The long shadow of loneliness in adolescence Loneliness can be understood as a painful emotion that arises when the quality or quantity of a person’s social relationships fails to match up with what they desire. It is different from solitude or isolation, in the sense that loneliness revolves around feeling alone rather than simply being alone. A person can feel lonely even when surrounded by others, particularly if they feel that they have nothing in common with those people, or that they are not understood or valued. Loneliness is not itself a mental health problem — some scientists argue that it actually serves a purpose, by giving us the urge to try and reconnect with others — however, it does frequently co-occur with many mental health problems, particularly in depression and anxiety. I am a Postdoctoral Researcher at King’s College London and have spent the past 10 years studying loneliness and its implications for health and functioning. During my undergraduate studies, I had noticed that loneliness was mentioned fleetingly in psychology textbooks, but I was convinced there had to be more to the story. When I first began my PhD research in this area, loneliness was widely assumed to be something that mainly affected older people. It is understandable that people might make that assumption: events in the latter years of life such as the death of a spouse, difficulties getting out and about, or moving into residential care, can lead people to lose sources of companionship that they may have relied on for many years. However, loneliness can affect people of all ages, and we now know it is particularly common in adolescence and early adulthood. This stage of life is a period of huge transition, when individuals are finishing school, moving out of the family home, potentially going away to university or entering the job market, and trying to establish their independence. Navigating these challenges is by no means easy, and this could leave them feeling alienated or isolated from their peers, family, or society in general. A 2018 report by the ONS found that half of people aged 16–24 reported feeling lonely at least some of the time, with around 10% saying they often or always feel this way. Feelings of loneliness in adolescence are often temporary and would be expected to subside as circumstances become more favourable. However, some individuals can become trapped in a vicious cycle of loneliness. When you feel like you’re all on your own, the world seems like a more dangerous place, and every social encounter becomes a gamble. Lonely individuals are more likely to be wary of potential threats or betrayals from those around them, and this can become a barrier to building the positive and trusting bonds that would help them to feel less lonely. Hence, loneliness can become a feedback loop that burdens them for months or even years. In a recent paper in the journal Development and Psychopathology, we investigated the timing and duration of loneliness in the adolescent years, and their implications for health and functioning at the onset of adulthood. The data came from the Environmental Risk Longitudinal Twin Study, a UK-based cohort of 2,232 individuals born in 1994–1995. Loneliness was measured at two stages of the study, when participants were aged 12 and 18. There is a lack of consensus on how long a person must experience loneliness in order for it to be considered long-term or chronic, but for the purpose of this study, we considered individuals to be chronically lonely if they scored high on loneliness at both these ages. We compared this group to those who experienced remitted loneliness (limited to age 12), new-onset loneliness (limited to age 18), and those who were not lonely at either age. Approximately one-fifth of the sample had experienced loneliness either at age 12 or at age 18. Within this group, the tendency was to move in and out of loneliness over time: only a minority (2.4% of the sample) were lonely at both ages. These individuals were at increased risk for poor mental health outcomes, including depression, anxiety, self-harm and use of mental health services. They also had poorer sleep quality and were more likely to be out of work. However, the same was also found for individuals whose loneliness had emerged more recently, and there was not a substantial difference between these two groups. Hence, there did not appear to be a cumulative load on mental health with longer durations of loneliness — instead, these problems co-occur with loneliness whether it is a recent development or something that has been ongoing for some time. Meanwhile, individuals who had been lonely at age 12 but were no longer lonely tended to do better on these outcomes at age 18. However, they were more likely to finish school with low qualifications (either none at all, or nothing higher than a D at GCSE level), compared to children who had not been lonely. Hence, there seems to be something about experiencing loneliness at the beginning of secondary school that foreshadows future risk of poor educational outcomes, even if the loneliness is no longer ongoing. The mechanism of this is not yet clear, but mental health difficulties could be a plausible candidate. This builds on previous research in the same sample, which found that lonely young adults were more likely to be out of work and struggling with job-seeking, and a possible implication is that loneliness could be a force for downward social mobility. A further implication of this study is that even children who are able to escape loneliness may still need additional support. However, given that loneliness goes hand-in-hand with diverse problems in mental health and functioning, tackling it in a timely manner should still be a priority, and in this age group the school environment could be an important setting for delivering interventions. An example of one such intervention is Promoting Alternative Thinking Strategies (PATHS), which focuses on helping children develop their social and emotional skills. It is a universal intervention that all children in a school could receive, but the evidence suggests that one of its benefits could be reducing feelings of loneliness. Loneliness can befall on people at any stage of the lifespan, and for a minority of people it can become a burden that stays with them for a long time. Our research shows that loneliness doesn’t occur in isolation so to speak, but is often part of a cluster of interrelated difficulties, with mental health problems being particularly salient. By preventing and reducing loneliness sooner rather than later, we can seek to prevent lonely young people of today from becoming the lonely older people of the future. Header image by Pawel Czerwinski on Unsplash

Midwifery, Mental Health and Maternal Journal — an interview with Laura Godfrey-Isaacs Given the success of the Maternal Journal project (which we have written about previously) as it expands more and more, now feels like the perfect time to catch-up with its creator, Laura Godfrey-Isaacs, to find out more about how the project has snowballed, why it resonates so much with mothers, and why you don’t need to be “good at art” to find value in journaling. This week is Maternal Mental Health week, and today, 4th May, is World Maternal Mental Health Day, the theme for which, this year, is “Stronger Together”. This theme recognises that our journey towards better maternal mental health care will only be productive through collaboration between everyone concerned, including all healthcare professionals who have contact with women in the perinatal period (the period including pregnancy and the first year post-birth). Unfortunately, as many as 1 in 5 women will suffer with a mental illness during this period, most commonly depression and anxiety, but other disorders such as post-traumatic stress disorder and postpartum psychosis are also present. Furthermore, it is likely that rates of mental illness during the perinatal period will have increased during the pandemic, so it has never been more important that appropriate resources and care are available to women. Midwives have a pivotal role to play in this, which is why it’s even more fitting that tomorrow, 5th May, is International Day of the Midwife: a day dedicated to observing the incredible work that midwives do in supporting and caring for women and birthing people, as well as their wider families, at such a pivotal time in their lives. As I reflect this week on the importance of these days, I am pleased to share with you an interview I had with one woman who connects all these things: Laura Godfrey-Isaacs, a midwife and birth activist, as well as an artist and a mother, who is making huge contributions to improving provision and resources for women experiencing mental health problems in the perinatal period. As a researcher in the field of perinatal psychiatry, in 2017, I was offered the opportunity to be included in the pilot phase of a project that she launched, which has now become global: Maternal Journal. When I asked Laura why she felt Maternal Journal would be of benefit to women, she explained that unfortunately, mental health problems are relatively common in the perinatal period, and, in her practice as a midwife, Laura observes that there are many women who are either currently suffering with, or have a history of, mild to moderate mental health challenges, but who don’t meet the threshold for referral to formal perinatal mental health services. They are therefore cared-for primarily by midwives, with signposting to other support which might be available in their communities. Laura isn’t the only one who has observed this, and as such, in this area of mental health, as well as across healthcare more generally, there has been a movement towards the inclusion of “social prescribing”, or community referrals, where healthcare professionals may point people in the direction of community groups and interventions to help them with their symptoms, as an addition or alternative to more formal psychological therapies or medication, where it is appropriate for them. This is where Maternal Journal comes in — the project was first designed as a group set up in South London, where women were brought together to learn journaling techniques, and use these as a basis to explore and share their feelings and experiences around motherhood. “It seemed like a bit of a no-brainer to me”, Laura said, “because it is building on this legacy of women’s journaling and women’s diary keeping, of which there’s a really strong history. It was an acceptable form for women to write, explore their creativity and express social and political views at a time historically when they didn’t have access to being professional artists, journalists, or poets, so there is a strong tradition, and I think it is rooted in that as a practice for women.” Inspire the Mind has featured blogs about this project before, but now is an important time to revisit the project, as since then it has expanded greatly, and last year the ‘Maternal Journal’ book was born. The book has allowed the project to diversify, and while the community element of coming together to be creative and share experiences still remains important, the book, along with the freely-available resources