I literally talk about my inner monologue and then sell it” Many know her as Låpsley, but to me she is Holly Lapsley Fletcher: singer, songwriter, musician and producer, not to mention strong advocate for women’s rights both inside and outside of the music industry. At the age of 16, Holly started recording music in her bedroom in Southport and performing in venues around the local area. It wasn’t long before she developed a strong and committed fan base, garnering over half a million listens of her EP Monday on Soundcloud. Since then, she’s added some pretty impressive credits to her name, playing the BBC introducing stage at Glastonbury in 2014 before signing with XL Recordings later that year. In 2016, she performed to packed out stages at some huge American festivals: Lollapalooza in Chicago and Coachella in California. I came to meet Holly in 2016 through friends in London, shortly before she released her debut album “Long Way Home”: an accumulation of songs that tackle loss, love, growth and insecurity using a wide musical range from minimal electronic pop, soul and disco, to big, bassy beats. We have maintained a close friendship since we first met and connect on many levels. One thing that unites us strongly is our mutual interest in issues around mental health. Holly has always taken a strong interest in my line of work due to her own personal experiences with mental illness. I called Holly a few weeks ago to talk her through my recent blog on mental health and the creative arts. She was quickly invested, and we set a date to talk more about it over a wholesome Sunday roast. Whilst it’s not unusual to hear of experiences of mental illness within the notoriously unsupportive music industry, what is unique is Holly’s frankness about these issues and her drive to expose and overcome them. When we speak, there is very little we don’t cover, from past relationships and breakups, to the realities of being on tour for prolonged periods and its impact on mental health. We also discuss the steps she has taken to support herself in preparing for the release of her new EP: THESE ELEMENTS which was released last Friday. Ellen (E): For the benefit of those reading this article, I want to ask you about how you first came to enter the music industry. How was that initial decision to leave school to pursue music? Holly (H): School was going really well, I was getting straight As, I was predicted A*s in my A levels, I had a place at Bristol University waiting for me. I was smashing it and I really valued academia, so it was a huge decision to pursue music rather than go to uni. My parents were grafters and really valued traditional career routes. They literally used to say to me "If you want all this, you need to get one of these jobs [meaning lawyer, doctor, finance etc.]" so it was a really hard decision. I still dwell on whether I made the right choice, and on some level, I think I regret not going. There is the stereotype of the "bum out" musician, you know like they flop school and they pursue music as an alternative cos there's nothing else for them, but that wasn't me. It was hard to compute. E: So how did you actually make the decision? Do you remember the day? H: Well it sort of got to the point where the music was affecting my A-level's and I didn't come out with the grades I was predicted. All of my teachers looked at me on results day like 'what the hell have you done?'. So, messing up the grades helped me to make the decision as I felt like I'd already messed up the academic route. It was really hard, it made me feel like 'who the hell am I? I never let myself fail' and I thought if I don't pursue the music now then I've let two things fail. It really affected my self-worth because everything I thought that I was, was just knocked. I've really had to battle my own stereotypes of what a musician is. It's taken the last five years for me to forgive myself for making that initial decision. But now I feel really proud of myself. I've started to really see this as being my career and to take myself seriously and respect what I do. I've really given my all to this new record. E: Cannot wait to hear the new record in full! You're always so open about your own mental health, especially in the context of the music industry. Do you think that the music industry played a part in any way? H: It's hard to answer because mental health is so individualistic. I feel like you have to look at it from two sides. There is the mental health which I feel is genetic… that we are predisposed to develop certain issues. But then there are the mental health issues which are created by the industry or made worse by the industry, the more situational ones. So, if I go back and look at teenage Holly, I suffered from Depression, Anxiety and OCD. I was very compulsive. For a large part, it was under control, but it was a daily struggle. Then you flip to the music industry, where life is a party and its like 'the ME show' all the time. So, the anxieties change. Everything just shifts onto different things. The compulsions I was experiencing before would just shift sideways into this new space, to do with things like sex, alcohol and drugs. Everything just got really unhealthy. During the last record, I had no choice but to take medication. I wasn't doing exercise, I couldn't attend all my therapy sessions because of my schedule, and everything had escalated. I was seeing it as 'I'm in a contract so I've got to deliver and get through today'. I wish someone in the label had actually considered my mental health and changed my diary to allow me more time for self-care. E: It sounds like you were finding it really tough at this point. Do you believe that your mental health wasn't taken seriously enough by the team around you? H: Unfortunately, it's just the done thing. The industry acts like you should be lucky they are even talking to you. But actually, it is them who are lucky that I exist. That's been the most significant shift in my mindset since my last album and it's definitely something that has helped me feel more resilient this time around. But also, now that I have been through it once I understand myself and my body a lot better. I know my triggers are a lack of sleep and too much drinking. But I think the industry makes things worse. It doesn't help, it doesn't offer any support and if you have these predispositions, it's honestly the worst place to be. Also, because I am a woman, people assume I don't produce my own songs. This press release was done for my album and it specifically said, "Written and produced by Lapsley with the engineer Joe Brown" and then three articles came out in the press that said, "produced by Joe Brown with the beautiful lyrics from Lapsley". It made me stressed, it made me rage, it made me ill. I don't graft on a computer in a windowless room for two years for you to call me a singer. That might sound precious to some people, but I just want to be acknowledged for the hard work that I put in. I work with a social media team and we have to deliberately post pictures of me in the studio, constantly perpetuating the idea that this is what I do. Men won't have to do that because its assumed that they're in the studio. E: That must be really frustrating. It sounds like you have to be incredibly resilient to work in the music industry. Do you find that your experience of mental illness has driven your creative process in any way? H: Honestly, part of me being me and me being creative is about this. The way I write involves an emotional maturity and awareness. You kind of need to experience all the highs and lows to do that. And when I took medication, the Holly I thought I knew felt like it lived within these tiny parameters. The medication really squashed me creatively. I'd actually rename creativity 'vulnerability'. It's like your ability to be vulnerable and then sell it. It's so weird, I literally talk about my inner monologue and then sell it and perform it. Like, who does that?! People struggle to tell their boyfriend or close friends what's going on in their mind. I guess that kind of proves the link between creativity and mental health. And as an artist, you know that your best stuff, the stuff that really sells, is the stuff that tears you apart. E: Do you think it's going to be hard to perform the new record on tour night after night? H: I actually don't know because I haven't performed it yet. Obviously, I know that the best performances are when you completely lose yourself within it. But to say whether I can do that over two years, and how good my mental health is going to be at the end of it is another thing. You talk about touring with a random person and they say "Oh, sounds so fun" but then you ask another artist and they talk about how savage it is. It's so savage, and you drink so much, and you drink because it's so savage. But there are highs too, like during a performance you just completely let yourself go, and by the time the encore comes you have the biggest high of your life. E: It's kind of insane. These emotions are something the average person just never experiences, and you are feeling that every night of the tour. H: The cortisol in your body, oh my god, as soon as you come off stage, you're so pumped. You want to go out and party. You're like, I want to celebrate how insane that show was, on and off for two years. And then you wake up the next day and have a whole day of press, a whole day of talking about yourself. So, it feels like you're indulging again. It's like the constant 'ME show', cross with indulgence, cross with partying. It's bizarre. Taken from the forthcoming EP, These Elements. Available 6th December. https://lapsley.ffm.to/theseelements https://www.instagram.com/lapsleyyyy https://twitter.com/lapsleyyyy https://www.facebook.com/lapsleyyyy https://soundcloud.com/hollylapsleyfletcher Director - Camille Summers-Valli Producer - Scarlett Barclay Executive Producer - Aaron Z. E: So why do you feel resilient enough now to re-enter the industry with a second album? How have you prepared yourself differently this time for the pressures you know you are going to face? H: I don’t know what’s happened, whether it’s a chemical change or if it’s just me getting older but I don’t have anywhere near as many issues as I did. I know myself now and that my mental state has the potential to escalate more than other people. I know my boundaries. I’m also ready to tell people what I’m not happy to do. For example, unless it’s the last show in a particular city, then I’m not going out. I don’t owe them. Last tour, everyone made me feel like I owed them the world. But when you understand the industry, you walk differently. I’m glad I’ve already been through it once. I’m resilient now, nothing breaks me. What has also really saved me over the past few years is volunteering. E: Oh yes, I remember! You worked in a charity shop and trained as a Doula, didn’t you? What did that involve? H: Yes! So, a Doula is a person who supports women through labour and birth, and sometimes after too. I worked with teenagers, I wrote a letter to the council for a girl who was pregnant and got her a flat within a week. I did it for free. I just found pregnant women that needed help in the community. I love it because it’s such a contrast to the ‘me, me, me show’ you get on tour. The last two years have made me recognise that I need to put these things in my life to balance myself out. To exist and not feel guilty for existing. I was feeling like my existence was insane. I had to find value in myself and what I do. Otherwise, I feel like I am too vain to be on this planet and then I self-punish. E: What do you think is going to be the thing that keeps you most level-headed this tour? H: I’d say it is quite centred around the compulsive side of me. OCD is such a broad thing. For me, I’m a very compulsive person, it’s like I have no fear. I skip the point where normal people stop and think. So, if I get good sleep and I exercise and eat well, I can slow those moments down where I can give myself enough time to recognise what it is and then make a decision. But if I’m hindered in any way by lack of sleep or stress, then there is no way that I am stopping myself to think. And the danger is if that doesn’t happen, then that pathway becomes strengthened and I get to the point where I am like eat, eat, eat, drink, drink, drink. The irrational thoughts become stronger and stronger and stronger and I can’t function day-to-day. And then it affects your sleep and then the problems cycle. E: I couldn’t agree with you more. You get out what you put into your body. H: Yes. It’s a full-time job! And you can indulge in it. I think the interesting thing is that there have been times in my life, mainly in my teenage years, where like I have let it take over because I just wanted a break. I just wanted to let myself do these things, let these things drive me. It’s thrilling sometimes, but it’s dangerous, just letting myself be what my brain tells me to be. It’s like an adrenaline rush. Until you stop, and then you’re like ‘wow I hate myself’. It’s not worth that adrenaline buzz for the guilt you feel after. “Remember when you said My love was like a rose Not the sweet bloom But the pain as it scratches your hand” “Remember when you said I’m a Lily in the spring So sad but so beautiful” E: Right we need to wrap up, but before we do tell me about the new EP. H: Oh, it’s so interesting, the EP. There’s only four tracks. The full album will be out early next year (2020). The first song is called “My Love Was Like The Rain”. It’s about the duality which I feel I am. Each verse is a metaphor for something that I feel has perceived duality. Like a rose has flowers but it also has thorns, and a lily is a flower at funerals, but I think that lilies are really beautiful. The song is about accepting the light and dark. It’s not good or bad, it’s kind of just human. It’s just me. The second song is called “Eve”. In this one, I’m basically saying that maybe Eve ate the apple because it was both her and Adam’s fault. I don’t think anything is one-sided. This song is about sex, guilt, shared blame. “I tried to make it work For the times you never heard You just sink into the solitude I can’t carry both of us You know I tried to go the distance I’d be screaming in the silence I tried to lift us up I tried to make it work” The third song is called “Ligne 3” [which was released last week]. It’s about my last relationship. It’s about breaking up with someone but also appreciating everything you did for them at the same time. Simultaneously feeling both when you split up. It’s about obsession and love and breaking rules. It’s funny, for the video I got the photographer of the video to go and film the area where we were living together and they were like ‘do you want to do it?’, and I was like no! I do not want to go to that city and cry!! Then the fourth song is called “Drowning”. I love this song. It’s about being such a competent teenager and then being such an incompetent adult, and about wondering when I will get back to that person before and that feeling. It incorporates quotes that my parents have said, and I end the whole show with it on the tour and it’s really intense. It’s so emotional. I have this violin part which I wrote, and I end up crying when I hear it. You can listen and pre-order Holly's EP here: https://musiclapsley.com/home/. She will also be performing in Berlin, Amsterdam, Paris and London in January of next year. Enjoy! NOTE FROM THE EDITORS: We would just like to say a huge thank you to Holly, AKA Låpsley, for opening up in this interview and for sharing her experiences with mental health and the music industry with us and our readers. Thank you Holly!

