My experiences in the mental health service, and my experiences as an artist, have led me to develop new ways to engage people in artistic activities. In 2011 I graduated in Fine Art, having used the mental health services for several years. I found there was a place for it in areas outside of the white cube-type galleries and found myself in a position to utilise both experiences to contribute to the wellbeing of others. Having used the social inclusion ‘hope and recovery’ project, after being diagnosed with schizophrenia in my late teens, I became involved in the art gallery in the building. The hope and recovery project was led by the ethos that social inclusion was a major factor in recovery and to progress in de-stigmatising diagnosis by offering ways for people to engage in social activities and their community. After the project closed, the gallery continued to occupy the space, and as curator, my role involved utilising the space to benefit people who used the SLAM (South London and Maudsley NHS Trust) service. The ethos that was developed, highlighted that the gallery was art focused, rather than on illness or diagnosis. People involved in the gallery are all artists, and therefore the space is open to anyone in the local community and beyond, whether they used mental health services or not — inclusion is still at the heart of the space. During my work I have discovered the role of a springboard for consideration, conversation, and curiosity. People grow when they are connecting in meaningful ways and art is a great catalyst for this exchange. A turning point for establishing a connection between looking after my mental health and letting it feed into my work, was when I followed my passion for the stories I found in songs, and started a lyrics discussion group. It was set out like a book group. We would listen to the song and read the lyrics. Thoughts, ideas and musings would bounce around the table. One week the song suggestion from the group was ‘Many Men’ by 50cent. The discussion went in many directions, from social divisions to 50cent himself, his business endeavours and the nature of fame and stardom. Following Covid and the attack on the arts, with the degradation of the value creative skills have to offer, I designed a course revolving around the transferrable skills that art gives to people. The course, titled ‘Art Can’, explored problem solving, critical thinking, communication and team work, writing and attention to detail. The most dynamic class was on communication and teamwork. Rather than instructing and delivering tips on skills, I set up discussion points, which generated feedback. Participants felt their understanding and appreciation of art had been broadened and the class had been positive for their wellbeing. The discussion points were arranged as a ‘peer mentoring’ session between participants. This set up highlighted the value of each person’s contribution. The class on writing, prompted participants to write a letter to anyone or anything about art. I asked them to consider the voice they were using as well as the addressee. The process used to develop the material for the letter, explored what art meant to participants and what or why they wanted to communicate it. There are many benefits to the various courses and projects I run in the space. The main endeavour, however, is to display the artists’ work. In the act of showcasing their art, they are being brave, and their creativity takes on a significance to them outside the creation of it. It generates a channel of communication, not necessarily verbal, which is a step out of isolation. At present, the gallery is working on a well-being map of South London, where people contribute the name of a location which has a positive impact on their mental health. It could be something like a particular tree, your favourite coffee shop or a section of your local library. This project is helping me develop an understanding in regards to how people use places, to contribute to their well-being, and is making me consider how the gallery can develop in the future as one of those key places. Having experienced and seen the potential of art to improve the mental health of individuals, I feel that finding new ways to engage different people will expand the scope of art activities beyond those who think getting involved in art is simply about being able to draw a picture.

What are the costs? We are a group of researchers from different parts of the world. We focus on mental health in the perinatal period, which goes from becoming pregnant up to one year after giving birth. With our research, we aim to explore the impact (what are the costs) of perinatal mental health problems for women, their children, and society. In this blog, we will discuss the example of South Africa. We estimate that the lifetime costs of perinatal mental health problems in South Africa amount to USD 2.8 to 2.9 billion. This includes costs linked to both, losses in quality-of-life (USD 1.8 billion), which capture years lost through premature death and years lived with disability, and losses in productivity (USD 1.1 billion), which capture a value for the loss of work, as well as additional need for hospital treatment during infancy. Costs to the public sector are relatively small (USD 3.5 million) — in part because of a gap in the evidence of healthcare use by women with perinatal mental health problems and their children, but mainly because of under-investment. Findings highlight the importance of investing in this area to support the health and wellbeing of this, and future generations. Why focus on perinatal mental health? Mental health problems have a greater incidence in the perinatal period, often with a range of negative consequences for women and their children. Prevalence is higher in low- and middle- income countries (LMICs) compared to high-income countries, and consequences may also be more severe. In South Africa, the estimated prevalence of perinatal depression, stress and anxiety is one in three women, although in some communities it is up to one in two. High rates are linked to the burden of socio-economic adversities faced by women. The COVID-19 pandemic has further worsened the situation. Despite recognition as a major public health concern by international bodies such as the World Health Organization (WHO), action in most countries falls short. In South Africa, important progress has been made with regards to maternity care policies, national guidelines, and the introduction of routine screening. Several studies have demonstrated the potential effectiveness of various treatments. Such studies also show that treatments can be delivered in resource-poor settings: task-sharing and shifting approaches, in which professionals or volunteers are trained to provide the interventions, are feasible and can be implemented (cost)-effectively. However, under-investment and under-resourcing have so far prevented progress and scale-up. What impacts were included in the costing calculations? Undiagnosed and untreated perinatal mental health problems, such as depression, anxiety and post-traumatic stress disorder, all lead to substantial losses in quality of life. Women with mental health problems are also at a significantly increased risk of dying by suicide. The health, economic and social challenges that women face during the perinatal period are worsened by mental health problems. Women struggle to continue earning an income, and their children are at increased risk of a range of negative health and social impacts. Thus, we included both quality of life and income losses in the costing calculations, using approaches used by the WHO. The direct and indirect impacts of perinatal mental health problems on children are also more severe in settings exposed to poverty and crises. Considerable evidence demonstrates the relationship between perinatal mental health problems and poor pregnancy outcomes, infant growth and development problems, poor child physical and mental health, and reduced children’s educational attainments. For example, maternal depression is the leading risk factor for impaired growth and development of children in LMICs, leading to costs of USD 14.5 billions across 137 countries. Thus, children’s quality of life and income losses were included in our costing models. Furthermore, we included costs to the public sector for the additional risk of children’s hospital admissions during the first year after birth. These occur as women with mental health conditions face greater challenges with childcare and may have less access to necessary support. This costing was necessarily conservative, as there are many additional impacts that could not be included due to a lack of quantifiable data. For example, women with perinatal mental health problems who live with HIV are less able to attend to their physical health and adherence to treatment may be impaired. In addition, perinatal mental health problems also affect siblings, partners, wider family members and communities, but we were unable to measure those impacts. Despite the conservative approach taken, the study shows: It’s too costly to do nothing. What should happen next in South Africa? In line with international and national policies and guidance, several actions should be taken to reduce the enormous impact of perinatal mental health problems, bearing in mind the under-resourcing and other systemic implementation challenges. This includes the development of intersectoral, collaborative, community-based strategies to address the social determinants of mental health (such as gender-based or childbirth-related violence, poverty, and social isolation), reduce stigma and increase demand for, and uptake of care. In many LMICs, such as South Africa, antenatal care visiting rates are as high as 80% to 90% thus making this a window of opportunity to offer mental health care and support. Competency-based training which enables providers to demonstrate the required skills, supervision and support for maternity staff and other frontline providers needs to be rolled out so that they can provide mental healthcare at each point of contact for people in need, in a whole-of-society approach. What is the role of economic research in achieving change? Context matters. Prevalence rates, as well as unit costs, often vary substantially between (and within) countries. However, data and methods can importantly be “transferable” from and to other countries. The study we conducted in South Africa builds on our own research in the United Kingdom, as part of a campaign by the Maternal Mental Health Alliance which advocated for increased access to specialist perinatal mental health services. The UK study estimated the cost of perinatal mental health problems were as high as £6.6 billion for anxiety and depression and £8.1 billion if other conditions were included. The work led to substantial government investment in specialist care, thus highlighting the role of economic evidence in supporting action. Our cost methodology has been replicated in other countries, such as France. Since cost estimates are strongly linked to local context, adapting the methodology to include country-specific evidence is highly recommended. For example, our recently published research on the lifetime costs of perinatal depression and anxiety in Brazil applied the methodology used for South Africa. A logical next step is to generate economic evidence on where to best invest state funds. For this, cost-effectiveness evidence is needed. We recently conducted research showing the economic benefits of increasing access to treatment for women with common mental health problems in the UK, and similar work is underway for Malawi. The South African Department of Health recently commissioned an Investment Case to estimate the costs, benefits and expected return on investment over a 15-year period from scaling up various mental health interventions, including perinatal depression. The work suggested an economic pay-off for the treatment of perinatal depression of USD 4.7 per 1 spent. However, the estimate assumed a significant investment for training, which was not included in the costs. At the same time, the analysis did not yet include longer-term returns. Further work on understanding the return on investment for a wider range of perinatal conditions, their costs and impacts, including the perspectives of mothers and children, is therefore warranted. This multi-disciplinary team plans to continue developing economic evidence in ways that can be used by decision-makers and influencers who want to invest in transforming maternal mental health care. Note from the Author: This article has been developed as part of the Global Economics in Maternal Mental Health (GEMMH) project, a 4-year study (2019 to 2022) funded by the Open Society Foundation. Researchers from the Care Policy and Evaluation Centre at the London School of Economics and Political Science (Annette Bauer, Martin Knapp), University of Cape Town (UCT)/ Perinatal Mental Health Project (Simone Honikman, Sally Field, Emily Garman), South African Medical Research Council (Donela Besada), as well as leaders (Alain Gregoire) from the Global Alliance for Maternal Mental Health have come together to produce economic evidence that can inform investment in maternal mental healthcare in South Africa.

