 Good evening, everybody, and welcome to MHPN's webinar tonight. We are fortunate in having 1,895 participants who have registered tonight, and I see that many of you are on already and sharing stories and locations. Just looking at the general chapter, we seem to have all states and territories represented, so that's great. Tonight's webinar is working together to manage substance use and mental health issues. Do feel free to say hello to each other and do feel free to ask questions as we go through the webinar. Tonight's panel is very talented. We have Adrian Dunlop, who is an addiction medicine specialist from New South Wales. Adrian, it's great to have you here with us tonight. Thanks very much, Michael. Pleased to be here. That's great. You've been instrumental in Australian drug policy for over two decades. Have you seen much change over those decades in drug policy? Our policy hasn't changed. I think what has changed is the level of awareness in the community of problems from alcohol to tobacco and other drugs has increased, and I think we're having a more mature conversation than we were some time ago. Great. Thank you very much, and we so look forward to your presentation and talk tonight. Now, I'd like to welcome Richard Clancy. Richard is a nurse and academic. Richard, you've been working on a project monitoring self-reported use of new and emerging psychoactive substances. What are some of the main findings from this research? Well, this particular study took place in an acute inpatient mental health unit that works with people who have serious mental illness as well as a substance use issue, and we found that over 50% of those people admitted to the unit had used some form of novel psychoactive substance at some point in the past, and we've been following that population through for a period of time, and we're certainly finding that the more recent use of synthetic substances, including synthetic cannabises, is reducing amongst this seriously mentally ill population. And that would influence future treatment and strategies? I think so. I think it's an important change. We think that perhaps the reason that people with mental illness were using these substances to such a high degree was that they believed that they were safe. They were freely available prior to the legislation changes. And now with the legislation changes, accessibility is more difficult, and people have an awareness that these are no longer considered to be safe, so certainly that means that the prevalence is down. Thanks, Richard, and thanks for such good research. And now I'd just like to introduce Margaret Terry. Margaret is also from New South Wales, and she's a psychologist. It's good to have you with us tonight, Margaret. Thanks, Michael. Margaret, what first inspired your interest in the field of mental health and substance use? It was a little bit serendipitous. It was the area that I first worked in. But I've been working in the field now for about 30 years, and the longer I've worked in it, the more interested I've become in the field. It's a very diverse field, very heterogeneous group of people, and there's lots of opportunities for putting evidence-based practice into my clinical work. Great, that's good. Thank you very much for coming along tonight. And last but certainly not least, I'd like to introduce Enrico Semonton, who is a psychiatrist in Victoria. Enrico, I believe that... Thank you very much for joining us tonight, Enrico. Thank you, thank you, Michael. I believe that you're quite involved in training medical and allied health staff in addiction and dual diagnosis. Can you tell me how you first became involved in training and interdisciplinary cooperation? Yes, certainly. So I've been a member of the Victorian Dual Diagnosis Initiative since 2000, up until last year. And the Dual Diagnosis Initiative in Victoria was set up back in the late 90s by the then Health Department of Department of Human Services, acknowledging the extent to the problems related to dual diagnosis or comorbidity, a bit like tonight's case, that existed in mental health services, alcohol and other drug services, and other health services within the state. And the idea was that we needed to deliver some sort of integrated response, integrated treatment, in particular to people presenting at the various services with multiple comorbidities. And so one of the major activities of the Dual Diagnosis Initiative in Victoria was to provide training and education with the aim or the goal to increase capacity, as we used to say, in relation to dual diagnosis in the various health services. Thanks very much, Enrico. My name is Michael Murray. I'm a GP and medical educator living in Tansul. I'm also on the board of the Tansul Makai Medical and Local and Health to be on the board of the Northern Australia Promenade Health Network whenever the government get around to announcing it. I have a special interest in mental health and substance abuse, and certainly regions that are just at a higher risk as major metropolitan areas from our population health body. So tonight is a very mood subject for all of our participants out there. So just a few grand rules. Be respectful of other participants and panelists, and behave as if this were a face-to-face activity. Please post your comments and questions for panelists in the general chat box. I will monitor that if you have technical problems, post in the technical health chat box. And be mindful that comments can be seen by all participants. Your feedback is important, and it's very important that you fill out your feedback exit surveys at the end of the webinar. And if you are distracted by the chat box, you can override this by clicking the arrow in the center at the top of the chat box. Now, you would have all received the PDF with Doug's story. We have three learning objectives or outcomes tonight. The first is to recognize the core components of the features, distance approach, and screening, diagnosing, and treating people with comorbid substance abuse and mental health issues. And this will be achieved by the slideshow that each participant will go through for about five minutes each shortly. And then we have two further learning outcomes. The first one is to better understand the key principles of providing an integrated approach in the early identification of people with comorbid substance abuse and mental health issues, increasing the likelihood of a successful course of treatment. Secondly, to better understand the challenges in providing a collaborative response to people with these comorbidities and to share tips to overcome these challenges. And this will be taken care of in a question and answer and discussion section between the panelists. And you, the audience, are extremely important in this because I will be taking some questions and translating them from the general chat box and posing those to our panelists tonight. So please keep those questions coming as they come to you. So without further ado, I would just like to ask Adrian to commence his slideshow. Great, thanks, Michael. So really, there's three key things that I want to try to get across to you tonight. So the three key things that I want to try to get across to you tonight. So the case history that we've got is about substance use and mental health and alcohol clearly is the major substance issue there. And so I'm going to talk to you about really three things, screening, brief intervention, and when to refer for treatment for primary care practitioners. So just the first key thing, I imagine most of the audience will be familiar with this concept of standard drinks. So