Medical Forum – June 2021 – Public Edition by Medical Forum WA

End of life choices

Mental Health | Self-harm, psychedelics revisited, TMS & pain, liver disease, exercise

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June 2021 www.mforum.com.au

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Cathy O’Leary | Editor

End of life choices There is simply another choice now, supported by the community, that will probably be taken up by few but will provide reassurance to many more.

It was not that long ago that the issue of voluntary euthanasia polarised West Australians as bluntly as the daylight savings debate (sigh, I have given up all hope of winning on that one). Many people worried about medically-assisted death, even in the terminally ill, not necessarily because of religious reasons but because it was unchartered territory. But more candid and open discussion about death – and the harrowingly prolonged experiences of some – has made more people question long-held beliefs about what is right or wrong for the end of life. For doctors, the decision is even more complex, as voluntary-assisted dying might seem at odds with their oath to save lives, and they may be asked to play an active role from July 1 when VAD laws kick in. That will be their decision alone. Many people who have had the privilege to witness a ‘good death’ in palliative care might believe that is what we should still aspire to as a community, providing the best care we can for the dying. There is simply another choice now, supported by the community, that will probably be taken up by few but will provide reassurance to many more. This month we also look at mental health, now considered a co-pandemic in our kids and teenagers. The cracks were already there but COVID has added an extra layer of anxiety, and it will take more than a vaccine to fix it.

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CONTENTS | JUNE 2021 – MENTAL HEALTH

Inside this issue 10 16 20 FEATURES

NEWS & VIEWS

10 Close-up – forensic

scientist Dr Paola Magni

End of life choices – Cathy O’Leary

16 VAD – a delicate balance

4 In the news

20 Youth mental health at

6 In brief

breaking point

26 Q&A: Mental Health Minister Stephen Dawson

LIFESTYLE

25 Putting seasonal flu on the radar 31 New focus on head injuries in kids 36 New portfolio gives hope to researchers – Professor Peter Leedman

37 Supporting safe, home-based withdrawal – Jupp Groenveld

56 Rediscovering Rottnest – Cathy O’Leary

40 Head for medicine, nose for business – Matthew Vaughan-Davies

59 Wine Review: Aravina Estate – Dr Louis Papaelias

60 Music of the spheres

41 Counting sheep in your sleep – Dr Jen Walsh

43 Fear, resilience and our mental health – Dr Joe Kosterich

61 West Side Story

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CONTENTS

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EDITORIAL TEAM

Responding to selfinjurious behaviours Dr Bethanie Gouldthorp

Screening for secondary hypertension Dr Aaron Simpson

TMS therapy for cortical pain neuromodulation Dr Vincenzo Mondello

Revisiting psychedelics in psychiatry Dr Jeremy Tannenbaum

Persistent oral ulceration Professor Camile S. Farah

Advances in stereotactic radiation therapy Dr Kasri Rahim

Editor Cathy O'Leary 0430 322 066 editor@mforum.com.au Journalist Dr Karl Gruber (PhD) 08 9203 5222 journalist@mforum.com.au Production Editor Ms Jan Hallam 08 9203 5222 jan@mforum.com.au Clinical Editor Dr Joe Kosterich 0417 998 697 joe@mforum.com.au Clinical Services Directory Editor Karen Walsh 0401 172 626 karen@mforum.com.au

Exercise for mental illness Cameron Lilly

Abnormal liver biochemistry – clinical relevance Professor John K. Olynyk

Potentials of Psychedelic-assisted therapy Dr Eli Kotler

GRAPHIC DESIGN Ryan Minchin ryan@mforum.com.au

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Vaccination and failing leadership Dr Bruce Powell

CaLD youth speak out Nadeen Laljee-Curran

Kicking the mental health can Kerry Hawkins

Recalibrating telehealth risks Enore Panetta & David McMullen

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IN THE NEWS

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It’s all smooth sailing Western Australia’s success with cruise ship COVID management has been highlighted in new research. The study into the response to the COVID-19 outbreak on the MV Artania cruise ship off WA’s coast last year was published in the Emerging Infectious Diseases Journal. State Health Incident Coordination Centre medical adviser Dr Tudor Codreanu and Communicable Disease Control Director Dr Paul Armstrong were among the authors of the paper. “What we did in WA, and how we did it, proved to be successful,” Dr Codreanu said. “In the current global pandemic, we wanted to share it with the rest of the healthcare world so they could take inspiration – and

On Budget The Royal Australian and New Zealand College of Psychiatrists has welcomed the $2.3 billion boost to mental health announced in the recent Federal Budget. Repetitive transcranial magnetic stimulation had been added as a treatment available under the MBS, and there is a big spend on suicide prevention and a goal to achieve universal aftercare services following a suicide attempt. The funding boost includes $11 million toward boosting the psychiatrist workforce by creating 30 additional training posts by 2023, including regional and remote pathways, and almost $1 million to develop a nationally recognised Diploma in Psychiatry for medical practitioners, including GPs and emergency medicine specialists, to support the broader mental health workforce.

Telehealth extended… The Consumers Health Forum has welcomed the extension of Medicare coverage for telehealth consultations for GPs, allied health and specialists to the end of 2021. It said that to be able to consult with a health care provider by phone or video was an important step in making ongoing healthcare safer for patients during the early days of the pandemic. “This was particularly essential for people with complex and chronic conditions who needed ongoing care.” said the CHF’s CEO Leanne Wells. She added that before telehealth, many people had stopped going to their regular medical appointments and were 4 | JUNE 2021

confidence – if they were presented with a similar situation. Contrary to the widely-held opinion at the time that on-board quarantining was not practicable, WA demonstrated its feasibility under certain circumstances.”

also not following up on referrals. “It makes good use of the technology we already have”, Ms Wells said.

…but GPs are not rushing An analysis of Medicare data for GP services over the past year shows that fewer than 1% were provided by video, despite the introduction of new telehealth items for the COVID-19 response in March 2020. The analysis of MBS data for GP services between April 2020 to March 2021 by Melbourne GP Andrew Baird shows that of the almost 150 million GP services, 72% were conducted in person, 27.4% were by phone and just 0.6% were by video.

Aged care on TV A new Edith Cowan University project will investigate how security cameras could be used to improve patient safety in aged care homes. ECU researchers are surveying residential aged care facility staff and family members to understand their views and attitudes about closed circuit television monitoring and how it is used. The survey follows a previous ECU pilot study at one Perth aged care facility, which found that 57% of family members and 38% of residents would like CCTV used in public spaces. The study also found 48% of family members and 25% of residents would like it used in bedrooms. Lead researcher Dr Caroline Vafeas said she hoped the findings from both studies would help inform the potential future use

of cameras in residential aged care facilities. “At the moment CCTV monitoring is not widely used by the aged care sector for patient safety, but there are growing community calls for their use to provide stronger protections for vulnerable residents,” she said.

Enabling all World-leading researcher and scientist Professor Bronwyn Myers has been appointed the foundation director of Curtin’s enAble Institute, a new research collaborative focused on enabling individuals living with physical and mental health needs or facing the challenges of ageing. The Curtin enAble Institute research will take a whole-of-life (from maternity to palliative care) and whole-of-person (body, mind and place) approach to meet the physical and mental health needs of people of all levels of ability and age to help them stay well and in their communities. Professor Myers was most recently Deputy Director of the Alcohol, Tobacco and Other Drug Research Unit of the South African Medical Research Council and has worked extensively in enhancing services for people with mental or physical health disorders to improve their quality of life.

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Understanding and responding to self-injurious behaviours There is an undeniable stigma associated with self-injurious behaviours. In frequently underresourced and over-loaded medical systems, it is understandable that health professionals might experience frustration when a patient presents with self-inflicted injuries (e.g. from NSSI) or physical sequelae of ‘deliberate’ behaviours (e.g. severely disordered eating, substance misuse). However, understanding the function of these behaviours is critical for health professionals, carers and, indeed, the patients themselves. This understanding can help increase compassion and reduce unwarranted stigma. It challenges the myths that these behaviours are ‘attention seeking’ or being used for some kind of manipulative purpose and highlights the unhelpfulness of common responses to these behaviours that the patient ‘just needs to try harder’.

Maladaptation It can be helpful for health professionals to think of these behaviours fundamentally as maladaptive coping mechanisms that function to regulate emotions. Emotion dysregulation occurs from a complex interaction between neurocognitive, genetic/epigenetic, and environmental factors that combine to result in a skills deficit. Difficulties in regulating emotions can result from learning and modelling of responses to emotional experience from key attachment figures in development (e.g. intolerance of emotional expression by caregivers, and modelling of maladaptive coping), and situational exposure (e.g. adverse life events, such as bullying, bereavement, or abuse). The outcome of these experiences is that the individual does not have opportunities to learn effective skills for self-regulating emotions. Effective skills are even more important when there is an underlying neurophysiological reactivity of emotions. A comprehensive body of research demonstrates that patients with behavioural symptoms of emotion

By Dr Bethanie Gouldthorp MPsych (Clin), PhD Dr Gouldthorp is a clinical psychologist and the clinical coordinator of the Dialectical Behaviour Therapy program at Hollywood Private Hospital. She is the Principal Investigator of current grant-funded research into emotion regulation and eating disorders. In clinical practice she works primarily with trauma, personality disorders and eating disorders.

dysregulation (e.g., with a primary diagnosis of Borderline Personality Disorder) have abnormalities in frontolimbic brain areas, with other research identifying potential links to genetic and epigenetic bases. Specifically, there is baseline hyperactivity of limbic regions, which demonstrates a neuropsychiatric correlate of increased emotional reactivity in these patients compared to non-affected controls. In addition, these patients also tend to have hypoactivity of areas in the prefrontal cortex. These regions would ordinarily downregulate limbic regions to reduce situationally inappropriate emotional reactivity. Consequently, these individuals experience, on a neurological level, an increased intensity and frequency of emotions and will find it comparatively more difficult to self-regulate these emotions. Faced with this skills deficit in being able to self-regulate an overactive emotion system, it is understandable that these individuals will develop strategies to externally regulate their emotions – even if these are harmful or maladaptive. By helping patients and carers to conceptualise self-injurious and other harmful mental healthrelated behaviours in this way, doctors and other health professionals can take an active role in counteracting the shame and stigma associated with their presentation.

Treatment and prevention

directly addresses the skills deficits associated with the presence of self-injurious coping behaviours and suicidality. Evidence also shows that DBT skills training attenuates baseline amygdala hyperactivity (i.e. reduces emotional over-reactivity), indicating that the observed behavioural changes are associated with neurocognitive changes. Specifically, DBT teaches a set of specific skills designed to: • Improve mindful awareness and attentional control • Reduce reliance on maladaptive and self-destructive urges through the development of distress tolerance and crisis survival skills • Modulate the intensity of emotions, as well as reduce vulnerability to emotional dysregulation by building up positive experiences and attending to health issues • Improve interpersonal relationships through effective expression of emotions and negotiation. By compassionately communicating to patients and carers the role of emotion dysregulation in underpinning self-injurious and destructive behaviours, doctors can play a critical part in reducing the stigma and shame that may otherwise prevent patients seeking or accessing appropriate treatment. It is through access to effective, evidence-based treatment such as DBT that we can begin to break the cycle of repeat presentations to emergency departments, and to reduce risk of suicide.

Doctors also have the critical task of assisting patients to obtain effective treatment. Dialectical Behaviour Therapy (DBT) is an evidencebased psychotherapeutic treatment for emotion dysregulation which

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The Type 1 Diabetes Family Centre has welcomed Dr Joey Kaye to the board. Dr Kaye is head of the Department of Diabetes and Endocrinology at Sir Charles Gairdner Hospital.

Plastic surgeon Dr Andrew Crocker has retired from operating at St John of God Murdoch after 27 years but continues to work at SJG Subiaco and Midland hospitals.

Professor Con Michael has stepped down as Chair of the WA Board of the Medical Board of Australia after more than 25 years in medical regulation. He will continue to serve as a member of both boards until October. Professor Mark Edwards has been appointed Chair of the WA Board.

IN THE NEWS

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Whiplash study Curtin University researchers are trialling an innovative approach to treating spine and neck injuries sustained in traffic crashes that integrates aspects of physiotherapy and psychology. The researchers have put out a call for anyone with whiplash or back pain from a road traffic crash to take part in the study. Dr Rob Schütze and Professor Peter O’Sullivan from the Curtin School of Allied Health will compare two different ways of treating neck or back pain associated with a road trauma to find out which might be best and what their associated costs are. Currently, it is unclear which treatment approach is best for neck and back pain and the benefits of treatment are often short-term.

New studies suggest that it may be useful to integrate treatment from various health care disciplines to address all aspects of a person’s pain experience. The current project will test this integrated approach in a pilot study of 60 people. Details at www.integrateclinicaltrial.com

Walking’s a killer More than 1100 Australians died while playing sport over the past two decades, an average of more than one a week, according to research from Edith Cowan University. It is the first national analysis of fatal injuries occurring during sport or active recreation. Lead researcher Dr Lauren Fortington from ECU’s School of Medical and Health Sciences said continued on Page 8

The Commonwealth Bank of Australia has acquired digital health services directory and appointment booking system vendor Whitecoat and will bring the company into its business banking arm.

Curtin University has welcomed world renowned mycologist Professor Wieland Meyer as the new Associate Dean of the Curtin Medical School. Prof Meyer was most recently chair of Molecular Medical Mycology at the University of Sydney and helped establish a globally recognised team to advance the understanding of fungal disease.

Frailty study Research investigating the effects of nurse-led volunteer care and new pain assessment technology could lead to improved health outcomes of frail patients in hospital. The two-year nurse-led Volunteer Support and PainChek Frailty Study will involve more than 700 patients at Hollywood Private Hospital. Dr Rosemary Saunders, a researcher at Edith Cowan University Centre for Research in Aged Care, said acute hospital inpatient populations were becoming older and this presented the potential for poorer outcomes. “Factors such as chronic health conditions and cognitive and functional decline are associated with increased risk of harm, such as falls, delirium and poor nutrition,” Dr Saunders said. “There is evidence that the provision of volunteer care and support with eating and drinking, mobilising and therapeutic activities can improve patient health outcomes. We hope to build on this body of evidence with nurse-led volunteers providing mobility, orientation, sensory and nutritional support as well as cognitive stimulation.” Dr Saunders said pain, which is common among the elderly, can also contribute to frailty if not managed effectively. The study also involves the use of the PainChek Universal app.

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IN BRIEF

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Screening for secondary hypertension Hypertension affects 30% of adults in Australia with most cases being primary (essential or idiopathic). A subgroup of approximately 15% have secondary hypertension for which there is an identifiable cause. Causes of secondary hypertension include renal causes (e.g. renal parenchymal disease) and endocrine causes with hypertension, often initial clinical presentation for other endocrine disorders. Diagnosis of endocrine hypertension provides clinicians with an opportunity to render a surgical cure or an optimal clinical response with targeted pharmacologic therapy. Endocrine hypertension is commonly caused by adrenal gland disorders, including primary hyperaldosteronism, Cushing syndrome and pheochromocytoma. While nonadrenal endocrine disorders are less common, they pose significant health issues, including growth hormone excess, thyroid disorders, obesity, insulin resistance and metabolic syndrome.

Primary aldosteronism

be noted that both false-negative and false-positive results are possible. False-negative results can be caused by dietary salt restriction, hypokalemia and medication including diuretics, ACE inhibitors, calcium channel blockers, and angiotensin receptor antagonists. ß-blockers, α-methyldopa or NSAIDs can cause false-positive results. Patients should be encouraged to follow a liberal sodium diet before ARR testing and efforts to correct hypokalemia should be implemented. Before ARR is measured, diuretics (specifically spironolactone) should be stopped for at least six weeks; other possible interfering medications stopped for four weeks. The ARR should be obtained on several occasions to confirm elevated readings. As the ARR is purely a screening method, further testing is required. Of the methods available, the seated saline suppression test (performed at Clinipath) is commonly used. It aims to suppress plasma aldosterone to < 170 nmol/L following an infusion of isotonic saline over four hours.

This occurs in 5-10% of all hypertensive patients and is a common cause of secondary hypertension. Historically, primary aldosteronism was considered rare and not generally included in a differential diagnosis for patients presenting with resistant hypertension. However, recent research indicates that it is more prevalent than previously thought.

Cushing syndrome

Patients develop this condition when there is increased aldosterone production independent of the renin-angiotensin system. As a result, sodium retention can lead to hypertension, hypokalemia, and high plasma aldosterone/renin ratio (ARR). Clinical findings and symptoms can be vague, increasing the difficulty of identifying primary aldosteronism. Patients may be asymptomatic with the only abnormal lab finding being hypokalemia which affects a third of patients. If hypokalemia is present, symptoms can include nocturia, polyuria, muscle weakness, cramps, paresthesias and palpitations.