My name is Cole Sommeling, and I am a placement student working at King’s College and currently getting my BSc in psychology. I’ve been inspired to write this blog piece to give light to a topic that I feel is rarely discussed, but yet, so often experienced. I’m writing this piece not only to bring light to what Relationship-OCD (or ROCD) is, but to support those who experience it, maybe even unknowingly. Recognizing and communicating experiences similar to others can be a powerful comfort for those who need it. I understand the feeling of seeing yourself as uniquely “troubled” and in searching for answers, finding pages worth of symptoms and experiences that are just like the ones you have, and no longer feeling alone. And finally, for those amazingly strong people in my life, who I know have experienced this firsthand, this is a page of thanks and praise for holding on and persevering though. You got this. More Than Meets the Camera Eye So often do we hear, in the media, about someone who flips the light switch off a certain number of times, or another who needs to align everything on their desk at a perfect 90° angle. And so often does this get attributed to OCD; it’s as if there is a dense fog obscuring the true facets that make up OCD. The only distinguishable features in sight are those that are overblown on television. It has even become part of our everyday ‘throw-around’ language — you could be in a restaurant with a group of friends, and perhaps one of them aligns their fork a little too deliberately beside their plate, causing another friend to remark, “Do you have OCD or something?” And I’m no angel, I’m sure I’ve done this too. But it just goes to show how this consistent portrayal of a select few symptoms has so strongly affected the general view of this disorder. As anyone with OCD, or their loved ones would know, these symptoms are the mere tip of the iceberg. It’s more than just doing everything in threes and making sure every inch of your house is neat and tidy. It can be persistent doubting, always checking for reassurance from others, having thoughts that you would never want to think… constantly. In reality, OCD is thought to be characterized by the presence of compulsions and obsessions. Obsessions being anything from thoughts and images to urges and impulses that aren’t wanted, and compulsions being repetitive behaviours that an individual feels forced to perform. Though OCD was thought to be quite rare in the past, current research suggests otherwise. There are even subtypes of OCD that fixate on different themes, from focusing on harming oneself or others (Harm OCD), to endlessly worrying about one’s own sexual orientation (SO-OCD). Another one of these themes being relationships, abbreviated as ROCD. ROCD: What is it? As the name suggests, ROCD obsesses over one’s own relationships, giving its target intrusive thoughts and doubts about their relationship typically with their significant other. Intrusive thoughts and doubts are normal in regular OCD, the only difference being that these thoughts are specifically centered around the relationship. These doubts can come in the form of questions such as: “Is this person the one I’m meant to be with?” “Do I really love this person?” “Do I care about this person?” “Do I do enough for this person?” Unfortunately, there isn’t a ton of research surrounding these subtypes, so it’s very rare you’ll hear about ROCD at all. We do know, just like regular OCD, ROCD is ego-dystonic, meaning that the thoughts and feelings you are experiencing are against what you truly value and believe — hence the name “instrusive” thoughts. This is why its impact can be so catastrophic. But still, I know it’s imperative that it be researched more for those who always feel as if they are inexplicably drifting from their partner despite having a great connection, and for those who are in relationships with someone they absolutely adore but their brain forces them to question that very fact. Not to mention, the majority of the symptoms of ROCD are internal, so unless you know about ROCD yourself through your own investigation and connect the dots, chances are you’ll never even know you have it. ROCD usually accompanies regular OCD, but even for those who know they have OCD, they still may have no idea that these subtypes exist and may feel that these symptoms are completely separate from their OCD. Having lived with someone with ROCD, I know far too well that the impact it can have on its target is crippling, since the intrusive thoughts focus on their partner who they care about deeply. ROCD not only stresses the relationship itself, but it also takes a good day out, a romantic dinner, a fun night out on the town, and shrouds it in a fog of panic and doubt with the only visible way out being a subsequent spiral of guilt. That is what typically follows these intrusive thoughts: days or weeks of guilt that make you regret thoughts you didn’t even want to think in the first place. It’s not what you think It may seem obvious to those who don’t experience this, but for those that do, it must be made clear that it is absolutely not your fault and the guilt should fall on no one, especially not yourself. It is not your fault that you are being forced to think terrible thoughts you wouldn’t ever dare to think on your own. It is not your fault that because of these terrible thoughts you don’t have the will to go outside or be “productive”. It is not your fault if you ask your significant other for the 100th time for reassurance. And it is not your fault if you can barely tell the difference between your normal thoughts and your ROCD thoughts. ROCD can be very deceptive and easily blur the lines between what is true and what is made up. Your intrusive thoughts do not represent reality and how you actually feel towards your partner and the relationship itself. All you need to know is that through it all, your partner is with you and will continue to support you as you mentally manoeuvre the proverbial labyrinth that is ROCD. Don’t think they will resent you for your thoughts, because chances are it couldn’t be further from the truth. Do your best to communicate to your partner how you are feeling, and they will surely stand by you. And know there may be dark moments, and sometimes it may seem never-ending, but there will also be many, many great moments together. Moments you will remember for decades. So, embrace them as much as you can and persevere, in the future you’ll be all the better for it. Just know, for now, you’ll be fine.

