 Good evening everybody and welcome to the Mental Health Professionals webinar understanding first episode psychosis. There are currently about 520 of you online, which is fantastic. So thanks and welcome to everybody who's joined us and also to those people who are going to watch it on the podcast later. We'd like to acknowledge the traditional custodians of the land and across Australia upon which our webinar presenters and participants are located. And we pay respect to the elder's past, present and future, for the memories, the traditions, the culture and the hopes of Indigenous Australia. I need to apologise, I normally have some printed instructions that my printer decided to break. And after a few episodes of behaving like Dennis De Nuto off the castle, I gave up and loaded it on my laptop. I'm walking across to the side a bit more than usual. I'm Mary Emelayas, I'm a GP and a psychotherapist from Cairns in Far North Queensland. I've facilitated a few webinars for MHPN, which I really enjoy. I have a particular interest in young people working at Headspace and particularly early psychosis. So it was a real privilege to be invited to join in tonight. And I'd like to introduce our panellists. So you will have seen their biographies before we started. So first of all, I'd just like to welcome you, Morlan. Now, I think you're based in Melbourne. What's it like down there today? It's been very, very wet this morning, but this afternoon not too bad. So we don't have to water our gardens. Well, welcome, Morlan. We actually had a thunderstorm brewing here and I was hoping we didn't lose power, but the thunderstorm went away. Now, I'd like next to welcome Toby, who's a mental health nurse and academic from Sydney. Toby, I just wonder if you could tell us a little, you have quite a bit of involvement with early psychosis, don't you? How did you get involved in that in the first place? Oh, it's a long story, Mary, but really just generally working with people with mental illness and comorbid problems. You know, started off Triple Care Farm, which was run the southern highlands up here in New South Wales. And then started working with people in the inner city of Homestead, in the city of Sydney through the Oasis Youth Support Network, and then led a nurse-led charity for about a decade before moving across into academia. So pleased to be here. Well, it's great to have you. Thanks, Toby. Now, Shona, I've actually forgotten. I think you're based in Victoria. Is that correct? Yes, that's right. I'm in Melbourne as well. And you're at Origin? That's right. I work at Origin. I started with the early psychosis program Epic when it first started way back in 1992. So I've seen Epic evolve and become the origin centre over those years. Well, it's great to have you with us tonight. And then, Grant, you're in Northern Beaches of Sydney, I believe, with a specialist youth mental health team. Is that right? Yes, I work with a team called Beak, which is Beaches Early Intervention Centre in Sydney, and also do a bit with public health and population health data around early psychosis and substance comorbidity as well. Well, it's great to have you. And I'm looking forward to the discussion with everyone tonight. And so we'll just go on to the ground rules for tonight's webinar. So just remembering that this is, as though it were a face-to-face activity. So if you're typing things into the chat box, remember that everybody can see them and be respectful of other panellists and the participants. Please post your comments and questions for the panellists in the general chat box. I've also received the questions that you submitted before when you registered for the webinar. We had about 600 questions. And so we're not going to be able to cover yours everybody's this evening. But hopefully a lot of them will be answered through the panel discussion. If you have any technical issues, post into the technical help chat box at the bottom. And just, again, remembering everybody can see what's there. So try and keep your comments on topics. If you find the chat distracting, you can click on the small down arrow at the top of the chat box and then you don't need to see it. And please remember at the end your feedback is really important. So if you can complete the exit survey, that's going to appear as a pop-up when you exit the webinar. Now, you've all read the story about our patient Tim. And we're just going to be going on to the learning outcomes with the slides there, Sarah. Thank you. So we're just going to be looking at Tim's story. And hopefully we get a better understanding of the warning signs, the indicators of and the prognosis for first-episode psychosis. Hopefully feel more confident to support young people who have experienced first-episode psychosis. And also to increase our confidence in working collaboratively in this field. Now, I hope you enjoyed reading the story of Tim because he certainly seemed very familiar to me. And I think that there would be elements of work with Tim that would be quite enjoyable. And then I can see that it might be starting to become a bit stressful. So what I'd like to do first, just to remind you that each of our panelists will give a sort of discipline specific response to this case. So how they might respond if they met Tim. And then we'll be having a discussion together between the panelists and also bringing in the questions that you have from the audience. So I would like to welcome Dr. Morton Rawlin, who's a general practitioner. And he's going to talk to us about how he might think about somebody like Tim. Welcome, Morton. Morton, I think we might have your audio and mute. Sorry, sorry about that. Hi, I'm Morton Rawlin. I'm a GP in Melbourne, but I've also worked really and have had a longstanding help and been working with psychosis and anxiety depression for quite some time. I'm going to speak basically as a GP and from that point of view, it's a very broad brush that we need to take as GPs to start with. But mainly our role in this situation is to try and gather the information together and work out what are the problems. Often these cases are actually brought to our attention by family members, not necessarily by the young person themselves, although it could be. Depending on the GP's needs and wants, they can be associated with some schools and things like that which might bring that information to their attention or the university, depending on how old. The main issues for a GP to start with is who's being impacted by this? Who, what are they doing that is making it socially difficult for that person? And indeed the question has to be asked, what is normal? Is this outside of the normal? Is it just flamboyant? It's sometimes difficult to get that right, particularly in the early stages for this. The other thing that the GP needs to do is start by setting some goals and expectations, both for the patient and also for the people who are concerned. GPs are going to be treating the patient, but also the family. And sometimes there is issues between who's actually got the problem? Is it the young person? Is it actually the family that's more concerned? And therefore we need to work out with that person how do we move forward? What are the services that might be needed and how we maintain particularly their confidentiality between different types of conversations? What that person is comfortable for others to know and what they may or may not be comfortable to know? The other issue is around some of the medical legal issues. Are they always in concern? And do they need to be scheduled or are they going to hurt themselves? Those sort of things we have statutory requirements for. At a more local level, what are the services that are available to me in order to send Tim to the best person? This is a difficult issue because the distribution of services can be sort of