Since the emergence of social media, debates have been consistently sparked about the line drawn between moderate use and a concerning degree of disengagement from real-life interactions. The most recent social media phenomena that begs this question is TikTok's ‘bedrotting’ trend. ‘Bedrotting’ involves users spending extended periods of time using social media, sleeping, eating, watching TV and other inactive hobbies in bed, perhaps paradoxically under the pretence of actually enhancing mental health. To many who have embraced it, 'bedrotting' is a form of self-care offering a reprieve from the stresses of everyday life. When we examine the social media aspect of ‘bedrotting’, the question arises as to whether social media has a positive impact in this context. A recent study from Neyshabur University of Medical Sciences described the positive effects of social media which included “accessing other people’s health experiences and expert health information, managing depression, emotional support and community building, expanding and strengthening offline networks and interactions, self-expression and self-identity, establishing and maintaining relationships.” However, concern has been expressed at the potentially unhealthy levels of isolation and disconnection involved in ‘bedrotting’. The aforementioned study also found the negative implications of high social media usage included “anxiety, depression, loneliness, poor sleep quality, poor mental health indicators, thoughts of self-harm and suicide, increased levels of psychological distress, cyber bullying, body image dissatisfaction, fear of missing out and decreased life satisfaction.” In addition, while 'bedrotting' may pose several negative impacts on mental health, its effects on physical health must not be disregarded. This can be attributed to the sedentary lifestyle promoted through ‘bedrotting’ which can lead to reduced physical activity and compromised sleep quality. To better understand the both positive and negative impacts of ‘bedrotting’, I reached out to a 19-year-old ‘bedrotting’ enthusiast from Chelmsford named Ed. Ed has been practising ‘bedrotting’ since he started his new online job this summer. His typical day starts at 8:58 am, just two minutes before he opens his laptop to start work. Apart from a lunch break, his workspace remains his bed until around 6 pm. If he's not going out with friends in the evening, he usually stays in bed until the end of the day. Ed is a regular 'bedrotter' usually practicing from Monday to Friday, and he admits that the frequency of his practice has increased since he started working. Interestingly, he views this lifestyle as advantageous. To him, the comfort of working from his bed feels beneficial. "Getting paid to work from my bed [has] been pretty great," he told me, asserting that he can deliver the same quality and amount of work from his unconventional and cosy setup. However, in spite of Ed’s praise of ‘bedrotting’ he does concede that the lifestyle affects his motivation levels. He admits to feeling less driven while working from bed compared to when he goes into an office setting. Despite this, he keeps a regular sleep schedule, sleeping every day for 8 hours from 1 am to 9 am. When asked about the effect he believes ‘bedrotting’ is having on his social relationships, Ed explains that the potential isolation from 'bedrotting' is mitigated by his active social life outside his 'bedrotting' hours. He goes out as much as he stays in bed while awake, maintaining a balance in his life. Ed's interview afforded me a valuable new perspective into the nuanced reality of 'bedrotting'. It showed not only the allure of this emerging Tiktok trend but also its disadvantages to motivation. Most notably perhaps, it demonstrates the possibility of practising ‘bedrotting’ without affecting one’s perceived mental health levels. Initially, I thought of 'bedrotting' as an inherently detrimental practice to mental health, given its sedentary and isolated nature. However, Ed's story shows that for some, 'bedrotting' can be intergrated in a more productive way into people’s lifestyle. Whilst it's crucial to note that this does not eliminate potential concerns for others, the variation in experiences and responses to 'bedrotting' are a testament to the complexity of this trend. This serves as a reminder that moderation, social balance and personal context are vital when partaking in trends such as ‘bedrotting’. Having said this, 'bedrotting' is not simply a trend on TikTok that we will eventually see become extinct. It's becoming a cultural phenomenon that is influencing the way that particularly Gen Z and even some millennials live. This shift in behaviour demonstrates a larger societal change towards remote work and social media consumption, which have been exacerbated by the COVID-19 pandemic. It is a lifestyle that will most likely become more prevalent as new technology such as the recent Apple Vision Pro (expected to be released in 2024) will enhance the convenience and appeal of 'bedrotting’. The reason I think the Apple Vision Pro will particularly cause ‘bedrotting’ to become more popular is that it is set to offer a ‘high-quality immersive experience’ that can be used from the comfort of a bed. The device will also have features that support work, entertainment, and social media, meaning it may further blur the lines between the physical and digital reality, potentially causing 'bedrotting' to be the new norm rather than a brief fad. Throughout the Gen-Z generation, the traditional separations between work, entertainment, and rest time are already becoming blurred in a way that is increasingly accepted and normalised. Despite the convenience of this trend, that seems so appealing for many, questions must be asked on a larger societal scale about whether merging our offices, bedrooms, and entertainment centres is a good idea. If this is the direction that we are heading in, we may face issues such as potential generational divides surrounding the differences in personal and professional boundaries. As we ponder these questions it becomes ever clear that the impact of 'bedrotting' extends far beyond a few individuals on Tiktok, as rather it outlines our changing relationship with technology and space during this digital revolution that we are currently living in. In conclusion, 'bedrotting', isn't the straightforward Tiktok fad as I had initially assumed it to be. Whilst in theory it is neither negative nor entirely beneficial, it is clear that more people need to look into this lifestyle as I found that since writing this article very little to no work has been done on this. While the charm and perceived benefits of 'bedrotting' are appealing, such as the ease of working from one's bed, the negatives are not to be dismissed lightly. As a member of Gen-Z myself, I often find myself having conversations with friends talking about how our attention spans aren’t what they used to be, largely due to Tiktok and other forms of social media. The key word for me in this entire subject is ‘convenience’ as we have the ability, through watching TikToks for example, to find unlimited amounts of entertainment, as the feed quite literally never ends and you can keep scrolling until you find something that interests you. This will affect our attention spans in all facets of life as things that previously seemed normal become more tedious and difficult to cope with. Examples of this cited by friends of mine are things as mundane as waiting for a bus, reading, queuing and much more becoming almost painful to our overstimulated brains. I predict that we will continue to see increased diagnoses of depression and ADHD as bingeing social media content for extended periods of time becomes common practice. The 'bedrotting' phenomenon serves as a warning that digital trends redefine our lifestyles, posing challenges we must address for the sake of our future mental and physical wellbeing. References Sadagheyani, H.E. and Tatari, F. (2021), "Investigating the role of social media on mental health", Mental Health and Social Inclusion, Vol. 25 No. 1, pp. 41-51. https://doi.org/10.1108/MHSI-06-2020-0039 Ra CK, Cho J, Stone MD, De La Cerda J, Goldenson NI, Moroney E, Tung I, Lee SS, Leventhal AM. Association of Digital Media Use With Subsequent Symptoms of Attention-Deficit/Hyperactivity Disorder Among Adolescents. JAMA. 2018 Jul 17;320(3):255-263. . doi: 10.1001/jama.2018.8931. PMID: 30027248; PMCID: PMC6553065.

