Eating disorders thrive in times of crisis. They pounce on any disruption to everyday life and turn your recovery on its head, and I know from personal experience how difficult this can be. I have lived with an eating disorder since my early teens, which means I have plenty of experience juggling my eating disorder in times of crisis, whether that’s my parents’ separation, family bereavements, or most recently, a global pandemic. As my recovery has progressed, I’ve established a toolbox of coping strategies to see me through unprecedented times, so I want to share that advice on maintaining recovery when chaos enters your life. 2020 in particular brought mayhem into the lives of people with eating disorders. The global health crisis sent my own treatment into a spin because so much was out of my hands, which is uncomfortable when you’ve spent years aggressively exercising control with an eating disorder. Lockdowns meant I moved around less, contributing to guilt for not exercising, being at home meant I ate more, and fewer social distractions meant more time to focus on my appearance and space for intrusive thoughts to invade my brain. Eating disorders do not care. They will not stop for any crisis to give you a break, which often means, rather than trying to forget about our EDs altogether, we simply have to find ways of managing them. Below are 10 tips on doing just that. 1. Know your coping mechanisms in case of relapse In times of crisis, it’s natural for something as violent as an eating disorder to flare up. When we’ve viewed them as friends, it’s understandable why we turn to them for comfort. However, try to establish coping strategies to prevent potential relapses from escalating. This will become easier as you better understand your triggers and how to respond to them. Coping strategies can include having a list of contacts to call for help, distraction techniques, meal plans, daily mantras, journaling, ensuring you have safe foods at home and throwing out the scale to avoid weighing yourself. It may be beneficial to list your coping mechanisms so next time your eating disorder gets obnoxious, you have a plan of action. The sooner you acknowledge signs of a relapse and act on them, the sooner you can climb out of it. 2. Find joy in the little things — which can also serve as a distraction No matter the scale of a crisis, nothing should stop you from enjoying things you love. Whether it’s a TV series you can quote word for word, delving into a book, playing sport or exchanging memes in group chats, continue to find pockets of happiness in every day, all of which can be distractions and stop you turning to harmful behaviours. Throwing yourself into a new hobby is also a good way of pushing eating disorder urges to the back of your mind as you work towards goals that don’t involve food or how your body looks. In lockdown earlier this year, I started knitting, which proved therapeutic, and other days I did nothing but listen to the entire High School Musical soundtracks. However, it’s important to remember there’s a line between being distracted from your problems and just ignoring them altogether in hope of them disappearing. This is something I often grapple with. If you need help, seek it, don’t just shove things aside for the thoughts to return later. 3. Never underestimate the power of rest When old trauma resurfaces, it puts our bodies under so much strain, which is why choosing to do nothing can be the most powerful and assertive choice you make in recovery. Your mind and body are already fighting so hard to keep you alive, you aren’t weak for needing rest every now and then — resting is necessary for your survival and resting is productive. Taking time out allows you to recharge and ensures you’re energised enough to make the most valuable contribution you can to the world in times of crisis — simply being in it, and being in it as your whole self, which you can’t do if you’re burnt out. 4. Remember how important it is to eat If there’s one thing I’ve learnt throughout the pandemic, it’s the importance of eating. I don’t think I truly understood how important it is to nourish my body until this year, or that no matter what’s happening in the world, our need to eat doesn’t decrease. During a health crisis especially, you need strength from food, because pursuing thinness at a time of real global uncertainty will not protect you and being thin won’t make you immune to illness. We always need to eat, regardless of the effects that has on our bodies, and when so many people will not make it out of 2020 alive, we owe it to ourselves to respond to hunger cues and celebrate the magic of how our bodies lovingly accept food and use it to carry us through the day. In times of crisis, there’s a chance your eating habits will change, you might eat more, snack out of boredom, eat erratically and change weight as a result. That’s fine. If the only thing you exit a crisis with is some extra pounds on your hips, you should celebrate. You being alive matters much more than the number on the scales. 5. Create a circle of support and utilise it Eating disorders thrive in isolation, so don’t cut yourself off from support. Establish a reliable support network and utilise it without guilt. You are not a burden for talking about your struggles, and even if loved ones don’t have first hand experience with eating disorders, it can feel freeing to just vent and allow someone else to carry some of the load. Make sure your support network includes professionals, whether it’s a doctor or a therapist, and remember those people don’t vanish in times of crisis. Even in pandemics, specialists still offer appointments, charities offer advice and social media is overflowing with people in the same boat. People want to be there for you and they want you safe and well, so lean on them, ask for advice and cry on their shoulders. Recovery is such a personal process and, at the end of the day, no one can recover for you (I wish they could!) but it’s less hellish if you’ve got pals with ears to listen and offer distractions when you just want to smile and be more than your eating disorder for a while. 6. Remember what you can and can’t control My own eating disorder grew when I developed a dangerous penchant for control, so now any situation that makes me feel like I don’t have a say in how things are going to turn out can bring about confusion and fear. In these times it’s understandable why we turn to eating disorders to grasp back some authority, but it’s ok to acknowledge that some situations are beyond our control as a whole, however within our own lives, we can exercise control in more positive ways, like taking charge of our self- care. We don’t need to turn to our eating disorders to feel powerful, especially when our disorders are actually the ones holding the reins. 7. Establish a routine — find some normality amongst the abnormality Eating disorders hate structure, so defy them by introducing routine, which includes eating regularly. Many find it helpful to create a meal plan, which can ease anxiety around meal preparation. You shouldn’t beat yourself up if you don’t always manage to stick to a schedule, but planning what you eat, as well as activities through the day, can make life feel more organised and less messy. I know you might think it’s impossible, and believe me there was a time when I thought I could never eat three meals each day, but eating is now firmly cemented into my day. 8. Be gentle with yourself Be patient — scrutinising yourself won’t make times of crisis any smoother. I understand you might feel frustrated in moments of uncertainty and need to take your frustration out, but don’t direct it towards yourself. You haven’t done anything wrong. All you can do is your best, and your best will look different every day. Sometimes it’ll mean merely surviving rather than thriving, but in times of chaos, surviving is one of the most powerful things a person can do. Forgive yourself when eating disorder urges get loud and always keep in mind that anything bad isn’t permanent. It’s just a glitch. 9. Curate social media feeds that bring out the best in your recovery When life throws us curve balls and especially when the world comes to a standstill like it did this year, we tend to spend more time on our phones, so make sure social media brings out the best in your recovery, just as you’d want your friendship circle offline to do. I find seeking reassurance from fellow ED survivors online extremely encouraging, and I’m proud of how I’ve transformed the way I use the internet to inspire my recovery as opposed to seeking out tips on restriction like I used to. I’ve now curated social media feeds that motivate me to look after myself. I recommend following eating disorder warriors for regular reminders that you are never as alone as your ED might make you feel, and diversifying who you follow so your feeds represent the real world. I find following people who share motivational quotes useful too, as well as sarcastic meme pages to inject humour into my scrolls! Think of each social media account as a magazine you want to read. You are the editor with power to create an issue that is uplifting, positive and authentic. Protect yourself as well, though. Report and block triggering content. 10. Remember why you started I decided to pursue recovery because I was tired of feeling trapped in my eating disorder and having it hold me back. When I feel despondent, I remind myself of how I felt before recovery entered my life. I don’t want to go back to that place, which is why I continue to choose recovery over and over, often when I don’t want to. I started this journey because I wanted to get better and I have seen and felt many times since how much more vibrant and fruitful life can be beyond an eating disorder. So, when times of crisis make you question if recovery is worth carrying on with, remember why you began recovering in the first place. You deserve recovery and there are so many wonderful opportunities awaiting you on the other side of this crisis. Visit eating disorder charity Beat for online support. Click here to view their website and access their groups. NOTE FROM THE EDITORS: A massive ‘thank you!’ to Emily from all of us at InSPIre the Mind for sharing this wonderful insight into living with an eating disorder during times of crisis. Emily is a writer and journalist specialising in mental well-being and has been featured in a variety of online and print publications, including Metro and Glamour, and an aspiring author. Much of Emily’s work focuses on her own experiences and about raising awareness of how harmful diet culture is, its impact on young girls, and the importance of equal access to eating disorder treatment and dispel the myths and stereotypes around EDs — you can read more about her journey to recovery on her blog Emily Recovers. Thank you, Emily!

