 webinar on comorbid mental health conditions in veterans, strategies for assessment case formulation and treatment. And it's being delivered as part of MHPN's inaugural online conference working better together. A very warm welcome to all of you who've joined us tonight for the live activity. And I should say that we've had around three and a half thousand registrations for this stream of the conference, the military mental health stream of the conference. And it's an incredible number and I think it's testament really to just how important this topic is for us as clinicians. Welcome also to those of you who are joining us later on the recording. And of course a very warm welcome to our panel who I will introduce in just a moment. First I'd like to acknowledge the traditional custodians of the land across Australia upon which our panel and our participants are located. And I'd like to pay our respects to their elders past, present and future. My name is Mark, Mark Kramer. I'm a clinical psychologist in private practice and also a professor in Department of Psychiatry at the University of Melbourne. And I've had a very long interest in the mental health effects of trauma and particularly in veteran and military mental health. And as a clinician I am constantly I guess struck by how complex some of my veteran clients are and just what a challenge it is to work with them. And so I'm very pleased tonight to be able to facilitate this panel and to pick the brains of our expert panelist. So without further ado let me introduce them. You've all had their bios and so I'll keep it very, very brief. First I'd like to introduce Kate Howell joining us tonight from rural Victoria. Kate is a very experienced general practitioner. She's also a therapist, an educator and an author and has written five books on mental health and cancer. She started her career in the RAAF and now works as a GP at Puckerpunyall Army Base. So she is very, very well qualified to be joining us tonight. Welcome Kate. Thank you for being here. It often strikes me that we do tend to work in an area that can be quite stressful. So I'm always interested to know what people do to get away from work. What do you do to relax? Well I guess I'm a bit more introverted by nature. So I quite enjoy just walking the dog, reading a book, reading the newspaper, having a coffee. But I actually work and live part of the time in Victoria. You'll see the suitcases behind me. I regularly go back to Adelaide which is my original home and I live near the coast there so I catch up with my friends and enjoy the beach. Right, yeah okay. So that must be interesting actually changing location on a regular basis every week I suppose. No, no I actually stay here for three and then go back to Adelaide for a week, three days. Yeah, great. All right, thank you very much Kate. Our next panelist is John Finch joining us from here in Melbourne tonight. John is a clinical psychologist specializing in PTSD. He started his career working with veterans and serving personnel and their families in the VVCS, what we now call open arms. And since then has worked with a number of organizations including Davidson Trahair, Victoria Police and Melbourne University Cancer. He's currently in private practice specializing in the treatment of people with complex trauma histories. Welcome John, thank you very much for joining us. Thank you. So let me follow the same theme and perhaps ask you the same question. What kind of things do you do to get away from work and to relax? Well literally getting away from work and then leaving it is on my bicycle most nights which helps me just move my attention away from what I've been doing to something else because you have to concentrate on the traffic until you get to the bike path. But then you have a little bit of relaxation if you like and sometimes out in nature a bit depending on which way I go. I would find that that's useful. Absolutely, I quite agree. That idea of having a very clear break from work I think is really useful isn't it. I when I was working full-time I always used to ride my bike home and I found it was a great way of doing it. Thank you John. Our final panel member tonight is Mary Frost who's joining us tonight from Darwin. Mary started her career as a GP before later going on to train and qualify as a psychiatrist. In her clinical practice in Darwin she specializes in the assessment and treatment of serving members and veterans and of course there's a lot of serving members and veterans in the Darwin area. She also has an academic position at Flinders University and is involved in teaching medical students. Welcome Mary, thanks very much for joining us tonight. I should say that everybody here is complaining of the cold certainly in Melbourne and I gathered that on the chat room as well people are complaining of it but presumably you're basking in beautiful sunshine are you? You're going to find a lot of sympathy here but still let me just follow up the same question ask the others because I've heard a rumor about you talking about what people do to relax. I understand that you're something of a musician. That's correct yeah I play a string instrument of the hour and I play in the Darwin Symphony Orchestra and so through the Darwin Symphony Orchestra we give concerts, we go on tour, sometimes we're asked to do small group digs at places like Government House and it's a lovely way to be part of a really enjoyable community though I've now lived into 20 years so yeah it's taken me many places both within Darwin and within the territory. That's wonderful and there is something special about making music with other people isn't there I reckon. Oh yeah yeah very good very good for the brain. Absolutely absolutely okay well thank you very much Mary thank you to all our panelists let me just if I could spend a few seconds talking about some tech stuff for our participants we've got a chat box if you just click on the open chat box you can post comments to the group there there's a supporting resources tab a resources library with a whole range of stuff around tonight's webinar I would perhaps encourage you not to look at it now but rather MHPN will send you a link to access all of those resources and you can go through them at your leisure there's a technical support tab if you get stuck for some FAQs there and we would encourage you please in the exit survey to give us your feedback on how you found this platform and whether you like it or not but for now I'd like to I've forgotten to forward the slide to the title but anyway you know the title for now I'd like to just say something about the webinar series so this DVA actually commissioned MHPN to deliver a series of 14 webinars on Veteran and Military Mental Health this is the 12th so there will be another two before the end of the year and previous ones have looked at topics like the PTSD and anger sleep substance use and so on and if you missed any of those and you'd like to catch up on them they're all available on the MHPN website as well as on the DVA at ease website so you can look at them there but tonight's webinar is looking at the issues raised by working with very complex cases with with multiple conditions and so when we use the shorthand of comorbidities we're really talking about people who have multiple diagnoses and we're going to be using a case vignette tom as a kind of jumping off point you've all had an opportunity to read the vignette I hope and I'm sure that it rings some bells for many of you two weeks ago we talked about tom as he was just about to leave the military leave the defense force but tonight we're going to go forward two years and we're going to look at how he's coping now two years down the track and the issues raised by that so we'll use tom's case