it's a way that we measure alcohol. Standard drinks are on all packaged alcohol in Australia and for those who aren't familiar. So a midi of Bedia in New South Wales or a pot in Victoria, 285 ml of standard strength beer, 30 ml of spirits, 100 ml of wine, or 60 ml of fortified wine is the measure of standard drinks. But again, you will see on a bottle of wine or a can of beer or on any prepackaged alcohol, the number of standard drinks will be written on the side of the package. Caution, just when taking histories, that very frequently if you go to a restaurant or to a hotel, they might fill up your glass considerably more than that, so you can fit in some large wine glasses, you can fit 200, 300 ml of wine. So caution is in taking history there. So the first thing to think about in a particular case is the amount of standard drinks and Doug was drinking, I think, half a bottle of wine, which is approximately four standard drinks, but there were nights when he was drinking three to four bottles of wine, so that would be something in the order of 24 to 32 standard drinks approximately. So that's significant. We have Australian Alcohol Guidelines that have been out for several years now. I've put the website for them on there. It's a good website. It's got some materials, some useful materials that you can use with patients or with clients, alcohol.gov.au. So the advice for Australians in terms of drinking is for men and women, on average, not to be having more than two standard drinks. So that decreases the risk of drinking in the long term. There's also advice about in the short term that people shouldn't have more than four standard drinks. So again, the same for men and for women. Used to be different measures in the past, but now it's been standardized for men and for women. And the way about talking or using this language with patients who are older, let's say to them, you know, on a special occasion, you might consider drinking up to four standard drinks, but on average, you should not be drinking more than two standard drinks. There's some exception to this. So clearly for women who are pregnant or breastfeeding or planning to become pregnant, zero is the limit and for young people, zero is the limit. So if we just go back to our particular case, it's one thing, you know, caution in taking history. A lot of people might be familiar or a lot of patients might be familiar with giving the answer of that they're a social drinker, if you ask about alcohol. But for our purposes, that's not an adequate answer. You need to drill down a bit more and find out exactly what they're talking about. So a social drinker could mean any sort of drinker, including very anti-social drinkers who are drinking large amounts. So ask them about how much they're drinking and again, go back to that guy that I've just talked about, about using standard drinks to try to quantify the use. So what you really want to try to get a sense of is how many days per week people are drinking and then how much they're drinking on those drinking days and standard drinks, again, being the measure. The risk of harm increases significantly once people start drinking four standard drinks. So that's why there's that limit for risking the short term. So people are more likely to have accidents, get into fights, have injuries, et cetera, when they're drinking more than four standard drinks in one setting. So if we think, sorry, just to give you a sense of the implications of that. So there is a tool that you can use. You don't have to use this, but I'm giving you this tool in case you want to use it. It's very easy to find on the internet. The audit C or a cut-down version of the audit is the tool and that has three questions about the frequency, how many drinks, and then how often do you have more than that limit of four? So that limit above which risk becomes more common. And there are cut-off scores of five for men, four for women in terms of risky drinking and more than nine for dependent or addicted or alcoholic, I guess in the old fashioned term, people could use. So again, if we think back to a particular case with Doug, what else we need to look for is in terms of other substance use. So you might, if you were smoking some cannabis as well, again, you'd want to try to quantify how much of that is smoking, how frequently. To look for medical problems, I'm not going to go through a long list of them, but particularly, so people who drink more than that amount of forced-down drinks in one setting are at increased risk of injuries. And something like one in seven to one in three people in our emergency departments are there because they've been drinking too much alcohol and they've had an injury or they've been involved in some sort of problem from acute alcohol use. There's a long list of long-term medical problems of people who suffer. I won't go through the list, but they include essentially every organ system in the body. Mental health problems are very common. Depression, particularly one of them, and you'll note again that Doug has some depression problems. Impulsive behavior is common. So young men, especially, but also young women with aggression and fights. Problems like unwanted sex are not uncommon. And probably the biggest harm in our community is the social harm. So problems being unable to work properly, parent properly, risks like motor car crashes, and you'll notice in this case that he's having some problems both in his relationship and in his ability to look after his kids appropriately. Very quickly to go through the concept of dependence with you. So dependence really means somebody's lost control of their substance use. Alcohol in this example. There's a brunch criteria. I won't go through them in detail. You'd be familiar, though, practically, especially in a general practice setting. If somebody has the signs of withdrawal or tolerance, then they're highly likely to be dependent. And the quickest way to assess dependent is if somebody drinking on a daily basis, then they're at a higher risk of dependence. Examination, clinically, look for things like current presentation of intoxication or withdrawal, blood pressure problems, and again, the wide range of other problems so I'll go through them in detail. Investigations are useful, but miss most problem drinkers. The most problem drinkers would have normal for blood examination or liver function tests. So in terms of what we do, clinically, if somebody's drinking at a low risk of harm, so zero to three, positively reinforce that, don't suggest that they start drinking to try to reduce their harm. So if somebody's not drinking, they forget about the J-curve, just encourage them to continue drinking. If somebody's drinking and they score on that audit score, drinking on a daily basis, so experiencing harms like our particular drinker, then advice to cut down. It might mean they need to stop first or stop and then reintroduce alcohol, but cut down at least to those levels that I've suggested and that they're at a high level. Essentially, we need to think about referring them for more intensive treatment that is management of their dependence with withdrawal management and aftercare. Back to you, Michael. Thanks very much, Adrienne. That was a great presentation. Thanks. Just a reminder about the case. We're just dealing with a 39-year-old teacher who's been married for 10 years and who's been encountering some vocational and social problems from a pattern of increased drinking alcohol over the past six months. And the effect is on a family and on his work as a teacher. And there's also some evidence from the case that