The benefits of platform trials This is the second article of a brand-new series inspired by EU-PEARL (EUropean-Patient-cEntric clinicAl tRial pLatforms). The EU-PEARL project aims to shape the future of clinical trials, creating a framework for platform trials. Before a new treatment can enter the market, it must undergo rigorous testing. This is usually done through a randomised controlled trial (RCT): a study considered to be the gold standard at comparing the therapeutic effect of a new intervention against a control such as treatment-as-usual (TAU) (a currently accepted treatment for a condition). Check out this blog to find out more about this topic. A standard RCT is suitable when investigating a single question focusing on the safety and effectiveness of a single intervention. However, this approach can be costly, take a long time to complete, and has resulted in many drugs failing to progress to the final stages of development. So, what if we want to identify new effective medications for serious conditions more rapidly while recruiting the minimal number of patients to do so? This is where platform trials come in. I am Nare, a research assistant working at the Stress, Psychiatry and Immunology (SPI) lab at King’s College London. As part of my work with the EU Patient-CEntric ClinicAl TRial PLatform (EU-PEARL) project, I am writing this blog to inform others about some of the benefits of adopting a platform trial design. The main goal of the project is to improve patient outcomes by developing the framework and infrastructure to conduct platform trials for major depressive disorder (MDD), as well as other diseases, with patient involvement. Platform trials are like the new kid on the block. The main defining features of their design include: Testing several treatments that show promise in treating a particular disease at the same time, with the potential to swap treatments in or out. Having a single common control group for comparing against different treatments being tested, instead of having a control for each treatment. The use of a single ‘master protocol’, as opposed to preparing a protocol or guide of key trial design elements, for each separate treatment trial. Examples of previous platform trials Platform trials are most commonly conducted in the field of cancer. STAMPEDE, an early and greatly successful platform trial for prostate cancer, adopted the platform design as a way to efficiently test several available potential treatments at the same time, thus overcoming the limitation of conducting a randomised trial for each treatment separately. Furthermore, the platform design allowed researchers to change the TAU, which was deemed more ethical than continuing with the previous TAU when new evidence indicated otherwise. More recently, the COVID-19 pandemic was the perfect example which demonstrated that it is possible to work collaboratively on a never-before-seen scale and get funding sooner in order to start testing multiple promising treatments in platform trials to meet the urgent need for reducing deaths and hospitalisations. One trial in particular has received much positive attention worldwide. With its large-scale design, the RECOVERY trialvery quickly began recruiting patients and obtaining findings that would inform key decision-making. This had a major beneficial impact for patient outcomes. The trial team managed to show that a particular anti-malarial drug did not work, and so it was discontinued, while also showing the therapeutic benefit of a seperate anti-inflammatory steroid drug at minimising deaths by a third among hospitalised patients requiring ventilators. This demonstrated the potential of applying this clinical design to other diseases. The field of mental health, however, has not seen substantial progress in drug development. It could, therefore, benefit from some of the advantages of platform trials. This includes having a single common control group, which reduces the differences that can arise between individual psychology trials based on the type of control group used, and so allows for comparisons to be made more easily between the treatment vs control groups. Positive aspects of platform trials Instead of focusing on testing a particular intervention, platform trials tend to be more disease-focused than standard clinical trials as they want to investigate which interventions would work for treating a particular disease. This allows for more patient involvement and will likely provide more information about the condition. Furthermore, with platform trials you are getting the best of both worlds. Similarly to basket and umbrella trials, which investigate either a single intervention for multiple diseases or vice versa, platform trials utilise a ‘master protocol’. This is essentially a single overarching manual describing how the trial is to be conducted that uses a single shared infrastructure under which all treatments are tested, to make sure that the same trial procedures are followed. But what differentiates platform trials from basket and umbrella trials is the ‘adaptive’ design used in, surprise surprise, adaptive trials which don’t have a master protocol. This design allows for flexibility and means that, if during the middle of the trial the results show that a particular treatment is not working very well, it can be dropped or a new treatment can be added. This can go on continually, instead of waiting until the end of the trial to find out the outcome for a particular intervention like for standard RCTs. Especially when lives can be saved. Moreover, in circumstances where a particular intervention is found to be successful at treating a disease and it receives approval to be the new TAU for that condition, then the control group can be updated halfway through — like in the STAMPEDE trial I mentioned earlier. Since a common control group is used, fewer participants will need to be recruited overall in order to test the therapeutic effect of a given treatment, thus saving time and resources. This also means that participants are more likely to be randomly allocated to one of the treatment groups than the control group. Furthermore, the probability of being allocated to the more effective treatments can be adjusted based on results that are obtained during the trial, which is a method called response-adaptive randomisation. These aspects of the trial design make platform trials more ethical than standard RCTs, since less participants will receive treatments that perform badly or the control intervention. This may encourage more recruitment and is beneficial in psychology trials where participants assigned to the control group may have to wait until after the trial to receive the therapy. Well, what about the cost? It is no secret that RCTs are very expensive to carry out. One study aimed to understand whether platform trials presented any economic benefit over conventional trials. They found that even though the initial cost and time of setting up a platform trial was generally higher, in the long-term this design was shown to be more efficient and incurred a lower total cost compared to conducting several separate trials; due to some of the benefits discussed already. Despite all these benefits, platform trials are no easy feat. They require a lot of careful planning and consideration of some of the challenges relating to the management and running of this type of trial, and whether it can realistically be done. The EU-PEARL project is aiming to address these difficulties by bringing together experts from various fields in order to successfully design platform trials for 4 diseases, with the hope of delivering much-needed effective treatments to patients more quickly. DISCLAIMER: This article reflects the author’s view. Neither Innovative Medicines Initiative (IMI) nor the European Union, EFPIA, or any Associated Partners are responsible for any use that may be made of the information contained therein. The EU-PEARL Project has received funding from the IMI 2 Joint Undertaking (JU) under grant agreement No 853966. The JU receives support from the European Union’s Horizon 2020 research and innovation programme and EFPIA and CHILDREN’S TUMOR FOUNDATION, GLOBAL ALLIANCE FOR TB DRUG DEVELOPMENT NON PROFIT ORGANISATION, SPRINGWORKS THERAPEUTICS INC.

And why platform trials are the only way to move it forward This is the first article of a brand-new series inspired by EU-PEARL (EUropean-Patient-cEntric clinicAl tRial pLatforms). The EU-PEARL project aims to shape the future of clinical trials, creating a framework for platform trials. I am a psychiatrist. And after a few years of clinical practice in a variety of facilities, I have decided to dedicate myself to research. I often discuss the status of psychiatric research in both formal and informal contexts. What strikes me every time is how psychiatry is perceived as something different from the rest of the medical world. “Why are you doing it?” “Do you believe in it?” “Does it work?” are only some of the questions I am typically asked. In this blog, I will talk about the status of psychiatric research, its unsolved issues, and the potential direction for the future. A different medicine? Psychiatry is the medical field focusing on the mind, as traditionally opposed to the other medical fields which are focusing on the body. This historical separation between physical and mental health has often gained a negative connotation for research. We could sum up the dilemma as: “If something is not in the body, it does not exist”. Of course, this is a dangerous misconception, but this is where prejudicial beliefs take shape and become rooted. These biased ideas are not unusual even among clinicians, healthcare professionals, and scientists. This really hits a nerve and always comes to me as a huge source of personal frustration. But it makes me question why the stigma around psychiatry is still there. Current gaps The main issue with psychiatry is probably that it still lacks a piece of hard evidence. If we think about other diseases, blood tests or other exams are routinely used to confirm a diagnosis. In infectious diseases, we can usually measure the presence of a specific pathogen (the organism causing disease). For example, we all experienced that a throat/nose swab could detect the presence of the COVID-19 virus. For most types of cancer, we have a combination of blood tests, scans (different images of the body), and biopsies (small samples of body tissues to analyse under a microscope). We can use this evidence for the diagnosis, to define the staging (how extended the cancer is), and the response to treatments. In psychiatry we still do not have this. For example, there is no psychiatric disorder for which we can perform a blood test or do a brain scan to confirm the diagnosis (yet). Significant research has already produced promising results, but they still need further validation. But, the fact that we don’t have this evidence now doesn’t mean that we will never have it, or that this evidence doesn’t even exist. Let me give you an example of gastric ulcer, a break in the stomach lining, and a frequent cause of stomach pain. The shared idea was that