as a kind of jumping off point each of our panelists will give a brief five-minute presentation from their unique perspective about tom and then we'll open it up for a more general discussion and questions which we'll take up the welcome so I think um oh yes I better just talk about the the learning objectives by the end of all that we hope that you will I guess be better able to recognize the the risk indicators the warning signs the protective factors for these complex clinical cases that you'll be better able to to describe the evidence-based assessment formulation treatment approaches most effective for this population and that as a result of both of those two you'll have more confidence in identifying and supporting veterans with psychiatric comorbidities and also I hope that we'll have an opportunity to take it a little bit further and also look at the complexities when we have physical and mental health conditions occurring together so I think at that point I will hand over to our first panelist Kate to talk a little bit about her perspective on Tom's case from a GP perspective Kate sir I'll hand over to you thank you all right so when I read the story of Tom it certainly many facets of it resonated with me you know both from experience within working with current army members but also as a GP in the community and I thought Tom might respond to his wife's ultimatum by actually heading off to a GP potentially now he may have stayed away from GPs in the two years I'm not sure that certainly the GP will need to focus on trying to build a relationship potentially that could be challenging given Tom is male and is a veteran and he's dealing with a whole range of issues on his own and has done so for quite a while and I'm sure there's a strong influence of a sense of shame for him that perhaps has held him back all the way through of accessing some help and support I think for GPs and other health professionals it's really important to get a good understanding of military and veteran health you know I spent the day at Puckapai Neil today and you know I saw a man who was very reluctant to access help and it was a very challenging consult but I think if we understand to a degree where they're coming from it helps to respond with listening and empathy and it will take some time and care and that can be a challenge in a busy general practice as well so there's been a lot going on for Tom over a number of years and the GP will need to try and unpack some of the background and story and the key symptoms and issues and that may take several consults because there are a range of complex issues you do want to explore what's going on physically for him physical health and functioning we heard about musculoskeletal issues which are a very common problem in veterans and there may be chronic pain so certainly before serving members who've been in the military for quite a while before they leave we often see that they have chronic ankle problems chronic knee problems or hip or low back or neck or shoulders so it's not surprising Tom's got some issues but also over the mental health side of him mood anxiety exposure to trauma we've heard Tom has been drinking more to sleep irritability with children anger issues and now just try and explore exactly what's going on in the many facets of Tom's life with family and partner and so on we want to explore whether there are any social connections or supports that may be helpful what resources are available to Tom whether he's aware of any or whether he's tapping into any at this point probably not always a mental state examination and always want to assess suicidal and homicidal risk particularly when someone is struggling with depression long-term or PTSD with reference to the physical illness and the impact of alcohol you'll be wanting as a GP to do some baseline investigations examine Tom check him over check blood pressure check for any signs of problems related to alcohol and do a range of blood tests so that's fairly standard there is an ADF post discharge assessment that we can access through Medicare as well as the mental health plan which may be a good way to go with Tom and allow some time to thoroughly look at all the issues provision of information you know is the platform that many of us use in the start at the start of trying to work with a patient or client and and trying to gauge what Tom understands what knowledge he already has and I guess think in terms of biopsychosocial and potentially spiritual aspects of some people in terms of how issues are caused but also management and the education can then lead into looking at what the next steps might be in terms of some help I think when we talk with Tom you know when we read the case we heard him using quite a few negative statements about himself that it was of no use of no value a loser and so we need to be mindful of that and supportive and foster some sense of hope within him that he can feel better and that he can contribute to family and community in the longer term over time a GP will hopefully look at aspects of lifestyle with Tom particularly the benefits of good nutrition and exercise he's struggling with sleep so looking at that and very much looking at small steps to improving lifestyle and small steps with reference to social connection or engaging in some sort of media meaningful activity over time it's very hard for veterans when they leave you know they've done a particular range of activities in the military and had a lot of social connection with their fellow soldiers and mates and to find something in the community that has that sense of purpose and meaning you know can be very challenging for them part of the process will be referral to mental health practitioners and a psychiatry for assessment and management and obviously we have to look at various ways to try and access those services and again it will depend on how long it takes to access those services if we assess that Tom may benefit from medication we may well start on that process if we can access further assessment very quickly we may hand over to the psychiatrists that they're saying but Tom's got quite a few signs that mood is deteriorating so we will want to get on to things as soon as possible and collaborate with other mental health practitioners very important to make sure safety plans are in place that follow up is organized and that we do monitor Tom for ongoing risk and you know sometimes the veterans or both in-service can deteriorate very quickly you know I've seen people become very unwell over days and need in patient treatment so always be mindful that may be needed our role may also be an advocacy assisting Tom to make claims with DVA for treatment support or compensation over time and encouraging access to resources lovely thank you very much Kate there's a whole wealth of issues there that I'm sure we'll pick up on in the discussion just briefly I guess that Tom is going to need to engage with DVA particularly around his mental health claim do you ever find that that some veterans are reluctant to engage with DVA is this a bit of a hurdle for some of them for some yes for many they are prior to separating from the military they will work through the DVA application process with support of DVA advocates and the doctors within defence but if someone has I suppose resentment around the military or anything associated with the military or for example shame around a mental health condition versus a physical condition that may deter them from making a claim yeah sure okay thank you very much indeed Kate let's move on now and hear something of a psychological psychology perspective from John can I hand over to you John to talk a little bit about a clinical psychology perspective okay thank you Mike so from the the clinical