 MHDM would like to acknowledge the traditional custodians of the land, the land season waterways across Australia, upon which our webinar presenters and participants are located. We wish to pay our respects to the elders past, present and future for the memories, the traditions, the cultures and the hopes of Aboriginal and Torres Strait Islander Australians. So I'm Nicola Palfrey and I'm clinical psychologist and I'm your host for this evening. We have an exciting panel for you, it should be very interesting and introduce a whole lot of topics that are new to you and also some really interesting conversations. So we've sent through the panellists bios before tonight, so we won't necessarily go through them again because we want to have enough time to get through their content and also to answer questions that come through for you tonight. So first of all, I'd like to introduce Dr Helen Stanley and ask her an introductory question for this evening. So Helen, welcome to the webinar. Nice to see you this evening. I wanted to start, Helen, you're a GP in a rural area. And I was wondering if you think that it could be more difficult to address the prevention of heart disease for people living with mental illness in rural areas? Thank you, Nicola. In my opinion, it can be more difficult to prevent heart disease for people living in rural areas because rural areas have a much higher rate of heart disease to start off with. And also we lack some members of the team. We have a shortage of health professionals as well and we're also going through a drought at the moment. So we've also got a lot of people who are facing not only geographical barriers but also financial barriers in rural Australia as well. Thank you. Thanks, Helen. And I've just been told we have 483 people online right now. So welcome, everybody. That's a very exciting turnout. Next, I'd like to introduce Dr Phillip Pully, a psychologist in South Australia, and Phil, we've been chatting about some of the research that you've been doing in Europe. And I was wondering if you did notice any differences in the area of prevention for people living with mental illness and heart disease in Europe compared to in Australia? Yeah, hi, Nicola. Thanks. I think for primary prevention, there's good guidelines in place. And assuming people were adhering to them, that the cardio-metabolic monitoring in bipolar is pretty consistent. However, I think there are differences in secondary prevention. Certain jurisdictions such as Germany are better equipped to deal with mental health in people with established heart disease, such as having a heart attack or heart failure. So I think the main difference is in secondary prevention. OK, great. Thank you, Phil. And finally, but certainly not least, we have Associate Professor David Culhoun joining us from Queensland, who's a cardiologist. Now, David, my question to you is you recently presented at the Australian Atherosclerosis. I hope I got back for exercise at your clinical meeting. And you were talking about the predimed diet. Could you just give us a brief intro to what the predimed diet is, please? Yes, the predimed diet is a diet based on the classic Mediterranean diet, as well as Gryphonon and Chuvain's diet. It's a diet that's a key element of belief of the Mediterranean region. It was comparing low fat diets, a classic boring low fat diet, to a diet enriched with extra virgin olive oil, or nut. And what we found in the 7,000 asymptomatic high risk elderly individuals within four years, 30% lower risk of heart attack and stroke. But more of interest, really, to I think this audience tonight, that we saw regression of diabetes with high nut intake, only 30 grams a day, actually, not very much, and 30 mils of olive oil, regression of diabetes, less new diabetes, but also, at baseline, better cognitive function if you had a Mediterranean type diet, and less onset of new depression. So a Mediterranean diet rich in all these incredible polyphenols does help the mind both cognition and mood, as well as prevent heart attacks and strokes. Unbelievably, almost too good to be believed, but the science fits in with the population study. So four and a half years, slight modification of diet, and we've got the realms of less heart attacks, less strokes, improved cognition, and less depression. So it's almost too good to be true, and better than any of the drugs that are around, actually. That's great. Thank you, Dave. So we keep eating our nuts and some delicious Mediterranean food and we'll all be okay. That's nice to hear. Okay, so just back to me for a little bit of housekeeping, not too much, because we want to get into it tonight. There's some ground rules that are up on your screen now. I'm sure everybody is aware of them, abiding by respectful conversations. The difference of opinion is really helpful, but obviously keep it constructive. We also have a chat box that a panelist, sorry, participants can use to chat amongst each other, which can be really helpful as the webinar is going on. We also have a questions tab for people who are joining us as they have questions that we can... I'll be looking at and collating to take to the panel later on in the webinar, which is always an interesting part to get some feedback from those of you that are joining us tonight. If you have any technical support questions, there's an FAQ tab at the top of your screen. And if you require support, there is a red-back number there that you can contact. So hopefully we might need any of that. If there's a major issue, we'll let you know, but let's not tinker ourselves and get going. So what are we going to do tonight? We're going to go through... Each of the panelists is going to present briefly for about the case study that you all read about Michael from their perspective as a practitioner. And then we're going to move through to some questions, as I said, and we'll bring it all together with some summaries at the end. So in terms of our learning outcomes for this evening, so hopefully by the end of the next hour or so, the webinar participants will be able to have an understanding and describe the complex bi-directional relationship between heart disease and mental health, as well as the risk factors for and warning signs of heart disease in persons with psychiatric illness, be able to describe the challenges, merits and opportunities and evidence-based approaches that are deemed most effective in treating and supporting people with heart disease related to mental health issues, and also a better target referral for people experiencing mental health issues who are at risk of heart disease as a result of improved understanding of the role of different disciplines. So let's hope at the end of tonight we all have achieved those. So now I'm going to pass over to Helen and let her take the stage. So thank you, Helen. Thank you, Nicola. I think the case of Michael is very similar to many of my patients I look after in general practice. I think, you know, he sounds very familiar. Now, when I look at through the vignette, there's some very encouraging features about