Prevention through Connection Given the combination of an already stretched mental health care system, the overwhelming need for mental health treatment post-pandemic, on a background of rising mental ill-health across the lifespan, it would be helpful to step back, reflect on the human condition, and understand how we can support this ever-increasing dilemma facing most nations across our world, including our own, here in the UK. What can be done to support families? Start with connection. My name is Gauri Seth; I am an emotional intelligence and connection coach, supporting people to connect with their authentic selves so that they can connect with others for healthy, supportive relationships. I have worked and trained as a psychiatry doctor and an academic clinical fellow. My experience as a mother of three, alongside working in clinical services, has led to wanting to support parents and caregivers with their emotional wellbeing and positively impact future generations. I now work with early connections (families with young children) and help support individuals through a coaching model that can support and empower them to make proactive intentional changes in their everyday lives. Caregiver-Child Connection Social connection is a fundamental player in emotional wellbeing, fulfilment and happiness. The link between social connection and wellbeing was established in the landmark ‘Harvard Study of Adult Development’, which highlighted social connection as the strongest contributor to physical and mental health and longevity. In parenting, it is paramount that parents and caregivers are supported with their emotional wellness to connect with their children. By helping parents’ and caregivers’ wellbeing, we can empower them to be their best selves and model emotional wellness to the next generations. Furthermore, parents being supported with their emotional wellbeing can be empowered to connect to their children through connection strategies. For example, ‘Love-Bombing’ is a popular and effective strategy involving regular one-to-one time with one child, enabling the child to choose the activity. This requires a no-distraction philosophy, where phones are put away, screens are off, and parents consciously and intentionally choose to be present, and in the moment, with their child. Another strategy to boost connection with children is to laugh together. Studies show that laughing together can boost trust and closeness in any relationship. This may be as simple as watching a funny television programme together. I believe that the power of connection is enormous. We feel stronger knowing we are not alone. No man is an island. The caregiver-child connection promotes self-esteem in children - because, if they feel connected, they are given an implicit message that they matter. This is powerful for self-esteem and self-worth, supporting behaviour in the family home. But it is harder for a parent to connect with their children if they are battling emotional distress, turbulence and stress. The CO-SPACE study of 6000 parents showed increased rates of depression, anxiety and stress following the COVID-19 pandemic. Given the transgenerational impact of parental stress on the ability to connect with children, supporting parents to connect with their authentic selves in order to connect with their children could be a powerful way to support emotional wellness. Researchers believe that the first seven years of life sets the tone for the emotional environment and patterns of behaviourwe subconsciously are more likely to repeat. If parents and caregivers can model emotional connection during a child’s early years, are they setting the tone for their future ideas around connecting and healthily relating with others? If so, this hopefully supports their chances of attracting connections and maintaining healthy relationships with their friends, future partners, and future children. This illuminates the transgenerational impact of helping parents with a connection within their families. Essential emotional skills from the early years to beyond In ‘On the Origin of the Species’, Charles Darwin stated that it’s not the strongest or most intelligent of the species that survives but the most adaptable to change. Cognitive flexibility and adaptability are essential life skills, enabling us to bend and flex when change or uncertainty presents itself. Parents and caregivers are in a prime position to support children early on with this essential life skill. We cannot control the external environmental factors that may stress our children when they are adults. We can, however, support them in developing a strong sense of self and adaptability, knowing they are safe in times of change. A sense of safety interacts with external factors and one’s inner world. We can support the internal personal factors when we can’t control the external environmental factors. Other important non-cognitive skills parents can support children with include gratitude, compassion, distress tolerance, patience, emotional regulation, and mindfulness. Some of these skills have been linked to emotional wellbeing and other positive longitudinal outcomes and help prepare children for life and all its uncertainties through a toolbox of skills. These skills can be seen as ‘life skills’, and parents are in a great position to help their children with these. It may seem a tall order to expect so much from parents and caregivers, which can support the argument of involving multiple caregivers, relieving pressure and sharing the journey with parents. Rearing young with many emotionally connected caregivers has numerous benefits for the growing mind. Studies understanding children growing up in multigenerational households show benefits in emotional and social learning skills. While there is no doubt there can be problems with this model, it does invite us to reflect on the importance of a tribe when rearing young. A household structure where there is non-parental caregiving support means less pressure on a mother or father, enabling them to have time to rest and restore their emotional wellbeing, catching up on sleep or tending to their own needs, which we know are so crucial for their ability to tend to their child’s needs. Should we discuss more openly how parents can accept help from friends and family, and encourage interdependence within communities, so the pressure on the new mother or father is diluted? Literature suggests that involving generations works well when all parties respect autonomy. Can we coach parents grandparents and other family members on how to navigate essential boundaries within a family system, where skills to support autonomy and respect are shared? Parenting is hard, and given the challenges of the juggle with work, it is so important that techniques are designed to support working parents who may not always be physically present as much as they would like. A non-judgemental curious, and compassionate perspective is essential, so parents feel they can turn to interesting scientific insights to help support their journey of parenthood. DISCLAIMER: Any information or advice I give is purely based on my own experience. Comments made are as a coach, this is not medical or psychiatry advice. There is no guarantee as there are many variables that will impact outcomes. Everything stated should be taken as an opinion.

You have probably had to deal with quite a few challenges over the years. Most of us have. Sure, some people seem to have been dealt a better hand than others. But if you ever get to take a look under the bonnet of even the most ebullient & outwardly ‘successful’ & happy person, I suspect you will find that they too have experienced a fair amount of distress & pain. Most of us have learnt to deny or hide our vulnerabilities & either aren’t aware of, or are aware of but are ashamed of our ‘shadow side’ (a key tenant of Carl Jung). In Hamlet, Shakespeare reminds us that we all have to face: ‘The slings and arrows of outrageous fortune’. The Buddhists chip in with: ‘Life is suffering’. Paradoxically, if you accept these simple but rather ominous & down-beat sounding truths, chances are you’ll be a lot more content. Go figure. Pain is inevitable, misery is optional. A poem my Mum & Dad were fond of quoting to me, when as an adolescent I argued vociferously that all my woes were a direct result of their inadequacies as parents: “They f*%k you up, your mum and dad. They may not mean to, but they do. They fill you with the faults they had And add some extra, just for you. But they were f*%ked up in their turn By fools in old-style hats and coats, Who half the time were soppy-stern And half at one another’s throats. Man hands on misery to man. It deepens like a coastal shelf. Get out as early as you can, And don’t have any kids yourself.” ― This Be The Verse, Philip Larkin So where am I going with this? For many years I lamented & resented the challenges I have had to face. Why do I have to have a mood disorder — often labelled Bipolar Affective Disorder? Why do I have to suffer from intense & destructive addiction issues that threaten my very survival? I have felt truly sorry for myself at points in my life. Jealous too, of those I felt, had a better run of things. While sharing my woes with a friend (who happened to be a retired psychotherapist), she kindly interrupted me & suggested the antidote to my complaint was: ‘To turn adversity into inspiration’. I was a bit confused at first & so at my request, she expanded her theory. Yes, I had had a lot of difficult stuff to deal with, maybe more than most. But, if I could learn to turn this adversity into inspiration, then over time, I may just be able to use these experiences to create something beautiful. The very act of me writing this prose, for example, which I hope is helpful to you (it’s certainly cathartic & satisfying for me), is in part a result of the years of distress I’ve experienced. I’m compassionate, reflective & wise not despite my suffering but because of it. In many ways, this ‘lemons-to-lemonade’ idea explains why most types of talking therapies work. Just like physical pain, psychological pain helps raise awareness that an emotional issue requires attention. Of course, there are a multitude of different types of therapy but at a basic level, they all pretty much encourage us to turn adversity into inspiration. To plant & grow flowers in the ‘manure’ of our psychic distress. We try to make peace with our pain or at least learn ways to deal constructively with it. As a result of the very experiences we have resented or lamented or tried to avoid or deny most of our lives — we eventually use this material, to shine like the stars we are. Friedrich Nietzsche points out: ‘One must still have chaos in oneself to be able to give birth to a dancing star.’ Ready for another metaphor!? Good. How we drive a car is a useful analogy for how we might approach life. We need to observe what is directly in front of us or we may crash. Sometimes we need to look further ahead to make sure there are no obstacles coming our way. And sometimes we need to look in the rear-view mirror to ensure we are aware of hazards that are behind us. And it’s helpful to remind ourselves that we all have blind spots that our wing mirrors fail to show us. The key concept is that if we spend all our time looking in the rear-view mirror (ruminating on past pain & grievances) or all our attention too far in front of us (worrying excessively about the future) or fixating on all the horrors that could be lurking beyond the scope of our wing mirrors (staying too long in therapy?) we are likely to crash. Balance of focus is key to us enjoying the journey as well as safely reaching our destination. Kierkegaard, a Danish philosopher, reminds us: ‘Life is something that can only be understood looking backwards but must be lived looking forwards’. Do you doubt this pain-to-potential thesis? Do you dismiss my logic as a way of avoiding or minimising the distress that can be caused by mental health issues, including addiction? Then I shall be forced to remind you of the following insight: ‘It ain’t what you don’t know that gets you in to trouble. It’s what you know for sure that just ain’t so.’ Mark Twain. I’ll end on this final thought. I’m not sure if a philosopher said the following or it is an idea I’ve created — but why don’t we give me the credit huh?’ ‘Go to your wound, therein lies your genius.’