on their website, can act as a companion to women who might want to have a go at journaling themselves, and perhaps even take it on as a lifelong practice after the perinatal period. I was keen to find out how the project transitioned from being community- and group-based, to include a large element of personal journaling. Laura explained that during the pandemic, as the social isolation of lockdowns made pregnancy and early motherhood even more challenging, her and Samantha McGowan (who took part in the first ever Maternal Journal group) were active in producing resources to help women to find an outlet for their feelings in the form of creative journaling. Calls were put out for artists to produce and share journaling guides, which were then shared for free on social media and their website. Soon, the team realised that they had curated a large number of resources, and began to consider making a book. With the help of money obtained from arts councils, additional artists were commissioned to create guides which covered a range of styles and genres of artistic practice, from poetry to cartooning and visual art to writing. The aim? To create a collection that was diverse and inclusive, where people could open the book and see people who look and sound like themselves. The book now contains over 80 contributions from amazing artists, not all of whom are mothers themselves, but who represent a range of voices and experiences of motherhood in all its forms. As with many “social prescribing” interventions, an important part is ensuring that the activities are accessible to anyone who might get benefit from them. In the case of ‘Maternal Journal’, some mothers may feel reluctant to try activities like this if they are not used to creating visual art or writing. I asked Laura how the project’s ethos of inclusivity had tried to combat this. “That can be a barrier for people”, she said. “People have been told, maybe at school, that they aren’t artistic, or can’t write, or can’t draw, and they carry that around with them and feel like art is for artists. We don’t believe that — we believe that art is for everyone, it’s a fundamental part of being a human being, and everyone is creative, they just need to find the way that suits them, they need to be supported, and to find a way that’s enjoyable. This isn’t really about making art either, it’s about being creative and exploring your creativity, as we say in the book: ‘this book is for everyone’.” It is clear from the book that a lot of care has been taken to make the guides user-friendly. Each guide is laid out simply, and accompanied by information on the time needed, the materials required and easy step-by-step instructions. There is artwork from other journals for inspiration, and the book showcases the wide variety of different modalities in which journaling can be done, even including some photography, sewing, collage and a piece from InSPIre the Mind on blogging. The activities are grouped into 5 main themes: beginnings, connection, identity, kindness and moments, so that different aspects of motherhood can be explored. The fact that the Maternal Journal movement has expanded from being a small group in South London to having groups meeting across the world and a published book, is testament to the importance of offering women and people who birth opportunities to explore and reflect upon not just the medical and physical aspects of becoming a mother and parent, for which our maternity services are generally well-equipped, but also the psychological shifts and challenges of parenthood. As Laura told me, “During pregnancy and the first few years of motherhood and parenting, you go through such enormous physical mental, and social changes. So, it’s a good thing to try and document that, to note what’s going on and have a way in which you can explore it and reflect on it. It’s also a time when you’re often reflecting back on your own childhood and how you were parented, and projecting forward to thinking about what kind of parent you want to be, so there’s an enormous amount going on and it’s great to have a space where you can unpack a lot of that.” This Maternal Mental Health Awareness Week, perhaps we should be reflecting on what more can be done not just to support women with severe and debilitating mental health problems, although of course that’s incredibly important, but also to normalise the idea that all parents will experience challenges in their journey of parenthood, and coming together to share stories, perhaps using creativity to explore experiences and emotions, can be of great benefit to mental wellness for everyone.

The Bow that Bends but Doesn’t Break: Might Flexibility Reduce Depression Risk? The COVID-19 pandemic forced us to get creative about how we spend our time. For me, that meant venturing out to an archery course for the first time. As a clinical psychology PhD candidate at The Ohio State University, I needed a break from staring at the computer screen. In my pandemic fog, it seemed like the most natural thing to do at the time was pick up a bow. Of the many things I learned that day, the one that stuck was that there is an optimal draw. You should not over- or under-draw the bow. And most importantly, you need a bow that bends and doesn’t break. For weeks after that experience, the bow analogy was apt to my pandemic experience as well as my research on how stress affects the body and mind in Dr. Jan Kiecolt-Glaser’s Stress and Health Lab. When we experience chronic stress, like the pandemic, it is as if there is a constant tension on that bow. Constant tension — that phrase may resonate. With this underlying tension, it is easy to lackadaisically underdraw; we’re tired and worn thin. Alternatively, every little stressor that arises may trigger an overdraw — like an overreaction with a flash of rage — or worse yet, the bow might break. Depression can onset, and we are off the course and out of the game altogether. Okay, Enough with the Analogy During the COVID-19 pandemic, depression rates soared to never-before-seen levels — affecting nearly one in three U.S. adults. And yet, even though we’ve all experienced some degree of difficulty in these unusual circumstances, many people never did develop depression. What protected them? This question has been floating through my mind as I have continued to conduct therapy with patients throughout the pandemic. Over the past couple of years, I have witnessed first-hand how pandemic mitigation efforts have had the unintended side effect of increasing depressive symptoms, and in turn, potentially hampered immune responses to both the virus and vaccine. I also saw how many of us, as chronically-stressed and socially-isolated people, did not handle daily hassles very well and fell into the trap of depression. A Brief Aside About the Complexity of Depression To say that depression is a complicated disorder is an understatement. We know that there are many different presentations of depression (e.g., one study found 1030 different symptom profiles in 3703 depressed people), and depression has many different causes, including a combination of gene and environmental factors. To make matters worse, some people are misdiagnosed with unipolar depression when in reality they have bipolar depression. No wonder depression can be hard to treat effectively. Another issue with depression is that it is self-perpetuating. It can increase physical and psychological responsivity to stressors. And there is emerging evidence that heightened and long-lasting physical responsivity to stress can worsen depression. What exactly is a physical response to stress? You may be familiar with the term “fight or flight,” which refers to how the nervous system immediately jumps into action, followed by the endocrine system with a release of stress hormones to facilitate a coordinated response conducive to combatting or escaping a stressor. Interestingly, the immune system also responds to a psychological stressor just as it would respond to a pathogen (although to a lesser extent) — via a cascade of inflammation. Over time, this stress-induced inflammation may increase depression risk. So What Can Be Done? One key strategy is depression prevention — minimising depression risk so that it never actually onsets. The way we respond to daily stressors may provide a window into depression risk, and in turn, it may be an important target for depression prevention. To pick up the bow analogy again, it is important to draw the bow with just the right amount of tension and release it at an appropriate time. Similarly, our physical stress response is meant to mobilise just enough resources to handle the situation and then return to baseline once it is handled. Overreactions are a waste of physical resources and can cause unnecessary wear and tear on the body, and underreactions do not allow for optimal performance in a potentially dangerous situation. Also, prolonged physical responses needlessly tax the body, leading to misalignment with the current environmental threat. Rumination and worry are often culprits of these prolonged responses. Another culprit is adverse experiences, especially childhood trauma, which can make it difficult to recognise safety, thereby leading to more frequent, intense, and prolonged physical stress responses. A New Framework With all of this as background, I’m suggesting a new framework for evaluating depression risk and a novel target for depression prevention: inflexible physical stress responses, or bodily responses, that are out of proportion to the current threat and do not return to baseline, but remain elevated, when the threat is resolved. So in our bow analogy, the bow is not released, and the bow is kept slightly taut. For example, if your supervisor unexpectedly asks you to meet with them later today, you might assume that you will be reprimanded. So you spend the whole morning and most of the afternoon having a prolonged (anticipatory) physical stress response that does not align with the calm office environment around you. Instead, your supervisor shatters these expectations and compliments you on your exceptional work performance. As the meeting wraps up, they mention that you have spinach in your teeth. You spend the next hour reprimanding yourself about the spinach, and in doing so, you perpetuate the prolonged stress response. You return home exhausted and collapse in a heap. Anyone familiar with cognitive reappraisal will recognise some thinking biases in the above paragraph (“thinking the worst,” anyone?). Indeed, our mental game can play a huge role in physical stress responsivity as well as depression risk. Cognitive-Behavioral Therapy boosts immune health, but it is not yet clear whether it changes how we physically respond to stress. There may be multiple ways to facilitate more flexible physical responses, including mindfulness techniques and exercise. Even as we move from one world crisis to another, it is possible — and beneficial — to find rest and return to baseline. We are all capable of learning to engage stressors to the best of our ability and then rest. Learning to quickly draw and release in line with the target (stressor) may help to prevent depression. We can become like bows that bend but do not break.