Michael. I think it's great that he's employed part-time in a job that's physically active, stacking shell. He's also connected to his sister, who's providing stable housing, and he's also been stable for 10 years and hasn't been hospitalized for 10 years. And he's got an ongoing relationship with his GP and psychiatrist. However, as a GP, I'm very concerned about his cardiovascular risk. Using the calculator, it's come out at 24%, i.e. Michael's got a one in four chance of a cardiovascular event in the next five years. And this event could be sudden, could be sudden death. And as a GP, I'd be very keen to do the new Medicare heart health check on Michael, which is a 699. And this would enable me to calculate his risk and also do some lifestyle counseling. This can be done once a year. However, I'd like to do a whole lot more. Now, I would, I guess I'd like to do a whole lot more with Michael. I'd particularly like to improve his lifestyle and build a long-term therapeutic relationship with him. I'd be really keen for him to quit smoking. I'd be encouraging him to reshape his body by eating less energy, i.e. less sugar, less fat and less alcohol, and encouraging him to be more active and sit less and have more movement. And 30 minutes of exercise, five days per week. I'd also be getting in to drink more water and to, of course, avoid salt. And I'd be wanting him to eat more fruition vegetables and more nuts, as David has described already, and fish and olive oil and all the much better diet. I'd also be keen to treat his risk factors and I'd be considering medication for his cholesterol, his hypertension, his diabetes and also for his quitting smoking, if he was indicated. Fortunately, I don't have to do this all by myself. I'm lucky that there is a team approach. I'd be, first of all, really keen to talk to his psychiatrist because I'd be really wanting to tell him about the 24% cardiovascular risk and his metabolic syndrome, his nearly diagnosed diabetes. And I'd be hoping that he might agree to stop the elanthropine or to use something else that was less metabolically harmful. I'd be also keen to work with his psychologist because I'd be wanting Michael to have any possible, all the possible non-drug mood stabilising interventions that we could do. I'd be particularly thinking here about the sleep-bake cycle because he's obviously been using the elanthropine to help with his sleep and we're going to have to have other strategies here when the elanthropine is stopped, if it's stopped. I'd also be keen for him to do some activity activation and get Michael more active and also to explore with Michael what makes life meaningful for him and what are Michael's values. Now, because Michael has diabetes, he's also eligible for a chronic disease management plan that I could do as a GP. And once that's done, he would be entitled to five Medicare-funded sessions in a 12-month period. I'd be very keen to use three of those with the excellent diabetic educator who I work with who was really able to get alongside people and help them with their lifestyle changes. I'd also be keen for him to see the pediatricist to check that he hasn't got any foot complications. However, it's also important to remember that in a newly diagnosed diabetic that we really must check their eyes because diabetes is a leading cause of blindness and also their kidneys as well. And I'd also be hoping that at our local hospital, I might be able to get him into a healthy lifestyle group or an exercise physiologist or something like that as well. I think the key thing would be to go slide with him and to refer where Michael was interested. Now, getting on to Michael's agenda, this may be entirely different to my agenda. And I think this is where the art of general practice is to work out how you move on from two very different agendas. I'd be really keen to explore with Michael what does a rich full-life look like for Michael? What does he value? Well, reading the vignette, it looks like he might value working, he might value his family, obviously his cars, maybe racing cars, maybe repairing cars. Certainly watching might as well be something he cares about. I'd also be keen to know how does he view his smoking and I'd be keen to sort of assess whether he was ready to quit or not. But I'd be really wanting to work with Michael. And it would be a key thing would be to go on this lifestyle journey with Michael. We don't really have to... We can't fix it all in one consultation. This is clearly going to be worked out over months. And I'd like to view... I like the acceptance and commitment therapy view that Michael is stuck. He's not diseased. He's not broken. And he can become unstuck and lead a rich and meaningful life. I'd also like to look at Michael as potential. He could go to school. He could go back to school. He could study. He could get involved with his local Maori museum. And the other great thing about Michael is his cardiovascular risk can be reduced. For example, if he quit smoking, it would be halved. And I think as a GP, it's also really important to reinforce his healthy behaviour and not reinforce his unhealthy behaviour. For example, I'd be really keen to praise him for being reactive and I'd be really keen to avoid prescribing sedatives to him so that he...that would just allow him to avoid life more and be more of a couch potato. I think Michael's also the sort of person who might not learn so well with just being talked at. And I think it'd be good to try and create some experiences within the consultation room that he can learn from. For example, I would like to get both of us to stand up and walk on the spot in the consultation to indicate to Michael that sitting is harmful and standing is better and just being a little bit active is helpful. And I'd be trying to get him to work out where he could do that at home. And I'll be hoping that he might come up with it while he's watching his motorsport thought he could be standing up and maybe walking. I'd also be keen to introduce the concepts of mindfulness to him and actually creates some experiences within. Now, but I'd be so pleased that I could work with the team but I'd still be wanting to regularly review him for long-term management. I think the most important thing would be to also be very non-judgmental about Michael, accepting Michael as he is and encouraging him in these lifestyle changes. And I would enjoy working with him. Thank you. That's wonderful. Thank you, Helen. That's that notion of the journey that you're going on together and that you're kind of partnering with Michael and working with him to help him move forward. I think that's fantastic. So now we're going to take you over to Phil to get the psychologist perspective. So I'll leave it to you, Phil. Thank you. Thank you. So I'll start my section out. Whenever it is. There you go. So by acknowledging that myself a psychologist along with other allied health professionals out there listening that we're not medically trained but it is important to see Michael's face from that medical perspective and one of heart disease prevention. As