The opportunities and dangers of predicting mental health using social media: should one status reveal the other? It’s time to have a conversation about diagnosing emotions using the parts of ourselves we put online As a science journalist, I try as much as possible to keep up with what’s happening in the world of mental health, whether it’s a change in our understanding of treatments, or what’s going on in our bodies when we’re depressed. Alongside this, ever since I wrote my master’s dissertation on the narratives surrounding “big data”, I’ve had a personal obsession with the wild-west that is big-data tech. So a few months ago when a friend got in touch about a strange experience of mental health on Instagram, their story really piqued my interest. A few months ago they messaged a group chat on Whatsapp to say they’d seen a lot of adverts and posts on their Instagram about ADHD, and it seemed as if some of the symptoms applied. My friend had been feeling easily distracted, bored, and unable to complete work tasks at their normal capacity. The group reassured them that in the midst of a pandemic, these were pretty typical experiences. Being trapped inside with reduced social contact, increased workloads and anxiety-inducing news appearing on our phones throughout the day is arguably the opposite of an environment conducive to efficiency and hard concentration. It was probably something to monitor, we said. And definitely speak to a doctor about it if you’re concerned. But, they replied, why is Instagram showing me this stuff? Has an algorithm decided that my behaviours or habits are associated with ADHD? Does Instagram know something I don’t? The answer is, in all probability, no. My friend is highly engaged with mental health, and with a recent rise in awareness of ADHD, the algorithms were in all likelihood doing what they always do; predicting what they might be interested in. But, it got me thinking. The suggestion that a social media algorithm might have detected a mental health disorder and then shown content about it didn’t seem outside the realms of possibility. And that’s because it’s not. Predicting mental health status using our social media posts — like what we say and how we say it — is a rapidly growing area of research. There are studies that have analysed data from platforms like Facebook, Twitter and Reddit to try and predict a range of mental health disorders, including depression, anxiety, eating disorders, suicidal ideation, PTSD, and schizophrenia. Some of them report being able do it with surprising accuracy. And why wouldn’t researchers want to develop tools that could take social media posts and make diagnoses, or even predict who is at risk of developing a mental health disorder? Digital epidemiology, as it’s come to be known, opens up opportunities for monitoring and addressing conditions that are under-diagnosed and under-treated. It presents a chance to reach many people who might not want to — for a plethora of reasons — to go to the doctors. Huge datasets with public access are therefore very appealing to clinicians and computer scientists alike. If it worked well, predicting when someone is feeling mentally unwell and intervening could save lives, increase treatment (as well as allow researchers to monitor their success rates), or catch people before they become seriously unwell. In the early days of developing a mental health disorder, a nudge in a different direction or towards help might be all someone needs. But despite all the potential positives, there are significant ethical questions and downsides to consider too. Below are the ones I think are the biggest, and perhaps hardest, to answer. 1. Should there be limits on what our social media posts are used for, without knowledge or consent? Or, just because the data can be analysed, does that mean it should be? Think about it like this. When you go to a park, you’re perfectly aware that people will be able to see you, hear you, and watch you. You’re in a public place, so fair enough. But what if there was someone with a clipboard hiding behind a tree, writing down everything you were doing. If you spotted the clipboarder you might not want to be in the park anymore, or feel self-conscious about what you were doing. You wanted to be out in public, sure, but you didn’t go there to be monitored. And I’m sure I don’t need to tell you this, but in the real-world, it would be extremely unethical for researchers to hide behind trees and watch people without their consent. 2. Who and what is the data being modelled on? We all use social media differently. I expect there is a huge range in how and why people use social media and what they say, depending on where they’re from, their class or their culture. I’ve got no doubt women express themselves differently to men (lest we are trolled). I’m sure the same applies for non-white people. Any analysis needs to take into account whose data the algorithms are being built from — otherwise we are recreating an old medical problem, that the default is the white, western, middle-class male. 3. How will this data be used This is a big question, with innumerable sub-questions leading off from it. I’ll run through a few. Imagine the algorithms are being used, you’ve given your consent, and the AI discovers you’ve got depression. What’s done with that information? Does your feed change? Do you get links to charities? Should you be told directly? Who else should be informed? If you’re told, how? In a pop-up? By email? What should that notification say? Should there be a follow up? If your GP was notified, how would they be expected to respond? What if you were hacked and that information was made public or used against you? 4. Who will be regulating the technology? Depending on who the technology is owned and run by, there are big questions as to who should be monitoring the algorithms, and where responsibility lies if things go wrong. Doctors and nurses go through years of medical training to then be registered with regulators. There are standards and checks. But what happens when a piece of software is playing clinician? Who checks that the algorithm meets proper standards — who even sets the standards? Who gets blamed if something goes awry? 5. Where is the technology headed? Predicting emotions doesn’t just apply to mental health, and isn’t just being worked on through what we say on social media. The tech researcher Kate Crawford recently wrote a fascinating article in Nature about how the pandemic is being used as a reason to push visual emotion-recognition software into workplaces and schools, which is both unproven and unregulated. I have a resting-frown face in meetings (despite my parent’s warning of early-onset wrinkles). I imagine an AI would think I was angry or upset, when (usually) I’m not. And that’s probably the least-bad outcome. Unproven and unverified AI software that purports it can read our emotions coming to a job interview, advertising company, or airport security gate near you? It’s a good premise for a dystopian novel. 6. How accurate is accurate enough? This takes me back to my friend. Let’s say an algorithm could predict your mental health status with a 99% accuracy. When deployed across a platform like Facebook with a couple billion users — there’s going to be a lot of people getting an incorrect diagnosis or being directed to organisations they don’t need help from. Our relationships with technology mean we often think our devices are infallible. I reckon even if I felt mentally well, if my Twitter feed started showing lots of posts about getting help for depression, I might start to second-guess myself, or worry. What next? Bearing in mind the tech is in development, all these questions, and many, many more, need to be thoroughly discussed by mental health professionals, computer scientists, clinicians, organisations representing vulnerable or minority groups, ethicists, and the public. And pretty soon too.

Bans Off Our Bodies: A Californian’s perspective on abortion rights Trigger warning: The following blog contains discussions about abortion and a brief mention of sexual assault. Some readers may find this distressing. On Tuesday the third of May, a Politico leak revealed that the Supreme Court, the highest court in the United States, intends to overturn a landmark ruling declaring the legal right to an abortion. The actual vote has yet to take place, but it’s predicted to happen sometime in late June or early July. If the Supreme Court votes to overturn the landmark case of Roe v Wade, then the legal status of abortion will be up to individual states. That doesn’t mean that abortion will be outlawed across the country overnight, but it gives states the right to restrict abortion and, in some cases, prosecute those who aid and abet abortions. A press release that followed the leak explains “Although the document described in yesterday’s reports is authentic, it does not represent a decision by the Court or the final position of any member on the issues in the case.” However, considering the fact that several of the justices have already voiced their intention to overturn Roe v Wade, I think it’s more than likely that abortion will become a state issue. Some more liberal states, like New York, have enshrined the right to an abortion in their state constitutions, and clinics in these states are already preparing for the influx of travellers crossing the state lines for abortions. I grew up in one of these states, California, in a family that is fiercely democratic. We are strong believers that every person has the right to govern their own life and their own body, even if we as individuals disagree with their choice. I won’t deny that I am proudly pro-choice. As a neuroscience student, I have tried to write objectively on this complex matter, but, as writers, we have to acknowledge that our own beliefs will bleed into the way we interpret and present information. What is Roe v Wade and why does it matter? Roe v Wade was a court case that arose from the district court in Dallas, Texas to the highest court in America. It was a lawsuit by a then anonymous woman rape victim who had tragically fallen pregnant and been forced to give birth against her will because she could not obtain an abortion. Four years after she filed her initial lawsuit, the case was heard by the US Supreme Court in 1973, which voted in her favor. The case of Planned Parenthood v Casey, which could also be overruled in the near future, gave states more freedom to restrict abortion. In 1990, Planned Parenthood sued the governor of Pennsylvania, Bob Casey Sr., arguing that the state’s abortion restrictions were unconstitutional. While most of Philadelphia’s laws were upheld by the Supreme Court’s decision, the Republican supermajority unexpectedly reaffirmed Roe v Wade. Ever since, abortion has been federally legal, but many states have worked tirelessly to restrict abortion, as you can see on this map by the Guttmacher Institute. Texas has already banned abortion at the point that embryonic cardiac activity can be detected, which is usually five or six weeks into a pregnancy. Lots of people claim that six weeks is plenty of time to make a decision and seek out an abortion, but there are many circumstances where that’s not the case. People taking birth control, on the onset of menopause, people who are anorexic or malnourished, people on hormonal medications, or people who have irregular periods, could all easily not notice a late or missed period, or dismiss it as normal for them. The University of Texas estimates that nearly 1,400 Texans travel out-of-state to have abortions every month, and that’s just one state. The financial obstacle of paying for an abortion can be huge, and even more so if travelling is required. Medicaid, which provides health insurance for low-income Americans, doesn’t cover the cost of an abortion in the vast majority of cases. According to Planned Parenthood, an abortion can cost between $750-$1500, and that’s not taking into account the cost of transportation, days off work, or staying at a hotel if you live in a state with a waiting period. What are the mental health consequences of having (or not having) an abortion? Although the results of studies are mixed, it is fairly undisputed that abortion is associated with poor mental health. Experiences of guilt and depression are commonly reported, but so are feelings of relief and freedom. For many people, abortion will be the hardest decision they ever have to make. The fact that people have a variety of responses to abortion, both positive and negative, emphasizes the need for unbiased and accessible counselling, more research into the mental health outcomes of abortion, and better legal protection for abortion patients and providers. It’s important to keep in mind the fact that abortion research has many limitations. In places where abortion is illegal, people will be hesitant to tell doctors and researchers about their experiences for fear of judgement or persecution. Some researchers believe that the stigma that surrounds abortion likely contributes to a great deal of the negative mental health outcomes that can follow. Research has shown that abortion patients who are harassed by anti-abortion picketers often experience anger and guilt as a result. Adoption is often presented as an alternative to abortion, but the mental and physical consequences of adoption for mothers (as well as the mental and physical consequences