“Adolescence is like having only enough light to see the step directly in front of you” The Girl Who Chased the Moon, Sarah Addison Allen). This is an enlightening definition of adolescence — the period in life when everything seems different and when many adolescents are finding their feet. Many see it as a time in life when you start making decisions without thinking too much about it, although this isn’t necessarily always the case. I still remember that age, I was feeling so curious and eager to behave like an adult, but at the same time I was also so uncertain about my future (even if I was pretending not to care about it). I was an adolescent just like all of you were, or are, or will be: both fearful and fearless at the same time. Adolescence represents the transition between childhood and adulthood in terms of psychology, neurodevelopment, interpersonal relationships and behaviour. During this stage, teenagers find themselves facing several exciting, brand-new situations, and everything smells like fresh air. They crave growing up and becoming an adult, sometimes rushing into things as ‘a grown-up’ but then often regretting these rash decisions a few years later. Nowadays, the massive rise in use of social networks has highly influenced the impact of often bad decisions in teen lives. For example, when I was an adolescent, the only people pressing me to do somewhat stupid things were my closest friends from school; today, facebook, twitter, telegram and Instagram (just to mention the more popular) create a huge group of online “friends” influencing you to do things. However, all that glitters is not gold: adolescence is all but smooth sailing since it is a critical time for the onset and development of psychiatric disorders, such as depression and bipolar disorder. For instance, depression is the leading cause of disability amongst adolescents, and it has been estimated that about a fifth of adolescents worldwide experience at least one depressive episode. Furthermore, depression is the number one cause of suicide among teenagers. Sadly, suicide is a global plague among adolescents: a recent study in U.S colleges showed that one out of five students reported experiencing suicidal thoughts, 9% of them had made a suicide attempt and a further 20% reported injuring themselves. Concerningly high statistics. This scenario is worsened by difficulties when diagnosing the disorder. Adolescents are often reluctant to seek help and the reason behind this can vary considerably: there is a lack of perceived need for help and often the perception that self-management is preferable. Moreover, lack of service availability within a reasonable time, a lack of information, and structural factors (such as distance or money) have been identified as the key barriers preventing adolescents from seeking help. However, several countries are now trying to enagage teenagers into mental health, for example creating hotlines, websites and chats where it is possible to talk with peers as well as adults and psychologists (for example, the Samaritans website in UK). These first-aid solutions are surely a good way to break down the barriers for seeking for help. Given the fact that depression is a real danger for adolescents, how should we deal with it? A stereotypical answer can be seen from this quote by Earl Wilson: “Snow and adolescence are the only problems that disappear if you ignore them long enough”. So what? Do we just let adolescents be adolescents and not care about their problems on the assumption that they will be gone by the time they reach adulthood? Nothing could be more wrong than this simplistic approach. Depression, as well as the other mental disorders, do not disappear simply by waving Harry Potter’s wand — they are a real threat and they must be taken into account unless the intention is to build a new generation of young adults incapable of facing real life. So, forget Wilson’s hypothesis. A more concrete approach is to deal with the harsh reality and take on the beast: teenagers can suffer from depression, and depression is a threat to teenagers. However, depression can be successfully defeated by using non-pharmacological approaches, such as psychotherapy. Although, sometimes defeating the monster is not easy, and in more severe cases, pharmacological interventions with antidepressants, under experienced care of a child and adolescents psychiatrists, can be a solution. An informed decision made jointly by the psychiatrist, care givers and the adolescent, and one not ever taken lightly. But what about a prompt intervention before the onset of the disorders and not once symptoms are already present? Prevention Strategies Prevention means understanding those who can be categorised as at ‘high-risk’ of developing depression and implementing appropriate strategies to prevent the start of the disorder. For example, it has been shown that increased levels of inflammation — the body’s defence response which protects us against threats such as infections and injuries — might represent a risk for developing depression. For this reason, clinical trials might aim to treat depressed patients with anti-inflammatory drugs in order to cure depression and reduce the risk for the disorder. To prevent also means to untangle the underpinning mechanisms, the causes behind depression, as well as the recognising the early signs for the identification of depression in early life. In the few last decades, several steps have been taken to identify the causes underlying adolescent depression, as well as to identify new and successful preventative strategies to tackle the risk of mental health problems in younger generations. During recent years, numerous programs have been developed for mental health safety, offering concrete help and support to children and adolescents who have difficulties with their emotional or behavioural wellbeing. For example, in the UK, CAMHS (Child and Adolescent Mental Health Services) has been established, whereas in Italy, where I live, several hospitals have established similar projects for 15 to 24 years-olds, such as the ones at Milan Niguarda and Padua Hospitals. However, it is important to note that adolescents from high income countries represent the lucky ones who can benefit from such associations, whereas those from middle to low-income countries are definitely not so blessed, for several (and I will say, crystal-clear) reasons. And then we had an ‘IDEA’… In this context, it is noteworthy to mention the IDEA project (Identifying Depression Early in Adolescence) -in which I am actively involved as it is my PhD project — funded by MQ Transforming Mental Health Through Reseach and led by Dr Valeria Mondelli from King’s College London and Dr Christian Kieling from the Universidade Federal do Rio Grande Do Sul (Brazil). The project aims to understand the cultural, social, genetic, and environmental factors leading to the development of depression in adolescence. This project seeks to identify risk factors in middle and low-income countries, focusing now on Brazil, Nepal, and Nigeria. By identifying the biological and cultural risk factors, researchers aim to possibly recognise adolescents at high or low risk of depression in advance, with the aim of immediately acting and implementing preventive strategies. The project is also involved in understanding the feasibility of using these strategies in low-income countries such as Nigeria and Nepal, as well as the possibility of developing a wider screening strategy for thousands of adolescents. For example, blood and saliva tests might be employed in schools and villages to theoretically divide adolescents into groups and try to prevent the onset of the disorder in those teenagers classified as most likely to develop depression at some point during their lives. Albeit the noble intention of such programs and ideas, much more is needed to be done, especially to explain the importance of preventing mental disorders and to act right away. Although early on, data from the IDEA project are starting to suggest how some adolescents feel worried about confiding in someone about their emotions, as well as feeling scared about a likely diagnosis of depression. Moreover, just to be classified as a “high risk” individual may cause some level of anxiety for some, as the possibility of becoming depressed represents a permanent black mark. The reason I say this is because of the undeniable stigma that often goes hand-in-hand with mental disorders, and which persists worldwide despite the effort of psychiatrists, psychologists, researchers and associations which desperately try to revert this unhealthy trend. We need to emphasise information about mental health, the symptoms, the therapies and the importance of seeking help when necessary, especially to younger generations. Adolescents should be taught that certain symptoms must be taken into account because they might be the first clue of a deeper disorder and that when identified early, such progress can be halted. Furthermore, we should also train educators and parents to recognize the early signs and how to successfully mediate the sometimes-tough relationship between adolescents and mental health experts. It is essential to tell adolescents that they are not alone and will be supported: depression is not a conviction and it is not their fault. On a more scientific level, a question arises: what is missing in this prevention machine? The answer is as much foreseeable as it is complex: a biomarker — that is a biological and measurable indicator of the risk for developing depression or the current presence of the disorder. To date, researchers have found neither a suitable panel of biomarkers able to classify youngsters at the risk of developing depression, nor indicators of its presence. The IDEA project also aims to identify such biomarkers to better distinguish depressed, low and high-risk adolescents, for starting successful prevention strategies, both pharmacological or not. For example, a well-characterized panel of biological markers can be the key point for a wide-spread screening strategy for adolescents — and especially in poorer countries where the majority struggle to obtain an adequate treatment for mental disorders. Given the difficulties in accessing basic treatments in these nations, over-diagnosis and over-treatment (always pinpointed by experts as drawbacks of screening programs) seem a remote and avoidable possibility. Moreover, please be careful in considering that screening adolescents does not mean to put a label on them, instead increasing their awareness and encouraging new ways to ameliorate monitoring strategies in schools as well as at home. In conclusion, to predict and prevent the development of adolescent depression is the first step for reducing the burden of the disorder, starting by eliminating its intrinsic stigma. To pay attention to adolescents’ health is the first step to make a real difference in their mental wellbeing. We can all make a difference, we can all contribute to ameliorating the quality of life of children and adolescents worldwide. Let’s start now! header image source: Patrick Buck on Unsplash

I’ve been working in forensic mental health, that is the system that manages men and women who commit a crime that is deemed to be a consequence of their mental disorder, for about fifteen years now. Most of that time has been doing research and clinical work in hospitals and prisons for people who would meet the criteria to be described as a psychopath. Three years ago, I made a fateful decision to advise a group of then fairly unknown writers and TV producers in creating a TV series about a psychopathic female assassin. Sound familiar? This was, of course Killing Eve: the runaway BBC America hit that made me realise that you can make even a clinically accurate psychopath into a compelling character (no thanks to me). But I’ll let you into a secret: I find psychopaths pretty boring. That might be an odd thing to say for someone in my position. That doesn’t mean it’s not true, however; and I’m not sure it’s such a bad thing. Let me explain. I came into studying psychopaths by accident. I didn’t pick up a copy of American Psycho one day and suddenly decide that Patrick Bateman’s misogynistic, misanthropic violence was the key to understanding other people; I just needed a job. So when my research proposal involving work with people with severe personality disorder in high-security conditions was accepted, psychopaths were part of the deal. And reader, I met them: many, many of them throughout the next fifteen years. When I started out on my career, I came into England’s maximum Rampton Hospital in the early 2000’s with the full expectation (even hope) of meeting Hannibal Lecter’s English equivalent. Someone intelligent and articulate, for whom psychopathy was simply a disorder of empathy: the inability to give a damn about other people. I expected skilled manipulation, games within games against which I would need all of my wits, like Jodie Foster’s endlessly resourceful Agent Starling, just to survive. However, the grim reality is that the vast majority of psychopaths (and I mean that in the strict sense of people with a score of 30+ on the ‘Psychopath test’, aka Robert Hare’s PCL-R) are… well, in my experience, pretty dull. Yes, their criminal history might have some morbidly salacious details, but in person… let’s say the durability of the Lecter archetype is definitely a testimony to Thomas Harris’s skills as a character writer than to any underlying reality. Criminal psychopaths, far from being charismatic geniuses, are — as one antagonist describes Killing Eve’s Villanelle — “a void”. Not just a void of empathy, but a void of personality, of substance. Research has shown that criminal psychopaths are less intelligent than the general population, they have little in the way of life experience and tend to dislike telling the truth, preferring stories that cast them in a positive light. Since, even in the era of fake news, a lot of us do still quite like