all over the place. And particularly in rural areas, it can sometimes be very difficult for GPs to restore alarm, although you may in fact be able to use things like tele-help, which may help. And predominantly we would be liking to treat these sort of cases as a theme because they can, as was intimated in the introduction, they can be very challenging and you don't necessarily want the person to completely attach to you. Lastly, we need to work out what are the supports that are going to be needed into the future, how we can counsel Tim and his family, how can we keep him in therapy and when to escalate the care and to where. So with that, I might hand it back. Thanks very much, Morlan. That was well within your allotted time frame. Look, it's really helpful to just think about the kinds of things that a GP needs to keep in mind. There are 735 people online now, which is great. And I noticed that we've got people from all over Australia, including someone from Lightning Ridge, which I think is fantastic. So people as diverse as Lightning Ridge, Perth, Rockhampton, Northern New South Wales, Tasmania are upskilling in early psychosis. That to me seems like great news. So Toby, I'd like to welcome you now to talk about how you might respond to Tim and his family from a mental health nurse perspective. Thanks, Toby. Sure. Thanks, Mary. Hello, everyone. My name's Toby Rayburn. I teach now the University of Sydney, but I'm a nurse practitioner in mental health. For many years before that, a credentialed mental health nurse and I've done things in a variety of settings. So tonight, I thought I'd start with this initial screen, which really highlights that mental health nurses may meet people like Tim, or Tim specifically, in a wide range of contexts. And context is crucial when it comes to these types of approaches that mental health nurses might use. So there are mental health nurses who work in GP surgeries with the mental health nurse incentive program. Nurses may visit Tim's home, which is very valuable and might talk a little bit more about that in a few minutes. Headspace centers. Mental health nurses work in private practice now. And there's obviously public hospital-based sort of community mental health teams based at centers, also based in mobile teams. And then there's large groups of mental health nurses who work in emergency wards and hospital inpatient units. If you look at Tim's case study, we can probably see that it's going to be a bit of a journey. And I'm sure most of us in the web meeting tonight would have come across people like Tim. And this next screen just highlights the idea that, as we know, recovery is not a linear process. So it's not something that we expect that Tim will sort of go through a diagnosis, treatment, and then get clear outcomes. Recovery in mental health tends to be more of a personal journey. And these are just some of the principles that have been written about by people with a lived experience of mental illness over many years. There's a huge amount of research now that's being conducted on the lived experience of people with mental illness and what they say actually assists them towards mental health recovery. And so these can give us a bit of a guiding light in Tim's case around the sorts of things that mental health nurses in whatever context that we work in might like to be moving towards the connectedness, hope and optimism, identity, meaning and purpose and empowerment. And so there's a goalpost, if you will, and they're taken from Mike Slade and his team's work from King's College in London. They've done a lot of good research over the last decade on recovery-orientated approaches to mental health care. So now moving through to these last screens of my understanding of focus now and again emphasizing the ideas that mental health nurses may work in a wide variety of contexts. I've tried to make these sorts of points as broad as possible so they can be adapted across a range of different contexts. But this is the first point highlighting that, you know, from a recovery-orientated point of view, we really want to be focusing on the idea of mental health assessment, focusing more on strengths, abilities and activities as opposed to indicators or symptoms and illness. And I really like something that Pat McGory said a couple of years ago where he was talking about the idea of whether a mental illness exists and he talked about the importance of perhaps talking instead of talking about mental illness, talking about mental ill health. I think that can provide a nice platform for us as we try to think about how can we assist him in a collaborative kind of way towards some of these sorts of principles which people with a lived experience of mental ill health tell us are useful. And so being interested in Tim's strengths and then also, you know, I think one of the things that the highlight, the case study highlights really nicely is the importance of holistic assessment. So, you know, taking, you know, a fuller look at Tim's drug and alcohol history will be an important part of the assessment. I think as Morton's already highlighted, there will be a wide-ranging sort of in-depth level of assessment that will need to take place in any context that we work with Tim. So then the second thing that mental health nurses do really well and he's psychotherapy and I've just used a motivational interviewing little mnemonic here, ores, open-ended questions, affirmations, reflections and summarizing. And those things are all pretty self-explanatory but they just give us a nice guide for starting out in engaging him in the initial kind of relationship. In the medium to long term, we'll be wanting to adapt our psychotherapeutic approach, whether or not we use a COVID behavior therapy type approach. In the personal, psychotherapy may be quite useful in Tim's case given his, you know, the strong emphasis in the case study around some of his relationships. And there may be narrative therapy. There may be a number of other psychotherapeutic techniques that might be useful for nurses working as part of the collaborative team with Tim. We want to be setting a foundation so that our relationship is one that Tim feels safe in and that he feels he can come back to it in future as needed. Third thing here is social advocacy. So, you know, an emphasis here on the importance of connecting Tim in with vocational pursuits, you know, his theatre community, education, obviously housing and relationships. So, a huge part of what nurses, mental health nurses need to do in any context is advocacy. And that may be writing a letter advocating for Tim for, you know, a particular job. It may be supporting him to, you know, get some assistance with his TAFE studies. It may be talking with his parents about ideas about where he's living and what might be most helpful depending on the context and where things are going in his case at the time. Another part of advocacy that's really important is defending Tim's right to choose. I think we would all agree that, you know, working collaboratively is one thing, but we also need to be, you know, providing Tim with information, which at times may clash with information that's given or information that's not given by other professionals and other services. And so we need to be very clear about what we know and what we don't know as much as possible and be forthright around Tim's right to choose. And so then the fourth point I had here was physical health promotion. So seeking to address Tim's drug and alcohol use obviously. If sleep-like cycle is something that towards the end of the case study has mentioned and isolated behaviour and diet, and pretty much we know that if we can move him towards a more, you know, physically healthy, satisfying life in areas to do with his body and the brain, you know, the mental health and physical health are