 Hi, I'm Lucy Brogdon, Chair of the National Mental Health Commission Advisory Board. Welcome to this online conference. What an innovative approach to sharing knowledge and learnings right across the country. I understand there are thousands of you online ready to learn and work. The Mental Health Professional Network is truly taking a novel way to share wisdom with all of you and it's to be applauded. Working Better Together is the theme of this conference and it's a great opportunity to learn more about mental health in the military, about grief and loss and about trauma and adverse childhood experiences, all important topics that need our best attention and our best minds tackling these issues. We know the issues faced by our military and the risk to develop mental illness. We also know there are protective factors. This conference will bring together that conversation and work out how we best protect our serving people. Grief and loss affect all of us at different stages in our life. Understanding what drives that in people and how to best support them in their journey is really important. One of the frustrations for me at the National Mental Health Commission is seeing how stubbornly our incidence of mental health sits when we look at other non-communicable diseases. And what we know is that it is trauma and adverse childhood experiences that often lead people to a journey in the mental health system. If we can better address those experiences in childhood, prevent them, mitigate their impact and try and understand trauma, we set so many people on a more positive journey through life. Thank you all for coming online to join the conference and to be part of these important conversations. I wish you every success. Thank you. Thank you Lucy. Welcome everybody to the MHPN Grief, Loss, Older People and Mental Health Interdisciplinary Response webinar. Thank you to the 780 participants who have joining us online tonight and also to the participants joining us later via the podcast. It's my pleasure to welcome you all to this Envy Path of this inaugural MHPN online conference, which has had about 7,000 registrations, or even 7,000 registrations of which this webinar is a part. I'd like to begin by acknowledging the traditional owners of the land in which our webinar presenters and participants are located. And I'd also like to pay my respects to elders past and present. Hi, I'm Dr. Ebony Vanzimir and I'll be facilitating some of my sessions. I am a rural general based in Cooktown in final Queensland and I have advanced skills in mental health. I work mostly at the hospital, but I work sort of between the general practice and primary care aspect of my community and also very closely with the mental health team and community services. And you know, grief and loss, particularly in older people is something that I see every day. So I'm really excited to learn from our panel today and really, you know, get a deeper understanding of what we can do to help and what the best ways forward are. So without further ado, I'd like to introduce tonight's panel. First off, we've got Rob, Dr. Rob McCabe, who is a psychiatrist based in Western New South Wales. And he's an older age psychiatrist and he has a passion, I guess, for improving the mental health of people of all ages and stages in their life. He does a lot of education and teaching as well through the university. The HETI, so Health Education and Training Institute, which is based in New South Wales, and has a number of other hats that he wears. So really excited to have you on board, Rob. How's the weather down there? It's pretty good down here. How's the doing for it all? OK, hopefully not too windy then. Pretty good. Thanks, Rob. Next, I'd like to welcome Dr. Paul, who is a psychologist based in Victoria. And he, for the past 23 years, has been really involved in grief and loss management and acts as the Director and Chief Executive Officer of the Australian Census of Grief and Bereavement. And, you know, has embedded his work life. His CV is quite impressive, embedded his work life in managing and helping and treating people with grief and loss. You know, not too far away from Rob there. How's the weather where you are? It's not too bad, actually, it's been unseasonably warm. So I'm very happy to enjoy the sunshine. Lovely, lovely. And last but not least, Dr. Kathy Andronis, who is a GP based in Inner Melbourne. Kathy has extensive experience in not only general practice, but also in family therapy and also where the number of cuts with the number of different organisations, I guess, bridging the links between general practice and psychiatry. She teaches medical students about, I guess, a patient-centered approach to consultations and patients. And she works with the Australian Psychological Medicine Society, the RSGP and Australian Colleges Psychiatrists. Welcome, Kathy. How's it, where you are in Inner City Melbourne? Same as, it is a rather beautiful day today. Lovely, lovely. Well, just in case you were wondering, it's really windy and cooked down, but a barn is 25. No quilts needed tonight. This webinar is designed as part of the content stream around grief and loss. And it's one of the three content streams that the NHPN online conference is running, the overall conference being around the theme of working better together. The two other content streams are mental health and the military experience. And trauma, the impact of adverse childhood experiences. This webinar, particularly tonight, will explore the relationships between grief, loss and mental health in older people. So to access your chat box, which is very important during the webinar, there is an open chat tab at the bottom of your screen. The chat box will open in a separate tab. Supporting resources, you can see down in the bottom corner of your screen there. It has the slideshow, the ground rules, the case vignette, and any relevant resources provided to us by our panel. And that's at the bottom of your screen on the right-hand side there. If you have any technical difficulties, you can ask the technical support frequently asked questions to help with those issues. And we really encourage you to provide feedback at the end of this session. You'll get an exit survey, which we really encourage you to complete. So you would have had access to Carmen's story and, I guess, the case vignette prior to this session and also the ground rules. But just in case you missed it, there will be a copy of the vignette in the supporting resources there. All right. So the format for the remainder of the session will be that each panelist will provide their stories. Their responses to the cases. And then we will open the floor to another general discussion between our panels. There'll be a bit of a poll where you guys as participants will have an opportunity to let us know what you'd like the panel to talk about in a little bit more further detail. And then everyone will sort of sum up. So, yeah, the learning outcomes for today are really to delve into this case and to be able to describe the complex relationship between grief and loss, mental health and aging, as well as the risk factors and warning signs for mental illness in older persons experiencing loss. Be able to describe the challenges, merits and opportunities in evidence-based approaches for a patient like Carmen and treating and supporting older people with mental health issues. And to better target referrals for older people with mental health issues as a result of gaining a better understanding of the roles that different professionals