Fish, and particularly fish oil, contains molecules called omega-3 polyunsaturated fatty acids. Walnuts, soybeans, and flaxseeds are other dietary sources of omega-3, but fish definitely has the spotlight. What’s all the buzz about then? It all began a (not so) long time ago, in the 1970’s, when researchers discovered that Greenland Inuits suffered less from diabetes, atherosclerosis, and cardiovascular disease than their Danish counterparts. This was associated with their higher levels of blood omega-3 and fish consumption. Decades down the line, evidence on the properties of omega-3 keeps adding up and principally attributes them to their anti-inflammatory actions. And while physical health benefits were observed in the Inuit population, it now appears that the brain, and consequently mental health, can also gain from an increased intake of omega-3. Indeed, omega-3 are important components of brain cells, and can influence the way brain cells connect and communicate with each other, in addition to limiting inflammation. These effects have been particularly relevant in conditions of the central nervous system such as Alzheimer’s disease or depression, which are linked to increased inflammation of the brain. This inflammation namely affects a process called neurogenesis, whereby new brain cells (neurons) develop and are integrated to the existing brain circuitry. Dysfunctions in processes related to neurogenesis can lead to problems with memory or storage of emotional information, which are commonly observed in neuropsychiatric and neurodegenerative conditions. Depression rates are indeed lower in countries where fish consumption is higher, such as Japan, compared with European countries. This may be partly related to their increased intake of omega-3. Additional evidence has shown that, through their anti-inflammatory effects, omega-3 are able to improve clinical symptoms of depression as well as cognition in Alzheimer’s disease patients. With regards to neurogenesis, omega-3 have also been proven to increase it at similar levels to antidepressants, in experiments, from our laboratory, using cells mimicking the inflammatory conditions observed in depression. So, should you eat more fish? Probably. Compared with red meat, fish does not increase the overall risk of mortality or cardiovascular disease, and is a source of omega-3. Unless you live in a high-income Asian country, chances are you do not meet the optimal daily intake of two portions of fish per week. Indeed, lower that recommended intake of omega-3 was highlighted as one of the leading dietary risk factors for mortality by the Global Burden of Disease Study 2017. However — as I explain to my curious friends — my interest lies not so much in the fish but in how exactly its omega-3 contents are helpful to the brain. So, what did I do? Similar to an engineer taking apart a complicated machine to understand its functioning, I delved into the ocean of research on omega-3 with the hope of identifying how they affect and fit in the intricate machinery of the brain. The outcome of this quest diving into the mechanisms of omega-3 in the brain are summarised in our recently published review. But before telling you all about the results of our search, here are two key pieces of information that got us started. Firstly, the main two omega-3 molecules are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), and they are broken down by the metabolism into smaller different molecules really quickly. These molecules are called “metabolites”, which in this case simply means that the molecule originates from a specific series of breakdowns whereby the metabolism transforms the bigger initial molecule to obtain smaller molecules down the line. For reference, EPA already goes through several metabolic transformations 45 seconds after its entry into the brain. Secondly, a group of those metabolites derived from EPA and DHA, called “specialised pro-resolving mediators”, was getting a lot of attention because of its very potent actions against inflammation in the body. Rather than shutting down the immune system and tipping the scales in the opposite direction, pro-resolving mediators re-establish a balance. They limit the inflammatory reaction of the body to its useful initial stage and prevent it from becoming chronic. Through this process, specialised pro-resolving mediators have been able, for example, to promote clearance of bacteria in human white blood cells and wound healing in animals. But what about the brain then? Do these molecules have any potential for brain diseases? So far, the research is mainly limited to animal studies, but yes, they do. I narrowed the focus of my research on disorders where inflammation plays a role, particularly those where it is detrimental to neurogenesis and cognitive functions, including depression, neurodegenerative disorders like Alzheimer’s and Parkinson’s disease, and neurological conditions such as stroke or traumatic brain injury. In essence, the body of literature reveals that the different pro-resolving mediators are not made equal: while all of them reduced inflammation, their effectiveness differ depending on the disease. I also observed that this might be influenced by the different molecular interactions they trigger in brain cells. For example, a subgroup of pro-resolving mediators named resolvin Es is more effective in alleviating depression-like symptoms in rodents, but others, such as maresins and protectins, are more beneficial in conditions like stroke or traumatic brain injury. This is interesting, because resolvin E, maresin, and protectin are derived from different omega-3 via different processes. In this case, resolvin E is a molecule derived from EPA, contrary to the others, which are derived from DHA. The therapeutic effects of resolvin E in depression mirror the clinical situation, as analyses of clinical trials with patients suffering from depression show that EPA is better than DHA in terms of improving symptoms. Now, what does this all mean? These results indicate an avenue for personalised treatment with those omega-3 metabolites, meaning that specific molecules might be better at targeting biological and clinical symptoms of particular disorders. More research is obviously needed to confirm this, and to eventually obtain the optimal therapeutic solution. We need more information on exactly how these molecules work in the human brain both in healthy people and patients, in order to figure out exactly how they might be helpful. Nonetheless, specialised pro-resolving mediators represent a possible treatment option without severe side-effects for patients suffering from these conditions. Now I know what to study for the rest of my PhD! Header image source: BRUNET

Is this #pandemic changing our approach to pollution? And to life? Let me start with an Editor’s Note. We don’t usually start a blog with an Editor’s Note, but we are in exceptional times. According to the last WHO report on Coronavirus infection on the 17th of March, there are 179,111 total confirmed cases, and 7,426 death. Today the numbers have changed to more than 200 thousand cases and more than 8 thousand deaths. Italy, where some of my closest friends and most of my relatives live, is in complete shutdown. France and Spain are following suit. I don’t even want to start discussing the controversy around UK strategy in dealing with the virus — I am a scientist, not an infective diseases epidemiologist. Like everybody else, we at InSPIre the Mind are reacting as we can to the shifting situation. We have cancelled our course on using creativity to talk about mental health. We have cancelled our last blog on pollution and mental health, scheduled for next week, and instead, we will have a blog on mental wellbeing at the time of coronavirus. We call upon all readers and writers who follow us and would like to write a blog on how coronavirus has affected their mental health and wellbeing, to contact us. And I am writing this blog, today. A blog which is a mixed bag of emotional reactions to the virus, considerations on public health, and news about pollution. So that we can mark the transition from what was, only a few weeks ago, the world’s most horrible nightmare — pollution and global warming — to this new nightmare. All confusedly conceived in my brain while running in a park. It is Sunday morning and I am breathing deeply while running in a park, hoping that, by magic or by some scientific processes I am not aware of, the oxygen in my throat and in my lungs will stop or weaken the virus, if (when?) I come into contact with it. Running on a Sunday always entails gymkhaning around dogs and little children that suddenly jump in from of you, but this time I do something new, something different: I avoid adults. I avoid other runners. I have always had the habit of smiling and waving at fellow runners who suffer and sweat like me in the park — often wondering, what are they thinking? Are they in a ‘mental zone’? Do they, like me, use running to reflect on worries and problems? This habit has now metamorphosised, as Gregor Samsa does into Kafka’s “monstrous vermin”, into active avoidance. I no longer smile and wave, I move on the other side of the trail, I turn my head around, I even hold my breath if there are too many people to go through safely — whatever safely may mean. Two years ago I had just finished a half marathon and, as often happens to runners, I burst into tears at the finish. Sitting sobbing on the pavement in the crowd, two total stranger fellow runners — not one, two — stopped and hugged me. Last week, while running, I saw a woman — again, a runner — in clear distress. Crouching on a bench, face buried in her hands, earphone on. I asked her three times whether she needed help — the music was perhaps too loud, or she did not want to answer — but I insisted and gently tapped her shoulder. I am a psychiatrist for a reason. She was crying, but reassured me that she was ok and that she did not need anything. On a normal day I would have stayed around for a few more beats, tried to talk, flagged down my wife who was running just behind me, offered some support and comfort. But this was not a normal day and the only thing I could think of was the possibility of coronavirus in her tears. Damned virus. But I am sure oxygen is not the only thing that I am breathing while I am running. One year ago, two million people in London were living with illegal air pollution. There was already a trend for a reduction in nitrogen dioxide levels, but they were still illegal — nitrogen dioxide is the pollutant responsible for, among other things, increasing the risk of miscarriage. More than 350 primary schools at that time were still in illegally polluted areas. In China, it was even worse. The country’s atmosphere was so densely polluted that it was blocking the sun’s rays. And pollution greatly increases mental health problems, as discussed in our two previous blogs on the link between pollution and psychiatric disorders or psychiatric medications. Most importantly, pollution causes one-quarter to one-third of all adult deaths from heart disease, stroke and lung cancer, and nearly half of all death from chronic obstructive pulmonary disease. Nearly 9 out of 10 people in the world live in areas where the air contains high levels of pollutants. And then COVID-19 arrived. I am running, and I am sweating, and I am avoiding dogs, children, other runners. I am running and I am thinking at the distressed runner I could barely acknowledge a few days ago. I am running and breathing deeply, hoping oxygen will save me. I am running and I am thinking at all the magical rituals we are doing to protect us from the virus: not the proved and effective strategies, such as washing hands with soap and water, but the other mythical rites like eating garlic, taking hot baths and drinking water every 15 minutes. I am running and I am hoping that air pollution will not kill me instead. There is clear evidence that the lockdown imposed by coronavirus is reducing pollution. Satellite images released by NASA and the European Space Agency show a dramatic reduction in nitrogen dioxide emissions in China in the last two months. CO2 emissions equally went down by a quarter in two months alone, and, since China contributes 30% of the world’s CO2 emissions annually, the impact of this kind of drop is huge. Milan — one of the most polluted cities in Europe — and the north of Italy, in general, is experiencing a similar drop in nitrogen dioxide levels. And of course, we are all flying less, and domestic and international flights contribute to CO2 emissions, even if just accounting for 2.4 per cent of energy-related CO2 emissions. But I would not go as far as saying that the planet may be a “beneficiary of coronavirus”. Not only because I really cannot look for a silver lining in a tragedy of this proportion — I am not an infective diseases epidemiologist, and I am not a philosopher, either. But also, the health damage due to air pollution is likely to increase the death rate from coronavirus infection, by affecting our hearts and our lungs. If coronavirus is having any even remotely positive effects, it is giving with one hand and taking away with the other. And, whatever benefits the epidemic can bring in terms of pollution, it is likely to be short-lived. “Revenge pollution” (a term which I first heard while preparing for this blog) is the likely increase on pollution that will occur when governments worldwide will try to jump-start industrial productivity again after the crisis has subsided. In 2009, the Chinese government gave more than 500 billion US dollars in response to the global financial crisis and to stimulate large-scale infrastructure projects, resulting in an explosion in pollution in the following years. And, above all, as all mental health practitioners know, the mental health impact of this epidemic will be overwhelming, even just considering the immediate consequences of the increased morbidity and mortality among our friends and relatives, the effects of social isolation, and the economic crisis that will afflict us all. Guidelines on how to tackle the mental health impact are welcomed. And we will do what we can with our blog to bring accurate information, personal accounts, and science development, to our readers. But it will be difficult. Very difficult. No hugging stranger runners in the park. Let’s just hope we will still be able to run. Header Image Source: Sajjad Hussain/Getty Images

