Let me preempt this piece by saying that I hate the coronavirus pandemic. As a professional magician and freelance writer, the uncertainty of the pandemic led to me losing all my work. I had to work gruelling shifts in a granola factory during the worst of the pandemic until things became a bit more normal. Sure, the factory smelled amazing and I felt like a background character in an L.S Lowry painting as I left work each day, but manual labour is not for me. I’m not in any way pro-pandemic. But I have found one plus point of the ‘new normal’ that has benefitted my personal OCD. My OCD I’ve felt abnormal for as long as I can remember. As a child, I recall wanting to take a party bag from a birthday party I was attending. But I was terrified of touching it because I thought the handles were dirty. In my teens, my parents took me and my brothers to a football match. We were allowed to drink Coke in the pub before. It should have been the greatest moment of my adolescent life. My brothers swigged their bottles of brown carbonated bubbles with glee and got high on the caffeine. I didn’t want to need the toilet as I was too scared to carry out my lengthy hand-washing ritual (as described in my previous blog) in a crowded pub toilet. So I snuck my bottle to my brother to secretly drink for me. My football team lost and I was dehydrated all day. But at least I managed to go 14-hours without urinating. I avoided rooms if I could see dust particles floating around, walked on the sides of carpets to avoid the centre space where other people’s feet had been, and constantly had my hands in my sleeves. This was all to prevent me from having to wash my hands non-stop. I was either washing my hands or doing something weird to avoid washing my hands. I was such an annoyingly weird child that even my atheist father once despairingly said “God gave you hands for a reason, to touch things.” My Diagnosis Despair for my mum was different. She went to see our family doctor. Her relationship with Dr. Dobson was akin to the fan of a football team that always loses yet they support them week-in, week-out. High blood pressure. Stroke. Hernia. Tonsillitis. Broken shoulder. Broken arm. Dr. Dobson dished out nothing but bad news yet mum came skipping back through the door enthralled by her visit to our charismatic GP. Dr. Dobson diagnosed me with Obsessive-Compulsive Disorder (OCD) in my teens. Mum reassured me that I wasn’t alone and that OCD was a normal thing other people suffered from. I’m pretty sure she was so relaxed because she associated OCD as standing for Outrageously Charismatic Doctor. Honestly, Dr. Dobson can do no wrong in her eyes. He offered mum some Ritalin — typically prescribed for ADHD — as a potential way to calm my OCD. She refused even though I was running up a large water bill. I worry that if I get dirty I will create widespread contamination of the planet that can’t be cured. It’s for this reason why I still protect my hands with sleeves or gloves, carry a hand sanitiser, and wash my hands at every opportunity. Fears Came True My fears seemingly came true when the COVID-19 pandemic happened and exposed how easily a virus could spread across the globe. I struggled with my OCD initially in the Spring of 2020. I started to do new things that I hadn’t done before. I’d change my entire outfit when I returned home from outside. I’d avoid public transport. Then, the world started changing. People were encouraged to wash their hands for at least 30 seconds. In the past, pub toilets have been a nightmare for me. At best someone will comment “I think you’ve washed them for long enough”, at worst I’ll be ejected from the pub for wasting water. Now, lots of people are carrying out hand-washing rituals. Builders sing the ‘Happy Birthday’ song whilst washing their hands. Punk rockers diligently follow along with a Government-prescribed laminated card for effective hand washing. I, for the first time in my life, feel a level of normality when I wash my hands in a public place. People no longer look at me as some sort of freak but instead just someone that probably doesn’t want to get his nan sick. I worry this will pass and people will go back to not washing their hands in line with the government guidance. People have despised the ‘new normal’ but it has helped me feel normal for the first time in my life. Shortly after Dr. Dobson’s diagnosis, I began carrying hand sanitizer and baby wipes to ease my OCD anxiety in the times when I couldn’t get to running water. I was everyone’s second favourite festival buddy as I was practically a walking tap. I was almost as popular as the guy who had little bags filled with things that would make you forget you even had hands. Outside of the festival season, I’d still get questioned why I was using hand sanitiser with every cleansing squirt of goo. That was until the ‘new normal’. Giant, glorious vats of hand sanitiser sit outside even the dingiest of venues. Hand sanitiser has practically replaced ID as being a requirement to enter most premises. Regardless of if you want to catch a train, sip a coffee, eat out to help out, or just eat a Twix — you have to sanitise. It has made my life dreamy. No longer do I have to rely on packing sanitiser for trips outside my home. It is on every street corner and free.

My name is Aida and I’m a second-year student at King’s College London, currently studying Global Health and Social Medicine BSc. I’d like to give a very brief introduction about myself, to add more context to this piece. As a GHSM student and someone who has also struggled with mental health issues, I bring a personal and academic perspective to the discussion about depression, its causes and potential solutions. Depression is not always the enemy. It’s not always the cloud that rains over our heads and makes it difficult to function throughout the day. And it’s not the problem we should be pointing our pitchforks at to get rid of. Sometimes, it’s simply a response to our struggles. It is important I make this clear before continuing, because the way we frame our problems can impact the way we create solutions, and until recently, I have been thinking of depression as an individual problem. I used to view depression as the enemy; the big villain in my life and in some ways it made my depression worse. Because I painted it as another problem I had to deal with, another issue. However, after I changed my perspective, a change inspired by the movie Inside Out and a film essay about it; I gained new insight on the potential solutions and treatment methods for depression! Let me explain how I now view depression; Imagine you’re in a forest and you see a bear. You start walking away, but alas the bear has noticed you and has started chasing after you. You, naturally, run for your dear life (at least I hope you do!). To me, depression is the act of running away, it’s not the bear. Let me explain. The running is a natural response to a dangerous situation, which in this case is the bear. The bear is the cause of the depression, which I will get into and discuss in the more technical jargon section and label ‘social determinants’, but for now let’s see them as the cause/s of your depression. If you view it like this, depression isn’t the actual problem, it’s just the response to the problem. It acts as a signal that you’re in a hostile situation and must react. Similar to the body’s fight or flight response. However, I should specify depression manifests itself in different ways and we all interpret it differently; some describe depression as drowning or feeling lost, some as a numb emptiness. Each interpretation is valid and unique in the way we understand our mental health. Your interpretation and idea of depression may change once, twice, or multiple times. My interpretation may resonate with some, and be completely confusing for others which is perfectly fine!! Social Determinants of Depression Michael Marmot, a well-known epidemiologist, discusses the concept of social determinants of health and achieving health equity. He mentions factors such as education, work, money, etc. and how it affects our health. Although he mainly aims it at physical health; the same idea can be applied to our mental health. Aspects such as our education, housing conditions, and our financial situation can affect our mental health and cause/worsen or improve depression. Research highlights depression is higher in those with financial difficulties and debt. And amongst university students, for example, the main factors associated with depression seem to be grades, family issues, social factors and even political factors. These causes are more so because depression is highly prevalent in late teens. Exposure to new social environments can be overwhelming to teenagers and young adults, especially to those who have not been equipped with the necessary social and emotional skills developed during childhood. Unstable family dynamics and conflict is also ranked high as a risk factor; children with depressed parents are 60% more likely to develop depression by age 25. Therefore tackling the social determinants can act as a wider treatment and preventative measure for mental health issues such as depression and anxiety. The use of conventional treatments such as therapy and medication as well as tackling social determinants can increase resources available for those with depression. But, if we already have these treatment methods, why don’t we just send everyone with depression to therapy or give them medication? It’s not that simple. Therapy is a more inclusive treatment method available for all ages and has shown long-term improvement for those with depression. It’s an option available for individuals to work with a professional and learn healthier thinking habits and improve their mental health, and therefore a great step to take. However, in some cases therapists are limited in the help they can provide to change the individual’s circumstances/environment that cause or worsen their depression, and therefore find it difficult to intervene. This is where being aware of social determinants and building solutions around patterns of social causes can fill in where therapy cannot reach. Most treatment methods have their pros and cons; with therapy’s cons being limited resources and therapists to see every individual. Certain social determinants such as poverty act as a barrier to treatment. Therapy is not always easily accessible to the public and often leads to long waiting lists with some struggling financially to pay for private treatment which simply isn’t sustainable and can lead to a cycle of worsening depression. Social Causes and Social Solutions Individual treatment for depression is important and effective for many with depression, with research highlighting therapy such as CBT and psychotherapy reducing depression long-term; however, tackling the wider social determinants is also equally important in the long-term prevention of depression. The social and cultural stigma surrounding depression can decrease the chances of those with depression seeking help. 60% of young people that attempt suicide never seek medical attention. This means that even if therapy is available, social and cultural barriers prevent those in need from accessing the resources. Therefore, as well as tackling depression when it is present; we can take actions to prevent depression through early childhood prevention methods by creating safe school environments that allow emotional and social development, stable family dynamics and services that support single-parent households and those struggling with financial issues, to remove or reduce the social risk factors of depression. Tackling social determinants has many benefits; not only can we simultaneously tackle several other social issues such as poverty but it also helps reduce the strain on conventional methods such as therapy. It helps reach more people that suffer from depression that may be hesitant on reaching out as well as adding another avenue of treatment, that all together tackle different causes of depression whether personal via therapy, chemical imbalances via medication or social causes via tackling social determinants.

