This week (1st-7th Feb, 2021) is Children’s Mental Health Week. This year, the event has special significance because it falls in the context of the pandemic that, as we know, experientially and through research, has far-reaching effects on the mental health of children, adolescents and their families. Most of us have had some taste of the mental health knock-on effects of COVID-19, whether we grieved someone lost to COVID, struggled with the virus ourselves, experienced social isolation in lockdown, had anxiety, or, coped with new sources of stress. This blog will take a look at some of the science of the effects of stress on young minds. As a researcher in child and adolescent mental health and a mother, I’m passionate about understanding the effects of stress on children and young people. Over the past 6 years, I’ve been involved with a national programme called HeadStart that aims to increase children and adolescents’ wellbeing in six areas of England. My research has examined how young people experience stressors and the factors that they report to reduce their negative effects and help them cope, as well as how this changes over time. As a parent that is working and home-schooling, I’m acutely aware that COVID-19 brings in new stressors for children and families, as well as new experiences and surprises. COVID-19 Stressors The COVID-19 pandemic has ushered in new stressors for everyone, and especially children and adolescents. Parents have been under more stress which can affect their children in both subtle and direct ways. Violence towards children increases during periods of crisis. During the pandemic, children and young people have been exposed to new stressors, such as being away from the support of friends, school, teachers, extracurricular activities and community groups. Experiences of key worker children and children classified as vulnerable may be different from those that are at home with their families. In any case, children may also experience losing loved ones, worries about the risk of exposure, separation from grandparents and worrying about family health, parental employment, family poverty and uncertain futures. An increase in stressors can decrease both parents and children’s wellbeing. But what is a stressor and how does it affect the brain? A stressor is an event or an experience that triggers a stress response. Stressors can include environmental stressors (negative life events, traumatic experiences, daily hassles) and internal stressors (mental and emotional states, such as worry or trouble regulating emotions), that may be temporary, intermittent or chronic. Stressors can be highly subjective. Some people may find wearing a mask stressful, for others, it is not stressful and simply a necessary behaviour change in the context of a pandemic. Or, to take another example, one person may love to take a flight in an airplane, whereas for others it is a highly stressful, anxiety-inducing experience. Thus, there is value in considering how stressors are subjectively perceived. Stressor research often examines one stressor and its effect on mental health in isolation, such as the effects of bullying or domestic violence on health outcomes. Research often separates external stressors, such as features of the environment, from internal stressors, such as moods and states of emotions (for example, some studies only look at external stressors). However, in some qualitative research I undertook with adolescents in receipt of preventative mental health interventions, we found that stressors were not always neatly delineated in adolescent’s narratives and can be experienced in parallel. When asking adolescents about the stressors they perceived, some young people described that both external and internal stressors were perceived interact to contribute to poor wellbeing and symptoms of a mental health disorder. An external stressor in the context of lockdown might include factors such as restrictions on meeting, or losing a job. An internal stressor might include worries about the risk of catching COVID or low mood from social isolation. Stressors can stack up and overwhelm, however. What happens to the body and brain under stress? The “fight and flight” response to stress occurs when the body has a physiological reaction to either run away from or fight a stressor (or freeze). Symptoms included increased heart rate, flushed cheeks, trembling and rapid breathing. But is the fight and flight response problematic for young brains? Under normal (non-chronic) circumstances, stress is not damaging. The stress response triggers communication between the HPA (Hypothalamus-Pituitary-Adrenal) axis that increases and decreases in response to doses of stress. The stress hormone, cortisol, shuts down other systems (such as digestion) so that the body can focus on responding to a stressor. The releases of hormones enable the individual to be poised to respond to a stressor as indicated by rapid heartbeat and increased focus. After the threat has gone, the body returns to normal. However, when stress occurs repeatedly over time, its chronicity alters the body’s resting state to a higher notch. The body stays primed in a state of anticipating constant threat and the stress pathways become overactive. This serves to reduce the flexibility between an absence and presence of stress. When the load of stressors increases, a new set point is created, akin to increasing the thermostat on the body’s systems. The cumulative weight of stressors on the brain is described as Allostatic Load (AL). Such a load of stressors are understood to overwhelm the balance of the body, described as allostasis. When the allostatic load becomes too great this contributes to “wear and tear” on the regulatory systems of the body and increases the risk of disease. Researchers can measure allostatic load by measuring biomarkers such as waist circumference. The effect of stress on the brain Studies from rats and primates show that stress can alter the physical structures of the brain. Under stress, the body produces increased cortisol from the adrenal glands. The adrenal glands are triangular structures that sit on the top of the kidneys and regulate metabolism and the immune system. In the brain, raised levels of cortisol can change the size of the amygdala (an almond-shaped part of the brain linked to emotion and memory), and decrease the size of the hippocampus and specific dendrites that are part of the function of the prefrontal cortex. Studies of rodents find that prolonged stress leads rodents to exhibit anxiety and deficits in attention as well as an enhanced preference for alcohol. Adolescence is a Sensitive Period of Brain Development Research suggests that adolescence is a unique period of brain development described as a sensitive period. This means that the brain may be more influenced by the external environment during this time. “It has been proposed that neural plasticity, the way the brain adapts to internal or external changes, is heightened, rendering the adolescent brain particularly susceptible to environmental input” Research from both rodents and human studies suggests that the effects of drugs and peers are particularly strong during this time in a young person’s life. It is possible that the increased sensitivity of adolescents’ brains makes them more vulnerable to stress and developing mental health disorders. Many mental health disorders have their onset during adolescence. A review by Kessler and colleagues (2007) found that half of all lifetime mental health disorders begin by 14 years of age, but tend to be undetected and untreated. Incredibly, not all children that are exposed to a stressor will experience poor outcomes later in childhood or adulthood. Some children are resilient to the stressors they experience, they overcome them, whereas others will not. The factors that contribute to resilience are described as protective factors and include aspects such as a sense of humour and positive self-esteem. In addition to protective factors, there are other factors that result in differences in outcomes. So given the damaging nature of stressors on the brain, what can be done about it? The power of emotions Emotional support from parents and friends has the potential to counterbalance the negative effects of stress on the mind and body, research finds. The presence of emotional support from parents, friends and school can reduce the risk of mental health disorders and poor outcomes. According to the Stress Buffering Hypothesis, if individuals perceive to be supported, this can reduce the negative effects of stressors on mental health or other outcomes. A study by Brody and colleagues (2014) found that rural African American children that had grown up in an area of poverty but received emotional support from their mothers had lower allostatic load than those that did not report emotional support. When children (or adults) feel that they do not have the resources to manage a stressor that it exceeds their coping resources, this is highly problematic. Equally, if individuals feel that whilst a stressor is challenging they have the coping resources to manage it, this has found to have less of a negative effect on mental health. We need to actively counter the effects of stress Stressors have a profound influence on the minds of children and adolescents. Countering the effects of stressors on children, through interventions to reduce the negative effects of stress, are vital to protect and safeguard young people’s mental and physical health. As I understand it, it is important to put support in place for young people, that is based on evidence-based science (as not all types of support work for all young people) and it is important to understand what children and adolescents themselves report as stressor reducing and wellbeing enhancing. What makes young feel better both mentally and emotionally, can be highly individualised. Often (but fortunately not always!) one size fits all approaches don’t work to reduce the harmful effects of stress. Next steps in terms of research Some of my PhD research involved identifying patterns in a range of protective factors that adolescents themselves described as reducing the effects of stress and increasing their wellbeing. With colleagues at the Evidence Based Practice Unit, we have published a range of coping strategies described by adolescents to manage stress. Later this month, we will publish research on protective factors that are specific to children from minority ethnic groups. In the next few months of 2021, we aim to publish quantitative research examining the gender differences in trajectories of mental health and wellbeing that occur in early adolescence. What are the avenues in stress research for the wider field? Here are three directions: 1. Understanding the differential effects of stress It is vital to understand how stress affects different social groups as a precursor to putting in place measures and interventions to alleviate stress. A recent piece of research has examined the different effects of stress and patterns of self-care across Latin American countries, genders and age groups. COVID has had differential effects on a range of social groups and it is well documented that BAME groups have been disproportionately affected (BIPOC in the US context). Understanding how stress affects various groups: young children, early adolescents, teenagers and young adults and how this intersects with factors such as race, class, nationality, geography, and sexual orientation is really important. It is important to understand minority stress and the specific challenges faced by people of colour as well as the ways that within the context of the pandemic, aspects of identity might increase vulnerability to stress or conversely, confer protection against it. It is important to consider the effects of COVID on groups that are suddenly thrust into poverty such as international students as well as service industry workers and other professions badly hit. 2. To investigate the role of technology and self-care in increasing or decreasing stress in the context of lockdown A lot of support for mental health and wellbeing is mediated by technology, particularly for countries in lockdown. Children and adults spend more time on their phones and interacting with technology through online classrooms, Netflix, video games and online chat forms. Further research could examine how does technology reduce or increase stress on children and their parents during lockdown? Where there were previously clear boundaries between school and home, or work and home, what are the mental health effects of having fuzzier and looser boundaries and changed horizons as breaks in the school year are less pronounced. The family home under lockdown becomes a place of work, schooling, leisure, eating and sleeping, what does that mean for children’s mental health? Can children and teens get burnout? Self-care can mitigate the negative effects of stress but the evidence base for self-care strategies is still in its’ infancy. In a 2019 systematic review of research evidence, only few self-care strategies had a strong evidence base of effectiveness to reduce anxiety and depression. Should adopting a self-care strategy (or encouraging a child to adopt one) be based on the subjective experience of its efficacy or the evidence base? 3. The links between stress and COVID related anger Worldwide, throughout the pandemic, we have seen the rise of anger and externalising behaviours, whether in the form of resistance to masks, Americans “storming the capital”, the global rise in domestic violence, or public anger to changes and inconsistencies in COVID restrictions. It would be immensely valuable to understand what exactly this increased anger means for mental health conditions, for children, their families and the longer-term effects on brain and behaviour and how this ties together with stress. #ChildrensMentalHealthWeek is a brilliant time to get these conversations started. But it’s just as, if not more, important to keep these discussions going beyond this week, so that we can both understand and support every child as much as we can, every day.