this study points out, Michael is doing relatively well from his psychiatrist report and this is evidence by not having any acute delfarm attempts for manic episodes in the past 10 years and he's able to work part-time. So clearly Michael's cardiovascular risk is the main priority here. Although, of course, there will be permanent aspects of his psychological functioning that will come into play when we're trying to engage him in some behaviour change or change to his daily routines. So being a non-medical professional, I mean, information I would want to gather. Having with the psychiatrist he is, of course, taking a combination of Vowper-8 and Olan-Syntone and we know that Olan-Syntone is associated with weight gain and diabetes risk and I want to clarify whether this augmentation strategy will remain in place in light of the recent weight gain and HVA1c and if a potential medication change was already flagged by Helen the GPs and so it's important to know as a change on which medication could be associated with an increase in delfarm, diabetes, mania and depression. So considering the possible medication changes I'd want to know from the psychiatrist whether and what early monitoring of warning signs is in place and work with the psychiatrist about their consistency in risk factor monitoring and of sleep and activity symptoms and moods and mania for mania prevention. And also in saying this keep in mind that a medication switch it might not be an ideal time point to engage in psychotherapy with Michael and it might be best to wait until the regimen is stabilised. Now to the GP they out on the real world assuming Helen isn't just simply an online chat away. I'd want to know from her it seems that some of his risk factors are quite urgent and might require some treatment but I'd want to get a sense from the GP if this is being approached through having an anti-hypotensia the statin, the cholesterol and insulin for diabetes and I'd want to know if there's going to be lifestyle medications in place to go alongside those medications and importantly whether Michael's actually supported to do those lifestyle changes. So some conditions like diabetes typically have a chronic care team associated with it to help people manage and so this along with the other risk factors might be feeling a bit overwhelmed here having so many risk factors and having to make multiple lifestyle changes so I could work with the GP to help support any of Michael's emotional needs and his time of change and risk factor management. Otherwise the GP suggested modelling some physical activity behaviours and it would be important to assist the GP to provide some structure in Michael's life for him to implement those and sustain behavioural change such as physical activity and now to the cardiologist what I'd want to know were there several aspects of his cardiac functioning that could be important whether he has a degree of atherosclerosis cardiomyopathy the results of his echocardiography or ECG but another piece of the puzzle that would be important is to get a sense of the likelihood that Michael will be experiencing somatic symptoms that could actually be part of cardiovascular disease and not to do with depression and examples of where those symptoms overlap could be feeling easily fatigued feeling flat, having inertia and low energy and it's important to emphasise here that we don't want to pathologise those symptoms that might be experienced as part of the chronic disease so gathering this information would get a sense of the severity of cardiac risk and how urgent respect to reduction is and again Michael I suspect will be feeling quite overwhelmed with this and about hearing his chances of developing heart disease or stroke and he might need some emotional support and working on some basic coping strategies so why am I telling you all this well there's a very good reason that I want to create links to explain getting that range of information from the different clinicians and people responsible for Michael's care and that's because one of the best approaches to severe mental illness co-morbid with chronic physical conditions such as cardiovascular disease or diabetes is a collaborative care approach it goes by other names such as integrated care or collaborative care now it's important to understand that historically the treatment of mental health and chronic disease such as cardiovascular disease was often quite independent of each other but this neglects the complexity of both mental health and cardiovascular risk and the needs and the importance of how those risk factors are controlled together and their management so what we're seeing in practice and certainly in literature support that is a shift away from this unitary approach of doing CBT on its own in favour of a more coordinated approach between different stakeholders involved in mental and physical healthcare then my experience with cardiologists has shown that they're more than happy to receive letters and updates about their patients mental health treatment so I encourage listeners out there to continually communicate with GP psychiatrists but also cardiologists because some of the work that's done in psychotherapy can help with chronic disease management now on to the first consultation and what we'd want to know from Mike or Welp I think the questioning and structure would be very similar to what clinicians looking in do in their normal daily practice however one unique aspect that I'd want to ask questions about is what Michael thinks about cardiovascular disease and its risk factors it's especially important here to explore Michael's understanding and insight of his cardiovascular disease risk going forward in future sessions it will be important to get a sense and his preparedness to change in terms of lifestyle risk factors I'd be asking some pretty basic questions as you would in bipolar about his mood as I mentioned he might be overwhelmed emotionally and it's prudent to get a sense of how he's coping and what strategies he has in place Other standard aspects related to bipolar should be covered such as irritability and also as I mentioned before our early warning signs and mania prevention is in place it's important to consider what is remembered from his time being treated by a psychiatrist over 10 years as always with patients with such severe mental illness consider under reporting of alcohol substance use so importantly I think it's working on some agreed upon treatment goals in Michael's case his cardiovascular behaviors and risk seem to be more important than his psychiatric needs so the diagram is slightly tilted towards cardiovascular risk that's on screen now and for Michael's perspective he might find it unusual to see a psychologist about his physical health so it would be important to be putting that in context for him about why it's important to get both aspects of his life in order and to ensure that Michael is likely to come back to the next session and move in with something tangible feeling hopeful motivated whether that's leaving with a clear homework task it could