Thoughts on guidelines from a mother and researcher As a mother of two small children, the subject of screen time is something that often occupies my mind. As many other parents can probably agree, an episode or two of Paw Patrol can be quite helpful in the afternoon if anyone is to ever have some sort of homecooked meal — but somehow, the “screen-guilt” still often creeps up on me, with all the different opinions out there about how much is too much, and an increased focus on the possible negative impact on the mental wellbeing of the children in the long run. In Denmark where I live, we have no official recommendation on cut-offs regarding screen time, and most of the time I am able to trust my gut and tell myself that my kids are not damaged by the amount of screen time that we currently allow at home. But recently, the debate flared up in Danish media once again, following the publication of new guidelines from the Norwegian health ministry, Helsedirektoratet, recommending no screen time at all for those under the age of two, and no more than an hour a day for those between three and five years of age. The reaction in Denmark (being quite close neighbours with Norway) was immediate - should we follow in their steps with an official recommendation on completely eliminating screen time for the youngest? Admittedly, my first reaction came from the mom within — we would of course have to completely turn off all devices at all times so as to not risk the development and future of our kids! I am a medical doctor from Copenhagen who completed her Ph.D. in neuroinflammatory processes in psychotic disorders. As well as being a mother, being also a researcher, I luckily tend to be quite skeptical by trait, and once I had gotten over my immediate panic I started to wonder; do we really know enough to be this confident in the discussion of children and screen time? So, I started researching on what grounds these new Norwegian guidelines had been formulated. Everywhere I looked — from the comments of those that highly welcomed this new banning of screens as a corroboration of their previous beliefs, to the established Danish media — all I could find was that it was based on the guidelines by the World Health Organization (WHO) as if that should be enough to end any debate on the topic. I quickly realized that I would have to go directly to the source to figure out what sort of evidence existed out there. But, digging into the material published by WHO themselves turned out to be quite the task, with more than 100 pages in total if one also wanted to evaluate the actual data behind the guidelines. So instead, I decided to approach the topic in a different way; I set out to read up on the opinions of researchers and experts on the matter, in the hopes that they would have been less lazy than me and had actually taken the time to read through it all. Gladly, I found that I was not the only one wanting to add nuances to the debate. In an article by the Guardian, experts raised concerns about the lack of evidence. They highlighted the complexities that arise with, for example, having a household with children of different ages, in which it seems next to impossible to spare the youngest of any exposure to television. Similarly, the Danish health ministry, Sundhedsstyrelsen, has reacted with caution to the guidelines, and will continue with a softer approach to guidelines for screen time, with recommendations for the youngest such as “make sure that your kid does other things than watch screens” and “do shared screen activities with your kids”. Likewise, the UK’s Royal College of Pediatrics and Child Health stated that they were unable to recommend specific cut-offs based on the current evidence, and highlighted instead the importance of individual needs and thoughtful use of screens. With this, I am in no way saying that children should just have completely unlimited access to screens, nor am I stating that screen time is harmless regardless of the amount. What I end up concluding is that we do not really know yet. There are a lot of problems with the current evidence, including the amount of studies, but also the impact of many factors other than the screen time itself, such as socioeconomic status. When both the American Academy of Pediatrics and WHO recommended no screen time at all for the youngest ones, they did not do so because we knew that it harmed the children — they did so because we did NOT know IF it harmed them, and it seems that the benefits of screens on development at this age is very limited. This distinction is important. The risk with strict recommendations, as opposed to an open and informative discussion, is that it adds a lot of pressure on the daily lives of parents, a group of people who rarely find themselves needing more things to worry about. Conveying not just the guidelines, but the evidence (or lack thereof) that was taken into account in the decision making, can help nuance the picture, and perhaps alleviate some of the screen-guilt that can arise with even just occasional use of screens in the busy lives of today’s families. So how will I approach screen time at home going forward? I am not sure that my mind is completely made up, and I will definitely keep an eye out for new evidence emerging. But one thing I can honestly say: there is no realistic chance of us reducing screen time to zero.

Trigger warning: This blog talks about eating disorders and disordered eating. Due to the context of this blog post, I will refrain from using exact calorie information. Details can be found in the sources mentioned where applicable. A triggering main with extra anxiety and a side of half-baked health policy, please! Calories on menus — are you optimistic about the autonomy this change promises, or fearful about damage it could be inflicting? Or are you indifferent, observing neither help nor threat to peoples’ eating behaviours? Having lived with an eating disorder during my undergraduate years, my reaction last year to the announcement of putting calories on menus was one of concern. How did we see almost 50% more eating disorder diagnoses in 2020, yet this new legislation may provide a more challenging environment for those developing and recovering from eating disorders? Especially in an environment where getting help for eating disorders, including early intervention, is harder than ever. Whilst acknowledging that for some individuals, calorie information may be a helpful starting point for looking after their health more, it’s quite the opposite for many who struggle with eating disorders and disordered eating behaviours. This legislation was proposed by the Department of Health as part of their plan to reduce obesity, and it will be interesting how the Office for Health Promotion plan to ‘tackle obesity and improve mental health’ with this universal change in food labelling. To note, this perspective of this blog does not necessarily extend to other topics regarding food, nutrition, and physical health. Broadly, there remains a need across the population for adequate and healthful movement, and sufficient nutritional intake that reflects up-to-date research about the roles of different foods in our health. Neither is this blog anti-diet, or written to discourage one to discard responsibility for their own health. Rather, this is an observation of a population-wide change that could be as intrusive and dangerous for some as it is helpful for others. A healthy relationship with food must also be considered alongside the challenge of defining a healthy intake of food. What is the calories on menus legislation? On 6th April 2022, the new Calorie Labelling Regulations came into force. This means that large businesses serving ready-to-eat food, e.g., restaurants, bars, bakeries, cafes, must display calorie information on menus (at tables, menu boards, electronic and take away) and on food items on display. This also includes all hot drinks. The following must be displayed: The energy content of the food in kcal The portion size to which the calorie information relates The statement that ‘adults need around [common number] kcal a day’ Additional guidance states that the information is easily visible “by using the same font type or style of lettering, colour, size and background [as the] corresponding food item.” What might be particularly challenging about calories on menus for those affected by disordered eating, especially with restrictive elements? Many of us will have been, or are, ruled by calories. Every decision surrounding food and physical activity can be difficult. Essentially, anything linked to energy input or energy use can be governed by the underlying fears that drive eating disorders, and followed by the related guilt. Whilst we are not asking the public to tread on tiptoes around disordered eating, there is no doubt that eating disorders can be damaging. For many, attempting to leave and recover from disordered eating, forgetting kcal figures from both food and physical activity is a vital challenge that’s necessary to overcome the automatic mental arithmetic that results in restrictive or dangerous choices. Therefore, it can be unnerving and even triggering to be confronted with calorie information that appeals to current and historic disordered thinking. Not to forget all those who may be vulnerable to developing an eating disorder and disordered eating patterns, due to the normalisation of reducing the role of food to the calories it provides, or as the rhetoric pushes, to the calories it ‘saves’. What about the existing calorie information on most packaged and supermarket food? Usually, the calorie information, unless advertised as a selling point, is much smaller in print that the name of the product, and not often near the price information. So it is much easier, as many of us are used to doing, to avoid calorie information on such packets because it is not forced in front of us in the same size font. Familiarity with these products can often help too. Additionally, it’s not the crude calories alone listed on these products, but more useful nutritional information for more people, eg. carbohydrate measures for those with diabetes. Considering reasons for calories These changes do help introduce a choice for those who are interested and have no underlying disordered eating cognitions. Also, it may help particular individuals with the management and prevention of health conditions, for whom, under medical supervision, it is advised they maintain a specific calorie intake. If only we had a blueprint As Prof Tim Spector commented, “While the calorie can crudely measure the amount of energy in a food, it fails to account for the differences