“Hello? Can you hear me?” was not something I thought I would be saying in the middle of my counselling session. Yet here I was, in my room, trying to hold back my tears after I exposed my emotional vulnerabilities with the only consolation being my frozen therapist on Zoom. This was not the first time it had happened, nor would it be the last, but I have come to accept it as an unavoidable part of online counselling. It is exactly one of the reasons why, as soon as I am able to again, I will be choosing to go for in-person therapy as opposed to sticking with the current virtual way of working. When the first lockdown struck the United Kingdom last March, it was a shock to the system for everybody. It hit at a particularly bad time for me, as I had just received a diagnosis of anorexia a few weeks before which subsequently surged me towards a mental health crisis. I had been studying law at the University of Oxford, and so the academic pressures from my degree were also mounting. To receive this news felt like the blow to the system that pushed it to shut-down. It was clear that I needed help immediately, and with everything shutting down, the only option available was online. Although I knew it was going to be far from ideal, I also knew that some form of support would have been better than nothing. What I was not as prepared for, was just how difficult I would find the experience and how detached I would feel. Telepsychiatry, and online interventions in general, have been discussed before in a blog in InSPIre the Mind. I know that there are potential advantages of this approach, such as improving the likelihood of a patient attending an appointment; for some patient groups, online consultations may actually be preferable to face-to-face consultations. But my experience was different. I reached out to my first therapist on email, and not too soon after we began our work together. The initial process of going to therapy is always going to be slightly unsettling, especially if you struggle with a mental health problem, as opening up may not be something you are used to, and you may have difficulties even with simply accepting your problems and getting to grips with them. It was something I had trouble with and trying to vocalise these doubts with an unfamiliar face on a screen made the words coming out of my mouth feel even more alien. There was nothing human or personal about this connection that made me feel like my therapist was someone I wanted to confide in — for all I know, I might as well have been talking to a stranger on the street and it would have felt no different. Although my therapist became more well-known to me as time went on and eased some of my tensions, it was not long before I experienced them again as my therapist announced that she was going on maternity leave and would have to stop our work. And so, I completed my first course of therapy without ever having met my therapist in-person and knowing her only as an onscreen figure. Not exactly the personal relationship that one would hope to achieve when undertaking something as intrinsically intimate as counselling. Moving onto my second therapist made the initial introductions a little less daunting, as I now had experience of it. Little did I know that a new wave of problems would arise. As mentioned, I had been diagnosed with anorexia last year and it was one of the issues that I was seeking help with. A big part of this was linked to my own body image issues, and one of the major downsides of doing online calls was seeing myself reflected by a webcam in a less-than-flattering angle. During a more conventional therapy session, I would not have to focus on my appearances at the same time as expressing my anxieties around them, yet I felt that I had no choice but to stare at myself and pick out my own flaws in the video setting. Additionally, my therapist had no idea of what I looked like beyond my face, and so while I could talk as much as I wanted to about my dissatisfactions with my body and the way I looked, it was difficult for them to envision this and I subsequently felt misunderstood. Virtual counselling created an environment where my insecurities felt amplified, which was the exact opposite of what I was hoping for. Not only did I feel more self-conscious and exposed, I also frequently found myself at the mercy of the strength of my Wi-Fi. Although the occasional buffering video on YouTube had never stuck me as a major inconvenience previously, it hit a different chord when my sessions lagged and froze, leaving me feeling abandoned. More often than not, the technological glitches would happen just as I had poured my heart out and was in need for some comfort, but the silent reality left many of these desires unsatisfied. It is not a scenario you can imagine happening in a therapy room; you would not dig up your past traumas and deeply hidden thoughts for there to be a complete absence of reaction, and you would likely leave any therapist who did fail to respond. However, this was taken to be inevitable in an Internet setting and creates a situation which is fair for neither the therapist nor the patient. Amidst this unresponsive cyberspace, I find myself yearning for face-to-face therapy where I wouldn’t have to enter every session already feeling anxious about the myriad of problems that could arise. My mind has tried to develop a protective mechanism against the technological difficulties by stopping me from diving into what is hurting the most, yet these are the precise parts that need to be addressed if I am to move on fully. My online therapy sessions feel akin to fixing the surface scratches; at first glance, I appear to be better — yet as soon as anyone tries to prod deeper, they will realise that the inner system is still dysfunctional. The full repair that’s needed can only be carried out in-person, where my therapist can keep a watchful eye out for anything that may derail by observing my body language and offering immediate support when I hit a wall. I am too scared to tread into the most uncomfortable parts of myself if I cannot be sure that I will have a safety guide to prevent me getting hurt or lost, and this is something that online counselling cannot offer as all parties involved have to rely on the unknowns of technology. Although virtual counselling may be better than having no support at all, it does not mean that it is a perfect alternative to working in-person. We need to work together to find better ways to help, whether that would be through socially-distanced appointments, investing in better facilities or providing additional support services. Like many other aspects of our lives, it cannot be denied that the virtual experience simply cannot replace the physical version and so to expect online counselling to be the solution for the ever-increasing amount of mental health issues would be a major misjudgement. If we continue down this route, we risk being confronted with a mentally unwell generation who lost connection with help — much like my Zoom calls.

Trigger warning: This blog discusses personal experiences of anorexia. I am an author and mental health advocate who has lived with an eating disorder for the past decade of my life. This is my story of how, in the process of recovering from my illness, I’ve been able to embrace my authentic self and reject the so-called “norm” I had spent years of my life desperately trying to fit into. Fitting in has never come easily to me. Even as a child, long before I spiraled into the clutches of an eating disorder, I struggled to connect with other kids my age. I was wildly creative and very independent, and I had a way of thinking about things that made those around me scratch their heads. Factor in some underlying anxiety and impulsivity, and suffice to say, I was not one of the “popular kids.” I had a couple of friends, but for the most part, I drifted through my childhood on my own. That was A-okay with me; if anything, it was how I preferred it. Enter middle school. Burdened by a myriad of body insecurities and an ever-growing pressure to perform academically, I quickly became caught up in the competitiveness that pervaded the halls of my school. I had to get the best grades, take the most challenging classes, score the most goals in soccer, lead the brass section in band, and so on. I also felt an immense obligation to fit in and be liked. Struggling to balance academics with my complicated social life, I felt myself spiraling out of control. I was trying so hard to be someone I wasn’t, to hide my authentic self behind a façade of what I thought I was supposed to be, that I was making myself miserable. I needed a way to cope with the stress and found that in restricting food. What began as an innocent diet quickly developed into anorexia nervosa, an eating disorder categorized by a persistent, paralyzing fear of food that ended up costing me a lot more than I had bargained for. In the span of a few months, my grades slipped, I pushed away all my friends, I lost interest in the trumpet, I quit soccer, and I was eventually taken out of school when my anxiety reached a new — and dangerous — level. Alone and afraid, I sunk deeper into my mental illness. The personality I had fabricated to fit in faded, and I became defined by my disorder instead. Anorexia was my identity, and back then, at a time when I was so insecure and unsure of who I was, I clung to that false sense of certainty as if my life depended on it. My closeness to my disorder inevitably made moving on from it very difficult. After two years of going in and out of hospitals, constantly at war with everything and everyone, I finally grew fed up with this hellacious cycle I had fallen into. Couple that with an eye-opening stay on an inpatient eating disorder ward that treated adults as well as teens, and I decided I didn’t want to be imprisoned to my illness for the rest of my life. For the first time since I got sick, I genuinely wanted to get better. In the long and tenuous process of getting better, I had to reject my eating disorder as my identity and essentially discover who I was, if not an anorexic. I also had to find non-traditional ways to accomplish my short- and long-term goals, as my circumstances made it virtually impossible to succeed on the path followed by most. For example, I was never able to return to school full-time, and as a result, I had to take a fifth year. I didn’t even attempt the eight class course loads many of my peers took on; although taking such a rigorous schedule would have allowed me to graduate on time, it could very well have come at the cost of my mental health. Having gone through what I did, I was committed to putting my mental health first, no matter what, as I knew when my mental health was lacking, that jeopardized every other aspect of my life. While my diligent prioritization of my mental wellbeing was often met with skepticism by teens and adults alike, it has been well worth it, as it has kept me solid in recovery and ultimately helped me get to a better place in my life. Returning to school after a nearly two-year absence, especially as someone who is inherently very introverted, made socializing even harder than it had been in my youth. Additionally, the more I was learning about my identity, and the more space I was allowing myself to come into that identity, the more I was realizing how different I was from most — and not only because of my experiences with mental illness. I was also realizing how very undesirable that “traditional” path was, and I was questioning the expectations society has for young people — expectations I had once held myself to. Why were college and a high-paying, nine-to-five job seen as the end-all-be-all? Surely, there was more to life than that; after