 Well, good evening everybody and welcome to this webinar this evening, all 741 of you who have signed in. Before we get started, I would like to acknowledge on behalf of MHPN the traditional custodians of the land, seas and waterways across Australia upon which our webinar presenters and participants are located. We do pay our respects to the oldest past, present and future, for the memories, traditions, culture and hopes of Aboriginal and Torres Strait Islander Australia. So Steve Trumbull is my name. I'm a general practitioner by training, but I'm head of medical education at the University of Melbourne. I'll be facilitating this evening's session, but what I really want to do is introduce you to tonight's panel. We've got a great panel this evening and with the number of people online, many of whom have submitted questions, we're going to have an excellent webinar I'm sure. You will have received the bios for each of the panel members with your registration, so we won't go through it in detail as we've got more time for discussion. But I'd like to just quickly meet each of the people who are presenting with us tonight. The first is Dr Paul Grinsey who's based in Victoria, general practitioner. Now Paul, you've done a fair bit of work with people who use drugs. We've seen quite an increase in the use of ice in rural areas, but can you tell us, in your experience, is cannabis still a popular choice for youth, particularly in rural areas? Thanks Steve. Yes, thank you for the introduction. It's an interesting question. The media and politicians and a lot of the community are very concerned about ice. It's a relatively novel substance of abuse within our communities compared to say ten years ago, but if we look historically, alcohol and cannabis are number one and two and they're remaining that way and there's certainly still a very, very strong cannabis using population within our younger adult and adolescent population. So it's still very much part of the picture. It's often, I suppose, less of an obvious concern. The media doesn't present to emergency departments with violence like the media like to portray ice, but it's certainly a big factor and I'm really pleased we've got this webinar to talk about the role of cannabis within our communities. Fantastic. We're looking forward to the conversation. The next person I'd like you to meet is Lee Bryant who's a psychologist based in Tasmania. Now, Lee, you're just nearing completion of a master's addictive behaviour through toining points and Monash, which is fine. Even though I'm from Melbourne, we don't compete. What do you think are some of the benefits to your work of having completed a master's in this area? Well, the units I've completed so far have emphasised a broad view in attempting to understand the complex issues surrounding addictive behaviours. And so the coursework has both provided and encouraged a world focus in the examination of how government policy impacts on minimising the harm for those that are either addicted to substances or to behaviours such as gambling. I hope that through gaining some expertise through completing the master's that ultimately I might be able to be in a position to influence some policy direction in the area. And I think that another benefit has been the repeated emphasis to consider the breadth of factors contributing to addictive behaviours, all of which can potentially be addressed in helping the clients improve their quality of life. And I've also been able to have increased confidence in my practice through increased knowledge of evidence-based treatments. That's about it. OK, well, that's great. That's a really good reason for doing further education in the area. Thank you for that. The next person to me is Monica, Monica Lord, who's a credited mental health social worker based in Queensland. And I've actually got 15 pages of questions that have been submitted for the webinar so far. What are the common ones? Well, actually, I'll put it to you. What are the common questions people ask you that practitioners ask you about drug use? Thanks, Steve. I think the big question I get asked in my practice is around how do we work with people, particularly young people who really don't want to change their behaviours? So I guess in my role as an accredited mental health social worker, I mostly work from a clinical perspective. And for me, it's really around harm minimisation approaches. So we know that young people are going to use substances and how can they do that in the safest way possible. And then following on from that is really the question about if you don't want to change your use now, well, if not now, when question. So if it's not going to be at the moment, then when in your life do you think that would be a good thing to do? And then we can explore that through a number of different therapeutic interventions. Great. Well, that's certainly going to come up in our case. The question of when is the right time for this young man to change his life if he can. So thank you. We'll look forward to hearing from you. And the final member of our panel is a psychiatrist also based in Victoria. So hello, Shalini Arumagiri. Welcome. Shalini, there you are. I can ask you a question which I'm sure we'll get to in the Q&A part. That's the major part of the webinar. But what's the current evidence for cannabis causing depression? Is it actually a cause of depression or are people using it to treat a pre-existing depression? Yeah, thanks. Thanks for that interest, even for that question. I'm not wanting to steal the thunder away from the rest of the discussion this evening, but I think that's going to be a core part of what we're discussing about the relationship between cannabis use and a whole range of mental health conditions, but specifically depression that we're talking about today. I think there's been a lot of research in this area, and I'm sure many of our participants will be aware. I think what the research is really showing is that this is a really complex space. I think trying to unpack the whole range of sort of social and psychological factors that can influence both cannabis and depression is difficult to do. The studies that have studied this most rigorously today suggest that there definitely is an association between cannabis use and depression. What's still not completely clear is how that association is unpacked, whether one leads to the other essentially. But we'll have lots of opportunity to talk about this in a bit more later this evening. Well, thanks for that. So let's get on with it then because it's certainly got plenty to discuss. The first thing to do though is just to quickly run you through the ground rules. You can see them there, and it's all about, obviously, that being respectful to other participants and panelists. So I'm sure that's to be expected. There is a chat box. You can see up the top right hand corners of your screen. There's an icon there where you can chat with each other. So please do make sure to keep your comments on topics so that people can scan the chats fairly easily. And that might be monitored for technical help, but there is an option to click for help for technical issues. And if things are really going badly, then you can contact the help desk on that phone number there. And if anything goes seriously wrong, which does happen in this country that telecommunications and announcement will let you know what's going on if there are webinar issues. But hopefully that will all go very simply for us. So that information is there. The learning outcomes are there. And what we really need to do is provide participants with the opportunity to describe the factors associated with depression use in cannabis users. And Sheen has already touched on that. We'll look at the challenges, merits and opportunities and evidence-based approaches deemed the most effective in treating and supporting people experiencing depression while using cannabis. And finally, and this is really what MHPN is all about, making sure that we can identify referral pathways to support people who are using cannabis who also have depression. So that's what we're aiming to achieve. And hopefully when you evaluate us, it'll be against those learning outcomes to see if we've got there. You've already read the, hopefully you've read the case that's been circulated. If you haven't, then I could encourage you to have a quick look at that before we really get started. But you'll notice that it ends up with this young man, Kyle, living in a rural area, who's using a lot of cannabis and who is obviously having some mental health issues in a complex family dynamic. And at the end of the case, Kyle's served up an ultimatum by his family to get himself sorted out, get off to the GP, get things fixed or move out. So this is what Kyle's confronted with. And the GP in the regional centre that Kyle is living in, who he goes to see is Paul Grinsey, who's well-known in the area for his support of young people who are using drugs. So over to you, Paul. Let's hear from you in about five minutes or so what the GP perspective would be when Kyle comes through your door. Thanks, Steve. Kyle's case is really interesting and very, very common for a GP to see. It's interesting