hearing truthful stories, even slightly embellished ones, this can make interactions with criminal psychopaths seem tiring, repetitive and honestly, tedious. It might well be exciting to meet a psychopathic career criminal once in your life — and it was for me, the first time — but after the fifth or sixth variant of ‘it wasn’t me, guv’ or ‘[my victim] were asking for it’, any sense of excitement has ebbed. And since the nature of their neurological dysfunction means that psychopaths lack impulse control and are primarily concerned with satisfying their own desires, interacting with one in any environment is a risky business. However, the relatively shallow charms of the criminal psychopath in prison are nothing next to the nonsense surrounding the “psychopath industry”. “Psychopaths live among us”, we are told, by someone who should know. “Are you in a relationship with a psychopath without knowing it”, we need to consider, as if a pattern of pathological lying and abusive manipulative behaviour could still be casually ignored by the victim. I understand that this could all be seen as good fun: testing our weird exes for signs of psychopathic behaviour (just one of a number of examples I could use). But to me, it also shows a fundamental confusion at the heart of our understanding of psychopathy. On the one hand, to be diagnosed as a psychopath using the PCL-R is extremely difficult if you are not either committing a serious crime or living an extremely criminal-type lifestyle. Not only is the administration of the PCL-R lengthy and requires extensive experience and training, but you need to be, as leading psychopathy researcher Craig Neumann directly put it, a ‘nasty son of a bitch’ even to start to get up the scale. This means that the average middle-class reader of ‘Psychology Today’ is very very unlikely to have had much contact with a ‘clinical psychopath’. And yet, on the other hand, there are piles of research being published about psychopaths in the community that tends to get a lot of press attention. These high profile studies purporting to identify psychopaths in the community get around the issue by asking people to fill in questionnaires about how psychopathic they are. Of course, however, there’s a big problem here: a core trait of psychopathy is ‘pathological lying’: the inability to tell the truth in pretty much any situation. So asking a psychopath if they are a psychopath is hit and miss at best and means that these scales are probably measuring something different. I would guess that ‘something’ is probably a kind of pathological narcissism, which shares a lot of features with psychopathy but has very different connotations for someone’s likely behaviour. None of this stops academics from pouring out articles and counter articles arguing about whether criminal behaviour is really a core part of psychopathy or not: and I am of course no less guilty of this than anybody else. Similarly, the media seize upon every new article about psychopaths among us to roll out the same tropes linking it — usually wrongly— with famous serial killers. Researchers know this gets attention and liberally sprinkle their research with judgement-laden and scientifically dubious terms such as ‘the Dark Triad’. This is all fun for a while but once you’ve seen the “methodologically suspect research > newspaper article > psychologist interview” cycle once you’re not on tenterhooks for the sequel saying the same things two years later. So why would someone so jaded about everything that psychopaths represent want to write books and articles? Well, alright: this is a blog post and I want you to read this so that I can make a broader point. There are actually a great deal of really really interesting things about psychopaths that step outside the iron cage of the Psychopathy Test, including the developing idea that psychopathy actually describes a range of very different personalities. I’ll give you two more for starters. The first idea, which goes all the way back to the first real account of psychopathy, Herve Cleckley’s The Mask of Sanity, is that psychopaths actually have a deep core of true psychotic insanity within them, overlaid with a superficial ‘mask’. Some psychiatrists and psychologists still put credence in this theory and that there is a significant connection between core psychopathic traits and psychosis, which might even make psychopathy protective of insanity. A second question is: how do you treat someone with a disorder such as psychopathy that means they struggle to learn from experience? In the face of an overwhelming therapeutic nihilism, overly inherited perhaps from some missteps such as naked encounter therapy or LSD treatment new ideas are thin on the ground. Some challenging groundwork on this was done by the UK Prison Service and the Westgate Unit with the Chromis Programme — that seeks to elicit treatment motivation on psychopathic offenders’ own life goals rather than desistance alone — and I am excited by new attempts to trial group-based mentalising therapies with sociopathic men. Mentalising effectively ‘teaches’ people skills of emotion recognition and description that they may never have learned whilst growing up: reconstructing the emotional development of personality. LSD, madness, mentalising… surely I can’t be alone in thinking these are more interesting things than another poorly-written media article on the Psychopathy checklist? NOTE FROM THE WRITER: Dr Mark Freestone is a Senior Lecturer in Psychiatry at Queen Mary University of London, a consultant on Series 1 and 2 of Killing Eve and author of ‘Making a Psychopath’, due to be published in May 2020 by Ebury Press. NOTE FROM THE EDITORS: We are so pleased that we are able to bring you a blog from Dr Mark Freestone this week. Mark has had a very impressive and unique career and we are so glad that he was willing to share with us his personal experience working with criminal psychopaths. Thank you very much, Mark!

I have wanted to work in Clinical Psychology for as long as I can remember. Being able to connect with people and offer emotional support on a daily basis is a challenging task, but incredibly fulfilling and rewarding. Of course, it can be hard when stories of past trauma or current distress are brought to sessions by patients that mirror your own personal circumstances. It can serve as a reminder of the pain or disorder currently present in your own life. No matter how much training you receive in “maintaining professional boundaries”, it is only natural to sometimes react emotionally to stories shared by a patient, whether in the moment or after a session. Because of this, individuals working in mental health are regularly encouraged to adopt their own therapeutic routines which allow them to transition successfully from work to relaxation mode. Last weekend, as I cycled home from a gallery in London, feeling mentally refreshed and rejuvenated, it became clear to me that my love of art was my own special therapeutic routine. Each time I pick up my camera or visit a gallery I am nurturing my mental health. So, I’ve decided to explore the relationship between art and mental health for my latest blog. I will begin by discussing some of my favourite artists and how mental illness has affected their lives and shaped their craft. I will then present a short, informal interview I conducted with my artist friend Tom Laishley. Finally, I’ll finish by stating what research really says about why art is positive for mental health. Art and Mental Health: A bidirectional relationship? It cannot be denied that a long list of famously creative individuals have been affected by mental illness. Examples include Sylvia Plath, Edvard Munch, Paul Gauguin and Vincent Van Gogh. It is an idea that goes back centuries. One of my favourite singer-songwriters, Nick Drake, lived with depression and personality disorder for many years. His struggle was documented a few years ago in a book compiled by his sister. The pages shed light on the last days of Drake’s life, and they depict in detail what his family describes as “the worst day of (their) lives” as they find him lifeless, having tragically overdosed on antidepressant medication. He was just 26. Perhaps making art was a way of coping for these individuals during difficult and dark times, or conversely maybe their artistic creations were born at times when their symptoms of mental illness were less present or less intense. It is hard to know for sure. Nick Drake’s depression sometimes caused him to lose interest in music altogether, but his psychological journey undeniably shaped his three exceptionally beautiful and melancholic albums. His fragility runs through them. It was not long before his death, that he recorded the song “Black Eyed Dog”. Heard now, it is an obvious metaphor for death. “A Black Eyed dog he called at my door A Black Eyed dog he called for more A Black Eyed dog he knew my name…” Anyone who has experienced either anxiety or depression will likely relate more to this idea of Drake losing interest in his craft altogether. When you think about it, the lack of confidence and motivation that frequently accompany anxiety and depression do not logically equate to creative productivity. In fact, James Blake, another talented musician has written and interviewed extensively on this topic. He is outspoken about making sure that people do not glorify depression and anxiety as stimuli for creativity: “There is this myth that you have to be anxious to be creative, that you have to be depressed to be a genius. I can truly say that anxiety has never helped me create. I’ve watched it destroy my friends’ creative process, too.” We therefore have to be careful when discussing the idea of mental illness as a creative force, because this notion may cause individuals living with a mental illness to feel disappointed in themselves for not being able to create a masterpiece of their own. Something which does appear to be much clearer cut, however, is the effectiveness of art as a therapeutic tool. The benefits of art for mental health Here is a quote from the artist, Eva Charkiewicz, whose photograph “Ghost Whisperer” is pictured above: “I want to show you my world (my four walls) — my photographs. I became interested in photography after being diagnosed with clinical depression. Photography helped me and still helps me with my emotions.” Like Eva, when I am photographing, I feel at peace. (And yes, that was an excuse for me to plug my own photography page, as all amateur artists do!) When taking pictures, I am so focused on my environment. I am focused on all the wonderful and weird individuals and events happening around me that I am no longer thinking about the many deadlines I have at work, the fact I have to pack and move houses in a few days, or the fact I have massively overspent this month. I was keen to understand more about specifically how art helps individuals living with mental illness to manage their condition. So, I called a friend, Tom Laishley, who is an artist living with bipolar disorder. I asked if I could interview him for the benefit of my research and he kindly obliged. Here is a snippet of our conversation… Ellen: “Tom, what is your background with mental health personally?” Tom: “I was diagnosed with Bipolar Disorder around 10 or 11 years ago. I was diagnosed and then voluntarily admitted myself to hospital. They trialed me on lots of different mood stabilising medications. It was a difficult and confusing time.” Ellen: “Do you think art played a part in helping you to manage your diagnosis?” Tom: “Yes, definitely. Art was an escape on the ward. During the daytime, there were lots of therapies available to us: music, art, even cooking therapy. Getting into art therapy facilitated my recovery. It provided an escape from all the chaos on the ward; from the other inpatients kicking off, and from the noises of nurses restraining patients who had become distressed. Art therapy was also a great place for socialising. They invited individuals from the women’s ward to join our classes. We would make a tea and have a chat. It gave me peace of mind. I also noticed that people who really engaged in the occupational therapy tended to recover more quickly.” Ellen: “What is your opinion on the relationship between art and mental health?” Tom: “I think it’s about forgetting about the daily stresses and anxieties in everyday life. It helps you escape them. I think it’s also about a sense of achievement. I am proud of all of my pieces. I put them all up on my wall… it’s completely covered now. That being said, I think it’s part of a bigger puzzle. My friends that came to visit me during my time as an inpatient definitely played a huge part in my recovery. Art also played a big part.” Ellen: “What is one piece of advice you have for someone struggling with their mental health? Tom: “Try new things. Experiment. Whether its painting, learning the guitar, even watching films. And try each therapy at least once. It gives you structure and routine. I think the discipline of going to art class every week gave me discipline in other areas of my life too. It’s really helped with my transition through discharge too. I often think of this quote from the movie ‘Trainspotting 2’: “You’re an addict! So be addicted, be addicted to something else”: I think it’s about finding an interest which isn’t bad for you but is nurturing instead. Art might not be for everyone, but it’s worth trying!” Art can also help to promote and reduce stigma around mental health. I remember an installation by Tracey Emin exhibited at the White Cube Gallery in London about a year ago. She depicted her Insomnia through fifty “selfies” printed two meters high. The images (pictured below) showed the artists face as she lay in bed crippled with fatigue but unable to sleep. For me, viewing these, I really felt the torment and loneliness she was experiencing during these wakeful hours. I was being educated about conditions I had no experience living with. I was feeling empathy through art. Another example