In September 2019, I was in Copenhagen at the ECNP (European College of Neuropsychopharmacology) conference. While I was reading the programme looking for interesting talks, my attention was captured by a symposium on Women in Academia. I decided to prioritise this over all the other interesting symposia, and I later felt glad that I made this choice. During the talk, the speakers introduced the ALBA Network, an initiative to promote women’s careers in Academia. You will have to wait the end of this article to know where the name ALBA came from! Wanting to know more, I decided to approach one of the organizers (naturally, I went for my Italian compatriot), and that’s how I met Dr Francesca Cirulli. Francesca is a senior researcher and group leader in the Center for Behavioral Sciences and Mental Health at the Instituto Superiore di Sanità, in Rome (the Italian equivalent of the American National Institute of Health). She is involved in research in the field of behavioral neuroscience, with a special interest in the neurobiology of stress. As my previous blog on ‘women in academia’ was very well-received, I thought that interviewing Francesca was an opportunity for writing my next blog on the topic. And she enthusiastically accepted. We met some months later at King’s College London to have our chat about ALBA, and my first question for her was about the origins of this project and how it is related to women in Academia. Francesca: Alba is a Network that has been created to promote equality and diversity in brain sciences with an important focus on counteracting gender bias. Everybody can have access to our initiatives and become a member just by accessing our website. Me: How did the idea of Alba come up? Francesca: Alba was an idea of Carmen Sandi, the current president of FENS (Federation of European Neuroscience Society). It developed around some informal discussions between a group of women colleagues working in the Neuroscience field. One important point of view we shared is that when women gain important roles in the scientific community, they feel part of a minority. This has happened to many of us when we had been appointed to leading roles in scientific societies. You feel a bit intimidated and you even start wondering why you are there, whether you really deserve that role. In special situations, when you get into a room full of men, the feeling is to be a guest, in a place you do not belong to. This part really got my attention, the way a huge project, like this network, could start just from a shared feeling. I admired the ability of these women to take a negative feeling like that and turn it into something positive. I thought that this was something I should take as an example for the future. Me: Is the feeling you had in common the reason why the ALBA Network was born? Francesca: Yes, ALBA was born with the aim of joining forces, to strengthen our position and welcome other women who have not received the same opportunities. We want to increase knowledge of gender biases and promote best practices to counteract it. We also want to structure some guidelines that could be a model for scientific institutions and facilitate career access for all minorities. Overall, ALBA aims to empower other women scientists and provide networking and mentoring opportunities to promote careers for members of underrepresented groups. This empowerment should be based on highlighting outstanding contribution to science from all minorities. This is what impressed me most about ALBA: it is an opportunity to promote diversity overall, not only for women. It is an incredible, easy way to learn how to create a work environment that is more diverse and inclusive. This is why everybody should join this Network, not only women. Me: Francesca, how can we achieve ALBA’s objectives? Francesca: We can do it with several initiatives that are already ongoing. First of all, we are creating and sharing documents that can be used by universities and institutions to give clear indications on the ways to fight discrimination. For example, we are trying to establish a declaration to raise awareness on gender and diversity issues. Another way is to create prizes and awards for women and minorities that have excelled in neurosciences. Francesca also told me how they are developing a community of women who are able to mentor and contact all the funding agencies in order to open job positions. Not only that! They are generating a database with information on all women scientists who can be considered when organizing a conference. In this way, it is easier to generate opportunities where women get involved. Me: How did you manage to create a network of people supporting ALBA? Francesca: We involved societies we were members of, and people close to us, like FENS, ECNP, EBBS (European Brain and Behaviour Society), Women in Neuroscience, SFN (Society for Neuroscience) and IBRO (International Brain Research Organisation) that have soon become sponsors for ALBA. Some of these societies have headquarters in Africa, Asia, America. In this way, gradually, people from the scientific communities of over the world have joined ALBA! This has been helped by the creation of our website, that we have spread through social media. Moreover, sponsors like pharmaceutical companies and editorial services have helped creating the financial awards. For example, there is the ALBA-FKNE Diversity Prize, that is awarded to an individual or a group that has made outstanding contributions to promoting equality and diversity in brain sciences, including advocacy, mentorship or the creation of diversity-promoting initiatives. The prize provides financial support for participation of one person to a conference. We also did several interviews with members of ALBA, like Carmen Sandi, that you can easily find on twitter. In these interviews, members talk about ALBA and why they decided to become part of it. This is also useful to highlight successful stories of individuals and organisations in order to create role models. And now, with my interview to Francesca, I have contributed to highlight another successful story that can be read by as many people as possible. Me: So, Alba’s main focus is gender bias. Can you give me an example of bias in your experience that is important to address? Francesca: In my opinion, an important bias is the one affecting job applications for research posts, where men are still more likely to be selected. This is probably because we all imagine researchers, and in particular those in leading positions, as being white males. I think there are practical things that can be immediately done to address this bias. For example, we could have job applications that do not require specification of gender, so that the candidate can be evaluated independently. In addition, something that could be quickly done is to institute a bonus for maternity-leave years. As an example, according to the conditions of some ERC (European Research Council) Grants, maternity or paternity leave are career breaks that can be considered for the extension of the eligibility window. This method can compensate the disadvantage when these candidates are compared with those who did not have children. Me: How did you get interested in gender imbalance? It must have been something that got your attention for a long time before this initiative! Francesca: It’s a topic that has interested me since my adolescence, when books on educational biases for males and females were very popular and I have continued to gather information about it later in life. When I was doing my PhD, I read an interesting book by Terri Apter, Why Women Don’t Have Wives: Professional Success and Motherhood. It made me reflect on the fact that a wife is commonly considered a person who takes care of the partner, and while men have a wife that takes care of them, who will take care of us as women? As I was about to start a career as a scientist, this was a very important concern for me, wanting also to build a family and have children. I could see many women giving up their career ambitions because they could not reconcile them to their “caring” role in the family. How could I do that without somebody looking after me in that way? Me: It is clear to me that acting on young generations is the key to promote gender equality and counteract implicit biases. But how can we do this? How do you educate your children and also your students to gender balance? Francesca: Giving the example is the key. My children have the example of a mother that has been able to build up a career, but they also see that there is a good balance with my husband in terms of taking care of the family. I know her husband is a successful scientist as well, they are an example of a couple with both people pursuing a career and having a family at the same time. Me: Now you are also a mentor, what suggestions do you give to young women and men who are at the beginning of their career? Francesca: Having a role that can have an impact on young people, I feel like I should do something more concrete to counteract gender bias. First of all, I try to create situations where is possible to reconcile private and work life, by providing some flexibility, especially in the balance between time at work and time with the children. I also try to encourage young people to be realistic about their career expectations, by explaining that pursuing an academic career involves high competition and a lot of dedication. This does not mean to give up the idea of having a family, but that young researchers will have to be highly motivated to keep going. Clearly, the help from institutions in this process could make a big difference. The truth is that several institutions want to help women but just don’t know how to do it. That is why I like ALBA, because it involves the opportunity to build pathways that can be joined by different institutions by providing simple guidelines. Me: So, it would be enough, for any institution, to be aware of ALBA Network and to go on the website to know how to proceed? Francesca: Yes, we can propose simple plans for all the Institutions. In fact, on the ALBA website there are several resources that can be accessed and downloaded by anyone. For instance, there is the Practical guide to improving gender equality in research organisations provided by Science Europe. It contains information on “How to avoid unconscious bias in peer review process”, or “How to monitor gender equality” and “How to improve Grant Management Practices” and please, stay tuned for the “Alba Network declaration” to be released soon. Me: So, how was the general reaction to ALBA? Francesca: Very positive, also from men. I think that when we increase interest for a theme, we create a more fertile environment for initiatives. Even men are requesting more gender balance in panels for jobs interview or in review panels. And I think that a committee that is gender balanced is not only fair but is also really enriching and can provide different points of view. Again, this means that ALBA is a useful initiative for everybody, including men. In the end, it is not only benefitting women, or minorities, but it has the greater purpose to help ANYONE building a better society. Me: How can we join the Alba Network? Francesca: Everyone can go on the website and become a member and if you want to contribute more actively there is much space for every kind of initiative. Now we count thousands of members! Naturally, after meeting with Francesca, I went online to register myself as a member of the ALBA Network. My second interview with an inspiring woman left me with so many ideas, but one was particularly resonating in my mind: the possibility to take an uncomfortable situation and transform it in something good, ambitious, empowering not only for women, but for the entire society. This can be done only by joining forces. Indeed, I have interviewed two women so far and the resulting feeling is that we can be not only incredibly strong and determined, but also very good at sharing our resources. I will leave you with one of the most important questions about this project: Why the name “Alba”? The answer is available to everybody on the ALBA Network website, in the “ABOUT US” page. www.alba.Network/user/register All of you are welcome to join ALBA as another way to celebrate women, in particular this week! Happy International Women Day to you all from me and Francesca!