Trigger warning: This blog talks about eating disorders and disordered eating. Eating disorders have long been a rather taboo topic, and so it often means that when faced with one, few know how to navigate it. It is also common for the person with the eating disorder to be hesitant about receiving help. This could be for a multitude of reasons — some believe that they do not need help and are in fact not sick, others just do not want help. There is a reason for eating disorders having the highest mortality rate amongst mental illnesses, it is a dangerous and wicked illness that thrives off of the comfort it provides its sufferers. When I was in eating disorder recovery between, 2018 and 2019, I believed both of those things: I simultaneously believed that I wasn’t sick at all and did not warrant help, yet, also knew deep down that I was sick, but wanted to stay as such. It seemed easier than recovery. I am happy and grateful to be able to say that I did recover from my eating disorder and was officially discharged from care in the summer of 2019. But it wasn’t an easy road, and recovery is certainly never linear. One thing I am certain of, however, is that I would not have been able to do it without the support of friends and family around me. I am, and always will be, eternally grateful to the people who stood by me at the hardest times. Before I list some of the ways in which I felt best supported, I want to disclaim that recovery looks different for everyone, therefore it is unlikely that these will resonate with all. Everyone’s journey is different and that’s okay. The balance between comfort and firmness I recognise this may sound like the criteria for finding a new sofa, but let me explain: My parents were with me during mealtimes, which could take up to 3 hours to get through, and they managed to find a way to both comfort me during my rollercoaster of anger and sadness, whilst also not letting me ‘negotiate’ my meal. At the beginning of my recovery I use to bargain, it would often look something like this: “I’ll eat all the blueberries if you let me skip the toast” or “if you remove one filling in my sandwich, I’ll eat all of it”. It was a method of pseudo-recovery and a way for the eating disorder to remain in control. Rather than giving into my (and the eating disorder’s) demands, my parents would recognise why I was feeling upset and angry, but would not budge on my meal plan. Rather than making me see recovery as me vs them (as my eating disorder led me to believe), they showed me that it was in fact me and them vs the eating disorder. Of course, it was difficult for me to fulfil my meal plan requirements, especially at the beginning, but it would have been a lot harder to fully recover if I knew I held bargaining power over what I ate. It’s not a big deal (unless I want it to be) I will never forget the Christmas of 2018, I had been diagnosed at the end of November, and it was my first year without an advent calendar (something I had always loved). Christmas dinner was something that my family and I were anxious about. A setting where the focus is food was, at the time, my worst nightmare. All my mum asked of me, is that I eat the Christmas dinner that she put onto my plate herself, and I did so without much fuss. Nothing was expected of me when it came to dessert. As the various cakes, yule logs, ice cream, and other sweet treats filled up the table, I had a moment where I felt my pre-eating disorder-self had returned. I saw the cheesecake and wanted some. So, I leant over to my mum, who was sitting next to me, and whispered asking if I could have a slice of it. She said “of course” and handed me a slice, returning to her conversation. She acted like it was completely normal (which, realistically, it should have been). By not making a big deal out of my unprompted want for the cheesecake, it did not become an overwhelming moment for me. I ate the cheesecake without anxiety or expectations. Fast forward to four months later, April of 2019, I was doing well with my recovery and was sticking to my meal plan consistently. We were out at a restaurant (something that used to overwhelm me with anxiety), and I willingly ordered a slice of chocolate cake. My family and I celebrated the moment, something that I would not have appreciated during Christmas. But as my recovery progressed, I began to associate pride with how much I was eating, not how little. Having my family celebrate alongside really made me want to continue with recovery. No Social Media Before I was diagnosed by doctors with my eating disorder, my parents had already recognised that something was wrong. I had agreed to delete all social media off my phone for a few months, and I didn’t end up returning to it until the spring of 2019. My Instagram especially, was contributing to my eating disorder. With a quick-paced algorithm that inundated me with weight loss tips, different diets to try, and pictures of models, it was essentially fuelling the already out of control fire. By not having an easy tool to compare myself to others, or to fall back into the dieting mindset, it helped me stay focused and on track with recovery. I know that if I were to have had access to this damaging, my recovery would have been a lot harder. Distractions Constantly Having an eating disorder is essentially having an obsession with food, weight, exercise, and body image. At least, that’s what it was like for me. My mind would never shut off unless I was asleep, and I struggled to think of anything else. At school I’d be comparing my body to everyone else’s in class, I’d be thinking about how little I can eat in order to make the thirty-minute walk home from school without collapsing, or how to discard my food without anyone noticing. When I first started recovery, my mindset was the same, except for the added anxiety because now I had to get better. So, I was grateful whenever I could tune out my thoughts and be distracted by something else entirely. For me that distraction came in the form of watching some of my favourite shows during mealtimes (shoutout to Horrible Histories for getting me through most of my recovery). I had to take the emotion out of eating to ensure that I did in fact eat, so I used to focus on shows or films and mechanically eat the food: bring food to mouth, open mouth, bite, chew, swallow, repeat. It was very robotic, but for a while it was the only way I could do it. When I started to stay in school for lunches, chatting with friends or members of staff who were helping support me during school helped. I’d often just ask that we chat about anything other than food, again it helped ground me in the present instead of overthinking about what I was eating. These are just a few things from the very long list of ways in which I was supported during my recovery. BEAT, the UK’s leading eating disorder charity, also have a section of their website dedicated on how to support someone struggling with an eating disorder. And it has some great advice that I’d recommended looking at. Eating disorders not only impact the life of the person struggling with one, but also effects those that are part of the support system. There is not one tried and tested method to support someone, and what works may change overtime as you recover. My message for those who are supporting someone with an eating disorder is that you are not to blame, and you cannot be expected to get it right 100% of the time, but most importantly, make sure you’ve got a support system in place for you too.