stress or food could cause this condition. In 1984, two scientists demonstrated that it was actually a bacterium causing it. This discovery drastically shifted the approach for the management of this condition. We can now treat most cases of gastric ulcer with antibiotics. I am not saying that I expect something similar will happen in psychiatry, at least not in the near future (as much as I wish). In mental health, we are dealing with complex diseases. There may be numerous factors with a small effect, rather than a single cause with a large effect (such as in the gastric ulcer case). Upsides and future directions These challenges should not divert attention from the upsides of current psychiatric research. We have validated instruments to conduct rigorous scientific research. These are interviews and scales, which are a structured list of targeted questions. We can use them to diagnose a disorder, or to assess the severity of symptoms and their change over time. We also have effective treatments, either pharmacological or non-pharmacological, such as psychotherapy. This concept is important; the fact that they do not always work, does not mean they do not work at all. Now, what can we do to produce better research in psychiatry and fill the gaps? The answer to this question could be not only related to psychiatry; what if it encompasses the way we are conducting overall medical research? Let me try to explain. Clinical trials and platform trials Currently, medical research is mainly carried out through clinical trials. These are, at their simplest, studies in which a specific intervention is tested in a specific medical condition. For example, a clinical trial in psychiatry could test how effective a pharmacological (drug) or psychotherapeutic (therapy) treatment is in a specific psychiatric disorder. Therefore, clinical trials usually examine one single treatment in a single population at a time. This often results in long cycles before having significant results (either positive or negative). In addition, different clinical trials on the same disease are likely to compete to find participants. At the same time, people who are suffering struggle to find the most suitable treatment for them. A novel concept developed in the past few years aims to overcome these issues: the platform trials. These are a platform to carry on different clinical trials without the time and space limitations of a traditional clinical trial. For example, we can assess different treatments at the same time for a given disease. We can include new treatments as they develop, and remove ineffective ones. As a consequence, we will have a more efficient process to get significant results in less time and with fewer participants. Almost three years ago, as part of a large European consortium, we launched a new project, EU-PEARL (EUropean-Patient-cEntric clinicAl tRial pLatforms). The main aim was to create an infrastructure to plan and complete platform trials in four different diseases. These included depression, a common psychiatric disorder. You can find more information in this piece, written by my colleague Courtney Worrell at the beginning of the project. Since then, many things have changed. We faced an unexpected pandemic. And can you guess which was one of the strategies employed to identify potential treatments? That’s right, platform trials. According to UK government data, platform trials helped in identifying eight effective treatments for COVID-19 so far (and managed to rule out ten ineffective ones). This is at a speed which may not have been possible by testing each treatment in a single clinical trial. From this, we understand the advantages of platform trials, as well as the potential benefits for people suffering. And I could mention other promising examples, mainly from cancer research. Advances in medical research are shifting the way we treat diseases towards a more tailored approach. This personalised medicine requires novel infrastructures such as platform trials. We are now approaching the completion of EU-PEARL. This means we are gathering all the hard work of the past three years, and we will soon have the infrastructure ready to perform clinical trials in depression. This is a critical first step for psychiatry to finally fill the gaps with other medical fields. I believe as a society we are gradually overcoming the mind and body separation and recognising mental health as part and parcel of the whole individual’s health. Platform trials are a golden opportunity to transform the way we conduct psychiatric research, and (perhaps) the only way to move it forward. DISCLAIMER: This article reflects the author’s view. Neither Innovative Medicines Initiative (IMI) nor the European Union, EFPIA, or any Associated Partners are responsible for any use that may be made of the information contained therein. The EU-PEARL Project has received funding from the IMI 2 Joint Undertaking (JU) under grant agreement No 853966. The JU receives support from the European Union’s Horizon 2020 research and innovation programme and EFPIA and CHILDREN’S TUMOR FOUNDATION, GLOBAL ALLIANCE FOR TB DRUG DEVELOPMENT NON PROFIT ORGANISATION, SPRINGWORKS THERAPEUTICS INC.

It seems nowadays both employees and employers alike now prefer making their decisions quietly and discreetly. At least when it comes to removing either themselves or someone else from their job, anyway. The concept of ‘quiet quitting’ has been making the rounds online as of late, where the employee does not directly quit their job but instead strives to complete only the bare minimum and does not go beyond what is asked of them. It is completely removing oneself from today's “hustle culture” mentality and not letting your work interfere with your personal life. For more on quiet quitting, check out Caitlin Pentland’s blog. But perhaps employers have found their own sneaky method to answer the trend of quiet quitting… Well, now there’s a new sheriff in town…and his name is ‘quiet firing’. As a former miserable employee of many loathsome jobs, I find the idea of quiet quitting and quiet firing interesting. For my past jobs, the moment I began to lose interest in working where I was, I probably began to quiet quit without realizing it. And those times at my job, I was feeling ignored and brushed aside; perhaps my manager was trying to quiet fire me (before it was “cool”). I believe in an age where the well-being of employees is being increasingly discussed, these concepts must be examined as well. What is ‘Quiet Firing’? ‘Quiet firing’ is a term used to describe when managers do not directly fire you but create a working environment that leaves you with no choice other than quitting. But how? This indirect method of firing could take many forms. Most often, it could be not inviting you to relevant meetings, purposefully withholding information from you, or failing to promote or reward you for completing tasks. Formerly known as “constructive dismissal” or “constructive termination”, the idea of an employer subtly nudging out an unwanted employee is not new to the working world (it has actually been around for quite some time!) —  it just has a new title. This tactic releases the manager from the long and arduous process of having to let an employee go themselves (and all the Human Resources implications, too!). Some may say this is simply a lazy way for managers to relieve themselves from the burden of firing an employee; others add that it could be a form of bullying. In many cases, involving constructive dismissal (or the new and improved “quit firing”), the resignation that follows results from actions that are perceived to be malicious and punitive. And I get it. It’s a seemingly easy solution for those in charge, but it could be devastating for those on the receiving end. You, the employee, are made to feel so underappreciated or unfulfilled that you have no other option but to leave a job you may have once enjoyed. While the employer, they have just narrowly avoided having to provide you with a severance package. And even though it looks simple to the employer, it gets a lot more complicated for the employee. A practical example Let’s say you’re in line at a restaurant waiting to order your food. Instead of the cashier taking people’s orders from the first person in line to the last person, they instead go through every person in line but ignore you, skipping to the next person behind you. When you attempt to speak up about being skipped over, you are disregarded and told to get back in line even though you just were. What would one do in that situation? Naturally, you would leave and go to another restaurant to look for better service. But that doesn’t resolve the way you were treated at the last restaurant. You might have felt ignored and cast aside, isolated from everyone else for no reason. The feeling of being ostracized doesn’t immediately go away because you’ve left that environment. The psychological toll that has could have a huge negative impact on a person’s wellbeing. Are you being quiet fired? What you need to do… You may be experiencing quiet firing and may not even know it. In a LinkedIn Survey of over 20,000 people, 48% say they have witnessed quiet firing in their workplace, while 35% report having experienced it themselves. If you find that you may be your manager’s next target for quiet firing, it is important to act fast. Advocate for yourself or find others to advocate for you. Come together with your peers looking for a change in the workplace environment and see if those changes happen. Perhaps even schedule a meeting with your manager directly and mention your concerns. It is better to be upfront if you are feeling cast aside at work rather than remaining passive. It is also imperative to keep your options open. Sometimes a job isn’t meant to be, and it has simply run its course. Explore other job opportunities, even in the same field, if that is what you are passionate about. Taking control of the situation and empowering yourself is good; don’t let what could be a debilitating experience consume you entirely. The bigger picture It is best to understand and recognize that just as much as quiet quitting, quiet firing is a reality in the workplace. Regardless, quiet firing is more telling of your manager’s work ethic than it is of yours. If your manager decides to passively leave you out in order to drive you away, that is their issue. In today’s society, we are learning to acknowledge toxic workplace habits as we see them. If you question whether or not you are in the process of being quiet fired, ask yourself if you would want to work somewhere that does not respect you enough to be open and honest with you in the first place. Does your manager have a history of behaving this way with past employees? Is your manager currently behaving this way only with you or with other colleagues as well? In order to make the best decision, you must observe what is going on around you, not only with yourself. If you discover your manager is trying to quiet fire you, but you would still prefer to stay in your current role, there is a solution to help you cope with your situation. Perhaps, try quiet quitting.

