A Reflection on America's Healthcare System and What It Means For The Mentally Ill Three months. I had to wait three months to see a specialist in Michigan, and I was told that I was lucky to get in during that time-frame. I was told in the spring that my specialist wouldn’t be back until September due to maternity leave, with no other physician replacing her. As I waited, I endured intense pain and had no answers. This is just a snippet of what the healthcare system in America looks like for patients seeking help for a mental health condition. This blog will provide an overview of what the American healthcare system can be like for those with mental illness and will reflect on upcoming changes that will hopefully help to improve the situation going forward. Two years later I was diagnosed with Vestibular Migraines (VM), alongside my diagnoses of anxiety and depression. I had been bounced around from so many medications that my body was shutting down. I was constantly nauseous, dizzy, and anxious. I felt controlled by my depression, making the smallest task difficult. My diagnosis had changed three times and my doctors were not communicating with each other. The process was debilitating and dramatically impacted both my mental and physical health. I am not alone. Even prior to COVID-19, the prevalence of mental illness in the United States was increasing, with a reported 19% of adults experiencing a mental illness. In June 2020 alone, during the pandemic, up to 40.1% of adults reported a behavioural condition such as anxiety or depression. As a social worker, I see the struggles of my clients suffering with mental illness, desperately trying to get better while the system works against them. The U.S. vs The U.K. In other countries, particularly the U.K., healthcare is managed very differently. The accessibility is much easier and less strenuous than its U.S. counterparts. In the United States, there is no national healthcare system or universal healthcare model. Here are some of the other major differences: Americans must purchase their insurance through their employer or through the “marketplace”, which serves as a hub for available insurance carriers for them. It goes by age and income. Americans are charged more money if they go out of the insurance carriers’ ‘network’. Within the insurance companies’ ‘network’, they have contracted physicians, where the typical cost of a visit alone is $20-$40. If a patient needs to see an out-of-network physician, in some cases this is unpaid for by the insurance company and becomes entirely the patient’s responsibility, resulting in hundreds of dollars at the patients’ expense. The U.K. requires patients go through their general practitioners (GPs) for mental health referrals, whereas in the U.S. patients can freely go to a mental health clinician without a referral . A referral must be provided by their Primary Care Doctor first, then the patient can schedule an appointment. These differences play largely into how the overall idea of mental health is perceived and addressed in different countries. For instance, the United States often treats each bodily system individually in isolation, where in the U.K., the common belief is that it should be treated holistically and collectively. Appointments Specifically to mental health, 6 in 10 Americans try at some point to get treatment for a psychiatric illness, but the market cannot meet the demand. Insurance is often a barrier here. As mental health services are typically reimbursed by the patients’ insurance at a lower rate, it often leaves healthcare providers being pickier about who they choose to see. Medicaid and Medicare are both federally funded insurance programs, however, they do have certain eligibility criteria, such as income level or age. These programs cover 1/3 of the U.S. population. This can be problematic for people since some health care providers will deny insurances such as Medicaid because of the aforementioned low reimbursement rates and others are so busy they refuse new patients altogether. Medications Prescription medications for psychiatric conditions can be expensive and come with a variety of obstacles. Many controlled substance medications can only be obtained by a face-to-face visit with your physician, typically every 30 days. With Doctors being overbooked, this often creates a barrier for patients, who find their physician does not have the availability needed for these repeat prescriptions, meaning some patients are left without their medication for a period of time. Medication costs vary widely according to insurance plan and type of medication. One of the strategies often used by physicians to overcome this financial barrier is to replace the brand-name medication with its generic version. For instance, with antidepressants, Paroxetine is then $40 for a month supply, versus its name-brand counterpart, Paxil, at $233. Despite this, the costs of psychiatric medications and the need for frequent visits (which also cost money) are still often too high leading to many patients going without medications which, in some cases, can lead to hospitalisation. Insurance Approximately 5.1 million adults in America are uninsured, which is about 10.8% nationally. There are a few insurance options available, however, for a large number of Americans, many of these options are unaffordable. This can be critical for mental health. If the person does not have insurance, they will not be covered and must pay the cost of care at a much higher rate. Often times, this is required at the time of the visit, meaning patients are denied the care that they need, simply because they cannot afford it. To combat not having insurance. The Affordable Care Act created the Marketplace, which is a hub to find plans if you are not offered them in other ways. However, many report that this also costs several hundred dollars per month, despite being the only option for some Americans. Even with insurance, the nation is struggling with medical debt, with approximately 16.2% still owing for medical costs. Lack of Transparency The cost of care in the United States is often unknown to patients at the time they receive the treatment, as each insurance carrier offers different healthcare service coverage. This results in many Americans neglecting their mental health by not seeking professional help when they need it most. As a result, much needed healthcare services such as mental health assessments, medication reviews, and general or specific therapy are missed. A psychological assessment can be rather expensive, and while some insurances cover therapy, others do not. But there is hope on the horizon. On October 29th 2021, a new rule was established that requires MOST private insurers to make their rates publicly available. It remains to be seen how this will play out, as it is proposed that this information will come through three ‘data files’, which will pull information from out-of-network costs, in-network costs, and prescription drugs (including rebates or discounts). The insurers are set to begin posting prices in 2022. Health Reform & What’s Expected Under President Joe Biden, there are plans to lower costs in the marketplace, lower drug costs, and expand the health plans through his American Rescue Plan. The American Rescue Plan makes subsidies more widely available for those who may not have qualified for certain insurance prior. The income cap, has been eliminated for the next few years, allowing more American’s to apply for assistance, whereas before these were strictly regulated based on income guidelines according to state. These calculations are completed by the household’s income and varies by state. Additionally, in 2021 a qualifying life event, such as marriage, divorce, or change of employment, is no longer necessary to change your medical plan or obtain insurance, as it has been historically, outside of the annual renewal date. While all have access to the healthcare plans available nationally, this will allow individuals to have more freedom in choosing employer-based plans at any point. The ability to have more affordable insurance and medications can be lifesaving for those suffering from severe mental health illnesses, such as depression or schizophrenia. It would allow them to see clinicians more often and obtain the prescriptions they may need at lower costs. Additionally, those who make less money would be able to qualify for insurance, opening new opportunities for getting the care they need. These give us hope that mental healthcare will be taken more seriously and become more widely accessible. While we are making great strides, America still has a lot to work to do. Header Image by Callie Gibson on Unsplash

The Vital Role of Mitochondria in Alzheimer’s Disease and Dementia I’m a PhD student at King’s College London, and when I’m not sheltering from a global pandemic, I’m scampering between Guy’s and St. Thomas’ hospitals doing my best impression of a scientist. My research attempts to help pinpoint the early warning signs of age-related diseases, which I hope will facilitate prevention of some of the world’s leading causes of death including Alzheimer’s disease and other dementias. To better prevent these diseases, we need to uncover the biological processes that cause ageing in the brain. As with most problems in science there are several theoretical threads we could pull, but I want to persuade you that mitochondria can help explain why our brains, cognition, and mental health worsen as we get old. What are mitochondria and where did they come from? If you’re like most people I know, I imagine you will be compelled to shout, ‘the powerhouse of the cell!’ However, the term ‘mitochondria’ was coined in the late 19th century meaning ‘granule thread’, which immediately made me think of gravy granules, although I would be surprised if mitochondria went as well with my Sunday roast. Now look at them. Teeny-weeny party balloons bursting with energy juice. Many biochemists like to refer to the protein molecules that help mitochondria function as machines. Hi-tech devices gradually moulded into sophisticated structures by evolution to perform specific tasks. They rotate with such rapidity that they could tear your limbs clean off (if they were human-sized). Mercifully, they reside in the watery cytoplasm of our cells, churning out the chemical energy that cells need to function, and jacketed in a double membrane to create the cosy conditions for doing this. Today, it is well-established that the original mitochondrion must have been an early bacterial cell. When it was out for a walk around 2.5 billion years ago, it was carelessly engulfed by a local bully and reduced to a meagre sausage through a series of evolutionary trade-offs. It was then compelled to provide its lunch money (energy) to the local bully in exchange for a quiet existence. As the mitochondrion gave up more of its responsibilities to the bully, it began making copies of itself to increase production despite its diminishing size. Maybe unsurprisingly, this type of strange event was remarkably rare and there is only evidence to prove that this happened successfully three times. Nevertheless, it may prove essential to the development of multicellular life. The extra energy produced by mitochondria maybe allowed cells to support larger, more complex collections of genes, so life could finally evolve beyond its humble beginnings into the ‘endless forms most beautiful’ we see today. Malfunction in the conveyor belt Well, how exactly do our mitochondria generate this ‘lunch money’? Within these subcellular factories exists conveyor belts of protein machines that use the products of food digestion and the oxygen we breathe to remove protons from inside the mitochondria (hydrogen atoms that have donated a subatomic particle called an electron). Protons will cascade back into the mitochondria through diffusion (where molecules move from high to low concentration) and the only way for them to enter is through a protein called ATP synthase. This molecular turbine functions like a hydroelectric dam, using the current of protons to rotate, which converts a molecule called adenosine diphosphate into adenosine triphosphate (ATP) by attaching a phosphate group. ATP is like a Pac Man power pellet for proteins and powers most cellular processes. Generating copious amounts of energy is so vital to life, if stopped, we would be dead in