Exploring mental health through art In this article, I share some of my learnings from taking part in The Big Anxiety festival in Melbourne as part of an action research trip funded by Arts Council England. For the past 20 years, I’ve been working at the intersection of arts and mental health, starting with my own experiences and subsequently those that I work alongside in participatory settings. In the autumn of 2022, I sidestepped the British winter, arriving into spring and summer in Melbourne, heading down under to undertake a period of action research into arts and mental health. Discovering photography as a young person myself enabled me to express feelings visually when I lacked the verbal vocabulary and confidence to speak. At the onset of my mental health difficulties, I struggled to understand and express what was happening as I descended into chaotic thought patterns and behaviours. Photography has supported me to stay tethered to the world around me, to process life experiences and connect with others, both then and now. My own experiences with arts and mental health have led me to work as a professional artist specialising in the Creative Health sector. No one week is the same as I deliver creative participatory projects with community groups, produce work for galleries, support other artists through my non-profit organisation Arts & Health Hub, and use my lived experience in advisory and consultancy roles. Arts & Mental Health in Melbourne In 2019 I was fortunate to work at The Big Anxiety festival in Sydney, Australia’s biggest mental health festival focusing on people, arts and science. This time around I was invited to work at the festival taking place across October 2022 in Melbourne. My trip included various activities from speaking on panel discussions to delivering workshops on suicide and grief and supporting artists to think about the complexity of working in arts and mental health. Mental health has historically been a difficult topic to talk about. What’s inside us, as opposed to our physical health, can be hard to describe, hard for others to see and hard to understand. As part of the festival, I ran sessions alongside other artists with a range of lived experiences as part of a programme called Awkward Conversations. In these sessions, members of the public could book a 30-minute slot to ask questions about topics they would usually avoid or find too uncomfortable. In my sessions participants started by selecting a singular image from my archive (a selection of images were laid out on the table) which we then built a conversation around. At points in our chat, they would add images to the narrative. Our conversation, rich in a tapestry of questions and comments about individual lives, ended as a series of images that represented our journey together. Working with images made it easier for people to ask questions about otherwise avoided subjects. I also participated in the festival’s event The Big Anxiety Forum - learning from lived experience, bringing together 2 days of talks and workshops that explored and celebrated the complexity of lived experience. In my own workshop, I screened an intimate film of mine, to bloom, that explores my own suicide attempt through the words of my mother, and my mother’s death through my words. Following the screening, I invited participants to write short stories about their own losses: deaths, job losses, or the loss of the option to have a child. People generously shared these stories with some participants returning the next morning for me to film their lips, as I had filmed my mother’s, recalling their words. It was a deeply powerful process for participants and myself to share and bear witness to each other’s stories. During the Forum event, we also held a long-table discussion on suicide, designed to support anyone in the room to talk uncensored about their experiences. I was struck by how we censor an individual's experiences in spaces where any potential distress feels impossible to manage. People openly shared their stories not to seek solutions but to find acceptance and validation with like-minded peers. I was touched by the range of language that was used to describe distress, reminding me of the importance of recognising the diverse ways in which differing cultures express mental turmoil. On my trip, I learnt a great deal about the cultural complexity of Australia, its painful and violent history of colonialism and the treatment of indigenous peoples. I left the event acknowledging that distress does have a place in our lives. It isn’t to say that we should invite it into our lives, but there is value in walking towards it, with all its learnings, instead of turning our backs on it and pretending it doesn’t exist. In recent weeks I’ve discussed the efficacy of trigger warnings, not only on pieces of art, but also on people’s experiences. Care for Artists in Creative Health Sector Alongside the privilege of being able to share in these rich and valued experiences, I was also reminded of the role and act of care for artists in this work. Whilst out in the Dandenong Ranges I delivered a workshop at Burrinja Cultural Centre for local artists on how to work on arts and mental health projects. Many of the provocations shared were around care - both individual and collective care. How can artists take care of themselves in this work, when so many of them come into the field because of their own lived experiences? What support is available to artists working with distressing content? How do artists know what support they need? There are a growing number of artists who have the drive and passion to do the work, but what infrastructure is in place to support their own wellbeing? I found that The Arts Wellbeing Collective (an initiative by Arts Centre Melbourne) has been doing interesting work around workplace mental health within the performing arts. Some of these issues felt a little more developed in the cultural context of the UK which has more formalised ways in which artists can work within health settings, namely through social prescribing. Many people that I mentioned social prescribing to on my trip had not heard of it before. Whilst there are guidance documents for artists (such as the Good Practice Charter by Artists Union England), aspects of care and support are very much a hot topic right now. In 2022 the Culture, Health & Wellbeing Alliance’s report From Surviving to Thriving acknowledges that approximately 40% of artists working in arts and mental health come into this work through their own (or close family/friend’s) lived experiences. The Alliance is now developing a Creative Health Quality Framework. My own organisation is delivering a 3-year project called the Support Hub across London, Manchester and nationally online, offering programmes of support for artists that work across the Creative Health sector. These include funding for clinical supervision for artists working in challenging environments and mental health support for artists with lived experience. Awe I decided to take my own work around care, space and rest seriously by adding time to my trip to travel around South East Australia and New Zealand, to fill up my awe tank. One of photography’s benefits for me is enabling me to document experiences of when I feel small and part of a much larger existence. For me, that is often being in expansive landscapes that allow me to put my worries into perspective. I like to walk for hours and document the beauty of nature, big or small, as it brings me closer to being present. Taking time out, whether it’s an hour for a walk or extended time off to process big life events has become really important for me to be able to sustainably do the work that I do.

‘Ted Lasso’ is an award-winning show that tells the story of an American-football coach hired to manage AFC Richmond, a British football team (or soccer, as the Americans call it); and what he lacks in knowledge of the sport, he makes up for in optimism, determination, and teamwork (…as well as some great biscuits and a whole lot of laughter). Whilst Ted Lasso is not based on a true story, it’s incredibly relatable and certainly draws from many real-life inspirations. From navigating relationship struggles to pushing oneself outside of the comfort zone and dealing with all the little complexities of life, the show has something for everyone. Throughout the series, Ted’s motto revolves around believing. “Believe” is a keyword to the “Lasso Way” and was originally meant as a simple expression that AFC Richmond players could use to pull themselves out of their very mediocre position in the Premier League. Yet, as the show continued, and as season 3 launched last week, viewers started to understand its application to the players’ off-pitch lives. Beyond football games, the show has tackled many mental health issues in its storyline thus far, especially through its main character, played by actor and comedian Jason Sudeikis, the devoted coach who seeks psychotherapy after dealing with panic attacks. "In regard to the mental health stuff", Sudeikis told US Weekly in 2021, "it was just there. It’s been there forever, but it’s really come up a lot in just knowing where the characters were headed and how important it is to work on yourself to help your team. And I think that we were trying to explore that, and personify it in a way of a trojan horse, showing that there are bigger issues in this fun, silly little comedy show." "People have really responded to that,2 Sudeikis continues. "Myself and other people in the cast, especially the writing staff, get messages daily from people thanking them for really opening their eyes to what it means to go to therapy and what it means for someone in their own life to go to therapy. Just speaking about these things and taking the stigma off of any form of health, whether it be nutrition or mental, emotional health." The White House Invitation Ted Lasso has captured so many viewers' hearts, has tapped into every emotion and has reached every established newspaper, to the point where US President Joe Biden personally invited the cast to the White House. Mental Health is part of Biden’s bipartisan “unity agenda”, calling for lawmakers to direct more resources towards supporting mental health. His administration has also increased funding for a professional emergency helpline and has requested counsellors to be added to schools, making sure Americans know about their options and addressing the mental well-being of all citizens. During his speech, Sudeikis united the room, saying: "no matter who you are, no matter where you live, no matter who you voted for, we all probably, I assume, know someone who has, or has been that someone ourselves, that's struggled, that's felt isolated, that's felt anxious, that has felt alone”. He continued, "It's actually one of the many things, believe it or not, that we all have in common as human beings”, encouraging the public to speak up and take action. ‘Ted Lasso’ is More than Representation The show’s portrayal of anxiety, panic attacks, trauma and treatment make it one of the few times that TV has not only been accurate but has made a real impact in the community. There are various pivotal moments throughout the seasons where Ted experiences panic attacks, causing him to run off the pitch after a game or abandon a karaoke night with his team. These experiences ultimately push the character to acknowledge that he needs help, to which he sets up an appointment with team psychiatrist, Dr. Sharon Fieldstone, in the final scene of episode 6, season 2. De-stigmatizing mental health through a show beloved by many, about a sport, which too often doesn’t leave room for self-expression, can help the viewers identify the signs of someone struggling and could potentially conquer any doubts fans may have about therapy and help. Soccer, or football, as many viewers would prefer to call it, has often been used as a tool for social change, especially throughout townships and disadvantaged rural areas. In many countries around the world, football is the most diffused sport and has a very important role in social change, seeking to help at-risk youth, creating communities, and building relationships. However, even though staying active releases endorphins, serotonin, and dopamine, which help promote happiness while reducing stress and anxiety, football has been associated with restrictive norms of toxic masculine behaviour that are harmful to all men and to the sports community. These traditionally include masculine ideals of behaviour, such as male dominance, emotional repression, and self-reliance, which in turn can promote aggression and superiority at the expense of emotional expression – a stereotype that coach Lasso combats at every training session. Ted Lasso', both the character and the show, have shone a light on the joys of football, while never glossing over the very real and important struggles of fans, coaches, owners, and players. As a fan of the show and an ex-varsity football player myself, and an advocate for mental health, I believe that the reach and impact of this show is a clear indication that this conversation is only the beginning. It is now time to think about how we can use sports to communicate mental health and its struggles to younger generations, so that we can collectively help each other, for the well-being of everyone around us.

