It’s possible to support wellbeing AND learning for university students through the curriculum! The curriculum refers to learning, teaching, and assessment. I am a research associate and teaching fellow in the Psychology Department at King’s College London. Throughout my PhD (in Diabetes and Health Psychology), I was a graduate teaching assistant for the Psychology department. It became apparent to me that students’ wellbeing had a real impact on their overall university experience (and vice versa!). Following my PhD, I became interested in research exploring how to support student wellbeing in the curriculum at university. Student mental health crisis Through personal tutoring, teaching, and project supervision, I have had many conversations with students, from first to final year. Many things impact a student’s wellbeing and their journey at university. For example, students face many pressures such as newfound independence, a new home (and flatmates!), a completely new learning environment and approach to learning as well as assessment, navigating new relationships with peers and staff, financial pressures, managing family expectations, major life events (illness, breakups, death, war) and discovering career goals. Mental health problems in university students are on the rise. Student support services are at capacity; and therefore, broader ways to support student wellbeing are necessary to help students thrive. Supporting wellbeing through the curriculum The University Mental Health charter developed by the student mental health charity, Student Minds, outlines the ‘Whole-University Approach’ to supporting student wellbeing at university that does not solely rely on university support services. The four domains of this approach are: ‘Learn’ (learning, teaching, assessment); ‘Support’ (support services); ‘Work’ (staff wellbeing and staff development); and ‘Live’ (residential accommodation, social belonging, and physical environment). My work focuses on the ‘Learn’ aspect of this approach. The curriculum is at the heart of university life and is the guaranteed contact point between students and the university. So, we must think about how to design and deliver curriculum and assessment to enhance wellbeing and learning simultaneously. Often this equates to good teaching practices. Education for Mental Health Project I joined the Education for Mental Health project team in January 2020. The project was funded by Office for Students, a collaboration between the University of Derby, King’s College London, Aston University, Student Minds, and Advance HE. We aimed to develop an online toolkit for university teaching staff to outline the best ways to support student wellbeing within the curriculum (i.e., through teaching, learning and assessment). Wariness about supporting wellbeing through the curriculum Some universities are wary of supporting student wellbeing within the curriculum as they believe this equates to making the curriculum easier to reduce stress and anxiety. However, this is not true, and the evidence does not support this is necessary. Challenge and stretch are good for wellbeing as it enhances personal development. It is not the learning that needs to be easier or the academic challenge that needs to be reduced; it is the way we think about teaching and how students engage with their learning that is key! Wellbeing and learning Research says that learning and wellbeing exist in a transactional relationship. Poor wellbeing is associated with poor academic performance. Also, how students engage with learning can influence wellbeing (positively or negatively). Therefore, our toolkit’s suggestions point toward improving wellbeing and learning. Some helpful examples from the Education for Mental Health toolkit I want to take you through a few main points covered in the Education for Mental Health toolkit that stand out for me. Social belonging was important in our discussions with students for the project. Students said that if they feared embarrassment in the classroom, this was a real barrier to learning and, in some cases, led to dropping out of classes. Social belonging within the classroom is about creating a sense of psychological safety. Students feel comfortable making mistakes and asking those dreaded ‘stupid questions’. Therefore, it is crucial to create a classroom space where everyone learns better in a safe and supportive environment that allows engagement in an academic challenge. The crucial thing in a learning-focused curriculum is: WHAT is hard & WHY is it hard? If we set our students a helpful academic challenge, students will: · Know what is required of them, and understand how to approach the work; · Be given opportunities to practice; · Already have the skills OR know they will develop the skills through this piece of work. WHEREAS a stress-inducing task, the student: · Does not know what is required of them; · Does not know how to develop the skills; · Assumptions might have been made about their skills level. SO, we need appropriate classroom activities and assessments to help students benefit from academic challenges, improving wellbeing and learning! A scaffolded design helps us achieve this and think about how to prepare students. It is important here to remove barriers to students accessing study skills support. For example, students who need help the most might not be able to access extracurricular content (during induction week or during term time) if they have responsibilities outside of university or must commute to campus. So, essential study skills should be taught through the subject and not all crammed into induction week! Let us teach students HOW to be students! We need to build them up to learning outcomes through assessment and classroom activities in a way that is helpful overall. So, how do we develop learners? Learner development is not just about delivering good content. Learning is not like a computer; we cannot just input information into students’ brains! Many things interact with learning and how we can support it — for example, self-managing emotions in the classroom, e.g., nerves and anxiety. Exam anxiety can result in avoidance behaviour, poor revision techniques, surface-level learning, and underperformance. This is a vicious cycle. But if we can intervene at the study skills level and teach students how to revise effectively, this will increase their confidence, lower their anxiety, and lead to better performance. A much healthier cycle! Overall, a helpful academic challenge is essential for good wellbeing and learning. This can be supported in several ways within the curriculum, including social belonging, scaffolded design, and promoting learner development. I only touch on a few points from the toolkit here, but please do review our toolkit, staff resources, and case studies for further information and references.

Content Warning: This blog is about mental health, OCD and intrusive thoughts of a violent and sexually harmful nature that some may find distressing. Getting to know a bit about me Welcome to my blog about living with OCD. Spoiler alert, if you don’t know a lot about OCD, it’s not simply enthusiasm for handwashing and checking that the oven is off. If you are well versed in the subject of OCD, I hope to bring honesty, lived experience, and comedy to this difficult and often upsetting subject. My name is Ria Fay and I am an actor, writer, director, and a “whatever pays the bills in-between” person. I was inspired to write this piece to debunk the common misconceptions that surround OCD and offer an insight into the reality of living with it day in and day out. It took me such a long time to find out that what I was experiencing as a child was a mental illness. I hope by spreading awareness about what it really means to have OCD, I can help reduce the time it takes others to recognise their symptoms and get the help they need as soon as possible. Growing up, mental health was not a subject discussed at school, in my home or anywhere I was aware. Anyone who knew me as a child described me as a “worrier”, “She’s always worrying.” Back then it was just called worrying when in reality it was intense anxiety, a common symptom of OCD. My intense anxiety was seen as a personality trait not a symptom of mental illness, as it is listed on the NHS page for OCD. Each day I would ask if I was going to die because of a pain in my (insert body part here) and each time the response would be the same. “Ria, you are not going to die.” in an almost comical repetitiveness. This would reassure me (at least for an hour or so). Anxiety for me was a general state of being, it wasn’t something I noticed in my day to day life, because it was always there. The many faces of OCD OCD is often described in themes that OCD UK has described perfectly on their website. Each one brings with it different triggers, obsessions and compulsions, I went through several themes of OCD, from the more “known” aspects like washing my hands (3 times), checking the oven was off (3 times) and counting everything, you’ve guessed it 3 times, to the more unspoken themes related to sexually harmful or violent intrusive thoughts. Let’s just say if OCD themes were a bingo card, I’m pretty close to a full house. A lot of people are living with OCD, OCD UK states “(OCD) affects as many as 12 in every 1,000 people (1.2% of the population) from young children to adults, regardless of gender, social or cultural background.” and that figure isn’t including those indirectly affected by the disorder such as family members or friends of those with OCD. The distressing nature of intrusive thoughts At the time of discovery, I was experiencing intrusive thoughts of a very disturbing, often violent nature. I kept these worries secret. Often awake for hours ruminating over the possibility of harming people or assessing whether I