One thing that all people (and even some animals) have in common is habits. Bad ones, good ones — our lives are all about changing them, and most, if not all, personal achievements result from sticking to a habit… or getting rid of one. Habits help our brains to be more efficient and free up the mental space for other tasks In the UK, we are in the 8th week of lockdown due to the COVID-19 outbreak. Habits are undergoing all sorts of transformations due to our altered daily routines, and mine are no exception. The most damage was done to my evening routine, and I spent hours on my phone before bedtime, mindlessly scrolling my feed. Needless to say, every morning I woke up exhausted, which started to affect my work productivity. I made an active decision to not use my phone at least an hour before bed each night, but it turns out it is more complicated than it seems. “We are what we repeatedly do. Excellence, then, is not an act, but a habit.” — Will Durant A habit is something that we do regularly, often automatically, without any forethought. When we first start forming a new habit, however, we have to be very deliberate and effortful in order to perform the desired action. We focus a lot on the results, too, imagining the future joys of good habits: job promotion, improved wellbeing, creative achievements, stronger body. In my case, I was dreaming about waking up and feeling rested without the usual gallons of coffee. Having background in both health psychology and neuroscience, I am not only interested in being good at changing my habits, but also in understanding how the brain regulates such an important process. In order to disentangle the neuroscience behind habits, it is important to understand two key processes: “action-outcome” and “stimulus-response”, the former leading to the latter for a successful habit forming. Let’s take a simple example of a light switch. When you come back to your dark flat, you flip the switch because you’re looking for an outcome — an illuminated flat. This is an “action-outcome” system — a deliberate action with the result in mind. When you repeat this enough times, it becomes so automatic that you stop considering the outcome. So, if your lightbulb goes out and you forgot to change it, chances are you will still flip the switch automatically when you come home, even though you know the desired outcome of your action is not there anymore. At this point, the action has moved from an action-outcome process and it becomes what we call a “stimulus-response” association — you see the switch, you habitually flip it. Presumably, our behaviour is a balance between these two systems, but they also compete when we try to form a new habit. When I first tried to reduce my phone use before bed, it was incredibly hard to make the effort — my “action-outcome” system was still in place, as I was having to consciously remind myself to stop looking at my phone to avoid morning tiredness. Both “action-outcome” and “stimulus-response” processes have corresponding parallel networks in our brains. The “Action-outcome” (sometimes called goal-directed) process happens primarily in the dorsomedial striatum (DMS), which is a part of a larger reward system in the brain. DMS is part of a neuronal network called an “associative loop” with other brain areas, such as thalamus (which is a relay center between sensory experiences and the rest of the brain) and associative cortex, which is responsible for language and abstract thinking. DMS also has an adjacent part, dorsolateral striatum (DLS), which is conveniently responsible for the “stimulus-response” (or habitual) association. DLS also forms a neuronal network, which is called “sensorimotor loop”. This circuit involves the thalamus as well, but then connects to the sensorimotor cortex, which is responsible for registering our body movements and senses, such as touch. Associative and sensorimotor loops are parallel pathways that overlap in the thalamus. Animal studies also provide a valuable contribution to habit research. Peculiar neural activity in the DLS (“habit” area) was detected in rats. When they performed a novel task, the neuronal firing was active during the whole performance. However, as the training continued, DLS activity was more pronounced at the beginning and the end of the task, while reduced mid-way. This suggests that the brain requires its full power only when the activity is novel; when the task becomes familiar, the brain can “rest” while completing it. This pattern is called “chunking”, suggesting that the brain chunks certain actions together to form a habit and perform it more efficiently. For example, when you habitually brush your teeth, you perform many smaller actions (take your toothbrush, open toothpaste, squeeze it on your toothbrush, put it in your mouth), but your brain considers it one automatic task. Other examples are parking, adding sugar to your tea, and many other activities we do in our daily lives. Chunking helps us turn familiar patterns into habits without requiring too much effort and concentration. One way to speed up the habit formation is to create cues, which are simply triggers associated with your behaviour, such as laying out your workout clothes the night before your morning run. Once you have effortfully and deliberately acted upon this cue enough times, it will become automatic. This applies to bad habits, too, and non-smokers who smoke in the bars are a perfect example: the drink is the cue, the automated behaviour is smoking. In breaking my habit of phone use before bed, my night-time routine became my cue — I knew that after I washed my face and brushed my teeth, my phone goes to the furthest corner of the room. Of course, some habits are harder to break than others, and the success will vary among individuals. Drug addiction, for example, can be considered a very strong, almost involuntary habit. It becomes so powerful largely due to the neurochemical disruptions and brain lesions associated with drug misuse. This habit is infinitely harder to break than more mundane habits, such as leaving a bathroom light on (which I am definitely guilty of). People with certain conditions, such as obsessive-compulsive disorder, also find it harder to break habits. We all know the saying “it gets worse before it gets better”. I have mentioned it in my “Neuroscience behind mindfulness” blog before, and I will mention it again: it takes time and effort for your brain to adapt to your actions and turn them into habits, but as long as you are creating cues for yourself and acting on them, rest assured it will get easier — your brain will make sure of it.

Disclaimer: this blog will discuss sensitive contents such as suicide, rape and bullying. This blog is for informational purposes only and it is not a substitute for professional medical advice or treatment. We discuss organisations that can provide help, but we could not provide extensive lists for every geographical context. Suicide: the act or an instance of taking one’s own life voluntarily and intentionally. Suicide is a worldwide plague, as someone takes their own life every 40 seconds and it is now the second leading cause of death for people from 15 to 29 years old and the third for 10-19-years-olds.This topic has been already broached in another Inspire the Mind blog (How can we stop suicide? By Jonny Benjamin MBE), but with this piece I would like to focus on how to seek help when you are experiencing suicidal thoughts and to address the question: which tools could an adolescent seek when feeling suicidal? If you are an adolescent, during difficult times, have you ever felt the need to ask for help? If you are not an adolescent, share this blog to teen friends and/or family members. However, everyone can benefit from the following suicide prevention options. Have you ever used Google to find a solution to your troubles, wishing for a magic-wand style solution? Let’s now imagine a teen, struggling with the worst imaginable thoughts and not knowing who to talk to, especially during a difficult time — for example, these days of social isolation due to the COVID-19 pandemic can be really hard — friends may laugh, family may get worried or angry. So, what’s the solution? The internet might help, social networks might help. Or not. Let’s start by looking back to a couple of years ago… The subject of adolescent suicide created a media firestorm in the spring of 2017, when Netflix released the American tv series 13 Reason Why (seeing Selena Gomez as the big-name executive producer) based on the story of high-school student Hannah Baker who leaves behind 13 tape records detailing why she took her own life. I binge watched the first season in less than a few days. This is not just a teen-drama, it is aimed to the entire family. Being actively involved in adolescent mental health myself— I talked about adolescent depression in my previous blog on Inspire the Mind — I strongly believe that there is an urgent need to increase the awareness about adolescent suicide. After the broadcasting of the show, the public opinion was completely split between those promoting it even in schools, for sensitizing teens about suicide and bullying, and those harshly criticizing the cruelty and bitterness of some scenes. Indeed, it is quite difficult to be untouched while watching bullying and rape scenes as well as the graphic depiction of suicide in the last episode of season 1 (this scene was then deleted by the producers, but unfortunately, we — almost all — saw it). Some have criticised the series for displaying suicide as a solution to difficulties in life, describing absent parents and sloppy guidance counsellor, others appreciated the fact that suicide was taken to the forefront of public attention, together with other frequent problems faced by adolescents, such as peer pressures, sexual assault, aggressions and bullying. Mental health groups tended to go against the series , pointing out that the show is ‘glorifying’ and ‘romanticising’ suicide, which might be a trigger for vulnerable child not coping with their struggles. The main fear is that the show might do “more harm than good” since it is not providing an alternative way out to suicide — but that suicide is actually ‘glamourized’— and little is discussed about depression and mental health as a possible cause underlying the risk for suicide. In the United States, some high schools even sent emails to parents cautioning them about allowing teens to watch the show. Yet on the other hand, the Michigan’s Oxford High School create the initiative “13 Reason Why Not” in which students praise the people who help them. Students recorde themselves talking about their struggles or everyday problems and broadcast them over the school intercom, thanking those who helped them during difficult times. The criticisms might be right but let’s not stop here. The writer of the show, Nic Sheff, suffers/ed himself from suicidal thoughts, as he explained in an open letter to Vanity Fair. He explained that the idea was to let adolescents know that they are not alone, let them see the light at the end of the tunnel and to not hide a topic that is real: reality should always be faced. The aim of the show was to sensitise the public regarding suicide and this is clearly visible by the help resources provided at the end of each episode, showing that they are aware of the strong impact of the show on adolescents as well as young adults. But how can you help yourself when you are experiencing your own troubles with suicidal thoughts? Firstly, don’t be afraid to ask for help… Sometimes admitting you are dealing with a problem is the hardest part. And things get even harder when you feel alone and abandoned, even if you are not. How many times have we found us facing insuperable problems? I guess too many times. But every time we ask for help, we take a massive step in fighting these struggles. Therefore, asking for help is crucial… so, how can we ask for help in the darkest moments? How can adolescents do it? Suicide and social networks As we all know, adolescents spend the highest amount of time social networking on so many platforms that all the grown-ups barely know — and I am saying this myself: I am 27 years old and I am surely the most into-it among my friends, but still don’t know many brand-new social networks. A recent survey among American teenagers showed that 95% of teens (aged between 13 to 17) have a direct access to a smartphone and 45% of them are online on a near-constant basis, which means almost always. Moreover, given the increase in popularity of social media, and that their use has been classified as a risk factor for adolescent mental health — as already described in this blog on Inspire the Mind — a “mental health and suicide prevention machine” has also been activated on social networks. Social media could be a double-edge sword: there, you can ask for help or find the trigger for precipitating further in the darkness. Adolescents themselves have pointed out the negative aspects of social networking, such as bullying and peer pressures. Given the significant amount of time spent on social media, the funders of these virtual playgrounds have tried to go for the “suicide prevention mission”, introducing security tools as well as an algorithm for screening dangerous posts. For example, in March 2017 in the United States, Facebook introduced the use of machine learning to expand their ability to get help to people in need. An algorithm flags a post as “dangerous” and sends it to the Facebook’s team of content moderators; in case the post’s content is concerning, it is sent to a trained team who can actively analyse the content and interact with the user. In milder cases, Facebook send the users suicide resource information, whereas in the worst cases it might ask for a wellness check, which means calling emergency responses regarding a possible suicide case. Please note: this procedure is not active in Europe due to the GDPR privacy legislation. And what if you read something alarming while scrolling your Facebook page? We can all report suicidal content on social media, as it is quite simple on both Facebook and Instagram. Other social media platforms include “help centres” where everyone can easily access in order to obtain information about who call in case of emergency. Hotlines and chats Hotlines and chats provide direct and immediate help. Here you can talk one-to-one to real people in real-time, without being personally face to face. In the UK, The Samaritans offers a 24-hours free hotline service as well as the possibility to write them an email (they guarantee a quick response within 24 hours). When calling the Samaritans, a volunteer picks up the phone and gives you free space to explain your problems, without any limitation. The volunteers do not judge the caller in any way but genuinely listen and give advice on what is more appropriate. The service is completely free and above all anonymous and confidential. Anyone can call, talk, cry or unload the burden. Some users have explained that being able to talk to a Samaritan means a lot, especially considering that you can call them in the middle of the night when is not possible to wake up a friend or a relative. Moreover, we all know that sometimes it is so much easier to express our feelings to a non-judgemental stranger rather than to someone we care about and cares about us, or that we are afraid how they might judge us. Besides the most famous ‘The Samaritans’, other valuable resources are available in UK: - NHS offers a website for those seeking for help - CALM (Campaign Against Living Miserably) offers a chat and hotlines service from 5pm to midnight - Papyrus (Suicide Prevention Charity) offers similar service for adolescents and young adults under the age of 35 - Childline helps children and adolescents under 19 years old - Shout (for support in a crisis): UK’s first 24/7 text service - 999 helps you in the worst case, when you are in real danger of hurting yourself or have hurt yourselves. Similar resources exist worldwide… Facebooks and Instagram provide an extended list of emergency number and website for several countries and languages. Since I am working also in Italy, I am quite familiar with the Italian service Telefono Azzurro, which provides help for adolescents and children. If you are reading this blog from other countries, please note some other examples: - Worldwide: Befrienders - U.S.A: National Suicide Prevention Lifeline - Germany: Telefonseelsorge - Australia: Lifeline Australia - Austria: Rat auf Draht - Brazil: CVV - France: S.O.S Amitié - Nigeria: Nigeria Suicide Prevention Initiative — NSPI - Spain: Teléfono de la Esperanza The important thing for you to know is that the most appropriate help centre number or chat in the country you are living in is usually suggested automatically if you search “suicide” or related topics on google. Fortunately, it is easier to reach helping sources rather than pro-suicidal forums and information. While writing this blog, I did not find any pro-suicide information, and every time I searched for suicide-related topic the first results were helping forums and useful numbers or chat. Are we doing enough regarding suicide help awareness? Before writing this blog, I was not aware of many of the help resources available for those struggling with suicidal thoughts. This is because I have never come across advertisement or social networks’ posts about sensibilisation and help resources. Maybe this is where we should all start, sharing help resources and paying more attention to those around us. Personally, I am also thinking about becoming a volunteer for one of the mentioned associations, like Telefono Azzurro in Italy. In conclusion, to all of you struggling and in pain: remember you are not alone, you can ask for help, and there are plenty of ways to get better. You got this, we got this together.