In 1962, marine biologist Rachel Carson reported in her book Silent Spring on the environmental effects caused by the indiscriminate use of pesticides. Her work and dedication inspired many scientists and environmental activists. More recently, the environmental activist on climate change, Greta Thunberg, has mobilised children all around the world for: ‘school strike for climate (Swedish: skolstrejk för klimatet)’. Her mottos are “No one is too small to make a difference” and “United behind science”. The voices of many other activists and scientists have been heard. People with busy everyday lives start to think about their impact on the environment. One of them is a patient of mine who has suffered from severe depression for many years. The antidepressant treatment helped her to enjoy life to its fullest. One day, she asked me a question: “Is my medication environmentally friendly?”. The answer?! A puzzled faced, as I murmured “I don’t know”. “Every problem cries in its own language.” (Tomas Tranströmer, About History 1966). In the same way, we see this with the effects of human activity on the environment. Sometimes we hear the loudest wails — enraged forest fires, devasting floods. Other times, we hear it as whimpers, present a little bit every day, and we try to find small solutions. The European Medicines Agency acknowledged the environmental risk of our medications, and ever since 2006 it requires an environmental risk assessment for the approval of new pharmaceuticals. Many medications out there were approved before 2006, and there is a lack of research on their environmental risk. We do not know how plants, animals, bacterias (e.g., aquatic environment), or other elements of biodiversity, are affected by long-term and low-level exposure to pharmaceuticals, including medication for psychiatric use. Environmental risk assessments need to be improved, and there are several recommendations for the future, such as requiring an environmental risk assessment for pharmaceutical products put on the market before 2006, and to increase transparency between environmental risk assessment and manufacturing sites. What we know so far is that psychiatric medication, other pharmacological compounds, and even drugs of abuse (such as cocaine, ketamine and methamphetamine) are present everywhere in our environment. Extremely small amounts can be measured in drinking water and are considered not harmful to humans. However, the effects on other species are largely unknown, and more research is needed. According to the European Medicines Agency, there are a few pathways on how pharmaceutical products disseminate in the environment. What do we know about medication for psychiatric use and its environmental risk? Most pharmaceutical companies report on the impact of new psychiatric medication regarding the effects on the growth, mortality, and reproduction of species. Although these pharmaceuticals alter wildlife behaviour, few studies are reported on behavioural changes. Moreover, the European Medicines Agency does not currently require studies on behavioural changes as part of the environmental risk assessment. What will the concentration of antidepressants in drinking water in Stockholm, Sweden (Photograph 1) be, compared with drinking water on Itsukushima (Deer Island), Japan (Photograph 2)? I am wondering if someone can say how common depression or anxiety is in an area by measuring the concentration of medication in drinking water. It is probably not that simple to answer this question as there is a long way to go from seeking care to receiving antidepressant medication. View fullsizePhotograph 2: courtesy of Kristian H. Reveles Jensen Antidepressant medications are usually prescribed for the treatment of depression, anxiety, or chronic pain. One of the common behavioural effects of antidepressants in humans is reducing impulsivity, while a common side effect is decreasing libido. Fluoxetine and citalopram are two of the most used antidepressants in Europe and USA and have consistently been reported in surface water and in very small amounts in our drinking water. Experimental studies suggest that fluoxetine can cause developmental delays in a species of amphibians (like frogs). Furthermore, fluoxetine can alter the behaviour of starlings and of different species of fish. In fish, antidepressants(fluoxetine, sertraline, venlafaxine, citalopram and bupropion) could also reduce aggressive behaviour and affect the feeding and reproductive behaviours. Other potent and widely used anxiolytics — medications which help reduce anxiety — include benzodiazepines such as oxazepam and diazepam. These medications persist in wastewater and are resistant to any breakdown by sunlight and air (known as the photodegradation process). This means that these medications remain, though in relatively low concentrations, in the aquatic environment. Studies from Sweden reported that oxazepam, a widely used benzodiazepine, increases the migration pattern of salmon and alters the behaviour and feeding rates of wild European perch, another type of fish. What can be done by patients and clinicians? The Swedish Prescribing Guide have some tips to minimise the environmental impact: 1. Prescribe a small number of tablets when a patient tries a new medication 2. The patient information leaflet of many / most of the psychopharmacological drugs contains information on environmental risks. Doctors also need to create a routine in informing the patient on this issue as I am quite sure that in time clinicians will receive this question a lot more often. 3. Patients should be informed that no medication should be discarded among household waste or flushed in the toilet. 4. Leftover drugs and pharmaceutical packing (such as aerosol containers, powder inhalers, vials and ampoules, packaging containing infusion fluids, depot injections, depot patches, vaginal rings etc) should be returned to pharmacies for disposal. 5. Empty pharmaceutical packing should be sorted as other household garbage. 6. Become a volunteer and support research and campaigns on assessing the environmental risk of our pharmaceuticals. How about the manufacturing of medications? In this blog, I have discussed mainly medications which are prescribed for personal use. The reality of the matter is that a large proportion of the pharmaceuticals found in waters around the world are the result of the manufacturing process. There is generally a lack of regulation on how much pharmaceutics can be eliminated in the waste waters close to the pharmaceutical factories. For more information on this topic please watch this talk of Professor Joakim Larsson from Gothenburg University, Sweden. And, while doing research for this blog, I found a wonderful short film which highlights what I want to leave you with as a take home message. From Charles Darwin’s time and his “On the origin of the species”, we know that the fittest have the highest chances to survive. We are the result of a permanent interaction between the genetic material from our parents and the environment. Given the rapidity with which human activity is impacting our environment including modifying the genetic material of other species, I am wondering where these changes will lead to. It looks like in the era of Anthropocene (the Human Era ) everything is possible. But do we really want to transform the useful frog in a handsome prince that we do not need? For more information, please check additional websites: · Medicine Waste UK · Meds Disposal · MistraPharma · Pharmaceuticals in Drinking Water — World Health Organisation · Environmental risk assessment of medicinal products for human use — European Medicines Agency · Environmental Classification of APIs on Fass.se Header image source Kristian H. Reveles Jensen

A little while ago, my colleague Giulia wrote a fabulous introduction into mindfulness practice. Before reading this blog, please check hers out first. Special bonus: there are some awesome references to Star Wars! Indeed, the popularity of mindfulness is on the rise, but many sceptics still see it as a spiritual ritual or *just another* health trend. How do I know? I was that sceptic until very recently, when I began my Master’s in Health Psychology. Exacerbated by increased pressure at my job, my mind was racing whenever I had a spare minute, causing me anxiety and insomnia. Having a background in neuroscience, I knew that our brains are plastic, meaning they can adapt and change upon different types of regular stimulation. It also became apparent that our mental health needs attention and care, just as our physical health. Therefore, the idea of mental training in the form of mindfulness particularly appealed to me, once I read up on it. Another bonus for me was that I didn’t need to commit to expensive memberships or equipment  —  a quiet place and 10 minutes of my time was enough. Hearing everyone around me raving about it as well, I finally decided to give it a try. And results did not disappoint. Apart from general improvement in anxiety, quick 5–10-minute guided meditation helps me fall asleep and ease my mind when I feel overwhelmed. Now, I personally no longer need proof that it works. Some people do though, so don’t take my word for it — continue reading if you want to find out more about the science behind mindfulness! Of course, it is important to remember that mindfulness research is still in its early years, with the first randomised controlled trials published in the 1990s and rapidly propagating since. Nevertheless, there is good evidence that regular mindfulness practice causes changes in brain structures and functioning. The human brain is an incredibly complex structure, and researchers are still far from disentangling all of its potential. The current state of research into mindfulness is incredibly promising, and mindfulness is one of the health trends that actually lives up to its hype. If I had to present the current state of mindfulness research in one sentence, it would be: “Regular mindfulness practice affects every single part of the brain”. This is obviously a very simplistic way of putting it, but taken together, published research reports an enormous amount of brain regions involved in meditation practice. And, of course, many brain structures are connected between each other, and interact within the same or overlapping pathways. In this short blog, I can cover only so much about the neuroscience behind mindfulness, so I focus on its 4 main benefits: improved attention, emotional regulation, self-perception and pain management. One aspect that mindfulness practice can improve is attention. Researchers found that at early stages of practice, mindfulness enhances our so-called executive attention, which simply means that our mind becomes better at regulating responses, especially in conflict situations where various responses are possible. Early stages of meditation also improve our ability to choose what to pay attention to, depending on what is more important in this moment — for example, when you cross the road, your mind will be better at directing your attention to the road and approaching cars, rather than your phone or your companion. More advanced meditators, in turn, experience improved vigilance. The brain area responsible for these changes is Anterior Cingulate Cortex (ACC). Researchers discovered that, in beginner meditators, ACC and other brain areas work harder than usual, just like our muscles when we start exercising. In those who practice meditation for longer, brain activity is actually reduced, meaning that with growing expertise in mindfulness state, our brains don’t require as much mental effort to activate attention. The same applies to emotion regulation — another benefit of meditation practice. Good news is, you don’t need a lifetime of practice to experience this, as even short-term training can have the desired effect! Mindfulness practice leads to reduced emotional arousal, courtesy of the amygdala — an emotional ‘hub’ of our brain. As mentioned in Giulia’s blog, mindfulness helps us to see events in a non-judgemental way, and this is exactly what happens when our amygdala becomes less active with meditation training. Additionally, changes in brain connectivity between amygdala and frontal lobe suggest that people who practice meditation tend to monitor their emotions rather than suppress them, and experience less anxiety. Mindfulness can also help those who suffer from chronic pain. Research suggests that meditators have decreased communication between executive and pain-related brain regions, meaning that their brain hinders pain-related signals to reach the consciousness, which helps us to pay less attention to the pain experience. Mindfulness is also thought to improve self-esteem, positive self-representation and self-acceptance. Although these are pretty hard to measure in a person, a set of brain regions that is thought to be involved is called Default Mode Network (DMN). As suggested by the name, DMN is most active when we function by default, for example when we are resting, daydreaming, mind wandering, or thinking about our past or future. These thoughts are automatic and often tend to be negative. Meditators tend to have reduced activation of DMN compared to those who don’t meditate. This means that when meditators rest, their mind often enters the so-called “flow” state, which is when we focus on the “now” and when most creative processes happen. The alternative of this would be rumination over the past, self-reflections, fears and desires, which can be highly distressing, but thankfully can be improved by mindfulness. There are many other brain changes associated with mindfulness meditation, and many more benefits that come from regular practice. According to the neuroimaging findings, it takes time for your brain to grasp mindfulness practice, so it can be hard to stick to it in the beginning — however once you start doing it consistently, your mind will start reaping the benefits. To practice mindfulness, you don’t need to go to Tibet or spend hours: even 10–20 minutes of daily meditation for 2 weeks can improve your well-being and reduce job strain, distress and irritability. It is important to remember that most research is done on relatively healthy people, and effects of mindfulness on those with mental health problems can vary. As mentioned in Giulia’s blog, it is by no means a replacement for therapy or medical treatment, and should only be used as a supplementary practice.