was a bad person. “Do these thoughts mean I want to do these things?” “Am I dangerous?” “Am I a horrible person?” Round and round the thoughts went like a carousel of guilt, shame, terror and anxiety. I wanted to confess to all these thoughts but the fear of what would happen if I did was too scary to comprehend. As I said, people didn’t speak about mental health then and like many others, I thought OCD was simply a keenness for cleanness. Congratulations, it’s OCD Somehow, I was able to keep up with life whilst the never-ending loop of “I’m a terrible person” played on repeat. I was studying performing arts at college and was set a devising task. Our group came up with the idea of a circus where each act represented a different mental health condition. At this time, I was completely unaware that I had been experiencing a mental illness for 12 years and ironically was given OCD to research. As I began to read about OCD on Wikipedia, of all the websites, (my teachers would have not been happy if they had known), a sense of relief flooded through my entire body. My heart began to race but it wasn’t out of fear it was out of hope. Until this point I had convinced myself that I would never be able to have children in case I harmed them, could never have a partner because they wouldn’t know the “true, evil” me, so this revelation was one of the most important turning points in my life. I’d like to say I rushed back into college the next day with a newfound understanding of OCD and created a show that would not only educate but entertain my class about the misconceptions surrounding OCD but that would come later. It’s odd to think that a project set at college, on a theme decided by a group of students, would be the way I found a diagnosis. Since then I have done a lot of research, had treatment from several mental health professionals, take medication daily and have had the pleasure of meeting and befriending others with similar experiences of OCD as my own. The lack of awareness surrounding mental health in general but specifically OCD is what drives the work I do. Alongside my writing, I have created a play with my theatre company Concept Theatre called “I’m Just a Little Bit OCD” which offers a brutally honest yet funny look at OCD. I use my writing to tackle the stigma, isolation and shame that can so often accompany OCD. I was very fortunate to have the project supported using public funding by the National Lottery through Arts Council England and The National Lottery Community Fund. With their help, I was able to share my message with audiences across London. I want to encourage people to learn more about OCD and step in when they hear it being misused. We need to start having honest, accurate and open conversations about what OCD actually is. If I can be that Wikipedia page (but more reliable) for someone, to give them an answer and a feeling that they are not alone, then that would be amazing. After my college project ended, I didn’t know what to do, who to tell or how to get any help but I did know that I was ill and if I was ill then I could get better. Resources For information about Concept Theatre visit https://www.concepttheatre.co.uk/ For information and support visit https://ocdaction.org.uk/ and https://www.ocduk.org/ For treatment options visit https://www.treatmyocd.com/

After returning to work from my third maternity leave, one thought still plagues my mind. Is my child going to be okay? I am an incoming faculty member at Northern Kentucky University in the Department of Psychological Science, with a PhD in neuroscience. I study how the prenatal environment (the period before birth) influences the brain. I am dedicated to understanding how early life experiences set the stage for how we think and act later in life. In this blog, I share my journey researching prenatal exposure to opioids and illustrate the complexity of this problem. Opioids are a class of pain-relieving drugs, such as fentanyl or heroin, and prescription varieties such as OxyContin®, Vicodin®, morphine, and more. I hope that my journey will help inform how we approach research on prenatal drug exposure. Parents all want one thing: an instruction manual I was once asked: what is the one thing that causes problems for kids? It’s a burning question for all parents, and we want a simple answer. We want a precise list of “what” to avoid during pregnancy to protect our baby, and later during their childhood and adolescence to guarantee their wellbeing — an instruction manual. If we had a manual to follow, we could have reassurance that our child is going to be okay. I am currently focused on understanding the consequences of prenatal opioid exposure. I intended to understand one thing. It sounded simple at first, if a mother takes this one drug while pregnant, then XYZ happens to the baby. I was ready to get my straightforward answers to help kids one day, but as I immersed myself in this work, it was not so simple. A complex leap from animals to humans Up until this point my research had been with animal models. Animal research improves the depth of our understanding, but it always seemed there was a disconnect between studying a mouse in a laboratory and what human beings go through. Therefore, I joined a group of neonatologists (i.e. Drs. Jae Kim, Jennifer McAllister, Scott Wexelblatt, and Stephanie Merhar) at Cincinnati Children’s Hospital who work with infants exposed prenatally to opioids. I listened to their stories, eager to incorporate their experiences into my work. The neonatologists immediately asked if my animal models could include several other exposures. Prevalent exposures in the pregnant opioid-using population, such as stress and nicotine use, are known to have a detrimental impact on child development, while others such as hepatitis C infection are poorly understood in how they impact the child. Animal researchers are taught to isolate just one “thing”, and study it, but this problem is more complex. Neonatologists have a murky crisis on their hands and want evidence to guide them in treating children exposed to opioids prenatally. The multifactorial problem What started as a journey to understand one thing became a much larger mission. To help children exposed to opioids prenatally, we need to consider more than just the exposure to this one type of drug. Beyond the immediate concern of neonatal opioid withdrawal syndrome (that is when the baby is born suffering the symptoms of opioid withdrawal), children exposed prenatally to opioids are more likely to display behavioral problems. Their learning and memory may be impaired, or they may have difficulties in controlling their impulses, attention, or emotions. They also have an increased risk of neurodevelopmental disorder diagnoses, such as attention deficit hyperactivity disorder (ADHD) and autism spectrum disorders. I began to wonder: is there more behind this association than just the opioid exposure? Mothers who use opioids are more likely to use multiple substances, such as nicotine, cocaine, methamphetamine, and benzodiazepines. Prenatal exposure to an opioid along with multiple other substances exacerbates neonatal opioid withdrawal syndrome, with emerging evidence suggesting it may further increase the risk for neurodevelopmental disorders. Opioid and nicotine use have an especially tight overlap. Nicotine exposure itself is associated with childhood impulsive behavior and self-control deficits, which may exacerbate issues associated with prenatal opioid exposure. Another factor to consider is infection risk, which is more common in pregnant women who use opioids, via both intravenous (i.e. injected into the vein) drug use and drug-induced suppression of the immune system. For instance, up to 40% of pregnant women using opioids are hepatitis C positive. Opioids can cross the placenta (the structure that nourishes the unborn baby and removes waste) and reach the fetal brain, where they can cause inflammation. Inflammation is the body’s natural defense mechanism but when it reaches the brain, it can be associated with behavioral problems. Exposure to multiple substances along with infection could induce a chronic inflammatory state. While prenatal exposure to opioids, hepatitis C, or nicotine alone has not been reported to cause structural damage to the infant brain, the exposure to all three factors together could in some cases result in mild brain injury. Beyond multiple substance use and infection, mothers who use opioid drugs are also more likely to face undernutrition, psychiatric illness, decreased prenatal care, and many other extreme stressors. Overall, opioid exposure is a red flag to a potential myriad of other adversities that the mother and child are facing. Adaptability against adversity Infants with prenatal substance exposure are more likely to encounter childhood adversity, such as abuse, neglect, or household dysfunction. The combination of prenatal substance exposure and childhood adversity further increases the risk of behavioral disorder diagnoses in adolescence and adulthood. However, this risk is not a guaranteed outcome. While adversity represents an environmental challenge, adaptability is the capacity to successfully adjust to those challenges. In fact, the immature brain is highly flexible and adaptable, offering a unique window of opportunity to intervene and make adjustments from infancy to adolescence. Beyond the exposure is adaptation to adversity, which varies from child to child. Initially, I wanted to study one exposure and ‘fix’ the outcome. Now, I am tempted to track down how these complex exposures may lead to a range of different outcomes. In animals and humans, can we predict risk based on exposure combinations, to develop preventative strategies tailored to the individual? All I know is that I have an entire career ahead of me to get answers.