Yoga is not “woo-woo” anymore: yoga can reduce inflammation, according to research The online space allows for easy access to health information, which may not always be from the most reputable sources. It doesn’t take much to find a lot of unfounded claims and fake news, making it hard to discern what to believe. Have you come across online articles that make you scratch your head in confusion? Can garlic really prevent COVID? Can meditation cure cancer?…and can certain yoga poses prevent hair loss? These questions can be answered by high-quality, peer-reviewed research published in reputable journals. When you want to look at the overall evidence that is out there for a certain topic, you look for scientific reviews — they summarise current knowledge giving an overview of what’s known at that point in time. I am a postdoctoral researcher and project manager at the Stress, Psychiatry and Immunology (SPI) Lab, and when I was asked to write a review for Brain, Behavior and Immunity — Health last year, I immediately knew what I was going to write about. Can you guess based on my previous blogs? Easy: yoga! Along with being a researcher, I am also a fervent yoga student and educator. You can see some of my publications on yoga philosophy & mental health, yoga and stress, and my recent paper on yoga and inflammatory markers. Yoga is an ancient system for integrating the mind, body, and spirit. Yoga promotes mental and physical health through lifestyle guidelines. Yoga practices are rooted in the belief that a practitioner’s mental state is the key to achieving holistic health. There is an abundance of compelling research on yoga for mental health, mainly in the areas of anxiety and depression…but being a researcher of the SPI lab, I wanted to take it a step further and look at the evidence on yoga for inflammation — after all, depression and anxiety have a bi-directional relationship with inflammation. Current medical knowledge recognises the role of stress in the development of psychiatric conditions and its interplay with the immune system; specifically, the field of psychoneuroimmunology and immunopsychiatry. Acute and chronic stress, mainly through the hypothalamic-pituitary-adrenal (HPA) axis (the name given to the hypothalamus, pituitary gland, and adrenal glands; it plays an important role in the body’s response to stress) and the sympathetic nervous system (one of the divisions of the nervous system), play a crucial role in immune system dysregulation and psychiatric disorders, as the last few decades of psychiatric research have unveiled. Chronically high levels of cortisol, known as the “stress hormone”, can induce the production of inflammatory cytokines. Inflammatory cytokines such as interleukin-6 (IL-6) and interleukin-1 beta (IL-1β), as well as tumour necrosis factor-alpha (TNF-α) and C-reactive protein (CRP) play a central role in mood disorders. They have also been identified as biomarkers in psychiatric diseases such as depression, psychosis, bipolar disorder and schizophrenia. Recently, the interaction of the immune system, stress, and mind-body practices has been attracting a lot of attention in academic research. Mind-body practices have been shown to induce positive effects on stress perception and the immune system. But wait, what about yoga? The current literature bears strong evidence for the benefits of yoga on the levels of circulating cortisol and classical inflammatory markers, such as CRP, IL-1β, IL-6, TNF-α, as well as interferon-gamma (INF-γ) and Immunoglobulin A (IgA). A study on people experiencing depression found that along with having anti-depressant effects, yoga reduces IL-6 levels. Regular practice of yoga has been shown to increase β-endorphins, and decreases IL-6, and TNF-α levels of yoga participants. β-endorphins are produced following HPA-axis stimulation and have inhibitory effects on the immune system. Furthermore, a recent study that investigated the immune functions in middle-aged and older women found that cortisol concentration and secretion were lower following a yoga intervention, suggesting a reduced stress response in older adults. There is also some evidence of the effects of yoga on inflammation in pregnant women. A randomised controlled trial that consisted of 94 healthy pregnant women and lasted 20 weeks, compared the effect of two weekly 70-minute yoga sessions. A randomised controlled study is a scientific study where participants are randomly assigned to two groups — a treatment group, receiving the treatment or intervention and a control group, that receives a comparator treatment or no treatment at all. The results of this study show that the yoga sessions reduced cortisol and enhanced IgA during pregnancy, indicating a diminishing of the inflammatory response. Additionally, studies on people at risk of cardiovascular disease, observed that yoga had significantly superior outcomes in the reduction of IL-6 and CRP levels. Yoga may also be relevant for patients with high cholesterol levels, as the practice led to reduced cholesterol, IL-6, TNF-α and CRP levels in a randomised controlled study. In the field of auto-immune diseases, studies on rheumatoid arthritis patients found that yoga resulted in significant decreases in CRP, IL-6, and TNF-α, alongside a reduction in depression scores. Finally, yoga has also been advised for stress in patients with breast cancer. A large randomised clinical trial found that yoga practice led to lower levels of IL-6, TNF-α, and IL-1β in breast cancer patients. Another earlier study found evidence for lower blood levels of CD56 and IgA in these patients. CD56 is a marker of natural killer and other immune cells including T cells, and alterations in CD56 levels are associated with infectious and autoimmune diseases and malignant tumours. In breast cancer, IgA is directly associated with tumour load, which is essentially the number of cancer cells or the size of a tumour — and so it can be used as an indicator of disease severity. Altogether, yoga as a physical and spiritual practice may be beneficial for the immunity of populations suffering from mental or physical health disorders and could be employed as a preventative intervention for at-risk groups. So, perhaps it’s time for you to get back on your yoga mat…

The Rise of Nostalgic Music During COVID-19: How it helped us cope Music has a constant presence in our lives. Whether it was playing in the background during our most precious moments or brought to life the scenes of our favourite movies, we always find songs that seem to perfectly express our feelings at a given space in time; songs that become meaningful reminders of important events in our past. Thus, it is to no surprise that music is one of the most powerful means through which people experience nostalgia, a sentimental longing for a bygone period or time in one’s life. During the COVID-19 pandemic and the lockdown restrictions, I found myself craving certain songs that reminded me of past moments in my life. I listened to songs that brought back memories of pre-COVID-19 times — summers spent with my closest friends, songs that reminded me of home and family. Data suggests a growing trend for nostalgic music during the COVID-19 lockdowns in Europe and the United States of America, symbolised by the increased streaming of songs released from over a decade ago, as well as songs from the 1980s and 1990s, on streaming platforms like Spotify. This suggests a collective desire for nostalgic music over this period, leading to questions such as why was this desire present? And what effects did this have on our wellbeing? Research on nostalgia suggests that we seek it during times of anxiety or uncertainty as a coping mechanism. For many, anxiety and uncertainty highlight their experience of the COVID-19 pandemic, particularly the period of lockdown restrictions and the unknowingness of when these would be lifted. I recall my isolation in university halls, far away from family and friends, not knowing when I could return home or see people again, experiencing a constant state of uncertainty. Looking back now, I realise that my yearning for music of the past was not simply a preference, but rather reflected a desire for stability and for memories of better days filled with positive emotions and connectedness. Indeed, a recent study conducted by Yu-Cheong Yeung investigating the association between nostalgic music and the COVID-19 pandemic, suggests that the increase in streaming older music demonstrates a common mechanism that individuals used to cope with all the negative emotions that arose over the lockdown period. Although music more generally has been shown to help foster social connectedness and improve mood during lockdown, nostalgic music seems to be associated with evoking a sense of comfort. The memories of significant people and experiences in our lives brought about by nostalgic music soothe us and evoke feelings of safety. Nostalgic music has also been associated to restoring meaning and purpose in our lives, as reminiscing about significant memories facilitates our sense of identity, by helping us see continuity between our past and present selves, providing stability to our sense of self. These feelings of comfort, safety and stability evoked by nostalgic music have been associated to increases in positive emotions felt during the lockdown period, better coping with the negative emotions that arose during this period and improved wellbeing throughout the period of the pandemic. However, nostalgic music is not always guaranteed to evoke positive emotions. A study conducted in the United Kingdom to explore personal accounts of nostalgic music listening during lockdown, found that despite most individuals reporting positive emotional experiences in response to nostalgic music, there were also many that experienced negative or mixed emotions. These feelings were said to have been evoked by memories of past times that reminded them of people they were separated from, or moments they could not relive due to the restrictions. While I was reading this, I thought to myself, if nostalgic music did evoke these negative feelings in many individuals, why was there such a big increase in the streaming of nostalgic music and why is this still continuing? I thought of this as counterproductive — we were driven towards listening