he suffered from childhood trauma. So just with that, we'll now just move on to Richard Clancy. Richard, may I hand over to you? Yes, thanks, Michael. Thanks, Michael. Yes, I'll start off with, I suppose, some topic that will come up again and again in this issue of engagement. As a nurse working with somebody who's got a substance use problem and a mental health problem, in this case, depression and perhaps some post-traumatic issues, engaging this person over time is going to help with getting a better history, better involvement in treatment and a better commitment to long-term behavior change. So one way to do that or a step along the way is working with Doug with his perceptions about what the issues are. So we've got an outline in the case here that there are some work issues and there are some family issues. But it's a little bit unclear. It's sometimes on the surface, they can see, and so we know what Doug's perceptions are. He wasn't happy to come along for treatment. But often, if we dig a little deeper, there's something underpinning there that perhaps there is some level of motivation, but it's not easily seen on the surface. Now, another point we're in dealing with people with these issues is just examining, certainly I'd like to look at my issues of transference and issues of counter-transference. So I'm quite concerned that perhaps I maybe have feelings about this person, perhaps with care of children, if I have children of the same age or if I have kids who are going to school and school as a teacher, there's that impact on my way that I work with this person. So I ask myself the question, do I have any strong feelings about this person, positive or negative, and if so, discussing those in some clinical supervision or reflective practice? In terms of working with this person, I think it's important we all provide consistent and clear and persistent messages. So providing information that doesn't contradict each other. So if he sees me as a nurse in a practice, he's also seeing perhaps a general practitioner or a psychiatrist or someone in another role, I have to be very careful that I'm working towards synthesizing the information the person is receiving. And also trying to use assessment as an ongoing issue that an assessment doesn't occur in isolation. Assessment is something that occurs over time and we get a better connection with the person over time. So on this slide here, I've put together some ideas for things that I would be looking at, certainly wanting to get a good understanding of Doug's substance use. So he's been drinking a bottle and a half of wine most evenings and on other evenings drinking far more. So that certainly is a major issue that will be a focus. So I'll be concerned about risk of withdrawal. Drinking over 10 standard drinks per day is something that could well put him at risk of withdrawal. I want to know has he had alcohol three days where he's experienced withdrawal symptoms? And certainly, it sounds as though he's finding it more difficult to get through days without alcohol. Also looking at his past use of alcohol, how that's travelled over time and use of other substances. The past trauma, I think that I'll leave that out here. Perhaps Margaret will want to move into the issue of past trauma more than I will. Certainly mood, a mental state examination is something that would be considered here. Looking at how Doug's mood is over time, over a longer period of time, but also through the day, how does it travel through the day is something that would be useful to follow up with. Then look at perhaps what are Doug's strengths and how does he cope with situations. So does he have any adaptive coping strategies that he currently uses and can rely on or has used in the past? And are there any maladaptive coping strategies that he's using and alcohol may well fall into that category? How are things at home and at work trying to get... We have the story about how things are going, what are Doug's perceptions about these, how is he internalising that conflict that he's experiencing at home and the difficulties in the workplace. Physical health, as Adrienne pointed out, alcohol certainly affects about every system in the body. So there may well be some underlying physical health issues that need exploration, looking at Doug's perception and his motivation. So in case we have information, that Doug has reluctantly presented for treatment, he's told his wife that there you go, see how he made an appointment with the doctor. And this occurred about three days after an altercation with his wife where he threw a plate. I'd be wanting to explore that with Doug to find out, well, what was it after three days? Was it three days of no talking and just to keep the peace you've decided to come along? Or did it make you think a little and exploring and trying to work with that? One of the issues with depression is that often people have a low sense of self-efficacy. So I would be trying to see whether perhaps this reluctance for treatment might be a sense of not being able to be in control of changing anything and that may well be the case. So I'd be wanting to explore that a little more. Adrian already spoke about substance dependence. DSM-5 uses a fairly similar, but slightly different scale to ICD. So it just looks at substance use disorder. Now Doug meets quite a few of these criteria for substance use disorder. There are certainly failing to fulfill some obligations. He's got some recurrent social and interpersonal problems, I suppose, with the put down to this relationship and with work. He seems to have some tolerance. He's drinking more alcohol than I could manage at one point in time, spending a lot of time using the substance and recovering from the effects. We'd probably meet criteria for that and he's beginning to have some craving and strong desire to use the substance. So he's likely to be moving towards a severe substance use disorder, so definitely a moderate and probably moving to severe substance use disorder. In terms of working with Doug, this is a stress vulnerability model that many people will have seen and it's a model that I think is terrific for working with clients. If we look at this from Doug's vulnerability to develop depressive symptoms, then I would be trying to form some relationship with him and getting to see some connection between using substances, alcohol use, and that increasing his vulnerability to develop depressive symptoms. He may see it the other way. He may see that the depression causes him to use alcohol, but there's also a movement back the other way as well. Stress being another factor that really contributes to development of symptoms, particularly with depression, the evidence is very strong for stress contributing to depressive symptoms. So I'd be working with him to draw that connection there, looking at how stresses are in his life, trying to see what strategies he has in place in terms of dealing with the stress. Does he have some relaxing activities that he undertakes in perhaps some exercise, healthy lifestyle, perhaps referral to another clinician, perhaps a psychologist, for a specific talking therapy, counseling with somebody? What does he currently do? Does he have some problem-solving skills for when his problem-solving skills are not working quite so well due to depression? And if he is prescribed the medication, how does he feel about the medication? Does it seem to work for him? Does it not seem to work? What's his understanding about its impact on his vulnerability to symptoms and work on the biology behind that? And talking about, I suppose, I would be trying