psychology perspective we're looking at trying to aim for a good diagnosis for for the for Tom and what we're looking at when we're looking at this is that we have sorry I'm just noticing I'm coming back on here I was off air for a second there so when we're looking at trying to aim for a good diagnosis in inverted commons a diagnosis that can help us look at Tom's experience and understand it from a clinical and diagnostic perspective there are a lot of issues that Tom is presenting with that actually could be many things so we've got things that are depressive symptoms PTSD symptoms and anxiety symptoms and as you can see in the slide things like anger irritability shame substance use his pain as not necessarily a diagnostic category for any of those disorders but something that complicates the presentation of those disorders and interacts with those disorders and those disorders interact with pain as well things like his relationship and personality factors are all things that we want to consider in terms of trying to understand what is Tom's presentation and how might we best help Tom to move forward from what's going on for him now some of the the reasons as to why we might use evidence-based assessment are that when we're thinking about an evidence-based assessment and someone fitting into a diagnostic category that's something to do with how we understand that disorder across place and time in terms of I could be talking about something like PTSD here in Australia and in America we'll know that we're talking about the same thing and that can actually help us inform treatment if from different perspectives part of that is that we can look at when we assess for trauma we're looking at not just the immediate sort of things that are going on for the client in terms of their history to do with the military where we're also assessing those things like depression and other things but their life history in particular for PTSD we want to know about a range of traumas whether they are pre-existing traumas we also want to know about pre-existing issues that might be related relating to depressive or anxiety symptoms now some of the things that can help us assess that screening measures and screening measures help us understand how someone may fit into a particular diagnosis and on the slide there you can see that I've got the LEC-5 the LEC-5 is a screening measure which actually just assesses all the different types of traumas that people have had it's linked with PTSD and assessing the number of and type of traumas whether it's from a natural disaster military service whether it's a motor vehicle accident whether it's sexual assault which of course all of those things could be traumas that someone in the military could have suffered that are not just specific to the military the PCL-5 is a measure of PTSD that's brief it's 20 questions just based on PTSD symptoms the PHQ-9 is a screening for depression nine short questions and the GAD-7 is a screening for generalized anxiety disorder and these can help us refine what we might look at when we're looking at someone at their first presentation and then a structured measure such as the CAP-5 is a clinician-administered PTSD scale which is a much longer form of assessment that looks at PTSD specifically but there are also those for depression and anxiety and all of this helps us make choices around treatment and particular evidence-based treatment in terms of what might work and evidence-based assessment when we know okay the person may be suffering from PTSD or depression or anxiety helps us make choices around evidence-based treatment the evidence-based treatment idea is important in terms of the research helps us understand the effect of the treatment and whether it is effective or not I like to think of it in terms of most of us might go to our GP try the medications there and if we had tried lots and lots of different medications we might consider alternatives that may not have an evidence base but we might give them a try to see what happened the research idea around therapy and treatment and how it works is a significant factor with the choice of evidence-based therapies in that it will help us we know a lot about how a particular therapy works when we've done the research so we know for example that in terms of the particular therapy that I focus on cognitive processing therapy that if family members support the person who face traumatic memories going through PTSD that actually the therapy works better we know that the research around evidence-based therapy also tells us it's actually short-term therapies can actually work we also know that the longer therapy tends to stretch out that the less effective it is and that there's more and more research showing with both prolonged exposure therapy and cognitive processing therapy tools that I had evidence-based therapies for PTSD that the more those therapies are frequent rather than stretched out the better the outcome we also know that the research tells us that men women veterans non-veterans a whole variety of people will respond to evidence-based therapies the research is actually showing that in particular for PTSD another important factor is that comorbid depression when treated in the context of PTSD if we treat the PTSD first then the depression often shifts as well so we don't have to focus on one or the other and that's where that evidence-based therapy and the research behind it is a really useful tool for us as clinicians okay great thank you very much John I think that's your last slide isn't it yep that's my last slide I think yes thank you very much for that and I do want to pick up Dan the truck a bit more about evidence-based treatment because it's going to be central to what we're talking about but um before I do I was interested in Tom's comment about somebody owes me and I'm wondering whether you've got any thoughts about whether or not this is a sort of common attitude whether it's more typical among veterans than other people but this perhaps sense of entitlement not unjustified necessarily but this idea that someone owes me have you got any comments on that yes I would say that it is a it is a um not not just common to to military but common to what we might turn first responders so we're looking at ambulance fire brigade SES and police members where they're in a culture where they give a lot they put their life on the line at times and part of that culture is that you will be looked after and so when that looking after is something that is not for coming forth with in in their eyes it can sometimes come across as well why aren't I getting what I was promised and of course at the same time you can have some people who actually think they are entitled to these things in a way that might be different to to other members within those sort of subcultures I guess so yeah I would very much think it is very much part of that that culture and that you you don't find the average person in the street who might have a trauma having that kind of idea that somebody needs to respond and often they might have that idea if somebody owes them but at the same time they don't want to accept that that treatment they want to be part of the group but independent as well yeah and I do want to come back to that idea of sort of ambivalence about treatment in just a minute but yellow thank you very much for that I think it is interesting and of course veterans are entitled to a whole lot of services and we mustn't lose sight of that it's a question of whether when and whether that attitude kind of becomes counter therapeutic but thank you very much John we'll pick up on some of those in a minute for now let's move on to Mary and see if we can get a psychiatry perspective on Tom's case over to you Mary okay thanks