I’ve cried on ashen floors of working men’s clubs. 96, 98, 2000, 2002, 2004. Oh my god, will it end? Oh my god! Oh my god! ‘Miserabillia’, Los Campesinos! I suffered my fair amount of childhood trauma; my parents' ultra-corrosive divorce, my alcoholic Dad going to prison for fraud at the age of seven while I was sharing a bedroom with my heroin-addicted brother. It wasn’t exactly let’s get the Panda Pops in down Sesame Street. But it wasn’t until 29 June 2000 that I truly understood what despair was, the type of sadness that breaches your skin and rattles your soul. The night in question was the semi-final of Euro 2000 between the Netherlands and Italy. This was my first international tournament, the first time I had felt the intense, permanent sugar-rush of non-stop football. The game, arguably the greatest 0–0 in the history of football, was mythic in its narrative; a cliched Shakespearean tragedy of emotional turmoil. The Netherlands, playing at home, did everything but win the game the football gods had handed them on a cheese platter. Over the course of 120 minutes, Italy had two players sent off and gave away two penalties. The first was missed by captain Frank de Boer, a granite-like stoic of a man, seemingly created in a laboratory to look as Dutch as possible. The second by Patrick Kluivert, in one of the worst penalties you’ll ever see. It goes to a shoot-out and de Boer takes the Netherlands’ first penalty. You can see it coming, his redemption will be writ large in blazing orange across the sky. He steps up. He misses. I remember the look on his face as clear as anything else from my childhood; it was despair beyond the bounds of normal comprehension. From Euphoria to Sorrow in 90 seconds That was the time between the Pickford save and the Saka miss in the Euro 2020 final between Italy and England. As an England fan, this was one of the best to the worst moments of my life in less time than it takes to boil a kettle, for a plane to reach three thousand feet or listen to one of the greatest songs ever written: ‘Carnival’ by Bikini Kill. As I sat on an eerily quiet bus on the way home after the match, the despair filling my chest was intolerable and a small trickle of tears gently ran down my cheek. I feel absolutely no shame in this level of emotional response, even if I recognize it is incredibly stupid. Arrigo Sacchi, the great A.C. Milan manager of the late 80s, summed up football’s unique place in almost every country’s culture; football, he said, ‘is the most important of the unimportant things in life.’ He’s right, football exists in that liminal space between essential and trivial, something that can seemingly change your life in an instant but if you're being truly honest, has no real effect on it at all. As I sat on the bus, quietly weeping over the failure of man to put a ball between two posts from 12 yards, I thought ‘is this good? Is voluntarily inflicting negative emotions onto yourself actually beneficial? Are there really any mental health benefits of watching football?’ An Emotional Workout The evidence for the relationship between playing sport and increased mental wellbeing is myriad and well documented. While the research about whether watching sport can engender similar benefits is less extensive, the evidence shows that putting yourself through the endless despair and occasional joy of being a football fan has mixed benefits for your mental health. Researchers from the University of Leeds teamed up with Bet Victor to study Leeds United fans across three key games during the 2018/19 season. During the games, the researchers monitored the participants’ heart rate, blood pressure and mood — using monitors, blood pressure checks and then surveys. Incredibly, heart rates increased in some participants to 130bpm, the equivalent of a 90-minute brisk walk. I’m going to take an educated guess these participants didn’t scoff two Pukka Pies at half-time. Football is a highly competitive, narrative-driven, intensely tribalized pastime; so as expected, the psychological response of the fans correlated with Leeds’s result: excitement and happiness when winning, dejection and anger when losing. This seems logical; if you have an emotional attachment to a football team and they win or lose (with the emotions derived from draws being contextual), then it follows that these outcomes will add a layer of intensity to the emotions. The feeling of winning an important match in the final seconds, as all hope seemed crushed to dust, cannot be replicated in anything else; like the luminous electricity that follows kissing someone special for the first time is unique to those seconds. However, as the human tendency is to brush off the good and trap the bad, referred to as ‘negativity bias’, the negative emotions that followed losses echoed in the fans' minds long after the game, sometimes for days. This seems obvious in a way; if you are an England fan like me, I bet you can remember every punishing second of the shootout against Italy but none of the goals against Ukraine in the quarter-final. This tendency can result in symptoms of depression, and in the most extreme cases outbreaks of physical violence, often heartbreakingly within a domestic abuse context. Is Football Good for You? This suggests then perhaps football isn’t good for you; it seems to bring only a brief beam of joy but the days-long gloom of a black sky. But this is what football is because that’s what life is. Human beings seem designed to forever remember the pitfalls, even though the good things in their life outnumber them 100 to 1. Your friends can give you a thousand compliments in an evening but what you end up remembering is that bloke at the bar who is slightly rude to you. We do care too much about football, I certainly do. I’m a 29-year-old who has lost nearly all his family to that eternal sleep, and I don’t remember crying at any of their funerals. Not because of indifference, or emotional detachment, it just isn’t how I process things. Yet, when Wes Morgan and Claudio Ranieri lifted the Premier League trophy for my beloved Leicester City in 2016, the tears came free and fast. Whether football exacerbates pain or lifts spirits so that they are dancing among the clouds is irrelevant to whether watching football is good for you, it’s how you approach it that matters, just like mental health in fact, and football is that in microcosm. So when your team wins and you feel the euphoria that could power the sun, remember it. So that when they lose and you feel the rain clouds speed up to catch you, you know that it won’t last forever, and that’s mental health in a nutshell really, isn’t it?