to work out, pull together information, consolidating information that he receives from the GP or whatever other health professionals he's seen and working with that and consolidating that, is probably the main focus of where I'd be delivering treatment. I'll hand back to you, Michael. Thanks very much, Richard. Adrienne has given us a very good exposition of the pathology and behind substances, and Richard has expanded on the effect on the psyche. And I now have a much better understanding of Doug following both of our speakers, and I'm sure that Margaret Terry is now going to speak on the psychology of this case. We'll expand further and give it further insight. Thank you, Margaret. Thanks, Michael. I just need to get my slide up. So I'd like to start off by looking at some of the epidemiology and prevalence of comorbidity. According to the NH and MRC review that was held in 2013, in treatment seeking populations up to 71% of people in mental health services, and 90% of people in substance use settings have comorbid mental health and substance use problems. So that's a very large number of people. So given this high prevalence of comorbidity, inquiries about each disorder should routinely be undertaken when the other is detected. In this instance, with the GP, in the case of Doug, he did identify the substance use on the mental health issues, but that's not always the case. If we don't screen for concurrent substance use and mental health issues, they may and often do get overlooked when just having trouble changing slide. Would you like me to move them forward for you? Yes, it's like it's not moving. No, that's fine, that's okay. Okay, so the second issue I'd like to raise is that lots of people realise that there's a high level of comorbidity, but still a lot of health professionals don't look at both mental health and drug and alcohol. And we have to ask ourselves why is that so... I think the first issue is that people often don't see it as their role. If they work in an acute mental health setting, they prioritise dealing with the mental health issues and see the drug and alcohol things as secondary, which they may or may not get to. And similarly in the drug and alcohol field, maybe less so in the generalist field. So I think that's an important thing to stress is that comorbidity is everybody's role as a health professional. The second issue that may get in the road of people dealing with comorbidity is that they may feel that they lack the skills or competencies to deal with the issues that arise. From a sociologist's perspective, the APS Physician Paper clearly says that psychologists have the competencies. I think sometimes people may lack the confidence. And different professionals have different competencies in skills, assessment, intervention and treatment, but all health professionals really have the competencies required to screen the comorbidity. The third thing that might get in the road of people addressing comorbidity is they feel that even if they do try to do that, that it doesn't make a difference. Particularly if the person's not motivated to address one or either of those problems. And I think that there's evidence accruing that to varying degrees with different comorbidities that in fact does make a difference. And what we do know is that if you deal with those mental health and drug and alcohol issues, it reduces the risk of relapse for those conditions, which is a very important outcome. Right, Michael. The third area I wanted to look at from a psychologist's perspective is our use of a psychological formulation. I think each profession has different things to bring to working with comorbidity. I think this is an important thing that psychologists bring. Because one of the problems that we can get caught up within comorbidity is what is the primary and what is the secondary diagnosis, which came first, the chicken or the egg. And using a formulation means that we don't have to get caught up with that, you know, the issue of what's primary. And that we can understand that a formulation provides a framework for us to understand the client's concerns and the interventions that may be useful. Many psychologists use the 4P and that is looking at the predisposing factors, the precipitating factors, perpetuating factors and protective factors, and the personal meaning for the client. So I could go through, and Richard's already done that, looking at some of those factors based on the referral. But I'd probably like to do that based on the story that I get some done. And then on the basis of accumulating together, all the incidents, sorry, the evidence from different areas, and Doug's perception of the problem, develop a formulation around what are the core issues in the rich relationship, and what sort of psychological theories would then indicate the intervention. The next one, please. Okay, so in this case, the GDP has elicited that Doug's drinking one to two bottles of wine routinely and three to four bottles sometime. And this seems obvious looking at at a very high level, and it does seem to be impacting on various aspects of Doug's life. But Doug's main concern in seeking treatment seems to be appeasing his wife. That's obviously hit the relationship with her, obviously very important to him. So one of the ways of working with people who don't seem to recognize that there's a problem around a particular issue is to use motivational interviewing. So often in practice, and as psychologists, people come to us because they're motivated to receive treatment for a particular issue. What often happens in co-morbidity is that people aren't necessarily motivated to address those issues. So not only do we look at the issue that the person is identifying, but we also see that building motivation to address issues is one of the focuses of treatment. And so motivational interviewing is a way of enhancing the client's perceived importance of change, and it also helps in those situations where the client sees it's an issue but lacks confidence to address it. And I might go with a motivational interview and most people would be familiar with it, but I think it's one of those things that people can underestimate their, or sorry, overestimate their skills in using. I think it takes quite a while to become proficient in the use of motivational interviewing, but I think it's a very effective way of intervening with those pre-connoplaters and connoplaters. Thanks, Michael. The next thing I'd like to emphasize is the no-wrong-door policy that comes from the New South Wales Clinical Guidelines for working with people with co-morbidity and acute settings from 2009. And what this basically says is that the service where the person first accesses treatment is the service that's responsible for working with that client until for which time they may hand it over to another service. And this is a very important concept because if this doesn't have a service, and this is a very important concept because if this doesn't happen, clients can frequently fall between the gaps when they're moving from one service to another. We have very complex service delivery systems, and even as clinicians within the system, we can find it difficult traversing at times. So we often get parallel care, people going, sorry, serial care, where a person goes from one service to another to get their issues dealt with. We may have parallel care where they say drug and alcohol and mental health patients at the same time, or we may get integrated care where one service, one clinician deals with both issues together. For the first two ways of providing service provision, this issue