mental health by emphasising the idea that no matter where on a continuum you find yourself and to what degree you are struggling: We all have mental health, therefore, we can all be part of the conversation!

Author's note: This story is about my experiences of finding social connection and belonging without overt social interaction, but by simply 'being' with others, no explanation needed. The story centres around an experience where I was 'allowed' to simply sit and be, and how rare an occurrence I noticed that to be. The bunting-draped hall bustles with animated faces, laughing and chatting with one another. Pockets of conversation bubble around the room’s seating and otherwise vacant spaces. I sit at an empty table, resisting the urge to pull out my phone and pretend to scroll. It's my least favourite part of my favourite night of the week - the tea break halfway through choir practice. Still inwardly gleaming from the catharsis of communal singing, I'd now love nothing more than for the ground to swallow me up, and spit me back out in about five minutes, preferably. I’ve been at work all day, at a job that I love. A job made up of smiling, and talking, and smiling, and talking. A job that I love. Kate, the choir leader, sits down across from me. I think this is the start of our first ever conversation, even though I’ve been coming here a while. My impression of Kate, from watching her interact with others, is of a kind person who knows herself - I like her. She notices that I'm staring into the middle distance and gently catches my eye. "Hey, how's it going?" Dread. Not the kind of dread that induces panic attacks or cold sweats, not a dread that can't be dealt with, but a kind of nano dread. The kind that bumps up against you while you're in the supermarket or on the tram, and wears away your edges. I should’ve pulled my phone out and pretended to scroll when I had the chance. But I didn’t want to look rude, or worse, ‘anti-social’. Everyone is so nice here. C'mon, I think, steeling myself. You must have some juice left. Otherwise why would you have come out? This is a community choir, for crying out loud. What did you expect, for everyone to coldly ignore your existence? A girl can dream. By this point in my life, I had become familiar with the term ‘social battery’, and was aware that mine is less Duracell Bunny, and more dodgy pound shop range, with limited use time on a single charge. Despite this, I have warm memories of sharing space with others, going as far back as I can remember. When my brother and I stayed at my grandma’s house on a Saturday, this would mean going to church with her on a Sunday morning too. Coming from an atheist household and attending a non-denominational school, these church visits were rare enough that they carried with them a sense of novelty and intrigue. My memory of these Sunday mornings consists of fragments from a world I hadn’t yet contextualised, with what I now know as religion - incense billowing from swinging metal, wide wooden benches beneath long narrow windows, the distribution of (what I could only assume were) big white chocolate buttons, and Vimto served from an ornate goblet. Words I didn’t understand, but that still gave me a sense of connection to the rows of peaceful (or maybe just sleepy) faces around me. Though I’m sure if given the choice, my brother and I would have likely opted to stay in our pyjamas watching cartoons on those Sunday mornings, there was something clearly lovely about the atmosphere in that church. A group of people coming together to face the same way at the same time, to share space and contemplation. Sitting in the pews, I remember the feeling of safety and belonging, being held by a group gathering for a common purpose, even if it was a purpose I didn't understand or share. Then we sang. Like the mass, the words were irrelevant at that point, but the chorus of worshipers to which I temporarily belonged resonated deeply. I was a fledgling learning to fly, somehow completely safe while stepping out of a comfort zone I previously didn’t know existed. I remember reading once about how birds fly in formation as a way of conserving collective energy, “positioning themselves in spots that were aerodynamically optimal” — allowing them to take advantage of swirls of upward-moving air generated by the wings of the bird ahead. I read that they would switch leaders periodically so everyone got a share of the trick’s benefits. There was something in that here. Amidst the reverberating chorus, I felt I was being carried through the air in some kind of effortless flight. This feeling harshly contrasted with the anxious pang I felt when everyone was required to turn to those around us, shake each other’s hands and say "peace be with