play across the different groups of persons that we're talking about in relation to older people and mental health tonight. So, as you would know, just a little bit of an overview of that common story. So, she's a 75-year-old woman and she's based in a small town in South Australia, and she lost her husband, Robert, about 10 years ago. She has noticed that she's been consistently sad over this time. She's had a huge hole in her life, but recently, with the news that her dog is unwell and may pass away, this grief is heightened, and she goes to see her GP and her GP is worried about her. So, Kathy, can I ask you to take the floor and respond to Carmen's case? Thanks, Ebony. Carmen's story is a very common story in general practice. We see people who come in for routine things all the time, like fluid injections, and we do notice what people are like. We've known them for a long time. Often, somebody like Carmen will have come over many years. We'll know quite a lot about her, so we're quite attuned to noticing small difference. She will have appeared, you know, for routine things in the past, but whenever lifestyle stresses come along, grief and losses are quite a common thing that we see. GPs are likely to see people like her over many years, and GPs like to take a bio-psychosocial approach to patients. So, by that, I mean that we will always be looking biologically and assessing her general health. I'll just get to the next slide there, yes. In the case of Carmen, we would basically think, okay, she's come into the fluid injection, but we've noticed that she's not looking well. She's looking sad. She's lost a lot of weight. She doesn't seem to be the person that we remember her. We may not have much time on that occasion to spend with her to find out what's been happening, but we will try to have a general little conversation, and our aim would probably be to see her again, to make a time to be available, because it's clear that she needs to have a few things sorted out. So, taking a bio-psychosocial approach, we'd be looking at her general health. She's obviously lost a lot of weight. We would always be looking at sort of preventative care issues with her. She's been generally well in the past, but when people have lost weight, it's quite possible that there'll be a number of causes that need to be sorted out, including cognitive decline. It's not uncommon for people to present with depression-type symptoms when they're beginning to decline cognitively. Psychologically, it seems like she's having a normal grief response, but certainly depression needs to be ruled out here, because it seems like there's been a big change from her previous functioning. And we're also thinking that because she's had a past history of having been depressed, postnatal depression, after her second and third children, it's very likely that this could be a depression scenario here, or a more complex grief, at least, because it's been quite a long time since her husband died and there's been quite a significant deterioration over the last few years. She's clearly socially isolated, so that we really need to be making an assessment about how connected she is with the people around her. The scenario paints her as being relatively isolated from her family and friends in Adelaide, but it's important to find out what she does do on a daily basis, who she sees, and to find out what else is available in the community that she might be interested in. We always have to be conscious that if we're living in a rural area, there may not be very many services, so there can be a mismatch between this idea that people in small communities all know each other and are sociable, and the reality that people still have busy lives. The ROCCP has guidelines that were updated a few years ago on aged care, but the only one that I'm aware of is called the Silver Book, the ROCCP Silver Book, and it's actually medical care of older people in residential aged care facilities. So there actually isn't particularly very much information about depression specifically for older people available for GPs. I mean, there is plenty of information about depression and mental illness, but specifically for older patients. This seems to be something that we're not quite up to date with really. In that Silver Book, there is a geriatric depression scale, so many GPs that may find that interesting to see have a look at and perhaps look at whether they need to ask more specific questions beyond a general screening test like the K10. So moving on to management, the GP would be listening to her and trying to maintain optimism, certainly giving her as much time as she needs. Social prescribing is something that is... things that GPs do when they're not reaching for the script pad for medication. And what we aim to do is to give the patient, as the client, an opportunity to think beyond medication and to think about what else do they need to do. We know that people who are isolated tend to see GPs much more. There was a study done in Queensland just in the last few years out of Brisbane, and this has been reproduced many times within general practice, that people who are older and isolated have more GP visits per annum than the general population when you match them for their age. And that's often a sign that they really don't have much to do and going to the doctor gives them an opportunity to have somebody to talk to. I mean, I sometimes see people who haven't spoken to anybody for two, three days, perhaps just to their dog or just to somebody in passing in a local shop. And GPs actually are quite important parts of the social life of some elderly people, especially if they become depressed or anxious or lonely. And GPs can offer focus psychological strategies, just like other allied health under the Better Access system. And if a GP is able to do that, particularly if they're working in a rural or isolated region, or if the patient doesn't want to access other services because they have a long relationship with the GP or they only seem to want to deal with the GP at that time, going through her grief and her isolation and using CBT, looking at her perhaps guilt issues, the fact that she's blaming herself, just talking about grief with her and certainly scheduling activities, including positive activities for her, can be a really helpful way to help her. Thank you. I don't want to interrupt you, but we are at six minutes now. Just give you 30 seconds to sum up the rest. Okay. And basically what I would be doing is making sure that she continues to have ongoing care. I would consider prescribing from the SSRI, SNRI Metazepine Group, perhaps even Melatonin to sleep. Very much would be working with the 10-care approach with her and looking at who else can be involved in her care and does she need to be assessed by a psychologist and or a psychiatrist regarding her depression. And this is just a very brief list of grief counselling. Thanks so much, Kathy. And, you know, I can feel the wealth of knowledge and experience that you have with these patients coming through in those slides. So thank you for summarising it so beautifully. Next, I'll invite Mr. Chris Paul to the stage. Thanks, Ebony. And it's great to be with you all. I just want to start, I guess, with some fundamentals on that. The grief is often defined as our emotional response to loss. And I think that's a very narrow perspective. Certainly it has a strong emotional dimension to it. Clearly, it impacts upon our physical well-being, our health, depression, the immune system. For many people, it's