of pregnancy) cannot be understated. Very little research has been conducted on the mental health consequences of relinquishing a newborn, and this area of study is subject to many, if not all, of the same limitations as abortion research that I discussed previously. The stigma that surrounds unplanned pregnancy, adoption, and grief makes studying the mental health impacts of adoption difficult. Still, studies have shown that the grief that comes with relinquishing a baby can be devastating and life-changing, with more grief symptoms than women who have lost a child to death. Of course, sometimes adoption is the best outcome for everyone involved, even if it’s painful, just as abortion is sometimes the best outcome. Both are incredibly personal choices that are often made in tragic circumstances, and no individual or government has the right to restrict that decision. One choice is not universally right or better; that’s why it’s essential that it remains a choice. Taking away that choice will result in injury and death for many. And, in some cases, it already has. In Poland, a 30-year-old mother named Izabela died of sepsis because her doctors refused to abort her 22-week-old fetus, even if they were aware of severe foetal defects. The fetus was unlikely to survive because of developmental defects, but under Polish law, the presence of a heartbeat meant that Izabela couldn’t legally get an abortion. One of the last text messages she sent before her death read “I hope that I don’t have septicaemia, otherwise I will not make it. It’s dreadful. And I have to wait.” Her death spurred massive protests in Poland and around the world, prompting the Polish government to clarify that abortion is allowed in circumstances where the life of the pregnant person is at risk. Unfortunately, says Katarzyna Kotula, one of the organizers of these protests, “the doctors will be afraid to perform abortions,”. Healthcare providers are in a difficult position where they could be forced to choose between their patient’s life and breaking the law. How can we reduce abortion rates? While abortion is an issue wrought with tragedy, there are success stories where abortion rates have been reduced without restricting it. The state of Colorado has one of the lowest abortion rates in the United States because they made family planning a public health issue. Intrauterine devices (IUD), which can prevent pregnancy for years and don’t require women to take a pill every day, are available for free if you qualify as low income. Pharmacists can prescribe birth control, so people don’t have to pay for a doctor’s appointment to access it. Also, the morning-after pill is available over-the-counter. As a result, the teen abortion rate decreased by 64%. It is estimated that these measures saved the state nearly $70 million. The percentage of high school drop-outs in the state has also reduced. While these measures are, in my opinion, the best way to reduce abortion, it’s important to remember that not everyone can take birth control and not everyone chooses to have sex. The most important thing is that our bodies remain our own to control, and this cannot happen if abortion is restricted. NHS Abortion Information & Resources Support Planned Parenthood

The COVID-19 outbreak hit us in March 2020, in the second year of my undergraduate Psychology degree. I experienced the national lockdown in London and was restricted by international flights and a 14 days hotel quarantine making it hard to get back to my home country, China. Last September, I came back to London for my professional placement programme, but the second lockdown kept me alone inside a 22m x 2 studio for most of my time. I believe many overseas students like me would have felt the same. Being away from family and friends for 6 months or even the whole academic year, while at the same time being exposed to uncertainty and changes, is definitely an unpleasant life experience. Cancellation of direct flights and extended quarantine duration made my way home a more complicated procedure. I found myself trapped in depressive thoughts and had the feeling that there was nothing I could do. I even thought to withdraw from my placement programme. But I am proud to say that eventually I was not defeated by these challenges because music guided me to escape from this trap. I spent most of my leisure time on music. I listened to my favourite songs every day before bedtime and after waking up. I also had online singing lessons once a week with my coach in China. Although I’m not able to tell you the whole story in these short paragraphs, I want to use this opportunity to tell everyone who had similar COVID experiences or who is currently suffering from long-term social isolation not to give up on music. If music is something you can’t live a day without; if music is one of your hobbies, just keep doing it. Music heals me, and I hope it can also heal you all. With this piece, I will introduce others’ stories with music and what science tells us about the power of music, specifically during this pandemic. Recently, I was deeply moved by a heart-warming story of a friendship formed during lockdown. I watched a video on YouTube, where a young man, Giorgio Lo Porto, found out that his new neighbour was a pianist. Driven by strong curiosity behind the piano sound, Giorgio left a note to request whether they could play “My Heart Will Go On” for him. After getting a reply of “Yes”, Giorgio started to meet his mysterious neighbour by playing duets every weekend. This was his way of saying, “I don’t know who you are, but I’m here. You are not alone”. Later, Giorgio finally got to know that his new friend, Emil, was a 78 years-old man originally from Poland. Coronavirus has taken his wife away last December, and the piano was all he had left. As a farewell gift, Giorgio wrote a song to picture Emil’s life and to memorise this special friendship. Unfortunately, the story didn’t get a happy ending because Emil sadly passed away one night before moving out. Nonetheless, the healing power and hope passed through the wall made Giorgio realise that playing duets with Emil was not only about fighting loneliness during lockdown, more importantly, it is about kindness. “I knew very little about you, but you’ve changed my life.” I believe that music connects us, even between strangers. Music brings hope during lockdown; also, music itself is hope. We saw this in a worldwide example showing that music can convey motivation with the famous balcony singing, which started in Italy during the first lockdown. Using balconies, windows and rooftops, people sang to each other and played music to applaud and show gratitude to their healthcare workers and lift one another’s spirits. What does science tell us about the impact of music during the pandemic? Music may be one of the most effective tools in maintaining mental wellbeing during the pandemic. While listening to music has been shown to improve life satisfaction, watching TV/movies/streaming videos were associated with reduced life satisfaction. As another example, a cross-cultural study demonstrated that music would be the most helpful activity for achieving different wellbeing goals across age, gender and culture. Compared with physical activity, reading, chatting, computer games, hobbies and meditation, music worked best to maintain a good mood, release negative emotions, and connect with oneself. Music was also efficient in distracting people from the COVID crisis and loneliness. Compared with sports and moving residence, listening to music may be the best strategy to manage stress under COVID restrictions. Although international students, like me, experienced greater COVID-related stress than local students, listening to music could maintain wellbeing scores around the same level in both cohorts. Music also maintains wellbeing in families during the COVID-19 pandemic. The interactive music engagement positively predicted attachment between parents and their children regardless of child age and change in time parents spent with children. Why does music help? Now you may be curious as to why music is so helpful for mental wellbeing, and here are some interpretations. Firstly,relative to social media use, listening to music is an active activity that involves more cognitive efforts. The more people have control over what is heard, the more positive outcomes they tend to experience. More importantly, music influences how we feel. Consistent evidence explains this aspect in three folds. Firstly, music can regulate emotions. Emotional regulation is an ability where people manage and respond to current emotions in order to maintain a state that favours them. Emotional regulation usually involves either down-regulation (e.g., reducing sadness by recalling something happy) and up-regulation (e.g. imminent challenge calls for excitement). For example, music distracts people from pain. In a recent study, adult participants focused their attention on a series of laser pauses which would make them experience pinprick sensations on their hands. The electric activity seen in the brain by scanning showed that participants reported the lowest pain unpleasantness while listening to their preferred music, compared with those who sit in silence or listened to white noise, who felt more pain from the pinprick. In this case, preferred music enables people to immerse themselves in a pleasant emotional state which offset pain perception. Secondly, music can induce desirable emotions which make people feel better. Unlike emotional regulation, emotion induction means genuine emotions can be generated or evoked from a relatively neutral state. It’s something just like crying at a moving movie. Due to differences in musical features, sad songs are usually thought to be unpleasant and less relaxing, whereas happy music would induce happiness and joy. This may be surprising as one of the studies I mentioned previously, by Vidas et al. (2021), where university students were asked to nominate a song that helped them get rid of COVID-related stress, they actually preferred “sad” songs. You may also find it counterintuitive because perceived emotions are sometimes different from felt emotions. Although sad music will be perceived as sad, the experience of listening would evoke positive emotions. In this study, participants perceived sad music as more miserable but actually felt more romantic, more delightful and less tragic. Thirdly, music promotes communication. Parent-child singing of lullabies and play songs contribute to better emotional regulation and development in children. Now you could understand why increased music engagement led to improved parent-children attachment during the pandemic. What about Music Therapy (MT)? Music therapy (MT) is the clinical use of music instructed by therapists, which usually involves receptive (e.g., listening to music) or active (e.g., improvisational and composing music) activities. MT is an evidence-based technique to address physical, emotional, cognitive, and social needs of individuals. Although there aren’t many studies published, the usefulness of MT in maintaining mental wellbeing during the pandemic is still promising. A 5-week receptive MT session could significantly reduce perceived sadness, fear, worry intensity, and tiredness. Listening to customised music tracks provided more of a profound positive influence than listening to pre-selected music tracks. Similarly, participants who received a combination of yoga and receptive MT session 30 minutes a day over one month reported alleviated severity of depression, anxiety and stress dramatically, regardless of whether they were diagnosed with mental disorders or not. If someone were to say that COVID restrictions close the door to the physical world, then I think that music is a key that could lead us to our spiritual world and to each other’s spiritual world. Although not many new studies have looked at music and mental health during this pandemic particularly, the effectiveness of music therapy can be generalised in treating a wide range of mental disorders. For example, the SHAPER project (Scaling-up Health-Arts Programmes: Implementation and Effectiveness Research), led by Prof. Carmine Pariante and Dr. Daisy Fancourt, aims to provide singing, dancing and music sessions to hundreds of patients with postnatal depression, Parkinson’s disease and stroke. According to previous literature, researchers expect that this large-scale study could help mums reduce symptoms of postnatal depression, improve social wellbeing and fluidity of movement in patients with Parkinson’s, and enhance recovery in stroke patients. If you are interested in reading more about music and mental health, you can read previous blogs on InSPIre the Mind, such as Singing Out: Music and Mental Health, When Hip-hop Meets Psychiatry, and When words fail, Music speaks: Dementia and the Power of Music. Every time when I look back on my past 6 months, I appreciate that this pandemic gives music a new meaning rather than it just being my favourite hobby. That is, music became the most effective tool to help me release COVID-related stress and it became my best friend, accompanying me through one of the most difficult moments while studying abroad. As we have seen, the research shows that both recreational and professional use of music can have some very powerful effects which will continue to impact our lives, even after the pandemic.