you". Why did the words sound all jumbled up and why did we have to touch each other’s hands? Next followed an odd queasiness while hanging around the exit as my grandma laughed and chatted with other churchgoers. “Aw, you’ve come with your granny today!” says a lady with dangly earrings and expectant eyes. I look blankly past the lady, unsure if this was a question or not. Too long passes. I missed the beat. If singing was effortless flight, conversation was its trickier cousin - a dance with steps to be learned over time. Though I could sense that these interactions were an important part of my grandma’s church experience, I would have happily done away with them in favour of more incense, more simply smiling faces, and of course, more singing. Education brought similarly conflicted feelings. I did have friends, and I understood that spending time with them was an important part of the whole school thing. But if I’m really honest with myself, I felt much more at peace behind a desk with a textbook in front of me; focused on absorbing information in the way that only really works when surrounded by others who are doing (or at least meant to be doing) the same. This is something I tried to emulate in cafes and libraries as I got older, with varying degrees of success. I appreciated that the classroom was, for the most part, a safe, boundaried space, with all minds directed to the same central point, towards the same central goal and clear rules on when and when not to speak. The playground, by comparison, was a wild west of confusion and unsettlement. I was not an athletic kid, so steered clear of footballs and skipping ropes, to which the alternative for girls was to ‘walk and talk’ around the perimeter of the yard. The walking was simple enough, the talking less so. This is where I first remember realising that there was clearly some choreography to this dance, but the steps weren't at all clear. What's more, the stakes felt unfathomably high - a misstep could cost you a lot. To save confusion I would follow someone else’s lead who presumably had been sent a copy of the playground rules, including what to say and when, but that wasn’t always enough to protect me. In case you don’t remember school, or haven’t seen the 2004 cinema classic - girls can be mean. I often spent lunchtimes orbiting dinner ladies for solace, and feeling very much like I was doing playtime wrong. Occasionally these two vastly different elements of school life would collide, such as on ‘Bring a Toy to Class Day’. One toy day, a two-headed girl walks over to me. As she approaches, I see that she is actually two girls walking side-by-side, arms linked - I assume they’d just finished a lap of walking and talking, and had not yet disentangled from their conversation. “That’s not a toy.” One of the two girls’ four hands points at the crayons and colouring book spread out in front of me. The classroom is filled with noise and movement, I am still and silent. If my brain had worked more quickly, I could have taken a look around the room at the Twister, Mousetrap, and Operation and pointed out that technically, none of those were toys either, they were games. I thought the word ‘toy’ in ‘Bring a Toy to Class Day’ could be generally understood as any item that you find enjoyable to engage with and that others might too, but the name ‘Bring Any Item That You Find Enjoyable to Engage With and That Others Might Too to Class Day’ was just a bit wordy. Instead, I just did the first bit and looked around the room at the Twister, Mousetrap, and Operation, and all the other toys and games brought in by the rest of the class. The two-headed girls, presumably bored of my silence, had slipped off, still linked. There was something I could intuitively feel, but hadn’t yet found words for in my brain. All of the other items I could see in the room invited others over to ask questions and give answers, make plans and negotiate team names and characters. They were conversation starters - conversation commanders. A colouring book spread out in front of you doesn’t need any of that. To join in, you just pick up a crayon and start. In fact, no words need be exchanged at all, provided those taking part are either a) sufficiently skilled at colouring to be trusted not to ruin the picture, or b) sufficiently chilled to be trusted not to shout at the child ruining the picture. Thankfully, I was both sufficiently skilled and chilled, so there was never an issue. Also, most kids preferred playing Twister, Mousetrap and Operation to colouring in. Their loss. Though I was alone in the corner of the room, I didn’t really feel left out. I liked the outer edges, I had a better view from there. I wanted to be in the room, but my feelings around other kids getting involved