 Thank you everybody for joining us tonight. We have had over 800 registrations for the webinar tonight We have an interdisciplinary panel discussion On a collaborative approach to supporting people with coronary heart disease and depression My name is Marco Murray. I'm a GP in town for with a special interest in wellness and psychological medicine and our panel tonight is Is eclectic and talented and covers many different disciplines and Rob Grenfell is a GP who practice near who practices near Horsham and Victoria He's a special interest in heart disease as well as being a rural doctor and he's well valued by the heart foundation for whom he consults David Calvoun is a cardiologist in Brisbane and he has also Has been for many years an associate professor at the University of Queensland. He also has a special interest in wellness and cardiology Dr. Rosemary Higgins is a psychologist. She practices at screening hospital in Melbourne She is a senior research fellow and at the heart of research foundation and lastly we have Nick Nick is a Practicers at the of all pH and Sydney he is associated with the brain and heart and mind Institute and in Sydney and he is a professor of psychiatry Now to ensure that everybody has an opportunity to participate to ask questions And we have a few ground rules be respectful about the participants and panelists behave as this would have faced the face activity Culture comments and questions for panels in the general chat box for help with technical issues post in the technical health chat box Be mindful that comments posted in the chat boxes can be seen by all participants and panelists Your feedback is very important So please complete the short exit survey which will appear as a pop-up when you exit the webinar We have some learning objectives for tonight So through an interdisciplinary panel discussion about Sheila you will have received the case study and read it If you haven't just picked back into NHPN and you'll be able to find it at the completion of the webinar Participants will better understand the mental health indicators in the context of coronary heart disease Identify the key principles of the featured disciplines approach in screening Diagnosing and supporting Sheila and lastly explore tips and strategies for interdisciplinary collaboration to support people like Sheila We are very grateful for your love to you tonight, and I trust that you have an enjoyable evening. We will now and Move on to our GP and Rob Grenfell and we will ask him to start his presentation. Thank you. Thanks so much Michael What we Have with Sheila is a patient that most of us in fact actually Know quite well in general practice someone who's been coming to see us for a good 20 or so years but the things that strikes me first about Sheila is how Stoic she is and in fact actually how she tends to be using her intellect as a cover and Sort of patients actually pretty resistant to Complaining about things and when they do complain about things the matter of Well, how sick are they and the question that I always ask with a patient coming to these types of problems at the beginning is what am I actually missing and the The thing behind that as we read through this case is that obviously from a general practice that Sometimes familiarity means that you actually do miss a lot of those cues because again patient like this is a real relief to see In most of your days because they're a big an intellectual conversation You'll have a lot of things to talk about and you may in fact actually be Outfoxed by them and not talk about the type of problems that she's really got or she may downplay those and be more Interested in talking about other things. Thank you Michael. We'll go to the next slide And and I guess as we move through there. We you know, thankfully saved her life around 56 by picking up some Occluded coronaries but That's reported by her husband. She just doesn't seem to be doing the best and You know why is it? You know for someone who's still you know a young person. Let's face it And and how serious is this condition and what's Again the question comes to me about what's actually not being said because we've got a report here from her husband that she just doesn't seem to be How she is but You know she herself is not letting on with that so next slide. Thanks Michael Now the thing with some when you when you're looking at You know the whole patients you tend to be thinking about Well, I guess the patient directs you to where and what you're going to be talking about and They will Unless you question them They probably won't talk about some of the insecurities and some of the problems and this of course is a is a major Major problem, but again physical conditions deteriorate and as we age The condition itself would deteriorate and this is this is where With this particular patient it suddenly to work out the queues that were picked up in this case was she's not doing the best that she could and That was the the trigger for going back to the cardiologist and the insistence from the GP and again I think I can relate to this this issue with intelligent patient is not really telling you a bit You've got your radar up and you think hold on. This is a complaint from someone who doesn't complain. We need to deal with this So next slide. Thanks Michael And I guess the thing is again, she's young At 72 years of age, this is not an old patient by my standards So many of my rural patients were well in their 80s and still farming. So someone at 72 is talking about some shortness of breath or Digitally in fact actually doing physical activity or Something that the alarm bells are going off for me And and why is the therapy not working? My first thing I often think about is they're knowing that adherence is an extremely Poor thing for particularly people after that heart a heart attack unfortunately most people at least their medications by two years and I'd be asking is she actually taking a medication as she complies to these and probably the last question I've always got myself is my diagnosis wrong and I guess that's really the essence of medical practice That's why we call it practice because we're forever practicing it And I guess ultimately we retire when we think we've got it right Michael Thank you very much Rob and now we'll move on to David cousin that's important cardiologist David Yeah, well an important thing in patients with coron disease if we go to the first slide is that 30 to 40 percent around the time of their admission to hospital have At least mild depression Major depression may be around about 20 percent And it's usually missed. This is a slide that demonstrates Six years after the heart attack in the Australian lipid trial Which was a trial and best to go to cover satin versus to see both we use the beck depression inventory, which is commonly used in research studies and 27 percent of miles and 38 percent of females had a BDI to greater than 10 which is at least mild depression So this is very prevalent condition And had nothing to do With baseline character what your cholesterol is or whether you're on statins or not that they make this is the first trial That really showed statins don't cause depression. They can see this is a very prevalent risk factor And the heart foundation 2003 reviewed all the data and pointed out that depression is an independent risk factor of heart disease