If Cushing syndrome is suspected, these screening tests apply: 24-hour urine-free cortisol, 1mg overnight dexamethasone suppression test or late-night salivary cortisol. Society guidelines recommend two of these tests be performed. If a patient has clinical features suggestive of Cushing syndrome but test results are normal, referral to an endocrinologist should be considered. Abnormal screening tests require follow-up.

The most common screening test for primary aldosterone is ARR. It should

Cushing syndrome, caused by chronic glucocorticoid excess, affects around one case per million a year. Signs and symptoms include centripetal obesity, moon facies, facial plethora, easy bruising, posterior cervical fat pad, hirsutism and peripheral striae. Up to 80% have hypertension.

Dr Aaron Simpson Head of Biochemistry

About the Author Aaron gained his MBBS at the University of Sydney and proceeded to complete fellowships in both Chemical Pathology and Endocrinology. He has been widely published in both disciplines with particular interests in endocrine hypertension, adrenal, pituitary, and calcium metabolism disorders. Aaron is Clinipath Pathology’s Head of Biochemistry.

common finding for patients with pheochromocytoma, with 80-90% presenting with this sign. The classic triad of symptoms are headache, sweating, and palpitations. If left untreated, there is risk for hypertensive retinopathy, nephropathy, myocardial infarction, stroke from cerebral infarction, intracranial haemorrhage or embolism. Due to the high rate of morbidity and mortality with untreated phaeochromocytoma, testing should be initiated upon suspicion of this diagnosis or if the patient has relevant family history. Pheochromocytoma is diagnosed by plasma metanephrines or 24-hour urine metanephrines. Some medications can interfere with the accuracy of lab results and therefore may need to be temporarily stopped. It is important to check the specific lab guidelines and review the patient’s medication lists before testing.

Always screen Although the causes of endocrinerelated hypertension are rare, screening patients who present with signs and symptoms is important. The endocrine disorders discussed here can be cured or controlled with appropriate diagnosis and treatment.

Phaeochromocytoma

Further reading

These are catecholamine-producing tumours located in the adrenal medulla and sympathetic ganglia and accounts for only 0.2-0.6% of all causes of hypertension. Hypertension (persistent or paroxysmal) is the most

ISH Global Hypertension Practice Guidelines: Information and resources related to the 2020 ISH Global Hypertension Practice Guidelines. https:// www.ahajournals.org/doi/10.1161/ HYPERTENSIONAHA.120.15026

Main Laboratory: 310 Selby St North, Osborne Park General Enquires: 9371 4200 Patient Results: 9371 4340 For information on our extensive network of Collection Centres, as well as other clinical information please visit our website at

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continued from Page 6 the findings showed the cost to everyday Australians for our national obsession. “We wouldn’t tolerate these injuries in a workplace, so we shouldn’t tolerate them on our playing fields,” she said. “If you look at the sports pages of a national media outlet, chances are there’ll be a story there about an Australian dying or experiencing serious injury while playing sport.” Motorcycling accounted for nearly a quarter of all recorded deaths, with road cycling and horse riding also featuring in the top three most deadly sports. Surprisingly, swimming and walking were also among the sports with the most deaths recorded over the study but this is linked to the popularity of the activities. The data was collected from coroners’ reports and investigations from around Australia from 1 July 2000 until 31 December 2019.

Spelling out ingredients Patient understanding of the active ingredient in their medicines is important. To help culturally and linguistically diverse communities have better access to information about medicines, NPS MedicineWise has created a consumer fact sheet on active ingredients available in English and 10 other languages.

GPs, nurses, pharmacists, other health professionals and carers who work with people who read Arabic, Simplified Chinese, Traditional Chinese, Greek, Hindi, Italian, Punjabi, Spanish, Tagalog and Vietnamese are encouraged to download the fact sheet to help people understand why the information on their prescription now looks different. Research has found that people from CALD backgrounds experience higher rates of adverse outcomes from poor medication management, including medicationrelated hospital admissions. The fact sheet can be found at www.nps.org.au/consumers.

Webinars for GPs St John of God Subiaco Hospital has launched a new GP education on-demand webinar series offering more convenience to members of the GP community. The series includes pre-recorded educational presentations which cover a range of medical topics relevant to GPs and their practice. Each webinar is delivered by leading SJG Subiaco Hospital specialists and can be accessed via the hospital’s GP Hub website. CPD points are available for each on-demand webinar as endorsed by the Royal Australian College of General Practitioners. SJG Subiaco’s Director of Business and Service Development Steve Cohen-Jones said the innovative series was

introduced in response to feedback from GPs, and their need for timely and current health care information. “This new initiative is one of the many ways that we provide GPs access to the latest specialist treatment and patient care information,” he said. For more information, visit www.sjog.org.au/subiacoondemand

Ovarian cancer trial blow Researchers from the UK Collaborative Trial of Ovarian Cancer Screening have reported that despite being able to detect ovarian cancer early, the trial did not translate into saving lives. The results, published in The Lancet, follow a study that spanned three decades and involved 200,000 postmenopausal women, looking into the long-term impact of screening on ovarian cancer mortality. Responding to the results, the CEO of Ovarian Cancer Australia, Jane Hill, said it was disappointing to learn that the screening trial had not delivered the outcome everyone had wished for, especially after so many years of hard work from the research team. “However, our disappointment pales in significance compared to the struggles and isolation that women living with ovarian cancer face on a daily basis,” she said. “But hope is not lost. There are many ups and downs in the world of research, and we continue to advocate for advances in ovarian cancer. We’re still hopeful we’re closer to a breakthrough than ever before.”

Mental health first south of river Bethesda Health Care has started building the first private mental health clinic and service south of the river. The Bethesda Clinic will explore new care models through innovation and digitisation, including multi-disciplinary care and an advanced electronic medical record system. The clinic will feature three wards on separate levels, comprising 45 overnight beds, a mental health and wellness recovery centre to provide therapy on an outpatient basis, and a state-of-the-art neurostimulation procedure suite. The clinic is expected to accept patients by July 2022. According to Cathy Thomas, Mental Health Clinical Nurse Consultant to the project, it will benefit consumers who currently have to travel long distances to get private mental health care. “Currently someone who may live south of Mandurah has to travel north of the river to access private mental health inpatient care, and we believe that this is unacceptable in 2021,” she said. The neurostimulation suite will offer evidence-based treatments for disorders such as depression, using electro-convulsive therapy and repetitive transcranial magnetic stimulation, both known to be effective treatments for a range of disorders. Bethesda CEO Dr Neale Fong, right, said the clinic would help meet the increasing demand for mental health services in Perth.

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IN THE NEWS

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Picture: Kelly Pilgrim-Byrne

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Insects yield up their secrets Cathy O’Leary talks to Perth’s own CSI-inspired forensic sleuth who communicates with the dead through insects.

Chat to Dr Paola Magni and chances are you will soon be talking about decomposing bodies, maggots and plankton. A senior lecturer in forensic science at Murdoch University, she has been dubbed the ‘bug whisperer’, admitting that even as a young child growing up in Italy she shunned dolls for dead insects. “I was certainly a weird child and would carry around a magnifying lens, and I didn’t want to eat animals because they were once alive, so my mum would trick me into eating meat,” Paola says. “She couldn’t say it was meat or fish, she had to give it another name.”

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Paola didn’t always have her sights set on forensics, initially taking a degree in natural sciences focusing on biology and geology, before randomly choosing a unit in entomology, or the study of insects.

jumping or being thrown into the river, and since my expertise was unique, I started getting involved in cases of people found in the sea, underwater, beached or floating,” Paola explains.

“I was in love with nature, but I wanted to apply that knowledge for a bigger cause, something that was useful for society.”

“Movies focus on dental records, fingerprints, footprints, DNA and toxicology but nobody thinks about crustaceans and plankton as the key of an investigation.”

She soon discovered that studying how insects and animals interacted with dead bodies could provide crucial forensic evidence, helping pathologists and police solve how and when crimes were committed, both on land and in water. In Italy – and later in Australia – she helped with murder investigations and cases of animal cruelty and biosecurity.

By land and water “Working as a ‘pure’ forensic entomologist is my bread and butter, but I was working in Italy in a city which had a huge river and several cases of people

Paola even became scientific adviser to the Italian equivalent of the television crime drama CSI, known as RIS Delitti Imperfetti (Unit of Scientific Investigations: Imperfect Crimes), which sometimes fictionalised events from her own cases. In 2010, she came to Perth to do part of her PhD in biology/forensic science, and returned in 2013 to take up a post-doctorate position at the University of WA, followed by an academic position at Murdoch University.

a three-year-old daughter and are expecting their second child) so here I am,” she says. And far from finding insects creepy, she remains fascinated by them and is adamant her line of work beats any desk job. “I don’t like paperwork and numbers but give me a jar of maggots and it’s not an issue,” she says. Paola is still called upon as an expert forensic witness in court, or provides media commentary on local homicide cases, such as the “body in the wheelie bin” earlier this year when a man’s body was found wrapped in plastic inside a wheelie bin in a Perth dam. The discovery of the decomposed foot of a missing Sydney woman, found in a sneaker washed up on a beach in February, also piqued her interest. continued on Page 12

“I’ve been here since, I found work and love (she and her husband have

Picture: Chantel Concei

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Insects yield up their secrets continued from Page 11

Fleet-footed In fact, Paola admits to a shoe fetish – not glamorous stiletto heels but more the soiled and muddy variety and has designed experiments with dozens of types of footwear to see how they attract marine life. Typically, barnacle growth on shoes and clothing can provide detectives with vital clues about how long a body has been in water or can help them reconstruct the crime scene. Paola is now considered one of the world’s leading experts on waterbased forensic entomology.

“My expertise is the decomposition of human bodies in the environment, and that can be terrestrial or aquatic. In real cases it is rare to find completely naked bodies, so my research is focused not just on the body, but also on the garments and shoes they’re wearing – the process of biological and zoological colonisation and the rate of decomposition. “I also have an interest in decomposition in confined environment such as suitcases because, believe it or not, every year several bodies are found concealed in bags and luggage and these can be an investigative dilemma.” She explains that if someone kills a person and puts them in a suitcase or a bin, and then puts that in the water, the combined effect of the confined environment and the aquatic environment can make the investigation extremely complicated for police. “But I find it interesting and challenging. DNA traces in salt water only last a limited time, bloodstains are washed away and footprints don’t even show. Fish eat the body, the body moves too, because in an aquatic environment you have tides, currents and waves so the body never stays in the same place.” When it comes to the role of insects in criminal investigations, 12 | JUNE 2021

Picture: Shivani Radia

“Some of my research oddly enough is about shoes, bad people and the ocean,” she says.

many people think of flies and dead bodies, but Paola says it can also be cockroaches, crustaceans and spiders – they all became clues from nature.

Flies and flies “People think of a fly as a single thing, but for me it can be 12 species, and they are specific to their environment, or they’re seasonal, so the fly you find in the city is not the same one you will find in the bush. So, if you find a particular fly, it can show that the body has been moved since death.”

look at it, look at the environment, and take samples from both,” she says. “Once the body is removed, I continue at the scene to see what was left by the body and I continue at the autopsy, because sometimes you find something inside, like maggots in the oesophagus or plankton in the liver or bone marrow, and I use different types of technology to find things that you wouldn’t see normally.

Paola argues the environment is everywhere and can be changed by events in criminal activity, whether that occurs in a clean apartment or in the middle of nowhere in the bush.

“Then the work continues in the lab and then in court, so the process can be long and complex, especially when you can work from pictures only, or you receive damaged samples, or you might have limited resources to work with.”

“In the ideal situation, they would call me when a body is still at the scene and I have the opportunity to

Paola says in cases of homicides involving a sexual attack, it may be possible to find evidence, such as

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CLOSE-UP the semen of the perpetrator, in the stomachs of maggots for a longer period of time compared to the window to obtain human DNA from the victim. Apart from homicides, forensics entomology can help in cases such as elder neglect, using insects to work out the time bed sores have been present. But some of her research is a hard slog and very unglamorous, including when she had to work on 116 decomposing piglets. “The decomposition doesn’t stop because it’s Sunday. I also remember a time during my PhD when I had to check on fly eggs every three hours, so I had a pillow and blanket in the lab and I slept there.”

A scientist’s eyes Paola says some circumstances can be confronting, and she always thought she would become upset dealing with a case like the body of a pregnant woman or child. “And what I found in those moments is that you close the eyes of the human being and you open the eyes of the scientist,” she says.

MEDICAL FORUM | MENTAL HEALTH

“You see it as a machine that isn’t working anymore and nature has taken over, and you try to forget about the sadness of the situation. You have to be objective, and I found myself very natural in that. I am lucky because some people find it more confronting. “What’s in front of me is a job and a challenge that only I might be able to help with, to get justice for the victim, the family and society.” Paola is aware that her work is different from that of a doctor or paramedic working to save a life. The person in front of her is not alive, so there is no immediate urgency. “I arrive when things are finished, so I feel luckier than the paramedic, or the doctor in the emergency room or the surgeon trying to save a life. “My brother-in-law is a paramedic and sees situations that are way worse than I see. If someone has to be brave and courageous, it’s someone like him because they see things in the moment they’re happening.

But she is satisfied that her job can provide vital information that can be used in the justice system, and ultimately contribute to society. At Murdoch, Paola actively encourages students, especially young women, to study science. “People think scientists are not creative, but that’s not true. When you’re doing an experiment, you need to think outside the box, and because women are good at multi-skilling, they’re so made for science,” she says. “The main thing is to do what interests you, and don’t be scared of sciences. You might think it’s about old men in lab coats but it doesn’t have to be like that. You can still wear a nice dress under the lab coat.” ED: Paola is a finalist in the 2021 Western Australian of the Year professions award. The winner will be announced on June 4.

“I arrive too late. My job is for the past, his job is for the future.”

JUNE 2021 | 13

Vaccination and failing leadership Dr Bruce Powell argues that we need to accept the small risks from COVID-19 vaccines and move on.

“Minister, are vaccines safe?” It seems such a simple question and yet apparently it is impossible to answer. What is the public to make of government ministers and health officials squirming under the understandably concerned scrutiny of the anxious Australian community? Is AstraZeneca’s vaccine safe? What if you are over 50 – or not? Yes, no, maybe? Well, it’s definitely safer than getting COVID-19, or

riding a bike, or being stung by a bee. But no, it’s not 100% safe. Of course, it depends on who you ask. The President of the Royal Australian College of General Practitioners recently hedged her bets: “We would schedule an appointment with the patient and discuss the options … make sure that the patient understands the risks.” Perhaps Qantas should adopt a similar stance when taxiing to takeoff?

“Good morning everybody, this is your captain. Before we take-off, I am obliged to remind you that, sometimes, plane wings snap off, engines catch fire and planes crash. We will be pausing for a moment before take-off in case anyone has changed their mind and wishes to get off.” The point is, the pilot is highly trained, the system that governs flying is massively regulated and the whole industry is scrutinised as much as is humanly possible.

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OPINION

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OPINION Canberra could even plan to blame and discredit the expert, if things go awry despite all the best evidence.

Does that preclude tragic accidents, terrible moments of loss? No. Yet we sit in our ‘extra legroom seat’ because we trust the airline and its captain. We also trust the executive board that manages the planes, and we respect their advice. The thing is, we want to fly to exotic places or embrace our loved ones. The plane satisfies that desire. The airline does not try to deny its responsibility for our safety. It does not have us sign waivers and consent forms. We all know that planes crash, and we accept that risk on a personal level. Then we sit back and wait for our gin and tonic and nibbles. Australia’s COVID-19 efforts are crying out for leadership. We are desperate to be told what to do. We need someone to tell us what time to turn up and which sleeve to roll up. We need a leader to stare into the camera and say, “All the vaccines are safe”. The tragic long-term consequences of the current debacle will further erode the public’s confidence in health and its leaders. Governments must stop playing out their indecision and uncertainty behind a podium in a press conference.

Medical staff, like many other professions, are compelled to make decisions, even when the outcome is unclear. That is our burden, our challenge. It is not a minister’s job to administer the vaccine or test its safety. The minister’s job is to lead, pure and simple, not covet votes nor approval ratings, just lead. Rather, they should retreat to a quiet back room, accept that uncertainty is the only certainty, and decide on a vaccination policy for the future. The PM must accept that mistakes may happen. and tragedies may occur, but that is the nature of health. By all means, let us appoint a charismatic medical expert on whom to rely, a personality to blame and to praise. Not a government appointee, but an independent, respected expert who is happy to acknowledge the public’s fears and hesitancy.

