The Comfort Book by Matt Haig: A hug in 260 pages When I picked up The Comfort Book this summer, at an unremarkable Waterstones in Gatwick Airport, I had very high expectations. Earlier in the year, after recommendations from friends over the years, I had read Reasons to Stay Alive and Notes on a Nervous Planet, two of Matt Haig’s best sellers. For those who don’t know him, Matt is a journalist and a novelist, who writes books both for adults and for children; his books for adults are emotionally nuanced, raw, and will strike a chord in anyone’s heart, and his children’s books, well, I’ll read them next! His latest, The Comfort Book, does exactly what it says on the tin; it gives you comfort, page after page. When navigating turbulent times, either at a personal or global level, one must find anchors and this book is one of them. Let me flick through the pages with you and tell you about my favourite poems, recipes, short stories, and quotes. Among the incredible short stories in the book, Matt writes of being lost in a forest as a child and the peace that ultimately came with being lost in nature; the true (!) story of the teenage daughter of zoologists that survived a plane crash and wandered alone for days in the Amazon forest, armed only with the knowledge that her parents imparted on her, and then the story of a castaway who drifted for 76 days with only his thoughts to keep him company. What transpires from these stories? A connection with nature, peace in the midst of despair and an overwhelming appreciation for life that could not have happened had the tragedy not occurred. What about the recipes, you ask? Food is fuel for the soul and sometimes only hummus or peanut butter on toast is enough - so Matt has given us his fail-proof instructions. If these don’t have you intrigued about what can be so special about hummus or peanut butter on toast, maybe read his one-liner page about the magic ingredient that is pasta. Let me share another gem with you. The unforgettable story of Nellie Bly tells you about the life of a 19th century orphan who became a journalist, out to change the way women’s mental asylums were run, visited a leper colony in China and then met Jules Verne (after herself going around the world in only 72 days). So much for dreaming small! Weaved through the book you’ll find so many lines on the present moment, acceptance, and hope. Paradoxically, alongside an appreciation for the present, Matt Haig focuses on the ever-changing dynamic of life, as a sequence of frames that together create our narrative. The Comfort Book is a hug in 260 pages, written by someone that from the deepest despair of mental illness, has carved deep knowledge on what is like to be human. There is some potentially triggering content — stories of pain and illness — but I’d urge you to keep reading it, as there is always a note of hope in a couple of paragraphs’ time.

Getting into the Rhythm of Things: What can our brain signals tell us about mental ill health? Every time you have to quickly adapt your behaviour after a mistake or in pursuit of a goal, you are using what cognitive scientists and psychologists call cognitive control. It is utilised both when the stakes are high, like when driving through new terrain on a stormy day, and when the stakes are lower, like during a friendly Sunday afternoon game of tennis. Cognitive control allows us to rapidly organise certain behaviours, including perception, planning, decision-making, problem solving, and responsive action to rapidly adapt to and successfully navigate the fast-changing world around us. It allows us to make decisions that best serve long-term interests over immediate rewards and is associated with emotional resilience, both of which are key indicators of mental wellbeing and improved quality of life. Why is it that, despite the existence of this critical ability, we are often vulnerable to irrational influences and can fail to stay focused on our tasks and goals? While our capacity for intelligent goal-directed behaviour is seemingly limitless and the ability to adapt is central to being human, so is making mistakes: to err is human, and we err often. These questions have prompted me and other researchers to attempt to identify precise brain markers of cognitive control that could provide clues as to how we engage strategies to realise our goals and avoid mistakes and why these mechanisms sometimes fail us. I am a Senior Lecturer at King’s College London in the Institute of Psychiatry, Psychology and Neuroscience, who has been working with electroencephalographic (EEG) measures of brain signals — or brain oscillations — in attention deficit/hyperactivity disorder (ADHD), autism, eating disorders and depression. What are brain oscillations? The collective behaviour of hundreds of thousands of neurons can be detected from outside the skull using electrodes placed on the scalp. Recording brain signals in this way is referred to as electroencephalography, or EEG. When large groups of neurons transmit electrical signals at the same time, you can observe oscillatory activity in the EEG. Oscillations in the brain occur over a large range of frequencies from very slow 1–4 Hz (or cycles per second) ‘delta’ waves, associated with deep sleep, to higher frequency ‘gamma’ oscillations above 40 Hz that are associated with conscious perception. EEG acts like a high-speed camera allowing precise measurement of brain activity on a millisecond timescale. This enables the study of rapid changes in the brain that are associated with cognitive control. Even if our environment is often changing and largely unpredictable, accommodation of this unpredictability is built into the operation of our brain. How does our brain do this? Brain regions are not continuously active, but rather work in ‘cycles’ of active and inactive periods. This rhythmic, or oscillatory, activity emerges partly due to the interplay between excitatory and inhibitory neurons and allows flexibility in response to the environment as well as predictability. First come, first served Much of the research on cognitive control has led us to the frontal lobes of the brain, including the prefrontal cortex (the very front of your brain, the parts right behind your forehead). For over a century, the brain’s frontal areas have been thought to be the seat of human reason, backed up by many neuroimaging studies. As research in cognitive control has developed, we have been further led to focus on a specific neural activity in this region, namely 4–8 Hz oscillations known as the ‘theta band’, which increase when cognitive control must be utilised and appear to play a key role in the recruitment and organisational timing of function across the brain. Brain oscillations in the theta band are thought to be fundamentally important for cognitive control in two ways. First, the predictability of the timing of theta allows the precise co-ordination of activity across brain areas. Imagine you are playing that game of tennis (or you are Emma Raducanu competing in the US Open!). The fast pace of volleys and return shots necessitates rapid and accurate decision-making. The incoming ball trajectory must be analysed, the return shot prepared, and finally executed at just the right time to strike the ball when and how you intend. The timing of the theta rhythms acts like a precise clock in your brain to predict the optimal time to strike the tennis racket against the ball so that you hit it at just the right speed to get it back across the net. Second, the relatively fast nature of these oscillations and the precise timing of the active groups of neurons allow for rapid and precise responses in fast changing environments. The timing of these oscillations facilitates the speed of information transfer in the brain so that they act as a gating mechanism for faster processing when necessary. This allows for flexibility and responsiveness in situations of increased conflict or changing demands. Continuing with the above example — when the opposing player sends the ball in an unexpected direction, your theta oscillations will initiate allocation of resources to perception of the ball, planning and action in your body to ensure you move to the optimal location to bat the ball with enough rigor to get it back across the net. Thus, frontal midline theta (like other brain oscillations) enables the balance between predictability and flexibility that is necessary for us to respond advantageously in fast changing environments. Theta in mental health As we discover more about how theta responds to challenges or conflicts in our environment, we understand more not only about the optimal function of theta, but also about how and when these oscillations perform suboptimally. In a recent paper in Biological Psychiatry, we set out to understand the role theta rhythms may play in mental ill health. Suboptimally functioning theta can manifest in different ways and take different forms. Lab studies using cognitive control tasks have shown that in those with anxiety disorders, theta can be imbalanced with an overly large signal strength or amplitude at certain instances, for example overreacting to a mistake. Such a large signal response doesn’t necessarily translate to improved performance and may be related to a weakness in amplitude at other instances, for example when preparing to respond to a stimulus. This has an impact on flexibility of responding so that we may be excessively distracted by unpredictability in our environment, including potential errors, and fail to plan for the next challenge adequately. We also see dysregulation in the timing of theta in people with disorders such as ADHD. In this case, the onset (or phase) of theta does not act like a precise frequency clock in the brain, which results in responding too quickly or too late to stimuli. As the precise timing of theta is critical for its function as a recruitment mechanism in the brain, dysregulation can have a negative impact on the organisation and overall ‘healthy’ brain function with the result that we do not respond optimally to our environment. How is this useful? In 2010, the National Institutes of Health in the United States proposed a new conceptual model to guide research of mental ill health, which focuses on the dimensions of human behaviour and neurobiology rather than on diagnoses based on symptoms. While current diagnostic systems succeed in providing a common clinical language for professionals and allow rough classification of patients for treatment, they can fail to capture the many differences within and across disorders in symptom profiles, causal pathways, and responses to treatment. Studying the functioning of the nervous system as it relates to critical human processes like cognitive control could help us identify individual issues with cognitive function and flexibility. For example, an individual with low cognitive flexibility, as indicated by irregularities in theta oscillations, could benefit from specific therapeutic treatments that aim to improve the regularity and timing of these rhythms. Initial studies investigating the modification of oscillations in the brain show promising results for a range of disorders, including theta oscillations in schizophrenia and gamma oscillations in Alzheimer’s Disease. Awareness of these brain dynamics and their role in behaviour is a critical first step towards designing interventions that support individuals’ capacity for healthy and robust cognitive control. This could mean interacting with the environment in a way that allows you to make the best decisions in the moment, to plan ahead and to learn from your mistakes. Life skills that have significance beyond that Sunday afternoon game of tennis.