be a refresher task on warning signs and relapse prevention mania monitoring a review of his mood strategies if the first session is going particularly well might include listening pros and cons of some of his behaviors that have adverse health consequences such as his alcohol intake I've put this next slide in it's really about evidence based approaches and the listeners might feel reassured that a broader approach could be taken for Michael depending on whether you have alliances with certain strategies or you prefer one over the other this is good news out there for the listeners I must point out amongst all those on screen so we have CBT integrated Cogniz interpersonal therapy family focus social rhythm CBT and mindfulness with the latter there's generally only evidence for people that use thymic that is not in a sense of the state of mania when entering therapy so there's merits for all of those aforementioned approaches and I just re-emphasize here that please ensure sleep activity, self harm suicide risk in the early morning monitoring is in place regardless of what approach is taken now the next slide I've got two potential directions based on interpersonal and social rhythm therapy as well as CBT so the interpersonal and social rhythm therapy approach might take the angle of Michael's current transitions and adjustment to having a chronic disease the social rhythm aspect of this approach it would be important to implement routine and structure in his daily life concerning his social life work exercise and sleep and continued monitoring of all these aspects motivational interviewing is wedged in between the two approaches and I believe it could be drawn upon in both and a motivational interviewing approach might be assessing his preparedness for change and identifying any barriers to behavior change that are in his current life promote self efficacy for him to implement any change and maintain adherence such as to exercise the fire and general disease self management now for the CBT approach which again could include motivational interviewing I would suspect Michael would need assistance with his distress tolerant and adjustment his prime major depressive episodes raised some questions about what basic coping strategies he has in place and a related point to adjustment in general with the cardiovascular patients I work with is on disease related cognition it's important to work with reappraisals of these and what can be overly pessimistic and sometimes overly optimistic and just finally I'll put some potential barriers on screen and the first one is that progress can be slow and that's okay there's certain aspects inherent to bipolar that could be potential barriers such as increase in goal focused activity and this could include any homework it's important to note that he has a history of non adherence and that will be important because his non adherence in the past has resulted in hospitalizations so that needs to be there in mind and we wouldn't want to give him the impression his new medications are the sole reason for his cardiovascular risk and I'll finish up there and hand it back to Nicola Thank you Phil, that was fantastic I think it's really helpful for people to see both ends of the spectrum that specialise knowledge on knowing what to ask the other specialised members of the care team as a psychologist need to be aware of but also coming back with Risha and Camille to think that actually when you're working with someone like Michael that knowledge around CBT or motivational interviewing is actually what we would go to with Sykes as well so that was really helpful, thank you we've had a couple of questions this quickly around our Michael that we're talking about and as with type 2 diabetes so just to clarify that for our audience I'm sorry that we hadn't made that clear we've almost got 600 online which is fantastic so I hope you're all sticking with us and now I'm excited to take us through to our cardiologist so over to you David Well thank you, thank you Nicola and thank you Helen and Phil as Helen said this is this only 46 is the ticking time bomb and Helen estimates his risk of a cardiovascular that's heart attack stroke or just simply not waking up in the morning is around 24% it would be at least 24% and no wonder Phil said I'm tilting towards cardiovascular risk as his major problem now it's fortunate that I'm a cardiologist and we have so many tools in our kit these days to dramatically decrease his risk of cardiovascular disease with lifestyle measures proven to work with drugs proven to work which does not upset his mental illness in fact we've got a lot to do heart wise to keep him on mother earth and make him feel better let's look at this chappy 46 I'm morbidities associated with severe mental illness whether it is from severe depression schizophrenia post-traumatic stress disorder isolation as a heart foundation I've been lucky to be part of a number of groups where we've looked at this in cardiovascular risk and in Australia we lead the world we lead the world in our recommendations for screening and treating from the cardiology point of view we are way in front of the Europeans way in front of Americans and we were 10 years ahead of the American Heart Association this chappy his risk is heart attack stroke and sudden death about a third of third of third by definition one in four chance and the least of dropping dead or having a stroke or heart attack and it is largely preventable his risk I've got down here is greater than the 74 year old well there's 130 risk factors that impinge on your heart arteries to cause atherosclerosis right the social factors are as important as the classic biological factors now the next slide the next slide please yeah if we look at the Australian recalculator it is based on data from North America and then truncated over five years we've got here 21% well on 24% doesn't matter a one in four chance at least of a heart attack stroke or sudden cardiac death this is an immediate problem or from the cardiac point of view which will lead to catastrophe and worsening mental illness next slide we'll look at another way and we go to the Australian recalculator by the way everyone can go to the Heart Foundation's website and look at the papers we have generated about treating depression and psych and social factors looking at heart age which is very powerful and extremely popular you can say to this chap you might be 46 but you your heart age your biological age is 67 look upon it that way but we can make you a 46 year old again we can make you even less than that by a few simple things in your lifestyle a few simple medications next slide this is some of the expected benefit from treatment we've got from the top channel there for every 1 millimole reduction of LDL and these days your doctor doesn't have to be a cardiologist is not trying unless they get 2 millimole reduction so just simply lowering the LDL in this chap decreases risk easily by 50% 24% 12% really simple with medication in more than 95% of people does not cause any symptoms whatsoever so you can have one