“We live in unprecedented times”. It’s been said so much, the phrase has lost its meaning. Lockdown brings its challenges, but it has also brought various blessings. Our family is made up of me, my husband, who is a teacher, and our two boys aged 5 and 7. I am currently training to be a Clinical Psychologist after having completed my PhD which examined stress, psychosis and cannabinoids. We are trying to get by in our two bedroom flat which has a small balcony. In our house, we are coming from a unique position in the lockdown parenting journey. As I write this, sitting on my balcony, we are having an unusually warm and sunny spring day. In our area, it is not clear that lockdown is happening. It is a hive of activity. Normally, I might be outraged at this, but I live a stone’s throw from the new NHS Nightingale which has valiantly been put together in a few short weeks. The monotony of lockdown is broken up by waving at police officers, running to see mounted police, the comings and goings of various NHS staff, army personnel, and my personal favourite, chatting with the security guards who open and close the gated access to the ExCeL centre; they even joined in when we sang ‘happy birthday’ to my neighbour from the balcony. Another aspect to our situation is that I have recently had three surgeries, six rounds of chemotherapy, and 23 fractions of radiotherapy. I have been told to be very strict about the social distancing guidance. Until recently, we did not go out at all as I was anxiously awaiting my third surgery. I did not want to risk contracting Covid-19 and delaying my surgery. As it was, very nearly didn’t go ahead as my hospital cancelled all operations, luckily a collaboration with a private hospital meant I was lucky to have got my surgery. Many other patients were not so lucky and have faced agonising delays and cancellations. Friends and acquaintances have been shocked by our ability to stay inside; at the time of my writing, we had stayed inside for 35 days and did not leave the house at all. Their shock is due to my boys’ activity levels. I wonder if the lock-down might be different with more placid children. A typical week for my eldest consists of four hours of gymnastics, one and a half hours of swimming, two hours of football and an hour of Karate. I’m no tiger Mum; they just love sports and have boundless energy. Normally on the weekend, if we have not left the house by 11am, they are bouncing off the walls, but today, it’s a leisurely 2.20pm and we are enjoying basking in the sunshine, using our own devices, but very much together in the small balcony. We are helped greatly by our school that has utilised educational technology, keeping them occupied during the school day. Our Karate club that does lessons three times a week, and local charity West Silvertown Foundation who host zoom quizzes and activities. We have also discovered that our boys are indeed capable of sitting for 4 hours and playing a board game: Monopoly which my husband lost, and I became bankrupt shortly after. I even persuaded my normally art averse kids, to paint a rainbow with me for the balcony window. I can’t help but feel grateful at our situation. We are inside, we are together and, we are safe. I can’t say the same for the gallant workers who are keeping our country running. I am a psychologist, and even my colleagues are donning the scarce PPE to do their job, a colleague in Ireland has even been redeployed as a COVID tester. Who would have ever thought that Psychologists would need the same equipment as our medical colleagues? This isolation has also shown me how many wonderful people we have in our community. From my neighbour across the dock who gave me half of her pack of precious toilet roll that she managed to track down, to the neighbour in our building who sent down cake when he was celebrating his boyfriend’s birthday. Almost daily I have someone texting telling me they are going shopping, and do I need anything. I have to go to the hospital next week and I’ve had several medical friends offering to bring me a mask to wear (one even offered to cycle from Barnes-which is 13 miles away!) I have also just seen a man set up a lemonade stand to give to NHS workers on their way to the Nightingale. Kindness and joy is all around us during this scary and sad time. All in all I think we have been quite lucky in this isolation, the boys have been very resilient, a bit of bickering, but nothing that has had me pulling my (very short) hair out! However, I have noticed that the boys sometimes look out the window and talk about how naughty people are for going outside. Clearly the message of ‘stay home, protect the NHS, save lives’ has really gotten through to them. I’m not sure how? I don’t think I’ve exposed them much to this advice. My eldest son has red raw hands from washing them which started before we started to isolate. I worry about the effect this isolation is having on them. How will the very real risk of contagion currently, affect them years down the line? Will they continue to feel like washing their hands keeps them safe, even when the risk of this virus is gone? Will it become problematic? Will they be frightened to go outside once we can safely go outside? Is there something I should be doing to prevent these things I’m worrying about? I asked my kids how they felt the other day. My eldest’s response? ““Me? I’m fine! I’m inside, I’m safe. I’m washing my hands, I’m safe. I’m with my family, I’m happy!”” Header imag by Eli Lune from Pexels

Part 2: The role of Governments By Ellen Lambert and Emily Hayes You might have caught part one of this blog series last week, where we introduced the subject of behavioural science. We defined a key model of behaviour change and reflected on what we have learned about human behaviour from past pandemics. If so, thanks for returning! And if not, you can check out what you missed here. In part two of this series, we will review messages from government and public health authorities both in the UK and internationally in response to the current pandemic we are facing. We are aware that government responses, in general, are a contentious and emotive issue. The scope of this article is, therefore to analyse these messages through the lens of behavioural science. We also acknowledge that when we look back at the early phases of any outbreak or disaster scenario, we are commenting from a place of informational privilege… a place with more data, more graphs and more clues. Therefore, it is easy to look back and say… “well, that was a silly idea!”, when in fact we did not have adequate information to know that it would have had such negative or unproductive consequences. We are mindful of this retrospective bias, and hence attempt to pursue a reflective stance that draws on as much objective data available as possible. Public beliefs and behaviours regarding the UK government’s coronavirus strategy — a look at the numbers Many surveys have been carried out in the UK to help us better understand public beliefs and behaviours during the coronavirus pandemic. Our twitter feeds are absolutely full to the brim with invitations to take part. Thankfully, what these surveys seem to show is that key messages are getting out there. In a poll conducted by Ipsos MORI (a private research company) in late March, 97% of individuals aged 18–75 who took part said they had heard about how to protect themselves from coronavirus from the government. More recently, in April (things move fast at the moment!), a similar poll was conducted by Ipsos MORI and King’s College London, with a larger sample of 2,250 UK residents. They found that: 58% thought the government had responded well to the shifting scientific advice and situation. 89% supported the current measures being used to contain the virus. 69% had at least ‘a fair amount’ of trust in the government’s ability to control the spread of coronavirus. 76% had at least ‘a fair amount’ of trust in the information the government is providing, though only 25% of these had ‘a great deal’ of trust. The importance of government trust was discussed in detail in our blog last week and will be further discussed in our international case studies later on in this blog. Interestingly, only 14% of respondents thought ‘too much fuss’ was being made about the risk of coronavirus, which contrasts with 55% who believed too much fuss was made about the swine flu outbreak in 2009. This is encouraging since evidence from the swine flu epidemic tells us that if governments are seen to be making ‘too much of a fuss’ early on, this can undermine public confidence. In the case of swine flu, those who had less confidence in the government were less likely to accept the vaccine once it became available. That being said, in the same April poll, 42% of respondents felt that the government’s response had been confused and inconsistent, whereas 31% disagreed with the statement. The problem is that confusion can be created by just a few words. For example, on the 3rd of March the Government was rightly keen to emphasise the importance of handwashing. However, the scientific guidance published on the same day also pointed to the avoidance of close-contact greetings, such as shaking hands, to avoid infection. The video shows the potential source of confusion: Boris Johnson said he was shaking hands with coronavirus patients just weeks before he tested positive for Covid-19. The prime minister confirmed he had ente... Washing hands? Shaking hands? Washing before shaking? A clearer message would have been easier to follow. In addition to this, on 16th March, 2020, the government recommended that “Everyone should avoid gatherings and crowded places, such as pubs, clubs and theatres”, and that “All ‘unnecessary’ visits to friends and relatives in care homes should cease”. Despite this, these venues were not officially closed until the 21st March — 5 days later. This might have generated confusion as to what ‘avoiding gatherings’ or ‘unnecessary trips’ meant. These mixed messages may have created barriers to behaviour-change (social distancing) as we were not presented with clear instructions (capability), we were still able to access crowded places (opportunity) and being told to try and avoid places did not convey the importance of social distancing (motivation). Of course, the other side of the ‘behavioral science’ coin is that the Government might have been worried that on the 16th of March it was ‘too soon’ to impose the full lockdown, as people might have not seen yet the intervention as proportionate to the threat, and thus not adhere fully, or not for long. This element also feeds in the ‘motivation’ process which brings the behaviour-change. In fact, according to the same April survey, a quarter of UK respondents believed the virus came from a laboratory (aka, was manmade!). Interestingly, these respondents were about twice as likely to break the lockdown measures by meeting up with friends, and to think too much fuss was being made about coronavirus. This clearly demonstrates the importance of our beliefs (motivation) and knowledge (capability) when it comes to adhering to protective behaviours — concepts which were discussed in last week’s blog. Simply put, it is just not that simple to change behaviour, or to plan how to best do it. Encouragingly though, most people appear to be following the measures and performing behaviours as advised by the government. The majority of respondents in April (87%) reported “leaving the house as little as possible” all or nearly all of the time. On the other hand, some reported performing behaviours that have not been recommended, though it is unclear whether they are performing these as well as, or instead of, the ones that are recommended. Particularly problematic amongst these statistics are the reports of individuals using antibiotics because they believe they may prevent the spread of coronavirus. Only 7% reported doing so, this amounts to 157 individuals in this particular survey. However, we know that antibiotics do not work for viruses — like coronavirus — and that overuse of antibiotics causes resistance which is a serious global health issue. This is because a growing number of infections are becoming harder to treat as the antibiotics used to treat them become less effective. So, let us use this blog to emphasise this one more time: do not take antibiotics unless prescribed by a doctor! Using behavioural science to tackle the spread of COVID-19 — what are the other countries doing? Governments around the world are taking a wide range of measures to tackle the current coronavirus outbreak, and their responses continue to vary widely both in timing and in stringency. Academics from the University of Oxford have launched a tool to track government responses called the Oxford COVID-19 Government Response Tracker (OxCGRT). This tool systematically tracks thirteen indicators such as school closures, travel bans, and public transport closures, to generate an index that compares the stringency of policy responses around the world. Whilst the ‘Stringency Index’ is not a direct measure of “the appropriateness or effectiveness of a country’s response” to the pandemic, it’s a great first step towards understanding which measures have been effective in certain contexts and why. From this “heat map” we can see that countries in red have the strictest policies to contain the spread of coronavirus according to the indicators considered in the research. On the 30th March, such countries included New Zealand, France, Italy, Mexico and Argentina, to name a few. It will be interesting to watch this infographic change over the next few months, as selected countries move out of lockdown and begin to open up again. In our previous blog, we talked about how government communication can support us to change our behaviours in protective ways by doing the following things… letting us know what is expected of us to reduce the spread of COVID-19 in a clear and succinct format, explaining why this is the case, and… stating clearly what support is available. An example of a country which seems to be ticking a lot of boxes is New Zealand; a country with so few deaths related to COVID-19 that the prime minister Jacinda Ardern still receives a personal phone call regarding each one. As well as continuously keeping the public informed, many have noted that the language Ardern has used in her public communication has been simple and clear: the nation should stay home and have no contact with anyone outside of their household “bubble”. Furthermore, “key workers” and “essential journeys” were clearly defined early on, which left very little room for interpretation. The New Zealand prime minister also released and clearly explained the rationale behind an “alert level framework” for her government’s decision-making regarding coronavirus. The framework enables her citizens to make sense of what is happening at any given moment and why — helping to reduce any confusion or