basically one thing. And so physical health promotion there is really important. That may include going for a walk with Tim as part of what we do in a psychotherapeutic kind of approach. It may include, you know, encouraging Tim to get down to the gym or try to network some other partnerships that we might have in those sorts of physical health areas. And the last point I've got there is medication management. Now I'm a nurse practitioner. I've prescribed medication over the years, certainly administered and managed a lot of medication over the years. And so look, I'm not, you know, anti-medication, but I do think that the older I've gotten, the more concerned I've gotten about the long-term effects of some of the stuff that we've been dosing out as nurses over the last couple of decades. And so I think taking a slow approach and staying low with medication is very important. Try to avoid anti-psychotics. You know, it would be ideal if we could move him towards a more satisfying life and try to assist him to stop his cannabis use. Then, you know, in an ideal world, things may resolve quite well for Tim, and I'm certainly, I'm sure, other people in the meeting would have seen people, you know, have moved towards a satisfying life after they can move past something like that. But in other occasions, there are more complex things in play. So that's where I leave it as an introduction tonight, I think. Thanks, Toby. I can see that the chat from the audience is certainly appreciating that very holistic approach, and particularly the strength focus. And now I would like to welcome Shona. She's going to talk to us about responses a clinical psychologist with this area of interest might have for Tim. Thanks, Shona. Thanks, Mary, and thanks, Toby. So when I thought about approaching Tim with my clinical psychology hat on, I guess I've come up with five slides, each of which talks to a principle or a process that I think is important in working with young people with early psychosis. And I guess the first and foremost is engagement. So I think it's absolutely essential to engage Tim, to get him into treatment, and to do this as quickly as possible. Because what we're wanting to do is limit the damage that comes from having an untreated psychosis. There's a term that's used DUP, duration of untreated psychosis. And we know that prior to early intervention in psychosis, lots of people developed psychosis and went untreated for periods of one, two, sometimes five, ten years. And that during this time, there's lots and lots of damage to their social networks, who they know and what they do, and that if we can get in early and prevent this damage, that's going to help Tim get better quickly and to achieve a better functional recovery. So we're wanting to gain Tim's trust to help him to feel safe. If possible, we need to engage him so that he will tell us everything that's going on. We want to try and avoid hospital if we can. But in order to avoid hospital, we need to have a really good idea about what's going on with him. So we need to have the ability to do a good risk assessment. The ability to put in place a good crisis plan, so should the risks escalate, that we know how we're going to respond to that. And we're usually going to need to involve the family in that as well. So we're going to want to know that there's some other people in the community keeping an eye on Tim between appointments if it proves that he's got a definite psychosis, which it does look like he has. So I guess just good clinical engagement skills are needed to get Tim to feel safe and trusted. So we want to be warm to display warmth. We want to be interested in his story. We want to show that we understand what he's going through. We want to provide information and we need to be flexible. It's really important for us to get a good understanding of what Tim thinks is happening, what he might be scared of, and to provide reassurance and to provide optimism and hope. I'll talk a little bit more about that in a minute. So the next thing is collaboration. So we really want Tim to engage. He's really just building more on engagement, I guess. We want to build a strong therapeutic relationship with him, a really good rapport, so that he can collaborate strongly with his psychologist, with his treating team to be involved in this assessment and then to go on to develop a formulation and to be engaged and collaborating in the treatment process. We find that collaboration is enhanced when we convey to Tim that we believe that he is the expert. He's the one who knows himself, he knows his strengths, he knows about his symptoms and he knows where he wants his life to go. So we want to be having a respectful, empowering approach to Tim so that he will collaborate with us in his treatment. We want him to be active in all aspects of his treatment. And as Toby spoke about, we want him to be involved in making decisions about his treatment. So there's an area of medicine that's gaining more permanent prominence in shared decision-making. So actually giving the client or the patient as much information as possible in order for them to be able to make decisions about treatment. So once again, it's about collaboration and engagement. The next title is psychoeducation. So psychoeducation really is a very important process in early psychosis. Once again, it builds on engagement, but it's also about providing information, a tailored information about what is psychosis and what is the mental health system. Because people with early psychosis are often coming up against the mental health system for the first time. We're wanting to once again engage people to be collaborative and then to tailor the information to each individual's experience. So it's not just a matter of giving people brochures, but actually work with the person about what they understand to be happening to them, what's their knowledge about psychosis. And often people with early psychosis have experience of psychosis in their family or in other places. And they might have some real fears that need to be addressed. Within psychoeducation the stress vulnerability model is a really good framework to explain psychosis. It's a really good place to start with teaching people about psychosis because it tells us that we all have a level of vulnerability so that under certain circumstances everyone will develop psychosis or develop psychotic symptoms and that's the interaction between personal level of vulnerability and the stress that you're experiencing that leads to the development of psychosis. So by conveying this model we're telling people that they can have an influence themselves so they can have hope about recovery and they can behave in ways that will help them stay well. I've just noted buckets and bridges. So there are lots of diagrams and stories and tools to talk to young people or any people about the stress vulnerability model and they involve us. And we know from research that psychoeducation has been shown to improve outcomes in psychosis. So it's a really important process in working with people with psychosis. So the next heading is formulation. So our case formulation is I guess the embodiment of the shared understanding between the psychologist and the client about how we understand this situation and what's happening and why. So based on our engagement and our collaboration we get a really comprehensive assessment so we want to understand Tim's developmental history, any past mental health issues, his history of substance use, his current substance use, his current symptoms when they started, how they evolved and it looks to me like Tim's symptoms are still evolving. We want to know about his recent and his current functioning, some of which we know. We know that he did well at school, that started to drop off towards the end of school, didn't do as well as he expected