Virtual reality (VR) has been finding more exciting applications for healthcare: VR tools help ease chronic pain, change body temperature, or improve coordination. As a Ukrainian, lately, I often feel like escaping to a different reality. Can VR provide new solutions for mental health challenges as well? This is the third blog in the series of mental health projects on Ukraine. This time, I interviewed Taya Kabaeva — a multidisciplinary artist with a passion for merging arts and science. Together with Olga Shyshlova, from our previous blog, she created a VR-based art therapy for children with autism — VR KIDS’ CITY. Now she is curious to apply the same logic to help refugee children in Ukraine to process their trauma. I asked her to write about her project and how did it start, and then to reflect on the events of the war. This is Taya’s account. About the project “In 2018, I was in close contact with a company developing affordable immersive technologies Sensorama Lab. They are very passionate about social impact and teaching new technologies to children. As an artist and a filmmaker, I was excited about the huge potential for creativity that VR was offering. I was also reading up a lot on the successful mental health applications of VR and with the co-founder of Sensorama Lab, Kyril Pokutnyy, we came up with an idea to explore using VR for the purposes of art therapy. We teamed up with Olga Shyshlova and came up with an unusual project — Kids VR city. Our project helped children on the autistic spectrum to learn socialization skills. They often experience problems with social interaction so we invited them to create their own city in the digital space and learn how to interact in it. Our group was small, with just eight children, from eight to seventeen years old — younger children can feel a bit queasy wearing VR glasses. Olga is a big fan of evidence-based practices, so we had a protocol for every possible situation and each child had a personal guide to help with the equipment. Each session was building on the previous one: we started with a small discussion about the topic of the session, then proceeded to visualize our ideas with traditional graphic techniques, like drawing with markers, paint, and sculpting with playdough, and, finally, moved to 3D modelling in the digital world. Topics of the sessions varied: first, we drew a landscape of our city, then built houses, planted trees around them, added roads, transportation, and infrastructure, and discussed public and private spaces. Then our houses started to have an interior, we painted our rooms. Finally, we drew our avatars and started to visit each other. In our last meeting, everyone had to draw their favourite fruits and vegetables in a magical garden that we created altogether. Collaborative work revealed unexpected social dynamics. Some children wanted to destroy the objects of others and paint their own over them. Others were ready for teamwork. One child painted fruits of different colours and walked into them (in a 3D world, walking into objects is possible) to see, which colour made him feel the most comfortable — it was orange. The toughest task was painting an auto portrait, to reflect on who you are in this 3D space. No one was trying to reach photographic similarity but rather reflect on some personal state or quality. One girl painted herself destroying tanks with two massive lasers coming out of her eyes. This was 4 years ago, she must have felt something was coming… In the last session, we presented our work — it looked like a full-scale professional art project: a huge interactive map, like a colourful amusement park with portraits of participants, plants, and architecture with a special terrain created entirely out of huge words…Children were very happy to go on a tour around it together and upon the recognition of the objects they have created, the room would fill up with laughter. It is often believed that children on the spectrum dislike touch and social interactions. Olga, however, said that years of experience working with this population, proved to her the complete opposite. They crave social connection, they are just lacking the tools to comfortably initiate it. We found that these tools can be taught! We clearly saw this during our presentation. Suddenly children, who normally dislike touch, started to approach each other in their avatars and hug. This new space opened the doors for them to feel comfortable initiating this communication. In the real world, they were all wearing huge headsets during those hugs — it was such a touching moment. About the war This project happened a long time ago but recently I started thinking about it again. Wearing VR glasses, one feels very private and isolated from the world, it feels like a really safe space to be in. In our previous project, we saw that some children were shy to paint in front of their peers but in VR they were quickly able to loosen up and express themselves. Since the war started, I have been contemplating a lot about what “safe space” means to me. This concept keeps changing almost daily, safe space does not exist for us anymore. A few weeks ago my house was my safe space — my fortress. On the day of the invasion, my safe space was my friend’s flat, then an underground station, then a bomb shelter, and now it is Uzhhorod — the Westernmost town in Ukraine. As adults, we are under immense stress because we are pushed to feel like we are constantly in the risk zone. It must be even harder for children that have to flee. Ukrainian refugee children have to travel and change places all the time now. They grow up very fast in this context. Their precocious conversations touch upon serious subjects of life and death, danger and safety. What is this “safe space” for them? What makes them feel at peace? Do they still have a concept of home? Perhaps together we can think about all the physical objects we decided to take in the haste of leaving, phrases we have heard on the way, and anything else that we find important and populate our new VR homes with them. The way people paint in a 3D space reveals a lot about their character. People have different quality of brushstrokes, they position objects differently, and they can move around. It is a fertile ground for interpretation of their inner dynamic. My dream is to team up with a psychologist and provoke a conversation not just about what we have lost in the war but also about what some of us have gained. I know some families bonded more because of the war. A lot of people tell me they value life now more than ever because its fragility became apparent. I would never wish for anyone to have to live through the war. However, we are in it and if there is a way to portray and share our reflections on the present, maybe they will help us build a better future.” After the interview, I felt compelled to help Taya find funds for this project. Together we applied for a grant to organize VR sessions for refugee children based on the concept of “safe space”, and were successful. I cannot wait to see the result of this collaboration. If you would like to support the creation of a digital gallery with children’s works, please reach out to Taya’s e-mail: tajakabaj@gmail.com

An Interdisciplinary Curriculum Development Workshop in Arts, Health and Humanities at King’s College London Today, our Inspire the Mind team were involved in FLEXchange, a 2-day collaborative workshop run by King’s College London aiming to kickstart the development of a flexible curriculum that encompasses ‘arts, health and humanities’. As explained nicely by Adam Fagan, Vice President of Education and Student Success, this pilot workshop provides a voice for students and academics to make sure the curriculum is “relevant, interesting and captures the attention of all our students.” This concept was further developed in the introductory section, hosted by the event’s organisers, Richard Wingate, Tony Woods, Nikki Crane, Joanna Kieniewicz, and Leigh Wilson all from King’s College London. With a creative spirit, our Inspire the Mind team are at the event to capture the key ideas and to facilitate further discussion from creative outputs for dissemination. So, at the end of the first day, what did we do at this interesting workshop? Throughout the day, we were introduced to a number of speakers all from different perspectives and all working in interdisciplinary fields. But we were also immersed in some engaging physical activity. To get people moving, in the morning Dr. Suzy Willson, Artistic Director of performance company Clod Ensemble, dove into an ice breaker session that encouraged the group to be present in the moment. Eyes closed and grouped together, we focused on our breathing and identified where in our bodies we carry our stress. We analysed our position in our space and used this as an opportunity to get to know other people. With this, we discovered how performance and movement can also be used to understand thoughts and feelings. In a subsequent talk, Suzy also showed us photos of examples of the cross-disciplinary projects run by Clod Ensemble, particularly performances inspired by medical practice. Building upon this concept, in the afternoon Artist Celia Pym conducted a more hands-on session in which she expressed the therapeutic value of ‘working with our hands’ to regulate thought and emotion. Teaching us the beauty of darning (a sewing technique for repairing holes or worn areas in fabric), Celia explored the concept of repairing our ‘seen and unseen damage.’ With years of experience mending clothes, Celia recognised that such damage speaks a story about a person. Who they were, what they did and how they spent their time. Both activities gave us a taste of how artistic approaches can facilitate wellbeing and help us understand ourselves and others. But the relevance to mental health doesn’t end here. The morning talks started with Professor of Biological Psychiatry, Carmine Pariante, who shared with us the work of SHAPER, a Wellcome Trust-funded intervention program to scale up the use of artistic mediums in mainstream clinical care. Carmine has written a previous blog on this. Dr Alex Mermikides, Senior Lecturer in Arts and Health, further opened our minds to the interesting perspective of medical humanities — a module that uses narration and film to better understand medicine and patient needs. In this intriguing talk, Alex explored the interfaculty drama projects that she has been involved with, as a means to integrate the departments of art and medicine. Meanwhile, Sam McLean, Philosopher of Science and Lecturer in Global Health and Social Medicine, took us on an enticing journey through western history to explore the artistic representations of madness and what this may tell us about the problems of modern day addiction. He spoke of how art has influenced his teaching and research, and that imagination is a very important quality of the mind. As such, he nicely summarised that art is a ‘“way of being in the world” and that it evokes an imaginative spark. In the afternoon, we also had Professor Seb Crutch and Artist Charlie Harrison, working closely with the Rare Dementia Support Group, presenting on ‘Created out of Mind’, a collaborative project for dementia patients that explored art through the painting of yellow lines. Not only was this an example of an interdisciplinary project, but they also told us about their emphasis on patient and public involvement and on improving public awareness for dementia. But what could this interdisciplinary curriculum actually look like? Professor of Culture & Creativity Nick Wilson told us that ‘art is caring about experience’ and that the interdisciplinary module should be a space for students to connect and create. A space to accommodate and integrate different aspects of care (e.g., for our bodies, for our environment and for others.) Reflecting on the clinical humanities module that has been added to the King’s College London Dentistry course, Dr Flora Smyth Zahra exampled how the curriculum may look. As described by one of the students, an assignment in which they had to relate a museum object to the themes of the module helped to promote a change in perspective. With this, Flora further emphasised that we need to ‘look outward towards arts and humanities to develop critical thinking.’ But what do the participants think? One undergraduate attendee notably said that they appreciated hearing the differing perspectives from academics across multiple faculties, and how it bridged together, giving a clearer picture of what the curriculum may look like. In an interview with our team, another undergraduate attendee commented that the reason they liked the concept was to be able “to have more of a holistic view of world.” There were also group discussions where a number of themes were reflected on. One of these themes was ‘learning space.’ While a variety of spaces (such as green spaces and the Science Gallery) are available, often students do not utilise this space unless they are told to go there or go with someone, based on the notion that you need ‘permission’ to use it. Students would therefore benefit from embedding these permissions into the curriculum. Another theme was the role of technology. Given the shift of care and communication to a digital platform following the Covid-19 pandemic, questions were raised about how digital technology could be utilised in the context of arts, health and humanities. Reflecting on various projects and initiatives that have adapted to digital media and found success, there was ample discussion on the concept of digital health and humanities. Overall, day 1 was really productive with plenty of discussion, and we are looking forward to day 2. While this is a whistle-stop tour of what was covered today, we’ll be sharing further ideas and discussions that will come from the whole event as further blogs, videos and podcasts. This will be used to facilitate further discussion, and hopefully we will see the future development of the FLEXchange curriculum implemented at King’s College London.