in how an individual will process that food and take energy from it, or how differently a food will be digested based on its processing or cooking methods.” Similar changes in calorie labelling in the US have resulted in little to no observable beneficial impact on peoples’ food choices, as found in this systematic review and meta-analysis. A 2018 Cochrane Review looking at nutritional labelling on menus found, little evidence that calorie labelling significantly reduces consumers’ choice and total consumption. There were only three randomised controlled trials, all of low quality, that suggested that calorie information on menus may result in a small reduction in the number of calories someone purchases. Numerous professionals, clinicians, and advocates have spoken out about the danger of calorie labelling in this format, as highlighted in Beat’s response to the government’s plan, before it was implemented. Beat is the UK’s leading eating disorder charity, providing a national helpline, advocating for more education and treatment of eating disorders, and supporting family and friends close to those with eating disorders. Beat’s recent survey of people affected by eating disorders in Wales shows that 98% of those surveyed think that calories on menus will have a negative or very negative impact, and 96% did not agree with the introduction of calorie labelling. Will calorie information ‘fix’ weight management? In a recent blog post about weight management, Registered Dietitian Kaego Okafor unpacks the complexities of weight management. Two of the key reasons why weight management may be difficult are emotional eating and habitual eating. Many of those who seek weight management identify emotional eating and/or habitual eating as a struggle, so things like finding coping mechanisms, forming new habits, and re-learning fullness and hunger signals. Kaego said that those who are encouraged to take part in weight management do know the basics of nutrition, but are not fairly equipped and encouraged to work through and process determinants, like emotions and stress, that influence eating behaviour. The relationship between nutrition and weight is not a simple, single-factored causal relationship. Are calories on menus just a sticking plaster? Calorie labelling is a relatively cheap strategy, and effectively attempts to shift the responsibility of eating behaviours, food choices, obesity and related health concerns onto the individuals in our population. This move bypasses the responsibility of the government, businesses, and societies to provide a variety of foods across the nutritional spectrum that are accessible and meet individuals’ needs. Even with disordered eating concerns aside, this calorie strategy alone sweeps a host of problems under the carpet. With increasing food poverty, demands on people’s time due to factors such as employment and financial stress, surely calories on labels are a savvy way to give the visual impression of public health change, but perhaps with little real health benefit across the population in this current context. — — — Do you struggle with calories on menus? Phone ahead to ask if a restaurant also has menus without calorie information — this is legal when provided upon request. Not all chains are aware this is allowed (discussion with waiting staff, May 2022). Choose the same dish as someone else on the table, or ask waiting staff what they would recommend Ask someone to read the menu aloud without saying the calories If the menu is single-use, ask someone or yourself score out the calorie information with a pen, or fold the menu to hide the numbers If comfortable, quietly let one of your party know you would prefer not to look at the menu but use one of these alternatives provided. They can help look out for anything helpful and minimise any attention. Resources Podcasts: Don’t Salt My Game, Train Happy Podcast, The Head First Podcast, Food Psych Podcast Instagram accounts: @DieteticallySpeaking (Disordered Eating Specialist Dietitian), @MyLifeIsForLiving (trainee Clinical Psychologist), @HopeVirgo_ (Campaigner), @R_McGregor Renee McGregor website (Sports Dietitian), @DrJoshuaWolrich (NHS Doctor & Nutritionist), @KaegosKitchen (Registered Dietitian), @HeadFirst0 (Health Psychologist), @PixieNutrition (Nutrition Counsellor & Psychotherapist), @IsaRobinson_Nutrition (Registered Nutritionist and Nutritional Therapist) @EmilyTalksRecovery (Journalist) Books: Just Eat It — Laura Thomas PhD The Inside Scoop on Eating Disorder Recovery: Advice from Two Therapists Who Have Been There — Reichmann & Rollin Beat (UK Eating Disorder Charity) Helplines and Getting Help Interested in taking part in eating disorder research? Find out more about EDGI (Eating Disorders Genetics Initiative), a research study exploring the genetic and environmental risk factors in individuals who have experienced an eating disorder. — — — Header photo by Anna Shvets

Last year, I wrote a blog on how early life stress can affect how our bodies work and how it can lead to feeling depressed. In particular, I spoke about how being repeatedly exposed to stress can sometimes overcome our coping strategies leading to feeling helpless, and even depressed. This happens when the stress hormone — cortisol, which we produce in response to stress and which helps us cope with it, is no longer efficient at doing its job, meaning its higher levels stay in our bodies. Often, adults with depression have higher levels of cortisol. I am a Research Psychologist and I am interested in depression in adolescents because that’s when it starts for a lot of young people, and that’s when we should start intervening. Depression in adolescence is a global health concern, being one of the leading causes of death in adolescence, with an estimated up to 11% worldwide prevalence pre-pandemic and 25% prevalence during the pandemic. Seeing the impact of this condition on young people’s lives, together with my colleagues as part of Identifying Depression Early in Adolescence (IDEA) project, launched by the MQ: Transforming Mental Health Charity, we wanted to understand the risk factors for depression in adolescents and young people worldwide, with the hope of informing more effective intervention strategies. We were particularly driven to do so when we saw that not many studies looked at depression in youth, with the majority focusing on adults. Now back to cortisol, seeing how it was linked with depression in adults, I delved into the literature to understand whether it was also the case in adolescents and young people, and this is what I would like to talk about in this blog. Cortisol and depression in adolescence — worldwide perspective I did a meta-analysis which is an analysis of the pooled results from all the studies available on the topic. I looked for all the scientific studies published worldwide that focused on cortisol as a risk factor for depression in adolescence. It is a powerful tool as it helps us look at patterns in bigger samples, much more than when looking at a single study. These findings were published this year in Psychoneuroendocrinology so if you are interested to read more about them, you can find them here. First of all, I found only 26 studies on the topic (compared with hundreds on cortisol in adults)! And, even less, only 3, were done in low-and-middle-income countries (LMICs)!! I mention this because 90% of adolescents worldwide live in LMICs, which means that we barely have any studies done to understand risk factors for depression in most of the adolescents out there! This is a massive research gap and one that needs to be addressed (for all of the researchers interested in the topic, that’s a hint there). Patterns of cortisol in adolescence — when healthy becomes unhealthy There are several ways to measure cortisol, which is most often analysed in saliva. We can look at resting cortisol levels right after waking up, in the first hour from awakening (cortisol awakening response), and at different times throughout the day, either individually or altogether to see how it changes throughout the day (diurnal cortisol). We can also look at how we produce cortisol at night from the urine. Then, we can look at cortisol reactivity, i.e., how our body reacts to stress — cortisol stress response. So, what do these measures tell us? When we are healthy, typically our cortisol would increase when we wake up and our cortisol awakening response will be higher compared to cortisol levels in the rest of the day. This is because we need that “boost” to start the day and as we wind down as the day comes to an end, we are relaxed and ready for bed. When we respond to stress, our cortisol levels rise just enough to cope with the situation, following which they return to baseline. When we experience depression, often what we see is that this pattern is dysregulated, and that self-regulation is disrupted. And this is what we found in our meta-analysis. Specifically, adolescents who went on to develop depression showed higher levels of morning cortisol compared to adolescents who did not develop depression at a later stage. What was interesting is that we did not see any difference in morning cortisol levels in adolescents who were already depressed compared with those who were not. This is interesting because it suggests that higher levels of cortisol can be detected before depression develops, almost like a signalling system telling us what might happen next. In terms of other cortisol measures, we had very few studies to be able to draw strong conclusions. However, it is worth mentioning that few studies reported higher night-time cortisol, cortisol awakening response, and cortisol stress response to be linked with depression. Neither diurnal nor afternoon nor evening cortisol was associated with depression. As much as what we found gives us a better picture of what might be happening in our bodies before we develop depression, this is only a fraction of the picture, based on a few studies. As a Research Psychologist, I am curious to understand what sets off the cortisol dysregulation in some but not others and what is the role of the environment in all of this. I guess these are the questions that I will be looking to answer in the future and once I learn more about them, I will most definitely share them with you on this platform! Header image source: Photo by Nataliya Vaitkevich on Pexels