seconds. Mutations in DNA coding for proteins in this conveyor belt (AKA the electron transport chain) are thought to be responsible for several different disorders that are characterised by dysfunction of the mitochondria and a lack of cellular energy. Fortunately, our cells have evolved mechanisms to identify anything troublesome, so they can fix mitochondria if they aren’t working properly, or in extreme circumstances elicit a response where defective cells eat themselves (autophagy) so everything can be replaced. Mitochondrial dysfunction is bad for the brain As we age, mutations and damage to the mitochondria accumulate and quality control processes to correct these become less efficient themselves. This is the perfect storm for metabolic mayhem where faulty mitochondria build-up, healthy mitochondria die, and cells are unable to make new ones. Scientists believe these fundamental changes to a cell’s ability to make energy underlies many age-related diseases, particularly of the heart and brain, where cellular energy demands are high. For example, the brain utilises 20% of all our bodily energy. Worryingly, this makes brains susceptible to disorders where neurons die due to mitochondrial dysfunction, and it is no surprise that some of the most common age-related diseases involve gradual degeneration of an energy-starved brain. Furthermore, neurons cannot divide, which evolutionary biologists argue is a useful property because it preserves the experiences and wisdom written into the neural networks of our brain where cells form up to 10,000 connections. However, if a neuron must eat itself in response to mitochondrial dysfunction, then those connections are lost forever with all the memories. Suffice to say, our neurons — a lot like Beyoncé — are irreplaceable. Cell death, Alzheimer’s disease, and other conditions Neuronal cell death, or neurodegeneration, characterises an entire group of age-related diseases including Alzheimer’s and Parkinson’s diseases. Alzheimer’s disease involves degeneration of neurons in the cerebral cortex, the newest layer of the brain responsible for attention, memory, thought, perception, and language. It has been shown that a protein found in Alzheimer’s disease called amyloid beta builds-up in the mitochondria and interferes with the conveyor belt, triggering a cascade of events resulting in cell death. On the other hand, Parkinson’s disease is characterised by degeneration in a motor region of the midbrain called the substantia nigra, leading to tremors, rigidity, and difficulty with movement. Current evidence suggests that accumulation of mutations in mitochondrial proteins such as PINK1 can trigger cell death in these instances as well. Interestingly, men tend to have a higher metabolic rate since testosterone increases muscle mass and muscle has a high energy demand. Also, men are usually larger and consume more food, and this hastens their metabolic rate. This increases the likelihood of mitochondrial dysfunction partly as a result of greater oxidative stress. When making ATP, mitochondria inadvertently create highly reactive oxygen molecules that cause damage. Higher metabolic rates and greater susceptibility to oxidative stress thus puts men at a higher risk for developing disorders such as Parkinson’s disease, which is twice as common in men! Breathe! It’s going to be okay. Thankfully, researchers are uncovering mutations and drug targets for treatment. Drugs like rapamycin can increase the clearance of damaged mitochondria and other potential therapies may be able to correct known mutations. Other approaches may involve stimulating cells to create more mitochondria, removing toxic compounds that inhibit or damage mitochondria like highly reactive oxygen molecules, and removing damaged mitochondria. Sadly, as mitochondria become more dysfunctional with time, our chances of experiencing neurodegeneration and cognitive decline increases. And since this happens later in life, there is no selective pressure to correct this apparent evolutionary mistake — thanks a lot Darwin! As a result, we must learn to take good care of these little sausages so that they can continue doing their jobs. Personally, I think understanding mitochondria as ‘powerhouses’ as well as troublemakers of neurodegeneration will embolden us to discover better ways to maintain them, so that we can support our brain function, cognition, and mental health as we grow old. Header image source: QuantaMagazine

Does lived experience really inform our duty of care in mental health? It is very hard to describe and express mental ill-health to people who are fortunate enough to have never experienced it. I am someone with lived experience of mental ill-health and am someone who has worked as a mental health professional for five years with young people living with various mental health disorders. Yet, despite both my personal and professional experience, I was ill-prepared for the pressures of the pandemic and the effects it had on the young people I worked with, my colleagues, and most importantly on me. I ignored my increasingly persistent symptoms in the name of resilience until eventually… I was overwhelmed. I broke down completely — and then, of course, I quit. There is so much value in bringing lived experience to a job within mental health, as it is grounded in evidence that lived experience in mental health is important for delivering an informed approach to mental healthcare. However, as much as my lived experience helped me excel in my role by aiding me with building quick rapport and trust with the young people I worked with, there was also a downside to this. Namely, how selfish it had made me in my duty of care towards them. I was still reckoning with a lot of my distrust for the mental health system and I did not realise how difficult making the transition of being a mental health patient myself to them being a provider would be. I spent most of my time working ‘hands on’ with young people, ensuring they were adhering to their care plans and by tending to their emotional and mental needs as and when they needed. Having been sectioned myself (compulsory admission to hospital under the Mental Health Act 1983), I naively went into this role thinking I had an advantage over most of my colleagues because I thought I really ‘got’ these young people. Whilst I didn’t explicitly disclose my lived experiences with mental ill-health or my time as an inpatient with my patients for obvious reasons, I think they knew who had that sort of background. It is a kind of implicit knowing — on some level in the relationship they know that you have been there and done it and that you just understand. It just showed in our interactions. I felt I had always done my part in giving them a space to just express themselves, instead of explaining every little thing. In my mind, I felt like I knew what they were thinking and exactly how they were feeling and so, at times, I feel I was quite arrogant in my approach with them. Instead of listening to them, I often found myself projecting my own feelings and thoughts to the situations and contexts they found themselves in, as I saw a lot of myself in them. A lot of the role did not meet my expectations. I was working within the confines of funding pressures, which was at odds with my own personal commitment to these young people and their mental health. The need to fulfil this purpose meant that I was always stressed and left feeling unfulfilled. I often felt that I bent myself backwards exhausting myself by trying to make a broken system work. One of the hardest things about working in a mental health setting is that there is a widespread assumption that as health professionals in the sector, we are hardened by our work and therefore less susceptible to the trauma from the things we deal with. This isn’t entirely true. Whilst it is true that I did feel desensitised to an extent, it didn’t remove the reality of the emotionally difficult work we had to do. There were so many times I would go back home and just cry. I’m glad I still allowed myself to feel these things because I feel like a complete desensitised approach would have been an unrealistic expectation and could have potentially meant the care I provided to these young people was less compassionate and engaging. For me, this is where the emphasis on having “lived experience” stops being a framework we should be working under. It’s clearly not the case that we only learn from direct experience. It was helpful for me to evolve in my role as a mental health professional by working with people from different backgrounds and experiences. That blend of skillset — having a mix of people with both lived experience and without it — offered a lot more to our young people than imagined. Mental healthcare sometimes needs to be driven by nuance and contextualisation instead of emotion, which is what I needed to learn. But I think for me it was vital to establish boundaries, such as when it was appropriate to relate my own experiences to the young people and when wasn’t. Over the five years, I learnt that if I was to disclose my experiences to the young people, it needs to benefit the young people — because ultimately it was about them and not me. Even if I did have similar experiences, I could never assume how the young people perceived my experience and what they felt hearing about them; my experiences could have been a triggering rather than a bonding moment. There is nothing wrong with us as professionals, using our individual lived experiences in our practical approach to mental healthcare. However, there is no such single lived experience. I learnt this the hard way; my individual experience was not representative of everyone with mental ill-health. Lived experiences are profoundly subjective and can make us susceptible to biases that may distort how we observe and perceive the social world, which could ultimately influence the most important thing we have set out to achieve as mental health professionals — our duty of care. Header image source: Children & Young People Now

We need to teach children to be kind to their bodies, before it’s too late Trigger warning: The following blog contains discussions of eating disorders, body dysmorphia and fatphobia, which some readers may find distressing. I had a conversation with a mother in a supermarket recently, and I haven’t been able to shake it from my mind. She was panicking in the milk aisle, unable to find semi-skimmed green-top milk. When I asked if she was okay, she told me it had to be green, because her daughter would not drink whole blue-top milk. Alas, she had to settle for the blue, telling me she keeps a spare green bottle top back at home to swap with the blue, just in case. “My daughter has anorexia,” she said. I was suddenly hit with a wave of emotions. I had merely seen this woman buy a pint of milk, but I somehow immediately felt all of her pain and knew exactly what she and her daughter were going through. She proceeded to tell me the story of her daughter’s eating disorder, which developed as a result of fatphobic bullying in primary school. Her daughter was just nine years old when classmates started making fun of her weight and commenting on what was in her packed lunch. Before long, she was skipping meals. That was three years ago and now aged 12, her daughter recently spent time in hospital after not eating for a month. She told me the devastation her daughter’s illness has brought upon their whole family, and how helpless she feels in just wanting her to get better. I don’t think I’ve ever wanted to hug someone quite so much in my life. Hearing this mother tell me her and her young daughter’s story not only shattered my heart, but it was all the more horrific because it was also mine. I have been the child sobbing to my parents about not being able to eat. I have disrupted my family’s lives for hospital visits. I have had panic attacks in supermarkets because foods I considered ‘safe’ weren’t available. I was also seven years old when I started obsessing over my weight and developed an eating disorder at 12. Now aged 22, I feel so deflated and despondent knowing children are still enduring traumatic relationships with food and their bodies, and being dragged through the mud of diet culture by society just as I was 10 years ago. I am a journalist and mental health writer. I advocate for equal access to treatment for eating disorders and share