 Hello, and welcome to this panel discussion on putting research into practice presented by the Centenary of ANZAC Centre as part of the MHPN online mental health conference working better together. A very warm welcome to all of you who've joined us today for the live activity. Welcome to those of you joining us later on a recording and of course a very warm welcome to our panel who I will introduce in just a moment. Before I do, I'd like to acknowledge the traditional custodians of the lands across Australia upon which our panellists and our participants are located and I'd like to pay our respects to their elders past, present and future. My name is Mark, I'm a clinical psychologist in private practice and a professor in the Department of Psychiatry at the University of Melbourne. I've had a very long interest in the mental health effects of trauma and particularly in veteran and military mental health. And both as a clinician and as a researcher, I'm constantly amazed at the amount of research that's being published in the area and just how difficult it is to keep on top of it all. And so it's a great honour today to be able to facilitate this panel and to pick the brains of our expert panellists. So without further ado, let me introduce them. You all have their biography, so I'll keep it very, very brief. Professor Malcolm Hopwood is a director of the professorial psychiatry unit at Albert Road Clinic and he's also a professor in Department of Psychiatry at the University of Melbourne. He specialises in mood and anxiety disorders as well as in acquired brain injury and he has an enormous amount of experience in veteran and military mental health. So welcome, Malcolm, thank you very much for joining us. Thank you, Mark. You know, I wasn't in Melbourne very long before I realised that at this time of year, you can't go for very long without the topic of conversation going to football. So I thought we should keep up the tradition and ask you how Richmond are going this year. The tides are going very well. I'm very proud of our boys. Are you? Not quite living up to the expectations from a year or two ago, but... Oh, Hope Springs Eternal, Mark. Hope Springs Eternal. Good. That's what I like to hear. That's what I like to hear. Jane Nursi is a clinical neuropsychologist and director of the Practitioner Support Service at the Centenary of Anzac Centre. Jane has many, many years of experience both as a clinician and as a consultant in areas of trauma, veteran and military mental health and knowledge translation. Welcome, Jane. Thank you very much for joining us. Thanks, Mark. So I should ask you the same question. Do you have a team that you support? No. I'm one of those rare Melbourne-born and bred people who has very loosal legions to different football teams. I'll follow whoever I like on the day, essentially. I don't think the real fans would approve of that, to be quite honest, Jane, but anyway, far be it from me to challenge you. Professor Megan O'Donnell is head of research at Phoenix Australia, a professor in department of psychiatry at the University of Melbourne, and she is also the research director of the newly established traumatic stress research clinic here in Melbourne. She specializes in early intervention and also in testing new and innovative treatments for trauma-related psychopathology. So welcome, Megan. Thank you. Thanks very much for joining us. Thank you. So what about yourself? Have you got a team that you follow? I feel like this is a personality test of some sort, so I'm going to admit to allegiance to Collingwood. I don't know what that says about my personality, but I've got it out there in the media that I'm a Collingwood. Collingwood? No, I thought that you were a WA girl. What about the Eagles? See, this is where it starts all turning pear-shaped, isn't it? So yes, I inherited Collingwood when I moved to Melbourne, but my family alliances are with West Coast Eagles. Okay. So I won't push you any further on that. No, I wouldn't. Thank you very much to all of you, and welcome to the panel. Before we get started, just a couple of very quick admin things. I think you've already had a quick video about the platform that we're looking at. If you've got any tech difficulties, there is a tab at the top of your screen. There's lots of good resources. There's a resources tab there, but I would encourage you to resist the temptation to look at it during the panel. MHPN will send you a link to all of those resources, and you can go through them at your leisure. The panel is being recorded, and it will be available in about 24 hours, so early tomorrow afternoon. So do let your colleagues know about it. We're going to ask you to complete a brief online survey at the end of the webinar. So there's a tab at the top of your screens to click for that. The webinar is going to go for about 45 minutes, and we'll be loosely basing it around the interview that I did with Professor Richard Bryant, and which I hope that most of you have had an opportunity to see. And in terms of the learning objectives for today, we hope that by the end you're going to have a better understanding of the current research in the field of Veteran and Military Mental Health, that you'll have a better understanding of how you might incorporate those research findings into your clinical practice, and that you'll have a better knowledge of how to access the recent research developments. So without further ado, let's get to it. And I'd like to perhaps start by