I live in Camberwell, in South East London, just a few minutes away from the Institute of Psychiatry, Psychology and Neuroscience where I currently work. A typical morning of my everyday commute would be to walk 20 minutes from my house to my son’s school and then another 20 minutes to my office. During my commute, I usually pass from four major roads, a bunch of leafy streets, two parks, a series of big estate buildings, a vibrant high street full of cafes and restaurants, construction sites and a small street full of Georgian houses before I arrive at my office. During my commute, there are few days especially in the springtime that I am thinking if and how the air I breathe is affecting my mental health and wellbeing … always with a little help from Bo Diddley, Herbert Leroy Needleman, General Motors, the Great London smog and my current research. “Pollution in the home Pollution in the streets Pollution everywhere Gonna get you and me Pollution” - Bo Diddley, Another Dimension (Chess; 1971)” At the same time that Bo Diddley (1928–2008) recorded “Pollution” in the early 1970s, Herbert Leroy Needleman (1927–2017) was about to embark to a seminal epidemiological study — the study of patterns and determinants of health and disease in defined populations — which showed the first link between children being highly exposed to lead from petrol derived from car engines and deficits in their psychologic and classroom performance in Chelsea and Somerville in Massachusetts, USA. Before Needleman’s study, there were few anecdotal accounts of lead poisoning, spanning from Roman times (a roman physician noted that “lead makes the mind give away”) to the ban of lead coils in rum in the Americas in the 18th century. However, the well-known neurotoxic effects of lead did not stop big industries such as General Motors to include lead as an additive in petrol in the early 1920s and making huge efforts to discredit Needleman’s work. The effects of these actions on the atmosphere and population health were profound at a global scale for the years to come. Primary air pollutants are typically released from ‘mobile’ sources (e.g., exhaust fumes from vehicles), ‘stationary’ sources (e.g., emissions from factories) and domestic activities (e.g., coal and wood for cooking and heating). Secondary air pollutants formed in the atmosphere through chemical reactions. Thus, traffic is not the only source of poor outdoor air quality, but it is the main driver for air pollution, specifically in cities. Children are particularly susceptible to harmful effects of traffic-related air pollution, because of central nervous system plasticity during early stages in life. In 1999, leaded petrol was finally banned in the UK to protect children’s brains from its damaging effects. However, studies continued to emerge linking children residing in areas with poor air quality with deficits in classroom performance and educational attainment. This mounting evidence is due to other components of traffic-related air pollution particles, including carbon monoxide, polycyclic aromatic hydrocarbons and nitrogen dioxides, which have also been shown to be neurotoxic. Support for these studies came recently from brain sciences. A recent review of the literature detected brain damages that might be targets of traffic-related air pollution. Also, in the last two decades, many studies have shown that air pollution is associated with increased risk of psychotic experiences such as delusions or hallucinations in adolescents and adults, depression, anxiety and suicide in adults, and dementia in elderly. However, the evidence is far from conclusive and there is little understanding of how inhaled pollutants gain access to the brain. The reason for this is that findings from these observational studies that link air pollution with neurological and mental health problems cannot sort out what causes what. It’s easy to find coincidental changes in the environment that correlate with the number of people receiving psychiatric diagnoses. Due to environmental inequalities, people who live in more polluted areas tend to be different (e.g. in terms of ethnicity, gender or socioeconomic status) from those who live in less polluted areas in many ways not caused by the pollution, and it could be that one or more of these other differences the real cause of differences in rates of psychiatric disorders. When analysing the data on this matter, statistical adjustments made by the researchers to try to allow for these other factors are not always adequate and some of them potential confounders have been estimated inadequately. Conducting a randomised controlled trial — a type of scientific experiment that aims to reduce these type of biases (read more about these trials in a previous blog here) — could resolve this and establish a causal link between air pollution and mental health, but it would be unethical to subject people in high levels of air pollution as we would do, for example, in a pharmaceutical drug trial. Furthermore, only one of the studies mentioned above investigates these associations over the lifetime of the participants, as ideally studies would wish to capture early life exposure in air pollution to provide a comprehensive understanding of how changes in individual cognitive development during childhood influence psychiatric symptoms in adulthood. But, this is just the beginning… We live in an era with unprecedented opportunities to harness on different types of data resources to answer the questions ahead of us. Here at King’s College London, we are part of a wider international research community which aims to tackle these issues. We recently had the ability to link high-resolution measures of air pollution with over 300,000 electronic mental health records from patients attending mental health services in South East London, and we are currently investigating for the first time the impact of air pollution in mental health service use and its associated costs over a period of over twelve years. In addition, the UK supports an unparalleled collection of large-scale population-based studies which follow individuals from birth providing a wealth of information of measurements of air pollution and mental health data across the lifetime of the participants. The advent of smartphone technologies has currently given us new opportunities to collect multiple environmental and mental health data. Specifically, via Urban Mind — a citizen-science project which uses a smartphone app to measure the experience of urban and rural living — we are currently investigating possible short-term associations between air pollution and mental wellbeing in real-time and as people go about their daily life. Most importantly, residents in London, since January 2019, have been all participants of a natural experiment a kind of a clinical trial with the implementation of the new Ultra Low Emission Zone (ULEZ) — an extra daily change to those driving polluting vehicles in central London on top of the existing congestion charge. ULEZ could act as the “therapeutic intervention” which aims to reduce harmful emissions from traffic, improve air quality and thus enhance the overall health of the population residing in the city, where improvements in mental health could also be possible and traceable. The study of air pollution and health was originally driven by dramatic events such as the 1943 Los Angeles eye-stinging smog where L.A residents believed that the Japanese were attacking them with chemical welfare. In Europe, the 1952 Great London Fog, in which a combination of water droplets with soot and sulphur from coal that powered industry and kept homes warm, resulted in thousands of deaths. However, smog events did not remain only memories of the past. In recent years, countries such as China, India and Nepal have been experiencing similar events and saw air pollution measurements reach record levels, conditions that led to significant increases in morbidity and mortality rates. Such events led to considerable debate with pressure from the media and the public which led towards policy (e.g., the UK 1956 Clean Air Act, the 1967 California Air Resources Board (CARB), the China 2015 Air Pollution Control Law) and heightened public awareness of the relationship between air quality and health. In 2016, the World Health Organization (WHO) reported that 91% of the world’s population lives in places where air quality exceeds WHO guideline limits with 4.2 million of premature deaths being a result of ambient air pollution with 91% of these premature deaths occurring in low- and middle-income countries. This is another example of environmental health inequalities at a global scale with current evidence from the research community indicating the need for revision of WHO air quality guidelines in even lower limits to protect human health. There should be special attention for innovative measures to improve air quality such as the ULEZ, the introduction of buses and cars powered by electricity, and boldly rethink the way that we plan our cities — some cities have announced car-less visions, including Milan, Copenhagen, Madrid and Paris and Oslo. Improving air quality is a tractable, though complex issue, and therefore measures to reduce air pollution may represent a potentially impactful and rare primary health measure for the prevention of psychiatric disorders, although we still need to learn much more about if and how this would work. The Herbert Leroy Needleman story — both his showing the link between exposure to lead and deficits in children classroom performance, and the efforts from car industries to discredit his work — is one of the many stories that has taught us that air pollution, like climate change and structural inequalities, is not a problem to be resolved by science, but an issue deeply embedded into our individual and societal decisions and the power relations of our political systems. Thus, we need to answer the question if we are willing to revert the neoliberal processes that generate these issues in favour of a better place to live in the future and bring this unhealthy love story to an end. NOTE FROM THE EDITORS: We are delighted to have Dr Ioannis Bakolis join our team of fantastic writers and share this piece. Dr Bakolis is a senior lecturer in Biostatistics and Epidemiology at the Institute of Psychiatry, Psychology and Neuroscience. Ioannis is interested in how social, built and physical environments affect the epidemiology of both physical and mental health. Some of his current work include exploring how exposure to road-traffic air and noise pollution affect mental disorders; and how neighbourhood deprivation relates to mental health over the life course. Once again, a massive thank you from us to him for this great insight into the impact of air pollution on mental health!