I can’t get the fog to lift: Deterioration progresses differently in people with different levels of memory problems Dementia research, which explores everything from risk factors, to diagnosis, to long–term treatment outcomes in patients, aims to address the growing health crisis of people suffering from dementia; a set of diseases characterised by memory and other cognitive issues. Worldwide, there are approximately 55 million people suffering from some form of dementia, such as Alzheimer’s, which is the most common type of dementia. Currently, we spend 1% of global GDP (Gross Domestic Product, the output of a country through manufacturing and services) caring for those with dementia and with the expected increases in global life expectancy, the number of those who need to be cared for in the long term, because of dementia, is only going to increase. However, none of these oft-quoted statistics captures the experience of those living with a dementia-type illness. I am a Data Scientist and a second-year PhD candidate at Goldsmiths, University of London. My PhD looks at the possibility of using artificial intelligence and machine learning; whereby computers can learn and make predictions, in order to predict those who go on to develop dementia in general, and in particular Alzheimer’s Disease. As a computer scientist and statistician, my work focuses less on a specific area of dementia research, but rather on the techniques used to produce robust and validated results. As a result, I have conducted research on healthy individuals and their risk of predicting Alzheimer’s, as well as those with a clinical diagnosis of Alzheimer’s disease, attempting to predict their long-term outcomes. I am also, somewhat frantically, a full-time data science contractor with my own business. When I was volunteering at a dementia activities group, we would see many older people, all of whom would be suffering from some form of memory complaint or other cognitive issues. What defined this group, besides receiving some form of dementia diagnosis, was just how different they all were and how the disease progressed differently in each of them. They came from various backgrounds with different, often fascinating, life stories to tell. One man had hiked the coast-to-coast trail whilst facing backwards to raise money for charity, another was one of the first postmistresses, at a time when the roles were predominantly for men. Another woman was in the Women’s Auxiliary Air Force during World War 2 and a man with early-onset Alzheimer’s had been a vet before his sudden and dramatic decline. It is decline specifically that our latest paper addresses. The paper is called A Machine Learning Approach for Predicting Deterioration in Alzheimer’s Disease. During my volunteer days, I would see some people I had grown to care about dramatically and tragically decline. However, some would persist in what seemed like a state of mild forgetfulness for a long time, sometimes even years. This paper sought to explore the problem of decline within disparate groups, and in the end, we discovered that the task of predicting deterioration in healthy individuals is quantifiably different to predicting deterioration within those who already had mild cognitive issues. One of the datasets I use to try and predict dementia is the Alzheimer’s Disease Neuroimaging Dataset or ADNI. This is a database consisting of different data types that were already collected from the same participants. This is so researchers could use this to create impactful research into Alzheimer’s Disease. Participants who attended the study did so at various points from 2004 onwards. The sample included those who had no cognitive issues (called ‘Cognitively Normal’ in our paper) and those who had been diagnosed with Mild Cognitive Impairment. This is a formal diagnosis that is used to assess individuals that are experiencing some form of memory complaint or other cognitive issues, but these issues are not yet serious enough to justify a diagnosis of Alzheimer’s Disease or another type of dementia. The data collected in ADNI included brain imaging data such as images collected from MRI or PET (these are different types of equipment that are used for brain imaging), and fluid biomarker data collected via the spinal cord using an injection which draws out cerebral spinal fluid from the spine. A biomarker is used in science as an indicator for a biological pathway that may be happening in the body. These biomarkers are known to reveal certain characteristics that indicate the possibility of dementia such as the build-up of amyloid plaque and tau. Both of these are specific types of protein that sometimes build up in the brain and are indicative of dementia pathology. The ADNI data also contains neuropsychological tests, such as the Mini-Mental State Exam, which are administered by a GP or a frontline health professional, as well as data on genetics, and participant demographics. Our paper used machine learning in order to predict deterioration in those who had been diagnosed as cognitively normal and those who had been diagnosed as having mild cognitive impairment at the start of the study. We defined deterioration as the participant receiving a worse diagnosis upon their final visit to the study. For example, if a participant received a diagnosis of cognitively normal at the start, but a diagnosis of either mild cognitive impairment or Alzheimer’s disease at their final visit, they were defined as having deteriorated. The same applied to participants who were diagnosed with mild cognitive impairment at the start of the study, except their definition of deterioration was having received a diagnosis of Alzheimer’s disease. We separated these two types of participants (cognitively normal and mild cognitive impairment) into two groups and applied machine learning models to those groups separately. As our paper specifically wanted to compare the difference in predicting deterioration between the two groups, it made sense to treat them separately so that the differences would hopefully be apparent. We applied six different machine learning models to each of these groups in turn. Machine learning uses statistics to build models that learn from the data and make predictions about future data based on those learnings. In essence, the models learn how to make decisions without a human telling them how to make those decisions. These models ranged in complexity from standard regression models that would be taught in any undergraduate statistics course, to much more complicated models such as Gradient Boosting Machine and Support Vectors Machines. The variety of models used is important because it allows for the possibility that one of our groups would produce better results in making predictions on a specific type of machine learning technique. As it turned out, we were able to clearly see several differences between the two groups, not only in terms of how well we were able to predict deterioration, but also in how the model was built to make those predictions. We found that, in general, all models were better at predicting deterioration in the cognitively normal group than in the group with mild cognitive impairment. The list of important predictors for the best models for each group was different as well. For the cognitively normal group, the top 6 most important predictors for their best model were all neuropsychological tests, such as the Mini-Mental State Exam. In comparison, the top predictors from the mild cognitive impairment group were more of a mixed bag, with imaging, demographics, neuropsychological testing, and even the effect of time being cited in the top 6 most important predictors for the best model. Another interesting finding was the type of models that tended to do best in the two groups, with the cognitively normal group favouring more complicated models, and the mild cognitive impairment group favouring less complicated modelling based on simple calculations to separate those who had deteriorated from those who remained stable. So what does this tell us? Ultimately the strongest conclusion one can draw from this work is that the task of predicting deterioration is more complicated than we might at first think. In particular, the task of predicting which cognitively normal person will deteriorate is different from predicting deterioration in those already suffering some form of cognitive issue. From a clinical perspective, it certainly gives pause for thought. We want to be able to predict deterioration so that we can either implement strategies to try and delay that deterioration or otherwise allow patients an informed understanding of their likely disease progression. However, as we tackle this problem of predicting deterioration, this paper has shown that perhaps the problem is in fact not one problem but two: Firstly, predicting a decline in healthy people and secondly, predicting a decline in those already struggling with cognitive complaints. Each of these challenges should be taken in isolation, according to this paper, and being able to predict each one will provide us with different opportunities in managing and improving a patient’s long-term outcome. However, given that this is a relatively small study, performed on a clinical dataset, an important next step is to validate these results on larger, community-based data, to see if the results can be replicated.

