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Cathy O’Leary | Editor
Life – and finding the balance It’s like the pre-flight advice that “in the unlikely event of an emergency” people should put on their own oxygen mask before helping others. But it’s often more easily said than done.
It’s always fascinating to learn the back stories of people – their background and what makes them tick. You realise what a diverse bunch of people we are. This month, you can read Ara Jansen’s story about Perth craniofacial surgeon Linda Monshizadeh, an Iranian-born triplet whose two sisters are identical (and both pharmacists). Her family left Iran as refugees when she was five, making their way to Pakistan with protection under the UN before coming to Australia. Linda is a greater believer in a work-life balance and dabs in oil painting, so it is fitting she graces the cover for this month’s mental health edition. Perhaps it is the added pressures of COVID, but it has struck me lately how much there is to be told about the mental health challenges around us. Many doctors are working at the health system’s frontline, which is being overwhelmed by demand from all corners, and they need to be reminded to look after their own wellbeing. It’s like the pre-flight advice that “in the unlikely event of an emergency” people should put on their own oxygen mask before helping others. But it’s often more easily said than done. And while we’re talking masks, you just have to wonder how long COVID is going to overstay its welcome. I’m currently one of the 600,000-plus West Australians who have seen twin lines on a piece of plastic or received a text message about a positive PCR test. By the time this is being read it will probably be more like 750,000 cases – possibly a lot more. I feel relieved I’ve had COVID and made it through unscathed. Many others have been left feeling flat, fatigued and struggling to get through their daily workload – a bit like our public hospital system at the moment.
SYNDICATION AND REPRODUCTION Contributors should be aware the publisher asserts the right to syndicate material appearing in Medical Forum on the mforum.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publisher for copyright permission. DISCLAIMER Medical Forum is published by Medforum Pty Ltd (Publisher) as an independent publication for health professionals in Western Australia. Neither the Publisher nor its personnel are medical practitioners, and do not give medical advice, treatment, cures or diagnoses. Nothing in Medical Forum is intended to be medical advice or a substitute for consulting a medical practitioner. You should seek immediate medical attention if you believe you may be suffering from a medical condition. The support of all advertisers, sponsors and contributors is welcome. To the maximum extent permitted by law, neither the Publisher nor any of its personnel will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reflect the views of the authors and do not represent the opinions, views or policies of Medical Forum or the Publisher. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the Publisher or its contributors for the promoted product, service or treatment. Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Competition and Consumer Act 2010 (Cth) as amended. All advertisements are accepted for publication on the condition that the advertiser indemnifies the Publisher and its personnel against all actions, suits, claims, loss or damages resulting from anything published on behalf of the advertiser. EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers. Medical Forum has no professional involvement with advertisers other than as publisher of promotional material. Medical Forum cannot and does not endorse any products.
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CONTENTS | JUNE 2022 – MENTAL HEALTH
Inside this issue 22
14
18
24
FEATURES
IN THE NEWS
14 Cover story:
1
Dr Linda Monshizadeh
18 Rural psychiatry training pathways 22 Kids mental health set for reform 24 Eating disorders hiding in plain sight
LIFESTYLE 62 Winter warmer – books 64 Wine Review: Cape Mentelle – Dr Craig Drummond MW
4 6 12
Editorial: Life – and finding the balance – Cathy O’Leary
29 Changing the
News & Views
31
exercise paradigm – Dr Noula Gibson
In brief Opinions: WA’s COVID response – Dr Nicholas McLernon & Dr Harvey Smith
40 Purple book health checks – Anne-Marie McHugh & Dr Yvonne Anderson
43 Mental health for all – Dr Joe Kosterich
28 Exercise scripts for sick kids
WINES AND WINS
Country medicine good for the soul
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Youth mental health By Dr Davinder Hans
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Looking beyond ADHD Dr Pradeep Rao
Time to rethink obesity treatment Dr Julie Manasseh
A good hearing for implants Dr Cathy Sucher
Exercise script for mental health Katie Stewart
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Breast surgery items off exclusion list HBF will remove three breast reconstruction procedures from its limited surgical items list, after talks with doctors critical of out-of-pocket costs for patients. The health insurer also says it remains committed to reforming the controversial list of items which are excluded from medical gap arrangements. Earlier this year, HBF announced a major overhaul of gap payments to doctors to take effect from July 1, including ditching the limited surgical Items list, which only pays patients benefits up to the MBS scheduled fee. Last month it put the plans on hold after a strong backlash from the profession, including the Australian Society of Anaesthetists and the Australian Medical Association WA.
Kids’ referrals explained Dozens of departments across Perth Children’s Hospital have helped produced a series of pre-referral guidelines for GPs and health professionals. PCH accepts referrals from private consultants and GPs to more than 50 outpatient and inpatient services for children and young people. The pre-referral guidelines explain when to refer and the process itself, including information on pre-referral investigations and management. They can be found at Pre-referral guidelines (health.wa.gov.au) and other referral guidelines for Community and Child Health, Mental Health and NETS WA are available on the CAHS website. The PCH outpatient reform team is also seeking feedback from health professionals by contacting PCH.OutpatientReform@health. wa.gov.au.
Scans for young brains Funding from the Channel 7 Telethon Trust is being used to develop imaging tools to help researchers study brain development and injuries in children. 4 | JUNE 2022
But since then, HBF has attracted criticism from other doctors who are unhappy with the excluded list, particularly items associated with breast reconstruction and implant surgery after breast cancer.
HBF members will not have a gap. If the service is provided by a participating known gap surgeon or anaesthetist, patients might have a reduced gap depending on the fees charged by the specialist.
HBF’s Executive General Manager Health and chief medical officer Dr Daniel Heredia told Medical Forum that three breast surgery MBS items would now be removed from the limited surgical items list from July 1.
Dr Heredia said members were strongly encouraged to use the new provider search tool on HBF’s website to determine whether their specialist participated in the HBF full cover or known gap arrangements.
They are 45530 (unilateral breast reconstruction); 45533 (breast reconstruction including breast reduction First Stage); and 45536 (breast reconstruction including breast reduction Second Stage.)
“We remain committed to addressing issues with the limited surgical items list, and while negotiations are ongoing, our strong desire is to attach a benefit above the MBS, including items on this list,” he said.
This means that if the service is provided by a participating fullcover surgeon or anaesthetist,
One of the projects at the Perron Institute involves MRI techniques to identify and diagnose neonatal encephalopathy within the first hours of birth. Described as disrupted brain function, this syndrome has various causes, the most common being lack of oxygen before, during or immediately after birth. Coordinating principal investigator Dr Adam Edwards said babies who survive are at high risk of severe and permanent neurological disabilities such as cerebral palsy and epilepsy. “Immediate treatment can improve outcomes, and that is why early diagnosis is vital,” he said. The advanced imaging will help the Perron Institute’s promising research on a peptide drug called poly-arginine-18 which has been shown to reduce brain cell death in preclinical models of preterm infant brain injury. Funding has also helped to buy a high-resolution Nikon A1R multiphoton microscope, which will be used to image the developing brain. Associate Professor Jenny Rodger, head of
brain plasticity research at Perron and UWA, said deep tissue imaging at cellular resolution was crucial to understanding the mechanisms of healthy brain development, as well as abnormal development and brain injuries. The microscope is due to arrive in August and will be the only one of its kind in WA.
Path of least resistance People battling with their weight who are unable to do aerobic exercise can hit the gym instead and still see positive results, a new study has shown. Despite the commonly held belief that aerobic exercise is essential for weight loss, Edith Cowan University research has found resistance training can also have positive results, when combined with reduced calorie intake. Lead researcher and PhD student Pedro Lopez said the findings showed resistance training could have a significant effect on fat mass, muscle mass and weight loss.
continued on Page 6
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Some big changes are underway at HBF, with John Van Der Wielen stepping down as CEO after five years, but staying as a non-executive director. Chief transformation officer Simon Walsh will be interim CEO while the search is on for a new chief. Dr Daniel Heredia has also moved to Executive General Manager Health and chief medical officer, while Dr Andy Papa-Adams becomes medical director. Envision Medical Imaging has joined the Qscan Group, one of Australia’s largest radiology groups. Envision’s clinics in Subiaco and Booragoon will join Qscan's WA clinics in Midland and Rockingham. Dr Shirley Bowen is the new Chief Executive of North Metropolitan Health Service, moving from her CEO role at St John of God Subiaco Hospital. Acting CEO is Adj/Prof Jenny Brenton. Dr Richard Bostwick has joined Bethesda Clinic as its inaugural General Manager. He was Deputy Director of Clinical Services at Ramsay Clinic Hollywood. Bethesda Clinic is due to open its doors in Cockburn by November. Silver Chain Group wounds expert Professor Keryln Carville has been recognised with a lifetime achievement award at the recent World Union of Wound Healing Societies 2022. Registration is open for the General Practice Conference and Exhibition Perth (GPCE Perth on July 23-24. The reformatted conference program is aimed at time-poor GPs and is being held at the Perth Convention and Exhibition Centre. Healthdirect has now made essential COVID-19 advice about managing symptoms available in 15 languages to help culturally and linguistically diverse communities.
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continued from Page 4 “Usually when we talk about obesity, body composition or weight loss, we only hear about aerobic exercise,” he said. “This paper shows we can use resistance training and achieve meaningful effects with a diet based on caloric reduction. We can reduce body fat percentage, whole-body fat mass, body weight and BMI.”
Recent research from the Australian and New Zealand Intensive Care Society’s Paediatric Study Group and Centre for Outcome and Resource Evaluation has shown an increase in PICU admissions following deliberate self-harm, coinciding with the COVID-19 lockdowns and social restrictions of 2020 and 2021.
Mr Lopez said it was important people battling obesity had options beyond just aerobic exercise to lose weight.
They found that the monthly incidence of deliberate self-harm ICU admissions per million children and adolescents increased from 7.2 admissions in March 2020 to a peak of 11.4 admissions by August 2020.
The kids are not okay
Diabetes research boost
The mental health effects of COVID-19 lockdowns and restrictions on children and adolescents may have been hard to pin down, but at the pointy end of the stick – paediatric intensive care units – it’s hard to deny the data.
Two diabetes research projects have been given a financial boost – the first a ground-breaking project to help manage gestational diabetes in rural WA. continued on Page 8
Calming an excitable spine Edith Cowan University researchers have made a breakthrough discovery which could have a big impact on the lives of people who have conditions such as multiple sclerosis or have suffered brain or spinal injuries. Many of these people suffer from painful muscle spasms due to motoneurons in their spinal cords becoming “excited” and overamplifying messages from their brain sent to their muscles. The researchers have discovered ways to calm spinal cords down, which could open the door to new therapies. To move our bodies, the brain sends messages to muscles via motoneurons in the spine which can amplify neural signals so the brain doesn’t need to work as hard to contract our muscles. PhD candidate and lead researcher Ricardo Mesquita (pictured) said this amplification was important but could also prove problematic following a spinal cord injury. “These amplification powers are great, but sometimes they can be
too much of a good thing,” he said. “We know some clinical conditions are characterised by hyperexcitable spinal motoneurons, with this amplification continuing without any inhibition to stop it. “This can lead to involuntary muscle spasms that can be painful, cause injuries when people hit something accidentally, restrict movement, and wake people up at night.” Mr Mesquita has found ways to decrease this neural amplification, the first involving electrical stimulation on specific nerves, which could reduce the amplification in the spinal cord. Relaxation could also help to calm the amplification and potentially reduce the severity of spasms. MEDICAL FORUM | MENTAL HEALTH
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Dispelling the myth: Medical practitioners, mental health and mandatory reporting. Dr Sarah Taylor - Medico-legal Adviser, MDA National
Health care workers can be reticent to seek mental health support due to the worry that seeking help may lead to a mandatory report to Ahpra. The key concept here is that a mandatory report to Ahpra is only required if there is a reasonable belief that the practitioner is practising with an impairment and placing the public at substantial risk of harm.1 The National Law defines ‘impairment’ as when ‘a person has a physical or mental impairment, disability, condition or disorder (including substance abuse or dependence) that detrimentally affects or is likely to detrimentally affect a person’s capacity to practise the profession. Forming a reasonable belief involves a judgement based on stronger knowledge than mere suspicion or rumour - it must involve direct knowledge or observation of the behaviour. 2 In March 2020, Ahpra provided clarification on this issue in an attempt to help ease the concern that Ahpra notifications were preventing practitioners from seeking help for their mental health. Ahpra introduced different thresholds for reporting practitioners for treating and non-treating practitioners and for employers. A mandatory notification is only required by a treating practitioner where there is a reasonable belief of ‘substantial risk of harm’ to the public. 3 When considering whether to make a mandatory notification, the treating practitioner can take into account any strategies put in place by a practitioner or their employer to reduce the risk of harm to patients. The treating practitioner must be able to form the belief that the impairment poses substantial risk of harm to patients. Practitioners who may be suffering from mental health issues can mitigate their risk of being reported to Ahpra, and reduce any risk to patient safety, by seeking treatment. This includes taking a break from practising, if felt to be warranted by their treating
There are some exemptions from mandatory reporting. In Western Australia a ‘treating’ medical practitioner is exempt from making a mandatory notification. However, they should still consider their obligations regarding patient safety and can decide to make a voluntary notification. Additionally, an exemption from mandatory reporting exists if you believe that someone else has made the report, including self-reporting by the doctor concerned. Medical practitioners assisting you with legal matters through your medical defence organisation are also exempt. If you have any concerns you should contact your medical defence organisation. Our Members’ health and wellbeing is our top priority and we don’t want anyone to suffer alone. Seeking help early can often prevent a mandatory report. It is so important that medical practitioners seek the mental health support they need. The Covid-19 pandemic has increased doctor burnout, depression and anxiety with increasing workloads, decreased holiday leave, lack of access to family supports and increased general worry about the state of the world. If you feel you need assistance with your mental health you can get help from your general practitioner or refer to the doctors’ health advisory service in your state. They can be accessed from: Australasian Doctors Health Network www.adhn.org.au/ DRS4DRS www.drs4drs.com.au/ and for those located rurally, also go to crana.org.au/mental-health-wellbeing/overview These organisations can provide doctors and medical students with confidential, mental health advice from qualified health practitioners who have experience in doctors’ health. Most states also provide free counselling sessions in this service .
team and returning to practise when ready, to a modified scope.
You can also contact Lifeline 13 11 14 – available 24 hours a day www.lifeline.org.au/
1 https://www.ahpra.gov.au/Notifications/mandatorynotifications/Mandatory-notifications.aspx 2 https://www.ahpra.gov.au/Notifications/mandatorynotifications/Mandatory-notifications.aspx 3 https://www.ahpra.gov.au/Notifications/mandatorynotifications/Mandatory-notifications.aspx
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continued from Page 6 The Medical Research Future Fund has provided $3.2 million to a team led by Professor Julia Marley from UWA’s medical school and the Rural Clinical School of WA (RCSWA). The ORCHID study aims to simplify screening and improve management of high blood glucose levels in pregnancy. Professor Marley said diabetes disproportionately impacted the lives of Aboriginal people, beginning in pregnancy. The ORCHID study is run by the RCSWA, Kimberley Aboriginal Medical Services and their member services, Diabetes WA, WA Country Health Service and Diabetes Research WA. Diabetes Research WA has also provided $60,000 for new research which has discovered that a single gene change may be putting people at increased risk of insulin resistance and fatty liver disease by changing calcium levels within energyproducing machines in cells. The research by University of WA Professor Aleksandra Filipovska found the common variation of a gene changed energy metabolism in cells. The group hopes to test how specific diets and exercise regimens may affect this single gene change.
Baby weight link to eye problems Perth researchers have found that weight gain could be a key to predicting a common eye condition that can cause blindness in premature babies. A joint neonatology and ophthalmology research project at the Child and Adolescent Health Service has found a simple method, based on a post-natal weight gain model, can predict retinopathy of prematurity which is the leading cause of blindness in premature babies. The findings could have a huge impact globally by reducing the number of premature babies who are screened for ROP. Neonatologist Dr Sam Athikarisamy, right, and Ophthalmologist Clinical Associate Professor Geoffrey Lam, left, recently published their review and analysis of 61 studies in the JAMA Network Open Journal. Dr Athikarisamy said current screening protocols for ROP require frequent retinal examinations which create a big workload for staff in neonatal ICUs. “We found the weight gain-based algorithm proved effective in identifying which babies were at risk of developing ROP. More targeted screening is a cost and time effective measure for staff but will also reduce the number of babies who experience the discomfort of an examination.” Researchers hope the findings could prompt a review of screening protocols for ROP internationally to ensure resources were better directed to babies most at risk.