looking at the broad issues of the nexus between research in Veteran and Military Mental Health and clinical practice. And I wonder if I could turn to you, Jane, to start with, and then start with a very basic question. Do you think that research in Veteran and Military Mental Health is important for clinicians? Is it relevant for clinicians to know about? Absolutely. And I think it's sort of is becoming increasingly important, really, for clinicians to keep up to date with what's going on in the research arena. You know, we know that the prevalence rate of mental health disorders in Veterans is higher than what we see in civilian populations, particularly during and after transition. And yet we don't have universally effective treatments. And I think we have a sort of ethical obligation, really, to, as clinicians, to keep up to date with understanding more about what causes these disorders, what changes in people in terms of their response to evidence-based treatments. So the how and why. Absolutely. So I'd go along with that. But that does present a real challenge, doesn't it, for clinicians. And I wonder if I could turn to you, Megan. I said in my intro that an enormous amount of research is being published in this area all the time. Have you got any suggestions about how clinicians can try and keep abreast of recent developments in the field? Yeah, absolutely. So of course, there's so much research out there. And as a full-time researcher, you know, I really struggle to keep on top of what's currently active and what's happening in the literature. Fortunately, there are a lot of people out there making literature very accessible, especially to clinicians. And I have this document that we've created. I think you'll see it in your tabs on the website. And this is a list of really great websites that clinicians can access that really help with veteran and military mental health and what's happening in the literature. And I'd point to especially the clinicians update. This is done by the National Center of PTSD in the US. And it's my favorite kind of clinically relevant website. It condenses clinically relevant information for clinicians. I'd really encourage people to see that one. And the Australian one that's particularly good is the website that Department of Veterans Affairs has. They've got, it's called Attee's Professional. And you'll see some great webinars on there led by Mr. Mann himself. And there's some really great, must say very congratulations. They're really great webinars and very focused, clinically focused on veteran-related mental health problems. And so I encourage everyone to go and have a look at those. Good. So that's, sorry. They have the evidence compass on that as well, don't they? That's right. So the evidence compass is the Department of Veterans Affairs specifically looks at developing systematic reviews of the literature in key areas that are of importance to veterans. And so you'll find those on the website as well, the Department of Veterans Affairs evidence compass website. Yeah. And I think it certainly endorse what you're saying there, Megan, about the material that comes out of the American National Center as well, the US National Center for PTSD. The address for that will be in your resources. So you talked about the clinicians' trauma updates. They also do a very good research update, don't they, where they take a single topic and they kind of do a review of the research evidence in that area? Yeah, that's a really useful one as well. I mean, it is very US-centric. So sometimes topics that are very relevant to US veterans may be not so relevant for our veterans. So dramatic brain injury is a big focus in the US. It's perhaps not so relevant for our veterans, but generally speaking, the National Center has a great deal of information that's useful for us. OK, and it's very, very easy just to sign up, get on their mailing list, and they'll send you this stuff. Couldn't be any easier. So thank you very much for that, Megan. Let's move on to some clinical kind of stuff. And talk about suicide. Richard and I discussed this issue of suicide, and he pointed out what I guess we all know, and that is that the research is showing that it's a very complex area, that there's a whole lot of perhaps intrinsic and extrinsic contributing factors. Mal, if I can turn to you just for a moment, as a clinician, do you think there are particular warning signs that might alert us to the risk of suicide when we're seeing a veteran or a serving member? I think there are, Mark. Of course, we've known for a long time the issues of current suicidal ideation, depth of plans, preparation, and so on. I think where the research has helped us recently is to realize that on top of that, historical factors, family history of suicide, for example, and also situational change factors like breakdown in relationship, major transition in employment, or indeed leaving the ADF are points of greater risk. So there's a matrix now above and beyond the traditional risk factors that we look for that we should be exploring at any or at risk. And it really highlights, I suppose, the point that this is very individual. We can't just rely on this big epi data that says, you know, because he's middle-aged, male, isolated, it's much more a clinical decision at the time. Correct. Although I do think that the recent Institute of Health and Welfare work pointing out the transition and the years immediately after appears to be a period of higher risk should be