tablet, two drugs and you can get there blood pressure or 10 millimetres of mercury systolic another 10% reduction of cardiovascular disease diet I've already mentioned the Mediterranean diet 30g of nuts you know when you're in the hotel you've got that little packet that's 50 30g of nuts or actually 30ml of extra virgin olive oil it can independently decrease the risk of heart disease it makes your cellar taste better and what a good snack to have with your glass of wine which is also part of the Mediterranean diet you can decrease the risk easily going for a walk most days really simple for people with mild to moderate depression going for a walk half an hour most days is as good sorry Phil cosy behavioural therapy and as good as your search links the most commonly used drugs and together they're addictive go for a walk decreases risk of heart attack and improves flow of mood for diabetes we now have at last a medication which has taken diabetes 4 since 1922 an STLT inhibitor great loss unfortunately does not have a very poor track record of decreasing cardiovascular event healthy ministers may focus on it your dolly your woman's weekly but that's not side unfortunately it's not useful and people fail losing weight and they get more depressed than anxious let's focus on these things that work next slide we'll move to the next slide on the classic risk calculator and remember everyone can go for half an hour everyone can download it please do it so just a few simple measures we can easily drop his risk dramatically and as Helen said stop smoking it's easier said than done but if you can do that fantastic next slide now these are basic investigations obviously examination history that sounds basic but many doctors don't bother taking a history of patients because it's so poorly paid general practice let me tell you in the United Kingdom particularly and we looked at the English in the past we have it's very rare for patients to have a stethoscope put on their chest ECG very important these are the important standard blood tests people with low mood look at the thyroid, look at the B12 look at the iron this is one of the great sleepers low total body iron a ferritin less than 100 a major role in poor cognitive function and low mood or depression and 60% when you fix patients up with the iron infusion feel dramatically better within a couple of days the advanced imaging which is now part and parcel of really knowing where the patient has got a high risk cardiac health insurance for an x-ray it's a CT scan and what we know with this it's cost about only cost about $150 50% of people have higher risk or lower risk so here we have in the heart failure position statement depression, major risk factors social isolation no question about independence and it's similar to conventional risk factors and after you've had your first heart attack as well as your second next one next slide, that'll be good next one and there we have a number of other so it's not just depression and recently two years ago Ralph Stuart from New Deal and I published a persistent perceived stress in our Australian Olympic style doubling the risk of mortality over 12 years independent of anything else so if someone feels just stressed on multiple occasions and feels this is bad for the heart they're absolutely correct, next slide next one, yes here we go so heart foundation recommendations for treatment of depression exercise most days as we said cognitive behavioural therapy, other therapy many of our patients have complementary therapies where there is some data that the only thing that he answers is the fish oil the St. John's Wart and Sammy can be affected, there's some data of that but many of our patients take it and the drugs for that we believe has got the safest tracker authority, sertraline loxacine, that's the doctor here but avoid trifocates there's evidence that that increases the risk of cardiomyopathy and sudden cardiac death I think we're probably just about to the end that's from the cardiologist point of view and is that the next one now or we're done for the moment we are, thank you Fantastic David, thank you so much thank you for reminding me of Dolly I haven't heard about thought about that magazine for a long time I feel like reading Dolly with a Mars bar but maybe I should have been having a Mediterranean salad with olive oil instead and I'd be better off I want to thank all the panellists so far that was a fascinating and really lively discussion from all of your perspectives and I think the audience will really benefit from getting that triangulation of the views but lots of consistency as well so now we move into the interesting part where we get the audience's questions answered hopefully we get the questions coming through from the audience, we also have some too that were sent through before the webinar from the audience so if it's okay with you Helen I might start with you with a question yes we haven't got a psychiatrist on the panel this evening we would obviously all of you have mentioned them and the care team however so I was wondering if you could speak a little bit what a psychiatrist role could be in terms of assisting with prevention of cardiovascular heart disease and working with someone like Michael well I think his psychiatrist could be really useful by reviewing the medication that he's on, he's on Alansapine and also Valparate, both of these are known to cause weight gain and Alansapine is the second worst drug for causing metabolic syndrome in all the antipsychotics Closiphon is the only thing that's worse so I mean I'd be really keen for this psychiatrist to really review his medications okay fantastic I was got a question maybe for Phil if you're ready for me to throw to you this is one from the audience but not necessarily one we've talked about before but I was wondering if you could give some tips on the best way to set up the collaborative approach that you spoke about with other health professionals and how that can be maintained in an ongoing way yeah excellent question I think people out there working in community mental health would certainly be working within a collaborative system already but those in private practice might not have such a luxury and I feel like perhaps writing letters with just some of that information that's required some questions to the GP psychiatrist and cardiologist is a good starting point and you might be surprised how engaged the different stakeholders or clinicians are in the patient's welfare so just I think getting that response and really an update of where a patient is at from the different clinicians is a really good starting point you might become more familiar with certain clinicians over time if you're receiving referrals from a certain GP clinic or certainly in the past I've had the luxury of working closely with certain cardiologists across a number of different hospitals which help get cardiologists on board if they're part of the process of identifying patients that need care but generally just an open communication I would think is the best starting point and it might not