Insight from the #5BigInsights “Parenthood isn’t a prerequisite to understand the importance of the early years” — HRH THE DUCHESS OF CAMBRIDGE These are the words of HRH the Duchess of Cambridge last week, in her Keynote Speech accompanying the presentation of the results from The Royal Foundation’s Landmark Study on the #5BigQuestions on the Early Years, now called 5BigInsights. I discussed the launch of the survey in my previous blog in February (pre-COVID times, it seems a lifetime ago!). This is a UK-wide survey about the under 5 year old children that anyone could answer, launched with the idea to listen to the country as a whole, to hear what they have to say and start a national conversation on the under-fives. Why are these questions so important? And what are the answers — what are the 5BigInsights? And why do I like the Duchess’s words so much? I am a psychiatrist, and for many years I have dedicated my clinical activity (and a lot of my research and educational activity) to perinatal mental health: helping mothers who are struggling with their mental health in pregnancy or in the first postnatal year, and studying the consequences of perinatal mental health problems for both the mothers and the babies. Perfectly resonating with the Duchess’s words, I found myself — a man with no children — passionate about the importance of the early years, and an advocate for the notion that supporting pregnancy and childhood is a societal priority and a societal duty: that every pregnant woman and every child matter. Research has clearly demonstrated that the early development of an individual, from the 9 months in mum’s tummy all the way to the first years of life, has the most profound effect on the future of that person: on their emotional and social development, on the way they will express their potential at school and in their working lives, on the type of close relationships they will develop, and on their vulnerability and resilience to mental health challenges. Of course, our trajectory as an individual is not set deterministically and irrevocably in the first years of life: we remain capable of great shifts, and a difficult start can become a blossoming youth and adulthood, especially if we are lucky enough to encounter positive and supportive people in our later years. But yet, at a ‘population’ level, when we are looking at big numbers, the effects of the early years are overwhelmingly clear. Children born from mothers who are depressed in pregnancy are more at risk of developing depression themselves when they later reach youth or adulthood. As I have said, it is not deterministic and irrevocable: most children born from mothers depressed in pregnancy will not develop depression; but more of them will, compared with children born from a healthy pregnancy. And this type of evidence is consistent across the early postnatal and childhood years. The research background summarised in the report accompanying the release of the #5BigInsights highlights the most important points. To mention just a few, more relevant to maternal mental health: nearly three-quarters of the cost associated with poor maternal health is related to adverse impacts on the child rather than the mother; there is a multitude of effects that poor parental mental health can have on children, including slower language development, poorer academic performance and emotional problems; and parents who report high levels of stress tend to use harsher forms of discipline and are more inconsistent in their parenting style. So, this is what clinicians and academics think. But what do people think? Here is a nice info-graphic summary of the #5BigInsights: The report draws not only on the survey of the general population (around 500 thousand individuals who decided to participate and as such were not representative of the UK population) but also on a face-to-face survey of a sample representative of the UK population, as well as in-depth interviews and observations of a smaller group of families, with an emphasis on parents of a 0 to 5-year-old child. This additional information allows us to better understand these answers to the #5BigQuestions, and to put them into context. Some answers are remarkably aligned with expert knowledge. Some are, surprisingly, not. There is a general understanding that both nature and nurture play a role in the healthy development of a child. In fact, almost all participants (98%) believe that the experiences of a child in the early years (i.e., nurture) influence how a child develops from the start of pregnancy to age 5. A large proportion (42%) believe that nurture, rather than nature, plays the primary role in determining lifelong outcomes. While the exact balance of the two is difficult to establish (even among scientists), and varies from trait to trait, it is absolutely true that genetics does not explain all of the trajectories of an individual’s development. In fact, even considering the most genetically identical individuals — monozygotic twins — if one twin has a mental disorder the other twin does not always have a mental disorder, although the risk is higher than the general population. So, yes, genetics (nature) is important, but it is not all. More concerning is that parents who believe that child development is genetic or pre-determined have a fatalistic attitude which may reduce their efforts to interact with the child, as they seem to place less emphasis on the importance of playing, talking, or reading with the child. Worryingly, this emphasis on a ‘predetermined’ child development is higher in those parents coming from an economically disadvantaged background — and this could constitute the basis of a self-fulfilling prophecy, exactly for those children who are more at risk of suffering and under-achieving at school. The second concerning aspect of the survey is that only one in four participants recognises the specific importance of the first five years for providing lifelong health and happiness. Instead, most participants (57%) perceive all periods of a child’s life to be important for health and happiness in adulthood. While I do not want to underplay the importance of all phases of life for the wellbeing of an individual — the trajectory of an individual can be changed at any time, as discussed above — yet research in all aspects of a person’s development, from the way the brain growth and brain connection forms, to the way that our basic emotional and rational understanding of the world consolidates, overwhelmingly emphasises the importance of the early years over and above the later periods. Finally, around half (53%) of those providing a response believe it is the shared responsibility of parents and others in society to give children aged 0 to 5 the best chance of health and happiness. However, a sizeable proportion (46%) believe it is primarily the responsibility of parents. So, what’s next? The full report explores many more topics and it is definitely an interesting read, either in its full 50 pages or the abbreviated version. As mentioned above, it touches on important factors affecting the experience of being a parent, including feeling judged by others, the lack of social support, and COVID. Overall, the survey and the report show that a lot of new educational and dissemination work is needed to put across the importance of the early years, not only to policy-makers but also, and perhaps even more, to parents and the general population. The conclusions of the report focus clearly on the area of concerns that I have highlighted here, indicating that there is a need for promoting education and dissemination of evidence on the primacy of the early years to the whole of society, for encouraging society as a whole to be more supportive of parents, carers and families in the early years, and for cultivating and sustaining more support networks for parents to enhance their mental health and wellbeing. There is a lot of work to do in education and dissemination, in research and clinical care. I am starting today, with this blog.

For years, many people have advocated that the majority of office work can be done from the comfort of one’s own home. If you are going into an office to spend the day sitting at a desk, with no meetings planned and access to all files on a laptop, why not do this from home? The emergence of covid-19 has put this proposal to the test. As a medical student interested in mental health, I have been wondering how these changes are affecting us. At the beginning of lockdown in March, thousands of people across the UK had to pack up their office equipment and adapt to a new work environment: their own homes. Working from home full-time has shifted major aspects of what was deemed as normal. According to a survey carried out by the Independent, many have seen this as a positive change and expressed hope for some form of flexible working in the future. For example, no longer having to commute has provided people with time they didn’t previously have. This time can now be spent on self-care, which is often overlooked in today’s working environment. Rather than spending those 30 minutes catching an 8am train, employees can spend 30 minutes meditating, reading a book, or going for a morning run, and generally improving work-life balance. Moreover, in the future, if there is less of an expectation to come into an office, it could also give ‘stay at home’ mothers or fathers the opportunity to work, which previously may not have been possible. However, what we also have to acknowledge is that many of us are not ‘flexible working’ (i.e., partly working from home). Instead, many are working from home full-time with uncertainty as to when we will be allowed to go back into the office. Additionally, there are considerable discrepancies in people’s home environments. Not everyone has access to Wi-Fi, a personal laptop, or private study space. Over the last few months, I have spoken to friends who have spoken out about feeling isolated and unmotivated, particularly when beginning new jobs and entering a new virtual ‘workplace’. They have struggled with not having a quiet space to work in, or the ability to talk to colleagues easily. In a recent survey of 500 home workers, 64% reported increased anxiety whilst a third felt isolated. Therefore, whilst there are many positive aspects to working from home, it is also important to consider the psychological impact of being in your own home five days a week, with limited direct social interaction. As we continue to work remotely and social distance, the number of relationships we have with people decreases. The spontaneity of having dinner with friends or colleagues is gone. This decrease in contact with people, which makes forming and maintaining relationships with others more difficult, may have implications on our mental health. For example, I recently listened to a podcast interviewing Tal Ben-Shahar, a Harvard psychology professor who studies the science of human happiness. He quoted a 75-year-long Harvard study, which showed the number one predictor of both human happiness, and physical health over our lifetime is our relationships. That is, time spent with people we care about whether it be romantic, friendly, or professional. This encouraged me to think further about the consequences of working from home, during a pandemic, on our psychological health. Working from home 24/7 means our old patterns of picking up a morning coffee, catching public transport, and saying hello to our colleagues before a day’s work have also been disrupted. That quick smile or hello when going to collect your lunch no longer happens. While these may seem like small, possibly inconsequential parts of the day, these little human interactions with ‘weak ties’ (peripheral members of our social network, like one’s work colleague, or coffee barista) have also been shown to play a role in determining our happiness. A study done at the University of British Columbia showed daily interaction with ‘weak ties’ significantly increased feelings of happiness and belonging. In fact, these ‘weak ties’ were shown to be as crucial to our happiness as ‘strong ties’. Therefore, while we can stay in contact with close friends over WhatsApp or Zoom, this doesn’t fully replace physical social interaction or connectivity with our community as a whole. In a recent New York Times interview, Microsoft CEO Satya Nadella commented ‘what I miss is when you walk into a physical meeting, you are talking to the person next to you, you’re able to connect with them for the two minutes before or after’, which is challenging to replicate virtually. Furthermore, an interesting meta-analysis (basically, a study putting together different studies) found that the absence of social connections is as large a health risk as obesity, smoking, or high blood pressure. This further highlights that social connection needs to be recognized as an important factor for wellbeing, which is missing during lockdowns and times of isolation. Another criticism frequently made in the past few months, is that there is no defined time to ‘switch off’ or stop working. With no commute, meetings are starting earlier and ending later, meaning the lines between work and home become blurred. A study carried out in 2013 reinforced the impact of this. Researchers looked into the effects of remote e-working and showed it had adverse implications on well-being due to over-working and a lack of time for recuperation. Therefore, while working from home in itself is not necessarily a bad thing, the presence of coronavirus, and thus working at home full-time with no choice, has created working conditions that may have an impact on our mental health. What one can hope going forward is that companies take this mental health impact into consideration, and create systems that support this change. According to a Financial Times article, Goldman Sachs has already taken this into account, and have been offering cooking classes, virtual prayer sessions, and virtual storytime for children via Zoom. Similarly, Linklaters has launched virtual choir workshops and virtualised many of its mental health resources such as on-site psychologists. Alongside companies provisions, there are strategies each of us can do to help keep our mental health strong while working from home. Recent blogs by Lokesh Agrawal and Paola Dazzan have covered these topics more in-depth, and include: Taking part in some form of physical activity each day Practicing mindfulness and gratitude Making social connections a priority Reducing screen time when not working Having a routine (as much as possible) and focusing on the things we can control. We have seen both positive and negative aspects of working from home during a pandemic. Looking forward, it could be beneficial for companies to change their perspective on flexible working. Rather than having one extreme or the other (work at home versus work at the office), a more flexible approach could be taken to create a more balanced work environment. This would allow the benefits of going into the office to be obtained, together with the benefits of occasionally working from home. Hopefully, the pandemic has placed more of an emphasis on work-life balance which we can all learn from, and take forward with us when it is over.