Australians know that sharks swim in the ocean and that redbacks hide in their wispy webs under our cane chairs. We accept that risk as part of the privilege of living in this land. So just tell us where and when to be for our vaccine, and we will trust you to do the rest. Then we can get back to the film, the snacks and the gin and tonic. ED: Dr Powell is a retired anaesthetist and former State Medical Director of DonateLife

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JUNE 2021 | 15

COVER STORY

VAD – a delicate balance

While the pandemic has been the all-consuming distraction of the past 12 months, preparations for a landmark change in how West Australians can choose to live their final days have been ticking along. Much of the passion and even anger that ran hot during last year’s emotive debates surrounding WA’s voluntary assisted dying legislation have settled down. Now there is cautious optimism that common ground can be found among sections of the community that once seemed poles apart on the issue of allowing terminally ill people to end their life using a lethal drug. Despite initially being seen as incompatible, two big end of life choices – voluntary euthanasia and palliative care – are now actively working to co-exist, with experts arguing VAD is not intended to be an alternative to palliative care. Rallies outside Parliament House have been replaced with the hard yards of community and health sector consultations and meetings to ensure the laws will be ready to go full steam ahead from July 1, when a backlog of patients is expected. The VAD landscape in Australia has changed markedly since WA’s Bill was passed in late 2019.

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WA’s voluntary euthanasia laws come into effect next month and, as Cathy O’Leary explains, palliative care is not the enemy.

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COVER STORY While Victoria is the only state in which voluntary assisted dying is currently available, WA will join it next month and Tasmania has passed laws which should be operational by the middle of next year. South Australia is also a step closer to having a voluntary assisted dying regime after its Upper House recently passed legislation, while Queensland is expected to debate the laws later this year.

WA laws in a nutshell Under WA’s laws, an eligible person must be terminally ill with a condition that causes intolerable suffering and is likely to cause death within six months, or 12 months for a neurodegenerative condition. Eligible doctors and nurse practitioners wanting to participate in VAD need to complete approved training. The person needs to make two verbal requests and one written request, which must be signed off by two doctors who are independent of each other. Self-administration is the preferred method, but in a departure from the Victorian system where a doctor can only administer the drug if a patient is physically incapable, a patient in WA can elect for a medical practitioner to administer. Not everyone is happy with the laws. While critics argue that even with many safeguards, the legislation is still dangerous and open to misuse, some VAD supporters believe the laws do not go far enough to allow people who are not terminally ill to access voluntary euthanasia. However, Dr Richard Lugg, WA convenor of Doctors for Assisted Dying Choice and a committee member of Dying with Dignity WA, believes VAD is a welcome option for West Australians. MEDICAL FORUM | MENTAL HEALTH

He told Medical Forum that palliative care and VAD were both valid end of life options and, while distinct areas of medical practice, they were not in competition with each other. “We’re talking small numbers of people who will take up the VAD option, and palliative care will always do the heavy lifting and requires appropriate funding to do so,” he said. “The movement forward is encouraging but it will take some time, and there will be some sticking points, and some people will never make that transition for their own religious or other reasons, and that’s fine, we understand that, but it won’t stop us from moving forward.”

Halo effect Dr Lugg said that while VAD would remain a minority choice, its mere existence would provide peace of mind and some therapeutic benefit to many end of life patients. “It has a sort of halo effect much wider than for the people who actually use it because it reassures people knowing it’s there, even if they never choose it,” he said. “There should be a seamless ability for patients to do whatever they feel is in their best interest, and there is early evidence that this is already starting to happen in Victoria.”

educate doctors and other health professionals about their roles and responsibilities. Palliative Care WA recently held an online forum at which Dr Blackwell stressed that the availability of voluntary euthanasia was not going to affect the majority of people. “It’s a new option but we don’t see it as a game-changer because, although it has a popularity of over 80% in WA, we know that only 1-2% of West Australians will choose it,” he said. “It’s simply a new choice for the people of WA, requested by them and granted to them by their parliament. We’re not implementing a new service, but we are providing a process by which eligible people can access VAD, if that is their choice at the end of their life.” Dr Blackwell said it was important that within the VAD process a person was informed of the many different aspects relating to treatment – acute treatment, palliative care as well as VAD. “It is important that a person has capacity both at the beginning of the process and right up to the time they take the substance,” he said. “Voluntary assisted dying is not to be seen as a simple, separate procedure, it’s part of comprehensive end of life care.

But Dr Lugg said he was concerned that there were not enough doctors on board in WA to help patients wanting to access VAD, which might cause an initial “traffic jam”.

“What we’re really talking about is a West Australian person, who will die soon and is suffering, and a person who of their will chooses VAD at the end of their life.”

“We’re working hard to reach out to doctors who may be considering it, to offer them moral support because. even if we have the best system in the world, we need the doctors to make it work,” he said.

Dr Blackwell told the forum there were also possible implications for the family of the person who requested VAD, in terms of needing bereavement support.

“There’s a backlog of people waiting for VAD when it starts on July 1, but there’s not a backlog of doctors who are going to be there for them – their numbers will increase more gradually.” The WA Health Department’s VAD Implementation Leadership Team, chaired by long-time GP and palliative care doctor Scott Blackwell, has been working to

“We also need to consider other people such as workforce considerations, because health practitioners are not required to support or assist in VAD, there’s choice for them too,” he said. continued on Page 18

JUNE 2021 | 17

VAD – a delicate balance continued from Page 17 “The extent to which they’re involved is a choice, either providing information or agreeing to being an active participant in the VAD process. They need to consider how they will react if someone asks them about VAD.” Paediatric nurse practitioner Stephanie Dowden, who is a member of the VAD implementation team, told the forum that there were professional

obligations for doctors and other health professionals who were approached about VAD. “I think the community feels a bit more ready for VAD than the health professionals,” she said. “This is a different system and role for practitioners so it’s very important they look to their selfcare. If you’re going to be assisting in VAD we’d really encourage you to join the WA VAD Community of Practice.”

WA’s voluntary assisted dying laws explained Who is eligible to end their life? Voluntary euthanasia is only available to a person who is: • 18 years of age or older • terminally ill with a condition that is causing intolerable suffering • likely to die within six months, or 12 months for neurodegenerative conditions • an Australian citizen or permanent resident • A WA resident for at least 12 months How will it work? To access the regime, an eligible person will have to make three requests to die — two verbal and one written. Those requests will have to be signed off by two doctors who are independent of each other. There will be a minimum of nine days between the initial request and final approval. Under an amendment introduced by the government during the Bill's debate, only doctors and nurse practitioners can initiate a discussion about voluntary euthanasia with a patient. But clearly the patient can raise the issue themselves with a health care worker. And when the time comes, who carries it out? A patient can administer the lethal drug themselves or choose for a medical or nurse practitioner to do it for them. A Voluntary Assisted Dying Board will ensure the law is being properly followed through each step of the process. From July 1, the WA VAD Statewide Pharmacy Service and the Statewide VAD Care Navigator Service will also start. The navigator service will support anyone involved with voluntary assisted dying in WA including health professionals and service providers. If this raises health concerns for you contact the Doctors Health Advisory Service WA on 9321 3098.

18 | JUNE 2021

Ms Dowden also stressed that the person accessing VAD had to be able to make that decision right up until the time of their death. “You must have capacity right up until the moment of being administered the substance, and I know this is an area that many people in the community are really struggling with,” she said. “It’s the question I get asked the most – is it OK if I get dementia, but the answer currently is no, not under our laws or anywhere in Australia.” Lana Glogowski, chief executive officer of Palliative Care WA, told Medical Forum that in some jurisdictions such as Canada the palliative care sector had spent a lot of time and effort fighting VAD. “But we have remained very neutral in the VAD debate, as it was not our place to take a position, and we recognise that the WA Government and the people have made a decision to go with VAD,” she said. “We’ve taken the view that palliative care is integral to the delivery of VAD in that, going by the international evidence, most people who receive VAD receive palliative care up until that point, so they’re inextricably linked. “What we want is for people to understand the difference between VAD and palliative care, and I think there are lot of people who don’t understand it and what this legislation means.” Ms Glogowski said palliative care did not set out to shorten or lengthen life, so by definition VAD does not sit within it. But there was a close connection because people who access VAD often had received palliative care. “There are still a lot of myths out

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COVER STORY

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COVER STORY there about palliative care and many people have it in their head that if you start talking to them about palliative care it means their loved one is going to die imminently, like tomorrow. “But people can be in and out of palliative care for a reasonable period of time, so it doesn’t mean they’re dying imminently. Palliative care is about ensuring a better quality of life for what life is left.” She said the VAD implementation and the debate around it had put a greater spotlight on palliative care, and that was a positive. The WA Government had invested more money in the sector, and from an education point of view, people were starting to get a clearer sense of what palliative care actually meant.

they had tried to model that at a leadership level by remaining as neutral as possible when talking to others. She said a staff survey had identified that the allied health and nursing teams were generally much more supportive than the medical teams. “I don’t think it’s changed end of life or palliative care per se, but as a palliative care physician, if someone is accessing VAD because of their physical symptoms, I feel like I have to try super hard to make sure I’ve addressed those symptoms, so that I’m not the person responsible for them taking their VAD earlier than otherwise. “You feel like you have to go that bit more now.”

Victorian-based doctors speaking at the Palliative Care WA forum said that since VAD laws were introduced into that state, efforts had been made to establish a culture of choice.

Professor Andrew Weickhardt, a medical oncologist at the Olivia Newton John Cancer Centre at Austin Hospital, said the number of requests for VAD were small and mostly from oncology patients, while a smaller number had chronic neurological disorders.

Dr Danielle Ko, a palliative care consultant and the Clinical Ethics Lead for Austin Health, said

Most were people who were welleducated and from higher socioeconomic backgrounds.

“From a personal perspective it’s been challenging at times, and each person presents unique and different challenges, whether it be specific requests or dealing with family,” he told the forum. “It’s very important to provide good support for physicians who embark on this because it can be stressful at times.” Some medical and allied health staff are also worried that if a patient asked about VAD it would be an issue “beyond their pay grade”. Dr Marie-Christine Carrier, a palliative medicine physician in Canada, told the forum that if people asked to access VAD it was not a failure of palliative care. “It’s just about their suffering and it’s an option for them,” she said.

Read this story on mforum.com.au

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JUNE 2021 | 19

Youth mental health at breaking point Children and adolescents are facing unprecedented mental health challenges. Dr Karl Gruber (PhD) asks if our health system up to the task of caring for them.

Mental health care for children and adolescents is costing Australia about $234 million annually. But this daunting figure from a recent study, published in the journal PLoS ONE, is the tip of the iceberg and points to a bigger problem – the deteriorating mental health of our children.

Some key stats A recent report, released on December 2017 by the University of Western Australia, analysed data from the Young Minds Matter (YMM), a survey led by the Telethon Kids Institute, which included 6,310 families across Australia, focusing on minors between the age of four and 17 years. All participants were surveyed for several mental disorders including major depressive, anxiety, behavioural (Attention-Deficit/Hyperactivity Disorder) and conduct disorders as well as oppositional problem behaviours. Among the key findings was that one in seven children were affected by some type of mental health disorder. Among smaller children, those in Year 1 to Year 6, 18.2% of boys and 12.4% of girls suffered from some type of mental disorder. For older children, these figures were 15.4% for boys and 12.3% for girls.

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FEATURE

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FEATURE

The most common mental health condition detected was ADHD (in boys), characterised by abnormally high levels of hyperactive and impulsive behaviours. In girls, anxiety disorders were the most common mental health problem, affecting 7.1% of younger girls and 7.5% of older girls. Depression was generally rare among younger children (1.3% in boys and 1.5% in girls), but was more common among adolescents, with a slightly higher prevalence among girls (5.6% in girls, compared to 4.1% in boys). Another worrisome statistic was the self-harming behaviours identified: more than 11% all students interviewed reported self-harming at some point in their lives, and over 8% said it had occurred in the past 12 months. The behaviour was also twice more common among girls (15.6%) than boys (6.7%). But these figures could be higher. “Young people had the option of not answering the questions on self-harm and about 5% chose not to answer. As such, the proportion of young people who have ever self-harmed may be higher than indicated in these estimates,” according to the 2017 report. Finally, the study also found that one in 13 students interviewed had seriously considered suicide, and a third of these children admitted having attempted to take their own lives. Girls between 16 and 17 years MEDICAL FORUM | MENTAL HEALTH

of age were most affected. More than 14% of girls in this age group had suicidal thoughts, compared to 6% in boys of the same age. In Western Australia, suicide is currently the leading cause of death for young people aged 15 to 24 years, so tackling this issue is an urgent matter. At the heart of these troubling statistics is a health care system unable to cope with the growing numbers of childhood mental health cases.

A crumbling system? According to Dr Lin, there is an urgent need to improve the capacity of our mental health care systems. “The child and youth mental health systems are completely overstretched. There is just not enough funding to meet the current demand. This is the case across the entire mental health system, across all ages,” Dr Lin told Medical Forum. “In WA, the demand for community child and adolescent mental health services has risen 50% between 2015 and 2019, which is similar to the national increase in demand for mental health services.” According to Dr Lin, in Perth alone there has been a staggering 214% increase in the number of children aged between 13 and 17 attending emergency departments due to self-harm, suicide risk or suicide attempts.

A study, published in the Australian and New Zealand Journal of Psychiatry on January 18, 2021, identified some key factors affecting our health care systems. The study interviewed 143 adolescent psychiatrists, paediatricians, psychologists and general practitioners from Victoria and South Australia asking for their views on what was affecting our health care systems when caring for the mental health of young people. The key findings pointed to multi-dimensional family issues, service fragmentation, long wait times and inadequate training for paediatricians and GPs. In addition to the increased mental health demand, the challenges posed by the COVID-19 pandemic, now into its second year, has worsened the situation. “The impact of COVID has been significant, although it is difficult to quantify the scope of the impact because we don’t have the specific data in WA. Anecdotally, services for children and youth saw an increase in referrals last year,” Dr Lin said.

Missed chance The shortage of mental health services for children is a missed opportunity, as childhood is considered the best time to address mental issues and to prevent chronic problems later in life, according to Dr Lin. continued on Page 23

JUNE 2021 | 21

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FEATURE

Youth mental health at breaking point continued from Page 21 “The underfunding of services in this area means that we are missing vital opportunities for this early intervention. In the long run, this will lead to huge economic and social costs to the state and Australia,” she said. The Telethon Kids Institute is currently running multiple projects to address children’s mental health challenges with three overarching goals, common and relevant to all their projects: • Identify the origins and causes of mental health difficulties in children and young people. • Develop and test new interventions. • Facilitate effective and efficient translation of findings into clinical practice and policy. With these goals in mind, TKI has established the EMBRACE program, a research collaboration focused on improving the mental health of children and young adults between the ages of 0 to 25. “Our work is very broad, ranging from multi-site randomised controlled trials for young people at risk of psychosis to developing interventions for children who have experienced a burn, understanding the impact of chronic ear infections and mental health outcomes for children, to interview studies of suicidality in LGBTQA+ youth,” Dr Lin told Medical Forum. “We have a particular interest in youth suicide prevention, the mental health of marginalised groups of young people, including those experiencing homelessness, Aboriginal and LGBTQA+ youth, and children and young people with chronic conditions. These groups often have unique needs but struggle to get safe and appropriate care.” One of their projects, Walkern Katatdjin, aims to understand the needs of young people (14-25 years old) who are Aboriginal and/or Torres Strait Islander and identify themselves as lesbian, gay, bisexual, transgender, queer, asexual or other (LGBTQA+). Member of this community may not receive MEDICAL FORUM | MENTAL HEALTH

the same level of mental health care services, compared to other groups, and may be at increased risk of a wide range of problems, such as poor social and emotional wellbeing and mental health problems. “We aim to understand their mental health needs and then work with local health services to develop interventions that can support them,” Dr Lin said. The project has now developed an online survey based on interviews conducted with members of the Aboriginal LGBTQA+ community in Perth. The survey will soon be launched across Australia and will help researchers better understand the needs and experiences of this community.

Suicide support Another project, SafeTALK, targets young people who experience homelessness and who might be at an increased risk of suicide. It provides support, training and identifies future targets for suicide prevention. “This program will equip young people experiencing homelessness with the skills to respond to peers who have suicidal thoughts and help connect them to life-saving interventions and resources,” Dr Lin said.

psychological outcomes of a burn injury for children. “Working with the parents and the children who have experienced a burn and their clinicians, we will co-design a brief trauma-focused intervention to help children and their families build resilience and good mental health following a burn injury,” Dr Lin explained. The outcomes of these and other projects led by the EMBRACE program hold great promise to improve the mental health of our youth. Previous EMBRACE projects have already produced some important tools such as a digital game called SPARX-T, inspired in a previous application called SPARX, created by researchers from the University of Auckland, aimed at helping children with depression. “SPARX is a digital ‘serious game’ which uses cognitive behavioural principles in a fun and interactive way and has been shown to prevent depression in young people in the general population,” Dr Lin said. “Working together with trans youth and app developers, we adapted SPARX to develop SPARX-T, an intervention specifically for trans adolescents that meets their unique needs and includes scenarios are that are specific to their experiences,” she added.