there in the matrix for us. That doesn't mean other periods aren't of risk, but it is useful to be aware of. And that's the time we get into that. I think it's a very good point. And it's a time, as you say, if you're aware that the veteran has recently transitioned out, high-risk time, we're going to talk about that a bit more in just a minute. But yes, very good point. So let's take it to the next step then. And I know this is a huge question to ask. But can you say something about what you think clinicians need to know about managing that risk? That if they are concerned about a veteran, are there any strategies that they should be aware of or what they should do? Well, I think the first key task as a clinician is accepting this is part of your job and part of your work, both to assess risk and then be an active participant in managing that risk. And if that means at times, you have to think about how am I going to find time to see this person to review urgently? That needs to be. I think part of being a clinician is being embedded in a network where you can get advice about how to manage a difficult situation and also being aware of what are the higher intensity resources in your region. Ideally, having a relationship with them before you really need them would be good. The first time you contact the CAT team, probably it's best if it's not when you've got a real crisis on your hands. Because most things in life work better if you've got an existing relationship, don't they? Absolutely, absolutely. And I guess this is an area that we as clinician are in a situation, but all of us, I think, do find very difficult. Suicide is a tricky thing. And I suppose one of the things that you're saying there really is about we shouldn't be managing it on our own. We should be accessing the resources and support that's around us. Yeah, absolutely, Mark. Suicide is clearly the consequence of severe mental health problems. And it's a challenge. And no one should think in a heroic manner they have to manage it all by themselves. It's a team effort. Yeah, yeah, yeah, absolutely. I was talking to Richard in the interview about the fact that we have a lot of research on, I guess, completed suicide, suicidal ideation, and suicide attempts. And what we find is that, of course, completed suicide is actually, thankfully, very rare. And suicide ideation is actually quite common. And it's that group in the middle who do take it to the next step and go to the suicide attempts that perhaps they're the ones we need to be researching and perhaps finding a little bit more about that. I think that's very true, that the current research would indicate our capacity to predict reliably who's going to move along that pathway and when we're still pretty limited in our capacity, if we're honest. And so there's a great deal of all work needs to be done. We can only act on our current knowledge and we can only exercise that knowledge by good clinical question taking, good history taking, and then acting in a direct manner should we find out something's amiss. Absolutely. And, of course, no amount of research is ever going to replace that good clinical decision making, is it? But I do think, having said that, that it's interesting that now we do have, I guess, the computing capacity to combine many very large data sets that might allow us to kind of explore the nuances of that transition that you're talking about. I don't think that's very important in suicide research because, as you say, thankfully, we're talking about a relatively rare event. So identifying significant risk factors is difficult in a relatively small population. Machine learning and large data will clearly be helpful. Yeah, absolutely. OK, let's move on and talk a bit about epidemiology. Richard talked about the data from the Transition and Well-Being Research Program, which has the unfortunate acronym of TWERP, TWRP, but I should say that it's a fantastic program of research and it's produced some really interesting findings. But one of the findings that Richard talked about was the fact, and this refers to something that's a comment that Malcolm made just earlier, suggesting that 50% of transitioned veterans, that's people coming out of the armed forces, will develop a mental health problem in their first 12 months or will be diagnosed with a mental health problem in the first 12 months. 50%, as it seems to me, an extraordinary figure, Megan, and we might chat about that generally. One of the first things that strikes me, though, is that I think as clinicians, we often tend to think immediately of PTSD. That's the kind of diagnosis that we're looking for. But I'm wondering whether we should, as clinicians, be thinking much more broadly in terms of other mental health problems and also, perhaps, of other psychosocial problems. Does the research tell us anything about that kind of question? Yeah, it does, actually. So the transition and well-being survey was multifactorial. We were able to look at a number of different areas. You're right that post-traumatic stress disorder is elevated with veterans, and we expect that. So around 20% had PTSD, but anxiety disorders were extremely elevated as well. So nearly 40% had an anxiety disorder. And I know Richard mentioned panic attacks and panic disorder as being elevated, but also social phobia and agrophobia were also elevated. Effective disorders are high in this population, so 20% of the transitioning population had an effective disorder, and alcohol substance use