The online arts movement helping brain injury survivors to tell their stories through music During the pandemic, we have adapted to new ways of working, socializing, learning and taking care of ourselves. For disabled people, being able to participate remotely has increased the accessibility of arts and culture. We are researching an online performing arts programme for people with brain injury, and asking if this has similar benefits to those experienced in a ‘real life’ group. If so, should the online arts movement become part of the ‘new normal’? As an occupational therapist, I am already a believer in the importance of engaging in meaningful occupations, using arts and creativity for well-being and rehabilitation, and connecting with others in shared participation. My previous research has looked at other aspects of stroke rehabilitation (the process of regaining skills that may have been impaired after stroke), so I am enjoying the opportunity to learn more about the existing body of research and history of ideas relating to the value of the arts and culture. Devoted readers of this blog may recall the launch of the world’s largest ever study into arts and health — a study called SHAPER. The programme is investigating the implementation and effectiveness of three health arts interventions in the areas of post-natal depression (depression after having a baby), Parkinson’s disease and stroke. This blog post launches Brain Waves, which will explore the translation of the stroke arts programme to the online world, and expand it to include anyone living with an acquired brain injury. What are the issues faced by people with brain injuries, including stroke? Acquired brain injury can have a number of causes, including meningitis (inflammation of the lining around your brain and spinal cord), tumour, traumatic head injury, lack of oxygen to the brain, and stroke. Even when brain injury is clinically categorized as “mild,” individuals can go on to experience longer‐term cognitive, psychological, emotional and social effects, frequently resulting in ‘hidden disability’. Families often have to navigate a complex, changing situation that may include mood disturbances associated with their relative’s injury, shifts in family relationships and changes in financial resources. We have all had a taster of social isolation as a result of the restrictions imposed to reduce the spread of Covid-19, but for millions of people living with the effects of brain injury, this experience is already their ‘new’ normal, as highlighted in Headway’s Life of Lockdown campaign. In many cases, the hidden effects of a brain injury can be life-long, and those living with these challenges (as survivors or carers) often feel stranded with very little support once state-funded rehabilitation has ended. What is Brain Waves? Stroke Odysseys and SHAPER were all ticking along nicely until you-know-what came along (you know, the pandemic), and meeting in person was no longer a good plan. Many people with stroke and other brain injuries were directed to shield indoors, compounding the isolation they may already experience as a result of their difficulties with movement, communication or cognitive function. Stroke Odysseys moved to online delivery and this raised new research questions about how well a tried and tested programme such as this would work in a new remote format. Brain Waves was then born. Brain Waves is modelled on Stroke Odysseys, a performance arts intervention for people who have had a stroke, designed and delivered by Rosetta Life. Rosetta Life describes itself as “a group of artists who work with those living with life-limiting illness to shape and share stories that matter through movement, song, image, film and writing. We aim to transform the stigma of illness and change the perception of disability.” Funded by The Arts for Health Research Council (AHRC), Brain Waves aims to create a sense of community and enable self-expression in a shared virtual space. There is a whole team of people involved in managing different aspects of the project, including those with specific expertise in music and dance. Together we hope to increase the visibility of people with brain injury and amplify their stories and experiences. Using the arts to improve physical and mental health and well-being is not new. Inspire the Mind has reported on the powerful potential of performing arts in previous blogs, in relation to mental health, dementia and self-expression. However, trying to translate these benefits to the virtual world is something that has been forced as a consequence of the need for social distancing. Brain injury survivors will work with artists and musicians to tell their stories through music and movement, with a 12-week online programme of participatory performing arts workshops culminating in a final performance of a piece that has been constructed together. As far as we are aware this is the first study of its kind and will provide new knowledge in the field of arts for health and well-being, regarding the development of an online community of participants. What are the questions we are trying to answer with the Brain Waves project? We will explore what it feels like to be a participant, and any challenges the online format presents for participants as well as the artists delivering the workshops. There may be advantages to virtual participation, for example for those who would find travelling to and participating in a face-to-face workshop too difficult. We know that people who have participated in similar programmes in a shared physical space have benefitted from the social interaction, connection with others, and sense of building a community together. We are curious about whether it will be possible to enjoy these social elements when participants are meeting online. The project will involve designing an online training programme so that others can implement what we have learnt with new online groups, and we will be testing this later in the year in Donegal. We expect that for some people, the online programme will enable new opportunities for participation, increasing access to culture, community and self-expression. For others, the technology may be a barrier or a poor substitute for physically meeting together in a real space. This project is exciting because it’s unpredictable — we just won’t know the answers until we’ve done it. The new normal? A positive consequence of the Covid lockdowns is that cultural activities and opportunities to connect with others have been made available for us to access from the comfort and safety of our own homes. Like many others, I have enjoyed zoom quizzes with friends as well as new experiences, all within reach of a computer keyboard. (A personal lockdown highlight was participating in a virtual biscuit icing workshop!). As government restrictions lift, we must remember that there are many people who still will not be able to enjoy the freedoms available to the able-bodied majority. Many of us are now proficient at working, socialising and learning via video-link, and the opportunities we have harnessed offer life-changing possibilities for those who will continue to have difficulty accessing ‘real life’ alternatives beyond the pandemic. Accessibility should be seen as a right for all and not a privilege, and whilst work must continue on the accessibility of physical spaces, we should also capitalise on the gains we have made in enabling everyone equal access to culture and connection via the virtual world. Do you have questions you would like to be addressed in future blogs on this project? If so, please let me know in the comments.

Addressing doctors’ suicide and mental health in the world of medicine. Suicide is not a subject that is talked about as openly or easily as it should be. It seems even more shrouded in the medical community, and a great deal of mystery still surrounds it. Too often when this topic is brought up, an unsettling silence stifles it and many will simply continue about their day. I recently completed my first year as a junior doctor and it has only increased my admiration for medicine. But I’d have to doubt the genuineness of that if I cannot also discuss what’s wrong in medical education and practise. Why does mental health seem like an almost taboo topic to talk about in our ranks? How many of our colleagues should suffer, or commit suicide, before we realise its seriousness? As someone passionate about mental health (and an aspiring Psychiatrist), I find the scale of such silence worrisome and dangerous. If awareness is the first step in minimising these attitudes, then we must meet this subject head-on, with honesty and acceptance. Besides, it also makes me wonder how much of this negative perception gets reflected in the wider world when we deliver care or advocate for mental health. An individual’s suffering is often difficult for others to understand, as is the grief of lost loved ones. But what about when the person is a doctor? In this two-part series, I hope to address the extent of mental illness and suicide in doctors, and what perpetuates it from an individual and institutional perspective. In this first part, I will cover the individual — problems facing a doctor and what leads to their suicide. Suicide ranks as a disproportionately high cause for death amongst doctors, with depression as a major risk factor. Reports show that doctors have higher rates of depression and anxiety compared to the general population and other professional groups. According to the American Foundation for Suicide Prevention, 300–400 doctors die by suicide every year in the U.S alone. In the U.K, one doctor dies every three to four weeks. In some other parts of the world, we believe the numbers are higher. We began this century with the tragic suicide of Dr Daksha Emson in October 2000, a young psychiatrist in the U.K. The report published in the aftermath, which includes her last diary entry before her death, is heart-rending to read. How much have things really changed since then? Dr Lauren Phillips, a 26-year-old Junior Doctor, 2019. Dr Louise Tebboth, a general practitioner, January 2015. Dr Lorna M. Breen, a top E.R doctor in Manhattan, took her own life in April 2019. “She tried to do her job, and it killed her,” her father said. Dr Poulami Saha, a young doctor in her internship year in Calcutta, Dr Kimoto Aya in Niigata. There are so many more names that I could give you. The problem is worldwide and affects all ages, genders, specialties and occurs regardless of seniority or rank. What we know of suicide is that there isn’t just a single factor that makes someone suicidal. As described by Edwin Schneidman, suicide is a ‘multidimensional malaise’. It involves facets of neurobiology, psychiatry, psychology, phenomenology, sociology, and culture. Despite an increase in mental health research and awareness in the last few decades, there are still several doctors who end up taking their lives every year. Why? At the level of the individual (the doctor as a patient): The most commonly associated psychiatric disorders with doctor’s suicide are major depressive disorder, bipolar affective disorder, alcohol and other drug abuse, anxiety disorders, and borderline personality disorder. Many doctors who live with mental health problems and/or substance misuse either treat themselves, remain untreated or are under-treated because they do not receive enough attention, or escape attention. Here are some reasons for that: Fear — they may not be honest about their mental struggles because they are afraid of facing discrimination. When they finally open up, they may not disclose suicidal ideations, any previous suicide attempts or plans of inflicting injury to themself because they are terrified of being forced into a hospital against their wishes. Stubbornness — many doctors prefer independence in their approach to work and often claim to know what is best for themselves. Should they fall ill, this may translate into a stubbornness to cooperate. Trust — they may be less trusting of their therapist because of issues related to confidentiality, ensuing investigations by licensing boards/councils and the likely detrimental effects on their career. Internalised stigma — clinicians who treat them may have negative attitudes to mental illness, too. This makes them