I’m an English instructor, so of course I’ve had the opportunity to teach horror writer Shirley Jackson’s legendary short story “The Lottery.” Though she is best known to readers as the author of The Haunting of Hill House — now adapted into a popular Netflix series — she is best known to academics as an ample opportunity to spook their pupils. What most teachers relish is the students’ aghast reactions when they reach the ending of this 1948 gem. I did relish it; introducing students to shocking and controversial literature is one of the many joys of my profession. But what “The Lottery” also did for my high school English-Lit program is allow myself and my pupils to segue into some uncomfortable, but enlightening, conversations. Mainly about the mental health of its exalted author. “Shirley Jackson mistrusted her own community,” I remember explaining during my brief lecture that preluded the class’s general discussion about the story. I make it a point to do a sort of psychological study into the background of each author we study, to give the students some insight into the inspiration and construction process behind each text. “It’s reflected in her work. It’s all too easy for the townspeople to turn on one person when it’s convenient for them. Or when they believe it’s necessary for their community’s survival. Sacrifice one to save all the rest, so to speak.” “Was Shirley Jackson scared of people?” one of my students asked me. It was the perfect question, and one that I was expecting. Never in my career as an English teacher have I encountered an author whose work had such overpowering misanthropic themes. I was glad to see that my students picked up on that, as I’d hoped. It showed they were making a conscious effort to understand the author, and why she dedicated her career to shining such an unflattering light on the darker side of humanity. “She was,” I answered, with a confirming nod. “And for a time, she was scared of everything. Shirley Jackson had agoraphobia.” “What is agoraphobia?” asked my student. I was prepared for this question too. “Someone who has a phobia, or debilitating fear, of the outside world and is afraid to leave their house,” I told them. “It’s often a result of trauma, and their biggest fear is having a panic attack in public. So they just stay home.” An awkward pause occurred while the irony of the situation sunk in, behind my screen and behind my students’ screens. This was a Zoom class, in the time of COVID. We were all scared to leave our homes. We still are. We were all suffering from anxiety. We still are. Had I just described a condition that afflicted us all? But there was no time to address that elephant in the room, as large and looming the elephant was (and how cramped and claustrophobic the room was). The focus of the class was the restless mind behind “The Lottery,” Shirley Jackson. We continued on to the discussion questions. I have a certain fascination with Jackson. She was a genius; her brilliantly morbid books and stories rattled the 1940s-1960s in ways these ultraconservative decades needed to be rattled. I relate to her. Her struggles with her mental health and body image are hauntingly similar to my own. I consider it an honor to teach her work, and a sacred duty to understand her life as much as her writing. That’s why I purchased a copy of Ruth Franklin’s Shirley Jackson: A Rather Haunted Life, which I consider the most honest, respectful, and bold biography of Jackson’s forty-eight years to ever be published (other than what Jackson wrote about herself). It’s through A Rather Haunted Life that readers get the full scope of what Jackson was up against as an adult: an emotionally abusive mother, a controlling and unfaithful husband, the overbearing responsibilities of running a household with four children, and a small community — this was North Bennington, Vermont — that collectively decided it didn’t like her. She was odd. She was intimidating. She was a career woman, a creative writer, a grave offense in itself, in a time period where societal-gender roles were rigid. She also practiced witchcraft as a hobby. The only place where she could be herself without persecution or ridicule was at home, so at home she stayed. Exemplified by numerous other health problems, including asthma and colitis (inflammatory bowel disease), she became reluctant to leave her house, severing ties with the only social circles she did have, according to Franklin’s commentary: “In the late years, when Shirley was suffering from agoraphobia,” Franklin recounts. “Students were no longer as welcome [in the Hyman family home], and Bennington alumni from the early and mid-1960s remember her as taciturn and withdrawn.” Jackson’s husband, Stanley Edgar Hyman, was a professor at Bennington College, but it was really Jackson who was financing the family expenses, penning successful stories like “The Lottery” that drew on the literary conflicts of character vs. society and character vs. self, to the point where they became her trademarks. But the masterpiece Jackson wrote that most intimately explores the theme of agoraphobia — and how it structures and limits human life — is her 1962 novel We Have Always Lived in the Castle, her last fully complete work. I personally believe this is the article of fiction in which Jackson put the most of herself, splitting her identity into the three reclusive Blackwood family members: Constance (the homemaker/caretaker/agoraphobe), Uncle Julian (the obsessive writer/disabled dependant) and most especially Merricat (the witch/loner). The Blackwood house takes on the dual roles of safe haven and prison for all three characters. Only Merricat ventures out, to do errands and buy groceries, putting herself at risk every single time she moves beyond the shielding sphere of the home. The rest of the town is openly hostile towards the decreased Blackwood family, as its remaining members are suspected of familicide. As seen later, the extent of the townsfolk’s hatred is fierce and (also seen later, no spoilers) the threat of retaliation against the outcasted Blackwoods is very real. In this way Jackson’s own adversity with the people of Bennington reaches a boiling point on paper that never actually occurred in real life. But it was always on the verge of upsetting her fragile peace, similar to the tense domestic atmosphere she devises for the Blackwoods in the text. Scholar Robert Rubenstein, in her compelling study of Jackson’s work, explains Merricat’s psychology with eloquence: “The most powerful magical metaphor — and object-relations issue — governing Merricat’s vision of the world is her attempt to maintain and control the unstable boundary between “inside” and “outside” in order to defend her conviction that destructive evil exists apart from, not within, herself. The Blackwood mansion is her fortress, and she repeatedly attempts to secure its boundaries.” In other words, the mind of an isolated person lacking self-awareness has warped to cling to their physical surroundings and adopt a dwelling place as not just a home but as a problematic extension of their identity. Protect the home and you protect yourself. Leave the home and you endanger yourself. Jackson knew what she was writing about. I was glad to learn from A Rather Haunted Life that by the end of her life, Jackson, through a program of therapy and strength of willpower, regained some authority over her own agoraphobia and left the house more often to speak at writers’ conferences. I doubt the audience members at these public talks fully appreciated the level of courage Jackson needed to summon just to make these excursions. As I’m discovering as the world progresses into a post-COVID era, educators transitioning back to the classroom setting aren’t exactly being hailed as “heroes.” But I hail Shirley Jackson as one. She was extraordinarily brave. In her writing, and in her most definitely haunted life. Further Reading about Shirley Jackson: A Faithful Anatomy of Our Times: Reassessing Shirley Jackson by Angela Hague Writer, Housewife, Witch — A Review of Shirley Jackson: A Rather Haunted Life

Editor’s Note: The language used in the following piece is in reference to the time period in which the events discussed take place. In my previous blog for Inspire the Mind on “Glass Delusion”, I discussed two royal figures afflicted with mental health issues that in some ways hindered their capacity for performing their royal roles. Further research into the subject of mental health within royal families has unveiled a fascinating find of two more figures with an extraordinary coincidence connecting them. Both were not only ruling monarchs who fell ill, but they also shared the same doctor. They were Maria I of Portugal and Brazil (1734–1816) and King George III of England (1738–1820). Francis Willis (1718–1807), a leading physician of his time, travelled across oceans to treat them both In 1786, the esteemed Maria I of House Braganza, queen of Portugal and later Brazil, was preparing to sign a document reversing legal policies put into place by her predecessor and father, Joseph I. But immediately after she’d put pen to paper and signed her name, a sudden fit of panic, despair, and possibly guilt seized hold of her. She quickly scratched out her signature on the state document and began screeching at the top of her lungs that she was doomed and damned to hell, much to the horror of the courtiers and clerks present. Maria had to be swiftly (and forcefully) escorted back to her private chambers, still screaming and delirious, and this set the precedent for the remainder of her reign. She really was doomed to follow in the wake of her notorious ancestor, Joanna I of Castile, and not only by being a female heir who’d unexpectedly inherited a crown. Maria would also come to be known as “the Mad” for her mental instability and assumed inability to rule alone. Both women had a son who had to rule in their place. But what does a court do with a displaced head of state who has lost their mind? Historically, there was only one real course of action; quietly lock them away and seek out doctors who were not only discreet, but experienced. The doctor, who was summoned to Lisbon in 1792 to take charge of Maria’s case, was one who was uniquely qualified to treat a monarch who had “gone mad,” because he had already treated one. Francis Willis had been royal physician to King George III, most recognizable to public audiences today as the kooky King who sang solo in Broadway’s Hamilton, a portrayal that while comedic and amusing on stage, wasn’t exactly sympathetic to the real royal’s tragic plight. Though not featured in the popular musical, Francis Willis would feature in the lives of both Queen Maria and King George as the only available health care provider with the expertise and semi-progressive methods to approach their cases. Unfortunately, Willis never succeeded in fully “curing” either monarch, but he managed at intervals to alleviate their symptoms before the interference and restrictions of political circumstances and general lack of knowledge about mental health crises in the eighteenth century sabotaged their treatments. When Willis arrived in Portugal and assessed Maria, he had the perception to determine immediately that the Queen’s ailments could be traced to the absence of what we now call “self-care” that accompanied a royal’s lifestyle at the time; Maria was not eating properly, not sleeping well, or enjoying any real privacy or free time in her very public life as a reigning ruler. Just like George III before her, there was no real relief from her duties, but rather counterproductive and physically draining medical procedures administered by her court physicians. Timothy J. Peters and Clive Willis, who composed a 2013 study of Maria’s I’s predicament for History of Psychiatry, analyzes Francis Willis’s course of treatment as contradictory and, from our current vantage point, modern, at least for the era: “The nature of [Willis’s] treatments are not specified but presumably were similar to those successfully employed on George III, i.e. stopping regular administration of powerful emetics, purgatives, and other medications, reducing venesection, blistering, and scarification, and adopting his regime of so-called directive psychotherapy and, as necessary, restraint but with adequate nutrition,” Willis also wanted Maria to receive rest and reprieve, but his ideas frequently clashed with those of Maria’s courtiers and especially her son, who would eventually succeed her as John VI of Portugal. He wanted Maria to travel back to England with him, to be placed entirely under his private