A personal account I’ve been studying Psychology for over five years, first as an undergraduate at the University of Edinburgh, then during a master’s in Behavioural Neuroscience at University College Dublin. But it’s only now — in the first year of my PhD — that I’m finding a sustainable work-life-balance. Throughout my entire academic journey, I’ve been a high-achieving student. I’ve also been able to maintain close relationships, exercise regularly, eat well, and all the rest of it. I seemed to be doing just fine overall — and so it didn’t really occur to me (or the people around me) to question my work habits. Yet, toward the end of my master’s degree a few months ago, it became obvious that my work mode was taking a toll. I was physically unwell, I felt burnt-out and most alarmingly, I felt like I was performing activities outside of work, rather than enjoying them. In my research, I actually investigate how engagement in leisure activities may impact cognitive abilities, such as memory, in multiple sclerosis. So it was high time for me to evaluate my own lifestyle. I’ve spent a good few weeks reflecting on old patterns and practicing new routines. I’m sharing aspects of this process and its outcomes here, in the hopes of normalising conversations around finding balance — especially amongst people who seem to be doing just fine. Past habits For most of my undergraduate and master’s degrees, I’ve attempted to give every task, assignment and project 100% of my energy and effort. I prioritised tasks in terms of the time they required, but not in terms of the attention they deserved. I was so used to giving my best, and subsequently achieving high grades — it didn’t occur to me that I might be doing just as well overall by adopting a ‘good enough’ approach. I certainly wouldn’t have wanted to risk achieving a lower grade by ‘trying less’. It seemed necessary to work on most weekends and to rarely take more than 2–3 consecutive days off. At the same time, I was able to maintain many ‘healthy habits’. I was going on walks and runs, practicing yoga, seeing friends and family, and preparing fresh meals regularly. For a long time, I felt like I was doing well. Then I started to perform well instead. I was still projecting a sense of being on top of things, but it stopped feeling like that. I no longer had the physical and mental resources to keep up with it all and I felt burnt-out. I realised that I had to change things and that some of my work habits had been unsustainable all along. This was the point where I couldn’t and didn’t want to support them anymore. My goals and what I’m doing differently now I now aim for a sustainable work-life balance, which centres my physical and mental health. In my academic work, this looks like prioritising tasks according to relevance, and adopting a ‘good enough’ approach when tasks just need to get done. This allows me to spend more effort on the things that really matter. It also gives me the space to reflect in between tasks, which I didn’t have when I was trying my best all of the time. Whilst I absolutely notice the benefits of this approach, both personally and in terms of productivity, it hasn’t come easy to me. I still strive for excellence in my research, and I try to manage that by setting even more realistic timelines and expectations. I’m grateful to have supportive supervisors. To give an example, I’m currently working on a big project and my progress over the next two weeks will be crucial in determining the timeline of future projects. When discussing this during supervision, we agreed that I would just see how far I can come in 10 days — not 14. For the first time in years, I haven’t worked a single weekend. I should mention here that I have a funded PhD position (I’m an Irish Research Council Government of Ireland Scholar), which certainly plays a role in allowing me to take the weekends off. It can be much harder for PhD researchers juggling a job alongside their research. On weekends, I enjoy going on long walks, catching up with family and friends, spending time in nature, doing yoga, baking, and so many other things. It’s not that I haven’t done these activities before, but when I do them now, I don’t feel guilty about it. I also try to plan fun activities and events in advance and I make an active effort to normalise taking time off in academia (and beyond), by talking and writing about it regularly. This has been a massive help in actually enjoying my time outside of research. What I’m still practicing I’ve come a long way, but I still have a bit to go. As the semester is getting busier, I’ve noticed that my default is still to stress and worry about tasks and to tackle things as soon as they come up. I still sometimes feel a sense of panic when a new email pops up and I’m in the middle of another task. I’m still practising letting things go or waiting until they fit my schedule. I’m also practising being kinder to myself. Sometimes I think I could have done better or worked harder, and then I feel guilty about not having achieved a perfect balance yet. I’m still learning to embrace the process and to share about it honestly. My goal for the next few months is to give myself the time and space to catch up with my new intentions and to make them my default mode. Why talk about it I’ve shared about my former work habits and the negative effects they had on me, my goals and intentions for a more sustainable work-life-balance, new routines, as well as aspects I continue to practice and reflect on. A lot of this is limited by my own experience, and likely won’t be new to you. But I chose to talk about them anyway, in the hope that they can provide a source of comfort for those in the process of finding their own work-life balance in academia, and beyond. I’m particularly thinking of those of us who seem to be doing just fine, whilst not feeling that way. It can be hard to acknowledge a need for change, and sharing about it will hopefully normalise having conversations around accepting and making change.

In December 2022, for the first time in 106 years, the Royal College of Nursing decided to strike after a ballot vote of more than 300,000 members. Shortly after, ambulance workers similarly voted to strike. Now, junior doctors are balloting to strike with the results coming out imminently. This, I believe, is an indicator of a system being stretched to its limit, and as a current medical student in London, sadly does not come as a surprise to me. Over the last 2 years of my training, I have seen the toll that long hours, high levels of stress, and treatment backlogs take on us — healthcare workers — and on the system we are working in. I have seen how a lunch break is now a rarity on long shifts, and that we can barely have a quick toilette break. As one junior doctor says, “You feel like you’re being put in a situation where you’re set up to fail, because you don’t have the resources and help around you to succeed”. I have seen the struggle with resources, from a lack of medical equipment, PPE like masks and gowns, and patient beds, to inadequate technologies and insufficient training. In recent months, the lack of resources has become evident, with many patients being treated in corridors, and vital supplies such as portable oxygen running low. As a future doctor in the NHS, this worries me. We enter the profession wanting to help people, however when the resources don’t allow for this, it is devastating and leads to high levels of burnout. Doctors are experiencing workplace burnout at the highest levels ever recorded. 39% of junior doctors report burnout to a high or very high degree, and 51% of doctors in training describe their work as emotionally exhausting to a high or very high degree. These figures are not exclusive to doctors, and experiences of burnout are seen across NHS healthcare workers — a significant contributing factor, alongside real-terms pay cuts, to the recent nursing and ambulance strikes. The question we then have to ask, is what is causing this burnout? A report by the House of Commons Health and Social Care Committee has found staff shortages are ultimately the biggest contributor to workforce burnout. These shortages often lead to one healthcare worker doing the work of three people, which is not sustainable long-term. With staff shortages also comes increased waiting time, with more than 1/3 of all patients waiting more than the target four hours to be seen in Accident & Emergency. In relation to understaffing the deputy chief executive of NHS Providers, Saffron Cordery, said, “NHS trusts and their overstretched staff are working incredibly hard to cut waiting times against a backdrop of worryingly high numbers of COVID-19 cases in hospitals, but they’re doing this with one hand tied behind their backs.” Workforce shortages ultimately come down to workforce training and retention. But a career in healthcare is becoming less feasible due to the significant lack of resources, difficult working conditions, and real terms pay cuts only exacerbated by the rise in the cost of living. Since 2010, experienced nurses in England have taken a 20% pay cut to their salary, while doctors pay has fallen by up to 30% since 2008. In the last year, 50% of junior doctors have struggled to pay for heating and light in their homes. While healthcare workers do not choose their career path for the pay, if we cannot afford the basic cost of living and payments for students loans, it is no longer a viable career path. Indeed, more than 50% of staff in the NHS feel undervalued and overworked, and I can see the ripple effect of this atmosphere on medical students. My colleagues and I talk nearly every week about what we will do when we graduate, with many talking about leaving the profession or moving abroad. I have also been told countless times by doctors on placement to ‘leave while you can’. According to new analysis of NHS digital figures over the last year, over 400 healthcare workers in England leave the NHS every week due to work-life balance pressures. As healthcare workers, we ultimately do our jobs to help people. It’s incredibly disheartening, however, when we’re not able to do this due to a lack of resources and support. We carry out our job with a duty of care and moral obligation to our patients. This duty guides our decision-making, and therefore the decision to strike is not one that is taken lightly. I hope the strikes are a wake-up call to the government to take action, as I do not believe the NHS can be sustained if things continue as they are.