avoid certain questions, assume too much and therefore misdiagnose. Ill doctors may not be managed with the same care and vigilance as other patients because of this. The work of a doctor demands a certain level of meticulousness in order to be competent and safe, so perfectionism is common in doctors and medical students. But in stressful times, these features can become excessive and drive a doctor to be so unforgiving and rigid to themselves. Perfectionism is a multidimensional concept and illness because of it is not surprising. When it goes too far, it can lead to suicide. Many doctors carry a lot of unresolved trauma they don’t know about or won’t admit to because of shame. They may silence or berate the part of them that aches for rest and help. Psychological defences are developed for the sake of surviving in medicine, some of which become hindrances to help-seeking in the long-run. It is important to point out that Post-Traumatic Stress Disorder (PTSD) is under-recognised in doctors, even though it may be more prevalent in them than the general population. In his book ‘Why People Die By Suicide’, Thomas Joiner postulates that suicide has three most important components that can lead toward suicide. Perceived burdensomeness Perceived failed belonging Learned fearlessness These may help us understand suicide in doctors. Perceived burdensomeness: An ill doctor may feel like they would become a liability to others if they disclosed their pain. For many doctors who have a saw-edged sense of individualism, this may intensify because they would not want to ‘bother’ anyone. Perceived failed belonging: Many doctors seem to live and work their entire lives mostly or only within the confines of medicine. When these doctors suffer an illness and cannot return to practice, they may feel severely neglected from being a name in a valued field. Learned fearlessness: As for this, Joiner places it in the chapter ‘The Capability to Enact Lethal Self-Injury Is Acquired.’ He calls it the ‘accrual of fearlessness about and the means for suicide’ or ‘accrued lethality.’ Doctors are trained to greet patient and colleague alike with a smile and so can be clever in masking their symptoms. You may see nothing but a smile. But it’s a misconception to think depression is always a sad, gloomy individual. The face of depression is often a smile. It’s an irony that healers rarely take advantage of healing for themselves. Many doctors may rationalise their symptoms as by-products of their work. They may be bent on the notion that it is their only way out. But if more doctors demonstrate healthy expression of emotion and how to receive care, it may help ease the silence and stigma around it. It will encourage other doctors to engage in mental health-promoting behaviour. Suicide is an illness, not a crime. Perhaps we can start with the emphasis on that. Convincing the individual alone, however, will not solve our problem. Even though we are in the 21st century, it’s quite shocking to think that mental health associated stigma remains a quiet, deadly serpent in the realm of medicine. Irrational fear and perceived stigma may (often because of mental illness impairing thoughts and perceptions) make the ailing doctor feel judged by their family and friends. But there is another type of stigma that is at play — one alive in the institutions and their cultures. In Part 2, I will discuss mental health-related issues at the level of the institution — from the culture of medicine to backward standards, under-funding and so on, and on working towards a better future.

Depression is a serious condition that interferes with your ability to work, sleep, to interact with friends and family. In fact, it profoundly affects almost all aspects of your life. To me, perhaps one of the most striking ways in which depression has been described is that “it is like drowning. Except you can see everyone else around you breathing”. Of increasing concern is that depression is exceptionally common and has been recognised as one of the leading causes of disability worldwide but unfortunately the development and implementation of effective treatments for depression is struggling to keep pace. To add to an already highly complicated issue, not all types of depression are the same and the biological causes can be widely different. Currently, the most common treatment for depression involves prescribing antidepressants, which essentially target one biological system and, thus, cause of depression. Unfortunately, this treatment strategy does not work for all forms of depression and treating depression has, therefore, become exceptionally challenging given the complexity of finding the most suitable treatment for an individual and the significant risks posed by the delay this may cause in treatment. Combating the burden imposed by depression has undeniably become a major global challenge for psychiatry. But why do some people go on to develop depression, while others remain well? There are many theories to account for this and one leading theory is linked to a dysfunctioning immune system, which leads to increased inflammation throughout the body and in the brain, that can subsequently lower mood. Another important theory concerns the body’s diminished ability to appropriately respond to stressors (such as financial concerns and worries, mounting work pressures, family tensions), so much so that the stress system either remains constantly active and in overdrive or, alternatively, does not respond to stressful stimuli as it should and becomes blunted. Both outcomes have been linked to depression as we have described before in this blog, but importantly these changes in the stress system can change the immune system, which, as already mentioned, the dysfunction of which has been linked to depression in its own right. However, it is important to point out that not everyone that experiences stress — as ultimately, we all do — goes on to develop depression. One potentially important factor might relate to the nature of the type of stress we are exposed to — an idea reinforced by research showing how different forms of trauma, neglect and abuse (which are in fact severe forms of stress) can promote distinct psychological profiles. And this is where my work comes in. I am a mental health neuroscientist keen to further understand the way in which stress (and inflammation) can lead to depression, hopefully, with a view to help develop more effective treatments for this debilitating condition. In this blog, I will discuss the work I have done trying to disentangle the effect of different stressors on depression and anxiety. For the most part, research has not dissected the effects of different types of chronic (prolonged and constant) stress but has instead focused on the overall effects of stress (both physical and psychosocial in nature) on the causes of depression. This is largely because of the exceptionally difficult task of cleanly defining and disentangling stressor types like physical stress (e.g., pain or illness) from psychosocial stress (e.g., social isolation and deprivation). But the distinction between the effect of different types of stress on behaviour and physiology may have some important implications. Indeed, why should we apply a one-size-fits-all approach when for the most part this has been widely deemed inappropriate in psychiatry. Although different stressors may promote several comparable behavioural outcomes (such as low mood, loss of pleasure or interest, loss of concentration, weight and sleep changes), the biological changes leading to these aberrant behaviours, for different types of stress, may be starkly different. So, based on this, I set myself the challenge of determining whether all types of stress are of equal measure using rodent models of stress and depression. Animal models are not only essential for furthering our understanding of depression and for identifying and developing much needed new treatments, but they make it somewhat easier to practically define and distinguish between stressors. My work, therefore, focused on understanding whether starkly different stressors could promote different depression outcomes in mice by investigating the effects of physical stress and psychosocial stress. This challenge became the sole basis of my doctoral research and from which stemmed two publications, one in Frontiers in Neuroendocrinology and another in Translational Psychiatry, forming the emphasis of this blog. To kick start my journey, I first reviewed just over 300 hundred animal studies on stress and depression to determine whether there was any evidence to support that different types of stress can indeed promote different depression outcomes in rodents — the results of which are published in Frontiers in Neuroendocrinology. Through this process, I found some evidence to indirectly support that different types of chronic stress may promote different behaviours and physiological responses. For example, I found how increased inflammation and less hippocampal neurogenesis (i.e., the birth of new brain cells that are needed for learning and memory and regulating mood) was more strongly linked with psychosocial and combined stress (both physical and psychosocial stress) in male rodents, whereas increased brain inflammation was more closely related to psychosocial stress in female rodents. I also found that reduced overall activity was more closely associated with psychosocial and combined stress but was not affected in response to physical stress. And a similar pattern was seen for body weight in female rodents, which was reduced only in mice exposed to combined stress and not psychosocial stress. Therefore, there appears to be some indirect evidence to support that different types of stress may provoke subtly different depression outcomes, ones that may have subtly different underlying biological mechanisms in male and female rodents. However, one of the main limitations to the research on stressor type thus far is the lack of directly comparable research, that is, studies that directly compare and evaluate the effects of different types of stress. Addressing this issue become my next priority and so I designed an animal experiment that did just this and directly compared the chronic effects of physical stress (in the form of a repeated injection) against the chronic effects of psychosocial stress (represented by permanent social isolation) — as published in Translational Psychiatry. Here, I now show direct evidence to support the idea that different forms of chronic stress may lead to different depression outcomes. For example, I found that physical stress promoted anxiety, decreased inflammation, overactivated the stress system, increased brain inflammation, and decreased hippocampal neurogenesis. While in contrast, psychosocial stress promoted depression, increased inflammation, blunted the stress system, decreased brain inflammation and increased hippocampal neurogenesis. Interestingly, combining the two stressor types did not have a more severe effect, and in fact did not alter the stress system or change levels of brain inflammation, but resulted in yet another profile, one characterised by increased anxiety, decreased inflammation and decreased hippocampal neurogenesis. Although this work helps shed light on my own research aspirations, it importantly highlights the need to now continue to explore the effects of different stressors in other animal models, so that we can understand more fully why this is happening, determine if this could influence treatment responses and, crucially, begin to apply this in a clinical setting. At the end of my journey, which has ultimately raised further questions and opened up more research avenues to explore, I bring to light that the type of stress may indeed matter when it comes to depression. Being able to more precisely identify the impact of different types of stress on depression could help to identify vulnerable individuals, help practitioners and individuals to monitor and report their experience of stress, and ultimately may aid in the discovery of new therapeutic treatments. Much like in other areas of psychiatry, we should move away from a one-size-fits-all approach to understanding the impact of stress on depression as all stressors may indeed not be of equal measure.