Rapid COVID test shows promise Perth researchers say a pilot project has added weight to the prospect of rapid, highly sensitive population screening for detecting viruses such as those causing COVID-19. The technology makes repeated testing quicker and easier without compromising quality. The Avicena Sentinel saliva sampling approach involves sensitive molecular processes and ultra-high throughput technology for screening potentially infectious, asymptomatic carriers.
Latest data published in the Nature journal Scientific Reports shows 98 per cent accuracy in identifying the SARS-CoV-2 virus in samples. The research team included Professor Sulev Koks, who heads genetic epidemiology research at the Perron Institute and Murdoch University, and local specialists from Avicena Systems, Telethon Kids Institute and UWA. Professor Koks said that while PCR tests accurately detected viruses such as SARS-CoV-2, they lacked the speed needed for large-scale routine screening and quarantine applications. PCR results took hours and required trained personnel to do the sampling. While rapid antigen tests were easier to use, they were not sufficiently sensitive in detecting the virus in people who were contagious but had no symptoms.
It can run up to 4000 samples per hour, with results in 25 minutes. 8 | JUNE 2022
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Looking beyond ADHD Children with ADHD often have mental health comorbidities that can increase their challenges, explains Dr Pradeep Rao. Attention deficit hyperactivity disorder is a common neurodevelopmental disorder affecting about 5% of children, characterised by hyperactivity, inattention and impulsivity with emotional and behavioural dysregulation common. ADHD has a high burden of disease and can impact school and family life, friendships and social relationships. It is also a highly comorbid disorder, so a comprehensive assessment must always include an assessment for comorbidities, as 30-50% of children with ADHD suffer from them. Early diagnosis and treatment of comorbidities results in better long-term prognosis. Mental health disorders commonly comorbid with ADHD include anxiety, mood and behavioural disorders, and other neurodevelopmental disorders. Anxiety disorders occur in about 25-50% of children with ADHD and can be highly debilitating and increase the burden of the condition. These children commonly have academic and social difficulties and need support in the school environment. Generalised anxiety disorder, social anxiety disorder and separation anxiety disorder are commonly seen comorbidities. Mood disorders such as depressive disorders are also relatively common. These can be a result of the social isolation, while academic difficulties may result in social difficulties and bullying at school, causing low self-esteem and, in some instances, a full-fledged mood disorder. There is increasing evidence that children with ADHD have a higher rate of suicidal thoughts and self-harm and attempted suicide compared to the general population. Presentation to an emergency department with low mood and self-harm/ suicidal ideation may be the first presentation of ADHD. 10 | JUNE 2022
Behavioural disorders such as oppositional defiant disorder and conduct disorder also commonly occur in children and adolescents with ADHD. In a school setting, they usually precipitate further social isolation and bullying and are also associated with disengagement. The presence of severe behavioural disorders comorbid with ADHD has been linked to increased offending behaviours and incarceration. The prevalence of ADHD in adult male prisoners is about 25%. Neurodevelopmental disorders such as autism spectrum disorder are also commonly comorbid with ADHD, although to a lesser extent than anxiety and behavioural disorders. Comorbidity of neurodevelopmental disorders can result in increased behavioural problems and can have significant impact on academic options. Children with ADHD often have difficulties with sleep. This could be a result of disorganisation leading to poor sleep hygiene, excessive use of technology/screens around bedtime, the effect of some of medications used in the treatment of ADHD or a disturbance of the circadian rhythm. Learning disorders such as dyslexia and dysgraphia, motor coordination difficulties, tic disorder and Tourette’s syndrome and substance abuse are other comorbidities of note. Comorbidity in ADHD complicates what is already a high burden of disease and impacts on all domains of the child and family’s life. There is a high carer burden on parents. Although the economic cost of ADHD itself is unknown, the annual costs to society of ADHD and comorbidities has been estimated to be over a $100 billion in the US. Screening questions for all comorbidities followed by detailed assessments including use of standardised questionnaires (for e.g. RCADS – Revised Children’s Anxiety and Depression Scale) are highly recommended.
An assessment of comorbidities is multidisciplinary and includes, where clinically indicated, a neuropsychological assessment, speech and language assessment and an occupational therapy assessment, as well as assessment by a paediatrician/ psychiatrist. Where a comorbid mental health condition is the predominant presenting feature, an assessment by a child and adolescent psychiatrist in addition to a paediatric assessment is recommended. Optimal treatment of ADHD may provide a beneficial impact on comorbidities such as behavioural disorders and anxiety. Occasionally, some medications used for the treatment of ADHD may worsen some comorbid conditions and may require careful dose titration or may need changing to alternate formulations. The Complex Attention and Hyperactivity Disorders Service (CAHDS) is part of the Child and Adolescent Health Service that works with children aged under 18 years and their families. Children and young people accessing CAHDS must have a diagnosis of ADHD and currently being treated by a paediatrician, child psychiatrist or neurologist. Clinicians work with children, young people and their families who have not responded to typical ADHD interventions, and are continuing to experience persistent problems with symptoms or functioning. CAHDS provides a comprehensive assessment for comorbidities in complex presentations but does not offer ongoing individual treatment or pharmacological intervention. It does recommend other services to work in partnership with the referrer. CAHDS also provides targeted group treatment programs to children and families accessing the service. ED: Dr Pradeep Rao is Clinical Associate Professor and Head of Service at CAHDS.
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Your future in public health As we traverse the COVID-19 pandemic and look to the future of healthcare, research in public health, big data and digital health at Curtin University coupled with its new range of postgraduate courses, is helping to change not just one life, but thousands. We spoke to Head of Curtin School of Population Health, Professor Rosa Alati, to find out more. COVID-19 has changed the world – what impact has the pandemic made on the public health sector? Many countries were insufficiently prepared to respond to the pandemic – exacerbating economic, social and health disparities. The pandemic has highlighted the critical role of epidemiology, the need for improved community health literacy and requirements for well-planned and resourced public health efforts that can be scaled up on-demand. How has the pandemic demonstrated the importance of health administration and management in ensuring quality patient care? It showed that visionary, inspirational, and proactive leadership has been critical to the COVID-19 response. Through foresight and effective management, necessary resources for healthcare organisations and essential facilities and services can be rapidly prepared, thereby minimising the disease’s spread and impact. Big data is changing the way we understand health care – how is big data improving public health outcomes? Perhaps no development has been more important than the capture, storage and analysis of large administrative and clinical data collections. These data collections, when linked across different areas of health care, provide valuable information on health and intervention outcomes across the entire
Professor Rosa Alati Head of Curtin School of Population Health Professor Rosa Alati is the Head of Curtin School of Population Health in Western Australia. She is an international leader in the field of life course epidemiology of health, linking familial administrative data longitudinally to develop large datasets to investigate causal pathways to health and diseases. Her research has been instrumental in identifying key risk factors for substance use and mental health disorders.
advanced facilities, give our students in-demand industry skills and knowledge while they study.
population. The benefits of these big data assets will expand over time as governments make them increasingly available and the skills and technologies required to unlock their potential grow. What foundation skills and qualities does a person need to succeed in public health? Public health professionals work across program management, policy development, research and surveillance so need strong communication and interpersonal skills. They must understand and respond to complexity, show a commitment to social justice, and have research, critical thinking and problem-solving skills. What courses does Curtin offer and what are the career outcomes? Curtin offers a range of postgraduate health courses in big data and digital health, health economics, health administration, public health, sexology, occupational health and safety, environmental health, dietetics and psychology. These courses equip students with knowledge, practical leadership and management skills that can be translated to the workplace, allowing them to lead and manage high performing teams in the healthcare environment. In particular, our strong industry partnerships with the WA Department of Health, WA Country Health Service, WA Primary Health Alliance, and our
Currently we offer Commonwealth Supported Places for some of our postgraduate certificates, where the government subsidises part of the fees, significantly reducing the cost of the courses. How is Curtin’s public health research driving positive change? One example is our Journey to Home project, where a multidisciplinary team across health promotion, psychology, health economics, epidemiology and biostatistics are exploring approaches to increase access to secure housing and improve mental health outcomes for people from culturally and linguistically diverse backgrounds. Another is CERIPH (The Collaboration for Evidence, Research and Impact in Public Health), which has achieved national and international recognition for its research over the past two decades, especially in the areas of injury control, drug use and mental health. We are also one of the core participants in the Digital Health Cooperative Research Centre (CRC) and have an alliance with the WA Country Health Service to transform how healthcare is delivered for people living in rural, remote and regional WA.
curtin.edu/pghealth
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Haven’t we done well?
economy recover? Without doubt, for a small portion of the population, the separation from family was very difficult.
Dear Editor, This rhetorical question is heard all too frequently in regard to WA’s approach to COVID. We have done well but what was the cost of our approach? In medicine we must always make assessments of any intervention critically. The next pandemic may occur in a few months or in a hundred years. It is likely that in the next year or three the usual non-SARS-COV2 respiratory viruses will return to our state with a vengeance. If we
do not assess our approach with a skeptical eye, we will fail to learn lessons for the future. The prolonged border closure was a popular measure but that does not mean that it was without long side effects that may yet emerge. Was there a subtle rise in xenophobia? Did key workers go elsewhere? Will the non-mining
Many children and parents were kept apart for two years, missing important life events. For some, the travel system was difficult to negotiate in the absence of high income, flexible work arrangements and physical/psychological ability to cope with quarantine. Even if one’s conclusion is that the border closure was appropriate, to ignore those who suffered is callous. I am grateful to live in Western Australia. All my family is here, and I had no need to leave the state. However, on a weekly basis I would sit with tearful patients who did need to leave. If they shared their grief with friends, they risked public shaming. Preference
A heavy hand Dear Editor, In 2019 the WHO published a pandemic plan. Nonpharmaceutical interventions (NPIs) were proportionate to the threat: measured; flexible; and tailored to different population risk. The remit was to keep modern society functioning. No threat imaginable could justify contact tracing, the quarantine of exposed individuals, entry/exit screening and international border closures. In less than a year, most countries ditched this approach, often in the absence of cost benefit analysis let alone public debate. NPIs were applied in a one-size-fits-all, including those counselled against in 2019. The impacts are now clear. The substitution of distance learning for schools has reduced maths and English skills, particularly for the least advantaged in society. In Japan, no alteration in community spread was found in closing schools. The closure of US public primary schools has been estimated to reduce life expectancy for students by almost a year. Households in low to middle-income countries experienced a nearly a 70% drop of income. The health of children in these households will be adversely impacted long term. The WHO in 2019 did not envisage that shelter-in-place would be mandated. Nations who kept SIPs as advisory rather than mandatory did no better or worse in terms of COVID spread and excess mortality than those who used police coercion. NPIs have impacted justice with criminals and victims waiting longer. In the UK serious sexual offence trials that 12 | JUNE 2022
were delayed for longer than a year increased over 400%. Pandemic alcohol-related deaths in the US increased by 25%, with opioid overdose deaths increasing 38%. Only a small proportion of these listed COVID as a complicating factor. The mental health of young people has been impacted by restrictive NPIs to the extent that one group of authors regarded it as causing a ‘wellbeing crisis’. The new plan resulted in many health systems being reorientated as COVID services. The excess deaths from neglected screening for cardiovascular and cancer are clearly documented. Many governments stoked fear of COVID as a nudge to ‘do the right thing’. Red-flag patients avoided hospital contributing to 8% of excess non-COVID deaths in one population. I would encourage readers to reflect on the link between health and economics. When this happens again, I would just make one plea. If we cannot become Florida, could we at least be a little more Swedish? Skol! ED: Dr Harvey Smith is a Perth dermatologist. MEDICAL FORUM | MENTAL HEALTH
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some of the unnecessary fear that was extant even in late 2021 has evaporated. The time has come to remove all measures that do not have a very high level of evidence (looking at you, vaccine mandates, tents outside of hospital entrances and hospital visitor restrictions).
falsification can lead to unforeseen consequences and may be a sign of an unhealthy democracy.
vaccination). I am not aware of any such studies being in place. I hope they are.
As the months wore on and we remained COVID naïve, it became absolutely clear that the virus would cross the border at some point. What has been our state’s contribution to the world’s understanding of COVID-19? Why did we not set up random surveillance testing, RCTs of ‘control’ measures such as masking, trials of different vaccine schedules by age and so on?
Unfortunately, the political situation was so charged no one wanted to touch some areas of COVID research with a barge pole. To question our response may have been seen as heresy. Other places conducted vaccine effectiveness RCTs (which could not be conducted in a COVID-free place), so we benefited from their COVID infections. Through good management and good luck, we have had a soft landing. WA doctors are increasing their confidence in the management of COVID and
Such studies could not be conducted anywhere else in the world (given their hybridised immunity from infection as well as
I have great respect for our public health physicians who had to make difficult calls over the past two years. I have great admiration for the many people who worked long hours in vaccine clinics, quarantine centres and so many jobs made harder over that time. Even so, to view our response over the past two years with rosecoloured glasses disrespects those that were collateral damage and misses an opportunity to refine future pandemic responses. Nicholas McLernon, MBBS (Hons) FRACGP ED: Dr McLernon is a GP in private practice. He declares these are his own views, with no conflicts of interest to declare and no affiliations with any political party or politician.
Can prescribing exercise really help your patient experiencing ill mental health? We don’t yet know everything about the link between physical and mental health. But with our evidence based approach, we’re constantly reviewing new evidence to inform our treatment of those people injured at work. A systematic review conducted by the British Journal of Sports Medicine considered if physical activity could protect against depression and found that physical activity was associated with lower odds of subclinical depressive symptoms. We believe that exercise is vital in assisting those with mental stress or ill health.. Even those suffering a physical injury because of a work accident can find their mental health affected by their injury and the rehabilitation process. A prescriptive exercise treatment designed to increase work capacity and self motivation can increase the likelihood of a return to work, or normal daily life . To read our full analysis of the British Journal of Sports Medicine’s review, scan here:
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Creativity meets the technical Driven to work and play, Dr Linda Monshizadeh transforms a passion for creative problem-solving and her interest in all things technical into the work she does in craniofacial surgery.
By Ara Jansen Main picture: Tony McDonough
As a child, a fascination with how things worked and fitted together led Dr Linda Monshizadeh to think she wanted to be a mechanic. She liked to draw and fix things with her hands. When she learnt human biology and biology at school, she started to wonder how she might use her hands and integrate her newly-found interest in those subjects. “In the back of my mind I recalled seeing documentaries of people doing reconstructive surgery overseas,” says Linda. “I didn’t know what it was called but it made me realise that is what I wanted to do.” It was the growing fascination with human biology which led Linda to choose medicine over mechanics. “Equally, there were lots of other things I was interested in – I loved physics, but I didn’t like the idea of studying so much mathematics, which I didn’t enjoy. I thought psychiatry was interesting, but therapy didn’t go far enough for me.” Once she started medicine, Linda was clear that she wanted to take the path to become a surgeon. She did everything she could to learn more about anatomy and surgical work, getting as much hands-on experience as possible. Her exposure to plastic surgery let her know she was in the right place, which led her to becoming a plastic and reconstructive surgeon with a subspecialty of craniomaxillofacial surgery. “I knew I wanted to get into plastic surgery before I started my first job as an intern,” says Linda. “When you had to put down your preferences for rotation, I put down as many plastics-related and relevant areas as possible, including working in intensive care and the emergency department.”