to songs that made us feel sadder and more alone, during an already difficult time. The researchers in this study reached a different conclusion, however. They suggested that there are differences between people reporting negative emotions when listening to nostalgic music. On one hand, some individuals tend to have more negative thinking patterns when trying to process their emotions. Thus, the feelings and memories evoked by nostalgic music can often be negatively interpreted, leading to the experience of negative emotions like sadness and loneliness. On the other hand, there are individuals which process these negative emotions in positive ways, arguing that they facilitate feelings of optimism and a sense of purpose. Reflecting on positive memories helps them regardless of the negative emotions evoked, as it gives them something to look forward to and remain positive about. This shows that nostalgic music can be beneficial to our wellbeing when processed positively, though these benefits may not extend to individuals with negative thinking styles, such as those with depression. Although all the studies focused on the lockdown period, I personally believe that this desire for nostalgic music has not yet ended. Even now, when I scroll through the comment sections of all the songs that make me nostalgic, I see a lot of recent comments from people describing the memories that each song reminds them of, reminiscing about their youth, and longing for moments that have been missed due to the pandemic. Nostalgic music during the lockdown period has helped us cope, in one way or another, with many of the negative emotions we’ve experienced. Much like the argument of the researchers I described earlier, the feelings expressed with each memory may seem sad on the surface, but they all end with a message of optimism, a message of hope that we are not alone in this and that the good old days will return. The lockdown restrictions and the pandemic may have brought about physical isolation and distancing, but I believe that music, particularly nostalgic music, has connected us all during these times, bringing us together to share our most important memories in search of comfort and positivity, improving our wellbeing and keeping us optimistic for the future. Header image by Eric Nopanen on Unsplash

What is ‘Play Therapy’, and could it be integrated into preschools? My name is Riddhi, and I am currently doing the MSc in Developmental Psychology and Psychopathology at King’s College London. My interests surround aspects of child development and child psychology, involving the emergence of attachment, and psychological therapies in children and adolescents. I am particularly interested in learning about the first 1001 days of life, and understanding how aspects of the perinatal environment impact dimensions of child development. I find the concept of play therapy intriguing and hope to understand its role within a preschool curriculum. Every day, emerging statistics portray the increasing number of young children experiencing mental health problems, and these numbers are likely to rise in the context of COVID-19. For example, 1 out of every 6 children in the age range of 2-8 years has a developmental, behavioural, or mental disorder. Mental health problems in early childhood impact a number of areas, and a lack of timely intervention is known to affect a child’s productivity in school. That’s why, from a mental health perspective, it’s important to consider integrating developmentally appropriate and inclusive therapeutic interventions into preschool as a part of the educational curriculum. And one of these therapeutic interventions is ‘Play Therapy’. The concept of play as part of an educational curriculum has been seen before, through methods such as Montessori, which has been an important aspect of kindergarten for a few decades. However, play therapy, though sounds synonymous, is a distinct concept that has recently sparked my interest for a number of reasons. The idea that therapeutic help can be provided through something as simple as play intrigued me, and I sought to understand more about it. I’ve grown up hearing about the concept of Montessori teaching and always assumed that it was simply teaching through play. As I grew older and realised that I want to someday be a Child Psychologist, I attempted to better understand the difference between Montessori and Play Therapy. Maria Montessori, the founder of the Montessori method described play as the “work of the child”. Montessori is essentially an educational aspect, in comparison to Play Therapy which has a mental health and psychological perspective. Montessori teaching takes place in a classroom with multiple children, whereas a playroom for play therapy would often have just one child, or a few children if it was being conducted for a group. Play therapy is often used as an intervention for children who have been exposed to neglect, abuse, or have emotional, social, or behavioural difficulties. The current definition of Play Therapy as defined by the British Association of Play Therapists is “… the dynamic process between child and Play Therapist in which the child explores at his or her own pace and with his or her own agenda those issues … that are affecting the child’s life in the present. … Play therapy is child-centred, in which play is the primary medium and speech is the secondary medium.” As I sat at my desk, highlighters and post-its ready for a relaxing evening of reading, I learned that there are several forms of play therapy, but Child-Centred Play Therapy (CCPT) is among the oldest and most well-known, dating back to the 1940s. CCPT is conducted in a playroom consisting of categories of toys including real-life toys, acting out toys, and toys for creative expression, each of which can be used by the child to express their emotions and experiences. I thought about applications of CCPT as a part of a preschool day and how it could be integrated into the daily schedule for children who require it, by setting up a playroom with specially selected toys and developing a timetable with the play therapist wherein the child can attend sessions a few days a week as a part of their school day. A playroom within a school setting provides a familiar and safe environment for the child and is accessible to all children. Previous studies have found support for using CCPT for children referred due to disruptive behaviour in school settings. Researchers from America conducted a study among 54 low-income preschool children who presented clinically significant disruptive behaviours and were assigned to a CCPT or an active control group. Results of this study portrayed that CCPT was an effective early intervention to reduce disruptive behaviours in the classroom, and the researchers concluded that CCPT is an intervention that can be used by mental health professionals in preschools, where children can easily access it. Play therapy within kindergarten settings can also be an intervention for children with autism. Conducting the session in an environment in which the child is familiar, with a school-based therapist they know can provide a safe environment where the child will feel comfortable. I recently came across a concept known as LEGO®-Based Therapy (LBT), an intervention developed for children on the autism spectrum. While the intervention has been seen in primary and secondary schools, there is limited research on its application in preschool. A primary school in East Sussex conducted a group based pilot project for children with autism and found that among the positive outcomes observed, listening skills and problem-solving had significant developments, length of spoken sentences improved, and children had a greater awareness of social expectations. The intervention consisted of a team of three students, wherein each child assumed a different role, as a “Supplier”, a “Builder, and an “Engineer”. LBT can be adapted for preschool-aged children on the autism spectrum with the use of LEGO DUPLO®, a form of the toy designed for younger children, and can be integrated as a group play activity within a designated time in their school day. One of the assumptions I always held about play therapy was that a typical session would use typical toys such as blocks, or puzzles. With further reading, I’ve come to understand that play therapy is not restricted to the mainstream definition of toys, but also includes sand and water-based play, art-based play, as well as roleplay and stories. While electronic games have started being included in play therapy, these wouldn’t be appropriate for preschool-aged children. In a school setting, a playroom designated for play therapy can consist of a wide range of play therapy tools not restricted to just toys. Having materials such as sand, and clay can be beneficial to work on different aspects of a child’s mental health, be it emotional regulation or helping deal with trauma or anxiety. All my reading on play therapy has led me to understand that most school-based play therapy interventions exist in primary and secondary schools, but there are a limited number of play therapy interventions in preschools. Given that the preschool age is one that often underpins mental wellbeing in later childhood, play therapeutic approaches have a wide scope for young children who have been exposed to trauma, neglect or are portraying neurodevelopmental disorder symptomology. It’s time to understand more about the topic and conduct future research in this field. Header image by Xavi Cabrera on Unsplash