always work but see what you get back fantastic thank you Phil I think that's a really important message I think in psychology land we're used to sending letters back and forth perhaps in just more of an operational way but really kind of bringing in that collaborative team I think when people are aware that you're keen to do that that can have great results for the clients that we're working with so that's fantastic now audience members if you've got any other questions please feel free to send them through to us we'd love to answer them as we go through we've still got a bit of time which is fantastic to answer your questions but while we're waiting for some more questions to come through I've got one here for you David if you're up for it which I'm sure you are we've talked a lot about drugs and medication this evening and that the benefits and otherwise of different medications for someone like Michael I was wondering do any cardiovascular drugs have side effects on mental health conditions and vice versa do cardiovascular drugs have effects on mood symptoms yeah well there's been a lot of confusion over the years partly because of the internet and Dr Google the science is this beta blockers can give some symptoms which can be confused beta blockers are very common drugs we use to slow the heart rate down to post heart attacks beta blockers however can make people feel a bit tired can influence dreams but they do not cause depression drugs that we use do they cause depression or anxiety the longer the shorter it is no they don't statins the most effective drugs ever in the history of medicine people attribute it's about 20% attribute some of their funny side effects and fatigue and low mood true statins but when we truly give blind testing we don't know whether they're on it or not it's less than 5% does not cause mood changes and more importantly it's minor aches and pains what we do know is and we did one of the most important studies in our stratinipitrile and that's why we measure anxiety and general feeling of unwellness and depression at the beginning multiple time points and at the end the people fought and cholesterol per se and statins in particular may precipitate depression short answer is does not have any effect on instant depression and severity of depression nor new onset and more importantly statins prevent cognitive decline they don't cause impaired cognition except in rare idiosyncratic circumstances which is about one in a thousand so no add drugs don't cause mood problems and more importantly we keep people alive who would otherwise not be here I think that's probably the short answer that's fantastic actually improved mood so that's what all our patients should be on that wonderful that's great thank you very much David Helen I have a question for you if that's okay in your conversation we were talking about you were talking about working on the journey with Michael and continuing along and Phil touched on that as well in terms of I can imagine in a consult with Michael that he could be quite overwhelming for him looking down at the kind of barrel of the diagnosis of physical and mental health conditions that he's experiencing I wonder if you could speak a little bit about how you might approach the steps and how you would know where to start and would you be scheduling regular appointments with Michael sorry how would you approach that thank you Nicola that's an excellent question I think the important thing would be to schedule regular appointments with somebody like Michael I'd love to look at a half an hour for him once a month and really go slowly through lifestyle things at his rate and do it according to what he's interested in and also to try and build up his self-esteem and praise him when he does take just small steps but I think it's you probably won't see much progress over one or two consultations but over a two or three year period I think he may see considerable progress and particularly if we can all remember that Michael's got a lot of potential and he can change his and he can reduce his cardiovascular risk with these single lifestyle changes thank you Helen David just a quick question back to you I think I maybe cut over you or in the last medication that you mentioned was it fatty acids so with this Chappie I just focus in the simplest thing to have his risk is to give him a combination of statin as in my and if you want to keep the pill count down I will put him on a combination of lippie to it as a trill that will lower his LDL by more than 2 millimoles per liter and have his risk even if he continues smoking even if he doesn't want to exercise that's really simple thing to do and I encourage him so what was the other question what would I also do that was just the clarification of the last medication that you mentioned I think it was there may have been fatty acids that you mentioned towards the end well I mentioned beta blockers as the medication gives symptoms of tiredness and fatigue and a number of people over the years their cardiologists and non-cardiologists jump on oh that tablet has caused depression it doesn't cause depression it causes tiredness and fatigue and vivid dreams but interestingly some people have had these terrible dreams for years and all sorts of medications just stop the beta blocker it's called metoprolol Atenolol they're the two common ones that are used and many people do not need to be on these tablets I mean one of the problems doctors in general we seem to be afraid to be prescribed it's not a problem giving people I like to call it a drug holiday it's a really cheap holiday simple holiday and you might feel better than going to Haiman Island well I've got you there David I've got a question from Jose who asked I think this was your point can you elaborate on why weight loss doesn't contribute to improve cardiovascular health and secondly is there any research in the future around the role of a diet rich in plant based foods given what we know about studies in China study you willing to take that one on Dave? yeah sure I mean I've been involved in this area since the 1970s so that's why I've got grey hair but you know I'm still around because of my fissures now just getting back to plant based food in other words vegetarian type food we have no one since the early 1950s in fact 1952 a vegetarian type food as in the traditional Mediterranean diet of creed is associated with low risk of heart attacks and strokes we know that but you can have very unhealthy vegetarian food as in India I was there in the last talk on prevention of coroner disease at the cardiological society last year half the population is vegetarian but their rates of heart attack and stroke officially that's officially though underestimated is 30 to 50 percent above what it is in Australia so you can have an unhealthy vegetarian diet but in the pretty med diet that I mentioned 7000 Spaniards 12 or 4 and a half years those whether or not you're on the low fat diet or the Mediterranean 2 diets, olive oil or nuts lower rates of heart attacks and strokes of the vegetarian type diet but fish