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At 37, Linda has been a consultant for three years. She works at Sir Charles Gairdner Hospital and Perth Children’s Hospital, doing craniofacial work. “Although my subspecialty is so focused, it is also quite varied which makes it very interesting,” she says. Craniomaxillofacial surgery encompasses surgery for congenital conditions such as craniosynostosis, cleft lip and palate, congenital tumours and malformations and acquired pathology such as trauma to the craniofacial skeleton and cancer of the head and neck region. In some cases, she will see patients through a series of surgeries over several years. A patient born with a cleft lip and palate, for example, will require operations at six months, nine months, nine years of age and sometimes jaw surgery at 18 years as well as other revision surgery for the lip and nose. The most common issue she treats in children is craniosynostosis, the premature fusing of the bones in a baby’s skull. It happens before the brain is formed and can cause problems when the brain doesn’t have enough space to grow. In adults, it’s mainly cancer of the head and neck and reconstructive surgery for trauma. MEDICAL FORUM | MENTAL HEALTH
“Cancer is seen predominantly in the older population and Australia and New Zealand have the highest skin cancer rates due in the world to our high UV exposure. Trauma is most commonly seen in males 18 to 30 or older people who sustain similar injuries in a fall leading to fractures of the eye socket and/or the jaw. “I didn’t pursue plastics to pursue any kind of cosmetic surgery. My
passion and interest has been primarily reconstructive surgery. However, to be able to do an excellent facelift you have to know the anatomy of the face very well and having that background on the reconstructive side is invaluable. “For example, we often use a facelift incision to perform the removal of tumours in the parotid continued on Page 17
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Where we live. How we live. What we’ve lived.
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Creativity meets the technical I was quite focused. This system works really well for me.”
continued from Page 15 gland (parotidectomy). We are very familiar with the facial nerve branches and how to protect them. This is what separates plastic and reconstructive surgeons from cosmetic surgeons.”
Linda’s siblings have all gone into medical fields, with her elder brother being a dentist and her sisters being pharmacists, as is her sister-in-law. Her father is a retired paediatrician and her mother an electrical engineer and both valued education, determined their children would make successful and fulfilling lives in Australia.
Born in Iran, Linda has an older brother and is a triplet with her sisters, who are identical, while she is fraternal. The family left Iran as refugees when she was five, making their way to Pakistan with protection under the UN. They initially settled in Adelaide, where Linda’s aunt and family lived and eventually moved to Perth.
“Our parents wanted us all to have fulfilling and stable occupations and they sacrificed a lot to make that happen. They left Iran because of religious persecution and gender inequality. This realisation from an early age fuelled my drive to succeed and reach my goals.”
All three sisters were born naturally and have names starting with L – Lily, Lila and Linda. She says there’s an Iranian tradition that children’s names either rhyme or have the same first letter. In their case, her aunt was convinced she was having a girl and loved the name Lily and asked Linda’s mum to call one of her children Lily, if she didn’t have a girl. Linda did her medical training at UWA and then trained at the at the internationally renowned Australian Craniofacial Unit in Adelaide and Westmead Children’s Hospital in Sydney. She has a Masters of Craniofacial Surgery through Macquarie University and won the university research prize, recognising academic excellence in evidence-based practice. Her family all live in Perth and her husband’s family are in New Zealand. The couple love to travel and hope to get back on the road soon. Since a young girl, Linda has had a passion for art. These days her medium of choice is oil painting. As she was getting her career established, painting took a bit of a back seat, but during COVID and bouts of isolation drew her back to it in earnest. “Painting allows me to express my creative side in another way but draws very similar parallels to surgery. Both require extreme focus, fine manual dexterity, patience and commitment to produce the desired outcome. MEDICAL FORUM | MENTAL HEALTH
Genetics also played a big role. “My sisters were not as interested academically. Study came much more naturally to me, and they were the social ones while I had my head in a book. Not much has changed.” These days, Linda enjoys documentaries and loves movies. She goes fishing “quite a bit” with her brother, whom she says is highly knowledgeable about the local catch.
“I am currently involved in drawing a series of paintings to raise money for the Navy Clearance Diver Trust, a project my husband and I are both passionate about. “Time spent with family and friends is precious and cherished because of a busy work schedule. Her husband Tomas is the business development director of their private practice in West Perth. She says they try their hardest not to talk shop outside work hours. It’s good to work hard and play hard. The work/life balance is crucial. Otherwise, you can lose your joy for the work you do. That’s been the key for us.
Linda is actively involved with a number of trusts and humanitarian organisations. She’s has been involved with missions with Operation Rainbow where she helped with reconstructive surgery for children with cleft lip and/or palate from rural regions of SouthEast Asia. Linda and Tomas hope to be walking the Kokoda Track in the near future to raise funds for the Navy Clearance Diver Trust, something they have had to postpone due to COVID.
Read this story on mforum.com.au
“I’m quite balanced and my family keeps me grounded. I am a really good procrastinator but at the same time I really enjoyed study and when exams came around, JUNE 2022 | 17
Country psychiatry a growing business Bunbury psychiatrist Dr Steve Blefari won’t let distance hold him back from helping solve the rural disadvantage in mental health care.
Jan Hallam reports Long before COVID, health workforce numbers and training in Western Australia have been worrisome issues that have kept health services searching for sustainable answers. While metropolitan Perth may have its workforce challenges, they pale against those at the frontline and in the engine rooms of health services in the seven regions of our vast state. Here, the population may be relatively few, but the burden of disease is great, with mental health one of the heavier items, and accessibility to services has undeniably played a significant role in that conundrum. The WA Country Health Service has warmly embraced the ‘grow your own’ strategy, which, in 2022 can bank on doctors being produced by three medical schools and reap the benefits of the success of the Rural Clinical School WA (RCSWA) and WAGPET (both 20 years in the making). There is mounting evidence that the longed-for ‘sticking’ of these locally grown medical students and young doctors after early exposure to regional practice is eventuating. However, there remains barriers to achieving a stable multi-layered workforce, and longer-term career development and prospects can be counted among them. Here there are some positive developments, with WACHS establishing a number of rural specialist pathways, and the newly minted psychiatry iteration is a good example of what happens when overwhelming need meets vision, leadership and commitment.
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Medical Forum spoke to Bunbury psychiatrist Dr Steve Blefari, left, who along with colleague Professor Mat Coleman in Albany, has been working with WACHS and the Royal Australian and New Zealand College of Psychiatrists (RANZCP) to develop an integrated specialist psychiatry program that would allow its trainees to fulfil their AMC accreditation and fellowship requirements all within country WA.
Building blocks “We have been working on this for a few years. With our work with the RCSWA and WACHS we have been running projects through the regional training hubs. And with Mat’s work as chair of the college’s Section of Rural Psychiatry we have found a synergy,” Dr Blefari said. Between WACHS’s Mental Health and Wellbeing Strategy 2019-2014 and the college’s Rural Psychiatry Roadmap 2021-2023, the will appears to have found a way. A 2015 Department of Health workforce projection of a ‘high’ psychiatry shortfall in 2021 has already played out, a ‘critical’ shortfall is forecast for 2025, while MEDICAL FORUM | MENTAL HEALTH
current and predicted demand for psychiatric services is far beyond capacity if action is not taken. Dr Blefari said that Australia had 13.5 psychiatrists per 100,000 people, and it was the same rate in metropolitan Perth. In the rankings, that puts Australia ninth, behind No. 1 Norway (48 per 100,00 and the OECD average of 15.3) “In rural and regional WA, there are 4.3 psychiatrists per 100,000 people, which is a little bit more than Mongolia (4) but less than Bahrain (5.5),” he said.
exacerbated the cycle of disadvantage. And yet through the 15 sites of the RCS, rural WA sees a lot of medical students, and specialist training hubs are beginning to develop where young doctors can do their internship and also some of junior medical years. “If you want to be a psychiatrist, you have to go back to Perth to do the bulk of your training.” This missing link in the training process is also a missed opportunity to train and retain psychiatrists in the regions.
“Looking at the WA training figures back in 2014, we took in 18 new trainees. Over the next six years we took annually 12, 21, 17, 19, 19 and 17 trainees. So, between 2014 to 2020, we have had no workforce growth at all,” Dr Blefari said.
The specialist training cycle can be one of ever decreasing circles that starts with the number of trainee positions, which is dictated by mandatory terms and the number of supervisors … and of course funding.
“We have a very metro-centric medical education system, and that's not just psychiatry. However, there has been an underinvestment in rural psychiatry and training, which means we have produced fewer trainees and that contributes even more inequity.
In their hands
“This training bottleneck has
“With the support of the WACHS Chief Executive and Board, WACHS is proposing to take control and do all of that, provide the funding, provide the supervisors and take continued on Page 20
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Country psychiatry a growing business continued from Page 19 over the training, essentially.” Dr Blefari said. “The long game is building mental health capacity in the regions. We have a lot of medical students on placement, we've got PGY1 and PGY2 placements doing mental health terms and we're also now starting to do some GP registrar placements as both GP colleges (RACGP and ACRRM) have curricula for advanced skills in mental health. And we also have international medical graduates coming through our services interested in training in mental health. “Interest in psychiatry is not the problem. In 2022, the WA metropolitan program had 70 applicants for 22 positions. So, there were nearly 50 people wanting to do psychiatry training who were turned away. This is not the case in other states. “We have lobbied the WA training committee to establish our own Rural Training Subcommittee and the original thought was to have a rural pathway within the metro training program. But now we will have a metro training program and a rural training program, though it will be nominated as a rural zone, which we are hopeful to have up and running in 2023. “This will allow us to recruit directly to WACHS for first year registrars, and we'll be able to keep them in placements all the way through their training, if they want to. “There'll be some opportunities for metro placements for subspecialty types if that's what they're interested in. For the rural zone, we're really promoting rural generalist psychiatry and we'll be able to provide the whole five-year program across many of our sites.” Commonwealth funding through RANZCP for four (out of 30) national specialist training positions (STPs) has been secured ($125,000 per trainee and $90,000 for supervisors) and that is now active, and Dr Blefari is hopeful that funding will remain for supervisors until 2026. The application 20 | JUNE 2022
nominates sites in the six of the seven regions. It is hoped that the Goldfields will follow once its capacity develops.
or Kununurra. If we give trainees these extraordinary experiences, they might then want to go back there to work.
Plan expands
“We work with experienced multidisciplinary teams and our supervisors are committed to producing excellent practitioners. There's also lots of research going on in a range of areas including Aboriginal mental health and plenty of work outside of the clinic and hospital setting. WACHS has Aboriginal Mental Health staff embedded in the multidisciplinary teams and this learning experience for psychiatry trainees is invaluable.
WACHS already provides placements in the South West, Great Southern and the Kimberley and those three sites will develop into the main training hubs. Additionally, there will be work to accredit posts in Pilbara, Midwest and Wheatbelt regions. When the rural zone starts, there will be experiences throughout the state. Given the unique needs within the regions, Dr Blefari said the diversity of experience for trainees will be vast. “Within a five-year program, a trainee might spend the majority of their time in a regional centre like Bunbury but have the opportunity to go to Karratha or Port Hedland
“We also provide accommodation, and we don't have any on-call, but we’re also honest about the downsides – the training cohort might be a little smaller and a lot of the education will be via video conference. You can't pop out to Leederville for a coffee, and you'll MEDICAL FORUM | MENTAL HEALTH
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Five-year plan “We have come up with a five-year growth plan that I think we can realistically achieve across WACHS. If the rural zone is approved and we can recruit trainees directly, instead of metro giving us people with a rural preference, and then only for a short time, we can start recruiting, conservatively in the first year. “When we recruit two to the South West and two to the Great Southern, on top of the trainees we've already got, which is about seven, then increase it incrementally, to have the first years come through those hubs initially then into Kimberley and Mid West and Kalgoorlie by 2027, we can graduate 34 psychiatrists over 10 years, which is really, really exciting. probably run into your supervisor at the pub. “Often you will have to travel for exams, but due to COVID we've already worked with the college to provide some of those exams locally. “In the hubs, we've got inpatient,
community, child and adolescent, older age and consultation experiences available and lots of supervision and study support.” For now, the rural zone is going through its accreditation with the college, but Dr Blefari is thinking long term.
“We know there are barriers and we are tackling them. “We have to be innovative and forge on. We are committed to welcoming new trainees from 2023 onwards.”
Going Bush There’s a buzz of activity and excitement in the health sector outside the city limits. New training pathways for GPs and specialists are opening up, there are more ways to keep docs in the bush supported and connected, and the Rural Clinical School and WAGPET are both celebrating 20 years of stellar service to rural communities and the medical profession. Along with our partners, Medical Forum is producing Going Bush, a magazine that celebrates past vision, pays tribute to the hard work being done now, and a look forward to equitable health care in the regions. Going Bush will be in your mailbox early June as a separate publication to your regular Medical Forum delivery. Keep an eye out for it!
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Sweeping reform set for child mental health While WA psychiatrists have welcomed a review into child mental health services, they warn that it cannot become another report that collects dust, as Eric Martin explains.
The final report from a recent review of public mental health services for children and teens in Western Australia makes for brutal reading. The ministerial taskforce, led by Robyn Kruk, was set up as a direct result of an inquiry by WA’s Chief Psychiatrist into the death of 13-year-old Kate Savage in 2020, and was tasked to outline a strategy to revamp the State’s public specialist childhood mental health services. The report describes the current system as being in “crisis”. Many doctors and other health care professionals have responded to the report, which was released in March, backing calls for reforms, particularly the development of integrated and collaborative multidisciplinary clinical services, but also warning that it required commitment – and resources – from the State Government. The WA branch chair of the Royal Australian and New Zealand College of Psychiatrists, Dr Michael Verheggen, said this recommendation signalled “an important and exciting phase of service development which recognises the increased mental health needs of the infant, child and adolescent population of WA, and the growth in demand that has occurred for services over several years without a matched expansion of service capacity.” “It will afford psychiatrists more opportunity to collaborate with 22 | JUNE 2022
paediatricians and other health service providers in the care of patients with complex care needs, including young people with intellectual disabilities and autism spectrum disorder,” he said. However, Dr Verheggen stressed that it was important to hold the government to account. “We call on the State Government to consider issues of governance and operational leadership in implementing the plan, so that this important work does not become yet another report on the shelf,” he said. Many experts argue that while the expenditure needed for reform is substantial, the cost of doing nothing would be higher. The life path for children is changed dramatically by the early onset of mental ill-health, impacting a range of educational, employment, social and health outcomes throughout their lives. The taskforce report found that since 2014, the number of children experiencing severe mental illhealth requiring a specialist service has increased by more than 70%, while the number of children presenting to hospitals due to risk of suicide has increased by 50% over the past four years. “About 14% of 4 to 17-year-olds in WA experience a mental health issue, with prevalence being even higher for children in regional areas and from vulnerable communities,” Ms Kruk stated.
“Services are much harder to access than they were 10 years ago, with less than one in five children being accepted into treatment programs and, increasingly, services are, in effect, rationing care to treat older children and those with more severe symptoms and at a higher risk.” Other key findings were equally worrying: • Between 2014 and 2020, 75% of acceptances for community mental health services in metropolitan Perth were for those aged 12-17 years • Every day in 2020, there was an average of 6.9 admissions of minors into hospitals across WA with a principal diagnosis of mental health • Between 2017 and 2020 there was a 168% increase in eating disorders admissions to CAHS inpatient units and a 200% increase to WA Country Health Services hospitals • Every day in 2020, there was an average of 24.5 presentations by minors to an emergency department across WA for a mental health reason • Between 2015 and 2019, 31% of school students who accessed a specialist mental health service had an attendance rate below 60%. One in five children who accessed mental health services also had contact with police, of whom 51% were prosecuted
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NEWS • Between 2009 and 2018, 60% of children who died by suicide had been subject to a child protection report. For those with lived experience, the impact of interacting with the system has often been as debilitating as the illness itself. As one parent noted: “After almost 18 months of trying to get help for my son, I was diagnosed with depression and put on medication. The whole experience has changed me, I used to be a completely different person.” Taskforce representatives Georgia Anderson and Wendy Cream shared that the onset of mental illhealth in a child presented a neverending question of what the future would bring. “It is at these times that our children, families and carers look to the public mental health system to understand, support and reassure them that recovery and a future is possible,” they wrote. “At a time when people are at their most vulnerable, depleted, frustrated, and often in crisis, they have faced the reality that getting help has meant negotiating a system fraught with rejections and handballs.” Currently, there is no organised
child mental health ‘system’, with specialist services often not connected to GPs or community services, and a recurrent theme throughout the report is the debilitating experience of children and families who have fallen through the gaps.
all of the recommendations in the final report,” Ms Sanderson said.
“Change will not happen overnight, but it must begin today,” Ms Kruk said. “Small changes to the current system will not address the issues identified, neither will simply adding more resources or piecemeal changes to services.
"By working together, we can make a real difference and improve mental health and wellbeing outcomes for our children."