currently being shown at the Science Gallery in London Bridge is the ON EDGE exhibition. This free exhibition, which ends in January 2020, aims to open the conversation around the causes of and responses to anxiety through science, art and design. Exhibited works draw on cutting-edge mental health research from the Institute of Psychiatry, Psychology & Neuroscience (IoPPN) at King’s College London where I work, and they examine anxiety from different perspectives and through lived experience. Art as therapy: What does the science say? As artists and people with life experience, we intuitively know that art therapy works. But a recent review of scientific studies looking at the effectiveness of art therapy as a specific intervention confirmed its effectiveness in improving a variety of symptoms for a variety of people of different ages. But how exactly does it work? A different group of researchers set out to identify the active ingredients of art therapy. They conducted in-depth interviews with adults with personality disorders to collect information on their responses to art therapy experiences. The following themes emerged: Self-perception — individuals mentioned that artistic expression helped them focus on the present moment, identify emotional responses and experience connections between emotion and body awareness. Personal integration — individuals mentioned that they could express their personal issues, emotional experiences and identity. They felt their identity and self-image could be strengthened and made more positive. Emotion regulation — individuals mentioned that artistic expression allowed them to modulate their emotional responses, and increased self-confidence. Insight and comprehension — individuals reported that art expression helped them to put their emotions and non-verbal experiences into words, when they did not feel they could not express themselves in another way. So, to conclude, what do we know about the link between the creative arts, mental health and wellbeing? There is increasing evidence that participation in arts has a positive impact on people’s lives, whether living with or without a psychological diagnosis. It can improve mental health and wellbeing and bring people and communities together. We are facing huge public health challenges in the UK, and mental illness accounts for more than 20 percent of these challenges. As the number of people living with mental ill health increases, innovative and effective treatments such as art therapy are needed more than ever. So, don’t hesitate. Buy your first sketch pad. Visit a local gallery. Go out and photograph an area you usually visit, but don’t necessarily “take in”. Give yourself a break from your mobile phone and pick up a pencil or a paintbrush. You don’t have to be the next Turner Prize winner, you can simply just do it for yourself. Over the years, I’ve learnt that my mental health is ever-evolving. I can’t just read a book one week, and hope that I stay cool, calm and collected for the next few months. I have to keep working on it. I’ve incorporated art into a special therapeutic routine that works for me. What’s stopping you? NOTE FROM THE EDITORS: We just want to say a massive thank you to Tom Laishley for agreeing to be interviewed for this blog and for sharing his thoughts and experiences with our readers. header image source hunger tv Five contemporary artists exploring mental health.

Almost twenty years have passed since the birth of the digital world (Berners Lee 1999). The creation and subsequent rise of the Internet was revolutionary, comparable to the invention of the locomotive by Stephenson in the early 1800’s. Needless to say, communication is one aspect of life which has been most significantly revolutionised by the Internet — getting in touch with one another is now cheaper, faster, and all-in-all easier. Thanks to the use of social media, it’s safe to say that we have in fact reinvented the concept of communication. Since it’s able to be so far-reaching and instant, social media has naturally evolved into a potentially damaging uninterrupted connection. With the spread of devices such as smartphones, smartwatches, and other gadgets alike, for most people, being connected has become something natural and automatic: there is no longer an on/off. We are never really disconnected, the only options contemplated are “available” or “occupied”. Today computers are no longer a privileged means of accessing the Web. It is smartphones which have literally revolutionised the way we live. With smartphones, there is no longer a time dedicated to internet use; it is a constant throughout everyone’s day, regardless of lifestyle, age, or profession. It seems that most of us aren’t fully aware of the sheer amount of time that we spend online: the use is constant, and so ingrained in us at this point, we pay no mind. It’s not that we are unaware either — Apple’s recent feature rolled out to tell us our screen time. We have simply normalised constant use of our phones and social media so much that we don’t bat an eye at the hours spent daily scrolling away. Being connected is a new way of life for the people of the new millennium, with its advantages, and despite its disadvantages. In fact, while on the one hand the Web represents a means to quickly satisfy curiosity and connect to the leaders of the world, sometimes the relationship with the Web can turn into a real compulsion, often resulting in becoming more and more detached from reality. This blog explores how the relationship with social media can become pathological. But, what does having a “pathological” relationship with social networks really mean? When we talk about social networks, the first thing we think about is probably Facebook. In reality, the social universe is far from being so circumscribed, but the fact is that Facebook was perhaps the first social network that gained the attention of the masses. Facebook opened its doors to the public on September 26th, 2006 and ever since, anyone over the age of thirteen can register free of charge. Over the years, several other social networks have been established, which have tried to depart from the initial format, proposing slightly different mechanics, but always aimed at creating a connection between its users. The possibility offered by social partners to be constantly connected with friends and acquaintances and, more generally, with the entire virtual community, has meant that for many people, being active online has assumed the meaning of being active and participatory in society — therefore having a social profile liked and visited equates to being appreciated by people. A blog by my colleague Frances, (also on InSPIre the Mind), looked further into the impact of social media use, specifically its effects on adolescent mental health. The idea that all our activity on social media is valuable in reality is continually reinforced to us: that having friends and being liked/followed online means being so also in the reality. That ‘likes’ mean popularity, on and off our phones. Often these transitions between reality and virtual spaces take place because real human relationships are so complicated that shortcuts, such as social networks, are often received with open arms, especially if people have true difficulties in the relational context. Social networks thus become a simpler but emptier world, in which having a substantial list of virtual friends (in reality, often including real strangers) brings greater fulfilment and satisfaction than the possibility of spending time with a real friend in the real word. One study calls this generation the “generation Y”, a generation that is unconsciously defined by their dependence on social media, given the total symbiotic relationship between real and virtual life. It is evident from this study that the age group most involved in this is people between 12 and 25 years. Older people (like me, although I am barely older than 25!) seem more difficult to capture within the social network world. This is not because they are digital natives, given that this type of application is really within everyone’s reach, but probably because, given their previous experience, they may not be able to reach the same depth of communication with social networks as young people do. Older people find it more difficult to get confused between virtual world and real world, because they have typically experienced more relationships in the real world. Social networks have brought many advantages and much progress, but we should not be so quick to dismiss, nor outright ignore, the problems brought on by it too. So, what are these “problems” social media has created and encouraged? Well, two examples are “engagement”and “‘FOMO”. ”Engagement” is a term used in the research field of user experience, and represents the level of attention activation when interacting with a particular application. The engagement on social networks specifically represents the need for participation. The social network has the power to create a sort of virtual alter ego for an individual. It creates a fictitious environment with characteristics that allow it to completely fit in with others who use it. This virtual reality therefore becomes preferred to the real world because it more easily confers security, personality and sociality. Starting to prefer the virtual world to the real one, thanks to its charm as a “more effective” means of communication and socialisation, will result in a distancing from “face to face” relationships, undoubtedly indispensable for a healthy and balanced life. The computer monitor or the smartphone display inherently anonymises us; any and all information we choose to share with the world online just acts to remove our “actual” individuality and instead create a fictitious version of ourselves, an alternate reality. This only goes to further isolate us from the real world. FoMO — which stands for “Fear of Missing Out” — is the morbid fear of losing out on events or occasions that will be remembered. This is a concrete manifestation of social anxiety: the fear of being cut off from something big and therefore not being socially accepted in the group one would like to be part of. Furthermore, with the term FoMO it is also possible to indicate “aura to be rejected”, connected to the fact that particular opportunities could be lost to establish new social ties. Those who live these particular conditions do not realize that they are preparing for an inevitable isolation from real society, replacing the time spent with real people with the time spent online, and not realizing that the dimension of social networks is anything but social. This condition will only increase their sense of isolation, in turn increasing the level of FoMO. The psychologist and researcher Andrew Przybylski, has defined scientific parameters to establish what the FoMO is, and has created a self-report measure of Fear of Missing Out. In his research, he finds that: FoMO is a driving force that influences the way social networks are used FoMO levels are higher in young users, particularly male ones Low levels of satisfaction (of one’s own life or needs) are linked to high levels of FoMO FoMO is greater in those that are used to drive distractedly FoMO is greater in students who use social networks during lessons. Does dependence on social networks really exist? The first studies concerning web addiction (IAD = Internet Addition Disorder) are attributed to the American psychiatrist Ivan Goldberg, who in 1995 identified the characteristic symptoms, today still considered valid, such as the need to spend more and more time on the net to get satisfaction, the marked reduction in interest in other activities that do not include the use of the internet, the development of abstinence symptoms, and the inability to stop or control the use of the internet. Expendium of large amounts of time spent on activities related to the network. Continue to use the internet, despite social, physical problems work or psychological caused by the network. The symptoms indicated by Goldberg can all be seen in a person addicted to social media — and indeed in people with any addiction — in order to seek novel sensations and mood altering effects: to experience pleasure, satisfaction, improved mood and increased self-esteem, just as it happens for drug addiction. Furthermore, the addiction to social networks, as well as IAD more generally, can occur in conjunction with other mental disorders, for example, compulsive obsessive disorders, depressions and alterations of mood. Similarly, IAD can exist alongside physical problems such as changes in the sleep-wake rhythm or a sedentary lifestyle with reduced physical activity. Addiction to social networks can also indeed give rise to symptoms of abstinence and to an uncontrollable desire to implement the pathological behaviour — in this case, the excessive use of social network. This condition has been labelled “nomophobia” : an uncontrollable fear of being disconnected from the network due to problems in connection or loss of device. The term is a combined word formed by “nomo” (that is, “no mobile”, or lack of cell phone), and “phobia”. Although, at this point, one can think that dependence on social networks should be treated as a pathology in its own right, very few studies speak of “social network addiction”: The majority of studies speak of IAD or more generally of Internet dependence, and as unusual as it may seem, not all studies discuss the correlation between IAD and addiction to social networks, something which is relevant. Nevertheless, it is indispensable to pay attention to the problem, to identify and help psychologically those who suffer from it. Social media, being a problem, which is especially prevalent in adolescents, parents should be informed about the existence of this new psychopathological field in order to support and help their children before it becomes a problem. At the risk of coming across as patronising, I want to it make clear that I am not here to demonise social media use nor to tell you not to use it. As with any tool, it’s how we interact with it that can change it from being a utility to a threat. With anything we do, it is crucial to find balance — as we know, there is a difference between drinking a glass of wine and a bottle… I began by talking about how social media has revolutionised the way we communicate and that will always hold true. Social media can be an incredible machine, we just need to know how to interact with it safely. header image source Adobe Stock