“Table for two?” It feels good being seated once again at my favourite local restaurant and I’ve never had a better excuse to spend my money now that I am officially ‘Eating Out to Help Out ’. The smell of food and the chatter of strangers in conversation around me is what I’ve been craving. It has been nearly 3 months since the UK began to emerge from lockdown. Despite the tables being carefully set 2 meters apart and my waiter smiling at me from behind a visor, life is beginning to feel normal again. I’m distracted by a sinking feeling when I think of the spikes in coronavirus cases being reported in cities around the world after easing of lockdown restrictions. What if it all happens again? I know I’m not alone in thinking this. With the threat of a second wave looming over us it is easy to feel pessimistic about the upcoming winter. My name is Ffion, I’m 25 years old, and COVID-19 came crashing down on me in the middle of my PhD studies at King’s College London. I work in a research lab in the Department of Immunobiology. You’d usually see me in my white lab coat, pipette in hand, running experiments to probe the function of a type of white blood cell called regulatory T cells which protect us against autoimmune diseases. But since March I’ve been working from home and although I feel lucky to have kept my source of income, prickles of tension run up my spine when I contemplate what another lockdown might mean for my PhD. Like many people, I’m also experiencing waves of apprehension about the future following this pandemic (e.g. financial insecurity and feeling powerless to help loved ones). One of my coping strategies has been to keep up to date with the ever-evolving coronavirus research. In this blog, I would like to share some recent research updates which have made me feel optimistic that we are now better equipped to deal with future outbreaks and that our efforts to contain the virus have not been in vain. The Great Vaccine Race From the first experiments in test tubes to the sharp scratch at your GP surgery, the journey of developing vaccines typically takes up to a decade of research. But with the pace of coronavirus research being repeatedly described as ‘unprecedented’, the first vaccine arrived in human trials in mid-March, just over two months after COVID-19 was declared a pandemic. Since then another 36 candidates have begun clinical trials in the hope of becoming the first preventative coronavirus therapy in humans. Some critics have expressed concerns that if safety is not prioritised over speed, this could endanger lives and fuel vaccine scepticism. But bodies such as the World Health Organisation and the Coalition for Epidemic Preparedness Innovation (Cepi) are overseeing the COVID-19 vaccine developments to ensure that rigorous safety testing is upheld. All these vaccines share the common goal of stimulating a pre-emptive immune response against coronavirus so that the immune system will be ready to fight off the virus when it’s encountered again. But the vaccines in trial are all slightly different in terms of the biological building blocks they contain which can trigger immune cells to recognise and attack the coronavirus. DNA/RNA vaccines use coronavirus gene sequences as these building blocks. These vaccines contain genetic material from the coronavirus which is used by our own cells to produce coronavirus proteins. These proteins can then trigger a protective response from our immune system against the virus. New drugs are put through to 3 main phases of clinical trials before they are approved for use in humans. The phases are put in place to ensure that the drug is safe (phase I) and effective compared to any existing treatments for a disease (phase II+III). The drug is tested in increasing numbers of people with each phase and it must pass each phase to progress to the next one. On the 27th of July an RNA vaccine developed by Moderna and the National Institutes of Health entered its third phase of clinical trials. Another promising candidate in the limelight is ChAdOx1 nCoV-19, developed by the University of Oxford and AstraZeneca. This is a viral vector vaccine which uses a harmless virus to actively deliver the coronavirus genetic material into human cells, and again this material can be used to make coronavirus proteins. This vaccine has passed its Phase I trial and is now in Phase II/III trials to test whether it is effective enough to prevent coronavirus in the general population. Another method is to use coronavirus proteins themselves as the vaccine’s building blocks; an approach used by Anhui Zhifei Longcom’s vaccine which is currently in phase II clinical trials. Historically, vaccines have had notoriously high failure rates in early stages of testing. Indeed, it has been 36 years since HIV was identified as the cause of AIDS and there is still no vaccine to protect against this virus. But I feel encouraged that there is a wide variety in the design of the coronavirus vaccines in clinical trials. In my view, this variety makes it more likely that one of these strategies will succeed. But it is also important to remember that the first vaccine will not necessarily be the best vaccine, so don’t be disheartened if these early candidates fail, as there will be many more to come. Long-term immunity to coronavirus: how long is a piece of string? A paper published by researchers in my department hit the headlines a few weeks ago. Naturally, I was keen to read up on the findings, but when I read the title my heart sank. The research led by Dr Katie Doores related to coronavirus antibodies — small proteins which our immune cells produce to help fight off the virus. Distressingly, the research showed that these antibodies diminish dramatically within months after a person recovers from coronavirus. The media reacted with horror. This finding suggested that the immune system may forget how to tackle coronavirus just months after an initial infection, meaning a person could become repeatedly unwell and pass on the virus. This would also spell bad news for vaccine trials as triggering immune memory of viruses and bacteria is the basis of vaccination . Our immune systems must remember how to eliminate the virus after vaccination to stop us falling ill from it again. But the good news is that antibodies are just one component in the complicated system which equips us with long-term immunity to diseases. The cells which produce these antibodies and allow your immune system to react rapidly to bugs that have made you sick in the past are called memory B cells and memory T cells, and these can survive for decades after exposure to some diseases (e.g., measles). Evidence now shows that coronavirus-specific memory T cells are detectable in the blood after coronavirus infections, and in some studies these memory cells could be detected in people without symptoms. It is too early to know how long a person is immune to coronavirus after an initial infection, but this data showing that coronavirus memory T cells do exist gives me hope that these cells could persist longer than the coronavirus antibodies analysed in the above-mentioned study. I remain optimistic that gaining long-term immunity to coronavirus may be possible, but only time will tell. Lockdown Logic Months of working from home and being separated from loved ones has inevitably tested our emotional endurance. I think it’s crucial to answer one question to ward off lockdown/social distancing fatigue: was lockdown really worth it? Well, new data from Italy answers this question with a resounding yes. Northern Italy saw coronavirus cases soar in March and so it was hoped that lockdown would prevent its spread to other regions. A survey carried out by Italy’s Health Ministry and National Statistics Agency has highlighted clear regional differences in the proportion of people who have coronavirus antibodies. In Lombardy in Northern Italy, 7.5% of the population were estimated to be positive for antibodies, compared with only 0.3% in Sicily in Southern Italy. This proves that their lockdown was effective in stopping the spread of the virus from the centre of the outbreak in Northern Italy to the rest of the country. Also, while Lombardy imposed lockdown when the coronavirus outbreak in the region was well established, lockdown in Sicily was imposed when there were very few cases in the region and this early lockdown clearly prevented more people from contracting the virus. Ultimately this shows that our efforts to adhere to lockdown rules in the UK have not been in vain. In addition, a recent outbreak in Herefordshire was successfully contained through strict testing and self-isolation procedures. I feel reassured that we are now better equipped to respond to local outbreaks than earlier this year. Beyond Vaccines: keeping the immune system in check with drugs Although vaccination is seen as the holy grail of coronavirus treatments, tackling this pandemic will also require effective drugs to help people make full recoveries if they do become ill with the virus. Researchers now know that some of the worst symptoms experienced by patients who end up in intensive care are actually caused by their immune cells over-reacting. If a person’s immune system runs completely out of control while trying to clear an infection this can cause irreversible damage to their lungs and other organs. Anti-inflammatory drugs are now being trialled to moderate the immune response towards the virus, with the aim of reducing the likelihood of people ending up with life-long tissue damage. Early-phase clinical trials of old, effective drugs, such as Dexamethasone and Interferon-β, are both showing promise as drugs which keep the reins on the immune system during active coronavirus infections. If these drugs are successful, people who do end up in hospital this winter could be more likely to survive than those who were admitted earlier this year. To conclude, I urge you to see past the grim headlines attempting to predict the future of this pandemic. It is too early to answer some of the most pressing questions, so we must focus on the positives that we are certain of: the number of coronavirus-related deaths in the UK are at their lowest since before lockdown, there are promising new vaccines being trialled every day, and localised outbreaks are being managed efficiently. For now, treat yourself to a bit of normality whether that’s a meal at your favourite restaurant, like me, or an appointment at your local hair salon. Take the optimist’s approach. Things will get better in time. NOTE FROM THE EDITORS: A huge thank you to Ffion, for sharing with us this lovely blog. Ffion Harris is an Immunology PhD student at King’s College London, whose research focuses on immune cells which protect against autoimmune diseases. It is so important for us to stay positive about the future and the search for a vaccine, and Ffion explains so well in this blog today exactly why we have so much to be optimistic about. Thank you, Ffion!