Freud, the founder of psychoanalysis, is widely credited with highlighting the importance of self-blame-related feelings in depression. Although, critical of many aspects of Freudian theories of depression, cognitive theory proposed by American psychiatrist Aaron Beck, is very much focussed on self-critical thinking as well and this theory underpins cognitive behavioural therapy (CBT), which is the most widely available type of therapy for depression in the UK. Beck had already proposed in his early work that cognitions (thinking) and affective disturbance (depressive feelings) are separable and criticised that Freudian theories of depression focussed too much on feelings of guilt rather than self-critical cognitions, which he hypothesised to be the primary vulnerability factors for subsequent depressive feelings. Teasdale, a British psychologist, proposed a modification to Beck’s cognitive model which assumes that depressive cognitions and emotions are intertwined and can activate each other in both directions. I am a Reader in Mood disorders at King’s College London and an Honorary Consultant Psychiatrist at the South London and Maudsley NHS Trust. I must admit that I have struggled to be convinced by the dualism between cognition and emotion, in that any emotionally relevant cognition (e.g. “I am always failing at things”) will always be inextricably linked with emotion, and any complex emotion (e.g. guilt) will always entail cognition (e.g. the outcome of my action). I was fortunate to work with two scientists during my time as a postdoc at the US National Institutes of Health in Bethesda who used brain imaging to understand this fundamental question. Brain imaging is the use of quantitative techniques to study the structure and function of the brain, in a non-invasive manner. My supervisor, Jordan Grafman, had formulated a model of the frontal cortex (located near the front of our heads) as a long-term memory for sequences of events and actions. Based on his model, we predicted that representations of preceding and subsequent events of social actions in the frontal cortex will be crucial for understanding blame attributions. My postdoc colleague, Jorge Moll, had just carried out pioneering functional magnetic resonance imaging (fMRI) studies of moral feelings such as guilt. fMRI measures brain activity by detecting changes associated with blood flow using brain scanners, and helps detect abnormalities as well as the normal function of different parts of our brain. Our collaboration led to the observation that people who were prone to feelings of guilt had a higher activation in the subgenual a part of the frontal cortex, which sits in the midline in the depth of the front part of our brain (see image below) and had been previously associated with depression. In a separate set of studies, I was interested to see whether there is a part of our brain which specialises in representing the meaning of social behaviour, (e.g. what it means to act in a “stingy” or “generous” way). Our work built on evidence from patients with a particular form of dementia in which the tip of the part of the brain beneath our temples, called anterior temporal lobes (as shown in the image below) were shrinking. This change resulted in a loss of understanding the meaning of things in these patients and was accompanied by inappropriate social behaviour. A group in Cambridge (led by Professors Patterson and Hodges) and Manchester (led by Professor Lambon-Ralph, whom I later joined) had produced a body of evidence showing that this loss of understanding was not because of a language impairment, but because these patients lost a more abstract representation of meaning independently of whether it was language- or picture-based. We extended this work by showing that the upper right part of the anterior temporal lobe was more relevant for social than general understanding. Based on the aforementioned work, we hypothesised that the integration of information between the right upper anterior temporal lobe and the subgenual frontal region is important for helping people interpret social behaviour in a nuanced way and thereby may protect them against gross overgeneralisations about themselves as Beck observed happening in people with depression (e.g., thinking of oneself as a total failure for a minor error and blaming oneself for things that are outside of one’s control). Indeed, we found evidence for abnormal crosstalk between the anterior temporal and subgenual region, when imagining self-blame-evoking situations in people with major depressive disorder who, despite recovering from symptoms, subsequently developed another depressive episode over the next year. This was measured by investigating how the fMRI signal in one region correlated with the signal in the other region over time and is called functional connectivity. This finding prompted us to wonder whether one could use brain training approaches to help people with depression change the way these two brain regions exchange information when feeling self-blame. In our first study, undertaken by Jorge Moll’s team at the D’Or Institute in Rio de Janeiro, we were able to show that people who had recovered from depression were indeed able to change the fMRI correlation between these brain regions in a single training session. This was done by giving people cue words which they had previously defined as being associated with a self-blame-related memory and measuring the level of correlation between the brain regions to provide visual feedback on a screen in the fMRI scanner to people for brain training. We showed that the active brain training, also called neurofeedback, changed the brain region correlations and increased people’s self-esteem which is what we predicted given that nuanced interpretations of one’s actions protect one’s self-esteem from devaluating oneself as a whole. Furthermore, in a second study which we carried out at King’s College London and published recently, Tanja Jaeckle recruited people who had not benefitted from a standard depression treatment and randomised them to two intervention groups: A solely psychological intervention, in which they were given strategies to choose from to tackle self-blame-related memories in three sessions, A functional MRI neurofeedback intervention, where these strategies were supported by giving people feedback about their subgenual-anterior temporal brain correlations in the scanner. Surprisingly, both groups had reduced depression levels by 46% after 5–6 weeks, and there was no added benefit of using our neurofeedback approach. However, on further analysis, we found an important clue why this may be the case. People with a depressive episode with anxious distress, a novel subtype of depression defined in the latest classification of the American Psychiatric Association (DSM-5), responded significantly better to the solely psychological intervention than people without anxious distress, who benefitted much more from neurofeedback. So, we concluded that the brain training signature we had been using may only be relevant for non-anxious depression and may be irrelevant for anxious depression, which could explain why people with anxious depression appeared to be distracted rather than aided by the brain training. If this is true, then future studies could be successful at tackling depression using brain training by providing different brain training signatures to different patients depending on their symptoms and fMRI patterns. For example, other promising neurofeedback approaches to depression developed by Drs Young, Bodurka and Prof. Linden’s groups are based on increasing brain responses to positive memories and images, respectively, and may be of particular relevance to anxious depression. We hope to be contributing to this exciting yet highly complex line of research over the next decade. Header image by Atormentado on Shutterstock

Mania is not your punchline Mania is a misunderstood symptom of bipolar disorder that comes with its unique challenges and, as I’ve experienced, is as serious as severe depression. Bipolar disorder is characterised by extreme lows and extreme highs. Lows result in depression, with a low mood and feeling constantly lethargic. It can lead to suicidal thoughts, planning and possibly acting on them. The highs result in mania or hypomania that can lead to impulsive, reckless behaviour, having boundless energy and confidence. A manic episode often makes me a bit odd. And not in a fun, cute “oh, you’re so kooky/eccentric” way. No. More in the form of concerned faces and looks of confusion and comments that boil down to, “what the hell is wrong with you?!” My words and actions can be jarring to the people that know me well, as my attitude and opinions are exaggerated as if I’m acting like a caricature of myself. This manic version of myself — some people in my life have poked fun at it. Friends I trusted, I’d later realise, had made me the butt of their jokes. Humour has helped me understand bipolar disorder and come to terms with some unusual behaviour when I’ve been ill, but I need to be in on the joke. Today is World Bipolar Day, so the perfect day to set the record straight on the symptom of mania! I was officially diagnosed with bipolar disorder in 2012 and I’ve been writing about my experiences ever since. Education is key in combating stigma and discrimination, so I’m passionate about myth-busting when it comes to misunderstood aspects of bipolar disorder. My book ‘Living at the Speed of Light’ is all about navigating life with bipolar disorder and explores how to talk to people and educate them about this condition. What is mania like to experience? First, let’s get this straight — mania is not a personality change. It doesn’t make the person unrecognisable, but it does make you impulsive, more oppositional and defiant, quicker to anger and full of ideas and passion. For me, I’ll feel intense frustration with everyone. Opinions and ‘lightbulb moments’ constantly flow out of me as I talk at such a fast pace I stumble over my words, or entire sentences come out as gibberish. Of course, the person I’m talking to has trouble following my train of thought, and they become overwhelmed with the barrage of information I’m presenting them with. There’s no denying that when I’m manic, I come across as strange. I’ll make the ultimate inside jokes — that only I understand and laugh as I tell them. But there’s more to mania than seemingly never-ending energy and acting like the life of the party twenty-four hours a day. It twists into something else. I’ll feel paranoid, believing everyone is watching me. I’ve confronted strangers on the street, shouting across the road as they walk in the opposite direction. I’ve yelled at people in their cars stuck in traffic as they’ve glanced in my direction. When I’m manic, I’m vulnerable too That confidence you see from someone who is hypomanic or manic? If you peel away that layer, you’ll find an intensely vulnerable, extremely poorly individual underneath. Although that confidence has helped me achieve ambitions in the past, it’s also put