I’m often asked if the effects of motherhood on the brain will last forever. Short answer — yes! And this looks like a good thing. I’m a neuroscientist, therapist, podcaster and mom of 2 who talks a lot about the neuroscience of parenting; shedding light on just how amazing your mom brain is and how much more we need to know about it in health and illness. I recently wrote about how our Mom Brain is our Superpower for Inspire the Mind but perhaps a more pressing question is - will your brain ever function like it did before? The short answer is — once a parent always a parent — but that doesn’t mean your brain will be the same now as it will be in 5, 10 or even 40 years. It is ever-changing in relation to the needs of your child, your biology and what’s going on around you. Ageing gracefully In 2019, a leading journal of scientific research, PNAS, published the first paper using neuroimaging data to investigate how motherhood may affect the brain in middle-age. Prior to this work, the human data showed an effect of motherhood on the brain up to 2 years postpartum, however, research in animal models had suggested more enduring effects of motherhood on the brain. The study, headed by Dr. Ann-Marie de Lange, principal investigator of Femilab at the University of Lausanne, and a recent guest on my podcast Mommy Brain Revisited, looked at the relationship between the number of childbirths and markers of brain ageing in brain images of thousands of middle-aged women (50–60-year-olds) provided from the UK Biobank. They investigated structural brain characteristics in grey matter using a magnetic resonance imaging (MRI)-derived biomarker of global brain ageing (basically fancy technology involving artificial intelligence and machine learning) and aimed to determine if measures of global brain age differed between middle-aged mothers and non-mothers as well as the impact of the number of births on these brain measures. They found that women who had given birth had ‘younger-looking’ brains in middle-age and this effect was related to the number of children they had — showing that up to 4 may be optimal for this ‘younger-looking’ brain effect. Interesting! I should also note that things such as age at menarche, age at menopause and number of incomplete pregnancies were controlled for as these factors can also affect brain health. More recently work from Ann-Marie’s team shows that in middle and aged mothers (50–80 years old) there are specific brain areas that look particularly ‘younger’. These brain areas include the amygdala, hippocampus (my favourite), thalamus, accumbens and putamen — areas important for aspects of maternal caregiving and that play a role in the ‘parental brain circuit’. The study further points out that the accumbens was most notably affected. The accumbens is part of the motivation and reward processing system in the brain which we know plays an important role in wanting to care for the baby in the early postpartum period. How and why the accumbens remains to be affected by childbirth decades later is intriguing but, perhaps, speaks the ongoing motivation to care for your child. I know my mom checks in with all of us (there are 4) on an almost daily basis. She also loves to see me, even 40+ years later. [I like to think I’m still ‘rewarding’ .😉 ] It should also be noted that you don’t have to have children to have an optimally functioning ageing brain. “It’s important to stress that these effects are quite moderate or small so whether you have children or not will definitely not determine how healthy your brain is when you age.…there are so many factors that influence how we age.” Ann-Marie told me on the podcast. This is important as many people are not parents for various reasons (choice, fertility challenges, etc). A fountain of youth Your mom brain is looking younger as you age, but how is this related to function and what about dads? In 2020 by a team of researchers University of California also looked at brain ageing but they looked at both mothers and fathers in middle age and also investigated how parenting may affect visual memory. In brief, they found that younger-looking brains were evident in middle-aged moms and dads that had 2–3 children, in particular, and that in both parents having children was associated with better visual memory and faster response times. Cool, right? This suggests that younger-looking brains could be linked to improved memory later in life but also that it’s not just the physiology of pregnancy and childbirth that is important, a number of lifestyle factors and time with children are likely key contributors to these younger-looking brains in both mothers and fathers. In addition to this global measure of brain ageing, research headed by Winnie Orchard, a PhD Candidate at Monash University, who also joined me on the podcast, shows that mothers in their 70s have better verbal memory than non-mothers at the same age. Her work goes on to suggest that this improved memory could be linked to changes in cortical thickness in the parahippocampal gyrus of these mothers, a brain region involved in memory formation — where increased cortical thickness has been associated with better memory in old age. Fewer effects were seen in fathers. Further work from Winnie and her co-authors goes beyond these structural brain changes to look at brain activity in ageing parents. Again, with parents in their 70s, they found that in aged mothers, but not in aged fathers, there was “widespread decreasing functional connectivity with an increasing number of children parented”; meaning that decades after becoming a mom there are many changes in mom brain activity, changes that are also pointing to a ‘younger-looking’ brain. Living life to the fullest We see structural and functional effects of parenting on the ageing brain, most remarkably in mothers, but why? From the recent literature, it seems that likely candidates for these age-related changes in females who birth are hormonal and immunological factors — at least this is a theory. Another likely contributor, in addition to these biological factors, is that time parenting matters. Many of the women in these studies were likely the primary caregivers given the typical gender roles of their time, but we must not forget that “Parenthood is a continuum of experience, and may represent a learning environment that is sustained for decades of an individual’s life” (Winnie Orchard) - A learning environment that can impact the brains of both mothers and fathers.

My name is Milad and I was born in Kabul in 1996. The same year that the Taliban took control of Afghanistan in a bitterly fought civil war between different Afghan factions in the wake of the Soviet withdrawal. Their bloody rise to power then was in stark contrast to their silent, orchestrated takeover on August 15th this year. Like many Afghans who have been fortunate enough to flee their regime, I feel a sense of survivor’s guilt having been afforded the luxury of an education in the Netherlands where I grew up and in the UK, where I currently live. Today, I live in the West Midlands and practise medicine as a hospital doctor but I wonder every day how my life would have been had I not been lucky enough to flee the conflict; that is, if I even was to survive. So many other young children, like me, had died as ‘collateral damage’ in a war they played no part in, their childhood and lives taken away from them by violence. Human rights under the Taliban government (1996–2001) Under the Taliban government of 1996–2001, girls were not allowed to be educated past the age of eight, the burqa was mandatory for women and they were not allowed to leave their homes without a male chaperone. This was especially draconian since many Afghan women were left widowed as a result of the previous decades of war. Women’s health was another upsetting matter; male doctors were not allowed to treat female patients (see also this blog here on this topic) and since girls were not allowed to be educated, this led to obvious problems. In other words, to be female in the Taliban’s idea of Afghanistan meant to live a purposeless existence merely treated as a liability and inconvenience rather than as a human being. Perceived infractions of the Taliban’s oppressive laws were ‘rectified’ by punishments ranging from brutal beatings on the streets to public executions that were decided upon in Taliban courts that were not judicially stringent by any definition of the term. These events are permanently imprinted in the memories of any and every Afghan old enough to have witnessed them. Growing up, I would hear my relatives tell stories of these times. Public floggings, executions and other exhibits of the Taliban’s brutality appeared to have been commonplace and it is little surprise that the levels of crime went down in Afghanistan (a favourite argument of pro-Taliban individuals). It goes without saying that a reduction in crime at the expense of all personal freedoms and at the cost of living in constant fear is not a worthwhile exchange. Given its central location within Asia, Afghanistan has more than a dozen different ethnic groups, each with slight variations in language, culture or religion. Some of these differences were not deemed compatible with the Taliban’s twisted interpretation of Islam and the Hazara community of Afghanistan, who are largely Shia and thereby considered non-Muslims by the Taliban, suffered this persecution the worst. Hazara civilians were targeted and killed in systematic massacres by the Taliban. In our neighbourhood in Kabul, many of our Hazara neighbours were also killed. The atrocities of those times could fill endless pages and have undoubtedly left a heavy mental health burden on those who survived them. Leaving Afghanistan for a New Life My father worked in the airlines and some of his friends had boarded planes with their families and sought refuge in other nations but as a patriot, and optimist, he believed things would get better eventually. However, following the deaths of several of my father’s colleagues in the airlines to military combat, he decided that it was too risky to stay. He deemed it only a matter of time before a similar tragedy would befall us. Therefore, despite holding out for years, my parents eventually decided to initiate the move out of Afghanistan. What followed was a yearlong perilous journey through different countries, culminating with our arrival and subsequent asylum claim in the Netherlands where I was to grow up. There was no mistaking the fact that we were foreigners in the Netherlands. Not a day went by that we weren’t reminded of this fact by the local population who treated us with suspicion and disdain. As refugees, we were some of the most vulnerable elements within society and this made it easy for us to be treated differently by others. I distinctly remember the day the 9/11 attacks happened. I was four years old and watching TV when there was a sudden news report showing the planes hitting the Twin Towers. At