independent of You know cholesterol Hypertension, so it's a very prevalent risk factor Now if we move on to the next slide, how does it Back up to classic risk factors. It would see depression down the bottom there If you've got in just depressed mood, you don't fulfill the criteria for depression according to DSM 5 That's still influences prognosis as you can see Similar to the classic risk factors The thing is it took at least a decade After get doctors to be Measuring cholesterol and treating it. I think we'll take a lot longer here. So this is a very prevalent risk factor But there's stigma associated with it. There's a lot of people believe I look at just a reaction to illness But more importantly if we go to the next slide Even when we go to the first teaching hospital in the world the creme de la creme if you like, you know The Johns Hopkins just focused down on my first dot point 75% of cardiologists missed it even though they knew without the patients of being screened in the curry care unit there nurses much the same Consultants registrar's are all equally not good using our impressionistic medicine when we're doing rounds in the curry care unit And then in the ones we said had depression look about 24% Positive so we're not very good clearly. We need a tool to help us Measuring diabetes and ancient Egypt We tasted the urine and we said oh sugar in the urine that's diabetes. We need something better We've got blood tests. We got to move to the next one the heart foundation Following the example next slide the example of the American Heart Association We reformed our stretch working group and Nick is part of our group Nick Glossier And we've read with the Americans that our screening tools they get the ball rolling The phq to the patient health questionnaire These two questions here really simple when you're using the patient health questionnaire The two questions it's over the past month and anyone can remember this. Have you Often been bothered by feeling down happy for the press Yes, or no during the past month. Have you often been bothered by a little interest or pleasure in doing things? These two simple questions Are more than 90 percent sensitive to the development before the diagnosis of depression in other words They're mandatory questions now look it's self-fulfilling because if you look at DSM 5 and here we have the handbook here The first two questions were diagnosed of major depression You must have one or two of those questions that they have is over the next two weeks Um, and then you need four out of five of the other questions And what are these other questions go to the heart foundation website here? It is here. We can see on the camera This is on the heart foundation website and you can if you want to do look at all the other questions here and score if you like And our patient here poor old, um, Sheila she has Probably if we answer directly She says yes to probably both of the above and she's also got trouble sleeping Feeling tired and worn out and short of the breath is frequently a cause Is related to depression the next slide is a very simple screening tool which we all can remember Four questions rather than a tool It has prognostic information. This is from the san francisco Heart and soul study. We just go to the next slide just saying yes to either of those two questions As a major influence on prognosis Saying yes to either 55 percent greater cardiovascular events over the next six year follow-up That is very powerful prediction. Now a lot of the uh, uh depression is accounted for by Smoking non-exercise always other things in non-compliance But that's very important predictor that we need to do something now How can we do it next slide those two questions? We're introducing into our hospital Uh, the nurses put the stamp on Okay, so there rather than stamps is someone at risk of dbt. This is far more important the nurses love Uh, uh, this idea of doing the screening because they do it anyway. They do it when the patient's going to rehab Let's do it formally there and that highlights to the doctors and anyone else this patient Maybe at risk of depression needs to have further follow-up So I think I might stop there Michael because uh, mccardial's perspective Depression or my low mood is frequent Frequently missed and it has important prognostic information there and it's as important as diabetes type attention hypercostalemia Thank you very much. David. That's that's the That's the tone for the rest of the evening. I think Yeah, we'll just hear from our psychologist Rosemary Oh, yes, Rosemary. I just want to firstly thank the um cardiologist for measuring depression. That was brilliant Now she was presenting with some worsening health issues She has that reluctance to bother the cardiologist that um, Rob was talking about as well with the gp fear of the emotional impact of further health issues some anxiety and panic Brief re loss of strength and aging some positive response to the depression screen And symptoms which you know depression symptoms cardiac symptoms other symptoms also sleep problems And low coping self efficacy. She's not sure if she'll be able to cope Then looking at it the precipitating factors for why now The husband has retired that retirement of a spouse can create quite a lot of pressure Canceled holiday there could be some guilt and tension regarding that Possible trauma and anxiety from the previous surgery in the infection She's an internalizer And person who seems to put her own needs last And there's been a large amount of threat to her role Pregnant if decline is possible and also what's the meaning of worn down? These are the sorts of things I'd like to know a little bit more about In terms of the perpetuating factors as we said, she's an internalizer We're not sure about her perceptions of the illness. You know what she thinks her illness is what it represents Um, we're not quite sure we know that she values strength and health And that's a big source of pride. So this is a major loss in terms of identity and perhaps these illnesses are weakness Her family relationship role She doesn't seem to be we don't have anything about her community or a friend So there's some concern that she might be isolated We don't know anything about her self management skills and capacity And it seems that she hasn't gone to cardiac rehabilitation In terms of the protective factors It would be really nice if she had an adult daughter That's a lovely thing to have as a patient Is her medical support her husband her own independence and resilience Whereas it gets in the way of her seeking help. It will also assist her in some ways A previous history of good coping But unsure at the moment better health behaviors or social support And really with with her I'd be wanting to work on values on what she values what her personal goals are Getting a physically active perhaps a bit of mindfulness Some cognitive behavior therapy But I'd really like to get her into the cardiac rehabilitation and get some group support going And possibly some sleep Intervention maybe self-management support or empowerment Thank you very much Rosemary. So that's really flashing it all out for us now Robert and David have set the scene from a medical point of view from a general practitioner's point of view Looking at things that can go wrong and looking at the possible and misdiagnosis of use time here rather