also a strong cognitive component that people need to wrap their head around this experience of loss. There's a strong behavioural component where we see underactivity or sort of hyperactivity and a whole range of behaviours around, particularly around avoidance. I think we often define grief in the seat very much an individual, intro-psychic experience. And it's important to recognise that, you know, it occurs in a social context. So families, communities, will are critically important. They will either enable or constrain the individual's experience of loss. And I think particularly somebody who is 10 years post-the-death of their partner, they may find that it's very difficult to access social support. And finally, I think the dimension that's often overlooked is the spiritual or philosophical, the meaning that people wrap around this loss. Why did this happen to me? How do I integrate this experience with my system's belief? And in a sense, any one of those dimensions can present more markedly than others. But I think it's important that we provide a kind of a comprehensive assessment of people's response to loss. And of course, when we're talking about grief, we can be talking about bereavement or adjusting to chronic illness, disability, relationship breakdown, et cetera. So for me, it provides unifying framework for lots of human conditions. So we know certainly that Carmen's experience is common. By 65, over half of all women will have been widowed at least once. And by 85, over 80% of all women are widowed. But I would argue that Carmen's response is, in fact, not common. I'm kind of quite concerned that 10 years after the death of her partner, she says that she yearns for Robert on a daily basis and her life feels poor with him no longer in it. And that her grief feels little different from those first weeks a month without Robert. She finds herself crying, et cetera. So again, what we often see is an acute period of grief that everybody experiences following a loss. And for most people, that will resolve over time. But there's certainly a proportion individual. And I think Carmen belongs in that group who experience a kind of a chronic and unrelenting experience of separation distress. So we've got good data in terms of who benefits from breathing intervention. And we know that for most bereaved individuals, probably around 90%, their uncomplicated grief is naturally self-limiting. But we do know from a lot of the review studies that there is a subgroup of mourners, perhaps around 9% of later speakers who are elevated risk to dysfunction and who respond well to more formal kinds of interventions. I think we can take a population, a public health model approach to bereavement care and recognize that at the bottom of this pyramid, most people with the support of family and friends, a good psychoeducation information is sufficient for most people to manage even profound and seismic experiences of loss with some resiliency. We know there's a middle group who may be at additional risk. Here we would include mothers following the death of a child, those who experience sudden, unexpected, or traumatic death. And then again, as I mentioned earlier, about 9% of bereaved individuals seem to go on and develop a more prolonged and chronic response to loss. Something derails what I would see as a very normal process of adjustment and accommodation to loss. This is often referred to as complicated grief, but more recently, following the RCD, prolonged grief disorder. And again, I want to be very careful here that we're talking about a significant minority of bereaved people here. Most people really don't require much sophisticated interventions. So we know that acute grief, the experience of loss, is virtually always painful and deeply disruptive. But we know that for a number of individuals, these symptoms persist. There's a lot of data that suggests that around six months post-death, which I know sounds terribly early, most people are talking about a kind of a qualitative and quantitative change in their experience of loss. But there is this particular group who, where these symptoms persist. And there are certain sorts of thoughtful behaviors or feelings that derail this process and gain a foothold in the mind and prevent the kind of resolution of loss. In terms of assessment, of course, we need to do a good and complete and comprehensive assessment of both the bereaved person. But also we need to know something about the person who died. What was the nature of that relationship? In the sense that we kind of need to do a kind of a psychological resuscitation of the deceased and often to bring them into the room. And what was the nature of that attachment? What was the nature of that relationship that they've lost? How people died is critically important. In this case, we've got somebody dying as a result of a cardiac arrest. Was she present at the time of death? Did she discover his body? Are there other traumatic elements as a result of the nature of his death? What was going on? We know there's a history of depression around a fatal depression. Is this different? How? What sort of strategies has she used in the past? What's the personality in terms of the style she brings to this? We know that social support is critically important. Being surrounded by people that care for us is very important. And this becomes more of a challenge the further we move away from the point of the loss. And finally, all the concurrent secondary losses that people are dealing with, all the life change events, the readjustment, the relearning of the world. So, again, I think it's good to access some good creeps and bereavement-specific tools such as social support and measures of meaning-making. So, again, we know that there are a number of good evidence-informed interventions. We can talk about some of these a little later and look forward to exploring this topic further with you in our discussion. Thank you so much, Chris. We'll have information there again. And it's good to see some literature around the evidence-based strategies for managing grief and loss. I'll hand over now to last but not least, Dr. Rod McKay to give his perspective from a psychiatrist's view. Thanks very much, Ebony. I'm very conscious that, just as we're talking, it's very likely that I'll be down the chain in actually seeing Carmen. And I think it's appropriate, but it does mean that as a psychiatrist, I think about actually how does Carmen get to me? Should she get to me? When will she get to me? And I think that's one of the challenges both in the community and particularly in the general practice surgery is how to make those decisions. And I can't help but picking up what Kathy said about the lack of information and education around working with depression and older people. That is a passion for me. And unfortunately, it is true there are limited things there. The call to psychiatrists guidelines, which now actually include lifestyle of extending the biopsychophysical approach, have got some notes that are worthwhile. But I'd have to note also that maybe partly because I'm there at Hetty, we do have some courses focusing on mental health care with older people. Back to Carmen, why will she or won't she come to see a psychiatrist? Or why won't the GP actually refer her? I think it's really important. That's going to involve actually overcoming quite complex things that happen as they meet. There's going to be stigma, there's going to be fear. There may well be avoidance from Carmen or sometimes the GP in actually moving an awareness