 Hello, and welcome to this expert interview recorded for the 2019 MHPN mental health online conference, Working Better Together. The topic of this interview is recent developments in military and veteran mental health research, and joining me to discuss this topic today is Professor Richard Bryant. Richard really requires no introduction, suffice to say that he's one of the world's leading experts in post-traumatic mental health. And one of his many titles is Scientia Professor in the School of Psychology at the University of New South Wales. So welcome, Richard. Thank you very much indeed for joining us. My pleasure. It strikes me that there's been a dramatic increase in the amount of research looking at veteran and military mental health over the last decade or two. Would you go along with that? Oh, without a doubt. And I think it's down to two reasons in particular. I think the first one is everybody knows we've had a series of major deployments and the major countries around the world. They have been involved, particularly in the Middle East. So all the deployments in Iraq and Afghanistan, that's seen a lot of people go there, a lot of people exposed to trauma. And that means there's a lot of psychological injury. I think that then flows into the second factor, which is a lot of departments of Veterans Affairs around the world have realized not just now, but for the next 10, 20, 30, 40 years, they're going to be picking up the pieces of the fallout of those deployments. And so there's been a phenomenal amount of research funding and practice funding to actually increase our knowledge so that it can actually result in better mental health services. So this is not, if I was going to be just a tiny bit cynical, it's not only about the human cost of these psychiatric casualties, it's also perhaps about the financial costs to our governments over the coming decades. I don't think we need to be apologetic about that. If we look at the projected costs of departments of Veterans Affairs around the world, they are astronomical, both in the physical domain, but the psychological is accounting for a huge proportion of it. And so they need to be planning now for how they're going to deal with those realities. Okay, so we've got to see this increased investment in research as being a good thing. We've got to applaud it. There are, of course, a whole range of areas that we could talk about and we've got a very limited time today. So we'll just focus on a few specific areas. And one area that seems to me has received a lot of attention and quite rightly recently is the area of suicide, suicide among military and veteran personnel. I wonder if you could just say a little bit about the kinds of research that's being done in that area and perhaps the key research questions that are being explored. Sure. I think in terms of where the field is going in terms of suicide at the moment, the major take-home message for me is that it is multi-pronged. I think for many years we've taken a very myopic approach, that it's this or it's that. And now if you look at some of the major reviews and meta-analyses that are coming out, what they're really telling us is that if we actually focus on one thing or the other, we're really not going to solve the problem. Underpinning this, there's for years being the notion that suicide is or suicidal risk is driven by a desire to die, the person wants to die. And there's been a shift, I think, in understanding that it's really not that the person wants to die. It's that a person is actually going through so much psychological or emotional pain. They just can't cope with it anymore. So it's actually more palatable to just get out of that painful situation and suicide is the only option. Now what that means is that the conclusion is that the person gets to a point where there are no other means to actually get the help. So the way we understand it is that there's a number of factors that can contribute to why a person might take their own life. Some of these are intracyclic and so there's been a lot of work done on risk factors in terms of cognitive mechanisms, impulse taking, those sort of psychological within an individual factors that contribute to suicidal. But then there's other contextual factors and so we know that family support, for example, is a massive factor in predicting whether somebody is actually going to attempt and complete suicide. And so people are understanding that when there is actually a successful suicide, it tends to be when these various factors all come together to the perfect storm. There's no other option and then the person does take their life. And presumably when we're looking at these kind of subtle combinations of factors, we need to do the research, we need big data sets, don't we? We need a lot of people. I mean, how are we going about that internationally? Well, that's exactly right because even though suicidal risk is very high in terms of prevalence rates, particularly in some populations, completed suicides is actually much, much lower. And so you really need to look at population data sets, which is what people are starting to do now, particularly when there are very large population-wide studies and some countries actually collect this in their death records, the nature of death. And you need that sort of data to actually inform us. But I think the point I'd make about what the main interventions are, again, it has to be multi-pronged. And so there's been a lot of work done on first contact. So for example, training up GPs, getting primary care to really understand how to detect suicidal risk and how to refer