Falling out of depression — does psychological therapy reverse the biological changes in depression? A few months ago, I wrote a blog on how the experience of early life stress can, at times, lead to changes in our immune system and neuronal processes, ultimately resulting in depression. I focused on depression in adolescence because often, first symptoms begin long before adulthood and I wanted to understand what biological and environmental factors can make a young person prone to developing depression. Answering these questions is important to me because they shed the light on ways to prevent or minimise experiencing depression among adolescents. This, however, is only one side of the coin. Like me, you might ask, but what if we can’t always act timely to prevent the onset of depression? Well, you might seek treatment, that being either antidepressant medication or psychological intervention, or both. The current National Institute for Health and Care Excellence (NICE) guidelines recommend psychological therapy as a first choice of treatment for adolescents with depression. And this, my reader, is the other side of the coin that I was also interested in - what happens, biologically, when a person with depression undergoes psychological therapy? Can we see biological signatures of recovery following psychological intervention? I am a postdoctoral mental health scientist, specialising in the neuroscience of depression. Last year, I received an invitation from the scientific journal — Brain, Behaviour and Immunity-Health, to write a single author scientific article for their special issue, where I had the freedom to choose the topic of interest. Without a moment of hesitation, I took up this excellent opportunity and decided to write about the topic I am passionate about- the biology of how depression unravels and how it dissipates with the help of psychological therapy. As I already talked about the biology of falling into depression in adolescence in my previous blog, here, I will focus on the “other side of the coin” — the biology of falling out of depression following psychological therapy. Psychological therapy Let’s start with the basics! Psychological therapy is a talking therapy, which is prescribed for common mental health problems across all ages. There are different types of psychological therapies which are tailored based on the individuals’ needs. In England, such treatments are available on the NHS and privately, and they must be delivered by an accredited professional, meaning that the therapist has received professional training and was certified by an officially recognised institution within a country, such as the British Association for Counselling and Psychotherapy, British Association for Behavioural and Cognitive Psychotherapy, or British Psychoanalytic Council, to name a few in the UK. It is always good to inquire about the therapist’s credentials before starting therapy. For adolescents with symptoms of mild depression, the first choice of treatment includes either of the following types of therapy: cognitive behavioural therapy (CBT), group interpersonal therapy (IPT), group non-directive supportive therapy (NDST) and attachment-based family therapy. If symptoms of depression persist, other forms of therapy are explored including brief psychosocial intervention (BPI), psychodynamic psychotherapy, or family therapy. Lots of fancy words, I know! So, let’s understand their meaning. Starting with the most widely practised therapy — CBT, which focuses on challenging the person’s thinking patterns, emotions, and behaviours. It tends to be short term, e.g., up to 3 months in treating mild symptoms of depression in adolescents. Other types of therapy may focus on more in-depth interpretation of the emotional states including exploration of past experiences, such as psychodynamic approaches and these tend to last longer, e.g., 30 weekly sessions in adolescents. Lastly, there are approaches that focus on relationships with others such as family therapy or IPT, or more directive approach such as BPI which includes psychoeducation and is task-oriented, i.e., guidance on building new skills and habits. Rebuilding the biology with psychological therapy Most studies that look at the biological changes in relation to psychological therapy focus on brain functioning. The most commonly investigated type of therapy is CBT. Both, studies in adults and adolescents suggest that psychological therapy leads to changes in the same areas of the brain which are initially involved in depression development. For example, lower activity of the “reward system” — part of the brain which is less responsive to positive information in depression, becomes more active following a successful course of CBT. We also see changes in the activity across areas of the brain involved in emotional processing and executive functions such as decision making, social and emotional regulation or planning which are commonly affected in depression. These findings suggest that some of the biological changes seen in depression can be reversible with therapeutic help. We also see involvement of cortisol, a stress hormone, in the recovery from depression. In some people, including adolescents, chronic higher levels of cortisol are linked with depression. One study showed that better improvement following psychological therapy in adolescents with depression was linked with lower levels of cortisol. Top that up with the results from a meta-analysis — a synthesised analysis of the results pooled from many studies — which showed that higher levels of cortisol predicted worse treatment response to CBT in adults with depression, we are beginning to see a pattern. We also know that psychotherapy affects the chronic low-grade inflammation seen in depression, although the extent of this knowledge is still limited. For example, one meta-analysis showed that psychological therapy led to lower levels of c-reactive protein (CRP), a substance produced in inflammation. However, another meta-analysis did not find psychological therapy to have any effect on CRP levels. It’s as if you were comparing apples and oranges. Coming back to my initial question — can we see biological signatures of recovery following psychological intervention? Yes, we can and you can read more about it in my recently published article. However, we do need more studies, particularly in adolescence, as these are falling short compared to the studies in adults. Nevertheless, these are very exciting findings and yet another example of how mind and body work together, not only in developing illness but also in recovering from it. Header Image source: Cottonbro on Pexels

How to Help Your Loved Ones Through Depression With Trust You don’t need to be a mental health professional to help a friend I was only 21 when someone with severe depression first asked for my support. I was a suicide help-line counselor and, officially, I was only allowed to give the man on the other end of the phone 20 minutes of my time. It’s now over 20 years since that call, but I still remember it vividly. Mental health is a topic that I write about often — like this story about the danger of “it’s all in your head” thinking— because mental health is a topic that has featured in both my professional and personal life. I was raised by mental health nurses and therapists, and then did formal counselling training myself. We openly discuss mental health and mental illness in our family and many of us have first-hand experience with various degrees of depression, burnout, and anxiety. Even with that background, it still took me a long time to learn how to effectively help others through periods of depression. One of the things I’m still learning is the importance of trust. The suicide help-line caller 20 years ago, was my first experience with the need for trust. Breaking the rules On that call, I broke the time-limit rule and stayed with him for an hour. I ran through our procedures for suicidal callers and offered numbers of places he could go, so he wasn’t alone. “Will you ring them?” I asked, well aware I’d stretched our time much further than I should have. He sounded calmer. “Yes. I will. Thank you.” There was no way to follow up on the helpline. I have no idea what happened to him that night or if he’s okay. I’d pushed the boundaries of my help, but I couldn’t ask for his details or trace his number. There was a saying drummed into us in our training: “We need to trust people to do the best for themselves with the information they have.” I was meant to trust people to use the information I could give, and then support themselves in the way they needed to next. I’m still finding it difficult to apply that principle in my real-life relationships, but I’m better at it than I used to be. When it came to depression, I struggled to trust my friends and family members. What if I lost them? I was the only one I trusted to do the supporting. I learned later, there’s a danger in having that kind of attitude… Overstepping Boundaries Shelley* handed me a box of pills and placed her bag in my hallway. “I don’t trust myself with these,” she said. “I’m worried I’ll overdose.” She looked exhausted, like she’d been battling something all night. “Thanks for letting me stay.” “Of course,” I replied, taking the box and reminding myself to hide it and my own medications later when she wasn’t looking. I hadn’t hesitated when she’d asked to stay for a few nights. I’d struggled with depression in my early 20s and knew how important support was to get through the worst of it. I’d had my parents to lean on, but she lived on her own and only had her friends nearby. Our small house was busy and crowded with two preschoolers, but I didn’t want to risk saying no and losing my friend. It was only a few nights. Shelley slept for two days, only waking up for meals and her medication. Then she called the doctor and arranged for therapy. She stayed a week and then, feeling the worst had passed, she returned home. Shelley struggled with long-term depression and needed occasional support, but mostly just a friend. She didn’t need me attempting to rescue her. She was quite capable of managing her own mental health. That didn’t stop me from trying. In the years I knew her, I’m sure I overstepped my helping boundaries — and hers — several times. I checked in too often. I worried too much. I took on the role of therapist, rather than a supportive friend. She needed me to trust her, and I struggled to do that. Our role is not easy, but it is simple Your friends and family members need you when they’re struggling with depression. There are times when you need to step in, care for them, cook their meals, love and support them. Depression is dark, exhausting, and lonely, and you can be the difference for someone between life and death. What you need to be aware of are your boundaries and your limits. As a trained suicide help-line counselor, I knew there should have been boundaries and limits. But in my personal life, I was too afraid to lose people I loved. I stepped into the role of a therapist, whether they wanted it or not. When we attempt to rescue people, we can actually make them dependent on us and take away their power. We can make people feel like a burden, which is the last thing anyone wants to feel. Good support is empowering The Eisenberg Family Depression Center, at the University of Michigan, states it’s empowering for people with depression to feel in charge of their own future and treatment. They explain that everyone’s experience