When Sir David Attenborough joined Instagram in September, his account gained over 1 million followers in less than 5 hours and broke a world record in the process. His first video titled ‘Hello Instagram’ has now been viewed over 18 million times. This overwhelming endeavour to engage with the 94-year-old naturalist and conservationist is testament to the sense of responsibility that young people feel for the planet. UK polls show that concern for the environment amongst young people is at an all-time high with nearly half of 18–24 year olds citing the environment as one of the nation’s top 3 most urgent issues. But while breeding a younger generation with an appetite for climate action is a good thing for the planet, many people experience feelings of frustration, helplessness, and distress when contemplating the enormity of the environmental crisis before us. This is known as eco-anxiety. This term is described by Psychology Today as “a fairly recent psychological disorder afflicting an increasing number of individuals who worry about the environmental crisis.” Eco-anxiety is not a specific diagnosis but in 2017 it was acknowledged and described by the American Psychiatry Association as “a chronic fear of environmental doom” that impacts negatively on an individual’s mental health. Sufferers of eco-anxiety can experience symptoms such as acute stress and anxiety, panic attacks, insomnia, and obsessive thoughts triggered by negative information on climate change (e.g. extreme weather, pollution, human impact on wildlife). Recent research estimates that “29% of Brits feel overwhelmed by the (climate) crisis, rising to 40% amongst younger people aged 16–24.” Some individuals report that the pandemic has made their eco-anxiety worse than ever as important conversations about climate change prompted by activists such as Greta Thunberg and Extinction Rebellion seem to have grinded to a halt. Additionally, being isolated at home has left many of us feeling insignificant and incapable of actions that will have a tangible impact on the problems we face as a society. An article by The Guardian has suggested that by constantly exposing readers to stories of environmental crises such as forest fires and melting of polar icecaps, this can trigger feelings of hopelessness which may actually hinder change. Many people will respond to these distressing images by changing their behaviour to minimise their own environmental impact, while others respond by burying their heads in the sand. In a recent BBC interview, David Attenborough was asked if our actions as individuals are irrelevant when entire countries are ignoring the climate crisis. His response provides an important message on empowerment to take action: “if there’s only a fragment of hope, we have a responsibility to do something about it… we must all do what’s in our power.” In other words, no person is too small to have an impact. What can I do to help reduce my eco-anxiety this winter? Firstly, if you find yourself worrying about the environment it shows that you are informed on an important global issue and that you empathise with the situation. Research shows that increased empathy can predispose individuals to clinical anxiety. However, chronic worrying can have a detrimental impact on mental wellbeing, and you should seek help if you are feeling overwhelmed. While anxiety is a complex issue with no quick fix, many sufferers of eco-anxiety feel that adopting eco-friendly lifestyle changes can help reduce feelings of powerlessness- my actions as an individual do matter. During this pandemic there are many things you can do at home to reduce your environmental impact and to help you feel in control. 1. Don’t waste This can apply to a myriad of different factors at home: reduce your food waste by planning meals in advance and only buying what you need. Invest in durable food storage containers as an alternative to single-use products such as foil and cling film. Turn off lights and electrical appliances when not in use. Consider that extra jumper before turning on the heating. Try keeping your showers under 4 minutes, fix any leaky taps or toilet flushes. Always make an effort to recycle. 2. Consider making changes to your diet Buying local produce and fruit and vegetables that are in season can drastically reduce the carbon emissions associated with food transport. We all know that plant-based diets are better for the planet, but even if cutting out meat entirely is not for you, reducing your intake by adopting a ‘flexitarian-diet’ can still make a difference. 3. Make sustainable clothing choices Curb your shopping addiction- go for quality over quantity. Repair or donate clothes rather than sending them to landfill. Wash your clothes at 30°C. 4. Spread the word about the changes you’ve made There is no doubt that this pandemic has left many of us feeling out of touch with the world around us. But this is a time where the importance of individuals coming together as a collective to make a change is more important than ever. Please follow these links for more information and support: https://www.bbc.co.uk/programmes/articles/1NGvFrTqWChr03LrYlw2Hkk/information-and-support-mental-health https://www.nhs.uk/oneyou/every-mind-matters/coronavirus-covid-19-anxiety-tips/ https://www.climatepsychologists.com/

I opened my phone a couple of days ago to a headline reading, “A Black doctor died in childbirth, highlighting a tragic trend that affects pregnant women of color in the US.” Chaniece Wallace, a Black physician, died while giving birth from complications due to pre-eclampsia (a pregnancy-related high blood pressure condition). For context, I am an American psychologist living and working in London, and so the majority of news I consume concerns what is happening in the States. 2020 has been a year of ongoing hardship, and in particular what my brain has become hyper-fixated on is the enduring systemic inequality sewn into the fabric of the nation in which I was raised. And, specifically, the disparity in the quality of maternal health care — including mental health care — that Black women receive. One reason this particular news saddened me to my core is because I work in the field of perinatal psychiatry, which means my everyday work revolves around pregnancy, the postpartum period, and the complications (specifically mental health) that women and their babies can experience throughout. So each time I see yet another headline, whether in the US or the UK, about a maternal or infant death that could have been prevented, it really hits home. For example, see our previously-written blog about unjust infant deaths among incarcerated women. What do we know about maternal health care in the US? In 2019, a comprehensive policy report estimated that the US has the highest rate of maternal and infant mortality among any developed nation in the world. What’s worse, is that when compared with white women and their babies, Black women are over three times more likely to die due to complications from pregnancy and childbirth, compared with white women, and their infants twice as likely. And so, while the overall mortality rate is 17.2 maternal deaths per 100,000 pregnancies — for context, the rate in Sweden is 4 per 100,000 and in South Africa, 119 per 100,000— when maternal ethnicity is parsed out, women of the Black, Indigenous, and people of color (BIPOC) community are at an especially heightened risk and the rates actually look more like this: Black women: 42.8 deaths for every 100,000 pregnancies American Indian/Alaskan native women: 32.5 deaths for every 100,000 pregnancies Asian/Pacific islander women: 13.5 deaths for every 100,000 pregnancies White women: 12.7 deaths for every 100,000 pregnancies Hispanic women: 11.4 deaths for every 100,000 pregnancies Even more problematic is that in New York City, where I lived before moving to London, the mortality rate for Black women is an astounding 12 times that of white women. In a country that is already struggling to reduce maternal mortality among all women for conditions identified as preventable — 60% of maternal deaths are classified as ‘preventable’ — it is even more inexcusable that giving birth while Black is considered to be especially dangerous. Of note, Black women are at significantly higher risk of cardiovascular (heart), circulatory (blood vessels), and pulmonological (lungs) emergencies during and after childbirth. In fact, a study in the US showed Black women are three times as likely to experience severe or life-threatening pregnancy-related complications, including pre-eclampsia, renal (kidney) failure, and need for a blood transfusion. Of note, the authors of the study found that this risk to Black women still persists over and above any possible external factors, including socio-demographic and economic difficulty, and other medical conditions, suggesting that something else is going on. Moreover, another study conducted in 2019 specifically looked at the intersection between maternal race and socioeconomic status in pre-eclampsia, a blood pressure condition that has a significantly higher risk for mortality among lower socioeconomic groups and Black women. Findings show that not only are white women less likely to experience pre-eclampsia, but where risk does exist, it appears to be mitigated by higher socioeconomic status. Meanwhile, Black women remain at greater risk for pre-eclampsia and, contrary to expectation, high socioeconomic status does not serve as this same protective factor. This unjust occurrence has been referred to as a ‘diminishing return,’ meaning that the addition of a positive variable (like high socioeconomic status) may not necessarily lead to a more desirable outcome — and in this case, essentially widens the gap in maternal healthcare equality between Black and white women. Again: something else is going on. In fact, two notable female figures in America, Beyoncé and Serena Williams, have spoken out in the last few years about their experiences of life-threatening preeclampsia to call attention to the experience of birthing while Black in America. This must be an America problem, right? While the US has received a lot of attention over this past year with regard to its ongoing struggles with systemic racism and inequality, what I have come to learn throughout my time in London is that this endemic is not just an American problem — in fact, the UK is just as guilty. Black women in the UK are five times more likely to die from pregnancy and childbirth-related complications, according to a recently released report by the Maternal, Newborn and Infant Clinical Outcome Review Programme, and overall, women from the Black, Asian, and minority ethnic (BAME) community are at greater risk than are white women. As such, for every 100,000 pregnancies in the UK, 40 Black women, 15 Asian women, and 23 Mixed women will die, compared with 8 white women, which of course is still 8 too many. A recent study conducted by the University of Oxford that examined the maternal mortality rates from 2009–2017 again shows that women of both Black and Asian ethnic groups are more at risk. Of significance is that as time went on across the eight-year period of this study, the rates of maternal mortality among Black women have steadily increased and the gap has widened, indicating that care is in fact worsening for Black women and their babies. In 2019, the BBC wrote about Candice Brathwaite, a Black woman who had just given birth in the UK. She felt her health wasn’t taken seriously by her healthcare professionals and that she was subjected to poorer care due to “racial bias within the NHS.” She writes that she was treated as if her pain was all in her head. Soon thereafter, she suffered from acute sepsis. Candice’s story is unfortunately not unique in the UK: just this past month The Guardian featured two mothers named Tinuke Awe and Clotilde Rebecca Abe, founders of a group called Fivexmore, which was formed as a response to the growing need for equality in maternal healthcare. Essentially, Fivexmore aims to improve care in the UK for Black women and amplify their voices given how universal a problem it has become and how little attention it has received. How can we explain this inequality? Candice Brathwaite recently wrote: “I think we are long past putting this wholly deplorable outcome on pre-pregnancy health risks and social economic circumstances. It’s time to say it like it is: this is happening due to racial bias.” — CANDICE BRATHWAITE While many factors have been named, including propensity for pre-existing health conditions, sociodemographic and economic influences, and difficulties in access to healthcare, it is now thought that a major explanation for this disparity is the quality of both prenatal (during pregnancy) and postnatal (after childbirth) care that Black women receive, compared with that of white women. In fact, Dr Ana Langer, director of the Women and Health Initiative at Harvard, has said that Black women are “undervalued” and “not monitored as carefully as white women are,” and, furthermore, that when Black women “present with symptoms, they are often dismissed.” This all-too-common phenomenon can be attributed to implicit bias and racism present not just in our society — that is, in both the UK and the US — but also within our healthcare systems. An article published just last month in the Journal of Law, Medicine, & Ethics discusses systemic racism present in maternal healthcare that Black women receive. The author writes: “I assert that structural racism is a powerful social determinant of maternal health that has roots in a historical system of oppression and devaluing of women of color, and persists today in more subtle health care policies and practices.” This hypothesis is based upon the notion that Black women have historically been subjected to reproductive oppression which has become ingrained in society and healthcare practices today. Furthermore, a survey conducted in California among new mothers finds that Black mothers are more likely to report discrimination in the care they received during their birthing experience. As a result of implicit bias, Black women have become primed for prejudice. In my opinion, until our systems de-centre whiteness and incorporate anti-racism training at all levels, including in education