The relational dimension of care has been core to our profession since its inception. Highlighted by Jaspers over a hundred years ago was the dialogical aspect of treatment; the relationships that we cultivate with our patients. This was seen as central to the art of psychiatry. Empathy was the gateway through which all phenomenology could be truly understood and it was only through a subsequent relationship, built on that empathy, that deeper levels of change and recovery became possible. There has also been an equally important technical aspect from the outset too. Since the latter half of the last century this has been pharmacotherapy. Good psychiatry always stood upon both these pillars. In recent years, however, the relational pillar has atrophied. I have been a Consultant Psychiatrist for nearly 20 years and in this time, I have worked across a range of different services from crisis/home treatment to rehabilitation to in-patient to Psychiatric Intensive Care Units (PICU) and I currently work in a community recovery team in North East London. I have also been increasingly engaged with the Royal College of Psychiatrists in recent years; sitting on the College Council as well as Special Interest Group, Regional and Faculty Executive Committees. This has given me a national vantage, which has brought into view a consistent story around our services and how they have been resourced and organised over the years. If we trace our current crisis to its origins, it began with the closure of asylums. While this was an essential, progressive step in the evolution and modernisation of mental health services, it was also combined with an unprecedented cull in staffing. It was expected that, without the asylums, there would no longer be any need for such large numbers of clinicians. As a result, local health authorities were able to cut over 20% of their total staff budgets within the first year alone, according to the King’s Fund. Indeed, for the Secretary of State at the time — Enoch Powell — a reduction in the financial burden of mental health services was a key driver from the start. This drastic reduction in staffing meant that the baby had effectively been thrown out with the bathwater from day one of de-institutionalisation. And this has continued to be the trajectory for most of the intervening years. For example, between 2010 and 2015, mental health Trusts faced cuts equivalent to £598 million a year, every year. The number of trained psychiatric nurses in this period also dropped from just over 41,000 to less than 37,000. All of this has been further compounded by the short-term thinking that has mostly pervaded policy and service development since then — focusing largely on ever more rapid throughput and briefer episodes of care — all of which almost completely ignores the therapeutic value of deep and lasting relationships. Policymakers started visualising mental health services as if they were some sort of conveyor belt. An increasingly fragmented system started to move patients from one team to another, leaving the therapeutic relationship as little more than an afterthought. Even NHS England today describes the current system as one in which “we have a team for everything and a place for no one”, with far too many teams, too many boundaries for patients to navigate and multiple cracks in the system that patients can all too easily fall between. The evidence has been pointing to the harm that these developments have the potential to cause for over 30 years now. It was back in 1993 that Arlene and Gunderson did a study in which they showed that the therapeutic relationships forged in the early months of treatment have a lasting impact on outcomes in the long term. Those who had experienced deeper therapeutic relationships were more likely to have fully engaged in treatment and thus demonstrated an overall reduction in symptom levels. A few years later in 1996, Krupnik et al published a study that showed the positive impact therapeutic relationships have on outcomes regardless of the modality of treatment they are otherwise receiving, whether that be pharmacotherapy or psychotherapy. In 2008, McCabe and Priebe took it one step further, looking at a range of psychiatric services and concluded that across a variety of mental health care settings, the quality of the therapeutic relationship can actually predict the outcome. It is the secret resource that we all have access to, yet it is one that has depleted over time as our hollowed-out services moved increasingly towards an exclusive focus on crisis and risk management. I believe, however, that it is possible to turn this tide. The pandemic has put the scarcity of the nation’s mental health provision into sharp focus. Late in 2021, Chris Whitty gave a speech to Medical Directors of Mental Health Trusts explaining how, having examined the impacts of COVID, he believed that mental health services now needed to be a key focus going forward. It was like the tide coming out so far that, for the first time, we were able to see the state of things on the seabed and mental health services fared among the worst. He argued for higher prioritisation of mental health services and better resources. This however, given the decade of talk around “parity of esteem” before it, is not the first time we have heard such language. Nevertheless, today we are at least presented with an opportunity. And if we don’t grasp it now, we will lose it. We need to make the case for the prioritisation of therapeutic relationships once more. To truly deliver better outcomes for patients we need to spend more time with them. The increase in resources needs to also be combined with a reduction in bureaucracy, not an increase in it, which is often the case with new investment. More targets, more KPIs and more boxes to tick will surely only result in more time with computers over patients. This needs to be guarded against at all costs. The Royal College of Psychiatrists needs to form alliances with other professional bodies as well as third sector and service user networks to lead a commission for compassionate care, in which we work together to locate and highlight best practice across the country and, through this process, make a compelling case for the increased investment we need. A return to a more relational approach also means a shift in culture. Embedding and prioritising listening skills into our training will be key. Clinicians of all backgrounds need to become experts in creating safe spaces that help build a sense of trust. This is essential if we want to make our services more trauma-informed. It is only through a single-minded determination to rebuild our resources and the skills we need, that I believe we can both reconnect to our roots and re-emerge into a new era. One in which meaningful relationships work hand in hand with new technologies to maximise hope and improve outcomes for many more of the men, women and children who seek our help.

Promoting student mental health at university necessitates changes in students’ educational and residential environments: A conversation with Professor Juliet Foster In January 2022, research carried out by Student Minds, the leading student mental health charity in the UK, highlighted that 64% of undergraduate and postgraduate students felt that the pandemic had negatively impacted their mental health, and 52% of the respondents felt lonely or isolated during the recent Autumn term, yet 47% of the students with experience of mental health issues said they had no intention of disclosing this to their university. Student mental health at universities has been a growing concern in recent years. I am a research assistant at the Stress, Psychiatry and Immunology lab, and I had the opportunity to talk to Professor Juliet Foster, the Dean of Education at the Institute of Psychiatry, Psychology and Neuroscience (IoPPN) and the the academic lead for King’s College London (KCL) on student mental health and wellbeing. I started by asking her how she became involved with student mental health. “When I was appointed to King’s, it was specifically written into my job description that I had a particular role around student mental health and wellbeing. This included integrating some of the research conducted at the IoPPN with student support services and other services.” Different initiatives at KCL KCL aim to develop the best practices and implement them because of the excellent research at the IoPPN. The Student Mental Health Research Network (SMaRteN), led by Dr. Nicola Byrom, has helped address some big evidence gaps related to young people’s mental health and build the momentum for research in this field at KCL. The network is also a part of a recent initiative, in collaboration with Transforming Access & Student Outcomes in Higher Education (TASO), Student minds, What works centre of wellbeing, AMOSSHE and Universities UK, to develop a central database to understand what kind of interventions work better to improve student mental health at university. This led to us discussing the different initiatives present at KCL to support student wellbeing. “KCL is one of the first universities to develop a sector-leading Student Mental Health and Wellbeing Report and Strategic Plan, based on the idea of a triangle of support.” At the bottom the triangle are initiatives such as mindfulness sessions and curriculum embedded approaches, which may help all students regardless of whether they identify as having a mental health problems. In the middle of the triangle are students who potentially might need additional support, such as the availability of counselling and disability services. Moving on to the top of the triangle are specific support services for students who are enduring more acute or severe mental health problems. At this level, it is important to recognize the boundaries of what the university can provide, along with other specialist services and the NHS. KCL has strong relationships with the South London and Maudsley Foundation Trust and other NHS trusts which enable the students and staff to seek the support they require. Furthermore, recent work at KCL, funded by the Office for Students and in collaboration with Advanced HE, Universities of Derby, Aston University and Student mind, helped develop the Education for Mental Health toolkit, an easy-to-use guide for academics and staff who develop the course curriculum and deliver it to students and want to embed mental health into their curriculum. One of Prof. Foster’s favourite sections of this toolkit is on belonging and connectedness. “It looks at how to build good positive relationships within the classroom between students, but also between the academic and the students as well, and this also includes establishing the boundaries that are required as part of that working relationship. One of the reasons why it is my favourite sections is because I do think it can be implemented