The Inner Journey for an Outer World It came from the east. A virus that changed the world. The mental health, especially of Gen Z and Millennials, was precarious at best. With lockdowns and a society transformed, a mental health and wellness shift was needed. We needed something more than apps, sayings, and hashtags. We needed something that resonated. Something that spoke to the individual among us, not just the face in the crowd. We needed the YouTopian Journey. The YouTopian Journey is more than just a newsletter and more than a graphic novel. It is an inner journey for an outer world. A mindset guide for a mindset shift that not only entertains, but benefits the reader. It launched in February of 2021 on Substack with almost one-hundred issues produced to date. The art continues to be created in preparation for launching the first issue comic of the graphic novel. My name is Shaun Gold. As a polymathic super-connector (which is a fancy term for someone who has lot of interests and who takes action), I was inspired to use my time in the lockdown to create something that could be beneficial to society. I wanted to do something different, something that clicked with readers, something that was uniquely my own. More importantly, I wanted to create something that could be useful…truly useful to inspiring and motivating readers to become mentally stronger. This is why YouTopian Journey was created, because before there was nothing like it. Before I started YouTopian Journey, I had a variety of roles. I worked with startups in every non-technical capacity one could imagine, wrote multiple books, appeared on the game show Jeopardy, was involved in promoting and marketing some of the highest grossing nightclubs in the world (which in turn provided me a street education in psychology and philosophy) and wrote multiple screenplays. As a result of my unique background I am an invited guest lecturer at universities across the United States (everywhere from Georgetown to University of Miami, my alma mater) on a variety of topics ranging from entrepreneurship to consumer behavior. As an avid reader, my knowledge from YouTopian Journey stems from some of my favorite books. This includes Man’s Search for Meaning by Viktor Frankl, Courage to Create by Rollo May, Man’ Search for Himself by Rollo May, Thus Spoke Zarathustra by Friedrich Nietzsche, Letters from a Stoic by Seneca, Dokkōdō by Miyamoto Musashi, and more. This led me to realize that knowledge in our society was lacking. Not just general knowledge that formed the backbone of our society, but knowledge of philosophy, psychology, and history. This is the knowledge that determines how we live, and more importantly, how we die. Additionally, we are losing our key values that as a species, are required. Fortitude, inner strength, personal meaning and purpose, mental wellness and endurance, kindness, and confidence. It is hard to have a strong mind when everyone around you appears to have lost theirs. It is even harder to build up your soul while everyone else is selling theirs to the highest bidder. A shift has happened and has taken our population to the abyss, where just a little push could be fatal. I wanted to solve this problem. I wanted to create a brand that dealt with high concepts and bring them to the masses in the form of a graphic novel and associated writings. I wanted to develop a following, so my plan for YouTopian Journey was twofold. First, create the graphic art itself and overall story. Second, create a Substack newsletter to begin helping readers as soon as possible. I teamed up with Fernando Melek who I worked with on my storyboard concepts for my original screenplays to do the art. As he is a professional comic book artist, he was intrigued by such a unique idea and quickly signed on. Developing the script was a fast and fun process, as the art can communicate a variety of feelings that people face each and everyday. I wanted to use the art to demonstrate a variety of different threats, especially the threat to the individuality of the main character (as it appears that everyday we lose the greatest part of ourselves to conform to others). The overall story follows the heroic journey that is demonstrated in the variety of myths and modern Hollywood blockbusters. But unlike heroic journeys of fighting Gods and saving the world, the YouTopian Journey is about becoming a hero to save yourself. Why is this important? Because as Samuel Beckett once remarked, “you’re on Earth, there is no cure for that.” The German polymath Johann Wolfgang von Goethe wrote that “our planet is the mental institution of the universe.” We need to aim to be heroic in everything we do. Yet this is difficult as we lack heroes. We have become so lackluster and feeble that we don’t believe the heroic is capable, especially for ourselves. And why should we? Our leaders aren’t heroes. Our managers and bosses at work are the antithesis of the heroic ideal. Yet we need to be heroic. It is in the DNA of our species. The material from YouTopian Journey comes from the great books and the great thinkers of history. For example, the concept of a YouTopian is heavily influenced by Nietzsche’s concept of the Übermensch from Thus Spoke Zarathustra. People often misinterpret Nietzsche due to his works being associated with the Nazi regime, yet this was the opposite of what he stood for. In fact, it was his sister who hijacked his writings and morphed them for her own goals. Other material for YouTopian Journey comes from a variety of concepts that I see in plain sight but few will admit to. Conformity, group think, submission to the herd mentality, dwindling courage, control of our minds by social media and technological devices, an inability to take action, fear, anxiety, the loss of the self, the validation vortex (where our actions need to be validated by social media to have any personal meaning), the manifestation maelstrom (where magical thinking serves to obliterate the reality of the situation), alienation, lacking purpose and meaning, the desire for safety over growth, and the wasting away of our time. And speaking of time, the Chronophage (the time eater) is our first major villain. I wanted to create something terrifying to make readers use their time and live their lives with a sense of urgency, not waste it on frivolous matters. The Chronophage is a constant threat. We live our lives as if we have unlimited days and infinite chances. The truth is that we don’t. Far too many people are only living for their next vacation, their next career accolade, and their next paycheck. We need to not only live in the present moment, but use it. Abraham Maslow once wrote that “the ability to be in the present moment is a major component of mental wellness.” My hope is that the Chronophage motivates people to use time wisely and fulfill their potentialities with the time they have. I often use quotes from significant historical figures and thinkers to illustrate the key points. Writings from Christian Saints (such as St. Augustine) to beatnik poets (Charles Bukowski) are utilized and no one is off the table if I find their knowledge beneficial to the reader. Sometimes a simple quote can change someone’s life for the better so I often use several in each and every issue. It is my hope that the quotes inspire, the art stirs something deep within the reader, and that eventually lives are changed for the better. For over the past year, the YouTopian Journey has been having a positive effect on thousands of people around the world. It gives me great joy to receive emails, tweets and comments that showcase the results of my efforts. I hope you subscribe and the lessons have a positive effect on you and your mental health and wellness. Furthermore, I hope it allows you to go after your goals and live…truly live as you walk your own YouTopian Journey. “A great man is one who affects the mind of his generation.”Benjamin Disraeli You can subscribe for free to YouTopian Journey here.

Recent estimates forecast that 1 billion people worldwide will be using wearable devices to track their levels of sleep and activity by the end of 2022. Even the most basic smart watches and fitness trackers can provide insight into daily hours of sleep, number of steps taken and heart rate, and with increasing investment in the wearable electronics sector, more advanced technologies are becoming progressively affordable and accessible. I am a lecturer in Clinical Psychology at the University of Sussex, and I have been involved in several projects in the field of digital health, often representing significant partnerships between private and public sector organisations. My first glimpse into this world was during my post-doctoral position based at King’s College London in the Remote Assessment of Disease and Relapse — Central Nervous System (RADAR-CNS) project. RADAR-CNS was a major international research project aiming to investigate the utility of remote measurement technologies (specifically wearable devices and smartphone sensors) to refine outcome measurement and predict outcomes across three central nervous system disorders: Epilepsy, Multiple Sclerosis and Major Depressive Disorder. But before I talk more about my research experience, let me discuss about wearable devices in general health! Can these devices can be used for more than just general fitness and sports training? Absolutely! The benefits of the real-time monitoring facilitated by these devices are beginning to be realised in healthcare research and services. Pairing this wearable device data with data collected from inbuilt smartphone sensors can provide a rich insight into our health and patterns of behaviour we’ve never seen before. This can allow us not only to track and monitor changes in health over time, but also to improve our ability to predict outcomes in long-term illnesses, track changes in response to treatment, and provide more timely, personalised interventions. In an under-resourced, over-burdened healthcare system, the move to digitalise medical care is inevitable, and a digital transformation has been well underway for decades. The COVID-19 pandemic has accelerated this evolution– with country wide lockdowns having pushed aspects of our lives, such as our education, employment, relationships and healthcare services, online. The responsibility, for businesses, researchers, clinicians, healthcare providers, funders, and regulators, is to ensure the digital transformation is fast, effective, inclusive, thoughtful, meets the needs of the people using it, and, critically, is evidence based. However, this, unfortunately, is not always a given. A recent review of digital health companies found that 44% of these businesses had zero evidence of clinical robustness. Furthermore, there was no association reported between the clinical robustness of the company and total funding, suggesting that a clear evidence-based approach