The cost of living crisis is not only dominating the news but also dominating the minds of the millions who will be affected by it. As a university student starting my second year, I am one of those people. I have spent weeks sitting at my desk, trying to figure out how I am going to afford to live this year. With the price of everything rising, from energy to groceries, students across the country are scrambling in an attempt to figure out how to make ends meet this year, at the grave expense of their mental health. Work-Study-Life Balance: Is it possible? I was fortunate enough to speak to Dr. Thomas Richardson, a clinical psychologist and expert on the relationship between financial difficulties and mental health problems. When I asked him how financial stress affects our mental health, he shared that “higher financial stress is linked to an increased risk of mental health problems such as depression and anxiety, as well as suicidal thoughts.” “Those in financial hardship are more likely to have worsening mental health over time.” — Dr. Thomas Richardson I, like so many students, have a student loan that doesn’t even cover my rent, let alone other essentials. As a result, I end up relying on my family, who are also facing the effects of the cost of living crisis — for which I am grateful and recognise the privilege I have from this, despite it not being easy for my family. The harsh reality is many students aren’t able to lean on their families for financial support, and in some cases actually hold the responsibility of supporting their family financially. This leads to students taking up part-time jobs to continue living at university, working in the time not spent studying, leaving little room for focusing on wellbeing, socialising with friends, or purely enjoying time as a student. I’m not saying students shouldn’t get jobs altogether, I’m simply saying they shouldn’t have to in order to make ends meet. This juggling act of balancing study and work means students risk both their ability to excel in their education, and their mental wellbeing. “What might be especially hard for students is struggling to top up income through work as this might be hard to fit around studies, and research has shown having to work lots of hours on top of studying can take its toll on students in terms of mental health.” — Dr. Thomas Richardson University has an accessibility problem I have lost sleep over the past few weeks, calculating the minimum budget I can spend and continue to live on, how cheap I can make my weekly food shop, and ensuring I have an emergency fund in case I lose my job, or bills skyrocket. I googled ‘can’t afford university’ to see what would pop up, seeking peace of mind more than anything. UCAS held the top results. I clicked on a page titled ‘what you can do if student finance isn’t enough’. It discussed bursaries and scholarships, trying to find the cheapest accommodation, and asking for help from family (which I have already established is not an option for many students). It was the last suggestion that really threw me off guard: “consider an alternative study path”. Of course, university isn’t the right path for everyone. I have friends who didn’t go to university and are the happiest I have ever seen them, and there are many other viable options. University is not the right choice for a lot of people. But, simultaneously, university is the right choice for many others. Is it right for those who choose university to be advised to pursue something else, because they cannot afford to support themselves financially, or enter mounting student debt for a degree? Access to university has become a privilege that few can afford. Some may agree that should be the case, but I believe higher education is a wonderful, enriching experience and something that everyone should have the opportunity to choose. Money vs. Mental Health In my experience, our society has become increasingly obsessed with money-making and hustle culture, placing immense value on our careers. Everything we do must be a potential income revenue. So, unless your degree is a requirement for your career, many will try to dissuade potential students by suggesting it’s a waste of money and time. Learning simply for the pleasure of learning is no longer a good enough reason to pursue higher education, particularly when it is so dear. This placed importance on the future monetary benefit of choosing higher education, alongside the cost of going to university in the first place, which is heightened drastically during the cost of living crisis. Because of the cost of living crisis, I have been trying to find ways to take control of my mental wellbeing, in an attempt to stay mindful. Dr. Richardson shared with me “research suggests that how much you stress and worry about your finances is more important than objectively how much you are financially struggling.” When I asked him what mental health practices and exercises he recommends, this is what he shared with me: “It is important to talk about it: you are not alone in struggling and it is nothing to be ashamed of. […] Try to socialise and plan activities which are free or cheap. It doesn’t cost anything to go for a run in the park but it can really lift your mood.” These upcoming months are going to be difficult for many across the UK, and millions of students will be facing the fiscal and psychological impact of the cost of living crisis. I hope conversations around the financial impact of student living continue, and we start to see new and improved support streams for students, both from the government and student mental health specialists. Resources NHS — Coping with financial worries Student Minds — Resources student finance Money Saving Expert — Guides and tools to help you save money while studying

Hosted by mental health researchers at King’s College London We were on the way out of the final UK lockdown when a group of young female scientists (spoiler alert, us!), already writing and editing for InSPIre the Mind, made a plan to take the blog off the page and into the ears of their audience. Yes, the blog was flourishing, and the format had worked for years, but we are part of the generation hooked on podcasts. We listen to them while having breakfast, when out for a run, doing food shopping, and even before bed. Why not create a podcast about mental health, science, and pop culture? And that’s how At the Back of Your Mind was born. What is At the Back of Your Mind? Welcome, welcome, welcome to At the Back of Your Mind, the new addition to the InSPIre the Mind family! This new podcast gives a voice to early career researchers and people with lived experience in the mental health space in a fun, relaxed, and short format. Join us, your hosts, Maryam, Juliette, Carolina and guests, to chat about all things mental health, from lived experiences to exciting new research and everything in between. You might also be surprised by Maryam’s giggles fuelled by Juliette’s timely jokes, Carolina’s non-stop curiosity, and the frankness and openness of our guests. Dear reader, what are you waiting for? Click here to listen to our trailer, and stay tuned! We’ll be releasing a brand-new episode every two weeks. Meet the team Maryam, Juliette and Carolina are your hosts! Maryam is a researcher on adolescent mental health, Juliette is a PhD student on depression and early life stress, and Carolina is a postdoc on arts and psychiatry. We are joined by our senior editor and overall badass producer, Melisa (also a researcher on treatment-resistant depression), and the behind-the-scenes team of researchers: Celeste, Amina, Subeyda, Nare and Lea (our new communications and impact editor!), who edit, produce, and create social media campaigns. Say hi to our new team member at ITM! Lea is currently finishing her master’s in International Marketing at King’s College London, to make information more accessible and raise awareness on important issues. You’ll hear these mysterious team members in the credits if you listen to the very end of each episode! Wait, not another mental health podcast! You might be thinking, another podcast about mental health? I have about 15 in my library that I can’t find the time to listen to! Well, this might be the podcast that changes all of that. At the Back of Your Mind has turned the typical mental health podcast on its head by asking, “What do we really need in this space?” We found out we need more experts that are truly relatable and who are willing to ask the big questions that listeners (and scientists themselves!) are itching to get the answers for. We can assure you that this podcast will tell new stories: we’ll explore fresh topics, hear novel perspectives, and, most importantly, discuss the science behind mental health. We are the scientists asking the questions and publishing the papers on topics that you, the listener, ask yourself about! You will be guided by academic researchers within the mental health space, who can translate the nitty-gritty science into digestible conversations, so you can learn from our guests and feel more empowered. In fact, consider yourself a guest, grab a cup of tea (or coffee!) and join the conversation. What will you get in the first season? In the first season of At the Back of Your Mind, you will hear from clinicians, researchers and people with lived experience of mental illness on the topics of, for example, women in science, depression, long COVID and mental health, childhood trauma, inflammation, men’s mental health, and Tik Tok, with guests such as Professor Paola Dazzan and Dr Akeem Sule, to name a few. We are having so much fun recording these episodes, and our guests are incredibly knowledgeable and passionate about their work and experiences. Make sure to share your thoughts with us on Instagram. Where to find us At the Back of Your Mind is a fortnightly podcast series, with new episodes every other Thursday. This podcast is for you, listener — listen to us on Spotify or wherever you get your podcasts and DM us on Instagram! We want to hear from you and get to know what you’d like to hear from us. Who would you like us to have a chat with in season 2 of At the Back of Your Mind? What are the burning questions you desperately need an answer to? Grab a cup of tea and join the conversation!