all, if you weren’t healthy or happy, what was the point of going to a top school, making lots of money, and adhering to society’s very rigid idea of success? In retrospect, it seems inevitable that I would turn to some type of self-destructive behavior when forced to conform to the norm. I’m not “normal,” I have never been normal, and the pressure, the expectation, to be quite literally drove me insane. But my struggles with mental illness, as deeply traumatic as they were, were ultimately a blessing in disguise, in that they instilled in me the importance of being myself and showed me the beauty in difference. Like everything else in my life, arriving at this powerful revelation has been a journey that has taken years. It wasn’t until a few months ago, just shy of my twenty-second birthday and nearly a decade after spiraling into mental unwellness, that I was able to completely reject the need to conform and wholeheartedly embrace the very unique individual that I am. Throughout my mental health battles, writing had been the one thing I consistently found solace in, and when I was seventeen, I wrote and published a novel based on my personal experiences called Changing Ways. In the years that followed, I published two more books centered around the same protagonist to create a trilogy. I’ve known writing is my passion since I was fourteen; recently, I decided writing is going to be my career too and have owned that decision, despite various family and friends — with good intent, I’m sure — telling me how difficult and lonely an artistic career path is bound to be. But I’ve already proven by surviving an eating disorder that I can handle difficulty, and anyway, I’m an independent introvert; I don’t mind being on my own! But my career of choice is really only the tipping point of all that differentiates me from the vast majority of those around me. My lifestyle, as well, as a vegan eco-minimalist, who would rather spend time in nature than on my phone, who doesn’t drink or smoke, and who has never been in a romantic relationship and isn’t yet sure whether that is something I even want, falls way outside of the norm. But, again, I don’t see the harm, nor fault, in that. Living my life this way has improved not only my mental and physical health but elevated my happiness as well. Why would I aspire for a more traditional life, when the one I lead now feels so right and so true to who I am at my core and is also kinder towards animals and the planet? When I reflect on the last decade of my life, it saddens me to think about all those years I spent pretending to be someone I wasn’t, sinking further into a pit of self-loathing despair as a result. Worse still, I know my experiences are not unique. I know there are many others who feel stuck in this system that not only doesn’t cater to difference but often dismisses and degrades it; others who, as a result, may find reprieve in self-destruction, just as I had when I was a teenager. I wish I had known then what I know now, but because I can’t change the past, I feel that the best I can do in this present moment is own my truth and live a life that works for me and that I feel good about — and encourage others to do so as well. There is power in being yourself, especially in a society where you have been made to feel unworthy or unacceptable, and there is freedom in rejecting that traditional path and paving your own. I have found that on my journey of self-discovery, and so can you. Header Photo by Annie Spratt on Unsplash

Attention-deficit and hyperactive disorder (ADHD) is a common mental disorder typically detected in childhood and is characterised by a short attention span, trouble controlling some behaviour (for example, waiting for one’s turn), or becoming overly physically active. This topic particularly interests me. I am studying a BSc in Cognitive and Clinical Neuroscience and am currently doing a placement year at King’s College London; more importantly, I have a cousin who developed ADHD, which led me to do more research on this mental disorder. In this blog, I will be touching on some environmental factors which affect a child’s development, focusing on pregnancy. It is important to note that I will be discussing research I have found which suggests that factors during this period may increase the risk of later development of ADHD, but there are many other risk factors of ADHD which all come into play and so the picture is far larger. Also, the fact that studies show that some factors might be associated with ADHD — as in, they are both present in the same individual — does not prove that they are causally related — that these factors cause ADHD. But they might be important leads to understand this condition. The early stages of an infant’s life are critical in the healthy development of the child and research has long shown that this strongly depends on the mother’s genes as well as her lifestyle, both during and after pregnancy. Experiences or circumstances — the good, the bad, and everything in between — which are present in the early stages of life are critical to the healthy development of a child, both for their physical and mental well-being. There are many factors that influence an infant’s cognitive development (how children think, explore and figure things out), and because of this, mothers are encouraged to be very careful, particularly during their pregnancy, as these lifestyle and environmental circumstances have the potential to have lifelong effects on their children. The Role of Stress Maternal stress during pregnancy can affect the development of the foetus which can result in a delay of cognitive and motor development (for example, a delay in jumping, walking and sprinting as well as a delay in acquiring knowledge and understanding through thoughts, experiences and senses) and possibly not being able to adapt well to stressful situations e.g. the child having constant fear and not being able to relax in a new environment. However, the effects of maternal stress are not clearly shown in the early stages of the child’s development but rather later on. The negative outcomes in research have shown to be more clear cut at 8 months rather than 3 months. Of course, the effects of prenatal (before birth) stress on infants' development seem rather mild, and these effects are only visible at a population level — by studying hundreds of women. Moreover, it’s difficult to establish during which period of pregnancy exposure to stress matters most to the development of the fetus. Research suggests that stress during pregnancy, reflected by a high early pregnancy hassle or a strong fear of giving birth when the women are halfway into their pregnancy, is associated with lower mental and psychomotor developmental scores 8 months after the infant’s birth. This means that the higher the amount of daily hassle in early pregnancy and strong fears of giving birth, the lower mental development scores. The same pattern is found when fear of giving birth occurred late into pregnancy. This means that there could be the potential for a negative impact on the child’s ability of, for example, eye-hand coordination, or memory. Recent findings show that mothers who experience high-stress levels or anxiety during pregnancy may be at a higher risk of having children with ADHD. This tells us that a mother experiencing stress is a very important factor and that this could be a factor influencing the possibility of their child developing ADHD. But how can stress lead to the development of ADHD? One possible explanation is the activity of the hypothalamic-pituitary-adrenal (HPA) axis. The HPA axis is our bodies’ in-built stress response centre and it includes the release of a stress hormone called cortisol, which helps us to cope when we are faced with a stressor, whether that be physical or psychological stress. So, as we discussed in a previous blog, when experiencing high stress during pregnancy, we see increased levels of cortisol release. The placenta acts as a major ‘barrier’ to cortisol and protects the baby from being exposed to too much cortisol as well as from the changes in stress hormones that occur around the time of labour. This increase in cortisol is required to boost the development of the unborn child, and in fact, an increase in this stress hormone improves the chances of the baby surviving in case of premature birth. But, on the other hand, as you can imagine, too much of anything is not good for you, and prolonged exposure of stress throughout the pregnancy increases the levels of cortisol in the amniotic fluid (the fluid surrounding the baby in the mum’s tummy). The role of diet, obesity and use of substances Another risk factor for children’s cognitive development is maternal obesity, and this is considered to be one of the most pressing health problems in this day and age. A pregnant mother having a poor diet — i.e., not obtaining the required nutrition for a healthy outcome — could be harmful to the developing baby as they would not be getting enough nutrition that is required for growth, which may lead to “low birth weight”, that is, babies that are smaller at birth. Research suggests that people who are born with low birth weight are at a higher risk of developing ADHD. Therefore, as always recommended, it is important for mothers to ensure they are consuming all the required nutrition during pregnancy. You may have heard of something called BMI, which is ‘body mass index’. This is a person’s weight in kilograms divided by the square of height in meters. It is an inexpensive and easy screening method for categorising weight — underweight, healthy weight, and overweight. Maternal BMI, so a mothers BMI during pregnancy, has been positively associated with difficulties in regulating emotions and high inattention scores in five-year-old children, as reported by their teachers. Studies show lower cognitive performance is also observed in children whose mothers have maternal weight gain during pregnancy. However, a population-based study found that although high pre-pregnancy BMI increases the risk of ADHD in children, the association is lost when the baby's sibling's BMI is taken into consideration in the analyses, which suggests that further unidentified risk factors may contribute to the propensity to both increased BMI and increased ADHD risk. Interestingly, racial and ethnic background may also play a role in the effects of maternal BMI on the susceptibility of the infant for later development, as suggested by a study which reported that maternal obesity is associated with an increased risk of ADHD in children born to Caucasian women, but not to African American women. There is also an interesting pattern of association between ADHD and substance abuse disorder. Use of drugs during pregnancy can have a direct effect on the fetus, whether it is smoking, drinking alcohol, or even consuming larger amounts of caffeine than recommended. Relevant to ADHD, these substances can affect the child’s developing brain, potentially leading to memory and attentiveness problems. There are many external factors that contribute to an infant’s development and the role of the mother before, during, and after pregnancy that cannot be underestimated. Factors such as stress, obesity, and drug abuse are seen to be associated with ADHD, and controlling these risk factors as best as possible during pregnancy may be important to prevent the risk of developing ADHD. However, we cannot make the assumption that all of these factors directly cause ADHD due to the many factors reported to contribute to ADHD. Later development of ADHD is not all down to a mother’s actions during pregnancy or even genes, but the genes and environment balanced to contribute to the development of every individual.