and act on it. That's a huge component and that actually does have a demonstrated effect. But then you've also got to have practitioners who then know how to help a person with more intracyclic factors. And so it's got to put these things have to come together. Sure. I wonder when we look at the research designs, it seems to me that suicidal ideation is quite common. Oh, yeah. Suicidal attempts of suicidal, completed suicides are rare. So it's presumably this group of suicide attempters that are going to give us the best understanding. Do you think in terms of understanding these various factors that lead someone to that point of making an attempt? Well, that's exactly right. And that's where a lot of work is happening. It's this, as you said, suicidal ideation is very, very common, both within mental disorders and outside mental disorders. But it's actually as we go up that continuum where I actually start to make a plan. So I have a plan. I'm thinking about it very seriously. Then the next stage is the people who then actually implement that plan and actually attempt it. And then there are degrees of attempt to the point of actually successful completion. So it's in that middle phase that we do learn a lot about what tips that person over. You know, to that really, really dangerous phase. And that's where we need to put so much energy, because these are the people who are really, really at risk. Yeah. Yeah. OK. So obviously a lot of people who attempt suicide have mental health problems, not all, but a lot do. Let's move on and talk a little bit about mental health problems and the prevalence. What have we been learning about the prevalence of mental health problems in military and veteran populations? Well, again, there's been a phenomenal amount since the Middle East deployments. And what's interesting is that and everyone's been arguing about this for 10 years, we get different prevalence rates according to different countries. And I won't bore everybody with the various reasons about why we get at different rates. I think from a local perspective and Australian perspective, the most interesting example to talk about is the recent transition and wellbeing study that was done here in Australia, which is quite a novel study in a way, because it actually looked at many, many personnel who were in the Army, or sorry, in the Defence Force, and then transitioned to the Veterans Affairs, and they were followed up. And that gave us a very good insight into the trajectories of how it's shifting. And some of the take-home messages from that study, and not all the reports are released yet, I should add, there'll be a lot more information coming out when they are released. But what we know so far is that the people who are transitioning are far more at risk of mental health problems. So we know for people who have transitioned out of defence, like half of them have had a mental disorder in the last 12 months, which is far greater than what we see in people who have remained in defence. That's a huge proportion. It's a massive... 50% of people coming out. Yeah. Now, we need to recognise that there's, again, numerous factors for why that might occur. So without a doubt, part of it's the healthy warrior effect. So the people who are not having psychological problems, they're actually staying in defence because they're healthy, psychologically healthy, they're enjoying it. They're probably performing their tasks very well within the organisation. So they stay and there's a career path. And the people where that's not happening, they are motivated to leave. But beyond that, there's also evidence from that data suggesting that even in the first period coming out of transition, that there is a real spike in the rate of mental disorders. And what's particularly interesting, it's not all mental disorders. It's particularly anxiety. So I was going to ask about that because when we think about mental disorders in this population, we automatically jump to PTSD as a diagnosis. I guess we need to be thinking more broadly than just PTSD. Well, it's funny you should say that. If we think about the transition study, for example, as I said, one in two people have had a psychological problem in the last 12 months. But what was really a standout was the anxiety disorders and particularly PTSD and panic. They were the two and over a third of the transition people had an anxiety disorder in the last 12 months. And again, that's a very, very high rate. And it does tell us something about the nature of the psychological problems that people are experiencing. And the fact that it's PTSD and panic, it's what I would mechanistically, you know, conceptualize is these are fear, circuitry type problems at heart. And these are the problems that the people are developing. Yeah. And then perhaps as time goes on, the problems become a bit more amorphous and we see more depression emerging, would you say? And perhaps in our veteran populations, we tend to see this general distress and depression. That'd be legitimate. To be to be absolutely objective about it, I don't think we really know. OK. Intuitively, I think with most chronic conditions across disorders, we tend to see depression and adjustment disorders clicking in. That that tends to be the case. If we continue with the transition study and I don't know whether it will continue, I mean, that that would actually allow us to map that out. Sure. Sure. Let me come back if I could to. We talked a lot about transition. You talked about identifying risk and so on. And I would just say that that statistic that you've got half the people coming out with