the time, I did not realise how much this was to affect me and my family back in Afghanistan. Shortly after September 11th 2001, the United States invaded Afghanistan, attributing a large part of the blame for the attacks to the Taliban for hosting terrorist organisations on Afghan soil. The invasion that followed led to heavy casualties among both the militants and civilians alike. Sadly, this was nothing out of the ordinary to the Afghan population who had become used to the violence. What followed as the dust settled, however, was a protracted 20-year pushback against the Taliban which, despite its casualties, was a period of relative peace for once in Afghanistan. In the government-controlled areas, girls were allowed to go to school, women were allowed to leave their homes and the Taliban’s oppressive rules were shunned in favour of less restrictive rules. For once, there was a glimmer of hope for the future of the Afghan people as they were inspired to learn crafts and pursue their dreams. The Future of Afghanistan Several of my cousins, both male and female, were born during this period of relative freedom and have gone on to pursue careers in medicine, finance, law and other fields. They have also enjoyed the social media revolution and actively use Instagram, Facebook and TikTok. It is perhaps this fact that makes the current Taliban takeover and the likely inevitable shift back to the laws of the 1990s especially frustrating. Soon, they may be able to see the freedoms the rest of the world enjoy while being bound by arbitrary laws created by men who have no experience (and no business) in running a country. As if trapped from the world in a glass cage. Unlike the elders in their family, they have no recollection of the Taliban era and are therefore especially afraid of what the future holds for them. My female relatives wonder whether their entire education is to become worthless and whether they will be forced to become second class citizens, just like the women who lived in the Taliban era. Hearing the news of the Taliban’s takeover of Afghanistan for a second time during my lifetime was a shock to me. I had seen the effect that their treatment had had on my relatives back in Afghanistan from conversations with them when visiting my home country. They would recount stories of those times with sadness, their trauma evident through their words. During the 1996–2001 Taliban regime of Afghanistan, they had made promises of granting women their freedoms but these were not fulfilled in reality. The Taliban are making similar promises today that they will not oppress women but to many Afghans, we remember the atrocities committed by them all too vividly and take their words in with great suspicion. How can we trust an organisation whose members have to assert themselves by carrying assault rifles and rocket-propelled grenade launchers at all times? Plenty of people (mostly non-Afghans) have ignorantly congratulated me on the Taliban takeover of Afghanistan as they see it as an example of Afghan self-governance. If the Taliban are welcome in Afghanistan, why do they require intimidation through carrying weapons as a tactic to get the population to comply? Make no mistake about it, the Taliban takeover of Afghanistan is yet another betrayal of the Afghan people and yet another tragedy that we will add to our endless list of tragedies. Quotes from Young Diaspora Afghans After decades of fighting, the Afghan people are exhausted. The onus is on the Taliban to prove that things will be different this time — that women will be allowed to work and study, that young boys will not be radicalised and used as weapons of war and that minorities, such as the Hazara community will have their rights upheld — Politics graduate, wished to remain anonymous People have not forgotten the crimes of the Taliban, but still, an air of optimism does indeed travel around Afghanistan — Afghan student, King’s College London, wished to remain anonymous The War on Terror was an imperialist project disguised as a human rights endeavour… Leaving our women, men and children abandoned and abused — Mariam, Politics graduate 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

The days of lockdowns ending were always going to be tricky. Is it too soon? Will there be another one (spoiler: probably)? Can we stop with Zoom calls now? When the enemy is an airborne virus, it’s hard to know specifically what we, the general public, should be concerned with. Most of us, it feels like, are twisting and turning in the mirror, trying on “The New Normal” for size (metaphorically speaking, of course). For those of us with anxiety, all of this is heightened. I was diagnosed with OCD (obsessive-compulsive disorder) during 2020, after the pandemic sharpened my symptoms to the point where I had no choice but to reach out for help, and so, I’ve had little else to do but try to gain some insight about my own neuroses. Luckily, I’m from a little city in the north of England and had access to mental health services from the National Health Service. I’ve been living with anxiety for a long time now — I was twelve when I received my first diagnosis of depression and anxiety. When you have one mental illness, you are likely to be diagnosed with another one — see, they tend to travel in packs. It’s a buy-one-get-seven-free sort of deal. You get diagnosed with one and sometimes it morphs into another. So, at the moment, the most prominent form of anxiety for me is currently OCD. For me, OCD is sort of like extreme superstition. Have you ever not wanted to stand on the cracks in the pavement because you need some good luck this week? Imagine your brain doing that all the time, without a break. My brain has convinced me of some utterly bizarre things, from: “you need to check the doors are locked and wash your hands or you’ll never be happy”, to “are you sure you didn’t murder someone, and you’ve just forgotten about it?”. The underlying theme is that my brain doesn’t really trust itself. I question if the doors are locked because, deep down, there’s an underlying feeling that needs to be resolved. Freud would say it has something to do with my parents, but this ain’t about them. The reality is that, despite my worries, the doors are almost always locked, and in the past, when they haven’t been, I’ve just gone back and locked them, and that’s the end of that. Hands, Face, Space So, when the pandemic hit and the government’s advice, resonating alongside my brain, was to “wash your hands or you’ll die”, things got a little tricky. The behaviours usually associated with my anxiety — hand washing, socially isolating, assuming there’s something dangerous out there — suddenly became behaviours that were justified for the betterment of mine and other people’s health. It became difficult to discern between appropriate “we’re-in-a-pandemic behaviour”, and anxious behaviour. Feeling anxious about catching coronavirus, especially when cases are high, is probably a good thing because it means you’ll be more cautious. In a pandemic, we have every reason to be anxious and to feel scared about what might or might not happen. Now, when lockdown rules are relaxing, despite case figures increasing, anxiety isn’t just reasonable anymore, it is to be expected. Open All Hours A lot of people, myself included, have been experiencing “reopening anxiety”, or “re-etntry” syndrome, a new form of anxiety felt by those that feel that the reopening of the world post-pandemic might be too soon and unsafe. This was also discussed by the editor of this blog in an interview in a magazine. For us, the thought of living our lives like we used to before COVID-19 is just too much. The virus is still out there, and so many of us have gone through monumental changes over the past 18 months. A lot of us have grieved for the world we’ve once known, and we’ve had to completely re-evaluate our ideas about what work means, what productivity looks like, and what connection means. To put it simply, we’re not the same people we were 18 months ago. I used to hate it when people said, “there’s no point in worrying about stuff because it doesn’t change anything”. The smugness of it all! Really, what I think people mean by this phrase is that things don’t always need to be worried over, and if you can keep a clear head, you’ll actually be able to handle it better. Easier said than done, though, but I digress. Thinking Differently For me, I’ve had to learn the difference between overthinking and critical thinking because the lines between the two haven’t always been clear. Anxious spirals can feel completely rational in the moment. I will give you my perspective: when the anxiety hits, it makes total sense why I’m thinking the way I am. I can’t see the flaws in my logic because the ideas and conclusions I’m jumping to make perfect sense in the distorted reality I’m creating in my head. The reality is, if you’re anxious, you’re not really reaching a conclusion. You’re reaching a judgement. It’s always “you’re a bad person and no one likes you,” and never “maybe you handled that thing badly and here’s how we can deal with it.” All that the self-critical voice in my head does is to sit there and criticize me, you know? It never brings anything to the table. It doesn’t help me in any way, it can’t even solve basic puzzles. When it comes to everything re-opening, overthinking and the critical voice in my head tell me it’s bad, bad, bad even worse and I’ll never be able to cope, whereas critical thinking tells me, “You’ve spent a year navigating this sort of thing now, and if you get COVID-19, you will isolate until it goes away”. And hopefully not die. The doors are almost always locked, and when they’re not, I can just lock them. More importantly, I’m trying not to beat myself up for feeling anxious. It’s fine to feel anxious. To quote Hannah Montana and probably Mother Theresa, “everybody has those days”.