I am 60 years old. I have lived with bipolar disorder since I was 21. It has been a difficult and bumpy ride. Looking back, it seems almost miraculous that I am still alive today. I have survived two near-fatal drug overdoses, which were serious suicide attempts, and several serious medical conditions. It is my experience of my physical health conditions that I particularly want to tell you about here. Through my 30s and 40s, I suffered with some medical conditions which were diagnosed at a very late stage after I had become very unwell. I cannot prove that my symptoms weren’t taken seriously by my GP because of my mental health diagnosis, but I strongly suspect it. I believe that I was on the receiving end of diagnostic overshadowing, which is the term used to describe a situation where symptoms of a physical illness are wrongly attributed to a person’s mental health condition or learning disability. In 2014, I started to feel very tired, which worsened and carried on for 18 months. It was a terrible time. I woke every morning aching from head to toe. My muscles and joints ached. I felt as though I had flu. I had no energy. Everything I managed to do took enormous effort, even pleasant things like going for a walk or having a bath. I had to give up work. I had been working as a volunteer mental health advocate, a job which I loved and found deeply rewarding. I had been working with some of the most alienated, vulnerable and misunderstood people in our society. This meant such a lot to me because there have been many times in my life when I have felt alienated and misunderstood. I think the assumption was that my fatigue was linked to psychological issues. My Consultant Psychiatrist wrote in one clinic letter that I had ‘Fatigue in the context of an affective disorder’. This didn’t make a lot of sense to me as I had by then suffered from bipolar disorder for 33 years without ever having experienced true fatigue. My GP did all the tests available to her to try to find a physical cause of the fatigue, but all the tests came back as normal. By chance, I was eventually diagnosed with a Stage 4 low-grade non-Hodgkin lymphoma, which was in my spleen and bone marrow. A lymphoma is a blood cancer that develops from lymphocytes, which are a type of white blood cell involved in the immune system. This lymphoma was treated with six cycles of Rituximab (a drug used to treat some cancers and autoimmune conditions). Following this treatment, my energy levels returned to normal, which felt miraculous. However, 18 months later, the fatigue had returned. Again, I could do very little, staying in bed a lot of the time and feeling completely defeated. However, I wasn’t depressed. I know clinical depression very well from past experience, and this feeling of defeatedness was definitely different from depression. I met with my Consultant Haematologist in July 2019 (a haematologist is a doctor who specialises in the diagnosis and treatment of diseases of the blood and bone marrow). She tried to persuade me that there was no active lymphoma anywhere in my body. I was very distressed and frustrated because I was sure that the lymphoma had come back. I was crying at times during this consultation. These were largely tears of frustration, as my scan results showed that my spleen was again enlarging, which the haematologist completely dismissed. She spent a long time explaining to me how measurements of the spleen taken from ultrasound scans were inaccurate. My experience through my life has been that if I show any quite normal emotions such as distress or anger then people around me assume that I am psychologically unwell — that I am in some kind of bipolar episode. This in itself has been extremely frustrating for me because people generally stop listening to what I am saying. The Consultant Haematologist, having dismissed my belief that the lymphoma had returned, recommended that I have a psychiatric evaluation. She told me that there was no way that the lymphoma would have caused my fatigue. Her final words to me were: “I’ll see you again in six months.” I left the consultation room completely distraught. Two very kind nurses in the waiting room noticed and guided me into a side room and sat me down. They gave me a cup of tea and told me that I shouldn’t leave until I felt calmer. Eventually I was able to leave and managed to get myself home safely. Following this consultation, I immediately went to see my excellent GP, who did believe that there was a lymphoma-fatigue connection. She instigated urgent investigations which revealed that I had a Stage 4 aggressive high-grade lymphoma. The low-grade lymphoma had transformed into a high-grade one. My intuition had been right. A PET-CT scan showed that there was high-grade lymphoma in my spleen and in lymph nodes throughout my body. I was started on an intensive chemotherapy regime very quickly after diagnosis — six cycles over four months. The chemotherapy was gruelling. I suffered from a lot of nausea and I had to be admitted to hospital for several days with pneumonia when my immune system crashed. Fortunately, it is looking as though the high-grade lymphoma has been cured. Had the chemotherapy been delayed by six or maybe nine months, my outlook would likely have been bleak. I am sure that the haematologist acted with the best of intentions in recommending that I have a psychiatric evaluation. I was frustrated and tearful. That is what she saw. Maybe she thought that I was depressed, and that is why she recommended that I see a psychiatrist. Our brains process first what is most obvious. A very wise Consultant Psychiatrist once told me that ‘diagnosis’ means ‘seeing through’. The haematologist was not able to see through my external presentation to see what was really going on. She was so sure about her interpretation of my symptoms that she couldn’t see the solid fact that my spleen had incrementally enlarged over the previous three ultrasound scans. The biggest mistake I made was to go alone to that consultation. I felt so vulnerable and utterly powerless meeting with the Consultant Haematologist and Clinical Nurse Specialist on my own. They both told me that I was wrong in thinking that the lymphoma had returned. I really ought to have had an advocate with me. That would have helped me to feel more centred, less misunderstood and less desperate. I have a lot of experience of meeting with doctors. The best and most effective doctors, in my view, are those who treat me as an equal and work with me collaboratively. They are experts in their field of medicine. I am expert in my experience of my personal health. I have learnt to trust my intuition into my own health and ill-health of body and mind, even if it means that I disagree with a doctor. This personal knowledge and intuition has most probably helped to keep me alive. I will always be grateful to my GP who really listened to me and believed me. I don’t think it can be easy for a GP to go against recommendations made by a medical consultant. Once I had recovered from the chemotherapy, my energy levels again returned to normal. I have generally had a good year, although my activities have been somewhat constrained by all the restrictions. I was very fortunate to have an amazing holiday in Scotland last September. I am still alive! Having experienced cancer-related fatigue for around three out of the past six years, I am very familiar with it. The most pronounced feature for me was that it felt very similar to a viral infection, without a fever. I feel sure that it must share a common pathway with chronic fatigue syndrome, a long-term illness most known for symptoms of extreme tiredness. The only thing that I found that helped was acupuncture. After each treatment, my energy levels picked up for 24 to 48 hours, which gave me a little relief, but it wasn’t long-lasting. I am hopeful that research will move forwards quickly so that there may be some effective treatment for chronic fatigue available soon. It is truly terrible to be stuck in a long-term fatigue state. I am hoping that the current spotlight on ‘long covid’ might focus the best of minds on this condition. What is it about having a mental health condition that blinds some doctors to what might really be going on physically? Is it possibly the historic belief that ill-defined symptoms such as headaches, fatigue or abdominal pain are likely to have psychological origins once anything obvious has been ruled out? Do some doctors hold the belief (most probably unconsciously) that patients with mental health conditions who return again and again to the surgery with the same physical symptoms are perhaps ‘attention-seeking’ or ‘help-seeking’? Do some doctors struggle to see through an outward appearance of distress, desperation and frustration, as I presented to the haematologist? I really don’t know. It is most probably a combination of factors. I had naively believed that diagnostic overshadowing of people with mental health conditions was in the past. It has been known about for a long time. It was shocking for me to be told by a Consultant Haematologist that I needed a psychiatric evaluation when in truth my symptoms were due to aggressive high-grade lymphoma. Diagnostic overshadowing is apparently alive and well. I suspect that people are still dying prematurely as a result of it. NOTE FROM THE EDITORS: We would like to say a big thank you to Angela Merriott for sharing this very powerful account of her experience with her health and her personal encounter with diagnostic overshadowing. It was a pleasure to be able to share this on our platform.