By Kevin Singer and Sam Ludlow-Broback Fresh off of a long-drawn pandemic, young Americans are struggling with mental health at startling rates. U.S. Surgeon General Vivek Murthy recently warned, “Even before the pandemic, an alarming number of young people struggled with feelings of helplessness, depression, and thoughts of suicide,” adding, “The COVID-19 pandemic further altered their experiences at home, school, and in the community, and the effect on their mental health has been devastating.” A new report from Springtide Research Institute, where we (Kevin and Sam) share about Gen Z with the world, sheds light on just how dire the situation for students at America’s schools and colleges can be. Mental Health & Gen Z: What Educators Need to Know, a result of over 3,000 surveys and 80 interviews with middle school, high school, and college/university students, prompts urgent questions about how schools can provide better support to students who are struggling. In this blog, we will share the most striking findings from the report, including a vision for how schools can better address the pervasive mental health issues faced by students. Schools continue to provide students with more mental health touchpoints than other spaces they frequent in life, making it all the more critical that schools provide the best possible interventions. Just how bad is it? Springtide’s new report suggests depression, anxiety, and trauma are in the air students breathe. Over 1 in 3 students told Springtide they’re not flourishing in their mental health, while 55% say they’ve experienced trauma in the past, and 49% have talked to a mental health professional in the last three months. At school, over a third of students say they feel lonely often or most of the time, while 45% say they don’t know who to go to for help at school with emotional challenges. A recent CDC survey made similar discoveries: 37% of U.S. high school students reported regular mental health struggles during the COVID-19 pandemic. Pressure at school While the pandemic surely contributed to these trends, there have been pressures at school that threatened student mental health long before COVID-19 struck our shared world. Springtide interviewed 80 students for Mental Health & Gen Z, an overarching theme being that schools don’t reflect enough on how unreasonable demands along with “performative” mental health resources create a toxic culture wherein the restless pursuit of college preparation outweighs student well-being. An already startling mental health forecast for students is only magnified for students in the LGBTQ+ community. Springtide found dramatic differences in student mental health when sexual and gender orientation were considered. LGBTQ+ students are more likely to say they feel lonely at school (48%) than heterosexual students (31%), while only 47% of LGBTQ+ students say “I feel safe at my school sharing things about my life” compared to 61% of straight students. Nonbinary students walk an exceptionally arduous path at America’s schools. Less than half (48%) of nonbinary students agree that their school helps them succeed, compared to 71% of female-identifying and 75% of male-identifying students. What can be done? In the interviews, young people continually shared that their school’s mental health initiatives are rooted more in crisis response than crisis prevention. While students struggle under the pressures that schools themselves often create, some felt school counselors placed too much emphasis on grades at the cost of students simply feeling better. “Even your guidance counsellors at school will be like, ‘I’ll help you, but you have to get a good grade on your test because you don’t want your grades suffering,’” Julie, a high school student, told Springtide. Addressing this crisis appropriately will require schools to fully understand and acknowledge the underlying pressures placed on today’s students while instilling a mental health conscious culture where teachers, staff, and students are speaking openly about mental health and supporting one another. Springtide has observed that mental health friendly cultures promote social connection, create achievable expectations, and help students develop a strong sense of purpose. When students feel like they belong at their school, have the tools to feel confident toward meeting expectations, and see a bigger purpose for their lives than “getting good grades,” they are more likely to say they’re flourishing in their mental health. Even more, schools need to rally around their LGBTQ+ students, who find their schools to be less hospitable to success than straight and cis-gender students. For example, LGBTQ+ students are more likely to hesitate to see the school counsellor because “I was afraid I’d be judged” (32%) than straight students (24%). “School counsellors need to advocate for and support LGBTQ students in the face of such victimization,” professors from several schools told Counseling Today. Roberto L. Abreu of Tennessee State University, Adriana G. McEachern and Maureen C. Kenny of Florida International University, and Jennifer Geddes Hall of Clemson University note that “providing training to all students, parents, and school staff is critical to reducing incidents of bullying and harassment and increasing awareness and sensitivity to the issues LGBTQ students confront in schools.” For many students, their school provides more mental health touchpoints than any other setting in their lives — schools are at the forefront of innovative mental health initiatives, and with good reason. Teachers, administrators, coaches, counsellors, professors, and staff meet young people during some of their most formative years. Schools that create connection, and foster alignment between tools and expectations can make a significant difference by engendering mental health friendly cultures where students are taught not just to succeed, but to flourish. If we want to truly promote the mental health and thriving of young people, we have to reimagine core values and metrics of success in American society — not only in our classrooms, but in our communities, and households too. Kevin Singer is Head of Media and Public Relations at Springtide Research Institute. Sam Ludlow-Broback (@SLudlowBroback) is media relations intern at Springtide Research Institute. Header image by Taylor Flowe on Unsplash

Everyone experiences loss at some point. Sooner or later, we all learn what bereavement, an unpleasant but unavoidable part of living, feels like. Humans have been grieving for millennia, and the past two years have been no exception. Recently, many across the United Kingdom mourned the death of Queen Elizabeth II, whilst the ongoing global pandemic has tragically led to more than six million people leaving empty chairs around tables across the world. As a result, millions have been bereaved: in the US, researchers estimate that each death from Covid-19 left, on average, nine people affected. I was bereaved, too. Towards the end of lockdown, my grandmother passed away from an aggressive cancer. She was my first proper loss. Her death stunned me, and everything compounded when travel restrictions forced me to miss her funeral. For several months, I felt eaten up by the grief that followed, and distressed by the strong feelings I had. “Her absence is like the sky, spread over everything” My name is Livia, and I write popular science blogs on everything from archaeology to mental health. As somebody who armours herself with knowledge when times get rough, I started researching grief whilst I was going through it. I read books like A Grief Observed by C. S. Lewis and listened to Sufjan Stevens. Art had an amazing way of making me feel less alone with my feelings, but something about literature and music did not feel enough to answer the questions I had. I wanted to learn the science behind grief and understand what was happening in my brain. Could science explain why human beings grieve — and why loss feels so bad? What I found surprised me, and taught me something really important about myself. In the end, some of the best comfort I found did not come from art and music, but from evolutionary psychology and bereavement science. Feeling intrigued? Here is the amazing — and oddly comforting — science behind grief. Sounding the alarm Before it happened to me, I thought that grieving was mostly like feeling sad, and I was surprised at the emotional turmoil I had. Researchers, however, actually consider bereavement one of the most stressful things we can go through. During the first few weeks of bereavement, the intense release of stress hormones often affects both physical and mental health. Scientific studies have shown that bereaved persons typically have faster heart rates and often have symptoms resembling depression, compared to similar persons who have not recently experienced bereavement. Other common effects after bereavement include abnormal sleep patterns and strong emotions, such as despair, anxiety and anger. This grieving response, which often feels like emotional chaos, originates in the evolution of our brains and how important human relationships continue to be for our species. In her book, The Grieving Brain, neuroscientist and bereavement expert Mary-Frances O’Connor explains that mammals and early humans developed the need for closeness with others for care and protection, which psychiatrist John Bowlby termed attachment theory. It might sound obvious, but our loved ones play very important psychological and biological roles in our lives because when our brains evolved thousands of years ago, our world was stalked by food scarcity and predators, and being separated from somebody was dangerous. Separation instantly had our limbic system sound the alarm so that we would find them again. Ancient brains in a modern world We could theoretically survive without human contact by ordering takeaway and working online from home, but compared to the lengthy timeline of human history, we are still closely related to our prehistoric ancestors and have kept the same prehistoric brains. We are still hardwired to nurture relationships, and when an important person dies, as O’Connor shares in her book, our palaeo brain sounds the same alarm, and struggles emotionally to understand that death means permanent separation. In fact, our emotional brain expects the lost person to return soon — as if they have only gone into the woods to pick berries. That “magical thinking,” O’Connor says, happens even though we can cognitively understand that they will not come back. This dissonance explains why grieving takes time and sometimes becomes complicated — the information simply does not square with the attachment formed inside our minds and the resulting conflict in the brain feels both confusing and upsetting. Adjusting can take many months of waking up and realising what has happened, but the brain works to update itself each day and predicts less and less that they will return, and eventually, the process allows most people to overcome the intensity of early grief. An expression of love Grief, then, seems to be more or less an unfortunate side effect that comes from having close relationships with other people. Some evolutionary biologists even mean that grieving has no biological purpose, as bereavement seems more debilitating than useful. The emotional turmoil instead becomes the tough price we pay for human attachment, which thereby reflects our attachment to the person we have lost. So, when my grandmother died, my strong reaction happened because my brain had been informed that somebody was missing — somebody who had cared for me and taught me about the world so that I could survive and thrive. Her physical absence made no sense because she was there inside my neural pathways, and in responding the way it did, my brain was doing everything it was supposed to, processing her death so that I could, in due time, move forward. Although devastating loss can never be “fixed” by any knowledge, understanding the biological roots of grieving can be really comforting for people going through the scary psychological landscape that bereavement puts you in. It certainly was for me — grieving felt completely overwhelming, but I found comfort knowing that grieving was not beyond scientific explanation, and by helping me understand my emotional state, experts like Mary-Frances O’Connor quelled any anxiety I had about my feelings. Science helped me feel normal during an abnormal time, and eventually, I was also able to find some meaning in it all — by reminding myself that when grief emerges, our brain expresses deep-rooted love for whomever or whatever we have lost. Header image by Brandi Redd on Unsplash.