care, believing her only chance to heal and recover depended on her renouncing court life completely, just as George III had done. But Portugal wasn’t about to let Willis whisk away their Queen from her native soil. Though no longer able to function as a politician, Maria was still a symbol of Portugal’s might and pride, and in her Kingdom she would remain, even at the cost of her health. Willis returned to England queen-less in August 1792. He had been Maria I’s doctor for six months. We now know that Maria was most likely suffering from what is clinically called major depressive disorder (MDD), and Willis’s departure reportedly led to a massive decline in her condition. Compare and contrast those relieving six months to the several years Willis spent with George III, being first called in as a consultant to George’s case in 1788. Some aspects of Willis’ dubious credentials should be noted. Even in his day, it was frowned upon that he was not a member of the Royal College of Physicians in Great Britain, and he may have practised medicine before being granted his license. But Willis’s episodes of victory with George III — who we now know likely suffered from porphyria and bipolar disorder — seemed to stem from the iron will of the physician’s personality as much as his methods. Biographer Christopher Hibbert’s George III: A Personal History and biographer Janice Hadlow’s A Royal Experiment both acknowledge and evaluate Willis’s winning strategy: his refusal to show deference to the King, in order to gain full control of his daily routine and activities. He would rule the ruler, so to speak, and enforce restraints and restrictions whenever necessary. This is what the court of Portugal would deny him with Maria. Hadlow describes Willis’s therapy plan as such: “Willis believed that the king would only improve when he was able to control himself and act calmy; but Willis was convinced measured behavior did not just emerge from within — it could be imposed from without. A patient could be compelled into calmness by the authority of another — especially if the other was himself,” (pg. 387). According to Hibbert, Willis’ treatment of George III operated on a reward system. The better George behaved, the more pleasures and privileges he enjoyed. The purpose was to motivate and steer George back towards his previous state of independence and freedom: “As Dr. Willis gained more mastery over his patient, he allowed him to do things previously forbidden”. These “previously forbidden” things included George being allowed to shave himself, play with his dog, and receive visits from his beloved wife Queen Charlotte and their daughters. George’s semi-recovery in 1789 is a tribute to the success of this system, though he would later relapse, and in 1811 his son (the future George IV) would replace his ill father as sovereign and assume power as Regent. Willis did not have access to the medications and facilities that could have been employed to help George today, so he couldn’t work the miracle everyone was hoping for and cure him completely. And he certainly had his contemporary critics. Other physicians of the English court, Dr. Warren and Dr. Reynolds, would attack Willis for mistaking performance for progress: “…although Dr. Willis and his son [his assistant] were admittedly making the king more manageable, they were certainly not curing him,”. From my own perspective as a historian, I can also see the missing links in Dr. Francis Willis’s practices, and at the same time recognize his noble intentions. He was a pioneer of the mental health care standards we apprehend and expect today. Not a founding father, but a step in the right direction. Further Reading: Hadlow, Janice (2014). A Royal Experiment: The Private Life of King George III. Henry Holt and Company, LLC. Hibbert, Christopher (1998). George III: A Personal History. Viking: Penguin Group. Hilliam, David (2008). Kings, Queens, Bones, and Bastards. The History Press. Pearce, John M.S (2017). “The Role of Dr. Francis Willis in the Madness of George III.” European Neurology. 78 (3–4), pgs. 196–199. Peters, Timothy. Willis, Clive (September 2013). “Maria I of Portugal: another royal patient of Francis Willis.” The British Journal of Psychiatry. 203 (3), pg. 167. Peters, Timothy. Willis, Clive (September 2013). “Mental health issues of Maria I of Portugal and her sisters: the contributions of the Willis family to the development of psychiatry.” History of Psychiatry. 24 (3), pg. 292–307.

I am a history enthusiast who studied European history at Wilfrid Laurier University and now I write about it for various websites and magazines. While conducting research for another article, I came across a rare psychological disorder that famously afflicted two royal individuals, from two different dynasties, in two different time eras. It immediately caught my attention and became a new fascination for me. I decided to write this blog in order to raise awareness of the condition, and hopefully educate others on the topic of the history of mental illness, especially in royal families, where it was virtually impossible to hide. There are many who assume that mental-ill health is a modern concern, but it’s far from that. In fact, one of my main examples here is medieval. As someone who has my own issues with anxiety, I understand fully how the mind can convince a person to believe the most outrageously irrational thoughts. Although my anxiety has, thankfully, never reached such extreme heights, I can still approach this topic with empathy for its sufferers. I can imagine with clarity the fear, frustration, and physical and emotional exhaustion that accompanies such a condition. As a historian, I can also see the impact this illness may have had on global politics as well, if only on a low scale. In general, it’s given me plenty to think about. From our early elementary school days, we are taught in science class what our bodies are made of. As adults, it’s common knowledge. We are bones, organs, veins, flesh, and blood. Simple stuff. But what if your mind complicated matters and tricked you into believing you were made of something far more delicate than these sturdy basic components? What if your mental illness convinced you that you were instead made of glass? This affliction, this mental disorder, is known as “glass delusion,” and its two aforementioned sufferers were King Charles VI of France (1368–1422) and Princess Alexandra of Bavaria (1826–1875). The archetype of the ‘Mad King’ we see so often in fantasy fiction stems from very real-life contemporaries, and Charles VI of France — famously known as “Charles the Mad” — was one of them. Interestingly, historians often suggest that his mother Joanna of Bourbon may have also suffered from mental health difficulties; specifically, what is now known as extreme postpartum depression (a condition following birth where the sufferer experiences heavy depression due to stress, trauma, and hormonal changes) following the birth of another child (born after Charles). And Charles suffered from glass delusion, believing his entire body to be made of glass. As a King, few dared to challenge this belief or stop him from taking what he deemed protective measures that only enabled the delusions more. He had a special suit of iron ribs built to wear around his upper half. And for the lower half, he wrapped himself in thick, cushiony blankets. Charles VI spent his entire adult life believing he could break into pieces at any moment. He often refused to be touched, even by his most trusted servants, and he once went a five-month stretch without bathing or changing his clothes, convinced his body was too brittle to do either. Expectedly, these behaviours harmed his image as a royal and as an effective head of state in the eyes of his people. Alexandra of Bavaria’s — she was a German princess born into the family of King Ludwig I of Bavaria — life story is equally tragic. Her case of glass delusion manifested in the form of a memory that she had convinced herself was real. She believed she’d swallowed a valuable, glass figurine of a piano as a child, and by young adulthood she was convinced it was still inside her, ready to shatter and puncture her organs at any moment. Historians have long speculated that Alexandra also most likely had obsessive-compulsive disorder (OCD) (a condition where the sufferer experiences/enacts irrational thoughts and behaviors) since her other preoccupations included wearing only white clothes and having her bed-chamber regularly deep-cleaned in accordance with her severe phobia of germs. Unlike the unfortunate Charles VI, she made up keeping her hygiene a priority. Citing his daughter’s poor health as making her physically unsuitable for marriage and childbirth, her father King Ludwig I turned down any proposal for Alexandra’s hand in marriage — one suitor she could have married was Emperor Napoleon’s nephew, Prince Louis Lucien Bonaparte. In fairness, I think this was probably a reasonable concern as I can’t imagine how Alexandra might have reacted to pregnancy if she already believed she’d swallowed a piano. She was the only one of King Ludwig I’s legitimate, living children to never marry. Under her father’s authority, it was clear that Princess Alexandra was to never have the chance to start her own family and she had no say in it. With Princess Alexandra, we can look past the gloom of her illness and lifetime loneliness and admire the fact that she developed a coping mechanism that was surprisingly modern. Most mental health websites nowadays will suggest journaling as a way of organizing and disposing of frantic, racing thoughts. Princess Alexandra took this tool a step further and created a whole career out of writing. To sharpen and distract her mind, she wrote poetry, stories, essays, and plays, and often donated the profits to charitable causes after these were published. As someone who also writes to release toxic feelings, I know personally what a comfort this must have been to her. Writing must have brought some semblance of control and identity back into her life when the typical path for a woman in her time — marriage, children, and a home of her own — was closed to her. And the fact that she gave so much to charity shows that it must have been an outlet for her generous heart as well as her creative spirit. She was never fully cured, but she learned to function. Royals did not exclusively suffer glass delusion, though. Back in 2015, BBC News commissioned an article on this disorder that includes some studies of more contemporary cases, and more contemporary explanations for its existence. It can happen to anyone, without an irregular genetic background. A pattern you may notice as you read these cases include the sufferers having an accompanying social anxiety disorder as well. They employ their glass delusion as a reason to actively avoid physical contact and social situations where they cannot be guaranteed personal space. One quote from the article is particularly interesting, and relevant: “The feeling of being made of glass could be a useful way of understanding how we negotiate society, a society that is increasingly crowded, in which modern technological advances isolate us and offer apparently boundary-less communication.” With the ongoing, COVID-19 social distancing measures that have become necessary to individual and community safety, is there a possibility of glass delusion cases rising again? This was an infliction recorded mainly in the time period of the 15th-17th centuries, but the BBC article discusses some isolated 20th-century cases, such as the case of a Dutch woman in the 1930s who believed her legs and back were made of glass. Could the stress of the Great Depression have been a factor in her condition? Will the stress of the current pandemic have the same devastating impact on some people mental states? If so, how will modern health care officials approach treating it? Like I said before, this topic has given me plenty to think about. This is the history they don’t teach you in school. If you would like to learn more about glass disorder and all that I have discussed in this blog, here are a few books and journals that I’d highly recommend as helpful further reading: Engstrom, Alfred Garvin (July 1970) “The Man Who Thought Himself Made of Glass.” Studies in Philology, Vol. 67, №3, pp. 390–405. Published by the University of North Carolina Press. Famiglietti, R.C. (1998 edition). Royal Intrigue: Crisis at the Court of Charles VI, 1392–1420. AMS Press. First published in 1986. Tuchman, Barbara W. (2011). A Distant Mirror: The Calamitous 14th Century. Random House Publishing Group.