I am a big “smiler”. I smile at strangers in the street. I smile when entering a shop. I smile every time I make eye contact, no matter with whom. I have never done research on this, but I am aware of studies showing the transformative power of a smile. And I like to smile when I am running. In fact, it is an important moment of human connection that builds my resilience and propels me for the next kilometre. I have talked about human connection while running in a previous InSPIre the Mind blog at the beginning of the pandemic. While I do try to smile at everybody, I find myself going a long way in order to make eye contact and to smile at some people in particular. It is not a choice I have rationally made, it is how my emotional, personal and professional experiences (I am a psychiatrist, for those of you who don’t know that) are instinctively guiding me at present. One day it may change. In no particular order: 1. Other runners You are the ones who truly know how much I am struggling and suffering, step after step. And I know your efforts, I see your sweating, huffing and puffing. But my empathy does not stop with the communion in physical efforts. I smile and I am wondering — why are you running? What stresses and tensions are you running away from, or running through? What are you thinking at the moment? What are your emotions while you are running? I hope you will feel better at the end of the run. 2. Pregnant women You are probably fed up with one more person smiling at you, another stranger’s congratulations. But I can’t help it. You are so brave — bringing another person into the world. I smile and I am thinking — how are you feeling? Are you happy? Are you scared? Do you have enough social, emotional and financial support to go through this challenge? As a perinatal psychiatrist I know that one in four pregnant women will experience some mental health difficulties: are you one of them? I wish I could ask you these questions. Offer my help. But I can only wish you luck from the deepest of my heart. 3. Skateboarders You are absolutely supercool. And supergood. And superfearless. You are fast. You jump. You do tricks. You slam, get up, dust off, and try again. And you are so much like my nephews. I smile, and I am remembering — a London Summer in 2011. When my nephews were 10 and 12, and I was 45, and we started skateboarding together (I took private lessons with an instructor to minimise the risk of injury, and I still managed to break my rib). So many things have changed since then, but their skateboards are still in my flat. So, I smile at skateboarders because they don’t know that this middle-aged smiling runner is an honorary member of their tribe. But I do. 4. Families with children In any combinations of single or multiple parents or caregivers, the more children the better. Let’s be honest, I am probably the only one smiling at them, most people in the park will anticipate their loud noise and move away. But I embrace their appearance. I wink to parents to tell them I am on their side, they also need support! But it is the children I smile at. I smile and I would like to know — who and what will you all become when you grow up? How are your lives going to be? What ups and down will you experience? What joys and sorrows? I was you, many moons ago, and all things considered I am happy with how things have turned out. I hope you will be happy too. 5. Older people I see you from a distance, walking slowly, perhaps with an aid, perhaps alone, perhaps with a dog, perhaps as an old couple. My first thought is to maintain distance, I don’t want to bump into you inadvertently, to spring on you and disrupt your unsteady gait. But I also want to smile at you. I smile and I would like to tell you — how much I admire you for all the things you have done. That I am so curious about how your lives have been. That I am thinking of the happiness and the pain that you have experienced. The people you have lost. Your regrets. The ‘sliding doors’ moments that you are still thinking about. And I know that one day I will be you, and I hope runners will smile at me.

COVID-19 has fundamentally changed the nature in which we have been interacting with our friends and reaching out for support. As the world catapulted into a digital form of operating, our relationships had to equally match this shift and we’ve found ourselves needing to seek support through our devices more than ever before. This has not only translated in the sphere of accessing professional support, which I previously bemoaned, but also in our normal interactions with those we trust. Over the last year, we’ve all picked up our phones more than ever before. If you’re anything like me, the thought of having to make or receive a call was enough to make me second-guess any decision to pick up my phone; there seems to be something about the disconnected space that makes any attempts to reach out feel a bit artificial, and maybe that explains why a lot of us prefer texting over calling. It feels like there is an awkward silence always demanding to be filled, even if by meaningless murmurings. Offering your support to a struggling friend would always be more easily fulfilled by an in-person visit, where you could embrace those mutual moments of unspoken understanding without any feeling of tension. You could take the time to consider over what would be helpful, instead of blurting out the first idea that pops into your head in a need to minimise the silence. Yet as soon as a phone call enters the picture, that seems to drop from the equation, and we start blundering around how best to support those we love. I’ve certainly had my fair share of humorous, good-intentioned attempts from friends to soothe me over the phone. The first time I tearfully called my best friend for some comfort and support in November last year, she asked me if I wanted to join a Discord gaming channel that she shared with some of her other friends — despite the fact that I am not a gamer, and didn’t know any of the friends on said Discord channel. Nor had I ever been into gaming in the 8 years that we’ve known each other. Almost immediately after she blurted the suggestion, there was a brief moment as her suggestion sunk in, and I could almost see her facepalming through the phone. Despite the seeming absurdity of the suggestion at the time, I didn’t feel too taken aback even though it was not what I had anticipated at all. I understood the difficult position that she must have been placed in; she was asked to do something that she had never done previously, nor had been taught about. It makes sense that in a panicked attempt to help, the first hurried suggestion wasn’t her brightest moment. While we both now look back at the situation with humour, it did open my eyes to the fact that we have previously been able to remain blissfully ignorant about how to support someone the first time they call you for support. Conversations around how to navigate this unfamiliar territory could have avoided this situation happening, but it was never something that occurred to us before when we could show our love in person. The prevalence of innocent oblivion struck me again on another occasion, when I was mid-panic attack and phoned a different friend for assistance. As she picked up the phone, her first question to me was whether I had some work I needed help with because she had called a few hours ago with that exact query. Before I had even opened my mouth to speak, she had made an assumption based upon our prior correspondence and thought that with the proximity of time, what I was calling about must be related to our previous conversation. While her dismissal of my problems was completely unintentional, it again raised some interesting points for me, about whether or not we needed ‘phone etiquette’ so that we don’t accidentally shut someone down before they have even had a chance to voice their issues. Supporting someone through the phone isn’t a topic that comes up in everyday conversation, nor is it a skill that we get explicitly taught, but the last year has highlighted the importance of speaking about this issue. Even when we’re able to hug our loved ones again, there will be moments when you cannot be there for them physically and so learning how to offer relief by the phone will still be invaluable. Although each interaction will be unique and require its own approach, there are a few general ‘dos and ‘don’ts that I have noticed from my own experiences which I hope will be generally applicable. Having had conversations with those around me, speaking with my therapist, reading, and drawing from my own experiences, there are a few pieces of advice I’d like to offer for thought. Whether you have provided relief over our cellular devices multiple times previously, or you have yet to confront this type of situation, I hope that what I can offer will be useful. Firstly, do listen to what your friend has to say. It sounds obvious enough, but being able to truly listen so you can understand your friend’s position, instead of listening to respond, requires concentration and conscious thought processing. In most of our everyday conversation, our minds are preoccupied with thoughts about how we can reply and what we will say next, instead of placing our focus on the immediate words being spoken by the other person. In a phone call, it’s particularly important to make an effort to hear the thoughts being shared, as it will be difficult otherwise to understand the perspective your friend is coming from and empathise with their difficulties. Instead of thinking about what you will say or do in response, try to use that energy in understanding why your friend is feeling the way they do. This links into my second piece of advice, which is to validate the emotions and feelings that are brought into a conversation. After you listen and gain insight into what is going through your friend’s head, do reaffirm your friend that what they are experiencing is valid. Personally, there have been far too many times where I have questioned my own feelings, wondering if I’m being overdramatic or reacting excessively to a situation. This fear and confusion then compound onto the negative feelings, leading me into a deeper rabbit hole of hopelessness. By reaffirming your friends’ experience, you show them that you are respecting the concerns and doubts they are entrusting you with, and gently guide them out of the cycle of self-doubt and reprimanding. Thirdly, do reassure your friend that they are not being a burden. It is far too easy for those reaching out for help to feel like they are impinging on the time of others and bringing inconvenience, making them reluctant to fully open up about the support needed. There’s an attached fear and anxiety when the caller has to go through the motions of picking up a phone, inputting a number, and then putting their hearts on the line as they uncertainly await for a loved one to answer. When the intense internal feelings are already wracking havoc, a kind but firm assertion that your friend is not burdening you will release the tension built-up with every ring of the phone. Turning to a few other ways you can respond, there are three ‘don’t’s that I would like to mention; don’t be afraid to embrace silences, don’t feel like you need to provide a solution, and don’t be afraid to ask questions. When someone calls, they are not doing so with the expectation that you will fix all of their issues; for the majority of the time, they just need someone to listen to them and help them cope with their instantaneous external environment. You don’t need to fill up every crevice with sound, and you don’t need to constantly be providing a productive resolution; unless they explicitly mention otherwise, it is unlikely that your friend is calling you to help them glue the pieces of their life together. They can do that themselves, but just not at that moment which is when they just need a listening ear. In a similar vein, don’t be afraid to clarify how you can best assist, or if there are any practical actions they would like you to take afterwards to follow up. As we continue maintaining virtual relationships, I hope that there will be less well-intentioned, but misinformed approaches to supporting your friends and loved ones through the phone.