One in seven adolescents worldwide experienced mental health difficulties in 2019, with depression being one of the leading causes of illness and disability, and the third leading cause of death among adolescents worldwide. As much as 90% of the world child and adolescent population come from low-and-middle-income countries (LMICs) and nearly 80% of the suicides globally come from LMICs, bearing in mind that many of these are left not recorded. These are striking statistics, yet many of these young people are left undiagnosed, without the help they need. The lack of awareness, persistence of stigma, and the lack of resources are some of the reasons we find ourselves in this heart-breaking scenario. But it’s not only that. It’s also the lack of knowledge. In order to help, we need to understand what exactly we are treating. Depression is a multi-layered condition and, as such, it develops as consequence of many factors — nature and nurture being equally important. Most evidence on what happens in depression, from the biological point of view, comes from the studies in adults. When depressed, our bodies are more likely to produce stress hormones such as cortisol or noradrenaline. Signs of chronic inflammation or changes in how different areas of the brain work (some areas showing less activity and some being overly active) are also commonly seen. A range of environmental risk factors, such as domestic violence, or experience of abuse and neglect in childhood, may also contribute to increased vulnerability of becoming depressed later in life. So, how do the pieces of the puzzle come together, and when is the best time to intervene? I asked myself this question some years ago, when I started my journey in the science of depression. I am a research psychologist and my PhD focused on depression and inflammation. Currently, I work on Identifying Depression Early in Adolescence (IDEA) project at King’s College London, which is part of the Brighter Futures programme launched by the MQ: Transforming Mental Health Charity. The IDEA project aims to identify universal risk factors for depression in adolescents and young people, with a particular focus on LMIC, including Brazil, Nepal and Nigeria, which you can read more about in one of our previous blogs published by my colleague. In this blog, I will share with you, what I have learnt so far about the development of depression and how much we know about depression in adolescence. Depression “behind the scenes” Starting from the beginning: if exposure to stress can increase risk for depression, then something must be happening biologically in response to stress. Indeed, when we are faced with a stressful situation, we release a hormone called cortisol, which helps us respond appropriately to the demands of the situation. This is a very clever and efficient system that our bodies have designed, and a very healthy one at that. Right up until it’s not… When we are exposed to chronic stress which repeatedly outgrows our coping strategies, we might end up in a situation where cortisol is no longer capable of doing its job. We become desensitized to its helpful action. Instead, we end up with high levels of cortisol flowing through our bodies which is something we see often in adults and adolescents with depression. Next, is our immune system, and more specifically inflammation. Think about the last time you had the flu and what your mood was like. The chances are, it wasn’t very upbeat, and that’s because your immune system was activated to fight the virus. The state of chronic, low grade inflammation is one of the biological changes often seen in depression, as well as in people who have experienced early life stress. Lastly, studies looking at how our brains function reveal that when we are depressed, certain areas of our brain are less, while others are more active compared with individuals who are not depressed. For example, the area of the brain responsible for processing emotions — the limbic area — tends to be overly active in people with depression whereas an area where higher executive functioning happens such as decision making, planning, social and emotional regulation — the prefrontal cortex — becomes less active. So, how is it all linked together? In a nutshell, early life stress, can push our bodies to manifest higher levels of cortisol, leading to higher inflammation which in turn, can affect our brain functioning. More recently, studies in animals have shown that being exposed to chronic early life stress, leads to higher inflammation through the release of a different stress hormone — noradrenaline — which is part of the “fight or flight” response. To answer my second question, “when is the best time to intervene?”, I would say: as early as possible. It is becoming clear that a large proportion of people develop depression in the first decades of their lives. If we were to develop effective prevention strategies, adolescence would be a window of opportunity to do that. Very recently, I reviewed a worldwide literature looking at the association between biological markers and environmental stress risk factors for adolescent depression. My first reaction was, wow, there are only a handful of studies available and only two from LMICs!!! This was also my first finding. My second finding was that for the most part, these studies seem to reflect what we already learnt in adult depression, i.e., higher levels of inflammation and changes in the activity in different areas of the brain. What’s interesting is that these biological changes are particularly relevant in the context of early life stress. There are two ways these mechanisms appear to work. One way suggests that biological vulnerabilities (e.g., increased inflammation) may only lead to the development of depression within stressful environmental contexts, i.e., experience of early life adversity, but not in contexts of low stress — in science, we call it a moderation effect. Another way implies that early life stress can modify our biology, e.g., how our brains function, which in turn leads to depression — a mediation effect. All in all, these studies seem to suggest that early life adversity and the immune system or changes in how the brain works are closely intertwined with each other, in the leading up to depression in adolescence. My third finding was that we desperately need more research, particularly in LMIC settings, to understand the science of adolescent depression but also to achieve the greatest public health impact. At the moment, we don’t know whether our findings are universal or specific to high-income-countries, as these populations are heavily overrepresented in the research. To wrap it up, I think that having done the worldwide literature review highlighted to me how much still needs to be done in understanding adolescent depression. But this was a good starting point in trying to paint a wider picture of what happens “behind the scenes” when we fall depressed at young age. I also hope that bridging the knowledge gap will bring us closer to identifying those at-risk, working towards raising awareness, reducing stigma, and increasing treatment accessibility, in particular in LMIC settings. If you would like to read more about it, my research findings have been recently published in The Journal of Psychiatric Research. Lastly, I would like to say that although I have been talking about the “path to depression” and how it can manifest in biological changes, it is only one side of the story. The more positive side of this story is that those biological changes can be reversible and that nothing is set in stone, and I will talk about it in my next blog. Stay tuned!