to do and then hasn't transitioned to university, which tertiary particularly well. We want to know how he sees himself and what he sees for the future, where he headed. And then we synthesise all of this into a story that's really a hypothesis about how and why the psychosis developed and then use all of this knowledge to devise a treatment plan that Tim agrees on. That's what we ultimately want. We want him to actively collaborate in all of these processes and the formulation should be constantly reviewed as recovery occurs or as other things happen. So it's really a formulation is a hypothesis that brings all the threads together and that forms the basis of the treatment plan that we're wanting to work on together. And then the final heading I've got is recovery. So it's really important with a number of us I think have talked about optimism and hope. I think that's absolutely essential in all words, but in working in early psychosis in particular. So I always work from a stand that recovery is assumed, that people I work with are going to get better and it's the focus right from the start. All right, there are some problems here. We've got finishes to deal with, but we are going to improve your situation and get you back on track. So we're wanting to embody this optimism and hope and convey it to Tim all of the time and to, I guess, helped by focusing on his strengths. So we also, in part of our assessment, we want to know what Tim's good at, what he thinks he's good at and what strengths he can bring to bear. Functional recovery. So actually getting back out into the world and doing things, education, work, hobbies is extremely important to all people, particularly young people. And our research tells us that it's more important to people to achieve functional recovery than to have additional symptoms. So it's really important for people to get back onto their developmental trajectory when we're talking about young people. So based on the formulation and the treatment plan that we've developed, recovery work with Tim would focus on substance use, issues around grief in the loss of his relationship, but also possibly the loss of his potential career or his academic success that he, I think, was dear to him. We might be looking at depression because there are certainly some signs there and we want to look at some vocational planning. So where's he heading? What are we going to be aiming for? And then if psychotic symptoms persist, then we may well be looking at targeting and doing some psychological intervention to psychotic symptoms. But early in psychosis, psychotic symptoms usually quite often resolve. The other thing is that we want to do some work to bolster his self-esteem, help him to adapt to having experienced an episode of psychosis, and also through good knowledge of himself, we want him to have a stress management plan because that's actually going to be his relapse management plan. So what does he need to do to get well and stay well? And yeah, that's my slide. Thanks, Mary. Thanks a lot, Jonah, and we will be coming back to discussing with the panel later. And I certainly find it really encouraging to hear about hope from the beginning because I think there often used to be a lot of nihilism about when a young person had first episode psychosis, even when I went to uni, which wasn't all that long ago, only 20 years. Now I'd like to welcome our psychiatrist, Grant, from Sydney, just to talk about how you would respond to Tim. And I imagine you see Tim's every day, Grant. Yeah, look, I think this scenario is very realistic one and very similar to a lot of young people that we do see. And look broadly, I agree entirely with all of the comments that have been made by the other presenters about the broad approach. Clearly I think we acknowledge all the work that particularly the team in Melbourne have done in changing some of the views of this over the last few years. So look, my perspective would be that Tim at this point definitely needs assessment as soon as possible. Clearly he's on the cusp of something here and the aim should be to try and help him resolve this as quickly as possible. It's at that point where it could be something that's developing into a psychosis, but it may not be. But I think he definitely needs assessment by a clinician experienced in working with psychosis. So a psychologist, a nurse practitioner or a psychiatrist, if you had a multidisciplinary psychiatry service in your area, that would be very suitable to refer Tim to that or a headspace. And I think there's all the reasons to be concerned that people have outlined that there's stress and disruption going on in Tim's life. There's some potential areas of risk although that's not the primary thing that jumps out here. And the points that Shona was just making, that we know that earlier treatment is more effective and that longer duration of untreated psychosis is associated with worse outcomes. So it means there's this really important window of opportunity and a real dilemma because on the one hand we've got the need to encourage choice and work with someone and take a sort of long, slow engagement approach but also we know that the clock's ticking as well and so there's a real need to try and help that person make a sensible choice as quickly as possible. It's also worth saying in terms of what informs the assessment, I think part of that changing view of psychosis highlights some of the things we should assess and also some of the complexities of assessment. So certainly when I trained, the view of psychosis was very much you had these kind of successive stages that always followed each other. There was a prodrome and then there was psychosis and really your task in assessment was just to separate schizophrenia from bipolar disorder. I think that view has changed completely. And now we see a much broader spectrum. We see that psychosis is being on a spectrum and there's quite a lot of people with a broad vulnerability to psychosis in the community that might manifest in all sorts of ways including brief and fleeting psychotic symptoms. And then about 2% or 3% of the community might get a psychotic syndrome and I guess it's worth saying what do we mean by psychosis as a syndrome? I guess it means more than just a fleeting symptom, more than an abnormality of perception or thought but where you've got a number of these things all coming together, abnormal perceptions, abnormal flow of thought, abnormal beliefs, abnormal organization of behavior, agitation, motor changes and you've got a number of these things and they're severe enough to cause you to stress or dysfunction and they're lasting several days or a week or longer. And so people crossing over into that threshold might happen to about 2% to 3% of people in their lifetime. And then of that only a subset of people will go on to a more enduring psychosis and there's a range of risk factors that overlay at different points in development that might influence where you are on that spectrum and whether you transition from one of those points to another and that includes your genetics and your family history whether your developing brain has been exposed to injury early in life through maternal illness, through head injury or through trauma and then whether there's been signs in your early development of learning and sensory and motor problems indicating some compromises with your brain and then the other things that you might get exposed to in later life in adolescence stress of transitions in life, trauma and drug and alcohol use cannabis and amphetamines in particular. So all of those things can come together in a varying mix in different people to contribute to their risk. I entirely agree with the points that others have made about the need to take a really person focused approach. So the most important thing in starting to talk to Tim