at the end of the case there, he's basically given an ultimatum from his parents to see the GP or else. So it's all coming to a head. And as a GP, I'm realising that I'm going to be hopefully there for the long term. So it's not just a one-off visit, it's really looking to start hopefully in many, many years of a relationship with a patient as they grow older. So this is a really important first visit. And it's really trying to make sure there is a connection. So to some extent, you don't want to dive deep in too deep too quickly and scare the guy off because he sounds like he's coming in under duress. So my first real role here is to really engage, try to get some engagement and report developing. He's clearly a reluctant attender. He otherwise would have come earlier possibly. So I'd be focusing on just getting to know him, taking the pressure off the medical assistants and looking at what music he listens to, what his previous sporting interests were like and exploring that just as an openness to make it a bit more of a conversation rather than the clinical assessment that people often fear. Developing trust, looking basically to sort of find out his interests and ensuring that he trusts that I'm focusing on him and not necessarily his parents' interests, even those parents may have even made the appointment for him. I think it's important to this sort of patient, actually for all patients, particularly for the young adults who haven't maybe seen a GP on their own to explain confidentiality and the limitations around that and provide some safety and security around the conversation that we'll be having. So that's really my first step is to try and develop that rapport and hopefully connect with him on some level that he's able to open up. The difficulty will be there's going to be a gap between what is the disease, my role and how I see it in a lot of people, especially young males in the rural setting, really see a doctor, a medical setting really for only acute injuries and don't see any of the above in depression and substance use is even being part of the agenda. So part of my job here is to try and bridge that gap and explain how I can help and really try and introduce and broaden the idea of emotional health. It's part of being part of the health spectrum that I can certainly help with other than just physical issues, which we can also say, so there's an expectation that's really important. Now, a lot of you listening, be aware of in adolescent health, the acronym of the Heads Assessment, it starts off with talking about the home and education and moving into activity, then looking at drugs and alcohol and sexuality and spirituality and suicide or so it actually escalates as you go through. Some of the history's already been given in our case, so I'm not going to go through all these in detail, but there's a couple of areas that I would want to explore a bit deeper within, but in a very gentle way to start with that being too interrogative. So things like exploring is cannabis use and just getting that history out, including tobacco use with that because the two often coincide and often hard to address cannabis if you want to address it without addressing the nicotine dependence that may go along with that. Looking at alcohol, which he's been using as well, and looking at his relationship to those substances, in addition to how much physical activity he's had in the past and also what he's doing recently, and also how it's affecting his sleep. And they're probably the areas that I'd focus much more so because I think they're much more pertinent in his case. So looking at a broader assessment and taking our time, now this may take a visit or two, but I'll be trying to get most of this done in the first visit, so at least I've got an idea and here's an idea of where we can sort of head from here. One of the key things that I think is really important here is the idea of assessing risk. And having been a rural GP, I'm well aware that on farms there are going to be possible access to firearms, some of them with substance use issues and contributing to possible depression here. There's a suicide risk, there's a homicide risk. And so really exploring that very gently, but making sure I'm thorough enough to make sure that we've got a safer situation and we're not running into a problem here that's going to risk someone's life. So that's the part of this assessment and it's very much a gentle, gentle approach without trying to scare him off, but they're still being thorough enough so it's a really good of an ask for consultation how to draw this out at the time. Now the key part here for me, if I'm getting all this information, is how to make a diagnosis and to some extent the link between depression and cannabis and how much of a link, I'm sure, as the rest of thinkers go through or expand this on this further. But I, at this stage, we're probably looking at more of a trans-diagnostic approach. It doesn't really matter whether it's a chicken or egg, exactly what's going on. He's certainly got features of clinical depression. He's certainly got features of possible alcohol and definite cannabis use disorder. And I would be wanting to explore his understanding between what depression means whether he's understanding what that actually is, whether he senses that he's suffering from depression symptoms or whether he miss labels then for something else. And also he likes to put cannabis and looking to see what that means for him and whether he sees it as a problem whether it's linking the two issues, a link together or which is in this quite disperse and unrelated. So exploring that will help me formulate a plan around him. I've only got limited time. So really at this stage, I'll be looking into looking at invitation to return and exploring things like whether he would like to look at social re-engagement, whether we'd like to access his physical health. And I don't be focused on his respiratory health giving, he's been smoking. But there's other areas we can look at there if he's concerned about things. If he's willing to explore depression, we're looking at his values around that and his ideas. Often young adults are concerned about the possible being prescribed medications. And so there's often a fear around that. And I would really be reserving consideration about medication. Only though symptoms are severe enough to prevent first-line therapy engagement, which is really psychotherapy and social re-engagement shows of concerns. I would be holding back on any of that discussion unless he brought that up. But I really want at this stage, want to be opening and broadening the treatment plan. And so with that, we'd be basically having a discussion about what he sees as his main health issues that he'd like to address. I would add my bits that I think are maybe important to address. And we try and negotiate a plan around this. Now, if this is going well and it's unlikely to happen in the first consultation, but I'd be inviting him back to formulate a plan with me and that may well translate into a mental health treatment plan. And so then we can engage our other treatment providers and have a more broader treatment plan. So I'll be sort of helping coordinate that with him and reassuring him that I'm going to be there for the long haul and helping him through this, navigate through this, but using some other expertise, which we'll hear about right now, will be sort of the next steps for me. So that's sort of the broad approach for me. It's less about, I suppose, the real true biomedical medicine and much more about that relationship with the patient and exploring and setting up treatments from those first few visits. Okay, Paul. So without rapport, you're going nowhere basically. You'll drive at the first hurdle or whatever you'll skip at the first hurdle if we don't get that connection with Kyle so that he actually trusts you to activate that sort of referral network. Without the rapport to start with, the referrals will never happen. Well, the referrals, you won't engage. So it's really an essential first step. Okay, really important. The first person I think you would be referring to, I'd imagine, would be a psychologist if you had one accessible. Now, I'm not sure if Leanne Bryant is able to speak with us. There's been a little technical hitch. Leanne, are you there? No, in which case, Paul's changing his mental health treatment plan and we're moving straight through the social work referral. Steve, if I can interrupt there. Yeah, sure, Paul. I may have opened up saying because as a psychologist, you want to be involved, but also I think getting you back involved with your social life. And it could well be that Kyle actually directs me towards a social worker as a preference rather than just focusing on my initial gut reaction to go for a psychologist. So it often will be that negotiation. So while there's a technical hitch here, I think it's an opportunity to say that patient will often drive part of the direction with our guidance. Okay, so how do you present that to Kyle? Is in fact going to see Monica as a social worker more about engaging with his community rather than necessarily seeing Leanne who I guess carries the psychological