of something isn't going right to actually having a discussion around it. And then there can be very practical things such as can Carmen afford to see a psychiatrist or a psychologist. So there's a real issue about actually getting the right information for both Carmen and the GP to be able to make a referral and then how do you get the right information to the psychiatrist. So when I see Carmen, I don't have to ask all the same questions again. I can try and probe and understand Carmen and fill in the gaps. So when should Carmen be referred? It's a really difficult question. If you refer too early, you really do risk pathologising what is a normal process. But if you wait too late, you can make it actually quite a lot more difficult for Carmen to have a common depression if depression is there. And particularly if Carmen was male, but being female is only partially protective, you also, this prolonged depression, increase that window where the risk of suicide can be increased. But I guess the key issue there is the answer is going to be individual and it's going to depend on the strengths and the views of the person and the GP. Some GPs will work with Carmen really well. Some will refer earlier. Some would like to refer earlier but haven't got options to refer to. I think what's important in all of that is that we need, as the GPs for all of us as health professionals and community, to have hopes for Carmen that she will get better. And I think some of that is missing when we're working with older people. So when Carmen comes to me, I'm going to be thinking about what's been the pathway she's got to me. How is it going to impact on how she responds to me? The referral is really important. I vividly remember an older lady, not so unlike Carmen, who for a long time just said, what have I done wrong? What have I done wrong? And it wasn't that she was depressed. It was that her perception of coming to a psychiatrist was she's done something wrong. So a key part of the start is just overcoming that. She's going to be trying to understand Carmen, trying to understand her problems, understand her, and do that biopsychosocial assessment without forgetting culture. I guess for Carmen in particular, what is the culture of actually living in a rural community with her family in a city? When I move then into thinking, actually trying to move that understanding of Carmen to a formulation of what might be happening, I'll be thinking about is it for long grief in a sense that psychological responses are most important, or is it that it's moving into something where medication might assist as well? And remembering that even though major depression continues throughout life, actually minor depression, whether it's not all the classic symptoms of major depression, can be just as disabling, increase the risk of suicide, reduce the quality of life just as much as major depression. So that sense of understanding is there an enjoyment in life that she's having? How does she see the future? Has she got a sense of meaning? Are probably just as important as actually whether she has a classic handful of major depression. What I want to understand as I'm doing that is though, are there factors that are going to guide my choice of treatment? If she has a lot of biological features, if her sleep pattern is particularly entrenched with early morning weightening, if she has constipation, I'm concerned about her weight loss if there's no physical cause, they would all indicate she's probably going to have require more assertive biological treatment than if she hasn't got those features. And then really where I'm going to from that is then to have a discussion with Carmen and normally recommendations back to her GP about what I think should be happening in terms of treatment rather than actually trying to take over treatment because really the GP has to stay at the centre of her care and the arts of the psychiatry is trying to support that and trying to empower Carmen to be involved in those discussions. Great, thanks so much Rod. And thank you so much Kathy and Chris for sharing your expertise in your different areas and giving us a really good overview of what Carmen's journey might be like as she travels along this experience of grief and loss. So I do want to open the floor now to a bit of a panel discussion and I'd like to start with you Chris. I want to give you a little bit more of an opportunity to really give us an overview of the effective treatment for complicated grief and talk to us about if a supportive psychotherapy enough. Yeah, I think there are four strong contenders around evidence-informed interventions. One would be family-focused grief therapy developed by David Cassane in Melbourne along with other colleagues which is an intervention designed generally during the palliative phase at improving family communication that draws very strongly from more family therapy approaches. The other would be the CBT approaches and many of the interventions, perhaps one of the best known ones would be complicated grief therapy that's come out of the US which is a structured and manualised intervention for people with a complicated grief. I think the bottom line is that in these instances, grief is a trauma and people avoid that trauma and so often in our work with bereavements about taking people to the most difficult part of their experience and in a sense tired-trading exposure to that particular experience. There are often particular things within CBT that we'd be focusing on such as self-blame, guilt, if only I should have. There's also another approach which is more of a meaning-making or a constructivist approach which suggests that those who struggle the most in bereavement are those who are searching for but have not yet found some meaning in this experience. This experience has kind of un-metabolised. They've found no way of re-learning the world and of operating in the world or the change in identity that often inevitably comes following bereavement. So I think we see avoidance as a very significant component within complicated grief and also a reluctance to be out in the world to engage in activities that derive pleasure. The evidence would suggest that in cases of prolonged grief disorder, supportive psychotherapy isn't enough. And again, this is where a lot of these interventions are drawing more from some of the trauma interventions and that in the same way that we know that social support generally is a powerful buffer, additional social support for people with prolonged grief disorder is not enough. The other thing that the data suggests is that these are individuals who are unlikely to spontaneously improve. These are individuals who, when you speak to them eight or ten years later, after the death, their grief still feels very raw and very fresh. And so it's really about the intensity and the duration of this distress which seems to be important. Chris, definitely much more to unpack in there. Kathy, I want to move on to you now and just talking about a little bit about accepting grief and loss as a normal part of the management and I guess the response to a death of bereavement and I guess that sense of wanting to avoid pathologizing people. Could you speak to that? Thank you, Jenny. The older people are very reluctant to be diagnosed with mental illness. I mean obviously the stigma applies to everybody but GPs are also reluctant to diagnose people especially with grief as having something more complex. It takes a long time actually to engage with patients especially if they're older and they have