“The ICA mental health system needs fundamental reform.” The taskforce has proposed a mental health strategy and roadmap, with a set of 32 recommendations aligned with existing WA policy commitments, and a sustainable plan to deliver the necessary change through eight key actions. Mental Health Minister Amber-Jade Sanderson said the Government was committed to progressing the recommendations in a targeted way, addressing both immediate need and longer-term outcomes. "The taskforce has given us very clear guidance to support wideranging reform and the government is fully committed to implementing
"It will require significant reform – a whole-of-government approach and working collaboratively with the Commonwealth because of the role it plays in providing critical primary healthcare services.
One of the ‘five pillars’ of the longterm strategy for improvement is the need to re-organise existing services and build more capacity and capability to care for children, families and carers closer to their homes. Practically, this means funding and building a comprehensive series of metropolitan (Perth North, South and East) and country hubs, which will act as a single entry-point for people to access and navigate the child mental health system. The hubs would have the capability to support children with complex, co-occurring and specialised needs, as well as acute care and response teams to provide emergency and intensive support and treatment, thereby freeing up hospitals and ensuring that children will not be turned away and will get the care they need. Ideally, each hub would house GPs, Headspace and Head-to-Health Kids centres, child development services, early childhood services and education support services, enabling them to: • Coordinate and drive consistency across the local clinics in their region, working with primary mental health services • Be the primary interface with local emergency departments and inpatient services • Be supported by a virtual care service that provides a 24/7 response when needed. The strong relationships forged with local communities by existing CAMHS clinics and WACHS services would be maintained but re-organised into ‘spokes’. They would be co-located with primary mental health services and GPs, and deliver specialist mental health care coordination, support, and treatment, as well as shared care and consultation liaison with schools, youth justice and child protection services.
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Eating disorders hidden in plain sight As if demand for eating disorder services was not already overwhelming, the pandemic has added a new stressor, as Cathy O’Leary explains.
Like many of her colleagues working in the eating disorders space, clinical psychologist Sue Byrne is doing her best to get to as many people on the long waiting lists. Demand for treatment services was already running hot before the COVID pandemic hit, but a combination of restrictions on people’s movements and more vulnerable people – some fuelled by social media posts that trigger body image concerns – has created the perfect storm for added pressure on limited public and private services. Researchers from Curtin University’s School of Population Health are currently looking at how an obsession with perfectionism and its links with eating disorders could be affecting teenage mental health. Rates of eating disorders increased during the height of the pandemic as teens were forced online to socialise and study.
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Eating disorders hidden in plain sight continued from Page 24 As clinical director of The Swan Centre, a private outpatient clinic which the UWA researcher opened more than four years ago, Dr Byrne, right, has seen a spike during COVID lockdowns and restrictions. “It’s probably been across the board for all psychological disorders but for people with eating disorders, they want to be in control, so they started overcompensating,” she said. “It has been difficult for them, and we did get a big increase in referrals around lockdown time – and it’s still ongoing. “While we used telehealth, the waiting list is still huge, and we’re trying to do our best to see people as quickly as possible, but it’s taking months.” Dr Byrne said her clinic had started offering a single session intervention within two to three weeks of anyone referring to them. This was to assess if they were suitable for the service and give them psycho-education about their eating disorder and resources to use while on the waiting list. “There is still only one public outpatient clinic, at CCI (Centre for Clinical Interventions, part of North Metropolitan Health Service) for adults 16 years and over, and while there’s our private service
and some others have sprung up, demand is absolutely huge,” Dr Byrne said.
Binge eating tops the list Research suggests binge eating disorders still make up almost half of eating disorders, while bulimia nervosa makes up about 12%, anorexia nervosa 3% and a range of others comprise the remainder. “Binge eating disorder is probably the most common and is equally distributed among males and females, and the most common time of presentation is middle-age,” Dr Byrne said. “That doesn’t mean they haven’t had the disorder for a long time, it’s just that they don’t present until middle-age, and it’s usually for weight loss treatment. They gain weight over time and don’t even realise they have an eating disorder. “It’s often missed by health professionals because these people go to a doctor and they’re told they just need to lose weight, so they go on a diet and that makes the binge eating disorder even worse.”
Overweight but starving She said what was often not understood, even by GPs and other health professionals, was that most people with an eating disorder were not underweight, and people with a high body mass index were often dismissed or misdiagnosed.
“They’ll say, ‘I think I have an eating disorder’ and the doctor or other professional will say ‘don’t be silly, look at your BMI.’ “But starvation syndrome can happen at any size. You can get someone with a high BMI, but they present with anorexia nervosa because they’ve been starving or malnourished – their genetic make-up stops them from being underweight. “But they’re still in starvation syndrome, and that’s often missed. “If someone who was 125kg presents weighing 85kg, that’s a huge amount of weight they’ve lost, but the doctor will say ‘well done, you’re fine.’ “They might not be underweight, but they have lost a precipitous amount of weight in a really short period of time and can be really unwell. We’re seeing a lot of these presentations.”
‘Clean eating’ not so healthy Eating disorder clinics are also seeing people presenting with anorexia or bulimia nervosa stemming from a behaviour known as orthorexia, or an obsession about ‘clean eating’. It is not considered an eating disorder because they are not so much worried about their weight, but rather putting something that is not ‘clean’ into their bodies. This in turn could trigger an eating disorder. Dr Byrne said it was not healthy eating at all because often these people were not getting enough nutrition, and the behaviour was being seen in young, primary school-aged children. She was concerned that the demonising of some foods was having a negative effect on at-risk children. “I can’t tell you how many times I’ve seen a 12 or 13-year-old kid – boys and girls – who’ve been in a school health class looking at the dangers of processed foods, or they’ve watched That Sugar Film movie,” she said. “In kids who are vulnerable psychologically or genetically,
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dubbed in the US as ‘bigorexia’ – mostly in teenage or young adult men. They sought a ‘ripped’ sixpack ab look and were obsessed with bulking up by extreme gym time, a focus on protein diets and intense muscle-building goals. Again, it was problematic if it started to impact on their functioning – physically, if they became medically unwell, or in their general functioning by interfering with their relationships, work or ability to function normally in society, or if it became their sole source of self-worth or self-esteem.
Over-thinking food Dr Byrne said one of the first things that happened when people severely restricted their eating was that they could become totally preoccupied with food. It was a survival mechanism from caveman days when food was scarce. Our brain was exquisitely sensitive to any sense that we were not getting enough nutrition. If the brain picked up on that, it could cause changes, including becoming totally preoccupied with food and the next meal. Despite most people having a plentiful supply of food – some would say over-supply – our brains still thought we were in a famine.
that can often kickstart an eating disorder. “Most people don’t take much notice, but the sort of kids who are going to develop anorexia are those who have a genetic vulnerability, and they’re also often high achievers. “They want to do the right thing and are perhaps a bit obsessive and can get really stuck.”
Restrictive eating Another issue taking up seats in clinic waiting rooms was avoidant restrictive food intake disorder (ARFID), which was only recently listed in the DSM-5 mental disorders diagnostic manual. Dr Byrne said it was often called fussy eating, where eating became very restricted but not because of weight and shape concerns. “One pathway is sensory sensitivities, where they have an aversion to certain textures and MEDICAL FORUM | MENTAL HEALTH
tastes, and it often comes up in kids with autism – they don’t like slimy foods,” she said. “There are also some people who are super-tasters and very sensitive to certain tastes, and we can treat them with graded exposure to different textures.” Another pathway was anxiety, where perhaps a child had choked on food or vomited after eating something, and that led to avoiding lots of foods. “And sometimes it’s just the way the kids are – they have a restricted range of eating, but it’s not to do with their weight,” she said. “Unless it’s causing a big problem in terms of nutrition, it’s not a big deal, but it is a problem if it’s not allowing them to grow or they’re malnourished, or if it restricts them socially because they can’t go out to eat with their friends.”
“For someone with an eating disorder when you ask them what’s the worst thing about how they feel, they say it’s that they can’t stop thinking about food – it’s on their mind all the time and it’s driving them crazy,” Dr Byrne said. “For anyone who is not getting enough nutrition, whatever their size, because of that cave person brain that’s how we behave. Our brains don’t realise it’s 2022 and there’s plenty of food around.” Dr Byrne said this made it difficult for health professionals when someone with anorexia said they really wanted to get over the disorder – they didn’t want to have this consuming preoccupation with food, but they also didn’t want to gain weight. “And I have to say to them ‘well that’s not going to happen, you cannot recover psychologically from an eating disorder while you’re malnourished – it just doesn’t happen.”
Clinics were also seeing a condition JUNE 2022 | 27
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NEWS
Exercise scripts for sick kids Research is paving the way for a clinical exercise service in Perth for kids with chronic conditions.
Cathy O’Leary reports
As many as one in five Australian children is thought to live with a chronic disease that can have a life-long impact on their mental and physical health. Now a ground-breaking research project is paving the way for an Australian-first clinical exercise service at Perth Children’s Hospital for children living with diseases and conditions such as cancer, diabetes and cerebral palsy, or burns-related injuries. Move to Improve will harness the concept of ‘exercise as medicine’, prescribing personalised exercise and health advice as part of routine clinical care.
The Stan Perron Charitable Foundation and Perth Children's Hospital Foundation, along with principal support from Mineral Resources Limited via Channel 7 Telethon Trust, and additional funding from Amazon, Globe BD and the WA community, have raised $5.6 million to fund the project. The Child and Adolescent Health Service has also committed almost $2 million in-kind support. PCH’s head of diabetes and endocrinology and co-lead of Move to Improve, Professor Liz Davis, said the program would help reintroduce exercise as a medicine to a range of children living with chronic diseases.
Mary Rogers at the Move to Improve clinic
“We’re really excited about Move to Improve, it’s an absolute first in Australia,” she said. “One in five kids lives with a chronic disease, which is a big number. “We’ve become really good at prescribing medicines and surgical treatments for kids with disease, but one thing we haven’t done is incorporate exercise as a medicine. “When a child suffers a severe burn or has been diagnosed with a serious condition, kids often disengage from their friends. If kids have been going through cancer treatment, they haven’t been engaged in community sport, sometimes for several years.
Prof Liz Davis with the Rogers family
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Changing the exercise paradigm Helping kids with chronic illness or disability to stay active can be challenging but has real benefits, says senior physiotherapist Dr Noula Gibson. In 2020, only 30% of children in Western Australia met the physical activity recommendations set by the Australian 24-Hour Movement Guidelines for Children and Young People aged 0-17 years. This report did not differentiate between healthy children and those with a chronic illness or disability, but inactivity is likely to be more of a problem in this latter group. Yet clinical research has long established exercise as a safe and effective intervention to counteract adverse physical and psychological effects of disabilities, and many chronic illnesses of childhood and their treatments. In my work with children with cerebral palsy, I find that parents are often aware of the benefits of physical activity and participation in sports for their child with a disability, but suitable activities are hard to find, particularly if their child has considerable physical challenges. While guidelines are an important first step for understanding what is needed, implementation is a challenge. To support exercise for children with chronic illness and disability we need to understand why physical activity is avoided and how change can occur, and not just what physical activity behaviours are desired. The COM-B framework from Professor Michie and colleagues from University College in London is an evidence-based behaviour change framework that links the components of Capabilities, (physical or psychological capability), Opportunity (physical and social), and Motivation (intrinsic and extrinsic), to drive Behaviour. It sits at the heart of a child and family-centred behavioural diagnosis and formulation and provides a simple model for understanding behaviours and designing interventions to change behaviour. Applying the COM-B model requires defining the problem in behavioural terms as precisely as possible. For example, physiotherapy exercise prescription isn’t
“Re-engaging or getting back into that community with not only the confidence to play sport but to reengage with friends can be really challenging.” Professor Davis said that for a child living with diabetes, for example, exercise could play havoc with MEDICAL FORUM | MENTAL HEALTH
just “your child needs to exercise vigorously for 60 minutes every day”. It needs to be specific in terms of who needs to do what differently, when, where, how and at what frequency. How can we make this fun, meet the childhood needs of friendship, ensure the physical activity is safe for the child’s illness or disability, and how do we build this into already established daily and family routines? The COM-B framework highlights the role of multidisciplinary teams in changing physical activity behaviours, that includes the family and child at the centre of physical activity prescription. The framework enables the doctor to assess physical activity behaviours to provide both appropriate support to the child and family, and to prescribe effective interventions, which will often include referral to allied health professionals and specialists. For example, a paediatric physiotherapist can deliver interventions when the issue is reduced physical capability or sourcing or adapting opportunities to engage in physical activity that is fun for the child. An occupational therapist can assist if the issue is too much sedentary time due to lack of social or other leisure opportunities and/or referral to social supports could be considered when the issue is reduced family resources, and so on. Changing physical activity behaviour is a complex interaction of barriers and facilitators. All health professionals can play a role in promoting the physical activity guidelines during their interactions with children who have a chronic illness or disability. Using the COM-B framework will enable these interactions to be more effective in achieving the desired change in physical activity behaviours. ED: Dr Noula Gibson, PHD, is a research coordinator and senior physiotherapist at Perth Children’s Hospital. She was recently awarded the Transformative Practice Award by the Australasian Academy of Cerebral Palsy and Developmental Medicine.
their blood glucose levels, so it was important to help them learn how to do that safely. “Similarly, kids who’ve come through cancer therapy don’t necessarily have the motor skills they had before their treatment, so, it’s about building their
confidence and finding a niche in the community where they can be regularly active and get the benefits from exercise,” she said. “We’re absolutely convinced that the benefits of this program will be far-reaching and impact large numbers of kids.” JUNE 2022 | 29
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Why country medicine is good for the soul A country boy at heart, semi-retired GP Allan Walley tells Cathy O’Leary why rural life has always suited him down to a tee.
After 40 years working across the A to Z of Western Australian towns, Dr Allan Walley has had plenty of time to reflect on what makes rural doctors a breed apart. The 74-year-old believes it is because they are part of the community. He remembers walking around small towns in the early days, when he knew everyone’s name and even the name of their dog. “When you work in rural areas, within a fairly short space of time people get to know who you are, and they can relax and let you know what’s really happening in their lives,” he says.
was a six-month stint working in the Amazon Basin in Peru, just 15 months after graduating. He worked there for six months, taking a trusty obstetrics book with him which guided him in delivering dozens of babies, as he gained experience in using forceps, manually removing placentas and delivering by caesarean.
“Once, when I was going away, one of my patients said to me, ‘I’ve only ever had one doctor, what am I going to do when you go away?’” That’s part of the reason he has continued to do locum work after retiring from full-time work at his practice in Margaret River and Augusta in 2013. He knows firsthand the importance of having doctors who can step in when country doctors need a break. “I felt I didn’t want to work fulltime anymore, but I still enjoy my medicine, so the locum work fulfils me too,” Allan says. MEDICAL FORUM | MENTAL HEALTH
WA all over
Born and raised in Bangor, North Wales, Allan was a teenager when his family migrated to WA, and he started studying medicine at the University of WA in 1968. His first taste of rural medicine
Allan moved to Augusta in 1979 and worked at the medical clinic in town for five years before working on Christmas Island from 1995 to 1999 and joining the Rural Health West roving locum team in 2000, before continued on Page 33
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Why country medicine is good for the soul continued from Page 31 returning to work in Augusta and Margaret River in 2003. In his younger days he was a commercial diver and took part in several expeditions with the Maritime Museum to Augusta and Thailand, serving as the medical officer. And in recent years he has visited Broome to carry out commercial dive medicals for the pearl drivers. Not surprisingly, he was Rural Health West’s Rural GP of the Year in 2011. Because he was born and bred in the country, he feels at home there rather than in a big city and dismisses the notion that country doctors can become too involved in the lives of patients. He firmly believes friends are your patients and patients are your friends.
Changing times “The bureaucrats said, ‘no you’re too isolated’ and in inverted commas ‘you don’t have the skills’ which of course we did. “You learned to manage things well and pick things early that needed to be transferred. In the 40 years that I’ve done medicine, we never lost a baby, never had an anaesthetic incident and never lost anyone in theatre because you learnt to predict so well. But now it’s not done like that, they just say your hospital’s too small so you can’t do it anymore.
“Because I was born on a farm in a little village, and I was used to everyone knowing everyone, to me medicine was medicine, so what happens inside the surgery happened in the surgery, and what happens outside it is something different,” he says. “I’ve always been very comfortable that. “When I worked on Christmas Island, once one of my friends who was also obviously one of my patients said to me, ‘oh god how do you cope with seeing patients in the surgery and then seeing them socially and having fun with them afterwards?’ and I said ‘well, it’s the way I’ve always been… what happens at work stays at work.