model? Look, Leanne, Monica will overlap in the discussions about what the where their roles are. From my point of view, I'd be exploring with him how he's out there with himself over time back in his room at the farm. And one of the ways he can actually be healthier is he's exploring, really engaging in his social life. Now social workers role isn't just about getting something with social life tax together. But I think it's important hook for him to buy into possibly so. Sure, all right. Well, in that case, it looks like the decision is to see the social worker first of all. So going to Monica as our mental health train social worker, if we've got your side up there now, Monica, can you take us through what your approach would be when you receive Kyle in your practice? Thanks, Steve. So I guess it's gonna be a little bit of overlap between what Lee and I are doing. I guess in a more traditional social work role then I'd be looking at re-engaging the young person into some of those social things. But my working role is an accredited mental health social worker. So I do, and as accredited mental health social workers do, we work under the Medicare system providing under the same system that psychologists do. So I will apologize to Lee in advance as they may cross over some of what she says. But I guess from my perspective, I'm going to start off working with a young person doing a comprehensive biopsychosocial assessment. So this is really just going to look at all of the different areas of the young person's life and what's going on in some of those areas. And that gets us a really broad overview not just of the person's substance use, but of life generally and what might be going on for them and some of the areas that might require some intervention. So everything from their home situation of family to school or employment and relationships, drugs and alcohol and mental health more broadly. So I'm not going to kind of cover this in too much detail. I really kind of want to skip to some of the intervention related stuff. I've included some information on this slide here. I guess just to briefly touch on, in terms of a broader drug and alcohol assessment, what are some of the questions that we might need to ask our young people to get a better sense of what's going on for them. And it's these questions that are really going to drive an intervention. So if we can identify what the person's using and not just in terms of the cannabis, but other substances like alcohol and tobacco and caffeine, illicit substances, unprescribed prescription medications or misused prescription medications, they're all going to be really important. So I guess this is the area that I really want to focus on and that's around intervention. So what I'm going to be looking at is a number of things and I'm really, you know, credit social workers will work from a variety of different perspectives. I'm really just going to talk from the frameworks that I would typically use. And that's going to be around things like cognitive behavioral therapy, motivational interview, dialectical behavior therapy and acceptance and commitment therapy. So we're going to be looking at, you know, some of the cognitive things that are going on. You know, this young person has had a lot going on. He's got friends who have moved ahead in life. And so there might be some of those negative cognitions around, you know, I'm useless, I'm not doing so well in life, I'm a failure, those sort of things. And so we're going to use therapy to address some of those. We might be looking at things like goal setting and activity scheduling. I do lots of work around sensory modulation so that we can regulate mood. And that's a really cool part of things like dialectical behavior therapy. I guess for me, one of the really big things is around the order that we work on substance use and getting that order right. So it's really around looking at kind of the chicken or the egg question, which came first. Was it the things that contributed to the person using substances or was it the substances? And usually from my experience, what we find is that there's always something underlying that substance use. Something that's happened in that person's life or is happening, that that person is using substances, I guess for one of a better way to describe it is self-medicating. And so it's really important to address that stuff first because until we get on top of that stuff, whether that's depression or anxiety or a trauma history, until we deal with those things, the person's going to really struggle with being able to actually manage their substance use. Once we've actually dealt with that, and we've got some strategies in place from the person stealing more confidence, then we can move on and address the substance use. So we're going to talk about things like psychophagication and harm minimization. I guess from my perspective, and I guess particularly from using that systemic perspective that social workers use, I'm going to be looking at a combination of individual work, first therapy with the young person themselves, to address some of the things that are going on with them and then to deal with some things around recovery planning for their substance use. I might also look at a family perspective if that's appropriate and if the young person is consenting. So looking at things like psychoeducation and parenting enhancement to improve the relationships between the young person and their family. And then I might look at a broader approach to the young person's life. So things like, you know, how are things functioning in their social life and education and employment and recreation? And how do we manage those things from a therapy point of view? I think there's a misconception that social workers are just the paper filler people that do central link applications and that sort of thing. But we are also able to use a lot of therapeutic interventions to be able to address those broader parts of the person's life. So I guess from the accredited mental and social worker point of view, that's how I'd be looking at being able to intervene from a more clinical perspective. Okay, great. Thank you very much. So it's obviously very comprehensive with the approach you're taking there. I'm just wondering if, well, it looks like Leanne is back. So if we can jump back to Leanne's slides here and find out her psychology perspective. Leanne, I think it's awfully hard for you. You've probably not heard what Monica's been talking about, but are you able to talk about your approach? Should Paul or should, I guess, Kyle find his way to you for care? What would your approach be? Okay, well, it's probably a slight advantage to not have heard Monica's because then I won't feel that I'm pinching her stuff because, yes, as I did hear the beginning part of it, we definitely do overlap in quite a lot of ways. There's a lot of things that a mental health social worker and a psychologist would do quite similarly. So I mean, my expected referral pathway for Kyle would be that the GP would refer him to me as a private psychologist through a mental health plan or alternatively, there may be a voluntary referral by himself, by the GP or by a family member to a drug and alcohol service, which employs both psychologists and mental health social workers. So that would, you wouldn't necessarily receive Kyle as a client, specifically as a psychologist. It may well be just under the umbrella counselor. And so we often do very similar work. Another way that we might potentially see Kyle in a drug and alcohol service is if he goes along to the fire service and that police officer happens to notice and he may then mandate Kyle's attendance as a part of a caution process. Now, that wouldn't necessarily be that effective in having Kyle's CCUs or want to CCUs because when people are forced to do things, they often decide not to. However, at least in part of the process there would commence with psychoeducation. So hopefully in that process, there might be some shift for Kyle along the motivational pathway. And I seem to recall from before that Monica was mentioning the stages of change. And so that that would certainly be something that we'd be hoping to push him along the pathway. Okay, and of course, at the point where Kyle becomes a, comes to a psychologist or the drug and alcohol service, he would magically become a client rather than a patient, sort of doing that shift from the, giving a reduced focus on the medical model. Okay, so then the next thing that we will be doing, or should I say the first, I suppose once we've got Kyle there with us is to do a comprehensive bio-psychosocial assessment to determine the range of factors that would be contributing to his presentation. And that largely we're looking at cannabis and depression, but obviously there's also some alcohol abuse there just because he's not a daily drinker. So doesn't fit the profile of his standard alcoholic. He is a binge drinker from what we've been given. So, you know, that is certainly something we'd want to address. But so, okay, so with regard to the assessment, we'd be looking at things like his father's drinking habits. Does that indicate that he may have a substance use issue? And that sort of genetic