with depression is different, and when people are active participants in their own healthcare, they can decide what path is best for them to feel and function better. We can help our loved ones feel empowered by: respecting them and being non-judgmental. listening without advice to their feelings and what they want. supporting them to make their own decisions about their healthcare and treatment. — adapted from New South Wales Government, Health Department You can support someone you love, listen to them and let them know you’re there for them. The rest they need to work on themselves with the help of professionals. Your job is to trust that they can. When you take on the role of therapist and doctor, you don’t acknowledge your own limits. Trust people and they’ll feel more comfortable asking for help knowing they won’t be a burden to you or cause you to burnout. Practical ways to help someone with depression Check-in regularly for a chat in person or on the phone. Let them know you’re there for them. Keep conversations supportive and non-judgmental. Make sure you learn about depression: they can’t “snap out of it,” “cheer up” or “pull themselves together”. That’s not how depression works. Send funny GIFs, messages, and other little reminders that you’re thinking of them. Do something small and fun together — watch a funny show, listen to music together, or go for a gentle walk. It can be hard for people to get moving or attempt to be social when they feel depressed. Invite them for meals or bring a meal to share at their house. Make plans for the near future. Having things to look forward to helps. Look after your own mental health. Contact an emergency mental health team in your area if you feel they are going to harm themselves. Don’t leave them alone, but get expert help. It might seem small, but just doing things together, being there and staying connected can be a big help. — Depression.org.nz *Name and details changed for privacy Header Image by Prostock-studio

Understanding ethnic inequalities in mental health and the need for an intersectional approach Reflections through the lens of the Determinants of Adolescent Social Well-being and Health (DASH) study I am a researcher in Social Epidemiology at King’s College London trying to understand how political, social, and economic processes can lead to unequal health outcomes over the life course. During the last few years, I have had the luck and opportunity to research how these processes might contribute to unequal social and health outcomes of young people from minority ethnic groups. This blog reflects my thoughts about research in ethnic inequalities in health and findings from the DASH study, a longitudinal multi-ethnic London-based study, which has highlighted better mental health for young people from ethnic minorities, and a higher likelihood of gaining a university degree than their White British peers despite common experiences of deprivation and racism. Adolescence is an especially challenging period of biological, emotional, and psychological maturation during which new identities are negotiated, independence from parental influence is growing, there are new friendship choices and an interest in intimate sexual relationships emerges. These complex maturational processes occur within specific social, cultural, and family contexts. Despite how well-documented differences in adult mental health across ethnic groups are in the United States and the United Kingdom, the social, particularly structural, and biological determinants of ethnic inequalities in adolescent mental health are not well understood. An in-depth understanding of ethnic inequalities in mental health requires an interrogation of intersectional axes such as socioeconomic position, gender, and racism. These social structural determinants cause and operate through intermediary social determinants of health, such as housing, physical environments, social support, health behaviours — to shape health outcomes. Different methods of understanding and measuring ethnicity across several studies have made it difficult to understand who, how and to what extent someone’s health is affected by social and economic inequalities. Assigning people to ethnic categories according to the colour of their skin, country of birth, nationality or self-reported ethnicity has been particularly problematic in that respect. In the UK, opportunistic use of studies that were not designed to examine ethnic inequalities has resulted in studies with small sample sizes of ethnic minority adolescents and less granular groupings (e.g. White, Black, Asian, and Other) lacking in statistical power to understand the intersectional influences. This has also promoted the use of confusing terminologies such as Black, Asian, and Minority Ethnic groups (BAME), particularly evident in the COVID-19 studies. Further, a lack of studies following the same group of people over a longer period has limited our understanding of when and how inequalities in mental health problems develop in ethnic minority adolescents. The DASH study was set up in 2001 with a theoretical emphasis on understanding the contributions of social structural influences on the development of ethnic inequalities in adolescent mental health. Initially, the study recruited ~6500 adolescents (approximately 1000 from the UK’s six main ethnic groups; White, Black Caribbean, Black African, Indian, Pakistani, and Bangladeshi, and Other) aged 11–13 years old in the most ethnically diverse London boroughs, which are also some of the poorest in the UK. The diversity of the cohort reflects the everyday diversity that young Londoners’ experience, with ~50 languages spoken in total and with parents from ~100 countries. The participants were followed up at 14–16 years old, and a subset were also followed up at 21–23 years old. Due to the detailed information on the ethnic origin of its participants (self-defined and cross-checked with the heritage of parents and grandparents) and the inclusion of rich information on social structural (including environmental), cultural and biological determinants, DASH remains a rare study worldwide to understand what contributes to ethnic differences in physical and mental health over the life course. Consistent with previous findings, DASH has shown that ethnic minority adolescents in London had better mental health than their White British peers. Additionally, it has shown that high proportions young adults from minority ethnic groups entered higher education and completed their undergraduate degree, despite greater exposure to adversity including more socio-economic disadvantage and more racism. Statistical analyses and interviews with DASH study participants have provided a nuanced understanding of cultural diversity and adversity in everyday lives of London’s ethnic minority adolescents. Strong evidence from DASH for “beating the odds” or adolescent mental health protection relates to family life, religion, and diversity of friendships: Family Life The parenting experiences of ethnic minorities varied but were generally consistent with a conservative parenting style that combined warmth and support with a disciplinary framework. Family connectedness was reflected by joint family activities such as eating a meal together, a considerable aspect of socialisation within the family as it involves repeated rituals which forge togetherness and belonging, reinforcing tradition and structure. These activities were crucial but did not fully explain this mental health advantage. Religion Personal faith and religious values contributed to ethnic minority mental health advantage, regardless of the extent of religious practice or attendance to religious ceremonies. When DASH participants were 21–23 years old, their reflections on their attendance to places of worship and participation in religious practices in adolescence with their parents anchored around identity formation and the embedding of morals and values. These morals and values included an ethic of tolerance and endurance, a sense of meaning, purpose and self-worth, and positive coping strategies in the face of adversity, including racism. Several participants, particularly Africans and Muslims and those who have become parents themselves, continued regular involvement with a place of worship in adulthood. Particularly poignant from some of the narratives was the perception of a seamless boundary between family and religious life, an insight that is difficult to obtain from simply quantitative analyses. Diversity of Friendships Cultural integration, measured in the DASH study by ethnicity of friends, was linked to greater protection in adolescent males than females. Having friends from different cultural groups increased over time and was associated with better mental health than those who reported that their friends belonged mainly to other ethnic groups than their own or to their own ethnic group. The cultural diversity of London’s neighbourhoods and schools provided many opportunities for developing ethnic, cultural, or religious solidarities and identities. The Effect of Racism Racism has been a consistent determinant of poorer mental health in the DASH study. In a recent paper, we reported on the intersectional influence of exposure to high levels of pollution and racism. Exposure to higher concentrations of Particulate Matter (fine inhalable particles) with diameters of 2.5 micrometres and smaller, which was more prevalent among Black Caribbean and Black African adolescents, was associated with worse symptoms of conduct problems during adolescence. Adolescents who reported experiencing racism and were exposed to higher concentrations of PM2.5 also had higher symptoms of conduct problems compared to adolescents who did not experience racism. Both racism and pollution represent structural influences that cause and maintain systemic inequalities, and the effects of pollution on mental health have been also discussed before in InSPIre The Mind. It is worth mentioning that racism has been a consistent determinant of some physical health indices such as cardio-respiratory health (e.g. lung function, pulse wave velocity) and of health behaviours (e.g. cigarette smoking). How these physical, physiological and behaviour changes interrelate with brain development and adolescent mental health is unknown but gaining increasing recognition. DASH has enabled an in-depth understanding of the social determinants of ethnic inequalities in adolescent mental health in the UK. It has been crucial to understanding how growing up with structural adversities can harm adolescents’ mental health, and how cultural practices can buffer against adversity for ethnic minority adolescents and young adults. Importantly, it has also contributed to a now growing body of evidence which emphasises the centrality of racism to understand ethnic inequalities in mental (and physical) health in adolescence and young adulthood. To sum up, DASH and other studies have consistently shown that racism can have a detrimental effect on lifetime opportunities of ethnic minority young people and promote intergenerational cycles of ethnic inequalities in health. Although understanding the context and processes that operate in ethnic inequalities in young people’s mental health is by no means straightforward, I believe that it is imperative that research, as well as culturally appropriate policy and practice interventions, adopt an intersectional framework that reflects the complexity of inequalities in the real world.