The TKI-designed IMPACT study aims to understand the JUNE 2021 | 23

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Insurance policies available through MIGA are underwritten by Medical Insurance Australia Pty Ltd (AFSL 255906). Membership services are provided by Medical Defence Association of South Australia Ltd. Before you make any decisions about our policies, please read our Product Disclosure Statement and Policy Wording and consider if it is appropriate for you. Call MIGA for a copy or visit our website. 1 75,000 bonus Qantas Point offer only available to registered Australian medical practitioners who first insure with MIGA in a fully insured category, as a doctor in private practice, for cover commencing on or after 30 June 2021 and on or before 31 July 2021, and who pay in full by 31 July 2021 or enter into a direct debit arrangement with MIGA by 31 July 2021, and have paid their first instalment and have not exercised their rights to cool off or had their insurance cancelled by MIGA, as per the terms of the Policy. MIGA Terms and Conditions for bonus Qantas Points for Fully Insured are available at www.miga.com.au/qantas-bonus-tc-pp. 2 A business must be a Qantas Business Rewards Member and an individual must be a Qantas Frequent Flyer Member to earn Qantas Points with MIGA. Qantas Points are offered under the MIGA Terms and Conditions at www.miga.com.au/qantas-tc. Qantas Business Rewards Members and Qantas Frequent Flyer Members will earn 1 Qantas Point for every eligible $1 spent (GST exclusive) on payments to MIGA for Eligible Products. Eligible Products are Insurance For Doctors: Medical Indemnity Insurance Policy, Eligible Midwives in Private Practice: Professional Indemnity Insurance Policy, Healthcare Companies: Professional Indemnity Insurance Policy. Eligible spend with MIGA is calculated on the total of the base premium and membership fee (where applicable) and after any government rebate, subsidies and risk management discount, excluding charges such as GST, Stamp Duty and ROCS. Qantas Points will be credited to the relevant Qantas account after receipt of payment for an Eligible Product and in any event within 30 days of payment by You. Any claims in relation to Qantas Points under this offer must be made directly to MIGA by calling National Free Call 1800 777 156 or emailing clientservices@miga.com.au. ©MIGA March 2021

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NEWS & VIEWS

Putting seasonal flu on the radar Winter is coming and while figures so far suggest a quiet flu season, Cathy O’Leary explains it’s too soon to be complacent.

It is one of the few upsides of the COVID-19 pandemic apart from a resurgence in jigsaws and homemade sourdough bread – an all-time low number of flu cases. Thanks to infection-suppressing hygiene and physical distancing measures, the flu has been largely missing in action for 18 months, but experts warn it is no time for complacency amid concerns that people who have not got around to having their seasonal flu jab might miss out on it altogether in the flurry to have their two shots of the COVID-19 vaccine. Recent figures from the crowdsourced FluTracking public health surveillance system show how the pandemic dramatically affected the 2020 flu season, with the number of laboratory-confirmed cases of flu in January 2021 just one per cent of those seen in January 2020. Developed by Hunter New England Health and the University of Newcastle, FluTracking started in 2006 with 400 participants but by 2020, the number of Australians and New Zealanders providing weekly data peaked at more than 150,000. So far this year, there have only been 235 lab-confirmed flu cases in Australia, compared to more than 20,000 cases at the same time last year, and 44,000 at the same time in 2019. In the week ending May 2 this year, almost 60,000 people had taken part in the FluTracking online survey – including 5895 West Australians – with only two participants reporting having laboratoryconfirmed flu.

Keeping track FluTracking founder Dr Craig Dalton, a Hunter New England public health physician and Conjoint Associate MEDICAL FORUM | MENTAL HEALTH

Professor at the University of Newcastle and the Hunter Medical Research Institute. said the typical flu season in Australia resulted in about 60,000 infections nationally in peak months.

“With FluTracking we can measure the community impact of these diseases, capturing information about people who showed symptoms but did not consult a doctor or present for a COVID test.”

In 2020, that dropped to less than 200 cases a month in July and August.

With the low number of flu cases so far this year, public experts remain cautiously optimistic but a drop off in flu vaccines is still possible.

“Ask any flu expert and we would say it’s not easy to stop flu transmission. What 2020 taught us is that physical distancing, hand washing and mask wearing can dramatically reduce the incidence of flu in the community,” Dr Dalton said. “The days of turning up to work with a cold or flu are probably gone forever, and masks may become part of our winter wardrobe. It will be interesting to see whether these behavioural changes will continue to keep flu in check this season.” Taking only 15 seconds to complete, the weekly webbased survey collects data about flu-like symptoms, harnessing the power of the Internet and community spirit to detect the potential spread of influenza. Participants who record a symptom are asked further questions about time absent from normal duties, visits to health care providers, results of laboratory tests for influenza or COVID-19, and current vaccine status. Dr Dalton said FluTracking had evolved over time to help health professionals monitor seasonal influenza, pandemic influenza and now COVID-19. “FluTracking can fill in the gaps in information not captured by hospitals and health services because many people with flu-like symptoms don’t enter the health system and therefore aren’t counted,” he said.

Spacing the jabs According to the Australian Technical Advisory Group on Immunisation (ATAGI), people should ideally receive their annual flu vaccination before the start of the season – typically June to September in most parts of Australia. And the current advice is to have the COVID-19 and flu vaccines at least two weeks apart. Professor Paul Effler, senior medical advisor at the WA Health Department’s Communicable Disease Control Directorate, told a recent podcast that there was no reason to think the vaccines would interfere with one another because they were inactivated viruses. “The major issue is if there is an adverse event, we will know which vaccine caused it,” he said. ATAGI says that if flu cases began to soar, giving the COVID-19 and flu vaccines together or within less than the currently recommended 14-day period could be considered in certain circumstances but more research was needed. ED: Anyone can take part in FluTracking through www.flutracking.net. It takes 30 seconds to join and 15-20 seconds a week to do the survey. Participants receive a link to a weekly report and an updated map of the latest respiratory symptom activity in their area.

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Q&A with... Stephen Dawson, who took on the Mental Health portfolio in the last State Cabinet reshuffle.

MF: You previously held the Disability Services portfolio, which had some overlap into health services. Does the Mental Health portfolio feel a good fit for you? SD: Yes, absolutely. I have a passion for mental health and kept in touch with the portfolio since being the shadow minister from 2013 to 2017. There are many similarities between the two with a strong community sector intersecting the two. Ultimately both sectors are about empowering people and supporting them to live productive, fulfilling and healthy lives. The importance of listening to those with lived experience, and delivering services that are right for the individual, are important in both portfolios. In terms of the National Disability Insurance Scheme, only 9% (3,310) of total NDIS participants in WA have a primary psychosocial disability; this is lower than the expected 14%. I am keen to see this figure trend upwards. Without support, many people with psychosocial disability will not engage with the NDIS or may not be aware of the existence of the scheme. It is important the state continues to monitor the progress of the NDIS roll-out for people with psychosocial disability in Western Australia and to implement strategies to ensure they have equitable access to the NDIS and the supports they require. MF: What are some of the key challenges in the provision of mental health services in WA? SD: One of the biggest challenges is finding the space and capacity to invest in community-based support and treatment, and prevention activities, while also ensuring we have enough acute services in the face of increasing demand. Other challenges include managing the impact of the COVID-19 pandemic on mental health, alcohol and other drug problems, particularly ensuring that our young people are provided the support they need to avoid major problems down the track. 26 | JUNE 2021

Staffing continues to be a challenge in the mental health sector in both clinical and community-based treatment settings. An early focus is on working with my ministerial colleagues to boost the trained workforce so we can deliver the services where they are most needed across the State. MF: Mental health advocacy groups and the AMA remain critical of the lack of capacity in the health system to manage the number of people with mental health issues. Do you accept more needs to be done? SD: We know that there is significant work to be done to manage the rise in demand we’ve seen in the mental health system. To address this, we have increased funding for mental health and alcohol and other drug services to a record $1.013 billion this year, an increase of 7.5% compared to the previous year. However, it is clear that more needs to be done and the Mental Health Commission is currently working on plans to expand services in key areas including expansions of youth community treatment services, eating disorder services and adult community bed-based services. Last year we released the WA Priorities for Mental Health and Alcohol and other Drugs 2020-2025, which outline the immediate priority areas for action. MF: Hospital emergency departments, in particular, are struggling to cope with the influx of mental health patients, even though doctors agree these busy and noisy environments are bad for these patients. How do we better help them? SD: Providing alternatives to emergency departments for people with mental health, alcohol and other drug issues is identified as one of the immediate priorities and we are doing a lot of work in this space. Earlier this year we opened the first Safe Haven(s) in WA, located near, but separate from, Royal Perth Hospital and Kununurra emergency departments, working alongside EDs afterhours and offering peer-based support for those who may MEDICAL FORUM | MENTAL HEALTH

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Q&A

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Q&A otherwise attend EDs, but do not need intensive clinical and medical support. There are currently mental health emergency centres (also called mental health observation areas) at RPH, SCGH and Joondalup hospitals, with funds committed for Rockingham and Bunbury hospitals to establish similar facilities. These areas provide a low-stimulus, short-stay environment for people experiencing mental health issues. MF: Where are some of the most pressing gaps that need addressing – are they more at the acute level or at the step-down/low-acuity level? SD: The Productivity Commission recently referred to the ‘missing middle’ – the area of service provision between higher end acute care (such as hospitals) and lower end primary care (provided by GPs, psychologists etc). One of the more pressing gaps is the need for community bed-based services to provide people with an alternative to hospital care. These services support people with both high needs (community care units) as well as moderate or shorter-term needs (such as step up/step down services) in the community and support their recovery. Another key area is providing sufficient and well-coordinated community mental health (outpatient) services. This is where our focus is now turning with active recovery teams being established this year, plans for expanded youth community treatment services and a roadmap to outline the models of care and pathways we will need in the future. MF: Overall, we are seeing a lot more people presenting with mental health issues. Why do you think this is occurring – is it a real increase or mostly reflective of more people seeking help? SD: There is definitely a greater awareness of mental health issues and reduced stigma has also gone a long way to encourage people to seek help. A recent report found that 10% of people using state-managed mental health services accessed 90% of the hospital care provided. The Auditor General investigated this in more detail in her report. This suggests that we need additional services to better support people with high-needs, which is why we are putting in place MEDICAL FORUM | MENTAL HEALTH

more high needs services in the community, such as community care units, youth community treatment services and developing plans for more of these services. MF: What impact is COVID-19 likely to be having on the mental health of West Australians, even if we have not had the big number of cases seen overseas? SD: In terms of mental distress presentations to EDs, there was a drop in the number of people at the height of the pandemic last year, however, this has since rebounded to pre-COVID levels. We saw a slight increase in levels of distress reported during the initial months of the pandemic last year, and while published reports have shown only minor changes in key indicators of mental health during the period, we will continue to monitor and support the community’s mental health. The measures we have implemented across the government to support the economy, families and children, the homeless and vulnerable, are also key to supporting mental health and wellbeing. MF: There are concerns that the recent coverage of the sexual violence/harassment experienced by women is impacting on the mental health of many women in the community? Are they being supported enough? SD: Widespread media coverage of the issue can certainly expose survivors to content that causes distress. There are sexual assault services available that provide counselling and support and I would encourage women or men to seek the support they need. • Services include: The Sexual Assault Resource Centre (SARC) who provides free advice, support and counselling for people who have experienced sexual assault. • 1800 Respect provides confidential sexual assault and family and domestic violence counselling via phone and webchat. (24/7 on 1800 737 732) • Mensline Australia (1300 789 978) supports men and boys who are dealing with family and relationship difficulties. MF: What is the role of the family GP in providing mental health support?

health. It’s a good place to start – a GP can refer people to appropriate supports, and can help develop a mental health plan. MF: How early do we need to address good mental health strategies in our children – is it ever too early? SD: Over 75% of mental health problems occur before the age of 25, and about half of mental health issues start by 14 years of age. These figures highlight the opportunity we have to intervene early. We know that supporting parents from the start results in better outcomes for children later in life. Parents play a crucial role in shaping their child’s health and wellbeing by modelling behaviours that promote and encourage good mental health such as resilience. To make sure our children get the best possible start in life, we’ve opened 22 Child and Parent Centres across WA. These innovative, familyfriendly centres are for parents with children up to eight years old in convenient locations at or near local primary schools. They provide a range of easily accessible programs and services for families, including early learning programs, maternal and child health services, and child support activities. Families can visit the child health nurse at the centre and there may be speech pathologists, physiotherapists and other health professionals on hand. Late last year, the Mental Health Commission released an evidenceinformed public education campaign to support parents, under the Think Mental Health banner. The Families Under Pressure campaign was adapted from a UK program, and was designed to help parents and carers support their child’s mental health and notice any signs and symptoms. It recognises for example that young people are more likely to seek help if they are able to express their feelings, and if they have some knowledge about mental health issues. In addition to the advice for parents and carers, the program also provides tools to help young people build resilience and equips them to look after their mental wellbeing.

Read this story on mforum.com.au

SD: A GP is often the first person someone talks to when they are experiencing issues with their mental JUNE 2021 | 27

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NEWS & VIEWS

New focus on head injuries in kids Updated guidelines aim to improve the management of paediatric head injuries, as Dr Karl Gruber (PhD) reports.

Imagine this scenario: an 18-monthold girl presents to an emergency department after falling from a high-chair and landing on her head. The child cried and vomited four times between the time of the fall and arriving at the ED. Otherwise, she is behaving normally, and no other clinical concerns are observed. As an ED doctor attending this child, what step would you take next? It all depends on the year. Before 2021, the standard guidelines would have required the child to receive a CT scan to ensure there was no swelling or bleeding in the brain or a fracture of the skull. This year, with the new guidelines in place, the child would have gone home without a CT scan. This scenario was an actual patient case. “The guidelines assisted the doctor to determine that she did not have any significant concerning features of head injury and that vomiting by itself in children less than two years was not a risk factor,” Prof Meredith Borland, Emergency Physician and Director of Emergency Research at Perth Children’s Hospital, told Medical Forum. “She had a period of structured observation over a few hours until she was back to her normal self for one hour. There was luckily no need for her to have a CT scan or admission. She ran out of the department chewing on a biscuit.”

Consensus all round The new guidelines, formally endorsed by the RACGP, are MEDICAL FORUM | MENTAL HEALTH

the product of a collaboration between emergency physicians, GPs, neurosurgeons, radiologists, paramedics, nurses and other health care providers from Australia and New Zealand. Perth Children’s Hospital ED staff were also closely involved in the development of these guidelines. The overarching goal is to improve the consistency and quality of head injury management across Australia and New Zealand. Another key aspect of the new guidelines is that they are built on up-to-date evidence from clinical studies and aim to give patients the best possible health outcomes. According to Prof Borland, other key objectives of these new guidelines are to: • improve outcomes for children with mild to moderate head injury; • identify those children who need neurosurgery and/or intensive care; • promote consistency of management in EDs in Australia and NZ; • reduce unnecessary interventions, including inappropriate use of head CT scans in children at very low risk of intracranial injury and • improve guidance for discharge and follow-up. For the case describe above, the new guidelines cover various scenarios to help clinicians make a decision about administering a CT scan or sending the child home after observation. Some of the new guidelines that are now in place are: • Children presenting to an acute care setting within 24 hours of a head injury and with a GCS score of 15, a head CT scan should not be performed without any risk factors for clinically-important traumatic brain injury. • Children presenting to an acute

care setting within 72 hours of a head injury and a GCS score of 13 or less should undergo an immediate head CT scan. • Children with delayed initial presentation (24–72 hours after head injury) and a GCS score of 15 should be risk stratified in the same way as children presenting within 24 hours. • In children with mild to moderate head injury, consider shared decision-making with parents, caregivers and adolescents (e.g. a head CT scan or structured observation). • All cases of head injured infants aged six months and younger should be discussed with a senior clinician. These infants should be considered at higher risk of intracranial injury, with a lower threshold for observation or imaging.

Help for parents Among these new recommendations and practice points, Prof Borland says that one of the most important areas covered involve the management of head injuries in children with specific health issues such as haemophilia or autism, or in children under six months of age. “This means there is a consistent approach and where indicated a reduction in CT scanning,” she said. Now Prof Borland and her team are working on a guide for parents, which may help them care for their children after they are discharged from the ED. “The Head Injury Guideline group is also developing support information with advice on returning to school, sport and other activities depending on the assessment of the child’s injury,” she said.