A blog written by Amina, Subeyda and Maryam (Assistant Editors of InSPIre the Mind) — — — Ramadan is a special time for Muslims all around the world and comes only once a year, taking place during the ninth month of the Islamic calendar. Ramadan, one of the five pillars of Islam, is when Muslims across the globe abstain from eating or drinking (yes, including no water!) from dawn to sunset for the entire month, otherwise known as fasting. But there is so much more to Ramadan than just refraining from food and drink. Most importantly, Ramadan is a month of reflection, focusing on our faith, giving to charity, connecting with our community, and exploring how we, as individuals, can improve ourselves, despite the challenges or struggles we may be facing in the months leading up to Ramadan. One of the most beautiful aspects of Ramadan is that everyone’s reflections and learning from this month are unique and personal to them. As Ramadan has come to an end, Subeyda, Maryam and I (Assistant Editors for InSPIre the Mind) would like to provide a personal insight on this blessed, joyful and spiritually uplifting month, explore research on mental health and Ramadan, and lastly, share our own reflections with you. We might make you a little hungry by the end of this blog! What does a typical day of fasting look like? Usually, a typical day of fasting during Ramadan consists of waking up very early in the morning, a time known as Suhoor: the meal before beginning your fast. Muslims would observe the morning prayer after Suhoor; this prayer is called Fajr, which is Arabic for dawn. This is also when fasting begins, and throughout the day, daily activities would consist of the five daily prayers and reading Quran (holy book for Muslims). During the night, Muslims usually attend the mosque for a night-time prayer called Tarawih. The beginning of Ramadan is always the most difficult period as your body is slowly feeling the physical effects of not eating or drinking during the day. However, fasting gradually becomes easier. “The most challenging and rewarding part of Ramadan, in my opinion, is pushing yourself to be a better individual, both physically and mentally” — Subeyda Mental Health and Ramadan The unique feeling of contentment throughout the month of Ramadan makes it incredibly interesting to explore research on mental health during this month. In 2011, the World Health Organization (WHO) introduced spirituality, religiousness, and personal beliefs as components of quality of life. One recent study found a significant reduction in stress levels after Ramadan in those that were fasting. Similarly, severe depression, anxiety, insomnia, and blood pressure were all found to have improved from Ramadan fasting amongst an elderly population in Egypt, Mansoura. Fasting in general has also been linked to increasing mood as research by the Journal of Nutrition Health & Aging whereby after 3 months of intermittent fasting participants had reported improved moods and decreased tension, anger and confusion. Furthermore, fasting may also improve microbiota disturbances and intestinal inflammation through decreased inflammatory foods intake and decreased blood flow dedicated to digestion. These findings show that there is a potential health benefit to fasting, but also that Ramadan does not only have a spiritual significance, but can also result in a positive change in overall health as well! What does Ramadan mean to me? Subeyda: Ramadan is a very special month for me as it allows me to disconnect from the world and solely focus on my spiritual wellbeing. Ramadan is something I have always observed from a young age, as I understood the importance of this month worldwide for Muslims. This month is a time of reflection for me as it encourages me to look internally, self-reflect and become a better person. It also makes me more grateful for the everyday necessities and resources, which we may often take for granted, such as having easy access to clean food and water. I spent my last ten nights of Ramadan in Saudia Arabia, which was such a beautiful experience for me, as Muslims worldwide travel to Saudi Arabia for Umrah, the Islamic pilgrimage to Mecca. I had the opportunity to meet a range of people from different cultures and backgrounds, which was amazing! Coming Together during Ramadan Amina: One of the special moments for me during this Ramadan was being able to share our meals and food prepared with family, friends and especially with my neighbors in my community, as we all break our fast together. Here in the UK during this month, mosques in local communities would hold Iftar gatherings whereby members of the community (anyone is welcome!) could come together and enjoy eating together. Sharing these moments with everyone allowed me to appreciate these small moments that we all share together and reminded me of the importance of being compassionate and kind towards each other. This is one of the beautiful and remarkable essences of Ramadan and it brings so much joy and unity. Culture and celebration during Ramadan Maryam: Ramadan, despite being a difficult (yet wholesome!) month, has always been a unique way to connect with my culture and heritage. My family are from Cairo, Egypt, which is an Islamic country, and as a child, I had the opportunity to experience Ramadan in Egypt, which was wildly different from observing Ramadan here in London. When celebrating Ramadan in the UK, I find myself missing the vibrant and lively atmosphere in Cairo. The streets come alive at night with colourful Ramadan lanterns (known as Fawanees, sg. Fanoos), enchanting fairy lights, and sounds of laughter and people enjoying each other’s company. We would visit family and friends across the country to share Iftar and joy, as well as our plans and hopes for the month. Luckily, I still get my fill of Ramadan in Egypt indirectly whenever I visit my grandma’s house. We would routinely watch Arabic soap operas, specials during Ramadan, and enjoy all of the interludes of Ramadan and Eid songs. For the first time, I was able to share my Ramadan experience this year with my husband, which made waking up super early for Suhoor, consistently fasting and sticking to my five prayers a day a lot easier. Being on this journey together with my husband reminded me of the significance of Ramadan and how we can always strive to be better in ourselves and how we present to the world. Final words Ramadan teaches us that we can simply enjoy the small things in life, as they matter the most, and to always try to be a kinder and more giving person to those less fortunate in the world. Ramadan helps to strengthen our faith and to understand the importance of being compassionate towards one another. Until next time, we are all truly grateful to have experienced this beautiful month and had the opportunity to share our stories with you.