was also very high. But I guess if we look broader than single diagnoses, we know that almost 50% of those presenting with a disorder will have a comorbid disorder. So in terms of assessment, it's really important to conduct a thorough assessment looking beyond PTSD and considering other disorders that are probably comorbid with the presenting problem. Looking past psychiatric disorders, we know that this population also presented with very high levels of pain. And so about 20% had a pain disorder. Another 15% presented with insomnia and sleep disorders. And then a really high level, 35% had physical health or perceived physical health problems. So we're getting a complex presentation here, and it's something to be very aware of when we're assessing our veteran patients. Yeah, and certainly that interaction between physical problems and certainly pain and PTSD is something that we really need to be aware of. I know there's some nice research around, a little bit old now, but talking about how they mutually reinforce each other, the pain and the PTSD, I suppose, with both physical arousal, making the pain worse and then the intrusions and all that kind of stuff. Yeah, absolutely. There does seem to be a mutually maintenance occurring between both PTSD and pain. And you especially see that with the re-experiencing symptoms as well as the hyperarousal symptoms, so intrusive memories triggering off pain, especially if the pain is associated with the traumatic events, which you often do see with veterans. I'm in the luxurious position at the moment of the time going quite well, so we're OK for time. I'm just telling the panel. So did you want to comment at all on that, Matt? Yeah, look, I think it is an important interaction and a frequent one we know from the data. And I think the other way it can cause a complication is by the divergent treatment pathways. So unfortunately, pain is often treated in a setting quite remote from treatment for mental health disorder as a primary problem. And so the potential interactions are often not recognized, both in terms of symptoms and in terms of treatments. So many of the mental health clinicians say, I think I could make better progress, except this patient is so full of opiates and sedative that I can't make progress. And yet the pain physician is clearly attempting to treat pain in a thoughtful manner, perhaps not recognizing necessarily that PTSD may be exacerbating the pain. And if that could be treated, things would be much simpler. And isn't that just such a problem for our systems generally? It's the same with substance abuse, isn't it? Alcohol and drug tends to get treated somewhere different to mental health and all those kinds of things. So yeah, very good point. Jane, we talked in the interview with Richard about the fact that there are some general risk factors for mental health. I'm wondering if you're seeing someone for the first time and perhaps if you're working in primary care, for example, you're seeing someone for the first time, do you think there are any red flags that would alert you to the fact this person might be at risk of a serious mental health problem or deterioration? Well, look, I think there are a few things. One of the primary problems, I think, is people who are really isolated and don't have support around. We know that that's a significant risk factor for the development of mental health disorders in everyone, really, regardless of whether or not they're veterans, but especially so for veterans. I think the other thing is that understanding their history, have they had early exposure to trauma, or is it just the military? Because we know that people, particularly with developmental histories of childhood trauma, are also at higher risk. I think the other thing is the level of functional capacity. I mean, those veterans who perhaps are withdrawing more from their usual activities, not able to engage in work and their usual sort of activities on a day-to-day basis, also are a sort of real red flag. You know, what's going on for them that they are no longer able to function at that level? And if we can pick that up early and start addressing things, then I think that's going to be useful. With, and I guess, it's common sense, although the research necessarily backs it up that strongly, but the earlier we can intervene, the better it is, and at the very least, if we can prevent a slide of deterioration and then the accumulation of all the associated problems of relationships and work, so it's got to be good, isn't it? I think also, sorry, the other one was just the importance of picking them up early in transition. As you mentioned before, you know, we know that those transitioning out are going to have a higher rate of mental health disorders and so being on the lookout for what is the amount of time since they've transitioned out as a potential red flag. So we talk a fair bit about risk factors and red flags and so on. I'm wondering, Meagan, whether or not we could usefully focus a bit more on protective factors. Is there anything that we as clinicians could be doing to, I guess, we could encourage people to do that might provide some protection against the deterioration? Yeah, look, I think so. And I know in my own clinical practice, I especially look at exercise. So if you do have someone who is exercising, just linking that with mental health. And even though they might not be enjoying it or might be really struggling with it, I do think it's really important to make that