Over recent weeks there has understandably been a huge amount of media coverage of the situation in Afghanistan. This has focused on the threats faced by the Afghan people in the wake of the Taliban resurgence and the stark changes to their way of life. There is no doubt that Afghanistan’s future is uncertain and only time will tell how the situation will evolve. However, we should not forget that over the last twenty or so years, many non-Afghans have been heavily involved in trying to de-risk the security implications of Afghanistan’s previous state support for terrorist organisations and, equally as importantly, trying to improve the lives of the country’s war-torn population. These Non-Afghan Workers include military personnel, diplomatic staff, media professionals and aid workers to name but a few. I am a professor of Defence Mental Health based at King’s College London. I served in the United Kingdom Armed Forces for more than 23 years and was deployed, as a psychiatrist and researcher, to a number of hostile environments including Afghanistan and Iraq. I am not an expert in Afghanistan, but I have been there and understand how complex an environment it was. Recent developments since military withdrawals in Afghanistan may have left some Non-Afghan Workers asking themselves “My colleagues and I risked our lives, what was it all for?” or similar questions relating to sacrifices they, their colleagues, and families made during and after their deployments to Afghanistan. Non-Afghan Workers, often deployed for lengthy periods of time, were exposed to risks to their life and wellbeing as well as seeing, and working, with Afghans who lived in terribly deprived conditions. These personnel may also fear reprisals against those who assisted them during the war with whom they had often built up trusting relationships and, in some cases, would have developed friendships with. Most Non-Afghan Workers would have strongly valued the work they did and there is evidence that work which has a positive and meaningful purpose is likely to promote good mental health. There is now the potential for some to perceive that their efforts may have been futile given the return of the Taliban to power. The possibility that Non-Afghan Workers may feel distressed that they have ‘abandoned’ Afghanistan can be understood in the context of appraisals that people make about their experiences. This topic very much falls under the umbrella of what has been termed ‘moral injury’ which describes the strong emotional and cognitive reactions that people can experience as a result of actions that breach their own moral or ethical code. Unsurprisingly, being exposed to morally challenging situations can lead to significant feelings of guilt, shame, disgust or anger. Although the usefulness of the moral injury construct is debated by some, the growing evidence base shows that it is associated with PTSD, depression, and suicidality. Unfortunately, media coverage of the withdrawal can exacerbate mental health issues in those who worked in, and for, Afghanistan. For instance, many stories have emerged in the international media of the “wasted years” in Afghanistan. This sort of language may increase the likelihood that some Non-Afghan Workers will develop moral injuries and thereby compound depression and PTSD. Those who comment publicly on the situation in Afghanistan should ensure that messages to media emphasize the merits of the international support to Afghanistan deployments such as the lives saved and improved as a result of the support. For example, in the wake of the withdrawal the NATO Secretary-General Jens Stoltenberg noted that “Due to our military presence and the support of the international community, a new generation of men and women have grown up in a new Afghanistan. Able to get an education, take part in the political process, run their own businesses… Today’s Afghanistan is very different to the Afghanistan of 2001. So those gains cannot be easily reversed”. Whilst it is somewhat inevitable that the media will focus on what has not worked, a balanced view is likely to help protect mental health. Furthermore, no one can accurately predict the future despite the media rhetoric that Afghanistan is doomed which can so easily adversely influence the mental health of Non-Afghan Workers. Awareness of the potential psychological fallout of the situation in Afghanistan has implications both for employers of Non-Afghan Workers and clinicians who interact with them. Employers of Non-Afghan Workers are likely to have focused efforts on getting staff out of Afghanistan before the closure of Kabul airport, but having done so they need to consider their ongoing duty of care towards them. Just as the NHS, and other key worker employers, have had to take account of how the Covid-19 pandemic may impact the mental health of staff so should Non-Afghan Worker employers take reasonable precautions to monitor staff and ensure that managers actively ask these workers about their wellbeing. Those who appear to be experiencing distress symptoms related to the current situation should be supported, and where that does not help resolve the situation, they should be helped to access professional support in a timely manner. Clinicians who provide care for Non-Afghan Workers should also be attentive to concerns about the current situation in Afghanistan in those they provide care for. These individuals may experience a new-onset mental health problem, or a worsening of a pre-existing condition, because of the guilt, shame, disgust or anger about the situation especially in relation to their perception that ‘it was all for nothing’ or that their prior allies in Afghanistan are not being properly protected. There is good evidence that treatment approaches which address appraisals regarding guilt, shame, and regrets in military personnel may be helpful. These approaches should focus on separating one’s actions and their outcomes or one’s intentions, from the eventual outcome of the conflict. The tendency to interpret the withdrawal as proof that it was all futile and my efforts were for nothing should be countered with discussion that a Non-Afghan worker did their duty, helped as much as they could, and their efforts may have still had positive impacts and outcomes for Afghans. Overall, the recent events in Afghanistan are likely to have mental health impact for many people. Most of these psychological reactions are likely to be short-lived; however, some may develop a moral injury or indeed a formal mental health disorder. It has been encouraging that many international leaders have voiced recognition of the positive aspects of support provided to Afghanistan over the last twenty or so years. Balanced messages about the impact of that support need to be echoed in the months ahead regardless of whatever unfolds in Afghanistan. Employers and clinicians also need to remain aware of the potential for the recent events in Afghanistan to cause intense distress and ensure that they take proactive measures to protect people’s mental health in the months and years ahead. 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

Suicide Prevention Day Did you know 1 in 5 of us will have suicidal thoughts in our lifetime? Not only that but it’s also estimated that 134 people are impacted for every suicide. As a result, approximately 15–20 are ‘injured’ and of those, 60% are more likely to start thinking about suicide themselves. Today is Suicide Prevention Day and I can’t imagine suicide won’t have touched you in one way or another. In 2019 there were 5691 completed suicides in England and Wales alone compared to a lesser 1752 road traffic accident deaths in the whole of England, Scotland, and Wales. As you may know from my previous blog, I am hugely passionate about encouraging everyone to be accountable, to upskill, and get educated about mental health. One case study I saw that really puts this into perspective was from Lend Lease about their roll-out of Mental Health First Aiders. They realised that construction workers (ie. their employees) are six times more likely to die by suicide than a workplace incident. Yet consider the budget and resource that goes into physical health & safety, rather than mental health support in the industry! This is eye-opening to say the least and can be applied in so many other circumstances. As I also mentioned in my previous blog, in 2017 we lost our friend Dan to suicide and as a result, I decided to complete a two-day Suicide First Aid course. I also recently became aware of the #BeThe1To campaign. Whilst this is more a US based campaign, their objective is to spread the word about actions we can all take to try to prevent suicide. So today, for Suicide Prevention day, I wanted to take the opportunity to share some of my tangible takeaways from the Suicide First Aid course that I think everyone has a duty to be aware of. The Importance of Language My first eyeopener was the misuse of language around suicide, specifically ‘committed suicide.’ This was completely new to me, but I quickly learned this terminology dates back to when suicide was a crime. Should we really use the same language for commit suicide vs commit murder? To help provide some clarity, here is a quick list with some suggestions for better language use. Instead of…Committed Suicide consider …Died by or completed suicide or ended their life Instead of…Successful attempt/Topped themselves consider …Suicide death/fatal suicide attempt Instead of…Unsuccessful/failed attempt consider …Suicide attempt/non-fatal attempt of suicide Instead of… Cry for help/Attention seeking consider…Describing the behaviour but using language that conveys hope over someone’s ability to restore their mental health Instead of…Suffering from/is a victim of consider …Lives with / has / experiences / has been diagnosed with Instead of…Suicide is selfish understand that… many people in this position often believe they are a burden to their loved ones, and it would be better for said loved ones if they were not around Upon reflection, I do wonder why society ever started using unsuccessful/ successful to describe suicide… One thing I also must get off my chest around the topic of language is using suicide within a frivolous joke about how mundane a task is for example. The litmus test here is to substitute suicide for cancer. We know it wouldn’t be morally correct to say “That meeting was so boring I just wanted to die of cancer”, so why would it be acceptable to say “That meeting was so boring I just wanted to kill myself”? Having lost Dan to suicide, my heart sinks when I hear references like this. Suicide Safety Guide Having addressed the importance of language, I thought it would be useful to cover the 3-step suicide safety guide. I’ll go into more detail about each topic which may seem complex but just remember: 1. Ask 2. Listen 3. Safeguard As I mentioned, everyone should try to become more aware of how you could help in case you were to ever find yourself in a suicide first aid scenario because, as a friend, colleague, or family member, you are likely to be the first person an individual confides in before getting support from a mental health professional. These three steps are there to act as a guide so that you can try to navigate this challenging situation as best as possible. Step 1 — Ask You really can’t underestimate the significance of step 1, ‘ask’. During the course we roleplayed asking the trainer ‘have you had thoughts of suicide?’ This really is harder than it sounds so I would encourage you to try saying it out loud. In a real-life scenario, it’s important to confidently complete step 1 as opposed to moving straight to step 2. This is because nervousness and avoidance of the subject indicates to the individual there is a need for them to hide their feelings, leaving them unlikely to disclose the truth whilst continuing to suffer in silence. So, ensuring you are asking directly, you could say ‘sometimes when people are upset or struggling, they are thinking of suicide. Are you thinking of suicide?’