Mental health is now mentioned on a daily basis — in the press and media, within industry and employers, health and social care, charities, the armed forces, parliament and with reference to schools and parents. Mental health is also promoted by sports, arts, creative industries, cultural and social activities. There is now so much attention to mental health, to the wider determinants, and to the collective response that we require to combat stigma and support each other, yet psychiatry seems to be less visible. Not only as a speciality branch of medicine, but also as a force in leading the mental health sector in the new proposed reforms and investment in England enshrined in the long term plan and the recommendations from the review of the mental health act (announced in the Queen’s speech on 14th October 2019). Psychiatrists can lead the sector in similar developments in the devolved nations and globally. It occurs to me that we, as psychiatrists, have not explained well what we do, with our multiple specialities, including, for example, medical psychotherapy or community psychiatry, the two areas of practice that have dominated my work over the last 30 years. There are so many varieties of psychiatry. They include perinatal psychiatry, child and adolescent, rehabilitation, addictions, intellectual disabilities, eating disorder, liaison and hospital-based psychiatry, older adults, adult psychiatry, the latter including further specialist teams like early intervention, crisis and home treatment teams, and assertive outreach, and inpatient, intensive care, and psychotherapies. And then, psychiatrists can be consultants, training and non-training grades, affiliates, possibly physician associates in the future, specialising in mental health. There are also clinical academics among us, with various research pathways to become future principal investigators. The public, and other professionals are rightly and modestly muddled. So, how do we summarise what we do in the clinical space? What is our clinical task? The ultimate objective of psychiatry is to promote the health and wellbeing of the population, families, carers, and to improve the care and treatment of people with complex needs around mental illness. All research, clinical activity and professional regulation seeks to deliver these aims. I recently attended a seminar at the Royal Society of Medicine on professionalism that included a variety of ‘performance’ lessons, from long distance running, martial arts, film and the cultural industries, as well as evidence on what professionalism entails from former Deans and Presidents. Following this, it occurred to me that psychiatry is in fact like a secret martial art or endurance sport, hidden and kept away from the masses. It is practised within guidance and professional boundaries that vary from country to country, and that in the UK are largely driven by the Royal College of Psychiatrists’ curricula. Here is my attempt to condense the components of what all psychiatrists do: Artists who notice and see and hear Being human and able to establish good communication and interpersonal relationships that are therapeutic. This applies to the patient, carer, and all team members, and the wider stakeholders. Every conversation embodies key messages about what we do and how we talk and relate. Listening to deep biographies of patients and families, as if learning from art and so connecting the past with the present and destinies. Noticing the multiple interlocking influences in a person’s life that are relevant to how they make meaning, and how they experience the world, including illness and misfortune, so as to propose therapeutic options in a way that makes sense and is helpful. The number of influences is rarely charted, or articulated explicitly in a formal history, or in guidelines and algorithms for care, as the relevance and importance of these varies so much from patient to patient and family to family. So, the role includes suspending preconceptions and letting the person’s world emerge and surround the psychiatrist, to see the world from the person’s perspective. Some trainings, like in psychotherapy, emphasise this way of being even more, placing importance on noticing and understanding feelings and histories being played out in the present. Clinician-Scientists Providing evidence-based interventions, weighing up risks and benefits, and sharing these openly with patients and families — which means knowing the evidence and how to appraise it. This also means knowing how to approach a care opportunity where the evidence is uncertain and to establish a good shared plan for what might help, and empowering patients and families to make decisions of what they would like to try and what they would not. Advocates seeking fairness and social justice Being a psychiatrist also means advocating for patient and families and the sector in policy and commissioning, within health and social care systems, and also reaching the wider public and government with anti-stigma and anti-discriminatory perspectives, as well as emphasising the importance of effective mental health care for society. Systems Leaders From this follows the ability to work with people in systems that are and always will be constantly in flux, and, by doing so, providing the best care possible irrespective of the wider systems changes which seek to streamline, improve, ration or rationalise NHS care. Here is the biggest secret: psychiatrists are systems leaders, and have negotiated complex systems of care from the minute they step into the NHS or wider sector of care. They are constantly showing system behaviours and leadership to improve the coordination of care and harmony across sectors, placing the person and the family at the heart of their toil. You may agree or not with my take on this, but I’d welcome discussion and debate. As a profession, we need to share with the world what we do, and not keep it a secret. NOTE FROM THE EDITORS: We are so pleased that Professor Kamaldeep Bhui CBE has written a piece for InSPIre the Mind! Professor Bhui has an impressive record of accreditations including being Professor of Cultural Psychiatry & Epidemiology, Consultant Psychiatrist, Psychotherapist, Editor of the British Journal of Psychiatry and a Careif Trustee, to name a few of his current roles. We would like to say a big thank you to him for writing this very interesting and much needed piece! HEADER IMAGE SOURCE WINDSOR

Singing and dancing is not something you routinely associate with our Parliamentarians — unless you think this expression applies to the Brexit saga, recently discussed in another of our blogs. Yet this (and other arts activities) is what the All-Party Parliamentary Group on Arts, Health & Wellbeing discusses in a report entitled Creative Health: The arts for health and wellbeing. The central premise of the report is that …engaging with the arts has a significant part to play in improving physical and mental health and wellbeing. The report promotes the embedding of art interventions in mainstream clinical care, and supports the view that the arts can make significant contributions in addressing a number of the pressing issues faced by our health and social care systems. It reflects the enormous amount of work that has been happening within communities and healthcare settings led by artists over the last few decades in the UK and is part of a wave of publications from the health sector and arts sector over the past 20 years aiming to unite the fields of arts and health. So, inspired by this ‘call to arms’ both from the Creative Health report and the broader developments in the field of arts and health internationally, today we are launching the world’s largest ever study into the effects of arts interventions on physical and mental health! Co-led by myself and Dr. Daisy Fancourt (who has an upcoming blog on InSPIre the Mind in a few weeks, on a new World Health Organisation report she has authored on arts and health), this project is a new enterprise that puts together not only two universities, King’s College London and UCL, but also three art organisations — the English National Ballet, Breathe Arts Health Research and Rosetta Life — as well as the Wellcome Trust, which supports the programme with a £2 million grant. Watch Dr Fancourt, here, talking about the importance of arts for health and wellbeing: This program is called SHAPER, and it does what is says on the tin: Scaling-up Health-Arts Programmes: Implementation and Effectiveness Research. And yes, we also hope that we will shape the future of art and health! Why scaling up? We have chosen three interventions that have been proven to improve patient health: singing groups for postnatal depression, dance classes for people with Parkinson’s, and movement and music sessions for stroke patients. We know that these interventions work, but the evidence so far has been largely in small studies. But now, we are scaling these interventions up, by offering them to hundreds of patients within NHS hospitals and health centres in London. Why do we need implementation and effectiveness research? We will have a stream of work specifically dedicated to examining how the art interventions can be implemented within the NHS, led by Professor Nick Sevdalis and Drs Ioannis Bakolis, Andy Healey, Rachel Davis and Tayana Soukup-Ascensao, all from the Centre for Implementation Science at King’s College London. Because these interventions will only make a true difference in the life of patients if we can demonstrate that they are acceptable to, and taken up by, patients, as well as feasible and cost-effective enough that they can be delivered in the NHS. So, what will we do, exactly? We have built a programme with three parallel interventions, for postnatal depression, Parkinson’s disease and stroke. POSTNATAL DEPRESSION Postnatal depression is a type of depression that many mothers experience after having a baby. It’s a common problem, affecting more than 1 in every 10 women within a year of giving birth. Postnatal depression can start any time in the first year after giving birth, and it can present with symptoms like persistent feelings of sadness and low mood, lack of enjoyment and loss of interest in the wider world, and a difficulty bonding with the baby. We published a touching personal account of postnatal depression in another of our blogs, here. Breathe Arts Health Research’s pioneering Melodies for Mums programme brings together new mothers — often referred by GPs, midwives and other health professionals — in singing and music sessions with their babies, with the aim of reducing symptoms of postnatal depression. Watch a 3-minutes “Melodies for Mums” film here. Myself, Dr Fancourt, and Professor Paola Dazzan (who was recently interviewed in an ‘InSPIre the Mind’ blog) will lead this part of the programme. Previous studies have already demonstrated that these singing sessions reduce symptoms of postnatal depression faster than usual care or social groups. Moreover, these sessions are a great way to engage mothers from minority backgrounds, who are less likely to seek professional support for their mental health needs in the postnatal period. In Dr Fancourt’s words: Postnatal depression is a condition for which there is currently a recognised gap in effective treatments and provision for mothers. Evidence from two years of clinical trials and mechanistic studies of singing has demonstrated the promise of community-led singing programmes as an effective and engaging intervention both for mothers’ mental health and to support the early development of their infants. This programme will allow us to further test the intervention to reach more mothers who could benefit. We will extend this evidence by studying a large number of women with postnatal depression, and by assessing the bonding between the mother and the child. We will also try to understand how the singing sessions work, by looking at possible changes in hormones related to stress and bonding. PARKINSON’S DISEASE Parkinson’s disease is a condition in which parts of the brain become progressively damaged over many years. The three main symptoms of Parkinson’s disease are involuntary shaking of particular parts of the body (tremor), slow movement and stiff and inflexible muscles. However, a person with Parkinson’s disease can also experience a wide range of other physical and psychological symptoms, including depression and anxiety, balance problems (which may increase the chances of a fall), and problems with sleeping and memory. Dance for Parkinson’s from English National Ballet will be upscaled and tested in a project led by Professor K Ray Chaudhuri and Dr Aleksandra Podlewskaat King’s College Hospital. It will see people with Parkinson’s join weekly ballet classes, incorporating live music, dance, rhythm and voice with specialist dance artists and musicians from the English National Ballet. Dance for Parkinson’s has been shown to reduce social isolation, benefit emotional and social wellbeing and improve stability, fluidity of movement and posture to support everyday life. In the words of Fleur Derbyshire-Fox, English National Ballet’s Engagement Director: Since creating our Dance for Parkinson’s programme in 2010 we have seen first-hand the incredible effects dance can have on a person living with Parkinson’s. We’re thrilled to be a part of this study, with the opportunity to embed the programme within secondary care social prescribing, increase reach and diversity, and in turn have a greater