I was first introduced to musical theatre when I was about 8 by my Papa — he had the Les Misérables soundtrack and after finding myself singing along to most of the songs, enjoying the melody, it was on repeat. I remember singing along to them in the car on the way to school when he would take me, especially Castle on a Cloud, being a child too. I mean what young girl who was just getting into musical theatre didn’t? A classic. From then on, my love for musical theatre only grew, I’ve loved a fair few musicals over the years — all different styles and musical messages throughout but Les Mis remains my firm favourite. Musical theatre isn’t just about enjoyment for me but also seeing the smiles from my family’s faces, enjoying it just as much as me. Being in the moment, surrounded by song and stage, it’s beautiful. I have Cerebral Palsy and I’m a full-time wheelchair user. As part of my disability, a have a slight stammer, when speaking this is very frustrating on a daily basis. My escape for this is singing — an outlet for me as I can be myself, and it’s a freeing feeling to not have to worry about the words. Fascinating how the other side of the brain differs and is a positive light for me. I’m glad I have this hobby which encourages me to continue my passion. I’m grateful that my family support me with anything that I want to achieve in life and I never let my disability hold me back as you only get one chance in life, so make it count. The joy of musical theatre for me is having the chance to show my emotions through the character and really connect with the song; in those moments my own thoughts don’t play a factor and I focus completely the role. There’s nothing more uplifting than having the audience enjoy your performance and feeling like you’ve done your best. Currently with the pandemic, like for many others, my mental health has taken a hit. Our sense of normality will forever be changed now from what was but I feel there are still positives for artists: having the capability to showcase their work online, making new connections from various platforms. Yes, social media is a vicious world but it can also be a handy tool for gaining any form of exposure. Since finding my love for music, it’s what I’m studying now and when you study what you love, it feels right. Music is something that means a lot to me as I have a stammer and not being able to talk fluently at times is very frustrating. I’m a singer and so when I sing my stammer leaves me and I can really be myself and not have to worry about the lyrics — it’s a wonderful feeling. I’m my own person when I sing, putting my own spin on songs — removing the pressure of others telling you how things should be done — your song your way, is always the mindset I have. However, it’s certainly hard knowing if your own portrayal is to everyone’s liking. It’s said that the first three takes of a song will be your best and as I’ve gotten older I’ve realised that’s true. Overthinking certainly plays a big factor with singing, always thinking you can do better but it’s also really tiring and frustrating, going over a song numerous times when really the best version has already been done. I’m still learning that. Yes, I have my good and bad days with my mental health. As I’ve gotten older, mental health has definitely played its part, especially anxiety. Mixed with my stammer, my disability, the stresses that come with being a wheelchair user, and making sure everything is accessible as possible, I’m glad I’ve found music and music’s found me, my escape. I wouldn’t change who I am, all my ‘quirks’ make me the person I am today. Not only am I doing music because I enjoy it, but I’m also doing it because I want to raise awareness of disabled musicians in the industry, using my platform for good. So many disabled musicians like myself get pushed away due to inaccessibility. Have you ever seen a singer who’s in a wheelchair live on stage? It’s time to change the narrative for the better. Anything is possible, don’t have anyone tell you otherwise, do what you love and make the most of it!

I was working as an assistant teacher in English in my hometown Qingdao, in China’s eastern Shandong province, during the summer before starting Medical school in the UK as an international student. After I had settled in, one of the first students that was introduced to me was a high school boy. His teacher mentioned that he is very talented and hardworking, but suffers from mental health problems. I knew this was something that I should bear in mind, but since nothing related to his condition had appeared obvious to me during our interactions, I soon threw this to the back of my mind. What happened later was not foreseen. The experience gave me a realisation of how much mental disorders can interfere with people’s lives, and this is where my interest in mental health began. As a medical student with some theoretical knowledge on mental health, I had never felt the effect of mental illness on people until encountering this student. And this quite unique experience on the stigma with OCD is what I would like to share in this blog. In one of our lessons, we practiced IELTS English speaking questions, which is an exam that international students need to sit in order to study in the UK. In a question on multitasking, the student mentioned something, something which went unnoticeable at the time. He mentioned in his answer that he was less able to focus now as he had Obsessive Compulsive Disorder (OCD). OCD is when people have obsessive thoughts or compulsive feelings. Usually people think of this as when people have to wash hands three times or having to organise things in a strict way, but that is not completely true. There are also other symptoms of OCD that are not commonly know by the public. Those may include being constantly aware and focused on body sensations such as breathing and blinking, worrying about being hurt, or having unpleasant thoughts or mental images suddenly dominatinng their minds. Moreover, OCD is not only about those obsessive behaviours, but also the mental sufferings that come with those actions. For example, a person without OCD may want to be super organised to achieve personal satisfaction and make themselves feel good, but a person with OCD doesn’t get any satisfaction or enjoyment out of the process. They may feel powerless to stop the thought of “have I locked my door?” from constantly emerging, and waste hours everyday just trying to check once and once again whether they have locked their door, in order to neutralise or make their obsessions go away. This process is torturing and distracting, and greatly interferes with people’s everyday life. In all of my previous knowledge with OCD, it was mentioned under joking contexts, whether online or in real life conversations, to describe people as being perfectionists. It was such a buzzword and had always seemed to be a ‘commendatory’ term. I had never realised that this is an actual medical disorder which can cause much distress to the people affected by it. With those presumptions in mind, I was a bit surprised to see that he was able to add a bit of ‘humour’ to his answer. ‘Great language proficiency and niche vocab’, I thought. The previous information that I was told about his mental health conditions was, well out of my mind, and my reactions were of course far from the perfect response I would have if I knew that this was not a joke. The flash of realisation only caught me after I finished work. It struck me all of a sudden when I was walking home. Mixed feelings rushed in. Guilt. Remorse. Sympathy. They were light, but persistent. This was unforgettable, especially considering that I am a medic who should have more prior knowledge on mental health. I had lost the chance to react to his answer, and never found an appropriate opportunity to apologise. A few weeks later, he was absent from one of our scheduled lessons. He sent me a long text explaining what had happened. “I’m very sorry, and I don’t know how to explain this to you.” His mental condition had worsened, and he had restarted taking medications for his disorder, which showed some obvious side effects. He had found himself extremely sleepy, and it was hard to gain consciousness until very late in the mornings. I remember him was trying to assure me it wasn’t a case of going to sleep late. He mentioned how he did doubt about his willpower, but his consciousness level had changed completely compared to when he was not taking the medication. That was absolutely fine and understandable. But the question I had immediately, was that why is he trying so hard to explain and apologise for something that should be so comprehensive and seemed to be common sense? It then was apparent from his descriptions, that the people around him, but perhaps himself too, were not well equipped with sufficient information about mental health. The fact that some drugs for mental disorders have side effects is not something that is generally known and understood, at least in the environment that surrounds him. He was afraid of being blamed and thought of as finding excuses, or putting off responsibility, so he had tried to confess that there were other personal elements in this as well. But there was not. It is a mental health condition, not a personal resilience issue. The experience with this student was a powerful one, and is one that is stuck in my mind until this day. It made me realise that the education on mental health at least in my city was far from enough, and there is still a big stigma yet to be resolved, on a regional, and likely, national level. Due to the hugely distorted images on mental illness created by media and film, and lack of exposure to more realistic and scientific resources, the negative associations with mental illness have nearly become a ‘fact’. Even when I simply look at words of some psychiatry related illness in mandarin, unpleasant scenes would still emerge in my mind. We have already known that the most effective way to reduce stigma is through social contact, like interaction and experience with people suffering from mental illness. Non-direct social contact through social media is also a very effective way to educate on a large scale. Hopefully with those methods in mind when advocating, more and more people will appreciate and understand the topic of mental health.