Trigger warning: This blog deals with the subject of infant death. It was the beginning of October last year when I read a disturbing article about the death of a baby, after a mother gave birth alone in her cell, in Europe’s largest female prison: the privately run HMP Bronzefield in Surrey. Being five-months pregnant myself at that time, I was struggling between the instinct to protect my mind as much as possible from negative thoughts, and the need to know more about other mothers’ experiences. Yet, I could not ignore this news, which was obviously raising questions about basic rights of these women, such as access to midwives, and to ante and post-natal care. I have been always interested in gender issues and women’s rights-related topics, and one of the most recurrent points is how men have exercised their power since forever; or how, with a critical lens, we can catch patriarchy in almost every aspect of life. Patriarchy is generally understood as system ruled by men, whose authority is enforced through social, political, economic and religious institutions, and which results in a subordinated position of most women in such a system. However, this is something different: most of the time childbirth is a matter of women, managed by women. So, I wondered how there can be such a lack of human care and compassion towards inmates, sometimes from other women (for example the female prison guards), probably mothers themselves? Please don’t take me wrong, I am not criticising prison staff or, indeed, individual prisons. My question here is: is this the result of a system that put so much pressure on people to make them focussed on policies and procedures rather than on human suffering? It did not help me to know that, around that time (late October 2019), speaking at a House of Lords debate, the justice minister Lord Keen, said that “this distressing incident is a rare occurrence. Every step is taken for women to give birth in hospital but, for a small number, this is not possible due to the unpredictability of labour.” Or that Ms Frazer, the Secretary of State for Justice, said that “pregnant prisoners have access to the same range of services as they would do in the community”. It did not help at all. So, I started researching about this topic. Let’s consider some numbers. Data from the Prison Reform Trust indicates that women made up 5% of the prison population in 2018, with 7,745 women incarcerated. 82% of them were sentenced for non-violent offences. 8 in 10 women in prison reported that they had mental health issues, and many other ones suffered histories of abuse. Nobody knows exactly how many births take place in prison or even how many prisoners are pregnant, because neither the Ministry of Justice nor the NHS collects the data. According to the Guardian, about 600 pregnant women are held in prisons in England and Wales every year, and about 100 babies are born there. In November, the BBC reported that the government revealed a number of 47 pregnant women currently in England and Wales prisons, however there was not reference to the official source. No figure was issued as of how many female prisoners had babies, and the number of miscarriages, stillbirths, or infant deaths whilst in prison. In April 2019, the HM Inspectorate of Prisons published a report on an unannounced inspection at Bronzefield at the end of December 2018. It was found that it was an ““overwhelmingly safe prison”, although nearly 70% of prisoners reported having mental health problems. In October 2019, Baroness Hussein-Ece, a Liberal Democrat peer, stated that, despite last year government’s commitment in female offender strategies to reduce the women’s prison population, it has increased. Numbers are one way to approach a problem. But I also wanted to understand what happened to these women, not as a number but as the individuals. I read some stories and started feeling like I knew them personally. I tried to imagine how they had experienced their pregnancy. Sometimes in comparison to how I was experiencing mine. What happened to the woman who lost her child is brutally simple: she gave birth on her own in a prison cell, with no help. The local police’s statement said that the death was being treated as “unexplained” and that an investigation was taking place. Perhaps the investigation could explain why a woman in her late stage of pregnancy did not come to the attention of prison staff for several hours. The reason why a woman is in prison should not really matter: their unborn baby should receive the same care as anyone else’s baby. The same care my unborn baby was being given. Unfortunately, it does not seem to be the case. There is another sad story of a woman who was sent to prison when she was 16 weeks pregnant. She was locked with a smoker inmate, not provided with the extra food or fresh fruit and vegetable for the growing baby, and even denied an extra pillow for the symphysis pubis dysfunction she developed. She tells her story, these are her own words: “While I was in prison I heard of four women who had had their babies in their cells because they weren’t believed when they said they were in labour — and were only assessed by untrained staff. You listen to the stories. You see it yourself. You’re petrified that this will happen to you.” How would we feel in her situation? How distressful are these fears? Polly (a name used by the journalist to protect the woman’s identity) was also unlucky: she lost her baby whilst in prison when she was four months’ pregnant. She was alone in her cell at night and started bleeding heavily. She rang the bell several times but nobody answered her cries for help. When a member of staff eventually arrived at the cell and acknowledged the situation, she was rushed to the hospital, in handcuffs. Unfortunately, nothing could be done to prevent a miscarriage. Pregnant women are strongly recommended to take multivitamins daily (which help to promote the healthy development of their baby), have a balanced diet, regularly exercise, get fresh air and sleep safely — this should be the norm whether in prison or not. Again, this seems not be the case for women in prisons, meaning that their babies will suffer the consequences of that. Is it fair that these children are somehow made to pay for the way their parents (or, often, their mothers) have decided to live their life? Every child deserves a chance for a better life and should not pay for their parents’ mistakes: this seems a redundant statement and most people would probably agree with it in theory. But in reality? Giving birth safely and with dignity should be an undisputable right for all women to enjoy, whether in prison or in hospital, or at home. It reminds me when I was studying for my MA in Human Rights and Social Justice, and I was learning how certain basic rights were almost taken for granted, at least in the developed western countries. Article 2 of the Human Rights Act 1998, which incorporates the rights set out in the European Convention on Human Rights into British law, sanctions everyone’s right to life. Article 3 states that no one shall be subjected to inhuman or degrading treatment. What about these babies and these women? Is the way they are treated compatible with an (allegedly) well-established human rights framework, as it is in England? Someone might argue that if a woman does not want to give birth in prison, she just needs to avoid committing a crime. That’s it. Unfortunately, this straightforward logic (and potentially judgmental attitude) cannot be applied to all circumstances. Mental health issues a nd a past history of domestic abuses and violence are often a recurrent factor in women who are associated to criminality. The nature of criminal activities committed by women is often different and peculiar compared to the crimes of males. Most of these women need care and support more than a prison sentence. I learnt that until 20 years ago it was the Prison Service’s policy to keep women handcuffed during labour, to mitigate the risk they could escape  —  well, we all know that during labour or soon after giving birth women are so energised that they could run away… In November 2018, the Guardian referred to a damning report, which warned that women were giving birth in prison without proper medical care and assisted (when they are assisted) by staff with no midwifery training. Such the experience of a woman, who went prematurely into labour, and the baby was in the breech position (e.g., bottom or feet first). This was her second baby and when the woman called the prison staff, telling them she was sure she was in labour, she was not believed. I found it difficult, when reading these stories, to digest that such mental sufferance could be tolerated, and that giving birth in such an inhuman and humiliating setting could be considered as a matter of routine, with pain and fears not being comforted, or being even ignored. Having in mind Fyodor Dostoyevsky who said that the degree of civilisation in a society is revealed by entering its prisons, it is difficult to accept a system that is unable to dispense some kindness even in a moment such as the birth of a baby, which is something in life that should be granted the highest respect. A new human being coming to this world deserves all possible attention: accomplishing this expectation dignifies the human nature as a whole, making the opposite a complete failure and degeneration of ethics and of the integrity of our conscience. It is now February 2020. For all of these months, I have felt that this is something I could not let it go of and hence why I decided to write this blog. I keep thinking of these women and their babies. It is February and no update from a possible investigation has come out yet. I found no evidence that this topic is part of an ongoing and meaningful debate. In the meantime, the woman whose newborn baby died has been released on bail. It seems that, when she gave birth at the end of September, she was on remand, rather than serving a full sentence. This detail makes the story even more unbearable. This is something that shouldn’t have happened. I wonder whether this case was important enough to raise general concern? Was it just unfortunate or unpredictable? I want to hope that the story of this poor baby could save other babies’ lives. This would somehow mitigate the horrible circumstance of this case and honour the memory of a life that was lost too soon after it started. NOTE FROM THE EDITORS: We would like to say a huge thank you to Margherita Noto for writing this incredibly powerful piece on InSPIre the Mind. Margherita is a Compliance Consultant in the Financial Services Sector, with a passion for human rights and gender topics. She has a background in gender violence, systems of social subordination, and women’s rights, after studing an MA in Human Rights and Social Justice. If you would like some support regarding the issues raised in this blog, please reach out to the following charities who specialise in these areas: Header image source Francesco Catania