. Don’t beat around the subject — just ask the question. It’s scary but it’s so important. Step 2 — Listening Step 2 is around listening, and it also can’t be underestimated how valuable this is. If you’re a doer like me, this is particularly difficult but remember 1) you don’t have to fix their problems and 2) listen to understand, not to reply. Don’t be dismissive, show empathy (amazing video here on this). You can summarise back to the person what they have told you to show they have been heard. After talking it through consider thinking about the concept: DEATH, PAUSE, LIFE. Do they need to choose between life and death today? What helps them with big decisions? Is now a good time to make a major decision? Ask questions and let them explain their situation. Some of the above questions may help to ‘derail’ their suicide plan. If this is the case, you may be able to start to segue into step 3 — safeguarding. Step 3 — Safeguard For this, consider what needs to be done right now to keep them safe. Who can you call? Where do they need to go? Next, create a safety plan together which you can use now, and they can keep it for the future too. I know this sounds complicated but work together to create this. Consider: · What helped before? · Who may they be able to contact if they are feeling alone or desperate? · How much is ‘safe’ for them in the context of alcohol or drugs? · What have they learnt about their own mental health? · Are there any activities that help them take their mind off things? · List out relevant help lines and their GPs details. The main one I would recommend memorising is the Samaritans as they are available 24hrs a day — call 116 123 or text SHOUT to 85258 Get them to read this plan back to you and offer to help by making the first call(s) with them whether this be to a helpline, GP, and/or loved one. This is another tangible step towards further ‘derailing’ their suicide plan. Importantly, they may be able to recognise suicidal thoughts in the future and have a mental link to the safety action plan in their toolkit — if they can do one thing from the list this could make a huge difference next time. Finally, if you do ever use these skills in a real situation, it’s so important to talk to someone close to you and get the support you need. This would be a hugely upsetting situation to find yourself in and you need to consider your own mental health and self-care. If you’ve got this far reading my blog, to be honest, I just want to say thank you. As I said at the start, I’m hugely passionate about education around mental health so even if you, the reader, have picked up one thing I’ll be over the moon. I really hope you don’t have to use Suicide First Aid in a real-life situation, but I guess a lot of this can be applied to general support for our loved ones too. I’m conscious it may all sound so simple and I understand it’s far from that, however conversations can be extremely powerful, and I truly believe the more conversations we have the better. Let’s fight the stigma together! Header image source:Priscilla Du Preez on Unsplash

Nearly 42 years of violent conflict is driving a growing mental health crisis in Afghanistan. I am an Afghan doctor currently working as a Psychiatrist in the NHS. I am also the co-founder and ex-chair of the Association of Afghan Healthcare Professionals-UK. I fled Afghanistan almost 20 years ago but I have never cut ties with my country. I am actively involved in improving the healthcare system in Afghanistan. In April 2019, I attended a one-week intensive training in ‘Professional Healthcare Regulation Consultancy’. The training was delivered by the General Medical Council of the UK in the GMC offices in London and Manchester on behalf of the Afghanistan Medical Council (AMC). AMC is a newly established regulatory body for doctors and dentists in Afghanistan. In July 2019, I went to Afghanistan where I spent two weeks and provided AMC staff with training on “Medical Registration, Licensing and Fitness to Practice”, I am now a formal trainer to AMC. Overall, I visited Afghanistan at least once a year. During my visits, I ran free clinics for poor people in my home town. Besides seeing patients, I visited hospitals where I gave presentations and shared my knowledge with colleagues. During these visits, I learned a lot about the healthcare services in Afghanistan in particular about mental health services. This was the tragic situation before the current events. While accurate data on mental health issues is not available in Afghanistan, according to the International Psychosocial Organisation (IPSO), as of 2019, about 70% of Afghans suffer from various forms of mental health problems. The mental health toll signifies a hidden consequence of war that is often overshadowed by bombed-out buildings and loss of life. During the last 20 years Afghan governmental and medical centres have made some medical achievements, but they are still not capable of providing patients with specialized services; consequently, many Afghans who need specialized treatment travel to other countries such as India, Pakistan, Turkey and Iran. Mental Health The Kabul hospital is the only mental health hospital for all of Afghanistan and is supposed to serve the needs of all psychiatric patients in the country. This facility is organizationally integrated with the mental health outpatient facilities. None of the beds in the mental health hospital are reserved for children or adolescents, and 18% of users are female. The patients admitted to mental health hospitals belong primarily to the following two diagnostic groups: psychoactive substance use (58%) and schizophrenia (24%). There are no long-stay patients (more than a year) in the mental health hospital. This data was collected from Kabul Psychiatric Hospital. In Afghanistan, mentally ill patients are generally looked after by their families. Some people still consider mental illness a punishment from God, possession by a djinn (devil) or black magic. They take the patients to shrines and mullahs (Imams) for treatment. Those patients who do not have family either end up on the streets or if lucky in a Marastoon (asylum house). During my visits to Afghanistan, I found that depression, anxiety and PTSD are alien terms there; people, and especially women, are more likely to present to a doctor complaining of somatic symptoms, which on further inquiry, it happens to be an undiagnosed mental health condition. Psychosomatic illness features commonly in general medical outpatient clinics and access to a psychiatrist is practically non-existent. I have found that treatments are generally medical and there are only a handful of psychologists who have received their training outside Afghanistan. I have found that Afghanistan is unequipped, unqualified and unprepared to deal with its mental health crisis. The country’s only mental health hospital in Kabul is in bad condition due to war damage and lack of maintenance. All other provincial hospitals only offer counselling services and no real mental health care; the counselling centres are staffed by partially retrained nurses. The European Union has supported the rehabilitation of the mental health hospital in Kabul and has paid for the construction of new building within it; the capacity of the hospital remains at 60 beds, however. Counselling is available in small clinics thinly distributed around the country. Even in Kabul they are few. Some international NGOs offered training and help to the Afghan mental health service. Greek NGO Klimaka, for example, provided some equipment, translated a training manual into local languages, renovated facilities and provided 8-week training courses. HealthNet is the largest NGO involved in mental health care in Afghanistan, but their impact has so far been limited; their main contribution was the supply of some medicines. According to a WHO report, “psychosocial interventions centres were established in 2005 by some international NGOs in the capital but they have not been implemented in rural areas”. The long-stay homeless patients reside in Marastoons (asylum houses) which are available only in four major cities of Afghanistan, including Kabul, Jalalabad, Heart and Kandahar Provinces. These Marastoons have limited capacity, the biggest of all is Kabul Marastoon with 78 female patients. There is no Marastoon for male patients in Kabul. Most of the residents are there for more than 5 years without any psychiatric care. I last went to Afghanistan in July 2019, during this visit I spent three days in the Red Crescent Society’s Marastoon in Kabul. They call this place a Qala (fortress): the gate is always locked for their protection. As soon as the door was opened for us, we were surrounded by a dozen patients greeting us in Pashto and Dari and touching us. I noticed that all patients’ heads were shaved, it was later explained to me this was for hygienic reasons (headlice). I was given a tour of the Marastoon. I noticed that between 12 and 16 patients were sleeping in one bedroom in bunk beds. The situation was heartbreaking and I could not control my emotion and broke into tears. I cut the tour short and asked the staff member to show me the clinic room they have prepared for me as I wanted to make the most of my time and see as many patients as possible. I managed to assess 32 out of 78 patients in three days. I let a psychologist, a nurse and a family medicine doctor sit with me during the assessments to learn how we assess mentally ill patients in the UK. There was a physical health clinic attached to this Marastoon but none of the patients had been seen by a psychiatrist before me, and some patients had been there for more than five years. Some patients in the shelter showed symptoms of mental health problems since their early life, the majority of them were there because they have developed psychological problems during the war. I also found that some people should not have been there, but because there are no social services and due to the lack of adequate outpatient mental health services, they remain. Psychiatry and mental health services were already limited and inadequate to meet the need of the population. Without a doubt, the current situation in Afghanistan is very bad. The humanitarian consequences will be severe. Conditions have been deteriorating for some time due to violence, natural disaster, and the COVID-19 pandemic. Already, half the population — some 18.4 million Afghans — need aid. Almost 17 million people are experiencing serious food insecurity. If the International community cut their ties with Afghanistan and stop their financial support the current fragile healthcare system will deteriorate further. If the Taliban can hold together and construct a viable, long-serving government, then the longer-term prognosis is better. The Taliban has already stated they intend to govern Afghanistan in a manner ‘that is good for Afghanistan’ although it remains to be seen how far this extends to extremist Islamic tendencies, at the expense of commerce and trade.