a mental health problem, the good side of that, I suppose, is we know where they are at that point and we should be able to intervene. But we're going to talk about treatment in just a minute. Come back to risk. Obviously, not everybody who joins the military develops a mental health problem. What's the research telling us about what are the risk factors? I mean, I guess it's it's a really high priority for military and emergency services organization to get better at identifying vulnerable people. Are we learning anything about this risk factors, vulnerability factors? Look, we've known what the major risk factors are for things like PTSD for years. And to be honest, the risk factors for PTSD are the risk factors for every, like access one disorder, to be honest, you know, if you haven't. I mean, we know genetics plays a big role. We know that childhood trauma, childhood psychological difficulties, low socioeconomic status, low social support. We know all these are risk factors. I think the big challenge for defense and emergency responders is really can they, one of the first questions is can they identify people at the recruitment stage who's actually going to develop a problem? Now, we know all around the world, every agency throws phenomenal resources into screening people. And it's not just psychological screening. They do all sorts of other screening in terms of looking at their histories, their work records, academic performance. Now, a lot of those factors are actually correlated with good mental health. So using those parameters, those hard parameters before you get to psychological screening is actually a very robust way of actually filtering out a lot of people who probably won't even cope with the training, let alone coping in the organization. When it comes down to the more traditional, like what we think is psychological screening, to be honest, the date is pretty poor. And so things like the MMPI, for example, and some of these very commonly used and also incredibly expensive and labor intensive measures, to be perfectly honest, they don't perform very well if you look at the systematic reviews across agencies. So I'm very dubious about their capacity. And even though there's a relationship for them, statistically, when you come down to screening, it boils down to a single question. And that is, does it have good specificity and sensitivity? So it might be a relationship, but if one particular individual comes in, can you say this cutoff, this person's this likely to develop a disorder or not? And are we anywhere near that? No. The answer's no. No, because we can't afford to have too many false positives because we'll never get enough people into the military if we kick out everyone who might possibly be at risk, I guess. Yes. Let's move on because I think a lot of clinicians will be very interested in treatment and talk about what the research is now telling us about treating, I guess, predominantly PTSD and related conditions in this kind of population. I suppose for a while we've been thinking of trauma-focused psychological treatments as being the frontline treatment. Will that still be the case for this population? Oh, without a doubt. I mean, for 20 years, to be honest, across every trauma-exposed population with PTSD, prolonged exposure, EMDR, cognitive processing therapy, et cetera, which for me, they're all the same. They're all tapping into the same mechanisms. There's emotional processing and there's cognitive reframing. We know that they are all frontline treatments. And also we know over the last 20 years that we've hit a brick wall because a half to a two-thirds of people are gonna benefit from them. And that's all. Let me come back to that because it's a very important point. But in terms of, I guess, the rollout of these first-line treatments, which I know the US has put a lot of money into, how effective are we at getting clinicians to actually do those trauma-focused psychological treatments as the first attempt as it were? Is it working? In a word, no. And this is not just the military or veteran provider community. This is across the entire community. You look at the numbers of people who get what I would call evidence-based or the frontline treatments, they don't. And again, let me just go back to the transition study. One of the reports there focused on pathways to care. And they looked into this sort of issue. And they did find surprisingly that most veterans, after they'd left defense, they did see care. But much, much fewer number, actually we're getting evidence-based care. And that's the worry because it means that a lot of veterans are going out there and getting assistance, but they're not getting the assistance that we think, or we know, rather, is going to give them the best chance of recovery. It's amazingly difficult, isn't it, to disseminate and implement these kinds of things. I mean, I remind you often, actually, shouldn't digress, but even simple things like washing hands is incredibly difficult to get health workers to do regularly. But anyway, that's a digression. I want to come back to your very... That's a huge digression. It is, it is. I want to come back to your very important point, which is that a third to a half of people are not responding well to these first-line treatments. So what are we doing about that? What are we doing in terms of trying to find something else? There is an enormous amount going on. And it's been going on, to be honest, for 10 to 15 years, where people are, to be honest, building mainly on neuroscience endeavors. And essentially the way most of these approaches have been sort of