impact on the physical and emotional wellbeing of people living with Parkinson’s. STROKE A stroke is a serious life-threatening medical condition that happens when the blood supply to part of the brain is cut off. The main symptoms of stroke at the time that it happens includes changes in the face (the face may have dropped on one side, the person may not be able to smile, or their mouth or eye may have dropped), arms (the person may not be able to lift both arms and keep them there because of weakness or numbness in one arm) or speech (their speech may be slurred or garbled, or the person may not be able to talk at all despite appearing to be awake; they may also have problems understanding what you’re saying to them). It’s time to dial for an ambulance immediately if you see any of these signs or symptoms. However, in this study we are seeking to help people who have survived a stroke and are left with some long-term problems caused by injury to their brain. Stroke Odysseys is a project delivered by the charity Rosetta Life and it was initially developed and funded by King’s College London and Guy’s and St Thomas’ Charity. It will be tested at scale for the first time, led by Professor Nick Ward and Stroke Specialist Consultant Nurse, Angela Roots. Stroke patients will be invited to join 60-minute sessions featuring movement, music, song and spoken word in the acute stroke ward at St Thomas’ Hospital in London and at community arts or rehabilitation centres. Co-designed with stroke communities in South London, preliminary research shows that the sessions deliver improvements to patients’ cognition, mobility and speech disabilities, enhancing recovery, agency and wellbeing for patients after stroke. In the words of Chris Rawlence, Co-Director of Rosetta Life: The experience of a stroke is life-changing. Your sense of who you are may be transformed overnight by stroke’s impact on speech, movement, vision, and the ability to think clearly. Participation in performance arts workshops, by highlighting the power to communicate to an audience through speech, song, and movement, powerfully addresses the losses resulting from stroke, enabling a recovery of identity and the positive embrace of living a new life with stroke. SHAPER will be supported by a multidisciplinary team of artists, scientists and clinicians together with research manager, Dr Tony Woods, and arts advisor, Nikki Crane. To learn more abour the coordinating team, visit King’s Arts, Health & Wellbeing Hub, or read today’s interview in The Guardian with Deborah Bull, our Vice President & Vice-Principal (and former Royal Ballet principal ballerina!). The report from the All-Party Parliamentary Group on Arts, Health and Wellbeing, mentioned above, specifically calls …for an informed and open-minded willingness to accept that the arts can make a significant contribution to addressing a number of the pressing issues faced by our health and social care systems. Our journey to answer this call begin today. header image source English National Ballet — Laurent Liotardo

It’s the 20th anniversary of The Matrix, one of the best Kung Fu movies ever. The Matrix. And, in a totally unrelated coincidence, yesterday I gave a talk at the Royal Society of Medicine on Kung Fu — not as an academic, but as a Kung Fu student: as a martial artist. The conference compared the medical culture in the UK with that of other countries (“east meets west”), with a particular focus on wellbeing. But, for me, this was just an excuse to talk about my personal, physical, and spiritual training as a martial artist. And I started with Crystal’s story. Actually no, first I showed this clip from the matrix Then I showed a picture of me doing White Crane Kung Fu, the style I have been practicing. Then I talked about Crystal. I met Crystal two years ago, at the grading to our next level of Kung Fu training. Kung Fu grading is a stressful business, and it is difficult for everybody. But for Crystal, it should have been impossible. Or at least, so it seemed to Crystal one year before we met. Crystal is still training today, but few people would have thought that possible when she started. Crystal is featured in an episode of the 2016 BBC Programme The Doctor Who Gave Up Drugs, dedicated to the excessive use of medications for pain in our society. At that time, Crystal was taking 30–40 painkiller pills a day: opiates, anti-inflammatory drugs, and drugs to counteract the side effects of the opiates. Her chronic pain was so bad that she would constantly be hunched over, or she would lie in bed on her back. Crystal’s pain was primarily physical, although, as we find to be the case for many others with such health problems, the physical pain often coexists with depression, the two worsening one another. In January 2016, Crystal stopped all medications over the course of two weeks, while starting to practise the slow, Suang Yang Tai Chi style of Kung Fu, and a few months later started the more active, hardstyle White Crane Kung Fu. Here is a clip of the programme, showing my Chief Instructor, Dennis Ngo, helping Crystal. If you take the time to watch it all (3 minutes), you will see my Chief Instructor and my fellow students practicing Tai Chi. (BTW, beware of Tai Chi practitioners, as Tai Chi is a martial art: movements have fighting applications). Today, Crystal rarely takes painkillers, and has learned, in her own words, to “exercise through the pain rather than remaining still and turning to pills”. I still meet her regularly when I go to Dennis’ classes. Crystal’s journey has made me reflect on the indissolubility of mental and physical health: on the bond between the mind, the brain, and the body. Her experience demonstrates that you cannot address one dimension without addressing the others. So, is Kung Fu good for health? There is a remarkable scarcity of good-quality studies in this field, but the signal that is coming out of science is pointing in the right direction. Most of the research on the health benefits of martial art is on Tai Chi, which focusses on developing a stable, balanced stance, on improving flexibility, and on using breathing as part of a light meditative element. There have been literally thousands of studies on the benefits of Tai Chi on health, and around 200 of those benefits are in mental health. The most recent scientific appraisal of the evidence finds that Tai Chi improves balance, reduces falls in the elderly, and helps with depression and pain. Like with Crystal. The scientific evidence of the health benefits for the ‘hard-style’ of Kung Fu is more difficult to gather, simply because there haven’t been many good clinical studies. However, there is some evidence that both Kung Fu and other martial arts, can help improve physical strengths and bone density, as well as reducing stress and improving mood and quality of life. Of course, we know that physical exercise has anti-pain and antidepressant effects, and the internet is full of personal accounts on how exercise helps with sadness and even with suicidal ideation. Experimental studies show that this might be due to the ability of physical exercise to dampen the activity of the immune system, and research from my group, amongst others, has shown that both pain and depression are associated with a hyperactive immune system, which participates to the development and maintenance of the symptoms. But is Kung Fu more than just simply an intense physical exercise? (This is a rhetorical question, of course — the answer is yes, and the explanation is right below). Kung Fu is more than just intense physical exercise. Kung Fu would be considered, in technical terms, a ‘complex intervention’, meaning that there are multiple ‘active ingredients’ that could help therapeutically, spanning biology, psychology, alternative medicine, and spirituality. First of all, not everybody knows that the words “Kung Fu” actually translate as hard work. In China, a calligrapher with excellent brush-work is said to possess good Kung Fu. The term is not just for a skilled fighter. The Philosopher Zhuang Zi (4th Century BCE) first wrote about the pursuit of enlightenment through the “dedicated practice of a skill.” These practices require a sustained application of effort over a period of time. If you are interested in learning more on this topic, you can read a recent blog written by one of the Kung Fu instructors in our club, and fellow Medium writer, Danil Mikhailov. Or, read his book. But the spiritual element of Kung Fu does not stop only with the pursuit of perfection. Kung Fu has taught me the acceptance of physical pain, and that pain is a normal part of learning. “We are martial artists — we all live with pain. If you train hard and regularly, you will know what pain is”, as my Chief Instructor writes in his blog. Of course, pain is never just physical; surviving a hard session of training, or getting punched and kicked while sparring, has also taught me about acceptance of emotional pain, about overcoming fears, and finding a stamina I never thought I had. And of course, clinical studies have shown that acceptance of physical and emotional pain is associated with less stress and better quality of life. Then, if you accept the principles of alternative medicine, Kung Fu also mobilises the same mental and physical spirituality that is accessed, in different ways, by yoga and meditation, both of which are also beneficial for health. My instructor once said to me that focussing on breathing as part of Kung Fu training helps to clear negative thoughts. And we know that meditation has a positive impact on mental health. Of course, we should also not forget that Kung Fu is a martial art, and thus all the movements that we learn have the technical potential to be lethal. Thus, Kung Fu has taught me the fragility of life. Action movies, with their lengthy fighting scenes, trick the viewers into thinking that it takes a lot of blows to take someone down. But Kung Fu has taught me the truth: that you could be killed in an instant, by a single blow of a bare hand. Understanding the fragility of life has enhanced my compassion, acceptance, and gratitude. And compassion meditation is an effective psychological intervention for depression. Finally, Kung Fu has offered me a strong, reliable and supportive social environment. Kung Fu students are all “brothers and sisters”. And of course, as many students spend years in training, people grow older together: children become adults, move from school to work, marry, have children. And we know that social support is essential for good mental health. To be clear, I do not think that Kung Fu (or yoga, or physical exercise) is the “cure-all” solution for every pain, for every person, nor for every occasion. But we should never dismiss nor forget that promoting mental health also means physical exercise, personal development, and spirituality. A previous version of this blog was published in 2017. HEADER IMAGE SOURCE THE MATRIX

Walking on an empty street of London: the illuminated windows, the colours and the shadows are always different. Behind every window there is a story, a relationship, a bond: we can look at figures, perceive desires, secrets, but mostly silence. What would it be like to have access to this space of mysterious intimacy? Silent Figures — a series of images straddling real life and fiction — was originated from my need to visually express the darkness I was feeling inside, the deep solitude I felt within a relationship that I was in at that time. I started taking self-portraits, looking through my inner window, but then came the desire to investigate other people, how they experience the contradictions of the couple’s relationship: on the one hand, the desire to share and the need to bond; on the other, a sense of estrangement, a desire for escape. The title was decided keeping in mind Hockney’s way of representing individuals and the silence that can be perceived from his representations. The conceptual idea of the work was inspired firstly by Barthes’ A Lover’s Discourse: Fragment, and then energized by the writing of Verhaeghe’s, a Belgian professor of clinical psychology and psychoanalysis. They suggest that the world outside, and the society with its rhythms and its temptations, act as a mirror to individuals, affecting their behaviour: identity is a balance of tensions, and individuals are torn between the urge to share with and the urge to distance themselves from the other. Hence, my curiosity to confront the subject of solitude and identity within a couple’s relationship. My aim was to develop a personal visual expression through scenes of everyday life set in a peculiar atmosphere, sometimes on the verge of strangeness. The silence is expressed by subjects being immobilised by overwhelming thoughts, fear, problems, and caught in the fleeting moments of daily life. The key words in this body of work are ‘loneliness’ and ‘alienation’. The couples never look at each other, there is no eye contact between them. This was my artistic choice to visualise this moment of solitude. Their ‘Home’ was the location for the shoot, where people feel relaxed and secure, the place where you’re not supposed to wear masks. I decided to work with authentic couples because I wanted my perception of reality to be grounded on a very genuine experience. Merging both my feelings and theirs, I created images which became the places for personal projection, where there are no theories nor solutions. There are just stories. Shot initially on film, pictures were then digitally combined and edited to make the final images, each with its own story within. It is worth pointing out how important the editing was in the process, in order to emphasise the colour palette and to give the pictures a different appeal, an element of surreality. Pictures were always taken in the evening, to achieve total darkness and to create a quiet mood, as many painters do. I like how the American Photgrapher, Crewdson, does this, evoking how darkness influences the human behaviour. The recruitment process was