may not be a priority in the funding of digital health solutions. Therefore, developing this evidence should be a first and foremost in everyone’s minds. RADAR-CNS Major Depressive Disorder project (RADAR-MDD) RADAR-CNS was pioneering in this approach of using remote measurement technologies — as well as representing clinicians, researchers, engineers, computer scientists and bioinformaticians from all over the world. It prioritised patient and public involvement, open science (creating an open mHealth platform for the collection and processing of mHealth data: RADAR-base), and clinical utility. With its own integrated Patient Advisory Board, RADAR-CNS pioneered the inclusion of people with lived-experience throughout the research process. This insight is critical to ensure that the technologies, that we as scientists are working hard to develop and test, really meets the needs of the people we’re trying to support. In parallel, incorporating the voices of clinicians in the development of novel technologies is essential for maintaining engagement with professionals and understanding the intricacies of implementing new technologies in clinical settings. Our key findings RADAR-CNS, and RADAR-MDD specifically, taught us all a lot about the capabilities of remote measurement technologies in the context of Major Depression (define). Although the funding for the programme has finished, we are still writing research papers now and have already published some of our key findings. We found that… 1. People are motivated to participate in remote measurement studies. One of our first papers arising from RADAR-MDD described the amount of data we collected throughout the study, and our recruitment and retention rates throughout the course of follow-up. We had very high retention rates, with 80% of participants continuing in the study until the end of follow-up. Participants wore their Fitbit for approximately 15 hours per day, and an average wear-time of 62% across a median follow-up time of 541 days (approximately 18 months). 2. Having depression does not stop people from engaging with these kinds of technology. Our recent paper published in the Journal of Affective Disorders examined the associations between symptoms of depression, anxiety and functional disability and i) perceptions of the usability of the technology and ii) the amount of time people spent wearing their Fitbit and the number of app-based questionnaires they completed. We found extremely small differences, indicating data collection via remote sensing is robust across depression, anxiety and functional disability severity. 3. There are associations between data collected via remote measurement technologies and depression outcomes. We have published papers showing associations between a range of parameters measured within RADAR-MDD and depression severity. In particular, we have reported associations between depression outcomes and homestay, mobility, Bluetooth connectivity, and sleep patterns. Questions still to be answered Despite the progress made in the field through this study and many others, there are outstanding questions which remain unanswered: Can this technology provide something of personal value to the patient? Might having access to one’s own health data inadvertently increase health anxiety, increase inappropriate help-seeking behaviour or even trigger a deterioration in symptoms or relapse? Can we improve self-management and a sense of empowerment over an otherwise unpredictable illness? How do we make sense of what the data mean, and what actions should be taken in response to it? How can we integrate high-volume data usefully into our existing healthcare infrastructures without over-burdening already over-worked healthcare professionals? If risk is detected via the online system, such as an adverse event related to treatment, who’s responsibility is it to intervene? Who “owns” the data, and how much data is too much data? The future of healthcare is digital, and it’s our responsibility as researchers to address these open questions and ensure that digital healthcare is implemented thoughtfully, conscientiously, and ethically. — — — Watch Faith discuss key RADAR-CNS findings, https://www.youtube.com/watch?v=M1peYybtvU0&t=6s RADAR-CNS was jointly led by King’s College London and Janssen Pharmaceutica NV. The project was funded by the Innovative Medicines Initiative. Find out more: https://www.radar-cns.org/. — — — Header image by Artur Łuczka on Unsplash

A vision for changing the wellbeing of future generations by tackling the longstanding shortcomings in maternal healthcare The development of new medicines for pregnant women has stood still for the last 40 years. Here’s what we need to do to change this. Did you know that the health of your grandmother during the conception and birth of your mother still plays a significant role in your health today? So, should she have needed medications while pregnant, what was available for her and the following generations over the last 100 years in the UK? Surprisingly, not too different from today. In the last few decades, only 2 medicines have been licensed for the treatment of pregnancy-specific conditions such as pre-eclampsia (early signs include high blood pressure and protein in urine) and pre-term labour. If you’re surprised by this, you wouldn’t be alone. When you or someone you know goes through a pregnancy with no complications and with no need for medications, it is easy to be oblivious to the fact that this is not the norm — indeed, three out of four women take some form of medication during pregnancy. However, a lack of data on the safety of many medicines in pregnancy means that GPs and patients are faced with very little information to make decisions on how to best manage taking medications during pregnancy. This includes many medications taken in the management of mental health conditions, where we know that the risk of developing a condition or relapsing during pregnancy and after birth is high. Without sufficient knowledge of the impacts of taking medicines to manage these conditions during pregnancy, women are faced with a difficult choice about whether to start or even continue with treatment. Tackling this problem could make a big difference for these women and their children, with maternal mental health being a key factor in a child’s mental and physical health as they grow up. This was one of the important issues explored in detail in 2021 by the Birmingham Health Partners Commission for Safer Medicines in Pregnancy and Breastfeeding, led by Baroness Manningham-Buller, currently a member of the House of Lords Science and Technology Committee, and Professor Peter Brocklehurst of the University of Birmingham. Their goal was to gather evidence from key opinion leaders in pregnancy and baby charities, the NHS, universities, industry, and government regulators to help set out a clear agenda for what needs to be done to improve the lives of women whilst they are pregnant, and the health of future generations. The findings spoke for themselves: if we do not develop new treatments for pregnancy-specific conditions and assess the safety of already available medications, pregnant women and babies throughout the world will continue to get sick and die from largely preventable or treatable causes. As heard by the Commission, the challenges around developing and testing medicines for pregnant women are complex. Not least the lack of understanding of basic human reproductive biology from the early embryo to the physiology of the mother. But, a collaborative effort across all parties involved in medicines research & development and healthcare delivery, combined with political will, could greatly change the outlook for mothers-to-be in the UK. The UK government has recently taken a step forward in this space, publishing its first Women’s Health Strategy on Wednesday 20th July 2022. Healthcare during pregnancy was highlighted as a priority area for change by the nearly 100,000 individuals who responded during the strategy’s call for evidence. Charged with bringing about the system-level changes required to close the gender health gap is Dame Lesley Regan, Professor of Obstetrics and Gynaecology at Imperial College London, who has been appointed as the government’s first-ever Women’s Health Ambassador. So how can the UK deliver on its commitments around women’s health set out in the recently published strategy and keep up the momentum on addressing the reality faced by the women and girls who make up 51% of our population? In May 2022, the Birmingham Health Partners Commission launched Healthy Mum, Healthy Baby, Healthy Future: The Case for UK Leadership in the Development of Safe Medicines for use in Pregnancy. It lays out 8 recommendations for bringing safe medicines to pregnant women, including the need to incentivise all parts of the system to develop pregnancy-specific treatments, as well as to increase the safety data and information on existing medicines. The report calls for the creation of a shared vision for safe medicines evaluation and development by reducing barriers to the inclusion of pregnant and breastfeeding women in clinical trials and setting up research centres that invest in pregnancy research. The pharmaceutical industry also has a critical role in finding solutions. Currently, companies are part of international projects like IMI ConcEPTION and TransCelerate to improve the data available for the regulators and researchers doing this work. The Association of the British Pharmaceutical Industry (ABPI) supports the aims of the Women’s Health Strategy, and as an industry, we co-proposed the development of new guidelines on the inclusion of pregnant and breastfeeding individuals in clinical trials at the top table of international regulation. To truly maximise the impact that we can have on the care of pregnant women and their babies, there is a need for collaborative action on a national and international scale. In the UK, the Women’s Health Strategy is an opportunity for change, with maternal health a key priority. We must bring together the public, scientific, clinical, industry, regulatory and government sectors to address the recommendations of the Commission’s report and make maternal healthcare the best it can be. Health in pregnancy reverberates down through the generations, and by addressing this, we can save lives and boost the wellbeing of mothers and babies in the UK and across the world. About the authors: Steve Hoare is a Policy Director for Quality, Regulatory Science and Safety at the Association of British Pharmaceutical Industry (ABPI), sat on the Commission and co-authored the report. Hannah Chance is a Research Policy Executive at ABPI, sits on the Maternal Health Group that provided some of the Commissioners and expert witnesses, and leads on policies to support Equality, Diversity and Inclusion (EDI) in medicines research.