Drawing a line “But it wasn’t like I was Dr Jekyll and Mr Hyde because when I saw them at work, they were still my friends as well as my patients. It’s just about drawing a line. I put my professional cap on and switch into that mode, but they can still be your friends.” There is an emotional downside, he admits, when your friends (and patients) get old and die. “That is difficult. You grieve, and that’s never comfortable, but you still have to do your best with the MEDICAL FORUM | MENTAL HEALTH
scenario that’s before you. It’s not that you harden up, but you have to adjust and do your job.” He found it relatively easy to slip back into the role in his locum work as needed, particularly as most practices make sure he has a good set of notes on patients. “The fact that it’s computerised makes a big difference and makes life a lot easier – even though it was challenging for me because computers weren’t even invented when I was doing my training,” he says. But he laments some changes in rural practice that he has seen in his later years. “One downside is that in places like Augusta we used to do a lot of minor operations, and we did anaesthetics for the visiting surgeons, and we delivered babies – we did the whole lot but now none of that happens there.
“I’d been delivering babies for 10 years, and I had a diploma in obstetrics and gynaecology as well, and I hadn’t had any incidents, and yet I had to justify why I should still be allowed to deliver babies.” Allan says the birth of a baby is always an exciting moment and that excitement never leaves you. “One of the things I love to hear is the baby crying because it means the baby’s OK,” he says. “People forget that. They want these quiet births, but a baby crying is a beautiful sound and very reassuring.” ED: For more on what’s happening in the State’s rural medicine landscape, watch our for our special publication, Going Bush, which will be arriving in your mailbox in early June.
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GUEST COLUMN
Time to rethink obesity treatment The popular mantra to lose weight by diet and exercise sometimes isn’t enough, argues Dr Julie Manasseh. We know obesity is a major contributor to health burden. Twothirds of the Australian population are either overweight or obese, and these are drivers for 22 diseases including diabetes, cardiovascular disease, musculoskeletal conditions, kidney disease, asthma, dementia and certain cancers. In 2019, the financial burden of obesity was estimated to be $11.8 billion, with $5.4 billion in direct health costs and $6.4 billion in indirect costs. Obesity is now recognised as a chronic disease of complex biopsychosocial aetiology which has only occurred in the past three decades. Despite of its overwhelming contribution to the burden of non-communicable diseases (NCDs), it has taken a long time for the medical profession to
recognise that the management of obesity requires specialised training and skills.
play to rigorously ‘defend’ the body’s higher set point weight from any attempts at weight loss.
Obesity is a chronic disease, not a lifestyle choice.
Hence attempts to lose weight by diet and exercise tend to have limited short-term success, as the body responds to weight loss by increasing hunger hormone signals to increase appetite, and by lowering resting metabolic rate so that less energy is used for vital metabolic functions.
The message from public health and medical authorities has been that obesity can be addressed by diet and exercise or the “eat less, move more” philosophy. The idea that obesity can be treated by diet and exercise alone is a fallacy, given that obesity is a chronic disease which involves multiple contributing factors including genetics, stress, sleep and lifestyle factors, mental health, medical conditions and medications in addition to diet and exercise. Furthermore, we now know that once obesity has been established, biological adaptations come into
These biological adaptations to weight loss are designed to cause weight regain, which inevitably occurs as the ‘diet’ cannot be sustained in the long-term. With the recognition that obesity is a chronic complex disease and not a lifestyle choice, and also the evidence which shows that weight loss of 5-10% or greater can improve obesity-related complications, it makes sense that a doctor who has specialty training in obesity and weight loss could improve obese patients’ health trajectory.
How does an obesity physician do to help patients lose weight? The obesity physician makes a thorough medical and weightfocused assessment of the patient, including factors that have led to weight gain and obesity-related health complications. Assessment of stress, sleep, mental health, diet and exercise are critical, as these all influence weight. My approach is to first address underlying factors that have led to weight gain such as poor sleep, depression/anxiety or menopausal symptoms. Once there are signs of improvement in the problem areas, I focus on weight loss using weight loss pharmacotherapy targeted to the patient’s eating behaviour profile. continued on Page 36
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A good hearing for implants Researcher and senior implant audiologist Dr Cathy Sucher explains what GPs need to know about cochlear implants. We know that hearing loss affects one in six West Australians, increasing to one in four for people over 65 years of age. The impact of hearing loss is farreaching, with a significant effect on relationships, mental health and physical wellbeing. And yet, many people with hearing loss remain untreated despite showing symptoms. Many GPs regularly encounter hearing loss in their daily practice, and they play a vital role in ensuring timely referral to treatment. Hearing aids help many people, but a cochlear implant may give better clarity and volume needed to understand speech as hearing loss progresses. Cochlear implants are life-changing devices that can help people hear sounds they no longer hear with hearing aids.
What is a cochlear implant? The implant is a sophisticated electronic medical device that bypasses damaged sensory hair cells within the cochlea (inner ear) to directly stimulate auditory nerves. It consists of two parts: • The external processor collects the sound, converting it into a radio frequency signal that is sent
through the skin to the internal part of the implant. • The internal implant consists of the receiver-stimulator and electrode. The electrode is inserted into the cochlea and provides electrical stimulation to the auditory nerve which, in turn, takes the sound to the brain.
When is it an option? If your patient wears hearing aids and is still struggling in specific listening situations ask them if they: • find it hard to hear on the phone • often ask people to repeat themselves • find it difficult to follow a group conversation and avoid social situations • struggle to understand what is being said if people are not facing them If they answer yes to one or more of these questions, then a cochlear implant might be life-changing for them.
A cochlear implant is surgically implanted by an ENT surgeon, programmed by an audiologist. Hearing aids are fitted by an audiologist and can be removed, whereas with cochlear implants, only the external processor can be removed, not the implant. Hearing aids amplify sounds while cochlear implants stimulate the auditory nerve to provide sound sensation. Cochlear implants use electrical signals, whereas hearing aids use acoustic signals.
Improved outcomes We have seen significant improvement in hearing outcomes for people who have transitioned from bilateral hearing aids to using a hearing aid and a cochlear implant in opposite ears.
Hearing aid vs cochlear implant
These include a better understanding of speech, hearing in background noise, ability to hear on the phone, improved appreciation of music and ability to understand television and radio.
Hearing aids and cochlear implants both improve hearing for people diagnosed with sensorineural hearing loss when there is damage to the hair cells in the inner ear.
Research has shown that at 3-12 months post-implantation, 82% of recipients score above 90% on tests of sentence understanding, which is a significant improvement.
Time to rethink obesity treatment continued from Page 35
maintain this lower weight in the long term.
There are regular reviews to monitor weight loss progress that involve coaching in making behavioural changes to improve diet, exercise, sleep and stress management.
The multidisciplinary team model of obesity management is important when the patient presents with specific problems that require the input of another health professional.
The goal is to achieve 10% or greater loss of body weight and to
Examples would be patients with deeply entrenched problem-eating
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behaviours such as binge eating disorder, who would benefit from seeing a psychologist, or those with specific dietary restrictions such as food intolerances that may require advice from a dietitian.
Who can benefit from medical weight loss? Given that overweight and obesity is a major contributor to almost every MEDICAL FORUM | MENTAL HEALTH
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include patients with asymmetrical hearing losses and single-sided deafness. These implant recipients are achieving improved localisation of sound, better hearing in noise and reduced listening fatigue postimplantation. There is now no upper age limit for candidacy. Many of recipients are in their 70s, 80s and even older. At this age, people enjoy communication and interaction, watching television, and this is when they require optimal hearing. Research shows that it is never too late to treat hearing loss to slow down dementia and reduce mental health issues, anxiety and loneliness. GPs should also be on the lookout for patients wearing hearing aids but still experiencing difficulties, especially in challenging environments such as background noise or phone conversations. These patients may benefit from a cochlear implant and should be referred to an implant audiologist. Referring for a cochlear implant can be done by sending a referral to an implant clinic or an ENT surgeon.
Only 10% of people who could benefit from a cochlear implant have one. Research has highlighted a range of barriers to cochlear implantation, including a lack of knowledge about cochlear implants and uncertainty surrounding referral pathways, surgery and outcomes. We know that GPs can help their patients overcome these barriers through confident referral of
medical condition, it would follow that if one can achieve and sustain weight loss of ideally 10% or greater, then there would be potential improvement in comorbidities such as diabetes, hypertension, cardiovascular disease and sleep apnoea, improvement in fertility and pregnancy outcomes, reduction in surgical complication rates and much more. Studies have shown that behavioural intervention (diet and exercise) can only achieve 3-10% weight loss with a very low MEDICAL FORUM | MENTAL HEALTH
potential candidates. Additionally, concerns about the cost of the device is often a barrier, but there are funding options available for people who fit the candidacy criteria.
When to refer
ED: Dr Sucher is a researcher and audiologist at the Ear Science Implant Clinic. The author acknowledges the contribution of senior implant audiologist Ronel Chester-Browne in the writing of this column.
Read this story on mforum.com.au
Gone are the days when candidates for cochlear implants were limited to people with bilateral severe hearing loss. The criteria have expanded to
incidence of long-term weight maintenance (50-70% weight regain within two years). However, with the advent of new ‘game-changer’ weight loss medications in the past few years, it is now possible to achieve 1025% weight loss with the addition of targeted pharmacotherapy to behavioural intervention – that is, medical weight loss.
of the population that is overweight or obese, it is both exciting and long overdue that medical weight loss in the hands of a trained obesity physician is now able to deliver significant weight loss that can improve health outcomes. ED: Dr Julie Manasseh is a GP with special interests in obesity and weight loss.
With the evidence to date that diet and exercise alone has failed to make any impact of the two thirds JUNE 2022 | 37
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Exercise script for mental health More than ever, the role of exercise in managing mental and physical conditions is crucial, explains exercise physiologist Katie Stewart. Health care is in the middle of a perfect storm. We are trying to manage skyrocketing frontline GP and mental health-related service demands, the clogging of EDs with non-urgent presentations, and long waiting lists for specialist service providers.
conditions at the same time, saving money, time and travel costs. Many physical chronic conditions come with secondary mental health conditions and vice-versa. One in four Australians have two or more chronic conditions that they have to manage at the same time. The problem is that too often these conditions are handled separately, leaving the person with exacerbated symptoms and unnecessary secondary and tertiary disease.
And, most worryingly, we are seeing rising levels of chronic disease rates. In the eye of this perfect storm lies an opportunity to escape the pending fallout. WA, in particular with its collective health data access and its Future Health WA initiative (FHWA), has an opportunity to explore new models of care that consider the whole health of West Australians, while embracing ways to prevent and dilute the untenable load of single service management on both the service provider and consumer. Value-based health care is one such opportunity. It is a framework for restructuring health care systems with the overarching goal of value for clients and efficiencies in service delivery. Value is defined as measured health outcomes per unit of costs. It incentivises health care providers to focus on the quality of the services rendered as opposed to the quantity. It engages GPs, allied health care and specialists to work together in what’s called integrative practice units. These practice units only call on team care providers to treat as required to achieve the best possible collective health outcomes. Consider the real possibilities of being able to introduce prevention, early intervention and collective mental and physical health outcomes into this revised formula of care at no extra cost. This is the tangible utopia that exists with the application of one of primary MEDICAL FORUM | MENTAL HEALTH
health care’s most cost-effective treatment modalities – exercise medicine. Exercise medicine has been clinically proven to be effective in the treatment of varied chronic conditions ranging from anxiety and depression through to cancer, heart disease, diabetes and arthritis. Currently, exercise medicine which can be prescribed and delivered by qualified exercise physiologists and some specialist physiotherapists, can only be accessed with Medicare rebates via a chronic disease management plan. Private health rebates are available for approved members and coverage varies from one insurer to another. The real value of exercise medicine in the face of the current healthcare service realities is its efficiencies as an auxiliary treatment. It’s been clinically proven to reduce the symptoms and side effects of varied concurrent mental and physical conditions.
Exercise, when prescribed well, can be used as a highly effective auxiliary treatment for many chronic conditions. It supports the clients by reducing symptoms and side effects as they navigate their specialist and GP treatment plans. A health care system that is valuebased and built on a foundational framework of exercise medicine has the potential to improve health outcomes, quality of life, increase service efficiencies and value while mitigating potential disease progression. More information about exercise physiologists and service providers in different areas can be found at www.essa.org.au and the Exercise Medicine Research Institute at Edith Cowan University www.exercisemedicine.org.au is a good resource. ED: Katie Stewart is an accredited exercise physiologist and managing director of exercise medicine company Chronic Care Australia.
Read this story on mforum.com.au
A well-prescribed exercise medicine plan can help resolve the varied symptoms of combined chronic JUNE 2022 | 39
Keep child health checks by the book ‘Purple book’ helps maintain early connections with health, according to experts Anne-Marie McHugh and Dr Yvonne Anderson. All babies and children in Western Australia are offered six free child health and development assessments – also known as the ‘purple book’ appointments – by their local community child health nurse.
encourage families of the value of the ‘purple book’ appointments to ensure we reach and engage with as many families as possible. There are a range of reasons why these assessments are so crucial to child health. The most sensitive period of human brain development is in the early years of a child’s life. It is a key period for shaping the capacity for learning, development, health and social and emotional wellbeing over the life course.
These are offered just after birth, at or around 2, 4, 12, and 24 months, and before starting school. Unsurprisingly, the COVID pandemic and ever-increasing demands on family life have impacted on the usual routine checks for many families, with 12-month attendance rates currently at around 50% and 30% at two years.
Universal health assessments offered by community child health nurses are designed to ensure that babies and children requiring extra support from health services are identified early.
We need all health professionals to
Engaging early with community health nurses allows for knowledgesharing with caregivers, enabling them to receive guidance about ‘what to expect’ in a child’s behaviour, growth and development in the immediate and long term. The assessments focus on ways to provide positive experiences and environments for optimal child development, which in turn, often reduces the anxiety often experienced by new parents and caregivers.
Wide-ranging topics Themes covered in the assessments are broad, including attachment, supporting fathers, settling babies, breastfeeding, when to introduce
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GUEST COLUMN
solids, child behaviour, injury prevention and sleep, to name a few. “By seeing the child health nurse we can ask if something is concerning us about our children’s development, nutrition or habits and get advice and new knowledge.” (Feedback from the Midland Child Health Checks Project client surveys.) Population screening and ongoing surveillance of growth, health and development in early childhood is internationally recognised best practice. A key function of universal child and family community health services is to identify early disability and delay, or health issues (both physical and socioemotional) and support the developing caregiver and infant/child relationship. Community health nurses serve as a gateway to a range of other early childhood services such as the Child Development Service, parenting/carer education and support, primary health care, social support, and specialist health services. Children and families identified
early with additional needs can then receive the support they need to achieve the best possible health, development and wellbeing. “Meeting and working with you all has helped not only my daughter but my husband, my son and myself so much separately and as a family as we walk through life and live with anxiety. For that I am truly grateful.” (Caregiver feedback received by clinical psychology, Child Development Service.) Prevention, early identification and intervention during the early years, when there is the greatest developmental plasticity, increases the odds of favourable child development outcomes and makes sound economic sense when compared with remediation later in life. It is hoped that this approach will increase the likelihood of children achieving their social, educational and personal aspirations. The free service for parents and carers of children aged 0-5 provides not just development checks, but also support, education and information on all aspects of parenting.
When we take a population and preventative approach to child health rather than focusing on a single condition, we not only have the opportunity to identify a range of issues for babies and children, but we have the privilege of partnering with families early in a child’s life course. This partnership not only means better health and developmental outcomes, but means we are learning from families to provide better, more accessible healthcare services. All health professionals are encouraged to remind families of purple book appointments for their baby or child, which can be made by phoning 1300 749 869. ED: Anne-Marie McHugh, Co-Director of Nursing for Community Child Health, is a registered nurse and midwife with experience managing child and school health services. Dr Yvonne Anderson, Associate Professor of Community Child Health, is a paediatrician working in community health, in partnership with Curtin University and Telethon Kids Institute.