Next generation of rapid-acting antidepressants: Can ketamine help prevent suicide? As a scientist with an interest in mental health and in particular depression, I became familiar with the devastating symptoms that people experience when they become clinically depressed and I also became aware that for nearly a third of those people, current treatments are not effective. I am a Senior Research Associate at the Institute of Psychiatry, Psychology & Neuroscience (IoPPN) and working on a project funded by the NIHR Maudsley BRC to investigate the use of ketamine as a medication for depression. In this blog, I talk about my research into depression and the immune system and what we currently know about ketamine as an anti-inflammatory antidepressant in psychiatric emergencies. I study the connection between the brain and the immune system — immunopsychiatry — and there is growing evidence that changes in a number of biological processes within the body can directly contribute to depression. The hope is that these connections between physical and mental health can help develop treatments for those people with depression who are not helped by current treatments. For some people, their depression can become so severe that they experience suicidal thoughts, which can then lead to suicide. If these thoughts are detected early, then it may be possible to put in place protective measures or treatments to lessen the risk of suicide. My hope is that a new approach using ketamine, that works on the biological systems involved in depression and inflammation, could become a new way to prevent suicide. But we need research to help us find out… Inflammation In the early stages of my career, I focussed on the link between heart disease and depression, where I found that patients with heart disease produce an excessive amount of chemicals called ‘inflammatory markers’, which are released by our immune cells. The amount is even higher in those patients who also have depression, or in patients that will develop depression over the subsequent three years. The body usually has systems in place to regulate this overactive immune response, through the anti-inflammatory, glucocorticoid hormones. However sometimes, when there is too much inflammation, this can disrupt the very processes that carry out this type of regulation, and it can become very difficult for the inflammatory levels to return to normal. This lack of regulation can lead to excessive levels of inflammatory markers in the body for a long period of time. Heart disease is known to be an inflammatory condition and long-term inflammation in the body can potentially affect our brain and its structure and function. This is known as ‘neuroinflammation’, which has been linked with depression. As much as inflammation seems to be linked with depression, it is not always due to physical conditions such as heart disease, likewise, not everyone with heart disease will develop depression. Sometimes, people who experience depression, but not any other specific diseases, have this inflammation in their body and brain, and are not even aware of it. For example, some individuals who experienced traumatic events in their childhood, either emotionally, physically, or sexually, may also show a higher immune response and disrupted regulatory mechanisms, making them more vulnerable to depression later in life and into adulthood. Effectiveness of antidepressants As much as we know a fair bit about the causes of depression, we have still a fair amount to discover. While there are thousands of studies in depression — its causes and what happens during the course of the disorder in the body and the brain, and how medications and therapies can be effective — we are still struggling with successfully treating about 30 per cent of those with depression. We now know that individuals who have both inflammation and depression tend to be those who are less likely to respond to antidepressants, and a combination of anti-inflammatory and antidepressant medications may help to improve their chance of response. However, this approach still requires time for the drugs to take effect which, for some, might be too much time. There is an urgent need for identifying alternative strategies for those patients with severe depressive symptoms, in particular suicidal ideations, who require effective but immediate intervention. Ketamine as an antidepressant Thanks to a National Health Institute for Research (NIHR) Maudsley Biomedical Research Centre (BRC) Project Grant, I have started investigating ketamine as a medication for depression, which has both anti-inflammatory and anti-depressive actions. This dual effect can also help us to understand the mechanisms of action of this medication with the aim of making new antidepressants that can target both inflammation and depression. My recently published review in Brain, Behaviour & Immunity — Health titled “Targeting inflammation in depression: Ketamine as an anti-inflammatory antidepressant in psychiatric emergency” provides a brief overview of antidepressant properties of ketamine as well as its effects on inflammation. The review aims to better understand the mechanisms underlying the potential therapeutic action of ketamine. Ketamine has multiple rapid actions on the brain areas associated with depression. It can normalise the pathways and chemicals in the brain that have been disrupted in depression. It also helps neurons to connect with each other, so the brain cells can communicate effectively. These are required for the healthy functioning of the brain and our mental health, and it seems this is how ketamine may act as an antidepressant. Ketamine also has anti-inflammatory properties, which makes it particularly unique for targeting the inflammatory aspects of depression. Indeed, ketamine can directly affect our immune cells to reduce inflammation both at the level of body and the brain. It also acts on the pathways within the brain linked to neuroinflammation, decreases the production of toxic substances, and increases the release of substances to promote the generation of new neurons. But perhaps the most important overarching feature of ketamine is that it can act very rapidly. Within hours its novel dual-action as an anti-inflammatory and an antidepressant can take effect. This is why it has the potential to be a valuable treatment for those severely depressed patients with suicidal thoughts and this is what I am investigating in my research. If we can use a clinically approved version of ketamine in psychiatric emergencies or design a new generation of rapid-acting antidepressants, we can give a better life to depressed patients as quickly as possible. Beware! Ketamine, which is being sold illegally in the black-market, is a drug of abuse. When used by clinicians and scientists as a medication, it is used within a therapeutic dosage and administrated in a clinical setting and under specific conditions. Do not attempt to use ketamine for depression unless you are under strict medical supervision. Editor’s Note The research discussed in the blog can be found in a journal article for Brain, Behavior, and Immunity - Health. This blog can also be found co-published in the NIHR Maudsley Biomedical Research Centre’s blog.

Nostalgia as a Sentimental Tool: Are you ready to look back for looking ahead? My name is Dhanishta and I am a writer who has recently started pursuing a Masters in Psychology. For me, writing means making sense of experience. I find myself often looking at life experiences through the lens of both psychology and written expression, trying a find a common ground. Like many others, I have often longed for the relative security and simplicity of “the good old days”. Nostalgia — “a sentimental longing or wistful affection for a period in the past” — seems just the right emotion today, as many of us grapple with the changes brought about by the pandemic and the new normal. It appears that nostalgia is a coping mechanism that helps many of us navigate these times. At the onset of the global pandemic, the frequently imposed lockdowns gave me lots of time to reflect and reminiscence on the course that I wanted my life to take. I am a freelance writer, but had a yearning to delve deep into the human mind, and understand the subtle forces that shape our behaviour. I became fascinated with how nostalgia was becoming a tool for me to understand my own evolution. This prompted me to look into more organised research on nostalgia. It seemed surprising then, when I discovered that nostalgia was originally described by Johannes Hofer (a Swiss doctor, credited with coining this term) as a “neurological disease of essentially demonic cause”. The term — a combination of the Greek nostos, or homecoming and algos, or pain — referred to homesickness, at the time mainly (and understandably) observed in soldiers. Treatments ranged from sending the affected back home to threatening them, and in some cases using leeches to draw out the negative emotion! This was way back in 1688 and of course, today we know better. What was considered a psychopathological condition, is now seen in a completely new light, and a positive one at that. Nostalgia has its uses. It provides you with a crutch to navigate the past and emerge with a new understanding. Maybe, with some kind of healing and with some deeper knowledge about your own self. It could become a flashlight directing us towards the future. Here are some of the ways we can harness the power of nostalgia in our own lives. Evoke the good times when you feel low In the book, Nostalgia: A Psychological Resource, psychologist Clay Routledge sees nostalgia as a resource that people use to regulate distress when they experience negative states like loneliness or meaninglessness. Whist engaging in nostalgia, most people experience a boost in mood, feelings of social connectedness, self-esteem, self-continuity, and perceptions of meaning in life. In short, the positive mental states that nostalgia invokes is reason enough for people to dip into it from time to time! A study by the University of Southern California psychologist David Newman and colleagues indicated that people experienced nostalgia more when they were feeling sad than when they were feeling more upbeat. Since this was a correlational study (a study that establishes a link or relationship between two variables) it is not possible to determine the direction of this relationship. In other words, did a low mood lead people to seek nostalgia to feel better? Or did nostalgia evoke the low mood? Whilst we cannot say for sure which direction this relationship goes in, it does give us plenty of food for thought! In my opinion, I believe that low mood may lead people to seek out events or aspects of their past which made them feel better. We all seek to maintain some kind of internal balance, and when our mental state is threatened, and we feel ‘down’ or low, it makes sense that we dip into the happier memories or simpler times of the past to feel a sense of balance and control. This has some lessons for real life. On occasions when one feels down, a trip down the nostalgia lane could help! It may not alleviate the feeling of sadness completely, but it may soften the blow. Foster emotional connection Nostalgia could also be a bonding experience. Family, friends, and food are most likely to evoke nostalgic feelings, though music, pop culture, and books also come pretty close. These act as cues to ‘reminisce’ about past events. Psychologist Clay Routledge and colleagues conducted a number of studies and found evidence to suggest that nostalgia helps to build strong relationships and “teams”. Nostalgic recollections made a group more likely to stick together for a common goal. In short, people who indulged in nostalgia were more committed to the group. In order to harness nostalgic potential to foster bonding, you can try some of these things next time you’re in a gathering of family, friends, or co-workers. Maybe some of these activities will foster nostalgia and reconnect the group in a different way: a retro music playlist, looking at old photographs or videos, revisiting old memories in conversation, specific movies or songs, eating a specific food, going through past letters or journals and so on. Unify the self Nostalgia can help us unify the self. It helps define who we are and who we can be, by referencing who we were in the past. It helps us consolidate the past into the present, so that we perceive ourselves as whole. All of us change over the years and indulging in nostalgia is a reminder of that journey. For some, it could be getting in touch with their authentic selves. For others, it could mean reliving just how much they have grown or changed. And this act in itself helps us create a unified sense of our present selves. In midst of a recent lockdown, I once sat down and read through all my old journals, hoping to ‘feel good’. As I relived the past, so many things suddenly made sense. I could see how some childhood experiences shaped me, and how some of my current insecurities were rooted in the past. I felt in control of myself. The experience made me revisit my love for psychology by signing up for a Masters course. For me, a random nostalgic episode changed the course of my future. Some of us may want to consciously use nostalgia as a tool to guide us into the future. If revelling in the beloved past can give us happiness, we could surely carry a bit of the magic further on! As we emerge stronger and more resilient, despite being scathed from the devastating impact of the pandemic, maybe a dose of nostalgia might just be the booster shot we need.