As temperatures exceeded a scorching 40°C degrees in parts of the UK this summer, global news channels shared climate crisis stories worldwide. From Iceland’s colossal volcanic eruption to extreme heatwaves and droughts across Europe, Spain and Greece, Portugal’s combat with wildfires, Bangladesh, Pakistan and South Korea’s most brutal floods and rainfall in decades, and the World Food Programme reporting hundreds of thousands of people experiencing starvation and acute malnutrition in parts of Africa, Asia and the Middle East due to flooding, hurricanes, cyclones and droughts. The ramifications of climate change are pushing us to the brink and propelling eco-anxiety, described as worry and distress induced by global warming and human activity causing harm to the environment. Do you ever experience this? My viewpoint and experience of eco-anxiety add to previous Inspire the Mind blogs addressing this salient topic. I am a photographer, completing training as an Occupational Therapist in London and have worked in the healthcare sector for a few years. On my recent travels to various parts of the UK and abroad, whenever I encounter iconic and beautiful landscapes and stop to capture these through my lens. I constantly deliberate our climate change crisis with a degree of eco-anxiety. Regardless of the stunning landscapes and scenic beauty, the harsh reality of the damage around me is clearly visible. Incessant plastic pollution on the shorelines everywhere I venture, the disappearing Dead Sea, chalk stalks on our Kent Coast disintegrating, falling lake levels, eroding coastlines, and the list goes on. As our natural world changes quicker than anticipated, we are witnessing economic, health and social effects due to rising sea levels, extreme storms, unprecedented heat waves, ocean acidification and starvation, to name a few dire consequences. Prompting the first unequivocal global commitment to combat the climate crisis in 2015, referred to as the Paris Agreement, the race against climate change is still not happening fast enough. In 2015, 197 countries and the European Union signed an agreement to significantly decrease global greenhouse gas emissions to curb global temperature increase to 1.5°C in the 21st Century. This 1.5°C limit anticipates smoother adaptation and the world enduring lesser negative repercussions. Despite world leaders recently attending the 27th Conference of Parties (COP27) in Egypt, one questions why the world is still way off track from its target of reducing pollution that propels climate change. Astoundingly, 43% of adults in the UK reported eco-anxiety and worry about the environment’s future in October 2021. In December 2021, a study of children and young people (aged 16–25 years) from countries globally found that nearly 60% are ‘very’ or ‘extremely’ anxious about climate change, negatively impacting the daily lives of more than 45% of participants. Its harrowing to fathom how many are being affected daily both emotionally and psychologically. I recently photographed a few climate change protests in London and the number of young people who shared experiencing eco-anxiety was staggering. Regardless of being motivated and empowered to make changes, they feel somewhat disappointed in government actions, support received and pace of change. Their response was not surprising if the current efforts to decrease and prevent the emissions of greenhouse gases by developed countries, who are the major emitters, is anything to be judged by. A survey in 2020 of child psychiatrists in England reported that more than 57% of children they have consultations with experience anguish and fear connected to climate change. Sadly, eco-anxiety is not restricted to the UK but has profound emotional, social, functional and cognitive effects on all generations worldwide. Pikhala’s 2019 publication describes the relationship between psychological and social defences and eco-anxiety as a method of coping and processing emotions and struggles associated with climate change. Denial and ‘socially constructed silence’ produce more anxiety and increase emotional stress, as explained by Norgaard, sociologist and professor of environmental studies in 2011. Flooding is becoming more prevalent in the UK due to climate change and is linked to anxiety, depression and PTSD (post-traumatic stress disorder). An astounding 40% of people globally, including those with present mental and physical health conditions, are considered most at risk due to the ramifications of global warming. Out of 95 countries surveyed in 2021 by the World Health Organisation (WHO), nine have incorporated mental health support in their climate change and national health schemes. Is this a caveat of what is to come? We need to heed this as a wake-up call, and countries must concentrate more on improving mental health access and services to support local communities of all ages in order to better tackle climate change. The approach to tackling climate change internationally should not only focus on government plans to reduce emissions and implement more sustainable solutions. Addressing the ensuing mental health crisis, especially in social inequality situations and disadvantaged groups, are also paramount. National and local policymakers, communities, businesses, charities, doctors, nurses, healthcare workers, and mental health professionals must work collaboratively to enhance resilience and provide support for those affected by climate change. Undoubtedly, this can inspire and empower people to take action and provide hope to better cope with eco-anxiety and the future. All images in this blog are photographs taken by the author, who published her photographic work under @Mica_Lens, 2022.

Me and my phobia I wasn’t always scared of spiders. I remember being very little and happily letting tiny red spiders run over my hands and along our garden wall. I don’t know for sure, but I have a hunch that my phobia was launched the day my mother was hoovering the sitting room when I was about 4 years old. We had long, heavy velvet curtains that hung to the floor. As she pulled one back to hoover underneath it, the floor filled with a tsunami of baby spiders surging across the carpet towards me. My mother screamed as she tried to suck them all up, and I leapt on a chair in horror. For decades now, I have been living in fear; hyper-alert and disproportionately sensitive to a danger that is not actually dangerous. It holds me back and stops me from feeling fully independent. I am an occupational therapist teaching students at St George’s University of London and conducting research in stroke rehabilitation, but today I speak to you as a (former?) arachnophobe. In this article, I share my experience of finally confronting my fear at London Zoo’s Friendly Spider Programme. I want fellow arachnophobes to feel comfortable reading this, so there will be no images or vivid descriptions of the arachnids. Facing my fear The friendly spider programme (FSP) at London Zoo is based on a combination of cognitive behavioural therapy (CBT), hypnotherapy, and exposure therapy, and is led by hypnotherapist John Clifford and London Zoo’s spider expert, Dave Clarke. A recent systematic review of research evidence found that hypnosis and CBT can be powerful in reducing phobias, and having been reliably informed that the FSP has a good reputation, I am optimistic that they can help me. As we settle into our afternoon at the zoo, John tells us we don’t really know where spider phobia comes from, but we do know that typically an arachnophobe is ‘a bit of a worrier… the kind of person who sees danger everywhere before it happens’. That’s me! As a group, we explore what it is we dislike about spiders (the legs, mainly), and where we worry about seeing them (the bath, the bed, the car, in a shoe, on a towel…). We share our common reactions to seeing them: crying, screaming, freezing, escaping. These are all natural survival responses. John acknowledges that people can relish exploiting our fears by teasing us, making us jump and frightening us. This can leave us feeling vulnerable, so it feels healing hearing my secret, shameful problem understood with empathy and kindness. From time to time, Dave interjects to correct any anti-spider words used. They are not ‘invading’, he says, they are just coming into the same space as us. We need to stop using language that infers they are out to get us. They are just another species making their own way in the world. Dave used to be scared of spiders himself, and now he’s the myth-busting spider expert at London Zoo. We learn that there are 50,000 species of spiders on the planet, and our fee for attending the day has helped spider conservation! It is NOT true that spiders crawl into our ears at night to lay their eggs, or that we eat them while we are asleep with our mouths open. That is a relief. They are over 350 million years old! Humans tend to fear that which we don’t understand, but we should promote and value diversity in the eco system, just as we do in our human communities. After a break, John leads group hypnosis. Lying down is a relief after so much spider talk, and John guides us to let all our negative thoughts and feelings about spiders float away on a cloud. We mentally rehearse: I am calm, safe and relaxed in the presence of spiders, now and ever more. Spiders are safe. The next part of the day is where the real work starts. We tread solemnly in quiet anticipation towards the part of the zoo where the spiders live. It’s time for encounters, and we are armed with the super-powers of exhaling, dropping our shoulders and repeating our mantras. It’s tough, and I am way out of my comfort zone. I sweat a lot and cry involuntarily as I push myself to face my fears. But incredibly, it really does get easier every time I do something new. Systematic desensitisation is a graded form of exposure therapy, where we gradually build up to engaging with something we are frightened of while using relaxation techniques. At the zoo, I objectively observe this in action. Horror wells up in me in a surge the first time I force myself to look at or get close to a new specimen, but the second time that visceral reaction is lessened, and the third time it’s really ok. The goal of the day is to be able to cover a spider with a pot, slide a piece of card underneath and lift pot, spider and card from a table. This is a huge goal for me, and is only made possible thanks to the unending patience and kindness of the volunteers who quietly support us as we take baby steps, panic, retreat, calm ourselves, and try again. We may not magically become spider lovers through this process, but we will be able to recall that we have dealt with them calmly before and can do it again. Goal achieved and certificate in hand, I am elated. I chose not to hold Carol the tarantula, but I did manage to get close enough to take photos for others as they stroked her soft fur. As Dave tells us, there is no normal and people will all have different experiences, but the success rate of the programme is high. From the zoo to the real world In the week that follows, I’m even more jumpy than before. Every hair or piece of fluff feels or looks spidery. I’m on edge, wondering when the next spider encounter will occur — because next time I will need to put my courage to the test. Dave has warned us we will still get a ‘surprise’ when we see a spider — that’s normal — but we need to remember we are safe and calm. I wonder what will happen when the time comes. And the time does come. Getting ready for bed, I hear my partner calling me: “If you would like the opportunity to try out your new skills, there is a spider in the bath!” I have never had an invitation like this, and certainly would not have accepted it before now. But, I am ready. I remember my strategies: exhale, drop shoulders, remember I am safe, calm and relaxed in the presence of spiders, now and ever more. No fuss, no drama, job done. I message someone I met at the course to share my monumental success story with someone who will understand. She replies saying, “That’s amazing!! I’m so proud of you!! I haven’t come across any yet, but I noticed I felt very friendly about one living in the window frame!”. She asks me how I feel now I have got the first one out of the way. I reply: “Amaaaaaziiing!!! Relieved! Proud.” I have learnt that fear is not something to be ashamed of, and it is certainly not something to tease or taunt others about. Spiders are animals making their way in the world, just like deer, dolphins, pandas, and people. It can take courage to challenge our prejudices as speciesism, (in this case, discrimination against spiders), but learning to understand and live alongside each other in harmony is in the interests of us all.