When I think of cannabis use, I can’t help but think about the stigma and controversy that has been around it for the past few decades, the back and forth arguments between scientists, legal authorities and people who have personal interests in the topic. I am a postdoctoral neuroscientist who is interested in the biopsychosocial aspects of depression and in my PhD, I explored the role of cannabinoids in depression. More on this later in this blog. Recent interest in selling and using cannabis supplements as panacea for many ailments, fuelled by anecdotal facts and personal (and often biased) perceptions, contributed to intensifying any pre-existing attitudes about either beneficial or harmful effects of the plant’s use. But what do we see when we take a moment to look at the existing evidence? With sufficient scientific evidence, most European countries allow the use of medicinal cannabis for some medical conditions. For example, currently in the UK, there are several cannabis-derived medications which have been approved for conditions like epilepsy, chemotherapy-related sickness in cancer, or muscle spasticity in multiple sclerosis. And what exactly do we mean by “sufficient scientific evidence”? Simply, this means that these drugs went through a lengthy process of testing their efficacy and safety starting from studies on cells, then animals (preclinical studies) and lastly on humans (clinical studies), before they could be approved. Several studies have highlighted the beneficial effects of cannabis-derived medications in the treatment of pain and inflammation, and in mental health, e.g., reducing anxiety. On the other hand, cannabis use has been also linked with increased risk for some psychiatric illnesses, such as psychosis. So, how does cannabis work? The main compounds of cannabis plants are ∆9-tetrahydrocannabinol (THC) and cannabidiol (CBD). Inside our brains, and in almost every cell in our bodies, we have designated areas of our cells (receptors) that “recognise” and bind to these external compounds (THC and CBD), which in turn causes cell activation leading to a cascade of cellular responses. In a nutshell, this means that when THC binds to its receptor, it has psychoactive (getting “high”) and pain modulation properties, whereas CBD is not psychoactive and shows anti-inflammatory, analgesic (pain-relieving), antiemetic (nausea-relieving) and anticonvulsant properties. CBD can also stop THC from binding to its receptor, therefore minimising its action. Of course, we do not have these receptors in our bodies so that we can respond to THC and CBD from plants — we produce our own “cannabis compounds” (so-called, endocannabinoids) which exist even if we do not use cannabis. The main endocannabinoids are called anandamide (AEA) and 2-arachidonoyglycerol (2-AG). Altogether, they are part of the endocannabinoid system, which the main role is to keep homeostasis within and between the cells, and is associated with behaviours such as eating, sleeping and relaxing, and of course, they do not “get you high”. These two endocannabinoids were the focus of my PhD, and I will focus on them in this blog. As I have mentioned before, in my PhD I studied the role of endocannabinoids (AEA and 2-AG) in depression, and especially in the context of inflammation-induced depression. Now a little bit about depression in the context of inflammation, since this was what primarily ignited my interest in doing this particular PhD. Over the past few decades, clinical studies have shown that increased systemic inflammation (measured in blood) may be a promising biological indicator of depression. This means that when our immune system is inflamed, we may be more likely to develop depression. For those interested in how the increase in systemic (blood) inflammation affects the brain and can lead to fatigue, low mood, loss of appetite and generally behaviours that are seen in depression, you can read more in one of our previous blogs. As studies continued, I was intrigued by this discovery. However, what does it have to do with endocannabinoids? The endocannabinoid system is a homeostatic system which means it is capable of regulating other systems within our body, such as the immune system. As the activity of the endocannabinoid system increases, it reduces inflammation. And this “communication” seems to go both ways. Inflamed cells produce more endocannabinoids, such as AEA and 2-AG, which in turn act as “brakes” on inflammation. In depression, on the other hand, previous studies suggest there may be reduced activity of the endocannabinoid system, and so in turn, increased inflammation. The involvement of the endocannabinoid system in both inflammation and depression inspired me to explore more. I was curious and the questions I asked myself were whether increased systemic inflammation increased blood levels of endocannabinoids, and whether individuals with reduced blood endocannabinoids were more likely to develop inflammation-induced depression. To achieve this, I chose to study patients who received Interferon-alpha (IFN-α) treatment for hepatitis C infection. IFN-α is a protein produced by the activated immune system and it helps to fight the infection. Administered in higher quantities as a medication, it helps fighting viral infections such as hepatitis C and B. However, the downfall of the treatment is the long duration and its side effects which include fatigue and low mood, and, in up to 40% of patients, also depression. My role was to see the patients throughout their treatment and ask them a series of questions to determine how they were doing and monitor whether they developed depression. During the visits, I also collected their blood samples from which I measured endocannabinoid levels. As expected, I found that both endocannabinoids increased following IFN-α treatment. Interestingly and unexpectedly, I found different patterns of change between AEA and 2-AG, where AEA increased later in treatment and remained increased 6 months after the treatment has ended, whilst 2-AG increased at the beginning of therapy and returned to its initial levels 6 months post-treatment. My findings suggest that AEA and 2-AG are involved in different stages of immunoregulation following IFN-α treatment, where AEA might be involved in chronic inflammation, providing further evidence that targeting endocannabinoids may be of interest as an anti-inflammatory treatment in the future. However, I did not find any difference in either AEA or 2-AG between individuals with and without IFN-α-induced depression. This may suggest that different biological mechanisms may be involved in inflammation-induced depression compared with classic “psychiatric” depression, or perhaps that any changes in the endocannabinoid system in this subtype of depression may not be captured by blood levels of AEA and 2-AG. If you would like to read more about this study, my research findings have been recently published in Brain, Behaviour and Immunity here. Research findings can be in agreement with what we already expect or be completely full of surprises, but one thing is for sure: they are true to the facts, and not affected by our personal views, preferences or opinions — or at least that’s the prerequisite. Although cannabis was legalised for medicinal use in the UK from the 1st November 2018, it can only be prescribed by a specialist and as a last resource, if other treatments fail. The reluctance to prescribe it is fuelled by the lack of robust research as reported by the Department of Health and Social Care, and for many people this means a struggle to get the right treatment, enormous costs associated with it, and even legal consequences. As I write this, there are strong concerns that Brexit will stop the importation of cannabis-derived medications from Europe, with potentially life-threatening consequences for patients. We are at the beginning of the right path, however, there is still uncertainty around the risks associated with the use of cannabis-derived medication, which can only be dispersed by more clinical trials. And that’s precisely what we need to focus on: scientific evidence and large scale studies that will allow us to understand the full scope of medicinal properties of cannabis as well as its risks.

100 different ways to deliver culture and create human connection in the time of COVID-19 At the beginning of the year, we knew 2020 was a stressful one because we’d put together a Salon to look at stress and anxiety with Inspire the Mind’s Prof Carmine Pariante and Prof Catherine Loveday to help us find out how we could manage the stress in our lives. However, this was in January, when we thought we were about to face a normal year, unaware that 2020 was about to reveal its own particular style. As discussed in my previous blog on InSPIre the Mind, our work at the not-for-profit Salon London hooks up interested audiences with academics, speaker, experts and their ideas, to bring them into our lives to make them better, brighter, more fun, and to equip ourselves with excellent and reliable information so we can make the best decisions we can. We’d run Salon for 12 years and over that time the subjects that interested our audience was really changing. Our sell-out Salons used to be the ones where we focused on the wonders of technology, AI or industries of the future, but over the last 3 or 4 years, this has given way — perhaps because of the amount of time we spend with tech — to huge levels of interest in ideas for how to hope to cope with the way we live our lives. In fact, the January Salon ‘The Science of Stress’ was one of the most popular Salons we’d ever done. So, when we look back at the start 2020, we already knew we were stressed out, anxious, edging towards being overwhelmed before we all started to fumble our way into the year. For most of us, the subsequent year has brought dramatic change, it’s meant loss for all of us — varying from the huge (losing loved ones, our jobs, our income, businesses and companies) to the intricate scaffolding that holds our lives together, the time spent with those we love, the things we do for fun, the things we have to do to make our lives make sense, and the things we work for — trips, holidays, and travel. And then there was the fear and misinformation and the U-turns. How on earth are we supposed to keep our mental health together? What had we been told about stress being overwhelming challenges and an inability to control what is coming? How on earth were we, a live events organisation, supposed to survive? We had a few weeks of blind panic, and more stress — pivoting into a space that we didn’t know would exist, to recreate what we do for an audience we didn’t know. We became one of the first to deliver our work in the digital space in March but, moving from being together in a packed room to broadcasting from our sofa out to an emptiness, was a completely different way of doing what we did. Audience members came from around the globe — posting in the Q&A boxes how glad they were to see us, to hear us, that Italy, Germany and France were going into something called ‘lockdown.’ We kept broadcasting our Salons and have done over 50 digital events this year, continuing to get helpful ideas to new audiences, and we learned that pre-recorded content doesn’t cut it — it has to be live — we humans need shared experiences — and if we can’t get them IRL (in real life) — we’ll take them on-line. By August we got the go-ahead to do our 2020 LIVE Festival, normally a couple of thousand people in the field, with beautiful flower dressed tents, shared banquet tables, a disco bunker, a big campfire for all the family to toast marshmallows. All were banned, along with any dancing, singing, choirs, and any inside space whatsoever. We worked with nine government agencies to get their approval, reduced our numbers to just over 500, set up our own track and trace system, provided private toilets for guests to hire, temperatures were taken on entry, wrist band put in envelopes 72 hours before. There are three things you don’t want as an outdoor festival organiser, a North wind, torrential rain and freezing cold. All three arrived Friday night and didn’t let up. And yet the people on stage would not give in and we got to see first-hand how much performers need to perform, how they live for that relationship with the people seeing their work. Many of them found it increasingly emotional as they realised how much they had missed that feeling, as their audience braved the grim weather, refusing to give in either. As I walked around the festival site early the next morning, I wasn’t expecting anyone to still be there after a freezing night under canvas. Instead, I nearly cried for joy when I saw the morning 5k runners come back from their — socially distanced — run — ‘we’re going round again’ one said to me — ‘great for keeping warm for the day’. The whole experience brought home to me how essential human interaction was — how much people needed to be together for shared experience — and how we, as humans, will put up with a lot to get it. We watched as people ‘self-medicated’ themselves back to better levels of health and mental health with nature, with being together — even at a distance, with music, and even dancing in their tiny household groups. It’s clear that the need for meaningful human interaction is essential in dealing with stress and for our mental health and yet is something that has been in such short supply in a year that, for many of us, is already overloaded. Where are we now? We’ve learned so much and we know we’re not going back into a packed room any time soon. So, instead, we’ve really made building community on-line the focus of the stuff we’re delivering digitally, and a big part of this is our Digital Twixtmas festival, taking place between Christmas and New Year. And Inspire the Mind is our guest, as we will interview the Editor in Chief, Carmine Pariante, in a special session available for free to anybody who connects. As much as we can, we’re bringing people together, to share an experience (albeit digitally), to chat, do something practical together (cooking, joke-writing, whisky tasting) and to learn something new. To that end, as part of the festival, we’re doing three events about processing the year and making them freely available to everyone. We’d love to see you there. Register to our Twixtmas festival here.