Those of you who have read my previous two blogs for Inspire the Mind, first on “Glass Delusion” and then on the physician Francis Willis, will know already that I am a history enthusiast who studied European history at Wilfrid Laurier University. With the following piece, I once again want to look back at how mental wellbeing was viewed and treated historically, in some parts of the world, particularly in England in the nineteenth-century. I am moving a little further along the timeline of mental health treatment, and focusing on a specific couple (and a specific case) which has caught my fascination. Ann Walker and Anne Lister were married on March 30th, 1834, at 10:35am, in the Holy Trinity Church in Goodramgate, York. And by “married,” it’s meant they took communion together and considered the union official, though the church and law would not recognize it. History at least acknowledges the pair as the first recorded married lesbian couple in England. Everything to do with their romance, engagement, and married life was meticulously recorded by Anne Lister, whose diaries remain one of the gems of LGBT history, though their contents also contained the Halifax-born landowner’s trials as well as her personal and professional triumphs. From her diaries, one can follow the well-documented mental health crisis of her partner, the wealthy heiress Ann Walker, who suffered profusely, casting a dark shadow over what should have been an idyllic courtship period. Lister had been warned by friends that Walker was not the most emotionally sound choice of companion. A string of family deaths had left Walker riddled with anxiety and depression, but that did not deter Lister, whose need for another woman’s company and love for her overrode any concerns or hesitations. She had made up her mind to take Walker in hand, in more than one sense of the word. In 1832, Lister and Walker made a trip to York, on the pretext of visiting friends and running errands, but the trip’s true purpose was medical. Walker was examined by Lister’s good friend Dr. Belcombe (who was, notably, the brother of one of Lister’s old loves, Mariana Lawton, born Belcombe). The casual misogyny of the time period can be found in Dr. Belcombe’s diagnosis, which dismissed Walker’s grief and stamped her with the damning label of the ‘hysterical’ woman, one whose condition was worsened rather than alleviated by financial security, according to Anne Chroma’s biography of Lister, Gentleman Jack: “Miss Walker had too much money and too little to do, and had managed to think herself into being ill,” (pg. 151). As crude as this conclusion was, was Dr. Belcombe onto something? Could Walker have found some relief by following the route of her partner Lister, and throwing herself into architectural projects and a more hands-on approach to managing her estate? In nineteenth-century England, there was no question of a rich, comfortably settled woman like Walker getting a job. If a woman didn’t have to work, she just didn’t, so Dr. Belcombe didn’t prescribe exertion and a busier schedule for Walker, but rather “tincture of henbane [a medicinal plant],” adding on “the advice that Anne should maintain the ‘upper hand’ by not unduly indulging her patient’s nervous complaints,” (pg. 151). In other words, Lister was to become Walker’s supporter, but not her caretaker. But was she up for the task? When they returned from York, the news of a friend’s death sent Walker into a downward spiral, one made even more nightmarish by the fact that her friend’s apparently undaunted widower began pressuring her into marriage. Walker’s mental state collapsed, and Lister found herself on-call for her lover’s distresses. The symptoms Walker was experiencing can nowadays be identified as post-traumatic stress disorder, obsessive-compulsion disorder, agoraphobia, and depression. Walker struggled with hygiene and insomnia especially, and the ever-practical Lister did her best to manage matters. I’ve had bouts of insomnia myself, and I recognize Lister’s tactics to get Walker to sleep: turning off the clock, consuming something hot for comfort (Lister insisted Walker eat gruel), and — as seen in this diary entry describing a particularly challenging night they spent together — reciting a soothing chant: “Talked and reasoned calmly, then turned, and pretended to sleep. She refused all affection, and I did not press it. She scarcely, I think, closed her eyes until after 3, when I bade her say the Lord’s prayer incessantly until I think she dropped off into a doze for a little while…” (11th January 1833). Lister soon became exhausted. The near-sleepless nights and Walker’s fast deterioration were wrecking havoc on the women’s relationship as well as their health, and Lister had always prized her own good health. Something drastic had to be done. It was eventually decided by Lister and Walker’s family that a getaway to Scotland was the cure. Walker would go alone. Lister made her own travel plans to go to Denmark. In Scotland, separated from the stress of her complicated love life, Walker was expected to make a full recovery. And when she returned, she and Lister would decide in which direction their liaison would go. Shipping mentally distressed relatives off to Ireland and Scotland to recuperate was a popular course of action among the British upper and middle classes in the nineteenth century. It was a kinder plan than arranging a stint in an ‘insane asylum’, and considerably more practical (as long as one had the funds or connections for it). The picturesque, rural landscapes of both countries tended to have a soothing effect on visitors who arrived ill or overwrought, and the remoteness of the locations made Scotland and Ireland ideal retreats for families who needed to squirrel away an inconvenient relative for a time, away from the prying eyes of their English neighbours. In the summer of 1812, the philosopher-writer William Godwin sent his depressed teenage daughter Mary Godwin (the future Mary Shelley) to stay with trusted friends in Scotland. By all accounts, the trip revived the young woman’s sunken spirits, emotionally and intellectually. Biographer Charlotte Gordon in her Romantic Outlaws even claims that it was the beauteous and almost savage setting of the Scottish wilderness where Mary experienced her first real awakening as a writer, writing that “it was here, [Mary] said later, that she first began to dream about writing ‘fantastic’ stories,” (pg. 54). For others, such as with the case of Ann Walker, it was an enforced holiday for an upper-crust patient, undertaken with the underlying purpose of making the sufferer disappear until they were deemed fit to re-enter respectable society. This is what happened to Lady Caroline Lamb, the socialite and later writer who experienced a complete mental breakdown after being rejected by her lover, the poet Lord Byron (who in turn would later develop a more solid — though platonic — relationship with Mary Shelley). Caroline, in 1812, was whisked off to Ireland by her distraught husband and family to recover not only her stability but their own tattered reputation as well. 1812 was an eventful year for therapeutic travel, it seems. But did it work for Ann Walker, in 1833? Did the Highlands enact their healing magic on her? On August 8th, Lister received a letter from a relative of Walker’s claiming that the Scottish air and food had helped her physically, but not emotionally. Walker longed for Lister and would have to wait almost a year until she got the secret wedding of her dreams. I do wish that I could call this a happily ever after, completely. It was for a time, but after Lister’s untimely death in 1840, Walker lost her true love and her rock. She would relapse and fall back once again under the private care of Dr. Belcombe, dying in 1854. The survival of her story is attributed to her wife’s pen, passed down to my own to share. If you are interested in reading more about Anne Lister and Ann Walker, here are some great resources I would recommend: Clark, Anna (July 1996). “Anne Lister’s Construction of Lesbian Identity.” Journal of the History of Sexuality, University of Texas Press. 7 (1), pgs. 23–50. Choma, Anne (2019). Forward by Sally Wainwright, executive producer. Gentleman Jack: The Real Anne Lister. Penguin Books. “Diary Comparison Portal: Comparing the Ann(e)s, 4th June 1834–19th February 1835.” In Search of Ann Walker. Gordon, Charlotte (2015). Romantic Outlaws: The Extraordinary Lives of Mary Wollstonecraft and Her Daughter Mary Shelley. Random House. Liddington, Jill (Spring, 1993). “Anne Lister of Shibden Hall, Halifax (1791–1840): Her Diaries and the Historians.” History Workshop, Oxford University Press. 35, pgs. 45–77. O’Brien, Edna (2009). Byron in Love: A Short Daring Life. W.W. Norton and Company. Who Was Ann Walker?” (12th August 2021). Visit Calderdale.