the most challenging part of the project. Creating trust was crucial in order to create a dynamic in which people who are not actors could be comfortably directed and staged, . As part of the commitment to the project, in one of the pictures I, the photographer, changed role — moving from just being an observer to also being observed (see my picture below). It was important to merge the photographer’s experience with that of the other couples involved: both parties are aware of being seen, and this leads the project from an unsatisfied voyeurism to the representation of a more intimate storytelling, not just recording a fact. In all pictures the two individuals are always opposed by visual elements that represent a psychological separation: a shadow, a line drawn by light, a physical barrier. There is always one of the two people, typically the woman, who is paralysed by her own thoughts, while the other is wrapped up in their state of unconsciousness. It could be argued that women play an incisive role in the meaning of the picture, although it is difficult to establish whether the woman plays a passive part or whether she is in a position of power in the relationship. My intention was to sublimate the ordinary and define my own narrative of the so-called ‘reality’. By proposing a disturbing mise-en-scene, the project describes the solitude within the couple, re-editing the concept of communication. Through working with real couples in their private environment, the series has a very personal approach, made visible by the explicit use of film lighting and directing poses of the subjects. Research and technical preparation are combined with improvisation, reaching unexpected images, simultaneously poetic and documentary. Silent Figures highlights much more than what remains imprinted in the camera; it presents a visual elaboration of the meaning of ‘identity’ in today’s society. NOTE FROM THE EDITORS: We are so pleased to have Francesco Catania guest writing for InSPIre the Mind! Francesco Catania is a photographer specialised in portraiture. Since the beginning of his photographic practice, the human element has been fundamental in his images. He is constantly interested in what concerns identity, relationships between individuals and individuals within society. His photography explores a visual elaboration of the questioning on the idea of identity in today’s society, creating a space in between fiction and reality. The project is exhibited in London and internationally. - Instagram: @francescocatania.photo - Website: www.francescocataniaphotographer.com

What comes to your mind when you hear the word “hip-hop”? DJ, break-dancing, rapper with gold chains and baggy pants, and graffiti writing? Well, you grasped most of the five key elements of hip-hop, which include MC (or Emcee)/rapping, DJing/scratching with turntables, break dancing, graffiti writing, and, most importantly, knowledge. But how does this relate to mental health? I attended a very interesting Public Lecture at this year’s British Association for Psychopharmacology (BAP) Summer Meeting. The public lecture was presented by Dr. Akeem Sule and Dr. Becky Inkster, who are the co-founders of Hip Hop Psych. Hip Hop Psych is the interface that links hip-hop music and culture with mental health, and wants to use hip-hop culture to help raise the awareness about mental health. During the one and a half-hour lecture, Akeem presented the history of hip-hop and its link to neuroscience and psychiatry, while Becky updated us on the new research projects they are working on linking hip-hop to neuroscience and psychiatry. Hip-hop to many of us maybe just a music performance, but it is more than that, it’s a culture. Hip-hop has been used to open up conversations on many areas including politics, sociology, and also mental health. Many may have the misconception that hip-hop originated from the Bronx in the Big Apple in the 70s, but it was actually originally from Africa, where political poets attempted to portray both facts and fiction in their work. Another part of hip-hop also comes from family tradition passed down from generation to generation thought oral stories of how one came into existence and what one’s role would be in the society. This tradition then travelled to the Caribbean and America, and is then officially coined with the name Hip-hop in 1973 when DJ Kool Herc played at his sister’s party in South Bronx. Akeem mentioned that Hip-hop is ‘like the CNN of the neighbourhood’ - from the lyrics you would be able to know what is going on around you. For example, one of the themes commonly used in Hip-hop music is substance use in the younger generation, something that is very much happening around us. There are many messages regarding mental health (addiction, psychosis, conduct disorder) and environmental risk factors (urbanicity, malnutrition, poor parental care) hidden in hip-hop lyrics, and part of what Hip Hop Psych do is to try to cultivate awareness, empower others and remove stigma surrounding mental health by engaging directly with youths and general public, and bring teaching innovation using a hip-hop frame work to the medical professionals and academics — indeed, such as this public lecture at BAP. For example, Hip-hop has its own slang terms when it comes to drug use: brown refers to heroin, coke is cocaine, bomb means good, indo refers to cannabis, slamming means being injected with drugs, and speed rolling refers to a special method of mixing heroin and cocaine in the crack pipe. One of the songs Akeem picked out in his talk allows us to understand the meaning of the slang terms while also providing messages about mental health. Listen to Lady Heroin while also reading the lyrics (and be prepared for some ‘controversial’ terms): Now when I first met her I was down in the dumps ’Cause my punks would funk Some cowed on some chunk like Willy Lumb Feelin’ sad and mad hurt That’s when this fly honey walked up to me In a brown leather skirt She sat on my lap She said “I heard that you rap” She said “I have some prime-time skill that you need to tap” I never met a girl So I front with it So I took it to crib Sparked a blunt with it Hit it It was the bomb … But all of a sudden she start flippin’ and scrip talkin’ Like what have you done for me lately Like she hate me I wasn’t no romance without the ends She had me drivin’ and stealin’ and illin’ Just to hit the skins I was open You could drive a bus up my nose My friends tell me I shouldn’t mess with these type of hoes…. Through the lyrics, the artist describes his encounter with heroin (the lady in the brown skirt), and how the use of heroin starts as recreational but then becomes problematic (she had me driving and stealing and illing), so much so that his friends tell him that he should stop using it (I shouldn’t mess with these type of hoes). ‘Hoe’ is a derogatory term for someone who is sexually promiscuous, and while this blog does not condone the use of such terms, it is important to highlight that in this context it is used as a critical metaphor for ‘heroin’. Many hip-hop artists also describe their experience with cannabis in their songs, about how they smoke cannabis to fight off the withdrawal symptoms from other drugs, but then the cannabis actually exacerbates their most distressing symptoms, which can reach the intensity of psychotic experiences, like ‘hearing voices’ or feeling intensely persecuted and paranoid. Thus, Hip-hop not only reflects the life experience of the artist, but it also provides a broader picture of the trend in cannabis use. In fact, there are two main components of cannabis, Tetrahydrocannabinol (THC) and cannabidol (CBD): THC is more prone to cause psychotic-like symptoms, while CBD is the component that has calming and relaxing effects. As the concentration of THC in cannabis has been steadily increasing over the years, this may be reflected by the awareness within the Hip-hop culture of the increased frequency of such distressing symptoms. Akeem also discussed how the life experiences of the artists will have an impact on their works in Hip-hop. Akeem told the story of 2Pac or Tupac Amaru Shakur, whose mother was a black nationalist and also had problems with cocaine addiction. 2Pac’s song, Death Around The Corner, illustrated the life experiences of a young man growing up in a bad neighbourhood with environmental adversities, and wonders if he will able to survive. The song continues to give a full description of a family life where both parents have substance use problems, with his mother also using alcohol while she was pregnant with him. Finally, Becky described several on-going research projects headed by Hip Hop Psych, some of them based on theme identified in this blog: for example, looking at the association between keywords in Hip-hop lyrics and the trends in our society, or changes in heart rate and vocal footprints in hip-hop artists. It was a fantastic lecture that combined the knowledge of culture, hip-hop and neuroscience. Perhaps on your spare time this weekend, try to listen to a recent hip-hop song and see what’s going on in our society. header source image Ben Wiens on Unsplash

As I sit here and write this, I find it hard to fathom the thought of wanting to end my own life. I’ve just returned to work after my summer holiday. I’m feeling energised and optimistic. Yet I know from previous experience that suicidal feelings can rear their ugly head at any time. When I start to feel suicidal, my world turns upside down. I often compare it to a physical injury, like breaking a bone in your body. If one breaks a bone, the intensity of pain is all consuming for the individual. For me personally, this is no different to what happens when my thoughts turn to suicide. My mind is so unbearably painful that removing myself from this existence becomes my only solution. I know that for some reading the last paragraph this may seem entirely irrational. However, I know that if I had a physical health crisis, such as breaking a bone, suffering a stroke or enduring a heart attack, it would be treated extremely differently to a mental health crisis like experiencing suicidal ideation. Even the very term “suicide” scares many of us to the point where we would rather avoid the subject altogether instead. Avoidance, though, is costing the lives of too many women and men in our society. Every 40 seconds someone around the world takes their own life. Whilst the numbers of people who end their own lives may be difficult to comprehend, the impact it has upon family and friends is even more difficult to imagine. Bereavement by suicide is an area that is just as taboo as suicide itself. I will never forget the moment a young woman came up to me after a talk I gave at a school in Grimsby last year. She immediately burst into tears and eventually told me that she had lost her Father to suicide at the age of 9, but that she had never been allowed to talk about what had happened because of the way in which he died. Finally, she felt immense relief to be able to speak about it. The shame associated with suicide, whether it be by the individual who is feeling suicidal, or by the loved ones of a person who has taken their own life, must stop if we really want to curb the rate of suicide. In the last couple of years, I’ve noticed a distinct change in the way we address mental health. Finally, the stigma attached to it is shifting, as more and more of us are becoming open to talking about it. I truly hope the fear and unease that surrounds the conversation of suicide will also subside. In many ways, it feels like the last taboo. We have seen society start to address everything from AIDS to cancer to FGM in the last few decades. But suicide remains a silent killer, particularly amongst men. The truth is that suicide is preventable. I don’t believe we hear this often enough. Neither do I consider that we realise how common suicidal ideation is. Since I began talking publicly about my own experiences, I have been stunned by the amount of people who have told me that they have experienced suicidal thoughts or feelings, or attempted to take their own life. The next time my own mind turns toward the notion of suicide, I don’t want to hide it. I want to be able to tell someone what I am experiencing, just as normally as I would if had a bad back or a stomach ache. We must all work together to make a conversation about suicide finally acceptable, not just during upcoming World Suicide Prevention Day on 10th September, but for the other 364 days of the year as well. I am uncertain of much in life, but I feel sure that we can reduce the tragic rate of suicide we currently see. NOTE FROM THE EDITORS: We are incredibly excited to have Jonny Benjamin MBE writing for InSPIre the Mind. Jonny is an incredibly inspiring (and award-winning!) mental health campaigner, film producer, public speaker, writer and vlogger. Beginning by talking of his own experiences on Youtube, Jonny is now a prominent mental health campaigner using his voice to help educate and break stigma. Jonny has produced documentaries for the BBC and Channel 4 on mental health and suicide and has launched social media campaigns with Rethink Mental Illness, a successful mental health programme for schools called ThinkWell, has written a book entitled ‘The Stranger on the Bridge: My Journey from Suicidal Despair to Hope’ and has most recently launched a new charity, Beyond Shame Beyond Stigma. It is a real honour that Jonny was happy to share his voice on our platform and to share such an important message — thank you Jonny! For more information on World Suicide Prevention day which is on the 10th September visit: https://www.iasp.info/wspd2019/. https://www.telegraph.co.uk/health-fitness/mind/stranger-saved-life-became-friend-fellow-mental-health-campaigner/