Mark um look as the other speakers have already touched on I think we're facing a number of potential diagnostic considerations here and as a psychiatrist that's going to be an important part of my assessment of Tom but also form the basis of treatment and the four areas that I've had concerns around a post-traumatic stress disorder we've heard that he's easily started weights at the gym the noise the noise of weights at the gym we've heard he's not sleeping well but his partner is noticing how disturbed his sleep is we know he's had traumatic exposure about which he doesn't want to talk and he also speaks of the cry of his children as sounding like triggering memories of time in the Middle East the depression I think hates pretty well touched on deteriorating mood sleep and so on the alcohol use disorder I'm quite concerned about because not only is it something that he's using to try and numb symptoms and detect himself but it's also something that is there genetically in his background with his father's death from liver disease when Tom was aged five sorry 15 and then the diagnosis was a chronic pain I'm not really making because I don't fully understand it at this stage and that is something that would require me to collaborate with the GP to get better understanding of what's happening from a musculoskeletal perspective before I even start to treat Tom I think it's really important to be aware of the context of his treatment so we know he lives in a regional town near Townsville not that he lives in Townsville but that he lives in a small town near Townsville so most treatment is likely to take place in Townsville which means he's got to get there there's a scarcity of specialised resources in Townsville in Darwin in most regional centres that means that there's an inevitable difficulty in accessing psychiatric services which often means that GPs tend to be the primary source of mental health care with psychiatric appointments being more kind of consultant having a sort of consultant rather than treatment role and obviously if he's not working his wife is and he then has to start travelling regularly to Townsville then that's going to make demands on family life which needs to be taken into consideration sorry my mouse just won't let me yep okay so thinking in a broader sense about Tom's presentation I fall back on a formulation and think about things like biological, psychological, social contributors to his current predicament I'm concerned about his father's death from alcohol use when Tom was age 15 I'm concerned about Tom's own alcohol use his pain and physical disability and whether or not he's using analgesics either prescribed or non-prescribed although these days with prescriptions for it's over the counter coden being less available that seems to have diminished some of the role of unprescribed non-prescribed analgesics I do wonder we don't know a lot about Tom's background but his father died when he was age 15 his mother died a few years later does he actually have a trauma history in that setting of family dysfunction his father's unavailability his mother's perhaps submission to a drinking dad and walking on eggshells as I hear from a lot of my military members and so Tom as a young man decided that he really needed a different kind of family he was seeking a father figure and he joined the army he then also kind of attacked himself to his partner's father Bruce and now feels that he's failing Bruce and so that's a significant loss he's already lost his own dad and now he feels like he's letting his other father figure down having lost his family the army and he talks about he was a hero and now he's a loser so there's a considerable loss of role and identity and grief I'm also concerned as is very often the case with veterans and military members that their reluctance to seek help characterizes a lot of their psychological battles or if they come in the throes of the marriage that's about to end at which point you're not quite sure of their own motivation for help we know that he's isolated he's living remotely I'm concerned about Sonya's mental health again we don't know much about that but she has been prescribed sleeping pills he's using his sleeping pills he's very detached from the family he worries about the children's crying Sonya's clearly indicated that she's finding him tough going and the in-laws which previously were our source of great support for him he's also distanced himself from and in that setting suicide starts to become a real concern for me so you know in thinking about safety I'm thinking about Tom's safety his risk of suicide I'm thinking about his anger and and the children and and Sonya I'm worried about his alcohol consumption and and possibly his use of analgesics illicit substances and so on and then the physical comorbidities which I'll I'll leave Kate cover those well earlier so like Kate I think the therapeutic alliance is slow cautious and requires a lot of patience on the part of the practitioner because he's told us he's ambivalent about treatment he's told us he's reluctant to attend so I think if we impose a model to prematurely on on Tom he'll run so you know sometimes in this setting and I think there are a variety of approaches if Sonya is the one that's declared the ultimatum to his help seeking then I might start fairly early by involving her um sometimes reminding Tom of his desire to be a good father figure means that I sort of established a therapeutic alliance by reminding him of being a dad and there's a lot of mentions of the children and sometimes in in veterans they become the primary caregiver and and I actually meet children they come to appointments um so the children can sometimes be away in as Kate's already mentioned um there are a number of symptoms that need to be targeted um and she and I the the list we have is is virtually identical um and I don't want to go a lot into biological treatment but I think it's important to mention that benzodiazepines shouldn't be used because this is a fellow that's already drinking excessively uh but the evidence around SSRI antidepressants is mixed but is probably there and there are a number of other agents used in the treatment of PTSD which I won't go through the the final and I think most important thing in the management of Tom is the the need for collaboration uh he's has complex comorbidities and uh if he were in the military I would indirectly be knowing about his musculoskeletal status through a physio not that I'd be contacting the physio but I'd be hearing from the GP about what the physio thinks about his musculoskeletal status so that's the sort of level that I think as a psychiatrist I need to have some awareness of um of the complexity thank you very much indeed Mary and again um a whole lot of points that we'll pick up on uh in the course of our discussion there um but I would like to just touch on that last point and you you kind of ended slightly more no perhaps more optimistically than I would um this idea of the importance of us collaborating amongst ourselves as professionals around a particular case do you think we're generally reasonably good at that or do you think it happens um look I think it depends on um us individually some of us are I think by nature collaborators and some of us tend to sort of ride the boat a bit a bit uh as a solo um as a solo oarsman but I've always really enjoyed collaboration and I think um working in a multidisciplinary setting which I can't do as a private psychiatrist means that I actually reach out a lot to particularly the psychologists that also treat the patients that I'm seeing and the GPs and without that I feel much more pessimistic about treatment but I think when others are contributing it makes me feel that there can be some kind