mental health presentations especially if they haven't had them in the past. Her postnatal depression was many, many years ago so this GP will see her as somebody who's been pretty good and they haven't noticed anything and now they've just noticed one year of her or haven't seen her for nearly a year and she's lost weight. So GPs will clearly try to think of a biological thing that needs to be ruled out first because we have to keep people safe. We will be thinking about their social isolation and grief and because we see so much grief so that pyramid that Chris talked about earlier we're seeing so much of the people at the normal end of the period down at the bottom and they really do just need somebody to talk to, somebody to put some perspective around their grief, somebody to give them a bit of a nudge and somebody to give them good preventative health strategies so that they can feel good about themselves physically and therefore able to participate in life sort of socially. We do probably, as GPs, become reluctant to talk about pathologising people, especially if they're older, but I think that's a two-way process. The patients, especially if they're older, really just don't have mental health language a lot of the time. They're used to being fairly resilient or expected to be resilient, to being self-sufficient and then not really up with as much digital sort of social media and so as things have changed for Carmen, for instance, over the years, it's likely that she's just gone underground which I think Chris mentioned as well that people with more complex grief just can appear to be well. So often people won't notice but one thing that doesn't necessarily apply to Carmen but can apply to a lot of other people in a general practice setting, we are likely to know their families and are likely to hear from another relative or family member or even a friend or neighbour that Carmen hasn't been herself usually or so it's really up to us to slowly engage with her, not to rush her. She's going to be understandably reluctant to be diagnosed, let alone to go and see somebody. So we just need to spend time to review her often. So I would say that because she's got biological things that need to be dealt with, that's a great opportunity to see her a number of times and to start off with this supportive work to build up her story. We really have very little story actually of what's been happening so we really need to slowly build that up and then work out what she thinks is happening to her, what's her understanding, how she thinks her grief is going, what thoughts she's had about could this be something else other than grief? We really slowly, slowly have to unpack this because the worst thing you can do with any patient but especially with older people is to rush, to reach for the prescription pad or to send them off to see somebody because you've decided that they've got a mental health condition but they're not convinced yet. So you really have to be very patient centred, very collaborative and go slowly. Unless of course you've got red flags or suicidal intention or something where you have to rush very quickly, it's important to go slowly and engage her. Thanks so much, Kathy. And I guess touching on and moving on to the next part of that, Ron, I wanted to bring back a point that you mentioned about that the engagement sometimes is lower and you're on the back foot sometimes because patients feel like they've done something wrong by going to a psychologist or a psychiatrist. So I want you to tell me about how we could improve, I guess, our patient's perceptions and engagements in being, you know, sent to a psychologist or psychiatrist and what your thoughts are around that. I'm probably not the best expert because I see the people who GPs are successful in getting to see me, not those who they're not successful in getting to see me. But the things I'll be thinking about, I think the first thing is actually having hope for the person and that if you maintain that sense of hope with your engagement, the person's going to pick up on their hope and they're going to trust more that you're referring because you think it's going to help them, not because you're referring because you've lost hope for them or you don't know what to do. I think that's really important because there's one study that stands in my mind from the Scandinavia about older people who died from suicide. And they mostly had told their GP and their family that they were thinking about suicide, but the families and GPs didn't think something could actually be done. So I think a key part is actually realizing that most older people aren't depressed. So if they are, something's not going right. It may not be depression as an illness, something isn't going right. And be on the front foot from the start rather than accepting it as being a normal part of aging. So I think that hope is a key starting place. The next thing is I think just try to slowly demystify what the medical professional may be. It helps if you've got a personal relationship and you can say something about the person who you're going to be referring them to as a person, as opposed to actually as a professional. And also if you can give them some sense of idea of actually what it might mean to see the person. I think one of the great fears people have, particularly older people, is that to see a mental health professional means they're at risk of actually going into hospital or being locked away. And as a younger audience that mightn't sound very likely, but it has been the experience of many older people, all those around them. I think the other thing is trying to build up a network of people who actually do work with older people. I think that may be the most challenging because unfortunately GPs and psychiatrists remain people in health professions currently who have some training how to work with older people and depression or mental illness. And I'll put grief counselling to the side there. And that's a real problem that I think systemically we have to overcome, but as an individual, I think trying to build up those referral networks is really important. Yeah, thanks Rod. And I do think I definitely agree that it's how often how you sell it. And so I wanted to bring you back into the conversation, Chris and Kathy, about giving some life on your approaches to how you introduce that idea of being referred from the GP. And Chris, how would you want the GP to explain your role in that care, for example? Yeah, I think grief is an idiosyncratic thing. And I think we need to look in terms of the support that we provide in an idiosyncratic way. So if we can provide, and again we're a state-wide specialist bereavement service, but part of our view is that we need to create safe places for people to be with others. And so we run a bereavement support group at a local pub. It's called Men at the Bar. Guys come together, they talk about their experience together. It's kind of loosely supported and facilitated by a member of staff. We've got walking groups where people walk together and talk. It's strengthened that sense of connection. Similarly for children, opportunities to meet with other children and they often say, you know, I thought I was the only one. And so I think there are a range of options. It's about supporting people to choose what works best for them, what is their safe place. And I think going back to Kathy's earlier kind of excellent point, this all happens in the context of relationships, that unless we develop strong collaborative relationships with