It goes without saying that this year has been unlike any other in our lifetime. Due to the pandemic, many of our usual Christmas celebrations and traditions simply won’t be possible. As I write this, I remember the family gatherings, dinners with friends, office parties and other festivities I took for granted in the past. I miss visiting cosy, bustling pubs in December, full of high spirits, dated decorations and the warming smell of mulled wine. I maybe even miss overheating at the bar whilst wearing three layers and a roll neck jumper. The thing I miss most, is being free to connect with others around me. I admit that I have been reminiscing with rose-tinted glasses and on varying scales, we can all relate to times of difficulty during the festive season. I have decided, however, that indulging in a little nostalgia is okay for now! In fact, it’s looking ahead to the future which has been more of a problem for me. I am a graduate psychologists with a keen interest in health psychology and public policy, and I have already discussed in a previous InSPIre the Mind blog that making changes to our behaviour can be challenging. Indeed, Public Health England have developed detailed guidance on mental health during the pandemic. In November, I got chatting with my good friend and housemate about all this — the long winter nights ahead, the lack of social connection, and the growing uncertainty about Christmas and beyond. She came up with a plan to lift our mood. Being a creative, her plan was based around crafts. For this blog, then, I wanted to explore worry during this (very unusual) festive period, and how craft —such as macramé and knitting — can be a useful tool to help us cope and foster much-needed connection. Winter worry-land As a natural over-thinker, worry and uncertainty caused by the pandemic has at times felt overwhelming, and evidence shows that I am not alone. In the UK, self-reported mental health and wellbeing has worsened since the pandemic began. What’s more, the Centre for Mental Health has predicted that around 20% of the population in England — that’s 10 million people — will need new or additional mental health support as a direct consequence of the pandemic. It is likely that existing uncertainty, worry, and loneliness will be amplified throughout winter. When we are worried or low, we often try to dismiss our feelings on the basis that others are in a worse situation. It is true that the pandemic has impacted people in different ways and to different severities — with the most vulnerable in society most at risk. However, the pandemic has impacted us all. The troubling predictions from the Centre for Mental Health highlight this perfectly. It is therefore really important that we acknowledge our feelings and take care of our wellbeing. There are many things we can do to support our wellbeing, including speaking to loved ones or professionals, taking regular exercise, adopting a regular sleep routine, practicing mindfulness and avoiding watching too much news. Last Christmas, I didn’t know how to craft Okay, so the headline is not strictly true but I enjoyed the Wham reference. Like most of us, I was crafting from a young age and my Mum had numerous unidentifiable creations stuck to the fridge, wonky clay sculptures on the windowsill and pasta necklaces on her dresser. I am not however a naturally ‘creative’ person and I haven’t really progressed much since the kitchen gallery stopped exhibiting my work. So, when the suggestion of craft workshops was first made to help us through winter, I was more convinced that these activities would bring me more stress than calm. Like anything though, it is important to start at your level and have the right support. If I were trying meditation to support my wellbeing, I would start with some short, guided exercises. The key to success with crafts was the same. We started with a simple macramé plant-hanger and my housemate was on hand to guide us through (there are tonnes of online walkthroughs for macramé and more). I found that I had to concentrate intensely on what I was doing to keep to the strings in the right order and tie the knots in the right places. There was nothing else going on in my mind. What’s more, I felt a genuine sense of achievement when it was finished — I had made something by hand and it looked good! My experience mirrors research by UCL and BBC Arts. In a survey with over 50,000 respondents, creative activities such as crafting were found to help participants cope by regulating their emotions. They distracted from stress, gave headspace for problem-solving and facilitated self-development by improving self-esteem and confidence. Other research involved a group of textile craft-makers where participants described how craft was a source of optimism and satisfaction, and these positive feelings helped them prepare for times of uncertainty. Furthermore, in a study that investigated knitting and wellbeing, respondents reported that the repetitive activity fostered calm and relaxation. The knitters were all members of an online community and they felt that knitting in a group improved social confidence and communication. All I want for Christmas is (to see) you It turns out that many people across the UK have been crafting this festive season. There have been online bauble, wreath making, and card making workshops, to name a few. Many businesses are turning to online crafts as an alternative to the traditional office Christmas party. I don’t know about you, but I reached my Zoom-quiz capacity during the first lockdown, so this sounds like a great way to mix things up! What’s more, in a qualitative study of 15 written narratives, participants described how their self-esteem was boosted when praised for crafts given as gifts. They also felt that self-made gifts were an expression of love that would strengthen relationships. So, even if we cannot see each other in the same way this year, crafting together online or giving self-made gifts can provide us with a powerful form of connection. Feeling inspired and enlightened, I reached out to friends and family to ask if they had been crafting this winter. Doing so ended up being a great way to connect in itself, and I was amazed by the variety and talent in their responses. So much so that I have shared (with permission) some of their creations below. This festive season has been both different and difficult. However, there are lots of things we can do to support our wellbeing through this period. Craft can promote wellbeing, by helping us stay in the present, by boosting our self-esteem and by facilitating connection. Another InSPIre the Mind blog previously explored the creative arts and mental health. It describes how other activities such as visiting galleries (many offer great online content) and listening to music can give us a boost, too. So, if making just isn’t for you, appreciating art can also benefit our minds. On that theme, I will take this opportunity to plug a charity raffle for Choose Love organised very by a dear friend at Find a Maker*. Twenty-five raffle prizes have been donated by talented, independent makers and I know I would certainly appreciate having one of their pieces in my house. All that is left to say is Merry Christmas, Happy Crafting and I hope that the new year brings us all a bit more normality. Closes 30th December 2020 Links: Mental health support: Public Health England The Craft Council: Online craft videos Find a Maker for Choose Love: Charity raffle

It’s a sunny day and I’m sitting in the living room with my eldest daughter reading her end of year school report. She’s worried about her grades because not all of them are A’s. She wants to excel in every subject. She wants to be perfect. ‘I’ll work harder,’ she promises. ‘I’ll do better.’ I want to tell her she can succeed at every single thing she sets her mind to, that she can be brilliant at everything all at once, if only she keeps working harder and pushing herself. But I stop myself, because that’s a dangerous lie I told myself for far too long. The Allure of Superwoman I’m a published author of many genres, a freelance marketing consultant, and a guest lecturer on various topics — including writing fiction, creative diversification, and self-branding. Recently I began to contemplate as to why my career is so varied and why I don’t feel fulfilled unless I have too much on my plate (I don’t even stay in the same place for very long, the first six months of 2022 I was in five different countries). The more I learned about the Superwoman archetype, the more I realised that as empowering as it sounds it can actually be very damaging to the physical and mental wellbeing of women. Like anything in life, our definition of worth begins with our childhood. And in my case it was a childhood full of busy women. I was brought up by a Superwoman. An inspirational and loving mother who fought against the limitations of the 60s and 70s, who wore her shoulder pads with pride in the 80s, who juggled children, a career, the home and further education in the 90s. And she wasn’t alone. All the women in my life growing up were like that. In my family it was a competition as to who was the most exhausted, everyone vying for the top spot of the busiest woman. Productive meant successful. Busy meant best. I can’t remember ever seeing any woman sitting down. If these women weren’t at work, they were cleaning, cooking, looking after the children, or sharing their creative skills. All while running their own businesses, teaching, studying, and volunteering on the school board of governors. I soon learned that if you wanted something done, you did it yourself. Asking for help was weak, relaxing was lazy, and lacking ambition was the biggest crime of all. ‘Women before you fought for our rights, so don’t you dare waste the opportunity to have it all,’ my mother would tell me. The Root of the Superwoman Myth The phrase and concept of “having it all” was coined by Cosmopolitan editor, Helen Gurley Brown, in her 1982 book,“Having It All: Love, Success, Sex, Money, Even If You’re Starting With Nothing.” At the beginning women wore the concept of having it all like armour as they smashed their way through the glass ceiling. These Superwomen were (quite rightly) striving for everything they were owed, demanding their right to do it all as a form of feminist defiance against the oppression of the patriarchy. They didn’t care that their workload had doubled overnight because work meant respect. I wanted to be like them. I wanted everything, everything, everything all at once, so I stepped into adulthood fully prepared to put myself last so I could come first. That