and in healthcare, this injustice will continue at the cost of both maternal and infant lives. On top of being endangered by systemic racism, women are also subject to ongoing sexism within our healthcare system, and thus the intersectionality — a term created by Kimberlé Crenshaw 30 years ago — of race and sex puts expectant mothers from BIPOC or BAME communities at further risk. A recent review of research in implicit bias in American medicine identified that healthcare professionals are just as likely to exhibit bias in patient-interactions as is the wider community, and that this can affect clinician decisions on diagnoses, treatment, and level of care. So: when thinking about maternal health care, we have to remember that women are already at a disadvantage for the quality of care they will receive and that this disadvantage is further compounded by race. What does this disparity mean for Black women’s mental health? I recently completed my PhD in perinatal psychiatry, and throughout it I worked with women (and their children) who were depressed during pregnancy and their postpartum. One finding that consistently came up was that within the group of women I worked with, mothers who were depressed during their perinatal period (and beyond) were more likely to be Black than white. Of course there are numerous explanations for this, and it is often difficult to disentangle all of the contributing factors to perinatal depression, but a few questions repeatedly came up in my mind: firstly, was the quality of healthcare that Black women in our study received any different — and, if so, could this have, at least in part, driven their mental health difficulties? And, furthermore, if this was the case, why haven’t we addressed this profound problem? It is thought that the mental health of Black expectant mothers may unfortunately already be vulnerable because of intergenerational or vicarious trauma — essentially secondhand trauma. That is, Black women inherit trauma from centuries of oppression and violence towards the Black community. It becomes complicated because this is then compounded by the possibility for birthing trauma. A Vox article recently highlighted the complex nature of Black motherhood in the year 2020, given the “emotional and physical burden of trauma on Black mothers’ bodies”, between enduring systemic racism, anticipating COVID-19 complications, and fearing pregnancy and childbirth complications. Kelly Glass, a journalist who often writes about parenting and race, recently discussed birthing trauma and how “it’s not enough, however, to simply and just barely survive childbirth.” If Black women, who are already primed for prejudice, do not feel listened to or treated well during childbirth, they are at risk for re-traumatization. Glass continues: “there’s no single change that can reverse traumatic birth experiences for Black women in a system built on racism.” On top of this, once Black women give birth and return home as new mothers, studies have found that those experiencing mental health difficulties have greater difficulty in accessing mental health care and may even present with different types of symptoms — more somatic and less psychological — leading to greater difficulties in identification to begin with. At the end of September, an organization called The Motherhood Group launched the UK’s first ever Black Maternal Mental Health Week. The impetus for this awareness week came from research that Black women are less likely to receive mental health treatment during their perinatal periods than white women, a disparity that needs addressing given that 1 in 4 maternal deaths in the postpartum are attributable to mental health causes including suicide. This is especially troubling because, according to The Motherhood Group, “healthcare professionals in the UK lacked the training and the confidence for identifying the specific needs of Black women — causing Black mothers to ‘fall through the net’”. Similarly, the US observed its own Black Maternal Mental Health Week given that Black mothers in America are also at greater risk of mental health difficulties and are less likely to receive adequate mental health care. The American College of Obstetrics and Gynecology recently stressed the urgency of adequately identifying and monitoring mental health difficulties in Black mothers, especially due to the inequality in healthcare likely received. What must happen going forward? A Black woman named Kira Johnson tragically and unnecessarily died after internal bleeding following a C-section; she was left bleeding for over 10 hours before her medical team took action and thus her death, like so many others’, could have been prevented. Since then her husband has become an activist fighting for better healthcare for mothers. Senator Kamala Harris recently tweeted in response to her death that going forward we must “listen to Black women when they say something doesn’t feel right” to “ensure women are listened to in our health care system.” 2020 has been a year of political unrest; yet, it feels like for the first time, real conversations have started to take place with regard to systemic inequality and what must change going forward. At this point, it’s unacceptable to continue to uphold a system built upon white, patriarchal ideals. It’s no longer enough to discuss how tragic these statistics are. It’s no longer enough to engage in performative activism. And it’s no longer enough to simply raise awareness. We are at a critical turning point where large groups of people are politically and socially mobilised and motivated and we cannot squander this opportunity. I am hopeful and anxious for a future where women, especially women of colour, need not fear for their own lives in the process of creating new life. But to get there, we must acknowledge and take responsibility for the oppression and trauma that Black mothers have been subjected to for centuries; we must dismantle the systemic racism and inequality still ingrained within ourselves and our society; we must undergo extensive anti-racist training and de-centre whiteness from our learning; we must train and hire more Black birth workers; we must step up and listen to and validate Black women; and, finally, we must not lose momentum. NOTE FROM THE EDITORS: This blog has been part of a special week covering #perinatalmentalhealth to celebrate the Royal College of Psychiatrists Annual Perinatal Psychiatry conference 2020 which has been taking place this week. On Wednesday we covered this theme with a personal account on postnatal depression by Hattie Gladwell.

One of the perks of getting older is the constant sense of déjà vu when listening to political debates. So, here we go again, #freeschoolmeals are under attack. It was 1995 and I was living in the United States when the Republicans tried to cut the school lunch programme, at that time subsidising the meals of 25 million eligible children, and also tried to scrap the “uniform national nutrition standards” to be implemented in these lunches — basically, their minimum quality standards in terms of nutritients. It wasn’t the first time, and it would not be last. In 1981, in the famous “ketchup as a vegetable” controversy, the Reagan administration attempted to deal with the cuts in the federal budget for school lunches by listing ketchup and pickle relish as vegetables, thus offering cheaper alternatives to previous ‘true’ vegetable options. And perhaps this went lost among the myriads of other recent news stories from the Trump administration, but just a few months ago the American Agricultural Department tried to reduce the amount of vegetables and fruits provided by the school lunch programme, and instead offer kids more pizza, burgers and fries. All of these attempts were rejected by public opinion — and yet we are hearing the same debate again today, following the refusal by the British Government to extend the free school meals scheme. And again, this is also not the first time in the UK: in 1979, under Margaret Thatcher, an Education bill proposed ending entitlement to free meals for thousands of children, as part of a plan to save £220 million from the educational budget. I do not want to even try to argue the moral imperative of feeding a hungry child — or a hungry person, for that matter. The generous response of people and businesses alike to support free school meals since the Parliament vote is a testimony that such an argument is not needed. And also I do not want to dwell on the well-described paradoxes of this political decision, like the fact that the costs of the free school meals are lower than the costs of the “eat out to help out” scheme, or the recent news that an Indian charity now offers free school meals in England. As a scientist and a clinician, however, I do want to emphasise the enormous long-term costs of such short-sighted decisions: the creation of a generation of malnourished children who will grow to become adults with mental, physical and social problems. Even mild forms of child undernutrition — both in terms of reduced quality intake and reduced quality of nutrients — is responsible for increased morbidity and mortality. Economic studies quantify the costs of these long-term consequences at around 1–2% of the gross domestic product and rising. Longitudinal studies (where we observe something over time) have shown that some of these consequences can last two or three generations. The list of these consequences is long and wide, as they affect all areas of health and wellbeing. Undernourished children tend to have a stunted growth and fewer years of schooling, and, as adults, they have reduced economic productivity, and, for women, lower offspring birthweight. Other studies indicate an association with high sugar and fats in the blood, high blood pressure, and, above all, obesity. Because the problem of cutting free school meals is not only that it makes children hungry — although this is a big problem; it is also that those hungry children, especially if from families with limited or no financial possibilities, will end up eating cheaper, more unhealthy foods, which then increase their risk of becoming overweight or obese. In fact, undernutrition and overweight are no longer considered two distinct problems but, quite the opposite, they are now understood as the “double burden of malnutrition”: the simultaneous manifestation of both undernutrition and being overweight. Let me state this again: the benefits of programmes such as free school meals are not just that they feed children — although this is important. It is also that these programmes often provide the only healthy and nutritional food intake for these children. And the evidence linking a nutritional deficiency to mental health is striking. An “unhealthy diet”, such as lots of fast foods or take-aways, and foods containing high fat and sugar levels, increases the risk of depression and poor mental health in children and adolescents, while lots of fruit and vegetables are protective for mental health, including depression and attention-deficit hyperactivity disorder (ADHD). Indeed, studies over the years have shown that higher intake of fish, vegetables and fruits are associated with a smaller risk of developing depression, both in adults and children. And we have also shown that children with ADHD have evidence of dietary deficit of omega-3 fatty acids, present in fish. Indeed, we have extensively discussed the importance of a healthy diet for our mental health, including for depression and ADHD, in previous blogs. Of note, the amount of good quality food required to have this effect is not negligible. For example, studies in adults show that at least 50 grams of fish per day, or three normal portions of 100–120 grams a week, are required to protect us from depression, which is more than the amount that the UK government currently recommends (that is, one portion of fish twice a week, and few of us eat that). Why would any governments recommend a specific amount of fish intake with one hand, and then take it away from children with the other hand, is obviously, and sadly, an unanswerable rhetorical question. Interestingly, a recent study assessed the economic benefits of school feeding programmes on undernutrition and obesity. The evidence shows that these programmes have truly beneficial effects, quantifiable as an increase in children’s growth and a reduction in children’s body mass index, an index of being overweight or obese. Most importantly, undernourished children can gain years of education from improved nutrition, as well as reduce their risk of premature adult death and disability due to being overweight. The conclusion was that providing school meals with improved quality of diet would lead to “substantial benefits that outweigh the costs of implementation, with return on investment”. So, if it makes moral and economic sense, why do some governments want to cut these programmes? Ultimately, it is, unfortunately, down to political views. Newspapers have reported how some politicians have expressed their views in crude ways, but, basically, it is down to two simple, contrasting views. Some people think that only parents should take responsibility for their children. And that children’s hunger is only their parents’ problem to solve. And that the only thing that the government should do is to help parents through welfare systems or support into work. This view has been emphasised with some MP’s justifying their vote by explaining that other welfare schemes, such as Universal Credit, were increased in response to the pandemic to support families meeting all welfare needs, including food. And some people, like me, think that we, as a society, are responsible for all children. And that we can and must step up and step in if parents — for whatever reasons: poverty, disability, ill health, and yes, even lack of parental abilities — cannot feed them. This too has been highlighted with much public upset, protests and of course, the generous response of people and businesses that I mentioned earlier. Only in this way we can break the vicious cycles of poverty leading to illness, and illness leading to poverty, from childhood to adulthood, from one generation to the next. People have understood this already. When will our governments understand?