pathway could be affecting Kyle. The father's drinking may also indicate a mood disorder, as might his general grumpiness and that sort of thing. So we'd be looking at that as something of interest rather than, oh, well, we've got to fix the dad, but it's just something in Kyle's history that would give us an indication of where these issues might have materialized from. I know his mother's demeanour is you've been quiet, et cetera, something that may also point to some sort of mood disorder. Then we'd be looking at things like his thinking patterns. And I'm sure Monica's addressed those, so I won't go further into that at this point. I will a little later. And there's quite a lot of social isolation, obvious in the case study due to his mates leaving for uni. There's no longer that participation in sport. And the fact that he doesn't have a job also isolates him socially. I mean, when he does work, it's in a solo sort of capacity on his father's farm. And it would be, in the part of that assessment, it'd be really important to explore his problems from his perspective. So basically what does Kyle see as impacting most on his wellbeing? Just because we might see cannabis as being a problem, he may not think that that's an issue for him, yet his mood being low is or vice versa. And so then basically working with whatever he identifies, I mean, and going with harm minimization principles. So for example, if he doesn't identify smoking cannabis as that big an issue for him, it's a little like, well, okay, would you be interested in maybe switching to joints that's less harm than smoking bongs or just things like that, little things you can find. So you'd also identify his triggers for either low mood or for smoking or drinking for that matter. And then develop the care plan and collaboration with him. And so of course, we've got those two overarching issues of substance use and depression. So I'll look at depression first briefly. So basically assessing the level of his depression symptoms and I tend to use the dash 21 in my practice. Of course, there is the dash 42, but dash 21 is just as good and takes half the time. So, and that also provides, of course, a measure of anxiety and stress symptoms, which often contribute to the levels of mood issue. Now, the results of the dash 21 would then guide to some extent the indicated treatment and the potential efficacy of that treatment. For example, if his depression symptoms are mild, well, it would be very unlikely that medication would be of any value to him. Counseling and other therapeutic work should be sufficient. Whereas when you get to moderate and severe depression, sometimes medication is a good starting point. And from there, you can then continue with therapy in a more efficacious way. And of course, there are interactions between the mood and the biopsychosocial factors, as in being on his own, being isolated, et cetera. Now, so then we go on to substance use. Oh, actually, sorry, I should say that, of course, a significant symptom of depression is demotivation. And so that is also the case with cannabis. So it's kind of, we were talking earlier about which causes which or that sort of thing. So chicken or egg, when both of them cause demotivation, it's very hard to tell which one's the most contributing factor. Okay, so then with substance use, we would be first and foremost assessing the level of use, which hopefully Kyle would be honest about, but generally speaking, taking these things with a bit of a grain of salt. But once again, going with what Kyle suggests is the case, but being aware that he may not be disclosing completely. And so I'd be assessing the cannabis level, I'd be assessing his alcohol level and it's also assessing his motivation. And then as I've already sort of mentioned, is he interested in reducing? Oh, does he want to cease completely and abstain? And of course, the interactions between the mood and, sorry, I did a repeat. The mud? Okay, so basically we then go on with psychoeducation regarding the effects of ongoing and chronic cannabis use. I mean, because the effects of use change over time with physical dependence, because initially it's experienced as calming, whereas the majority of users who use chronically end up having some sort of anger and explosive episodes occurring very commonly when they're withdrawing. And so it tends to lead to the client perception of low self-worth and powerlessness. And it's, I have to keep using because otherwise I get angry. And so of course with some psychoeducation around that, they can be aware that that symptom will reduce over time and they won't then have that issue as much. And also it's important to consider that he's probably got nicotine dependence as well. Some people don't smoke with nicotine or with tobacco mixed in, but the vast majority do in Australia. And so then if abstinence or reduction is his goal, ongoing treatment would be around urge surging to delay, distract, decide, model. And then further is psychoeducation, really the psychoeducation aspect of thing often empowers people to make their own choices that are better for them. And so psychoeducation regarding the effects of the alcohol used in conjunction with cannabis and the assessment with an audit, that's the Alcohol Use Disorders Identification Test. Yes, that's what it is, to identify the level of risk associated with his binge pattern. Okay, so then if we, yes, also one thing that I didn't mention earlier is that with our DAS, if there's issues with anxiety and stress revealed there, they may well respond well to mindfulness based stress reduction techniques. And that may also provide a better coping behavior because if his substance use has arisen out of his inability to cope with low mood or unhelpful thinking habits, then mindfulness techniques can be very helpful in that regard. Okay, so then getting to the treatment plan, which I think is potentially my last file there, slide. So psychoeducation, and as I've already said that that's really a key thing. And the treatment plans then likely to include cognitive strategies. So particularly if there's unhelpful thinking habits identified, we would be looking at going with something like the A, B, C model, cognitive restructuring. So we're A being the activating event, what starts him smoking, the underlying belief that causes and then the consequence of that. And so that may be that substance use that then feeds into that motivational interviewing. Many different aspects of that, but a decisional matrix may particularly be useful for Kyle, especially around what he wants to do because he's had that difficulty of making up his mind where the rest of his life is heading and that could be part of why he's using cannabis to cope and also why he has low mood. It is possible to have some medication potentially to withdraw from cannabis. It would be very short term. It would depend on how chronic his smoking was and whether that was really indicated. And some antidepressants to improve his mood, as I already mentioned before, if his mood is low enough, then that may be indicated. But ceasing drug use is unlikely to improve his mood immediately, but might be more likely to leave the client vulnerable without a coping mechanism. So that's where potentially medications to help be that raft to help him do that would be a good thing. And so then if that was the case, if we needed further assessment, it would be at that point that I would be thinking of collaborating with the GP to have a referral made to a psychiatrist to determine whether that's a valid way to go. OK, so thanks, Anne. So really the question about medication would be a bit of a threshold point where you might consider referring through the GP to a psychiatrist. There's certainly plenty of people involved or potentially involved in child's care to this point. We've already talked about general practice, social work, psychology. We haven't even touched on OT, mental health nurses, other people who might be available. But in this situation, the case we're looking at here, we are going to refer to Shalini as our psychiatrist. So what would your approach be, Shalini, when you receive this referral? Thanks, Steve. And I think my first approach would be, you know, understanding all the work that's already been done with Kyle. I'm recognising that, you know, the team approach here and also recognising that as Paul mentioned, Kyle himself may be a reluctant participant in the whole process. So I think the first thing for most specialists, most psychiatrists would be to understand why Kyle's coming to see me, the role that I'd be playing in his management, understanding why he thinks he needs to be there. It sounds a little bit like where he's at might be more an ultimatum that he knows that risk is potentially being kicked out of home if he doesn't get his act together in his dad's words. So it's really kind of understanding from his perspective, why is he here and how can I help? And perhaps changing that conversation to align with what he's interested in actually achieving by coming in. I think something that we touched on in the question earlier on was really about talking about causality here and depression and cannabis, what's driving the one question