my own story to remind others they aren’t alone in their struggles. I love what I do, but I shouldn’t have to do it. However, mental health activists like myself will have to continue screaming and shouting unless things improve. We owe children so much more than a world that too often encourages self-hate, forces impossible beauty standards upon them, and promotes restrictive eating habits. Learning that this poor girl was essentially bullied into under-eating gave me all the proof I needed that, if we do not change how we speak to children about their bodies, and instead continue perpetuating diet culture, then children will grow up thinking there’s something wrong with how they look. When a seven-year-old feels so unworthy that she stops eating, there is a major problem that should force society to look at its reflection and question how it allowed eating disorder culture to thrive to this extent. It’s very easy to get wrapped up in social media and to believe the progress we see online is everywhere. But the reality is, we live in bubbles online. We only follow people whose content we want to see and technically create an echo chamber of the ideas and beliefs we hold personally. We follow people who make us feel good and like pages that reassure us that the world is evolving the way we want it to. However, although there may be, for example, more size-inclusive clothing brands, more plus-size models walking down runways, more conversation around the futility of diets and the importance of body positivity… it feels like too much energy is spent healing those who have already been chewed up and spat back out by the demons of diet culture, rather than preventing the harm from ever happening to young people in the first place. Children shouldn’t have to wait until their 30s to overcome completely destructive attitudes towards food. They shouldn’t have to struggle for years before they learn that, actually, eating cake doesn’t make you a terrible person destined to burn in hell — which is what I thought for so many years. Young girls shouldn’t have to develop eating disorders before they are taught that they don’t have to look a certain way in order to be accepted. Fat kids shouldn’t have to sink into a deep pit of self-hatred and endure years of body shaming and bullying before they learn that beauty doesn’t have a weight limit and they are worthy of respect, regardless of body size. All kids need to know that to be ‘fat’ is not to be lesser. But they will not so long as the stigma surrounding fatness remains. The word ‘fat’ is stigmatised in a way that ‘thin’ and ‘skinny’ never are, which are frequently used as compliments. By normalising and destigmatising the concept of fatness, within and beyond conversations about diet, eating, and mental health, we can save youngsters years of abuse as the word ‘fat’ is disarmed and is no longer an insult to hurl across the playground. We have an eating disorder epidemic, one that will continue unless we start putting the work in at the very bottom because, by the time children get to their 20s, the damage has been done and it’s a lot harder to rewire someone’s brain to think a different way to what they’ve been taught for years. It’s much more difficult to convince someone who has hated their body since childhood to love themselves as they are than it is to teach a carefree, fun-loving child who has not yet been swept up by the diet culture storm that there is never anything wrong with their body. I’m in disbelief and horror that we ever reached a point where children consider skipping meals for weight loss because they believe it will make them more desirable to their peers and successful in the future. The risk is, they won’t have a future at all. So, what do we do? How do we start convincing children that they need to eat and look after their bodies, especially when many adults don’t practise what they preach? Well, regardless of our own experiences with eating disorders and views on our own self-worth, we have a duty of care for children. Are there times when I engage in eating disorder behaviours? Forgo meals? Compensate with exercise? Talk badly about my body? Yes. But I also have an 11-year-old step-sister, and I wouldn’t dream of doing such things around her, because I’m aware of how easily my own brain internalised diet culture when I was little. I was a sponge who absorbed every hateful comment my grandma made about her big bum, every remark my aunties made about ‘cheating’ on their diets for eating bread, and every joke made by my teachers at fat people’s expense. And I have yet to be squeezed out. It’s all still in here. Not only do we need to start teaching children the importance of nourishment and being kind to their bodies, we need to ensure they understand that how their body looks is by far the least important aspect of life. We need to make sure they don’t equate health to thinness or assume a fat person even needs to justify their ‘health’ in order to be treated with respect. We are still drilling into young girls that being thin will make them more successful and that ‘beautiful’ is the highest compliment they can receive. We are still teaching young boys that to be strong and athletic is to be cool and powerful. What we actually need to be doing is encouraging children’s hobbies and passions, watering their interests and helping them pursue what brings them joy. We need to teach children that their weight is not a limiting factor; all that matters is these young children are happy and that they are healthy. Weight is just one part of that. We need to teach children that they have brilliant, imaginative minds and they are capable of so much. I have a vivid memory of my eating disorder outpatient nurse congratulating me for eating a packet of crisps as a 19-year-old. I cried. I cried because that was the first time in my life that I had heard crisps being talked about in a positive way. No one had ever mentioned crisps to me before without demonising them, but this wonderful nurse reminded me that crisps are carbohydrates, and they are a form of energy. They also just taste really good and eating crisps when you are hungry is always better than eating nothing at all. It shouldn’t have taken me two decades to understand that eating a packet of crisps is not a sin, and I don’t want another child to go through that. I want children to be unapologetically hungry and to eat without shame. I want children to say nice things about their bodies and never feel conceited or embarrassed. I want children to have healthy relationships with food and with their bodies so they don’t require appointments with therapists, nurses and dietitians in the future to help them rebuild the undernourished relationships between their bodies, minds, and food. Every day now, I think about the 12-year-old girl and her mother, wondering how her family are doing and whether she’s getting better. I doubt I’ll ever find out but if somehow she ends up reading this, I want her to know it’s okay to drink blue-top milk.

The Fate of Mental Health in Afghanistan under the Taliban Blue scars concealed under the black burkha yearn for emancipation, as a teardrop rolls down the face of an Afghan woman, just like the slackening hope for a better tomorrow. While the eyes long for the clement kiss of sun rays, the quotidian headlines only seem to thicken the black clouds hovering over Afghanistan. The thread of hapless images going viral on the internet has perturbed each one of us. Meanwhile, the Taliban continues to stitch and seal the pipe-dream of the majority of the Afghans. Individuals across the globe are well-versed with the ongoing predicament in Afghanistan. Plagued by destitution, bloodshed and social inequality, this war-torn country has witnessed extreme terror for generations and generations together. During the Taliban rule from 1996–2001, various human rights violations have been carried out over the years — from massive systematic exploitation of women and brutal carnal punishments to the proscription of education, religion, and expression, and effects remained even after this period. Post the end of the Taliban rule, women gained autonomy over their choice of clothing, with over 8.2 million students enrolled in school, 40% were female. Now, with the Taliban in power once again, the world is fearing the repetition of a traumatic history. I wonder, what will all of this mean for mental health? As an Indian woman living in India, and a media student at Manipal Institute of Communication who has also studied some psychology, the devastating situation in Afghanistan has gravitated my attention towards its citizens’ plight, especially their mental health. Seeing the inhumane trauma women are being put through, I hope to voice their struggle through my words. “I want my daughters to be respected as human beings; that’s the country I’m fighting for.” — Fawzia Koofi (Former Afghan Politician and Women’s Right Activist) Previously, women’s mobility, conduct, attire, and almost every aspect of their lives was severely controlled by the Taliban regulations. They were prohibited from working outside the house, female education was forbidden, and public floggings were common. Reading through these autocratic rules imposed by the Taliban leaves us fearfully wondering what circumstances will be once again constructed for these women in the 21st century. “We have to change this idea that women are only supposed to work in the house. Women should go out and be what they want.” — Malala Yousafzai (Pakistani activist for female education and a Nobel Peace Prize laureate) Prior to the promulgation of the Afghan national constitution of 2003, eliminating discrimination against Afghan women in all forms, the situation of women under the Taliban was abysmal. War traumas, sexual oppression, rape, premature and involuntary marriages, sex slavery, conservative detrimental behaviours, domestic violence, and cultural restrictions on social activities were all facets of the degradation of Afghan women’s mental health issues. Due to the direct repercussions of violence and the war-induced destruction of public health, security, and infrastructure, the conflict in Afghanistan continued to claim lives in the post-Taliban era as well. Crossfire, improvised explosive devices (IEDs), killings, bombings, and night raids on suspected militants’ homes led to the murder of many civilians. Thus, even the democratic period could not thwart the practise of certain violation of human rights. Ever since the recent Taliban takeover, the women have again been locked behind closed doors as futile laws have been implemented. Women teaching boys above 6th grade or at co-ed institutes has been banned, new dress code and gender segregation rules have been introduced, women protesting for equal rights were whipped and beaten with electric batons, strict interpretation of Sharia Law are to be practised, the newly formed Taliban government has also replaced the Women’s Affairs Ministry with the Ministry of Vice and Virtue. While there is no recent data available on the current status of women, the news updates undoubtedly hint towards the ever so exacerbating mental health concerns across Afghanistan. Real men don’t cry.’ The problem of toxic masculinity has been on the table for decades, and for an orthodox country like Afghanistan, there is little room for the importance of mental health. Under the previous Taliban rule, men were coerced into wearing turbans in all government offices, men with trimmed beards were beaten up, sports were banned, executions and amputations of hands were carried out, and men were compelled to go to the mosque five times a day for prayers. Activities like these impacted the mental health of Afghan men. The stigma associated with mental disorders is grim enough for people to believe that mental illness is synonymous with weakness and disability, leading to some being utterly oblivious to their illness and going about their daily lives. Consequently, victims of mental health ailments, especially Afghan men, prefer to conceal their maladaptive behaviour and psychological distress. Arguably, Afghan women are the worst affected and most tormented among the general population of Afghanistan. In 2002, the prevalence of mental health issues was less pervasive in Afghan men in contrast with Afghan women. As the previous Taliban era witnessed its end, drastic measures were taken for the improvement of mental health across Afghanistan. In 2008, 85% of healthcare institutions saw at least 750 new patients per month. More than 900 community health workers and hundreds of doctors, nurses, and midwives were trained in mental health services between 2002 and 2012 when mental health care programmes were introduced. Fast forward to 2018, resulting from the after-effects of the Taliban regime, a total of 66% of Afghans had personally experienced at least one traumatic event, while 84% had either personally suffered or witnessed a traumatic event. As of June 2021, the overall prevalence of psychological distress stood at 47%. The 12-month Post Traumatic Stress Disorder (PTSD) prevalence rate was 5%, the Generalised Anxiety Disorder (GAD) prevalence rate was 3%, and the Major Depressive Episode (MDE) prevalence rate was 12%. Thus, prior to the forceful acquisition of the country and mental health services available, Afghanistan still exhibited high numbers of mental health issues post the end of the Taliban regime and overall trauma of war and violence experienced. “There are a lot of children in Afghanistan, but little childhood.” — Khaled Hosseini (Afghan-American novelist and UNHCR goodwill ambassador) But what future are we referring to when Afghanistan’s youth take a leap in the dark with the passage of every day? In a country, ripped apart by war and weapons for more than 40 years, the future of the next generation can’t help but seem sombre and forlorn. Will children, who are the torchbearers of tomorrow, see their years of happiness and freedom fading into an illusion? Will they suffer the same fate of prior generations? Will history repeat? Previously, minors have been exposed to severe armed brutality, been victims of inadequate protection systems, and been on move — running away from conflicts and poverty in search of a better place. The traumatic experiences of the Afghan children have made them prey to severe chronic mental health disorders. For example, in 2019, 62% and 73% of parents reported, respectively, that their children had direct or indirect experiences of conflict, or that their children suffered terror and anxiety resulting from violence. Moreover, 48% of parents reported their children experienced prolonged sadness and insomnia, and 38% said their children self-harmed. However, now that the Taliban is back in power, it would not be hard to assume that these numbers may escalate. “The problem with the stigma around mental health is really about the stories that we tell ourselves as a society.” — Matthew Quick (American writer of adult and young adult fiction) The Ministry of Public Health (MoPH)’s establishment in 2005 paved the way for mental health to be in the top five priorities, making it one of the ‘Basic Package of Health Services’ (BPHS) components. However, in 2006, Afghanistan’s massive gap between the deficit in mental health services and a dearth of human resources with experience in the treatment of mental illnesses was brought to light. Following the WHO’s report on the severe lack of mental health facilities in Afghanistan, the Afghan Government introduced a Health and Nutrition Sector (HNS) Strategy in 2008. With the Taliban all set to rewrite the horrid tales of misery post its recapture of Afghanistan in 2021, the minimal mental health facilities offered under a democratic regime have surely met their end. The impositions implied post the recent Taliban takeover has begun alarming towards major red flags. Dreading their existence and battling through the excruciating directives, the Afghanistan population is undergoing a massive humanitarian crisis, which is coercing them into fleeing their own country. The displacement of Afghan women and children due to the conflict has reached 80% of nearly a quarter of a million population that has been forced to abscond since the end of May. Struggling to meet the daily ends of food, shelter and water, caring about their dwindling mental health is probably not even the last priority of the struggling Afghans. While the scars from the nightmares of the previous Taliban rule have not healed for the majority of the Afghan people, the band-aid is already being ripped off. We can only hope for a better dawn. — — — Here are some relevant mental health resources: The UK Government has established helplines for British and non-British nationals (on GOV.UK) in need of assistance. The Mental Health Helpline has been made available for 24 hours to listen and offer assistance. Call: 0800 132737 Text ‘Help’ to 81066 Non-British Nationals: Call +44 2475 389 980 if you are a non-British national in Afghanistan or a family member of a non-British national in Afghanistan in need of assistance (or 02475 389 980 in the UK). Editors Note We, at Inspire the Mind, are proud to continue to provide a platform and an opportunity for those affected by the events in Afghanistan to share their stories. You can read more at the following: During the Last 20 Years, Women Had Become Much More Confident In Afghanistan, But Everything Has Changed This Week The Peril and Plight of Afghan Women Needing to Escape: The Mosaic Edges of an Afghanistan in Trauma The Growing Mental Health Crisis in Afghanistan The Mental Health of People Who Have Worked in Afghanistan Since 2003 Afghanistan: Through the Lens of a Former Child Refugee

Tips & Tricks to Combat Your Morning Anxiety Apart from the Sunday Scaries, weekday morning anxiety is more commonplace than it might seem. I have been living with it for as long as I can remember, although some mornings are better than others. Everyone will experience this particular kind of anxiety to a different degree, but if you do have bouts of morning anxiety, know that you are certainly not alone and in good company! There are different ways to combat your morning anxiety and in this blog, I would like to share with you simple, natural, and drug-free ways to do that in about five minutes. This small time investment could make your morning, and potentially your whole day a lot better and less stressful. Morning anxiety can be caused by many factors that contribute to certain anxiety disorders, the most common one being generalized anxiety disorder, or GAD in short. I have come to learn that scientifically it is usually a heightened reaction to stress and worries of future things that need to be accomplished/resolved, have yet to even happen, or the fear, or panic of something going wrong (that hasn’t yet). I tend to ruminate and catastrophize about things that occurred the day before, and of course what might happen in the near future. When I get up in the morning, I am reminded of what is on my plate for the day, on top of what wasn’t completed yesterday, or items still unchecked on my to-do list, and sometimes that fills me with a sense of morning dread. When we perceive something as stressful, our bodies produce a hormone called cortisol. Typically, cortisol levels are highest in the morning, to prepare us to start and face the day, and this is a healthy response. However, at times, when we experience anxiety, those levels might be higher, causing us to feel stomach knots, sweaty palms, heart racing, and even feeling panicky. At times, this can feel debilitating, especially when it happens in the morning before we even start the day. I am a mental health & wellness writer, and an educator, with a graduate degree in Psychology. I have also been tackling morning anxiety for about a decade. If you, like me, have a similar experience, I would like to share a few tips below as I found them helpful in lowering stress levels, boosting the mood, and getting more energy. The strategies I’m about to share with you gave me that extra spark which I needed to meet the challenges of the day, or at the very least, got me through the morning in a good and calm headspace before embracing the day ahead. While they may not be a cure for anxiety, they might be helpful in managing it better, which is more than half the battle from my perspective! Maintain a good sleep/wake schedule Getting adequate sleep is crucial to controlling your morning anxiety or at least minimizing it. I realized that if I skimp on the number of hours of sleep that I need to function, I suffer a lot more in the morning. Make your bed to get out of your head It’s a small ritual that can help create a calm environment for you in your bedroom. Author Gretchen Rubin recommends making your bed as a daily habit in her book, The Happiness Project. She recommends doing it the first thing in the morning. This way, you’ve got one less thing to worry about for the rest of the day, and you can look forward to slipping under the clean and neat covers when you turn in for the night. This is actually something I look forward to all day. Stop Snoozing Soaking up those last minutes of sleep by pressing the snooze button will only make you more anxious when you finally do get up. Although it may feel good in the moment, it might not be worth the mental anguish it will cause you upon awakening. Pack a snack, and clean up your diet Before you head out the door in the morning, prep a healthy snack to take with you, or eat from home if that is your work schedule. This might include fruit, unsalted nuts, and low-fat cheese or yoghurt. When you get hungry later in the afternoon, you’ll be ready! Cutting back on processed food will derail you from midday mood/hunger swings and sugar crashes. I find that when I don’t aim to eat healthy food groups like good carbs, veggies, and protein, my anxiety gets worse. This also happens when I skip a meal. Curb Clutter From stray papers to scattered coffee mugs, clutter can make you lose focus, curb productivity, and create chaos and stress within. Avoid this at all costs. Declutter your outer environment, and you may feel more organized and calmer within, and better able to concentrate on the task(s) at hand for the day. If it seems overwhelming, throw out one thing at a time so things will not accumulate. Pump up the Jam Several studies have found that listening to music can help to lower blood pressure, reduce stress, and boost your mood. The right music has the power to change your attitude. Create a playlist that will make you smile, and increase your endorphin levels, whether you’re working or working out. This is a safe and healthy way to make your day more enjoyable and manageable. Smell an uplifting scent For a quick de-stressing trick, I like to smell something citrusy. Researchers found that limonene, a substance found in lemons, may turn down the classic “flight-or-fight” stress response. If lemons aren’t your thing, there are other scents that have been found to have beneficial properties, like lavender, or eucalyptus, which have been found to lower your cortisol levels. I find that sniffing these scents in a napkin while in transit to work is enough to alleviate some stress. Stretch On most mornings before getting out of bed, the first thing that I do is stretch, even as little as stretching my arms over my head, or doing a gentle torso twist in bed helps. Other types of stretches I found relaxing are bringing my knees over into my chest, and hugging it, while holding that stretch for a minute or two. It brings me comfort. Be gentle with yourself. Stretching can help improve your circulation and flexibility and may help ease the tightness in muscles and joints, including sore neck and shoulders where we tend to carry the most tension, and stress. The key is just to get up and move without even thinking about it. Sometimes just the act of physically stretching helps me from feeling frozen and trapped in my head. Embrace the 3–3–3 rule Psychologist Tamar Chansky, and author of Freeing Yourself from Anxiety, suggests this unique rule. The idea behind it is to look around you and name three things you can see, followed by three sounds you hear, and finally moving three parts of your body. This trick helps to calm your mind and recenter you to the present moment. This is especially helpful when your mind starts to wonder with worry, and you need to reorient yourself quickly. Meditate Although it is not for everyone, it’s worth trying. Settle into a comfortable position in a chair, or on the floor. Proceed to follow your breath, in and out, for a few minutes. Thoughts are bound to bubble up in your mind. Let them float on by like a passing train, and turn your attention back to your breath. Meditating daily, even for