New look mobile breast screening units BreastScreen WA’s fleet of mobile screening units have been fitted with new livery. The mobile units visit more than 100 different towns every 2 years across WA, so it was time to refresh the weather-worn exterior. The mobile units incorporate eye-catching Aboriginal designs by local artist Valerie Ah Chee and images of hand painted flowers (Desert Rose, Desert Pea, Boronia and Grevillea) by Amy Vickery, a UK medical imaging technologist and friend of the service. BreastScreen WA is a State-wide service and the mobile units are essential in providing equitable access to screening across WA. As well as servicing rural and remote communities, mobile screening services are also provided to outer metro Perth, and at special events (eg. EveryWoman Expo) and Bandyup Prison. Screening locations can be found on the BreastScreen WA website.
Women may book online www.breastscreen.health.wa.gov.au or phone 13 20 50 Mar ‘18
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OPINION BACK TO CONTENTS
Dr Joe Kosterich | Clinical Editor
Mental health for all When you read this, it is likely (remember 2010) but not certain that we will know who will form the next government. Health barely rated a mention during the campaign, which given the events of the past two years was surprising.
We are reluctant to seek help and need to improve on this, notwithstanding the shoot first, ask questions later attitude of regulatory bodies doesn’t help.
Maybe everyone has had enough or maybe there is no daylight between the major parties on health policy. Also, in May, the State Government handed down an iron ore royalty and GST laden surplus. Mental health funding was increased 13%. Is more money the answer? Increased mental health problems have been a hidden adverse effect of lockdowns and border closures. The Australian Health Consumers Sentiment survey showed 26% of women to have reported serious levels of psychological distress, with that number peaking at 31% in Victoria. Some 42% of those aged 18-24 reported severe psychological distress and this age bracket was most likely to have lost their job or have reduced hours. This is not surprising given this age group is disproportionately employed in hospitality and tourism. The UK education watchdog, Ofsted, reported in April that an increasing number of young children has been left unable to understand facial expressions. Its chair Amanda Spielmen was quoted in The Guardian: “I’m particularly worried about younger children’s development, which, if left unaddressed, could potentially cause problems for primary schools down the line.” We know poorer mental health correlates with this. In the US, adolescent suicides increased as did self-harm in Australia. This month’s theme is mental health including two articles on the mental health of doctors. Stress levels are high in medicine on a good day and the past two years have not been good. We are reluctant to seek help and need to improve on this, notwithstanding the shoot first, ask questions later attitude of regulatory bodies doesn’t help. The role of diet in stress management, managing unsettled babies, youth mental health and new treatments approaches are examined. We also have articles on spondylitis, low carb diets in diabetes and managing rotator cuff issues in an older age group. On the plus side, human beings have contended with far worse in previous centuries and whilst it is not PC to say so, most are actually resilient. An increasing number of young (and not so young) people are reclaiming their lives including travelling again. Enjoyment of life is a big part of good mental health. All of us, each day, should focus on what is good in our lives and what we are grateful for.
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Emerging trends in mental health – interventional psychiatry By Dr Jeremy Tannenbaum, Psychiatrist, Subiaco Psychiatrists have utilised interventional techniques for nearly a century. Electroconvulsive therapy (ECT) signalled a new era of biological treatments. Sadly, historical uses of ‘unmodified’ (unanaesthetised) ECT and lobotomies tainted the perception of interventional psychiatry as barbaric. Of course, modern ECT administered under anaesthetic is now considered to be one of our most effective treatments. Unfortunately, despite developments in the basic sciences and clinical practice, psychiatric disorders remain difficult to treat. Mental health professionals and services struggle to meet the needs and expectations of our patients and communities. Existing pharmacological and psychotherapeutic modalities may be ineffective or poorly tolerated for many people. Therefore, new tools are greatly needed. The emerging field of interventional psychiatry employs various neuromodulation and novel pharmacological treatments. These approaches harness our growing understanding of underlying pathophysiology of mental disorders and increased awareness of the profound and often lifelong adverse consequences of trauma and stress. One method of categorising neuromodulation is invasive and non-invasive modalities. Deep brain stimulation involves permanent neurosurgical implantation and is largely in the research domain and for compassionate reasons for treatment of resistant obsessive compulsive disorder and depression through highly specialised neuropsychiatric services. Vagus nerve stimulation devices have been approved in the US for treatment resistant depression since 2005 but are rarely used in Australia, ranging from implanted to transcutaneous devices. Implantable devices are likely to MEDICAL FORUM | MENTAL HEALTH
become much more common in the treatment of neuropsychiatric disorders over the next 30-50 years with advances in brain-machine interfaces and neuroprosthetics. Stellate ganglion blocks (SGBs) involve the injection of local anaesthetic under image guidance to target the cervical sympathetic chain. SGBs have been utilised for decades in the treatment of upper limb complex regional pain syndrome (CRPS), menopausal symptoms and peripheral vascular disease, to name a few. SGBs may provide benefit for people with post-traumatic stress disorder, perhaps through interrupting sympathetically mediated hyperarousal and anxiety. In my own practice, SGBs have been extremely helpful for most people with PTSD related to singleevent trauma, who had either not responded to or poorly tolerated psychotropics and psychotherapy. Interestingly, I have seen many people with comorbid PTSD and related pain syndromes experience improvements in their pain! Non-invasive neuromodulation includes ECT, repetitive transcranial magnetic stimulation (rTMS), and transcranial direct current stimulation (tDCS). ECT is the gold standard in psychotic depression and treatment resistant depression (TRD) and continues to evolve. Along with ECT, other seizure therapies being investigated include magnetic seizure therapy (MST) and focal electrically administered stimulation (FEAST). From November 2021, rTMS is subsidised under Medicare for TRD. rTMS has building evidence for other psychiatric (e.g. OCD, PTSD), neurological (e.g. post-stroke rehab, tinnitus) and pain indications (e.g. neuropathic pain, migraine, fibromyalgia). tDCS is likely to play an increasingly important role in the management of a range of neuropsychiatric and other disorders.
point in the treatment of mental disorders, heralded by an explosion of investment, research and broad community interest in ketamine and psychedelic therapies (e.g. psilocybin, MDMA, etc). These treatments may be considered interventional in that they involve structured protocols and monitoring in a specialist clinical setting. Evidence indicates that ketamine and psychedelics administered in these settings are associated with low risks of harm. Racemic ketamine infusions (offlabel) and intranasal esketamine are increasingly utilised in TRD. In the author’s experience, ketamine infusions have been helpful for people with TRD, PTSD, substance use disorders and chronic pain conditions. I predict that MDMA-assisted psychotherapy will be approved in Australia for PTSD within the next 3-4 years, and psilocybinassisted psychotherapy in endof-life distress and TRD a few years later. Novel psychedelics are being actively developed, with the intention of harnessing all the advantages and avoiding the drawbacks of existing drugs. The long-term effects of ketamine and psychedelics needs ongoing research. The broader use of interventional treatments, including socalled ‘psychedelic-assisted psychotherapy’ (PAP), will require paradigm shifts in service and funding models, education and training, and regulatory and medicolegal frameworks. Awareness is increasing and stigma amongst health professionals and the broader community is shifting rapidly. Importantly, these approaches complement, rather than replace, existing biopsychosocial and lifestyle management approaches. – References provided on request. Author competing interests – nil
We are witnessing a key turning JUNE 2022 | 45
The Urologist told me my PSMA PET scan shows the tumour is localised and surgery may be curative. To tell the truth I was a bit anxious before the PET scan. Perth Radiological Clinic made it so easy AND it was covered by Medicare.
PSMA PET
available at Perth Radiological Clinic Medicare rebateable after 1 July for initial staging and restaging of recurrent prostate adenocarcinoma.
perthradclinic.com.au
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CLINICAL UPDATE
Save the saviours By Dr Taj Singh, Psychiatrist, Murdoch Australia faces a mental health crisis as life settles post-pandemic (or ramps up!). Mental health issues are prevalent throughout the community, however, here I will highlight the plight of my colleagues. Doctors want to deliver their best, endeavouring to keep providing services in a pandemic. Examination cancellations, fear-anger, socialeconomic-career uncertainty, medico-legal issues, burnout and family commitments are some of the many challenges we have faced. Not surprisingly, the cumulative effect impact negatively on doctors' mental health. Psychiatrist Dr Patrick McGorry said Australia needs a "dramatic upswing" and double the number of psychiatrists and psychologists to meet the increased pressure postpandemic on the already strained mental health system. That echoes a recent survey among 1456 Australian Psychological Society (APS) members finding that 88% of psychologists report increased demand since the pandemic began. Similarly, RACGP advised that waiting lists for mental health care were growing nationwide, with some patients advised they may need to wait a year for a psychiatry appointment. The international literature highlights growing chronic stress and burnout threatening doctors' mental health. Australian literature indicates that 61% of both GPs and non-GP specialists reported feelings of stress more often than usual during the 30 days from mid-April to mid-May 2020. Current AIHW data suggests Australia has 3615 psychiatrists and 28,412 psychologists. WA has one of the lowest rates of employed psychiatrists in Australia, at just 12.2 psychiatrists per 100,000 population. This reflects the tremendous pressure on GPs and emergency departments for the provision of mental health support. They face the brunt of a lack of psychiatric support whilst MEDICAL FORUM | MENTAL HEALTH
Key messages Mental health issues are prevalent, and doctors are not immune Workforce shortages are acute in mental health services Doctors need to care for their own mental health. continuing to provide the best possible care within their capacity. The RACGP is advocating for GP services to better manage mental health issues in the community by increasing access to training and better remuneration for managing mental health issues. This includes extending Medicare item numbers to allow for longer Telehealth and in-person consults, and incentives to train in Focused Psychological Therapies and the college is advocating developing GP psychiatry pathways similar to those for GP obstetrics and GP anaesthetics. The RANZCP Draft strategy for 2021-2031 talks about workforce shortages, including more significant deficiencies within some specialisations, to address workforce maldistribution. It highlights significant workforce shortages faced in rural and remote regions of Australia and the upskilling required within the mental health workforce. The core question though is, what's happening now and who's saving the saviour? This is where we can benefit from resources like the Doctor's Health Advisory Service WA (DHAS WA). DHAS WA is experienced in the unique health needs of doctors by offering services such as a 24/7 advice line for doctors and medical students, and a list of GPs, psychiatrists and psychologists who express interest in treating and prioritising doctors and medical students. “Depleted, overwhelmed and exhausted”, is how a member of the DHASWA Drs for Drs group described their current
circumstances. “We are a resilient lot”, advised another colleague who compared the largely informal, ad-hoc debriefing provided for doctor's mental health support versus the integrated and structured psychological care model of the Department of Fire and Emergency Services. Taking a solution-centric approach, I suggest: • Commitment to resolving mental health crises for the medical workforce at all levels, by governments, colleges, and other organisations • By utilising support services such as DHAS WA, we can have some safety net while the Government and the respective colleges aim to deliver their promises. I support continued federal recognition and funding for peer support services • There is a need for a more solicited, integrated network of seamless services like DHAS WA, providing multimodal support to our colleagues including peer support above and beyond existing services and EAPs. Support for rural, remote, and isolated GPs/practitioners to be prioritised • Education of doctors to mitigate the fear of consequence and stigma and accessible support to encourage early help-seeking • The recruitment (both for mental health and general) needs to be fast-tracked at the national (if possible) and international levels • Continued push for every doctor to have their own trusted GP, at least. For the Australian medical system to deliver more effectively, we need to look after the mental health and wellbeing of the ground workforce in order to enhance the delivery of mental health to the community. “Care for us because we care for you” – an anonymous doctor. Author competing interests – nil
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Perth Breast Cancer Institute (PBCI) Breast Clinic A newly established Breast Clinic providing rapid assessment for patients with Breast Problems, located in the new Hollywood Hospital Consulting Centre.
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Providing assessment and investigation for your patients with a breast symptom, such as a benign or suspicious breast lump, breast pain, nipple discharge. Rapid investigation for your patients with an imaging (mammogram or ultrasound) detected abnormality. This assessment is performed in conjunction with Perth Radiological Clinic, now located at the Hollywood Consulting Centre. Patients can be seen by one of three very experienced Breast Physicians, and where appropriate, undergo breast imaging and diagnostic biopsy on the same day.
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Assessment of women with dense breasts.
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Advice regarding family history of breast cancer or other risk factors.
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Patients requiring further management can be on-referred (after discussion with their General Practitioner) to the Multidisciplinary team of Breast and Oncoplastic Surgeons, Medical Oncologists, Genetic Counsellor, Breast Nurses, Clinical Psychologists and other dedicated support personnel at BCRC-WA.
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The Perth Breast Cancer Institute - Breast Clinic is located at Suite 404 on Level 4 of the Hollywood Consulting Centre. A referral template can be found on our website. https://bcrc-wa.com.au/perth-breastcancer-institute-pbci/ breast-clinic/
Where appropriate, patients will also have access to a Comprehensive Clinical Trial Program.
Referrals to: Suite 404, Level 4 Hollywood Consulting Centre, 91 Monash Avenue Nedlands 6009 P (08) 6500 5576 | F (08) 6500 5574 E reception@bcrc-wa.com.au Healthlink EDI breastci
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Goodbye AS, hello ax-SpA By Dr Hans Nossent, Rheumatologist, Shenton Park The field of spondyloarthritis (SpA) has undergone remarkable changes over the last decade, triggered by the increasing availability of MRI machines, the advent of effective targeted therapies and more refined criteria for classification and assessment. The international Assessment of Spondylarthritis Society (ASAS) study group has been instrumental in driving these changes that have led to redefining SpA into two major categories: 1. SpA associated with predominantly peripheral arthritis (e.g., psoriasis or post infective/ reactive arthritis) referred to as p-SpA and 2. SpA with predominantly axial (spinal) symptoms (ax-SpA). While Ankylosing Spondylitis (AS) is a familiar entity, the condition has been reclassified as radiographic axial spondyloarthritis (r-axSpA) as it represents the extreme end on the spectrum of ax-SpA, where there is demonstrable damage on x-rays of SI joints and/or spine in the form of erosions, syndesmophyte formation or even complete ankylosis. These radiographic changes have long been standard in classifying and diagnosing AS/r-axSpA, but especially in the era where effective drug therapy has become available it was and remains counterintuitive and illogical to wait for joint damage due to sacroiliitis to appear (evolution time for gr 2-3 radiographic abnormalities is around eight years) and not treat the underlying spinal inflammation in the meantime. Non-radiographic axial spondyloarthritis (nr-axSpA) has since been recognised as an important clinical entity that represents the other end of the ax-SpA spectrum where patients experience typical axSpA symptoms and while these patients do not have definitive abnormalities on plain x-rays, they demonstrate clear evidence of spinal and/or sacroiliac joint inflammation on MRI. The clinical features of nr-axSpA are MEDICAL FORUM | MENTAL HEALTH
protein, and a high degree of inflammation as seen on an SI joint MRI. Most of the studies report some people with nr-axSpA progress to r-axSpA with rates of progression of 10% seen over two years and 40% over 10 years. However, timely therapeutic interventions can relieve the significant clinical burden of disease in nr-axSpA patients, which has been found to be equal to the disease burden seen in AS/r-axSpa patients in terms of pain, stiffness, and loss of productivity.