I am a graduate in Biomedical Sciences with Professional Experience from Brunel University London. During my studies, I have grown to become fascinated by mental health and more specifically this topic of alternative treatments to depression due to the considerable lack of adequate understanding of the fundamental causes and the mechanisms involved in the development of mental disorders. Therefore I would not only like to have the opportunity to conduct research in this area but I would also like to inform the general public about the science behind mental health and ultimately contribute to ending the stigma surrounding the idea that mental disorders are all in the head. According to the World Health Organisation (WHO), depression has become the major cause of disability in the world. The current treatment for depression involves using conventional antidepressants, which have been limited in terms of their effectiveness, safety and how well they’re tolerated. In other words, they display modest therapeutic benefit but are frequently associated with side effects. So, attention has shifted to questioning whether changes in lifestyle and diet can be a novel therapeutic strategy for this disease. What are omega-3 fatty acids? Omega-3 polyunsaturated fatty acids (ω-3 PUFAs) are a class of compounds that include essential fatty acids like eicosapentanoic acid (EPA) and docosahexanoic acid (DHA), which must be obtained through dietary intake since the body cannot produce them. These compounds are mainly found as components of fish oils derived from oily fish such as salmon, herring, sardines and mackerel. What are their functions? You may be asking, what impact do fish oil supplements actually have on the human body? Well, it turns out that ω-3 PUFAs — like EPA and DHA — have an important role in brain function. Interestingly, these compounds are not only involved in the signalling that takes place between neurons and in maintaining the structure of neuron membranes, but they are also involved in regulating the function of the immune system and have an anti-inflammatory action in the brain — meaning that these compounds are able to decrease inflammation. This anti-inflammatory action is thought to be one of the mechanisms by which ω-3 PUFAs mediate their antidepressant effects. Additional information on this area can be found in two excellent reviews from the Neurosignals and Nature journals. Furthermore, a diet supplemented with ω-3 PUFAs can significantly reduce cortisol (a hormone produced in response to stress) after the induction of mental stress in one study, thus indicating their possible impact on our stress response system. The role of stress, the immune system, and inflammation on the development of depression has been widely discussed in the scientific literature and is the central theme of discussion for some of the blog posts on ‘InSPIre the Mind’, such as those written by Andrew Perrin and Professor Carmine Pariante (which I highly recommend you to read). Therefore, ω-3 PUFAs could not only improve the symptoms of depression but could also be therapeutically beneficial for patients with conditions such as diabetes, coronary heart disease and cancer, for which chronic inflammation is an important contributing factor. ω-3 PUFAs have also been implicated in the treatment of Alzheimer’s disease and ADHD (Attention Deficit Hyperactivity Disorder), suggesting their probable role in cognition and neurodevelopment. What do the studies say? As a result of their discovered antidepressant effects, ω-3 PUFAs have been gaining a lot of attention from the clinical and medical community, with a large number of scientific articles being published in the last two decades discussing their potential use as treatment for depression. Depressed patients have lower levels of ω-3 PUFAs in the brain than in healthy controls, suggesting a link between dietary fish consumption and the risk of depression. In fact, countries that consume a larger amount of oily fish rich in ω-3 PUFAs as part of their diet such as Taiwan, Japan and Korea have lower incidences of depression. So, does that mean that the more oily fish or fish oil supplements you consume, the higher the levels of ω-3 PUFAs in your brain, and thus resulting in a reduced risk of depression? Well, not quite — before running off to your local fishmonger or chemist, it’s important to note that further validation is needed. Results from various studies have been encouraging and support the use of ω-3 PUFAs as adjunctive treatment. This means that they can be taken in addition to conventional antidepressants to enhance antidepressant effects, rather than being a treatment used alone. The tolerability and safety of these compounds have also been noted, with the occurrence of side effects being very rare. There are also studies that focus on the development of personalised treatment strategies and have identified biomarkers — such as inflammation, which can be detected in the blood — to predict how individuals will respond to ω-3 PUFAs. For example, one such study reported that patients with depression displaying higher levels of inflammation before treatment, were shown to have better responses to EPA than those displaying low inflammation. This could mean that ω-3 PUFAs are more effective in patients with inflammation-associated depression. And you might have read a recent blog on this platform talking about another study (admittedly, not in depression) which found that children with ADHD and lower levels of endogenous ω-3 PUFAs are more likely to respond to EPA than children with normal or high endogenous levels — another example of ‘personalised treatment’. As mentioned above, two forms of ω-3 PUFAs are EPA and DHA. Studies have shown that EPA may display stronger antidepressant effects than DHA, with EPA successfully preventing depression but DHA only delaying the start of the disorder. This may be the type of findings that have informed the recently published guidelines by the ‘International Society for Nutritional Psychiatry Research’ (ISNPR) for the treatment of depression using ω-3 PUFAs. But what about children and pregnant women with depression? The ISNPR agrees to the use of ω-3 PUFAs for the treatment of depression in pregnant women and children, as well as the elderly, and for the prevention of depression in high-risk populations. The research suggests that ω-3 PUFAs seem to hold great potential as a safer alternative for these patients. However, despite the evidence demonstrating the therapeutic benefit of ω-3 PUFAs used as a standalone treatment in children and pregnant women with depression, due to the use of small sample sizes in research studies as well as an overall low number of studies investigating these populations, the ISNPR urges clinicians to carefully consider the use of this treatment for these patients until there is further research evidence. So, what does this all mean for the future of ω-3 PUFAs as treatment for depression? As discussed above, there is a lot of evidence supporting the use of ω-3 PUFAs in combination with conventional antidepressants — potentially being more beneficial in their effectiveness in depressed patients with underlying inflammation. Undeniably, this is all very promising for the field of mental health research, and a step in the right direction. But, there is still a way to go before ω-3 PUFAs are implemented regularly by clinicians in their treatment strategies for patients. More randomised clinical trials, comparing the use of ω-3 PUFAs against a placebo (i.e. a sugar pill) or even other treatments, with larger populations are needed to validate the efficacy of these compounds both as an add-on treatment in adults and as a standalone treatment in pregnant women and children. There is also the prospect of a personalised approach to the treatment of depression based on biomarkers that deserves further study, including levels of endogenous ω-3 PUFAs themselves. With further research, this has the potential to help predict an individual patients’ response to different types of treatments, as well as identify the mechanisms behind the disorder. The potential side effects cannot be ignored either — gastrointestinal (stomach and digestive system) and dermatological (skin, hair and nail) problems should be monitored, according to the ISNPR. Nonetheless, I am looking forward to what future studies uncover and whether this evidence will have an impact in the clinic, and I hope you are too! NOTE FROM THE EDITORS: We would like to extend a big thank you to Nare Amasi-Hartoonian for this wonderful blog. Nare is a Biomedical Sciences graduate from the University of Brunel who became interested in mental health during her undergraduate studies and it is a great pleasure that she has written a piece for our InSPIre the Mind readers! Photo by Adrianna Calvo from Pexels

I am a fourth-year medical student studying at the University of Southampton. Though I don’t know what I want to specialise in yet, I have always found psychiatry interesting and I enjoy reading and writing so I thought I would lend my voice. I enjoy long walks on the beach, warm sunsets, and the green bloom that Spring brings – and these are some of my thoughts I had while reflecting on my psychiatry placement, during my long walks. Being a medical student and having just finished my psychiatry placement, it has been a real privilege, as always, to listen to patients’ stories and be able to get insight into their health and private lives. I can only speak about my experiences and discuss what I have personally witnessed but I find it incredible how much stigma there still is around the topic of mental health. The stigma that we – those in the profession of healthcare – are fighting so hard to break still exists in our communities. A great starting point to this discussion was written by Melisa Kose for InSPIre the Mind. This piece will be a continuation of that discussion and an opportunity to lend my voice, having seen first-hand how the stigma of mental health can affect patients and doctors. There are many misconceptions towards the work that mental health professionals do. A good example that I have witnessed is surrounding electro-convulsive therapy (ECT). The stigma towards ECT can be split between three parts: my own views, the general public’s, and the stigma from the patients receiving ECT themselves. If we go back to the theme of movies as described in the previous blog mentioned, ‘One Flew Over the Cuckoo’s Nest’, one of Jack Nicholson’s most well-known roles, portrays psychiatry and ECT in an intense manner; pretending to walk like a zombie after a round of ECT, Randall jokes “they was giving me 10,000 watts a day… The next woman that takes me up is going to light up like a pinball.” Developed in the 1930s, ECT has suffered in popularity throughout the years, due to films like this. Having heard individuals use words such as ‘barbaric’ and ‘controversial’ a lot of people aren’t aware that ECT is still a part of clinical practice and can be life-saving for those with treatment-resistant depression, resistant mania, and catatonia. The fact that I was apprehensive myself, an open-minded medical student interested in the field of Psychiatry, shows that the stigma around ECT really runs deep. I was not even aware that it was a treatment that was offered; the media had portrayed the idea as so ‘crazy’ to me that I never thought it could actually be used in a controlled manner to save lives. My ignorance