is not to understand the psychosis but to understand and try and meet Tim and to understand who he is, who the person he wants to be is how that matches his family expectations and what does he think and fear and understand is what's going on. What does all this mean to him? And I guess just to show that this recovery idea is not a completely newfangled idea that the hypocrisy said it's more important to know what sort of person has a disease and to know what sort of disease a person has. And certainly in terms of assessment I do think the diagnostic label, what subset of psychosis someone has, actually isn't a critical thing for treatment at this point. It's important to understand the symptoms, it's important to understand the risk factors but quite which of the diagnostic boxes of DSM you put someone in at this stage isn't necessarily that helpful. None of them really guide treatment that much but it's too early to really allocate any of those to Tim so I think making a broad decision does Tim have a psychosis or not really the only important diagnostic issue at this point. Here's some of the things that I would assess if I was seeing Tim, some of the things that sort of jumped out of the story for me and clearly you would do a comprehensive assessment but I wondered about his family history. I'd really like to explore that story about the grandmother. It doesn't sound like that might have been potentially a psychosis and it'll be important for both understanding his genetic risk factors but also his expectations and his family's expectations about illness and recovery. You would like to get a good early development history. Young adults often don't know that, you often do have to get that corroboratively from their family or from their mother. I'd be interested to explore the relationships and the academic decline. It does sound like he's been through a lot and lost a lot in his last couple of years both with the relationship with Beth and with his expectations and his academic performance. It'll be important although sometimes difficult to try and tease out has that been a trigger for this stress that he's under or has it been an effect of his state of mind changing or is it a bit of both? Is it a bit of a vicious circle? The substance use would be critical and it's such a common part of these sort of presentations and you'd like to know what he's been using in detail, how long for? There's some good evidence that earlier age of onset of cannabis was associated with later development of psychosis, so how young he was. And amphetamines, particularly with this slightly manic, slightly agitated and elevated sort of presentation, you wonder about amphetamines. Has he been using anything to help him stay up all night writing his play? And that could be important. There's a mention of him holding his jaw oddly and sometimes in psychosis people can have mannerisms and changes in their motor behaviour that would make me think, is there something else going on affecting him neurologically? Unlikely but important to exclude. And of course you'd go through in detail his symptoms, his other perceptions, his beliefs and so on. And RISC, Shona mentioned talking about RISC and I agree although I would say it's important to say we shouldn't do a risk assessment as such. What we should do is do a comprehensive assessment and within that think about RISC and particularly think about if I was Tim, are there things that would make push me to acting violently or recklessly or in a way that's going to damage me and my chances of recovery. The other thing I've got there is just to say a corroborative history is obviously critical wherever possible and it should be the default option where we have family and supports and loved ones who know the person we should aim to speak to them as well and get some history. So just to finish with two slides talking about medication and again I agree with the principles and points that others have made that I don't think medication would be a first line option here. I don't think reading the story of Tim as he is at the end of that vignette that you would immediately reach for the prescription pad. I do think your first urgent priority is to assess and engage and monitor. But there may be a need for medication if this continues to evolve and some of the indications for medication would be if he's becoming more and more distressed and anxious, if his condition continues to worsen despite your efforts to engage him and support him and if there's worsening sleep disturbance or the perceptual abnormalities and the suspiciousness of getting stronger and more distressing or if the risk or consequences are there. The other important part of medication might be choice and some people you can discuss the pros and cons of early medication with them and some people might choose, look I would rather try that because I'm so distressed by what's happening. If you were choosing to go with medication the three likely candidates here would be are listed there, a benzodiazepine, an anti-psychotic or a mood stabilizer and in someone like this with very brief and rapidly evolving symptoms and a degree of sleep disturbance, you might want to just try a small amount of a sleeping tablet at night for example, a tomazepam or diazepam and to see if even just breaking the getting someone a few good nights sleep can sometimes really calm things down a lot. If that wasn't successful you might want to use an anti-psychotic. I think one of the big shifts has been a recognition of the real burden that anti-psychotics do cause and I think Toby mentioned that and so I think the old idea of well it can't do any harm to try an anti-psychotic I think is clearly wrong. It can do harm to try an anti-psychotic so you need to be clear that the benefits are going to outweigh the potential harms and look, there is a flavor of elevated mood in this presentation and sometimes you might consider a mood stabilizer and Valprite as a first line in this sort of situation probably less often. And just finally then to say if you were wanting to choose an anti-psychotic what would you choose and it isn't an easy choice. Here's my kind of oversimplified and unevidence based view but I've included in the references an excellent meta-analysis in the Lancet from a couple of years ago that summarizes a large number of these medications and their relative properties. Overall all of these medications are equally effective and the difference between them is about the side-effect profile and it is a difficult choice. On the one hand we've got medications whose primary side-effects are to make you sedated and gain weight and for some people when they're highly agitated that sedation can be beneficial. So Lanzapine and Quartypen and often when people admitted to hospital they started on those but the weight gain is a substantial problem and an increasingly recognized one. At the other end you've got side-effect medications which are much less sedating and can have other side-effects though in terms of movement side-effects or prolactin or akathisia. They're less common and not everyone gets them but a substantial minority do. And usually in a community setting for a young person with a first-episode psychosis mostly I would be choosing something more in the middle there or towards the right hand end of that arrow particularly a Bilify or Solian or Arapiprazole or MSulprite which most young people seem to find more tolerable and highly sedating and you're able to get on with work and study but some people won't tolerate them. Respiradone is sometimes used and my experience has been it's very poorly tolerated especially in young women where it causes a lot of prolactin related problems and in a community setting I'd very, really use the Lanzapine as a first line just because of those concerns about other things. So happy to talk