Key messages MRI scanning has changed our approach to ankylosing spondylitis Radiological change is not a rational basis for treatment of axSpA Biologics have been a significant advance in treatment.
largely similar as for r-axSpA and include chronic inflammatory lower back pain (LBP) (i.e. insidious onset of LBP in a person under age 40, often improving with activity but not with rest, leading to pain at night with improvement upon getting up and responsive to NSAID). LBP is primarily due to the involvement of the sacroiliac (SI) joints but pain and stiffness due to enthesitis can occur in neck, shoulders, hips, ribs, heel and as hand/feet dactylitis. Recent demographic reviews showed that 55-60% of patients with nr-axSpA are women, although it is still not fully clear if this is a true feature of nr-axSpA or a sign that r-axSpA in women has traditionally been under underestimated. Patients with nr-axSpa can also present peripheral synovitis and/or extra-articular features such uveitis, psoriasis, and inflammatory bowel disease similar to r-axSpA. While the severity of nr-axSpA varies from person to person, risk factors for progression from nr-axSpA to AS are male sex, a high level of C-reactive
Medicare, in 2018, approved biological therapy for nr-SpA patients who fail a 12-week trial of NSAID. There are currently two TNF inhibitor drugs (golimumab and certolizumab pegol) and recently also the IL-17A blocker secukinumab available for patients with ASAS criteria based nr-axSPA. While biologicals, by switching off/ reducing the inflammatory spinal process, are often effective in symptom reduction, there is limited data on the longer-term effect of biological treatment in arresting the development of joint damage in nr-axSpA, for which large, long-term studies will be needed. Finally, the very limited or absent need for NSAID therapy for symptom relief is an important additional, although little recognised clinical benefit of biologicals in ax-SpA patients in general. In conclusion, while once a valuable diagnostic marker of AS/r-axSpA, radiographic change is no longer a rational guide to treatment of axSpA. The same treatment modalities are appropriate across the full spectrum of axSpA irrespective of radiographic status. Biologicals are similarly effective in nr-axSpA and AS/r-axSpA and represent a major advance in the medical management of these disorders. – References available on request Author competing interests – nil
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Supporting junior doctors to access support By Dr Helen Wilcox, Doctors Health Advisory Service (DHASWA) Publications on the rising rates of burnout, popular press features, and recent coverage by high profile individuals and platforms add daily to a developing professional and public awareness of doctors’ mental health. Concurrently, doctors’ health resources are proliferating. Statebased and national telephone support, crisis services and extensive e-mental health offerings complement physical spaces and resources provided by wellbeing networks within health services, medical schools and specialty colleges. So why do so many junior doctors remain in difficulty despite abundant resources? The pandemic, related workforce issues, chronic underfunding of health service delivery and competitiveness of specialty training are a few current systemic issues beyond the remit of the individual doctor. Cultural and interpersonal factors within a department may be well established when a junior doctor enters that environment. Individual personality factors conferring vulnerability to burnout may be amplified during medical school and postgraduate training. Working in a reactive environment under a burden of chronic stress with limited autonomy generates physiological arousal that, over time, reduces the ability to manage a high cognitive load. Maladaptive coping mechanisms in response to chronic arousal may further reduce cognitive capabilities. Concerns about privacy, fears of mandatory reporting and invalidating effects of stigma, may discourage doctors seeding help. Taken together, there appear to be few determinants of doctors’ mental health within an individual’s control. Identifying and accessing preferred care options are within their control, and those supervising junior doctors and students can facilitate help-seeking. 50 | JUNE 2022
When supervisors know the components of primary care management of doctors in distress, they can normalise help-seeking, instil hope that distress can be alleviated, and emphasise the importance of not being deterred by initial barriers. An early port of call for a doctor in distress should be their GP. Accessing GP care is not straightforward for a doctor working standard hours and is made more difficult with unpredictable on-call and overtime demands. A GP who is otherwise very well suited to managing stress, or who has a longstanding existing relationship, may only work office hours, or be geographically distant from the doctor’s workplace. If psychological or psychiatric support is indicated, waitlists for the right practitioner can be months, and changing placements or rotation can disrupt a sequence of regular appointments. And copayments can be prohibitive for some junior doctors or students. These logistical barriers can deter a junior doctor otherwise motivated to seek assistance.
Barriers not insurmountable Many GPs and psychologists offer evening and Saturday appointments. DHASWA provides lists of GPs and psychologists happy to see doctor (and medical student) patients, even if their books are closed. Telehealth consultations can remove the need to be co-located (particularly helpful in rural rotations). Where indicated, a GP with established networks can generally refer to psychologists or psychiatrists with capacity for new patients. Waiting time can be used productively, especially if stabilisation and recovery are conceptualised as slow processes of incremental improvements (versus the short-term solution of leaving medicine or taking a prolonged leave of absence). Not all doctors in distress require specialist mental health care; many can be supported in primary care with advocacy to approach their supervisor to broach workplace and workload factors, and to approach their employer to seek leave, and to use this leave for restorative activities rather than administrative tasks. MEDICAL FORUM | MENTAL HEALTH
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Key messages Junior doctors face pressure from many directions Barriers to treatment are not insurmountable Small scale adjustments can assist considerably. Activities that can be initiated in collaboration with a GP, and in some cases a mentor, include: • establishing or maintaining adequate quality sleep • determining severity of symptoms, goals of treatment and markers of recovery; standardised burnout inventories can encourage awareness of physical and mental features of burnout and aid development of insight into contributing factors • reflecting on mindset and identity factors that predispose to doctor distress and burnout via curated reading (the Perth-based psychology group, The Skill Collective, has an excellent book, Planet Burnout, and Professor Gordon Parker’s Burnout: A guide to identifying burnout and
• • • •
•
pathways to recover is also worth reading. selecting and commencing, or prioritising exercise monitoring and moderating alcohol intake diagnosing co-existing mental health conditions trialling pharmacotherapy for depressive or anxiety disorders, if warranted incorporating small-scale adjustments into daily activities.
Small-scale adjustments contribute cumulatively to lowered arousal and an increased ability to access cognitive capacity and positive emotions in the workplace. Adjustments might be individual, with examples being brief activities such as paced breathing, focusing on natural objects, stretching, and potentially cued to repetitive workplace activities such as waiting for a lift or entering a new ward. Other adjustments relate to interaction with peers and colleagues. Examples include the practice of kindness (there are several Australian clinician interest groups), a focus on the meaningful aspects of work, and accessing a
peer network, seeking out peers who can facilitate co-regulation. Many experienced and compassionate supervisors and education leads in WA model these behaviours, systemically facilitate their uptake by junior doctors, and proactively identify and support junior doctors in distress. Despite the inherent challenges in the clinical environment, doctors in distress can be guided through their difficulties to undergo personal growth, and progress to be future supervisors, supporting the next generation of junior doctors. – References available on request. Author competing interests – nil DHASWA is an independent, not for profit association supporting health and wellbeing of WA doctors and medical students. Urgent health or wellbeing advice is available 24/7 by calling the Advice Line 08 9321 3098, staffed by GPs experienced in doctors’ health who will be in contact within four hours. Calls can be anonymous, are confidential and exempt from mandatory reporting. Follow us on socials.
Stimulating pathways to recovery Modalis specialises in MRI-guided Transcranial Magnetic Stimulation (TMS) which can improve the treatment options in pain management, psychiatry (depression, OCD, PTSD), neurology, rehabilitation and other areas of medicine, such as treatment of tinnitus. TMS therapy has advantages over other treatments including: • • • • •
non-invasive with a superior safety profile drug-free comparable success rates to pharmacological therapy good tolerance with few side-effects quick, convenient sessions on an outpatient basis
Visit modalis.com.au to find out more about our services, locations, referral pathways and screening process. The referral template for rTMS services at Modalis will be available on Best Practice software from May 2022. 08 6166 3733
4245 Modalis Medicus half Page Ad.indd 1
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tms@modalis.com.au
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CLINICAL UPDATE
Youth mental health – disclosing the shrouded By Dr Davinder Hans, Psychiatrist, Nedlands Although mental health issues are the key health concern of youth today, contributing to 45% of the total burden of disease, youth have the poorest access to mental health care of all ages and less than one third have access to professional help – for several reasons. Firstly, youth may not recognise the need for mental health care and there are unhelpful beliefs around “strength if I can get better myself.” Most first point-of-contact services can appear to be designed for physical ill health. Because youth are usually in good physical health, they may not routinely visit their general practitioner and, when they do, they may not feel comfortable to discuss their mental health. Youth can also present with a heterogeneous and evolving symptom profile, often not meeting stringent diagnostic criteria required for acceptance into services. Their presentation is further confounded by comorbidities such as substance abuse, evolving personality disorder traits, and self-identification with autism spectrum or dysexecutive syndrome (ADHD) features. Acknowledging and catering for the complex and evolving pattern of symptoms and morbidity in the youth age group is essential. A non-judgemental approach, with a willingness to listen and simultaneously providing an empathetically delivered honest clinical assessment rather than an overreach to ascribe a diagnostic label or prematurely prescribe psychotropic medications, is an appropriate approach. Notwithstanding, in tailoring a nuanced care for this population, together with endeavouring to provide psychological therapy options, we must still consider appropriate medication use, keeping in mind their tolerability and side effect profile compared with adults. It is also important for youth to be able to recognise when, how and where to seek help. A candid discussion with young people about MEDICAL FORUM | MENTAL HEALTH
Key messages Mental health issues are the key concern for youth. Open conversation assists building trust, making youth feel more at ease in discussing their challenges Youth can present with pleomorphic phenomenology. Premature overreaching diagnoses with insufficient observation and collateral information can lead to premature pathologisation and disproportionate pharmacological treatment Consider pharmacological and psychological treatment in youth where indicated in a nuanced patient centred treatment approach. mental health issues when we get an opportunity to talk with them helps foster a sense that their mental health challenges can be freely discussed. Accessible, affordable, and acceptable care that is developmentally appropriate should be available. This can range from enhanced primary care services to specialist youth services for complex presentations and more severe illness. With this, there is a dedicated team organised around the youth, family and the unique needs, providing a full cycle of care – a “one-stop-shop.” Regardless of whether a larger proportion of youth might be considered mature minors and adults from a consent point of view, it is essential practice to provide clear information and developmentally appropriate explanation of treatment to the youth.
Best practice is to obtain agreement of those with parental responsibility. In the event that a youth goes against the opinion of caregivers, we must be even more mindful and continue to maintain a collaborative relationship with carers and continue to endeavour to engage them in the treatment plan. This applies especially to those under age 18. The issue of communication leads to the importance of confidentiality. It goes without saying that the issue of clinician-patient confidentiality needs to be discussed at the outset of the therapeutic engagement, whereby the type and detail of information that might be fed back to carers or other services must be made clear to the youth. This will help impress a more trusting rapport. A care approach for youth should adopt a preventative and optimistic framework emphasising early intervention and offer a holistic, evidence-based care and shared-decision making with the improvement of function, social and vocational outcomes as important targets. Much literature focuses on treatment of illness and considerably less work has been done on the promotion of wellness and resilience. Promisingly, more recently, there have been effective preventative programs for at risk youth and psychosocial treatments have included focus on building strengths as opposed to addressing deficits. This approach promotes the presence of wellness instead of just achieving an absence of illness. – Author competing interest – nil
When a youth is not competent, consent can be provided by the parent or agency holding the parental responsibility. When a youth is competent with capacity to consent to treatment, he or she can consent irrespective of the wishes of those with parental responsibility. JUNE 2022 | 53
Unsettled babies in the ‘4th trimester’: Birth to 3-4 months By Dr Ian Everitt, Paediatrician, Hollywood The challenge of managing unsettledness in babies is the most common reason parents seek early medical attention for their newborn. It can present early in a baby’s life or at subsequent routine checks when it can dominate the discussion and may have been labelled and treated with a plethora of diagnoses and therapies. Often parents may be told “your baby’s crying is normal” but have no clear understanding of why, particularly when given the ‘colic’ label. Without clear explanation, this label does not reassure parents. Multiple sources of advice (other mothers, relatives, multiple health care contacts and Dr Google) are usually extremely confusing and unhelpful for desperate, sleep
deprived, and understandably emotionally fragile parent(s) bombarded by a plethora of diagnoses. This often leads to concurrent trials of numerous concoctions, whilst not addressing the most common contributor to unsettledness: PURPLE Crying and resultant wind from air swallowing. Addressing these two, (invariably present to some extent in most babies,) often reduces overall unsettledness dramatically. Identifying these may help to rule in or out concurrent issues (e.g., unhappy “refluxer” intolerance colitis) which may also need addressing. Distinguishing abrupt changes in a baby’s behaviour warrants careful exclusion of serious pathological causes. Subacute, gradual onset
and increasing unsettledness over time (from around age two weeks) is the pattern of PURPLE Crying. Pathological causes can be screened by a top-to-toe, front and back examination for causes not always readily observed by parents. More subtle signs may not be appreciated without this careful screen (hair tourniquet of digits, hernia, torsion, spider envenomation, corneal abrasion, ICP and NAI). The most common cause for non-acute onset unsettledness is the challenge of adapting from intrauterine existence to extra uterine life. All babies journey through this 4th trimester period with variable need for maternal comforting strategies. These are designed to simply mimic the intrauterine environment, which
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CLINICAL UPDATE settles most babies. An acronym can explain what “colic” actually is.
PURPLE Crying P – Peaks at 8-12 weeks of age; after commencing around two weeks. U – Unexpected, with no clear reason for crying (hunger, nappy change, symptoms, or signs of unwellness). R – Resists soothing with usual strategies (trials of feeding, jiggles, car rides, colic mixtures). P – A crying baby’s Painful Appearance is due to the physiology needed to create a cry. This involves facial muscle contraction which causes closing of eyes and grimacing. The contraction of abdominal wall and psoas muscles to produce the forced expiration of a cry, resulting in leg flexion, a hard stomach and arching of the trunk. This often leads to a false conclusion of abdominal pathology such as reflux or the ‘C word’ (colic), which should be condemned to ancient literature. L – Long lasting, where a fourth trimester-aged baby may cry more than three hours each day.
E – Evening and afternoons, predominance in the “witching hours”. PURPLE Crying may be attenuated by the 5 S’s of Settling Babies creating an environment where the baby feels “back in the womb”.
The 5 S’s of Settling Babies 1. Swaddle – DUDU (down, up, down, up method – the key is holding arms down alongside trunk). 2. Side/Stomach – Position of holding baby during settling. 3. Shushing – Mimicking the intrauterine souffle blood flow sound (needs to be LOUD). 4. Swing/Sway – To mimic the previous foetal movements in amniotic fluid in utero due to pregnant mother’s activity. 5. Suck – Calming reflex (by pacifier or mother’s breast). It is useful to include a demonstration of the 5 S’s of Settling Babies at antenatal classes or upon discharge from hospital. If proactive and anticipatory of PURPLE Crying, the 5 S’s will alter the unsettledness trajectory significantly.
• Consider stopping medications, specialised formulas, maternal dietary exclusions or colic mixtures individually if not clearly indicated. • Supporting the mother-baby dyad provides holistic care. • Removing over medicalisation of unsettledness is therapeutic to parental anxiety and the 5 S’s often breaks the cycle of crying, causing air swallowing and resultant wind. • Provide confidence-boosting parental support by reinforcing the positive aspects of a mother’s care is so important. Ongoing support may involve their family’s local doctor, child health nurse, extended family and psychological input when needed, to support parental emotional wellness. – References available on request Author competing interests – nil
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To express interest, or have a friendly chat please email tajsingh@murdochpsychiatry.org or call 0434 252 672
JUNE 2022 | 55
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CLINICAL UPDATE
Fruit and veg may improve mental wellbeing By Dr Simone Radavelli-Bagatini, School of Medical & Health Sciences, ECU Stress is part of our daily lives and can be considered normal to some extent. The stress we feel when we have a work deadline or a competition, for example, prepares our body to react and perform better. However prolonged or chronic stress can increase the risk of mental and physical health issues such as depression and cardiovascular diseases. The COVID-19 pandemic has further exacerbated chronic stress worldwide, with people reporting increases in tension, being impatient, having an unbalanced mood, or yelling at a loved one more often.
Key messages Stress is a major health issue and has been exacerbated by the pandemic Diet may be an additional option in stress management. A short-term (14-day) randomised controlled trial (RCT) has shown that increasing FV intake can improve psychological well-being (vitality, flourishing, and motivation) whilst consumption of FV has been associated with lower stress in young people (<30 years).
Proven approaches to reduce stress include relaxation, meditation and increased physical activity. New stress-busting strategies are also needed. Typically, when stressed, people switch to the so called ‘comfort foods’, (e.g. sweets, fatty food, sugary drinks and alcoholic beverages) to attempt to compensate for negative mood and stress. My research focuses on whether diet can be used to reduce chronic stress.
However, it is unclear whether these short-term effects may lead to longer-term benefits and whether the link between FV and stress is seen in older adults. To address these gaps, data was used from over 8,000 Australian adults aged between 25-92 years with dietary and mental wellbeing outcomes including a 30-item perceived stress scale and 10-item depression symptoms questionnaire.
Fruit and vegetables (FV) are considered a cornerstone of a healthy diet. Yet only 50% of Australians eat the recommended two serves of fruit and under one in 10 eat the recommended five serves of vegetables a day. The physical health benefits of FV intakes are well known, but remarkably little is known about their mental wellbeing benefits.
In my first study, a higher FV intake was associated with 10% less stress, independent of other lifestyle factors, such as physical activity. These findings indicate the potential benefits of FV intake for stress across the adult lifespan.