I am not a clinician, but I have come to acknowledge the 3 C’s of the clinic: communication between the patient and physician, comprehension of the illness by the physician, and curing the illness. The middle ‘C’, that is, to comprehend the illness, is perhaps the most difficult to attain for several reasons. One being that illnesses are often multifaceted, and therefore to define the cause is a difficult task. I remember when I had first started my A-level in Psychology, my teacher asked us if it is possible to comprehend a problem in a truly objective manner. My initial response was of course it is possible, you focus upon the problem you are trying to answer and forget all else. My teacher then explained, that no one can abandon their cultural, moral and political views, along with all else that constitutes the framework of their mind. Some subjectivity will always remain whether we are consciously aware of this or not. From this experience, I then began to wonder if attaining objectivity is just a mere fallacy. Must I push my personality aside so that I can view a problem in its true nature? Is this possible? How can we actually understand the problems of the body and world when we ourselves are so affected by everything and anything? At that time, I failed to find an answer I was satisfied with, and therefore ignored the philosophical problem at best. As you might have guessed when reading my previous blog, I am interested in the philosophy and morality underpinning choices. Since this time, I have come to acknowledge that we cannot escape from our thoughts, nor can we prevent ourselves from purchasing and owning new beliefs to clothe our mind. So instead we must advance and use our thoughts, to help function and achieve our goals in the best way possible. Objectivity is therefore a different perspective, and one that we can acquire through learning, rather than a ‘non-human’ one. What sparked the recollection of such memories, is what I learnt from my thesis, and what I am currently learning in my degree in Genomic medicine. This being the creation and use of ‘Next-generation sequencing technologies’ in the scientific and clinical realm. This is an umbrella term for processes that determine the DNA structure of a person’s entire genetic material and encompass the dream triad to genomic investigation: the collection of large datasets of information, low in cost and time efficiency. Specifically, such techniques are being utilised by psychiatrists, since a vast number of studies have identified a genetic basis underlying psychiatric disorders such as depression, anxiety and schizophrenia. Another effective innovation is Babylon, an app designed to increase access to healthcare worldwide, whereby users are diagnosed, given treatment recommendation, combined with face-to face consultations with a clinician 24/7. I have come to classify such innovations as the ‘objective friend’. Often when we are faced with a difficult situation, the alternative perspective of a friend is able to guide us. In a similar manner, when faced with a complex medical case, innovations such as these next generation sequencing techniques provide guidance, in an objective way. The general consensus of the challenges of such technologies, however, is the effectiveness of their clinical integration. In other words, are these innovations effectively able to navigate medical decisions? Specifically, what I would like to know is how such tools, and future tools, are able to effectively prevent and treat mental illness globally? The low cost of such tools does not correspond to easy access, since their use is dependent upon healthcare policies. Furthermore, the odyssey to prevent and treat mental illness is stymied by the cost of treatment, and those whom fear the shame and stigma related to their illness. In science, omission allows us to refine and understand in detail, but our ultimate mission in science is to care for all. There are several effective innovations that have been utilised in mental health. An example being the communication of mental illness across social media, that is reducing stigma. Now when I scroll through Instagram, I am met with at least one post concerning this. Additionally, there are successful clinical treatments, such as counselling, cognitive behavioural therapy and mindfulness-based approaches, along with pharmaceutical therapies. But recently, the question I have been asking myself is how the “objective friend” can help transform psychiatry? Would the objective friend benefit psychiatry? Starting with the first ‘C’ of the clinic: communication. In psychiatry, diagnosis is based upon the patient detailing their symptoms, the responses to the questions a psychiatrist may ask, previous medical history, and other signs that may be observed, all referring to a diagnostic and statistical manual of mental disorders. Complications to achieving diagnosis involve comorbidity, whereby two different mental disorders may occur simultaneously, along with the severity of the disorder. Therefore, diagnosis can often be a lengthy process. Once a diagnosis is made, and if a talking therapy, for instance was the agreed treatment, choosing and creating the most suitable one may take time, given the range of therapies to choose from. Furthermore, the benefit of such therapies can also take time. For some, pharmaceutical treatment may be prescribed alone or in combination with a talking therapy, however, to say this ensures a cure or improvement in the patient’s mental health would be false. Some patients do not improve with available pharmacological or psychological interventions. Could the integration of neuroimaging be of help? For his final reddit post, Professor Stephen Hawkings wrote: “If machines produce everything we need, the outcome will depend on how things are distributed. Everyone can enjoy a life of luxurious leisure if the machine-produced wealth is shared, or most people can end up miserably poor if the machine-owners successfully lobby against wealth redistribution. So far, the trend seems to be toward the second option, with technology driving ever-increasing inequality.” — STEPHEN HAWKINGS T echnology was originally made for those of a more affluent background, however this is not the case now. It is clear that with time and revision of a repertoire of innovations, their use increased across populations of varying economic backgrounds. Next generation techniques give hope that low cost, highly effective neuroimaging techniques, can be made attainable, rather than a mere science fiction fantasy. For neuroimaging techniques to be endorsing equity in the healthcare system, revision is needed. The questions to consider now, are how can we adapt such techniques so that they are lower in cost and more available for use? How and to what extent can we integrate them into psychiatry? And most importantly, how can we use technology to help those who are suffering severely from mental illness? As mentioned previously, the goal of objectivity is consciousness of several perspectives, rather than establishing a ‘non-human’ one. The same can be said for integrating technology into medical practice. Neuroimaging as the objective friend in psychiatry, will incorporate several algorithms, facilitate deep analysis and produce a large quantity of data, to create a baseline to the diagnosis of psychiatry that is sensitive to cultural, social and political differences. This, in combination with the experience, empathy and compassion of psychiatrists themselves, can invest into the ultimate goal of global mental health. Psychiatry is complex, and whilst most are familiar with the saying ‘the happiest person that you see with a smile on their face every day, could be the most depressed person that hides it from everyone’, some may not be aware that it is not so simple as to label neurons as having depression, anxiety or schizophrenia. But just as we talk to a person and can begin to understand their experience, we can study our biology and begin to deepen our understanding. I believe that by focusing on how we can utilise neuroimaging in a way that does not discriminate against our social, cultural and political differences, can embrace the complexity of psychiatry.