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GUEST COLUMN

CaLD youth speak out A community approach to mental health is key for culturally and linguistically diverse youth, says Nadeen Laljee-Curran. Young people are at a crucial stage where early intervention for mental health could have a long-term benefit on wellbeing, but there is significant underuse of mental health services by (CaLD) communities generally, and younger people from CaLD backgrounds typically present at an older age, by which time the impacts are more developed. In November 2020, Health Consumers’ Council partnered with Consumers of Mental Health WA for a panel discussion to explore mental health in CaLD youth (aged 12 to 25), looking at the barriers and enablers for seeking diagnosis and treatment from a health professional. The forum focused on the issues faced by young people born or being raised in Australia by migrant parents. This group is in a unique position as they navigate Western mental health labels and the contrasting opinions of their families and communities. Identity was raised as a key issue for children of migrants and one that can contribute to mental health issues. Often young people felt they were not recognised as Australian, despite being born/raised here, but they also felt they did not fit in with community members raised overseas. Young people gravitated to those with a similar skin colour at school, with those from a mixed-race background finding it challenging as they were neither white nor black ‘enough’. The young people all said they had experienced racism and felt that stereotyping and racial profiling had affected their mental health. One panellist (who migrated with her parents as a teenager) spoke about how she was abused as a child and spent many years battling this trauma. She explained how the first mental health professional she saw made a generalisation about sexual abuse being common in African communities and this put her off accessing further treatment for some time. MEDICAL FORUM | MENTAL HEALTH

break away from the family doctor to seek another health professional with whom they felt safe. In terms of enablers and supports, the panellists spoke about how services with CaLD liaison officers often felt safer and more approachable (even considering the diversity of the CaLD population). The power of peer-to-peer support and storytelling was also identified as paramount.

All the panellists said it was important for services to be person-centred and open-minded, and to not make judgments based on stereotypes or assumptions. When it came to barriers for young people seeking mental health support, the panellists also spoke to costs and accessibility. This was often compounded by young people’s perceptions that power was held by service providers. Other key barriers were low community mental health literacy (with culture, heritage, community and religion all playing a part in the way mental health is viewed/ interpreted), distrust of the ‘system’ and concerns around confidentiality (particularly fear of the community knowing about private business). Advocates explained that young people could find it difficult approaching family about mental health concerns due to a fear of rejection, but also because they felt their mental health issues were invalidated because of the hardships endured by parents in their asylum seeking or migration. Some young people also felt guilt for their privilege compared to family living overseas and this has been exacerbated in COVID times. Importantly, GPs and health providers from the same cultural background were seen as a barrier to accessing treatment and many young people had found it difficult to

Organisations such as the Multicultural Youth Advocacy Network WA (MYAN WA) and Headspace were valuable for young people and “How’s your Haal”, a community initiative aiming to empower young people from CaLD backgrounds to tackle the taboo of mental health and to share their experiences with their communities, was an example of a program that really worked. The importance of empowering young mental health advocates and young people in general to self-advocate (and in some cases the generation above them) was highlighted, and MYAN WA given as an example for providing young people with these kinds of resources. The young panellists felt that mental health initiatives needed to look through a community health lens rather than a tertiary or medical lens. If services were being developed, co-design was the best approach as young people knew what they needed and what worked. What young people wanted was for health service providers to acknowledge differences but not generalise, look at a person as a whole being and advocate for them, ask questions and think about location and costs of services, and build relationships to allow them to feel safe to open up. ED: Ms Laljee-Curran is Cultural Diversity Engagement Coordinator at Health Consumers' Council.

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Kicking the mental health can down the road Respected mental health advocate Kerry Hawkins calls out the WA Government’s lack of support for community-based services. Year on year, increasing demand from children, youth and adults for emergency mental health support is testing the limits of Western Australia’s overstretched mental health system. The system is currently geared towards acute and hospitalbased services which means people frequently must reach crisis to access support. In our hospitals, EDs and community clinics, dedicated staff face so much demand they have little to offer beyond medication and stabilisation, with limited time to support recovery or work with people to resolve the issues that contribute to their distress. These workers know that many of the people they support will be

back when they next reach crisis. While hospital and treatmentfocused options are important, investment must be made in creating and supporting better community-based recovery pathways, which will ultimately relieve pressure on hospital staff and place us in a better position to face a potential mental health pandemic. Once people leave hospital or a transition facility, there are few resources to support and prevent them from returning to clinical environments. This can be distressing for people and prolong their recovery. It is also more expensive. The 2019 Mental Health Commission

snapshot found 27% of mental health inpatient beds, at $1595 a day, are occupied by people who could be discharged if a community service was available. Already groaning under decades of underfunding, community and non-clinical services respond to people’s mental health needs where people tell us they want support – in their community, near their homes and not just at the crisis end of care. However, investment remains out of reach. Victoria’s recent Royal Commission report into mental health reiterated the need to shift away from a crisis-oriented mental health system, aligning with dozens of other mental health and suicide prevention inquiries, reports and

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GUEST COLUMN plans in WA and nationally. When will things change?

intensive, skilled and peer-based community support services for adults to complement clinical teams and keep people well and participating in their community.

In WA we have witnessed a wave of spending thrown at hospital beds and short-stay step-up, step-down facilities, but a similar injection directed at community support and prevention remains unmatched.

Current trends in investment contradict international and national evidence and best practice for improving mental health outcomes and actually work against the government’s own 10-year plan, Better Choices. Better Lives, which the Minister keeps rhetorically affirming his commitment to.

The government is spending record amounts on mental health, but it is not being strategic and consequently we are not seeing improvements in mental health outcomes.

This plan outlines the optimal mix of services to deliver an efficient and effective mental health system. It states investment in prevention and community support needs to increase as a proportion of spending, while investment in acute and hospital-based services should comprise a smaller part of the total budget.

When families asked then-Mental Health Minister Roger Cook why the government had not focused more on prevention and community support, he acknowledged more needed to be done. Only 1% of current mental health funding is for prevention, when it should be 5%. We are going backwards. Every other major public health issue has a strong prevention and early intervention focus, but mental health just can’t seem to get onboard.

This does not mean taking money away from, or getting rid of, acute services. Rather, it means growing the overall pot of money for mental health and moving towards a better balance of service types, leading to efficiency and better outcomes.

We want to see the WA Government commit to a range of

The plan has been endorsed by people with lived experience, the community sector, as well as the likes of the Sustainable Health Review Final Report and the Office of the Auditor General – its targets are not controversial or fringe. Despite this, moves towards achieving them are small at best. The Western Australian Association for Mental Health is raising this issue through the Prevent Support Heal campaign because people with mental health challenges, their families and the people who support them are sick of waiting for real change. Our community knows the only way forward to ease unsustainable working conditions at the coalface, is by preventing mental health problems before they escalate; ending the revolving door of distress; and providing early community support for people to recover and live a contributing life. ED: Kerry Hawkins is the WA Association for Mental Health President and a National Mental Health Commissioner.

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New portfolio gives hope to researchers Perkins Institute head Professor Peter Leedman hopes a state minister for medical research will sharpen the government’s focus. Following the March 2021 WA election, three new ministerial portfolios were created, one was for medical research, which is a great initiative for the state.

but only 9.8% were funded, down from 11.1% the year before. That means for the significant time dedicated to writing one grant application, a researcher has less than a one in 10 chance of success.

The value of a thriving medical research sector is irrefutable. The health and wellbeing of the community benefits when research discoveries are integrated into patient care and health policy and when health needs influence research areas of focus. Recently Australia’s first National Biobanking Summit was held in NSW. It brought together 90 national and state experts in biobanking, policy, clinical care, health and medical research, data management and linkage and consumer perspectives. While such a summit doesn’t rely on the existence of a medical research portfolio, ministerial support for this type of big-picture thinking does bring a sharper focus to developing announcements and achieving milestones. Just how WA’s medical research portfolio will develop and what roles it will play in enhancing the sector is yet to be seen, but as the bulk of research grants are from Federal Government programs, it will be interesting to see the ways in which this new portfolio supports WA medical research. WA already has the Future Health Research and Innovation Fund providing an important source of funding. This is fortunate as the challenge of securing funding from Australia’s primary funding agency, the National Health and Medical Research Council (NHMRC), is as high as ever despite changes to its programs. Up to the time of the NHMRC’s structural review of its grant program in 2016, project grant funding success rates had dropped from about 35% to less than 15% from 1980 to 2015. 36 | JUNE 2021

A 10% funding success rate makes a career in research a challenging choice. Perhaps some of the near-miss grant applications and fellowships could be supported under an innovative state scheme governed by the new medical research portfolio.

While Federal Government funding has since increased through the creation of the Medical Research Future Fund (MRFF), which runs parallel with the NHMRC, it is mostly directed toward the clinical end of health and medical research and responds to calls to address specific problems or issues. For example, the $20m Mackenzie’s Mission, which is rolling out the national pre-pregnancy screening program, is MRFF-funded. Therefore, where Australia’s funding concern lies is with the declining success rates for what used to be called NHMRC project grants and are now called NHMRC ideas grants and with declining success rates for early to mid-career researchers (EMCRs) in what used to be called NHMRC fellowships but are now called NHMRC investigator grants.  The investigator grant scheme, which is the NHMRC’s largest funding scheme, received 1780 applications in the 2020 round but only 13.3% were funded. The success rate is much higher for the most senior investigator grants, but the success rates for EMCRs is much lower, at around 10%. The NHMRC ideas grant scheme, implemented in 2019, is the NHMRC’s second largest. It received 2995 applications in 2020

Nationally, the fundamental issue with health and medical research funding is that Australia simply does not spend enough of its GDP on research. Australia’s gross domestic research spending has been steadily falling since 2010. Australia only reached the OECD average in 2008. Yet the economic, health and community benefits of a thriving medical research sector are overwhelming. For every dollar invested, Australian medical research returns $3.90 in benefits to the population. Therapies developed from medical research reduce health care costs enormously by preventing disease and reducing the health care burden. And commercialisation of research discoveries offers more than just the opportunities for financial returns to spin-off companies and investors, but also employment for a wide range of support services from patent lawyers and tax accountants to regulatory experts and clinical trials specialists. On clinical trials, WA’s major early phase facility, Linear Clinical Research, where I am the Chair, has provided a tenfold return on its initial state government investment

continued on Page 37

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Supporting safe, home-based withdrawal Clinical Nurse Specialist Jupp Groenveld explains the DAWN program which helps vulnerable people overcome their addictions. St John of God Drug and Alcohol Withdrawal Network (DAWN) is operated by St John of God Health Care and fully funded by the WA Mental Health Commission. Our team of clinical nurse specialists help people to stop or reduce their substance use by providing planned care and support at home. Our services are provided free of charge. The most common substance our clients are struggling with is alcohol, followed by methamphetamines, but we deal with a broad range of illicit, prescription and over-the-counter medication dependencies. We work across the Perth metropolitan area with clients of all ages and from all walks of life. The one thing they usually have in common is a history of trauma. Almost without exception, substance use is a symptom of something more that a person is dealing with. Connecting clients to counselling and other support services is an important part of our role and helps position them for long-term success. We accept self-referrals as well as GP referrals and ensuring a person’s GP is happy to support a homebased withdrawal is always the first step in the process. From there, we keep the GP informed each step of the way, from a detailed initial assessment and shared-care plan before the withdrawal process starts, through

to a discharge summary when the withdrawal process has concluded. DAWN has prescribing guidelines for GPs, along with a range of resources, and our triage nurses are available during business hours to provide advice and support. To be a suitable candidate for a successful, safe, home-based withdrawal, people need to be low on the complexity spectrum. We cannot offer a home-based withdrawal if a person has a seizure history or is pregnant, and if a person is using multiple substances it may not be safe to withdraw at home. It is crucial that our clients have stable accommodation and a support person available for the duration of their withdrawal. The role of the support person is vital. Our clients don’t just have to get through physical withdrawal symptoms, they also have to deal with the grief that comes from ceasing or reducing their use of the substance that has become integral to their ability to get through each day. It’s a neuroplasticity process and they need someone who knows them well to help them through the significant emotional challenges they may face. During the withdrawal, we visit clients for between 45 minutes to an hour daily (Monday to Friday) and are always available by phone during

business hours. Support resources are also provided to clients if they experience any issues after hours. Providing a flexible, individualised approach is crucial. We also place a big emphasis on supporting clients’ families and support people and will often refer them for counselling. When clients have children at home, we advise them of the range of services available for families, and we are happy to facilitate referrals to services for children living with parents with dependencies. By doing a home-based withdrawal, our clients learn to manage their substance-use triggers from the start. Generally, it also means they’re staying in the place where they feel most comfortable and don’t have to be separated from their family, which is significant, particularly for people with young children. Tackling a substance dependency is not easy, and people with problematic alcohol and substanceuse are very often marginalised. They may be struggling with a lot of shame over their dependency on top of the trauma, hardship, neglect and abuse that may have led to their substance use. It takes a lot of courage for our clients to reach out for help, so it is crucial that we treat them with the respect, kindness and compassion they deserve.

New portfolio gives hope to researchers continued from Page 36 generating over $100m in direct economic and supplier activity. Of course, the value of medical research extends well beyond pure economics. Career paths are created that retain our best and brightest and attract MEDICAL FORUM | MENTAL HEALTH

international experts in diverse fields to WA. Medical research provides essential information and data for health policy development – from disease trends and risk factors to the outcomes of treatment or the effectiveness of public health campaigns.

It is exciting to think how a dedicated medical research portfolio could benefit Western Australia. References on request ED: Professor Peter Leedman AO is Director of the Harry Perkins Institute of Medical Research.

JUNE 2021 | 37

Recalibrating telehealth risks Lawyers Enore Panetta and David McMullen explain how to manage the legal risks of telehealth during COVID-19 and beyond. Since March 2020 (and, at the time of writing, continuing at least until the end of the year) temporary telehealth items have been made available on the Medicare Benefits Schedule in response to COVID-19. Whether due to pandemics or as a product of new and evolving technologies, it seems telehealth is going to play a growing role in the healthcare of the future. However, while telehealth may seem more informal compared to a physical consultation, it is important that medical practitioners stay mindful of the legal risks and challenges associated with using telehealth. Some of the main considerations include: 1. The standard of care must be

38 | JUNE 2021

maintained. Telehealth does not excuse a lesser standard of patient care. You must still meet your legal duty to the patient with quality and safety informing everything you do via telehealth. Just because you are consulting by telehealth, don’t forget the usual risk management practices that you would undertake when consulting in person. Obtain fully informed consent to provide medical treatment or perform tests or procedures. Keep accurate and contemporaneous records including the start and end times of consultations and all elements of your professional assessment and decisionmaking processes. Identify your patient, taking particular care if

consulting by voice/audio only. Reduce medical legal risk by adhering to the Good Medical Practice Code of Conduct and the Medical Board’s Guidelines for Technology-Based Patient Consultations. 2. Patient and case selection: Telehealth is not a substitute for physical consults. Is the patient suited to telehealth? Where the patient has special needs, is impaired or elderly or a child, or there are language barriers, telehealth may not be appropriate. Is the patient’s health condition suited to telehealth? Consider the limitations of non-face-to-face consultation. If the inability to physically examine could lead to

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GUEST COLUMN errors in diagnosis or treatment, or missed opportunities for preventative care, then a physical consult may be needed. This requires a case by case assessment. Stand by your assessment and insist on a traditional physical consultation if appropriate – even if a patient asks for services via telehealth due to perceived accessibility or convenience. 3. Fragmentation of continuing care: Fragmentation of care can occur because patients have easier access to services via telehealth from providers other than their usual doctor. Telehealth services should ideally be provided by a patient’s usual medical practitioner or practice wherever possible (i.e. practitioners with knowledge of the patient’s history and access to complete medical records). Practitioners must recognise the increased risks of advice without having the patient’s medical history. 4. Ensure a suitable consulting environment: When a patient visits you at your practice, you control the environment. You lose this level of control when you consult by telehealth. Put clear protocols in place for both you and your patients around the setting in which telehealth consultations will be performed. 5. Technological limitations: The type and standard of equipment,

and the speed and bandwidth of data connections, is important when providing services via telehealth, as interruptions to video and/or audio can compromise the delivery of care and therefore lead to increased risk. In short, equipment and connections must be fit for purpose. As a practical matter, the onus is on the practitioner to ensure the integrity of electronic communications. For example, a specialist who needs to receive and interpret medical imaging must be able to receive images with sufficient clarity to perform their work. These needs will differ from, say, a GP who is performing a more routine task such as writing a repeat prescription for a returning patient. 6. Privacy and confidentiality: Healthcare providers should already be aware of their obligations under the Privacy Act 1988 (Cth) and the Australian Privacy Principles (“APPs”) (and additional state/territory legislation in some locations). Of particular relevance in a telehealth setting is the obligation to protect personal information from misuse, interference and loss; and from unauthorised access, modification or disclosure (under APP 11.1). Telehealth providers therefore must use secure systems to conduct telehealth consults and always transmit

personal information (including health information) in a secure manner. 7. Insurance: Ensure that your telehealth consultations are covered by your professional indemnity insurer. Pay particular attention to how ‘telehealth’ is defined in your policy, and whether you or the patient must be in a particular location. Some policies will not, for example, cover claims relating to telehealth provided to patients outside Australia. With the right measures in place, telehealth can be a viable and prominent part of the future healthcare landscape, without opening up areas of undue legal risk for the practitioner. The key is to recognise the purpose, limitations and inherent risks of telehealth and to remain vigilant. ED: Enore Panetta and David McMullen are lawyers with Panetta McGrath. The content of this article is intended to provide a general overview and guide to the subject matter. Specialist advice should be sought about your specific circumstances.