was the way of the woman. It’s what made us strong, powerful, unbeatable. Superwoman and Your Health Yet with having it all comes the caveat of doing it all — something that the Superwomen I emulated never viewed as oppressive or exploitative, because they were told to wear that exhaustion like a prefect badge. They weren’t to know the long-term effect it would have on their health and that of every woman to come. And how did these women feel? Were they happy, fulfilled, enjoying themselves? They don’t know because no one ever asked them, and they never stopped long enough to ask themselves. Being congratulated and admired for taking on more than your fair share is a very insidious type of control. Women are led to believe that the extra load should be an honour to carry, that they’re ungrateful or selfish if they complain. After all, isn’t that what they’ve been fighting for all these years? And when they can’t cope, they take that as proof that they’re not capable enough, smart enough, strong enough to have everything they want. They don’t want to fail, so they push on through…even if it makes them ill. The Superwoman Archetype is a Con No person should ever have to choose between all the things they want in life, but neither should they feel they have to singularly carry the mental and physical strain of juggling it all at once. The danger of women defining their worth by how busy they are is that there’s always someone whose load has been lightened in return, and they’re normally the ones congratulating us. Because when we keep busy, we don’t have the time to stop and ask ourselves why we are doing double the work. When we are tricked into thinking that exhaustion, a packed schedule, and putting everyone before ourselves makes us a better woman, we ignore our bodies and minds telling us that there is only so much one person can manage. And how do we feel when we reach our goal? Sated? Victorious? Calm? No. We look for more things to do, because it’s the doing that makes us feel like we matter. When we’re busy it’s impossible to remember that our exhaustion doesn’t mean we’re getting ahead in life, it means we’re being exploited. Women are Human. Superwoman is Not It took me thirty-eight years to learn that vulnerability isn’t a weakness but a strength. That true joy is not in how much we do, but how much we enjoy what we do. And that in reality, the world keeps spinning perfectly well when we say no, delegate, or accept help. There’s nothing un-feminist about saying ‘I’m taking a break, someone else can deal with all of this. It was never my job to do it all in the first place.’ My daughter is waiting for my reaction to her school grades. She needs to hear it from me that she is worthy, that she is enough. ‘I am proud of you,’ I say to her, my sweet girl who has spent her whole life watching her mother fight against the urge to keep running, even when her legs can no longer hold her up. Her mother, the woman who finally found the courage to scratch out the ‘super’ from her gender. ‘You can have it all, and you will, but not all at once,’ I say. ‘Who you are is all that matters, not what you do. The only thing you have to strive for in life is health and happiness, so pace yourself.’ She smiles and we sit on the couch together in silence, her head on my shoulder, her hand in mine. There is a lot my daughter will achieve in her life, and I know whatever she sets out to do she will try her very hardest, but this stillness, this quiet, this matters too.

Intellectual ability, such as thinking, reasoning, and remembering, is tricky to measure. This may be the reason why no major advancement has taken place in this field for decades, until recently. I am a neuroscientist, and I spent the past four and a half years researching whether virtual reality (VR) can be used to assess cognitive functions at the Institute of Psychiatry, Psychology & Neuroscience. My PhD focused on developing and validating a novel VR grocery shopping task — VStore. I am passionate about VR because of its potential for the treatment and assessment of mental health conditions. To put my research into context, I will briefly explain what cognition is, why and how it is measured, and finally, I will share what I have learned from my PhD. What is cognition? The word “cognition” is derived from the Latin word cognoscere, meaning “to get to know”. In neuroscience, it refers to the mental processes involved in the acquisition, storage, manipulation, and retrieval of information. For example, the speed with which information is processed, attention, learning and memory, reasoning and problem solving, planning, language, and motor skills. Why and how cognition is assessed? We measure cognition because it is essential for our day-to-day living. Your cognition is at work throughout your waking hours: when you plan your day, learn new information or skills in your job or studies, travel from one location to another, shop, or socialize. Impaired cognition has a dramatic impact on quality of life, as people may no longer be able to carry out their daily activities. This is often the case in traumatic brain injury, neuropsychiatric conditions, such as psychosis (a condition when you perceive or interpret reality in a very different way from others and you may experience hallucinations or delusions), depression, dementia, and even healthy ageing. For this reason, the accurate measurement of cognitive performance is crucial, so we can detect impairment, track changes, and inform treatment decisions. Traditionally, cognition is assessed with pen-and-paper or computerized test batteries that include several tasks — each measuring specific intellectual functions. One example is the Stroop test, which is thought to engage processing speed, selective attention, and cognitive control. When you complete this assessment, you have to name the colour of the word, instead of the word itself. Sometimes the word matches the colour, other times it does not. People can name the colours of words that match the word faster and more accurately, than the ones that do not. This approach to cognitive testing has been in place for a century. However, it is not without limitations. While cognition and successful everyday functioning are closely linked, the measures we get from cognitive tests are poor, and, arguably, how well people manage their daily tasks is more important and informative than some abstract test results. VR cognitive testing VR technology now enables scientists to mirror the challenges of everyday life in a simulated (and controlled!) environment, so real-world or functional cognition (as I like to call it) can be measured accurately. Despite VR being around for a while, we know very little about how people interact with these environments — could the sort of people we want to test complete these assessments, do they cause side effects, do they even measure what we think they are measuring? As part of my PhD, I set out to answer a number of these questions using VStore. First, I wanted to know if doing shopping in VR was something people were able to do easily and whether it caused any unwanted effects associated with VR (i.e. nausea, eyestrain, or headache). I also wanted to test how VStore relates to traditional cognitive assessments and if it can be used to identify people with poorer cognitive performance. We recruited three groups of people and had them complete VStore alongside other measures. The first study included all participants — two groups of healthy volunteers from across the age spectrum (20–79) and a group of people with psychosis. In this study, we found that 99.95% of participants were able to complete VStore, and the task did not cause any unwanted side effects. Hence, we concluded that VStore was safe and viable to use. At this early stage of research, we also found evidence that ageing participants completed the task less efficiently than younger participants. Indeed, volunteers aged from 20 to 29 took ten minutes, while volunteers aged from 70 to 79 took fifteen minutes on average to complete VStore. Our prediction that VStore can be used to spot people with declining cognition was confirmed in the second study, where we successfully sorted participants into young (20–30) and ageing (65–79) groups based on their VStore performance alone. We were also able to predict the participants’ exact age fairly accurately using the VR task. Additionally, we were pleased to find that VStore engages the same cognitive functions as a commonly used computerized cognitive battery. While grocery shopping in VStore, participants had to pay attention, navigate the environment, and learn and process information from it as quickly as possible, use their verbal and visual memory, and plan ahead, just like during standard cognitive testing. You may wonder at this point if VR assessments truly measure cognitive performance or if they may measure something else, such as technological ability. The answer is that they probably measure both. Nonetheless, we found that, while age was certainly important, the difference in VStore performance between younger and older participants was not simply because younger people were more used to high-tech devices. As a matter of fact, most young participants never used VR before taking part in the study. We found similar results in people with psychosis, who took sixteen minutes to complete VStore, while healthy volunteers of the same age and gender completed the task in ten minutes. This helped us differentiate participants with psychosis from participants who did not have psychosis in a similar way we did with age groups in the second study. Why does this matter? The goal of treatment for cognitive impairment is not increasing a score on the cognitive test. Instead, patients, their friends and family, and clinicians hope to improve or even restore people’s everyday functioning so that they can lead fulfilling lives. And, ironically, the simulated VR world can help us assess real-world cognitive functions with a high degree of accuracy and control. VR is an immensely flexible environment where you can put people in different situations. Just with a simple grocery shopping scenario, you can test people in small shops, and larger shops, and control other factors such as the number of people around, the length of the shopping list, or having a shopping list in the first place. These small changes alter what aspects of cognition are measured with a few clicks. The adaptable nature of VR means that it can be practically used for anything, from surgical training through physical therapy to the treatment of mental health conditions. What an exciting future!