One of the few constants in my life has been the constant need and desire to be perfect, or at least to be perceived as perfect. But what is perfect? I think not only does that change every few years, but ‘perfect’ means something different for everyone. Everyone has different goals and therefore different ideas of what ‘perfect’ means. So, I had my own vision of what perfect was and was desperate to achieve all of it: perfect grades, perfect job, perfect body, perfect clothes — I wanted it all. This blog will explore my personal experience with my mental health and how it’s been influenced by factors such as social media, looking at how this shaped my mentality of what perfect is, and to remind myself and you, the reader, that we will never live up to our own and others’ ‘perfect’ standards — and that is okay. The impact of social media The discussion around social media, and its effects on young people’s mental health is far from new. A quick Google search and countless statistics on social media and mental health appear. For example, the Royal Society for Public Health (RSPH) found that social media use is linked with increased rates of anxiety and depression. Another study found that “the earlier teens start using social media, the greater impact the platforms have on mental health”. I, like most of Generation Z, grew up on social media. Instagram’s logo was still blue when I had it installed, and Snapchat didn’t even have filters, so I grew up alongside the drastic growth of social media and all the features designed to keep us on these platforms for as long as possible, that we see and experience today. Throughout my adolescence I got used to seeing my appearance through a distorted filter, one that would slim my face and make my eyes bigger and brighter, to the point where it was unheard of to post a picture of yourself without a filter. The result of spending almost half of my life on social media has been very interesting, and I’d argue there have been various outcomes, but I want to focus on one in particular: my constant strive for perfection, and the comfort that I find within it. One of the biggest impacts of social media I have found is the idea that I will never be good enough. I am constantly being told that if I have just ‘one more thing’ I will be perfect, I will become the girl everyone wants to be. I would restrict myself from exploring who I am, and what I like, and would just settle for what was being fed to me every day through incessant algorithms and billboards. The goalpost of perfection is constantly moving and ultimately unattainable. I am self-aware, as I just mentioned, I know that in the eyes of big corporations trying to market products to me, the majority of social media users, and even in my own eyes, I will never be perfect — which is exactly what they want me to feel, to continue purchasing unnecessary products and services to achieve this unreachable ‘perfection’. I also know that perfection isn’t a trait in humans, nobody is perfect, and therefore I have in fact lost the battle of becoming ‘perfect’ before it’s even begun — and that’s okay. At least that’s what I keep telling myself. See, whilst I acknowledge and recognise that perfection is something that will never be achieved, as well as the negative effect that trying to appear perfect on social media has on my mental health, I can’t help but consistently strive for it. Whilst self-improvement isn’t necessarily a negative thing, I, like so many other young people, flip it on its head until it becomes something toxic and all-consuming. The ‘that girl’ phenomenon and toxic positivity For young women and girls, like myself, I think this idea of becoming ‘perfect’ is especially damaging. Social media influencers and companies try and rebrand what is fundamentally a toxic form of positivity. The idea of ‘becoming your best self’ or being ‘that girl’. The label ‘that girl’ gained traction on TikTok initially, but quickly took over internet culture as a whole. Playlists were created centred around being ‘that girl’, and brands would often use the label to try and sell their products, claiming it was what every ‘that girl’ owned. These girls — who, might I add, do not exist in real life and are merely an illusion online — are typically thin, white, financially stable, have trendy clothes, the latest technology and so on. So already, women and girls who do not fit into these categories are at a disadvantage when trying to present themselves as ‘perfect’ online. Not to mention that the majority of users’ social media feeds aren’t a true representation of a person’s daily life, only showing the ‘best bits’, the highlights. ‘That girl’ has a smoothie for breakfast, protein bowl for lunch, and a salad for dinner — only with the most organic produce! She wakes up at 7am and goes straight to the gym, she journals and is always positive. None of these things are inherently bad but selling the unrealistic idea that this is how young people should feel and act constantly ropes us back to this idea of toxic positivity. Young people consuming this content can become wired to feel like if they aren’t doing these things then what they are doing just isn’t enough or is somehow fundamentally bad. Most of us don’t have the time or money to buy the freshest, healthiest food, or a gym membership. The biggest lie of it all is that we do it for ourselves — I feel we don’t. Or at least I don’t. I follow this ‘lifestyle’ to post pictures of my salad on social media, to show TikToks of my ‘daily routine’ — which doesn’t match up with reality. Social media is just a constant competition of who is better, who is most successful and most happy. And I’m not sure if anyone wins. Breaking out of the cycle I have repeatedly been caught in this cycle of trying to become ‘perfect’ and be ‘that girl’. I view it as a glamorous, repackaged crash diet. I normally last about a week before I resort to my old habits, that weren’t even that bad in the first place. It’s just that I simply don’t want fruit for breakfast or salmon and broccoli for dinner every day. I’d rather just eat what brings me joy, which sometimes is salmon and broccoli, but other days it’s a nacho night with my flat mates, or a takeaway after a night out. But the validation from strangers online, friends, and even the validation and praise I give myself those first few days I try and ‘eat clean’ or workout every day, the feeling of becoming the girl that you read about in magazines, that people aspire to be, well, it’s a damn good feeling. And I’m not the only one. Dr Alexandra Hamlet, a clinical psychologist at the Child Mind Institute said, “many girls are bombarded with their friends posting the most perfect pictures of themselves, or they’re following celebrities and influencers who do a lot of Photoshopping and have makeup and hair teams”. Furthermore, Dove found that 61% of 10 to 17-year-old girls have low self-esteem. In order to break out of this damaging cycle, I believe we need to start educating people, especially young people, on this idea of toxic positivity, and create healthy conversations around social media content, and how the same old lies, diets, and in extreme cases, disordered eating habits (juice cleanses, heavy restricting and workout obsession, for example), are constantly evolving and being repackaged as the ideal lifestyle. That those who seem perfect on social media are shaping the narrative around themselves, the exact same way we do, and make sure that their feed reflects their highlight reel, rather than their everyday reality. It’s completely healthy and natural to not be positive all the time. Social media isn’t going away, so it’s critical that we educate young people early on about the possible effects of social media sooner rather than later. Resources: Young Minds Samaritans The Mix What’s Up with Everyone? Dove: Building self-esteem in the social media age Dove: #NoLikesNeeded

I am a final year PhD student in Professor Stephen ‘Mac’ McMahon’s laboratory at the Wolfson Centre for Age-Related Diseases, King’s College London. Sadly, Mac recently passed away, and I feel incredibly privileged to have been able to work with him for the past six years. I am pleased to have the opportunity to talk about one of our collaborative research projects. Broadly, the focus of my PhD research has been on pain mechanisms in humans, and I use psychophysical testing, which is studying the relationship between physical sensation and our own judgement of sensory experiences. I specifically use quantitative sensory testing (QST), to measure my participants’ perception to different types of painful and non-painful sensations. One of the QST techniques I use is a highly standardised protocol that was developed by the German Research Network on Neuropathic Pain (DFNS). During testing, the participant is presented with different types of precisely calibrated mechanical and thermal sensations, such as vibration stimulation and gentle heating. In this way, I can generate a sensory sensitivity profile of that person and compare that with data from other participants. In this blog, I will be discussing our recently published study on pain sensitivity as a biological marker for self-harm in young people, where we used DFNS QST to estimate the sensory sensitivity of young people with and without self-harm. Suicide remains a major public health concern and is the second leading cause of death in young people. According to the World Health Organisation, approximately 800,000 people die by suicide every year, and it is among the top twenty leading causes of death worldwide. Identification of ‘risk and protective factors’ has been highlighted as critical to the prevention of suicide, but as yet, and despite decades of research, none have been identified that could be applied clinically with confidence. Self-harm necessitating hospital treatment is considered the strongest known predictor of suicide. Interpersonal-psychological theories of suicidal behaviour propose that people who engage in suicidal behaviour must develop an acquired capability to do so “through a process of repeatedly experiencing painful and otherwise provocative events”. Within this framework, repeated self-harm is one mechanism by which individuals may habituate