of like division of the pie and I can focus on this area knowing that somebody else is monitoring analgesics or checking liver function tests in the case of alcohol so yeah I think it's really important yeah I certainly agree that it that it is very important and I'm just not sure that it always happens as much as it should but but I certainly agree with the importance and it's up to each of us I suppose to make sure that we do we do communicate don't necessarily wait for others to contact us anyway thank you very much Mary thank you indeed to all our panelists for those presentations very enlightening I'd like to now kick off the broader discussion and I'm going to invite the panel members to just jump in uh and uh and add alternative perspectives or disagree if they want to but I will direct questions at each of them and I should say that I've been very impressed by the number and the quality of questions that we've received from the participants and indeed are continuing to receive and we will try to get through as many of those as possible but we have very limited time so please bear with us if we don't get to your particular question but let's kick it off with something that that I think all our panelists mentioned and I'm going to turn to you Kate if I could to start with because you made a particular point about the importance of engaging Tom in a therapeutic relationship and some of the challenges that that might bring up for you so um I guess yeah I'm wondering really whether you think it's more difficult to engage veterans in treatment than it is other populations okay uh I think it varies um certainly with Tom it sounds like it would be um you'd have to work fairly hard and make sure that you get him back um sometimes sometimes I remember a thing that helps me is sort of looping back if I if I'm finding a bit of a resistance or he doesn't want to talk about something putting it on the shelf in my mind and coming back to it later it might be later that session or later and in another appointment but you know certainly um there are there's a lot more openness in the military around mental health issues for example and a lot more support than in years gone by so a lot of people who are leaving the military have already had treatment for mental health issues have accessed cva etc so it it is a bit individual um you will always get those individuals who uh perceive that a mental health issue in particular is um represents weakness um and their concern is that other soldiers will will put them in the basket of you know that soldier's broken because they're weak um and they're not my words they're words some soldiers I've worked with yeah absolutely and certainly um there's a clear ambivalence I guess with Tom which is is perhaps born out of that um military culture in part perhaps and also part of his own personality um I guess I'm wondering whether uh well perhaps I'll move on to John um do you don't have any tips for us about how you would go about engaging someone like um like Tom in treatment uh in terms of uh someone like Tom things like knowing the military language can be really helpful uh you know where he has a sense of this person understands him so you can find you can find lists of of military language um something knowing something like what a grunt is for example might actually which is an infantry soldier might actually help engage Tom to to see that you understand some of his perspective uh a time a time sort of factor is also often part of the situation uh and also I guess engaging him in his in his motivation what what are the reasons okay there's the ultimatum from Sonja but also you know he's chosen to come in himself rather than just ignore that ultimatum and that working on with that motivation and building that can be a really important factor as well as helping him to understand what the options might be in terms of treatment and that doesn't necessarily have to happen straight away you can build some trust first but once um he does do something he can actually have change as well yeah yes absolutely absolutely okay so let's assume then sorry that that um Tom has turned up treatment I wanted to marry if I could turn to you uh you did comment a bit about some of the things you were worried about I wonder if we could just have a bit of a general chat both in Tom's case and more generally about what you think are the red flags what are the kind of warning signs that someone might actually be perhaps on a downward spiral or heading for something fairly serious what what kinds of things concern you well in the case of Tom I think um we we know that his mental health considerations are actually quite I won't use the word chronic in a sort of chronic psychiatric patient setting but meaning that some years ago um he acknowledged that his mental health was compromised and agreed to seek counselling but didn't that in itself is a red flag that it it got to a point where he accepted the need for help but didn't follow through and now he's following through with possible reluctance or at Sonya's insistence or maybe he's there as John has said because he now wants to be so so the actual engagement is itself a red flag the big one is his social isolation I really worry about um Kate was talking earlier about the sort of the family of army the number of peer supports the number of mates that are serving members have that very quickly drop off the radar once someone is um discharged he's living in a remote town he's not working he's he's disengaged from family he's drinking he's possibly using analgesics and virtually nothing that's given him meaning or satisfaction is currently working for him um one of the ways I sometimes engage with my veteran and military patients is through their fitness and so I asked them a lot about their physical capacity and their regime at the gym and then talk to them about how that physical discipline we can use we can use the same discipline in a psychological sense but when I hear that somebody has stopped going to the gym or they're going erratically or they're hardly going at all because you know they don't like crowds or they don't like the noise at the gym then that to me is a red flag as well because these are guys who are who've always prided themselves on their physical prowess and you know that very act of being a strong tough soldier um has formed such a huge part of their identity that many of them try and retain um once they leave the military and so when they start to lose that that's another red flag and then obviously asking the um the usual questions about suicidal thoughts suicidal intent suicidal planning protective factors in his case I think the protective factors are probably um Sonja and the children but I'm not really sure what other protective factors there are and if Sonja were to leave him I think that that would be um I concur with Kate that sometimes a social a shift in the social dynamic like losing his relationship can suddenly mean somebody's um at high risk of suicide and then I would be thinking about inpatient management right yes absolutely um if I could turn to you Kate because very often the GP is of course the well I've kind of a linchpin that the sort of perhaps the case manager for one of a better word and you talked about the the post discharge mental health assessment my understanding is that there are plans to increase that I'm not sure if you're aware of that whether it's been announced yet or I just did have you heard of plans to increase the number of sessions available to GPs for assessment I um I have heard about it um I haven't uh gone on a search to um confirm that so I probably can't exactly answer that but I'm not sure that it's gone live yet I'm not sure that it's been launched it's I think it's imminent yeah