of no wrongdoer is very important. Thanks, Michael. And the last point I just wanted to make is a quote from William Miller, one of the people who developed Motivational Interviewing. And he says, in my early professional years, I was asking the question, how can I treat or cure or change this person? Now I would phrase the question in this way, how can I provide a relationship which this person may use for his own personal growth? And I think this really highlights the importance of engagement and a strong therapeutic relationship to get effective outcomes. Over to you, Michael, thanks. Thanks very much, Margaret. That was a great presentation. I'll never, ever forget that phrase, no wrongdoer now. Thanks very much. And now, Enrico, we'll just move over to you. Thanks. Yeah, thank you very much. Michael and Hygien, everyone. So I'm going to report to you now the psychiatrist's perspective on the case of Doug's presentation. And so I wanted to, over my next few slides, cover these areas. That is the integrated assessment of all the issues that Doug's presenting with, that is alcohol misuse, his possible depression and possible post-traumatic stress disorder. And as Margaret's been telling us, the formation of a formulation, which then leads us to developing a provisional or working diagnosis with, I think, a realistic and important differential diagnosis. And from there, the clinician or the team of clinicians able to form an individualized integrated management plan, which is tailored to the needs of Doug, is really presenting to us with potentially a complex set of problems. And then finally, I'd like to just touch on the contingencies that we may need in order to manage the various challenges and dilemmas that arise in Doug's management. So when it comes to integrated assessment, as I said, and as the other speakers tonight have said, there are a number of problems there. And the assessment is not going to be done in the one session. I think you would realistically expect to have to spend at least two, three, maybe four hours with Doug in order to assess all the different presenting problems, starting with the severity of his alcohol misuse and the other presence of other mental health symptoms, such as depression and those of the post-traumatic stress disorder. So I'd be wanting to know what the duration of those symptoms has been and what sort of risks and harms are presented or occurring. So we've heard about some of the physical harms, but in terms of risk as a psychiatrist, I very much get interested in whether there's any risk to self or other people. That is suicidal risk or risk of violence, aggression, or indeed homicidal ideation. We can never assume that that's not present. I think it's important to ask. And people are sometimes reluctant to us thinking, I might be planting a seed or an idea in this person's head. Whereas really, I think asking about these risks really gives us the person, the patient, an opportunity to disclose. And I think in the long run, the situation is improved as a result of that. We've heard about how to assess the drinking patterns. I won't spend any more time on that, but I think in relation to all these problems, the degree of functional impact, how this is impairing Doug's day-to-day function is important, not just his drinking, but also the other emotional and anxiety symptoms that are present. What I call the guts of dual diagnosis is to understand that relationship between his drinking, if there's any other substance use going on, and the depressive and anxiety symptoms. As Richard had told us about, I think it was Richard, we need to assess Doug's internal and external strengths and resources. And we also need to do a motivational assessment. And a commonly used framework for that is the old Prochesco and DiClemente stage of change cycle. And then looking at how we can engage Doug into our treatment. The mental state examination has been included. I would also look, in addition to the anxiety symptoms, the depression and so forth, look for psychosis that can occasionally be present. And we mustn't forget the cognitive assessment because we've heard in the history that Doug has been drinking for quite a long time. And I think a 10-year, a greater than 10-year history of heavy drinking does correlate quite strongly with some early cognitive impairment or acquired brain injury or ABI as the other term that we use in this situation. And I won't cover the physical examination as Adrian has already discussed that one. As I said, the assessment, which should be conducted longitudinally, takes us to a formulation and a diagnosis. And here, as I said, we understand the relationship between his substance use, his depression, and PTSD. The motivational assessment in the information that we've been given so far makes me think that Doug is on that stage of change cycle on the pre-contemplation side. That is, he's been coerced, I suppose, to coming in for this assessment as a result of his wife's concerns and potentially her threats to leave the relationship if he doesn't do anything about it. So it's not like he's there of his own accord. But an immediate goal in the assessment is to establish this working diagnosis. We've heard about the different diagnostic frameworks for alcohol use disorder. And I agree with Richard that he's probably got quite a severe alcohol use disorder, at least. But another goal is to work out whether there's an independent, depressive, or anxiety disorder presence, or whether, in fact, his anxiety and depressive symptoms are alcohol induced. That will govern our treatment plan. And so as a result, we have to, yes, make an initial diagnosis, but we also need to entertain a broad differential diagnosis and keep our options open there. In the end, we consider all the diagnosis that is made primary diagnosis, but we have to prioritize them according to the risks that they pose for Doug. And from there, we can develop a framework for his management. The first goal of the management is to engage, and we've heard this now a few times today, but there's no doubt from substance misuse research that it's engagement and the strength of the therapeutic alliance, which ultimately dictates the success or failure of the intervention. So an extremely important part of the management is the engagement. With time, we'll become clearer in terms of what the likely diagnoses are. And you'll also engage in obtaining collateral information from other informants, such as his family or other practitioners that know Doug, as well as investigations that Adrian told us about. So we developed this longitudinal integrated perspective on Doug. Then with treatment proper, I think it's important to prioritize the more acute risks and stabilize those as much as possible. So in relation to his alcohol and drinking, then there may be intoxication and or withdrawal, which needs to be managed from the outset. And what other risks have been identified, be them physical risks, some acute physical disease, whether they're psychosocial risks, such as suicidal ideation or homicidal ideation. Well, then those problems need to be prioritized and managed down immediately. Subsequently, we can move on to a more longer-term management goal, such as symptom remission, relapse prevention, rehabilitation and recovery, as I've listed on the slide. Generally speaking, the lowest severity of the problems will then brief interventions are realistic and possible. Whereas the highest severity problems and the longer that they've been there, and I think realistically we're looking at longer-term interventions for Doug. And remember when we're