than a suppress of episodes when somebody presents the heart disease And and Rosemary has looked at the factors the protective factors and these are the perpetuating factors and the perpetuating factors And now we're going to move on to our psychiatrist Nick And Okay, thank you very much So the role of a psychiatrist in this is I see very much really about Supporting the general practitioner in the primary sort of pivotal management of someone like this And potentially being there as part of a stepped or collaborative care approach To managing someone like this and also potentially helping The psychologist as well. These are the people I see very much as the first line and we really Psychiatrist role is very much for Information advice and potentially if things don't go well or there's a failure to improve So on one level, you know, people may like a diagnosis confirmed Certainly, of course, you've got the by the time someone actually agrees to come to see someone like me They have taken on board the idea that they may or They may have a A psychiatric or psychological condition Now in many of these cases many of her symptoms could be both anxiety or depression or the mixture of the two of them And I think that actually the difference is moved at the often at the at the initial level Um, I think what what we will probably be doing is looking at a initial one-off assessment to provide advice The kind of sort of 291 or 296 and actually examine what kind of treatment that Sheila and or Hugh Would prefer whether we can go to a sort of time limited treatment for Problem-solving CBT into personal therapy or medication or both as well as some other treatments. I'll talk about Interesting, although in this particular case, I would advocate taking a patient or couple centered approach Given the background some of the data shows that bringing the family and actually can be negative at times Potentially to do with stigma So if you can move on to the next slide, please so if we confirm that she's depressed or it's obviously and One of the areas we're looking at is actually extending the phq2 into the phq9 and those tools actually make Psychiatrists diagnosed better as well than when they're allowed to do things just off their own back Um, you can look at what kind of treatment recommendations And I think the one that actually has by far the most evidence behind it the best evidence is actually exercise So everyone's talking about behavioral activation and exercise and people might we might have to help address A how that happens and B potentially have fears about that of how one might start that and tailor that to her Then as I said, you've got to talk about the potential for sort of more focused Anti-depressant treatments be that both medication or time limited psychotherapy and access could be an issue for the psychotherapy beauty Interventions, I've got a trial actually showing that some of the internet-based psychotherapeutic interventions are not as effective But they are effective and they're free and they are readily available if people can't get to see a psychotherapist or other treating clinician in that way If you do go down to the medication route, then I think it'd be very important to actually Treat this in a very sort of standardized way keeping track of her symptoms Which are keeping track of the side effects particularly any of the more severe side effects and very much looking at adherence as rob said I think adherence compliance concordance Really really important people are depressed three times more likely to be non adherent than people are not depressed There's a really big issue And again, we can use other other parts of the health system as well So sessions with an exercise physiologist or dietician to help in addressing diet and other well-being factors Next slide, please There's another Symptoms and others have highlighted the idea of sleep disorder So one of the areas I'm particularly interested in is actually treating sleep disorder and evaluating whether it's an insomnia She has whether we're looking at some kind of phase advance i.e. people whose Phase system their body clock becomes out of kilter with their environment And actually treating this specifically and there are a range of things from the very sort of simple sleep hygiene To the more specific cbti approaches again both face-to-face or the internet which could be done Um, I wouldn't necessarily be going down the benzodiazepine route And if this is a problem one might consider some of the more sedating antidepressants if required We talked about the psychological impacts or her role change from coping care to what is she now? What does she see herself and all the aspects that have been brought up earlier on? I think the fatigue is an interesting issue people have flagged up the idea. Well, what is the cause? Is this some heart failure? Is this depression? Is there something else going on? Is there another is this a result of sleep disturbance of some cause? And again with someone who's expressing some health anxieties You've always got to balance those issues around how far do you investigate versus good history taking and Continual investigation can actually exacerbate people's health anxieties rather than Rather than actually making people more reassured, you know the classic I don't think there's anything wrong with you, but I'm just going to do a brain scan just in case Next slide please We've all talked about very much the family concerns and particularly the husband's concerns You know, what is what are his concerns about her illness and what the impact might be on there looking at diet Looking at enjoyable activities. This is someone who's been a coper and care all of her life What things does she want? What does she actually want out of treatment? What does she want to achieve in her life as ever and said she's still really quite young? Family involvement and one thing I'd be quite concerned about with with this woman is just checking her cognition I do a mini mental state exam or gets asked someone else to do that particularly early on There's quite likely if she is depressed and potentially with a cardiac history that she has some Cognitive impairment But I'd be interested to see whether this improves as her depression and cardiovascular risks are addressed Or whether there might be something underlying Her cognitive in some underlying cognitive dysfunction that may be driving some of her anxiety and concerns And the other area particularly if she's technically literate is we're using increasing amounts of the measured self You know sleep and moot diaries sleep applications sleep cognitive cognitive training through things like luminosity The use of pedometers so really getting her engaged in our own health management And that's it. I think for my my particular aspect. Thank you. Thank you very much, Nick So we've gone through the four panelists. We've had the setting of The general practice aspect the specialist aspect And We're now going to move on to the panel and conversation start discussions And I did note that there was a question from one of our attendees John Clark Where is the exercise physiologist and that leads me on to ask rosemary to You were concerned rosemary that then this patient Hadn't been for cardiac rehabilitation and you had some questions to ask around us Yes, um Many patients do miss out on cardiac rehabilitation