was short-lived once I attended an ECT clinic and I saw the benefit that it brought to patients, especially in those that are at high risk to self. The same stigma is shared by psychiatric patients themselves; a lady I saw in the clinic said that she felt ashamed to tell people she was receiving ECT. She felt that people would often judge her, saying she was ‘brainwashed’. Though shame in psychiatry is not new phenomenon, it disheartened me to hear this, finding myself surprised at how little progress it felt like we were making in breaking these attitudes. On another day, I was shadowing a consultant when a woman came in presenting with low mood. Her opening sentence as soon as she sat down was “I’m ashamed that I’m here and that things have gotten to the point of seeing a psychiatrist”. The tone she set for the appointment was clear: that she wishes she was anywhere else but here. It is difficult to deal with a patient who doesn’t want your help; no one enjoys seeing a psychiatrist. But from what I’ve seen over the last few months, it is one of the specialties for the most scope of change in people’s health. Saving lives is just a small aspect of medicine – the majority of it is management of conditions. To go from psychotic episodes, rapid mood changes and extreme self-harm to being able to go work, afford rent and back into a somewhat relatively ‘normal’ lifestyle, I have seen psychiatry change lives for the better. And psychiatry saves lives too: one person dies due to suicide every 40 seconds, and psychiatry tries to prevent as many suicides as possible. Other remarkable examples that hit the news include the thousands of mothers who are helped by the expansion of services and the thousands of children who are treated two years earlier than the government targets set out. So, changes are happening. But what does the future hold and what else can we do? With a high prevalence of the public experiencing a mental health condition each year and an increase in the use of mental health services, this isn’t something we can ignore. It’s time to take it further than just acknowledging the importance of mental health, and the time for doing is long overdue. Attitudes amongst my peers and I shifted drastically after the 8 weeks of placement and seeing first-hand the effect of the specialty is one way to change views and debunk myths. Politicians can do an awful lot of change by using their platforms, and mental health was a big topic across the campaigns in the latest general election, including the three biggest UK party campaigns bringing the important issue to light in their manifestos. Stories being written, whether it is through the use of anecdotes in the likes of Adam Key in ‘This Is Going to Hurt’ or through more formal accounts, have highlighted important matters in healthcare and have enabled the public to get an insight into the profession of medicine. Celebrities have gotten involved with the ‘Time To Change’ campaign, the Royal College of Psychiatrists have written a manifesto outlining points on how to improve the country’s mental health and improve services, and even the Royal Family has gotten involved, showing that even royalty suffers like the rest of us. So, here’s a dedication of hope for this decade and the prospect of bringing better change in the UK in what sometimes feels like trying times. Perhaps I’ll go into this field, a tad too hopeful about the change that I, a single human, can bring. I often hear that “no truly sane person goes into psychiatry” and I wonder if maybe I’ll find myself like Randall did in ‘One Flew Over the Cuckoo’s Nest’: “I must be crazy to end up in a loony bin like this.” Header image source Bluscreen

We are only a few days away from the one year anniversary of our blog platform — our first blog was published on the 1st of March 2019 — and we could not be happier for our success. We have published more than 60 blogs, and reached more than 45 thousand readers. We have talked about mental health in its broadest possible remit: from medications to psychotherapy, from life-style to cinema, from stigma to politics, from culture to lived experience. We have had blogs written by researchers, clinicians, students, activists, journalists, artists, musicians. We have had personal accounts and interviews to celebrities, scientific discussions and creative pieces — and embedded original photos, videos, and podcasts. And this is why we are changing the logo! Because our old logo, as much as we love it, it is now ‘too small’ to represent everything that we are doing. We loved the idea of a human being observed in their entirity ‘under a microscope’. It did convey our initial focus on being scientifically-evident while respectful of the complexity and holistic nature of people’s mental and physical health. But the breadth and depth of the blogs that we have received — and published with great pride — has convinced us that the time has arrived to fly even higher, above the clouds. We firmly remain a science-based blog platform, hence the brain at the centre of our logo, and the cartesian axes that symbolise our ambition to measure, to study, to understand. But we are also a floating brain, flying high between the clouds. With a helicopter view on everything that is going on in mental health. But also a little bit ‘with our heads in the clouds’ — open to be creative, personal, and , of course, inspiring. But our announcements today do not stop with a new logo. Of course, we will also continue to publish our blogs on Medium (update: since March 2023 we moved). And, talking about activities, we are also announcing our first InSPIre the Mind Course: Using Creativity to Talk About Mental Health. This is a two-day event in London, to inspire creative approaches for talking about mental health effectively and truthfully. Targeted to activists, artists, aspiring journalists and people with lived experience, the course will have interactive lessons and practical sessions led by experienced tutors and will cover photography, public speaking, blog writing, and podcasting. Targeted to activists, artists, aspiring journalists and people with lived experience, the course will have interactive lessons and practical sessions led by experienced tutors and will cover photography, public speaking, blog writing, and podcasting. So, keep watching this space, read our blog here on or our new website, and follow us on Twitter, Instagram and Facebook to know about our courses and future initiatives. It’s time to be even more inSPIred!

How to build the healthiest generation in history. The first time that I met HRH the Duchess of Cambridge, it had just been announced that she was pregnant with her third child. In fact, she had to delay our initial meeting for a few weeks, because of the severe morning sickness that she suffered at the beginning of her pregnancies. I knew at that time that she had always been interested in the mental health of mothers and children, and in the fact that — in the words of a recent document by the Royal Foundation — “what we experience in the earliest years, from in the womb to the age of five, is instrumental in shaping our future lives”. But little I had known at that time that her activities in this field would have been so momentous. Today’s launch of the #5BigQuestions on the importance of the early years (more about these questions further down) is her greatest public initiative so far in this area. We first met at the end of 2017, at Kensington Palace, together with my friend, and consultant perinatal psychiatrist, Dr Trudi Seneviratne. We talked about how common mental health problems are in pregnancy, with one in four pregnant women experiencing problems such as depression, anxiety disorders and post-traumatic stress disorder. We talked about how these mental health problems can be transmitted across generations, with our own research showing that the children of women with perinatal mental health problems are twice as likely to develop mental health problems themselves when adolescents or young adults. Trudi and I were really impressed by her keen interest in maternal mental health and her knowledge on the field. Two months went by, and the Duchess (as The Sun said, showing off her growing baby bump while sporting a baby blue overcoat), came to visit my University, King’s College London, and the Mother and Baby Unit at the Royal Bethlem Hospital, South London and Maudsley NHS Foundation Trust, the clinical unit led by Dr Seneviratne, which specialises in the treatment of antenatal and postnatal mental health illnesses, including postnatal depression and post-partum psychosis. She wanted to meet experts in the fields of maternal mental health, as well as clinicians and patients. She wanted to know more about the consequences of maternal mental problems on children, and about the science that underpins this evidence. How the hormonal environment in utero is influenced by mental health problems, leading to measurable changes in the development of the infants and in their ability to cope with stress as early as in the first year of life. How mothers who develop postpartum psychosis, the most severe perinatal mental health problem, have some brain regions that are smaller when studied with brain imaging. How infants born prematurely, a condition of very high stress for both mother and child, have abnormal developments in the brain that continue into adult life and are associated with mental health problems in adulthood. How we can develop psychological interventions for women with depression or anxiety in the perinatal period. How new treatments offered at the Mother and Baby Unit, such as filming mothers and infants playing together to optimise their interaction, and baby massage, can help mothers with mental health problems. How, in the UK, perinatal mental health problems cost society £8.1 billion per year, or £10,000 for every single birth in the country — and how three-quarters of these costs relate to adverse impacts on the child rather than the mother. How treating perinatal mental health problems successfully by building specialist perinatal mental health services in the whole country would only cost £400 for every single birth. And there are approximately 730 thousand births per year in the UK — yes, this is in the title — and a quarter of these will be touched by maternal mental health problems. Newspapers loved that she opened up about the pressure on new mothers. That she “sympathised with the mental plight faced by many mothers”. That she said that “new mothers were supposed to feel super-happy after birth, but one in four was not”. For me, the best bit was seeing her interacting with the women with mental health problems that were staying in the Mother and Baby Unit — how she just transformed this official visit, with staff, police and photographers all around, into a private, intimate occasion. My third encounter with Duchess, was at the Royal Society of Medicine, after yet another couple of months, when she launched, through the Royal Foundation, the gathering of a group of experts to develop, in her own words, “the thinking in this critical area”. Not that she had not done some thinking herself before — you can watch her speech here: (21 Mar 2018) THE DUCHESS OF CAMBRIDGE MAKES