to the other. We'll talk about it in a bit more detail, but I think this is a really helpful diagram, I think, to think about the relationship between substance use and mental health symptoms more broadly. It's often a quite complex relationship and as we've touched on already, it's often an issue around kind of bi-directional associations here. For many people, we're also talking about self-medication being an issue, where people are actually having mental health problems that predate their substance use and they end up in a situation where the substances are helping them actually manage in the short term that people often end up with longer-term dependence as a result. So I think on an individual basis, people are able to kind of develop a bit of an understanding of the interaction between the mental health symptoms and their substance use problems that can actually help unpack what's happening to them. For Kyle, I think I'd be really trying to flag for him that what I'm hearing is that really there's been a transition for him from cannabis use in as well as his drinking being really a social activity that has been fun and has been something that's relegated to the weekend. And over time, this has really transitioned to something where it's causing problems for him, where it's causing conflict to the family. And he's also started smoking largely to help himself function as well. So he's talking about smoking to help him get to sleep. And that's a bit of an alarm bell where he's actually using it to sort of regulate what he needs to do day to day. So I'd be starting to unpack some of these things with Kyle and trying to understand how changes in his mood and changes in his kind of lower function could relate to cannabis and vice versa. Sometimes I tend to use rating scales in my practice as Lee's already mentioned that can include depression rating scales and anxiety instruments. I think it's really helpful to also track sleep exercise and mood day to day in relation to cannabis use. That can be really rewarding as well for people and reinforcing if they're trying to cut down you if they then see changes in that day to day. For instance, if you're drinking less, if you have more refreshing sleep or if you're smoking less, you actually have an improvement in mood and anxiety that can help you stay motivated to keep going. I think thinking about diagnosis that can also serve a range of functions. And I guess moving on to our next slide and thinking about how depression might relate to cannabis use. The existing evidence as I was touching on before really kind of points to this complexity in the relationship between cannabis and mood. The studies that have been done so far, there's been a small number of studies that followed people up over time, longitudinally and prospectively. So they started off with people not using cannabis, followed them up over time and looked at depressive symptoms that newly developed. And that's kind of the most rigorous way to actually understand what that relationship might be. Even there, the evidence is quite mixed because lots of different things that can lead you to use cannabis and become dependent on cannabis might also be things that independently have an association with depression. So for instance, relating this back to Kyle's case, what we're hearing is that social isolation, perhaps disengagement, these are factors that would potentially drive cannabis use and heavier cannabis use, but it would also independently drive depression in and off themselves. The pictures here really highlight that in the studies today, what we know is that heavy cannabis use is associated with a higher likelihood of having depressive symptoms, but it's still really unclear as to whether this is an independent association or whether that actually comes down to what is a causality situation. So I guess in terms of speaking to Kyle and working through what might be most relevant to him, what comes to mind, thinking about his case and something that I think psychiatrists can sometimes assist with, is thinking about how Kyle's current situation actually fits in with his broader sort of developmental stage, fits into his family and thinking about how he fits into community and where he's at. I think Lee and Monica have already touched on this, trying to understand how Kyle actually sees himself. And I think for a 19-year-old, for a young person, identity is definitely a bit of a life stage. He's really at a point where most of his mates are from the city and he's a little bit lost. So I think for us trying to understand for Kyle how we can actually shift between that would be really helpful. Where does he see himself going? What are the things that he's actually wanting to look at in terms of his own identity? And how can we help him sort of individuate away from his family? It sounds like his dad clearly has some ideas in mind of what he'd like Kyle to do and they might not match with what Kyle sees himself as. And we're also hearing that his sisters, for instance, are high achieving young women themselves and being the youngest boy in that family can be difficult. So I think it's trying to understand for him where he sees himself and where he also can derive some sense of self-efficacy. So I think across sort of substance use and sort of this is something that can be really helpful trying to find ways that we can talk with people about resilience and ways that people actually find a sense of self-efficacy day to day. Moving on from that, I think something that Paul's already touched on is really around risk assessment. We're hearing that Kyle has some clear perspectives for the depression and potentially might be having sort of those subtle parts, the parts of self-harm. These are things that we'd really want to unpack in a lot of detail. Certainly with Kyle's consent, he might agree for us to be able to talk to his parents and to potentially his friends or any other people who are involved to try and get a better understanding of where he's at in terms of those risks. I think in terms of psychosis, we haven't really touched on this and it's not particularly failing to Kyle's case, but certainly that's a mental health risk that has clear association with cannabis use and heavier cannabis use. So we'd be trying to understand whether Kyle has ever experienced any psychotic symptoms when he's been using and whether he's at risk of developing these symptoms in future. Something we haven't really touched on so far is really around driving and impairment, both in driving but also on the farm. So we know that he may potentially be operating heavy equipment but also being in a rural area, he might be doing a lot of driving. And I think with really only starting to understand the impact of cannabis on motor function and on driving impairment, it's a very tricky space. With cannabis, it's not very reliable the level of the level you smoke or even the level in your bloodstream or in saliva, how those levels actually relate to impairment per se. So I think for Kyle, it's certainly a risk for him that he might get across a drug bust so I actually get drug tested and could potentially be at risk of losing a license for instance in that context, which would be pretty terrible for him, I think. So I think it's really trying to understand for him how that actually impacts on a state of their function. And finally, I think trying to understand how his recovery actually looked. So from a recovery perspective, we've talked about a whole range of things that the different parts of the team would actually look at. I think certainly everyone's sort of on the same page about the same sort of goals that Kyle might be identifying that we want to work on. The question is really by the time someone gets to see me or see if the guy just, what's the role of medication in that space? Is it necessary and really what's Kyle's choice in the space? Certainly say for by far and away, the majority of people I would see who use cannabis regularly, we wouldn't necessarily be looking at medication as being a key part of their plan. But in Kyle's case, I guess, what we'd be wanting to do is really weigh up the risks and benefits of medication if they are indicated at all. Medication here is really driven by what the symptoms are that Kyle's experiencing. What I'm hearing from Kyle is that sleep in particular might be an issue for him. And certainly kind of getting energy and getting out of bed in the morning wanting to do things. So these are the sort of things that an antidepressant might be able to potentially help with. And I think it's really kind of talking through with Kyle and getting some informed consent in that space, talking to him about what the risks might be with starting an antidepressant, but also highlighting that any medication kind of is in the context of a trial and error process. So we'd be prescribing it for a period of time and seeing if it actually helps them day to day. And if it doesn't, it's a question about stopping that. In terms of antidepressant choice, there's no kind of clear evidence-based guidelines to say a particular one is more helpful than others. But what I'd say here is that we're really informed on what's gonna work for Kyle. And