in what I was doing were neutral at most. Despite that, I once again had the feeling that I was ‘doing it wrong’. I felt embarrassed about my colouring book. In my high school, there was a room called the Rubicon. At the time, this name meant nothing more to me than a type of juice. Having since learned that the phrase to ‘cross the Rubicon’ means ‘passing a point of no return’, the room’s name seems even more bizarre, and actually, borderline sadistic. It was isolation-based discipline - which, for most kids I knew at the time, was the worst conceivable punishment for bad behaviour. It had office cubicle-style boards up around each desk, a nod to a future we were either being pushed towards or warned of (I’m still unsure which). I was put in the Rubicon one day for forgetting my blazer. I don’t remember particularly liking or disliking my time in there. I was likely more preoccupied with how odd, as well as wholly unjust my being punished for this reason was, and feeling mortified at being lumped in with ‘the bad kids’ for the day. Weird name and prison-parallel punishment aside, something like the Rubicon would have actually been great during high school - a space to just sit and decompress, to pause all the voices for a bit. I could have kept “forgetting” my blazer for another chance to sit unquestioned in a quiet space, but I wasn’t a rule breaker, I wanted to do things right. After school I’d slump wearily onto the sofa and hide behind my curtains, pretending not to be in when my friends knocked on the door for me. The idea of seeking yet more interaction with the people you’ve just spent six hours talking to, and will be seeing again the very next morning was, to me, bizarre. As I got older, I got better at the conversational dance, through imitation and a lot of missteps. I even got quite good at it, eventually. My moves became more natural as I built my strength, and increased my flexibility, balance, and coordination around difficult topics. But more than my own proficiency, I came to understand the value of this dance to others. I learned that the act of extending a conversational hand out to someone, whether it be for five minutes at a bus stop, or three hours on a train platform, could have a profound effect on all participants. Substituting toy-filled classrooms with cafes, kitchens and beer gardens, I began to find myself once again still and silent in spaces filled with noise and movement. But this time, I wasn’t alone. Through my stillness and silence, I’d inadvertently created space for people to come and share something of themselves, their experiences, perspectives, joys, fears, hopes, hesitations... and it was fascinating. People are some of the weirdest and most beautiful creatures I’ve ever come across. I came to be known as someone who was “easy to talk to”, and I liked that. I knew how difficult conversation could feel, so making it easier for others was something I was very happy to do. I even ended up in a career that’s all about talking. Paradoxically, the social dance I’d struggled so hard to understand and improve at was becoming one of my biggest strengths and keenest interests. But that didn't change how tiring dancing all day is. Fuelled by a combination of fear of missing out, people pleasing, and genuine desire for human contact, a dodgy pound shop battery-powered pattern emerged. I became a yes-woman, accepting any and all invitations that came my way. Not just from friends, acquaintances and colleagues, but newsletters, events listings and flyers. My Google calendar looked like a badly played game of Tetris, colour-coded blocks slotting into any space they could find. Meetings, workshops, catch-ups, check-ins, coffees, lunches, drinks… followed by tear-soaked duvet-cocooning, feeling only able to say “I don’t want to do anything”. At times, feeling like I didn’t want to be anything. I counted myself lucky that I can sleep so easily. I used to say sleeping was my superpower, though in reality, it’s more of an ongoing battle to stay awake. However, I’d then wake up from 14-hour naps feeling less than rested, and more than ashamed. As soon as my energy stores began to replenish themselves, I’d get the calendar out and start depleting them all over again - now I really was obliged, to make up for the time I’d missed while in cocoon mode. The cycle continued, but along the way, I was developing strategies to protect my social battery while getting the communal experiences I craved. Early on, I found a neat little hack, a way to game the system. I’d seek out places I could easily slip into unnoticed and soak up the atmosphere like a scavenging social freeloader, hanging around the buffet table at an event I had no invite for, or cleaning up at a potluck I’d brought