by anybody in a classroom setting, regardless of whether they have developed the content or are delivering it.” Mental health support in universities is not just about the availability of support services, although that’s one important pillar. It’s also about the educational settings, how students learn, the physical environments that students live in, the broader university environment, as well as staff mental health. These are the pillars of the University Mental Health Charter, which KCL is a part of. The University Mental Health Charter, which Prof. Foster considers as a game changer in this sector, built a set of evidence-informed principles to support universities to adopt a whole-university approach to mental health and wellbeing. “You join the programme and attend workshops, share best practice with other institutions and discuss how university governance works for mental health across the board. It is an exciting collaborative effort. The charter also recognises that there is work that has never been attempted, and we are never at the end of the journey in this sector.” The effect of the pandemic on student mental health This charter was published at the beginning of 2020, along with a revision of the Universities UK and Stepchange report and numerous significant developments to help address student mental health. The pandemic, however, dampened this spirit, but drove universities to reform how they provide current support services. “We [at KCL] moved counselling appointments online, KCL residences undertook initiatives for students who were stuck in residences and who couldn’t get home, King’s Sport moved all of their classes online within 24 hours and they were getting huge engagement, and the pandemic enabled us to push for innovation in some ways.” Of course, the pandemic also exacerbated the situation for a lot of students. Not only has it affected their mental health, but it has worsened the financial situation, home life and learning. Prof. Foster believes that the consequences of the pandemic would be visible in students who join universities for the next 10 years, and universities have to work harder to make the transition period between school and university easier for students. “However, what strikes me is that we haven’t seen a wholesale shift as a result of the pandemic, we’ve just seen an exaggeration of issues that were already present.” Therefore, after the pandemic, universities need to build on the innovations that arose during this period, whilst returning to the position that they were in 2020 and nurture new initiatives in this field. Future aims and challenges in this sector Prof. Foster also hopes for more progress in the development of a whole-university approach to mental health. “To provide services around curriculum, physical environment and staff wellbeing, requires staff time and money, which has been a prevalent challenge. I would love to see more funding made available specifically for universities to apply for initiatives, where they could really show that they were using it to develop a more robust system. I sat on the Student Futures Commission to look at how to best support students after the pandemic and one of the recommendations was that additional government funding could be made available for universities.” On the other hand, there is also a need to understand the boundaries of what comes under the university’s jurisdiction when it comes to student mental health. Some staff members feel like universities were developed to teach students and shouldn’t have a strong focus on mental health. However, only when student feel good will they perform well, therefore, these initiatives are important to help change students’ lives. Prof. Foster’s tips on navigating through academia I concluded my interview by asking Prof. Foster, who is a social psychologist by training, about her academic experience and suggestions for women and early career researchers. “I really enjoy my original research area of sociocultural psychology, but it has been quite niche and is never going to attract a massive amount of funding. I was really interested in education and student welfare and I took up other roles as well, and that has led me to use my research skills in other ways too. My progression in academia hasn’t been very traditional, but I think it is important to realise that there are different ways in which you can carve out your space within academia. Don’t think that there isn’t any scope if you don’t follow a particular trajectory because there are different ways of doing things.” Indeed, Prof. Foster leads by example when she says this, both in terms of her academic career, as well as with her unique approach in steering different student mental health and wellbeing initiatives at KCL.

As a Ukrainian researcher doing a rotation at the SPI lab, the home of Inspire the Mind, I can’t help but wonder what the impact of war on mental health is and how can we even start processing this topic. In my second blog in this series about mental health projects in Ukraine, I interviewed Olga Shyshlova, a pioneer in inclusive education using art therapy practices in Ukraine. In a collaboration with PinchukArtCentre, the biggest hub of contemporary art in Ukraine, she created multiple successful projects for children and young adults with autism, Down’s Syndrome, impeded psycho-verbal development, and learning difficulties. I started by asking how did she start in the field of inclusive education, how did the project develop, and what has happened since the war. This is her account. How did you start in the field of inclusive education? So interesting to go back in time and remember those events at times of war — feels like I was on a different planet back then! For me this is a personal story — I have a daughter on the autistic spectrum. People with autism often have problems with social interaction. After her diagnosis, I became very active seeking any opportunities for her development: meeting other parents, organizations, and psychologists. At the time, in 2011, there was almost nothing around. As this journey progressed, I decided to become a specialist in autism myself — started a degree in Applied Psychology and dedicated my thesis to the effectiveness of museum pedagogy in the support of children on the autistic spectrum. It took me a year to conduct my research. I initially worked with 25 children, from 3 to 11 years old, with different autism severity. After the research was over, parents were very happy and the museum I collaborated with, PinchukArtCentre, agreed to fund free, inclusive art-based classes regularly. What exactly is museum pedagogy? Museum pedagogy is a method of using the safe space of the museum to assist children on the spectrum to socialize. In Ukraine, or the whole post-Soviet space, art therapy practices were almost non-existent so I got in touch with specialists internationally, researched similar programs in big international museums like MOMA, and finally approached PinchukArtCentre to create a similar project. In a museum, there is space for creativity but also for learning social rules and limits. The rules are very clear — no touching the objects, no loud behavior, sticking to the group. Our sessions always happened on Sundays — the busiest day in the museum. I wanted to help parents get rid of their social embarrassment; when kids throw themselves on the floor and start screaming, the first instinct is to run away and never leave the house again. I am a mother too and I understand that the main goal is creating the conditions for this person to grow and develop to be able to retain autonomy. And how did those sessions look? Were they just regular art classes? No, each session had a precise structure, as ritualization is important for people with autism. We used art as an engaging medium but the focus was on teaching social adaptation. For kids on the spectrum that have learning disabilities, one and a half hour sessions is a lot of time to sustain the focus, so the activities have to be diverse. We always started with a greeting, then went on a little quest around the museum’s current exhibition with the task of finding some artwork. Afterwards, we created our own art related to the topic of the exhibition. Topics were always very simple and connected to everyday life, and materials were matched to the level of sensory development. We had huge canvases and all kinds of paint, play dough and clay, dried leaves, grains, stones, crayons, coal, textiles, and cotton balls. Even napkins can become an art form with the right attitude! It was important to create an art object that kids could later play with together and take home. And does this project still exist now? No, the format changed with time. Kids became teens and some were very passionate about art and wanted to develop it as a craft. I gathered young contemporary artists and started a Workshop of Possibilities — a place where young adults with learning disabilities can collaborate artistically with young contemporary artists: Katya Buchatska, Nikita Kadan, Katya Lisovenko, David Chichkan, and others. In this project, the focus was on artistic expression. It was magical — so different from the children’s sessions: we discussed topics related to our identity and made creative decisions together: what is art, which color to choose, when is the next exhibition… After 4 years of work, we had an exhibition called “Dot, Line, Possibilities”. Then Covid hit, and we moved online. Some people have dropped out because online sessions need a lot more parent engagement. We just got back offline, started planning the next exhibition and then the war happened… What has happened since the beginning of the war? For the first three weeks after the invasion, we met online every day because it felt of utmost importance to stay connected under those circumstances. Everything was changing, and the only source of stability was our group sessions. There was a lot of anxiety, air raid sirens went off all the time, and we had to spend nights in the bomb shelter. Together we would discuss what scares us and find a sense of safety in the familiar things surrounding us — our moms (since dads had left for war), the food we eat, brushing teeth — simple rituals. Most of us have left Kyiv by now and are in the West of Ukraine or abroad. My daughter and I are in Belgium, it was too exhausting to listen to sirens daily and worry about her safety. I did not know how to explain our fleeing to my daughter. Then I showed her the house of our friend in Bucha, where she spent a lot of time before. The house is in ruins and she understood everything. We always have our sessions in the morning to motivate ourselves to wake up with a smile. Right now the topic is the change of seasons. Nature is blooming, changing… I know, the change will soon come to us too! Olga Shyshlova is gathering donations for temporarily displaced teenagers with developmental disabilities from the Workshop of Possibilities. If you would like to support these young adults, please send donations to her Paypal: Shishlova.olya1@gmail.com