and and that is a concern cardiac rehabilitation is very good for mobilizing patients And it also explains and talks about emotional health as well as physical health They can get access to all the health professionals and They um, there's enough evidence to say that it it does help it does assist And I think that Sheila had she gone to cardiac rehabilitation would have Early tackled the exercise and got a lot more confidence and maybe that would have helped her with her mood issues as well And rob from Europe from Europe consulting with the heart foundation What would be the main reason why somebody wouldn't be able to get into rehab? Uh, unfortunately, um, Michael in in today's climate only one in four Heart attack sufferers actually referred in the first place to cardiac rehab. So the problem begins at the hospital And some of our therapies of course are lasting You know two three four days at the maximum and sometimes they're padded on the shoulder and said you fix After a sense being put in and so they they're not even encouraged from the care team in the hospital That's something that from the heart foundation's perspective that we're we're trying to address from the health professional The the next challenge of course is when they turn up to you in your general practice and I used to play this sort of game How long will the discharge summary take to get to me? Um, and particularly the more rural you are and I was um isolated rural often You'd never see the discharge summary. So you you wouldn't have an idea about where the follow-up was the next is Is the patient's um, do they think that rehab is relevant? So a young patient versus an older patient group therapy if you've got a drive 50 or 100 kilometer round trip to go to cardiac rehab Are you going to go? How does this in fact actually fit into my life as to where it is? And probably the other pressing thing is denial. Another patient's factor is that um, I'm right now my symptoms are resolved I don't need to do this or I'm not going to deal with this and those are those are some of the Reasons why someone won't get rehab, but probably the main one is doctors. We're failing our patients by not referring them on David do you have any comments on this? Yeah, well at the two hospitals that I picked us at we agreed 25 years ago that all patients Can be approached the cardiologist can be approached by our liaison tactic rehabilitation this and every single patient is invited to join So you don't have to it's just silly to say you have to be referred. It's a routine thing So i'm at a private hospital everyone gets involved now I can't say that happens in our public hospitals That necessarily happens that way because then they don't necessarily have rehab units But with cost cutting and other things Honestly, there's no excuse for it But let me just say my colleagues are more interested in doing the high end doing balloons and stents and stuff And the patients are in and out very quickly as Rob points out and they're focused on this stuff Using the toys if you like rather than the long-term things that are very important The most important to have patients feel about themselves and what are they like? So it's partly the system But let me just say all you have to do is get your mates together and you have the meeting and the nurses love this They support the patients and everyone's approached in my part in my hospital for the last 20 something years Thanks very much Nick. Do you have any comments? Davidson and Robert leave it to us there on the the benefits of group therapies via cardiac rehab as against individual therapies The first comment I have in this particular area that I think we we heard it alluded to there is if you want to do things and get and get Good treatment across everybody one of the things we you know We we understand is that some people get stigmatized certain groups Either through their own denial or because of the way that doctors consider them Tend to not be invited to certain treatments We know that people with depression get fewer angioplasty and fewer stents despite being a high-risk group And in fact they have in a paper I've viewed recently a longer door to needle time in the emergency department as well So there's a whole bunch of system things And as they've alluded to I think something interesting is the idea if you ask doctors to do things Often things fall through for cracks really whereas when you actually set up systems And you use the professions allied to medicine and it becomes part of their systematic jobs things happen systems happen Patients get better care. So establishing those systems for cardiac rehab identification Really can work well when the systems are embedded and put in place Come go ahead. Sorry Uh in terms of actual the the cardiac rehabilitation The rehab areas is not my my specific area But I've certainly seen some really good results from group treatments there And the group can often sort of help break down some of the barriers about how people Feel about their illness the implications the perceptions and actually can lead to a kind of sort of group think about Treatment and particularly around behavioral modifications as well rather than necessarily adherence to medication You had a question that you wanted to ask In relation to the issues that that we noticed between the couples In relation to confidentiality care or family discord, etc. Could you expand on that please? the I think several of us have alluded to The issue that this is a couple they share the same gp There appear to be some imbalances. So for instance Sheila has been caring for Hugh for many many years care for the family She's taken on a specific role Um potentially enabled him to live his to live his life do other things He's retired wants to do wants to do something go on a trip that has failed because of her illness So looking at the different roles that the two of them are playing and how those may be changing could be really really important And particularly potentially some of Hugh's anxieties about what he's actually going on with his wife This sort of stoic solid supporting rock who's been with him for so many years and what his concerns might be And the flags have interesting confidentiality issues Don't will Sheila want her husband to know about her diagnosis Will Sheila want any communication about a potential psychological or psychiatric condition being given to someone like Hugh So the confidentiality and the boundaries will be a really important one to play out and This is where all those really really important gp management and sort of social skills come into it Anybody else have any thoughts on the concept how to how to broach the problem with the couple Oh Yeah, I I think that You know, there might well be some tensions there between With the holiday cancelled and Sheila feeling like she's led Hugh down Um, there's I would like them to just get them both in together and get Them to actually try and talk about the bit and for him to realize, you know What's going on with her in her mood that it might not be his fault or might not be anything He's done And but it also might not be something that he can fix because he is probably quite a practical man and likes to get things fixed and You know move on to the next problem So that's that's a bit of a challenge Yes David you've had a very good question For the rest of the panel in