nothing to. The first time I went to the cinema on my own was a revelation. I was doing something, I was out in the world, but between the silhouetted heads I sank lazily down into the plush seat, with a warm feeling of comfort. I could rest that part of my brain that at this point, would normally be wondering if anyone minded that the person I’d come with was talking to me through the trailers. However actually, I minded, because the trailers are my favourite bit. Cinemas, libraries, cafes, parks - some of my most cherished spaces to be alone with others. Public transport. I spent my 30th birthday alone on an especially nice bus route with a flask and a Spotify playlist. Being able to silently slip into a crowded environment without turning any heads, inviting any greetings or prompting any questions brings me deep comfort. The non-reaction says wordlessly, "you belong here, and there is space for you". A privilege I know lots of people do not have in many spaces. A nameless fellow runner at a recent Parkrun event (another great place to be alone with others) summed it up when I overheard him saying to his friend: “being in the crowd takes the pressure off”. Exactly. I thought back to the birds flying in formation, reducing air resistance - taking the pressure off. This feeling was a treat, but a treat I had only ever granted myself. By this point, I’d become pretty good at looking after myself and my social battery. I came to know my ‘drainers’ - the things that would flatten my battery fast. And I also knew my ‘sustainers’ - the things I knew helped. At the top of this list was singing, something I’d kept with me since going to church with my grandma as a child. There is always a song in my head wanting to get out. Any moment I can snatch, to belt it out in the kitchen while the house was empty, or whisper-sing it at the back of the bus, provided a bit of lightness that I could save up and use when I needed it later. So it was with caution that I signed up to join a community choir. I considered that the social aspect, combined with it directly following a workday, might make it more of a drainer than a sustainer. But there were no auditions to join, and no minimum attendance, so I didn’t need to worry about letting people down on unexpected duvet cocoon days. The first time I sang with them was pure joy. I was back in church, only this time I wasn’t a fledgling. I was in full flight, simultaneously carrying and carried by the flock. My voice was strong and the words made more sense this time - we were singing Beyoncé. I had to go back for more. That feeling was worth being drained. I felt guilty thinking of people as ‘drainers’, especially these choir members, who all seemed so kind, intelligent and interesting. I felt lucky, and wholly inadequate. In the sessions that followed, I met some brilliant people and gave some subpar conversational performances. But more often than not, when we weren’t singing, I just wanted to sit out of the way and rest the internal machinery that makes conversation happen. I was aware that that might not be what you’re supposed to do here, and maybe I was doing things wrong again. Back in the bunting-draped hall, as Kate the choir leader sits down across from me for what might be our first ever conversation, I wonder if that’s what what she wants to say to me. Maybe she wants to “have a little chat” about how I’m fitting in here, and if I’m not going to “get involved” then maybe this isn’t the choir for me. "Hey, how's it going?" The time in between Kate’s first and second sentences is less than a second, less than a breath - but perhaps enough time to see my thought process whirring into life. Before I get a chance to roll out my best-and-most-polished "Oh hey, I'm great thanks! How are you?", she says casually, with what I interpret as a knowing smile, something nobody has ever said to me before. “No worries if you don’t feel like talking.” The words bounce out of her mouth so effortlessly, I almost don’t catch them. Okay, so it was nothing especially earth-shattering, and it sounded so commonplace once she’d said it. Except it wasn’t. For all the times I’ve been asked some version of ‘what’s wrong?’ for being quiet, I cannot recall being actively assured that my silence was, rather than an indication of some emotional deficit, a scathing review of the event I’m at, or an affront to those around me, actually, totally fine. Just neutral. Just me, at that moment. The nano dread begins to dissipate. I want to respond to Kate’s kindness with an apology, an explanation, a justification. “Oh no, sorry, yeah, I’m just knackered sorry, just finished work and my head’s a bit... sorry, how are you?” Except I don’t. Instead, I proffer a grateful smile and then, blissfully, nothing.