our clients or patients, then we can have the best programs in the world. And often the difficult work needs to be done where there's an enormous amount of trust that somebody is going to be safe. So, you know, I think it's important also to recognize that a lot of good grief therapy is good grief education, to provide people with language, a way of understanding their experience, to normalize their experience. And we know that people will kind of move, they'll need different things at different times as well. So, you know, empowering people, giving them choices and ensuring that they have an awareness that this grief will wash over them from time to time. It's not about getting people to let go or this idea that the grief somehow disappears. You know, we continue to grieve a loss as we live and as we change. So I think some basic messages there about, you know, the nature of grief. You know, grief is the price we pay for love. It's unavoidable. We all experience it. But giving people as many options as possible is always great. Thanks very much, Chris. I'm going to pause the discussion there, although, you know, really great topics and vibrant discussion there. Thank you so much. To throw to our audience an open for a poll around what, you know, we've got sort of 20 minutes, half an hour left. What would you like to discuss in more detail? What would you like to hear from our panelists? So that poll is open now. The topics that we have to discuss are the prevalence and impact of ageism, something we haven't talked about yet in great detail. But what is the impact of age have on presentations with grief and loss and the care that individuals receive? What is the overlap between grief and depression around this? And, you know, so where do those thin lines meet and intersect? What is the difference between normal versus abnormal grief? And how do you define that? And how does that look over time? And then access and availability of allied health or aged care services, particularly in, I guess, regional and remote centres. But also in the city, you know, we heard from Rod before about whether you can or you can't get access to somebody who deals with older people. So I'll give you a few more seconds there just to lodge your preference in regards to topic. And then we'll open those questions up to the panel. All right. You can close the topic. Thank you. Read back. Well, we've got normal versus abnormal grief as the winner by 10. So overlap between grief and depression also very highly rated. So we might spend the rest of the discussion exploring those two topics. So I'll open to you then, Rod. Anyone in the panel, actually, about the overlap between grief and depression. If you could talk a little bit more about how you differentiate the two there. I think that... I think the difficult differentiation is the first thing. And I think there's many approaches to it. So I think in many ways, Chris will give them a better response about some of the diagnostic patterns and the changes to the ASM-5, which in some ways have blurred the differentiation between depression and grief. As a psychiatrist, I think many psychiatrists often take a more functional approach. It is matching what symptoms are there. In younger people, having a classic handful of major depressive symptoms makes it a bit easier. But older people, depression often doesn't present that way anyway. So I'm often looking for, are there some cardinal things that really make me feel the person is depressed, particularly a pervasiveness of either their mood or often in older people. It's actually their loss of enjoyment in life. And so I will try to explore that sense of can they react to things they would normally enjoy? Can they say anything they can enjoy? I sometimes try to get them to project how they see things in the future, either ask them that or ask them what colour the future is. And it's really interesting that some people actually are a little bit impaired maybe from depression and really have trouble with the question. Those who get the question and depressed often talk about black or move into a discussion about there's no hope. So I'm looking for those speeches as much as I'm looking for things like is there associated with the depression. With the depression, changes in their sleep, changes in their appetite, constipation, overall picture. And then there's a question, I think for the person, what it means and actually what options they're willing to explore. Absolutely. Chris, with how many did you have anything to add? I agree with you, Rod, about the functional changes. That's one of the things in general practice that I see a lot and it's a warning sign. People start to not cook as much. They start to dress differently. They may look a bit more unkempt. It's really common to see that people are just not taking care of themselves. They get out to the shops less. They start missing meals. I mean, this is obviously perhaps what's been happening with Carmen. She's lost 10 kilos. So looking at that functional decline in their way that they're living their everyday life, the ADL decline, that's what comes up as being a warning sign, particularly for older people. Chris, did you have anything to add there? Yeah, I think it is a challenge. And as Rod mentioned, the most recent addition of the DSM removed the bereavement exclusion, which meant that if you would bereave within a period of two months, you couldn't be given a diagnosis of major depressive disorder. Larger because there was no data to suggest that bereavement is any special kind of stressor. But we certainly know that the loss of a loved one is a major stressor. I guess there's some of the things that I've heard from clients is that those who have a history or have had depression in the past will often talk about this being different. It's been their bereavement-related depression being somewhat different. What we see in prolonged grief disorder is the sort of intense yearning and longing for the deceased. We often don't see that in major depressive disorders. We often see interest in things, particularly as they're related to the loved one. We don't necessarily see that in depression. We also see in prolonged grief disorder, positives are most often experienced alongside more negative ones. And again, in major depressive disorder, the ability to experience pleasure is compromised. I think we also see in complicated grief greater guilt around the caregiver self-blame. And finally, we would see in prolonged grief disorder the avoidance of certain places because they're reminders of the loss. Whereas I think in major depressive disorder, you generally see a general withdrawal from activities and people-people. But yes, it is a challenge. And certainly they can exist together. I mean, some suggestion about 15% of people with prolonged grief disorder would meet the criteria for a major depressive disorder in the first year. So I think we could do with better guidance around making some of those calls. Chris, the issue of dementia is one of the things of the GP that I would be really concerned about a lot. And I'm always worried about when somebody has lost a lot of weight and seems to not be taking part in life very much, are they demented? And because it's such an important thing for us not to miss, we do get caught down that track with a patient like Carmen. She's lost 10 kilograms of weight. We do have to go through all the biological things first. And that does take time. But hopefully at the same time we are talking to her about her social life and about her