me in some precarious situations. As much as I’ve had the confidence to pursue new relationships or nail a job interview, that belief has led me to believe I’m always the most intelligent person in the room — alienating friends and colleagues. It becomes self-destructive and, in the long run, has destroyed relationships, cost me work and harmed my career. People have seen it as an opportunity to take advantage of me in various ways. An ex knew something was wrong, but they would take advantage of how blasé I’d become about money. They’d hint about designer items they’d been eyeing or trips they wished they could go on. So, I would buy them everything they wanted and more. When I was no longer manic and faced with the reality of a mountain of debt I now had, I was devastated at how someone I’d loved and trusted had manipulated me at my most vulnerable. Hypersexuality has meant I’ve put myself in dangerous situations. I’ve gone home with strangers on nights out and walked home alone at three in the morning, without a thought for the consequences. When I’m in a manic episode, I’m not capable of making decisions that keep me safe. My impulses have taken over, so I need people in my life that understand and recognise that I’m unwell and can help keep me safe. When I’m manic, I become obsessive. Obsessions range from problems at work to business and creative ideas to exercise. They appear out of nowhere, and I’m unaware of how irrational I have become. There will be someone in my life who annoys me, frustrates me, or I simply have taken a dislike to, that my world will then revolve around. The obsession begins without my noticing but has as much subtlety as a sledgehammer to those around me. The obsession will last for months, and there have been two or three noticeable incidents of this in my life. It’s not just people I become obsessed with; I will feel the need to exercise every day. It will be an incessant need, to the point where my world turns grey, and I can hardly stand. After exercising at the gym, I once drove home, my vision blurry. I managed the journey home, where I took a shower. As I stepped out, everything went black, and I passed out onto the floor. This obsessive behaviour finds its way into all aspects of my life. I won’t be able to stop thinking about a new business idea I’ve had and will convince myself it will work and be determined to leave my job. I’ll either be obsessed with eating and won’t be able to stop thinking about food, or will dive into a diet or healthy eating plan that isn’t healthy for me in the slightest. I’ll become obsessed that my relationship will fail or that my partner will be in a dreadful accident and I’ll be left alone. When mania hits, these obsessions inevitably follow. They wreak havoc with my day-to-day life and affect my relationships, health, and job. The takeaway Laughing at someone going through a manic episode is cruel. Someone with bipolar disorder doesn’t deserve friends gossiping about their behaviour. They don’t deserve to be the anecdote at a party when someone wants to show off how they’ve ‘gone off the deep end.’ Mania can be challenging to understand, but treating someone who is obviously unwell with empathy and compassion should never be difficult. Header image by Hello I’m Nik on Unsplash

Cars & Cameras: How the Car Community Benefits our Mental Health What if I told you Herbie Car was real? That cars have feelings and a mind of their own? Well, no. Not quite. But to the car community, cars are more than pieces of metal that take us from A to B. They are a passion. A creativity. An escape. As a Mental Health Researcher at King’s College London and a lover of cars, I thought I’d do some digging into how the car community benefits mental health. Speaking with several friends from a car group I recently joined (BMW.M.UK) and touching upon my experience, in this blog I share the positive impacts this somewhat unusual hobby has on people’s lives. What is BMW.M.UK? BMW.M.UK is a fairly small group of car enthusiasts that conduct drives across the rural areas of the UK. For members, this is a chance to explore new places and take incredible photos of their cars amongst the breathtaking scenery. Not to mention the great pub lunches in and amongst the day! To put this into perspective, take a look at these incredible photos taken by Andy Sephton and Micky Wilson, two founders of the group whose passion for cars are coupled with their love of photography. This car-photography duo is a common love amongst many of the group members, whether it’s taking photos or simply admiring those taken by Andy and Micky. Though BMW.M.UK is only one group in the rapidly expanding car community, it perfectly reflects the sheer beauty of this hobby. So, what does BMW.M.UK mean to me? To me, this group is an escape. A freedom. A sense of belonging. Prior to the group, I didn’t have any like-minded people to share my passion with. I felt somewhat alone in my hobby. But now I feel a sense of belonging. Not only in my hobby but in the unconditional support from the group when life gets a little tough. And as an extension of that, I also have an incredible circle of wisdom to help me develop my knowledge and support me in hopefully modifying my own car one day. As for an escape, driving has always been a therapy to me. Growing up in the countryside, whenever I felt overwhelmed or at a crossroads in life, the tranquility of driving the rural routes with beautiful scenery always brought me clarity. Now living in London, driving out to the rural parts of the UK to meet the group offers an escape from the hustle & bustle of the city, allowing me to reset my focus. And, as an added bonus, the group allows me to do something else I absolutely love — travel. With meets around the UK, I get to see so many amazing new places! We visit areas of outstanding natural beauty often with breathtaking mountain ranges. Driving on some of the best roads in the UK and stopping to look at the incredible scenery really brings a freedom like no other. But anyway, enough about me. How does BMW.M.UK help other group members? Community and like-mindedness Similar to my experience, several of the group members emphasise a sense of community in their shared passion for cars. For example, group member Paul Craffey expresses that: “Aside from the feeling of freedom I get when I go for a drive, the people I have met along the way have enhanced that love and passion. A sense of community where like-minded people get together and share a common interest and hobby. Great days out and memories made with people I would have never met if it wasn’t for the love of cars.” Andy further reinforces that: “Creating the group [BMW.M.UK] has helped provide a positive outlet to support my mental health and meant I am now surrounded by like-minded people who I can share my hobby with.” Micky highlights how sharing his modification journey on Instagram particularly helped him face the loneliness of lockdown: “When covid lockdown occurred, life became very lonely and tedious. During this period I started posting more of my car on Instagram and got talking to some other like-minded people about car modifying and photography. This gave me something to focus on as cars have always been my passion and logging the cars progression on Instagram gave me chance to interact with people who have the same passion.” Emotional connection and support Many group members highlight the positive impact cars have had on their mental health. For Paul, modifying his car got him through a very difficult period: “For the past 18 months, I have gone on a journey modifying the car and forming an emotional connection that has quite simply got me through the worst months of my life. It has been an incredibly positive outlet for me and provided reasons to smile and be grateful.” Similarly, the connections Micky has established with other group members has improved his mental health: “This [interaction with other like-minded people in the car community] coupled with a new found interest in photography has made a big difference to my mental health, particularly as I’ve now made some great, life-long friends from it all.’’ Moreover, Andy emphasises how cars help him make sense of life: “Cars have always helped me make sense of life. When I’m struggling, they are always a constant thing that puts a smile on my face. Being at car shows and racing events, anything like that makes me happy.” Expressive outlet For Andy, modifying his car has also been an expressive and creative outlet: “Cars are an extension of my personality — the way I customise my car and make it unique represents who I am.” Preserving our inner child Many of the car events and group activities continue an excitement developed in childhood. For Paul, buying his M240i and joining the BMW group has allowed him to fully immerse himself in the car scene and satisfy his early fascination: “I’ve always really loved cars. From as young as I can remember I was fascinated by the sound and the feeling of excitement they gave me. But it wasn’t until fairly recently that I fully immersed myself in the car scene, having spent the last 10 years with company cars. On a whim I gave back my company car and bought my BMW M240i which, outside of marrying my wife, was the best decision I have ever made.” Though Andy cannot pin-point the true route of his passion, he also expresses an early interest in cars that continues to excite him: “Cars are something that, from an early age, I had a passion for. I couldn’t tell you why, it’s just an interest that grew deeper and eventually became an outlet to support my mental health when I am struggling. I often feel like a kid in the way I get excited about it and often makes me forget about the pressure of other people’s opinions.” Final words This may be a small snapshot of the experiences and thoughts shared by our group members, but I hope this blog highlights the importance of the car community to those who partake in the hobby. And though cars may not be your interest, I hope this blog also inspires you to get involved in any group hobby you may be considering; Trust me, it’s worth it. Header image by Tom Davis (t7ykd)