Words are powerful. They seek to inspire, elicit emotions, and can emerge into making a positive change. All around the world there are many journalists that share with us stories that might often be forgotten or stories that we wouldn’t have been aware of, if not told. Journalists put their lives at risk to do so, reporting stories from dangerous conflicts zones or in some instances, by being targeted for uncovering hidden truths that reveal injustice across countries and communities. According to UNESCO, current data shows that, since 1993, more than 1500 journalists around the world have been killed. Al Jazeera, an independent news organisation, has highlighted that a total of 12 of its own journalists have been killed whilst at work since the organisation had launched back in 1996. These violent attacks will not serve as a tactic to silent journalists but rather loudly echo to the world the change that must be done for their safety, so that they can continue to report the stories that we must all hear. This is exactly what I would like to highlight in this blog. Here on Inspire the Mind, we provide an opportunity to shed light on the news and the current global issues that are affecting mental health through societal impact — as shown by some of the topics that we have published previously. We thus feel we also are storytellers and journalists ourselves, even if we are just students and mental health researchers, and we want to speak up against the brutal attacks against journalists. The commitment of journalists, ensuring that every story is told, greatly resonates with us all — and so does the need to support their safety, and to bring to justice those who attack them. As we acknowledge their courage and bravery, the journalists and writers who have fallen in their duties deserve to have justice, and their stories must be told. One of the most recent such stories is the one of reporter Ivan Safronov, who in September this year has been sentenced to prison for 22 years, after the Russian authority have accused him of sharing confidential information, even if Ivan highlighted that the information shared was “open-source public information”. The sentencing of Ivan not only has been painful for his family, but also has pushed many Russian media outlets to urge for his release. In a statement by the independent media in Russia, they have highlighted that “We believe this decision is unjust and politically motivated. Journalism is not a crime.” Just two months earlier, in June, British journalist Dom Phillips and Brazilian indigenous expert Bruno Pereira were tragically murdered. They were reported to have been missing when returning from the Javari Valley in the Amazon. Dom was previously a writer for the Guardian, and the focus of his trip was about writing his book and learning about the indigenous people that resided within the area. Sian Phillips (Dom’s Sister) now sadly grieving the loss of her brother, highlighted “He was killed because he tried to tell the world what was happening to the rainforest and its inhabitants” The Editor in Chief of the Guardian, Katharine Viner, described Dom as “a brave, passionate journalist who died doing a thing he loved — seeking out and exposing wrongdoing. Just one month before that, in May, journalists Yesina Mollinedo and her colleague Sheila Johana García were assassinated in front of a convenience store in Mexico. Prior to their attack, Yesina was receiving threats and had to change her contact details on multiple occasions. And in the same month, Al — Jazeera journalist, Shireen Abu Akleh was killed whilst reporting from Jenin, a Palestinian city located in Northern West Bank. Although visibly identifiable as a journalist, indicated by a visible bullet proof vest and helmet both labelled with a clear sign PRESS, this did not deter a bullet leading to her tragic death. Her fellow journalist colleague Ali Al-Samudi, who was working as a Producer with Shireen, was also shot and left hospitalised. After four months from this tragedy, the Israeli military have issued a statement highlighting there was a “high probability” that Shireen was killed by an Israeli military. One month before — we are only in April — and it is Alfonso Margarito Martínez Esquivel’s life that is lost. He was a photojournalist in Mexico, and another life sadly lost by these horrific killings. He used his camera lens to illustrate the criminal activity and violence that was happening in his country. His close friend and mentor Bibi Gutiérrez described him as “he was always smiling” and that he was “a sweetie to everyone”. Six months, six journalists killed or imprisoned. Sadly, these violent attacks on journalist are way too frequent. According to a report from the newspaper Guardian, in 2021 around 62 journalists were found to have experienced physical attacks, and 7 have tragically lost their life because of their work in Mexico. In 2021, Journalists Maria Ressa and Dmitry Andreyevich Muratov were awarded the Nobel Peace prize “for their efforts to safeguard freedom of expression, which is a precondition for democracy and lasting peace”. Their extensive contribution fully deserves this recognition, and Muratov highlights that in Russia many journalists, media outlets as well as human right activists are viewed as “enemies of the people”. Indeed, the award of a Nobel prize serves as symbol and a recognition to journalists, by acknowledging their amazing courage and the hard work that they do for everyone. Not only do the stories matter, but the people behind the stories, that work tirelessly, must matter too. This year on World Press Freedom Day, celebrated on 3rd May 2022, the UN Secretary General António Guterres has spoken on the violence towards the press and journalists. In his speech, he highlights the rise of violence through online platforms, against female journalists in particular, and further emphasises that “without freedom of the press, there are no real democratic societies. Without freedom of the press, there is no freedom”. Ten years ago the United Nations issued recommendations known as the UN plan of action on the safety of journalist and the issue of impunity, which describes the importance for journalists and media workers, and their freedom of expression, to be protected. Furthermore, the European Commission has highlighted some recommendations for protecting journalists, such as providing training for journalists on safety, working alongside authorities as well as encouraging female journalists and journalists belonging to minority groups to report on equality-related issues. Yet they continue to die. Reading the news articles of these violent attacks against journalists makes me feel confused and frustrated as to the continuation of these attacks, especially when we live in a society where we value knowledge, honesty, and most importantly the freedom of speech. Whilst it is said that actions speaks louder than words, I hope that we all shall remember and recognise the acts of bravery that these journalists have taken to speak against injustice. Lastly, I wanted to share a quote that truly captures the importance of the notion that defending journalists’ safety is a duty for all of us: “We don’t carry weapons. We only have a pen and a notebook to defend ourselves.” Armando Linares, the director of Monitor Michoacán, commenting on the murder of Roberto Toledo in January 2022.