finally, just touching on something we've spoken a little bit about, I think wanting to actually talk to Kyle's family, parents in particular, with the consent and trying understanding whether we could get some conversations happening around some shared goals, but also identifying if Kyle's parents might want their own independent support. There are lots of really helpful supports that are parent-specific and family-specific out there, so trying to see if we can help with that as well. I might wrap up there so we can have some time to talk through some of the questions we've got lined up for us. Okay, fabulous. Thank you very much indeed, Shalini. We've certainly got a good handful of questions here. I'm waving around these. We've still got over 1,100 people on the webinar. And what I think I should do is pick some questions that have obviously cropped up for one or for more than one person. One that was pretty frequent, and I'm not sure, Paul, whether this is something you'll be able to best answer for us, and I must say I'm gonna reveal my own ignorance of this area, but thinking about other forms of cannabinoids, thinking about particularly CBD oil and hydroponic marijuana versus other forms or other cultivated varieties, do you see a difference in the way people present, depending on how they've got their cannabinoid, THC or CBD oil or whatever it might be? Yeah, so as a lot of you will know, the cannabis plant has hundreds and hundreds of different chemicals and the different cultivars and the different ways the substances are extracted in terms of from hemp all the way through to hashish and smoke marijuana, the leaves, the buds, all these different factors lead to a whole bunch of different arrangements of chemicals. I'm not particularly aware of any particular focus in a practical sense. In the end, you assess what you see in front of you and how it actually got there doesn't mean so much. We do know that THC has a lot of very different effects than the CBD path of things and the medicinal cannabis space tries to focus on the right balance of those, particularly those two, but there are hundreds of chemicals out there, but from my point of view, I haven't particularly seen a clinical syndrome that's one way or the other depending on what people are taking. And as I said, I don't think from a practical point of view, it really matters to me. You assess and then you try and direct therapy around what's in front of you, not what could be there in theory. Even if somebody is on medicinal cannabis, I guess, same thing, you treat what the person presents to you. Yeah, yeah, so like the medicinal cannabis space is also very mixed, it would tend to be probably a bit more CBD than THC based. I have a lot less of the negative side effects of cannabis, but not necessarily. So again, it depends on the patient. You'll have the occasional patient who becomes psychotic with minimal THC, and although that's a rare occurrence. So again, you need to assess the patient and not necessarily trying to be too theoretical about things. Okay, well, there's a number of questions people are asking about comorbidities, including autistic spectrum disorder, psychosis, I don't know, does any of the panel have any approach that they use when trying to tease apart the effects of cannabis usage and other mental health issues, such as autistic spectrum disorder or emerging psychosis? Yeah, I'm happy to take that question, Steve. I think in terms of teasing that apart, it kind of comes back, I think too, that image I had before about trying to understand what comes first, a little bit of the chicken and the egg issue. I think for a lot of people, what can be helpful is trying to identify if there's been any times at all when the person hasn't used. So if that's, for instance, for a period of a month, they might have gone on holiday or something, trying to understand what their mental health looked like at that time. So where you have an absence of substance use, for some people that's a rehab setting or a detox setting, for others that might be a period predating the use. And then you have a clearer picture to some extent of what's happening in terms of mental health. Now, when we're thinking about comorbidities, I mean, cannabis is one of the most widely used illicit drugs, certainly the most widely used illicit drugs worldwide. So when we think about prevalence, certainly many more people use cannabis and there are people who've developed mental health problems in association with it. So I think, you know, trying to unpack here, for those people who have mental health problems, how that interaction actually occurs, clearly there are a whole range of mental health problems that can develop in association with cannabis in itself. In terms of psychosis, I think that's a clear link there. And I think that's something that you'd want to kind of unpack and clarify in a lot of detail if you thought that was happening to a person. With autism spectrum disorder, it's a little bit more complicated in that usually there are some symptoms of signs that can go missed. Certainly by the time someone's an adolescent or a late adolescent, you'd just be looking kind of backwards to try and understand what social interactions look like prior to cannabis use and cannabis onset. That would help to some extent, but certainly as Monica and others have touched on, lots of people actually end up in a pattern of self-medicating some problems, including sort of social anxiety or difficulty relating to others. And I think that's where, you know, trying to understand how that relationship actually occurs with them. Okay, great. Dutch, I'm wondering if anybody on the panel has any particular tips. There's been a number of questions on how we can tell whether the young person's presenting their usage of illicit drugs. Truthfully, what do people do to try and find out whether they're hearing an accurate story about usage? Yes, I had a thought about that one. Essentially, rapport. I mean, Paul has certainly said about that. I mean, establishing a rapport which includes a non-judgmental approach. So basically, for them to be telling the truth, they first and foremost need to be feeling safe and they need to feel that if they tell the truth that they're not going to be regarded poorly. If you suspect that the individual isn't telling you the truth about their levels of use or whatever, then perhaps providing some information about common usage, as in a lot of people who use this amount end up at this point. I mean, his presentation is fairly typical. The fact that he started only using, you know, I've forgotten exactly where he went, but a quarter a week, I think, yes. And now, yeah, he was a quarter over a fortnight and or something like that anyway, it increased. And so therefore giving him some, you know, feedback as to what is common and so that he's not feeling as if he is that strange creature who's obviously using far too much and therefore makes him feel worse about himself. And hopefully that would help him feel safe enough to reveal the truth. But yeah, it's a difficult thing. Okay, thanks for that, Leanne. What about you, Monica? What are your thoughts on this? Hello, Monica. Sorry, I just wanted to add. I guess one of the things for me is also one of the reasons why or how the young person is presenting to us. So whether or not they're voluntarily presenting versus the coerced client. At the initially aged group, I find that lots of our young people are being brought along by their family members. So it's not always voluntarily. And the less voluntary that client is, the more inclined they might be to be less truthful about what their usage is. So I think Leigh's comments about engagement are entirely spot on. You know, building that engagement and the rapport is super important, particularly for our clients who really don't want to be in the therapy room. So I would really be looking at, you know, I guess trying to discourage some of our families from forcing young people into therapy because it's not the greatest way to go, particularly with substance use issues. It really goes against a lot of that stages of change stuff where, you know, we're just not meeting them where they're at. And instead, maybe educating our families on how they can have conversations with young people to really encourage them to actually want to get help as opposed to feeling like they're being forced to do that. Yeah, well, clearly Kyle's under duress here is attending as a passenger. And I think this has been a focus for every practitioner in how to actually win his trust and make him an active participant in his own recovery from what is heading into a really chronic situation. I'm also curious about, and a few people have been asking questions about the particular rural aspects of this case. We've touched on access to harm through access to firearms, high-speed roads and various things like that. I did warn Paul in the lead-up to the tournament conference of the webinar that somebody was going to ask about Q-FEVA or brucellosis, and that's duly happened, but I guess that's part of the workup. Has anybody observed differences in the way rural youth present in this sort of situation to urban youth? Paul, I know you've