International Foreign Students’ lives should be a priority as Ukraine Refugees Since 24th February 2022, and since the Russian military, under the orders of its President Vladimir Putin, initiated a full-scale invasion of Ukraine, there has been an outcry on the humanitarian crisis for refugees; homes and hospitals are being bombed, people are being mercilessly killed, and cities are being destroyed. News media platforms are shocked by the outpouring of Ukraine refugees who have not only lost their homes, education and their security, but also are desperate to stay alive. However, to me what is shocking, is the lack of attention, that amongst the disaster of the war, there is on the racial segregation on International Foreign Students in Ukraine. These include UK citizens, who are fighting for their lives, have lost their hope to achieve their dreamed profession, and are desperate to return home. I am a UK-born International Medical Graduate from the University of Debrecen, (the second-largest city in Hungary, after Budapest), an International Medical School. I now work under the Core Training Psychiatry programme at the Cornwall Partnership NHS Trust. I passionately advocate 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 leadership in the UN, and how COVID-19 unmasked the ongoing pandemic of gender-based violence. I have also written two blogs in InSPIre the Mind, on Mental Health of Women and Children in conflict zones: Their Bodies and Health are the Battlefields of War and on Gender-gap in training for Assertiveness: Does it have a place in Psychiatry and in Clinical Practice? Since the Russian-Ukraine war erupted, causing a surge of Ukrainian refugees, thousands of International Students from Africa, Asia and Middle East are fleeing for their lives, whilst leaving their pursuit for a promising education and career behind. Ukraine host over 76,000 foreign students; nearly a quarter of that figure are from Africa, with the largest numbers of foreign students originating from Nigeria, Morocco and Egypt. India accounts for over 20,000 students. These students arrived in Ukraine to achieve an education that they couldn’t get in their own home country — studying medicine, engineering and business. Even British-born ethnic minority students went to Ukraine to achieve the education that the United Kingdom couldn’t provide. They are left with uncertainty about their fate of not fulfilling their undergraduate or postgraduate degree. However, what is surprising to many, but not surprising to me, is the persisted racial treatment at the border, with footage circulating online showing Ukrainian officials and refugees preventing international students from passing through the borders. One Indian student, who hadn’t been able to return home, was killed as he stepped outside to buy food. More reports came to light that international students fleeing Ukraine, are dying by the side of the road from hypothermia and heart attacks, after being blocked and stranded by the Ukrainian soldiers. Nevertheless, I am irate that there isn’t enough coverage on our current news media on the abhorrent racial mistreatment of these international medical students. In fact, reporters were commenting on their disbelief that “refugees” can be white civilians of neighbouring countries, rather than how the UK-citizen International Medical Students are being attacked and prevented from returning home safely. And what about the International Medical Students from Asia and Africa, whose only safe route is to pass the European borders, in order to fly back to their native countries? The students are being attacked by nationalists, and are fearing for their own lives. Yet, there is very little coverage on the rise of racial attacks on the ethnic minority groups of international students, who are continuously fearing for their lives as they cross the borders. Everyone is trying to escape a certain death (I describe the little news coverage below). Personal Experience I was born and raised in the UK, but I ended up studying medicine in Hungary. I had the grades, but my parents encouraged me to study abroad, in hope that I would have the confidence to settle anywhere in the world. Whilst studying in an international medical school, I remember the surreal moments as I entered lecture halls and classrooms. There were students from Iceland, Norway, Sweden, the USA, Canada, Australia, as well as those from Africa, Asia and the Middle East. All you could hear were the melodies of multi-languages erupting in the rooms; for me I was nervous that I might not fit in. I travelled alone and ended up living in Hungary for 7 years ( I had to postpone my education due to sickness). It took me a long time to make friends, but I eventually did, and I wouldn’t change the experience that I had gained by being an international medical graduate. Not only did I encounter close international relationships and friendships, but I know I became stronger, more perspective and confident in my skills. I faced many barriers in my medical school journey, and I came out resilient and assertive in character. Amongst those barriers was the racial abuse from Hungarian natives and Hungarian officials. You were constantly being reminded that unless you are white (I am actually UK-born Sri-Lankan Tamil), you are treated worse than a stray animal. I also faced sexual harassment from my Hungarian professors. On one occasion, when I was waiting to scrub into a theatre for my Obstetrics & Gynaecology rotation, I was told by the Consultant how my “boobs look gorgeous” and I should “greet him “Good Morning” by sitting on his lap”. Not only was I humiliated on the ward amongst my classmates, but I was told to just smile and take it. After all, my male classmates, and later some Consultants who I complained to, had said that I am “a pretty exotic Indian” and should “get used to it” (as I have mentioned above, I am actually UK- born Sri-Lankan Tamil, and I SHOULDN’T HAVE to get used to it). These constant sexual harassments aren’t new, and racial segregation happens more often than you think. Nevertheless, it seemed that raising complaints on racial and sexual harassment fell on deaf ears and so we focused on one main goal: receive our graduate certificates, and return to the safety and security of our home. None of us thought about potential war conflicts from neighbouring countries, or immigration influx through the borders. We must acquire it (education), whether it is at home or abroad. Psychological Impacts on Trauma and Racial Segregation in War-Conflicts Only a few times was there news coverage showing how the Ukraine officials are pointing guns at international medical students, being blocked to board at the Ukrainian train stations, being forced to turn around at Poland’s border and being told “ if you are Black, you should walk”. After enduring the bitter cold, no food and walking for three days, to be told that you cannot cross the borders for safety based on your skin colour, it seems the racial segregation mindsets are still prevalent here. However, this is not news to me, as I am all too familiar with this behaviour and language. United Nations and international embassies are themselves appalled by the racial abuse at these borders; the International Medical Students are either being stranded or killed amidst the Russia-Ukraine war. Even when these students do return to their home country, the trauma from witnessing the bombings, the racial abuse and the killings will have significant mental health impacts, such as post-traumatic stress disorder. It will be imperative to provide these students trauma-care, whilst subsequently coping with the stress on completing their graduation. The loss of faith, the sense of worthlessness and the possibility of starting their education with a huge gap in the academic years. All these factors can contribute to poor mental wellbeing. I consider myself incredibly lucky to have graduated in 2016, and I have been welcomed into the training programme of the Royal College of Psychiatrists. However, I cannot help but wonder if many of our potential psychiatrists are trapped in this war conflict, and what could we do to ensure the safety of these students. NOTE FROM THE EDITORS: Inspire the Mind continues to be deeply saddened by and concerned about the terrible events in Ukraine and our thoughts and prayers are with the people affected. It is heartwarming to see the kindness and solidarity shown in these frightening times with campaigns such as the JustGiving page from Dennis Ougrin, a psychiatrist who has been delivering medical supplies to those in desperate need. He was interviewed by InSPIre the Mind here. Header image source: Kevin Bückert on Unsplash

How can architecture support our mental health? Part 2 Last week, we began with an overview of how architecture can influence our mental health, ranging from noise and light to proximity and social interaction. Today, we will take a closer look at the history and future of mental health hospitals, and the emerging field of neuroarchitecture. Historically, mental health asylums were akin to prisons; a lock-up with bare bones supervision for its unfortunate inmates. For example, the previous home of the Bethlem Royal Hospital from 1676 to 1815 was said to resemble the Palace of Versailles, but its grandiose façade belied the dire conditions inside. Not only were the patients confined to their cells, but paying visitors could gain access to stare at the patients through the bars, and even taunted them for reactions. Architecturally, it evidenced the sad results of poor spatial planning, when public and private spheres collided in a most disastrous way. Unsurprisingly, the Bethlem Royal Hospital’s shortened name soon gave rise to the term “Bedlam”, meaning chaos or confusion. Considering that times have fortunately moved on, how would I design a better mental health hospital today? For me, the answer lies in working closely with the service users and health professionals to better understand their needs, wishes and aspirations. The provocatively named arts project “Madlove: A Designer Asylum” has done exactly that. Its idealised design endeavours to co-create a new type of mental health hospital where users are listened to, inhibition to seek out mental health services is reduced, and the stigma attached to mental health distress is challenged. Through careful design, it has translated the needs of the users into a comforting and colourful scale model that destroys