Results
The second study explored the relationship of specific FV types with perceived stress. We found that a higher consumption of apples
and pears, oranges and other citrus, and bananas, as well as cruciferous, yellow/orange/red, and legume vegetables were associated with 24-31% lower odds of having high perceived stress (highest 25% of the population by age and gender). These findings suggest that eating a ‘rainbow’ may be more beneficial. The third study found that greater FV intake was associated with lower odds (16-36%) of tension, worries, and lack of joy (stress reactions). These findings suggest that FV can help alleviate different types of stresses, which may be important to tackle specific stress domains such as anxiety and lack of joy. In my fourth study we found a FV-rich diet, consisting of a diverse range of vegetables, particularly yellow/orange/red and leafy green vegetables may help to lower depressive symptoms. Limitations of this series of studies are that these were observational, which does not allow for causality, and some were cross-sectional meaning the temporal nature could not be determined. Additionally, we could not determine whether it is the nutritive (e.g., vitamins), non-nutritive (e.g., polyphenols) of the FV, or psychological effects of eating brightly coloured FV, or the tasks of preparing and cooking the foods (mindfulness) that may relax individuals and reduce stress. Taken together, these studies provide further evidence that what we eat may alleviate stress and potentiality improve mental wellbeing. Longer-term studies are needed to strengthen current evidence from observational studies and short-term RCTs on the beneficial effects of FV for stress. Results from these studies could be used to refine current guidelines and public health messages. – References available on request The author is a research fellow at the Nutrition & Health Innovation Research Institute and was involved in studies described.
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CLINICAL UPDATE
Managing full thickness rotator cuff tears in ‘older’ age By Dr Jonathan Spencer, Orthopaedic Surgeon, Hollywood Shoulder pain and dysfunction are common presentations in the older age group. Presentations may be atraumatic or precipitated by ‘minor’ trauma. Patients will usually wait a few weeks or months before seeking treatment in hope symptoms settle. Today’s ‘older age group’ comprises a heterogeneous group of patients ranging from the extremely fit, strong, active and mobile to the frail with multiple medical comorbidities. Individualised management based on the patient’s needs and demands is needed. Plain x-rays and ultrasound scans, commonly performed, will frequently report full thickness rotator cuff tears causing concern for both the patient and the treating doctor. While the rotator tear may be the cause of the patients’ symptoms, there is a reported rate of 20-40% of rotator cuff tears in the asymptomatic population aged 60-80.
Judgment needed If the patient falls into the fit active ‘high demand group’ then early referral to a shoulder specialist for consideration of surgical repair should be considered. This should be no different to the usual treatment algorithms in young patients with full thickness rotator cuff tears. If the patient is lower demand, in poorer physiological condition with medical comorbidities, then a more conservative approach may be reasonable. Initial non-operative treatment could include: 1) Giving the patient time to recover as functional improvement can be significant in the first 6-12 weeks or even longer 2) Non steroid anti-inflammatory drugs 3) Local anaesthetic and steroid injections into the subacromial space 4) Good quality shoulder rehabilitation with a musculoskeletal physiotherapist MEDICAL FORUM | MENTAL HEALTH
Key messages Full thickness rotator cuff tears are common in over 65s and symptoms may vary The rotator cuff tendons and articular cartilage may be markedly degenerate and of poor quality Individualised treatment is needed and several options exist.
with an interest in shoulder rehabilitation. Physiotherapy with an experienced shoulder physiotherapist is important as ineffective and prolonged therapy with little improvement can be expensive and disillusioning for the patient, leading to the statement that ‘physio does not work’. In patients failing non-operative treatment, referral to a shoulder specialist surgeon may be appropriate. Once the patient reaches the surgeon, consideration is needed to establish if the patient is a surgical candidate and, if so, what surgery may be appropriate. This is usually done (in addition to clinical examination) with an MRI scan which gives useful information that a plain x-ray and an USS may not. The MRI scan can provide information on the size of the tendon tear and also the quality of the rotator cuff muscle bellies. Generally, rotator cuff tears involving more than two tendons, that are larger (>3-4cm) and retracted to the glenoid with muscle belly atrophy have a poorer prognosis after repair (with poorer outcome). They also have a higher re-rupture rate after repair. The MRI scan may also show other soft tissue pathology (e.g., inflamed or subluxed biceps tendon) and glenohumeral joint degeneration.
1) Arthroscopic debridement and biceps tenotomy for irreparable rotator cuff tears in which pain relief the main goal 2) Arthroscopic rotator cuff repair in ‘smaller’ tears with good quality muscle bellies in which a good outcome from surgery can be predicted 3) Reverse total shoulder replacement is a good option in patients with irreparable rotator cuff tears, particularly with glenohumeral joint degeneration All surgeries have pros and cons. Arthroscopic surgery may be ‘low risk’ but may also be ‘low yield’ particularly in poorly selected patients. Recovery from rotator cuff repair can be prolonged, taking three to six months to get a reasonable result and up to 12 months for maximal improvement. So, it is important the surgery ‘works’. Reverse total shoulder replacement is being done with increasing frequency. It is particularly useful in cases where there is glenohumeral joint degeneration and irreparable rotator cuff tendons where attempted repair would lead to a predictably poor outcome. Recovery from reverse total shoulder replacement can seem much quicker than rotator cuff repair, with two to four weeks in a sling and a good outcome by three months post-surgery in most cases. However, the surgery is no panacea as even a good result of a reverse total shoulder replacement does not produce a normal shoulder. There is also a small risk of a serious adverse outcome including fracture and infection. We all need to choose wisely and endeavour to get the treatment right the first time. Author competing interests – nil
Surgical procedures that may be considered in this age group: JUNE 2022 | 59
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CLINICAL UPDATE
Very low-calorie diets as a therapy for obesity By Sophie McGough, Dietitian, Diabetes WA Obesity is a chronic, relapsing condition requiring ongoing self-management and support. People living with obesity need empathy, not judgment. They need recognition that the root cause of obesity is more complex than energy in versus energy out and that weight management is challenging in our obesogenic environment. They need a supportive team offering multiple options for medical nutrition therapy and the opportunity to be guided through these options to determine the best fit. Very Low-Calorie Diets (VLCD) are a medical nutrition therapy option that can be offered to consumers. Unfortunately, when VLCD products changed classification from medicine to food, the regulations requiring medical supervision and dietetic support were lost. We have all witnessed the outcomes of people ‘going it alone’ with the latest VLCD fad, often with limited success. This has led to a healthy level of skepticism around the effectiveness of VLCD. Diabetes WA has been monitoring the recent resurgence in use of VLCD with interest, observing their potential effectiveness in research trials focusing on remission in type 2 diabetes. These trials have demonstrated that there is a role for VLCD (as total meal replacement) for some people, with intensive dietetic support integral to these study outcomes. Over a decade ago, Diabetes WA made a deliberate, strategic shift to commit to person-centred care. All programs and services invested in and developed align with this philosophy and the behavioural theories and empowerment approach enabling health professionals to translate this into practice. This empowerment approach focuses on the behaviour of the health professional and quality of their interactions with individuals. It reduces the burden on health MEDICAL FORUM | MENTAL HEALTH
professionals having to provide external motivation and try to ‘make’ people change.
Proof of Concept Funded by Health Networks and WAPHA, the ‘Supported Weight Management Program’ was a ‘real world’ proof of concept using VLCD as Total Meal Replacement (TMR) and led by dietitians and exercise physiologists trained and accredited in this empowerment approach. Implemented in partnership with three general practices, all appointments were conducted via telehealth from Diabetes WA. GPs and practice staff met with Diabetes WA prior to the intervention to ensure that roles were defined, to clarify referral criteria and build confidence in the proposed model of care and approach. Endocrinologists from Fiona Stanley Hospital provided an update on medication management during VLCD for those with comorbidities. Consumers involved in the intervention design indicated that it was critical for all health professionals involved to listen to their personal weight stories without judgment, seek insight into what people have experienced to date, and view previous attempts as learning experiences, not failures. Building this rapport and trust with people would improve their experience and increase engagement with the service.
Lessons Learned As expected, people lost weight rapidly, maintaining this loss at six months. More surprising were the ease of recruitment, low attrition rate (15%), high engagement with telehealth and quality of life improvements. An unexpected benefit to VLCD (when used as TMR) was the reduced ‘food decision making’ burden reported by individuals. With hunger controlled, people become acutely aware of other triggers for eating and ingrained eating habits. This awareness
Key messages VLCDs have value as a medical nutrition therapy option for people living with obesity, where there is a strong partnership and agreed model of care between dietitian, GP and practice nurse Quality conversations about weight and an empowerment approach are key to keeping individuals engaged and supported for long-term weight maintenance after VLCD Individuals with pre-existing conditions require medical management during VLCD and should be discouraged from ‘going it alone’ without multidisciplinary support.
provided the opportunity to explore their relationship with food and consider areas for change, building confidence as people moved into the food reintroduction phase. Rather than a prescribed food reintroduction regime, individuals were guided to plan their own dietary intake, specific to their needs and what they could realistically sustain based on previous experiences. This approach encouraged mastering of dietary planning and a continuous improvement mindset. Those with pre-existing comorbidities (42%) were more clinically and psychosocially complex and required medication management and significant clinical care coordination. This provided great insights into the risks for people living with obesity using VLCD without support and reinforced the need for models of care that provide access to dietitians working collaboratively with general practice. ED: Sophie McGough is general manager Innovation and Growth at Diabetes WA Author competing interests – nil
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Winter warmer: Smart crime for thoughtful readers
Author Vaseem Khan wants his crime stories to be smart but he also wants readers to get new insights into the culture and politics of his ancestral homeland of India.
By Ara Jansen While reading the works of Terry Pratchett, 17-year-old Vaseem Khan wrote a comic fantasy novel. He duly sent it off to some publishers and had the talk with his parents – he was going to be a famous and rich author. They said no. That was it. Khan went to university. After doing accounting, finance and political science at the London School of Economics, he spent 10 years as an international management consultant to an Indian hotel group, building environmentally friendly hotels. That decade in India – and more than 20 years after he first started writing – inspired the crime novel The Unexpected Inheritance of Inspector Chopra which led to a four-book deal. What is now known as the Baby Ganesh Detective Agency series is a fivebook and two novella series featuring a retired Indian police inspector who is gifted a baby elephant by a long-lost uncle. Together Inspector Chopra and Ganesha solve crime and reveal the heart of modern India.
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LIFESTYLE
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LIFESTYLE
Khan’s most recent book, The Dying Day, is the second in a new series featuring India’s first female police detective, Persis Wadia. Set in Bombay in 1950, on the eve of India becoming a republic, the author says he wanted to explore the myriad issues around Partition, including the fast-evolving place of women in Indian society. While lots has been written about that period, Khan was keen to explore a story which included the Brits who chose to stay in India or couldn’t handle going back. “Now they were no longer the masters,” says Khan. “I could kill off a few of them and see how Persis reacts and explore the environment around post-colonialism.” Persis is also fighting her own battles to be taken seriously amidst an all-male police force. Alongside being an author, Khan works at University College London’s Department of Security and Crime Science, managing some of their bigger projects and research centres as the department attempts to apply science and engineering to prevent, reduce and better detect crime. He also raises funds while spending half his time “herding very smart cats” and reminding academics what they promised to deliver with their grants. “I love them really and I love the work which is why I don’t leave my day job. They are also really good sources for crime information.” While writing a short story recently, he was able to find a colleague who MEDICAL FORUM | MENTAL HEALTH
could explain the big and small details of how to burn someone alive. It’s so much nicer than doing internet research. Khan suggests some of his colleagues are also angling to have a character named after them. When he’s not writing or working, he’s also a proud member of The Authors XI, a wandering cricket team which formed in the early 1890s and counted PG Wodehouse, Arthur Conan Doyle and JM Barrie as early players. Today the team includes sports writers, biographers, novelists, poets, media and publishing types and a few crime writers. The first Persis Wadia book, Midnight at Malabar House, won the Crime Writers Association Historical Dagger 2021 award and is up for a second prestigious crime novel award.
Khan says, “but I love the crime genre and used to love watching Agatha Christie’s Poirot. My dad would watch it with me and loved the Golden Age sensibility. “I’ve always wanted to write that type of crime novel – an intelligent challenge with puzzles and clues and working up a whole bunch of suspects who could be the killer. Rather than a lot of sex and violence I wanted to make it about the history, the prose and the story with the main element being a satisfying and compelling crime mystery.”
Read this story on mforum.com.au
“I could have written political fiction,” JUNE 2022 | 63
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WINE REVIEW
The impeccable wines of Cape Mentelle Cape Mentelle is one of the pioneers and great names of the Margaret River region. The vines were planted in 1970 by skilled winemaker and astute businessman David Hohnen and it has now grown to 145ha of estate vineyards. This gives the winemaker total viticultural control, with non-estate fruit not required to meet its needs. Instrumental in putting Cape Mentelle and Margaret River on the Australian wine map was the winning of consecutive Jimmy Watson Memorial Trophies. This award is seen as one of Australia’s most important and is awarded annually to the best Australian one or two-year-old dry red wine. They won it with the 1982 Cabernet in ’83 and the 1983 Cabernet in ’84, rocketing this then little-known winery to national prominence. Famous for its distinctively Margaret River Cabernet style, which is internationally sought after, its other wines also show consistently high quality that reflect their regionality. The four wines in this tasting were all excellent.
Cape Mentelle 2018 Shiraz (RRP $49)
Review by Dr Craig Drummond Master of Wine
Cape Mentelle 2017 Wallcliffe Merlot Petit Verdot Malbec (RRP $49)
This is great Margaret River Shiraz – it displays an attractive purple/ brick red colour, a spicy nose with mulberry, cinnamon and cardamon. Palate is full-bodied showing plush flavours of sweet berry fruits, blueberry, black olive, black pepper. Plenty of oak (17 months in a combination of French and American – 18% new) which is integrating. The high 15% alcohol is disguised by concentrated fruit. This is a 10-year wine. Interesting is the inclusion of Viognier (3%) for brighter colour and lifted aromatics, traces of Grenache for complexity and Alicante Bouschet for juiciness.
An interesting blend of these three Bordeaux varieties (Merlot 54%, Petit Verdot 26% and Malbec 20%). Vibrant brick red in colour. Austere and savory aromas initially, then evolving dark cherry, violets, and anise. Savory and herbal flavours. Mulberry, cranberry, beetroot. Cedar from oak. Dominant, tight, finegrained tannins – no surprise with Petit Verdot and Malbec in the blend. Compact, balanced with good length. Has the structure, acidity and tannins to age 10 to 12 years.
Cape Mentelle 2017 Cabernet Sauvignon (RRP $110) A blockbuster of a wine and the Cape Mentelle’s flagship. This wine is big, complex, powerful and wonderful. At five years of age it still displays a youthful purple/dark plum colour. The nose captivates with loads of cassis, leafy characters and cashew from oak. The palate is powerful, with depth and intensity. Flavours of blackcurrant, forest floor, satsuma plum. There is plenty of oak here which is integrating. Fine persistent tannins from skins and oak. Complex and long. As much as I enjoyed this wine now, it will integrate and improve. A 20-year wine.
'S EWER REVI
PICK
Cape Mentelle 2018 Chardonnay (RRP $49)
This is my wine of the tasting based on incredible quality for price and that it is drinking optimally now. Shows a luminescent mid-gold colour. The nose is rich, opulent and ripe. Shows ripe melon, honey and hazelnut. A full-bodied style, palate is textural and unctuous, with pineapple and rockmelon flavours. Added creaminess from malolactic ferment. Great length and a clean finish. Although wonderful current drinking, it will go for a further seven years. A truly great Margaret River expression of the Chardonnay grape.
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PERTH RADIOLOGICAL CLINIC
New Partners Perth Radiological Clinic is pleased to welcome Drs Stephen Tiang, Mark Teh and Rory McPherson as new Partners of the Practice. By investing in talent and recognising and rewarding excellence with Partnership, Perth Radiological Clinic is securing high end sub-speciality patient care for your Radiology patients in Western Australia.
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Looking to sell your practice? )RU D FRQǓGHQWLDO GLVFXVVLRQ FRQWDFW XV WRGD\ Dr BrHQGD 0XUUison 0 0418 921 073 ( Brenda.Murrison@breckenhealth.com.au Damian Green 0 0423 844 268 ( Damian.Green@breckenhealth.com.au