Hospital setting. A child is born and cries at the top of his lungs. The hospital personnel carefully takes the newborn from the mother and collect a blood sample from his heel. One drop of blood is deposited in a machine that few seconds later expels a paper sheet. A doctor reads out loud the output of the genetic analyses: “Neurological conditions 60% probability. Manic depression 42% probability. Attention deficit disorder 89%. Heart disorders 99% probability, early fatal potential. Life expectancy 30.2 years”. This scene is taken from GATTACA, a 1997 cult science-fiction movie directed by Andrew Niccol and starring Ethan Hawke, Uma Thurman, and Jude Law. I am a researcher at Department of Psychiatry of Amsterdam UMC, where I lead the genetic research activities. I am also a clinical psychologist by training and sci-fi aficionado. While recently celebrating the 25th anniversary of the release of GATTACA, I asked myself whether the future application of genomics in clinical psychiatry may resemble the one seen in the movie. GATTACA depicts a dystopian future in which society is rigidly structured in classes demarcated by the results of genetic predictions of the individuals’ potential. But not necessarily of its actual realization as the story will teach us. The main focus is the societal abuse of these predictions to impose an order based on inequalities and discrimination. As the main character narrates “I belonged to a new underclass, no longer determined by social status or the colour of your skin.” Predicting disorders with genetic data GATTACA - released 6 years before the completion of the Human Genome Project that provided a first full reading of human DNA - included clever foresights of the potential future application of genomics (the study of the genetic sequence of organisms), including the possibility to predict the risk to develop physical or mental disorders. This is slowly becoming reality in research with the development of tools called Polygenic Risk Scores (PRS). These are scores which predict the lifetime risk of developing specific disorders. The last two decades of genomic research taught us that the risk for psychiatric disorders is not determined by one or a few genes, but rather from hundreds if not thousands of genetic variants scattered across the entire genome, each one determining a very small increase in the overall genetic risk. PRS captures the additive effect of this myriad of small risks in the attempt to predict the overall genetic risk of disorders. PRS are built using parameters derived from large studies called GWAS (Genome-Wide Association Studies), in which millions of genetic variants (points in the DNA sequence differing between individuals, also known as single-nucleotide polymorphism or SNPs) are compared across thousands to hundreds of thousands of subjects with a certain disorder versus healthy controls. Psychiatric genetics has been at the forefront of this field, with the first study applying PRS in 2009. The limits of genomic prediction In GATTACA genomic prediction tools were applied at birth in the entire population to derive the probabilities of developing different conditions. Will this be the most rationale use of PRS for psychiatric disorders in our future? Highly unlikely, based on the knowledge we are rapidly accumulating. There are inherent limits to the predictive capacity of PRS. The risk of developing any disorder is differently distributed in the population: some persons have high risk, others low risk and all the others will lay in the middle of these extremes. This risk distribution is partly due to genetic factors (“heritability” is the technical term indicating the portion of this distribution explained by genetics) and partly due to other non-genetic and environmental factors such as, for instance, trauma or socioeconomic deprivation. Here we could appreciate the most obvious limit of genetic prediction: a genomic-based tool like a PRS could capture only the genetic portion – the heritability - of the risk, which is only one part of the overall disease risk. PRS for psychiatric disorders currently capture only a very minimal part of this “heritability”, which represent an even smaller proportion (<10%) of the overall risk. Another limitation is that a PRS built from GWAS performed in subjects of a certain ancestry (e.g. north-European) have lower prediction ability when applied to populations of different ancestral background (e.g. east-Asians). To date the overwhelming majority of GWAS has been performed in subjects of European ancestry, with only less than 5% of the studies including participants of different populations. Application of PRS without realising their skewed ancestry representativeness could not only impair their predictive performance, but also further exacerbate existing health inequalities. Finally, the public health value of screening an entire population for a certain disorder depends on the number of cases that could be identified. Let’s consider conditions with low population prevalence like schizophrenia or bipolar disorder (~1%); after a (logistically challenging and expensive) full-population screening effort, even among the small subgroup of subjects with the highest PRS, only a very limited number of individuals is expected to develop the disorder. A more interesting future Rather than applied to the whole population as in GATTACA, genomic tools may become more relevant in groups at higher risk, such as subjects with family history of psychiatric disorders or those presenting at early stages with undifferentiated prodromal symptoms. For these people, PRS could be helpful in resolving diagnostic uncertainties or as prognostic predictors at different stages of their clinical trajectory. The emerging field of pharmacogenomics is also showing that genetic data may be crucial for the selection of the appropriate medication regimen aimed at improve clinical effects and reduce adverse drug reactions. Research on these potential applications has just begun and important issues need to be addressed before this technology will be ready for clinical implementation. The predictive accuracy of PRS for psychiatric disorders must improve trough increasingly larger GWAS testing not only diagnostic status (cases versus controls), but also other key outcomes of clinical relevance such as treatment response. Furthermore, GWAS studies in samples from diverse populations are highly needed in order to ensure that PRS would be useful for subjects of different ancestry and not be limited to privileged groups (e.g. those with European ancestry). Finally, a new generation of clinicians need to be properly trained in the use and communication of genetic probabilistic risk predictions to patients. In all these promising future applications, genomics tool will never be used alone, but always as part of a broader clinical appraisal together with all other established environmental risk factors, psychopathological features and biomarkers. In this context, PRS may have an appealing advantage as compared to other type of biomarkers: genetic data need to be measured only once in life trough affordable technologies (currently <100$ per sample) and from that unique measurement PRS for multiple traits and disorders can be continuously generated and updated. An alternative scene The application of genomics in clinical psychiatry will unlikely resemble the one in GATTACA. Could we imagine an alternative scene for an hypothetical sci-fi movie? Fade in. Visit room in a hospital. A man in his thirties has been referred to a specialized psychiatric evaluation. The psychiatrist connects her terminal to the microchip implanted under the skin of the patient containing his electronic medical records. In the meantime, the man describes the depressive symptoms he experienced in the previous months. The psychiatrist reads on the terminal that the general practitioner has prescribed antidepressants. However, after several weeks of treatment the symptoms are worsening. The psychiatrist asks additional diagnostic questions to the patient and collect further information on his family history and relevant risk factors. Then the clinician checks on the patient’s data for available biomarker measurements and activates a newly developed application that allows to generate on the spot - from the encrypted genetic data of the patients stored in his microchip - PRS for different psychiatric disorders based on the latest GWAS studies. She explores the output screen starting from the section on bipolar disorder. Later. The psychiatrist and the patient sit together discussing the potential treatment options. The doctor explains to the patient her clinical hypothesis: the lack of response to antidepressant and the increased genetic risk for bipolar disorder measured by PRS led her to think that his mood symptoms may represent the onset of such disorder. Together they agree in starting a treatment course tailored for bipolar disorder. Fade to black.

An EU-PEARL podcast with Professor Carmine Pariante and Patient Advocate Fanni-Laura Mäntylä Today, October 10th, is an important day. It’s World Mental Health Day (WMHD). Every year this day is marked by the World Health Organisation with a different theme in focus. This year’s theme is ‘Make Mental Health and Wellbeing for all a Global Priority.’ Such days exist to put mental health at the forefront of the conversation. To raise awareness, to show support, to show people how to look after it, and to recognise how fundamentally important it is. To mark this day, we want to share a podcast with you hosted by the European Patients’ Forum (EPF), the leading voice of patient organisations. Inspire the Mind Editor in Chief Professor Carmine Pariante, and Patient Advocate (and writer of this great ITM blog) Fanni-Laura Mäntylä, sat down to talk to host Estefania Cordero about WMHD and the work they have been doing in a research project, EU-PEARL (EU patient-centric clinical trial platforms) — an Innovative Medicines Initiative (IMI) funded programme working to shape the future of clinical trials and drug development in four areas of medicine, including major depressive disorder. World Mental Health Day has a key focus on making mental health equal to physical health — something that was a huge part of Carmine and Fanni-Laura’s conversation. They discuss everything from the refocusing of priorities, especially in times of societal disruption as we are experiencing now, to the broad effect that mental health can have on life. The trio also discuss the importance of work in the EU-PEARL project, and similar initiatives, through the lens of making mental health a global priority for all; showing it has an important role to play in reducing stigma, both in demystifying the clinical trial methodology needed to make new treatments available, and for the individuals involved. The important role of the patients in this project was explained from Fanni-Laura’s own experience as she spoke about her own role in the project and how this collaborative work with patients and scientists is really crucial, giving voice to the people affected by mental ill health. Concluding with their individual hopes for the project, the importance of improving mental health for all was very apparent and gave a strong sense of hope for change. If you would like to listen to the podcast, you can find it here on the EPF Anchor channel, or by searching ‘Marking #WorldMentalHealthDay with the EU-PEARL project’ on Spotify or your favourite podcast streaming platforms! You can also read more about the EU-PEARL project by visiting https://eu-pearl.eu.