more in the question section but that'd be my thoughts about some of the possibilities that might lie ahead with Toby. Thanks very much, Brass. Actually before you go there's been a lot of questions in the general chat about the definition of psychosis. So we're clearly not wanting to jump into any DSM-5 diagnosis right now because we don't know what the future is going to be but it's probably a bit unfair to just drop you in it How would you define psychosis? Well look I think as I think psychosis if you distinguish just a symptom of psychosis to define a syndrome of psychosis I would say it is the presence of two or more of hallucinations in other words abnormal perceptions and any modality, delusions, abnormal beliefs, suspiciousness and so on and thought disorder in the presence of other associated symptoms like agitation, motor disturbance, cognitive difficulty and that those things are present and distinct of a duration of more than a few days and I mean if they're very severe and intense you could describe that in a very brief way someone with a brief and very acute drug induced psychosis for example all those features might occur together but only last a day or two so you'd still call that a psychosis but it's the combination of all of those symptoms in a way that's more than just for a few fleeting moments or hours. Thank you that's really helpful now the other thing that's been coming up a lot and I think even the panel we're wanting to discuss with each other too is that many many people are emphasising the importance of involving the family not just to find out more information but out of recognition that Tim lives with his family we might see him for an hour a week but they're within the rest of the time so how do we support them? How do we help them to help him? We might deal with issues of consent so his parents clearly want to know what's going on but he's 19 and he might say he doesn't want them involved so I thought perhaps we might ask you first Morton because you're a GP there are many situations particularly in rural areas where not only would you know the family but they'd all be your patients and in some professions that wouldn't be possible but in general practice it happens every day so how would you think about negotiating this issue of conversation with the family and with Tim? Look thanks it's a really important conversation that we have to have with patients and families quite frequently it's certainly very much an issue in rural areas where you treat the family and the grandparents and uncles and aunts and everybody and everybody knows everybody else's business particularly in small towns but it also occurs in metropolitan areas as well I guess the first thing is really being very clear as to where the rules are making sure that people are aware of the legal aspects what is right, what is appropriate and where you're not going to allow it to go so the main issue for everybody is being very very clear that these are the rules that you'll be able to ask questions and so forth but at the point of some things you know as a GP will need to talk with the individual and it works both ways it's also the family not necessarily things being told to Tim from the family either so it sometimes does put us in a very difficult situation often we do have some information that can be critical to the situation that we do need to talk with Tim about and sometimes you get around it by making you know trying to lead the conversation to those sort of things without giving away where that information came from talking generalities you know often people with these sort of things might have and see what the responses are it is difficult sometimes in terms of allowing people to feel safe in the relationship which is really important and also to particularly in rural situations saying look you know there's always going to be a bit of a rumor mill it's not coming from here if you have any concerns talk to me about it because obviously particularly with people such as Tim there may be or may develop an area of paranoia and that can complicate matters as well. Thanks Morlan. I mean a lot of people in the discussion have been talking about the small community issues as well. Now Toby how would you go about handling this thing where maybe Tim doesn't want well we know can we assume Tim doesn't want us to talk to his family or have we asked him but I suppose you know how do you go about that as a mental health nurse in your practice? Yeah Mary good question it's a real tension isn't it I think Morlan was sort of making that point between you know Tim's not any years old and we're wanting to encourage you know his growth as a young man you know his autonomy his rights to self-determination and so forth on the other hand you know as a mental health nurse in a community based practice I might see Tim once a week for about 45 minutes and so my window into his life is so much smaller than the window of his family generally speaking or if we sort of move it out a little bit further from his blood relatives and imagine that Tim perhaps has some other associates or friends in his theatre group or the community of people involved in that sort of area of his life then there may be real potential there for those people whether it's his mother whether it's his father whether it's those other friends to have a really positive impact on him and so I am always at pains to take an approach from the very beginning in a community centre with people generally to make the point that everything that we talk about is confidential except for two things one is if they're going to hurt themselves or if they're going to hurt other people I make the point that we want to talk about those things and that I'm going to be calling the police or anything but I will be discussing those things most likely in a collaborative way with the team that I work with and then as the journey progresses with people and let's imagine that Tim or someone like Tim requests that information is not shared with people who are close to them I will generally, obviously I'll respect that given he's a 19 year old male and so forth and you're wanting to work with him to build a sense of choice and assist him to see the results of those choices on the other hand as things progress if I may make suggestions down the track that it would be good to involve family or friends depending on what the challenges are and so I think the whole case study is really relevant and there's been some great questions in the general chat around the idea of what is this? Is it that we're working with a person with an early developing psychosis? Do we start to use terms like schizophreniform disorder schizophrenia and I think Grant made some good points about burying away from those things but if we frame it as a young man who's trying to pursue a satisfying life then we can't go far wrong because we'll be able to bring conversations in the context of a relationship with him around to what are in his best interest from his perspective and so that's the way things normally roll in my neck of the woods I'm in an urban centre though I've got to say and normally working in a community based context and so I realise that things can vary tremendously for mental health nurses and others in inpatient settings and in other settings Thanks Toby I'd like to bring Shona back in Shona, one of the issues you know, Toby's been talking about helping him to lead a satisfying life but one of the, you notice a potential concern in Tim's story about his kind of obsession with his ex-girlfriend I just wondered if you wanted to comment on that Well I think it comes to I guess what a lot of the panel has said but I think it's important to do a really careful assessment with Tim so I don't think we've got any signs at the moment that there's anything to worry about we're best concerned but