themselves to the experience of pain and strengthen opponent processes, whereby initial fear and pain is replaced by relief and analgesia. This may lead to at-risk individuals overcoming the instinct for self-preservation and attempting lethal self-injury. There is some evidence that reduced sensitivity to painful sensations is a feature of people with self-harm, and much of the evidence for this comes from studies in adults with borderline personality disorder (BPD). While it is unclear whether reduced pain sensitivity arises as a consequence of repeated self-harm, is an effect of psychiatric comorbidity, or whether pain sensitivity changes are present prior to the onset of self-harm, we questioned whether pain sensitivity could be used to identify individuals at-risk of repeated self-harm and suicide. To investigate this, we studied a particularly high-risk group for self-harm and suicide: young people living in local authority-run group homes and foster care. These young people had been removed from the family home due to experience of abuse and neglect, and although looked-after young people only make up less than 1% of the UK’s under-18s, they account for about half of all completed suicides. Using DFNS QST, we showed that young people living in care with and without self-harm have significantly reduced sensitivity to a wide range of painful sensations compared to age and gender matched young people living at home and, surprisingly, this reduced sensitivity was also evident in response to a range of non-painful sensations. In almost all instances, we saw that reduced sensitivity increased with the incidence and frequency of self-harm within the previous year. The young people in our sample living in care with no self-harm also had reduced sensitivity compared to young people living at home; this suggests that these sensory changes may be present prior to the onset of self-harm and are a consequence of adverse childhood experiences. The extent of these sensory differences across our sample was surprising, and to our knowledge this is the first study to report this in response to such a broad range of sensations. So how do we account for these differences in sensory sensitivity? What is pain? Pain is a highly adaptive and salient sensory experience, but we also have an innate ability to modulate our experience of pain. This capacity for pain modulation enables us to ignore injury and escape danger, and also explains why sometimes pain can feel good, like the ‘runners high’ or eating very spicy food. But taking these examples, motivation and the context within which pain is experienced is very important! Anxious feelings, grief or being in a bad mood can make pain feel much worse. Tissue damage, or threats to our body, activates specialised sensory nerve fibres called nociceptors. Nociceptor activity is sent into the spinal cord for initial processing in the dorsal horn region. The output from the spinal dorsal horn is transmitted to the brain, where pain-related activity is processed in multiple brain regions, including the thalamus, the somatosensory cortex and the amygdala. The processing in these areas together results in what we feel as pain. It is a multidimensional experience with sensory, cognitive and emotional components. This can be described as ‘bottom-up’ processing. However, processing in the brain can result in descending neural activity which feeds back to the dorsal horn of the spinal cord, where incoming nociceptive information can be modulated in a positive or negative direction. This is called ‘top-down’ processing. Many circumstances, for instance, physical activity or positive mood, can activate these descending controls to reduce sensory inputs, and this is called descending inhibition. Conversely, chronic pain or negative affect can amplify sensory inputs and augment the experience of pain, and this is called descending facilitation. We are still trying to understand how descending perceptual signals influence spinal neuronal activity, but it is clear that our past experiences, expectations, attention and emotions profoundly influence how we perceive current pain. In this video, Mac and I demonstrated a psychophysical experiment called conditioned pain modulation for the BBC, which is designed to measure descending pain inhibition (from 38–43 mins). There are many reasons why people self-harm, and two cited examples are to regulate emotions and reduce dissociative symptoms. In this context, physical pain is used to modulate affective arousal, and the findings from our study suggests one of the outcomes of this is an enhancement of descending pain inhibition. This provides a potential mechanistic basis for the sensory hyposensitivity we observed and supports the interpersonal-psychological theories of suicidal behaviour, i.e., habituation to pain and strengthening of opponent processes. Therefore, at-risk individuals habituated to pain may be more likely to frequently self-harm and attempt suicide. We concluded from our results that pain sensitivity is a biomarker for incidence and frequency of self-harm in young people, and that a simple, clinical measure of pain sensitivity (pressure pain threshold) could be used for assessment of risk of self-harm in young people. Leading on from this study, future research should examine whether pressure pain sensitivity predicts the onset of self-harm and suicide attempts. This was an exceptionally interesting project to work on, and my deepest thanks go to Mac, Professor Dennis Ougrin, Mr Oliver English, and Professor Helen Minnis for making this study possible. Rangitoto Island, Auckland, New Zealand. Photo taken by a family member

Do we eat to live or live to eat? For most of us, the answer may be both. We eat food every day to get sufficient energy that maintains our daily life. We have developed various eating habits, different food preferences and preferred food patterns since childhood, and they are constantly changing. People in different countries, even in different towns, have diverse and iconic recipes, such as fish and chips in the UK, pizzas in Italy, sushi in Japan and tacos in Mexico. People across the world also have some shared diet patterns, for example, Western people prefer coffee and Eastern people consider tea as part of their lifestyle. There is an old saying in Chinese: “Mín yǐ shí wéi tiān”, which literally means “people regard food as heaven”. Eating healthily and deliciously is the goal we have pursued for thousands of years, not only having developed diverse food patterns in different areas but also seeing eating together as a social activity to solidify family relationships as well as friendships. People in Northern China even greet each other by saying “Have you eaten yet?” instead of “How are you?”. Apart from the imprint of Chinese culture on me, fuelling my interest in the role that food plays in health, my previous research experiences in public health remind me that nutrition can be one of the most cost-effective interventions to promote health of vulnerable people at a population level. Thus, I chose to pursue my PhD degree (I’m currently in my 3rd year) in nutrition and psychiatry at the Institute of Psychiatry, Psychology and Neuroscience, to investigate the effects of dietary patterns and dietary polyphenols on adolescent mental health. Other ITM authors have discussed important topics in the area of nutritional psychiatry, including the protective effect of omega-3 fatty acids on attention deficit hyperactivity disorder (ADHD), the association between dietary intake and neuroinflammatory biomarkers, and diet even being as a treatment for melancholy in the 18th century. However, in this blog, I will be discussing the beneficial impact of polyphenols on mental health, which are the most abundant bioactive molecules in the diet, especially found in berries, vegetables, coffee, and tea. Mental health: an increasingly serious issue Mental health is a growing public health issue, not just in the UK, but around the world. It is estimated that 1 in 6 people in UK experienced a common mental health problem in the past week, and mental health problems are one of the main causes of the overall disease burden worldwide. What’s more, this issue became worse as we faced the COVID pandemic and had to experience social isolation during last year. For instance, a UK study showed that women, young people aged 18–29, those from more socially disadvantaged backgrounds and those with pre-existing mental health problems have worse mental health outcomes during the pandemic. It has been extremely difficult to overcome the fear of infection, the loneliness during the lockdown, the psychological stress, and the economic pressure. As for me, I had to celebrate my birthday with my friends virtually during the 2nd lockdown in the UK, which was fine but not as exciting as usual. To deal with the stress during the lockdown, I tried cooking, baking and growing plants with my flatmates, to make life fulfilling and maintain our mental health. As I have been a big fan of fruit since childhood, I also became more careful about eating a balanced diet during pandemic. Interestingly, existing evidence has shown that dietary intake can indeed impact our mental health, which means we can also boost our mental health through what we eat! Better diet, better mental health A large body of evidence supports the association between poor diet quality and greater risk of developing mental health problems. For instance, a well-known healthy diet is the Mediterranean diet, which is categorised by a high intake of olive oil, fish and whole grains, as well as fruits and vegetables. Adherence to the Mediterranean diet has been related to decreased risk of depression and better cognitive function in adults. A systematic review has confirmed a positive association between higher unhealthy diet, characterised by a higher intake of foods with increased saturated fat, refined carbohydrates, and processed food products, and poorer mental health outcomes in children and adolescents. Furthermore, some research suggests that Mediterranean diet exerts anti-inflammatory and immunomodulating activities by decreasing some proinflammatory cytokines, thus reducing the risk of disorders related to oxidative