relation to how long we could wait before we see an improvement in depression Could you expand on that please? Well, first I'd just like to say rehabilitation literature has shown over the last 30 years improvement in cardiovascular outcomes and This is what nick said an exercise Only programs that have an exercise component is here to be associated with improved cardiovascular outcomes So we've had two major trials in the last 12 months that have shown Improvement not only depression But also improve cardiovascular outcomes with the exercise and it appears that exercise into most patients is mild depression is as good as a drug So it's it's what we've been saying for the last 30 years, but it's good to hear a psychiatrist saying get out and exercise I think it's fantastic, Nick But in terms of the response You know, I mean response to any therapy often we say take six great weeks with depression, but Honestly, in my experience a lot of people feel a lot better within a week or two when you've been able to You know, just say look what's troubling you is not a blocked artery. You know, you're not flibby not you're feeling down um, and it this is to do with you know, you move and um, people often respond much faster than they're meant to By simply unloading a little to their cardiologists like we actually pay attention I think paying attention makes a lot of A lot of sense and that's why so many placebo treatments work well because um, you know patients do heal themselves by just That's just paying attention to being nice to them Yeah, Michael, I'd have to agree is Talking to a patient's a good good idea And asking that question. I think this is where we've been remiss is Which we haven't posed that question about you know, how are you going and that's what's so good about the bq2 because it's really That's effectively you're asking that age old question how things going How are you feeling and and and then in fact actually allowing to listen because I think with this case Again the trust and I've been looking at some of the comments that have coming up there the the trust is the issue Is the GP over 20 odd years? You will have that trust and you will have a fair idea about how far you can go with regards to talking The two patients through the issues separately and then bringing them together Can I just come in on a comment by a david drummond talking about an mi survivor? And I think he's made a very interesting point about how Rehabilitation is often short term and many of the things we see post myocardial infarction post Stroke is really Looking at the impact About the polypharmacy the number of drugs and treatments that people are meant to be on. I wondered uh With david and robb how they deal with those kind of aspects I guess robb There are key drugs that improve survival need to be last term It's really the lipid lowering therapy and the aspirin After that Only if you have heart failure of some complications. So for the simple uncomplicated infarct It's the the statin possible minus the fire rate and the aspirin long term after the first year They actually can be quite simple. I must admit. I try and make it as simple as possible Because I'm only so much you can swallow in you know, honestly in a day Yes Right you have to agree with you there david that you're number one on your list in the long term, of course Is your is your statin as the you know the evidence has shown Uh on how it works. Um, uh the aspirin, of course, uh, again There's substantial evidence for that for preventing further events And I'd agree with you that uh, we we talk about in our guidelines the use of Ate inhibition and that really depends on where's the blood pressure setting but also what's the um cardiac muscle function like and You know ceasing that from a gps perspective is really something you talk to your cardiologist about if you if you're looking at that But it's fair in mind, you know, once you start to get over three tablets people stop taking them And you've got to wonder are they in fact actually on them or not? Um, but largely I would tend to say that secondary prevention which is taking the medications after a heart attack is for the rest of your life You don't have a Much of a say in those if you want to prevent that because the most likely person to have a heart attack in australia today someone who's already had one That can be Can I say something to pop in here? Yes, certainly. Yeah, uh that it can be quite confronting for patients to be put on on those drugs When when I it is so important for them to take it But there might be a lot of psychological work in there as well because they can it's really about confronting the fact that they have a chronic illness not an acute illness and um people may see this illness as something with episodes like Serious episodes like Sheila seems to have had a serious episode but not really been uh looking at this as a chronic long-term illness to manage for the rest of their life And that can be quite a challenge and part of that can be around confronting that death anxiety as well That knowing that you're mortal so there's there's quite a lot of um you know Ways to work with Sheila around that or any patient Yeah, right because I just come in here And I think we need to put the bed It's uh nonsense on catalyst the rob was on I explained to patients. It is fantastic what we can do now Whether you have quest ran to lower cholesterol or niacin or the statin for to the easiest Over 200 000 patients in randomized trials has shown the same thing for every one minimal reduction Of LDL cholesterol. There's 25 reduction of heart attack 20 percent reduction of stroke 10 percent reduction of mortality And in my patients and in all patients you honestly can get too many more reductions So we say look we are halving your risk of having a heart attack And this is incredible. We couldn't do this in the past And I I say to them the biggest side effect of taking these drugs is that you may well live longer So it's a great side effect. Yeah, and living with chronic illness isn't success. It's fantastic Not like there's business stuff here from health and this is always chronic illness It's fantastic in the past people died We live longer than any other country in the world and we are apparently the happiest apparently Outside it within the OECD, but that's a miserable group of people, right? What about Denmark? No, we're happier than them That's just you in brisbane Well, we are the most miserable city in the world is quite like this Oh, you're making this up now. Look at you Can I We're going back to to someone like Sheila. This is someone who comes in she screams I'm interested with Robert. What do you feel his Colleagues what would happen in primary care? Would she immediately be referred on would you try an initial treatment? Would you actually do a watching and waiting for a couple of weeks? What would you do Robby with this person? Look, Nick with this with this patient. This depression has clearly been going on for some time and It's a lot more complicated than this rock standard one I mean, I guess somebody straight after a heart attack my my first thought is bring it to the floor talk about it Talk about this normalizing normalizing this but also understanding What they are and the changes that it's actually brought on in their life and Seriously following them up and working it. Is this a problem