it could develop that way so sometimes people become obsessed with people in their lives and they start to act in dangerous or frightening ways we're best concerned so I'm not saying that that's happening now but what I'm saying is that you do need to be very careful in our assessment and to really understand what's going on for Tim and what's behind the ways in which he's behaving so in terms of I take it that risk assessment wasn't seen as the best term to use but I think it is really important to have a thorough assessment and to be aware of where there might be risk for Tim and for other people in little Sure thanks for that Shania I think you'd noticed that he'd been watching Beth's flat in the evening and yet following her round at uni and in the community which was worth noting Now I'd like to bring Grant back in so there's quite a lot of questions also about what kind of prognosis might Tim have and I suppose right now when we've just met him we can't really answer that what would be good prognostic sign? Yeah well look I think overall as people have said the view of prognosis is much more positive than it used to be and part of that complexity of people being on a spectrum is the view of prognosis and the research and the data on prognosis very much depends on where you're looking in that spectrum whether you're looking at people in high risk states or after they've had a first episode of psychosis or after they've had a first admission to hospital and I agree one of the essential goals here is to avoid hospital so broadly the good prognostic signs might be an older age of onset so if someone has a very young age of onset of psychosis in early adolescence in the 14, 15, 16 that's concerning the absence of so when you look at Tim's story he's been apparently functioning well, had a good personality good strengths good academic and social functioning so they're all good prognostic signs and in a funny way the presence of drugs paradoxically can be a good prognostic sign if there's a clear external trigger such as cannabis or amphetamines provided that can be bought under control then in fact there's quite a bit of research that shows that people with drug-induced psychosis and drug-related psychosis can actually have amongst the best outcomes but only if the substance use is well controlled so there's a number of things here that would make you feel quite hopeful Tim's a healthy young man with good supports where there's drugs playing a part at a time of stress and loss and you would hope that if you can help get all those things under control he could be back on his feet again quickly and Grant, is it right that the understanding in early psychosis now is that because there are many many things that might be contributing so there might be stress, there might be developmental trauma there might be substance use but there's a lot of other things that can help all kinds of things but the issue is that we provide a collaborative holistic approach to this psychosis without at this moment worrying too much about where it came from Is that right? That's true and in every person there's going to be a different combination of known risk factors in their past and in their current situation and trying to understand those through assessments and the person themselves understand that can be really important so one real dilemma that can come up is the dilemma about cannabis and I know there's been some questions in the chat there as well about what if Tim decides he wants to keep smoking or keep using drugs and then that often is a real dilemma and sort of a moralistic and lecturing approach usually doesn't work that well but a framework that says well it's important for you to understand your risk factors and if you're someone who's got a strong family history you might have a genetic loading towards this sort of problem then exposing yourself to other risk factors like cannabis is not necessarily a great choice for you it might mean your friends can get away with it but you can't so I often use the example as a former redhead I've got a risk vulnerability with a family history of melanoma I've got a vulnerability towards skin cancer so I have to be careful about the things I expose myself to and you know people are kind of used to that idea there's a lot more familiarity with that sense of people having personal risk factors in genetics and breast cancer and so on that people are aware of so I think that's important and I mean there's some research that's been done looking at rates of progression and so on which I could mention if it was relevant as well Okay, thanks that's really helpful Shona I just wondered some people have been asking if the young person will not go and see any of the experts and you're like a private practitioner of a psychologist or a GP in the community and they won't go are there any particular assessment tools that practitioners can use to get more of a sense of this themselves? Yeah, well there are a lot of different assessment tools that are available and I guess in Tim's case we might be thinking of something like the CARMS the comprehensive assessment of at-risk mental state so that's a questionnaire interview-based assessment that helps people decide whether someone is at high risk of developing psychosis or has actually crossed the line into what would be considered a psychotic episode at which point more assertive treatment might be indicated so that's a tool that was developed here in Australia but there are other versions or instruments like that in other parts of the world they're called I've just forgotten the name there are some American versions of those sorts of instruments as well a lot of those sorts of tools are available from the origin website people wanted to look so they could find information about those tools there Is the CARMS tool there, Shona? Yeah, there's a manual available about the CARMS so that is there Oh that's excellent, thank you for that now Morton I know that you had a comment there about from a general practitioner perspective because it's often you guys that are sort of left in this situation Yeah, absolutely I mean, not uncommonly you actually have to support the family to improve their skills of how to deal with the situation if the young person or older person for that matter won't come and seek help particularly if they're actually functioning okay in that you can't absolutely intervene so letting them know what is what they can do to perhaps de-escalate some of his thoughts good listening practices sometimes is really helpful to remind family that they actually should listen what the person is saying and certainly not get the person angry or upside balance because often we tread the line between keeping the person engaged in order to maintain a therapeutic relationship at a later date and actually intervening too fast and both can be difficult Thank you and look I know one of the other areas of support that we haven't covered at all tonight I think I might ask you about this Toby because I expect you have experience is that there are also many consumer care and support groups so there are families who experience caring for someone with mental ill health who support each other and also groups of people who experience mental ill health themselves and they can be a great support so I just wonder if you wanted to comment on that Yeah, sure Recently conducted PhD research actually looking at things called the Clubhouse Psychosocial Model of Rehabilitation and it's a fantastic model that works mostly with adults with lived experience of mental illness and assisting them with a very sort of employment vocational work focus getting them working alongside each other in non-paid work and then trying to assist them towards transitioning to paid jobs in the community and other socially satisfying activities I mean there's other