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JUNE 2021 | 39

Head for medicine, nose for business Matthew Vaughan-Davies explains the challenging but rewarding road to financial success through private practice Leaving the secure employment of the hospital system to start a medical practice can be thrilling and daunting at the same time. Suddenly the challenges of being a business owner are added to the already time-consuming tasks of providing quality patient care. While years of medical training and professional development might have provided doctors with the skills and tools to treat and care for patients, essential business development and management skills are often absent or insufficient. The private practice lifecycle can be divided into three key segments – planning and set-up, operations and growth and business succession phase. During the initial planning phase, there are key considerations to get the practice started correctly and efficiently. Most complexities arise when operating within a group of practitioners and other health service providers. Multiple moving parts and business segments require strict time, people and operations organisation. Staffing needs, managing medical practitioners and setting and enforcing KPI guidelines all come on top of the day-to-day tasks of running a medical clinic. The financial success of the practice largely depends on key decisions made during the planning, design and set-up phase. The location and availability of medical services such as pathology, pharmacy and allied health can significantly contribute to the financial success of the practice, as well as the overall satisfaction and convenience for your patients. Once a clear vision of the clinic’s ideal patient profile, practice location and pricing strategy has been formulated and documented, attention needs to turn to the legal structure and financial plan of the entity. 40 | JUNE 2021

Without adequate structure planning and an initial financial and business plan, the practice’s financial wellbeing can be exposed to adverse yet avoidable financial outcomes, creating unnecessary financial and operational distress on the practice, as well as impacting on your valuable family life and financial security. Before establishing the practice, seek professional advice about the compulsory ASIC and ATO registrations, incorporation and registration of business entities, and understand your tax obligations including income tax, GST, PAYG withholding and superannuation. Knowing how much money to set aside to meet tax obligations and cash flow needs of the practice will help set and control realistic expectations around lifestyle and investment spending. Once the practice is up and running, regular maintenance is needed to assist with the daily operations of the clinic as well as attending to administrative tasks including patient billing, staff and medical practitioner rostering, book-keeping and bill payments.

Dealing with these tasks in the most effective way will help narrow the focus on providing care to patients, allowing higher volumes of patients which in turn will lead to an increase in practice profitability. The long-term goal of operating a private practice is to create income and wealth over and above what could be achieved as an employee in the public health system. However, it is essential to ensure that the additional revenue stream being generated results in the creation of family wealth and the lifestyle you want. The final hurdle is to establish a retirement plan surrounding the practice. Once practice goodwill and profitability have been created, a transition plan to a successor needs to be established, and professional help can assist in a comfortable transition into retirement. Establishing, operating and growing business and personal wealth takes a combination of medical expertise, hard work and good advice. ED: Matthew Vaughan-Davies is a partner in the Carbon Group

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Counting sheep in your sleep Dr Jen Walsh explains how lucid dreaming could help us to sleep productively and even do simple maths sums. In the current world where time is becoming an increasing valuable commodity, wouldn’t it be great if we could use our sleeping time a little more productively? A group of scientists believe that this might be possible if we can tap into our dream state. Specifically, lucid dreaming – when the dreamer becomes aware that they are dreaming and is perhaps even able to control the content or events – is thought to hold the key. Dreaming typically occurs during the rapid eye movement (REM) sleep stage when the brain becomes relatively active compared to the non-REM sleep stages. A crucial feature of normal REM is that, with the exception of the diaphragm and eye muscles, there is complete suppression of skeletal muscle activity throughout the body. This serves to keep us from ‘acting out our dreams’ – if we do act out our dreams this is a hallmark feature of the sleep disorder known as REM sleep behaviour disorder. Despite reports of lucid dreaming by Aristotle as early as 350 BC, the first empirical evidence of lucid dreaming wasn’t published until 1978. Individuals equipped with brain, muscle and eye movement sensors to confirm that they were in REM sleep, signalled that they were aware that they were dreaming with a specific eye movement pattern (four times left to right in quick succession). Prior to these recordings of volitional eye movements during sleep, evidence for lucid dreaming consisted of personal reports, which scientists largely considered sceptically. The ‘lucidity signal’ has since been utilised in all subsequent lucid dreaming studies. Recent research done in the US, Germany, France and the Netherlands (see reference) has progressed our understanding of lucid dreaming further by MEDICAL FORUM | MENTAL HEALTH

demonstrating that it is possible to communicate with someone while they are dreaming. Scientists recruited people with minimal prior experience who were trained to lucid dream as well those who were experienced lucid dreamers. The participants were prepared with equipment for monitoring their brain, muscle and eye movements and instructed to ‘signal’ (left to right eye movements) when they were aware that they were dreaming. They were then asked a series of maths questions, either verbally spoken or signalled with auditory tones or flashing light in Morse code, to which they were instructed to respond with rapid left to right eye movements corresponding to the answer (ie 8 minus 6 resulted in 2 left to right maximal eye movements). The lucid dream signal was not observed in all sessions and not all attempts at communication with the participant resulted in responses, or correct responses. However, the study convincingly demonstrated that individuals can be aware of their external

environment, whether it is light, sound or someone speaking, and that they can communicate while in the dream state. It has previously been demonstrated that the dream time can be utilised, through lucid dreaming, for activities such as rehearsing skills, solving problems or reducing impact of emotional trauma. These new findings open up even further opportunities such as using light or sound cues to modify dream/nightmare content in people with PTSD or using verbal communication to focus the practice of musical or athletic skills. Perhaps in the coming years we might all be able to better use our 1-2 hours per night spent dreaming. Reference Konkoly et al., Real-time dialogue between experimenters and dreamers during REM sleep. Current Biology (2021) + Dr Jen Walsh is director of the University of WA’s Centre for Sleep Sciences.

JUNE 2021 | 41

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Spike in demand for

adolescent and addictions private mental health treatment A 47-bed expansion of Healthe Care’s Abbotsford Private Hospital in West Leederville will pave the way for additonal private mental health services to cater for a spike in adolescent and addiction mental health concerns. The 6-storey development, earmarked for completion in 2022 will boost the hospital’s existing 30 beds to 77; with an adjoining, purpose-built building comprising 47 private mental health beds and group

Above: Artist impression of Abbotsford Private’s $15m mental health expansion

therapy rooms, including a dedicated youth ward to assist people aged 16 and over experiencing mental health concerns and/or addiction. It represents a $15m investment into the mental health sector in Perth.

Adolescent mental health treatment to be provided close to home The expansion of Abbotsford Private Hospital’s specialist substance dependence and mental health facility will help a growing number of West Australians struggling with the pressures of financial difficulties, family breakdowns, anxiety and depression.

those addicted to gaming, mobile phones and social media can often develop substance abuse as a result of such behaviour, with specialised private mental health services and treatment planned, accordingly.

It will alleviate the region’s shortage of beds and longer treatment waiting times, treating the underyling mental health concern and addiction that goes hand-in-hand. It will provide early intervention for addiction, which can start from an early age - sometimes as young as 10 - with the nature of addiction changing depending on age. The hospital recognises that addiction is not always about substance abuse - however

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The adolescents ward is modelled from Healthe Care’s highly-successful The Hills Clinic in Sydney, which services people from across Australia and abroad. It is an evidence-based model that will soon be available to young people in Western Australia, so they can stay close to their homes, families and loved ones to support the recovery process. Treatment combines cognitive behaviour therapy (CBT), dialectical behaviour therapy (DBT), mindfulness and group therapy. Abbotsford Private Hospital is one of the only facilities in Western Australia to work with people to treat underlying mental illness and trauma at the same time as addressing addictive behaviour as a complete solution. Abbotsford Private’s nearby sister hospital, the 69-bed Marian Centre provides inpatient, day patient and outpatient treatment and consultations for depression, anxiety, PTSD and mood disorders. Combined both hospitals are one of the largest private mental health providers, now with 146 beds for private mental health treatment in Western Australia.

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42 | JUNE 2021

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Referral Pathway T: 08 9380 4999 (ext 1180) F: 08 9388 3179 E: mrn.tlo@healthecare.com.au mariancentre.com.au MEDICAL FORUM | MENTAL HEALTH

OPINION BACK TO CONTENTS

Dr Joe Kosterich | Clinical Editor

Fear, resilience and our mental health It can take time for the consequences of actions to occur. A melanoma does not develop the day after sunburn nor lung cancer a week after starting smoking. Thus, the mental health problems related to lockdowns and fear may not all be visible yet.

Philosophically one wonders if there is a connection between the rise in mental health illness and reduced resilience in society.

Last year there were predictions that Australia could see an additional 7500 suicides over the next five years – a 50% increase on current numbers. Statistics are not yet available but anecdotally this does not seem to be coming to pass, which is great! However, mental health problems are increasing and how the fear which has taken hold (especially in children and teenagers) will manifest in the future is unknown. It was a strange juxtaposition that the Perth and Peel regions went into lockdown over ANZAC Day. On this day we remember those who volunteered to fight for freedom and who volunteered, literally in some instances, to run towards bullets. For those who haven’t seen the movie 1917, I would recommend it as it gives just a tiny insight into what life was like for soldiers a century ago. This edition looks at mental health. In particular we examine some new treatments. It is fair to say that despite significant spending and no shortage of prescribing, mental health problems are not diminishing. Two pieces examine the re-emergence of psychedelics. These drugs were caught up in the Nixon administration’s war on drugs (and the counterculture) and for 50 years have been ignored or vilified. New research is picking up from where it was left off and the results are encouraging. Transcranial magnetic stimulation has been used for depression and is now being expanded into pain management. Pain and depression often coincide. The importance of exercise in mental health is covered and how to better understand self- injurious behaviour. Changing gears, oral ulcers, assessing abnormal liver function tests, and new radiation treatments are examined too. Philosophically one wonders if there is a connection between the rise in mental health illness and reduced resilience in society. Niall Ferguson writes in the Wall Street Journal comparing this pandemic to the Asian flu of 1957: “…American society at the time was better prepared — culturally, institutionally and politically — to deal with it.” Ditto for Australia. Ferguson compares the Beat Generation of Jack Kerouac to the “beaten generation’ of today. Humanity has faced far worse and with way less resources. Maybe we need to remind ourselves and our children of this. https://www.wsj.com/articles/how-a-more-resilient-america-beat-a-midcenturypandemic-11619794711

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TMS therapy for cortical pain neuromodulation By Dr Vincenzo Mondello, pain specialist & psychiatrist, Subiaco Transcranial magnetic stimulation therapy (TMS) is a TGA-approved treatment for depression. Its role in the management of other nonpsychiatric conditions is only just revealing itself. As a cortical neuromodulation technique, it normalises the connectivity of damaged cortical networks through top-down processing. Research shows potential benefit of TMS in multiple sclerosis, tinnitus, traumatic brain injury, stroke-related disability, Alzheimer’s disease, Parkinson’s disease, autism, amyotrophic lateral sclerosis, obsessive compulsive disorder and post traumatic stress disorder. Neuropathic pain is one area leading the charge of its clinical application. The modern use of neuromodulation as a pain treatment came from Melzack and Wall’s gate theory of pain in 1965. In 1967, Wall, Sweet and Avery created the first implantable stimulator and Shealy and Mortimer designed the implantable electrode for dorsal column stimulation. Tsubokawa (1991) demonstrated that stimulating the motor cortex could be of benefit and Migita (1995) reported the first case of extracranial magnetic motor cortex stimulation successfully treating a patient with centrally mediated deafferentation pain. Jean-Pascal Lefaucheur led the way in subsequent research of TMS’s application to pain, concluding in 2020 that “high frequency stimulation of the motor cortex has level A evidence for analgesic efficacy in neuropathic pain”. Benefit was reported in other pain conditions ( migraine, complex regional pain syndrome, fibromyalgia, phantom limb and bladder pain syndromes). TMS’s mechanism of action in pain is complex, involving downward modulation of cortical excitability at the stimulation site and transynaptically at more distant areas. These areas include the affective, cognitive and emotional aspects of pain processing via 44 | JUNE 2021

it has not revealed any adverse interaction with other medical therapies. With sessions lasing around 20 minutes, it is convenient and time effective. Patients could be back at work before their 30-minute lunch break ends!

Key messages

TMS is a novel, effective treatment for neuropathic and nociplastic pain conditions

It is a non-invasive and safe alternative when other conventional pain treatments have failed

Patients with comorbid chronic pain and mental illness may particularly benefit. the cingulate, prefrontal and orbitofrontal cortices. In this network, known as the pain matrix, TMS enhances the release of endogenous opioids and inhibitory neurotransmitters (e.g. GABA). In localised neuropathic pain the contralateral motor cortex is the primary stimulation site. In more widespread nociplastic type pain the left motor cortex and dorsolateral pre-frontal cortex are often targeted. Lefaucher and Nguyen (2019) reported at least 10 sessions were needed before any analgesic benefit was likely to be seen.

Advantages TMS could be a viable and safer alternative to opioids and may help to reduce opioid use in patients with chronic pain. TMS has few side effects – scalp tenderness and headache being the most common but typically resolving by the third treatment. A theoretical risk of seizures is lower than the use of an opioid analgesic. As a noninvasive non-medication treatment

Cost is now less of a barrier. The 2021 federal budget announced funding of TMS for patients with medication-resistant depression. The Medicare code is set to begin on November 1. Similarly, Department of Veteran Affairs supports TMS treatment of depression. Worker’s compensation and motor vehicle insurance providers variably support its use. TMS for pain does have limitations. How to best sustain the analgesic efficacy is not yet clear and it is likely to have wide variation across the population. However, maintenance therapy (possibly monthly sessions for six months) may be the best technique in achieving this objective. Pain treatment necessitates MRIguided brain mapping to ensure safe and precise cortical targeting. The surface anatomy approach used in the treatment of depression does not afford the accuracy required to target pain. TMS uses magnetic energy, so the contraindications are similar to MRI brain imaging – metalware above the cervical area. Care needs to be taken when there is a history of epilepsy. As an off-label treatment, TMS’s role in pain management requires full disclosure and informed consent. TMS is an emerging treatment in the pain management arsenal. A neuromodulatory technique that offers a non-opioid option. Refreshingly, it could serve the goal of facilitating the patient’s own self efficacy, the decisive goal of chronic pain management. – References available on request Author competing interests – the author is director of a company providing TMS services

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CLINICAL UPDATE

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CLINICAL UPDATE

Revisiting psychedelics in psychiatry By Dr Jeremy Tannenbaum, psychiatrist, Hollywood Psychedelics are psychoactive substances that profoundly alter mood, cognition and perception. They include a diverse group of plant and fungus-derived compounds and, in the modern era, synthetic derivatives. Psychedelics have been used since prehistory in traditional cultural practices, ceremonies and as medicines. Founders of the modern psychedelic movement include Albert Hofmann, who discovered LSD and first isolated psilocybin, and Dr Stanislav Grof, who conducted early research into LSD and introduced psychedelicassisted psychotherapy (PAP). The association of drug use with the counter-culture movement during the Vietnam War led to socio-political demonisation of drug use, prohibition, and the ‘War on Drugs’. Unfortunately, this stifled clinical research into psychedelics. Recent studies are renewing enthusiasm for psychedelics as medicines, in an era of diminishing pharmaceutical company investment in the neurosciences amidst a mental health pandemic. There are over a hundred trials underway, including at prominent institutions (Johns Hopkins and Imperial College). The US FDA has designated psilocybin and MDMA as ‘breakthrough therapies’ for depression and PTSD, respectively. In February 2021, the Australian Government announced the establishment of a $15 million research fund, an internationally unprecedented show of support from government for psychedelic research. The Therapeutic Goods Administration voted against the down-scheduling of psilocybin and MDMA from Schedule 9 (Prohibited Substance) to Schedule 8 (Controlled Drug) last February due to the need for further research, lack of an established implementation plan and safety concerns, particularly the risk of psychosis in vulnerable individuals. MEDICAL FORUM | MENTAL HEALTH

This decision is currently under review after release of new trial results.