moved from rural Victoria to very much the inner city now. And any others? Paul, first. Yeah, it's, I think, before I go into the differences, I think there's certainly a lot more commonality than there are differences. I don't want to sort of suggest that there's very different populations in terms of how people present. But having said that, the geographic and social differences, there's much more isolation. The traffic of substances into a rural community, how they get there, the networks around that are quite different from our conventional urban community. So a lot of that social networking around drug use does vary a fair bit. And therefore the treatment process and the planning around that has to take those things into consideration. And in an urban environment, there are different things to be considered as well. But certainly there are unique challenges in terms of engaging, accessing therapists. And I know when I've worked in rural settings, some of them have been lucky enough, really lucky to have some great therapists very accessible. And other times, for other therapies, it just hasn't been around. All the affordability has been a bigger issue, so there hasn't been as much choice. So there's a number of areas where the rural does have some differences. But I think in general, I see a lot more commonality across all our population between rural and urban. We often emphasize the differences, but certainly a lot of things are very much the same. OK, I'm just going to... Thanks, Paul, I'm just going to ask Leanne for an interpretation here. She's written to me, Bush, but in the rural hydro in the urban. Can you help me with that? Yes, so, I mean, like, the differences of presentation, I would agree, are not very different. However, where I live in Tasmania, but in my area, which is more a country area, there's a lot of people growing their own. And so, therefore, and that's referred to as bushbud, as opposed to the hydroponic. And so, therefore, the hydroponic stuff is quite often higher in THC levels. So, of course, that can affect presentation to some extent because people become accustomed to a much higher use much more quickly. OK, thanks for clarifying that. I feel quite out of touch. I'm going to ask, though, about... We've been talking a lot about young people using marijuana and having depression, chicken egg, bit of both, as we've found out. People have been asking also about the older person who's probably been using marijuana for many years, people in their 50s or even older. Do any of the panel have a different approach to dealing with really long-term users in this situation? Steve, I'm happy to talk to this one. Please do. I thought we'd lost the satellite. This is good news. That's OK. So, I guess, from my perspective, I'm really going to be looking at a more planned approach to addressing the person's cannabis use. So, really having a look at what's led up to the person using cannabis for as long as what they have, doing a really comprehensive assessment of their usage so that we can gauge exactly what's going on for them, particularly things like the patterns around when they're using. So, are there particular patterns to things like time of day, you know, things like moods that are affecting it, so, you know, do particular types of mood affect the levels of their use? I'm going to use a couple of different questionnaires with the person, and that's going to then inform my interventions. So, I'm going to use things like what's called the high-risk confidence questionnaire, the severity-independent scale, and then I might also use things like the DAF 21 or a basic K10. But what I'm really going to be looking for is what's the high-risk situations for that person because the longer that the person has been using, the more likely they are to have built up things like habits and routines around their use, and those are going to be the really complicated things to try to address. It's not as simple as, you know, the elderly person comes home from work and they have a joint and that's their routine, so we address that by saying, okay, we'll just never go home again. We've got to be able to work with the person in their environment, so developing a really comprehensive plan before we even talk about setting a quit date is going to be really important. Okay, great. Thanks for that. What about also physical health in older adults? Shalini, and also with cannabis use without medicinal cannabis? What are your thoughts on that? Yes, I think, I mean, that's really irrelevant to people who have been using for a long term of their life, and I think with an older adult population, so not only people in their 50s, but with talking about, you know, people who are actually coming into one and changed their use to who are now in their 60s, 70s and above, and I think what we're seeing there is also a lot of people who are experiencing pain and chronic pain conditions, and who often say that, you know, the cannabis is actually also helping with that, it could potentially also be helping with sleep, so it might be serving a whole range of different functions for them, and I think in that sort of context, you're really, if the person's trying to cut down on use, they're trying to understand how it's actually subserving what functions in their life and how we can actually unpack that. I think in relation to medical cannabinoids, I mean, the jury's still very, you know, the jury's still out on that in terms of whether cannabis is really helpful for pain in itself. Certainly the most recent evidence suggests that the current preparations aren't particularly helpful for pain, but certainly we hear lots of anecdotal reports from people who find that it's really helpful, so I think, sorry, what we need to understand here is really that when we talk about cannabis, the plan for polls that's mentioned is really consists of a whole range of different compounds, and one person's cannabis isn't the next person's cannabis, so when we look at, you know, medical cannabinoids in trials, if we really need to understand what we're talking about there is that a pharmaceutical product, is that a mix of different chemicals, and that can also point to whether it's effective for pain, et cetera. So I think with older adults it's understanding why the person's continuing to use, as Monica's mentioned, but understanding how it relates to not only mental health problems, but physical health problems for the person. Okay, thanks. There've actually been a couple more questions coming up about medication, and the question of using medication, even such as syracal off-label for withdrawal, diazepam and things like that, what would be your go-to for somebody who was withdrawing from cannabis after many years of use? Yep, so I guess building on that in terms of, you know, these are off-label prescribing for both diazepam, catalepsy, and syracal, other types of medication for withdrawal symptoms. There's no sort of clear guidelines to guide that space, and you are prescribing in an area where you're prescribing it off-label. That being said, it's not an uncommon practice, I think it's just something that needs to be undertaken with the clear awareness of the risks of these particular medications in and of themselves. So occasionally these medications can get started and they're not followed up on. And I think, you know, that can be an issue because long-term use of benzodiazepines like diazepam or cotypine as well can be associated with a whole range of it, their own independent harm. So, you know, indications might be, you know, as someone mentioned, extreme agitation might be for a shop here at the time, might be for days to a week rather than months, and really having kind of dates in mind to review that and to try and understand when that incident stopped. Thanks, Archelene. The diagram you showed earlier, showing the pathways to comorbidity, is there some curiosity about where that came from? Yes, that's great. So that is actually from the National Converting Guidelines. I think someone said that they've set shit up. It's in the first section. It's a very large guideline. It's created from the Matilda Centre. So if you go back to the Matilda Centre and Google that, National Comorbidity Guidelines, it's from section 1A of those guidelines, that infographic. Great. All right. Well, thanks very much. Maybe just one more question before we get on to the wrap-up. There's been questions about social engagement and the difficulty that heavy cannabis users experience in remaining socially engaged or maintaining employment. Any thoughts from the panel about what sort of strategies you might put in place to try and keep people engaged with the community and employment as they deal with their health issues? Well, for starters, I mean, I'd approach it in a very bit-by-bit way, one step at a time. If you set a huge goal like, OK, within a week or two or even within a month, you'll have a job and this and that, that's not really going to be that helpful. So to begin with, starting with something like, OK, well, some sort of regular exercise and whether that's a 30-minute walk a day or whatever he feels is going to be manageable and that's where the collaborative treatment plan is really