yeah but certainly um the assessment and also but you know utilizing the Medicare mental health plan it at least provides more opportunity and you know the the post discharge assessment is very good in that it's quite holistic and looks across physical well-being as well as um uh mental health pain a whole range of issues yeah yeah it wasn't tapping me into absolutely absolutely well just picking up on on one issue that we might want to do some assessment on and and you mentioned particularly about the importance of meaningful activity which I 100% agree with um so in a case like Tom's how important do you think it is to get him a vocational assessment and to to be looking at perhaps some kind of employment opportunities even if they are very low key is that is that an important thing for someone like him I think it will be important once um he's on the path to recovery it may be a bit early at this stage but um before I was a doctor I was an occupational therapist so I'm very really I'm very into um activities and you know it may be that again you have to start small and find out from him what has been meaningful in the past and as Mary said it may be well related to fitness it it may be something else you know we don't we don't quite know um but you know looking for some opportunities based on uh what he what he says is has been meaningful to him before um or sometimes reconnecting uh it may be meaningful for him to reconnect with other veterans through rsl etc so you know part of it's just going to depend on discussion with him and what you identify and I suppose you want to set him up for success by by starting with small brief activities yeah yes absolutely absolutely and I would I would like to come back to some of that stuff later if I can turn to you John though um as part of the assessment how good do you think we are at um actually asking that the person the veteran if you like what their goals are um rather than kind of the form of assessment that you talked about do we also need to be asking them what they want out of treatment what they expect out of treatment absolutely yes we need to really look at how how our treatment might move them towards what they want it's where we're not going to go anywhere if we're not not working on that and being able to identify that is is a really strong key to to people's success and uh is is often a challenge in that that they have they might meet a criteria for something but that's not what they understand their experience and in terms of uh not understanding the experience they might not understand how that may impact on their life for example you know most often people present to me with a relationships kind of issue that is actually part of a previous trauma and it's a job for the clinician to integrate well they want their relationship to be better what are the things that are affecting them and what are their goals with that relationship so understanding that side of a person's experience is a really important part of why they come in to start with but also their their success and understanding that i'm withdrawing from things i'm finding the kids irritable and but i don't want these things well what is it that's driving those yeah absolutely and and i guess tom like um well certainly like so many of the veterans that that i've come across over my career is primarily presenting for treatment not necessarily because he particularly wants to but because his wife has said she's going to leave him if he doesn't so he's been pushed into treatment for um yeah specifically so i take your point that how important it is to really work out to come some collaborative agreement i suppose about what we need to work on in treatment yeah um okay tom is presenting with a whole range of um mental health conditions that's the nature of our talk tonight is about co-morbidities and obviously we don't have time to go through them all um i would recommend to you actually that you do go back if you would like to look at the treatment of specific conditions like ptsd or substance use or whatever that you do go back and have a look at the earlier webinar but i would like to pick up on a couple and one that i'd like to start with actually is anger because i think that anger often gets in the way of treatment and perhaps if i could come to you mary first and just pick up on something that you said about um safety issues um how concerned do you think we should be mary with um uh i guess with safety issues of his family of tom's family for his wife and children look i think there are a number of um red flags in relation to the safety of his wife and children and one is tom's withdrawal um so sonia's kind of almost said to him she doesn't want him in the bedroom he's a he's a he's another child he's a burden uh she's already got two children she doesn't need a third she's spending more time with her family and they've offered to have her live with them and so i suspect that tom's anger and irritability is really driving a major wedge between himself and his family and for him kind of developmentally that's really significant because he was a a fellow who lost his dad quite young lost his mum a few years later joined the military so this notion of his own family is is i would suspect a very strong value to him and you know when we're talking about engagement and um what are his goals i suspect one of his goals would well be to re-engage with his family and to preserve his family so i think he's trying to help him manage and modulate and modify that anger is uh is going to be a critical part of therapeutic alliance in saying that um i don't think that psychiatrists have a lot of very helpful medications that specifically just target anger i think we target arousal anxiety and then sometimes people say that that makes them less irritable but it's almost as if that's a kind of spin-off from um from modifying uh anger so sorry by reducing arousal it makes people less angry but i don't think it's a direct effect on anger i think most of the medications that psychiatrists have that make people less angry are actually very sedative and then people complain of feeling like a zombie and that's not helpful either because when you're a zombie you don't go to the gym you don't interact so yeah i think it's that's a very fine balance from a biological perspective absolutely i quite agree but let's turn if i could to non-biological and perhaps bring you in kate um i wonder whether you have any i don't know for any tips for managing angry patients in the consulting room perhaps for clinicians and or perhaps what you might be saying to families about how they can uh i guess de-escalate the anger at home and so on do you have any any tips or strategies for people there um i think um you know in terms of in the consulting room we uh you know in the first instance we have to be mindful of um our own safety um as well as the safety of the the patient and um you know earlier today i was concerned about someone who was escalating and uh it in terms of their um anger with the situation and i actually brought the consultation to a close um it was appropriate to do so but i thought i i just need to sort of contain this by bringing it to a close and and took him out to make the next appointment and to organize an appointment with the psychologist so i sort of changed the the um i didn't let it run on and on i mean obviously us remain in calm um and and i think two military um uh members are used to people um you know even though you're there as a therapist or a doctor you still have a degree of authority and and i don't use it often but occasionally um you know you need to be clear in your communication and say look this is not okay we need to calm down take some breath um let's just sort of settle things down