You’ve probably seen the expression ‘quiet quitting’ gathering momentum on social media and news outlets. What appeared to start as a TikTok by Zaid Khan, a 24-year old engineer from New York, is now a debated topic amongst employees, HR (human resource) professionals and CEOs (Chief Executive Officers) alike. In his TikTok, Zaid defines quitting as “…not outright quitting your job but quitting the idea of going above and beyond in work. You’re still performing your duties, but you’re no longer subscribing to the hustle culture mentality that work has to be your life”. The intended definition of quiet quitting describes an employee who fulfils reasonable expectations within working hours but does not take on extra work beyond what they are contracted for. Nor does their work and career fully define their identity, or worries about work define their non-working hours. Additionally, the term quiet quitting builds on concepts we are familiar with, such as setting boundaries, protecting health, achieving work-life balance and meeting expectations. As a young professional in research who entered the workplace at the start of the pandemic, I’ve seen from the inside the environment that quiet quitting is a reaction to. A few years before my first job, I’d already experienced burnout, witnessing the all-consuming nature of my university studies taking over almost every waking hour. The lengthy process of reconstructing my work-life balance and recognising my needs shaped how I perceive similar challenges and pressures today. In the past year, when realising my job no longer met my needs, I didn’t actually quiet quit. It was better for me to move on entirely. I knew where I could have a more specialised role and could identify how my previous employer was not meeting my needs nor utilising the breadth of my skills in clinical research, especially within the therapeutic area of mental health. But what happens if your next steps are not clear? As the conversation around quiet quitting has evolved, so has the meaning of the expression. Opinions are split around the validity, fairness and meaning of quiet quitting. It is essential to acknowledge that the concept behind Zaid’s version of quiet quitting did not originate with him, as the creator later explained. The lying flat movement, or “tangping” originated in China in April 2021, with the aim to protest against long working hours (often 9am — 9pm, 6 days a week). The movement aimed to empower workers to regain more of their life back and advocate for more reasonable working hours. However, the expression “tangping” was shortly censored from social media and wider internet searches. So, why has quiet quitting become such a heightened topic of conversation? Several factors could have possibly contributed towards this current landscape. The covid pandemic changed what work looked like for many of us, in particular during the first two years, with some alterations still remaining. The adoption of remote working brought about advantages and disadvantages. Greater flexibility and reduced commuting time and costs were welcomed, but especially for those relatively new to the working world, remote employment led to an increased risk of weaker work boundaries, thus blurring the lines between home life and work life. As most of us experienced, social aspects of work decreased during the pandemic, and connection was more difficult. Whilst offices have opened again, and we’re experiencing more contact with our peers and managers, the former two years of poorer quality communication and insight could have a lasting impact on those who were silently struggling with demands, now worn out. Additionally, whilst the current world we experience can be politically unstable, with mounting financial pressures and increasing humanitarian concerns, continuing in this ‘hustle culture’ does not seem to be as popular post-pandemic. Especially when career progression and recognition at work don’t compensate for fall-out like poorer home life, strained family relationships, stress, burnout and worsening mental health. Due to its controversy, quiet quitting has stirred up strong criticisms. Or, as I see it, individual perspectives of quiet quitting have shaped such criticisms. One rather blunt article describes quiet quitting as a ‘self-indulgent sulk’, invalidating and downplaying the link between workplace stress and poorer mental health. They view quiet quitting as a lazy refusal to work contracted hours and fulfil outlined duties, fuelled by pessimism, low tolerance for boredom and the avoidance of challenge. However, people’s mental health in relation to work must be taken seriously, and we know that external stresses and pressure can contribute to worsening mental health and burnout. Experts in workplace psychology and HR professionals suggest that if a job no longer meets your needs, actually quitting may be more appropriate than quiet quitting. This can start by looking for opportunities that are either more fulfilling, offer increased progression or provide work-life balance. Of course, this is much easier said than done and not promised as a quick solution to poor mental health in the workplace or toxic workplace cultures. Also, it’s important to consider risks that could accompany quiet quitting, independently of individual understanding of the term. Depending on how obvious a reduction in over-working is, there may be a risk of not being considered as highly for promotions or progression, and peers may not appreciate unequal matching of team effort. Some of the following actions might be options for moving forward instead of quiet quitting: talking to your manager about your workload, setting boundaries and asking for help in maintaining them, engaging in employee support, actively seeking out other opportunities or using some annual leave for a break. Additionally, it can be helpful to check that any support unique to the individual’s circumstances is fully and freely given, such as sick leave, maternity/paternity leave and reasonable adjustments for disclosed disabilities. So, whilst quiet quitting has trended recently, I think our real concern should be what it signposts to, namely unsustainable workplace pressures, mental health and burnout consequences, which thrive in poorly equipped workplaces. Ultimately, we can’t fix this ourselves, although we might be able to change our individual environment for some time. A better understanding of workplace stress and its consequences on our mental health is needed by employers and individuals, accompanied by creating safe environments for employee disclosure.

Molecular Investigation of Bear Bile: A gift from Nature and Traditional Chinese Medicine to the World Disclaimer: In presenting the scientific evidence of the use of bear bile, or its synthetic derivatives, demonstrating benefits to a range of health benefits including mental health, it does not confer that we at ITM in any way support or condone the inhumane treatment of any animals. Dried bear bile has been utilized since before the Tang Dynasty (659 Common Era) in China as traditional medicine, and its day-to-day medical use has been implemented in Korea and Japan several centuries ago. At the beginning of the modern era, when international travel increased, the application of Traditional Chinese Medicine (TCM) spread across Asia, and then quickly circulated among Asian communities in other parts of the world, including the European Union and the United States. The majority of consumers bought bear bile medicines, as they were found in TCM pharmacies, or as a result of them regarding bear bile as a beneficial traditional medicine. The use of bear bile is controversial and has understandably raised concerns from the public, media, and animal rights activists all over the world. There are two main concerns, the first surrounds the very high consumption of bear bile by China, and other countries, which has resulted in bears becoming an endangered species; the second is the inhumane method used to extract bile from living bears. In this blog, I will be discussing these concerns, in the context of why bear bile is a popular traditional medicine and what it brings to the world. I am a visiting researcher at the Stress, Psychiatry and Immunology (SPI) Lab at King’s College London, and a part of the team that brings you InSPIre the Mind. I am also an Associate Professor in Shanghai University of TCM. I have been working on the potential effect of bear bile and its active ingredients in neuropsychiatric disorders, for more than 7 years now. Together with my supervisor Dr. Alessandra Borsini, a Senior Postdoctoral Neuroscientist, we have recently written a systematic review: from dried bear bile to molecular investigation. Let’s start with the historical use of bear bile. From the perspective of TCM, dried bear bile (usually called bear bile powder) is categorized as ‘cold’ medicine. It is bitter in flavour and shows remarkable capabilities to clear “liver heat” and “reduce liver fire” , which can cause symptoms like “irritability, outbursts of anger, temporal headache, dizziness, red face and eyes, thirst and bitter taste”. What is Bear Bile used to treat? Dried bear bile can be dissolved in milk or plant syrup to treat febrile seizures in children. Such seizures cause “stiffness, twitching in the arms and legs, loss of consciousness”, and sometimes incontinence. In addition, bear bile powder can also be administered orally or externally to treat syndromes such as skin boils), piles and sore throat. Also, bear bile has been widely used across East and Southeast Asia. For instance, it is generally taken by young mothers and expecting mothers in Cambodia, for symptoms considered as post-natal fatigue (named toas in Khmer, the Cambodian language), also known as post-natal depression. Apart from these traditional applications, the use of bear bile has broadly extended to the treatment of many other diseases defined by western medicine, based on modern pharmacological studies, such as inflammation, or liver cancer. However, from a place of empathy to other living creatures, we must ask why and how it comes at a cost to individual bears’ welfare? and further, could there be an alternative? Although bears are listed in the Convention on International Trade in Endangered Species of Wild Fauna and Flora, the illegal abuse of innocent bears for huge profits worldwide is continuing. Further, the extraction method is controversial. Over the decades, in view of these significant concerns, scientists have developed several substitutes for bear bile, such as artificial bear bile and synthetic