*A Neurodivergent lens Due to Covid-19 there maybe even more pressure to enjoy the festive season this year and the social expectations attached to it, not only for people in the mainstream, but for neurodivergents too. In a previous blog in InSPIre the Mind, I had already discussed the challenges of the lockdown experience from a neurodivergent perspective. As Disability History Month officially draws to a close and the festive season begins, the final milestone of the year bombards the senses of those without sensory challenges, if you enjoy it excellent, however for some who are sensitive to this, they may experience sensory overloads. The needs and personalities of those within the wider Neurodivergent family vary, this is just one perspective on the holiday season. It’s important to remember that plurality is key. Neurodivergents are more than our social and sensory differences, more than fractals, we consist of layers with differing thresholds for a variety of things. This year’s collective focus seems more in step with a differentiated approach to celebrating the holidays, perhaps nearing the end of an unprecedented and challenging 2020, we can embrace the complexities together. With the required modifications for celebrating the first holiday season due to COVID-19, the national office of statistics has said that half of the adults who have taken the recent survey would adapt celebrations and form bubbles. As everyone wants to celebrate safely, there is just enough willingness for adaptations to change celebrations during the holidays to facilitate and accommodate differing needs with less resistance and social penalties. For some, the most recent announcement from the UK Government may have changed this. We have covered the terrain that makes this possible but what are the metrics for thriving as a neurodivergent during the holidays? Spoon conserving activities and engagements are part of these ‘Thriving in the Holiday Season 2020’ metrics; Spoon Theory, created by Christine Miserandino, is used by people living with chronic illness and the autistic community. It describes energy in the form of a tangible object(s) “spoons”, each spoon represents one unit of energy, there are 10 units for an individual to use per day. What exactly saves spoons? Planning and routines: Structure helps with the framing and managing of expectations. No hugs required: Adapted communication/social engagement and for those who enjoy deep pressure, weighted blankets may help. Picking an intergenerational mode that suits everyone best is good as this helps put more structure into the interactions, methods, timings and expectations. Gifts/no Gift exchanges: This can be managed so giving of presents can be factored in or out of your celebrations, staggering interactions thereby limiting the spoons used to convey your reactions to the gift. Social: Social distance is key, although there are temporary support bubbles allowed, some are still shielding so alternate ways to connect with loved ones is vital, there are also other aspects such as mask wearing, do we, don’t we? Some may feel that this helps to manage the situation and attached social anxieties. Managing expectations: There is less pressure for the onsite physical and social performances and interactions, this leaves enough time for a choice to be made as to where, when and how interaction takes place. Meaning, the interactions are delivered in short bursts but retain the meaningful elements. Final Thoughts This is not the end of celebrating the festive season but a new way of observing it, which factors everyone in, resulting in adaptations and staggering interactions as well as using multiple mediums in order to facilitate interactions which may aid spoon preservation.

If you could go back in time, what do you wish you had learnt to increase your confidence in navigating your mental health? Being in my early twenties with several years of lived experience of depression, I can start to empathise with anyone who’s been asking similar questions, both inquisitively and out of despair. For me, I could identify general facts and figures that would’ve increased my alertness of mental illness, building a fuller picture of what to be aware of… or probably, scared of. But practically, what could’ve equipped me to face my mental health more confidently in the future, rather than being filled with fear and trying to outrun it? When I’m acutely aware of the current poor mental health I want to escape, I struggle to tangibly recollect and imagine the better mental health I could get close to again. You see, when I had good mental health, I’d never observed or taken note of it, until it had slipped away. We need to learn to recognise and value good mental health when we experience it, especially pre-crisis, to lay stronger foundations for future fluctuations in our mental health. Often, when one experiences poor mental health and mental illness for the first time, they learn and recognise more about their mental health, emotions and thoughts than perhaps they had noticed before. Mental illness or declining mental health is already destabilising and strange, and when we have little foundational knowledge about what makes us tick on the better days, it’s like finding our way through unfamiliar roads, when we’re without a map and there’s not a sign to be seen. In hindsight, I wish I’d been encouraged to learn about my mental health, particularly tuning into what made up my good mental health. So how would you answer the question: What is mental health? 5–10 years ago, my answer only covered mental illnesses, constrained to predominantly the visible symptoms of the ‘stereotypical teen’ with anxiety, depression or an eating disorder, who met all the diagnostic criteria. It was something that was ‘out there in the world’ but not considered personally. But mental health is much more than the presence or absence of mental illness. That’s just one dimension. Another dimension includes how well one is able to cope with life, and these dimensions can be related to each other. Models like this one can help me start thinking about the whole space mental health. Taking you back to how this piece started, I wasn’t aware of how far from ideal my mental health was, until (seemingly) quite suddenly, I was sat in front of my new GP, two weeks into starting my natural sciences degree. In the short 10 minutes, I was patiently listened to, and then, succinctly but empathetically, given a couple of diagnoses, a green paper prescription, and a spot on a talking therapy waiting list. Personally, the hardest part when starting recovery wasn’t the diagnosis itself, although it was simultaneously a shock and a relief for the grey raincloud I’d been carrying round to finally be given a name. Neither was it taking multiple tiny pills each day to help rebalance my chemistry (less fun than popping out chocolate from an advent calendar, but more essential in my case!), or knowing that I needed therapy to get to a better headspace. (Of course, I can’t take for granted the encouragement, tough love and absence of judgement from my family and network of friends, which I am immeasurably grateful for.) For me, the hardest part was trying to imagine, and recall, how my life could be, and probably was once, less grey. Better mental health was clearly the goal, but I didn’t know how that could happen for me. It’s a little like if I asked you to conceptualise a completely new colour — different to all the hues available in the existing visible spectrum, one that can’t be mixed from pots of primary coloured paints. Success? I can cautiously guess that over the years, my poor mental health had developing, slowly taking up space, pushing out and shouting over the things which were perhaps good for my mental health. It was as if almost everything I did, whether it was academic work or extracurricular activities, was laced with the common fear of my efforts not being enough. Anything I could possibly ‘fail at’ petrified me, and stopping short of overworking seemed too lazy to bear. Check out Courtney’s piece on perfectionism and mental health here. When battling poor mental health and mental illness, it can be a challenge to do anything more than just survive, since you are living in an all-consuming situation. Often, part of getting your mixture of emotions and behaviours ‘back on track’ will be doing things that you enjoy, providing momentary relief from inside your head, and building up your wellbeing as a whole. Perhaps that could be picking back up a hobby, reconnecting with some friends, getting a good amount of sleep, exercising, and eating well. But when you’re in the midst of struggling, having the capacity and stamina to know where to start with these things, let alone do them, is a huge challenge. It’s difficult to recall positive memories, to have the imagination to think about ways of helping yourself, to have any confidence about your recovery and to regain self-worth when you have less motivation. I found myself becoming fearful that nothing would ‘work’, inevitably leading to me having more evidence that I am a true failure and a fraud, so maybe it was safer to just hibernate in survival mode. Like most people, my sleep and appetite felt like they were part of the vicious cycle, being disrupted by mood, and then the lack of them weakened my ability to cope with my mood. Friendships felt fragile, despite being supported and encouraged, because I was afraid of being a burden. The idea of doing something just because I enjoyed it was both unimaginable and scary, because, over the years, everything was done out of an intense need to be ‘productive’ — forming an intricately controlled coping mechanism. I’d fallen out of practice of doing the things that were good for my mental health, and following what seemed like easy advice to ‘go for a walk, try painting or bake something’ felt impossible, requiring time and attention that was already fully engaged in preventing my mood from tumbling even lower. The possibility of expending a little energy re-adjusting my grip, since I