misinterpretation. Such clarity and decisive action seem to have won her many fans. But more importantly it has won her public trust and confidence, and importantly high levels of behavioural compliance. New Zealand’s prime minister has utilised other techniques from behavioural science too. You might remember from our blog last week that behaviour can be influenced by drawing on emotions such as empathy and solidarity. For example, by highlighting how our behaviour can benefit others in our community — especially those more vulnerable — and by using language that centres around “we” and “us” rather than “I” or “you”. Jacinda Ardern, has drawn on emotions such as empathy and solidarity, and has added a real personal touch to her formal and informal briefings. Instead of declaring war on COVID-19 like many other countries such as the United States, the NZ government’s narrative was that of a country uniting against the virus, with Ardern repeatedly calling the country a “team of 5 million” and asking her citizens to come together and “be kind” in personal videos from her sofa at home. After putting her daughter to bed, New Zealand prime minister Jacinda Ardern hosted a Facebook live Q&A focused on coronavirus. Ardern implored New Zealander... A different country, a little closer to our home, that also communicated its strategy to its public very clearly and accurately is Germany. In a speech which has since gone viral, Chancellor Angela Merkel (who holds a doctorate in quantum chemistry) was able to personally deliver to the public the science of transmission, and hence the rationale behind her lockdown strategy. Similar to New Zealand’s leader, Merkel’s confident and clear leadership is believed to have contributed to recent approval and confidence in her approach to managing the pandemic. The German chancellor, Angela Merkel. has been praised for her explanation of how the coronavirus spreads and why deciding when to lift a lockdown is such a ... As two female scientists ourselves, it is really interesting and encouraging for us to see that female leaders appear to be “disproportionately represented to a rather startling degree” among countries successfully managing the crisis. You can read more about other female leaders in this Guardian article. So, how are we doing in the UK? Since we are both living here, we were able to more closely follow the timeline of communication as it has developed in this country. As we noted earlier, initial communication had room for improvement. However, when looking at the UK guidance currently available on the gov.uk website (see screenshot below), we can see that it does well to spell out what is required of the UK population without using jargon like “social distancing” (WHAT & WHERE) The message explains the reasons we should enact these behaviours: not spreading the virus, protecting NHS, saving lives (WHY) And it explains two ways of preventing the spread — washing hands, staying at home (HOW) If we are being picky, it could be more explicit about individuals who need to collect medicines, what the rules are about exercise, and what is expected of vulnerable people. But keeping things simple, concise, and easy to remember is best. The unintended consequences of behaviour change We should not forget that behaviour change interventions can have spill over effects beyond the health-related behaviours they intend to target. A critical issue concerns how the measures taken to curb the spread of coronavirus are affecting mental wellbeing worldwide. The April survey referenced earlier in this blog in relation to public opinion of government strategy also recorded information about public wellbeing and other health-related behaviours in UK citizens. It reported some negative changes in health-related behaviours as a result of the coronavirus. For example, around a third reported eating more or unhealthier food than normal, and around a fifth reported drinking more alcohol (for more information on the nuanced ways our drinking behaviours are changing with coronavirus, check out this interesting report from Alcohol Change UK). Regarding the psychological wellbeing of respondents, half of individuals surveyed felt more anxious or depressed than normal as a result of coronavirus, and 38% had problems with sleep. Worryingly, 15% were already finding it extremely difficult to cope with the lockdown measures, and younger people aged 16–24 seem to be struggling the most according to this survey. Positive behaviours were also found. For example, the majority of those surveyed were contacting friends and family more by phone, video or text, and were offering help to others during the lockdown. However, a quarter of those surveyed reported checking social media several times a day for coronavirus updates, a behaviour believed to negatively affect psychological wellbeing. For example, a study conducted in China found that excessive social media use can take its toll on mental wellbeing, with higher rates of social media exposure associated with poor mental health during the pandemic. It is thought that the pandemic may have a ‘profound’ and ‘pervasive impact’ on global mental health. To maintain motivation for the lockdown measures, appropriate support must be provided to those in need. For example, governments can invest in tools to provide us with an opportunity to support our wellbeing during the lockdown. One example of a country thinking ahead and doing just that — as if we haven’t fangirled them enough already — is, again, New Zealand. Their government has diverted part of their Covid-19 response health package to fund three mental health apps to enable people to cope with the tremendous changes they are facing in their daily lives. In the UK, the NHS Every Mind Matters campaign also offers great advice and varied support for mental wellbeing during the lockdown — covering mental and physical health, practicalities like employment and benefits, and advice on limiting social media and identifying trustworthy sources. Finally, we already know that the virus will have the greatest impact on the most deprived in our society. This is due to things like the economic impact hitting hardest those on the poverty line and those living in cramped conditions where the virus can spread more easily. It is also expected that the virus will lead to wider inequality in society. The United Nations are working on a global response to support the most vulnerable groups, “women, children, people with disabilities, the marginalized and the displaced“. Poignantly, the United Nations Network on Migration have stated: “COVID-19 does not discriminate, nor should our response”. People need to know how and where to find food, appropriate shelter and safety from abuse — to name just a few. Whilst the greatest responsibility sits with governments and relevant organisations, we can also play a part. For example, by supporting charities that protect the vulnerable — whether that’s through donations, fundraising, volunteering or spreading the word — and by looking out for the people around us. Behavioural science can help us understand how to change behaviour — but only empathy can help us make sure that nobody is left behind. Header Image Source: 10 Downing Street

When I was invited to write about mental health for this blog, I struggled to find a topic. I was suggested: just think about why you find mental health research particularly interesting. As an undergraduate Neuroscience student, my answer would be expected to be relatively ‘scientific’ — maybe there is a specific mechanism that attracted me to it, maybe I recognize the toll mental health has taken on our youth today etc. The truth is: most researchers will have a personal reason that drew them to their field. My personal reason? I grew up in contact with close friends and close relatives struggling with depression or other mental health disorders. Moreover, I grew up in Italy and Brazil — countries where the stigma is still heavily felt. A study has shown that, in a cohort of 1000 Italians, 75% believed that those suffering from depression should avoid talking about their problems, and most seemed to look down on pharmacological treatments as addictive. In Brazil, access to psychiatric treatment is still insufficient despite its world-leading rates of depression and anxiety. I am currently involved in a research project regarding Major Depressive Disorder. If you are reading this blog, chances are you know, or know of someone in your family, amongst your friends, in your group of extended acquaintances, that struggles with it. It seems that it is very common. According to the WHO, over 300 million sufferers worldwide. I will tell you the story of someone I know, a close relative. She has been suffering from depression for years. The first diagnosis only came during her late teenage years, following a tormented youth filled with teenage anxiety and angst. During a certain period of crisis that seemed to be endless, she uttered the words to our close-knit family: ‘I think I have depression’. It wasn’t completely unexpected — it can happen to anyone, right? My first thoughts? This could not happen so close to me, not to her. It had to be a mistake. We had grown up so close, we share our lives, we share genes. Despite our same genetic background, I could not understand what she was going through. How could this be? I consider myself outspoken in many social causes and movements, and the fight towards the breakdown of stigma around mental illness is no exception. However, when you find yourself or a loved one under the critical magnifying lens of society, it becomes difficult to accept. Internalized scrutiny can get to you. Today, I regret my first reaction. My first reaction was to say that she was wrong. She visited psychiatrists and I hoped they would say that was not her diagnosis. After all, no one wishes to receive such a diagnosis. However, in context of suffering and desperation, diagnostics can be freeing. It provides you with an explanation, a possible cause for what seemed to occur out of the blue. It provides a patient with hope of finding help. Now I know I was young and, frankly, ignorant. All of this unraveled when I was only sixteen. I could barely understand my own feelings, let alone explain them rationally. I had never experienced open conversations about mental health. Although I had heard of it, I could not entirely grasp what was taking place and what was to follow. When it came, my first thought was that they would follow a treatment plan and it would pass. The process of actually finding the combination of pharmacological and psychological treatment was long and strenuous. Eventually she did feel better, but as anyone in this situation knows, the road to recovery is not a straight line. Some days are better than others, some months are better than others, some therapists and antidepressants will work better than others. Unfortunately, statistics are not favourable. Following a first depressive episode, the probability of having a second one skyrockets. So, it can become a life-long illness. This story is mainly about the millions of sufferers — but also involves me and you, if you, like me, are close to someone suffering from depression. The so-called support network around each patient. We each play a role in these personal stories. Depression is heterogeneous and affects many areas of life leading to a range of symptoms that may change from individual to individual. Symptoms include loss or gain of appetite, weight gain or weight loss, cognitive problems, sleep disturbances of hypersomnia or insomnia, memory deficits, suicidal thoughts, feelings of hopelessness and excessive guilt, negative rumination. Therefore, my personal experience will not apply specifically to someone else’s interpersonal relationship with a sufferer of depression. Although the overall grief, sadness, lack of motivation and pleasure are core traits of this disorder, each individual will cope with them in different ways. Some more openly, wanting to talk about it. Others, simply wishing to be distracted from the situation. In any case, this shows that many approaches can be taken to provide at least a sliver of help to those around you. Why is this important? Research has shown that having a strong social support base is essential to learn how to cope. This places part of the responsibility on us, those who play the supporting role. What can we do? Help them manage stress. We have seen in a previous InSPIre the Mind blog how stress plays an important role in depression. Doctors often tell their patients about stress management, and it seems like the solution for everything. First of all, one can help a close friend manage their stress by helping their nutrition: eating together, providing a nutritional diet, cooking together. The importance of nutrients such as omega-3 fatty acids in a depressive patient’s diet has been explained previously in another of our blog. Another easy tip is to possibly go with them for a walk or even on a run, if possible. Physical activity has repeatedly been shown to be effective in the treatment of depression. Moreover, sunlight exposure also seems to have beneficial effects and so it could definitely be helpful to get out in the sun for some exercise. You can even help them with chores. For depressed individuals, it becomes difficult to get out of bed at times, and chores become insurmountable obstacles. This shows that you are there for them and a support. Most importantly: understand them. Seek to understand what they are going through and try to put yourself in their shoes. Giving them a call, checking in on them once in a while, having a get together: this can help them feel loved and may also influence their decision to seek help. Research has shown that putting your feelings and thoughts into words, also known as ‘mentalizing’, can help you cope and work through them. In my experience, understanding can include reassuring them that they have done nothing wrong or embarrassing at a social gathering. That they were invited for a reason and people were happy to see them. It has included helping them take a bath. Trying to distract them from their thoughts and trying to drag them out of bed. Making them laugh at their own obsessive thoughts and negative feelings. It includes understanding that if they show distance to you, it does not necessarily have to do with anything you have done. The relationship may feel one-sided at times, but try to stay close. Asking them to help you understand is not only helpful to you to gain insight into their situation, but it also helps them get their thoughts out. Finally, what NOT to do. An easy ‘manual’, I have found the ‘What Not To Say’ campaign by Sarah-Louise Bingley, designer and art director, consisting of a series of prints presenting unhelpful phrases that are usually suggested to sufferers of depression. These include: “You can’t be sad all the time”, “Lighten up” or the most common “Snap out of it!”