or is this just a transient thing? I think with Sheila. This is this is not transient the issue of medication is one that I I would think because there is Some significant issues with regards to life functioning and others Although I again I come back to your point about cognition testing because we all know that the brain is A heart that thinks really The blood vessels around your heart are no good the ones around your brain are probably no good either And we all know that dementia is one of the most rapid Diseases in Australia. So I'd be worried about cognition The the the thing about medication. I probably would be talking with the cardiologist first about Would I use this and is this the issue? But the the second part for either treatment Um The data now that if if someone like Sheila is amenable then cardiologists and gps Should with someone with a relatively severe depression be starting access our eyes pretty quickly I think that we you know that we can argue the pros and cons of whether or not We over prescribe I bought under prescribed I think it's more in Australia the targeting of prescription And I think the world you know after a heart attack or whatever it's right to feel depressed And certainly I think if you take an approach where they've had it for you've seen these people and you know What they're previously like and now they've changed and you've seen them took a couple of times You know multiple the tendencies with different symptoms aren't necessarily heart heart condition and again Multiple symptom complaints would be a real flag for depression. I think people should be starting SSRIs Probably quite quickly. We know that they are effective or you know, they're not magic bullets They're reasonably effective and we know that they're generally safe in people with heart conditions You don't have to consider what else she's thinking But I'm certainly being advocate that we should probably be using more of these in a targeted fashion and earlier and by non psychiatrists You are yes, go ahead. Yeah. Yeah. Oh, I would say it investigated in the sad heart trial post heart attack one of the two sites in Australia and that showed clearly the safety of surgery and the efficacy above placebo So it is certainly a safe safe There's only 300 pacers in that trial and we almost got statistical significant decrease cardiovascular events over six months so You know, it is there's no doubt about it being safe And if you know, you know, you can always stop later And the thing is we need to screen not just as a company in fact But you know from Sydney where you are now as you know Gordon Parker has demonstrated Prince of Wales in part patients if they develop depression a month afterwards That actually is worth prognosis at least some people in Sydney that people have at the time of the heart attack But yes, too many of my colleagues have dismissed Depression oh, it's just reaction the illness are going to get better. Well, that's you later 30% of them have got depression still We found the same at the heart research centre that it's the It's the later depression rather than the in-hospital distress that is predictive of mortality so it's really Not not just thinking about their distress in hospital, but looking at two months down the track and looking at the trajectory of depression where the Depression improves over time their distress improves over time Or it gets worse and we really worry about the ones to guess worse or that it doesn't change because for Many people it will improve because it's having distress early on is probably a natural normal response to a life-threatening or perceived life-threatening event sure think I mean Then you're playing up something interesting I just pop in there because there are a few other topics we need to cover before we finish It sounds as if everybody knows what should be done and everybody agrees on what should be done You had a question Sheila in relation to increasing the empowerment of Sheila and To improve self-management management. Could you expand on that? Sheila is that Rosemary? Sorry, sorry Rosemary. Yes, sorry Yeah, um Now her Her feelings about managing her illness knowledge of her illness and I think it'd be very important to To work very closely with her about her establishing her goals for You know for getting as well as she can in terms of whether it's physical fitness or mental health or You know social relationships what it is And getting her to set her goals and working with her to achieve her goals. That's where So we'll be talking about using a combination of cardio and psycho education I would say so. Yes Does anybody else have any thoughts about that about coordinating that pair? I just want to raise my hand before David here, don't you think? Um in navy or be she's scared to death of dropping dead And that's why we have units started up in the 60s and 70s by the Heart Foundation But they're absolutely scared. They're in bed for, you know, two or three months And the doctors everyone kept them in bed, you know, it may be very well other liners has raised me in as it before Scared to death of you know, catastrophe around the corner. And I guess that needs to be important But he's very competent lady. She's a retired professor of art. So she's no bill And it could be also that the husband scared to death of her Dropping dead and he's restricting her as well on doing we're not quite sure what's going on who's where the anxiety is I believe so yes, I think it's be very important to Get her to talk about, you know, what the values that she has and how she Thinks about her life what she's achieved what she's created What the meaning Is, you know, all of that I think is very important with the patient who's coming to terms of the fact that they're mortal Thanks very much. Nick, do you have any comments on that because you put up a A corner of therapy And, you know, going all the way from IPT down Yeah, I mean, I want to get across very much the idea that I think that the Sheila should be involved in the treatment modality And the evidence is that Both antidepressants and psychological therapies both work in this context And the evidence is that we can take problem-solving therapies And a lot of it really depends upon her preference for the approach Interestingly, we spend a lot of time talking about Matching treatments to particular characteristics of patients the reality from all of the studies is It's not so much whether the particular treatment modality Better or worse because we really can't show that it's how good the therapist is, you know, the reason why You know, the all blacks are better rugby players is not because they play a different type of rugby They just have different different players That's probably other teams So I put up those particular things because it really depends upon actually getting good therapists to do good therapy So if you're a CBT therapist, if you're an ITT therapist, if you're a problem-solving therapist You do that and you do that well Most therapists are actually eclectic when it comes down to them and use a bunch of different modalities That might be appropriate for the right kind of for the person who is involved And again, you know, so the better the therapist and we you know, we all know who are the good therapists The ones that we work with Quite consistently in those areas Whether or not the two are actually complimentary