Classification and Mechanisms Psychedelics are often categorised into ‘classical’ 5HT-2A agonists (psilocybin from ‘magic’ mushroom species, lysergic acid diethylamide [LSD] and dimethyltryptamine [DMT] from ayahuasca), atypical psychedelics (ibogaine from the iboga plant, mescaline from the peyote cactus, ketamine) and the empathogens, including 3,4-methylenedioxymethamphetamine (MDMA). Psychedelics cause marked functional and structural changes in the brain. They act through heterogeneous mechanisms including actions on monoaminergic, glutamatergic and other neurotransmitter pathways, secondary messengers, the endocrine system, as well as alterations in neurogenesis, synaptic plasticity and activity in functional networks. The RElaxed Beliefs Under psychedelicS (REBUS) model, from Dr Robin Carhart-Harris, proposes that psychedelics ‘relax’ normally fixed neural pathways, thus derestricting the normally stable but inflexible nature of spontaneous brain activity. This enables the weakening and revision of overweighted pathological ‘priors’ or beliefs, for example those present in certain mental illnesses such as depression and anxiety, aiding insight and change through ‘unconstrained cognition’. Functional MRI research has indicated that psilocybin decreased activity and connectivity in the Default Mode Network (DMN), a large, distributed functional network, mainly active during the resting state. Interestingly, the DMN is considered by some to be a neural correlate of ego. Psychedelic experiences are often described as amongst the most profound experiences of participants’ lives. The ‘integration’

of psychedelic experiences with psychotherapy is considered a critical element for therapeutic effectiveness. Themes described in qualitative studies include transcendental experiences, increased feelings of acceptance and connectedness, insights and altered perception of self and the world, expanded emotional spectrum and symptom relief.

Clinical scenarios Psychedelic-assisted psychotherapy (PAP) may be a helpful treatment modality for a range of conditions, including endof-life distress, depression, PTSD, and substance use disorders. The strongest results so far are seen with MDMA in PTSD, psilocybin in depression and end-of-life anxiety, and LSD for alcohol use disorder. Only one serious adverse event (reversible hypertension and tachycardia with MDMA) in over 150 recent trials and 4000 participants has been observed. Used in clinical settings, there is no evidence of addiction. Psychosis and hallucinogen-persisting perception disorder characterised by flashbacks or visual disturbances after using psychedelics appear to be rare. Nevertheless, researchers and clinicians agree that psychedelics should be avoided in those with a personal or family history of psychosis or bipolar disorder. Ibogaine has been associated with rare deaths, perhaps secondary to arrhythmias. Socio-political and clinical interest in psychedelics is growing rapidly. High rates of mental illness and treatment-resistance increases the urgency to develop innovative treatments and clinical care models. PAP may be an important tool in managing a range of mental disorders within the next 5-10 years. More research, clinician education, the development of international frameworks and guidelines, and health service restructuring are essential for safe clinical implementation. Author competing interests – nil

JUNE 2021 | 45

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They happen infrequently Many times no one is around to observe them, or eye-witness accounts are unreliable The person experiencing the event may not remember what happened Causes can be neurological, psychological or cardiac

46 | JUNE 2021

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Persistent oral ulceration By Professor Camile S. Farah, oral physician & maxillofacial pathologist, Nedlands Oral ulceration can occur for myriad reasons. Many result from immune-mediated or autoimmune pathologies, while others from physical, chemical or thermal irritation such as trauma. Others herald the development of oral cancer. Oral ulcers can be single or multiple, acute, or chronic, can occur in different anatomical sites, or persist in the same location. A persistent chronic oral ulcer should always raise the possibility of oral malignancy until proven otherwise. Persistent oral ulcers can be caused by ongoing chronic irritation from a physical stimulus such as a sharp tooth, but if appropriate therapy is instigated (e.g. polishing of the offending sharp edge), the ulcer will typically resolve in two weeks. Ulcers persisting beyond two weeks, regardless of active intervention, should be considered as potentially malignant, and biopsied or referred without delay. Definitive histopathology remains the gold standard for assessment of possible malignancy. Single persistent ulcers should be biopsied with malignancy in mind. Critically, an inadequate biopsy can delay diagnosis or render an incorrect diagnosis and hence inappropriate treatment. Oral squamous cell carcinoma (OSCC) is the most common oral cancer accounting for up to 95% of all oral malignancies. It has traditionally been considered an environmentally induced (tobacco smoking and/or heavy alcohol consumption) tumour, commonly seen in older males. There is, however, a significant increase in incidence in younger

Key messages

A persistent oral ulcer should always raise the suspicion of oral malignancy

An ulcer persisting two weeks after appropriate therapy requires biopsy

Fixation and induration are features of advanced oral cancers and should not be relied on to exclude early malignancy.

patients (under 40) and in females. Typically, it has been described as indurated and fixated. Whilst true, these features are usually seen in advanced and not early cases.

Two cases The first, a 92-year-old female was referred by her GP with a history of smoking and regular alcohol consumption and a reported chronic persistent painful ulcer on the left lateral surface of the tongue which had been present for four to five weeks and not relieved by topical steroid cream (Fig 1). The complex medical history included renal failure, hypertension, gout, multiple myeloma, cutaneous squamous cell carcinoma, depression, discoid eczema, postherpetic neuralgia, and prior breast cancer. Polypharmacy was another issue. The oral ulcer measured 10mm x 8mm in greatest dimension, was not indurated on palpation, and was reasonably well circumscribed. It did not appear associated with an offending tooth, did not respond to intra-lesional steroid injection, and following a two-

week review, was excised. The histopathology showed a traumatic ulcerative granuloma with stromal eosinophilia with no evidence of dysplasia or malignancy. The second case is a 74-year-old male, non-smoker, teetotaller, referred by his GP for a persistent oral ulcer present on the left lateral surface of the tongue for three months (Fig 2). The patient’s medical history was also complex with associated polypharmacy for gastro-esophageal reflux, noninsulin dependent diabetes, acute myocardial infarction, fatty liver, pulmonary hypertension, coronary angiography, and stent with coronary artery bypass graft. Clinically the oral ulcer was irregular in appearance with a ragged margin, was not indurated, did not appear associated with an offending tooth, but did present with an area of white hyperkeratosis both anteriorly and posteriorly. The entire lesion, including the ulcer and keratosis was excised and the histopathology demonstrated moderately well-differentiated keratinising invasive squamous cell carcinoma. The cases demonstrate that induration and fixation are not seen in early cases of oral cancer, and as such their use as indicators of early oral malignancy should be abandoned. Instead, continual presence of a persistent ulcer in the same anatomical location which has been present for more than two weeks after instigation of appropriate therapy should be used as a sign for early detection of an oral malignancy. As highlighted in the second case, epithelial changes accompanying the ulceration may include the presence of leukoplakia (white patches) which signal precancerous tissue changes. – References available on request Author competing interests – the author has written a book on the topic

Fig 1: Traumatic ulcer

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Fig 2: Ulcerated early oral cancer

JUNE 2021 | 47

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Stereotactic radiation therapy: technological advances By Dr Kasri Rahim, radiation oncologist, Hollywood What is stereotactic radiation therapy, which patients are suitable, and what does the future hold? Stereotactic radiation therapy (SRT) is a highly advanced and precise technique differing from other external beam radiation treatments in that it delivers highdose, highly focused radiation in one to a few short treatments. When used in brain/head tumours, SRT is known as stereotactic radiosurgery (SRS). For other parts of the body, it is called stereotactic body radiation therapy (SBRT) or stereotactic ablative radiotherapy (SABR). The technique aims to safely ablate the tumour and achieve permanent local control whilst minimising dose to surrounding healthy tissue and organs. As radiation therapy is non-invasive and avoids the need for an anaesthetic, SRT offers an alternative to surgery when surgery may be impossible, too risky, is contraindicated or refused, or when patients are too frail. The treatment itself is performed in the outpatient setting, is not painful, and is generally welltolerated. Patients are usually referred following careful consideration and discussion at a multidisciplinary team meeting. A meticulous planning and quality assurance process is required prior to treatment with the aid of experienced radiation therapists, medical physicists, nurses, and the treating radiation oncologist. SRS is commonly used to treat brain metastases, benign tumours (e.g. acoustic neuromas, pituitary tumours and meningiomas), and other conditions such as arteriovenous malformations and complex cases of trigeminal neuralgia. SBRT/SABR can be used in primary as well as metastatic disease. Suitable primary tumours include early-stage non-small cell lung cancer, liver, renal and localised prostate cancer. In the metastatic MEDICAL FORUM | MENTAL HEALTH

Key messages

Stereotactic radiation therapy (SRT) is a non-invasive, advanced technique that delivers high-dose, highly focused radiation in one or a few treatments

SRT can be used to treat a variety of primary tumours (e.g., lung, liver, prostate) and metastatic disease (e.g., brain, spine, lung)

A next generation patient positioning and monitoring system is now in Perth.

setting, the technique can be used in patients with isolated or up to three lung metastases, adrenal tumours, disease in the spine, and other metastatic deposits known as oligometastases. Various machines can be used to deliver SRT including Gamma Knife®, Cyberknife®, TomoTherapy® and linear accelerator (linac)-based systems. The latter may not require the insertion of fiducial markers and offers a more rapid treatment time. While there are subtle differences, all have the same key features enabled by advances in technology since SRT was first conceived in Sweden about 50 years ago. The latest linac-based technology, Elekta Versa HD™ with the Brainlab ExacTrac® Dynamic X-ray System, is a patient positioning and monitoring system. It was introduced to WA in February 2021 at Hollywood Private Hospital’s new Consulting Centre. A linac with similar capabilities is located at Fiona Stanley Hospital. While the radiobiology of tumours and the dose of radiation required for cell kill is well established, the ongoing technological advances in radiation oncology focus on enhanced imaging and accuracy.

therapy (IGRT), the 4D thermal camera with its 300,000 surface points can externally monitor patient position and detect movement even during treatment. This ‘motion management’ adds another dimension in patient tracking so that treatment is delivered with submillimetre accuracy. Any changes in position can be corrected using the specialised robotic ‘couch’ which can be adjusted along six independent degrees of freedom including pitch, roll and yaw. This removes the need in some patients for the small but permanent tattoo markers used traditionally to help position patients for treatment. Patients with brain tumours may also be able to avoid the full immobilisation mask. Radiation oncology technology and treatment techniques continue to evolve and to date have resulted in higher cure rates, faster treatment times, reduced number of treatments, enhanced patient comfort and less side effects. The recent world launch of the MR-linac has heralded the next major advance. By integrating an MRI scanner into a linac, real-time visualisation of the tumour during treatment is possible together with the ability to reshape the dose based on daily changes in shape, size, and position of the tumour. There are currently two MR-linacs in Australia (Sydney and Townsville). We await news for Perth. – References available on request Author competing interests – the author consults with GenesisCare which has the machine described

The new linac is equipped with thermal-surface camera technology which works in tandem with realtime X-ray tracking. In addition to standard image-guided radiation JUNE 2021 | 49

Exercise for mental illness By Cameron Lilly, Senior Exercise Physiologist, Perth It has become common practice to recommend engagement in physical activity for those who are ill-affected with severe mental illness. However, this population typically engages in low levels of physical activity with poor adherence to exercise interventions. For practitioners and allied health professionals, understanding how exercise can positively impact mental health, as well as patientfocused motivators and barriers, can assist with patient engagement and ultimately them taking the first steps towards sustainable behavioural change. Generic physical activity guidelines show that adults need at least 150 minutes of moderate (or 75 minutes of vigorous) aerobic activity and

muscle training on two or more days a week to achieve significant health benefits. Extensive research has been completed investigating what modality, intensity, duration and/or frequency is most effective for those with mental illness. While some evidence has suggested intensity can impact certain neurotransmitter and inflammatory processes, a recent systematic review has suggested inconclusive findings around exact specifics, with contradicting verdicts around parameters in both aerobic and resistance training. Despite the specific parameters being debatable, most researchers within the field agree the first step in eliciting the benefits of exercise is establishing regular engagement in physical activity. If

we appreciate that improvements in physiological and psychometric measures of mental health have been displayed through various exercise interventions – including yoga, walking, running, cycling, rock climbing, resistance training and more – messaging to those prescribing exercise should focus on satisfaction, empowerment and promoting self-efficacy of exercise.

Barriers, motivators, and goals Research has shown that 91% of people with severe mental illness have outlined ‘improving health’ as a reason for exercising, with most common specific motivators being ‘losing weight’ (83%), ‘improving mood’ (81%) and ‘reducing stress’ (78%). Interestingly, low mood and increased stress were identified as the most prevalent barriers to engaging

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Key messages

Exercise is beneficial for those with mental health problems

This cohort will need additional support

Set realistic and open goals.

in regular exercise (61%), with ‘lack of support’ (50%) being the most prominent socio-ecological barrier. Importantly, exercise interventions delivered and supported by qualified exercise professionals (with a university qualification in physiotherapy or exercise physiology) have significantly greater physical and psychological benefits and adherence compared with interventions delivered by nonspecialised practitioners. When accounting for the dropout rates among sedentary individuals who commence exercise/physical activity (47% by the second month and 96% by the 12th month), the importance of identifying the stages

of behavioural change is evident. In addition to understanding motivators for exercise, an important component of developing adherence to regular physical activity – particularly for those currently inactive with mental illness – is goal setting. Traditional principles have consisted of ‘SMART’ goals, which implement specific, time measurable parameters. However, leading researchers and exercise professionals have identified a gap with SMART goals, with the multitude of potential barriers that can impact the trajectory of achieving established goals, ultimately negatively affecting selfesteem and adherence.

A common example is the goal of achieving 10,000 steps a day, which on the surface is evidence-based, however, for sedentary individuals with severe mental illness, this is often unachievable in the initial stages of behavioural change. As a result, a transition towards open and stepped goals is gaining traction, with researchers terming this new approach as ‘do your best’ and ‘open’ goals. Following the previous example of achieving 10,000 steps per day, this ‘do your best’ approach encourages a gradual increasing of steps with messages such as “a little is better than none” to reinforce positive changes and responses to increases in physical activity, despite not completing the desired 10,000 steps. In summary, understanding that exercise has been identified as a complex learning task, additional support through exercise professionals, the implementation of open-goals and education around the benefits of exercise can assist in overcoming dropout rates. – References available on request Author competing interests – nil

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Abnormal liver biochemistry – clinical relevance By Professor John K. Olynyk, gastroenterologist & hepatologist, Murdoch Abnormalities of standard liver biochemical tests are common – about 14% of adults have Alanine Aminotransferase (ALT) levels above the upper end of reference range while over 20% have elevated Gamma-Glutamyl Transferase (GGT) levels. So, what is the relevance to health outcomes? Elevated levels of both are associated with significantly elevated risks (up to 20-fold) of mortality from liver disease. Elevated GGT levels are also a marker of increased cardiovascular disease mortality, largely due to its reflection of the metabolic syndrome and non-alcoholic fatty liver disease (the liver component of the metabolic syndrome). Furthermore, many serious conditions ranging from gallstones or malignancy through to hepatic drug reaction can manifest as jaundice, ‘cholestatic patterns’ (elevated alkaline phosphatase, GGT and/or bilirubin) or various combinations of abnormal liver biochemistry results. Cirrhosis of the liver is the 11th commonest cause of mortality world-wide, being higher in men than women. Mortality from chronic liver disease is largely due to the development of cirrhosis, portal hypertension and its clinical sequelae (ascites, variceal bleeding, encephalopathy, and renal failure) ultimately resulting in liver failure, and hepatocellular carcinoma (the second commonest global cause of cancer death after primary lung cancer). Significant liver disease can be completely asymptomatic thus clinicians are required to evaluate the cause and requirement for further investigation and treatment of patients presenting with this problem. Navigating the pathway by which abnormal liver biochemistry is evaluated can be challenging. The free resource, Abnormal Liver Function Test pathway at HealthPathway WA, helps clinicians in the evaluation and decision for referral of patients with abnormal MEDICAL FORUM | MENTAL HEALTH

Key messages

Adopt a logical approach when considering management

Free resources are available to assist

Not all new assessments have been clinically validated.