was weak and already slipping, seemed logical, but, in the moment, was outweighed by the fear of falling and not being able to get back up. Consider the benefit your normal activities and interests may be providing for your mental health. For example, recognising that when you run, in addition to keeping you agile and gaining competitive Strava stats, it gives you the headspace to process your emotions in a safe space. Or when studying, in addition to making your family proud and gaining a qualification, it gives you confidence as you master the workings of a corner of the universe. When time gets tight later in life, you’ll be better equipped to decide what prioritise and why, by having an explored what helps your mental health in the good times. Affirm and reflect the positive and supportive elements in our friendships. We know how important social connection is in supporting individuals with poor mental health. But, as we’ve seen, talking about mental health, across the whole spectrum from good to poor, could help us to recognise the support we have, before one of us needs it. Normalising everyday conversations around our mental health could help reduce the pressure for there to be a ‘big enough reason’ to talk about it, in all its forms. Practise putting into words (consciously thinking, writing or speaking) what you are grateful for and what you are proud of yourself for. By reinforcing and dwelling on some of the good in our lives, we’re not being big-headed or pretending that everything’s perfect, we’re just being real and letting ourselves appreciate that. Even if worries spring up, you feel a little silly, or some days you can’t seem to think of anything. It doesn’t matter how small or seemingly trivial your points are. You’re not trying to change the world, you’re simply tuning into what our fast-paced, results-driven, comparison-prone culture often doesn’t give time to do. We’re edging closer to the point where mental illness can be spoken about without shame or fear. Let’s also not forget the whole picture of mental health, recognising it’s something we all have, even without or before mental illness. Treatment is life-saving for many people, and there is yet more research to be done, but without recognition and sustaining of good mental health, the burden of poor mental health will be almost intolerable. Your mental health should matter, both during crisis and without crisis. Notes: A book about mental health that I absolutely love by the Clinical Psychologist, Dr Emma Hepburn @thepsychologymum — A Toolkit for Modern Life: 53 Ways to Look After Your Mind Other blogs mentioned o Why Perfectionism May Be Damaging for our Mental Health — Courtney Worrell o Should Psychiatry be working to prevent Mental Illness in the first place? — Danish Hafeez Blogs I also learned from (not linked in text) o A Birds Eye View — Reflections from the President of the Royal College of Psychiatrists on the latest series of PsychStar blogs o An Adolescent Boy’s View of Why Adolescent Boys Should Learn How to Express Their Emotions

The festive period is a time of high spirits and gift-giving, or at least as much of that as is possible in the midst of a global pandemic. But one thing that has stayed the same for me this year is my pervasive anxiety about the impact of this consumerist holiday on the environment. For me, along with the awkwardness of receiving an unwanted gift comes the guilt over the carbon that was added to the atmosphere for the production and transportation of it. And while my family have made fun of me for desperately trying to save as much wrapping paper as possible, climate change is something which has worried many of us recently. Feeling helpless, frustrated, anxious and depressed about climate change — also known as eco-anxiety — is becoming more commonplace. A 2019 survey by the American Psychological Foundation found that 68% of adults experience at least a little eco-anxiety. Even more so for younger age groups, with 47% of 18–34 year olds reporting that this stress affects their daily lives. In a previous blog, Ffion Harris spoke in depth about eco-anxiety, so be sure to give it a read if you want to learn more. But this brought my attention to an often overlooked question: what effect is climate change having on our mental health? As a psychology student, mental health has always been something that I care about deeply. And though I haven’t been much of an outdoorsy person until recently, over the last few years, climate change, and the impact it will have on our lives in the future, is an issue I have become very passionate about. Though it’s not often spoken about, climate change can have a severe impact on mental health as well as physical health, and we see this most clearly today with extreme weather events such as the tragic wildfires in Australia last year, which the World Wide Fund for Nature Australia called “one of the worst wildlife disasters in modern history”. Even the United States has had its first climate refugees, as rising sea levels in Isle de Jean Charles, Louisiana, have taken 98% of its land and the residents are being relocated. This is the first time that the US has used federal tax dollars to help a whole community that has been directly impacted by climate change. Seeing the place that you grew up in get destroyed or losing it forever to the sea can be an incredibly traumatic experience. A report released by the White House in 2016 which reviewed the health impacts of climate change highlighted the mental health risk for many of those directly affected by climate disasters. It warned that a number may go on to develop disorders such as post-traumatic stress disorder (PTSD), depression and general anxiety. Some people are at higher risk of these mental health outcomes than others, including the elderly, women (especially pregnant and post-partum women, which is the period after childbirth) and children. These disasters can destroy entire communities and the vital health infrastructure that they need, especially during such an emergency, posing a significant new challenge for psychiatry and mental health services over the years that we must prepare for. But the stress and anxiety that is caused by the existential threat posed by climate change also has an impact on our mental wellbeing. While it’s not yet clear whether eco-anxiety can be considered a disorder — and research is still in the early stages — people have reported symptoms such as panic attacks, loss of appetite and insomnia. A U.S. study also found that perceived ecological stress predict depressive symptoms, suggesting that people are struggling to cope with the stress of climate change. Psychiatrist Lise van Susteren describes it as a ‘Pre-Traumatic Stress Disorder’ likening it to the symptoms of PTSD but experienced in anticipation of the forthcoming trauma. She elaborates further that it should be considered a condition rather than a disorder, remarking that: “given everything the scientists are telling us, given how late the hour is, and how grave the consequences, the abnormality now is not having a Pre-Traumatic Stress condition.” — LISE VAN SUSTEREN This brings us to an important question about whether it is normal to experience eco-anxiety; the very question that led me on the journey of writing this in the first place. My own mental and emotional wellbeing has certainly been impacted over the past few years by the threat of climate change and when no one else around you is panicking, you can feel a bit crazy. But whenever I hear new reports about the awful situation that we’re in and how little is being done, panic seems like a rational response. After all, anxiety is adaptive. It helps us to foresee potential problems and motivates us to solve or avoid them. Therefore, a good long-term coping strategy is to solve the problem. But when you’re dealing with a problem so vast, that requires widescale societal action, there’s not much an individual can do. So, is it normal, then, to feel powerless? Being young and having my whole future ahead of me, I can’t help but worry about how climate change might impact that. I’ve daydreamed about having a carbon neutral wedding, I’ve worried about feeding my future children during famines, I’ve even thought about moving somewhere high above sea-level so that my future grandchildren have ‘dibs’ and won’t become climate refugees. Of course, the reality of what happens to the planet in the future is still very much in our hands. But the lack of meaningful action when the risk is so great can be disheartening to say the least. Sometimes it feels like I’m in a burning building and everyone around me is just going about their lives and I am the only one that is panicking. But through writing this, I surprisingly found myself feeling hopeful for the first time that I can remember. I learned that I am not alone, and that others are feeling this way too. Even Greta Thunberg stopped eating and stopped going to school because it depressed her so much, something which she talks about in her TED talk. It’s what made her decide to start doing something about it. And perhaps that’s exactly what we need for us to finally take action to stop damaging our environment. Greta ends her talk by refusing to offer hope. She comments on how hope has cushioned us and allowed us to believe that things will magically turn out okay, and that we need action first in order to inspire hope. As the reality of what climate change really means starts to set in, it’s going to affect our mental and emotional wellbeing. But maybe we need to be scared before we actually do something. Maybe this anxiety that we’re feeling is exactly what we need to inspire action and to give us hope. It’s important to recognise that climate change will affect each of us directly in many ways, including our mental wellbeing. And so, as well as taking action to mitigate the damage caused, we need to build resilience in ourselves and in our communities in order to overcome this challenge. And we need to use this growing anxiety to push ourselves to action and towards hope.