I am a Clinical Psychologist and Assistant Professor of Epidemiology and Psychiatry at the Department of Psychiatry of Amsterdam UMC in the Netherlands. In this piece, I would like to share my personal experience with Long-COVID and some thoughts on the research perspectives around it. June 27th: I woke up feeling something strange in my legs. I‘m used to tiredness as I play volleyball at intense levels but this was something qualitatively different; my legs were unnaturally heavy. In those days, I had something else exciting on my mind — I was about to leave for Berlin to meet with colleagues of the Department of Psychiatry and Psychotherapy at Charité Hospital — so I decided to simply ignore that interfering sensation (“maybe it’s just a temporary sickness” I said to myself). But the symptom did not disappear, and instead grew stronger until two weeks later I could barely climb my stairs. I slowly developed all kinds of other symptoms: general fatigue, pain in my arms and chest, and — those that scared me the most — neurocognitive symptoms such as brain fog and confusion. Furthermore, days with cognitive symptoms were also accompanied by sudden and intense states of anxiety. The first routine health checks did not reveal any specific issues. But the symptoms were growing and reached their peak a few days later when I became extremely confused and incapable of functioning. My general practitioner referred me to the hospital to start a deeper examination, but a couple of hours after our appointment he called me back: “I was reviewing your files, I see that you actually had COVID-19 at the end of March (I had a breakthrough infection that, being fully vaccinated, resolved in a couple of days with very minor symptoms). Now you will do all the exams required by the hospital to rule out other explanations. If everything comes back negative, we will reconsider this info”. That is when I started to familiarize myself with what is commonly known as ‘Long-COVID’. The many names of Long-COVID and its impact on public health Several different terms and definitions have been proposed for the long-term sequelae of COVID-19 infection, among which the most commonly used is Long-COVID. More recently, the World Health Organization (WHO) formally adopted the label of “Post-COVID” and proposed a clinical case definition based on expert consensus — for the remainder of this article I will use this label. Post-COVID occurs usually 3 months from the onset of COVID-19; the list of symptoms, which last for at least 2 months and may represent both new onset or persist from the illness, is very long and include, among others, fatigue, shortness of breath, and cognitive dysfunctions. These symptoms have an impact on daily functioning and cannot be explained by an alternative diagnosis. The Lancet recently published a large-scale epidemiological study on more than 75,000 subjects in the Netherlands, showing that one out of eight people with COVID-19 in the general population suffers from somatic symptoms of Post-COVID such as painful muscles, heavy limbs or general fatigue. This concerningly high estimate comes from one of the most robust studies performed so far, in which the severity of Post-COVID symptoms was compared to the severity of the same type of symptoms present before the infection and in non-infected subjects. Nevertheless, an important limitation of the study reflects our evolving comprehension of COVID-19 consequences; the studies developed in the initial phase of the pandemic did not consider including the measurement of neuropsychiatric symptoms. A new overarching review by Penninx et al. showed that neuropsychiatric consequences are instead a hallmark of COVID-19 sequelae, with cognitive impairments, anxiety, and depressive symptoms present months after the infection. The authors of the Lancet study defined Post-COVID as “the next public health disaster in the making”. Considering the actual trend, Post-COVID is projected to have a disastrous impact on disability, healthcare costs, and lost productivity. The WHO states that it is difficult to predict how long Post-COVID will last for any given patient. In my experience, two months after the onset of the strongest symptoms and five months after the infection, major cognitive difficulties have attenuated and I could slowly restart working. But somatic complaints such as fatigue and pain still linger; what if had a physically challenging job? Yet, my daily functioning has been disrupted: I had to re-arrange and reduce my working schedule, I had to give up volleyball, which has been an integral part of my physical activity routine and personal identity since I was a child. Furthermore, reliable diagnostic biomarkers for Post-COVID, such as the result on a specific blood test for instance, are still unavailable; thus, I remain only with a probable clinical diagnosis that could be reached only through a long, burdensome, and expensive path of exclusion of other potential conditions. Research perspectives The unavailability of diagnostic biomarkers is a consequence of our lack of understanding of the underlying biological mechanisms of Post-COVID, further precluding the development of effective treatment strategies. Preliminary hypotheses and data point toward the activation of the immune system, which is the body’s main defence against infections from viruses and bacteria. In Post-COVID, the immune system activity seems unrestrained by the failure of breaking mechanisms such as cortisol (known as the ‘stress hormone’) or triggered by the awakening of latent virus, producing chronic inflammation; the author of a recent study stated that “the bodies of people with Long-COVID are actively fighting something”. There is an urgent need for further research on Post-COVID, measuring not only physical symptoms but also neuropsychiatric consequences, identifying its underlying pathophysiology and the segments of the population at higher risk. Such effort may also deliver useful insights for other fields. For instance, deciphering Post-COVID biological mechanisms may be relevant for psychoneuroimmunology, which studies how immuno-inflammatory dysregulations impact the development of mental disorders, and how such pathways could be targeted and modulated to ameliorate mental health. I am personally involved in such lines of research. At Amsterdam UMC, I am co-PI, together with my colleague Femke Lamers, of the INFLAMED clinical trial testing the efficacy of anti-inflammatory add-on in the treatment of what we call “immuno-metabolic depression”, a form of depression characterized by signs and symptoms very similar to those I experienced such as inflammation, fatigue, and leaden paralyses (feeling that the limbs are weighed down). These days, I’m returning to my work at INFLAMED with the only useful insight I distilled from this otherwise very difficult period: a renewed awareness of the role of immune-related mechanisms in shaping our somatic and mental health. Header image by Georg Eiermann on Unsplash

Major Depressive Disorder (MDD) is a common but serious mental illness that causes symptoms affecting emotions, thoughts, and daily activities, such as sleeping, eating, or working. To be diagnosed with MDD, the symptoms must be present for most of the day, almost every day, for at least two weeks. Though there are many characteristics that are similar between patients with depression, no two people diagnosed with the disorder will have symptom profiles that are exactly alike. I am an Expert by Experience, a Patient Advocate and a Mental Health Professional. I have personal experience with depression. I was first diagnosed in 2010 at just 21 years old, though looking back I believe it had begun a few years earlier already. Recovery was difficult and the illness stuck with me for almost a decade, in lighter and darker shades. Today I feel good, but acknowledge that in daily life I need to be mindful of my thoughts and actions perhaps a bit more than the average joe. The tendencies for depression cannot be shaken away easily; it walks by my side. In my work as a patient advocate, I’ve met hundreds of individuals who have had the same illness, some for a shorter and others for longer periods of time. I’ve lived and witnessed the struggle to find help and suitable treatment. I’ve seen some people struggle with issues that I found easy and personally tripped up again and again on obstacles easy for someone else. What then makes MDD so hard to treat? It is exactly that. Successful treatment is usually defined by the absence of symptoms. However, depression's difficulty lies with its influence on the way an individual thinks. Lowered self-esteem, self-blame, the inability to enjoy the moment and fear for relapse are some issues that often hunt the patient even after a clinical remission of the illness, preventing a full recovery. Often even when a clinical remission has been achieved, a patient with a long history with the illness does not feel this way. This is why measuring outcomes of treatment should always emphasize the patient perspective and medical treatment of depressive symptoms accompanied by psychotherapy, psychoeducation or other psychosocial support. Patient perspective today is measured mostly by interviews and assessments made at an appointment with a professional. More than in the current treatment, professionals should show interest in what depression means to the patient as an individual. There are various symptoms listed in the diagnosis for MDD but not all single symptoms, let alone combinations, present in the same way for different individuals. Some very typical symptoms are indeed almost opposites to one another, such as fatigue, exhaustion and difficulty to self-initiate action, compared with the inability to concentrate or difficulty to rest and relax. For a professional to personalize and recommend a treatment suitable for the patient’s needs, it’s crucial to discuss and measure how the different symptoms present in this individual and which ones the patient feels are the most distressing and obstructive to their recovery. For example insomnia, as a part of depression, can be damaging if not dealt with right. If the sleeplessness continues for a long period of time, it may even develop an impulse to the individual to get stressed by the very thought of going to sleep. However, with an understanding of their issue of sleeplessness the patient and the professional can prepare a coping strategy — for example, organising daily activities to begin later in the morning, which enables them to learn to not get agitated by staying up, which may even make falling asleep easier and less anxious. Another point in the assessment of symptoms of depression that needs to be considered is the patients’ view on meeting a professional. An appointment can be a stressful situation which may alter the results gained by standard testing. Depression is a holistic experience: it is not just a mindset of the blues, but rather the sensation of tiresomeness and anxiety can be very physical. When a patient gets an appointment they already know that the appointments are short and scarce, and that it is their only opportunity to convince the professional of their ill-feeling. Adding pressure to the situation, this causes stress levels to rise which affect the physical body (e.g., causing change in heart rate, glucose levels and alter in hormonal function), which again has a negative effect on the mental health status as well as social competence at that moment. Even though many questionnaires used to determine the severity of depression ask for the patient to answer in regards to the last two weeks, it can be difficult for the patient to exclude themselves from the situation of stress they’re in, and think in a more common approach. A more suitable assessment might be found by asking a patient to fill out the measure, or perhaps several copies, in the previous weeks in situations they feel A) more and B) less depressed, or to keep a journal of ratings for different emotions (“11:30 a.m.: feeling 6/10, not too bad, but don’t have the energy to go out” etc.) for example. This would bring more work to the professional and the patient, but it would also bring very valuable information now lost in translation by focusing on a medium, on how the feelings of depression change in the course of the week or a day, and potentially highlight any correlations between moods, for example, in regards to time, daily activities, eating, sleeping, social interactions or others. It would also propose a great opportunity for a more conversational approach in the realisation that, indeed, even with a severe case of depression, the feeling is not always as depressed as it is when it’s at its worst, which can present an opportunity to discuss thinking how to make the most of even the slightest positive change. Unfortunately, recovery from a severe or long case of MDD seldom means a life without any depressive symptoms — the brain has learned to think in a specific way. For an individual who has suffered from depression, even after recovery, the “negative” feelings may persist —  but what’s worse is they may bring a reminiscing of the past and trigger a reaction towards depression and depressive thinking once again. However, when treatment of depression includes psychotherapy, psychoeducation or other psychosocial help with the possible medication, individuals dealing with depressive tendencies can learn to trust their wellbeing even with all the ups and downs, seek help before a relapse and all in all live a perfectly sound life, such as any other. I should know what I’m talking about; with 10 years of living with the diagnosis, I’m a living example. Recovery from depression is not necessarily an absence of all symptoms, but a way to live regardless of them. NOTE FROM THE EDITORS: Thank you, Fanni-Laura, for sharing this lovely piece on your personal experience with depression and for highlighting the importance of the patient perspective — and for your pictures and photos! Fanni-Laura Mäntylä is a Mental Health Activist, a Patient Advocate and a Mental Health and Substance Abuse Work Professional. She was also the Chair of the 5th Edition of European Health Parliament: Committee on Mental Health and Healthy Workforce (2019–2020). Thanks again, Fanni-Laura — look forward to reading your next piece!