Gender-gap in training for Assertiveness: Does it have a place in Psychiatry and in clinical practice? As a female British psychiatrist of ethnic minority background, I consider myself as an honest, assertive feminist who strongly advocates for patient care. My feedback? I am “too aggressive”, and I need to be more “delicate” in my communication. In Leadership teaching, junior doctors are taught to display confidence, assertiveness, and the ability to raise safety concerns to their seniors. However, women have found that when behaving assertively, they are stereotyped as being “unlikeable”, “dominating” and “aggressive”. Gender bias at work is still frequently occurring and no profession is immune, including psychiatry. I am a Core Trainee Psychiatrist, passionately advocating for human rights and mental health. I am part of the executive committee for the Royal College of Psychiatrists’ Women’s Mental Health Special Interests Group. I am a leader of Geopsychiatry, an NGO (non-governmental organisation) which studies the impact of war conflict, climate change, public health issues, globalisation and foreign policy on mental health. I have written articles, such as the need for women leadership in the UN, and how COVID-19 unmasked the ongoing pandemic of gender-based violence. As I write this article, I remember some of the feedback I have received for giving honest opinions about uncomfortable situations I experienced at work. There was a patient who was grossly racist towards me, and a male colleague said that I was “wasting my time reporting to the police”. I was hurt and offended by his suggestion, as he clearly didn’t experience the trauma of that abuse. I told him that I respect myself to report the hate crime. I went as far as to question his self-respect if he didn’t choose to report a hate crime towards him, to the police. I’ll admit I was angry and hurt at the time, but I felt I had to justify my pain. However, my response was reported to my Clinical Supervisor, and I was deemed “too aggressive” in my reply and viewed as having “difficulty interacting with colleagues”. In other cases, I have questioned my senior colleagues when I have concerns about patients’ wellbeing. At the time of the discussion, I advocated for the patient’s safety and best interests. My feedback? I was being “difficult” in my encounter. I am described as “too emotive” in my emails, or “hypervigilant” in stressful situations “amongst colleagues”. It seems that whatever I do, I can do nothing right. As a gender equity advocate, I am told to go against everything I stand for — I have to lower my voice, reduce my space, and stand aside. Women + Confidence = Aggressive; Man + Confidence = Assertiveness In early 2021, an article was published on sharing leadership lessons from successful women medicine. It was shared that assertive women would have to make adjustments to earn respect. Dr. Sharon Gustowski an osteopathic doctor based in Texas (USA) said that she learned “how to lower the tone of (her) voice and smile more to not come off as controlling”. As a young adult, she was deemed independent and assertive; as a doctor, she was alienated from her peers and came across as “snobby” and unfriendly”. To be heard in certain male-dominated atmospheres, we are advised that assertive women may have to “adjust facial expressions, hand movements, volume and tone”. Dr Candace Walkley, an internal medicine doctor in the USA, was advised that she was perceived as a “go-getter” and it created tension, therefore creating interference with communication and expectations. She referred that being assertive is having “a sword with two sides”. The experiences can help shape your leadership skills to better assess and control yourself in interaction, but it comes with a “few bumps in the road” with co-workers and colleagues. An Inspire the Mind blog by a female medical student on “The Future is Feminist: tackling gender inequalities in psychiatric medicine and practice” highlighted the implicated biases towards women and their behaviour as “more irrational and hyperbolised”. The blog astutely states that equal representation of women within a professional field won’t automate a definite power of changing attitudes towards women. Arwa Mahdawi, author of Strong Female Lead: Lessons from Women of Power, said that having more female leaders is not necessarily a good thing…if the female leaders are still following patriarchal leadership. Instead, leadership should be cultivated into thinking of what we have been trained to think of as “female behaviour.” There is no doubt that conflict can occur frequently in any workplace. However, the sense of feeling discriminated and isolated at work whilst tacking sexism can leave assertive female doctors at the risk of developing depression, anxiety, and worsening burnout. At worst, the female doctors leave the training programme due to unhappiness and having a sense of systemic gender discrimination at work. In my experience, it was dehumanising when it was put to me that my assertiveness is a symptom of “being mentally unwell”. Gender — Discrimination via feedback can harm the doctors’ mental health In a BMJ article, a psychiatric trainee Rory Conn, said that all doctors need to be assertive… but we are rarely told how to acquire it. A BMA study in August 2021, showed that 9 out of 10 female doctors experience sexism at work. Yet, when we assert ourselves and lay boundaries in our job, the backlash may result in poor feedback in portfolios and difficulty to progress career-wise. Tackling the impact of structural discrimination does take time, but instead, it’s easier to blame the “assertiveness issue” than the actual systemic issue. We are profusely taught about leadership and time management, but this doesn’t hide the wide training gap between male and female doctors, especially in gender-stereotyped feedbacks. The urgency for ingrained assertiveness training and feminist thinking in Psychiatry will subsequently help narrow the leadership gap between male and female doctors acquiring senior roles. If we want to put an end to the sexism in female doctors’ career progression, we need “assertiveness training” platforms in our training programmes, encouragement of feminist thinking in Psychiatry, and tackling systemic prejudices. Only then, will Psychiatry training be more inclusive for future practices. Header image by cottonbro from Pexels

Compliments — more than what meets the eye Why do you give compliments? Do you feel genuine when giving compliments? How do you feel receiving them? Before we start thinking about compliments and this nature of communication with others, I must begin by saying that it is something which can vary from person to person, their likes and dislikes, and the contexts they find themselves in. Take what you like and leave what you don’t. This is simply a space to start, and continue, thinking about the compliments we give. Although by the end, hopefully, you’ll see it’s best not to overthink it. We’ll explore the purpose our compliments have and where they may fall short. Throughout, we’ll learn how to grow the compliments we give, from selective, formal praises into genuine and purposeful encouragement. Definition of a compliment, Oxford Dictionary: a comment that expresses praise or approval of somebody I’ll just say it — compliments used to make me feel really awkward, for at least a couple of reasons. I exist in an environment where I could be defined by just the qualifications on my CV, my physical appearance on my social media profile or my historical achievements in my academic transcripts. For example, I work in clinical research and currently study Psychiatric Research at KCL, and maybe that appears to be a great achievement. And yet for me, to be recognised as learning, reflecting on and communicating aspects of our mental health, in the context of my past and present experience, carries greater value. To see more of my work here, you can read my blog recognising our good mental health. The nature of our compliments Firstly, the nature of giving and responding to compliments seemed like an automated process, not always requiring intention or meaning behind the words. How often in polite small talk do you respond to a compliment by saying “Thanks, you too!”, without registering what you’re saying? It’s as automatic as replying “Hi” after the first “Hello”, or “Bye!” after the first “Ok, see you soon” in our daily conversations. I still find myself doing it now. Our brains sometimes run on autopilot, and relying on social cues is no exception. Research has shown that overcomplimenting, especially when focussed on achievements and person-focused attributes, can result in decreased confidence and challenge seeking in children with existing low self-esteem. It’s thought that compliments in this context appear to set a high standard, that the child feels unable to meet this. If the child fails to meet the praised standard again, they are likely to feel ashamed. In turn, this fear and possible shame lead to a further decrease in the child’s self-esteem. The authors of this research suggested that process-focused compliments do not induce this chain reaction of lowering self-esteem and fear of failure. In this context, person-focused compliments evaluate the person, whereas process-focused compliments evaluate aspects shown like effort, strategies and attitudes. The compliments we give can communicate so much more than just polite social formalities and expectations. Our compliments can highlight where we think someone’s value lies — whether this is intentional or not. Recognition of a person’s achievements and results have their place, but why limit ourselves to standard, automated dialogues when we can give and receive so much more? The content of our compliments Secondly, especially growing up as a teen, compliments people usually gave were focussed on either something you’d achieved or the way you looked/appeared. Neither of these are inherently poor aspects to highlight in balance, but the subtle praising of exclusively these factors naturally shifts our attention towards these aspects and away from others. In a society where our perception of our self-worth is perhaps quite fragile and vulnerable to decline, can we add purpose and value into the interactions we already have? Our interactions can both build up a person and build connection between us, if we shift from giving surface-level compliments to meaningful encouragements. Compliments based on abilities and appearance describes what someone was like or has achieved in the past. Instead of just looking backwards, we can highlight the qualities a person has for future challenges by focussing on their efforts, values and choices. Granted, you can’t substitute every pre-requisite or criteria in life with some sort of objective measure of the effort you’ve put in. But equally, how far can you progress by just looking back at your past achievements? We need to see what aspects surrounding our past achievements mean we face future opportunities and challenges. When we give and receive compliments based on a person’s appearance, they are made with good intention. Sometimes, receiving such compliments can be encouraging, help us feel good and like we’ve been acknowledged. However, we can also find ourselves striving for such compliments if we notice we haven’t received them. We can be prone to focus on the way we appear and make particular efforts to present a certain way. Like receiving praise