talking about treatment interventions, we're talking about the combination of pharmacological and psychosocial interventions, which addressed all the different problems that we've identified. This is what we call integrated treatment. And so I'd like to close with just a mention of some of the things that may happen. I often hear about treatments not working, and one of the first questions I ask is whether there's been a good match between the management plan and our motivational assessment of Doug. So if Doug's a pre-consumplator, as I've speculated before, well, then that requires a specific intervention rather than treating Doug as someone who's already made a decision about what he wants to do in relation to his drinking. And in the dual diagnosis field, we also talk about stages of treatment where the person sequentially needs to go through these four stages in order to achieve recovery and remission. And so the first step is one of actively engaging Doug in treatment, and then from there, we can move on to persuading him to have more active treatment and ultimately relapse prevention. Another important question to ask ourselves as clinicians is have we agreed on treatment goals? There's no point in me having one treatment goal for Doug and Doug having something else in mind, and the thing is that we go in different directions here, and ultimately the whole intervention breaks down. And it's important to know when to refer to other practitioners in order to have collaboration and coordination going on. Continuity of care balances on needs therapist are being empathically attuned with Doug, but also detached, but offering Doug opportunities to make decisions to empower him, as well as at times having to contract him and set limits and then learning from these experiences and setting more points from there. And then one also needs to ask oneself, I also say things aren't going well and his substance misuse continues. Well, I need to ask myself, what's the role and the efficacy of the medications that I'm prescribing, Doug, if I've gone ahead and prescribed something such as an antidepressant? What may be the risks, such as alcohol and medication interactions, and are there any other risks here? But rather than discharging, Doug is saying, look, there's nothing more I can do for you. You're not following my directions or you're harming yourself further and further. I think this really requires closer monitoring of the situation and a reevaluation, as I was saying before, whether I've directed my intervention in the right way, second to his stage of change and stage of treatment. So thanks for that and over to you, Michael. Thank you very much, Enrico, and thank you all the panelists. Enrico, that rounded off very good presentations from all four of our panelists. I particularly took your point, Enrico, about engagement, the therapeutic alliance and the treatment goals. I think they're really important as you're stressed. Now, I would just like to pose to our panel just a question that came from one of our participants from Hugh Wolford. He felt that in his management of patients with clients with dual-dark noses, he feels that anxiety is more of a problem than depression, particularly in demographics such as this, a teacher, where there's often a mismatch between responsibility and authority, which he feels often occurs in police and emergency services as well. Would anybody like to comment on that, please? Richard, can I ask you to comment on that? There's no doubt that anxiety and depression are cousins, so anxiety is a very common disorder as is depression, and often people, even like Doug who has a depressive disorder, it appears, he's likely to have some anxiety symptoms as well as part of that depression or could well have a separate anxiety disorder. For people with an anxiety disorder, alcohol seems to work as something to reduce the anxiety that they often experience, whether it be work-related or whatever cause, so often people do end up with that kind of morbidity as a result of self-medication, if you like. But it is a catch-22. While people learn that alcohol reduces anxiety during intoxication, it also contributes to the worsening of the disorder over time, so it is a win on one hand and a lose on another. So just to add to that, Adrian here, alcohol is probably the most widely used anti-anxiety drug in our society. I think there's been a whole bunch of very interesting comments that people have been posting, and one of them I noticed was Australia is an alcohol-soaked society, and that's absolutely true. And as a country, we're almost blind at recognising the problems from alcohol, and I wholeheartedly agree with that. It's very commonly used. It's used for social anxiety. People drink to go out, to talk with nerves, et cetera. They drink to have interactions with the opposite sex or the same sex. It's used for a whole bunch of reasons, but I guess we're talking about how to try to assess and manage people who are running into problems from their alcohol, and anxiety is very common, as you said, as is depression. Margaret here. After add, I think it's an important thing too when we're talking with the client to get their story, and I like when I'm working with someone to start off by saying, I will need to ask you a lot of different questions, but I'd like to first hear your story, what brought up to you coming here today and what were you hoping to get out of coming here today, because I'm very interested to see how the person sees the issue, and they may or may not identify anxiety during that, you know, in that story that they tell me. I think that we should have a whole lot of things that we're looking at, but not drunken to conclusions about what the issues are for individuals, because comorbidity is a very heterogeneous group of people. They're using lots of different substances. They have lots of different levels. They have lots of different mental health issues. They may be illnesses or problems. They have lots of psychosocial problems as a result of their substance use avoidance that occurs, so a lot of their responsibilities may not have been there. So there's so many possibilities that are there. I just think it's really important that we hear what the person in front of us is saying. Thanks very much, Margaret. I believe, Enrico, that you had a question around engagement. Would you like to address that to the panel, please? Yes, thanks, Michael. Given my point that the engagement is the necessary first step in treating someone with multiple problems, such as Doug, and also given that the therapeutic alliance, which can only really be developed by engaging Doug in treatment, is the best predictor of the long-term outcome of the treatment. And thirdly, the fact that the information that we've been given shows that the Doug's there only because his wife has been coercing him in a way to come along. I'm just wondering what the sort of strategies might be to help engage Doug in a conversation and encourage him to come back and eventually to look at the fact that he's streaking excessively and that it's having an impact on him and that something needs to be done about that. I might pop in there if I can. It's Richard here. So engagement and measuring stage of change early on is a complex thing. As Enrico pointed out, Doug seems to be pre-contemplative about making a long-term change at the moment. But I think he's in determination or action stage to get Jackie off his back. So he needs to feel some need to make her happy at the moment. So if he's in determination stage to do that, then that's an area for engagement. If we can help