How first experiences impact the infant development Two days after my daughter was born, in Milan, Italy, I was in the hospital nursery room. When I was there, another baby girl was ready to go home with her parents, when her dad said, loudly (in Italian), “Can you see how all the other babies and parents are happy to see you go finally, so they can stop hearing you cry? We cannot hold you all the time darling, life is painful, so you’d better get used to it”. I found these words very stressful, and, although it may have been an isolated episode for a new parent, I started to think about what this girl could experience going forward, if this style of parental relationship continued. She most likely would not feel understood, listened to, or supported by others. This episode reminded me once again of the importance of sensitive parent-infant relationships starting from the very beginning. I am psychologist, with a PhD in perinatal psychiatry at King’s College London, and my work has always focused on the mother-infant relationship and infant development. In the past few years, I have worked on different research projects on perinatal mental illness, investigating both risk factors and the potential impact on the mother-infant relationship and the infant's development. I have previously written about these topics in Inspire the Mind, and was also inspired by the birth of my own daughter two years ago, and so I have decided to launch this column (the Perinatal Journey - Walking through the first years of life) dedicated to parenthood and infant development. As I explained in my interview with fellow researcher and ITM writer Zuzanna Zajkowska, this column will focus on the perinatal period and the first years of life, a time so incredibly important for infant development. Why sensitive parenting is so important Research has now documented how the first 1001 days (from conception to around age two) are an extremely sensitive period for a child’s future development. During this time, babies are growing very fast, and their brains are being shaped by the experiences they have with their parents and the environment around them. Photo by Sergiu Vălenaș on Unsplash Babies are in fact highly dependent on their caregivers. The type of relationship they develop with their parents early on will be internalised and will guide their future development and relationships, as well as their mental and physical health. This may seem a strong statement to make, but we indeed know from many studies that sensitive parent-infant relationships sustain offspring’s physical and mental health, through childhood, adolescence and adulthood. For example, sensitive relationships predict better infant social and cognitive abilities, good (secure) attachment towards the caregiver, lower risk for problems at school, and for mental health problems in childhood, as well as better development during the lifetime. Conversely, infants who have not experienced a sensitive relationship are at greater risk of less optimal mental health outcomes during their lifetime. How early relationships affect infant development Using simple words, in a sensitive parent-infant relationship, the caregiver (usually a parent) values, understands, and responds appropriately to the child’s signals and needs, adjusting her behaviour to comfort the infant and reduce her distress and disengagement. The experience of a sensitive and consistent relationship with a caregiver will make the infant feel content, understood, and secure. As time passes, the infant will be able to use this relationship as a “secure base”, from which to explore the environment and open-up to the world, but also a place to return for comfort and reassurance, certain that the caregiver will be there to help in case of need. Photo by Anna Shvets on Pexels Because of this early positive relationship with their caregiver, the infants’ internal representation of themselves, the world, and others will generally be positive and, therefore, they will be more likely to be able to explore and interact successfully with other adults and children, to show empathy and social-emotional engagement and have good self-esteem. Growing up, the child will also be more likely to successfully deal with negative emotions and stressful situations independently, while also be able to return to the caregivers if needed. In adult life, these characteristics will remain. Therefore, adults who had sensitive parents will generally be more likely to have good self-esteem, to form positive intimate relationships, to succeed in their studies and career, to manage stress and emotions, and to remain resilient in the face of difficult situations, reducing the risk of suffering from both mental and physical disorders. Of course, this is not a deterministic, univocal association, as many other factors influence the course of development. Some resilient adults might have had a difficult childhood, and some adults who grew up in optimal parental conditions may manifest mental health vulnerabilities. Nevertheless, the association between sensitive parenting and better health is undeniable – this is why it is so important that everyone knows about it. The crucial but demanding role of the “good enough” caregiver Responding to a baby in a sensitive and consistent way is crucial for the infant. Common advice given, such as: “don’t hold the baby too much, don’t respond to her every time she cries, otherwise she will be spoiled and will never be independent”, is now considered false. There is no scientific evidence supporting the idea that a mother can respond “too much” to a baby. In fact, the opposite is true: the more an infant receives consistent and sensitive responses to their needs, the more they will be able to grow-up as an independent adult. Of course, it is important to highlight that the caregiver does not need to be perfect but just “good enough” for the child, using the words of the paediatrician and child psychoanalyst, Dr. Winnicott. There are in fact many practical life situations where the caregiver cannot always respond in the best way to the baby. It is the caregivers’ repeated, regular failure to respond to the baby that can generate problems. It is also important to mention that taking care of a baby in a sensitive way is a demanding job for a parent, even in the best of circumstances. All of this is a process and requires time for adjustment, and this is why the role of the support network is essential for a family when a baby is born. As another ITM writer has reminded us, “it does take a village to raise a child”. Photo by Kyle Nieber on Unsplash When a supporting intervention is needed Difficulties in the parent-infant relationship can develop even in the best of circumstances and are even more likely when vulnerability factors are present. Many factors can increase the risk of parent-infant relationship difficulties, by directly affecting the interaction or, indirectly, by increasing the probability of maternal mental health problems, such as depression during pregnancy and in the postpartum period. Depression can represent a risk for the mother-infant relationship and the infant secure attachment, particularly when the illness is prolonged and severe. Other factors include the caregiver having a difficult relationship with their own parents in childhood, or with their current partner, lack of support, socio-economic disadvantage, stressful events, and severe pregnancy/delivery complications. In these situations, it can be harder for the parent to provide an attuned response to the baby, and the more vulnerability factors are present, the more difficult it can be. When difficulties arise, it is important to intervene as early as possible with supporting interventions dedicated to improve the mother-infant relationship and infant security. We will discuss possible interventions in one of the next articles. “Good enough” parenting is a strong protective factor for infant long-term development. If you would like to know more about this – to receive compassionate, evidence-based advice on parenting – come back to my monthly column!