in any context, it’s natural to become subconsciously focused on the goal of winning approval from others. Whilst social media may provide some good, we see how it can amplify this cycle. As such platforms facilitate dynamic opportunities for peer feedback, ie. social validation, you’d be swimming against the tide if you venture away from presenting the most likeable ‘version’ of yourself. You can read Frances’ blog about the effects of social media on adolescents here. Realistically, how we look is really not the most interesting thing about us. But continual praise affirming our appearance, or the absence of such praise, whilst other aspects about us are not praised, helps to reinforce the narrative that our appearance matters and is intrinsically linked to our happiness and acceptance. If we compliment people based only on their appearance, we ignore other things, for example, the creativity, helpfulness or thoughtfulness they show. So how can we make meaningful compliments? Well, what we have is a good start — we have some connection, some authenticity and many good intentions. Let’s build on that, let’s do addition, not subtraction Focus on the ‘how’ instead of just the ‘what’ — notice the processes and behaviours someone displays, in addition to what they are and have achieved Actively pay attention — a key part of making genuine compliments is taking time to reflect and appreciate what qualities you admire about that person, what things you’re grateful for or have noticed. Authentic compliments are then easier to make without over-thinking, because making a compliment is just saying out loud an encouraging observation. Compliment the whole person — your friend/colleague/family member is so much more than just their achievements. Yes, those things may be wonderful and due appreciation, and yet compliments can also recognise their efforts, values and choices. If compliments are to be an encouragement and provide connection, then compliments can recognise parts of a person that aren’t just in the past. A compliment, if it recognises the attitudes, approach and values someone has or has shown, communicates strengths they currently have and can use in the future. Header image by Eduardo Barrios on Unsplash

With glimmering fairy lights all over the city, the glowing conifer trees, the beautiful décor, the holiday fervour, Christmas starts making its presence known about two months before the day, depending where you live in the world. Extravagant family meals and all kinds of traditional dishes, the candy canes, cookies, chocolates, and the gifts that Santa leaves on Christmas Eve, everything seems to be so cheerful. It’s a season of joy after all, or is it? The fact that this season coincides with a spike in mental health issues is a matter of concern. A survey done by the Royal Society for Public Health (RSPH) in 2017 in the UK, found that family arguments are the most nerve-racking part of Christmas, with 76% of people claiming that this affects their mental well-being negatively. Financial pressure, loneliness, burnout, anxiousness, unpleasant associated memories, are just some of the challenges that Christmas can trigger. In the last two years, the pandemic has added itself to the list. Feeling low in spirits around Christmas is especially true for the unemployed (38%), divorced (35%), or widowed (31%), according to a recent government report. It’s less so, but not unusual, for parents with kids living at home (23%). The same report interestingly highlights that, while only 35% of men feel stressed around Christmas, for women the figure is 51%. Perhaps the burden of preparing dinners, choosing gifts, décor and making all ‘perfect’ arrangements is more burdensome on the women. My memory of Christmas as a kid is limited to drawing zig-zag lines of a fir tree on a card that said Merry Christmas in art class. I saw it just as a day off. I was curious though about Santa Claus who brought gifts only to Christian kids. Twenty years later, as a Human Resource professional, I facilitated the Secret Santa tradition in my office and decorated the Christmas tree. We wore Santa hats, relished on delicious rum cake, and exchanged thoughtful presents. I am a writer on mental health and I also write on other topics, from spirituality to nature. In my fourth piece on Inspire the Mind, I decided to understand how Christmas is viewed by different people across the world by interviewing a few online friends. I started by talking to Amelia Canaris, a mum in her 40's living in Brisbane, Australia. Her rituals are similar to the ones in the UK except for hanging stockings — with the summer in full swing, the woollens don't make sense! Amelia’s focus has always been to ensure that kids understand that Christmas is not a season of excess. Gifts are always meaningful and based on what the children really need. The only real excess in her celebrations is the feast, thanks to the Italian nonna who cooks Italian Christmas dishes for the family! Nonna is also famous for living minimalistically and being generous when it comes to giving gifts to her family, especially the kids. While in conversation, she asked a significant and valid question “When is enough, [enough]?” “It’s always been a challenge to provide anything above the normal almost every year. I wondered you’d have to be really rich to ever feel like you did Christmas ‘right’! I was once a young broke mum amongst much older and well-established families. My kids always got gifts but often I couldn’t escape the feeling of ‘it’s not what it is supposed to be’.” What is it supposed to be? Who decides that? You. Just you. Ways to cope Don’t compare, just share With lavish decorations and parties being posted on social media, the festivity often turns into a race of “who’s done it the best”. Not only scientistsbut wise old sages and their spiritual knowledge also tell us that comparing is the easiest way to spiral down on to emotions of inadequacy and irritability, stealing our joy and inner peace. Listen, you can scroll through your Instagram feed and look at the posts with incredible décor and traditions and you can look at others’ way of celebrations and admire their beauty, without comparison. Everyone has their own way of celebrating and none is “better”. However, the best way is to share. Not the posts, but your kindness, empathy, and charity. A 2008 study in Harvard Business School found that spending money on others promoted participants’ happiness more than spending it on themselves. Charity does give a sense of satisfaction. What better way to celebrate a festival than by sharing our fortune with the ones in need? In a 2006 study, Jorge Moll and colleagues at the National Institutes of Health found that when people donate, it activates the mesolimbic system of the brain that is associated with pleasure, social connection, and trust, creating a “warm glow” effect. Various studies confirm that altruistic behaviour releases endorphins in the brain, producing the positive feeling known as the “helper’s high.” Guilt-free boundaries You need to figure a way for Christmas to work for you. If you feel overwhelmed, allow yourself to take a break. Go for a short walk, get away from whatever is making you anxious. The festive season exists to bring joy to everyone’s heart, starting with your own. If extended family dinners are a source of stress for you, consider skipping those. If you cannot, avoid conflict-prone topics and people. If you are the one hosting, remember that it should not be an energy-draining time for you too but a time of celebration. Melissa Ostrom, an author living in the United States, tells me how she loves preparing meals for her extended family during the holidays but makes sure that on Christmas day, there is no pressure to do anything. It is just five of them — the couple, two kids and their fur-baby, Mocha, doing their Christmas rituals — opening gifts, a walk nearby, sledding on the snow, watching ‘A Christmas Story’ together, and a lot of lounging around and cookie eating. A merry one indeed! Three studies done in September 2016 and published in the Journal of the Association for Consumer Research tested the relationship between family rituals and holiday enjoyment and established that family rituals improve the holidays because they amplify family closeness and involvement in the experience. However, family dinners frequently turn into a political battlefield or a place to settle old family scores. Related to this, there is another phenomenon called holiday regression, which happens when we go back to our childhood homes where we revert to our old roles — our teenage selves. There is chaos with the old schemas(cognitive framework or concept that helps organize and interpret information) trying to confuse our mind space with the now-adult self. Your personal boundaries — physical, time, financial, expectations and more — would have to be defined and followed by you. There should be no guilt for prioritizing your mental health before anything else. Help those with mental health concerns People who are struggling with their mental health are in a vulnerable position at this time of year. To understand how we can help others struggling, I spoke with Carmine Pariante, a Professor of Biological Psychiatry at King’s College London, and Consultant Perinatal Psychiatrist at the South London and Maudsley NHS Foundation Trust. He agrees that the festive season is difficult for people with a mental disorder because they are socially isolated, and the comparison with society’s perceived happiness makes it even more upsetting. It is difficult to give one piece of advice that works widely because it varies on a case by case basis but he suggests to try making an effort to engage in social contact through family, friends, or local society (religious groups, voluntary organizations, for example) even if it feels very difficult to do so. “Avoid being alone for a long period of time, especially since health and social services support may decrease during the festive period.” Friends and relatives of people with mental disorders should understand their role in such times and reach out to them as Professor Carmine suggests personal contact and meaningful human support is key. “If they resist and say no, try to find alternative ways that you can help. If someone is resisting spending a whole afternoon with a larger group of friends and relatives, you can offer a five minutes’ visit bringing some food as a gesture to express caring.” Less is more The traditional and mainstream portrayal of Christmas is just picture-perfect. And while every festive event brings the promise of joy, it can often fall into chaos and a messy maze to achieve that perfection. Solutions? Limit splurging on gifts. Children can receive gifts and adults can decide not to gift anything to each other — perhaps a small token of love that doesn’t cost much. The way you teach kids about gifting can change their whole perspective. There is a Greek word, haplotes. It means ‘sincerely, generously and without pretense or hypocrisy.’ This is how we should give and receive gifts. Always! I loved what Amelia, the Australian friend who I chatted with at the start of this blog, told me: “I remember one year not doing a big tree and feeling deliciously wrong. I did a potted tree with bows and loved it so hard. You have to just do your best.” And everyone’s best can look different. Yet it remains the best. May the Holiday season bring more reasons for your heart to smile!