features in that, because it's OK, well, what can you improve? I tend to look at positive steps to wellbeing, which has a whole raft of things like balance sleep, exercise, having a hobby, looking at the bigger picture is also a part of that. And so, as I say, there's a whole range of things that you can look at and if you can address one thing and make one small improvement, that usually has a knock-on effect and makes the next thing a little more possible and a little more possible until you're far enough down the path that the big things like, OK, start looking for work can be achievable, perhaps. OK, great. Thank you very much. So we've still got over 1,100 people online. I think now what we should do is just hear from each of the presenters about how they see Kyle being at this point. Paul, can we start with you? What are you thinking about, Kyle, at this point? I think I'll just reiterate some of the things that I started with. All of us are focusing on making sure we develop a rapport and, as a GP, I see myself as really primary in terms of coordinating this treatment team and make sure communication flows in the right directions where necessary. We need a sort of a conduit to do that. And taking Kyle along for that journey, as he helps direct us, all of us have got our expertise in the areas. As a GP, I'm hoping that I can eventually congratulate Kyle to becoming a grandparent and being in there for the long haul because he recalls back when he was 19 and first came to see me and we joke about those times. It's that long-term process. And so there's lots of things we can do from all the biomedical, the social, the psychological aspects. And as an owner of us alluded to, he's chipping away small bits at a time and I'm really in there for the long haul. So it's really setting up a good relationship to start with and making sure that he feels that there's someone by his side that he can turn to and hopefully it would be me as a GP. Hence the relationship again being so important to sustain that journey. Wonderful, thanks for that. Monica, what about you? What are your thoughts about Kyle at this point? Thank you, Steve. I guess what I really just want to emphasize out of what I've spoken about today is focusing on where the young persons are in terms of their stage of change, making sure that we're meeting the young person where they're at, not jumping the gun. So if they're really resistant to changing, not pushing that further than what they're ready for because all we do is breathe more resistance. And really encouraging people to have a look at the reasons that underlying substance use address those reasons first and then have a really managed plan in terms of how we're intervening for the substance use rather than addressing the substance use first because it's often a band aid for the bigger problems that are going on. And then after that, looking at things like the broader approach to the young person's life. So social things, education, employment, recreation, all of those other things that really make up what a person's life looks like. Great. All right. Thank you. Again, a challenge ahead, but hopefully Kyle's more supported in meeting us. Let's now hear from Leanne. Your thoughts on where we are with Kyle at this point. Well, my thoughts are that while he's not been particularly willing necessarily to come along and seek help, life isn't good for him. So if that rapport can be established and he can be shown how he might improve his own life, I mean, and that's a thing unlike Paul, I'm not in it for the long haul. I mean, if I need to be sure I am, I mean, you know, let's see, I've got clients that I still see after years. However, not somebody in Kyle's position. I would hope that within a shorter period as possible, Kyle would reduce his sense of powerlessness and hopelessness and show him that he can have a life that is fulfilling and, yeah, and that he can do it on his own. I mean, certainly support to be shown the pathways that he might take, but he is the one that has to take those pathways. Okay, thanks. And you would use something like the DAS 21, the Depression Anxiety Scale, to monitor his progress and show him some progress? Yeah, absolutely, absolutely. And I mean, yes, as things change, I mean, quite often the client will identify themselves that things are improving, but to then, as you say, well, okay, here's some black and white. This is how you started and this is how you are now. So, you know, having that verifiable stuff in black and white is really useful. Sure, that sounds great. Thank you. What about you, Shalini? How are we going with Kyle at this stage? Yeah, look, I mean, I think the fact that he's actually turned up to see all of us is brilliant in itself. I think we'd be trying to help him kind of get going from where he wants to be, I think. I think we've touched a little bit on kind of diagnostic relationships if that's relevant for him and he wants to understand how that fits into his bigger picture. I think that's important. But I think also understanding the role of medication, you know, coming to see as a psychiatrist doesn't always mean that you walk away with a script. I think it's trying to understand where that might fit in for him and if it's something that actually might help improve his function, thinking about antidepressants in the world, where he might play in his kind of broader management. But I think, you know, everyone's really touched on, you know, the issues here are really around his sense of identity and sort of how he fits into his family and his life. And I think it's really trying to get those conversations happening, not just with Kyle potentially, but with his family and his parents as well. Great. All right. Well, thank you all very much. There have been a few questions coming up. People have struggled a little bit with the technology and this will be, the recording will be available on the MHPN website. So hopefully people will be able to review it there. Couple of minutes left. I'm just suddenly realizing we've not had a lot to do with Kyle's family. Would any of the practitioners actually, I mean, it was mentioned, but seeking Kyle's permission to contact the family and provide some sort of therapy through them. Does that fit anybody's framework? That's definitely an area that I would be working from, Steve. For me, working with the family is really important because at the end of the day, they're Kyle's support network. They're the people that know him the best, better than any of us do. And I think being able to engage their perspective because they're going to see lots of things that we don't as practitioners. They spend so many hours with their kid. So if we can engage them, we can use them to provide things like psychoeducation to them about what's going on with their child. We can look at doing some parenting enhancement stuff. So how can they improve the relationship with the young person? I think being able to engage the family is super important because once we finish, and I guess being realistic about our interventions, the Medicare system only affords the 10 sessions per calendar year, which doesn't give us a lot of space to do some really intensive work. So being able to upskill the family to do the work when we can't be there can be really useful. Okay, great. Well, thank you very much. We're out of time and we do need to finish up. I just wanted to remind you and to encourage people before you go that there is an evaluation form. There's a yellow button up at the top right on your screens, I believe. So if you could please respond to that throughout the survey, it's very helpful. There are several more webinars coming up too just to mention to you before you do go and get on with your evenings is the Emerging Minds webinar, which is about engaging children and mothers who are affected by family and domestic violence. That's occurring on the 7th of August and another one on the 19th of September, a very interesting one again, on engaging Indigenous people and whether we as practitioners already have what it takes to engage Indigenous people, if not what we need to do to make our services culturally available. We also wanted to point out that we do support the engagement through MHPN of the ongoing maintenance of practitioner networks and it's all about getting practitioners from different disciplines to meet regularly. So if you're interested in joining your local practitioner network, please do contact MHPN or look at the new section on the website to find out what's going on and also when you do fill out the evaluation form you can indicate your interest there in the exit survey if you wish. So thank you all very much. Thank you to all of our panel members. It's been a really active panel tonight and I'm very pleased to have had the opportunity to work with such practitioners. Before I close, I would like to acknowledge the lived experience of people and carers including people on this webinar tonight who have lived with mental illness and drug use themselves in the past and those who continue to live with mental illness in the present. So thank you everyone for your participation in this evening and we look forward to seeing you at another webinar. Good night.