Better me: smartphone wellbeing support The stats are overwhelming: back in 2017, 84.6 % of Ukrainians from the general population reported having experienced post-traumatic stress disorder (PTSD) at least once in their lifetime, coming first on the worldwide traumatic exposure list, according to World Mental Health Survey. Four months into the war, although no official information has been gathered, I believe the figure is probably 100% of Ukrainians. As a Ukrainian researcher focusing on mental health, I feel completely overwhelmed, thinking about when and how we will be able to recover from this collective trauma. In search of answers, I talked to two Ukrainian projects that provide mental health solutions: can their solutions address rapidly growing needs in this sector and, once the war ends, who is taking care of the well-being of mental health workers themselves affected by the trauma? This is the first blog in the two-blog series in which I am interviewing the team of BetterMe. In addition, I asked Ukrainian illustrators to draw their mental state, since the war has started. BetterMe is a leading Ukraine-based behavioural healthcare company providing self-help apps that promote physical and mental health. The first app appeared in 2016 as a weight loss solution, in line with the trends. However, its founder, Victoria Repa, throughout its existence, concluded that promoting non-medically supervised weight loss may not be entirely helpful for everyone. Since then, BetterMe has transformed and offered different behavioural daily programs centered around physical aspects of health like easy exercise and meal plans, as well as mental health support — breathing exercises, relaxing soundscapes, and interactive microlearning courses. The app’s component targeting mental health has a chatbot, where people can answer questions and be guided to programs to help improve their daily routine. According to the team, this can be useful in the early stages of experiencing psychological problems. The team adds: “The point is self-awareness and reflection. We explain what happens to the body when people are going through a certain emotional state and recommend manageable coping strategies that could improve the situation. We do not tell people what to do but rather ask questions that could help them identify where the trouble stems from on their own. People report the most typical issues: burnout, recovery from a breakup, sleep problems, stress, anger management, and baby blues.” Where were you when the war started? Like every Ukrainian on February 24th, we were in a state of complete shock. In the first days, our priority was the health and safety of our team, so we formed a department of crisis management and started to evacuate everyone to Western Ukraine as fast as we could. Now 60% of the team is in Western Ukraine; some have returned to Kyiv, although we are not recommending it, and 10% relocated to Poland, where we offer to work from our partners’ office. Everyone was utterly shocked, but the sense of urgency this situation created gave us wings. What are your social projects related to the war in Ukraine? Already in the first days of the war, we made two of our apps — Mental Health and Health Coaching — free for all Ukrainians. Before the war, most of our users were from English-speaking Western countries, but the percentage of Ukrainian users has quadrupled. At first, we wanted to create a new micro-learning program about handling the post-traumatic stress created by war. Still, we realised that it is not appropriate, at the moment, because traumatic events keep happening to everybody and people have different problems. Instead, we collaborated with UNICEF UKRAINE and added some components that helped parents handle the stress of the war while still raising children. For example, we added calming audio fairytales in Ukrainian, de-stressing games, and advice for different scenarios that can happen to children during the war — e.g. how to soothe your child in a bomb shelter, what to do if a child is experiencing a panic attack. Our next collaboration is with the Ministry of Science and Education, where they recommend the best Physical Education (PE) teachers in Ukraine to give online PE classes through our app BetterMe: Health Coaching. To engage the financial help of our international audience supporting Ukraine, we released a collection of sportswear in the colours of the Ukrainian flag, and 50% of the sales are going towards UNICEF Ukraine’s fund supporting children harmed through the war. It seemed like many projects to start in three months, but we could not sit still. Do you see any feedback from your Ukrainian users on the effectiveness of including app-based solutions as an additional way of supporting their mental and physical health right now? And what do you think will happen after the war? I think after the war, it will be essential to provide solutions for handling the stress brought on by the war trauma. As we said, we are still keen to add a program centered around this centered the time is right. We want to create something useful not just for the war veterans but for everyone who has been affected by the war directly or indirectly. We have had 100 000 new Ukrainian users join since February 24th. From the beginning of the war, 64.6% of Ukrainian users used the app to reduce stress, 64.2% to feel happier, and 58% to combat anxiety. Our audio fairytales for children are also among the most popular features. Of course, we understand that an app can only do so much, and it is instead a supplementary solution to the mental health challenges our country is and will be facing. As a mental health researcher and a Ukrainian woman going through this war, I am hopeful too. While I do not think smartphone apps should be seen as a panacea, they can certainly help plan a healthy routine and send reminders to take care of yourself, and sometimes that is already enough.

When it comes to diagnosing physical illnesses, there are a myriad of different biological tests that can be done to correctly diagnose the condition. Take for example, hypertension (otherwise known as high blood pressure), after carrying out some simple biological tests such as a blood pressure reading, it is possible to diagnose the patient and provide the correct treatment. These measurable medical signs that provide an objective way to indicate an illness or condition are also known as biomarkers. There has been a huge focus in recent years to find an equivalent measure, or biomarker, for diagnosing and monitoring mental health disorders with the hope of preventing, improving diagnosis and monitoring mental illness. The problem? There is a lack of reliable and broadly accessible biological measures to accurately diagnose mental illness. Introducing… heart rate variability Heart rate variability is the small variations in the amount of time between each heartbeat. This measure, which can be obtained through an electrocardiogram otherwise known as an ECG (a simple test that can be used to check your heart’s rhythm and electrical activity), has been put forward as a promising and exciting candidate for helping to diagnose and monitor symptoms of common mental health conditions such as depression and anxiety. I am a Researcher at King’s College London and as part of my work I have been investigating how heart rate variability could be a useful tool in mental healthcare practices. In this blog, I will give you an overview of what heart rate variability is and share some of the evidence which suggests heart rate variability might be a promising candidate as a biomarker for psychiatric illnesses such as depression and anxiety. What is Heart Rate Variability? Heart rate variability or, HRV, is the fluctuation in time intervals between each consecutive heartbeat. These variations are controlled by the autonomic nervous system, an important component of the body’s nervous system, in charge of regulating involuntary processes like heart rate, blood pressure, breathing, digestion, and emotional response. The autonomic nervous system is made up of two components, the sympathetic branch which prepares the body for stressful or emergency situations — ‘fight or flight’, and the parasympathetic branch which controls bodily processes and dominates during quiet, resting conditions — ‘rest and digest’. High HRV reflects the autonomic nervous system’s ability efficiently adapt to the demands of the environment by effectively switching between the sympathetic ‘fight and flight’ and the parasympathetic ‘rest and digest’ modes. Insufficient or low HRV, on the other hand, suggests a reduced ability to switch between these two modes and respond effectively to environmental and psychological stress. Given the importance of the autonomic nervous system in regulating emotion, it is not surprising that dysregulation of this important biological system measured through HRV, is associated with reduced emotional wellbeing and mental health problems such as depression. So, is there a link between HRV and depression? So far, strong evidence has emerged for a link between depression and HRV. Findings from a meta-analysis (a method through which the results from many studies are pooled together) which compared 2250 patients with depression with 1982 healthy controls (i.e., those without depression), demonstrated that in comparison to those without, those with depression had significantly lower HRV. In another meta-analysis, results were taken from 18 different studies which looked at whether the severity of depressive symptoms were relative to the degree of HRV reduction. In total 673 depressed participants and 407 healthy controls were included and found that overall, the more severe patient’s symptoms were the lower their HRV was found to be. Further studies have shown evidence that HRV could even be used to help predict later development of depression. One study investigated whether HRV measured at an earlier time point was associated with later depressive symptoms. Participant’s HRV and depressive symptoms were measured at visit one and then seven years later at visit two. It was found that lower HRV at visit one was associated with increased depressive symptoms at visit two, seven years later. The findings from this study were particularly interesting as they allow us to understand more about the direction of the relationship between HRV and depression. In other words, it shed some light on whether reduced HRV came before or after the development of depression. Overall, there was stronger evidence that reduced HRV was present before the onset of depression, rather than occuring as a consequence of having depression. So, could HRV be useful in real world settings for depression? There are many promising ways HRV could be used in real world clinical settings for depression. One of the key ways that HRV could be used is to help identify those who are at risk of developing depression. Several studies have suggested that reduced HRV is a risk factor for the development of depression. If we can clearly understand the HRV patterns that are associated with the development of depression, it may be possible to identify those at risk at an earlier stage and prevent the onset of depression by providing treatment and intervening earlier. Encouraging evidence suggests HRV could also be used in clinical settings to decide the best treatment option for patients with depression. One study found that measures of pre-treatment HRV (i.e., HRV before patients received any treatment) could predict whether patient’s symptoms improved after taking antidepressant medication when considering the type of symptoms patients were experiencing. Often patients will have to try several types of treatments before they find the one that works for them. Excitingly, these findings suggest HRV could be used to find the correct treatment more quickly without patients having to go through a long and often frustrating trial and error process. However, although findings so far are promising, the number of participants included in previous studies have been relatively small. Further studies require larger sample sizes and more representative samples (for example, participants from wider age ranges and different ethnicities) in order for the conclusions to be applied to the general population. In addition, there is a limited number of prospective studies which follow participants from before they develop depression to illness onset. These types of longitudinal studies are important to understand whether HRV and more specifcally, what HRV patterns are an indication of risk for depression onset. Despite the need for more research on HRV and depression, and how HRV could be utilised in clinical settings for depression, the evidence so far, which clearly demonstrates the importance of HRV in depression, is exciting for future clinical care. Who knows, just as some of us use blood pressure monitors routinely to check our blood pressure, we may find ourselves routinely checking our HRV for helping to monitor our mental health. Header Image source: Towfiqu barbhuiya on Unsplash