The Power of Fake Fires: How Journey Dancing Helped A Grieving Mother Process Her Anger A Grieving Mother’s Retreat All my life I dreamt of being a mother. I knew from the time I was a little girl that motherhood was for me. As a child, I was the one who always wanted to play house. In my teenage years, I babysat all ages of children. During my college years, I volunteered at the elementary school that bordered our campus. Being around children woke something in me. I always felt that they saw qualities in me that I couldn’t see in myself. Perhaps this was merely because someone was paying them extra attention. For me, though, it cemented my dream of motherhood. My high school sweetheart and I married in 2004. Just months later I began teaching first grade. It was not only a job but a passion. Given the chance to play a pivotal role in children’s lives made me feel like I was making a difference in the world. My husband and I were on the threshold of beginning our own family and I could not wait. In December 2007, our first child was born, Christian. We brought him home on Christmas morning. He will forever be the best Christmas gift I ever received. We even had him blessed by our priest on the way home from the hospital. Surely, we safeguarded our tiny new son from the harm of the world. It seemed to be true until the fateful evening of August 28, 2014, when a cement pole, improperly installed, fell on him. Christian’s death sent me into a depressive whirlwind. I didn’t know where to turn, what to do or how to find comfort. His death was a sudden, random, and tragic accident. I couldn’t make sense of losing my healthy six-year-old boy. From the start, I tried anything that would bring me peace: acupuncture, talk therapy, hiking, coloring, exercising, and journaling were just a few. I found refuge in all of them at one point, but as time went on and my shock faded, it was clear that I had to delve deeper into emotional release. A little over a year into my healing journey, I learned about Borrowed Angels: A Spiritual Retreat For Grieving Mothers, facilitated by healer, Anna Raimondi. The agenda included activities such as “Redecorating Your Soul”, “Transforming The Stone” and “Journey Dance”. I was hesitant to register, but with encouragement from my husband, mom, and therapist, I decided that it had the potential to be quite healing. The retreat began with everyone sharing stories of loss. I could feel my own pain intensify when the other grieving mothers opened their hearts and spoke. I immediately felt a level of unprecedented understanding and similarity. While the connection with others was a balm to my soul, it was crucial to find tools that I would be able to use outside of this nurturing environment. Directly after a nutritious breakfast on the second morning, we dove into our activities. For the first activity, “Redecorating Your Soul”, we were invited to fill clear plastic globes with small, meaningful items that conjured connection to our children. We redecorated our souls with symbolic mini figures such as cardinals, beads that we used to spell out names or phrases, and we were able to write a message to our beloved children and place it inside. This was symbolic of the soul level connections we are all able to access, even with our beloved children. For the “Transforming The Stone” activity, Ms. Raimondi placed rocks under each of our chairs while we had been redecorating our souls. Upon returning to our seats, she instructed us to reach under them and read the word engraved on our given rocks. She had placed them randomly and explained that whatever the message was on our stone, held importance for each of us. My word was, “hope”. She led us in a short meditation and then gave us time to journal about how the word on our stones was, or could be, transformational in our lives. As a newbie to meditating, I was shocked at how much insight it provided me within my own writing. I found hope in many ways during that activity. On the second afternoon, we were introduced to Joanne Keane of Connecticut, a Journey Dance instructor. The name itself conjured up self-deprecating thoughts of me “dancing” through this journey. Our retreat leader shared research with us about how helpful it was for moving through emotions. Until that point, I was familiar with the activities we had done at the retreat. I had even tried all of them as a means of emotional release prior to the retreat. It was the journey dancing that I had never heard of and had yet to try. Dance for Healing and Wholeness Not knowing anything about journey dancing, I felt open to the new experience. The instructor began by sharing about her own personal trauma. For her, journey dancing had been a part of her spiritual journey and healing. As she began to explain what journey dancing actually was, nervous giggles could be heard around the room. She described it as free, expressive movement done barefoot to the sound of music. She then added we would have our eyes closed to keep us from feeling inhibited. She demonstrated what journey dancing looked like for her, emphasizing that it was the process not what it looked like. Her demonstration reminded me of how concert-goers moved at Woodstock. Closing my eyes and dancing around a room with a group of women I had just met was not what I had planned on. At first, I was hesitant and had trouble moving freely. As the music filled my ears, my body became more limber. During that first dance I definitely loosened up, but tension still resided in my body. The next dance had us using beautiful, brightly colored scarves. The calming rhythm of the music lilted through the air. My body swayed around the room feeling the notes. The free flow movement of the scarf gliding through the air helped me to relax. It mirrored my own grief journey. At times my emotions were buoyed by air and floating but then they would drop back down, gravity and grief tugging at them. Energy needed to be exerted to bring them back up once again. Though the scarf was light it felt like my arms strained to bring it back up. After we were done with the scarves, we explored our chakras and did some chanting. Again, the chanting was quite soothing as we felt the vibrations move through our bodies. We moved our limbs, vibrated our vocal chords, and released emotion. The healing value could be felt in real time. As the session neared the end, we embarked on an activity that I could never have imagined to be as spiritual as it was. Our instructor informed us that we were going to hold a fire of sorts. My misconceptions were present immediately. The instructor directed us to pretend there was a fire and throw all of our hurt, anguish, anger, and pain into it. I was skeptical. Release Anger, Embrace Freedom The music began and although it was a spiritual sounding song, it did have a more “aggressive” feel. Our leader detailed what the fire “looked” like. She emphasized the flames, burning bright and hot. She led us to grab hold of our pain and anger, to pick it up and truly feel its weight. Then she directed us to throw it into the fire. At this point, our eyes were open. As I reached down, I could feel the enormity of my anger. It was massive in size and weight. My arms ached holding on to it. I dragged it to the fire and threw it in. Something in me was immediately released. I went back for more. Once again, I leaned down and picked up another armful of anger and pain. I was aware again of the strength it required to throw it into the fire. This time I felt even more satisfaction. As the music continued to play, I seemed to go on autopilot. The more I threw into the fire, the more I wanted to throw in. My heart was beating furiously, and I could feel the heat rising in my body. Prior to this, I had been unaware that so much anger was pent up in my body. I knew it was there but the sheer volume and weight that I had been carrying around was unknown to me and unbelievable. I could feel layers being shed. It felt so amazing to get some relief. The music slowed and it was clear that the exercise was coming to a close, disappointment washed over me. What started as an activity I believed to have little value for me ended as the most valuable healing tool I had found yet! This exercise opened the door that I had kept tightly closed. The final song of our journey dancing experience was a cool down. The music had a soothing melody and helped our bodies readjust to reality. It was a beautiful close to an intensely spiritual experience. It had been some time since I had been that in tune with my body. Practicing self-compassion bequeathed nourishment to my soul. It left me feeling thirsty for more. Leaving the retreat that weekend, I was lighter, more engaged in life, and felt better than I had in a long time. My breath came easier. Lifelong Transformational Tool So many other emotions took the forefront after losing my son, but the underlying anger was eating away at me. Journey dancing afforded me access to my innermost demons. The weight of the anger that would have destroyed me had it not been purged, was forever lightened. Now, as the creator of the non-profit, Love From Heaven — Christian Martinisi Memorial Fund, and as a grief coach, I often share this story with those I work with. Many people look at me skeptically. They are leery to believe in the healing power of free form dance and imaginative fires. I urge them to open their minds to anything that can help ease their pain. In the healing journey we walk after child loss, all resources available to us are valuable. Journey dancing is one of the most valuable to me.