so we can talk more and actually use that that bit of authority to to contain the situation sure and i guess they're setting clear boundaries about what what is the need like that's all behavior yeah yeah yeah and i suppose with fact with family um as well it's it's uh you know the usual sort of psycho education about what's reasonable and what's not um and strategies such as um taking time out or um breathing or counting to ten um uh you know i did have one couple who used the the stress bucket metaphor so that um they talked about their own stress bucket how it was building up and when they were near the top they could communicate to the other person that my stress bucket's really full i need to just sort of work on getting that down um so they were able to share that between them both of them yeah okay so having a shared language to kind of communicate about that issue i think is yeah a very good idea um just while you're there kate we've had a number a few themes coming in on the chat box and one of them has been a concern that uh there are long waiting lists for veterans it's probably hard for you to comment because it's been so much where you are i suppose geographically but do you think that long waiting lists for veterans to get help is a problem uh you know it certainly can be it depends a bit on the area um you can you know try and prioritize the patient if you're really concerned um but yes i presume this is in relation to open arms or psychiatry or yeah yes exactly i think yeah but all of those yeah yeah so um yes okay so so it's the way it is i guess and and uh yeah hopefully the waiting list is not too long and as we were saying some regional areas they're really there aren't too many services um i suppose you know something to always bear in mind is you know are there um phone services available either through various agencies or with private psychologists for example or telehealth psychiatry yeah yes quite okay let's um go on if we could and talk a bit about specific kinds of treatments and um as i said you know we clearly can't go into detail about all the available treatments for multiple conditions even just for PTSD actually but i wonder if i could start with you john and um and ask you literally just to give us one or two sentences and really know more on the key sort of evidence-based treatments and i suppose i'm thinking CPT which you mentioned prolonged exposure maybe EMDR just one or two sentences to orientate people as to what they are okay so they're they're all therapies that have a lot of research behind them which means we know that they do work we know how well they work we also know the factors that make make them work um they're all relatively short-term they're not years and years they can be completed in a matter of months and um on average about two-thirds of people will come out of that without a diagnosis and we know that there also is work being done because of the research to actually look at what factors can be um tweaked if you like to try and improve outcomes so i guess evidence-based therapies have have lots of support and they there's ongoing research i guess and that helps us understand how they work and what factors sort of improve or or potentially make them not work as well such as the more we space out sessions for example we know that doesn't work yeah and so really to emphasize the point i think you really made in your talk which is that everything else being equal these really should be our first-line treatments in something like PTSD absolutely absolutely and i think in terms of just short brief how they work we know that all of those treatments work by stopping avoidance which is the key PTSD symptoms yeah and and they they deal with that yeah okay cognitive and behavioral avoidance i guess i'm thinking we're thinking yeah in in all its forms yeah in all its forms okay thank you john um mary if i could turn to you and talk about um meds you you spend a bit of time well you mentioned very briefly some of the medications you might consider um i guess i'm wondering what might be your for i i guess i'm assuming probably that that perhaps an ssri or similar might be one of the first line would that be right yes that would be correct yeah and i wonder if you could comment on um i guess the side effect profile i'm thinking particularly about the impact on on um weight gain perhaps but also sexual dysfunction particularly for someone like tom where we might get a rectile dysfunction as a side effect of ssri sure because i think one of the difficulties about the assessment of sexual side effects and antidepressants is that often the first time somebody reports sexual dysfunction is as medication has been after medications has been commenced but when you take a history of the sexual dysfunction it actually predated the prescription of antidepressants and somebody who's feeling ashamed who's lost identity who's feeling um less powerful in a relationship will often have sexual dysfunction as part of that and that's not to avoid that i mean there is a very definite link between um sexual dysfunction and particularly ssri's there are a number of newer antidepressants which are less likely to cause sexual dysfunction there's an antidepressant that's come onto the market in Australia in the last few years called vortioxazine um mclobamide which has been around for some years agamellatine but i don't think in the case of agamellatine or mclobamide they really have a strongly established evidence base in the treatment of ptsd but nevertheless i will sometimes change patients from an ssri to one of those other agents um weight gain is generally less of an issue on the ssri's although i think again there's inter-individual variation there uh weight gain tends to particularly happen with the atypical antipsychotics such as quitypen which is prescribed quite commonly to treat nightmares um there has been some uh work in the last 10 years to do with non-psychotropic agents having a role in the treatment of arousal and nightmares things like clonidine prasicin but again i think the um the evidence base is not firmly established but nevertheless i will sometimes use those medications where somebody's um been intolerant of the psychotropic agents and uh trial them on the non-psychotropic agents to see if that reduces arousal but that requires quite a lot of monitoring particularly blood pressure with prasicin and clonidine yeah okay complex issue isn't it um and to turn to you Kate if i could you mentioned a number of things um i guess relatively quickly but things that i think are crucial but i wonder how important you think they are i mean i guess i'm thinking about more lifestyle kinds of things social engagement being a big one but also things like exercise and diet and rest and so on how important do you think these things are and i actually think they're really uh really really important so you know those you know when we eat well when we get some sunshine when we exercise a bit when we engage with it we you know it it has a very positive effect on mood um so you know and a lot of those things will drop out of the person's life as they feel worse so i actually have a what i call a well-being script and i go through it with people and i've typed it all up and i can actually we can light on there where there perhaps some changes can be made um and from there then go to some you know basic goal setting and i find people respond to that really well so making it very meaningful and concrete yeah so yeah i i absolutely agree i think that that things like that can make a huge difference and and um yeah re-engaging re-enjoyable activities and things like that and i think you know just to i do think sometimes that we as clinicians um sort of get involved in very high level therapies