just a few minutes, has helped me tame my stress. Dr Andrew Weil created the 4–7–8 breathing exercise which I regularly do. All it involves is simply breathing in through your nose to a count of 4, holding your breath in for a count of 7, and then simply exhaling through your mouth for a count of 8. It has really helped me to stay in the present moment, and maintain a positive mindset in the AM. Adjust your mindset It’s helpful to remember that it all comes down to your attitude, and reaction to stress. Stanford Psychologist Kelly McGonigal says that “embracing stress is more important than reducing stress.” While difficult to do at times, that concept always struck a chord in me. I do what I can, and try to have an action plan to combat particular stressors, and if I feel I reached my limit, I call it a day. Keep a gratitude diary Keeping a gratitude journal is another helpful strategy I have been using for years, and I find that it helps to remove anxious thoughts from my head as I think about something positive to counteract any negative emotions I feel. I take a minute every day before going to bed to write down what I am thankful for, big or small. It’s easy to vent about anything that is not to our liking, or things we can’t change, but complaining brings negative energy along with it. Being thankful for what you have can make you appreciate all the positive things in your life. Additionally, I also keep a little notepad by my night stand to jot down all of my worries before I go to bed. I set a timer on my phone for 15 minutes. This helps me to get all of my anxieties and worries down on paper, but with a time limit. Once the timer is up, I close my notepad and put it away. I am not allowed to worry any more, because that dedicated time is over. That’s it. I usually go to bed right after knowing I have done the best that I can on a particular day. Sometimes that’s enough to lull me into a deep sleep. Turn off your electronics in the AM Taking a little break from all my gadgets, especially as soon as I wake up has helped me a great deal. Staring at computer screens and electronics in the AM can zap your energy and encourage inactivity, dread, and fear. Just because the world is on 24/7, doesn’t mean that we have to be. While it’s tempting to get obsessed, and worried about the latest Coronavirus variant, it will only add more stress to your sacred AM. Be mindful of what you watch and listen to as that negative energy can be very powerful, and draining on your psyche. I make it a rule to not look at my phone or emails immediately upon waking up, and I would recommend trying it to anyone who shares my struggles. Know that you can’t do it all Learning how to prioritize goes a long way. Not everything is an emergency, so take the time to figure out what’s truly important on your list of tasks, and go from there. Other less important things can wait. This method has helped me sharpen my focus and raise my productivity levels. So, make a list, figure out what really matters, what can wait, and what you can skip. Work your way down the list, handling your top priorities first. This method might seem elementary, but it can help in reducing the number of stressors you may feel, and help you feel less overwhelmed and anxious. The suggestions above may sound very simple, and intuitive, yet many of us wake up in a panic without making any adjustments to our mental health routine in the AM. These suggestions, when practised consistently, can help you bring a sense of calm and wellness and appreciate your mornings more. However, if you continue having problems managing your symptoms, talk to a mental health professional to help you get to the root of your morning anxieties and stressors. Header Image source: Alexandra Gorn on Unsplash

Expressing the Mind: reflecting on my experience of writing a blog Some time ago, during an email exchange, I received a suggestion from Professor Carmine Pariante for today’s piece that focused on my experience writing a blog. However, with everything that has been going on in the world, I questioned the relevance of the subject matter; I procrastinated for quite some time and deliberated about how to make this post more pertinent to you, the readers, and how to relate it to mental health. After an encouraging conversation with my friend regarding writing and blogging, I came to the decision to not only write about my personal experience, as Professor Pariante suggested, but to also discuss the power of writing in terms of how it can have a positive impact on a person’s mental health. So this time I’m going to put down my scientific-analytical cap and do some self-reflecting and maybe even offer some advice and insight for people who would like to start writing and contribute to InSPIre the Mind, as well as mention the benefits of writing on your mental health. My overall opinions (of writing a blog post) I recently completed my MSc in Psychiatry from King’s College London and I am currently pursuing a career in research. For those of you who are interested, I’ve written for InSPIre the Mind before — a scientific piece on the benefits and potential use of omega-3 fatty acids in the treatment of depression. Initially, I was a bit reluctant about writing this scientific blog on omega-3 fatty acids, and quite doubtful of my abilities. This wasn’t something that I had always wanted to do. But nonetheless, I was drawn in by the idea of informing people about a topic I care about related to mental health and contributing to such an insightful publication that includes compelling posts by writers from a variety of backgrounds and perspectives. I can happily say now that I found it to be a rewarding experience and was surprised by my skills and felt a sense of pride in what I had written based on the positive feedback that I received. What did I enjoy and find difficult during the process? Probably my biggest enemy during the writing process and, frankly, during other tasks, as is the case with a lot of people, was…… procrastination! There were times when I was either not in the mood to write, was too tired, was unsatisfied with what I had written, or ran out of ideas, and therefore I would delay its completion. This is not beneficial as you soon realise that hours become days, days become weeks, and weeks become months and you haven’t made a single bit of progress. However, I noticed that when I would remind myself of the motivating factor (which I will discuss in a moment) and focus on the chosen topic, only then would I become completely engrossed in the activity and be able to make some progress in completing the task. This progress doesn’t have to be immense; it can be finishing a paragraph or two or re-organising the sections of your article. I think that the important thing is to make progress and to do it as frequently as possible (ironically, I have procrastinated on this section quite a bit). I also have the tendency to be perfectionistic in a lot of what I do, which can push me to complete work thoroughly but it can also be a hindrance. It can create a lot of unnecessary pressure and anxiety since I would feel self-conscious and worried about what others may think about my writing and so I would frequently filter my thoughts. An insightful InSPIre the Mind post by Courtney Worrell delves deeper into this relationship between perfectionism and mental health. However, I think that it’s important to allow yourself to freely express your opinions before reading through your work and making any edits so that you don’t stop the flow of ideas. Despite the small setbacks that I faced, my biggest motivating factor was feeling as though I was doing something important — impacting the public by engaging with them and educating them about the science behind mental health. It was also a great opportunity for me to articulate my views in a concise and organised manner, as well as develop my ideas and get my thoughts out there. In the end, I felt a sense of completion and achievement, which gave me greater confidence in myself. It felt satisfying to have my work validated and read and seen by other people. Some tips on writing a blog post (from my point of view) I believe that the beauty of blog writing is that anyone can do it. It is about expressing your opinion and discussing a particular subject area that you’re interested in using evidence to back up your points where necessary. It is essentially a more informal form of a written article. Important tips based on what I learned: Create a plan or structure — I think it’s useful to outline headings in the beginning so that you can be aware of what you need or are going to include. Furthermore, I think that it’s helpful to have a narrative layout, which allows your readers to easily follow your train of thought. Include pictures — I find that this is a really good way of visually engaging your audience and helps emphasise the points that you are addressing through association, thus making them more memorable for the reader. Beating procrastination — sometimes it can be difficult to come up with ideas or our perfectionistic nature can sometimes impede us from starting or finishing the task. But it’s about changing your mindset and knowing that you will have the chance to go over it and it will be proofread by editors. So just put down the ideas you have (even if it’s not in chronological order — you can focus on one section and then go to another), and then you can refine them. Split the big task into smaller more manageable tasks and think about the emotion of finishing the task. Come up with an earlier deadline for yourself before the real deadline. Remember the reader — keep the reader in mind when writing. Don’t use overly technical language, since blogs are usually accessible to a wide audience and so you don’t want to alienate any of your readers. Reading other peoples blogs can give you an idea about the type of writing style or language to use. The link between writing and mental health There may not be any obvious link between writing and mental health — some think of it as more of a burdensome task — however, there is evidence that indicates the potential therapeutic benefits of creativity, gratitude and positive writing. A relatively recent research study reported that participants who received talk therapy along with gratitude writing (writing letters thanking others) had significantly better mental health (scored higher in a questionnaire measuring well-being, psychological symptoms and life functioning) after 4 and 12 weeks than those receiving only talk therapy or talk therapy with expressive writing. This was considered to be due to the use of fewer negative emotion words. Another study noted that a 4-week positive writing course given to recently discharged psychiatric patients, not only helped them manage their emotions and stabilise their mental health, but also resulted in significantly lower depression scores compared with those who did not receive this course. A third study found that patients with long-term mental health conditions who participated in arts-based groups that included a creative writing activity reported a short-term significant increase in positive emotions and a longer-lasting significant reduction in negative emotions. Writing about different experiences and perceptions of mental health through, for example, blogs, can create a dialogue and a space for individuals going through these difficulties to connect and provide emotional support. One review highlighted that the act of blogging allows for catharsis and social connectedness and also improves peoples’ coping strategies. Most importantly, personal writing can promote self-awareness and self-reflection as well as strengthen the bond with oneself, which can lead to personal growth. Conclusion I hope my blog was able to convince you that writing can be not only an enjoyable experience but also a healing one. Especially now, when we are living in unprecedented times and living with a great deal of uncertainty, writing can be a powerful tool that we can use to verbalise how we are all currently feeling and what we are going through. Ultimately, I believe that sharing our experiences with each other will allow us to come out of this COVID ordeal with a greater sense of awareness about ourselves and understanding the most pressing issues that face the world and move in a progressive direction globally to create a better future for all.