psychological well-being. But we really do need to be convinced that we've excluded those things before we can think about where we go to next. And it's very, very important to have her on board when you start to present that scenario to her that perhaps there isn't anything biologically wrong with her, that this is a complicated or grief or a depression process and that the treatment is going to involve very specific things that perhaps she hasn't had to deal with in the past that are very new to her. And Kathy, I think it's really important that... I think there's a different way we treat those priorities in older people than younger people. If it's a younger person and they're worried they're depressed and something's going on medically, we treat both. I think the older person... there is so much stress on identifying dementia early that we forget that actually one early dementia is often associated with depression and that they benefit from being treated. And the other thing actually is depression can mimic dementia and I think often actually treatment for depression is delayed by I think a mutual fear of the person and the GP and the family that dementia is going on and no one wants to discuss that because of the sense of what we can't do for that. Whereas a discussion around depression or the other thing which we haven't discussed is the possibility of substances, alcohol being the most common, or medication actually impacting on her. These discussions where something can be done often get delayed and I think that's one thing that really worries me that they only get a different sort of treatment and they don't get referred for treatment. If you look at the stats for referral to psychologists or psychiatrists once you're over 65 you've got much, much less chance of actually getting access to somebody for specialist treatment. Once you're over 85 it's extremely rare. Absolutely. So I had Kathy. No, one of the things that's very different about older people being referred to other people is that finances are often a major consideration. A lot of people who are older have perhaps also been used to being managed in the public system particularly if they're in the city and used to going to public outpatient departments. A lot of those have really decreased their funding for psychological services with older people. You really have to be really unwell now to be managed publicly with a mental illness. And the financial consideration for profit practitioners is a really major issue for older people and I don't know what it's like where people may be listening to this evening but in Melbourne there are not many people who will both build who are psychologists or psychiatrists and it's a big disincentive for people to want to go. I think it's important though that actually I think whatever their name may be in the different states actually the specialist mental health services for older people in the different states I think R&M Tap Resource, but I know New South Wales they're actually under referred to and people they're looking more at complexity than absolute severity for the referrals. So I actually think one of the options for Carmen at least in getting advice and then possibly ongoing treatment in much of Australia actually would be that specialist service and as I said mostly they're actually underutilised. I think it depends very much on where you are really. In Melbourne I've had times when I've had months before I could get somebody assessed in the public system and there is a lot more emphasis now with the changes to the aged care assessment to do biological assessments of people and to look at what sort of financial or home health support can be offered to them as part of a plan. So it has veered away from mental health in some of the ways that a lot of GPs see older people today. I think it does vary a lot from state to state but I think it's worthwhile people knowing it is important that the ACATs have changed quite markedly and they're really not a source of help in terms of assessment for depression in the way they used to be. If you're going to go public you really do need to find your networks into the mental health type services rather than the aged care is the reality for most people. Chris, did you have anything else to add to that discussion? Well, I guess, again, I'm a Victoria and Operator Services funded by the Department of Health. We see over a thousand very people a year and all our clinical services are free. And so Victoria is in a very fortunate position and increasingly we're actually seeing many older people using telehealth and it's really quite surprised just the number of people that are willing to kind of use an iPad or a computer to connect with a counselor. It certainly is very difficult to access more specialist services more generally. I mean, we have a 1-800 number and can refer people to practitioners and programs and services that we're aware of in other states. But, you know, availability is one thing. Actually getting people to engage with services is another challenge and I think particularly with very complex experiences and particularly where there's a high level of distress and arousal and avoidance, it's not always easy for people to navigate the service system and to find the supports that they want. And again, we'll often work with other professionals whether they're psychiatrists or drug and alcohol counselors because people don't come with this one, you know, neatly package for recent experience. It happens in the context of, you know, their complex lives. Yeah, thank you. And I guess, I mean, I can't resist putting my two cents worth in. In final Queensland, we have a visiting psychiatry service that visits from a bigger centre about four and a half hours away. And it's not an older age psychiatrist, although there is a service in that area that we can, the psychiatry, the general psychiatrist can end through phone consults with. But there just isn't anything like that around. And if it's going to be a service that we refer a patient through, it's got to be telehealth usually. And then there's that technology barrier often. And so I guess I'd be interested in hearing from the panel suggestions for clinicians out there that are trying to provide this care as best they can to their patients. How could they upskill? Where could they go? How could they find the people around that they can build their networks? Certainly from the Greek environment perspective, this is one of the data that people are generally relying on quite old models, whether it's Kubler-Osses 1969 five stages of grief. And the field moved on a great deal. So again, there's some good resources out there. Grief counseling and grief therapy is probably one of the most popular books by William Warden that goes into, is a great synthesiser of the research. And provides a good therapeutic framework for supporting people with complex and also more kind of acute experiences. Certainly our website has lots of resources for both the general public and practitioners. So that's grief.all.au. And suddenly we've got a national toll free number as well. So there is a lot of material out there. I think it's really important that if we're talking about assessing depression that we also look at some of the very good tools out there for assessing complicated grief and getting an idea of the level of distress and difficulty. But I appreciate people are time poor. But I think there are some really good readily accessible frameworks that can help people perhaps develop a more nuanced understanding