Sharing a part of yourself is never easy. Raising awareness for matters that are not widely discussed, especially amongst young women, has always been an important aspect of me. Especially now with the current pandemic where a lot of people suffer from long-COVID, I feel this blog will help me reach those who have been suffering from several unexplained symptoms and want to understand what is happening. My name is Christina, and I come from Athens, Greece. I was always intrigued by the connection between mind and body. My main degrees are in Psychology and Neuroscience, but I have also obtained degrees in Classical guitar Performance and Music Theory & Composition. In this piece, I run through my personal experience with several physical and mental diagnosis leading to the dominant one. But I never feel it is either this or that. We should always take into account that as humans, one will accompany the other. There is no health without mental health — there is no difference between mental and physical health. It is only health. As an aspiring researcher interested in psychoneuroimmunology, I will try to break down some relevant notions. Starting my early school years, my friends and I would bet that whoever missed a day of school was a ‘loser’. Loving school anyway and never getting sick would give me an easy win. However, after the age of 11, the only thing I remember is being sick. By referring to being sick throughout the passage I mean either having the flu, a bug or inflammation causing me to get fever and several flu-like symptoms. While at the same time, tendonitis in my dominant-left hand (a condition where your tendon, the thick cord attaching a muscle to a bone, is swelling) knocked on my door. Doctors prescribed me anti-inflammatories for this, however, I had to be on and off these, as they would not help the acid reflux I had since I was a baby (a condition in which acidic gastric fluid flows backwards into the oesophagus, resulting in heartburn). Being an active kid and entering adolescence with lust for life, it destroyed me when doctors said to quit my activities, such as playing basketball. At the age of 15, I got a new diagnosis: hypothyroidism, a condition when the thyroid gland is underactive and does not produce enough hormones. Not only I had to give up basketball, soon, I had to also quit my guitar lessons because the pain caused by tendonitis was unbearable, even if I was a year away from my diploma. I could not write a single thing in school, which undoubtedly affected my mental health. Having my left hand affected by tendonitis, I tried to write with my right hand, which was a disaster. I remember writing during an English spelling test, and even knowing the words, my brain would not cooperate. My frustration at these experiences sparked my interest in the brain’s function. Studying science subjects in school and being a good student secured me a scholarship to study psychology in the U.K. I do not remember how I came with this choice as my symptoms impaired my cognitive functions a lot — all my teen and early adult years are hazy memories with gaps in between. Have you watched the movie “Brain on Fire”? If not, I recommend it to understand a part of the story. Funny fact: since my early teen years, I have been exercising, eating healthy, sleeping well and doing all the scientifically proven things to boost my memory and energy. Nothing helped me, maybe just a little to keep going. Along with my pain and struggles, I tried to stay energetic by studying, working, playing in an orchestra, doing volunteering work and being socially active. Neither do I know how I managed all of these, nor do I remember, but I kept going to the point where my body failed me. The beginning of the end Fast-forward to age 23 — my liver was failing for a year despite that I never smoked, did drugs or being obese, by a condition called chronic liver failure which is a form of chronic inflammation in the liver that causes bone and joint aches as well as pain or discomfort in the upper right side of their tummy. My memory was fading, the fatigue was overwhelming, but my will for life never failed me. While living my dreams (married to the love of my life, moved to London, and started studying Neuroscience), I had a traumatic experience that led me to the psychiatrist in December 2019. It was the only doctor I had not visited all these years, so I was trying to be open-minded. To the psychiatrist, that incident combined with my difficulty concentrating and lack of energy translated to a diagnosis of clinical depression. My inner self would tell me that cannot be right, however, as a person desperate to feel healthy again, I decided to take the antidepressants. But my health was declining — this meant I was lying in bed almost all day experiencing pain and confusion. After eight extremely painful years since 2011, the search about finding out what was wrong with me began. At this point, I am grateful to my parents, who forced me to return home, as it was impossible to find an answer in London. Following five months of visiting several doctors and hospitals, having done nearly all tests — plus having my mum by my side to support that I was not depressed; there it was! My redemption: autoimmune diseases. In short, this type of condition develops when the immune system produces antibodies that attack healthy tissue. I was prescribed immunosuppressants in October 2020, and after a month of revisiting the doctors, they were surprised that indeed, I did not have depression. I could breathe again! Sometimes it can be our immune system that fails us. The resulting inflammation causes fatigue, low mood, low fever, pain all over the body and other exciting symptoms, which is not clinical depression per se. When you are young and experience many different symptoms that doctors ignore for a long time, you start thinking that it is normal, you do not pay attention, believing that this is adulthood. Inflammation is the body’s function of fighting against harmful “invaders” from injuries, infections and toxins, in order to heal itself. This process takes place when something for example damages our cells and the body starts releasing chemicals that trigger a response from our immune system. As a result, inflammation can disrupt your mood as well. Who jumps up and down while being in bed with flu? Does that mean everyone has periodic depression? Not necessarily! It means your body is fighting and does not have enough energy, and this is something termed as ‘sickness behaviours’. A nicely explained article written by Dr Nettis about inflammation and sickness behaviour at InSPIre the Mind, gives a scientific perspective to that. Behavioural changes are observed in physically ill animals as well as humans during an infection. These behaviours include several symptoms such as lethargy, sleepiness, depressed mood, reduced social exploration, loss of appetite, hyperalgesia, and confusion. The set of these behaviours might be accompanied by fever in order to help the individuals to reorganise their perception and actions, to activate the mechanisms to cope with the infection. But imagine that 24/7 every single day when you are battling with an autoimmune disease. To shed some light, I would like to share my recovery that started almost two years ago. My treatment consists of prescribed vitamins and medications (one is hydroxychloroquine — thanks to COVID-19 this drug has become quite famous) by my doctor, eating a plant-based diet and doing some light exercising. I have also started meditation which helps with pain management and brain-fog. Flare-ups are always around the corner, yet you learn to live with them. Being a healthy energetic individual will never be the same but at least I try to value what I have. By embarrassing my struggles, I came off a stronger warrior. Somehow in my story, being a young girl did not justify me having abnormal blood results for years. It used to be overshadowed by the fact that the age of onset of autoimmune diseases is usually over 40 years old, albeit recent literature has shown, it may start even around adolescence. It affects more women than men, who are noticed by the doctors, usually when the situation is out of hand. Being young does not indicate absolute physical or mental health. This is why I believe we need more empathetic doctors. Personally, all the ones I visited as a teenager believed it was all in my head. After a severe fainting episode, a doctor in the ER told my parents: “She won’t make it to complete a university degree”. Well, here I am, completed my postgraduate while having a tough time, and I now start my baby steps into research. Depression is real and affects a vast proportion of young people, but it would be great to diagnose only when we have excluded other parameters. As I explained previously, I have experienced depressive episodes due to the physical battle of my body. But I could not relate to the description people with depression give. And experiencing all these as a teenager who enters adulthood was surely not the ideal circumstance. But thanks to my husband, family and friends, I did not give up. To conclude, nothing ever is just in your head. You need to keep searching till you have your answer. It does not mean we have to give up our dreams, but we might need a little more time to reach them, than we initially thought. As one of my favourite poets, Cavafy wrote, it is not about the destination than enjoying the journey. Connect with your happiness, connect with your sorrow because nothing is permanent, and all kind of feelings enable us to experience the journey of life to the fullest.