The Power of Gut Bacteria to Influence Mental Health I am a final year PhD student at the Centre for Affective Disorders at King’s College London. I would like to share with you some of our latest work on my topic of interest — the involvement of the gut in mental health. Have you ever had butterflies in your stomach? Or maybe a gut feeling? How about describing a big disappointment as being ‘gutted’? Expressions like these appear in many languages throughout the world. They are evidence that on an instinctive level we associate the gut with a range of emotions from sadness and disappointment to excitement, intuition, and even love. And even though Hippocrates postulated a role for the gut in mental illness as early as 4th century BC, modern science dismissed the gut-brain-mood relationship until fairly recently. The bacteria in and on our bodies vastly outnumber the cells and the largest proportion of these reside in the gastrointestinal tract (the pathway in which food enters and leaves our bodies). There, they form a complex, dynamic and ever-changing ecosystem, also known as the gut microbiota. The gut microbiota performs various crucial functions for our wellbeing and survival, such as digestion, production of metabolites (that is, any substance produced during digestion), development and regulation of the immune system, and production of neurochemicals involved in mood regulation, such as serotonin. An imbalance in the microbiota (that is an increase of harmful bacteria at the expense of beneficial bacteria or a lack of bacterial diversity) has been linked to numerous medical conditions, among which are inflammatory bowel disease (IBD), obesity and some autoimmune diseases. The Gut and Mental Illness Most recently, owing to advances in sequencing technologies, we have been able to discover the complex bidirectional ways through which the gut microbiota communicates with the brain (also known as the gut-brain axis) and have begun to unpick its involvement in the development and progression of mental illness. For example, we have seen that microbial imbalance in the gut can increase the production of inflammatory molecules, lead to an overactivation of the hypothalamus-pituitary-adrenal (HPA) axis, which produces the stress hormone cortisol, and reductions in brain-derived neurotrophic factor (BDNF) — a protein necessary for normal neuron development and function. Interestingly, by using animal models of mental illness, researchers have shown that mice that have been transplanted microbiota (via a fecal microbiota transplant, or FMT) from a person with a condition such as depression, anxiety, autism spectrum disorder or schizophrenia developed behavioural and physiological symptoms of the respective condition, whereas mice receiving FMT from healthy people did not. So what is different in the gut microbiota of people with mental health conditions? Many studies have now shown that, when compared to healthy controls, people with mental health conditions have notable differences in the composition of their gut microbiota, and specifically, in the levels of specific bacteria. This has led people to believe that we could potentially treat or even diagnose mental health conditions by analysing the levels of such bacteria (via stool sample analysis) when a patient comes to the clinic. However, for us to be able to use these microbial differences to assist diagnosis, we need to first demonstrate that they are unique to the condition we want to diagnose (i.e. that they aren’t the same in someone with bipolar disorder and someone with psychosis, for example). Therefore, we first need to meticulously compare these bacterial differences across the range of psychiatric conditions. That’s what we set out to do in our most recent paper. We reviewed and analysed the results of 59 studies of adults with a range of psychiatric conditions. You can see the full paper here, or listen to the podcast version here. What we found was that the most consistent microbial changes in the guts of people with depression, bipolar disorder, psychosis/schizophrenia and anxiety overlapped. For example, the levels of the bacteria Faecalibacterium and Coprococcus were decreased and the levels of Eggerthella were increased in these patient groups compared to controls. Faecalibacterium and Coprococcus are involved in the production of butyrate — an essential short-chain fatty acid (SCFA) that maintains a healthy gut lining and prevents inflammation. On the other hand, Eggerthella, which was enriched in patients, is involved in butyrate depletion and has also been linked to gastrointestinal inflammation. While it is likely that the changes in the microbiota are a lot more complex than that, these are examples of some notable shared features in people with several mental health conditions. Interestingly, these conditions have also been shown to have an overlap in genetic studies and inflammatory marker studies. Why is that important? Because it may suggest that the current diagnostic categories we use (which then determine the course of treatment) do not accurately represent what seems to be shared underlying biology and, also, some shared symptomatology (for example, a depressed state or problems with cognition can be a feature of all of these conditions). What’s next? It is now clear that mental illness affects systems beyond the brain and that gut health may be vital for mental health. Our review and meta-analysis (that is, analysis of the results of all published studies) demonstrated that changes in the gut microbiota are widespread and pointed to some of the most prominent changes that can represent direct or indirect treatment targets for several mental health conditions. However, we have a lot more to learn before specific treatment recommendations can be made. In recent years, one of the most popular approaches to improve the health of the gut microbiota is probiotics. The idea of the probiotic (that is, a food supplement containing beneficial bacteria) is by no means new. In fact, one of the earliest scientific reports of probiotics used as a treatment for mental illness came out of the Bethlem Royal Hospital in London in 1910. Following, in the 1920s, numerous probiotics were marketed for their ability to improve mental wellbeing and treat psychiatric conditions. However, this approach was soon abandoned, due to a lack of scientific understanding of the underlying mechanisms. Now that probiotics are back in the spotlight (as indeed, many studies over the past few years have shown them to improve anxiety, stress, depression, etc.), we must make every effort to understand their mechanism of action and answer some key questions. For example, what is the optimal dosing, duration, or contents of treatment? Are there any potential side effects? As a PhD student, I am aiming to do exactly that — I am conducting the PROMEX study to assess how probiotics affect the gut microbiota itself, inflammation, and brain chemistry in people with clinical depression and, in turn, how this impacts the depressive symptoms. I hope that the results of this study, along with other similar studies in the field, will contribute towards a shift in the way we see mental illness by emphasising the role of gut health and nutrition. This is an important step towards more holistic approaches to prevention and treatment, which will help close gaps that current pharmacological treatments alone cannot.

TRUE FRIENDS REALLY LISTEN My grandmother always told me that, in order to have a friend, you must be a friend. This couldn’t be more true especially in the past year and a half with the enforced isolation under the multiple (and often confusing) pandemic-induced orders. Some of us settled into the new norm with little more than a cursory reluctance. Others have suffered greatly as their need for constant socialization was jeopardized. The entire exercise of self-isolation challenged the concept of friendship and what it really means to be a friend. As a writer, I have managed to maintain my sanity through the written word. I’m not much of a talker, but I do like to write. Here are a few links to some of my short pieces of writing: Is There Something Else You Can Write About? Look, Don’t Touch! How I Launched My Food Writing Career And, of course, my books are listed here However, even with my daily regimen of writing exercises, I have felt the weight of the world on my shoulders, so to speak. My journals, letter-writing (the old-fashioned put in the mailbox with a postage stamp type of letter), occasional telephone calls, and virtual meets add another dimension to my reaching beyond the confines of my home. It was an ordeal for all of us to follow the rules and guidelines and stay home and to use mask and social distance on the occasional outing for essentials. Just like everyone else, I missed the social contact. My need for exchanging dialogue in person was clearly evident when placing my groceries at the check-out counter. It became a welcome change in routine to strike up a lengthy conversation with a total stranger. For me, opening up in public with a complete stranger (in this case, the cashier) was a clear sign that even I, a diehard introvert, needed to talk, just talk, about anything and everything. The cashier would listen as they bagged my groceries and took my payment; and they would also talk. We shared what was once revered as a real conversation. We all need that release brought about through a real conversation. But, during the lockdowns, we’ve been encouraged to reach out to others, and to listen. Not to talk, but to listen. I have friends I call once a week and that is exactly what happens: I listen, they talk. My grandmother always said that all you needed to start a simple conversation was the three words: “How are you?” So true. I’d call these friends, provide my standard greeting and ask, “How are you?” And the one-sided conversation would begin. Frustrating. I always knew I was a good listener, but this new experience was pointing out that even I needed someone to listen to me. All I needed was for the tables to be turned, ever so slightly, and for someone to ask me, how I was doing. What I have come to realize, through all the isolationist strategies, is that introverts and extroverts alike have suffered this new norm. We have been advised by mental health experts to reach out to others and to listen, empathetically. As stated by the Mental Health First Aid (from National Council for Mental Wellbeing) “For a person experiencing a mental health problem, having an empathetic listener can be calming and reassuring — even healing.” The key word to this advice is the word, ‘listen’. But, the question begs an answer: who is supposed to be listening to whom? And doesn’t the designated listener also need someone to listen to them? We need to reach out and listen just as often as we reach out to be heard. Both talking and listening are therapeutic and good for our mental health. Covid has affected each and every one of us. We all need someone to listen to us. As much as I care for my friends, and I reach out to them often, to listen, I want my turn to talk, too, my turn to be listened to. In her post for InSPIre the Mind, “How to be there for a Friend the first time they call you for support”, Athena Kam covers some valid and useful do’s and don’ts for being the friend on the other end of the line (phone or virtual meet), the one who listens. Summing up, reaching out is good for one’s mental health, both listening and talking, sharing and caring. Here are some of her key points in a healthy, friendly conversation: Reach out and phone friends and really listen to what they have to say. Assess and validate the emotions being expressed. Offer assurances that your friend is not alone and what he/she is experiencing is quite common and to be expected. Be positive and reassure the friend that he/she is not being a burden. Letter writing Personally, I also need to be the communicator, as well as the listener. I have embraced another way to communicate that is beneficial to everyone and just as rewarding. Letter writing. Not the current electronic form of emails and private messaging. Not even the stilted forms of texting. Writing a real letter, with pen or pencil, on paper, folding it, tucking it in an envelope, addressing it and putting it in the mailbox. Yes, I’m quite serious. I have fond memories of years of letters exchanged that helped and healed both the sender and the receiver. There is that unique feeling that comes with a letter in the mailbox. I know from personal experience. Living in the country, seeing the arm up on the mailbox sparks anticipation of something other than a flyer or a bill waiting to be opened and enjoyed. It is like taking a step back to my childhood when I’d be the first to collect the mail and the most excited to find something addressed specifically to me. In her article, “The Surprising Mental Health Benefits of Letter Writing,” Amelia Diamond shares some key points, including the research of John F. Evans, a former English professor turned expressive writing clinician and researcher. One of Evans’ clear quotes used in this article, “for a good number of people, expressive writing helps relieve depressive symptoms,” this simple statement sums it up. Why? Because writing down your thoughts, in a personal journal or a personal letter, can, and does, improve one’s mood as well as building reliance. Essential attributes to surviving this repeated chain of Covid lockdowns and restrictions. As Diamond points out, the simple act of writing uses different parts of the brain and helps ease one’s overwhelming feelings of despair and fear. In short, writing letters makes us think differently. And, by writing these letters, one can be both the listener and the talker as letters back and forth allow both recipients the benefit of a true sharing exercise in communication. True letter writing becomes, in itself, a narrative, a story. It can be happy, sad, congratulatory, apologetic, full of compassion, or just a story. But, as Evans promotes, “One of the things that we can do when we take control of the narrative is decide where we want to put our focus.” This makes writing a powerful tool that can be beneficial on so many different levels to both the writer and the recipient and anyone else along the way who may have the opportunity to read the missive. By reading a letter, we all have the potential of becoming astute listeners; by writing a letter, we all have the opportunity to talk, to be listened to, to be heard. The therapy is in the communication, the act of sharing in a conversation by both talking and listening. I’m not saying I can’t and don’t want to listen anymore. I do like to talk and to be listened to, while I tell my story. In writing letters, I have the power to be both. And that, I truly believe, is the true meaning of friendship: listening and being listened to.