him deal with that issue, so providing some practical assistance is the best way to engage someone. And I should point out too that when we're talking about engagement here, we're talking about engagement into staying into treatment and later on we might get the agreement on treatment goals happening between the clinician and the client. But just in terms of continuing in treatment, I think thinking of things in terms of how motivated is this person for long-term change? How motivated are they for short-term change? How motivated are they to enter treatment? So providing some practical assistance is a good way to help engage Doug in this situation. Perhaps working with him, what are his greatest issues in his life at the moment? What are the things that he would like to have changed in his life? It's amazing what a difference taking a person's perspective in this and helping them achieve some change. What that does if you're a clinician who has luxury of being able to spend a little time with a person to work with them on something like this makes a big difference. But of course not every clinician is in that situation where they can spend a lot of time with a person that often it does take that to engage. Yes Richard. May I just ask a question though? I can hear what everybody is saying. Would anybody like to comment on what are the major barriers to health professionals working collaboratively to provide integrated care to patients like Doug? Doug has presented to one of us and he may or may not be motivated but let's say he is motivated. How can we best collaborate? Sure can I start by answering the question? The single biggest point that I'd like to make to start and this is because if we can do this it has a great population health effect and that's asking the question about alcohol. If we can start to ask the question of all our patients and encourage all of the participants to ask those questions then we'll be a step forward and we'll have a population health effect and there will be a population benefit in reducing alcohol. So that's the first step. I guess the second thing you're asking about how we work between professions and that's to accept that it's an issue for all of the professions. Greg, summed it up very eloquently. No single profession. Student practice, psychology, addiction medicine, psychiatry, nursing owns addiction. Nobody has a single answer. It's all of our responsibility to ask about drug and alcohol and mental health problems. Anybody else like to comment on this? Thanks, Adrian. Mark, would you like to comment on this? We work in a tertiary facility that's a designated mental health and drug and alcohol service. So for us it's got acute inpatient, psychiatric beds and the community team. So for us it's a bit easier for us because all the clinicians who work in our service know that their job is to deal with both the mental health and the drug and alcohol. But we also, but we were at the tertiary end at the most severe end of working with this client group. But I think one of the other issues is knowing your other service providers. We work very well with the drug and alcohol clinical services in our areas because we know the individuals, we know what they can provide, they know what we can provide. We frequently talk to each other about our clients. And that may be easier in rural areas too, where you know most of the people who provide services. But I know in some of the bigger, urban areas, people really don't know what the other services are and I think that's one of the big barriers. So more collaboration on the ground would be better and more knowledge of what's available on the ground. That's what I'm hearing you say. I do have a question that Beth Shook posited. She's one of our viewers tonight. She wanted to know, were there any tricks in commitment to change? So in the, I would imagine that that's around the motivational interview. Would anybody like to comment on that? Enrico, would you like to comment on that? I think with Doug, the commitment to change I think comes from, as Margaret was saying, a good sort of formulation and understanding of what Doug's perceptions of his problems are now. And there is some message that he's come along because I think he sees value in his relationship with his wife. And he wants, I presume he wants to preserve that one. So there's one goal that he has. And so one of the techniques in motivational interviewing is to what's called deployed discrepancy. To help the patient or the client become aware that he may on the one hand have one goal in this case to preserve his marital relationship. On the other hand, there are some things that he's doing which would compromise that or go against that. And so by increasing the anxiety that he feels or the ambivalence that he feels in relation to his drinking, then you can start to help Doug start thinking that change is necessary in relation to his drinking and that it's also possible. And then you would bring in the other motivational, classic motivational interviewing techniques such as supporting his self-efficacy and enabling him to think that change is possible. Perhaps drawing on his previous experiences of change and that he was able to change other things in his life and helping him develop a range of options of different types of change options that he has available for him. But again, engaging Doug in this sort of discussion is paramount from the outset. Thank you very much, Enrico. And I would like to thank our panel. Unfortunately, time has really, really run past us tonight. I'm going to have to bring this session to a close shortly. But having listened to each other's presentations, I would like to go back over all of our panelists again and just ask them to sum up the key messages from their discipline in relation to the management of Doug and also to touch on cooperation between disciplines as well. So, Adrian, I'll ask you to start. Sure. So I guess the key messages from my perspective are first thing, ask everybody about alcohol. Be familiar with the alcohol guidelines and reinforce them to the patients or the clients that you see. If people are not drinking at harmful levels, encourage them. If they are drinking at harmful levels, then you need to talk to them about safe levels of alcohol use and to follow up to see them again. If they're drinking at dependent levels, so it was nine plus on the audit C or if they're daily drinkers with obvious significant problems, they need to stop. They need a period of abstinence and usually they need a thorough or specialist treatment. In terms of working with other practitioners, it's really important. I guess two things to reinforce. Every state in Australia has an alcohol and drug helpline for patients. It's called the Addis Line. It's got different names in different states, but alcohol and drug information system. If you punch that into your Google search, you'll find it. And many states have professional lines to help professionals as well. It's called different things in different states, but that's where you can call up and get advice from professionals in managing patients with clinical problems. That's great. Thank you very much, Adrian. And now Richard, I'll go to you. Okay. I suppose to summarise from a nursing perspective particularly with this case is the idea of spending more time on engaging the person in order to continue that process of assessment. It's an ongoing process, not a one-off event. Engagement is key not just for assessment, but also for getting the person to look at the situation, working with them towards a particular goal and bringing about a change. I