and we think they're really great and it's a you know and we sometimes forget about these things that are actually so important starting points you know lay that basis i'm often struck by the as i understand it the literature on depression that says you know behavioural activation is far and away the most important thing get people doing things you know so basic kind of stuff a couple of recent examples um you know a woman with anxiety lots of you know lots of issues but when we went through that script she um she was drinking two litres of coke and cola every day and you know there's a lot of caffeine and sugar in in coke and you know she actually felt a lot better when she changed what she was drinking as her name fluid um someone else who's um you know depressed someone like tom if he actually manages to get out and walk the dog around the block in the sunshine or get out into nature you know townsville there's some beautiful spots go for a walk along the sea front or something it you know take the kids that may well um do a lot of good for his mood absolutely and we've got a mounting body of evidence and we're around the benefits of physical exercise generally a mental health while i've got you kate um and we are running out of time we've only got a few minutes left so very briefly and i know it's a big issue but would you want to involve tom's partner in treatment should we be involving his partner uh yes very much so um i think uh you know it says that tom well i'm presuming tom goes to the gp he may well go with sonia in the first instance it's not uncommon for a husband and wife to turn up or a partner partners to come together um and so you know it's important to see tom obviously on his own as well but that for sonia um uh you know information is important understanding what's happening for tom um obviously with his consent um but also she may well need therapy as well and support and so it you know it may be that um she needs to see her gp and you know perhaps see a therapist herself or count well or you know get some of that support as well absolutely and it's um yeah i think it is an interesting i gotta say dilemma that's not the right word but but how much we're seeing the partner so that they can help the veteran and how much we're seeing the partner actually yeah good point okay final question before i begin to wind things up and i might chuck this one at you uh john if i could we talked a bit about the lack of um well the difficulty i guess in rural and remote areas of getting access to treatment uh john do you have any um uh suggestions about what we can do in terms of perhaps online internet based treatments have we got any evidence that they are helpful we we do have evidence that they are helpful and in particular i guess cognitive processing therapy i have my must declare my bias um there there's a number of research studies done in the u.s that show that they actually have equal outcomes to face to face um counseling and and in in fact even in groups done on the internet which i find really surprising but even in groups done on the internet they have uh outcomes that are the same and they also have better bonding across the internet which one with biases about that it seems to be but yeah so there is there is research that shows that it that it can work uh and certainly uh from what i know of the u.s context which would be very similar here it was it was developed in the u.s because of those difficulties for people in rural and remote areas yeah so that is very encouraging but just to be clear there you're talking about um a therapist working online through Skype or or something like that is that right yeah absolutely there's there's not much evidence in terms of somebody doing a sort of structured program that that might be like a an online education program having an opportunity to get feedback from a therapist and understand the experience and understand where where your kind of beliefs go that have been changed through traumatic experiences is something that the therapist is a key for that absolutely still no doubt we will uh continue to see a growth i guess in online and and technologically based treatments um but alas we're running out of time we really only have a couple of minutes left and so i would like to if i could ask each of our panelists whether they have one or two uh take home messages that they'd like to leave our participants with and perhaps if i could start with you Kate is there any any final messages you'd like to leave our participants with uh i think um think holistically there's my dog in the background making an appearance so you know people have all sorts of um aspects to their lives so you know think about um all of the problems but also think of all the many facets to Tom's life um and i think you know if you can uh create a team around Tom that's going to be most helpful great okay thanks for that it's very nice to see your dog wandering around in the back there John uh any any take home messages from you for for our participants tonight i guess the take home message for me would be that uh you know the evidence-based therapies are really good they they work very well and the key that that they have is that they are trauma focused and that's uh that's a really important thing and and i guess in terms of thinking about the holistic things that the that Kate has mentioned the holistic idea we might be engaging with the GP with the psychiatrist helping the client move towards an evidence-based treatment that's trauma focused it can be a difficult thing to think about to start with but if a team is there that can be helpful so interacting with your team so the veteran is is good and uh evidence-based therapies have that uh edge in terms of that trauma focus that helps people change things significantly lovely thanks John and Mary any final take home messages from you yeah look i i think i'm uh just endorsing the messages of the others but it's really kind of the seawards collaborate communicate and care and i think uh sometimes we you know we open this discussion around entitlement and sometimes the tom's of this world can have a very abrasive quality that puts us off and makes it hard to care for them and so sometimes finding your way in and finding the sort of you know the softee the marshmallow inside um uh can be really helpful to then be able to better care for tom as well as obviously the collaboration and communication great thank you thank you mary thank you very much to all of you uh look i've just got a few very quick closing comments to make uh first of all a reminder to everybody that mhpn runs uh local networks and uh in particular a number of networks that are specifically oriented towards veterans mental health so uh for more information about those you can join a network or indeed if you'd like to start one uh do contact mhpn a reminder as I said at the beginning that there are a number of resources uh to go along with this webinar tonight and mhpn will send you a link to all of those resources so that you can uh but for now uh it's really time to sign off and say thank you uh i would ask you please to make sure that you complete the feedback survey uh before you log off um but basically thank you very much to everyone for what i thought was a great webinar this is the uh last activity in this particular stream of the mhpn online conference and tonight's activity will be up uh on the website i think in around 24 hours so thank you very much to mhpn to dva and to redback for their support of this and other webinars in this series thanks very much to our panel tonight to kate to john and to mary and thank you very much to all of you participants for your involvement and engagement in the webinar thanks very much and good night to everybody