Predicting Children’s Health: The Promise of Blood Tests What if children could get a test at the doctor’s office that would tell them if stress experienced in their early lives is putting themselves at high risk of poor health and early death? And what if the results of that test could tell them exactly what treatment would help? Childhood Adversity — and why it matters For several decades, physicians, neuroscientists, and psychologists have been mapping the harmful impacts of high levels of stress on the body. Significant childhood adversity, such as abuse and neglect, is a form of stress that can affect brain architecture, neurochemistry, and biological processes. Childhood adversity is a particularly strong predictor for poor health across the lifespan, as shown by the famous Adverse Childhood Experiences (ACE) Study, conducted at Kaiser Permanente and the Center for Disease Control (CDC). The ACE story was born out of the frustration and curiosity of endocrinologist, Dr. Vincent Felitti. The story goes that nearly 25 years ago, Dr. Felitti was running a weight-loss clinic. He could not understand why some patients were losing weight, but then gaining it back, or prematurely dropping out of the study. He began to interview these patients and a pattern emerged: a disproportionately high percentage of these patients had histories of childhood adversity, specifically childhood abuse, neglect, and house dysfunction. With his colleague, Dr. Robert Anda, they ran a study where 17,000 US adults filled out a questionnaire about ten potential adverse childhood experiences, called ACEs, at their annual health exam. ACEs covered a range of stressful experiences from more common stressful experiences, such as divorce, to even more severe experiences, such as physical abuse. The findings were clear. Firstly, ACEs were incredibly common (50% of people have at least one). But ACEs were also the strongest predictor of adult disease and early death. Importantly, ACEs predicted both physical and mental health outcomes. For individuals with four or more ACEs, the likelihood of developing physical diseases (e.g., stroke) and psychological disorders (e.g., depression) was particularly high. ACEs had long-reaching and widespread influences on virtually all aspects of health from injury to mental health to risky behaviors to chronic diseases. These findings entered our public stream of consciousness. Over two decades later, renowned American pediatrician Dr. Nadine Burke Harris delivered a Ted Talk (“How Childhood Trauma Affects Health Across a Lifetime”); it would amass over 2.8 million views. You can even find out your own ACE score with a quick Internet quiz. But, what does this score mean? What can it tell us, and what can it not tell us? Could we just get an ACE score at the doctor? What would it mean? Moving Beyond an ACE Score An ACE score is a solid predictor of health outcomes in a large research study. But it may not be able to accurately predict your individual health outlook. While ACE exposure generally predicts poor health, it is not true for all people. In other words, some people are more resilient to adversity than others — or, better, some children are more resilient than others. One important reason is the caregiving environment. Caregiving high in warmth, sensitivity, and responsiveness is a powerful buffer against stress. Positive caregiving can buffer children against the negative impacts of adversity One other important reason is children’s biological functioning. In some children, ACEs “get under the skin,” and may negatively impact a variety of biological health processes — how their cells communicate and function, the circuitry of their brain, and more. These may be the children that, when they become adults, are at risk of poor health. And perhaps these children can be identified, and helped, early on in their lives. As a Clinical Psychology doctoral student at the University of Oregon, my research is rooted in these two primary goals: 1) examine the impact of childhood adversity on children’s biological systems and 2) translate this knowledge to help predict which children may be at highest risk for poor health trajectories. Is it that simple though? Could something like a blood test really tell us that which child is at high risk for poor health, all the way from metabolic problems (for example, diabetes or obesity) to mental health problems (for example, depression or anxiety)? Biomarkers of Adversity and Risk Neuroscientists believe that there are tests, or biomarkers, that can tell us if childhood adversity has “gotten under the skin.” Such markers may help us understand if the stress is high enough to have infiltrated the body’s biological functions early on in development — which may, in turn, serve as an initial sign for future poor health, before symptoms or disorders have developed. Unfortunately, nothing in neuroscience is that simple. Here, I discuss what stands in the way of this worthy goal, and what can be done to reach it. Which blood tests should we use? If your pediatrician thinks a child has diabetes, they will likely order a blood test to examine blood sugar, or the blood levels of a protein called ‘glycosylated hemoglobin’ which is basically a protein where excess sugar sticks. Those one or two biomarkers, in combination with early symptoms, are usually enough information to make a diagnosis and guide your child to the proper treatment. But blood tests become much trickier when you are trying to predict future possible diseases, ones where symptoms may not be obvious yet. Blood test at the pediatrician’s office may provide valuable information about children’s future health. Source: Dell Children And that is an unanswered question when it comes to biomarkers — can they actually predict the early formation of an illness, before you can see it? Even more tricky is that we are trying to predict diseases that span across mental and physical health domains. Is it realistic that a blood test would predict both depression and obesity? Future Direction: A Panel of blood tests Childhood adversity predicts a wide range of negative health outcomes, many of which do not fully manifest until adulthood. As such, careful attention must be paid to selecting which biomarkers are most likely to connect early signs of stress to a host of diseases and disorders. One advantage is that we now know a lot more about how physical and mental health coincide. Broadly, neuroscientists study what we call stress responsivity systems. In other words, these are the systems in our body responsible for responding to stress and helping our body regulate properly. Chronic levels of stress and adversity can alter how these systems work in important ways. And these systems are key players in a child’s health and development. Altered functioning in the immune, metabolic and neuroendocrine systems can influence both physical health (think, diabetes) andmental health (think, depression). My own work has focused primarily on immune and metabolic functions, trying to understand if and how childhood adversity influences these systems. From there, we can make stronger predictions about how immune and metabolic function then impacts health. There are many examples of types of immune and metabolic markers, but two I discuss here inflammation and oxidative stress. Inflammation is a hot topic, often featured in news articles about everything from diet and exercise to depression to cardiovascular health. Inflammation is a key part of your body’s immune system and is critical to healing. Inflammation has received a lot of attention in the news because it is implicated in many physical and mental health diseases. There are many biomarkers of inflammation, including C-reactive protein, Interleukin-6, and white blood cell count. Source: needpix.com Inflammation has received a lot of attention in the news because it is implicated in many physical and mental health diseases. There are many biomarkers of inflammation, including C-reactive protein, Interleukin-6, and white blood cell count. Source: needpix.com What is important is that both physical stress, like a cold, and psychological stress, like chronic childhood adversity, can set off inflammation. Crucially, inflammation is important to healing in the short-term but can be problematic when it becomes chronic. Higher inflammation has been observed in adults with a history of childhood adversity. But we need more research on this in children. We also see high levels of inflammation in both depression and cancer as well as cardiovascular disease. Depression is one example of mental health disorder where we see high levels of inflammation. Schizophrenia, post-traumatic stress disorder (PTSD), and Obsessive Compulsive Disorder (OCD) are other examples. Source: pixabay.com Depression is one example of mental health disorder where we see high levels of inflammation. Schizophrenia, posttraumatic stress disorder (PTSD), and Obsessive Compulsive Disorder (OCD) are other examples. Source: pixabay.com Oxidative stress is another critical factor in many diseases, such as cancer and obesity. Oxidative stress occurs when there is an imbalance between the body’s production of free radicals and antioxidants. Free radicals are highly-reactive molecules that are missing an electron in their outer shell. Electrons prefer to be in pairs, so these free radicals will doanything to seek out other electrons to become a pair, including “stealing” from other cells. Left unchecked, this cellular thievery can lead to damage in the cell’s membranes and eventually start to harm important components of the cell, like the DNA, lipids, or proteins. Thankfully, our bodies have antioxidants that act as neutralizers by donating an electron to these free radicals, and thus protecting cell health. Antioxidants neutralize free radicals (sometimes called Reactive Oxygen Species) by donating an electron. Source: Medical News Today Unfortunately, stress can lead to an excess of free radicals, which can then overwhelm those antioxidant defenses, leading to poor metabolic health and cell damage. In my work, we demonstrated that a biomarker of oxidative stress was detectable in the urine of teens exposed to childhood adversity. That marker was also associated with emerging symptoms of mental health problems, like depression. This work is very new, but it provides some initial evidence that childhood adversity may affect metabolic health in teens and is linked with initial warning signs of mental health problems. These are just two examples, but a panel of blood tests will be the most helpful in predicting risk, rather than one single marker. A panel of biomarkers could enhance pediatrician’s ability to predict which children are at highest risk for poor health outcomes, especially when results from a blood panel are paired with other risk markers, like early behavioral problems or developmental delays. Source: Wikipedia A panel of biomarkers could enhance pediatrician’s ability to predict which children are at highest risk for poor health outcomes, especially when results from a blood panel are paired with other risk markers, like early behavioral problems or developmental delays. Source: commons.wikimedia.org Even more helpful will be to pair these biomarkers with psychological risk markers, such as early behavior problems and developmental delays. However, for these blood tests to be clinically useful, we need to know what the results of a blood test would mean for the child’s health. The issue is that we do not necessarily know yet how reliable these biomarkers are or how to interpret them. Simply put, more research is needed that connects these biomarkers to both childhood adversity and poor health. This requires longitudinal studies, or studies that start by measuring these biomarkers at early ages and then follow the children as they age to start tracking their health. Of course, these studies are costly and time-consuming. But they will be instrumental to helping us understand which biomarkers are the most reliable and how we can interpret them effectively. Integrating into Clinical Services In the United States, the average pediatric primary care visit lasts 16.4 minutes. In 16.4 minutes, the following is done: a child’s history, measurements (e.g., height/weight), sensory screening, behavioral health screening (e.g., developmental milestones), a physical examination, bloodwork, and immunizations. Doctor’s visits are very short — often under 20 minutes! And there is a lot to cover in that visit. It is important that new screening tools are implemented in a way that minimizes disruption to the patients and medical staff. Source: health.mil Doctor’s visits are very short — often under 20 minutes! And there is a lot to cover in that visit. It is important that new screening tools are implemented in a way that minimizes disruption to the patients and medical staff. Source: health.mil The constraints of quick visits will make it harder to add biomarkers into screening. Collaboration is thus essential. This will take on-site efforts in pediatrician offices to test out the feasibility of adding in new biomarker testing and conversations. Important considerations, such as the ethics of biological screening, cost and complexity of assays, and invasiveness to the patients, must be considered. This will take collaborative efforts with pediatricians, nurses, and medical assistants and patients. Cultural differences — such as how health access, payment and insurance work in different countries, varying cultural norms — must also be considered when we think about this on a global scale. Conclusion We can all recognize that a blood test alone will never tell us everything we need to know. But it could be an important tool in identifying high-risk children and families. From there, the next step is key: we bridge to the fields of clinical and intervention sciences. Once we know a child is at high-risk, we can arm parents with more knowledge about how to help their child, including connecting families to parenting services or programs. It could mean adding in more frequent preventative testing for certain diseases or disorders. The possibilities have yet to be fully explored, but the promise is bright. Header image source: The Honest Company on Unsplash