in this particular group of people We actually don't know we do know that that is true and that drugs and therapy are a little bit complementary Generally, you don't get an additive effect. You don't get the effect of the drugs and of the therapy together They're a little bit additive So I've bunged up a bunch of different things, but you can pick and choose I think the issue is about access about rurality is important And knowing that there are many of these interventions available over the net And more importantly that these interventions are much better than health information There is some good health information on the net. There's some rubbish health information on the net And these interventions delivered by I can give you a number of them. There's e-couch. There's beating the blues There's shut-eye for insomnia We know they are better than good health information and better than placebo So looking at those access issues, I think it can be really important in many areas of Australia Thanks, Nick. Rob, do you have any comments on how we should engage the patient? Yes, sorry, Michael. I just missed that last bit for this question Sorry, do you have any comments on how we should engage the patient? Assuming that you don't have any cognitive deficits, what's the best way to engage the patient? Well, again, this is to talk about how she doesn't seem to be making as much progress as she should be The position that she's in is that she's a young woman and that you'd expect that she would be able to enjoy her retirement far better than she is If you've got anything to think about or anything to say about in that perspective and then then opening up on Exploring what her thoughts and fears are about that because often the patient will say we've had a lot of Comments here about she's worried about dying and I think David sort of put that as well that These things need to be opened up and once you have opened those up This is a term of whether or not it's the GP I can deal with that and I really do like one of the comments there was absolutely good old-fashioned active listening and And that would be the start if you're isolated rural great idea Sit back and listen and then work out. Well, what resources have I gotten? I'd agree with what Nick said You can arrange in a number of rural areas contact through even it's just for yourself as a GP to be Discussing a case with a psychiatrist or even better still is increasing access to telemedicine services for that But the most important thing is trust that the patient's got trying to get involved with us we talked about with other family members definitely the partner and This person needs a care plan a chronic disease management care plan be effectively managed across range of activities and one of the interesting things that I've often found is that sometimes help comes in in some of the most unusual perspective some of my difficult chronic disease patients Would sometimes find with either say a nurse specialist in areas of rehabilitation The dain fact would actually break the veneer and Would develop a quite a deep before so it's a matter of really working with other people In in in having these patients come back to see you for a six-week check safe. Are there still the press in general? Well, it's the quick screen hospital But the real screen for me is the everyone who is under me in hospital sees me four to six weeks afterwards And we get an appointment before they leave And that's usually where where you know things really really move because Almost always it's with their spouse Now some feel a bit better some don't But you know, I usually do the ph q2 then And you know what the thing is a nickel. I'm sure and others will say look, it's not important Which treatment used for depression as long as you use something and we've got long-term follow-up You know people feel better with obviously with the treatment of depression whatever you use go for a walk You know use your ssr i are cognitive therapy But that does lead on to increase compliance with everything else we like people to do And those who get better ill expect whether it's placebo or whatever. They have better cardiovascular outcomes. So It's uh, I haven't quite answered your question But it's just part of the routine asking questions. How are you going today? Look at the routine being able to last month since I saw you you're feeling Been bothered by feeling down. I hope or you know, and then I and then we ask about You know pleasure in doing things So it's just sort of rolls off. I know it's called formal ph q2, but it's only just to make sure that we think about it but You know, it is surprising how subtle it can be in mouth and Disagree and you see the wife saying rubbish, you know, like sometimes she doesn't want to talk about the mouth Thanks very much, david Now as usual with mhpn webinars, they fly by the time has sped we're coming towards the end of this webinar I'm now going to ask this excellent panel and to sum up their message In two and a half minutes each panel. I would start with you rope Great. Thanks, Michael again. I'd be first looking at Recognizing the problem and that really means looking at yourself as the practitioner and Using that. Well, I guess it's expense. Why aren't things getting better? Why are things getting worse and what else is going on behind the scenes? And if we don't ask the question, no one's in fact actually going to give us the answer And we may in fact just have a superficial patient off the patient relationship and not really get to the core of what's causing this person's problem I think we've brought up a number of key issues One is that we need to look at a chronic disease management situation and the team approach We need to look at what team members are available to us around there The value of physical activity, but also the idea of Cognition and an assessment of this patient in a broader perspective is going to be a lot of helping And Working with the patient herself. What does she want? What's her expectations and what does she in fact actually think and believe? And and trying to get to those so that we can make sure she's taking a medication and also complying with a lot of the lifestyle changes that are needed to make her better and If necessary, as Nick has put in Certainly considerations for someone who's got a longer standing depression. We need to give a trial of medication If nothing's happening with lifestyle intervention Thanks very much Rob. That was excellent excellent something else Rosemary Yeah, just really just really um focusing on what Sheila wants what her perception of her disease is what her thoughts about her future are How how she sees her role and whether she believes she'll be able to facilitate whether that Needs adjustment and really developing the trust with her and finding out what she values What what are these that um, she wants to do and achieve and how she wants to how she sees herself recovering That's fantastic so much in so few words That was lovely Nick would you like to To just summarize how you have used this case and what we talked about this evening Also, we've talked about loads a load of huge range of approaches. Um, we should really center upon one thing which is really about Identifying what Sheila wants to do and imparting the information to her to enable her to make informed decisions We've screened if we identify