working is it's presuming that exposure therapy, which is the main mechanism, works on the basis of extinction learning. And to put this very simply, it's that if I get exposed to the reminders of the trauma in PTSD case, the memories, that I'm going to do this repeatedly, I'm going to learn that it's no longer hurting me. And in essence, what we think happening, or we're pretty sure is happening, is it's a rewiring of the brain. Because we know that for people with PTSD, the medial prefrontal cortex up here, we know that that's critical in terms of down-regulating the amygdala. And that's basically how extinction learning works. And PTSD folk are deficient in that. So what a lot of studies are doing are trying to actually augment extinction learning. And they've been looking at a lot of the rat literature because a lot of gains have been made there. So a lot of them use pharmacological interventions. So there's... Things like MDMA, is that right? Well, MDMA is one example, or ecstasy is one example of, in very recent years, that's got a lot of energy. People are jumping up and down about it. Okay, but anyway, so it's really, I'm sorry to interrupt, but it's really about trying to improve our existing treatments predominantly at this point. Are we... Is there anything on the horizon as something completely novel coming at it from a different perspective altogether? Or perhaps... I don't think so. And my personal feeling is the reason, I think, a lot of these attempts, and that's... I mean, there's MDMA, but there's a bunch of other... People trying to do glucocorticoids in terms of augmenting or noragenergic agents. But none of these are really making a breakthrough, if you like. And I think, for me, the reason is, they're all focusing on extinction learning and fear circuitry. And they're basically saying, this extinction learning, which is like getting at the fear aspect, that's what is going to drive person getting better. And that's what all the energy, because it's been driven by the neuroscience. I'm a great fan of that, and I think there's value in it. But if you actually look at a lot of the literature on why people don't respond to treatment like the trauma-focused therapies, it's often not because of their difficulties in responding to the exposure. It's, of course, of all, often the comorbidity. You know, there's entrenched depression. There's cognitive features. There's very strong rumination. There's interpersonal difficulties. Now, all of these factors come into play, and as you speak to a lot of clinicians, and in fact, a lot of the data, it'll tell you these are the reasons a person's not responding to treatment. So hammering away at the extinction learning might not really be getting at the core reasons why a person's not responding. We've got to wind up very shortly, but it just does strike me that these are very complex people to treat very often, aren't they? And I wonder whether in Australia we're making any strides in terms of, I guess, strategies to support clinicians in the field when they're confronted by this incredibly complex clinical presentation. Look, it's a great challenge for a lot of practitioners, and I'm the same, often you feel out of depth in terms of how to deal with something. I mean, I think there are initiatives at the moment. I know that, for example, Phoenix, Australia, in Melbourne, I mean, they have an initiative at the moment, part of their ANZAC centenary initiative, and basically it's a practitioner support service, and that's actually making itself available, and it's free of charge. Any practitioner can actually get on the phone and talk to a psychiatrist or a clinical psychologist or somebody and say, look, I've got this really tough case, what do I do? That's a very good service, isn't it? I must say, very good service. Okay, now we have to wind up, unfortunately. I think we could have actually devoted the whole interview to talking about treatment, really, because it's so interesting what's happening there. I want you to finish just with a couple of very quick reflections on how you see the future. What do you think are the big research questions that we need to be addressing over the next five years? Where I'd like to see the field go is I think we need to broaden things a lot more from PTSD and we need to get away from diagnosis. Now, a lot of people think that's funny coming from me because I wrote a lot of the diagnoses, I was on all the committees, but I think the problem is we label somebody as PTSD or depression or panic disorder. And then we sort of, as a package, we think, let me throw this treatment module at that person. When really, I think where the research is going to go, which hopefully will then lead to the practitioners following, where there are mechanisms, there are processes at play, and these are often trans-diagnostic. And I think the more we can actually focus on that, we will actually get to far more tailored, nuanced approaches that actually meet the individual need of a particular veteran who walks in the door rather than just in a whole diagnosis. It's a quantum leap, almost, to the whole new level of sophistication, really, to be looking at treatment from that much broader perspective. Yes, and so in that sense, I don't think we'll be there in five years, but I think the field is just starting to open that door. Yeah, brilliant. Thank you very much, Richard. There's a veritable goldmine of information there and we could have followed multitude of leads, but we haven't got the time, unfortunately. So we'll leave it there. Thank you very much indeed for your time. Always a pleasure.