A major topic in research over the past couple of decades has been understanding biological correlates (or as often referred to, biomarkers) of mental health and illness. Millions of dollars have gone into this work, including measuring biometrics such as skin conductance (or how much a person sweats), how much they startle, their heart rate, their brain scans, and genetics, and whether it correlates with their disorder status or personality traits. I am a biological psychologist by training, and this puzzle is one that has intrigued me, for both scientific and philosophical reasons, since it is inherent in all the work that I have done to date and continue to do in my current role as Research and Innovation Manager at the National Institute of Mental Health’s Research Domain Criteria (NIMH RDoC) Unit. It is also particularly relevant now with the plethora of digital health apps and devices like fitness trackers that have taken over this arena in recent years. Why is this so fascinating to researchers like me? Let us take a step back and examine: What is a mental disorder? One of the curious things involved in diagnosing mental disorders, as compared to other medical disorders such as heart disease, diabetes, or cancer, is that the criteria used for it are mostly based on self-report (or other’s reports) of feelings, cognition, and behavior. In other words, unlike other disorders that implicate other body systems, there are no brains scans, blood markers, or proteins, or related biomarkers that can be used to diagnose, predict, or treat them. In and of itself, this is not a problem — it does make intuitive sense that mental disorders should after all be based on mental phenomena such as thoughts and feelings, which presumably are related to an individual’s actions. However, this does lead to some very interesting problems, when researchers try to correlate biology and behavior. One major issue that is not discussed often in the science news about such articles, or even in the more academic articles, is that these two factors often don’t correlate well — especially the larger the sample size of a study grows. The first time I was exposed to this was in my early graduate school research work, where my lab worked on understanding psychopaths. A common theory about what drives psychopaths is that such individuals are unemotional, unempathetic, and do (or can) not show emotional reactivity the way the rest of the population does. One of the methods often employed to study emotional reactivity in lab settings is to show images with emotional content to participants and then measure their emotional and biological reactivity to these pictures. Since a substantial part of mental health and illness deal with emotions, thoughts, and feelings, and what happens when they go awry, the theory behind this idea is that if we can examine differences between groups of people with different mental health issues (including psychopaths), then perhaps we can trace what exactly goes awry in the particular mental disorder they may have. The images shown in such studies included unpleasant pictures (such as pictures of dead people — some of these can be pretty gory! — or those of insects, or dirty toilets), pleasant pictures (such as soothing natural scenes, babies, or romantic couples, and even erotica), and neutral pictures (such as photos of fire hydrants, everyday furniture, and people with neutral expressions). Participants are also asked to simultaneously rate how pleasant or unpleasant the images while viewing them, and various parameters such as their startle reactivity, sweat rate, heart rate, and brain waves are recorded. My lab undertook such studies with participants from the general population, incarcerated individuals (some, but not all of them, were psychopaths), and people with mental disorders. Interestingly, how people across these samples rated these pictures didn’t always match up with the various biomarkers we measured. For example, one of the biomarkers we measured is called the eyeblink startle response — where we literally quantify how hard the person blinked (eyeblink muscle activity; shown in image below) when they were startled while watching the picture. In the general population, on average, people startle the most when watching unpleasant pictures (think about you how you react when you are startled while watching a horror movie), medium while watching neutral pictures, and the least while watching pleasant pictures. Generally, the more unpleasant a picture is rated, the more a participant startles while watching it. If you plot this in a graph, the results generally look like this: Interestingly, when this same effect was studied amongst incarcerated individuals, those high in psychopathic traits appeared to show the linear increase in startle from pleasant to neutral, but not from neutral to unpleasant. On the other hand, prisoners who did not score high on such trait or were in a mixed group reacted more like individuals from the general population. Perhaps you could conclude that such individuals did not find such pictures as aversive as the general population. However, here’s where the ratings of such pictures came handy. These individuals rated the unpleasant pictures as being similarly aversive to subjects in the general population, but did not startle to them as though they were unpleasant. How about individuals who are depressed — what is their startle reactivity like? Yet again, while such participants rated emotional pictures the way you would expect, even more intriguingly didn’t differ statistically in their reactivity between any of the types of pictures — pleasant, neutral, or unpleasant. There are many other studies that show variations of this discrepancy for other forms of mental disorders such as post-traumatic stress disorder (PTSD), social phobia, and so on. Why is this the case? Why does biological reactivity not correlate as much with what people say they are feeling? The short answer is: we don’t know. There are many theories in the scientific literature as to why, but we don’t really know why people’s biology doesn’t correlate that strongly with their behavior or feelings when it comes to mental health. Now, we could stop our studies here and just shrug our shoulders and move on. But, if you pause and think about it, beyond being just a scientific curiosity, results such as these have very interesting fundamental implications. Are people really feeling something if they say they are feeling it, but their biology doesn’t show it? What about the opposite situation — do we rely solely on their biology and disregard what people say? For example, is it alright for me to insist you must be feeling sad because your brain activity showed so, even if you say you aren’t feeling that way? What is a feeling, anyway — what we say it is, what our brains show, some combination of the above? How much control do we vs our brain have over it? Is there such a thing as a feeling independent of a brain? Our answers to these sorts questions have many practical implications as well ranging from settings such as mental health treatment facilities to courtroom settings, to more daily circumstances, such as how we feel we should deal with a bad mood. These are topics that individuals from a variety of traditions such as neuroscience, biology, philosophy, and psychology, have tried to answer for hundreds of years without any universal agreement. My own views of this topic have continued to evolve over the years, from my time as a graduate student to where I am currently in my research career. At this stage, my personal view is this: mental phenomena such as feelings, thoughts, and disorders wouldn’t exist without the brain. After all, they are not pathogens like a virus or a bacterium that can infect you after floating around in the air or living on surfaces. However, unlike other disorders such as heart disease, there is no way to diagnose a mental disorder without someone reporting a problem with thoughts or feelings. After all, you don’t go to a doctor saying your frontal lobe isn’t functioning well, but that you are feeling fine. In other words, my belief is that for us to truly understand mental health and illness, we will need to study both the experience of a feeling and associated biological events. Fortunately for me, we live in a time where both types of research and their integration, especially, are encouraged by various initiatives (such as RDoC). I look forward in the coming years to see what kinds of light these can shed on this extremely interesting topic. NOTE FROM THE EDITORS: We are delighted to share with you this fantastic blog from our friend Dr. Uma Vaidyanathan from the RDoC Unit for The National Institute of Mental Health @NIMH_RDoC. You can find out more about the work done by The National Institute of Mental Health’s RDoC Unit here. Thank you so much for writing this piece for InSPIre the Mind, Uma — look forward to reading your next piece soon!

Many psychiatrists would say that while we treat depression in many ways, all these many treatments can be grouped into one of a few c­­­ategories, usually based upon how the treatment is delivered to a patient. For example, treatment that is ingested, such as in the form of a pill, tablet or liquid, is called pharmacotherapy. Antidepressant drugs are the type of pharmacotherapy that most people are familiar with, although nutritional interventions, like fish oil, also represent a form of pharmacotherapy. Another large category of depression treatment is psychotherapy or talk therapy. Psychotherapy for depression involves the patient working with a therapist, often within the confines of a specific type of psychotherapy — for example, Cognitive Behavioral Therapy — to help them reduce their symptoms and ultimately recover from their depression. In psychotherapy, we focus on our thoughts, so that thought patterns that commonly occur in depression are identified and addressed. This category of depression treatment is becoming as used as pharmacotherapy already is. Perhaps a lesser known category of depression treatment is neurostimulation. What is neurostimulation? In neurostimulation, depressed patients’ nerve cells are exposed to electric or magnetic fields. These energy fields change how nerve cells communicate with each other and can drive improvements in symptoms and ultimate recovery from depression. Neurostimulation can even be targeted at specific areas of a depressed patient’s brain or body, areas of the brain or body at which nerve cell communication is thought or known to be altered by depression. Many have likely heard of a type of neurostimulation called Electroconvulsive Therapy or ECT. ECT is a very effective treatment for depression, but it is also a very controversial one for many. However, the purpose of this post is to talk about neurostimulation techniques other than ECT. For those interested in learning more about ECT, further information can be found on the websites of many national psychiatric associations, including the British Royal College of Psychiatrists, the American Psychiatric Association and the Canadian Psychiatric Association. Moreover, you can read more about ECT in our recent blog here. Additional neurostimulation techniques currently used and/or studied in the treatment of depression include: Repetitive Transcranial Magnetic Stimulation, or rTMS for short, is the only neurostimulation technique listed above that relies exclusively on magnets to alter nerve cell communication in depression. Transcranial Direct Current Stimulation (tDCS), Deep Brain Stimulation (DBS), Vagal Nerve Stimulation (VNS) and electroacupuncture (EA) all use electrical fields delivered at various sites across the body to alter nerve cell communication in depression. Why are we interested in neurostimulation? In a previous post, I wrote about how hormone signals caused by stress affect the functioning of the immune system in depression and vice versa. In depression, patients with long-term increases in the blood level of the stress hormone cortisol are also often found to have very severe depressive symptoms. At the same time, these depressed patients with high blood cortisol often show changes in the function of their immune systems. Generally, this is an over-activity of the immune system, leading immune cells to react like there is an infection in the body, but there isn’t. All of the neurostimulation techniques listed in the above table show some ability to improve symptoms in depressed patients. I was interested in knowing whether neurostimulation could also cause changes in stress hormone levels and immune system function in depressed patients, and whether these changes may be involved in the therapeutic action of these interventions. What did we do? We reviewed all published studies that examine how neurostimulation affects stress hormones levels and/or the immune system in depression. This process is called a systematic review. The systematic review method is an internationally agreed upon way to ensure that we find all published information on topic of interest, in this case, how neurostimulation affects stress hormones and/or immune function in depression. So, what did we find? Our work was the first to systematically review the literature on this topic. We found that rTMS, tDCS, VNS and EA were all able to decrease elevated blood levels of stress hormones, including cortisol, and change the levels of immune signals — also known as cytokines — in depressed patients. Interestingly, in depressed patients who experienced improvements in the blood levels of stress hormones and/or immune function due to treatment with neurostimulation, concurrent improvement in depressive symptoms did not always occur. This indicates that these changes may not always be involved in the therapeutic action, or at least not immediately. Our systematic review identified the need for more carefully designed and conducted studies. These additional studies will allow researchers to determine if the neurostimulation techniques reviewed can improve symptoms and stress hormones/immune function in depression at the same time. Why is this important? Neurostimulation offers depressed patients the chance to receive a non-drug treatment for their disease. If neurostimulation techniques are proven to help the hormonal and immune system changes that accompany depression, in addition to improving depressive symptoms, then neurostimulation could represent a new multi-pronged treatment for all. Our work therefore lays a foundation upon which more far reaching depression treatments can arise. It also highlights the possibility of combining neurostimulation with other categories of depression treatment, hopefully to generate more successful recoveries for all patients.