Why does Burnout Matter at this Stage of the Pandemic? If you are reading this blog and you are not feeling tired then you may be one of the lucky ones. Many people in a range of professions have fallen fowl to burnout over the course of the pandemic. This blog is part of a 3-part InSPIre the Mind series. This introductory blog explores the science of burnout and what research tell us about burnout amongst people working “on the frontlines” during the pandemic, such as medical staff and teachers. Part 2 explores how working from home can affect our mental health. Part 3 will share some of the emerging evidence for preventing and recovering from burnout. Burnout is a pandemic buzzword, but what is it? Burnout refers to feeling an increased sense of cynicism, tiredness and reduced sense of competence at one’s job according to burnout researcher Maslach and colleagues (1996). In 2019, the World Health Organization officially recognized burnout in its International Classification of Diseases (a global standard in disease identification) but clearly stated that the term “should not be applied to describe experiences in other [nonoccupational] areas of life.” So, if burnout is a phenomenon strictly in the work domain, who may be at risk of burnout at this point in the ‘pingdemic’? In this blog, we will look at some of the emerging research conducted over the course of the pandemic 2020–2021 and consider how and why does it affect our bodies and minds? I’m a research associate at the Evidence Based Practice Unit, a partnership between UCL and the Anna Freud Centre. As a psychologist, I’m passionate about research that seeks to understand the factors that promote human wellbeing or reduce the risk of developing mental ill health both in-person and online. At this stage in the pandemic, I cannot deny, like many people, I’m a little tired. The shifting demands of the pandemic has been difficult for many. There have been new stressors to accommodate and sources of existential uncertainty, new ways of living and new ways of working to adjust to. From furlough to self-isolation, many have felt increased stress at multiple levels. The pandemic has had a profoundly affected both physical and mental health with reported rates of depression and anxiety increased globally, as well as the rise of burnout. Burnout was Identified in New York Psychologist Herbert Freudenberger coined the term when he noticed that volunteers at a New York mental health clinic who had previously begun their involvement at the clinic with optimism and zeal, had become increasingly exhausted and began to show “quickness to anger” and closed thinking. Freudenberger wrote about burnout in his book that became an authority on the subject. “Joyful activities, like playing with my infant daughter, suddenly felt like an obligation and a chore…. I felt incapable, overwhelmed, and trapped — and when people pointed out that something was wrong, it only dug the hole even deeper.” — Kieran Ti Recent research suggests that there may be 4 phases of burnout. Each phase is linked with a measurable change in cortisol levels (a stress hormone) in the body. More cortisol increases glucose levels in the bloodstream, ramps up the brains use of glucose and makes available substance that repair body tissue. Cortisol, in concert with another important hormone, Adrenaline, renders us in a state of flight or flight, directing the blood flow away from digestion, reproduction and growth activity. Cortisol reminds the brain that something is wrong, influencing mood, motivation and levels of fear. Cortisol is essential, if levels are too low then a person can experience an adrenal crisis (for example in a medical condition called Addison’s disease where the adrenal glands are damaged). Too much cortisol release over time (with the HPA continually activated) however, can be damaging to both the body and the brain. The levels of cortisol in the body are finely tuned by the HPA axis, the pathways that connect the brain and the adrenal glands, the small triangles that sit on the top of the kidneys. Four Phases of Burnout 1) Engagement — in this stage there is some cortisol but this is a normal level that is associated with energetic engagement and hard work, similarly to feelings of stress linked to coping with a difficult exam or deadline. The HPA axis is functioning. 2) Strain- in this phase the employee is still engaged and dedicated to the job, but tiredness is common and levels of cortisol are high. 3) Cynicism- this is where dedication drops off and cortisol levels peak. It is increasingly difficult to cope. Sustained high levels of cortisol are linked with mental ill health. HPA activity reduces. 4) Burnout- in this phase exhaustion sets in, cynicism reduces, the HPA activity further reduces, an individual may overreact to smaller moderate stressors. So, what does it mean to be not burned out? Burnout experts Maslach and Leiter suggest that the opposite of burnout has been thought about as feeling energised at work — such as having vigour and get up and go, and a sense of commitment to the role and organisation. Google ran some research to understand what characteristics make a team successful at work in their research project Project Aristotle, an in-house research initiative that sought to understand through interviews with 180 different teams made up of between 3–50 employees. The project found that a key ingredient was “psychological safety” which they defined as “Team members always need a safe space to work, question, take risks and even make mistakes, without the fear of judgment, feeling incompetent or the greater ramifications”. Other ingredients included dependability, structure and clarity, meaning and impact. Healthcare Workers and Burnout: Reaching Breaking Point? Whilst burnout can occur in any profession, there has been a marked rise of burnout within healthcare workers during the Covid-19 pandemic. Healthcare workers operating on the “front line” in providing care to Covid-19 patients have been found to have high rates of burnout, and especially among staff in intensive care and nurses. A British Medical Association questionnaire with 6126 health care staff in April 2020 found that more than 40% of doctors were experiencing depression, anxiety, stress, or burnout that had been ramped up by the pandemic. 60% reported more fatigue or exhaustion than pre-pandemic. Research found that factors contributing to stress in healthcare workers in the UK included: · Worries about their own health · Worries about their family’s health · Worries about access to personal protective equipment (PPE) (e.g. masks and gloves and other protective clothing/equipment) · Worries about being able to do their job effectively · Managing the higher number of patient deaths at work If a healthcare worker was female and redeployed, this same research found that they were more likely at risk of burnout. Research for all professions finds that burnout is not gender-neutral and because of additional household and possible childcare duties, women are often at greater risk. Barriers to Getting Help The problem is further compounded by the fact that many people suffering will not get, receive or have access to suitable support. In the chart below by Ferry et al, 2021, it shows that as many as 77% of health workers felt stressed but did not access support. Reasons that healthcare workers didn’t get it included: · Feeling support wasn’t needed · Not having time · The support offered didn’t feel relevant to the person · Not wanting colleagues to know they were suffering from stress Teachers and educational staff and burnout Teachers already had a demanding job before the pandemic. However, the return to teaching required management of both in-person teaching, and online teaching, keeping in step with changing government guidance and managing children that had been emotionally and educationally impacted by the pandemic, placed an additional burden on teaching staff. Further still, teachers were further at risk of getting Covid-19. In the UK and in many other countries, teachers had to provide both in person and online teaching during the pandemic. Research conducted on the topic of levels of burnout among Spanish teachers in five regions in Spain found that burnout was high in teachers, and that female teachers were more negatively affected, again, as per other research, showing a gendered dimension. Of the sample of teachers included in the study, 60.2% had high levels of emotional exhaustion and 69.3% of teachers surveyed reported low professional efficacy. Interestingly, teachers with higher levels of emotional intelligence had lower levels of burnout, suggesting that socio-emotional skills may help protect teachers from burnout. Older teachers had lower levels of burnout also that could mean experience played a protective role. It is perhaps important to note that a lack of professional efficacy in the context of the pandemic doesn’t mean suddenly not being able to do one’s job, it’s about the capacity to do an existing job in a completely new set of circumstances. What about people working from home via Zoom — does that contribute to burnout? What can we do about it? In Part Two of this InSPIre the Mind blog, we will explore how working from home and “Zoom fatigue” can affect our mental health and risk of burnout. In Part Three, I will look at the evidence for beating burnout and achieving greater wellbeing. There is a lot of advice on the internet, but what is the evidence of effectiveness to reduce burnout and stay well? Thanks for reading.