compounds. What does bear bile contain? Among the numerous chemical components of bear bile, ursodeoxycholic acid (UDCA), is one of the bile acids that is considered to be a major active component. In the 1950s, it was successfully synthesized by scientists and applied in the clinical treatment of liver diseases. Currently, UDCA (the commercial name called Ursodiol) is widely used as the first-line drug for the treatment of liver diseases and the therapy was also approved by the United States Food and Drug Administration for primary biliary cirrhosis -a specific type of liver disease. Moreover, its application has been expanded to other liver diseases, like intrahepatic cholestasis of pregnancy (“a liver condition that occurs in late pregnancy”), and even to non-liver diseases, such as inflammatory bowel diseases (“long-term conditions that involve inflammation of the gut”). During the COVID-19 pandemic, scientists have recently highlighted a clinical trial of UDCA as a preventive treatment in patients who have early symptoms in the onset of COVID-19, in addition to those who are especially at high risk with chronic diseases, such as “diabetes, obesity, cardiac and lung disease, and any immune-compromised state”. At the moment there is no results for UDCA treatment in COVID-19 just yet. The adaptability and the wider use of UDCA are due to its multiple mechanisms of action. When administered orally, UDCA is immediately changed to form another type of bile acid named glycoursodeoxycholic acid (GUDCA) in humans, and to a lesser extent in to bile acid tauroursodeoxycholic acid (TUDCA). Various studies have now started to investigate the effect and the mechanism of UDCA, GUDCA and TUDCA in the context of neurological, neurodegenerative, and neuropsychiatric disorders. So, what did they find out? In laboratory studies of neurological, neurodegenerative, and neuropsychiatric disorders, all three bile acids were able to slow down the process of cell death, this is the event of a biological cell whereby the cell no longer carries out its functions. Bile acids do this by preventing damage to cells caused by free radicals (unstable molecules that the body produces as a reaction to environmental and other pressures) and also help the immune system to defend the body from harmful agents, such as bacteria. In addition, findings from these studies also suggest that all three bile acids would be equally beneficial in laboratory studies of Huntington’s disease (“a condition that stops parts of the brain working properly over time”), whereas UDCA and TUDCA would be more beneficial in models of Parkinson’s disease (“a condition in which parts of the brain become progressively damaged over many years”) and even in Alzheimer’s disease (“the most common cause of dementia”). On the other hand, the use of GUDCA would be most beneficial in models of bilirubin encephalopathy (brain damage caused by high levels of a yellowish pigment that is made during the normal breakdown of red blood cells) and TUDCA in models of depression. What would be the next step? As discussed, scientific research has shown that there is a wide range of opportunities for bear bile to have an application use in neurological, neurodegenerative, neuropsychiatric disorders. Future research will allow scientists to identify specific bile acids that would be most effective for each specific disorder, and ultimately to develop more personalized strategies for patients suffering from these conditions. Additionally, given its clinical safety, the three bile acids also could be given in addition to conventional medicines to improve the treatment outcomes in neurological, neurodegenerative and neuropsychiatric disorders. But for now, I believe this is enough of a gift from nature and traditional Chinese medicine to the world!

I remember vividly the first time I was called fat. I remember the name of the person who said it, where it was and what I was wearing. We were having a kickabout in the park, and a lad who I used to play football with said pretty much word-for-word; ‘You used to be really good at football, but now you are just fat.’ It hit me suddenly, like a head cracking into a doorframe you didn’t realize was so low. At that point I had never thought of myself as fat, I was just an 11-year-old kid playing football in the park with his mates. It may seem dramatic, an overreaction the size of Belgium, but looking back my entire conception of self was changed with that throwaway, if brutal, comment. The Puberty Expansion From the ages of 11–14, I gained a lot of weight. This was mainly due to poor diet; my Mum worked late nights and given I was only 13, my cooking skills were not exactly Gordon Ramsey level. They were only marginally better than chippy and cafe owner Ian Beale from the British TV soap Eastenders. This meant I ended up eating a lot of ready-meals, especially chicken nuggets and curly fries, and I had a John Keats-intense love for all things sugary. I was a very non-sexual teenager, which except for a long-term relationship, has somewhat carried on into my adult life. I didn’t kiss anyone until I was 16. I considered myself an ugly, fat, spotty, weirdo and had an almost sickness-inducing anxiety at any social interaction, especially with girls. I slowly became disgusted with how I looked, afraid to look in the mirror and terrified at the thought of having my top off in public. I became panicked buying food in front of people, worried they were judging everything I ate. This anxiety continued through my 20s; I have literally hidden from some of best friends in supermarkets for fear of them peeking into my basket. In my mind, my lack of sex was completely down to how much I weighed, that any right-thinking person would be appalled at the idea of my belly. The Second Year Shrinking During the second year of university, this years-long toxic mess of body image issues finally burst forth and my weight became the overriding obsession of my life. It started by skipping occasional meals, which then grew to eating once on a good day. I started extreme calorie counting, knowing by heart the intake of a single piece of bread or a single tomato. The scale in my shared bathroom soon became my constant companion. I would weigh myself at least 20 times a day, each time a digit was removed from the scale it sent a surge of joy through my body I had barely experienced before, like the first time you heard the riff of ‘Just Like Heaven’. At the start of this period, which lasted approximately a year between 2012–2013, I weighed roughly 13–14st (83–89kg) and at my lowest I was 7st 3lb (45.8kg). Half my body eroded, lost not to sea but the blank expanse of an empty plate. I used to stand in front of the mirror, watching myself contract inch-by-inch. I thought I had never felt so happy or looked so good. The further my ribs protruded out, pushing firmer against my skin, and as my stomach became flatter and flatter, I became convinced that a sparkling coat of beauty was covering my body. No Diagnosis, No Problem I never sought out any medical help for my apparent anorexia nor my debilitating clinical depression, which had caused me to fail my second year of university. I had an utter conviction that I was not ill, so why would I need help? This was what I wanted, I wanted to be as thin as possible, to make barely a blemish in the world. To me, thinness would lead to an El Dorado of sex and happiness, and I would be freed from the shackles of being me. Anorexia is almost unique in its ability to distort a person’s worldview without lost lucidity, deforming it until the reality of their choices is long lost. As I grew thinner and thinner, I remember a friend begging me to start eating again. My response was simple: ‘I don’t need to eat.’ As Jenny Stevens, Guardian editor and anorexia sufferer wrote, ‘restricting what I ate made me feel invincible: if I could conquer this basic human need then I wouldn’t need anything or anyone.’ As I never sought medical attention, I obviously never received any diagnosis. This, in some ways, has haunted me in the years since I recovered (except for an eight-month relapse during a particularly bad depressive episode, I have never starved myself again) and cast doubt on the legitimacy of my claim to be anorexic. I Was Anorexic. (I think). By any objective measure, I was 100% suffering from anorexia during this period. According to a set of guidelines written by the NHS for diagnosing and identifying eating disorders, my symptoms qualify for 16 out of 22 diagnostic criteria. Had I actually sought treatment from a GP or an eating disorder specialist, it is hard to imagine I would not have received a diagnosis of anorexia. Yet to this day, doubts still gnaw at the back of my mind. Was I really that ill? Given the speed of my recovery, which only took a couple of months following a literal intervention from my friends, is it grandiose for me to claim this label? Am I hoisting my experience atop a flagpole where it does not belong? For me, the lack of diagnosis will always cast a faint shadow of suspicion over this period. I can never fully commit to saying I was anorexic; I always hedge it by saying I’m using the word as an adjective rather than a clinical term. Given the average waiting time for access to NHS mental health services is three months (with some people waiting an astonishing FOUR years), a lack of diagnosis is inevitably going to impact many people. Without a diagnosis, you can fall back into internalizing society’s age-old prejudices against mentally ill people — that it doesn’t exist, that you aren’t ill, that you are wholly responsible for how you feel. In some cases, diagnosis can give validation to their feelings and symptoms, allowing them to accept they have an illness and begin rejecting the idea that their current state is a result of personal deficiency. Of course, diagnosis can be negative, particularly if administered poorly, and can potentially lead to increased symptoms due to fear and anxiety of what these specific clinical terms mean, and how it might affect them in the future. For me personally, diagnosis has been helpful. When I received my diagnosis of Major Depressive-disorder, I felt something shift —  a sense of identity formed, and I had a new language in which to describe myself. We can sometimes fall into the trap of thinking things published on the internet are scrawled in ephemera, words with the substance of breath on a mirror. But they aren’t, they are printed in bold, permanent ink. So, I will say, without hesitation or hedge, I was anorexic. Header Image Source: Diana Polekhina on Unsplash