link for them that doing even just a little bit of exercise every day does improve mental health in and of its own self and that we're seeing more and more research that shows that exercise is not just a protective factor but also therapeutic in its own right. I, you know, just picking up on Jane's point that seeing people who are presenting with social isolation, that the other side of that is if people are presenting with strong social networks or even just a relationship with someone that has the strength to it, talking to them about that and seeing that as a very strong protective factor. We know that good social networks are very strong protective factors for mental health problems. And I also link things, just simple things like eating well. If they don't have insomnia, encouraging them to have early, get to bed early, to just really those simple things that people may have as they're becoming mentally unwell, just kind of lost a little bit and linking those things with mental health. So eating well, decreasing drinking, trying to get good sleep patterns in place are really important as well. I agree entirely. And so it is important, isn't it, to remember that there's a whole lot we can do or the person can do to help themselves before we even start any high level psychological or pharmacological treatment and that kind of stuff you're talking about. And I think particularly the first two you mentioned about exercise and perhaps regular aerobic exercise and also social support. The trouble is they sound so simple, don't they? And yet actually getting people to do them or helping people to do them is not easy. It is surprisingly difficult often. So, but anyway, as clinicians I agree, keeping it in the back of our minds. And that takes us on really to the idea of treatment. And if we go back to the transition and wellbeing research program, the TWERP, it also showed us, I guess it came up with some good news and that is that the majority of veterans who have mental health problems are seeking some kind of treatment. The bad news is that only a minority are getting access to evidence-based mental health care. And I think that's got to be a concern, Mal. I mean, have you got any theories as to why that might be? I think there are probably a series of factors. I don't think it's important to acknowledge some of them probably emanate from the personal choices, first of all, of the patient. Just because a treatment's evidence-based doesn't mean I want it. And where, for example, we're talking about trauma-focused therapies, we know many people don't want it or find it difficult to tolerate. There's also the very nature of disorders like PTSD with the avoidance inherent in them that can often lead to misdiagnosis at the outset or a lack of certainty and clarity about diagnosis. And sometimes hidden comorbidities as well, drugs and alcohol being an obvious example. Clearly, on the other hand, there are also factors within the clinician and that's a more difficult one to confront in some ways, but confront it, we should. That reflects sometimes just a familiarity with the kind of issues and particularly the culture in which veterans' mental health problems will present. Some clinicians have great familiarity and find it easy to bridge into a good discussion about treatment. And others haven't been in that spot very often. Perhaps particularly in some rural and remote areas where the access to clinicians is a bit more restricted. Is there a need for continuing professional development in the area and greater awareness of both the research and what guidelines, for example, are going to have to say? And I know we'll talk about that a bit more in a minute. Yes, undoubtedly there is. And I think we've got data that says, clinicians' knowledge does vary about what truly are evidence-based treatments. Part of that is our skill in reading the evidence and I think we should acknowledge that not all evidence is the same and the capacity to interpret what truly constitutes first-line evidence as opposed to something of interest that requires further development is an essential skill for all clinicians to possess. Isn't it just, I agree entirely, and look, I do think that while we need to be open to new and innovative treatments, we don't want to be so wide open. Reading is the same. Just because you see a report in the age that says this particular thing helped a particular veteran doesn't mean that it's going to be necessary the right thing to do. I want to put you on the spot a little bit, Mal, and just I wonder what our responsibility is as clinicians, if we're aware that a veteran is not getting appropriate treatment, if perhaps they're on the wrong medications or they're not getting appropriate psychological care, do you think that we as clinicians have any responsibility in a situation like that? Yes, I do. I think that responsibility starts when we first meet a person to tell them what are the best evidence treatments. Sometimes it's easy to fall into the trap of I'll discuss more of the treatments I feel comfortable and confident in delivering. That's not what the person's entitled to. They're entitled to a review of what is the best evidence treatment and then perhaps what in particular you offer. It is a more awkward situation when they're already in treatment and you see them and perhaps you feel that really that isn't the best evidence treatment. I think there is an ethical responsibility to discuss that. It's a question of how to do so without