During childhood and adolescence, parents play a crucial role in their child’s development, acting as their first teachers and preparing them for independence. Children rely on parents to provide them with the love and care they need to grow and develop well, so it is no surprise that much research looks at parenting in relation to early development, and early neurodevelopment in particular. What is neurodevelopment? The term neurodevelopment refers to the development of the brain and its influence on a multitude of basic functions including reading ability, memory, emotion regulation and social skills. A disturbance in this process can lead to neurodevelopmental disorders, such as Autism and Attention Deficit Hyperactivity Disorder (ADHD), or difficulties in motor function, learning and communication. Studies on the effects of parenting have focused primarily on maternal aspects such as postnatal depression, suggesting that if a mother is depressed during pregnancy or after giving birth, her child is more likely to have emotional or cognitive problems. This is of great importance to health professionals and new mums alike, however, one factor remains unaccounted for, the father! Fathers play an integral role in a child’s life, yet little research is conducted into how fathers might affect this developmental process, either directly through their parenting behaviour or indirectly via their relationship with the mother. That is why I am taking this opportunity to discuss what exactly is the father’s role in their child’s neurodevelopment and might it be possible for fathers to mediate the negative impact of depressed mothers? This area of psychology is of particular interest to me as a former MSc student in Clinical Neurodevelopmental Sciences. Having conducted research to understand the potential impact of maternal stress on children’s neurodevelopment, I have turned my attention towards fathers, not only because it is a topic less discussed but also because one day I hope to have children of my own and the dynamics of family life has always been something I am keen to understand. Involved Father Traditional roles of men and women have changed over the last generation, and although mothers have taken more responsibility for infant care than fathers have historically, times are changing. This could be very beneficial for future generations as research has found associations between involved fathers and children’s educational outcomes. One such association suggests that fathers who are more loving and playful have children with higher IQs. However, this may be due to ‘reverse causality’ in which the direction of cause-and-effect is the opposite to what is proposed. In this way it might be possible that children with higher IQs are able to engage more with their fathers and enable the father to in turn be more involved. None of these associations conclude that children born to disengaged fathers are less intelligent. However, these associations are a good starting point to understand more about the effect of fathers. But what does it mean to be an ‘involved father’? In fact, researchers have outlined three essential facets of father involvement in order to build a happy and nurturing relationship between child and father. These include; positive engagement activities, warmth and responsiveness, and control. Incorporating these components, I was interested to learn that father-child play is important in supporting healthy neurodevelopment as it is both physical and stimulating yet in a safe and responsive environment, allowing the child to experience and regulate arousal. Fathers tend to spend much more of their one-on-one interaction with their children in stimulating, playful activity than mothers do. ‘Rough-and-tumble’ play for example, can teach children to deal with aggressive impulses without losing control of their emotions. In addition to parenting quality, fathers may influence their child’s neurodevelopment through their relationship with the mother. Supportive Partner Fathers are unquestionably able to lighten the load for their partners by being active and involved in raising their children, this much is clear. Moreover, by emotionally supporting their partners, research has shown that women feel better, have better pregnancies, births and improved postpartum mental health, which in turn enables the mother to be more responsive to their children — eliciting a healthy development for the child. Something I find quite interesting is that mothers with depression are more likely to turn to their partner for support than to any other person. One survey conducted in the UK found that, of 3000 mothers and 2000 grandmothers, 70% of new mothers turned to their partners for emotional support, compared with only 47% in the 1960's. Thus, an available, supportive partner is really important for all, but especially for a mother experiencing mental health difficulties during pregnancy and after birth. There is concerning evidence that prenatal depression can predict fearfulness and child maladjustment (failure to cope with the demands of a normal social environment) and a higher stress response in infancy, with other findings proposing that mothers with a previous diagnosis of depression have between two and three times the odds of having a child with Autism. By acting as a supportive partner and involved father, is it possible for the father to be a protective resource for children born to depressed mothers? Could the father act as a buffer between maternal depression and child’s neurodevelopment? Few studies have been conducted to understand whether active involvement from the father could help moderate any potential negative impact to the child that’s associated with having a mother with depression, but research holds promise. When reviewing the literature, I was excited to learn of studies which found that involved fathers were able to lessen the potential negative impact of maternal depression on infant distress. This protective effect was seen when the father delivered more stimulating activities that the mother couldn’t provide, promoting better maternal responsiveness to their child and minimising any potential negative impact by providing a second point of contact for the child. One explanation for this could be down to a critical component of parenting: sensitivity. Sensitivity without a doubt has an impact on children’s emotional and social development. Parents that are sensitive tend to be more attuned to their children’s needs and react in a responsive, non-intrusive way. In contrast, parents who act intrusively tend to dominate tasks that their children could do alone and impose their own agenda, such as limiting children’s independent wishes and offering excessive directions. Unfortunately, research has indicated that mothers with depression can show diminished sensitivity and high intrusiveness, causing children to have fewer chances for social engagement. This is where research has found that partners who are sensitive and non-intrusive are in fact able to engage their child socially and prevent any social and emotional difficulties that might otherwise have occurred. However, when family problems are extreme and maternal warmth is very low, this ‘buffering’ effect is not always evident, and the father-child relationship may not be a sufficient buffer on its own, particularly if the child is very young or the father is depressed himself. Nevertheless, this area of research is novel and more is needed to understand the intricacies of this effect. Clearly though, there is evidence that fathers have a profound effect on the neurodevelopment of their children, both directly through parenting and indirectly through supporting the mother. An involved father is responsive, warm and engaged whilst being sensitive and supportive to both children and mother. What should we do? Children are found to be more socially and emotionally developed when their fathers are involved, so would it not be wise for midwives and other health care professionals to effectively involve fathers and thus help creating good family cohesion, especially when mothers have health problems? I believe that educating new parents on the unrealistic expectations of mother and father roles, whilst helping both partners to boost opportunities for more equal roles in child care, is important for creating a healthy family environment for children to flourish socially and emotionally. Furthermore, improved father involvement could be supported by creating opportunities for fathers to develop skills and self-confidence in caring for infants. Key to this, however, would be to address the assumptions relating to gender roles within our society. Luckily, as I mentioned, times are indeed changing and I, for one, can’t wait to witness this new age of fathering.

Attention deficit hyperactivity disorder (ADHD) is a common childhood disorder with a global prevalence rate of 5–10%. ADHD presents with symptoms such as inattention, hyperactivity and impulsivity. A child with ADHD often has difficulty sitting still in class, is easily distracted by noises or actions of other classmates, and they are often unable to complete tests or assignments on time. Moreover, the inattention and hyperactivity may result in a slip in academic grades, in frequent conflict with peers, or in increased parent-child conflicts. I am a child and adolescent psychiatrist and neuroscientist working with the Stress, Psychiatry and Immunology Laboratory (the team who brought you the Inspire the Mind blog), as well as the China Medical University Hospital in Taiwan. I am interested in understanding the mechanisms behind ADHD, so that we can develop treatments that are specifically targeting the relevant brain systems in ADHD. This blog is about our recent study published in the scientific journal Brain Behavior and Immunity about the imbalance of the different systems, including hypothalamus-pituitary-adrenal (HPA) axis, inflammation and neurotrophins in ADHD. If you are interested in nutrition and mental health, please also read my previous blogs, More Fish, Better Attention? It Really Depends and Diet and Exercise for Melancholy: A Throwback to The 18th Century; and, though unrelated to this topic, I also wrote a blog on When Hip-Hop Meets Psychiatry. First of all, let me provide a brief introduction to ADHD. There are generally 3 subtypes of ADHD classified according to the presentations of the symptoms. The inattentive subtype is when the child mainly has problems concentrating on homework, is forgetful of personal belongings or things needed for daily activities, and often procrastinates on tasks that require concentration. The hyperactive-impulsive subtype is when the child is restless during a lecture, exhibits a large amount of energy, is unable to sit through a class, often interrupts others during conversation and games, and cuts in lines. And lastly, the combined subtype is when the child exhibits the symptoms of both inattentive and hyperactive-impulsive subtypes and usually has higher aseverity of symptoms than the other two subtypes. ADHD also has high comorbidity with other psychiatric disorders, including anxiety, depression, and substance use disorder, meaning that they often go hand in hand. Thus, recent studies have focused on investigating the root mechanisms causing ADHD, in the hope of preventing the development of other psychiatric comorbidities that may develop during the course of ADHD. The ‘dopamine deficit theory’, has long been proposed as a possible mechanism in ADHD. Dopamine is a type of neurotransmitter that is important to both our body and brain and will affect our mood, attention, motivation and movement. It has been reported that people with ADHD tend to have a much higher concentration of dopamine transporters (DAT) in the brain and so dopamine is removed too quickly from brain cells. And the imbalance of dopamine results in the manifestation of inattention, hyperactivity and impulsivity symptoms in ADHD. However, the ‘dopamine deficit theory’, seems only to provide a partial explanation for ADHD. More recent studies have pointed to the involvement of several biological systems in the mechanisms leading up to ADHD: one of them is inflammation. Interestingly, this theory is further supported by medical observations, since children with ADHD often present with other disorders associated with chronic inflammation, including atopic dermatitis (otherwise known as eczema), allergic rhinitis (inflammation in the nose which causes symptoms like the runny nose we see with the common cold) and autoimmune diseases (diseases where your immune system mistakenly attacks the body). Inflammation is the protective reaction caused by our body when we are trying to fight off foreign invaders such as bacteria and viruses, and to heal injuries. However, prolonged inflammation may be harmful in the long run in that it will leave our bodies in a constant state of alertness and has negative impact on our tissues and organs. Other proposed mechanisms include the dysregulation of the HPA axis (reflecting on the levels of cortisol) and the imbalance of neurotrophins (nutrients for brain cells). The HPA axis is responsible for our fight or flight response. For example, when we see a lion ready to attack us during our hike, our brain and body will process the information for us to make a decision on whether to fight the lion head-on with the tree branch next to our feet or to run for our lives. Neurotrophins, on the other hand, are the nutrients that help to stimulate and control the growth of new brain cells from brain stem cells. Cortisol, inflammation, and brain development An additional amount of cortisol, also known as the stress hormone, will be released into our bloodstreams when we are under great stress or engage in situations that will elicit the fight or flight response. Cortisol and inflammation have been shown to have a great impact on general growth and cognitive development in children. Previous research showed that those children with relatively high or low levels of cortisol, when compared with children with a normal range of cortisol levels, tend to have poorer cognitive function, such as attention. Too high or too low levels of cortisol may be ‘toxic’ for our brains, especially to the areas important for cognitive function. On the other hand, a lack of cortisol will prevent our body from absorbing the nutrients that are crucial for cognitive development. It has also been shown that too low of a cortisol level has also been positively associated with novelty-seeking behaviours, such as activities that are new and challenging for the children, and sometimes risky. Moreover, chronic inflammation of our bodies has also been associated with inflammation of our minds, which may further affect the developing brain. There is a study showing that chronic inflammation in children has a negative impact on social cognition and facial recognition, and these are deficits, such as being unable to pick up social clues at a dinner party, or being unable to recognize familiar faces, that are commonly observed in children with ADHD. Previous studies have usually only examined the association between ADHD and one of the three systems- HPA axis, inflammation or neurotrophins- aforementioned, but not all of them. Moreover, the results of the existing research have been mixed, where some children with ADHD show dysregulation of some of the systems, and some do not. Thus, our study investigates on the imbalance of all three systems in children with ADHD. ADHD has lower cortisol and BDNF and higher inflammatory biomarkers In our study, we examined 98 children all aged 6 to 18 years, diagnosed with ADHD, and 21 children, aged 6 to 18, without ADHD. We compared the cortisol levels in saliva, and blood inflammatory biomarkers (such as high sensitivity C-reactive protein, or hs-CRP) and brain-derived neurotrophic factors (BDNF), a type of neurotrophin, between the two groups. BDNF tend to help the survival of the existing brain cells and encourage the growth of new brain cells, and is important for brain development and long-term memory. Cortisol levels tend to follow a pattern across the day, reaching its peak within an hour after waking and declining thereafter, until reaching the lowest point at approximately midnight. In our study, we found that children with ADHD have lower salivary cortisol levels at bedtime. Moreover, we also found that children with ADHD have higher levels of inflammatory biomarkers, in this case, measured by hs-CRP, and lower levels of BDNF, than children without ADHD. The missing pieces to the ADHD puzzle ~ inflammation, neurotrophin and cortisol? Our study not only supports the role of inflammation in ADHD, but it also suggests that normalising stress hormones such as cortisol may offer another treatment direction for ADHD. Moreover, the lower levels of brain nutrients such as BDNF in ADHD also indicate that BDNF may be a potential biomarker in this disorder. In sum, children with ADHD may have a broader biological dysfunction than just in the brain, and future treatment aims should focus on specific mechanisms including anti-inflammation, nourishing the brain cells, and normalising cortisol actions in ADHD.