would recommend for every mental health professional if they have an undertaken training in motivational interviewing that that is something that could be a core skill to contribute to their professional development, working with people through change. It's something that does take time to develop the skills. Doing a one-off training often isn't enough to embed that. Often that does need to be topped up. And also I would recommend the stress vulnerability model as a way to work with people regardless of the substance use disorder, regardless of the mental health disorder. It's a great tool to use with people to help make a connection for them between their substance use and their symptoms. And as a non-prescribing health professional, I take the view that whether this is a primary substance use disorder, or primary mental health disorder, or both primary disorders, it doesn't change the practice I provide. And in fact, a client can probably tell me at some point down the track whether their substances contribute significantly to their mental health disorder if they choose to significantly reduce or stop their substance use for a period of time. Often I'll try to contract for say six weeks and see if there's an improvement in symptoms. That's a great way to start. Thank you very much. Now, Marcus, would you like to comment? I know I'm raising this right at the end now, but I thought I might get a chance to talk about PTSD and the timing of treatment and people who are using substances. So without going into details, I'd refer people to the NULS et al. in our technical report that talks about if a person doesn't need to have stopped their substance use before you can start treatment for the PTSD, which we used to think in years past. So they've done some research that indicates that that's a useful thing to do. The other thing I'd like to say is that if people do have a severe dependency, it's often a chronic relapsing problem. So treatment is a process and we need to build in relapsed prevention into our intervention. So from the beginning of raising the issue, prevention into our intervention. So from the beginning of raising the issue, developing what are the core concerns for that person, developing a formulation that's a shared formulation based on their story, it's constructed rather than discovered. And that we're constantly moving along as we go as more evidence comes in. So we're also working in an area where there's a lot of stigma or discrimination for the people in actually acknowledging they have these issues and I think we need to be very mindful that those are happening for a lot of our clients as well and take them into account in being non-judgmental and very gentle sometimes with our clients. Thank you. Thank you very much, Margaret. And thank you for reminding us about the PTSD in this case. I think this happens with dual diagnosis and comorbidities that it's just such a big, big area that it's very difficult to address all the issues in an hour and 15 minutes, but you guys have certainly made a very regular tent of doing so. And now lastly, I'll ask you, Enrico, just to sum up. Thanks, Locally. In fact, I'm going to just defer my summary by a second, because I think Margaret was quite right in raising the PTSD issue in the way Doug reports he's drinking. It's a type of self-medication. And of course, the risk is that if we stop Doug from drinking immediately, and I've seen this a number of times, the patient's PTSD symptoms become much worse because they have been dampened in the short term by drinking or by taking some other central nervous system to present. So we do need to have some interventions in place. Indeed, there is a PTSD problem here following our assessment. Anyway, to summarize, I think Doug presents us with a very common scenario and we've heard about the epidemiology of dual diagnosis being so common that really it should be the expectation seen as the expectation rather than the exception. And so there's an onus on all us clinicians to be dual diagnosis capable to a certain extent. And so we should be able to screen, identify, and assess patients' substance use problems and their other mental health problems as they present. And from there, perhaps form a diagnosis, but certainly form a problem list which of course needs to be prioritized from those problems that are the riskiest and more urgent to those that are less risky and can be deferred perhaps or treated a little bit further down the track. And to think, with integrated treatment, we bring together both psychosocial treatments and pharmacological treatments. And I'd like to conclude by saying that there have been a number of meta-analyses in relation to both psychosocial treatments and pharmacological treatments for people with substance use disorder and in particular depression, but to a certain extent substance use disorder and anxiety. And overwhelmingly, these meta-analyses are demonstrating some effectiveness of integrated treatment and that we can provide, which to me means that we can provide very positive, therapeutic and compatible responses to patients such as by presenting with this whole range of substance use mental health problems. Thank you very much, Enrico. And thank you very much all of our panel, Margaret, Richard, Adrian. We're just coming towards the end of this session and it's been a very, very good webinar, a lot of good information, extremely good participants and attendees, very good questions, kept us all going all evening. Some of the points that I picked up from this evening were the importance of engagement, that co-mobility is everybody's responsibility, the importance of the motivational interview and motivational therapy, and that there's no wrong door that the patient comes through and he may present, he or she may present to any one of us. The importance of using both psychosocial and pharmacological management, for which there is an evidence base, the importance of the stress vulnerability model, and also I will take away what Adrian said, that if you don't ask the question about alcohol, you are not going to get anywhere with the client. We have an expression in general practice that there's more myths from not looking than from not knowing. So asking the question is really important. Knowing what the safe levels are for alcohol, knowing the recommendations for different types of alcohol, intake of management recommendations, the engagement, as I said before, is really, really important. And also, and perhaps we may go into this in another webinar because this case, even though it was just a page and a bit, it had so much in it. The issues, it was quite interesting that it took Margaret to pull us back and remind us about the PTSD and I was particularly interested in hearing the thoughts on allowing the patient to drink to some extent while you treated the PTSD first. I'd like to thank everybody for their participation. Please ensure that you complete the exit survey for 1,895 of you. There will be a link. You will get the slides and our next webinar will be working together to support the mental health of older adults in the community. Please keep an eye out on www.mhpn.org.au slash upcoming webinars for the days and registration information. You have been a very, very good audience. You made very, very good points. I have learned from reading what you said. You asked very, very good questions. I think our panels are one of the best panels that we've had. They've been very knowledgeable and I certainly learned a lot from this webinar tonight. I still wish you all the best and if you're away from home, drive home safely.