Let’s talk about the MINDEP study, my PhD journey and life after it. As a clinical scientist, it’s sometimes difficult to understand whether your ideas and research are good enough to have a future. You might present your project to your peers, or a much-feared funding panel, and, if unlucky, hear back three heart-sinking words: “And so what?” I have learned that a good question to ask yourself — to better understand whether you are going in the right direction — is: how is my work helping others? And if you are a medical doctor, like me, the ‘others’ I refer to are often people suffering from a debilitating disease. Depression is a very debilitating disease, and this is why people affected by it were the focus of one of my PhD projects, the recently published MINDEP study. MINDEP (MINocycline in DEPression) aims to improve the quality of care for people with Major Depressive Disorder. The results are the first step in the right direction, and I really hope they can be helpful for patients. In this blog, as promised in my previous one where I wrote about how inflammation can affect our mood and behaviour, I will describe this study and its findings, and I will do it through the lens of my recently concluded PhD journey. Let’s take a step back to understand exactly who I am trying to help with MINDEP, together with the members of my research group. I want to tell the story of a particular person suffering from depression: Colin (not their real name), the person who is waving at you in the picture. The story of Colin Colin is part of a group of three close friends. Unfortunately, there was a time when they all suffered from depressive symptoms. Colin, in particular, had a very low mood, no energy, nor appetite … some days he didn’t even want to get out of bed to go to work. His family was getting increasingly worried, so, during one of his sleepless nights, he decided to ask for help from the Doctor, and his two friends did the same. Colin and his friends were diagnosed with Major Depressive Disorder. The Doctor prescribed them an antidepressant that can have several effects, but the main one is to increase the levels of serotonin. This is a chemical messenger in our body, which helps with sleep, eating and mood regulation, but its function might be low in people with Major Depressive Disorder. After a while, both Colin’s friends felt much better and they went out to the park to celebrate together in the sunshine. However, Colin was quite disappointed, because the treatment did not work for him: he felt exactly the same as before. And that’s where the MINDEP study comes in! The MINDEP study Approximately 1 out of 3 people with Major Depressive Disorder (MDD) do not benefit from standard antidepressant therapy. You all might have a friend, a relative like Colin, who, despite therapy with antidepressants, don’t seem to get any better. Or you might be Colin. MINDEP focused on those people who don’t respond to antidepressants and whose depression probably is not only related to a deficit of serotonin. Some of these people have shown to have an alteration in their Immune System. We have already encountered the Immune System in my previous blog, where I used the picture below to describe it as an army of soldiers defending the body from stress or infections, through a process called inflammation. The most interesting part is that inflammation, reflecting the activity of the Immune System, can be assessed with a simple blood test, measuring the levels of a protein called C-reactive protein (CRP), which is directly associated with inflammation. If CRP is high, inflammation in the body is high, and vice versa. The blood tests of some patients, like Colin, show that their CRP levels tend to be elevated compared to the general population and research has shown that this is correlated with the severity of their depression. So, if increased inflammation in some people can contribute to depression, reducing inflammation might improve it! This is one of the novel approaches that researchers, including my research group, are adopting in recent times to help patients who do not benefit from antidepressants alone. When the MINDEP study started, at the end of 2016, I was a Visiting Researcher at the Institute of Psychiatry (King’s College, London) and had only recently moved to the UK from Italy. Having joined the Stress Psychiatry and Immunology Lab (the team who bring you InSPIre the Mind), I started to wonder whether in the long term I would make a good researcher. In the end, I decided to seize this opportunity to find out. A few months later, I started a PhD with MINDEP as one of my projects. MINDEP is a Clinical Trial designed for a particular group of people with Major Depressive Disorder, not benefitting from antidepressants and with high levels of inflammation. Participants who took part in the study carried on taking their prescribed antidepressants and we then added a drug called minocycline, an antibiotic, regularly used to treat acne vulgaris and inflammatory diseases, with the ability to decrease levels of inflammation in the body. To be sure that we were including patients who could actually benefit from this intervention, we specifically looked for participants like Colin: unresponsive to antidepressants and with elevated inflammation (CRP equal or above 1 mg/L) when entering the study. It wasn’t easy to identify eligible participants and to engage them, and it took longer than we thought, but we did it. Eventually. By the end of 2019, 39 patients suffering from MDD and who did not respond to at least one trial with antidepressant took part in MINDEP. Following a process called Randomization, these 39 participants were randomly assigned minocycline or placebo for 4 weeks. In particular, 18 took minocycline for 4 weeks alongside their antidepressant, while 21 took placebo, a pill which looked like the minocycline one, but did not contain any active treatment (see the picture below). My results I have a vivid memory of the period when the analysis of MINDEP data started: It was the beginning of 2020, when Covid-19 suddenly appeared, overwhelming all aspects of everybody’s life. I remember spending my lock-down months at home, looking at the data, trying to work and not think about anything else. What I found sounded interesting. At first, I found that minocycline was not more effective than placebo in improving depressive symptoms in our participants selected for CRP above or equal to 1 mg/L. However, I explored whether using another — slightly higher — threshold for inflammation, CRP = 3 mg/L, gave different results. This threshold (CRP above 3 mg/L) identifies people with a higher risk of cardiovascular disorders, and, interestingly, it has also been associated with having “treatment-resistant” depression. Among our 39 patients, 6 patients had CRP above or equal to 3 mg/L at the Baseline visit and were taking minocycline for the following 4 weeks. They showed a larger improvement in their depressive symptoms by the Week 4 visit when compared to all the other participants (those on minocycline with Baseline CRP below 3 mg/L and those on Placebo (as described in the picture below). Another important aspect to add is that minocycline was not associated with significantly more side effects than placebo, so it resulted to be an overall safe intervention. As mentioned above, these results were recently published in the scientific journal Neuropsychopharmacology, where you can find details about other clinical questionnaires that we used to assess depressive symptoms and other indicators of inflammation that we measured, in addition to CRP. From a scientific point of view, the results from MINDEP indicate that we might have identified the threshold levels of inflammation (CRP~=3 mg/L) that patients like Colin should have in order to benefit from minocycline. If known at the stage of the diagnosis, this information could help identify early those patients with Major Depressive Disorder who could respond to anti-inflammatory treatments like minocycline. Of course, we should interpret the data with caution. The number of patients who took part in our study, 39, is not a large number. Therefore, although positive, these results will need to be confirmed by future, larger studies. This is the intention of my research group! By the time results from MINDEP were published, I had submitted my PhD thesis (and I also received my first dose of Covid-19 vaccine, as I have face-to-face clinical contacts). My PhD final exam was a constructive and stimulating discussion on my research work, its impact and its future implications. I think the MINDEP study is important to me because it coincided with my personal trajectory into research. It was very exciting, painful at times, but I think this project and I grew up together. I have now resumed working as a clinical psychiatrist, but I have not abandoned research, which is still a big part of my daily life. Indeed, being in contact with patients reminds me very clearly what the final aim of my work as a researcher should be. With regards to MINDEP, if these findings are confirmed, they might contribute to help that 1 patient out of 3 who, like Colin, feels left behind in the battle against depression. I really hope this idea, and the research behind it, will have a future.