groups that just grow which someone's mentioned tonight in the general chat there's a new approach in the consumer movement called Recovery Colleges I'm aware of one that's been set up in South Australia and also over here in South Eastern area in Sydney I think one thing to say about those approaches is that we don't have many of those approaches that are focused on young people and it would be fantastic in the future to see places like the Clubhouse Model of Psychosocial Rehabilitation or Recovery Colleges actually developed for that young adult age group from maybe from sort of 16 to 25 year old age group the head space approach has been rolled out and that's certainly you know in a lot of locations it's a fairly professional focus sort of approach it would be great to see consumer led groups get the sort of support that's due I think if you look at Richard Warner's meta-analysis of recovery from schizophrenia where he looked at sort of a hundred years worth of research going back to the early 1900s and looked at what actually assists people towards recovery the main thing that he found was that it's employment and it's employment for people with schizophrenia are more than pills more than access to professional services and I think that one of our approaches in Australia has been to rely very heavily on experts clinicians for one of a better way of describing a bio sort of medical approach to mental health some of these other approaches perhaps from overseas perhaps yet to be discovered here in Australia may be fantastic things for the future yes thanks a lot for that Toby and it sounds as though there is a lot of research in this area internationally and some of the questions before I mentioned the open dialogue approach from Finland essentially based in family therapy we don't have time to go into it but people are saying there is good evidence for that when is it going to happen in Australia so we don't probably have time to discuss that right now but thanks for talking to us about those as well now I'd like to we're just actually as usual running out of time to have such a fantastic conversation so I'd like to start bringing in the panelist to just give us their sort of parting message that I'd like people to go away with so I think that I might start with you Grant if that's okay yeah look I think the overall parting message is that you need a difficult balance here it's really critical that there's an attempt to engage and assess and I think that window of opportunity idea that you've got to work with Tim but there's an urgency and you need to both respect the choice and his right to choice but also he's got a right to treatment and you need to do that as quickly as you can so I think that's where there's a real urgency to work and while the view is more positive than it used to be and for good reasons there's still substantial minorities so up to a third of young people at risk in an at risk mental state will transition to psychosis within two to three years and so it's really important to try and do what you can as early as you can thanks thanks very much Grant I think Shona we might go to you now is there anything that you'd like us to think about as we finish up thanks Mary I guess perhaps to just inject a little bit of hope there are some places around Australia that are developing open dialogue approach is being trialled in the south east Melbourne area in the space early psychosis program and there are recovery colleges also there and in other parts of Australia that are specifically for young people so I think we are seeing an improvement and a growing focus on functional recovery including peer led peer support programs and an increased focus on physical health and I guess generally the area of functional recovery is being given appropriately more and more prominence in helping young people recover from psychosis so I think there's plenty more work to do and there's loads more services to develop but there is light on the horizon in our area thanks Shona and now Morton since we just mentioned physical health it's great to have your contribution as a GP is there anything that you'd like to leave us with tonight the thing that I would leave people with although it's really hard is making sure that we all talk together as a team otherwise some of the opportunities that we have get lost and although sometimes it's really hard to make those opportunities to spend some time talking about it it actually does work really well for the patient because these cases usually start very much as a grey area and you need to be across it so that you can pick up on things as quickly as you can thanks a lot Morton and Toby I'd like to bring you in to finish you had my favourite slide of the night which was that lovely one of recovery with the arrow and then the completely secures scribble which has been my experience anything that you'd like to finish with tonight I'd just like to thank everyone for their enthusiasm I'm just seeing the screen here I think I can see nearly 800 people online at the moment just a fantastic reflection of the amount of care that there is in our community for people with a lived experience of mental illness and I just think it chose the sort of the great possibilities of the internet doesn't it for us to collaborate in this kind of a way mind you I was listening recently to someone talking about the need for us to have more what they called narrow band conversations and they talked about you know just switching off the internet switching off the phone and actually just talking one to one with individual people and so I think just encourage everyone to do as much of that as possible when we talk about collaboration it's all over the web but let's do it in person and there's great things to come in mental health Thanks Toby it's a really positive note to end on you know I think that's been one of the key messages for tonight is that developing that relationship with Tim and ideally with his family in fact I think assuming that the family are involved unless there's a really good reason not to be and also working together as a team is going to bring the best outcomes and there's an increasing body of evidence for that so it's just been really positive and hopeful to have such a collaborative view and to know that this is the best way forward also recognising that many people are in remote places and just have to do the best they can but sometimes feeling part of the greatest work through the MHPN can help with that too and one thing that perhaps didn't come up is that we need to remember to care for ourselves particularly when we're dealing with really stressful situations like this so I hope people have peers who they can debrief with or supervisors if that's their profession practice Thanks everyone for your participation tonight please make sure that you complete the exit survey before you log out it'll be on your screen after the session closes so just stay online till you see it you will be emailed a certificate of attendance for this webinar if you register and you'll also be sent a link to the online resources associated with the webinar within a week so the next webinar will be in February 2017 have a rest filled break and we look forward to seeing you refreshed in 2017 for another series of MHPN webinars and make sure you sign up and then you'll receive the notification so I hope that you'll have a very happy new year and if you're interested in joining an MHPN network in your local area you can see a list of those on the website and also there's more information about the other online activities and the webinar library and so on so once again thanks everyone for your contribution to the panel and also to the 800 participants who logged in tonight and the really lively engagement in the chat box was very welcome so good evening everyone and see you in 2017