Is Zoom Burning All of Us Out? Are women more at-risk from mental health difficulties linked to Zoom than men? My name is Dr Mia Eisenstadt and I’m a Research Associate at the Evidence-Based Practice Unit. I spend a lot of time thinking about about how we can improve our mental wellbeing in the current context and amidst a growing demand for mental health support (you can see a recent review of online interventions here). I’ve been involved in both innovation in child, adolescent and adult wellbeing, and the evaluation of new interventions, such as HeadStart, a national portfolio of interventions aimed to increased young people’s wellbeing in England. I’m the proud parent of a child and a cat. This is the second blog on a three-part series on the timely topic of burnout for Inspire the Mind. This three-part series gives a rapid overview of the science. The first blog was an introduction to the science of burnout, and this current blog will cover the effects of Zoom on our brains and consider if it’s in fact bad for our mental health. The final part will then explore evidence-based strategies for tackling burnout. Since the first blog, a number of readers have got in touch (thank you for reaching out) to ask about the specific effects of burnout on women. In response, we will also the possible differential effects of Zoom and burnout on men and women. It’s part of the new normal of 2021 that for many industries, much of work is now performed online, via shared team working platforms and meetings via Zoom or Teams. With COVID cases on the rise in particular countries and the number of benefits of staying at home, remote working is likely to stay. Zoom is incredibly economically efficient and reduces barriers to participation. From an environmental point of view, Zoom also reduces greenhouse gas emissions and is more energy efficient. But increasingly, Zoom is burning employees out. Some companies have gone as far to enshrine Zoom-free Fridays. Why should a video call have a negative impact on our mental health? 1) We can experience “mirror anxiety” Zoom can trigger a type of anxiety that is a consequence of hours of viewing our own reflection mediated by a screen. Research suggests that seeing ourselves on screens can trigger self-consciousness and self-criticism. Such feelings are more likely in women. Looking at our own reflection for too long (self-focusing) can increase the risk of depression. Whilst there are things we can do (e.g., “Hide Self-View” on Zoom), many work across multiple different platforms that represent our reflection in different formats from Zoom, to Teams, to Google Hangouts. Why might seeing ourselves be stressful? The media exerts immense pressure conveyed through adverts and magazines for women (and men) to conform to ideal body images. Media messages encourage women to be thinner, younger, less tired, have better skin and less wrinkles. Men are also pressured to conform to an ideal body type and receive a different set of messages. It is difficult to ignore advertising campaigns. Feeling dissatisfied with how we look can lead to bad moods and low self-esteem. Anyone that suffers with specific issues in relation to body image, or body dysmorphia may find Zoom especially challenging. Body Dysmorphic Disorder (BDD) is a mental health condition where people focus too much on their flaws and may be involved in obsessive behaviours such as frequent mirror checking or grooming. People with BDD can feel strong emotions such as shame, self-hate and self-criticism. They can find it hard to leave the house and engage in day-to-day activities. People with BDD can spend long amounts of time looking in the mirror or avoid it completely. Issues with body image are not well understood by many employers. For those that experience no concerns about their appearance, it may be hard to empathise with people that suffer with the condition. There have been a minority of cases of employees asking to turn their video off and such requests being met with an unfavorable response from HR. 2) On a Zoom call, we are subjected to “hyper-gaze” Being constantly watched by your colleagues when speaking or just listening increases the cognitive load on the brain. We have to interpret non-verbal cues via a screen with the faces of our colleagues in small rectangular boxes — this takes more brain power, too. In fact, studies find that cooperation can be easier when we are assisted with cues that would be easier in person. Note, there is some research which suggests that Zoom calls may be experienced in different ways for neurodiverse than neurotypical people. For some people with autism, for example, less time is needed to process verbal cues and so such people can focus on the meaning of what is being said. Conversely, for some people with autism, the increased cognitive load and having to make small talk via a screen can be even harder to manage than in person interaction, as well as imposed eye contact which can also be challenging. 3) We are restricted to a desk and a computer with no shared physical space As well as the challenge with long hours of sedentary behaviour, research suggests that a lack of contact with a regular geographic place, such as office, can contribute to a feeling of “placelessness” — an absence of belonging to a place. Feeling that we belong is good for our mental wellbeing. Office workplaces and universities are often a source of extra-curricular activities that further boost connectedness and belonging with others. By working from home, we can face increasing lone working and possible isolation. Loneliness has negative effects on mental health. 4) There are less informal opportunities for care for one another A lot of caring for our colleagues, or having a brief catch up, occurs in the spaces in between, a chat with a colleague in a toilet, checking in in the lobby with another colleague who is having a tough day after a meeting. These chance, corridor, occurrences are more likely in person and can be lacking from home offices. Zoom increases cognitive load, what is it? Cognitive load refers to the amount of information that we can store in our working memory at any one time. The theory of cognitive load was formulated by John Sweller in the 1980s. Sweller argued that educationalists should not overwhelm students with information so that they could retain the important information being taught. With Zoom, we are processing seeing several faces via a screen, so we may be trying to give a presentation whilst also trying to gauge what others are thinking mediated by small rectangular boxes of faces. Are women more at risk than men? There is some evidence women are more negatively affected by Zoom through being both more affected by hyper-gaze, as well as scheduling longer meetings and taking less breaks, though more research is needed. In any case, women are more at greater risk from burnout, a range of studies show that women have been disproportionally effected by the pandemic. The Hartford Survey found that as many as 68% of American female workers reported burnout, as compared to 52% of males. In the graph below featured in a recent McKinsey report, women reported higher levels of burnout, chronic stress, and exhaustion than men, across several levels of seniority. In the context of #WFH (Working From Home), women are increasingly face a double or triple shift. When work ends, domestic and family responsibilities begin. Or, when working from home, women may be managing two sets of responsibilities in parallel. By way of recap, though not a medical condition, burnout that results from work stress is increasingly recognised as a major public health problem at this stage of the pandemic. Burnout has many definitions but there are three widely agreed aspects: Emotional exhaustion (e.g.,-feeling empty and drained) Depersonalisation (a growing negative attitude to the nature of work or the organisation itself) Feeling less personally accomplished and less professionally effective. Burnout involves emotional exhaustion, why is that any different from just exhaustion? Emotional exhaustion refers to feeling emotionally worn-out from chronic stress from the personal or work domain, or both. Generally, symptoms can include lack of motivation, disturbed sleep, irritability, apathy, headaches, difficulties with concentration, irrational anger, increased cynicism, dread, and depression. In the world of work and business, it may be unpopular to discuss the mundane aspects of daily life such as taking a child to the dentist, or, a PTA meeting, but these aspects are all part of the reality of working parenthood. Another perspective on burnout However, whilst it may be tempting to say that women experience more burnout, the picture may be more complex. Whilst there is no doubt that many women have more responsibilities and face more discrimination, there are different components of burnout and experiences vary. A meta-analysis conducted in 2010 that analysed 183 studies found that women are more emotionally exhausted than men, whilst men tend to experience more depersonalisation. The authors of the paper felt that in 2010 women were not more at risk of burnout, but of emotional exhaustion. This conclusion may not still be still relevant in the context of the pandemic, however and more research is needed. Burnout: what can we do about it? — Part 3 In the third and final blog of this three-part series for Inspire the Mind, we will look at what the evidence says about what is actually effective in beating burnout. The internet is full of advice aiming to tackle burnout, but what strategies are tried and tested? What can employers do to create environments that support positive wellbeing and mental health and reduce the risk of more of the workforce burning out? What can we do as individuals do to reduce the risk of wearing out our valuable hearts and minds?