of the brief client. One point about how to get more people to access some services despite their reluctance. I've already alluded to the bulk billing issue and sort of the cost issue. It really is quite an impediment for a lot of older people. The majority of people who are aged are pensioners and don't really have a lot of money to spare. So I think that any allied health person who wanted to see more older people would have to be a bit more flexible about some fees. That's one point. And my second point is that older people often like to do things in groups because in this situation she may want a social setting. There's a program that I'm aware of in my local community for people who have osteoarthritis of the hips and knees. And they've been referred to a very simple group session, physiotherapy session. And they do very, very simple exercises. But in reality what, and the pain improves dramatically even though they're doing very little exercise. But what's actually the difference is that they're connected to other people and they suddenly develop something to look forward to. And they develop a community spirit around it. So that sort of makes me think that any group sessions that a psychologist or another allied health provider might want to provide around groups might be something that an older person might be interested in attending. They might be a bit concerned about speaking to a stranger one-on-one. But that's another way to try to get people to think about going to see somebody else. And what I would add is that there are some resources you can access through Google. You can be very careful in terms of actually their origins. But there are some things put out by the professional colleges and psychiatry in Canada and UK as well as Australia that have got some useful resources. And I can't help but plug it really is a gap in terms of access to courses and in healthy with a higher education to both non-medical and medical people. It's a gap that we're really trying to fill with our distance courses. So there are some sources of either professional development or higher education if people want to go that little bit further in working with other people. Because unfortunately the reality is we do have very low levels of specialist training and small changes in practice can make a massive difference to the engagement or avoiding problems to the person and then actually see them get better. So I'd encourage everyone to have that hope and see that working with other people can be really just so rewarding and just a little bit of extra knowledge can make all the difference. Great. Thank you, Ross and Kathy and Chris. That was a really engaging discussion and I learned a lot. So I'm going to give you the opportunity now just to have two minutes to really sum up I guess your thoughts from tonight and if you had anything else to add. I'll throw to you first, Kathy. My main thought really is to go slowly to expect that we do have a problem with managing older people. They often have so many other problems in their lives usually biologically and they are not used to the counseling process. They're used to being more self-reliant and that we have to think a little bit more laterally about how we engage them and that we go slowly and always put it in a supportive framework and also always present to them the possibility that this is just something they can try. They have control. We need to maintain their autonomy and involve them in their management so that we're not really treating them as somebody who's dependent. In my experience older people want to stay as independent as possible for as long as possible. Great. Thank you, Kathy. Over to you, Chris. I think it's really important. We do have a non-pathological view that grief is the price we pay for love. It's unavoidable that we don't undermine people's resiliency and their own capacity to respond to loss with their own resources. I think it's also important that we recognize that there is a significant minority of individuals where their grief does not resolve. It still feels very fresh and raw. We should work with individuals we should work with in terms of exploring the nature of their story. The thing about a case study is such a teaser, really, because there's so much detail and context that we're missing. We're also seeing Kathy who's going to be experiencing another loss with the death of her animal, which may in itself be a connection to previous losses. So I think it's really important to take kind of a rich history and, of course, change only happens in the context of a supportive collaborative relationship. Absolutely. Thank you, Chris. And last but not least, Rod. I think older people are great to work with. They have so much richness and we have to draw out that richness. We mustn't jump into early. We do know that older people receive too much medication and too much psychotropic medication, but they actually respond just as well as younger people to talking therapy and medication therapy, whether it's grief or depression, as long as you do it well. And we need to maintain hope for the older person. Young, old age, mentally, is the healthiest time of our life. Older, old age is still a healthy time, but people are vulnerable. So I would agree with Kathy, go slow, but go and hold that hope for the person. Great. Thank you. Thanks, Kathy. Thanks, Chris. Thanks, Rod. So I think you'll agree, you know, tonight's been a fantastic discussion around the very, you know, essence of complexity around managing older persons with grief and loss. And the things that come through to me is really that hope for the patient. Getting a really broad and holistic understanding of them as an individual and their context, and applying that to the kind of treatment that's going to work for them. You know, it's about aligning goals and really tuning in to that person's level. Some of the things that we talked about as well is that there's this, you know, emerging evidence space that can update and inform our practice around managing grief and loss for older people, but grief and loss more broadly that some of us will be interested in learning more about, and there's some resources, you know, attached to this webinar, which you can look at later and further yourself. And just a real sense of, you know, you can do this, and it's a really exciting and lovely space to work in, and you can make a real difference to people's lives, you know, now and into the future. So thank you again for joining us tonight. The next webinar stream in this, next webinar content in this stream is entitled Disenfranchised Griefs Exploring the Impact of Infertility on Mental Health, and it'll be broadcast as part of the MHPN conference inaugural online conference Working Better Together on Wednesday the 5th of June, so I invite you to come along to that. There's also a range of activities in the next two weeks, continuing exploration of grief and loss and mental health. Visit the MHPN website at MHPN conference to all get AU to learn more, and I'd just like to thank Redback Contency for hosting us tonight on their webinar platform. Just reminding you again that all of the supporting documents provided by your panelists are available down in that corner box there on your platform in the resource library tab at the bottom right-hand corner of the screen. You will get a certificate of attendance within about six weeks from tonight for those who attended the live activity, and we encourage all participants on exiting to fill out the exit survey. Thanks everyone, and good night.