stress, chronic inflammation, and the immune system, including mental disorders. This evidence all suggests that maintaining a healthy diet pattern is helpful to maintaining better mental health both for adults and children. Polyphenols’ contribution to mental health The anti-inflammatory effect of healthy diets, like the Mediterranean diet, has been proposed to be related to the presence of high levels of polyphenols, the most abundant bioactive molecules in the diet (intakes ∼1 g/day). The main polyphenol dietary sources are fruit and beverages, like fruit juice, wine, tea, coffee and beer, and, to a lesser extent, vegetables, dry legumes, and cereals. Researchers found that higher levels of polyphenols in the diet are associated with a positive effect on mood and cognition. For example, individuals who frequently consume curry or drink green tea, which are rich in polyphenols (i.e., curcumin and catechin), are less likely to experience cognitive impairment, in comparison with those who rarely consume curry or drink green tea. Similarly, a positive association has been reported between higher dietary polyphenols and better language and verbal memory as well as less depressive symptoms. In our recent preliminary results from 316 healthy people (aged between 8 and 80), we found that higher dietary intakes of some flavonoids (flavanols, flavanones, and flavonols) and hydroxybenzoic acids were significantly associated with better mood. Although it is not published yet, it inspired us to explore more of the mechanism between polyphenol intake and mood, as well as wider mental health outcomes. Currently, we are exploring the association between mood and polyphenol metabolites in urine and plasma, and our next step is to replicate these results in the association between polyphenols and depression, anxiety and externalising behaviours in adolescents. Polyphenols: potentially mental resilience Apart from the protective effect of high dietary polyphenols intake on mental health, recent studies indicate it can also enhance mental resilience, which will help us stay healthy in the face of adversity. For instance, increased dietary polyphenol intake and greater diversity in fruit and vegetable consumption are linked with enhanced psychological resilience. A study conducted in Australian university students found higher fruit and vegetable consumption per day, more consistently having breakfast, and less frequent intake of soft drinks and takeaway foods, were all significantly associated with both lower psychological distress and higher resilience. These findings give us insight into the positive associations between adherence to a high polyphenol diet and psychological resilience, and suggest that by adopting a similar diet and keeping good eating habits, we can better handle psychological distress and even improve resilience. Now, what can we do? Despite us developing a better understanding of the health role that dietary polyphenols play, more studies are needed to confirm the biological mechanisms and public health implications. As consumers, we are now aware of the potential protective effects of polyphenols on mental health, so we can better align ourselves with a healthier diet pattern and select polyphenol-rich food intentionally in daily life. However, we should be careful when choosing polyphenol supplement before the publication of Dietary Reference Intakes (DRIs) for common and potentially harmful polyphenols.

I am a London-based medical student, currently taking a master’s degree in Neuroscience at the Institute of Psychiatry, Psychology and Neuroscience (IoPPN), home to the Stress, Psychiatry and Immunology (SPI) lab. While it may seem rather unusual for a medical student to stick his nose into the complexities of the biology of depression, one title among our list of Year 3 research projects particularly caught my attention: “The role of Aquaporin-4 (AQP4) in the pathogenesis of depression”. How important could the role of this basic protein be in such a complex disorder like depression? In this blog, we are going to have a look at some of the findings from our research on this topic. I will start by explaining the importance of AQP4 in the pathology of depression, then summarise findings from animal and human studies, briefly explore the role of autoimmunity and conclude by reporting the relevance of our work to patients with depression. Aquaporins, otherwise known as water pores or channels, are very tiny gates embedded into the outer membrane of a cell. Their function is to control the amount of water either going outside, or coming inside the cell, like a border police officer. There are many different types of aquaporins in the body, actually about a dozen, which all serve a specific function. For instance, it is known that the first-ever discovered aquaporin, AQP1, is essential to make urine more or less concentrated in the kidney. The same principle occurs in the brain, where the most common aquaporin is AQP4. In an immensely complex organ such as the brain, made of around 75% water, it seems highly possible that a disruption in the organisation of water could disrupt the brain’s function as well. Given that brain function is known to be impaired in depression, we had to know whether AQP4, the brain’s “Minister of Water”, really had a role in the development of this serious psychiatric condition. To do this, we conducted a review of the literature. This means that we looked at all existing research articles on this topic to try to make conclusions. The link between stress, inflammation, depression and AQP4 It has been known for a while now that both stress and inflammation are important parameters in depression. One possible way for stress and inflammation to cause this condition is through decreasing neurogenesis, the formation of new neurons (brain cells), in critical areas of the brain. The decrease of neurogenesis is very strongly implicated in depression. Interestingly, more evidence has recently shown that AQP4 has a role in the regulation of stress, inflammation and importantly, neurogenesis! This is why we wanted to take a step back to summarise the link between AQP4 and depression. Animal studies First of all, we looked at studies performed on mice exposed to stress or inflammation, which reported the change in AQP4 levels before and after the exposure. There are several established protocols and conditioning experiments which can be used to induce stress or inflammation in mice. What about the results? Exposing animals to stress and inflammation usually decreased the levels of AQP4 in their brains. This decrease happened in the cortex, but also in the hippocampus, the region of the brain where neurogenesis is known to take place… Moreover, injecting anti-depressant medication to animals restored their AQP4 levels. But what role exactly does AQP4 play in the brain? The best way to understand the importance of something is to take it away. If you want to know the role of salt, try cooking without any. In the same way, to understand the role of AQP4, the best way is to produce an animal which does not have any AQP4 in its brain. This is what we call a “knock-out”, carried out using genetic techniques. From these studies, we understood that AQP4 acts sort of like a shield, protecting against the depression-causing effects of inflammation on brain cells. While AQP4 did not protect against the effects of psychological stress, it was necessary for the action of anti-depressants. Human studies The next step was to look at the role of AQP4 in more “real life” situations, from studies using human tissue. There were three types of studies in this case: some studies using brain tissue from deceased patients, some using brain tissue collected from neurosurgery, and some studies using patients’ blood. In all of these studies, the main idea was to compare AQP4 levels in individuals with or without depression. In tissue from deceased patients and from surgery, AQP4 levels were significantly lower in depression patients. Guess where? Again, especially in the hippocampus. However, in blood tissue, no difference in AQP4 levels was observed between patients with depression and individuals without depression. This finding needs to be taken with caution, given that AQP4 is also generally less expressed in places other than the brain. Autoimmunity Autoimmunity refers to the targeting and destruction of good cells by our immune system, which mistakenly believes them to be bad cells. This is the basis for many serious diseases, such as type 1 diabetes. Another autoimmune disease, called neuromyelitis optica or Devic’s disease, is caused by a wrong targeting of AQP4 in the eye nerves, thereby affecting vision. We wanted to know whether a similar event happens in depression, in which the wrong targeting of AQP4 could be causing depression. Only two studies have investigated autoimmunity towards AQP4 in the context of depression. None of the patients had AQP4 auto-antibodies. It is very difficult to draw meaningful conclusions from such a little number of studies, especially given that the first one only included a single patient, who developed symptoms of neuromyelitis optica later. More work is needed to determine if AQP4 autoimmunity really has a role in depression. Ok but why is this so important? In our review, now published in Brain, Behavior, and Immunity, we open the door for a new area of research, which could help us further understand the link between AQP4 and depression. In summary: In animals we found that biological and psychological stress, as well as inflammation, decrease brain AQP4 expression, and that AQP4 prevents the effects of stress and inflammation on depression-causing mechanisms. In humans, AQP4 is decreased in the brain tissue, but not the blood tissue, of patients with depression. Autoimmunity towards AQP4 does not seem to be really implicated at this stage. This means that AQP4 could be used as a therapeutic agent in order to protect the brain from depression! While it is known to be difficult to modify genes in humans to make them produce more of a molecule (gene therapy), it is an interesting avenue to explore, which could yield highly positive results for patients. Wishing everyone high levels of AQP4 water channels!