. We often hear in mainstream media “Happiness is a choice” but, unfortunately, it is not. And sadness is not a choice either. All in all, there is no exact advice you should follow. This is what I have learnt from my experience. Each relationship will follow a different dynamic. Depression and antidepressant treatment affect each individual in a unique way and this will determine the suitable course of action for who is close. The important thing is to stay close. Read about it. Understand. This is the reason why I do what I do today. This is the reason why I have written this blog. I felt limited in the way I could help, but in this way I have been able to combine my passion for neuroscience and activism with my love for my own support network, into one. I aim to continue to contribute to the treatment of this illness. Below you can find a poem from the button poetry project by Neil Hilborn. This is a written transcript from a spoken word poem, and I do not claim to have any rights over it. I believe this can summarize how it can be difficult to accept that other people may be going through the same struggles as you. Button Poetry Neil Hilborn — “You can’t be depressed” “Aaron Rodgers, probably the best Quarterback to ever play the game, Has those bags under his eyes that tell me he’s been eating a lot of cold Mac ’n’ Cheese in bed with the lights off. Aaron Rodgers looks how I really feel when I say ‘I’m doing great.’ Aaron Rodgers makes $22 million a year, And yet he still looks like his dog bit him after calling him a selfish person. Aaron looks like he last slept in 2011, maybe, And he’s playing like he’s thinking about how he needs to wash his sheets. He’s playing like, how he hasn’t washed his sheets in 5 or 6 months. He’s playing like he’d was his […] sheets if he could stop […] crying for one […] minute, But maybe I’m reading too much into this. I find myself saying out loud, ‘How is he depressed? He makes so much money and his life is perfect.’ That sounds like the last time someone said to me ‘How are you sad when you have your dream job?’ Or, ‘you get paid to do your art, and you’re in perfect health, and you’re engaged to someone who loves you, You don’t have any reason to be depressed.’ But there doesn’t have to be a reason. The brain is clay but the mold is persistent. The brain is a shape, and you can only see the shadows. The brain remains a brain no matter how much cash you stack around it.” Header image Source: Natalia Mikhaleva’s ‘Mental Health Support’ Project

(Part One of Two) By Ellen Lambert and Emily Hayes Pandemics like the current one with COVID-19 are caused and contained by how people behave: each person’s chance of contracting the virus depends not only on their own behaviour, but also on the behaviour of their fellow citizens. There are a number of things we can all do to slow the spread of infection, reduce strain on the NHS, support our wellbeing and the wellbeing of others. The authors of this blog (Ellen and Emily) are two graduate psychologists with a keen interest in health psychology and public policy. We graduated together from the Department of Behavioural Science and Health at University College London a few years ago. Emily currently works at the Centre for Behaviour Change at UCL and Ellen is a member of the Stress, Psychiatry and Immunology Lab, the team who bring you InSPIre the Mind! We have chosen to write this blog together because we think it’s important to consider how scientific theory and evidence can help us understand and change behaviour in these testing times. In part one of a two part series, we define a key model of behaviour change and we reflect on what we have learned about human behaviour from past pandemics. Part two will be published next week and will review messages from government and public health authorities in response to the Coronavirus both in the UK and internationally. Capability is our physical and psychological ability to enact a behaviour. For example, our psychological capability is increased when we receive clear and simple guidance and instruction, like learning how, when, how long and where to hand wash properly. Repeatedly practising a behaviour helps us to perform it effectively and self-imposed action plans and if-then rules can also help to increase our capability. For example, if we leave the house, we will wash our hands immediately on our return. Opportunity relates to our social and physical environment. We can try to remove social barriers that might get in the way of us changing our behaviour. For example, we can ask others to remind us not to touch our face when they catch us in the act, and we can normalise new behaviours by explaining them aloud. Before the lockdown, we were in a café when a man arrived for a job interview at the opposite table. He politely announced that he would not shake the interviewer’s hand due to the current situation. This prevented any awkwardness, and everyone understood why the usual social custom had been avoided. You can apply the same idea during essential trips outside, if you feel unsure that others will observe the 2-meter rule. A signal of sticking an arm out has become a visual “nudge” to remind others to keep to the recommended distance. To improve the physical environment to promote health behaviours, we can ensure we have resources to hand, like a sensible amount (e.g., without stockpiling) of soap, tissues and sanitiser, and we can use prompts to remind us to enact a behaviour. This excellent website creates hand washing posters with the song lyrics of your choice — great for if you need a break from singing happy birthday! Motivation can involve conscious intentions and evaluations (reflective motivation), and habits and emotions (automatic motivation). Choosing to support the NHS and avoiding breaking the law/having to pay fines are examples of reflective evaluations that drive our motivation to stay indoors. We have both also created an action plan for exercise, where every day at 5pm, Ellen practices yoga and Emily does a fitness video for half an hour, both of us trying to stick to routine and so doing this in the same room each time. Repeating behaviours, especially when done at the same time and in the same place, can eventually help us to form lasting habits — thus increasing automatic motivation. Authorities can influence automatic motivation by drawing on emotions such as empathy and solidarity. For example, by highlighting how our behaviour can benefit others in our community — especially those more vulnerable — and by using language that centres around “we” and “us” rather than “I” or “you”. Public health and government messages can support us by: letting us know what is expected of us to reduce the spread of COVID-19 in a clear and succinct format, explaining why this is the case, and stating clearly what support is available. Experiencing positive emotions, such as enjoyment, can make new behaviours easier to maintain. Video calling apps like Zoom and Houseparty have soared in popularity and allow us to substitute actual meet ups with virtual ones. They can provide us with much needed social contact and enjoyment whilst staying at home. They helped us to plan this blog and have been used to host quizzes, movie nights and soon, Emily’s 30th birthday (not quite the party that was originally planned…). We can also apply the COM-B model to help us to perform behaviours that can support our wellbeing during the lockdown. For example, after listening to a presentation by Dr. Ben Gardner at the ‘health and wellbeing during the Covid-19 pandemic’ public webinar series hosted by the Institute of Psychiatry, Psychology and Neuroscience at King’s College London, we were both inspired to try to reduce the amount of time we spent sitting at home. Emily created a standing-desk (from books and an ironing board), whilst Ellen filled up small glasses of water rather than pint glasses — both of which provided opportunities to reduce our sedentary behaviour. Most importantly, we must try to be kind to ourselves. Changing and maintaining new behaviour is not easy at the best of times and slip ups happen. We must be worried enough to take action but not so worried that we start to panic (read here for a great guide on dealing with worry during the pandemic). Diving into the past: examples of human behaviour during past epidemics Now that we’re clear on the fundamentals of the COM-B model, let’s take a look back at some epidemics that occurred in the past and how humans behaved, keeping in mind the three key components of the model… Capability Regarding “capability”, the importance of clear communication from trustworthy institutions, and the damage that disinformation can cause, were clearly exhibited during the outbreak of the Ebola virus disease in the Democratic Republic of the Congo a few years ago. During this time, internet trolls were spreading fake news across Facebook and WhatsApp that accused the USA of bringing Ebola to the region, blamed foreigners for the ongoing spread in the Congo, and recommended false cures such as eating bitter nuts from the kola tree or bathing in hot water and salt. In a study recently published in the Lancet journal, it was reported that over 90% of 961 interviewees from Beni and Butembo (two cities affected by the virus) had heard either that Ebola did not exist, or that it was fabricated for financial gains or to destabilise the region. These rumours became foundations for belief in some citizens, as the same study reported that less than a third of interviewees felt that they could trust official authorities, and more shockingly that more than 25% believed that Ebola was not real. Tragically, this led to targeted attacks on medical centers treating patients with Ebola, and contributed to the widespread distrust of health workers, reluctance to seek health care, hesitancy to accept the vaccine, and a lack of engagement in general protective and preventative behaviours that would have helped to stop the spread. The fast spread of misinformation through social media has also occurred during the current coronavirus pandemic. For example, did you hear over the last few weeks that: The army was about to shut down London? People were in hospital because they took ibuprofen when they had the virus? You can tell if you have the virus by how long you can hold your breath for? Oh, and let’s not forget to mention that gargling water for 15 seconds can cure you?! We’ve both been sent some combination of these messages via social media platforms like WhatsApp and Facebook, and a number of dangerous conspiracy theories have also been circulating. You can read a blog from a fellow InSPIre the Mind writer who is writing a series debunking such myths. So, we guess the next big question is: how can governments and public health officials fight conspiracy theories and dispel false claims that so often mislead people about the risks they face and how to protect themselves? Well, it’s complicated. Research in behavioural science suggests authorities are likely to face an uphill struggle to maintain public trust whilst ensuring their own clear and authoritative guidance, as our use of social media to share information continues to increase. During the Zika outbreak in Brazil in 2015, two online experiments showed how efforts to counter misperceptions about diseases during epidemics can be counter effective. The researchers found that providing corrective information to the public that had been adapted from the World Health Organisation not only failed to reduce misconceptions about Zika, but actually reduced levels of confidence in their beliefs about the disease that were actually correct. Providing corrective information also contributed to panic and uncertainty in this particular case. Taken together, these examples show that, to ensure capability, it is exceptionally important that the public receives accurate information and clear guidance from a trustworthy source (e.g., Public Health England/ World Health Organisation) at the earliest possible timepoint, so as to reduce the potential for speculation. Opportunity Regarding the “opportunity” aspect of the model, we noted several examples showing how a change in social norms or a removal of social barriers can affect behaviour in a positive way during outbreak scenarios. One example occurred during the HIV outbreak in the 1980’s. Amongst the UK public, there was a lack of understanding as well as misinformation about how the HIV could be transmitted. This led to large amounts of unjustified AIDS phobia and homophobia. At the time, the Los Angeles Times conducted a poll and found that 50% of respondents voted in favour of quarantining people with AIDs and 15% wanted individuals with AIDS to receive a tattoo to make it apparent to other members of the public that they carried the disease. Shocking statistics. Princess Diana famously acted to change widespread beliefs about AIDS and attitudes towards people who had contracted HIV when she made a public appearance to open the first specialist HIV/AIDS unit. Without wearing gloves, she was photographed shaking hands with nurses and doctors working on the ward, as well as a patient on the ward who was suffering from the illness. These images became headline news at the time, and Diana was able to publicly challenge the notion that HIV could be passed from person to person by touch, which was widespread at the time. This contributed to a change in culture and a greater opportunity to enact safe and appropriate health behaviours. Another example occurred in Hong Kong after the SARS outbreak in 2002. From a stage at a busy shopping centre, the paediatrician Alvin Yee-Shing Chan broke out in song, reminding people to use gong fai — which is Cantonese for “serving chopsticks” — rather than using the same pair to serve and eat with. The same message: “Dine with serving chopsticks. Thou will not be sick” was promoted via television adverts. The Hong Kong Medical Association also gave away 150,000 pairs of neon orange chopsticks at hospitals and doctor’s offices. In order to increase hygiene and stem disease outbreaks, restaurants began to provide guests with two pairs of chopsticks that were decorated with different colours and accompanied by clear instructions: One pair is intended for serving food from a central sharing plate to your own plate, and the other pair is used to pass food from your plate to your mouth. This custom increased in prevalence and gave guests the physical opportunity to change their behaviour. Motivation Regarding “motivation”, the importance of initiating enough worry for the population to act was demonstrated in a study looking at behaviour during the Swine Flu outbreak in 2009. The research attempted to understand why not enough protective behaviours were taken up by the public during this time, and why vaccination rates were low. The national survey conducted at the time concluded that this was partly down to the low level of public worry about the possibility of catching swine flu. The same study found that motivation to perform a protective behaviour, such as handwashing, was linked to the level of belief that it would be effective against swine flu. On the other hand, whilst a little worry can be motivating, too much can have a negative impact when attempting to tackle an epidemic. Public health campaigns have been used since the 80’s to support HIV education and prevention, but despite this, nearly a million people globally still die from the virus every year. In a review of research from Australia, Canada and the UK, fear of a positive diagnosis and internalised stigmatisation were commonly reported as barriers to testing for HIV. Today, the UK-based “It Starts With Me” campaign aims to reduce fear and stigma by explaining that it is possible to live a long and healthy life after a positive diagnosis, and that testing should be part of a regular sexual health routine. The campaign also shows that it is easy to get tested for HIV — “a finger-prick test is all it takes” — and that this can even be done at home, by using a postal kit. These messages may target reflective motivation by improving people’s beliefs about their capability and the opportunity to get tested. Part one of our two-part series has demonstrated that the application of behavioural science is vital when considering human behaviour during a pandemic. We can learn from past experiences and theoretical frameworks allow us to systematically develop and evaluate interventions. Stay tuned for part two of this series, where we explore responses from government and public health authorities to the current COVID-19 outbreak. All in all, this is a challenging time for all of us affected around the world. We would both like to extend our gratitude to all of the frontline workers, social distancers and public health heroes. www.who.int/emergencies/diseases/novel-coronavirus-2019/donate Header Image Source: Poemsuk Kinchokawat on Dreamstime.com