associations with the clinical environments of old. Instead, it emerges as a beautiful village that allows space for mutual care. And as a collaboration between artists James Leadbitter and Hannah Hull, architects Projects Office and muf, set designer Sascha Gilmours and 432 people with and without personal mental health experiences, it shows that it can truly take a village to achieve new visions that serve a wide range of people. On a larger scale, Projects Office has begun to translate the typology developed in this project into a real-life building. Again, they consulted with artist James Leadbitter to develop a new design for the Child and Adolescent Mental Health Services hub in Edinburgh. It provides inpatient and outpatient spaces for young people and thrives on colour, pattern and flexibility. By experimenting with standard materials and furnishings in surprising colours, the architects were able to achieve an innovative space on a tight budget. In addition, by choosing items that can be easily reconfigured and planning for quiet nooks in communal spaces, the architects not only establish a successful relationship between the public and the private that is so essential to inpatient services, but also provide spatial metaphors for respite and reflection, opening up and communicating. As a result, a variety of strategies can be employed to work with young people using the service. When architecture meets neuroscience Considering that designers thrive on individual client briefs and intuition, I wonder if there is hard evidence to support the effect of architecture on humans in terms of psychology. I know that architects and neuroscientists are clubbing together to understand how our built environment affects the brain in a new field called neuroarchitecture. I have asked architect and happiness advocate Frven Lim, director of DP Architects’ Studio London, to explain how he sees the relation between mental health and architecture: “Fundamentally, architecture is about providing shelter, creating a sense of security and privacy. But up to 90% of our time is now spent indoors surrounded by modern materials, while the human psyche is still hardwired through evolution to enjoy biophilic spaces and dislike sharp edges. We cannot reprogramme our brains, unless we wait another 50,000 years. So we must find ways to make the time we spend indoors more meaningful.” What is the biggest thing we should change about our built environment, I ask? “There is no big bang — sometimes, many small things can make a difference”, says Frven. “For example, when designing offices, I think of stairs as more than circulatory spaces. They can encourage physical activity and be spaces to connect with each other. And especially since the pandemic, we want offices to be much more than places that provide a desk. Connecting with somebody can be a small gesture but have a huge effect. This way, we can transform the world in lots of small ways.” While neuroarchitecture is still a relatively new field, scientists Alex Coburn, Oshin Vartanian and Anjan Chatterjee have surveyed the current literature in their 2017 publication, “Buildings, Beauty, and the Brain: A Neuroscience of Architectural Experience”. They explain that there is likely a link between emotions raised by architecture and the brain’s reward system. Interestingly, the authors also point out that most lab-based experiments are set up to show participants 2D imagery, while architecture is by nature enveloping and three-dimensional. Considering the inherent complexity of both architecture and human behaviour, it seems we still have a lot of discoveries ahead in regard to studying its effects on the brain. But even if neuroarchitecture cannot yet provide us with one crystal-clear conclusion, every piece of knowledge brings us one step closer to solving the puzzle. Until then, architects will continue to rely on their field work by experimenting with different designs, speaking with our clients and consulting with our building users, always striving to translate many individual experiences of happiness into better buildings for us all.

Agnosia: Looking to Your Surroundings from a Different Perspective As a Neuroscience postgraduate student at King’s College London, I have always found the unknowns of the brain and the brain disorders that keep their mystery, fascinating. I believe agnosia is one of those disorders that need to be deciphered. Imagine not being able to successfully recognise objects, sounds, or people by utilising your senses (sight, hearing, touch, smell and taste); you will most probably get diagnosed with agnosia. In this blog, I will try to provide some insight into this rare neurological disorder. What actually is agnosia? If you are in the neuroscience field or have read the patient tales of Oliver Sacks (the man who mistook his wife for a hat), you might have an idea of the term ‘agnosia’. If not, let me introduce the complex neurological disorder that leads to the inability to identify or recognise everyday objects, loved ones or sounds through their senses despite otherwise normally functioning senses. Can you imagine being able to smell, see or sense things but not being able to correctly interpret without even realising? Imagine having an internal model of the world where the things you perceive are interpreted differently from the real world. Agnosia can result from a variety of things ranging from dementia, strokes, neurological disorders, brain infection or head injury. Brain damage usually occurs in the temporal, parietal or occipital lobes. The temporal lobe is located close to ear level and is mainly involved in long-term and conscious memory; the parietal lobe is roughly located at the upper back area in the skull and processes sensory information it receives from the outside world, mainly relating to touch, taste and temperature. In contrast, the occipital lobe is primarily involved in interpreting visual information. These areas are vital parts of the brain that are involved in higher perceptions related to vision, hearing and sensations. Primary Visual Agnosia: Seeing without identifying Now, given the different functions of each of the brain lobes, it makes sense that depending on which area is affected, different symptoms or types of agnosia will result. It is essential to mention that agnosia usually alters one sensory modality. For instance, visual agnosia refers to the inability to identify or recognise familiar people and/or objects despite having normal vision. Indeed, patients with associative agnosia cannot categorise different visual stimuli. For example, a such a patient would not associate a glove and a hand or a rectangle and a book with one another; hence, verbal identification of the object would not be possible. On the other hand, the second main category of visual agnosia — apperceptive agnosia — refers to the inability to identify the shape of the objects. These patients can verbally interpret the objects’ colour and texture, yet, they fail to match identical objects. Therefore, as shown in the right side set in the figure below, although a circle can be identified verbally from a drawing, these patients fail to copy the image of the circle. Hard to imagine? To further classify visual agnosia, I would like to mention one of the most interesting and challenging types of apperceptive agnosia: Prosopagnosia — the inability to recognise familiar faces. Take some time to imagine waking up and not being able to identify your loved ones, close friends, and family, even though you can see them. Patients with this brain disorder cannot process facial features and are usually unable to differentiate faces. However, as a remarkable fact, they can identify a person by their smell, speech or even walking style. Glen Alperin, a prosopagnosic patient and writer, mentions that this condition affects all aspects of his life. In his blog, he describes how he can only recognise ice hockey players by their names and the numbers on the uniforms. Indeed, patients with prosopagnosia have a much harder time recognising people they do not often see; hence specific striking characteristics like hair colour or even the numbers/names on the uniforms can be the visual cues helping them identify the person they ‘see’. Word Deafness: Hearing without awareness One of the other forms of agnosia is auditory agnosia which refers to the inability to process sounds despite unaffected hearing and intact speaking, reading and writing abilities. This is thought to be associated with a disconnection between the language centres and sound processing brain areas. For instance, a person with auditory agnosia can interpret the sound of a car horn as a loud sound that lasts for a short period but would not be able to recognise the car horn itself. Not being able to identify someone, a usual sound, or inability to categorise and interpret objects make agnosia a form of a communication disorder despite the preserved sensory functions. The unknowns of agnosia highlight the knowledge gaps in neuroprocessing networks and memory formation within the brain that are yet to be solved. The Prognosis, Treatment, and the Future Diagnosis of agnosia includes neuropsychologic testing to measure the brain’s cognitive function, neurologic examination to examine impairment of the nervous system, and brain imaging (MRI or CT scan) to characterise the lesion (the area that has been damaged). Following diagnosis, occupational therapy and rehabilitation with speech are recommended to aid patients with their deficits. If the cause of agnosia is reversible and can be treated with surgery and/or radiation, often a recovery period of between 3 months to 1 year is needed. Although agnosia can be cured in some cases, for others, the condition can be lifelong, with those needing to adapt their lives around this condition. While it may take us forever to understand the visual, auditory and tactile experiences of agnostic patients, the study of these patients can provide insight into this neuropsychological syndrome, as well as helping to provide further understanding of normal visual, auditory and sensory processing mechanisms. Undoubtedly, studying these rare disorders can help the addition of new ideas into the knowledge box and decipher the mysteries about our most fascinating and intricate organ — the brain.