SPEECH AT THE ROYAL SOCIETY OF MEDICINE The Duchess of Cambridge says mental health support should be available in primary schools "before the biological changes and academic pressures of adolescence kick in." Some of the solutions she proposed in her speech echo with what many of us in the field see as the top priorities: Mental health support in primary schools, before the biological changes and academic pressures of adolescence kick in. Parenting and family support, so that parents feel able to get their children school ready and are confident that they themselves can cope with the mental and emotional needs of their own children. Support to mothers, potentially before they even give birth, so that they are aware of how vulnerable they might be and critically know where they can find help for themselves as well as for their babies and toddlers. Teaching parenting and relationship skills to teenagers to get the next generation of parents child ready well before they have to put these skills into practice. But she did not mention the #5BigQuestions. So, what are the #5BigQuestions? There are approximately 3.9 million children under the age of 5 in the UK — yes, this is also in the title — and these questions are about them. Go to the website and check it out! It’s a quick UK-wide survey about the under 5s that anyone can answer. The Royal Foundation information sheet explains this very well: The Duchess has spent time meeting with families across the country and hearing about the issues they deal with day-to-day, in addition to speaking with academics, experts, organisations and practitioners. Now it is the time to listen to the country as a whole, to hear what they have to say and start a national conversation on the under-fives. OK, here are the questions — sorry you can only read them here, you have to go to the website to answer them: The findings should provide a vital source of information for the early years sector, helping it to better understand public perceptions of the importance of the early years, and the first-hand experiences of parents, families and carers. To me, as a scientist, it will be fascinating to know what people think. I will not tell you my answers — yes, I did the survey already, last night — but I can tell I only knew exactly what to answer for two questions. For the other two, I had to think about it. For a fifth one, I could not really decide. And I am supposed to be the expert! So, now it is time for you to do what I did — go to the website, and answer the #5BigQuestions. Feel, like me, that these are pivotal questions that dig into what makes us humans and members of a society. Struggle with finding the right answer, then follow your heart and choose the best one. Not the right one, but the best one. It will only take a minute. As the Royal Foundation says, by taking a minute to answer these questions, you can help them build the healthiest generation in history by giving every child the best start in life. And I like that. Header image credit Hannah McKay/PA

Bringing the brain and the mind back together again In the 1600’s French philosopher Rene Descartes proposed that the mind and the body were distinct: that thought could exist outside of the body, and the body could not think. This ‘Cartesian dualism’ has preoccupied philosophy ever since but has also had long-lasting and significant consequences for psychiatry. If physical matter is distinct from mental processes, then the physical brain is separated from the mind. This has, in part, perpetuated the development of research streams within mental health, neuroscience, psychiatry, and psychology in separated and distinct silos. The end result of this may be slower than the acceptable pace in developing new treatments for illnesses such as depression, anxiety and psychosis. Yet our thoughts and behaviours are products of brain function, and this is influenced by development, environment and exposure. The immense growth in neuroscience understanding over the past two decades has been matched only by that in immunology, the body system that controls, monitors and responds to environmental challenges. There is now the opportunity to bring the mind, environment and the brain back together again, and with this accelerate the development of better treatments. On the 6th December, 2019, the Psychosis Immune Mechanism Stratified Medicine Study was launched. This collaboration will join together immunologists, psychiatrists, data scientists, pharmacologists and young people with lived experience of psychosis in a joint effort to tackle key challenges in developing new immune-based treatments for psychosis. The Universities of Birmingham, Cambridge, Manchester, Kings College, University College London and the University of Ireland Galway came together at the launch event, in Birmingham’s Institute for Mental Health. What is psychosis? Psychosis affects up to 3% of the population, usually starts in late adolescence and early adulthood. Common symptoms are hallucinations (hearing or seeing things that others cannot) delusions (false beliefs) and difficulty with memory, concentration, motivation and organisation of thoughts. Two thousand young people in England develop a psychosis for the first time (first episode psychosis) every year. Current treatments include medication, talking therapies, family therapy and employment support. Evidence suggests that medication has an important role to play in treating psychosis, and in preventing it coming back, but the medications we have to use right now are not ideal. They all work in the same way, by blocking receptors for a neurochemical called dopamine and have significant side effects for a lot of people who take them. The current medications we have also do not work well enough in over 30% of people with psychosis. PIMS and new treatments We want to develop new treatments for psychosis that work in different ways, looking at targeting the immune system which may lead to better and personalised treatments. PIMS is a 5-year program that will be the start of a number of avenues of investigation into the immune system in psychosis. We have a lot of work to do to test whether the immune system could be causally related to psychosis, where exactly in the immune system to target treatments and what difficulties in psychosis these treatments should be best used to treat. We came together to celebrate the significant amount of funding RCUK has dedicated to this project, and to begin this work. PIMS Launch The launch afternoon began with input from Times Journalist and Author Sathnam Sanghera reading from “The Boy with The Topknot” highlighting the continued stigma of psychosis, the paucity of treatments and the need for significant investment in research. This was followed by a discussion on the key aims and objectives of PIMS with The Birmingham Institute for Mental Health Youth Advisory Group. Experts Zaynab (@ZeZeJonesBoi) and Sarisha (@sarishagoodman) spoke powerfully about the need for new, and targeted treatments for psychosis with fewer side effects and a more preventative approach. PIMS will focus on a small inflammatory protein called Interleukin 6 (IL-6) and its pathway in the immune system as a potential new therapeutic target for psychosis using a number of approaches. First, we will complete an analysis of existing large genetic data to find out whether IL-6 and related immune markers are causally linked with psychosis. We will then use a data science-driven approach with existing large clinical and epidemiological samples to identify what symptoms would be best to target any immune-based interventions at, and how early these interventions should be offered. We will then complete a double-blind experimental medicine study, giving volunteers with psychosis a routinely used treatment for rheumatoid arthritis (Tocilizumab) or placebo to find out whether blocking IL-6 has effect and on circulating inflammatory markers and measures of oxidative stress (using brain imaging techniques such as magnetic resonance spectroscopy). Blood samples will be taken to allow deep immunophenotyping and modelled brain cells from specific blood cells (monocytes) to test whether they act differently from people without psychosis. We hope that PIMS will be the catalyst for new investment and ongoing research into immune-based treatments for psychosis, building on this work and establishing a multidisciplinary consortium. It is a challenging program of work. On the 6th of December, we heard from Rachel Upthegrove (Lead Investigator for PIMS) who opened the afternoon outlining work done to date, the overarching aims of PIMS and key questions that will be addressed: can we establish causality? what symptoms should be targeted and when? Can data science help and would targeting peripheral immune markers improve brain health? Preliminary data suggest that these questions can be addressed with PIMS. Georgious Gkoutos outlined how a multi-omic AI can advance the pace and scale of discovery, as evidenced by his work with Health Data Research-UK pioneering work in cancer and other physical health disorders. Carmine Pariante gave an entertaining and engaging lessons-to-be-learned from his considerable experience in the immune investigation of depression, that the study team can learn from: these included don’t be afraid of controversy, expect some failures and build on what is already known. Golam Khandaker (Co-lead Investigator PIMS) detailed the clinical experimental medicine study that will begin in 18 months time, and how this will build on the current approach in depression and extend with deeper immunophenotyping. Nicholas Barnes showed the type of work that will be completed in PIMS, with data from more advanced Traumatic Brain Injury studies and pilot work developing blood cell models of microglia (brain active inflammatory cells). Charles Large (founder of Autifony) showed the exemplar of taking a potential idea to a validated target and on to full clinical trials with work from Bill Deakin, Jo Neill and Oli Howes on voltage potassium channel blockade. Yet the most important and powerful presentations were undoubtedly those bringing the stark reality of the limited treatment options for psychosis alive: @Sathnam, @ZeZeJonesBoi and @sarishagoodman with personal accounts of the stress psychosis can inflict on individuals and their families, and how the environment and childhood experiences are key. The environment, mind and neuroscience came together for this afternoon, the start of a strong and continued collaboration with a common goal: better, personalised treatments for psychosis! NOTE FROM THE EDITORS: We are so pleased to have Professor Rachel Upthegrove write this interesting piece for InSPIre the Mind! Professor Upthegrove is Professor of Psychiatry and Youth Mental Health at the University of Birmingham and Consultant Psychiatrist in the Birmingham Early Interventions Services. Her research on mental health focuses on schizophrenia and co-morbid depression in the early stages of the illness, as well as inflammation-based models of psychosis. Once again, a massive thank you from us to her for this great insight into the PIMS Study and the need to develop novel treatments for psychosis! Header image source Ehimetalor Unuabona on Unsplash