You may be bored of hearing about blockchain as the panacea to all problems of the world. So am I (and I’m so intrigued by it that I even research it as a law lecturer). Nevertheless, the technology behind Bitcoin holds promises for the medical sector — from ensuring more accurate patient records to facilitating data collection for medical research. And, if we are to believe some tech companies, even contributing to a COVID-19 solution. Whether you are a medical doctor, a policymaker, a scientist relying on medical data for your research, or you are just curious, it’s worth knowing how blockchain can help you achieve your goals (and when it can’t). Still not quite sure what blockchain is? You’ve heard about blockchain so many times, but you’re still not quite sure what it is exactly? You are not the only one. Blockchain is the technology behind Bitcoin, thrown into the world after the 2008 financial crisis. Dis-intermediation was one of its core objectives: to bypass financial intermediaries (banks), it created a peer-to-peer digital network for financial transactions. Transactions are added to a blockchain ‘ledger’, which records every transaction ever submitted to it. The ledger is like an accounting book: it archives previous entries and shows you the current state of affairs. Blocks of transactions are grouped together chronologically, timestamped and linked by cryptography (computer code to keep data secure) , creating a chain of blocks that is very difficult to alter. This makes blockchain a transparent, auditable and tamper-resilient record-keeping technology. What’s special about this type of network is that it is distributed: all data ever added to a blockchain are distributed across all participants and the chain of information is constantly updated across the network. If a participant’s computer crashes, that’s no problem: all other participants still have a full copy of the chain of blocks and can continue adding data to it, constantly broadcasting new entries to all other participants. Soon it became clear that this type of distributed ledger technology held promising applications in many industries, not just the financial sector. Blockchain has been used to track the provenance of artworks and diamonds, to increase transparency in supply chains and to ensure authenticity of second-hand aerospace parts, for example. For the medical sector, too, there are a myriad of applications promising efficiency and transparency improvements, better data management and easier access to data for scientific research. Better management of medical data A person’s health data are often scattered around different, siloed (isolated), databases. Imagine Alice, an international student who recently moved to London. Part of Alice’s health records may be with her current GP in London, parts may be with her previous GP in Italy (where she used to live), parts may be with the psychiatrist she consulted while studying in France. Her FitBit may store some of her health data and a DNA-testing company has other bits. Now imagine you are an A&E doctor in London having to diagnose Alice during a medical emergency. Or a scientific researcher looking to recruit Alice for a scientific study. Or Alice herself, who would like to have access to, and control over, all her health data. Would life be made any easier if there was a tool collecting all of Alice’s health data in one place? A number of blockchain companies think so. And they think blockchain can help achieve this. How? A blockchain keeps a record of all medical data about Alice, chronologically ordered. It will show the latest status (the last prescription medicine Alice bought, or the last scan she had), as well as Alice’s entire medical history (every prescription medicine she has ever bought, every scan ever taken of her body, every immunization she has had since birth). Ownership of all that data can be given to Alice, who decides whom to share it with. Alice can decide to share information about her allergies with her dentist, but not her record of psychiatric consultations. She can decide to share her data for a research study and receive instant compensation for it through smart contracts. Or she could donate her mammography data to an organization like BreastWeCan!, which uses blockchain to collect breast cancer screening data and applies machine learning to advance medical research on the topic. Several companies and organisations have started to use blockchain to create a more complete and accurate health record for each patient. Projects such as Massachusets Insitute of Technology’s MedRec and companies such as MedicalChain use blockchain to gather a patient’s health data from across siloed sources, promising patients to gain control over their medical history and health data. Estonia already uses blockchain to retrieve health data from different health providers and create a common record for every patient. The data stored on-chain allow the government automatically to compile national statistics, which can help track epidemics or identify health patterns. Companies such as Iryo use blockchain to help refugees and migrants keep a copy of their health records, as they move from country to country or from camp to camp. There is one great concern, of course: privacy and data protection. Scattered medical records may make life harder for an A&E medic to diagnose Alice during an emergency. However, they equally make it harder for a hacker to steal Alice’s health data in one go. If all of Alice’s health data are stored on a blockchain platform, it becomes a highly appealing target for hackers and thieves. Blockchain companies are working on some promising solutions. For example, health data can be stored on so-called ‘private blockchains’, which limit access and editing privileges to pre-approved participants only, as opposed to public blockchains (like Bitcoin and Ethereum), which allow anyone to read data, propose and approve new entries. The advantage is more privacy. However, if we start using different private blockchains to store medical data, we need to ensure these blockchains can ‘talk’ to each other (the so-called ‘inter-operability’ issue). If not, we simply end up with new data siloes. Clinical trials and medical studies Blockchain could also facilitate data collection and monitoring for clinical trials and other medical studies. These require large troves of data to be collected from particular patient groups and monitored throughout the study. Right now, identifying and recruiting the relevant patient population for a particular study is a complex process, which relies mostly on word-of-mouth and personal connections. Blockchain could help identify and recruit patients for a study and automatically reward them for sharing their data. For example, Alice may only know about a clinical trial measuring the effect of tai-chi breathing exercises on mental well-being because her psychiatrist happens to be running the trial. In constrats, blockchain could automatically alert Alice if there is a trial or study looking for patients like her to share data or participate. Smart contracts could automatically compensate Alice for enrolling and for submitting health updates at regular intervals. As a transparent record-keeping technology, blockchain could also record all of the clinical trial or study data in real-time, improving accuracy, facilitating data-sharing and regulatory compliance with patient safety requirements. Drug discovery Because blockchain is a distributed peer-to-peer network to exchange data, it can be used to foster collaboration on medical research and drug discovery. Anonymised health data and other scientific information can be stored on-chain, creating a transparent, time-stamped data pool for researchers to work with. Smart contracts can be used for data-sharing among researchers and research institutions. While we obviously don’t need blockchain to share data, this distributed ledger technology can make it easier to identify relevant data and have selective data-sharing. Instead of sending entire data collections around to different institutions, the blockchain can collect all relevant information (e.g., lab data from various organisations) and selectively grant access to parts of the data to specific researchers. The blockchain itself keeps a record of who has accessed which part of the dataset. This creates an audit trail that can improve data protection and privacy. Checking health providers’ records Blockchain projects have been set up to record a digital fingerprint of university degrees: as data are tamper-resilient and therefore hard to alter, blockchains can help verify the authenticity of university degrees and other qualifications. Likewise, it can also help track licenses of health providers and physicians, making it harder to commit fraud through fabricated credentials. In the US, the State of Illinois experimented with a pilot project using blockchain to issue and track medical licenses. Companies such as Hashed Health equally use blockchain to accelerate the credentialing of medical practitioners. Provenance and recalls of medication (and blood diamonds and fake artworks) In December last year, KPMG, IBM, Walmart and Merck completed a blockchain pilot to facilitate compliance with medical supply chain laws, prevent the distribution of counterfeit drugs and facilitate recalls of medication. MediLedger (counting Pfizer and Gilead among its working group members) likewise relies on blockchain to track pharmaceutical products across the entire supply chain. This should help regulatory compliance for pharma companies. For example, the US Drug Supply Chain Security Act imposes strict electronic track & trace obligations on pharma companies for certain prescription drugs, to reduce the risk of counterfeit drugs, among other things. A blockchain-based track & trace system can also help with recalls of medication thought to be contaminated or otherwise harmful. If each batch of medication receives a unique blockchain-ID and is tracked on-chain throughout the supply chain, faulty or contaminated batches can be tracked and recalled more easily and swiftly. Others initiatives, like that of adjunct-professor Mackey of the University of California San Diego, use blockchain to study medical supply chains and make them more transparent. This can help governments or international health organizations to “more easily identify ‘choke points’ in medical supply chains and anticipate shortages,” Mackey explained to Forbes. Several companies already use blockchain for supply chain management in other sectors. Distributed ledger technology is already used in food supply chains: Walmart, Nestlé, Carrefour and many others are using IBM’s Food Trust blockchain technology to track the provenance of their food supplies. Interestingly, Everledger uses blockchain to track the provenance of diamonds and prevent ‘blood diamonds’ from entering the supply chain. And Christie’s partnered up with blockchain company Artory to bring transparency to a notoriously opaque art world by tracking the provenance of artworks. The main difficulty in supply chains is to link a physical item to a unique digital identifier and ensure that this link cannot be manipulated throughout a product’s lifecycle. For example, before a batch of prescription drugs leaves the manufacturer’s gates, the manufacturer can give it a unique identifying code and put the code on-chain. However, how can you ensure no one manipulated the physical batch of drugs, replacing it with a counterfeit batch that copied the original batch’s unique identifying code? One obvious solution is to make it as hard as possible to imitate the original ID-code. However, you can aggregate many different data sources to verify the authenticity of the batch of drugs arriving at the hospital. For example, you could use IoT (Internet of Things) devices in the truck transporting the drugs, measuring and recording on-chain the temperatures at which the medication was stored as well as its geographical coordinates, following its precise trajectory. You could have intermediaries involved in the supply chain sign (with a unique private ‘key’ or digital password) for delivery on-chain. If anything suspicious or abnormal happens in the supply chain (e.g., the cold chain is broken or the truck transporting the medication leaves a certain radius), the blockchain could automatically flag this. The system is not 100% waterproof, but it can improve the trust and auditability of medical supply chains. COVID-19 Unsurprisingly, in the wake of the coronavirus outbreak, we’ve seen several companies claim their blockchain technology can aid the fight against the coronavirus pandemic. Last month, the World Health Organization got together with Oracle, IBM, Microsoft and others to create a blockchain-powered open data platform to verify the accuracy of coronavirus data. Called MiPasa, the hub wants to help health officials with early detection of COVID-19 carriers and hotspots. In Germany, a start-up uses blockchain and decentralized identity to help people get prescription medicines without physically having to go to a doctor, to avoid unnecessary contact. Other blockchain-based tools simply offer better visualization of the spread of the coronavirus. You don’t need blockchain to create such a visualization tool, although distributed records and smart contracts can help feed more data, in real-time, to the tool. However, not all experts agree. Sam Smith of MedConfidential described the slew of tech press releases on COVID-19 tools as “completely irrelevant” but something tech companies do “to promote their new shiny”, Forbes reported. Health experts undoubtedly have much more COVID-19-related pressing things on their mind than figuring out how to integrate blockchain into their existing toolbox. Nevertheless, the opacity of medical supply chains and the recent scandals of fraudulent suppliers and defective equipment being offered to desperate medical staff show there is much room for improvement in medical supply chains. Blockchain can be one tool to make supply chains more transparent and trustworthy. Conclusion Blockchain is no miracle cure, but just another tool in the toolbox of health professionals and companies. It can improve the accuracy and completeness of patient records, facilitate gathering data for medical studies and clinical trials, and bring more transparency to medical supply chains. The greatest potential of blockchain lies in the opportunity to combine it with other technological innovations to improve medical procedures, services and research, such as sensors in IoT (Internet of Things) or Machine Learning. Large-scale applications will take time to develop and may look very different from what we see now. However, it seems a matter of time before it enters doctors’ cabinets, medical supply chains and patient applications. If you still don’t quite get how blockchain really works: don’t worry. If it is truly successful, you should not even notice blockchain replacing our existing databases behind the scenes. Header image source: Gerd Altmann from Pixabay