The festive period is a time of high spirits and gift-giving, or at least as much of that as is possible in the midst of a global pandemic. But one thing that has stayed the same for me this year is my pervasive anxiety about the impact of this consumerist holiday on the environment. For me, along with the awkwardness of receiving an unwanted gift comes the guilt over the carbon that was added to the atmosphere for the production and transportation of it. And while my family have made fun of me for desperately trying to save as much wrapping paper as possible, climate change is something which has worried many of us recently. Feeling helpless, frustrated, anxious and depressed about climate change — also known as eco-anxiety — is becoming more commonplace. A 2019 survey by the American Psychological Foundation found that 68% of adults experience at least a little eco-anxiety. Even more so for younger age groups, with 47% of 18–34 year olds reporting that this stress affects their daily lives. In a previous blog, Ffion Harris spoke in depth about eco-anxiety, so be sure to give it a read if you want to learn more. But this brought my attention to an often overlooked question: what effect is climate change having on our mental health? As a psychology student, mental health has always been something that I care about deeply. And though I haven’t been much of an outdoorsy person until recently, over the last few years, climate change, and the impact it will have on our lives in the future, is an issue I have become very passionate about. Though it’s not often spoken about, climate change can have a severe impact on mental health as well as physical health, and we see this most clearly today with extreme weather events such as the tragic wildfires in Australia last year, which the World Wide Fund for Nature Australia called “one of the worst wildlife disasters in modern history”. Even the United States has had its first climate refugees, as rising sea levels in Isle de Jean Charles, Louisiana, have taken 98% of its land and the residents are being relocated. This is the first time that the US has used federal tax dollars to help a whole community that has been directly impacted by climate change. Seeing the place that you grew up in get destroyed or losing it forever to the sea can be an incredibly traumatic experience. A report released by the White House in 2016 which reviewed the health impacts of climate change highlighted the mental health risk for many of those directly affected by climate disasters. It warned that a number may go on to develop disorders such as post-traumatic stress disorder (PTSD), depression and general anxiety. Some people are at higher risk of these mental health outcomes than others, including the elderly, women (especially pregnant and post-partum women, which is the period after childbirth) and children. These disasters can destroy entire communities and the vital health infrastructure that they need, especially during such an emergency, posing a significant new challenge for psychiatry and mental health services over the years that we must prepare for. But the stress and anxiety that is caused by the existential threat posed by climate change also has an impact on our mental wellbeing. While it’s not yet clear whether eco-anxiety can be considered a disorder — and research is still in the early stages — people have reported symptoms such as panic attacks, loss of appetite and insomnia. A U.S. study also found that perceived ecological stress predict depressive symptoms, suggesting that people are struggling to cope with the stress of climate change. Psychiatrist Lise van Susteren describes it as a ‘Pre-Traumatic Stress Disorder’ likening it to the symptoms of PTSD but experienced in anticipation of the forthcoming trauma. She elaborates further that it should be considered a condition rather than a disorder, remarking that: “given everything the scientists are telling us, given how late the hour is, and how grave the consequences, the abnormality now is not having a Pre-Traumatic Stress condition.” — LISE VAN SUSTEREN This brings us to an important question about whether it is normal to experience eco-anxiety; the very question that led me on the journey of writing this in the first place. My own mental and emotional wellbeing has certainly been impacted over the past few years by the threat of climate change and when no one else around you is panicking, you can feel a bit crazy. But whenever I hear new reports about the awful situation that we’re in and how little is being done, panic seems like a rational response. After all, anxiety is adaptive. It helps us to foresee potential problems and motivates us to solve or avoid them. Therefore, a good long-term coping strategy is to solve the problem. But when you’re dealing with a problem so vast, that requires widescale societal action, there’s not much an individual can do. So, is it normal, then, to feel powerless? Being young and having my whole future ahead of me, I can’t help but worry about how climate change might impact that. I’ve daydreamed about having a carbon neutral wedding, I’ve worried about feeding my future children during famines, I’ve even thought about moving somewhere high above sea-level so that my future grandchildren have ‘dibs’ and won’t become climate refugees. Of course, the reality of what happens to the planet in the future is still very much in our hands. But the lack of meaningful action when the risk is so great can be disheartening to say the least. Sometimes it feels like I’m in a burning building and everyone around me is just going about their lives and I am the only one that is panicking. But through writing this, I surprisingly found myself feeling hopeful for the first time that I can remember. I learned that I am not alone, and that others are feeling this way too. Even Greta Thunberg stopped eating and stopped going to school because it depressed her so much, something which she talks about in her TED talk. It’s what made her decide to start doing something about it. And perhaps that’s exactly what we need for us to finally take action to stop damaging our environment. Greta ends her talk by refusing to offer hope. She comments on how hope has cushioned us and allowed us to believe that things will magically turn out okay, and that we need action first in order to inspire hope. As the reality of what climate change really means starts to set in, it’s going to affect our mental and emotional wellbeing. But maybe we need to be scared before we actually do something. Maybe this anxiety that we’re feeling is exactly what we need to inspire action and to give us hope. It’s important to recognise that climate change will affect each of us directly in many ways, including our mental wellbeing. And so, as well as taking action to mitigate the damage caused, we need to build resilience in ourselves and in our communities in order to overcome this challenge. And we need to use this growing anxiety to push ourselves to action and towards hope.

I am working as a psychiatrist in a large hospital in Stockholm, Sweden. I will never forget the night between 11th and 12th of April this year, it was the Holy Saturday for many Christians around the world. Sweden already reported up to 80 deaths per day due to COVID. I was on call, and after midnight a colleague from the emergency department called me for a patient with severe agitation. The emergency room had completely transformed from a crowded, noisy place to a strange, almost surrealistic place in charge of receiving and treating almost only suspected COVID individuals. Patients were in their own rooms connected to oxygen supplies, up to 10- 15 litres of oxygen per minute. Health professionals wearing gasmasks were performing imaginary acrobatic somersaults from one room to another. Only the constant beep of the machines was the same, but the rhythm of the beat was awkward. Since then I have heard about some of my colleagues from all around Europe who got sick, some of them requiring a ventilator. Some of them are fully recovered and back to work, others are still recovering. I hope we will never forget the efforts of the frontline and essential workers. Many of them payed with their own health and some with their own life during this pandemic. It is Wednesday 11th of March, I’ve just arrived home from work. I am sipping my tea and listening to the news. The World Health Organisation declare COVID-19 a pandemic. It is an expected declaration; the number of new cases has increased exponentially around the world. I think about to a common film sequence from the films on Second World War —  that sequence when people across Commonwealth listen live on radio to the Britain’s declaration of war on Nazi Germany. I understand the intensity and solemnity of that moment. The time is expanding. Nine months have passed since then, we made it through the first wave. And now, the second wave of COVID-19 is here … with anxiety, new cases, full ICU beds, deaths, lockdown and face masks, but also hope for a vaccine. I remember the anguish of the first wave, the medical staff with bruised faces and intense gazes, gasmasks, the empty streets, job losses, essential workers, the morgues, the PPE… the love, compassion, altruism, empathy and the solidarity. For me, health is freedom; freedom from sickness, infirmity, dependency on someone or on the medical system. To preserve this freedom in a pandemic is challenging and requires a lot of solidarity. Different forms of lockdown and restrictions imply a compromise on other freedoms, particularly the freedom of movement and of gathering. This is unbearable for many of us and the uncertainty about the future amplifies the agony. But the history of pandemics tells us that this is going to pass and solidarity is the way out of it. What is solidarity? The Oxford Dictionary of English defines solidarity as “unity or agreement of feeling or action, especially among individuals with a common interest; mutual support within a group (origin mid-19th century from French “solidarité”)” Acts of solidarity are usually public and aim to bring about social change. We go out to protest to express our solidarity with the marginalised — Black Lives Matter activists, refugees seeking safety –, or in solidarity with people and animals affected by climate change, deforestation, forest fires… We gather on the streets in solidarity against injustice, discriminations towards other human beings or other species (solidarity between species). “The keys to defeating COVID 19 are unity and solidarity. That is true in families, neighbourhoods and communities, and it’s true at the regional and global level.” — TEDROS ADHANOM GHEBREYESUS, THE DIRECTOR-GENERAL OF THE WORLD HEALTH ORGANIZATION In times of pandemic we are all vulnerable. The COVID-19 crisis has devastated almost every aspect of our lives and ethnic minorities, elderly people living at home or in nursing homes and individuals with underlying conditions have been disproportionately affected. The solidarity I have experienced since the beginning of the pandemic is impressive — particularly during the first wave. “It’s difficult to be a clinician and not to work clinically during the pandemic”, as one of my colleagues tells me. I meet retired doctors and young medical students who raised their hands in support of healthcare workers and volunteered to help at emergency departments and intensive care units (ICU). One of my friends is a basic scientist, she works in a laboratory for COVID testing, helping the hospital to cope with the large number of samples. There are many more people like her. International research collaboration on COVID 19 evolved like never before and in a record time we have identified the virus and have developed promising vaccines. The most impressive acts of solidarity and altruism occur in local communities, anonymously and genuinely. There have been many volunteers to help the NHS in the UK with reducing pressure on the health system (deliver medicine, driving patients to appointments), neighbours help the vulnerable who self-isolated with groceries , inmates help the morgues workers, therapists volunteer to offer psychological help to those affected by stress reactions while self-isolating, fitness instructors offer exercises to people who are quarantined. There are many groups on social media encouraging people to seek and to offer help. Canadians called it “caremongering”. Even the industry replied with solidarity as the automobile industry manufacture ventilators, designer companies manufacture masks, gowns and hand sanitizers. Opera and theater plays are available online. Musicians gives virtual concerts to raise money for the pandemic relief. In these pandemic times, the most valuable act of solidarity is social distancing — avoiding crowded palaces, close contact with others, and confined places. Social distancing is the practice of maintaining at least 2 meters distance from other people. It is the most efficient way to reduce the spread of the virus and in this way to protect ourselves and the most vulnerable. The evidence for using a facial surgical mask is still under evaluation, some studies have found that it can reduce the spread of the virus, while one randomised control trial in a population with a low rate of transmission of the virus found no clear effects. But that’s not to say that we shouldn’t all be wearing our masks in public! Other recommendations are to avoid touching your face and to frequently wash your hands with soap for at least 20 seconds. Stay home if you are sick and test yourself for coronavirus. Isolate yourself 14 days after being in contact with someone confirmed with coronavirus infection. But keeping to social distancing is probably one of the most important things we can do. It is best to avoid indoor environments such as shops, malls, museums, libraries, bathhouses and gyms where possible. Plan to safely travel to the grocery shop and pharmacies. Avoid unnecessary journeys. Avoid traveling from areas with a high prevalence of the virus towards an area with a low prevalence of the virus. Work from home if you can. Avoid participating in face-to-face meetings, concerts, performances, sports training, matches and competitions for example. Where possible, avoid having physical contact with people other than those you live with. Over the past 9 months we have definitely become more prepared and optimistic about how to deal with the pandemic. The anxiety has dissipated a little bit, we do not read the same desperate news about the lack of preparedness in the face of the pandemic. People are seeking help earlier, there are protocols and treatment guidelines for symptom relief and when to use the only approved antiviral drug. We have vaccines in different testing phases, there is hope. Social distancing is not an easy practice but is the best way in which we can overcome these difficult times and it is probably the greatest act of solidarity. Keep calm the pandemic will soon be over! I hope we will be able to hug, kiss and shake hands again after Christmas.