bringing unreasonable opprobrium on your colleague because at the end of the day you didn't know how that conversation went. I'd often start those conversations with something like, well, look, my reading of the evidence suggests that this is the kind of treatment we would often consider first line and in all reasonable likelihood you wouldn't be here if things were going perfectly. So perhaps we can review that and this is what I might recommend now and if you want some further reading, for example, here's some opportunities. Yeah, and that discussion with the veteran I think and perhaps their family as well is so important, isn't it? We started off by talking about the fact that some people, some veterans may reject the idea of some of the evidence-based treatments but I think often that's a lot to do with the way the clinician is presented and the education so on. So as you say, having that very open discussion and pointing out things is perhaps important. Oh, look, undoubtedly and I think people respond very strongly to a clinician they see as being open and honest. And informed. Yes, and informed, of course. And in the reverse, they respond very poorly to a clinician that they don't see as being open and honest. That's not probably an evidence-based statement but I don't have much doubt that it's true. Absolutely, absolutely. But there is no doubt that it isn't easy to make sure that everybody gets an evidence-based treatment. In fact, I'm struck by the American experience where they put a massive amount of time and energy and money into rolling out evidence-based treatments, particularly things like trauma-focused psychological treatments and EMDR and so on. And still the number of veterans that actually get it is fairly small. So I think actually we're probably not doing too badly in Australia when we look at models like that. But let me go on because I think you mentioned it, Mal. One of the things that we might use to assist clinicians or to help us as clinicians to make sure that we're using evidence-based treatment are the treatment and practice guidelines. And I know that the Australian guidelines for the treatment of PTSD and acute stress disorder ASD are currently under review and I understand that they're going to be released next year, Megan, under this heading of living guidelines. So living guidelines mean. So a living guideline is, I guess it's quite different from what we've seen from guidelines in the past in that they're often very static and you get this big bulk in front of you and you flick through it to try and find the information that you're looking for. The lovely thing about living guidelines is that they will be updated very regularly. They'll live on the web and people can actually, the actual website that we're using is very user-friendly. So practitioners can go in and search for particular topics and you'll get access to the information you need at a very high level and so very readable and accessible. But also if you're interested in drilling down into the details, you'll be able to access that as well. So the exciting thing, and I think this is really relevant for clinicians who are interested in emerging treatments, because they're updated more frequently than a static guideline, what we'll see is those emerging treatments as new and more evidence exists to support them, then they'll be able to be integrated into clinical practice a bit more frequently than what they have been in the past. So I do think this is a very exciting addition to guidelines. Absolutely. And my next question was actually going to be, will they be useful for clinicians? But the answer quite clearly is yes, and with this new innovation, even more useful actually. I think more useful, yeah. And the adjunctive treatments as well. The idea that they potentially, they'll know a lot more about the adjunctive treatments and when they might be able to apply them and what they might be useful for. Yeah. And I might just also just jump in to say this year, this time we're doing two new questions as well. So there'll be more information and guidelines on looking at can we develop resilience in people who are going to be exposed to trauma. So is there any pre-incident preparedness interventions that we can adopt? So we're looking at the literature around that. And the other, the second question is around complex PTSD. So that will, again, with ICD-11, introducing complex PTSD as a new diagnosis, it'll be great to start looking at the evidence for treating complex PTSD. Good, good, good. Two very important innovations, I have to say that I am not over-optimistic about the preparing people well, but anyway, one of these, it is the- It'd be a surprise what literature's out there. Okay, good, good. I look forward to being surprised. It certainly is the $64,000 question, isn't it? How can we help you prevent them? But we know, Mal, that even if people adhere to the guidelines and they are using first-line treatments and so on, that a significant proportion of people will not respond as we want, maybe a third or perhaps even more. What do you think the implications of that are for clinicians when we're doing our treatment planning? Do we need to bear that in mind? Oh, I think we definitely do. I think there are probably two main implications. The first really starts from the outset of treatment. What can I do that will maximize the likelihood of response? And I think in practical terms, that's often in the case of PTSD, particularly about making sure