Solitude is a widely misunderstood concept, often classified as loneliness, and a depressed state of being; however, it is proven that people who find comfort in solitude are less likely to have depression. It is important to understand that there is a thick line that separates solitude and loneliness. Solitude might look less fancy as it often involves no posts on social media, and is more tedious as it requires internal work aligning the mind, body, and soul but is a key to happiness that is locked within you. (Check out our recent article on loneliness in adolescence here). I am a writer with Inspire the Mind (you can find my other blogs here), and other well-being magazines. Over the years, I realized how solitude is an essential tool for my mental peace. In this blog, we shall swim to the depths of the solitude ocean and understand why it is important to be with our thoughts, alone. We will discover what research says about human behaviour and the distinction between loneliness and solitude. In a study conducted at the University of Virginia in 2014, researchers asked participants to put away any distractions and entertain themselves with their own thoughts for 6 to 15 minutes. 58% of participants rated it difficult and 32% admitted to cheating. In the series of this experiment, participants were wired up and were told that they could shock themselves during the thinking period if they desired. Shockingly, 25% of women and 66% of men chose to subject themselves to electric shock while being alone with their thoughts. Why should you be so afraid of your own thoughts coming to the forefront that you’d rather electrocute yourself? Even when one could be alone, there is always a pair of headphones clutched to our ears, or the TV is on, as background noise. If not anything else, we’re always scrolling through social media on our phones. We are sending our thoughts way back into the slush pile, so deep, that they can never be sorted or known. Though it is considered a trait of introverts, there are reasons- apart from the dreaded social anxiousness- that solitude is often sought by ambiverts (a personality with a balance of extrovert and introvert features) as well. I believe extroverts haven’t yet explored the vast recharge value offered by solitude, and studies agree. What does solitude feel like? Solitude doesn’t mean you are sent to a prison with four white walls and an absence of any stimuli. It is the mindfulness that you seek in the moments away from the chaos of people. Sitting with no company, other than your own thoughts. Watching the thoughts chase by in the field of your mind’s space. An internal dialogue will happen on its own, which would let you reach levels of self-awareness over a period of time. The richness of this experience leaves you rejuvenated and instills a better understanding of life. Why is solitude so important to me, and what techniques do I use? I was a born introvert, taking on a career that requires one to be an extrovert. A career in Human Resources requires an individual to talk to an average of seventy different people in a week, adjusting their own tone and mental process to everyone’s concerns and queries while also taking care of their own boundaries. At the end of the week, I seek solitude so badly that I am at risk of exhaustion if I am unable to get some quality me-time. The only voices I need to hear are birds chirping, and the only thing I need to see is the greenery of plants. I have often observed that when life begins to feel heavy, even though there is nothing wrong, it is because I have not had mindful moments for a long time and I’m just revolving into the meaningless churn of life. I consciously make an effort to sit in silence and think of ‘nothing’. I empty my mind using Bhramari Pranayam (Bee-Humming Breathing technique) which is proven to have benefits such as improvement in cognition, reduction in irritability caused by tinnitus, increased paroxysmal EEG waves and reduction in stress levels. After just fifteen minutes of this exercise, my mind feels as if it has been through the clean cycle. Sometimes, however, it might take more effort to empty all the lint your mind has been accumulating while going through the rigmarole of daily life. Does solitude have any prerequisites? Kenneth Rubin, a developmental psychologist at the University of Maryland determined some “ifs” for solitude to be productive. Some of these conditions include: 1. If it is voluntary, 2. If one can regulate one’s emotions effectively 3. If one can join a social group when desired 4. If one can maintain positive relationships outside of it. These four pre-conditions make sense because you cannot seek solitude when you are feeling lonely due to life’s ups and downs. Going through something such as losing a loved one, or experiencing depression aren’t the times when you seek solitude. Such instances might require something more, such as seeking social contact or even therapy if needed. You seek solitude when you want to take a break from outer chaos to get in touch with your inner being. It is beneficial when sought with internal driving reasons instead of life’s pressures. For solitude to be fruitful, we need to be comfortable with introspection. It might feel like an agonizing and extensive task and can take a bit of time before our mind knows and understands why it is a pleasant experience. Once it does, you will start to crave solitude the moment your energy barometer starts dipping, because the mind knows that is where the charging point is. It also improves your relationship with yourself. The more self-aware you are, the more you are in touch with your inner self, and the more your life hits the harmony with all other aspects of your life. What does research have to say about solitude? Studies have proven the benefits of solitude. From increasing productivity to sparking creativity, solitude is seen as a tool for personal growth and self-discovery. Nature-based interventions involving varying periods of time spent in solitude and silence in the wilderness are commonly implemented among therapeutic and educational nature-based approaches and are linked to beneficial outcomes, involving personal outcomes such as self-discovery, as well as therapeutic outcomes. When you have the capacity to be alone, you are far less likely to feel lonely when alone. This capacity can be exercised through little joyful moments. You can find mindful moments even while washing dishes or my favourite- tending to plants. In conclusion, if you haven’t yet explored the sensory richness felt after spending some quality solitude time, you are missing an entire inner personality development course. The solitude flow shall come unhurriedly and would eventually grow upon you. That’s when you’d be able to unplug and know when to put yourself in the solitude recharge. Invite solitude in your life and see how you bloom in peace.

In the last 5 years, hospital admissions for eating disorders have risen by 84%, with over 9,000 admissions for anorexia nervosa between 2020 and 2021. Characterised by excessive weight loss and malnutrition, anorexia nervosa is a complex eating disorder attributed to extreme dietary restriction, distorted body image, and often excessive exercise. Though a highly debilitating disorder with often fatal outcomes, successful treatment options are somewhat sparse in comparison to other psychiatric conditions. As part of the current treatment, patients tend to undergo a refeed process in which food is reintroduced to encourage monitored weight restoration and re-nourishment. Unfortunately, many patients often experience gastrointestinal distress, including bloating, stomach pain, and constipation, which often resembles symptoms of gastrointestinal disorders. Given that many core features of anorexia nervosa overlap with those in gastrointestinal conditions (including loss of appetite, weight reduction, and altered mood), it may be worth investigating the gut in the hunt for new treatments. Although never diagnosed with an eating disorder, throughout my teenage years I struggled with restrictive eating and overexercising due to poor body image (why not check out my previous blog on this). Understanding, at the basic level, how difficult a poor relationship with food can be, I wanted to learn more about the potential contributors to eating disorder psychopathology and how, on the back of this, we can help people to recover. So now, as a mental health researcher in the SPI Lab at King’s College London, I thought I would do some digging into this. Without further ado, let’s get into it! Gut microbiome and microbial diversity In our intestines, we have trillions of microscopic organisms, known as microbes or microbiota, that collectively form a diverse community called the gut microbiome. Though our specific collection of microbiota is unique to each of us, the gut microbiome usually contains 5 main microbial species: bacteria, fungi, parasites, viruses, and archaea. However, one progressing line of evidence is that individuals with anorexia nervosa have an imbalance in the expected prevalence of these microbial species in the community (aka microbiota dysbiosis). So, what does the research say about this microbial imbalance? As highlighted in a recent review, patients with anorexia nervosa often have an abundance of Methanobrevibacter Smithii (the most dominant methane-producing bacteria in the gut). This has also been reported in patients with irritable bowel syndrome (IBS; a disorder that affects the digestive system, mainly the large intestine), particularly in those experiencing constipation. Considering its methane-producing properties and its role in slowing intestinal transit, it is understandable that Methanobrevibacteri Smithii is associated with constipation and bloating, and that its enrichment could contribute to these complications in patients with anorexia nervosa. In addition, overrepresentation of this bacteria has also been reported in patients with non-alcoholic fatty liver disease (build-up of fat in the liver) and cirrhosis (scarring of the liver from long-term liver damage). Such association may therefore also translate to instances of liver dysfunction in anorexia nervosa patients. Comparatively, patients with anorexia nervosa show a decrease in butyrate-producing microbes, such as Roseburia, Ruminococcus, and Clostridium. As a short-chain fatty acid supporting digestive health, butyrate could also be a suspect for gastrointestinal distress in these patients. In a recent study with IBS patients, a 12-week course of treatment with sodium butyrate showed promising improvements for gastrointestinal symptoms including abdominal pain, constipation, and flatulence, suggesting that