Salut, Hålla, Olá, Ciao, Kumusta: these are all ways to say ‘hello’ in various languages. The first letters also happen to spell out the word shock. Culture shock is a term that we hear in our everyday language; the feeling that might happen when we move abroad and experience a different cultural environment to the one we know. But do we really know the ins and outs of culture shock? I have been living in Italy, my home country, for most of my life. At 24, I was finishing my Masters degree in Pharmacy at the University of Milan when I decided I would apply for a research internship abroad. Although I did not travel to the other side of the world, looking back, Ireland is where I first experienced a culture shock. I will never forget the wind gusts and the taxi driver’s accent upon my arrival in Cork. The first obstacle to my integration was no doubt my scarce knowledge of English, followed by a tendency to hang out with Italian friends. Life in Ireland differed from that of Italy in numerous ways, from distinct food habits to a strong pub culture — which was for me a pleasant discovery — as well as getting used to cycling in the rain. At the time, I was not fully aware of what culture shock meant. Lately I have grown increasing interested in this topic, for two main reasons. First, as a researcher, I am very aware that mobility is a crucial aspect of a career path in the scientific field. You might just have a glance at funding opportunities for researchers and you will notice that most of them encourage (if not compel) flexibility and mobility. Indeed, researchers gain skills and experience by working in different countries, different laboratories and by taking part in international collaborations. The second reason is more personal, as I have recently moved to yet another country, France. Not only am I facing some minor cultural changes like wine instead of beer, or a prolonged summer heatwave instead of an all-year-round duvet; the real problem arises when you have to choose between more than two languages, and they now seem to be fighting each other over who gets to talk first. Culture shock might influence our mental health in various ways; difficulties adjusting to the new culture can lead to disorientation, confusion and significant psychological distress. The idea behind this blog is to share some of the interesting information I found on culture shock, its features and some ideas on how to cope with it. What exactly is culture shock? The term culture shock was coined by the Canadian anthropologist Kalervo Oberg in the sixties. In his publication, he refers to it as “a malady which I am sure has afflicted most of us in varying degree” adding that “when an individual enters a strange culture, […] he is like a fish out of water”. An extensive list of symptoms includes excessive hand-washing; the absent-minded, far-away stare; a feeling of helplessness and a desire for dependence on residents of one’s own nationality; delay and refusal to learn the new language; and finally, that terrible longing to be back home. While the word “shock” makes me think about obstructive or cardiogenic shock (a condition which affects the cardiovascular system) I never really thought of culture shock as a disease and I find Oberg’s point of view very intriguing. Culture shock follows a developmental curve that reminds me, in a way, of that of a classic disease. It is characterised by a recurrent pattern divided in four distinct phases. In the honeymoon phase, the newcomers are fascinated by the new culture and appreciate the discrepancies between the old and the new one in a romantic fashion. Often they associate with nationals who speak their language. This phase lasts from few weeks to few months and eventually ends. By the time they realise they must cope with the real conditions of life, the newcomers find themselves deep in the culture shock phase, characterised by increasing anxiety and a hostile attitude towards the host country. The anxiety grows out of the difficulties which the visitor experiences in the process of adjustment. In this phase, the language barrier represents a major obstacle in creating new relationships and a very common risk is the tendency to think of members of the host country in terms of stereotypes, which results in a denial and misinterpretation of the cultural differences. Oberg describes this phase “a crisis in the disease: if you overcome it, you stay; if not, you leave before you reach the stage of a nervous breakdown”. The adjustment phase starts when newcomers get accustomed to the new culture and develop routines. The new culture is now approached with a positive attitude and considered just another way of living. During the final adaptation phase, individuals are able to participate fully and comfortably to the host culture. This is more or less the course of this “disease”, but there is something more. While I was digging into Oberg’s theories, I discovered the existence of a different type of shock, the reverse culture shock, which might take place when the travellers are returning to their home country after getting accustomed to a new one. A sense of discomfort and psychological distress can arise mainly from the realisation that the life back home is now different from when they left. The editor of this blog platform, Carmine Pariante, has recently talked about reverse culture shock in returning to normal life after COVID lockdown, in an interview for British Vogue. If culture shock was a classified disease, I think it should be placed among the whole-body disorders, as it affects different areas and systems. The difficulties that the newcomer experiences are real and derive from a variety of factors: food/drink habits and consequent effects on the intestinal equilibrium; climate conditions and associated emotional status; anxieties and frustrations derived from loss of social relations; sleep alterations; sadness; and many others. So, what are the possible outcomes? Culture shock can have different outcomes. For some individuals it becomes impossible to integrate, they isolate themselves and cannot exit the shock phase: they never really reach the adjustment and adaptation phases. Some other people manage to adapt to some aspects of the new culture while still keeping some of their own. And a minority of individuals will integrate fully and lose their original culture, in the process of cultural integration. These are the people for whom the host country has now become home country. How can we deal with it? To get to know the people of the host country is a key step for counteracting the detrimental effects of culture shock. In order to do this, we need to know their language. This task alone can cause frustration and anxiety, but in the long-term it will help with gaining confidence, in addition to opening up a whole new world. Yet, we should not forget our cultural background. As Oberg says, “Understanding the ways of people is essential but this does not mean that you have to give up your own. What happens is that you have developed two patterns of behaviour.” — OBERG The newcomers should give themselves the space and time they need to adjust, in order to smooth the transition and develop their own coping mechanisms. The adaptability in this case is crucial, together with an attitude of openness towards the new culture. Being aware of cultural differences is also an important starting point for handling culture shock. These differences can include a diverse sense of time (such as punctuality versus lateness), or a different sense of humour and differing communication styles. For expatriates who experience prolonged emotional stress, counselling and psychological support might be beneficial in speeding the “healing” process. Finally, emotional distress can cause physical tension, therefore good physical habits and self-care are extremely important. Not just negative… From my own experience, I believe that culture shock is not just a negative and frustrating process, but also an exceptional opportunity for growth. I think it should not be equated to personal weakness but rather a normal physical and psychological reaction to a new environment. Being aware of its course and symptoms should not put off our plans to move abroad or to travel, it should instead encourage us to approach the new experience with a positive attitude. Our self-awareness will be deeper as a result of the cross-cultural confrontations and even misunderstandings. Why? Our home culture, with its cues and symbols, is often accepted as the normal way of living. But when we move to a different cultural environment, we have to contrast or adjust our behaviours, attitudes and assumptions, thus increasing our self-awareness. Five years later, here I am: new country, new language, new culture. It has been an exciting rollercoaster and I do not deny there have been moments when I really felt like the only option would be to go back home. With time, I realised that “home” is not such a strict concept, from my experience a good dose of adaptation and the willingness to exit the comfort zone have been decisive to overcome culture shock. “I am not born for one corner; the whole world is my native land.” — SENECA

A is for apocalypse — an uncovering. As we create alternative approaches to actions it is as if we are planting an acorn amidst Armageddon. B is for busy small hands brick building and bus routes that bring box lunches as we begin schooling in our home bonding amid the blankets in our big cozy bed bending our understanding of the day to day. C is for creative care crafted by the conditions of the Coronavirus contagion. When contact is contaminated we connect remotely to form community. D is for doctors directly in contact with the disease. It was they who discovered its deadly nature and directed us to disinfect daily. E is for emergency has been declared. Eager to slow the progression, we engage in social distancing measures as the eminent threat slowly takes hold of elders and loved ones in each state. We are encountering an unprecedented experience. F is for facing adversity fearlessly with friendship and forgiveness, finding a way forward with focus and flowers. G is for gratitude for growth in small humans and gardens that won’t succumb to viremia. Green golden glow of daffodils gathering gives us a feeling of the good earth’s generosity. H is for the hope we have in our hearts for health and healing by hand washing, homeschooling, and holding loved ones in hard times. Healthcare workers have heavy loads and homeschooling parents carry hard questions. I is for infected individuals ignorant of their symptoms that unknowingly are inhabited by the virus. We don’t know what’s inside us. We long for insight or information. Some sort of intention instead of ignorance. J is for joining forces. Joint effort brings joy. Yet the