you've got the comorbidities as well managed as you can. So we have good evidence that higher levels of depression decrease the likelihood of response to trauma-focused therapy and active substance abuse, clearly so as well. And a failure to treat those effectively before trialing what might be a useful trauma-focused therapy is poor practice, in my view. I think the second implication is about the information you give the patient beforehand. It's a challenging thing as a clinician to say the treatment we're about to deliver may not work. And there's a test of your confidence and self-esteem in many ways, isn't it? I've got the good news and the bad news. But I think it is important because what we do know as part of that failure rate is that the dropout rate from treatment is significant. And that includes dropping out between that and the next treatment. I've given it a shot, that was your best shot. Informing people will try this first. This has the best line of evidence. If it doesn't work, and we know that sometimes that's the case, there are other options we can move to, is really important advice. But I suppose that there are no sort of book of rules, there's no absolute algorithm to help the clinician. Absolutely. It has to be a clinical decision? Yes, at the end of the day, that's right. And I think that goes to the sequence of treatments very much. So the choice of treatment is a dialogue between you and the patient. And no matter what you think, if the patient doesn't want to do the treatment, our evidence pretty clearly suggests across the board with mental health disorders, it's much less likely to work. So it does have to be the result of a dialogue, definitely. I wonder if we just come back, because a number of you have actually talked about co-mobility. And you just mentioned now that it does seem to interfere with treatment, we don't get such good effects. And I was interested in what Richard talked about, which was that the extinction-based treatment options we have, like exposure, also tend not to work very well with people with high levels of co-mobility. That means PTSD, along with depression, anxiety, substance use, whatever. I'm just wondering, Jane, whether, just very quickly now, whether you have any recommendations for working with co-mobility over and above what Mal mentioned? Well, I think absolutely what Mal mentioned goes. And if the depression and alcohol and other things are very severe, you've got to get them under control before you address PTSD. But I think on the other hand, doing a thorough assessment and identifying what are the sort of perpetuating factors that are keeping this person trapped in this disorder and using that as your target. So, and often I think addressing PTSD in the first instance, when those issues are there but not as prevalent is the way to go, because addressing the PTSD will address a lot of the other co-morbid issues. There'll still be residual problems, sure, and just very briefly, if we've got clinicians out there who are perhaps a bit isolated and feeling they're struggling a little bit, can we, is there any support we can offer them? Yeah, so I think that, well, I would argue you can't do this work without good supervision and mentoring, and you shouldn't be doing it without that, but regardless of how experienced you are. But I think these days, there's more and more groups out there that can provide peer support and those sorts of things. But the Australian Centre for Post-traumatic Mental Health runs the Centenary of Anzac Centre. We call it Phoenix Australia, no? Phoenix Australia. Well, it is still the... Yeah, of course it is, of course it is, yeah. But you're very right. My mistake. Runs a Practitioner Support Service, and that's a free service available to any type of clinician or support worker working with veterans and their families with mental health disorders. We have a multidisciplinary panel of experts. We've got psychiatrists, GPs, social workers, family therapists, psychologists, and others that we can access. So if you've got a complex client, you're a spit-stuck, you don't know where to go, or if you're just venturing into the world of working in veteran mental health and want to understand more about how to do that, send us a question. Ring us up. It's a free 1-800 number. 1-800-382-777, I think? No, that's not right. 383. Anyway, it's on the website, look at it. And, or send us an email via the website. I think it's a fantastic service, and yeah, I hope that people are aware of it, and that they use it, I think it's a great thing. I've got to move on. There's a whole lot of other treatment things that we could talk about, including things like how we involve families and so on, but I'm afraid that we don't have time today because I would just like to spend the last few minutes talking a little bit about the future directions. And in our interview, in my interview with Richard, he talked about one of the key future directions, one of the key innovations, if you like, being trans-diagnostic treatments which tend to focus more on underlying mechanisms. And if I could turn to you, Megan, do you think that's true? Is that a direction we should be heading? I think so. We've talked about comorbidity, and this is exactly why trans-diagnostic interventions are really important. So these are interventions that are looking at common psychological processes. So there's a couple of different sorts of trans-diagnostic interventions. There's ones that look at common