Visiting the app store for a mental health app can be mind-boggling today. With more than 10,000 apps for mindfulness, stress relief, depression, anxiety, bipolar disorder, and substance abuse, how do we choose which one to download? How do we know if the app we are about to download is safe to use? Are the tools offered by the app evidence-based? Has the app been tested in a research trial to make sure it is effective? That is what our team in the Centre for Population Health Sciences (CePHaS) in Singapore sets out to study. I am a medical doctor, currently completing my PhD where I performed in-depth evaluations of apps found in commercial app stores that may be used by people with depression. Together with my supervisor, Prof. Josip Car, we are based in the Lee Kong Chian School of Medicine, a partnership between Nanyang Technological University, Singapore, and Imperial College London. We have been researching health apps, to systematically evaluate them, using carefully defined criteria based on evidence-based clinical practice guidelines. Over the last five years, we have assessed apps for diabetes, eczema and suicide prevention for their agreement with best-evidence practice, privacy, how easy to use and accessible they were, and more. Seeing the ever so growing number of mental health apps in the app stores, we decided to focus on cognitive behavioural therapy (CBT) based apps for depression, and this is what we are going to talk about in this blog. Why is depression important? There are more than 300 million people, or about 4.4% of the global population, affected by depression. However, the majority afflicted with depression do not receive treatment. The figure is staggering, with about half the people with depression in high- income countries and up to 80–90% of those living in low- and middle-income countries not seeking treatment. There are many reasons for this, including the lack of adequate care available, the fact that treatment can be time-consuming, expensive, and often not covered by medical insurance, and the stigma of having a mental health disorder, all of which might prevent many of the affected people from seeking help. Mental health apps could fill some of these gaps as they could offer affordable, confidential, and convenient tools to manage depression. What is CBT? Cognitive behavioural therapy (CBT) is a talking therapy recommended by the NHS to treat depression. The NICE guidelines for treating depression recommend self-guided or computer-based CBT as the preferred treatment for people with persistent subclinical depression or those with mild to moderate depression. Antidepressants should be used only in people who do not improve with psychological treatment, or if the individual presents with moderate to severe depression. CBT supports individuals in developing more adaptive ways of thinking and behaving by challenging and modifying dysfunctional thoughts and behaviours. However, such treatment, delivered by a trained professional in a clinic, can be time-consuming (requiring 45 min to 1 hour weekly or bi-weekly meetings with the therapist for at least 3 months, and costly for some individuals. This is where using apps to help manage symptoms of depression comes to the rescue. However, how do we know which apps would be best suited to help? Evidence behind mental health apps The COVID-19 pandemic and accompanying social distancing measures are associated with an increase in the rate of anxiety and depression in the population, which stresses the need to improve mental health care. Digital technologies are particularly well placed to make this happen. Apps, with their immense reach and scalability due to the extensive use of smartphones, are increasingly being used to bridge these gaps. But despite their ubiquity, many of these apps are developed by individuals without healthcare training and only a few apps are tested in clinical trials before being offered to the public. As such, little is known about the concordance of mental health apps content with the best clinical evidence. With more people downloading apps to help monitor their health conditions, it becomes ever more important to evaluate the quality of health apps offered by the app stores. Our researchers, comprising physicians, psychologists, and digital health experts conducted a study recently, looking at existing mental health apps offering CBT-based interventions that people with depression could use without the assistance of a healthcare provider. The focus of our evaluation was whether the information and exercises offered by the apps followed well-established norms set by research and well-recognized practice manuals. To do this, we focused on three aspects: 1. Basic information about the apps, 2. Information about the CBT strategies included in the apps, 3. Technical aspects, such as how easy it is to use the app if it includes information about the users’ privacy, and composition of the app development team (does it include mental healthcare providers, academic institutions, or relevant non-governmental organizations (NGOs)?) To develop a CBT-related evaluation checklist, we consulted a recognized CBT manual, used to train healthcare providers and a list of skills CBT therapists should be familiar with. We looked for six important evidence-based techniques: education about depression and CBT; behavioural activation techniques to encourage the user to engage in different activities; cognitive restructuring, to monitor negative thoughts, and try to come up with a different, more positive explanation for these thoughts; problem-solving techniques, relaxation exercises such as mindfulness and meditation; and exposure techniques commonly used for people who also have anxiety. We also checked if the apps monitored the users’ mood and risk of suicide, gave access to crises helplines for individuals at risk, provided homework in-between sessions, and encouraged users to continue the programme. As this evaluation was done after the start of the COVID-19 pandemic we also checked if the apps included information about the virus and how it affected mental health. We searched Apple’s App Store and Google Play for self-guided CBT apps that complied with predetermined characteristics. We found 1955 apps, of which we included 98 apps. We grouped them into three distinct categories: wellbeing apps (20 apps) aimed to improve the general wellbeing of otherwise healthy users; mental health apps (65 apps) included CBT exercises to manage two or more common mental health disorders, including depression; and depression apps (13 apps) aimed exclusively to people with depression. What did we find? Wellbeing apps offered up to three evidence-based techniques, mainly cognitive restructuring, and relaxation. They also frequently checked the users’ mood, but only 2 (10%) of the apps checked the risk of suicide or included crisis information. Mental health apps commonly offered up to five evidence-based techniques, although there was great variety in the number of techniques offered by each app. Most apps offered cognitive restructuring and CBT education, and less often behavioural activation and relaxation exercises. Two-thirds of the apps monitored users’ mood, but only 35% evaluated suicide risk or offered crisis information. Finally, depression apps commonly offered four evidence-based techniques including cognitive restructuring, behavioural activation and CBT and depression education, with about half of the apps offering relaxation techniques and mood monitoring. Suicide risk management was included in two-thirds of depression apps. Are these apps trustworthy? In our assessment, we found that the apps published in commercial app stores differ from each other in terms of standards and make-up. For example, only half of the apps we evaluated were developed in teams including psychiatrists, psychologists, or institutions with mental health expertise, and only about 60% included references to the information they provided; only 17 apps were backed up by research published in scientific journals. Another area of concern with these apps is the protection of user privacy and user data management. On the one hand, in two thirds of apps, the users are required to set up a password or PIN to access the content, and almost all apps (90%) include a privacy policy. Most privacy policies declared sharing data with service providers, but they were not clear on the type of data that was shared or the companies they shared the data with. This is concerning, especially since a recent study demonstrated that most apps share data with Google and Facebook, even if this is not declared in their privacy policies. Takeaway message In summary, our research showed that few apps in the app stores offer comprehensive CBT programs, and most do not address suicide risk by offering emergency contact information such as crisis helpline phone numbers. Also, we found that privacy policies are not always clear on sharing user data, with little oversight from regulatory agencies. Given a large number of apps, and the fluidity of the app market with apps constantly being published and removed, it is not easy for the general public to find the one “right app” for their mental health needs. However, there are promising apps that provide evidence-based content and privacy settings but you will need to review them with a critical eye before downloading. Here are some tips on what to look for before downloading a mental health app: 1- Who developed the app? Is it a well-known healthcare institution? If not, are mental healthcare professionals part of the development team? 2- Does the app include links or references to reputable books, journals, or websites? 3- Does the app include a disclaimer saying that the app does not replace the provider’s advice? 4- Does the app include emergency information if the user is at risk of suicide? 5- Does the app include a privacy policy written in easy-to-understand language? 6- Are the app settings modifiable to fit users’ needs, including the option of setting up passwords if needed? 7- Are the techniques and exercises offered by the app based on best evidence? Mental health apps could play an important role in helping people with depression or other mental health problems, particularly for people in low- and middle-income countries. Although many apps found in the app stores present several shortcomings, our main message would not be to avoid such apps completely, but to approach them with a ‘buyer beware’ mindset and do the research before deciding to commit to one.