Trigger warning: This blog discusses personal experiences of self-harm. Disclaimer: While this blog shares personal accounts of self-harm, I in no way condone self-harm and it has not served me in any positive way. The experiences discussed happened in the distant past and are not currently ongoing. My first introduction to self-harm was Thirteen, an 18-rated film about two wayward teenage girls. I was thirteen years old and, having learned that my group of girlfriends had spoken cruelly about me behind my back, I decided to give cutting a shot. While anyone is capable of self-harm, it’s an act commonly associated with teenagers; and though there are myriad reasons for choosing to do so, it’s commonly brushed off as attention-seeking. What we aren’t asking is: why does this person need attention? What do they hope to gain, and how does it help them? I have borderline personality disorder (BPD), a disorder of mood which means my emotions feel like they’re cranked up to a 100. Find my previous blog published on InSPIre the Mind on my experiences of having BPD, here. A minor event can have a catastrophic effect on my day, leaving me with what feels like emotional whiplash. Self-harm is something I have used in an attempt to calm myself. Sometimes, that self-harm looks like depriving myself of medication for my mental health (another topic that I have covered in more detail in a previous blog). I hid my wounds with sweatbands and stacked bracelets before gradually moving on to my stomach. Already obsessed with my waistline and confident no one would see that part of my body, I remember the searing pain during PE lessons as dozens of tiny wounds burst open, arms stretched towards the netball hoop. The wounds were a protective blanket, a reminder that no matter how much the world hurt me, no one could hurt me like I could hurt myself. I was consumed by the agony inside my head but for a few moments a cold numbness enveloped me as my emotional pain fell by the wayside. The nature of BPD means a heightened mood can last only hours. Even at my worst, I often reasoned that stitches and scars were a permanent response to a temporary mood, and so minor wounds which quickly healed became my go-to. I didn’t want to be haunted weeks after the now-forgotten catastrophe had passed. Of course, my methods escalated. My teen years were characterised by sharp household objects being locked inside Dad’s briefcase; I was careful not to stain my white school polo shirt, and there was always an excuse when I was inevitably caught. I remember the intense shame of Mum bursting in on me in a changing room. My parents despaired. I was marched to counselors and therapists, one of whom suggested alternate methods of release: snapping an elastic band against my wrist, grasping an ice cube, scribbling over my arms in red marker… I reluctantly gave the ice cube a chance, and while I could imagine how the burning sensation might prove satisfying for some, I craved those little bubbles of blood. No method would have worked because I lacked any desire to stop. I felt certain I wasn’t causing myself any real harm. I never did anything I couldn’t come back from, I reasoned. But was I in a state of mind to evaluate what I couldn’t come back from? As my despair increased, my self-harm escalated along with my ability to think critically. It makes sense that I may have reached a point where I’d cause serious physical damage, or worse. Aged 17, I acquired a 24-year-old boyfriend, a salesman who’d first flirted with me as I browsed CDs. Weeks into our relationship, on discovering my secret, he’d said, ‘If you’re going to cut yourself, at least do it properly,’ before asking if he could cut me while being intimate. I wish I could tell that vulnerable 17 year old girl to run. Despite refusing his request, I wondered how this boy who said he loved me could bear to hurt me. I came to believe I was worthless and deserving of pain, which brings me to my next point. Another hallmark of BPD is feeling like a “bad” person. You see, these moods are a lot to handle, and sometimes I don’t handle them the best. My anger can be like dropping a lit match onto a puddle of petrol and watching as it burns everything to the ground. I am left with an all-consuming shame. Taking this into account, to me it made sense that my reasons for self-harm would evolve to include punishment; every time a loved one forgave me, I saw it as my duty to punish myself since they wouldn’t. Hurting myself made me feel able to live with myself. Having managed to access a short stint of therapy over the pandemic, I’m now able to challenge this deeply ingrained belief that I deserve pain. While in days gone by I looked at my scars with affection, today they’re more likely to plunge me back into a past I would rather forget; when a mood can pass as quickly as a tornado, it becomes an exercise in picking through the rubble instead of rebuilding the house. A long-term solution to a short-term catastrophe. I still self-harm but can at least acknowledge it will not serve me in any positive way. Sometimes I’m even able to resist. The pain never lasts; if I’m brave enough to ride the wave, it soon subsides, and I’m always grateful I didn’t act in the moment. Distraction helps; I ask friends if we can talk awhile, forbidding myself from feeling bad, because if the roles were reversed I’d welcome the chance to take on a little of their pain. And though it’s difficult to remember in the depths of despair, I try to use a mindfulness exercise I learned in therapy. The next time you’re in a heightened state of stress, notice what you’re experiencing through any or all of the senses. How many sounds can you hear? Is there one bird outside your window or several having a conversation? Practice when you’re happy. At 30 years old, I can now accept that by hurting myself as punishment — for the human mistakes we all make — I’m reinforcing the damaging belief that I don’t deserve happiness. And guess what? I do. If you are struggling and in need of support, below are a few helpful organisations which provide both resources and direct help: distrACT - App which provides information and advice about self-harm. nhs.uk/apps-library/distract Harmless - User-led organisation that supports people who self-harm, and their friends and family. harmless.org.uk LifeSIGNS - User-led self-harm guidance and support network. lifesigns.org.uk The Mix - Support and advice for under 25s, including a helpline, crisis messenger service and webchat. 0808 808 4994 85258 (crisis messenger service, text THEMIX) themix.org.uk Samaritans 116 123 (freephone) jo@samaritans.org Freepost SAMARITANS LETTERS samaritans.org

“Anna has openly shared in a variety of settings her mental health difficulties. This has led me at times to be concerned about her welfare and her fitness to practice as a doctor.” As I read this feedback on my portfolio, which the ARCP (Annual Review of Competence Progression) panel would have reviewed and considered the next level of my career progression, it made me wonder about the safety of doctors’ honest disclosure of their challenges for “being different” to their peers and senior colleagues. This includes the challenges with their physical and mental health, as well as being of different racial origin, being neurodiverse or belonging to the LGBTQ+ community. I can only apologise for making people uncomfortable as an autistic individual. However, I wouldn’t have known that I was making people uncomfortable unless someone had told me. For 32 years I have never exactly “fitted” along with anyone. I had made unreasonable adjustments for myself to have myself work within the neurotypical world. Once I received the diagnosis, I felt I was finally liberated to be myself with no shame. Coming forward with my diagnosis means I can be proud to be who I am. Now, after reading these comments, I am not so sure. I am a Core Trainee Psychiatrist, passionately advocating for human rights and mental health. I am part of the executive committee for the Royal College of Psychiatrists’ Women’s Mental Health Special Interests Group. I am a leader of Geopsychiatry, an NGO (non-governmental organisation) which studies the impact of war conflict, climate change, public health issues, globalisation and foreign policy on mental health. I have written articles, such as the need for women's leadership in the UN, and how COVID-19 unmasked the ongoing pandemic of gender-based violence. In my previous blog, I had written about the gender gap in our training I have now become more aware that it is not only a gender gap in our training. There is also a gap in addressing racial inequality and neurodiversity in our training, especially when the feedback of our colleagues is captured in the Multi-Source Feedbacks (MSFs). As I read the above feedback comment again, it reminded me of a book called “Beneath the White Coat: Doctors, Their Minds and Their Mental Health” edited by Clara Gerada. This book explored the growing mental health crisis among medical professionals, examining the secrecy surrounding doctors with mental illnesses and highlighting the limited resources available to them. This book is a reminder that mental illness is still stigmatised today. In the Psychiatry field, we applaud doctors coming forward about their mental illnesses and their struggles. However, behind the scenes, we do not know the stigmatisation, the challenges and the lack of empathy they faced. Were these doctors questioned on their fitness to practice? When the doctor did seek support via therapy and mental health services, was their training delayed because supervisors said that they were currently using mental health services, and were therefore not “fit” to progress further in their career and fitness to practice? You would think this doesn’t happen, but the book, other peers’ stories and personal experiences have informed me that this is all too common. Have we been too gullible to believe that our colleagues and supervisors cannot be discriminating against other doctors for just “being different”? “To establish and maintain good partnerships” with everyone in the organisation (patients, teams, peers and senior colleagues) is extremely exhausting for autistics; I can imagine it is just as tiring for other neurodiverse doctors as well. In a survey, 1% of general practitioners and 1.1% of psychiatrists identified as autistic; alongside the general UK population figures of 1.1%, this means at least 3000 UK doctors are likely to be autistic. Autism is already subject to employment law regarding associated disabilities. However, autistic and many other