As a person with insomnia, I often have trouble falling asleep and have always wondered why I feel cranky after a night of only a few hours sleep. Most people, at least once in our lives, will have experienced the sense of irritability and nervousness after a sleepless night, especially in case of a subsequent busy day. During my degree course in Health Psychology, I studied the relationship between cognitive and emotional factors, as well as behavioral variables, such as sleep quality, and clinical variables like depression and anxiety. Therefore, my background in this field led me to ponder on the link between our emotions and the previous night's sleep. Although the precise functions of sleep remains elusive, evidence shows that sleep disturbances and sleep loss might have a crucial role in multiple domains of our affective functioning, which includes emotion, emotion regulation, emotional intelligence, emotional memory, and facial recognition of emotion, and I aim to discuss by introducing the concept of the Cognitive Energy Model in this article. Emotions, mood and emotion regulation It is first important to define the difference between emotions, mood and emotion regulation. We use the term “emotion” all the time and what often comes to mind is something like anger, sadness, or happiness, but all these instances have different components. In fact, when we talk about emotions, we refer to the subjective aspects of our experiences, which are reflected as either positive or negative feelings. Therefore, we describe happiness as a positive emotion, while anger as a negative one. In addition to that, emotions have a behavioural component because they are displayed on facial expressions or through behaviour. They also have a physiological component represented by bodily responses such as change in blood pressure or sweaty palms. Thus, emotions could be defined as the connecting point of these subjective experiences as well as behavioural and physiological responses. When it comes to the difference between emotion and mood, the latter is described as a longer-lasting state of mind that could persist hours to weeks. Moreover, emotions are caused by specific events so that a person is happy about something, angry at someone or afraid of something, whereas mood isn’t always associated with a specific and clear cause. Finally, emotions usually have a high intensity, whereas mood has a lower one. When talking about emotion regulation, this could be defined as the process that takes place every day when we try to modify the emotions that we feel, how we express them and how they affect our behaviour. For example when we feel grumpy in the morning but we have to be kind with our colleagues or friends, or when we feel down but we need to attend our best friend’s birthday party. In both situations we try to change and modify our bodily and emotional responses in order to keep up with our schedule. The relationship between emotions, emotion regulation and sleep loss Research shows that the relationship between emotion, emotion regulation, and sleep loss might be bidirectional. This means that not only can poor sleep take a heavy toll on affective functioning, but also a daily affective state can affect the quality and duration of sleep. For example, experiencing a sleepless night can make us feel grumpy or cranky in the morning. Even being nervous or broody can disturb our sleep. Although this phenomenon may be something we all encounter at some point in our lives, its causes and underlying mechanisms are not fully understood. Several studies demonstrated how major long-term sleep disturbances are associated with more persistently negative emotions such as irritability, anxiety and nervousness, whereas higher levels of positive emotions, such as tranquillity, happiness, and a good mood, are connected with better sleep quality, as perceived subjectively. The Cognitive Energy Model Zohar and his team proposed the Cognitive Energy Model in order to explain the link between sleep loss and negative emotions. Cognitive Energy is an important resource because it allows us to not only regulate and sustain our actions, but also to apply emotion regulation to our experiences. Cognitive energy is the element that helps us perform everyday tasks, as well as concentrate on our work and socialise with people and friends. It is the ingredient that enables us to achieve our goals while also dealing with the unforeseen (when we perceive it in trouble). Cognitive energy is extremely important because it has a crucial role in our lives even though it’s finite, rapidly consumed and slow to recover. Cognitive energy is supposed to be linked with sleep because during the day we consume all of this energy in our daily activities, and it is then recharged during our time asleep at night. For this reason, and according to this model, sleep loss reduces cognitive energy supplies for our activities, leading to impaired performance, frustration, and irritability because we are not able to do what we have to do during our daily life. In addition to that, the lack of availability of cognitive energy holds us from regulating negative emotions and it can even exacerbate them. Why the Cognitive Energy Model is linked to sleep loss Everyday life is full of affective events, situations or circumstances that provoke emotional reactions in people (for example, an argument or receiving good news) and that require a change of plans, along with regulation of behaviours and emotions. Unless the available energy resources match the demands associated with our activities, this misfit will be assessed as a threat, resulting in negative emotions such as irritability and nervousness. So cognitive energy is a very crucial element within the relation between sleep loss and negative emotions. This construct helps us to better understand the reason why after a sleepless night we experience more negative emotions like frustration and nervousness.