elements. So these are, you have a series of modules and a decision-making tree, and you look at your presentation of your client and say, well, they need some behavioral activation, they might need something to do with their avoidance, a bit of cognitive restructuring, and you develop a kind of flexible approach to looking at how to best intervene for them. So that's a common elements approach to trans-diagnostic interventions, but the one that I'm really interested in does take more of a mechanistic perspective. So this is looking at, are there mechanisms that underpin a group of disorders that if we target, we can actually address those disorders? We're doing a lot of research at the moment with the United Protocol, which was developed in Boston. David Barlow is very central to the development of that intervention. And this is looking at negative affect and seeing that a lot of emotional disorders are driven by people experiencing high levels of distress associated with negative affect and then avoiding the negative affect. So United Protocol targets that with pretty much an emotion regulation approach. And we're doing a lot of research using trans-diagnostic interventions and the United Protocol to see how well this works in a trauma population. In fact, there's a lot of evidence to support trans-diagnostic interventions for a lot of disorders, but there's less evidence in a trauma population. So we're trying to translate the research to see what happens with trauma. And I think it's great because it does, and I don't want to minimize it, but it does in some ways sort of operationalize a bit what a lot of clinicians do when someone walks through our door that we do try and look at their particular clinical presentation and think about what will work for them. Yeah, absolutely. What about future research? Just in the minute or so we've got left. Has anybody, if you're looking after the purse strings for the research funding in veterinary and mental health, have you got any wish list questions? Anybody? Mal, have you got any questions you want to put on the agenda? Well, I certainly wouldn't want to forget biology. I think that the very nature of trauma often pushes away from thinking about in biological terms, and yet our biological treatments for PTSD and related disorders haven't really developed in a significant way for quite a while now, nor has our basic biological understanding. There are a lot of new tools out there around genetics, neuro-inflammation. We really should be looking to apply them to disorders like PTSD. Thank you. Go ahead. And look, I think one of the important gaps to really, one is understanding how some people respond and others don't to evidence-based treatment. Know more about those factors. And I think the other thing is really more research into family impacts and understanding the role of the family in recovery, but also potentially in perpetuation. It is a pity we didn't get a chance to talk about it today, but we didn't. Megan, your wish list, sort. Look, I'm very interested in how do we get the right treatment to the right person? So a precision medicine approach, and I think biological assessments are really key to that. So we're focusing a lot on biological and mechanistic assessments at this point. Yeah, it sort of speaks, doesn't it, to the complexity of PTSD and related conditions that we really are talking about, a bio-psycho-social kind of model, and we need to better understand all of those and how they kind of fit together. Time has run out. Before we wrap up, are there any very quick take-home messages that any of you would like to leave? Any dot points, Mal? Oh, I think staying informed, Mark. There's no excuse for not keeping up today. Good. That puts a challenge out there, doesn't it, Jane? Oh, look, I think mine is the same. Push yourself to go out and get more information and to be aware of what's coming out in the research and thinking about how to incorporate that into practice and seek good supervision. Good supervision, I agree. And, Tali, Megan? I'm just commenting on the guidelines. They're going to be released very early in 2020, but we'll be doing some community... ...getting feedback about the guidelines in September. So, join our mailing list if you want to be part of that process. We'd love to hear from you. Our mailing list is on the website. Great. Thank you very much. Before we finish, just a reminder to you all to check out the resources associated with this webinar. As I say, MHPN will send you a link to those resources. And among those, some that Megan has referred to and others have been referred to, but among those will be the contact details for the centenary of Anzac Centre. And if you have any questions or comments about the issues raised today or, as Jane says, if you need any assistance with your work with serving members or veterans, do get in touch with them. That's what they're there for. I'd like to just encourage you to complete the feedback survey. It really is important for us to know how best we can tailor our education initiatives, the tab at the top of your screens. We'll take you to the survey. So, finally, thank you very much to all of you for participating in today's webinar. I hope you found it valuable. Thank you also to the Centenary of Anzac Centre, MHPN, and Redback for supporting today's webinar. And of course, a very, very warm thank you to our three panelists, Malcolm Hopwood, Jane Nersi, and Regan O'Donnell. Thanks again for participating and goodbye.