is positively healthy so if you're a pescatarian that's even better so vegetarian like in Spain, like in southern Italy like in Greece and I suspect Jose knows what I'm talking about very, very healthy now the Mediterranean diet is enriched with foods from South America such as avocados very healthy similar benefits nuts such as peanuts of course they don't come from they come from again South America so I think that's the plant based diet yes, there's plenty of studies intervention, there's only been two really well done trials comparing a low fat diet to a Mediterranean diet after a heart attack or a normal heart attack with the other ones the lion diet trial, the runs are on the border and it fits in with the epidemiological data looking at populations there is no question about it a Mediterranean type diet which is basically vegetarian and fish and some meat occasionally traditionally is the best examined diet for prevention of heart attack stroke low depression and improved survival unless cancer is some sort the China thing I think you're talking about, an epidemiological study most relevant to physical living in Australia is the Mediterranean type diet and a Mediterranean type diet has been looked at in the United States and that's been associated in 170,000 nurses for 25 years a 30% lower rate of heart disease than a classic American diet I might just stop there but the data is I'm not going to say overwhelming but it's as good as anything we haven't met great, thank you so much for some great questions coming in I might throw to you Phil take one from Michael in our audience and Michael asks what does psycho education look like for Michael around needed lifestyle changes and behavioural activation I suppose from your perspective yeah I think there would firstly there needs to be a balance being that he's bipolar we can't have too little but we certainly can't have too much we don't want to increase the physical activity to the point that we induce mania so we need to start light and psycho education on physical activity would be around the importance of it just for his general cardiovascular risk we would try and reiterate the messages from the GP and that Helen has said about increasing and modelling activity now I think in this particular case someone who's a car enthusiast and potential resistance there might be when talking about the merits of physical activity to discuss some potential incidental exercise such as walking to work one day a week or riding a bicycle and try and distinguish between what's sort of over cardiovascular really high intensity exercise this is just gentle walking for half an hour a day and incorporating that into his routine and I would also consider discussing with a case such as Michael about just the general benefit to the mood there could be social aspects as well the National Heart Foundation run walking groups so we might be eligible to participate in one of those make some new friendships but I think really it's about balancing what is essentially really urgent need by Helen and David have discussed how severe his risk is so some physical exercise is incredibly important but we'd need to start quite gently for him and trying getting him in a routine one that he sees as beneficial to himself to his long-term longevity and potentially discuss some of those associated benefits that might include the socialization aspect by participating in a walking group that's great thank you Phil I think you make a really good point about linking whenever we're wanting people to change their lifestyle I think often much more likely that they're going to engage in it if we show some interest and insight into what they're interested in and link it to that rather than setting realistic goals that they feel that they're going to fail out that was great thank you now Helen I've got a question for you Anna asks as a psychiatrist I see a lot of patients who are not well linked with GPs and getting them to a GP or specialist can be difficult please offer some guidelines about how to best manage the metabolically complex patient and is there a possibility to have secondary consults with GPs and cardiologists thank you that's an excellent question I think one of the key things in general practice is if somebody can actually keep going to see the same GP it's not always easy but I think some clinics are probably better at maintaining that continuity than others and I think that really helps with the lifestyle journey and I think we've just got to keep on measuring measuring cholesterol and liver function and electrolytes and doing all those blood tests regularly and keep up with the lifestyle counselling and then prescribing the statins as needed and certainly the results of the statins are really quite exciting when you do see somebody's cholesterol go from 6 down to 4.5 it really is very exciting and the patient is very excited too so I think it's a matter of keeping on with just persevering with those changes and keep on measuring and I think what's important is that all members of the team are on the same page length and all members of the team are interested in not only the psychiatric illness but also how Michael is surviving part-wise and metabolically as well thank you and Helen so in your experience it sounds like GPs such as yourself who have an interest in this would be open to secondary consult from other psychologists or other practitioners working with someone like Michael yes I think we would be and I think that's also one thing we're having Skype consultations with psychiatrists and the patient can be very useful now I have a fascinating question which I want to know the answer to I'm not sure who in the panel is going to put their hand up for it so I'll throw it out there and first in best rest so this is from Elizabeth and Elizabeth says what I'd like to know is is someone considered at risk after one episode of major depression two episodes, three episodes etc so ultimately does heart disease risk increase after one episode of major depression and then increase further with continuing episodes of depression so is there a graded risk I suppose with ongoing episodes who's happy to take that one I imagine maybe David or Helen yep go for it David well we reviewed this on two occasions it's a heart foundation in terms of cardiovascular risk first publication was 15 years ago and then 10 years ago the short answer is wouldn't it say someone's had an episode of depression as the psychiatrist in our group pointed out many people have never had resolution of their depression and we do know that that might be the signature depression but we know severity of depression like any other risk factor and chronicity acts to increase cardiovascular risk so we reviewed the data we're quite happy with that one episode that you know of increases your risk but it's probably not the only episode so maybe I'll hand it over to everybody else on that one anybody else want to buy into that one Helen do you have anything to add on that or Phil I can jump in just to clarify I guess it's important to not just concentrate