Aristotele once said that “the aim of art is to represent not the outward appearance of things, but their inner significance; for this, and not the external manner and detail, it constitutes true reality.” I am a photographer specialised in portraiture. Since the beginning of my photographic practice, the human element has been fundamental in my images. I have written about my interest in identity, and relationships between individuals and society in another Inspire the Mind blog. I love listening to people’s stories and exchanging feelings and experiences. But suddenly, everything was put on standby…the world was stuck, as the pandemic arrived! Fear and uncertainty took place, what if I cannot meet people anymore? This caused me a period of anxiety and uncertainty. This experience led me to turn to photography in a different way to what I was doing before. I began thinking that I had to change the way that I looked at my surroundings, and the kind of work I was making. Then, I realised that the pandemic was giving me the opportunity to slowdown and breathe. I wanted to understand if, through photography, I could figure out what had happened to me. What became important to me was to look at issues that were relevant to my life rather than attempting to follow the latest photography trends. As a result, my work became more intimate. With this blog I would like to offer food for thought about photography, when it triggers a creative process and transforms emotions, pain, and self-perception for a better understanding of ourselves. I describe my personal experience and how I got to a new approach to photography. Identity During this tough period, I started to rethink identity: what it means to me and how our perception could change given that we are all forced to stay away from each other. If we want to understand the nature of identity, I feel we need to approach it in the flickering screen of the outside world, which acts as a constant mirror of identity. It is a construction, meaning that our psychological identity is shaped by our surroundings, as discussed by the professor psychoanalysis, Paul Verhaeghe. It has more to do with becoming than with being, and it’s a process that starts right from birth. It’s no coincidence that the philosopher Hegel traced the origin of self-consciousness back to the gaze of the other. It is through that gaze, monitoring or loving, that we know that we exist. So, by affirming our existence through images, we can empower ourselves. Before the invention of the camera, people who could afford it relied on painters in order to be represented. When photography made its arrival in 1839, it did not take long before it became a much cheaper and quicker method of making a portrait of someone. People started exploring new ways to depict the surrounding and their self. The photographic revolution created, in the words of the art historian, John Tagg, a democracy of the image, where to be pictured was no longer a privilege but allowed anyone in possession of a camera to maintain an independent control of what was represented. After many more years, technologies allowed the self-portrait to evolve into the creation of selfies as a form communication. Healing Portraits, self portraits and selfies allow us to learn a lot about human beings and about that expressive jewel that is our face. To learn about the healing power of photography and how it can help us better express, understand and overcome mental problems. In fact, being a means of artistic expression, photography can also have a therapeutic function as it allows those who practice it to get in touch with their emotional state and to acquire a greater awareness of their inner self. The marriage between photography and psychology is not new. Many studies confirm that photography also represents a form of therapy used by people to acquire a greater awareness on some aspects of their personality. I have to say that phototherapy should be distinguished from therapeutic photography. In phototherapy, the use of photography is placed in a clinical setting and the images (photographs made by the patient or other people) are part of a psychological journey with a psychologist, as a personal and symbolic communication. By taking pictures and discussing them with others, and under the guidance and supervision of a specialist of the sector, this therapy could help with mental health problems. Therapeutic photography, instead, has no proper therapeutic purpose and can be used as a means to start introspective processes and personal growth. In therapeutic photography the photographer is driven by the need to communicate, to himself or to others, emotions with respect to the reality and what is happening around him. Nevertheless, you do not need to be a professional photographer: a mobile phone, curiosity, and the urge for a deeper perception of the self are sufficient when struggling with some aspects of mental health or when going through difficult times. There are many artists (Cristina Nunez, Jo Spence) who have expressly presented work on themselves as a form of self-therapy that unconsciously, in some cases, or more conscious in others, have affirmed their need to tell a moment, a feeling of discomfort or particular emotional charge … a negative event, illness or bereavement. Many photographers have dealt with themes related to death, relationships or (loss of) identity through photography as a form of self-expression. I found that out myself, and it proved helpful with my anxiety and sense of isolation. When I thought that I had no channel for being creative — being stuck at home — taking and posting or commenting on photographs helped me to remain connected with the external world. I can now say that photography practices can definitely improve the quality of life, especially during a long-term lockdown. For example, this research from 2018 at Lancaster University confirmed that a daily photography routine and posting images online improve wellbeing through self-care, interaction, and the potential for reminiscence. Tips Photography, especially in these times, is so at our fingertips: it is a very interesting, easy and fast way to voice our unconscious. We can use portrait and self-portrait as pain therapy and self-esteem growth. Here are some tips for improvised photography practice and for helping you with aesthetic choices: Put your emotions on your face, no matter our wrinkles or imperfections Translate them into a pose Find a location that could calm you, possibly with good light Eyes closed, head down, muscles abandoned, sitting there on a chair curled up … without clothes … or with our best dress… these are all signs of a life that flows inside us, that is beyond our control. Let the creative flow to guide you into your inner world. This type of photography allows us to unleash an unconscious creative process to transform our emotions and pain into images, and then work on photos and transform our own perception. Let’s break the mental patterns that lead us to always do certain things. It is about getting rid of difficult emotions and pain and enclosing them in photographs. Whether it’s a portrait of someone or a selfie…let’s just do it, let’s dedicate this space to understand something more about ourselves. In life it takes courage, not the courage of great deeds, but the daily courage to face all our fears and insecurities. Because ‘as Aristotele said, it is all about the inner significance’ and, this is pure exercise in love of the inner self. A creative process that is therapeutic in its affirmation of one’s identity to love and feel loved.

From a young age, I always wanted to perform. As a toddler, my mum put me in all of the ‘little girl’ classes — ballet, gym-bunnies, the list goes on. Little did she know that I was going to scream and cry as soon as she left the room, so much that she would end up having to sit outside the room for my 2 years at playgroup. In primary 1, when I’d grown out of my abandonment issues, she decided to let me go to active school dance, once a week after school. After our final performance, the teacher came up to her and said ‘don’t ever let her stop dancing, she far too talented’ and I think that’s when my mum knew that this was more than something that only she thought I was good at. Looking back on that video, I still wonder what on earth was that teacher talking about. I was awful!! At age 12, I was the youngest cast member at the Edinburgh Playhouse’s production of Footloose. I was in the amateur cast for the Brunton Theatre’s pantomime for 5 or 6 years. I was addicted to the stage and how it made me feel. I somehow managed to juggle all of this along with school work. I decided to work really hard at dancing; switching dance schools to a more advanced teacher, where I started improving so quickly that I soon developed the nickname of being like a sponge. I was serious about it, and the amazing thing was, my mum was so supportive. If there was an extra class, I was there. Even if the tuition fees were a lot, it somehow still happened. When I was around 10 years old, my sister was diagnosed with MS (multiple sclerosis) and my mum was diagnosed with Fibromyalgia. As a young carer back then, as cliché as it sounds, dance was always my happy place, being able to set aside my home life from my studio life. I didn’t realise at the time truly how much it helped. Don’t get me wrong, home life was still very happy, but dancing was truly where I could escape for a while. Looking back, I see this outwardly confident young girl, but I know it was all for show. The truth was, I had it in my head that I should come across confident and happy all the time, even if that’s not truly how I felt. I was a people pleaser and that weighed me down. In my 4th year of high school, I decided to take on one of the hardest and toughest ballet exams I had ever sat. I would be at the studio 4 or 5 times a week— even catching a bus from school during PE twice a week. I was determined to push harder than ever to be what I believed to be perfect. And that’s when I ruined it for myself. I’d put far too much pressure on myself. This is when I broke. I guess I had to learn the hard way that perfection was something every dancer was striving for. That no one is ever truly perfect, and the only person I really had to please was me. It’s a hard pill to swallow, and I feel to be happy, nearly every performer, dancer, singer, actress experiences this to some degree. So, I started looking for other ways to express myself, and one of those outlets was musical theatre. It’s helped my mental health, as it was a way to let my feelings out in a safe space, and acting/musical theatre let me become a completely different character than who I actually am. I swear every theatre kid says this, but it is true, I could become what I felt inside. If I was sad I could sing about it. I could relate to more serious monologues. It also made me more confident in both presenting myself but also communicating with people. This time, it was real, genuine confidence. Fast forward a few years, I am now in my second year of studying dance at Performing Arts Studio Scotland in Edinburgh and I am loving every second. I have such amazing lecturers around me, and friends who are genuine due to being interested in all the same things. I’ve had so many opportunities that I would never have taken if I hadn’t had come so far internally. All thanks to dance and being able to express myself. When COVID and lockdown hit, I thought this was it. Everything was over. However, I was still able to dance, stretch, and take classes from people all over the world. I was able to keep myself occupied doing what I loved, even if what was going on elsewhere in the world wasn’t good. Even since January, I feel I have accepted the way things are. Three lockdowns later and I feel like a pro. I've mastered ballet in the kitchen without sticking my knees in the washing machine. I've become a whiz on Zoom. I feel now like I can tackle anything and find a way to make it work. My mental health has gotten a lot better too. I’ve finally, for the first time in ages, allowed myself to take that day off when I get overwhelmed. I've learned to ask for help when I need it. Whenever life gets too much, I remember I am able to vent to my flatmates and my lecturers. They truly know how it feels and we are all just carrying each other through to the other side. I'm not going to lie, I'm nervous about how the world and the performing arts industry is going to look when we are finally out of lockdown. In a way I'm glad I still have a year of training ahead of me before I have to go back out into the ‘real’ world on my own. I suppose it is really us – the performers – that will truly dictate how it is going to look, and we are shaping the industry into what it will eventually be. Silverlings, I suppose; in some ways, I guess you could say COVID was somewhat of a blessing, giving myself and so many others time to pause, work on ourselves, and do the things we love.