As a PhD student, my research does not always go smoothly. Actually — it rarely does. A few weeks ago, I found myself in one of those all-too-familiar situations where things were not working out the way I had planned. I had nicely organized my experiments for the coming weeks but quickly noticed I was behind on schedule. I was desperately clinging onto my original plan and ended up frustrated and at loss of patience. It took a pandemic crisis for me to stop ruminating and take a step back. And I went way back. In our current western society, we need to go fast. We need to make choices, we need to produce, we need to get a degree, get a job, we need to show up, dress up, speak up, always impress, never disappoint. We need to go forward, always. We need to. If this current crisis teaches us anything, it’s for us to learn how to stop and take a step back. To step away from daily struggles and failing experiments, and go back to asking fundamental questions. To re-evaluate our lives and the world we live in. To rethink the choices we make regarding ourselves, our loved ones and our planet. To reconnect with our core values, our actions and our intentions. I’m not claiming that that’s easy. With the insecurity of not knowing how long this will last, the increasing stress of not being able to plan out coming months, the pain of having to say our final goodbyes to people close to our hearts, the financial burden this situation creates for so many of us — we have a lot of reasons to feel distressed and worried right now. But isn’t it that even the most challenging times trigger self-growth and open up doors to new and brighter opportunities? As Ella Fitzgerald sang: “Into each life some rain must fall, but too much is falling in mine. Into each heart some tears must fall, but some day the sun will shine.” If, from the comforts of our own homes, we all take time to gently yet deeply reflect upon ourselves and our lives, support our loved ones and accept their loving thoughts, maybe — just maybe, we can start building a different world. A world in which we all share a common mindset. One of full commitment and connectedness to the essence of life. Two friends recently shared two incredible poems which align beautifully with the above, and truly hit home. By sharing them here, I hope they will ignite something in you, too. Pandemic “What if you thought of it as the Jews consider the Sabbath -  the most sacred of times? Cease from travel. Cease from buying and selling. Give up, just for now, on trying to make the world different than it is. Sing. Pray. Touch only those to whom you commit your life. Center down. And when your body has become still, reach out with your heart. Know that we are connected in ways that are terrifying and beautiful. (You could hardly deny it now.) Know that our lives are in one another’s hands. (Surely, that has come clear.) Do not reach out your hands. Reach out your heart. Reach out your words. Reach out all the tendrils of compassion that move, invisibly, where we cannot touch. Promise this world your love -  for better or for worse, in sickness and in health, so long as we all shall live.” — - LYNN UNGAR What if… “And, what if… We subscribe to the philosophy that life is always working out for us, that there is an intelligence far greater than humans at work… That all is interconnected. What if… The virus is here to help us? To reset. To remember. What is truly important. Reconnecting with family and community. Reducing travel so that the environment, the skies, the air, our lungs, All get a break. Parts of China are seeing blue sky and clouds for the first time in forever with the factories being shut down. Working from home rather than commuting to work (less pollution, more personal time). Reconnecting with family as there is more time at home. An invitation to turn inward, A deep meditation, Rather than the usual extroverted going out to self-soothe. To reconnect with self, ’What is really important to me?’ A reset economically. The working poor. The lack of healthcare access for over 30 million in the US. The need for paid sick leave. How hard does one need to work to be able to live, to have a life outside of work? To face our mortality, Check back into “living” life rather than simply working, working, working. To reconnect with our elders, who are so susceptible to this virus. And, washing our hands, How did that become a “new” thing that we needed to remember?! But, yes, we did. The presence of Grace for all. There is a shift underway in our society, What if it is one that is favorable for us? What if this virus is an ally in our evolution? In our remembrance of what it means to be connected, humane, living a simpler life, to be less impactful/ more kind to our environment. An offering from my heart this morning. Offered as another perspective. Another way of relating to this virus, this unfolding, this evolution. It was time for a change, we all knew that. And, change has arrived. What if…” — - GURPREET K. GILL Whether you are struggling with the disease yourself, whether you are a frontline worker, a single parent, a confused teenager, or anyone in between — know that you are not alone. These challenging times have the power to bring people’s hearts closer together in spirit. And my heart truly goes out to each and every one of you. HEADER Photo by elCarito on Unsplash

I am writing from Italy, where I am spending my quarantine… but I do not remember how many days I have spent in lockdown so far, maybe because it is a lot. As those of you who have read my previous blog on how to prevent adolescent depression will remember, I am a researcher at King’s College London during my second year of PhD, working across Italy and the UK. And in Italy I live and work in Lombardy, in the very red zone. For me, being a researcher means spending hours working in the lab with state-of-the-art equipment as well as constantly discussing and exchanging of ideas with my colleagues and supervisors. Thus, the lockdown in Italy has affected me and my work a lot. It was the 20th of February when the first young man was hospitalized for COVID-19 related pneumonia in Codogno, a small city in the north of Italy less than a hundred km from where I live. Then, I clearly remember the last time I was with my friends: on Friday 21st, one of my dearest friends told us that she was expecting a baby boy. At the time we had no clue of what it was going to happen to us all, only few days later. In the meantime, the number of the Italian positive cases was increasing, and on Sunday evening, 23rd of February, my supervisor suggested that we should work from home for the following week, in order to avoid traveling on public transportation and being in crowded places. “OK, it is just one week” — I thought — “I have some work to catch up on, and this is the right moment to get it properly done”. At the end of the week I was ready to get back to the lab. At this point everything was odd but still under control in Italy. Schools and universities in Lombardy had been closed for precaution, but restaurants and bars were still open. Then something changed: all of a sudden, the number of cases exploded and on the 8th of March, the entire region of Lombardy and other fourteen surrounding cities were declared “red zones” and put into lockdown. Panic spread… the night trains from Milan to the south of Italy were literally mobbed with thousands of people trying to escape from the red zones to get home. Moreover, lots of people emptied shops of groceries and essentials. The following day, on the 9th of March, the Italian PM declared quarantine for the entirety of Italy: schools and universities closed everywhere with the advice to “stay home, stay safe” as much as possible. Again, a couple of days later a new communication: Italy is in complete lockdown, restaurants and pubs must close as well as every shop apart from grocery stores, pharmacies and essential industries. And here we are, today Wednesday 8th of April, still in quarantine and holding on. The number of positive cases has increased steadily, together with the deaths, and the hospitals are full, with no more critical-care beds. Here is the most updated data (Tuesday 7th of April): 135,586 total cases, 17,127 deaths and 24,392 recovered. These have been difficult days indeed. I live in a small town near Bergamo, the city most hit by the virus and with highest number of deaths. The images of the army drafted in to help move corpses have been broadcasted throughout the world. Channels are broadcasting news related to COVID-19 every hour. This is exhausting and has a negative impact on our emotions as well as on our mental health. Speaking for myself, I have deleted the Facebook app from my phone, and I try not to overdose with the news that hammers us constantly. There is no need to be updated 24/7 because it’s likely you will actually get more anxious. Moreover, it is essential to avoid fake-news and stop believing false myths. How do we cope with this heavy burden and all the stress that comes with it? During the first two weeks of quarantine I was full of energy. I shifted from being a desperate housewife to a perfect cook. I attended yoga classes, group meetings with colleagues and drink meetups on Skype. I also spent several hours in front of the computer writing, sending emails and reading. Then something slightly changed… We all realized that things would not come back to reality as soon as we thought. As I mentioned, the number of cases, and sadly deaths, is rapidly growing and I have been really worried for my relatives’ health. We all have also felt overwhelmed and anxious — and this is perfectly normal. To quarantine means to stay home, always. You are allowed to go out to buy food and medicines, for going to work (only when smart working is not possible) or for real emergencies. Walks seem to no longer be allowed. Policemen even stop you along the streets asking where you are going and why you are not at home — if you cannot provide proof for why you are out or where you live, they press charges against you (fines from 400 to 3,000 euros; COVID-19 positives who violate quarantine can be charged from 3 to 18 months of detention and a 500–5,000 euros fine). Supermarkets and pharmacies are open, but only a few people can enter at any time, which means queuing outside at least one meter between others in line. Glass shields appeared everywhere, making human contacts almost impossible. Moreover, you can only enter a shop after having your temperature taken. This is a difficult situation, but it is essential to respect these restrictions for our safety. However, Italians have figured out some ways to be together even in lockdown. How? My country has sung the national anthem as well as iconic Italian songs on the rooftops and balconing, while waving the Italian flag. Even in the north of Italy and in my Bergamo, we are trying to do our best to boost the moral, to stay strong and copy with this nightmare, but we rarely sing from the balcony. However, in order to face the urgent need of new critical-care beds, two brand-new field hospitals have been set up in Milan and Bergamo in about 10 days thanks to the incredible work of thousands of volunteers. During a pandemic, thanks are due to doctors, nurses, pharmacists and everyone working in the hospitals (and not only); to couriers, grocery shop assistants, policemen, guards and all the workers still doing their job everywhere. It is amazing to see that the desire to thank them is spreading from country to country — a positive contagion — like in UK, where people clap for NHS staff and key workers. So, this is my quarantine in Italy so far. I got through difficult times missing my loved ones, my friends and simply my daily routine. I have some good days when I am very focused and calm, but also some (very) bad days, when I feel overwhelmed or just worried and exhausted. I am sure everyone feels quite the same. Be kind to yourselves, don’t judge the way you are copying with your emotions during these difficult times. Don’t be hard to yourself because you are totally allowed to not be able to deal with a quarantine. Everything will get better, sooner or later. HEADER IMAGE Angels by Franco Rivolli