that there is a condition the most important thing is that we actually treat it In this country more depression is not treated than treated And we're often doing things that really have very little evidence to support them rather than actually doing the things that we do Know that work Conversely, and I've seen a few sort of slightly concerning comments in the general chat saying well Why wouldn't you be depressed if you were like this? Well conversely? Two thirds or more people are not depressed. So this is something that is different It's something that different for her if we identify it and identify with her What are the best ways of treating it and making sure that we do treat it adequately? Thanks very much Nick Davis Yeah, well, I can give you a little bit more time because the other speakers have been Summarized fairly very briefly and comprehensively your You're the guy who's seen these patients In ice the year. So I'll give you about five minutes to summarize how you see the situation Okay, well depression is called as the forgotten risk factor It's common. It's prevalent make people feel miserable And unless we seek it out and it's in at least 25 percent of our patients low mood Maybe higher than that Then we don't know about it and the influences whether the patients Do follow our lifestyle measures and do that take their medication. So it is common It's easy to screen for and I see in the comments how about some other tools and complex tools Yes, that'd be great. No problem. But at least get our practitioners asking two simple questions Which will help to identify patients at low mood It's a risk factor which is important as diabetes. It's more common than diabetes It's more important than smoking dare I say But many of our patients won't stop smoking because they do feel depressed and when they stop This is what happens actually it can get worse. It's easily missed Let's scream with the phq2 to start with the influences prognosis and look as nick pointed out another Look, there are many treatments. There are many roads to Rome. You don't have to use necessarily drugs But you know what we don't have to be afraid of drugs there because we know it is safe and effective And you know, it's the therapist that counts be positive. We do know Cardials and doctors who are depressed have or have low mood. I'm happy with their job Why don't I say go do something else? But patients are far more happier and adherent if You are happy and enjoying your job. And you know, we're in an incredible position here A privileged position. Look after patients and we have a duty to do the major thing in the quality of life Recognize that they may be depressed or anxious Acknowledge it and if you don't know how to initiate therapy, there are plenty of good people out there who can help So I think we need to be positive and positive emotions also associated with a better outcome as well Now it doesn't matter how you improve the depression if it improves Life improves people feel happier and they probably also have less further heart attacks. So Really, I think it's time to bring it out of the closet Should we should de-stigmatize and I try and do that and say to patients look, it's no big deal You know, this is a common phenomenon. Don't feel as if this is an embarrassment and you know, we've got help for that so Maybe that's enough the message is it's common. It's an important risk factor. It's forgotten It should de-stigmatize it and I think it's time to treat and treatment work As I said, we're talking to the converted here We can be positive while our cardiologists say leave it to me. We'll look after it to everyone out there in the web land Thank you very much Um, I feel a very humble um summing up here tonight and we've had four excellent speakers from different disciplines from general practice from Psychology from cardiology and psychiatry all playing the same tune and all of one mind So if I may just briefly sum up what we've heard tonight And the most important thing I feel is to recognize the problem Not to be afraid to ask the question and the questions are not are not Um Great. Do you have a low mood? Um, are you getting closer? Have you been getting closer out of life in the last month? So I think um That David has put the name on the head is that we really need to have a fast and brutal way of Assessing patients in the mail from that they meet when they go into a um a cardiac care unit There's no doubt From all the evidence and everybody is reiterated. It's tonight. That's improving depression improves at outcomes when people have cardiac events And that's between 25 and 30 33 percent of people are depressed following a myocardial infarction We need to recognize it and we need to be positive We need to engage with the patients We need to Do both cardiac education and psycho education simultaneously This is often only Possible to do, you know, in a large unit. It's often difficult for people in rural areas But in fact in rural areas or in inner city areas where people don't have the access as they do The private sphere they can all they can often have a good GP or a good psychologist or a good Social worker who can help to improve their life This activity is important Both for cardiac well-being And for depression and this has been brought out by many speakers The team approach, of course, is very important and that's what NHPN is all about Coordinating conversations between different team members and improving outcomes for all of our patients and clients through team activities Nick made the points very well that we need to screen And treat and recognize that our treatment does have positive outcomes And it's not that it isn't difficult and no matter what the therapy it often comes back down To you our attendees the therapist Who makes the biggest difference to our clients and patients? I thought that that rosemary's contribution was was fantastic and She talked about those real-time things that we all talk about with our patients and clients What their perception is of what's happened to them? What how they see the future? And how the patient or client sees their role in being engaging with the patient Finding out what their key values are and engendering a sense of trust And with the patient So all in all this has been a very valuable night. I would hope for all the attendees And certainly I have very much enjoyed the expertise that has been on show tonight I would ask all attendees and to please mature that you complete the exit survey before you log out It will appear on the screen after the session closes The typical of attendance for this webinar will be issued in four to five weeks Each participant will be sent a link to online resources associated with this webinar within one to two days This is our final webinar in 2013 We thank you very much. Many of you repeat attendees and I see the names coming up time and time again And for attending it is you who makes this These sessions good for our clients and patients And if you wish to keep up the date with upcoming webinars for 2014, please go to the upcoming webinars Hashtag slash after you log into MHPN.org Once again, I would like to thank everybody from MHPN. I would like to thank all our attendees and mostly I'm very important tonight for our very very talented presenters, David Colhoun, Nick Glowsier, Rob Grenfell and Rose McGinn. Thank you all and good night