Imparting a Love of Music — But Does it Go Beyond Enjoyment? I remember the feeling of euphoria the first time I played the drums. At 14-years old I thought I sounded world-class, although my neighbors probably would have disagreed! Practising for hours a day, over many years, I climbed my way to the top of my profession. During my career, I have drummed for some of the world’s biggest pop stars. Playing on live television with artists like Lionel Richie, Ricky Martin, Rhianna, and Nelly Furtado came with prestige but also a great deal of pressure. When an artist performs on television they need to sound amazing to not only sell as many singles or downloads as they can but to maintain their reputation. The supporting musicians need to play their parts perfectly, leaving no margin for error! That being said, it was a great deal of fun sharing the spotlight with someone who had sold over 40 million CDs. Playing live shows also means a lot of travelling and a lot of late nights. Once my first son was born I decided I wanted to stay closer to home so I could help raise him. In the past, I had been offered teaching jobs at schools but turned them down due to a hectic touring schedule. When my son turned 3 months old I was offered a job teaching drums at a school, the timing (which is always crucial in all aspects of music!) was right. I truly found that teaching children gave me a powerful sense of fulfilment, one that I hadn’t found on the stage. It brought back the emotions I myself had felt as a child the first time I learned how to master a complex drumbeat. I was now experiencing this again but through other kids' eyes.# Fast forward to the now, and over my 23-year career as a drummer, I have taught music to hundreds of students. Interestingly, this has included many with learning difficulties such as Asperger’s, autism, and attention deficit hyperactivity disorder. I find teaching these students simultaneously the most challenging and the most fulfilling. ADHD is especially interesting to me as it impacts attention span. Something crucial in learning, and especially in learning a musical instrument! But more so what I have found over the years is that music really helps these children! Let me give you an example. I recently started teaching an 8-year-old boy who has ADHD. In our first lesson, I started with some warm-up exercises, playing a few simple rhythms on the snare drum and having the student copy. I was amazed at how quickly he was able to correctly replicate the rhythms I was playing. During the lesson, his face lit up with joy each time he could play a new beat, and I could see the boy’s energy level change to the point where the drums made it easy for him to relax. This newfound ability he had tapped into boosted his confidence and made him smile from ear to ear. Next, I wrote out some basic music notation which he had no problem understanding. He told me that drum music was like the maths he was doing at school. Spot on! This is because music notation is fractions; quarter notes, eighth notes, and sixteenth notes. Making the connection between music and maths was a light-bulb moment for this young boy. Fast forward a few weeks and I received a very emotional call from the boy’s mother, where she described her son’s prior struggles with learning and being able to focus on tasks. She then went on to explain just how engaged he was in the drum lessons, practising daily without being asked and the difference it had made to his everyday behaviors. He had found something that he was in tune with that brought him joy, and also focus. Drumming is such a social instrument because of the interaction with other members of the band. Having to concentrate and focus on the beats to stay in time with the other instrumentalists takes a tremendous amount of skill. This sense of achievement can greatly help people with ADHD, as often those with the disorder can have difficulty making or keeping friends. In fact, there is a growing body of scientific evidence suggesting that the practice of music is related to a number of cognitive benefits. Specifically, with regards to ADHD, scientists have found that musical therapy strengthens attention and focus, as well as social skills and it reduces hyperactivity. Music provides a structure, through rhythm, which is very soothing to a person with ADHD who is struggling to regulate themselves to stay on a linear path. I think this is simply amazing, and while I wouldn’t suggest my life-long career could be considered a rigorous scientific experiment, I can honestly say I have seen these benefits for myself over the years. I don’t profess to be an expert in learning difficulties per se, but after 23 years I’d like to think I have learned a thing or two along the way with regards to drumming! I have noticed several key elements that make a difference when teaching students music, especially those with learning difficulties. I’d like to share some of what I have learned and maybe it might inspire another teacher, lead to the discovery of the next Dave Grohl, or more importantly help someone else navigate their ADHD journey: Engagement For me, the most important thing to do in teaching someone with ADHD is to look for ways to actively engage them. Asking the students questions, having them write things out, and copying things that I do, I find really helps the students learn things in a timely and efficient manner. Timing Timing isn’t only important from a musical sense, but the length of a lesson also needs careful consideration. The attention span is one of the biggest variants in learning, and keeping students interested, is key. This is especially important in students with ADHD given the nature of the disorder directly affects attention span. I break down each 30-minute lesson into six five-minute segments. This means the student only needs to focus on 1 piece of information at a time, for a short amount of time. This very simple system has helped me over the years. Material I have found it is a lot easier to keep the attention of a student with ADHD if they are learning music that they thoroughly enjoy! This probably applies to all students really, to all of us as we are learning! I always ask my students what their three favourite songs are. I then pick the one that has the most lively and funky beat and we focus on learning that. In general, playing upbeat music makes people feel good. The performer cannot help but feel lifted by the positive and frenetic energy of a great drumbeat. Singing Music Notation This is essentially ‘beatboxing’ where I sing the rhythm with my mouth instead of playing it on the drums. It is a lot easier for a student to do this initially because there is no coordination of the limbs. It is also a lot of fun! Singing drumbeats can make even the most sophisticated-sounding person sound like a caveman, “Boom, boom, cha, chuga,chuga, boom!”, and illicit a lot of laughs which we all know helps with anxiety and the release of tension. Fun None of the above components would work if music lessons weren’t fun! I always spend the last few minutes of the lessons letting students with ADHD play whatever they want on the drums. Regardless of if it is right or wrong. Playing the drums loud and fast gives many people immense joy. Me included! Music is more than just sounds and enjoyment, it is a way for people to express themselves, to be understood, and to find a place for themselves in this world. Every student I have taught with ADHD has flourished while having this outlet in their lives.… My hope in writing this is that it might spread the word a little more on the magic and power of music!