I moved to the UK around 9 years ago for education, and recently started my PhD in neuroscience and immunology, looking at how the brain and immune system interact during development. I feel that my interest in this topic is partly due to my experience growing up, and my mother’s experiences of mental health and motherhood. I come from a high-pressure, nuclear family, with a father working in IT, a stay-at-home Mom for most of my childhood, and an older brother. I have always felt that all of us experienced some mental health difficulties without knowing what they were, and without much support because mental health problems are largely ignored and not considered ‘real problems’ in our Eastern European culture. Growing up in this environment led to my interest in mental health, with the hopes of processing what happened in my childhood, understanding family dynamics, and finding a way to move on to healthier interactions. During my childhood I noticed my Mom went through periods of depression, struggling to cope with her family relations, my father’s family, and our own family unit, which was difficult for all of us, as she has always been the person that made our family feel cohesive. I have always been interested in my mother’s experiences of raising us children, as it seemed like her relationship with my brother was quite negative from the start. Growing up, I remember my brother’s outbursts of anger most vividly. When he was angry, he would become aggressive and struggle to regulate his emotions. Though his anger has subsided, he still has issues understanding how to cope with strong emotions and this greatly affects his relationship with our parents. I would frequently ask about our mother’s experiences of mental health and motherhood. Initially, I was convinced that she had suffered from postpartum depression, which is experienced by around 1 in 10 women in the months following birth, and is characterised by the presence of low moods, being very tired, having issues with sleeping, feeling tearful, and having problems concentrating. This may have been the catalyst for the negative interactions with my brother early on. My mother mentioned that she felt powerless when my brother was born, and very scared. She had very little support as her family was away and my father was not allowed in the birthing room, as was customary at the time. Once born, my brother was constantly crying and my Mom found it difficult to transition to motherhood. She remembers not feeling like herself, struggling to take care of herself, struggling with sleep, being more aggressive, and irritable, and having quite severe problems with her memory in the months after birth. All of these symptoms seemed to align well with what I had learned about postpartum depression. However, when I asked about her mental health and how she was feeling at the time, she did not refer to feelings of depression, but more so ‘being overwhelmed’. When asked if she had ever been depressed, she said that she had felt sad in the past but did not even think she experienced mental health issues. She did mention that after a bad break-up in her early 20s, she developed some physical health issues. The break-up was so difficult that she moved back in with her parents and missed out on her university exams, but she still did not think that she was depressed. Other people would likely accept these episodes as having mental health difficulties; however, she did not describe her experiences as more of a ‘struggle’ or being ‘overwhelmed’. This type of mentality is very common in Eastern Europe; however, this was the first time I noticed it so obviously in my mother. Although it seemed as though she had a history of mental health struggles and found motherhood very overwhelming, it is very difficult to say whether she did or did not experience postpartum depression. As mental health was and still is a difficult topic of discussion, and much more focus is put on the physical health of children than anything else, she did not receive any diagnosis or support. She did not seek out these things either. She was very certain that she was going to do it all by herself as if accepting help was a failure on her part. Things became harder for her when I was born, a year and a half after my brother. She struggled even more. She felt alone and trapped, at times running out the door to escape what she perceived as a cage, as soon as my father came back home from work. When I asked whether motherhood ever felt natural to her, she replied that it never did. It never became more intuitive, and she always struggled with being a mother, which was hard to hear. For me, understanding my mother’s mindset about mental health has been very helpful but it is still difficult to understand what she actually went through. It is impossible to untangle the effects of societal ignorance of mental health in Eastern Europe, the lack of support for new mothers, the lack of psychologists or the opportunity to receive a mental health diagnosis, my mother’s refusal to seek support, and how all of these factors affected her relationship with motherhood and my brother. However, talking to her made me realise that mental health awareness and postnatal care for mother and child needs a dynamic reform, with significant emphasis on emotional support and regulation. This would hugely improve the mental health of new mothers, enable healthy emotional development and bonding in their children for future generations, and ultimately prevent negative relationships between parents and children from forming.