Will and his children Source: authors own photo I’m William Nicholson, a dad of 3 and an activist for social and systems change. I’m passionate about supporting health and wellbeing through positive storytelling and I’m a keen advocate for men’s mental health, and fatherhood in particular. Today is International Men’s Day in the UK. Its key aim is promoting a positive conversation about men, manhood, and masculinity and there are many brilliant initiatives across the UK doing just this. One of those is the recent Inspire the Mind series of blogs on fathers’ mental health, which has been incredibly refreshing to read. For a long time, fatherhood, and men’s mental health in general, have been low on the agenda, largely swept under the carpet while a culture of ‘toxic masculinity’ has permeated our society. Men talking about mental health is seen as a sign of weakness. We’ve dealt with issues with the traditional ‘stiff upper lip’, getting on with it. When it comes to parenting, we rarely hear about the Dad’s perspective. Recently there has been a positive step change. I feel men’s mental health has become a ‘thing’ we are happy to talk about. It is much more on the public consciousness with high-profile campaigns such as Heads Together supported by Prince William, who has talked openly about the importance of fatherhood and mental health. There are increasing numbers of celebrities sharing their stories from cricketer Ben Stokes to actor Dwayne ‘The Rock’ Johnson. The Mental Forge, in partnership with NHS England, recently brought together over 400 organisations at ‘MENtalHealth’, a webinar exploring the potential for collaboration to support men’s mental health. Collectively, this movement has disrupted the status quo and begun to change the narrative on men’s mental health. However, I feel we need to do more. The International Futures Forum’s Three Horizons Model provides a helpful framework to support the achievement of transformative social change. It distinguishes between disruptive innovation, which challenges the status quo and builds the case for change, and transformative innovation, which creates a whole new vision of what the world could be. I believe this Inspire the Mind series stands out as being transformative. Why? The answer for me lies in the depth of the discussion and many layers of narrative change: Positive storytelling about fatherhood It is hard to find positive stories on fatherhood that provide you with insight into how to be a good dad and help dads to understand and manage our mental health. If you search the fatherhood book charts, you’ll come across books along the lines of “The Dad Survival Guide”, “Strong Fathers Strong Daughters” “Commando Elite Dad” or “The Dad Joke book!”. The language in these titles tells you everything about the current narrative on fatherhood! It reinforces the culture of ‘toxic masculinity’, creating an expectation that fathers need to be tough and strong or to joke about it to survive. This image from a fatherhood book chart says a thousand words: What’s wonderful about the Inspire the Mind series is that it creates a new narrative. It presents genuine lived-experience pieces from fathers who contributed to DAD who speak openly and honestly about their fatherhood experiences — not about winning or being elite but about vulnerability and the challenges they have faced — and it shows that this is normal. Blending science AND lived experience I’ve been inspired and moved by each of the fathers’ stories. As a Dad, I empathise with the raw human emotion each man has expressed. I haven’t directly experienced their issues, but I can connect with them as fathers who have gone through challenges in life. I am incredibly grateful for their honesty and their courage to talk so openly about their experiences. I’ve also found each of the related scientific pieces enlightening. Having read the ‘real life’ story, it was fascinating learning about the science behind the feelings that each dad was describing. I’ve learned much more about each topic and how the human mind and body operate. Each time I read the scientific explanation there was an ‘ah ha’ moment — “That makes sense doesn’t it!?”. Normally we are only given one perspective, one side of the story — The science OR the lived experience. There is a greater depth to this series because it does both. Ordinary men telling extraordinary stories Much of the current narrative on fatherhood and mental health is dominated by celebrities and high-profile men. What makes this series special is that it is ordinary men who have been given the opportunity to tell their stories in their raw and authentic voices without judgment or hierarchy. This ensures underrepresented voices, ordinary people whose stories often go unheard, are listened to and part of the mainstream conversation. Elliott Rae, the curator of DAD, sums it up perfectly… “These are ordinary men, being extraordinary by sharing their story with the world”. The writers from Dad. Source: Elliot Rae Equality and Diversity The series presents a diverse range of blogs from contributors representing all aspects of race, class, age, sexuality and professional background. This gives the reader choice, to engage in the discussion on fatherhood and mental health from many different perspectives at the same time. Each contributor is equally valued. In a world where deep-rooted social and racial inequalities have an enormous effect on mental health, there is a powerful underlying statement of equality throughout the series that changes the narrative. Individual stories as part of a collective What is refreshing about this series is that it enables each contributor to describe their individual story AND also communicates an interconnectedness between them — that they are part of something bigger. Not only is this changing the narrative through individual stories, but it also transforms the narrative through the collective. In a world where isolation is prevalent and where we are increasingly disconnected from our neighbours and communities, this is hugely powerful. Transforming the narrative through partnership The story of how this series has been brought together is as important as the individual stories within it. On the surface, the two initiatives and their founders appear very different. Carmine is a white psychiatrist who founded Inspire the Mind to increase awareness of the clinical and scientific aspects of mental health. Elliott is a black civil servant turned social entrepreneur who founded Music Football Fatherhood to provide greater opportunities for men to connect and share stories of fatherhood to support one another. However, both initiatives and their inspirational founders share the same vision, approach and values. Both are collaborative, creative humans, passionate about changing the world and full of energy and positivity. As this series shows, they share a depth to their work. In the current world, disruptive initiatives like Inspire the Mind and Music Football Fatherhood often exist in splendid isolation. Dad Matters UK, a mental health peer support charity for Dad’s, sums this up beautifully: “Working in Men’s mental health is like travelling on a motorway… there are many great organisations and services travelling alongside us, each in their own lane, but ultimately heading in the same direction.” The trouble is, most of us are unaware of the different lanes or that there is even a motorway… What sets this series aside as transformative, is that they have found a way to come together and combine their experiences and expertise. Through this, they have begun to create a whole new system and culture — and transform the narrative on fatherhood and mental health. Editor's Note: The team at Inspire the Mind would like to thank all of those who contributed to bringing this special 10-part series, that has explored aspects of modern-day fatherhood, men’s mental health, and the science behind it, to publication. Especially to the Dad’s who so openly and courageously shared their stories.

The Life and Times of ex-Chelsea Football Player Paul Canoville: Mental illness, addiction, cancer and finding help In this exclusive InSPIre The Mind three-part series, I have spoken to Charlie Duffield about gambling addiction and Michael Watson about his mental and physical battles following his second fight with Chris Eubank. In the final part of the series, I sat down for an eye-opening chat with ex-Chelsea football club player Paul Canoville. I grew up in a family that adored Chelsea Football Club. Despite being of a young age I remember my dad talking fondly of Paul regarding his football journey, and interviewing a hero of my dad’s was a humbling experience. Paul has had an eventful life that has been nothing short of a rollercoaster and the strength he has shown during difficult times in his life is inspiring: whether it was racist abuse from his own teams’ supporters, recovering from COVID-19 or his battle with addiction to drugs. Despite the challenges in his life, he continues to give back to the community through the Paul Canoville foundation, a foundation that works with schools and youth organisations to promote confidence, well being, diversity and resilience through workshops and sporting activities. Experiencing racism on the pitch The rising football start, Paul Canoville’s life changed forever on 12 April 1982, in the Chelsea match against Crystal Palace: he was named a substitute for Chelsea Football Club for the first time. Paul described the excitement of being in the squad as “A feeling I will never forget.” Paul continued: “I was so excited to be in the squad. All the lads were giving me good luck messages.” Paul added: “Once I got the call to get warmed up, all the excitement left my body. All I could hear was racist abuse. I turned around, and to my shock, the Chelsea fans who were racially abusing me.” Paul had waited his whole life for an opportunity like this; joining Chelsea from non-league Hillingdon Borough FC was a huge break for him. The excitement of realising a dream is something many of us never get to experience and for Paul, that moment was destroyed by the racist abuse he encountered at Selhurst Park (Crystal Palace’s home ground). The racist abuse that Paul was a victim of took a massive toll on his mental health. “I was thinking of quitting,” he said when asked about the impact this incident had on his mental health. A few years later, in 1987, Paul had to retire from professional football due to a persistent knee injury. He had to go through the heartbreak of retiring from professional football at only 24 and worry about providing for his eight children at the time. When I asked him about his mental health during that time, I could sense the pain he felt. “I missed training, having a day-to-day schedule.” He continued: “My mental health was taking a beating. I missed being a footballer. I told everyone I was fine, but I was far from fine.” Addiction, recovery and Black and Blue Paul has suffered from substance addiction at different points in his life, beginning in 1988 soon after retirement, and I wanted to find out more about that moment in his life. “Drugs took me away from thinking about the retirement. It was my escapism. I was hiding it from my family. I shut myself away and ignored everyone”. Addiction affects the addict, but it also affects their loved ones. During this interview, Paul was adamant to speak about his experience of opening up and seeking help. “Rehab [rehabilitation] was therapeutic. It gave me the balance and schedule that I had lacked in my life at that point.” Paul continued: “I had to get to the bottom before I went to rehab. You have to decide for yourself you need help.” Paul added: “I finally got to that point where I accepted help.” Every story of addiction and recovery is different, and Paul’s story really impacted me. After speaking of how therapeutic Paul found talking therapy, I wanted to find out how he found the whole process of writing his memoirs and if it helped him process past events. In 2008, Paul co-wrote with Rick Glanvill, the official historian of Chelsea FC, his memoirs: Black and Blue. Paul added: “Rick helped me so much during this process, and I am so grateful for the whole process. The reactions I got from the book were touching.” He continued, “I asked my mum if I could talk about my childhood, and she gave me her blessing.” Paul continued: “We spoke about Cherry Avenue [childhood home]. The whole process was so therapeutic.” After battling addiction and spending time in rehab, Paul had another test in his life to overcome. After being in constant pain, in 1996, Paul went to the hospital, where he underwent emergency surgery and was subsequently diagnosed with non-Hodgkin lymphoma. “I was in shock. I lost weight, and because of my background, I kept the diagnosis to myself. Once people saw my weight loss, there was a rumour that I had AIDS.” Paul continued: “The chemo destroyed my immune system. I was 36, and I felt old. After I had a shower one day, my hair fell out. When I caught the flu, I nearly died.” Hearing Paul explain the side effects of chemotherapy is devastating to hear, it highlighted the pain and anguish he felt during this time. Another Ex-Chelsea player, David Rocastle, sadly passed away because of non-Hodgkin lymphoma, aged only 33. When speaking about this, Paul described it as: “One of the saddest moments.” He continued: “I felt triggered. It bought all the uncertainty back, and I was petrified I was going to die next.” The COVID-19 pandemic With the world going through a pandemic, I wanted to see how Paul has handled the last 18 months. “It has been difficult. I caught COVID twice. They noticed I had bowel issues while recovering from COVID”. Paul added: “They removed a large cyst. I just kept thinking how much more could I take; my body was being put through it again. But I am still here and fighting.” Canoville Suite at Stamford Bridge On 14 August 2021, Paul Canoville’s life went full circle. Chelsea Football Club invited Paul to Stamford Bridge as Chelsea played Crystal Palace. Paul was there to open a matchday and hospitality area and non-matchday events location called the Canoville Suite, 39 years after his Chelsea debut against Crystal Palace. When speaking to Paul about this, he was full of pride: “This is my legacy. Alongside the work I do with the Paul Canoville Foundation where we aim to improve diversity and build confidence in youngsters, I was full of pride.” Paul has shown we can all lead a fulfilling life no matter what obstacles are in our way. Whether we have a difficult medical diagnosis, struggling with addiction or find life hard in any way, Paul Canoville is a shining example of what we can overcome and achieve.