neurodivergent doctors are too often not able to achieve their potential due to misunderstanding stigma, under-recognition or lack of reasonable accommodations. Autistic doctors tend to speak out against injustices — for example, unsafe patient care or staff mistreatment. As an article in the British Journal of Psychiatry had recently written: along with the risk of being misinterpreted and marginalised, when policies have been followed on raising issues in regards to patient safety concerns or other “high risk” issues, autistic doctors are described as “trouble-making, lacking team skills and confronted for being unprofessional…” Therefore, undiagnosed and unsupported autistic colleagues may sometimes present as “doctors in difficulty”. Looking at again the comment on my portfolio, I do wonder if some of my colleagues, whom I thought understood and empathised with my disability and mental illness, used it as reasons to halter my career progression and cast doubt on my profession. Some might argue that my colleagues were genuinely concerned about my mental health and my disability, as reasons to question my fitness to practice. However, I believe many doctors aren’t aware of the GMC Standards and Guidelines for Welcome and Valued: Supporting disabled learners in medical education and training. The GMC has recognised that doctors can experience ill health or disability throughout any point of their careers, and having a health condition or disability alone is not a fitness to practice concern. Reasonable adjustments and support are required to remove the barriers individuals will face, in line with equality legislation. At a personal level, I want to emphasise that the GMC’s guidance specifically recognises that transitions during training can be challenging for doctors with disabilities, including those with an autism spectrum disorder. The Royal College of Psychiatrists Equality Action Plan In January 2021, The Royal College of Psychiatrists released the Equality Action Plan, led by the Presidential Leads Dr Shubulade Smith and Dr Rajesh Mohan. The Equality Action Plan aims at promoting equality and equitable outcomes between 2021–2023. This includes opposing all forms of discrimination, delivering equity of opportunities for all members of the College, as well as encouraging all doctors and students from all backgrounds, to be supported and encouraged to become members. The RCPSYCH Equality Action Plan aspire to an approach known by the acronym CIRCLE: Courage, Innovation, Respect, Collaboration, Learning and Excellence. Furthermore, autistic doctors have come forward to be acknowledged and included in the RCPSYCH Equity Action Plan, to seek collaboration in regard to specific support and adjustments. As Sue McCowen and Mary Doherty had written in a BJPSYCH article: A diverse workforce is a well-rounded workforce and a full CIRCLE. Conclusions The NHS and Training Programmes are meant to encourage trainees to be themselves, in order to enrich our culture with diversity, inclusivity and equity. However, the feedback and the assessments we send to complete our training portfolios may be used as “tools” to discriminate and harass victimised trainees under the guises of terminologies (such as competencies and probity), as well as impair their careers — thus, widening the gap in gender, sexuality and race. Personally, as an autistic woman of colour who has passion, and an advocate for justice and human rights, I have been made to feel ashamed of being who I am. We are constantly reminded that we do not come to work for NHS to be abused and discriminated from those who we are treating. However, do we have to tolerate the abuse and discrimination from our colleagues, supervisors and line managers? Where and with whom can we feel safe to work to ensure the best clinical practice and patient care, if we do not feel safe in our environment and with the people we work with? The culture shouldn’t be “us alike versus them not alike”, instead it should be “all of us”: all specialities in medicine will advance in every aspect if we allow diversity and equity to thrive.

The COVID-19 pandemic has highlighted fundamental truths about infectious disease in humans. First, the makeup of our societies helps determine who is vulnerable to disease by shaping the risks and protections that dictate pathogen exposure. Second, infectious disease is a social phenomenon, whether it’s pathogens moving between people, the collective efforts necessary to minimize transmission, the role of caregivers, or the effect of sickness — and, unfortunately, mortality — on families. Furthermore, a growing body of literature suggests that the social conditions in which we live can even influence our immune systems. The power of our social lives over our health and wellbeing is not trivial, nor is it new. We humans are not particularly well equipped for survival, relative to other animals. We’re not very fast or strong. We’re devoid of fang and claw and our senses are mediocre. But we’ve managed to survive as a species for roughly 300,000 years and spread from Africa to every habitable area of the planet — and even some marginally habitable ones. We have accomplished this, in part, by being very good at being social. In fact, it’s reasonable to hypothesize that because our sociability has contributed so much to our survival over our evolutionary history, any threats to our “social safety” are felt more strongly by our mind and body and therefore cause a greater biological reaction than other stressors. This reaction includes inflammatory and immune responses, likely to protect against injury and subsequent infection, harkening back to our evolutionary history. Over the last 300,000 years, of course, our social systems have become increasingly complex. Each of us is bound up in multiple interconnected levels of social interaction, from our individual networks to our place in wider society. We are further embedded in our culture(s), that “internalized and shared framework” through which we experience the world. Understanding precisely how these different social forces intersect to shape our immune responses is the goal of what, in my review article for BBI Health, I have called “social immunology.” There is evidence that social connections affect our immune systems. For example, social integration is linked with lower circulating levels of multiple inflammatory markers, like C-reactive protein (CRP) and pro-inflammatory cytokines. While inflammation is an important component of immune responses, chronic inflammation is associated with several negative health outcomes, like cardiovascular disease and cancer. An unrestrained inflammatory response is also a component of the so-called “cytokine storm,” which contributes to COVID-19 mortality. People with a more diverse social network were also less likely to develop a symptomatic cold after experimental exposure to the virus. However, social relationships can also impose health costs. More interpersonal contacts mean more opportunities to come into contact with pathogens, and some research suggests that frequent pathogen exposure can contribute to accelerated immune system ageing and a decline in efficacy. Additionally, perceived social role conflict — that is, the degree to which our various social responsibilities conflict with each other — has been linked with greater inflammatory responses. As noted above, chronic exposure to inflammatory factors can be unhealthy. While elevated inflammation might help fight off infections faster in the short term, chronic social role conflict could lead to a greater inflammatory burden and downstream health consequences. So, while social integration and healthy relationships are generally a net positive, our social lives are highly complex. It takes time, effort, and attention to maintain our multiple personal and professional social relationships and roles, and this can come at a cost. What’s more, our networks and social roles are shaped by wider societal institutions. These institutions — things like families, governments, and economic systems — constrain our behaviours through ideologies, rules and norms, and other forms of explicit or implicit guidance. A considerable amount of research shows that factors like work/unemployment status, social support, adequate nutrition, and other social determinants of health (SDoH) affect multiple health domains. The COVID-19 pandemic has highlighted how unequal burdens of chronic health conditions and health behaviours can affect morbidity and mortality. For instance, asthma — an important underlying COVID-19 vulnerability, is frequently associated with low socioeconomic status, smoke exposure, and racial/ethnic minority status. Indeed, systemic discrimination and racism can lead to chronic inflammation and accelerated biological ageing, again contributing to diminished immunity. Adequate nutrition is another SDoH that can affect immunity. Malnutrition affects the ability of immune cells to differentiate and replicate, so it is linked with increased infectious disease susceptibility. Obesity — a state of malnutrition due to increased consumption of energy-rich foods — is also implicated in reduced immune function, including decreased influenza vaccine efficacy. Much as economic systems and governments set behavioural parameters, so do cultures. Cultural norms like stoicism or gender roles can influence symptom appraisal and health-seeking behaviour. But there is also intriguing research suggesting that differences in norms surrounding negative emotions between the US and Japan can shape biological responses to these emotions, with generally lower inflammation among the latter. Importantly, we shouldn’t think of cultures as monolithic (that is, one “American culture” for instance). Instead, we often navigate and engage with cultures differently and embody multiple culturally constructed identities. Like social role conflict, conflicting cultural frameworks can be a significant stressor. In one study in Western Samoa, more exposure to non-traditional cultural influences and subsequent stress of navigating between traditional and non-traditional cultural norms was linked with immunosuppression. Given these different lines of evidence, it becomes clear that immunity is affected by social factors across multiple levels. Crucially, none of these levels are independent of the others. Despite the evidence outlined above, further research is required to better understand the impact of social factors on immune function. While we can observe white blood cell counts or inflammatory markers rise or fall in association with social stress, nutrition, or cultural incompatibility, direct evidence of either improved or impaired ability to fight infections is necessary. The COVID-19 pandemic has driven home the impact that pathogens can have on individuals and societies, but infectious diseases are a significant public health risk even outside of pandemics. For instance, there were an estimated 54.5 million cases of lower respiratory tract infections attributable to influenza in 2017. Around 8 million of these were severe, with about 145,000 deaths. Like COVID, influenza can lead to health complications, such as cardiovascular events. Understanding who is at higher risk for contracting flu, COVID, tuberculosis, HIV, or other diseases is critical to public health. Social immunology can help identify the most vulnerable, such as immigrants facing conflicting cultural norms combined with potentially low social support and systemic barriers to accessing healthcare. Social immunology calls attention to the complex interactions between biology, social institutions, interpersonal relationships, and cultural milieus and reminds us that we are, at the core, social animals. Our social environments, then, should be treated with as much care and consideration as our physical environments.