In light of recent events with coronavirus, the national burden on mental health services is only set to rise over the coming few years — could finding a solution to the psychiatry recruitment problem help us cope? A medical student’s take on this increasingly concerning and important issue. The early months of 2020 has seen the world gripped by the Coronavirus (COVID-19) pandemic. At a time when the focus is (very rightly) on frontline acute medicine, it’s impossible to ignore the fact that other medical and surgical specialties will struggle to continue providing a specialist service to their patients. In psychiatry, there is likely to be a significant backlog of routine appointments, assessments and reviews once some normality resumes. Furthermore, with anxiety and bereavement becoming increasingly prevalent as a result of this pandemic, the demand for mental health services will most likely escalate. With a shortage of psychiatrists already compounding this issue, how will our mental health service cope? This blog is a student’s perspective on why we have a shortage of psychiatrists in the UK and will consider potential solutions to address this problem. Applying for medical school is a long and exhausting process. After a gruelling 12ish-month medical school application cycle, (which includes at least one — and frequently two — admissions exams, multiple work experience placements in different healthcare settings and, for the lucky, several interviews) it is understandable that successful medical school applicants desire to make the best use of their degree upon graduation. And for some, a future in psychiatry seems to be at complete odds with how they envisage their future career. Why? In a nutshell, because many medical students don’t get enough positive exposure to the most exciting areas of psychiatry whilst in medical school. At the start of October 2019, the BBC reported an article on how ‘psychiatrist vacancies ‘threaten’ NHS transformation.’ Within it, they wrote that nearly one in 10 consultant posts is vacant, ‘up from 1 in 20 in 2013.’ They also quoted the dean of the Royal College of Psychiatrists, Dr Kate Lovett, as saying “Medical students just don’t seem to be attracted to work in mental health […] It’s not seen as a prestigious area to go into.” With this article prompting discussion amongst my peers as to why so few of us are excited by the prospect of becoming psychiatrists, I thought now would be a good time to unpick some of those key reasons. So why aren’t we choosing psychiatry? Psychiatry is considered a challenging and daunting career by many of my peers. There is a widely-held stereotype that there is little job satisfaction and many of the conditions encountered are far too complex to wrap our heads around, owing to some psychiatric disorders having poorly understood, complex causes. Furthermore, some consider psychiatry to be relatively isolated from many other medical and surgical specialties — they often have separate units with little cross-specialty care. This is unappealing to students who have spent so long studying general medicine and surgery, as many would wish to employ more of this knowledge directly. However, I believe the core cause is still rooted in an archaic — and now nearly totally incorrect — stigma around the actual role of a psychiatrist… Distinct and fiercely academic doctors who must rely solely on experienced and unique intuition rather than the usual clear-cut diagnostic tests seen in other specialties to treat their patients. Whilst steps are being taken to address these, such as including more psychiatry in the curriculum at medical school, personally, I don’t think enough is being done to convince medical students that this isn’t accurate. So, what IS being done to address this currently? Psychiatry is currently considered a ‘hard to fill’ training programme by the NHS. Trainees in core psychiatric training and higher-level training are paid a small flexible pay premium to financially incentivise them to pursue the specialty. Promoting the specialty in this way would seem to also go hand-in-hand with the career providing greater job security as well. Whilst certainly these aren’t unhelpful incentives, there are reasons that neither of these are fully satisfactory reasons for pursuing a career. To address the former, if doctors were primarily incentivised by money, they quite frankly probably would not have become doctors in the first place. Instead, they would have used their strong A-Level grades to make a bid for a more lucrative career. As such, pay premia may strengthen one’s resolve to pursue a career in psychiatry once already interested in the field, but would not likely in and of itself help to recruit more trainees to the specialty. When it comes to job security, most medical students and junior doctors are relatively immune to the idea of competition, having faced around 1/10 odds of getting into medical school in the first place and then having to compete for where you want to initially train immediately after medical school. The prospect of job security is appealing, but not typically an immediate issue, and again, is not enough to attract individuals to the specialty in the first place. Personally, I feel only one idea implemented thus far has the power to effect change, and that is by increasing the amount of psychiatry we are exposed to and taught within the curriculum whilst we are still training. Only by actually seeing the tremendous role psychiatrists play in patients’ lives and by dispelling the myths of therapeutic options being limited and ineffective will real change begin to happen. So how else can we change the way we make psychiatry appealing to students? In my opinion, recruiting students into psychiatry should centre upon the innate attractions of the job. I recently had a conversation with one of my peers, who indicated a desire to pursue a career in liaison psychiatry — a branch of psychiatry which involves psychiatrists working in general hospitals e.g. in A&E departments. When we discussed this further, it transpired that the decision stemmed from the simple fact that he had really enjoyed his 5-week clinical placement in the specialty during his 4th year of medical school. This is a prime example of exactly why an emphasis should be placed on promoting the positive aspects of a career in psychiatry career itself, rather than any extrinsic motivators. Such positive aspects include a chance to tackle an increasingly prevalent health burden on the national service through working with the development and implementation of novel treatments. For example, research around Ketamine as a therapeutic agent for treatment-resistant depression may offer the potential to revolutionise the treatment of a previously notoriously difficult-to-treat disorder. Our understanding of the mechanisms of complex psychiatric disorders such as schizophrenia is also ever increasing, and this is very exciting for much-needed future treatment options. Teaching students about these developments from early in medical school will encourage them to consider the specialty. So, what are my pragmatic, potential solutions? There have already been some fantastic initiatives launched by the Royal College of Psychiatrists and medical schools. One of the most exciting, in my opinion, is ‘Pathfinder,’ which allows students to connect with psychiatrists and receive mentoring, journal subscriptions and access to conferences, alongside many other benefits. However, I believe that more can be done. It is important to target medical students that would previously not have considered psychiatry as a career as well. In my opinion, the best way to do this, is to expose pre-clinical medical students to the career from first year. Leading academic psychiatrists should be encouraged to deliver guest lectures to pre-clinical students to talk about their careers and their research. Connecting different medical schools’ psychiatry societies regularly through social media should also be encouraged, so that outstanding events can be shared on a regional and national level. An interesting article was written on the value of these student-led societies and similarly argued that they are have enormous potential to foster interest in psychiatry. I believe that all medical schools should have well-advertised schemes, encouraging students to engage with psychiatry research at both a laboratory and clinical level. Blogs such as Inspire the Mind are also useful to my peers and I — only a few months ago, Professor Kamaldeep Bhui CBE wrote a thought-provoking blog shedding light on the true and practical role of a psychiatrist. Perhaps, a blog competition run by different psychiatry departments is a way to allow students to dip their toe into engaging with psychiatry. Promoting regional essay competitions, which encourage students to engage with modern psychiatric literature is another way to develop interest. Most importantly, psychiatrists themselves must try to engage positively with the medical students on their attachments — it is those experiences that are most formative in how we choose our specialties in the future. After all, psychiatrists are the best ambassadors for their discipline. And we will need more psychiatrists than ever, to deal with the long-term consequences of this epidemic. HEADER IMAGE SOURCE Tim Gouw on Unsplash

Working from home has never been as important as it is now. COVID-19 has changed the day to day working patterns of employees and employers — but now the question is, is it for good? If you think about it positively, this is one of the very best ways of reacting towards something we cannot control, like the COVID-19 outbreak we are currently facing. Yes, we all know that it is very easy to go to work and communicate with your colleagues and bosses face-to-face to come to decisions, and this is in stark comparison to sitting behind a screen, writing hundreds of emails trying to communicate just as well. Never mind waiting to take video calls and having to work out how it all works! But think, this is a fantastic opportunity to gain new vital skills. You can take this opportunity to develop skills such as writing to be persuasive and develop better explanations, to communicate more clearly, holding and organising virtual meetings via ‘Skype for Business’ or ‘Microsoft Teams’ — all things that you may not have been exposed to before. This can be an opportunity to build your confidence and positive outlook towards new technologies, which may, in the end, help your long-term career success. At the same time, abruptly and rapidly-changing situations like this are, you must focus on your mental health while you are working from home. You shouldn’t forget that you are working from home because you don’t have any other choice. You are already doing a great service by providing support to keep important day to day business functioning. For some people, this is may be the first time working from home, hence it can be bit weird at first, but I am sure we will all get used to it. Like my friend, Sue. When I asked, she said “It’s funny, I thought I was going to feel very isolated at home, but I feel more connected than ever!” I was so happy and glad to hear that as now I am certain that she is not feeling alone, which many of us may now be experiencing. One great idea — which our team have already tried and tested — is to get together with your colleagues for virtual drinks and lunches to avoid isolation. BBC — five ways of working from home has very useful practices that you could perform to feel less isolated, as 19% of employees working from home have agreed that loneliness is the second biggest struggle when they are working from home, right after the inability to unplug from work. You don’t need to be glued to the computer and over communicate, however. While you are working from home, you need to move around when needed, and go for a walk, run or cycle to get some fresh air, which will refresh your body and mind and increase productivity. Our attitude has changed over the past few weeks as the first thing that comes to mind is Coronavirus. Hence, we started to avoid other runners as much as we can and hold the breath while we are passing them. Professor Carmine Pariante has managed to read the minds of runners during Covid-19 — well, at least he read mine. In swiftly changing conditions like this, you can use largely available free virtual yoga lessons to keep you calm and to face the situation with mindfulness. The purpose of yoga is that you practice breathing while stretching your body, to find the balance of peace in your mind and body, which will help you to focus, to reduce anxiety, to reduce stress, to increase the attention and concentration, and to reduce the sleep deprivation. As a mother myself, I also know that it is very difficult to work from home when there is a family to look after. So, on a normal half term working from home day, I am dreaming of going back to work on the following day, but what can we do now??? I don’t know when I will return to my usual workplace now — most of us don’t. At least we are not alone when we have a family — this is very important as this is not a normal “working from home” practice. We all are doing it for a very good reason, to isolate and reduce the risk of spreading the virus. We must look after our family and friends. We should give them more attention, to make them feel good and safe. There is nothing we could do when our child jumped in front of the camera during a meeting, it’s fine. What could they do? We as parents, should listen to the demands of children around the clock, so work smart, not hard. You can always catch up with your work during the day. Anxiousness and uncertainty will always be there until we pass this difficult period, but we must act and control, it and we must do something to keep our minds and bodies healthy. When we reach full lockdown phase, let’s keep focusing on light exercises, yoga, reading books, listening to music or singing out loud, like Italians do. As Italy entered its fourth day of a nationwide lockdown, Italy residents took to their balconies on Friday evening to sing the national anthem in a 'flash m... I know it is particularly hard at this time, but we must hang in there and support one another. Header image source Alexander Dummer on Unsplash