In the UK, COVID-19 restrictions have begun to ease from March 8th, 2021 after a punishing 3rd lockdown during the British winter. The new roadmap has plotted a path to removal of all legal limits on social contact in England by the 21st of June. In the oncoming months of gradual easing, what might the mental health landscape post-lockdown look like? What emotions may be likely? What evidence-based strategies might help with the emotions of transition and coping with the profound changes that the pandemic has brought? My name is Mia Eisenstadt, I’m a writer and researcher at The Evidence Based Practice Unit and Paradym. My research over the past 4 years has focused on the lived experience of stressors and understanding the protective factors that reduce the harmful effects of stress and bolster resilience. My interest in blogging during the pandemic has been to raise awareness of mental health during COVID-19, as well as to bring attention to those groups that may struggle more in these uncertain times, or belong to communities that have been disproportionately affected by the pandemic, such as BAME communities and minoritised groups. I’m particularly interested in the diversity of experience. For example, for many people the lockdown has been difficult and challenging, but for others, it’s been an opportunity to stay at home and focus on the things they love doing. My previous blog focused on the topic of the way that stress affects young minds. In this new blog, I discuss some possible emotions that may arise in the transition out of lockdown. I offer existing evidence-based strategies that may help with a possibly bumpy, and certainly gradual, transition. Direction of travel: The roadmap for lifting lockdown Whilst the transition out of lockdown is a welcome change for many, it is not a clear trajectory towards normalcy. It is difficult to say that the ‘R’ (the average number of people I would infect if I were to be infected with the COVID virus) will continue to go down until the summer and into the winter. Whilst the outlook is optimistic, scientists are keen to emphasise that careful observation is needed to check that the R won’t leap up again following opening up of public places and large events. It’s possible that it is not a linear path and there could be setbacks. Sage member Professor Andrew Hayworth has cautioned that it’s difficult to accurately predict. Many of us, who have not booked holidays or attended gatherings with friends and family for some time, eagerly await the chance to make fun plans and attend special events and trips. Such plans bring hope, eager anticipation and positive feelings that stems from seeing family, having a hug with a loved one, social meet ups, holidays, day trips and many of the aspects of life that lead to a lot of excitement and joi de vivre. Planning positive activities is proven to improve mental health and increase feelings of happiness and wellbeing. In fact, a number of evidence-based mental health therapeutic approaches encourage people in therapy to organise positive activities to support their mental health, enhance social connection and improve quality of life. Things to look forward to are needed to provide hope in a context where many grim changes have resulted from the pandemic. The rise in anxiety, depression and distress in both children and adults is well documented world over. Increased substance use, and particularly alcohol consumption has become a major problem. In the US, younger adults, people from BAME communities and essential workers reported increased alcohol intake and suicidal ideation. The far-reaching effects of the pandemic The pandemic has brought in drastic ruinous economic and social changes such as unemployment, business failure, poverty, a rise in reliance on foodbanks, distrust of government and science and increased uncertainty. Whilst there are many positive prospects of moving out of lockdown and the vast coverage of the vaccine roll out in the UK, there remain a number of unknowns. Will I need to get a vaccine regularly, annually? What do I do about my aunt that does not want to get the vaccine? Will I need a vaccine passport? Will there be new mutations? Is the pandemic a blip or here to stay? The number of uncertainties about the future has drastically increased. A context of uncertainty, lockdown restrictions and increased risk of exposure to Covid-19 is a fertile ground for increased worry and anxiety. Fortunately, there are a number of approaches from psychology that can support the reduction of worry and anxiety. Here, I’ll discuss two approaches: emotional reasoning and mindfulness. Emotional reasoning Four years ago I was in a car accident. Luckily neither myself nor the passengers in the other car were badly hurt (my car came to the end of its life). It was terrifying and ever since I am a nervous driver, specifically on four-lane British motorways. Whilst any driver would agree that four-lane motorways require caution and careful driving, they do not require sweaty palms and racing thoughts. My stress response on a four-lane motorway resulted from my perception that they were more frightening than they are in reality and my thoughts could be described as reasoning from my emotions. If I noted my emotions and take steps to make myself feel safer, I will feel better. If, however, I suddenly reached conclusions about four-lane motorways that may not be true- this would constitute emotional reasoning, a common type of cognitive distortion (an unhelpful thinking style). Emotional reasoning is where a person assumes that their own experience or emotional reaction to an event defines the nature of the event itself. There are many instances where our emotions can influence our accurate perception of the situation. Part of Cognitive Behavioural Therapy (CBT) involves learning to separate thoughts and emotions and stop an internal narrative forming that is based on emotion, rather than objective fact. In the context of new vaccines and the uncertainty about the virus and its possible variants, it’s possible to fall victim to emotional reasoning. When being separated from particular friends and family for a long time, it’s possible to draw negative conclusions stemming from months or even a year of separation. From a CBT perspective, it would be advantageous to check individual assumptions before reaching any conclusions about the nature of a relationship after lockdown. With the emotion of missing others and fear of missing out (FOMO), it’s possible to misinterpret others’ behaviour. However, via considered questions and seeking answers as it’s likely friends and family reciprocate the longing that is part of separation. The end of lockdown may bring some intense emotions. The highs of being able to have a BBQ with family, attend a party or take a long-desired trip. The lows of the changes in relationships, jobs, mental health or even the wider social landscape. Many people have moved house or moved across the country. More people are suffering from symptoms of anxiety and depression. Some continue to struggle with long Covid. Some people have experienced positive events, such as a wedding or a book launch, other’s are bereaved and have struggled to grieve during lockdown or have suffered a massive loss of income, such as many musicians and artists. There is a vast range of possible emotions, from elation to despair, as we both collectively and personally navigate out of lockdown. Emotions that may be influenced by a likely inevitable aspect of social comparison perhaps compounded by the fact that our lives are increasingly mediated by the internet. What strategies help with managing emotions? Mindfulness can help with managing emotions. “Mindfulness has been described as the practice of “bringing attention and awareness to one’s momentary experience with a sense of acceptance and non-judgment” — (2017, P. 109) Whilst mindfulness is currently well known in the West, the philosophy and practice originates from the East. In a western context, mindfulness was introduced by Jon Kabat-Zinn who founded a university-based Mindfulness-Based Stress Reduction programme in 1979. Mindfulness originates from Indian Buddhist, Tibetan Buddhist and the Japanese Zen practise of Zazen (“sitting meditation). A more in-depth view of mindfulness can be found here. Mindfulness requires attention to the present moment and task at hand. This can be counter current to our current Western culture where multi-tasking is the new norm. This is common in the pandemic, where the boundaries between work, home life and socialising can blur. Technology can enable us to do many things at once that can be both empowering but serve to divide our attention and potentially have negative effects on our memories. In a therapeutic context, mindfulness has been applied in a range of approaches such as mindfulness-based stress reduction or mindfulness-based cognitive therapy (MBCT). This often involves group meditation and support and individual practice at home. In a non-therapeutic or self-help context, mindfulness can also be performed at home and there are a range of videos, and apps online that can teach users the basics of the mindfulness practice. The neuroscience of mindfulness is explained in this blog. Some of the concepts of mindfulness can also be applied to everyday life A mindfulness approach would suggest being fully present to what we are doing (not focused on past or future), whether that is doing the washing up or listening to a partner or a friend. “If while washing dishes, we think only of the cup of tea that awaits us, thus hurrying to get the dishes out of the way as if they were a nuisance, then we are not “washing the dishes to wash the dishes.” What’s more, we are not alive during the time we are washing the dishes. In fact, we are completely incapable of realizing the miracle of life while standing at the sink. If we can’t wash the dishes, the chances are we won’t be able to drink our tea either. While drinking the cup of tea, we will only be thinking of other things, barely aware of the cup in our hands. Thus, we are sucked away into the future -and we are incapable of actually living one minute of life.” — THÍCH NHẤT HẠNH, THE MIRACLE OF MINDFULNESS So, does mindfulness work to improve mental health? What is the scientific evidence? In research, in order to understand how effective an intervention or drug is, researchers pool together the quantitative results of different clinical studies to understand how effective a particular approach is overall based on data from a range of studies. This type of research is called a meta-analysis. Evidence gathered via a meta-analysis is much more powerful than via individual studies and considered the gold standard of scientific research. In the case of mindfulness, a number of meta-analyses have been conducted to understand the effects of mindfulness programmes. In one meta-analysis of the effectiveness of mindfulness-based therapy, effect size estimates suggested that it was moderately effective for reducing anxiety and mood symptoms when comparing the mental state of participants at the beginning and end of the programme. In a more recent meta-analysis of the effectiveness of standalone mindfulness (not in a therapeutic intervention), the authors found it had a small and medium effect on lowering anxiety and depression. Why is mindfulness relevant to coming out of lockdown? Lockdown for many of us has involved dealing with feelings with a reduced range of coping strategies available to us due to living within four walls. There has been a rise in drinking alcohol and domestic violence that could be interpreted as poor coping with the stressors of the pandemic and being confined to a home. Maladaptive and adaptive coping Coping with stress can be broadly divided into two types, maladaptive (unhealthy) and adaptive (healthy) coping. Adaptive coping helps us to respond to a stress and may even “fix” the stress (such as resolving a conflict, or extending a deadline). Maladaptive coping might numb or distract us to the effects of a stressor (such as drinking our troubles away), but does not change the stressor itself, and may add new stressors as the same stressor is present as the effects of the alcohol have worn off. Understandably, with reduced access to things to do and access to support, such as people to hug and talk to, possibly most of us have had some experiences with maladaptive coping during lockdown. This may have involved drinking too much, eating too much or too little, ruminating over a topic, or not reaching out for support when we needed it. Mindfulness can be added to our menu of coping If mindfulness enables awareness of our emotions- (e.g., “I feel stressed, edgy and tired”), then it can either be possible to manage the feelings (rather than avoiding or numbing them). In turn, this can facilitate selection of coping strategies that are more healthy in the long term. This may include talking to a friend, going to sleep earlier, doing exercise, spending less time on social media, practicing a meditation or asking for help, speaking to an employer to let them know about the stress, doing an activity and so on). A final note Whilst mindfulness is not a magic bullet, research suggests that it can reduce the symptoms of anxiety and depression and assist with understanding our emotions. Keeping our emotional reasoning in check and practicing mindfulness meditation may be a few strategies to support making sense of our emotions during the transition out of lockdown. As we begin to have more contact with our family and friends, we can begin to cognize the vast changes to daily life and the communities around us. Whether we either adjust to the eventual end of the pandemic, or, we adapt and adjust to COVID-19 measures being an integrated thread of modern life, connecting to and accepting our emotions may assist us to be ready for any eventuality.