on depression that some of the risk of heart disease is a range of psychiatric disorders PTSD there's a controversial link with panic disorder major depression unipolar bipolar and psychosis but I think that there's definitely a greater the exposure for the longer more persistent the duration of illness the more likely that there would be changes to the autonomic functioning of the heart to atherosclerosis to the respiratory processes but let's keep in mind that a large proportion of that risk is attributable to behavioural and socio-economic aspects some things people can't actually change such as their social status their race but also behaviours such as liking alcohol intake and physical activity so in short I would reassure the person that's asked this question in one episode of two weeks of major depression would not significantly increase your cardiovascular risk Fantastic Thank you Phil. That was fantastic of those questions that came through I was fascinated to hear those answers so thank you so much for panellists for sending them through I've got a few more minutes we're going to go around and wrap up with our panellists I've got one very quick question for you David Does it matter what type of nuts Well, yeah we'll review this again our research the short answer is nuts put aside coconut because it's very high saturated fat nuts that are associated with low rates of heart disease five large epidemiological studies it doesn't seem to matter whether it's almond macadamia nuts peanuts they're not really nuts but they count as well they're legumes that lower rates of heart disease are more harmful per day or harmful a few times a week is even better than none at all so walnuts cashews all the nuts we like coconut a little bit for flavor is okay but can I just add as well in the epidemiological studies looking at depression if for one and had a one diagnosis of depression that increased the risk of time epidemiologically Phil's right if they truly had 90% of depression and would totally recover it well probably wouldn't have an effect but even sub-substantial has epidemiologically increased risk Thank you David so now we get to wrap up so I'm going to throw to each of our panelists in turn and I was wondering if you could just leave us with a take home message or a key point that maybe you haven't covered yet that you wanted to to get in before we finish so Helen we'll start with you you've got a wrap up message for our attendees today I think you might be muted Helen we might need to Thank you Nicola I think one I think one key thing for us is to also consider self-care because we all need to do self-care and that also involves self-care of our cardiovascular risk factors because we're not immune from heart disease we can also suffer from it and I think also if we look after our own cardiovascular risk factors and we're much better at being able to go on a lifestyle journey with our patients and helping them Thank you Wonderful, thank you Helen How about you Phil have you got a message to leave us all with for tonight? Yeah Thanks Nicola I think the main message is that sometimes psychologists and mental health professionals might see ourselves as exclusively working with mental health and in a scenario such as this case we can work towards improving someone's physical health and there's a sense of urgency with this case and that would apply whether someone is at risk of disease or actually has heart disease we can contribute in both of those scenarios as a psychologist to improve someone's cardiovascular risk and outcomes Great, thank you Phil and over to you David too Well I think this has been a fantastic forum and I wish everybody was living around where I work that I think it's a great opportunity this patient and many of your patients are at high risk and they are not a trouble they are an opportunity we could do something to make them live longer they are passionate so everyone it's our duty to do the best for our patients everybody, I don't care who you are please do the risk calculator and then if it comes up more than 5% right over the GP to everybody cardiologist this patient is at high risk and we need to further assessment put down the blood test and consider getting into this century with a cardiac calcium score it's like the mammogram of a heart disease and breast cancer and our chappie here he's at very high risk but we can do something about it today and he will be your patient a grateful patient when you make him feel better and live longer it's everyone's responsibility not just the GP not just the cardiologist all the psychologists other people out there, thank you Wonderful, thank you David and I think that's a beautiful message to wrap up on which is people that we work with are not a problem they're an opportunity I think that's a lovely sentiment and I think it's one that we can all carry with it particularly we can feel daunted I think working with clients with complex needs and feel daunted for them in terms of what they're facing so I think approaching them with that positivity and a fantastic evidence base behind what we do we can feel confident that we can help help Michael on this journey to recovery I thank all of you so much I've learned a lot tonight and I really want to encourage people who have come along tonight to listen to look at additional resources that we will provide for you at the end of this session I also want to encourage people to complete the exit survey at the end of this webinar it is really helpful feedback it gets read I assure you and it helps to shape future webinars and content so we can make sure the MHPN are providing you with the content that is relevant to your workplace and make sure that we keep improving so please don't forget to fill it out it only takes a couple of minutes so the next webinar just to let everybody know we'll be on collaborating to recognise and address depression in cannabis users on Wednesday the 17th of July so again a really interesting topic and trying to single some complex behaviours and mood issues with people that we're working with so finally MHPN supports engagement and ongoing maintenance of practitioner networks where clinicians from different disciplines meet regularly together with mental health practitioners to share tips and resources build local referral pathways and engage in CPT activities so to learn more about your local practitioner networks are these national ones but there's also ones in your community please contact MHPN we'll go to the news section of the website if you're interested in joining in a network over the next couple of weeks those of you who are having some breaks for school holidays maybe have a look at the website but before I close and thank all of our panellists once more for joining us tonight and all our attendees I'd like to acknowledge the consumers and carers who have lived with mental illness in the past and those who continue to live with mental illness in the present and I want to thank everybody for your participation this evening and I wish you all a good evening thanks and good night bye bye