Let’s look at some pictures of real data The coronavirus pandemic has swept across the globe at breakneck speed, bringing whole countries to their knees in a matter of weeks. In tandem with the virus, we have been inundated with a daily torrent of news updates, scientific discoveries and rapidly changing government policies. We have also been inundated with conflicting ‘facts’ about coronavirus, ranging from misquoted statistics, to rather convincing pseudo-science and downright laughable conspiracy theories. This quickly becomes overwhelming for everyone and soon it’s hard to remember which advice came from a meme and which advice came from the World Health Organisation. Unsurprisingly, for most of us this uncertainty leads to poor mental health, increased stress and further confusion about how to approach the problem, along with a mistrust of the sources who deliver information to us. This is why we have collected and debunked the top 10 most dangerous myths about the coronavirus disease pandemic (COVID-19), using the best charts and illustrations from around the web to visually guide you. This is the start of a new series of myth-debunking blogs from Inspire the Mind, so as more myths are inevitably created, keep an eye out for more articles like this in future. Myth 1: I don’t have a cough or fever, so I don’t have the virus Symptoms are varied and not limited to coughs and fevers. The confusion around this likely came from coughs and fevers being the most common symptoms, but less common symptoms include myalgia (muscle pain), nausea, vomiting and diarrhoea. What is most surprising, is that a large number of patients may also lose their sense of smell and taste. This can occur in the absence of any other symptoms, meaning this discovery could be key in identifying very mild cases of coronavirus that would not otherwise be identified, according to the medical body ENT UK. The most typical symptoms are shown here: Myth 2: I don’t have any symptoms, so I don’t have the virus. Most people who get sick from the virus will only show symptoms approximately 5 days after being infected, but it can take up to 15 days in some cases. One study found that during those initial 5 days (where people feel completely fine), is when the highest amount of viral shedding likely occurs, which is when infectious particles from the virus spread from one person to another. Young children might not be as vulnerable to the virus, but they may be an important source of transmission, as a study published in Nature Medicine and another study in China both found that children without symptoms were still highly infectious. In reality, we do not know how many people might be completely asymptomatic (meaning, without symptoms) while carrying the virus. Early research of Japanese evacuees from Wuhan suggests that about 30% of infected people may have no symptoms at all. Another study of German evacuees found that screening for the virus based on symptoms was ineffective, because even asymptomatic patients were infectious. This is why it’s so important to isolate yourself for at least 14 days, if there’s any possibility that you might have been exposed, and why social distancing is essential for everyone (see myth #8 for more info). It usually takes 5 days to start showing symptoms, but in some cases may take 10–15 days: Myth 3: Coronavirus is just like the flu. This myth was used to downplay the danger of the virus when it was first beginning to spread from Wuhan to Europe, along with rumours about the danger of the virus being blown out of proportion. It’s now very easy to say, without a doubt, that:1. Coronavirus is far more deadly than the flu, not just for older people, but for all people.2. Coronavirus has a much higher hospitalisation rate compared with the flu (19% vs. 2%).3. The duration of hospitalisation for coronavirus is approximately 10 days longer than the flu.4. Transmission rates of coronavirus (how quickly the infection spreads) are much higher than the flu.5. The flu has been around for over 100 years, so we built up an immunity to it. Despite this, thousands of people require flu vaccines every year because the influenza virus continuously mutates. In contrast, humans have no immunity to coronavirus, because it is a brand-new type of virus, making the whole population far more vulnerable.6. We don’t have any known treatments or a vaccine for coronavirus yet.7. Due to all of the above, the risk that coronavirus poses to humans is far greater than the common flu. Myth 4: I can only catch coronavirus directly from infected people. Unfortunately, coronavirus can live easily on a range of surfaces for several days. One peer-reviewed study found it could last on some surfaces, like plastic, for up to 9 days. However, the Centres for Disease Control and Prevention discovered that the virus survived on surfaces for 17 days, after infected passengers disembarked from a cruise ship. This is why disinfecting surfaces and washing your hands regularly is so important. Luckily, a simple alcohol-based disinfectant is enough to deactivate the virus. Myth 5: I’m young and have no health problems, so I’m not at risk. Although being young and not having any underlying health problems means you do have a lower risk, young and healthy people are still very much vulnerable to the virus. A review of over 500 US patients found that 20% of those aged 20 to 44 were hospitalised due to serious complications and 20% of deaths occurred in those aged between 20 to 64 years. Pneumonia is one of the most common causes for hospitalisation in patients with coronavirus. Between 15–20 days of mechanical ventilation is typically required to assist breathing for those recovering from pneumonia. This means younger generations should seriously consider that simply contracting coronavirus could put a huge strain on an already overburdened healthcare system. Furthermore, the risk of death is not simply down to older age. Anyone with an underlying health condition is at an increased risk of death, even those with common conditions such as cardiovascular disease, diabetes, chronic asthma and hypertension. Risk is also far higher those with weakened immune systems, including people with autoimmune diseases and cancer patients. It is impossible to be aware of all the health conditions of each person you interact with, so anyone who knowingly puts themselves at risk of contracting and passing on the virus is seriously jeopardising other people’s lives. Consider that one of the youngest coronavirus deaths was a 21 year old male football coach , Francisco Garcia, who unexpectedly went to hospital for breathing difficulties. At hospital, he was diagnosed with pneumonia (caused by coronavirus), as well as leukaemia. Prior to his hospital trip, Francisco was completely unaware he had either disease. Within one hour he went from being in a stable condition to being pronounced dead. Francisco never even had an opportunity to receive potentially life-saving cancer treatment for his leukaemia. Myth 6: Wearing a mask will stop me from catching it. With this myth it’s easy to see where the misunderstanding has come from. While masks are most helpful in preventing infected people from spreading the virus (by stopping viral particles from sneezing and coughing being released), they are not as effective in preventing the general public from catching the virus, especially if people are already practicing social distancing when traveling on public transport or walking around. In fact, intermittently putting a mask on and taking it off actually increases the amount of times you touch your face, which could increase the likelihood of putting infectious particles around your mouth, nose and eyes. While masks are in short supply, they should be predominantly reserved for healthcare workers and carers, who work in very close proximity with large numbers of infected patients. For the general public, more effective methods of protecting yourself from infection include regularly washing your hands, not touching your face, disinfecting surfaces, and social distancing. If you already have a mask then there is no harm in wearing it, but make sure your mask is sanitised and that your hands are clean when taking it off and putting it on. And wash your hands again after taking it off. Myth 7: It would be better to let everyone catch the virus so that we become immune to it, even if it causes some deaths in the short-term. Although this strategy (known as herd immunity) is not something that many people might admit to thinking, it is naturally on people’s minds when the current alternative we are facing includes widespread job losses, school closures, economic recession, and being confined in our own homes for an indefinite period of time. To put things in perspective, if everyone caught the virus without any strategies in place to suppress it, this would lead to an enormous number of deaths, a devastated healthcare system and subsequent irreparable breakdown of society and the economy. A team of scientists at Imperial College London modelled what this would look like in the UK and predicted that it could lead to a quarter of a million deaths that would completely overwhelm the healthcare system for months. In fact, all sectors would become overwhelmed if a large proportion of the workforce suddenly became ill around the same time (including the doctors and nurses who are meant to treat patients). It would also prevent people from accessing healthcare, emergency services and even prescriptions for normal medical reasons, and people could begin dying from minor conditions such as asthma attacks, heart attacks, pregnancy complications, everyday accidents, bacterial infections and so on. Instead of this scenario, governments are aiming to eventually achieve widespread immunity with vaccination, when one becomes available. This way a large part of the population will become immunised in a controlled manner, drastically minimising the devastating potential of the virus. Flattening the curve using social distancing: Myth 8: Social distancing should only apply to people who might be infected. Unfortunately, we cannot distinguish who is infected and who is not, because of the amount of time it takes infected people to develop symptoms and the large number of infected people without any symptoms at all (see myth #2). One study of Wuhan patients estimated that undocumented cases (undiagnosed) were responsible for infecting 79% of documented cases, explaining the rapid spread of the virus. The transmission rate of the virus is incredibly high, so until we know more about the virus and until testing and tracking infections becomes easier, the most effective method of reducing infection rates is through social distancing (by reducing exposure to other people by 75%). If you don’t think social distancing will have much of an impact, consider that if you happen to be carrying the virus and are unaware, within 30 days you could infect 406 people, and then each of them could go on to infect another 406 people… If we conservatively estimate that the mortality rate is around 2% and hospitalisation rate is 19%, that means with every month of normal interaction you put 8 people at risk of death and 77 people at risk of hospitalisation. For those of you who do not see any harm in a quick bite at a restaurant or fitting in a gym class, studies have found that the transmission rates of the virus were 18.7 times higher in closed environments, compared with open-air environments. Myth 9: Things will get better over the summer when the weather warms up. Although this is true for influenza, which declines over summer periods, we don’t know if it will be true for coronavirus yet. Some diseases vary with seasons while some vary with latitude, some diseases depend on temperature and some largely depend on seasonal human behaviour. Some diseases do not vary seasonally at all. To further complicate things, coronavirus is a brand-new virus, meaning that humans haven’t built up any immunity to it yet. So even if it is seasonal, the prevalence may continue to increase regardless of seasonality, as it infects more of the population. The calendar of epidemics: Myth 10: This will all blow over in a couple of weeks. Unfortunately, this is very unlikely because the virus has already been widely transmitted throughout so many different countries. The most viable option for controlling it now is keeping infection rates low until a vaccine or other treatments are developed. Without either of these, the best way infection rates can be managed in the coming weeks is through: · Social distancing (not socialising with people outside of your household and staying home as much as possible). · Widespread testing to isolate cases. · Tracking and testing anyone cases have had contact with. Observing how the situations in China, Singapore, South Korea and Italy develop will give us some indication of what might lay ahead for the rest of the world, but how quickly government policies are implemented and how well citizens respond to those policies will largely dictate if the virus can be contained. Trajectories of coronavirus cases by country: For an effective vaccine to be created, and a sufficient proportion of the population to be immunised with it, estimates are currently between 12–18 months at a minimum. Until then, the suppression model (see below) put forward by the COVID-19 response team at Imperial College Londonpredicts that the best way to keep infection rates at a manageable level will be by interspersing longer periods of social distancing (signified by the straight blue lines) with shorter periods of normal interaction. The time periods of each will need to be adjusted continuously depending on the number of new cases and number of patients in intensive care (orange spikes). However, if the public can adhere to strict social distancing measures now, this will limit the spread of the virus, ensure cases are isolated and buy more time for the healthcare system to prepare itself. This would mean that social distancing measures would not need to be as draconian or prolonged after we get through this initial outbreak. Worst-case scenario of what the next 18 months could look like: In summary, coronavirus is currently one of the biggest threats many of us will have experienced in our lifetimes. The only way to keep infection rates at manageable levels for now is through limiting the spread of the virus as much as possible. To successfully implement this globally, each person and each community needs to be aware of how to do so. Now is not the time to bury your head in the sand, or blindly quote the statistics you saw on Facebook about the virus not being that serious. Nor is it the time to forward scare-mongering chain messages, passed on by a friend of a friend, who claims to be the sister of a doctor, sergeant or Boris Johnson’s dog walker. Consider that, on Twitter alone, of the 5.9 million tweets related to news stories on coronavirus in the last two months, 1.7 million tweets (one third) were from websites containing unreliable or false information, according to the Bruno Kessler Foundation. The dangers of passing on false information in a crisis like this can have very profound effects on the physical and mental health of others. For example, following rumours circulated about an enforced London lockdown, hordes of people panicked and emptied supermarkets, leaving elderly people, vulnerable people and even nurses without food. Humour is a fantastic way to help us cope with an increasingly bleak situation, but when situations like this become life threatening for a large part of the population (which it has) we each have a duty to fact-check and stay updated with reliable sources. Focus on sharing helpful and practical information, rather than sensationalist, clickbait articles. If you can’t verify something, or someone’s credibility, ask yourself whether you would really benefit others by sharing it. However, do share this blog, as it is edited from a team of researchers and it is based on scientific evidence. It’s time to accept the gravity of the situation and act in everyone’s interest, rather than personal interest. Until we can venture out again, try to have fun and connect with loved ones virtually. Stay safe, but most importantly keep others safe too! HEADER IMAGE SOURCE Markus Spiske on Unsplash