*Trigger warning: this blog discusses mental health struggles and suicidal thoughts. I’m crouched beneath the desk of my university dorm room, hands planted over my ears as I rock back and forth and hum the tune to Teddybear’s Picnic. I remember thinking: something is wrong. I’ve always found it easier to express myself on paper. I recently wrote this piece on why I deprive myself of medication for my mental health, and this time, I’ll give you more insight into my diagnosis of borderline personality disorder. Much is said about those of us with this diagnosis, little of it kind, and even less from our perspective. I was a quiet kid and noticed myself becoming more emotional in my teens. Every mood seemed magnified, leaving me less able to cope with life’s ebb and flow. Each ache and pain felt catastrophic; like being trapped in a pinball machine, mercilessly flung from one mood to the other at breakneck speed. The emotional whiplash was exhausting, for me and everyone around me. Often, the feelings were so overwhelming that I lashed out, my fury like dropping a glowing match on a puddle of petrol. No matter how sorry I was, people can only tolerate that behaviour for so long before they feel the need to walk on eggshells. Not everyone with borderline personality disorder (BPD) will behave this way, but the stigma affects everyone regardless. According to the NHS, borderline personality disorder (BPD) is a disorder of mood and how a person interacts with others… In general, people with personality disorders differ significantly from others in terms of how he or she thinks, perceives, feels or relates to others. Symptoms which characterise the disorder — also known as emotionally unstable personality disorder (EUPD) — include intense fear of abandonment, chaotic relationships, inappropriate, intense anger, impulsivity and self-harm. My diagnosis didn’t come until university. My boyfriend at the time, Ryan, lived in the building next door; we met during freshers week and immediately became inseparable. Despite having already planned the decor of our future home (same tastes!) — I couldn’t escape the terror that Ryan would abandon me. On impulse, I’d end the relationship, desperate to put an end to my anxiety. Each time I would leave him devastated and begging me to stay. I self-harmed in a bid to keep a lid on my emotions, and when he eventually walked away, I became suicidal, overdosing on vodka and pills which did nothing more than knock me out for the day. I’d suspected maybe I was bipolar, so the diagnosis of BPD came as a shock. I’d never heard of BPD but cried with relief, and then fear. A quote by psychologist Marsha Linehan put into words what I’d been unable to articulate: ‘people with BPD are like people with third degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement.’ The statistic that 8–10% of those with BPD will commit suicide hovered over me. Compared to the low lows, the highs felt extra high. BPD has the addictive quality of a drug; just when you think the lows might kill you, the euphoria of a mood swing flings you into oblivion, and you question whether you imagined it all. Another characteristic is black and white thinking. I have no problem cutting people out of my life over the smallest slight, because every slight is so excruciating I want to protect myself from future distress. Aged 24, following the end of another relationship, I voluntarily spent a fortnight on a psychiatric ward. I’d fallen into a cycle of desperately searching for someone to make me happy, unwilling to admit that only I held that responsibility. I was so distraught at this perceived abandonment that I no longer felt able to keep myself safe. I’d imagined this to be my chance to finally get help; finally, someone would see how much I was hurting. But there was no help. The hospital was just a holding pen, its only goal: to keep me alive. I learned that the dialectical behaviour therapy (DBT) therapy I needed was no longer offered in my area, and that private therapy would cost around £700 a month. Even more distressing than the extreme emotions is the isolation. While conditions like depression and anxiety have become part of everyday conversation, when I share my diagnosis with friends or family, they have a tendency to respond, ‘Ah, I prefer not to use labels.’ The mysterious nature of BPD makes people uncomfortable. Research shows that even medical professionals can be wary of, and sometimes unwilling to work with BPD patients. By disregarding my diagnosis, it makes me feel that at best, people would rather not get involved, or at worst, they don’t believe what I’m feeling is real. Looking to the internet for advice and community is risky, too. It’s easy to stumble on vicious comments by people who have been burned; we’re selfish, manipulative, without remorse or empathy. Crazy. It’s painful to read, but I do understand. It’s hard not to internalise the comments. It’s true that, when I’m very distressed, I can turn off my empathy like a switch because to feel it all just might kill me. But I pay for this later, when the guilt and shame hurtle towards me like a tsunami. My biggest challenge is finding it in my heart to forgive myself. If you believe wholeheartedly, you’re rotten inside, you become a self-fulfilling prophecy. I’m trying to remind myself that just because I’ve stumbled in the past, it doesn’t mean I can’t do better now. I’ve begun distancing myself from the label ‘BPD’ because I don’t want it to form my identity. But even so, knowledge is power; it’s the anchor I desperately cling to when it feels like I’m losing my mind. It allows me to apply logic to the storm inside my head and remind myself that this, too, will pass. Romantic relationships can be especially tumultuous for those with BPD, and I’ve made a conscious decision to remain single for the past five years. It’s liberating to know I can make myself happy. But, the future scares me; friends assure me I could have anyone I wanted, but they don’t realize it’s me that has historically been the problem, not my looks. I’m afraid to disappoint myself, and prefer being the girl who got away rather than the girl who let them down. Sometimes I catch myself thinking it would be nice to have a family of my own, but I’m not sure that life is meant for me. We need to talk about stigmatised mental health conditions, but I also need to learn not to stigmatise myself. I’m so much more than my mental health. If you are struggling and are in need of support, below are a few incredibly helpful organisations that provide both resources and direct help: Shout Crisis Text Line — you can text Shout to 85258 if you are experiencing a personal crisis, are unable to cope and need support. Talk to the Samaritans — they offer 24-hour emotional support in full confidence. You can call them for free on 116 123 CALM (Campaign Against Living Miserably) offers a chat and hotlines service from 5pm to midnight Papyrus (Suicide Prevention Charity) offers similar service for adolescents and young adults under the age of 35 Mind — you can call the Mind Infoline on 0300 123 3393 / info@mind.org.uk, the Mind Legal Advice service on 0300 466 6463 / legal@mind.org.uk Talk to your GP

A step-by-step guide on how to break free and make a fresh start *Trigger warning: this blog discusses domestic abuse. My name is Rosy, and I was in an abusive relationship for over a decade. The trouble was that I didn’t realize how deeply my ex-partner’s treatment of me was affecting my mental health. I had lost my identity — I was a puppet, and he pulled the strings. In the UK 1 in 3 women (1.6 million) experience domestic abuse throughout their lifetime, and the police receive a call every 30 seconds for help relating to such abuse. These figures show only the ‘official reports’, with the real figures likely to be much higher. How many cases, like mine, remain hidden? It can be described as a pattern of behaviour on the part of the abuser, designed to control their partner. It can happen at any point in a relationship, including after a relationship ends. It can be physical, emotional, economic, and sexual, and can happen to anyone, regardless of age, gender, religion, background, ethnicity, or sexuality. Whilst it happens to both men and women, statistics show it is far more prevalent in women who experience higher rates of repeated victimisation and are more likely to be seriously hurt or worse, than male victims. Research has also shown that there is a two-directional relationship between domestic abuse and mental health. Sadly, individuals who have experienced domestic abuse are more likely to experience long term mental ill-health. Women subject to domestic abuse are 3 times more likely to suffer adverse mental health outcomes including depression, anxiety as well as more severe conditions such as bipolar disorder. Importantly, domestic abuse is never the fault of the person who is experiencing it. So maybe you are thinking “why didn’t she just leave?” Many factors make leaving an abusive relationship so hard. It can be a very daunting task to take those first steps to freedom and safety, which I undoubtedly experienced. For me, my confidence had been slowly destroyed over time, I was drowning in a sea of unhappiness, my life savings had been drained away making any move to safety on my behalf seem impossible — I had no car, no job, and was completely dependent on my abuser, and I had slowly been isolated from my family and friends over time. Who would I turn to for help? Danger, fear, shame, trauma, and isolation can be powerful tools… Asking for help is not easy, but I finally found the strength to do so. Reconnecting with my family and their offers of help, also boosted my confidence and spurred me into action, although I couldn’t accept them as they live too far away. What truly helped me take the first crucial steps was having a well-thought-through plan of action. This ensured that I remained safe as well as focused on my end goal — reclaiming my life. Find somewhere to live My priority was finding somewhere affordable to live, to remove myself from the immediate danger of my situation. The internet can be a powerful tool in providing help. Search it out. I found a website called Spare Room, through which I found a kind stranger who let me move my few possessions into their spare room. Alternatively, family or friends might be able to help out until you get back on your feet again. The National Domestic Abuse Helpline is also available, where you can talk through your options with a Helpline worker who can also help you access refuge accommodation. Find an ally If leaving is something you can’t safely do on your own, on the day you plan to leave, it is important to have a friend or family member to help out and provide moral and emotional support. Alternatively, you can call a Helpline in confidence, such as the refuge helpline, which can support you to understand options and to help create a plan. Moving on — Importance of a support network In my experience, seeking medical and/or professional advice was very helpful. Speak to your General Practitioner and ask to be referred for professional help. He or she can point you in the right direction. My doctor was patient and understanding and he took the time to listen to me. When he told me that I needed to find the root of my unhappiness, it was a light bulb moment. I knew then that I had to extricate myself from the abusive relationship, whatever it took. Talk to professionals — they are there to help. Talking therapies can help you understand and deal with negative thoughts, and help make positive changes — opening up to my counsellor helped me enormously. My family was also very supportive and my daughter and a friend helped me to move my things into my new temporary accommodation. I will never forget the feeling of relief that very first night when I slept safely in my own bed with my whole future stretching out ahead of me. Nor will I forget the kindness of the relative stranger I moved in with. She provided amazing support and, many years on, she is still one of my closest friends. Learning to trust again, and who to place your trust in, can be daunting at first, but each day your confidence will grow, with the support of the right people. With each additional day that I forged ahead with my new life, I became stronger, happier, and more empowered. I was able to increase my part-time job to full-time and begin to turn my financial situation around and provide for myself, which in turn increased my confidence. It is difficult to take the initial steps to leave, it is like riding an emotional roller coaster. The ending of any relationship, be it good or bad, is the end of a chapter in your life and that has emotional consequences. Perhaps more so when the experience has had such a deeply negative impact. However, starting that new chapter, your new beginning, can be incredibly empowering. I also learnt that if you don’t break free from an abusive or toxic relationship, you will never know what is out there for you — and what is out there can be beautiful, you just need to find the strength to take those first crucial steps. My life has changed for the better, over and above anything that I could ever have dreamed of. I hope that in reading this, someone in a similar circumstance may find their light bulb moment, and the courage to make a change… If you are a victim of domestic abuse there are several different organisations that can help and provide support, below are links to some suggestions: Refuge National Domestic Abuse Helpline Women’s Aid DASH Men’s Advice Line