low butyrate production is associated with gastrointestinal distress. As is the case with Methanobrevibacteri Smithii, there appears to be an overlap in butyrate-producing microbe diversity in patients with IBS and anorexia nervosa; such findings may therefore also explain these gastrointestinal symptoms. What about psychological symptoms and eating behaviour? As touched upon in our previous InSPIre the Mind blogs by Viktoriya Nikolova and Lisa Hantso, research indicates a link between altered microbial diversity and poor mental health outcomes, including depression and anxiety. Such conditions are highly prevalent in patients with anorexia nervosa. Indeed, greater levels of depression and anxiety have been associated with reduced microbial diversity in these patients. Not only this, patients’ microbial compositions have also been associated with disordered eating behaviours and experiences, including dietary restraint and concerns with weight, shape, and eating. Those with lower microbial diversity scored higher across these different aspects. More specifically, as a core feature of anorexia nervosa, dietary restriction may, in fact, be influenced by an abundance of Enterobacteriaceae (a bacteria associated with gut inflammation and infection). As a producer of protein ClpB, a hormone that causes loss of appetite, it is plausible that enriched Enterobacteriaceae in the gut could contribute to poor appetite regulation in patients with anorexia nervosa. So, how can this be applied to therapeutic intervention? As mentioned earlier, patients tend to undergo nutritional rehabilitation as part of the current treatment process. This often involves the introduction of a high-fat diet as this macronutrient (a nutrient that we need in large amounts in the diet) is high in calories and thus contributes to quick weight gain. Each macronutrient, however, impacts the gut microbiome differentially, and thus a better understanding of the microbial composition in anorexia nervosa patients may allow us to better tailor their nutritional rehabilitation. This may reduce gastrointestinal-related side effects and improve long-term recovery. In addition to this, researchers may also be able to screen probiotic supplements(substances that promote the growth of microorganisms with beneficial properties) to find promising interventions that restore microbial imbalances. For example, lactobacilli and bifidobacteria supplementation have been said to increase Roseburia and thus improve butyrate production in both animals and humans. A recent study conducted in adolescent patients with anorexia nervosa showed promising effects of lactobacillus on improving symptoms of constipation over a 6 month period. Though these effects were not evident in the shorter term (across 3 months), findings may suggest probiotics as a complementary therapy to ease gastrointestinal symptoms throughout the recovery process. Probiotic strains that act against ClpB protein producers may also be helpful in eating disorder treatment, perhaps due to the potential role of ClpB in psychobehavioural symptoms. Though the use of probiotics in psychiatric disorders with overlapping psychological symptoms (such as anxiety and depression) is advancing, application to anorexia nervosa is still largely suggestive. A recent trial protocol (a document describing the breakdown of a proposed trial) has proposed to investigate the clinical efficacy of a multistrain probiotic in patients with anorexia nervosa, related to psychological outcomes (i.e. eating-disorder-related psychopathology, depression, and anxiety). Such research, however, is limited. Nevertheless, the publication of a recent trial in adolescent patients and submission of a protocol aiming to investigate the effects of probiotic use in anorexia nervosa indicates that this field of research is actively trying to use this approach to improve treatment. Final note Though covering only a few examples, I hope this blog highlights the possible effects of the gut microbiome on eating disorder psychopathology and the start of a potentially promising journey to better treatment for patients struggling with anorexia nervosa.

I have recently written an academic piece on the putative debate on whether depression is a medical disorder or a psychosocial condition, and whether people with depression should be helped by prescribing antidepressants or through societal change. I call this a “putative debate” because people who are critical of antidepressants often force such a dichotomous choice where none should be: all health problems are both medical and psychosocial; all people with a health problem can be helped by both medications and societal changes. Gemma Harris’ blog, which was published yesterday, touches on some of these themes from the point of view of her lived experience. Inspired by her sincere account of how antidepressant medications have helped her, and of the stigma that still surrounds people who take medications for mental health problems, I have suggested to her that I could republish a shorter version of my academic piece as a complement to her blog. Depression is physical, as physical is the mind, and physical are emotions and behaviours I often get accused of having a ‘reductionist’ point of view, because, as a neuroscientist, I firmly believe that all our mental processes, all our emotions and behaviours — friendship, love, sadness, happiness — have a physical substrate, as they reside in the brain, even if we do not yet fully understand this biological substrate. If all mental processes are in the brain, then so is depression. What else can depression be, if not “physical”? The only alternative to this view is that the mind is an independent, non-physical entity: that it is, basically, a “spirit”, a “soul”. But this is the domain of faith and religion, not science and medicine. Yes, the brain regulates emotions and behaviours, in the same way that the heart pumps blood, the stomach absorbs nutrients, and the spleen hosts immune cells. Hippocrates said it: Men ought to know that from the brain and from the brain only arise our pleasures, joys, laughter and jests as well as our sorrows, pains, grieves and tears. Antidepressants do not “cure” the causes of depression — and most of the other medications that we use in medicine also do not “cure” the causes of the disorder Painkillers take the pain away, not the cause of the pain; anti-hypertensives lower blood pressure, they do not cure hypertension; statins lower cholesterol, they do not cure the genetic problem that generates the high levels. Dexamethasone and heparin save people infected by COVID, even if these drugs do not even remotely affect the virus infection. And so on, and so forth. Arguably, only antibiotics or antivirals tackle the cause of a disorder. Or surgery (and not every time). Instead, people who are critical of antidepressants argue that medications for depression should have a different value threshold: that antidepressants should not be prescribed because they do not act on the cause of the disorder. Antidepressants improve depressed mood One of the problems of research on antidepressants is that some of the measurable therapeutic effects are influenced by the way depression is assessed, and in particular the type of symptoms scales used. Some of the most used scales are chosen not because they are the best, but because they have always been historically requested by the regulatory agencies that approve new medications. Some were developed before I was born, when we used antidepressants that we are no longer using today. Notwithstanding these limitations, there is clear evidence that, when people with depression are asked the simple question of whether antidepressants improve their mood, there is a clear, positive effect compared with dummy-pills. The ‘number needed to treat’ for antidepressants, a clinically-relevant measure of the effectiveness of medications, is around 7–10, which is similar to medications for other disorders. This is perhaps the most straightforward scientific validation of Gemma’s personal lived experience, and shows that research in big numbers and personal stories lead to the same conclusion: antidepressants are helpful. Not for all people with depression, but certainly, for many. Are antidepressants perfect drugs? The best we can ask for? Of course not. Even with multiple medication exposures, one third of individuals do not achieve full disappearance of depressive symptoms. Side effects, including withdrawal effects at suspension, can be challenging for some patients, as recent guidelines from the Royal College of Psychiatrists emphasise. We need to conduct more research and get better medications. While maximising the benefits that people can obtain from the medications that are available today. Antidepressants are one of the tools to help people cope with the adverse circumstances and the societal problems that have led to their depression, while we are fighting for societal changes Imagine that you are a patient with cancer, and that you are told that the reasons why you have cancer is a combination of genetic predisposition and of societal factors that are worsened by adverse life circumstances, such as lack of healthy food and high pollution levels in the area where you live now or grew up as a child. This is an accurate statement. Now imagine saying to this patient with cancer that, since the causes of cancer are societal, they should not be receiving any pharmacological treatment, but instead all the efforts should be focussed on improving society. What would people with cancer say? What would people say? Yet, this is what people who are critical of antidepressants seem to advocate: that, because people’s depression is precipitated by societal problems — and of course, it is: by poverty, discrimination, abuse, wars — , then we should not treat these societal problems with antidepressants. Yet we are not treating the societal problems with antidepressants. We are treating people who are depressed. While we are fighting for societal changes. I firmly believe that we, mental health scientists and clinicians, have a duty to participate in the societal debate on behalf of the people who suffer most. In fact, Inspire the Mind was born not only to talk to the public about mental disorders but also to advocate on behalf of the people who are struggling: children with no food, pregnant women in prisons, migrants and refugees, ethnic minorities, victims of war; those living in poverty, polluted areas, countries with limited access to medical care. We can all fight for societal change: write to your parliament representative, sign a petition — and yes, write a blog, for Inspire The Mind or for another platform fighting for health and social justice. In the meantime, as clinicians, we will also continue to support individual people with the psychological and pharmacological support we can provide.