jarring, jolting reality of a difficult journey remains. K is for kindness kindling hope for humanity. Kids and kites can’t be stopped by contagion — our kinship is found among kind words, actions, thoughts. L is for the love that longs to lift others, but lays low to level the curve of COVID-19. Here we are learning to let life be lived in long-distance layers and light up when language launches laughter. M is for maintaining our composure. Maintaining 6 feet of social distance while managing to connect. We are managing stress. Managing conflict. Managing routines. Managing to get by. We are making do with less. Making food. Making memories. Making it one day at a time. N is for neighbors behaving as a network. Needs arise and others notice, send notes, navigate this new chapter in our nation. We see the true nature of nurture and now know Novel Coronavirus cannot become an impenetrable night. O is for orienting ourselves toward others and creating openness for our collective good when we would otherwise feel up-ended, cut off, closed. P is for prayers for peace. Push to be present to each person in our presence. Perfect the perfect peanut butter pickle sandwich and put peaches on the side. “Pass the plate, please.” “Are there more peach preserves?” “Pace yourself.” These words passed among the people at the lunch table as we preserve normalcy in the midst of a pandemic. Planning, playing, participating at home. Q is for the quiet of traffic quelled, school and work quit. We try to quiet ourselves and find quiet determination. We will never quit trying to find a way forward. R is for resilience, resourcefulness, remembrance, and respect. Reminded each day how resilient children and communities can be, we sense a resurrection of resourcefulness and remember those essential workers — healthcare, grocery, sanitation — with resounding gratitude. S is for the stability we seek while we are sending support and searching for solace. In the secret stillness, stretch in to a spirit of surrender and ask for strength, looking for something to make sense of it all. It’s okay to sigh, to say you’re not okay, to see the world differently, to stop hurrying and allow space. T is for time turning, the way things are taken away, and the truth of all transformation through tumult. Trying our best today, tomorrow to stop totaling up the dead and tallying the casualties, but the clock ticks on. U is for the unprecedented upheaval of it all. Understory exposed, unity untied, unexpected emergence of our underbelly. Under pressure trying to understand, we bury ourselves underneath. Underground, we are searching for understanding and seeking to go up again and back toward us. V is for the victory gardens, vegetables, village we belong to even when we seem to be on a solitary voyage of quarantine. Value in very small and unexpected places, Voices of visitors that bring a varied perspective, a view from the porch that brings a variety of colors, sights, sounds, smells, and sensations we can vanish in to and violets that remind us — spring still came. W is for the way we wake, work, walk, watch with wide eyes as the weather changes, worldwide pandemic spreads, warning takes shape. We wait. Then, wait and wait. Women wail, we collectively weep for the ones lost. Where’s the way forward when the world is awash in the worst, weirdest, wildest? We want to wander, feel warmth, and wash away the germs, but instead, we dwell with one another and wait. X is for the uneXpected eXperiences of living through a pandemic that won’t eXercise restraint. We eXpress our lament, find ourselves eXhausted and use eXtreme caution because we now see, we are all ineXtricably linked. In the totally ineXplicable there is eXtra grace. Y is for the yearning and yielding as we yoke ourselves in unity to staying healthy at home. Yeast to bake bread, yoga to move our bodies, yarn to craft beauty, yard to connect back to nature. Z is for the zoom meeting in which we gather to muse and manage. Zooming with classmates, grandparents with grandkids. Zeroing in on a zone of safe passage, we reach a zenith of connectivity with a zoom-based piano recital, uniting family that zigzag the globe. This blog was originally published on www.inspirethemind.org in collaboration with Maternal Journal. Header Photo by Felice Salmon

With very few people given access to testing for covid-19, those of us experiencing mild symptoms are left wondering if we have the virus and just how concerned we should be. If it is coronavirus, the questions on all our minds are, what symptoms can you expect and for how long are you going to be ill? I am sharing with you my experience, what I have learnt from this and from other people (friends and family) who had covid-19, and adding a bit of the knowledge from scientific publications. As a scientist interested in the effects of inflammation on the brain and the body myself, I have also a professional interest in this topic! It was mid-March when I started to have a dry annoying cough. Being a psychiatrist, the first thing I thought was that I was nervous and worried about covid-19 and so I had developed a nervous cough… However, a couple of days later my temperature went up and I started to feel extremely fatigued — I quickly realized this could not possibly be just my anxiety. My temperature was not very high, and it has never gone above 38°C, but the extreme feeling of exhaustion and the aches I was experiencing reminded me of times when I had a very high fever. The glands in my neck felt very swollen for the few the first few days and I had a feeling of tightness in my chest. I remember at that time trying to read about the experience of other people who were suffering with covid-19 and coming across the interview of Dr Clare Gerada describing a very bad and painful sore throat in the first few days. After a few days, I developed strong nausea and for a couple of days I could hardly eat. At around days 5–6, I found myself so physically drained that I could hardly sit up in bed and I had the feeling I was fainting, even if I was just laying down on my bed. About 1 week after the first symptoms I completely lost my sense of smell, my nose was not blocked andI could breathe easily from my nose, but I could not smell anything at all, not even the strongest smells. This had never happened to me before and it felt very strange. The first 10–13 days were the toughest and although my temperature was not high, it was always about 37.1.-37.4 C so not really my normal temperature. The feeling of physical exhaustion and a feeling of tightness on my chest were the main issues during the second week. My cough was not very bad initially and it felt gradually improving in the first week but then became again worse around day 10; although gradually improving over time, it took nearly 5 weeks to get over it. Luckily my strength started to come back after 2 weeks and I started to go back very slowly to my routine, trying not to push myself too much. When trying to play football with my daughter in the third week, I could not last more than 2 minutes before becoming breathless and having to sit down. Now, I am not a very fit woman, but this was not normal for me, and it felt like my lungs still needed more time to recover. Another symptom I developed after 1–2 weeks was severe headaches and vertigo; however, I usually suffer with these symptoms so these may not be specific for everyone who is affected by covid-19 and it may just be that since your body is weakened by the virus, some symptoms you are more prone to experience are re-exacerbated. Other people tested positive for covid-19 experienced severe headache or dizziness for few days, and indeed from scientific publications these have also been reported in a small percentage of patients in China. In particular, in a paper published in JAMA Neurology, focusing on patients hospitalized in China for COVID-19, the most common neurological symptoms reported were dizziness (in 17% of their patients) and headache (in 13% of their patients). In another study, patients also reported gastro-intestinal symptoms such as diarrhoea which appears to be associated with longer duration of symptoms and viral clearance, which means the virus may stay in the body a bit longer than in those with only respiratory symptoms. Most of the people I have been in touch with and who were tested for covid-19 had high temperature which lasted sometimes over 1 week, in some cases until day 12–13, and this is also similar to what you see in publications from the data in China. From what you read from scientific publications, possible critical days go from day 6 to day 10 from the onset of the symptoms, as this is the range of days where people started to get admitted to hospital for breathing difficulties or in the worse cases transferred to the intensive care unit. The psychological pressure you feel while you develop these symptoms is very high as what you read from the newspaper is extremely scary. But, the truth is that the majority of people will get over this without ending up in hospital and by taking good care of yourselves, by resting, drinking plenty of water/fluids, and taking paracetamol even if your temperature is not extremely high. I extremely appreciate how difficult it is to understand when you should contact 111 or your GP as one of the main messages we get is to contact them if you have difficulty breathing. You also do not want to put pressure on the NHS with all we hear about the healthcare professionals being overwhelmed. That being said, GP practices are still working and GPs can do phone consultations that could be very helpful in this situation, so I would advise to contact your GP or 111 if you are struggling and if you are not sure whether you need to be seen or go to hospital. I think my message here is to try to not feel too anxious if you are starting to experience covid-19 symptoms and to take things one day at the time, knowing that it may take longer than a week to recover and maybe more than 2 weeks to get back to your normal self. Some recent newspaper articles have described symptoms lasting many weeks. But the most important thing is to take care of yourself and ask for help if you feel you are struggling. I have a little disclosure to make here… I have never been tested for covid-19 so I cannot say for sure that I had covid-19 and I guess most of you reading this will be probably in a similar situation. However, I hope that sharing my experience and what I have heard and read about it may help some of you struggling to find some answers and some reassurance about what you are experiencing. Let’s try to use this time to learn about taking better care of ourselves and of the world around us, and to bring with us what we have learnt to the future… a future world where covid-19 will be no more a threat to anyone. Header image source Freepik