liver biochemistry. For login details email healthpathways@wapha.org.au. The key issues when considering a liver problem are • What is the cause and is it treatable? • How severe is the condition? • What should the follow-up be? The most important clinical sequelae of liver disease are red flagged in the pathway to enable rapid identification of those requiring urgent referral (ascites, jaundice, encephalopathy, acute gastrointestinal bleeding, or acute severe hepatitis). The commonest causes of liver disease in our community are nonalcoholic fatty liver disease (now renamed as metabolic associated fatty liver disease to better align with the metabolic syndrome), alcohol-related liver disease (still the commonest cause for emergency department presentation with decompensated liver disease), chronic viral hepatitis (B and C), and drug induced liver injury (from many prescribed and non-prescribed medications or supplements). Collectively these causes account for up to 80% of all liver disease in our community with fatty liver diseases (alcohol or non-alcoholic/metabolic) accounting for half the cases. Less common, but important, conditions also cause liver disease. Hereditary haemochromatosis is common enough (one in every 190 individuals of northern European descent) to warrant consideration and even has its own HealthPathway for assistance. The Abnormal Liver Function Test pathway will guide the clinician through common

causes, how to investigate, what to do, how to treat, when to refer and provides links for patients to access information. Finally, a word of caution. There has been considerable advancement in the availability of non-invasive biochemical or radiological tests for the determination of advanced hepatic fibrosis (very advanced fibrosis or cirrhosis). Whilst these are useful, many of the cut-off values for these parameters vary for the different aetiologies of liver disease or in some cases the tests have not been validated in a particular liver disease. By and large, most of the noninvasive tests, AST to platelet ratio index (APRI), Fibrosis-4 (Fib-4) and Hepascore, have been validated in chronic viral hepatitis and alcoholrelated liver disease. The APRI or Fib4 can be calculated from rebatable simple blood tests (ALT, AST, platelet count and patient age only required). Hepascore is not currently rebated by Medicare. Non-alcoholic fatty liver disease is more complex and has its own biomarker panel. The biomarker scores and their interpretation can be found at https://www.hepatitisc.uw.edu/ page/clinical-calculators/apri and https://nafldscore.com Elastography is useful for detecting fibrosis or cirrhosis but is confounded by liver inflammation (which can provide false positive elevations suggesting fibrosis or cirrhosis is present) and can be technically difficult in obese individuals. Fibroscan is used primarily in major teaching hospitals, requires a dedicated machine, and is not rebated by Medicare. Radiology providers can also provide elastography when performing hepatic ultrasound at little or no additional cost to the ultrasound in most instances. If in doubt, refer the patient for a clinical review by your favourite gastroenterologist or hepatologist. – References available on request Author competing interests – nil

JUNE 2021 | 53

Psychedelic-assisted therapies – potential cures for mental illness By Dr Eli Kotler, psychiatrist, Malvern Private Hospital If the latest clinical research holds true, Psychedelic-Assisted Therapy (PAT) could revolutionise our understanding and treatment paradigms for mental illness. Psychedelics are psychoactive compounds which impact our subjective experiences, allowing people to work through emotional conflicts and traumas which underlie and fuel mental illness. The neural correlates of these experiences are understood. Massive neuroplasticity and reorganisations are triggered by serotonin 2A receptors in the neo-cortex. These non-patentable compounds are unattractive to big pharma, leaving research and ‘marketing’ largely to not-for-profits and forward-thinking universities. Psychedelic compounds are mostly found in nature, in fungi, plants and a few animals. They have been used by humanity as sacred healing compounds for millennia. The Nixon government’s ‘war on drugs’ led to these compounds being unscientifically banned in 1971. More recently, LSD and MDMA were synthesized in laboratories, and the search for synthetic psychedelics with clinically useful properties continues. Psychedelics appear to work through serotonin-2A receptors in the neo-cortex. These receptors radically increase the connectivity between cortical neural networks which usually don’t talk to each other. This increases entropy in the brain, “dissolving” previously hardwired and rigid connectivity. Focus has been placed on the Default Mode Network (DMN), a ‘resting-state’ neural network correlated with selfreferential thoughts and musings (like ‘ego’). 5HT2A receptors trigger neuroplastic changes, both functional and structural. These neurological shifts and events correlate nicely with the phenomenological experience of patients taking psychedelics. The subjective experiences of patients include ego-dissolution 54 | JUNE 2021

Homological Scaffolds. Source: The Royal Society: Nature Reviews Neuroscience 10, 186-198

Key messages

Psychedelic-assisted psychotherapy may revolutionise mental health treatment

Research is promising but lacks funding

There are ethical as well as scientific questions.

(breaking down thought-filled, controlling, and rigid aspects of our minds), connection, access to emotions, memories and conflicts, access to unconscious material, and a reorganisation of previously firmly held beliefs about oneself and the world. Often difficult and challenging initially, like any good therapy, it is through the shadow, fear, and pain that true healing is found. The subjective experiences correlate with therapeutic efficacy. This is fundamental in the mechanism of action of psychedelics and underlies their paradigm-shifting potential in treatment of mental illness. Often, psychiatric medications treat the symptoms by removing them (e.g. fear, anger, sadness). Psychedelics appear to work by giving us the courage to face disturbing parts of ourselves and work through them.

Thus, psychedelics are prescribed in the context of therapy. PAT is a new paradigm in which the power of a medication enhances good therapy to create a powerful modality of treatment allowing people to work through the underlying emotional conflicts and traumas, which may have triggered and maintained their mental illness. Patients say it can be akin to having a decade of therapy in a month. In this paradigm, mental illness can be seen as a symptom, a manifestation of unresolved emotional conflict. Most people with chronic treatment-resistant mental illnesses had difficult developmental experiences, or other trauma. This can be ignored in our current paradigms, which focus on syndromes often at the cost of the individual’s personal narrative (what is different in this person?). Carl Jung forewarned that this approach to mental illness would jeopardise patients. Over 160 current and recent trials demonstrate effect sizes well in excess of current treatments. In a series of MAPS Phase 2 trials with 105 participants (PTSD for average 18 years), 52% went into remission immediately after just three medicinal sessions combined with MEDICAL FORUM | MENTAL HEALTH

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CLINICAL UPDATE psychotherapy, and 68% after 12 months. Most of the remaining 32% had clinically significant decreases in symptoms. A phase-3 trial by MAPS will soon be published and preliminary results are even better. Recent research found 68% of patients in remission from moderate to severe depression at six weeks after two sessions of psilocybinassisted psychotherapy versus 34% taking daily escitalopram combined with psychotherapy. Psilocybin had quicker effects of greater magnitude in reducing depressive symptoms and was well tolerated. Anxiety and suicidal ideation were also reduced significantly. Numerous smaller open-label trials have had similarly outstanding results in a broad range of conditions. A trial of 15 chronic smokers had a 60% remission rate from nicotine at 2.5 years after a few sessions of psilocybin in addition to basic CBT. A similar trial of 14 subjects for alcohol use disorder found at nine months post eightweeks of therapy including 2 MDMA sessions, only 21% of participants were drinking more than the recommended daily intake, and nine

were abstinent, compared to 75% of participants who were subject to Treatment as Usual. Equally impressive results have been found in death-related anxiety (up to 80% response) in those with terminal illnesses. The Canadian Government recently legalised psilocybin therapy for end-of-life mental-health treatment. Not surprisingly, both psilocybin and MDMA have been granted ‘Breakthrough Therapy Status’ by the FDA. This rare designation is granted to medicines which are potentially significantly superior to existing treatments, to fast-track their approval. The medicines are also being made available as treatments in the US, Switzerland and Israel through Expanded and Compassionate Use pathways. Several Australian doctors have received SAS-B approvals from the TGA (federally) for MDMA and psilocybin-assisted therapies. However, state-level regulation currently prohibits the use of these medicines for compassionate use in treatmentresistant patients.

Society needs to weigh a delicate balance. On the one hand, we have potential breakthrough treatments to heal treatment-resistant people suffering with chronic mental illnesses. People continue to suffer daily, and some may kill themselves. Without industry funding, resources are scarce to conduct large scale RCTs. On the other hand, we have standards of evidence which we have come to expect for all new treatments. How long do we wait to allow compassionate use of these medications? How much evidence is enough? Who will push for access to these medications? Currently, due to regulatory issues (most significantly at the state level), these medications are not available to Australians. Given the suffering in our community, these questions are ethical as much as they are scientific. They demand deep consideration by all doctors caring for those with chronic mental health conditions. References available on request Author competing interests – the author is a director of Mind Medicine Australia

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LIFESTYLE

If you haven’t been to Perth’s favourite island playground for a while, Cathy O’Leary suggests you get reacquainted.

56 | JUNE 2021

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LIFESTYLE Rottnest Island has always polarised West Australians – they either love it and are prepared to ignore its shortcomings, or they dismiss it as overrated and overpriced. I’m firmly in the first camp, although I understand grizzles about the price tag, primarily the cost of accommodation but compounded by the ferry fare and the compulsory government entrance fee. And in the past, criticism of the charges for accommodation that was barely two-star were fair. I remember staying in so-called premium units at Thomson Bay or the Geordie Bay-Longreach outposts many years ago, when the first thing that needed to be purchased from the shamelessly expensive and under-stocked grocery store was cockroach and mouse bait. Second item on the shopping list was the awful soap and shampoo needed to garner even a hint of lather in the delightful salt water showers. Oh, did I mention the one-hour ferry trip over from the mainland, before the advent of fast boats and ocean stabilisers, when some people (read: me) spent the better part of the journey with their head in a toilet bowl suffering sea sickness? Once safely ensconced in a unit with the vermin bait in place next to the oven too dirty to use, the holiday-maker’s bedding consisted of uncomfortable mattresses with crinkly plastic coverings and thin, scratchy army blankets which reeked of who-knows-what.

Bay, and then to Longreach and Geordie bays. Many are self-contained, while others are basic camping-style cabins, and the price varies considerably depending on the view and the season. In the premium accommodation price-range, Karma Rottnest (aka Rottnest Lodge) is looking very tired and badly needs an overhaul, with better-value options at Discovery Rottnest’s Pinky’s glamping site or the oh-so-plush Samphire Resort adjoining Hotel Rottnest. These two newish establishments are expensive, particularly with dynamic pricing which can see the prices sky-rocket on weekends and peak holiday period. My experience at Samphire and its restaurant Lontara was only positive – I tried to book another weekend online as soon as I left on the ferry back to Fremantle – but others have found it hit-and-miss. I suspect it opened too early, before it had all its ducks in a row, and has been playing catch-up ever since. And while the premium tents at Pinky’s are literally only a few steps to the beach, the tariff can be eyewateringly expensive. During my recent stay in one of Samphire’s beachfront units – its best accommodation type and one of the most ‘beach chic’ rooms I have ever stayed in – the daily tariff

was actually less than the rate for the best tent at Pinky’s so go figure that! Despite the luxe options, for most people staying in self-contained units with family and friends remains the quintessential Rottnest experience, and the ambience has vastly improved over the years. As such, they remain in hot demand, and securing one over Easter or the January school holidays is akin to winning lotto. In another major improvement to the island, there is no need to haul over groceries from the mainland like we did in the olden days. The general store is now a fully-fledged gourmet supermarket as good as anything you will find in Perth, with anything from grain-fed beef to French brie and quince paste – and no sign of the dreaded salt water soap. But a holiday at Rottnest is not all about staying in at your digs – it’s about getting out and seeing the island. A lot of work has gone into making the 11km long island more accessible, with a great network of clearlymarked walk trails developed, no doubt as a result of the surging popularity in group hikes in Perth. Another game-changer for people who have struggled in the past to see a lot of the island on bike continued on Page 58

The memories! Fast-forward to 2021, and while Rottnest still has all its charms, thankfully there are more accommodation options which, while not cheap, seem better value. Ferry fares are more affordable and provide more incentives for daytrippers, with day returns of $49 in summer, including the island fee, or as low as $35 for people happy to catch an afternoon ferry and return home by 10pm. Accommodation consists of units managed through the Rottnest Island Authority, with dozens of them stretching across the eastern and northern side of the island, from Kingstown Barracks across south (nappy alley) and north Thomson MEDICAL FORUM | MENTAL HEALTH

JUNE 2021 | 57

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Rediscovering Rotto continued from Page 57 because of the daunting killer hills (pick me) has been the inclusion of electric bikes at the bike hire shop. Again, not that cheap at $60 for a 24-hour period, but e-bikes open up the whole island, allowing visitors to get around it all in one day, even with plenty of stops along the way. On my circuit I enjoyed a refreshing dip at Little Salmon Bay, had a decent barista coffee overlooking the view from the inland Wadjemup Lighthouse, and visited the impressive West End with its boardwalk and seal viewing platform. From there it was off to Ricey Beach, the stunning Little Parakeet Bay (another swim stop) and then through Geordie and Longreach bays before arriving back in Thomson Bay in time for the obligatory pie and cream bun at the bakery. The next day we were a tad saddlesore, even with the assistance of the electric powered bikes, and decided we would opt for a less adventurous day back at some of the quieter beaches we visited on the previous day, and go by bus. But in the end, it was better sense to pay the $40 second-day hire rate for our e-bikes rather than the $20 daily bus ticket. Another issue that has long complicated the relationship many visitors have with Rottnest is its past, specifically the disturbing incarceration of Aboriginal prisoners in the 1800s. There is no way to gloss over this dark period in time, but there are now efforts to acknowledge this history, warts and all, and recognise the Whadjuk people as the traditional custodians of Wadjemup (Rottnest Island).

you traverse the Island’s unique landscapes along the Wadjemup Bidi – a series of walk trails that take you across spectacular coastal headlands, past stunning inland lakes and natural and man-made attractions along the way. "Bidi" means trail or track in Noongar, the language of the Whadjuk people. The trail is 45 kilometres in its entirety and made up of five sections, each boasting significant landmarks to interpret and experience, connecting Rottnest’s beautiful natural features to its cultural history. A popular walk trail is the 9.7km Gabbi Karniny Bidi trail in the north, which starts from the Thomson Bay settlement and heads west out of Digby Drive, meandering through the lake systems including a magical stroll along the Lakes Boardwalk which provides the impression of walking on water.

A project is underway to properly recognise the Quod and the Burial Ground, as well as other sites connected to the Aboriginal prison era, and determine a future use for them in consultation with the WA Aboriginal community.

Equally impressive and worth the leg-work is the 7.6km Ngank Wen Bidi on the western end of the Island which is a marine wildlife haven. New Zealand fur seals can be seen from the viewing platform at Cathedral Rocks and the West End boardwalk is a great place to spot dolphins and the seasonal migration of humpback whales.

It is wonderful to see Aboriginal names pop up everywhere as

The loop circumnavigates the entire West End, guiding you along one of

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the most remote trails on the Island. The views from the south coast span back to the mainland and all the way to Garden Island. If longer walks seem too much like hard work while on holiday, the Rottnest Voluntary Guides Association offers shorter guided walking tours each day, leaving from the Salt Store located between the Dome café and the main settlement shopping mall. It sounds trite but there really is something for everyone at Rottnest, whether you want to walk, cycle and swim your heart out, or just sit around and read a book while smugly gazing at the mainland haze. Of course, no visit is complete without quokkas and it is good to see visitors largely adhering to the prominent message boards advising not to feed or touch the wildlife, however cute they look. Still, quokkas can’t read signs, so there is nothing to stop the occasional one from slipping in quietly under a bench table at the pub to snaffle up the odd discarded crust of margarita pizza. A photo of that and you can tick all the boxes of the perfect holiday. ED: For more details on accommodation, ferries and things to do, go to www.rottnestisland.com. For free guides tours go to www.rvga.asn.au MEDICAL FORUM | MENTAL HEALTH

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WINE REVIEW

Aravina sets new heights The current Aravina Estate began its life in 1986 as Amberley Estate. Located in the northern Yallingup sub-district of the Margaret River appellation, it boasts a fine vineyard with lovely surrounding gardens, a fine restaurant, a brewery and a popular sports car and surfing museum. The vineyard is roughly 32ha planted with the usual Margaret River varieties of Cabernet, Chardonnay, Semillon and Sauvignon Blanc. Pleasingly, some less than usual varieties including Tempranillo, Chenin Blanc, Touriga and Grenache help to make up the mix. Older readers may remember the Amberley Chenin Blanc, which was hugely popular in the 1990s. It was a pleasant, slightly sweet wine which at one stage made up 60% of the estate’s production. The current owners since 2010, sixth generation West Australian Steve Tobin and his wife Hayley Munro-Tobin, have significantly improved and refined the viticulture and winemaking and are now able to offer a large range of quality wine. An important development has been the construction of a new winery on site in 2018. Prior to this, wines were made at Nannup in a winery belonging to the Constellation group, the former owners. The four wines reviewed are all from Aravina’s premium range and are well worth a taste.

2019 Block 4 Chenin Blanc A far cry from the old Amberley Chenin, this wine is all about finesse and power. White flower and honeysuckle aromas, generosity of fruit and a steely backbone make for a serious food wine that can age for years if so desired. Worth seeking out. (12% alcohol, $35)

Review by Dr Louis Papaelias

2019 Wildwood Reserve Chardonnay

2018 Wildwood Ridge Reserve Cabernet Sauvignon

A very well-crafted wine. Attractive white peach and complexity resulting from judicious barrel fermentation and maturation. This is more restrained than many other Margaret River Chardonnays. Alcohol level is 12.5%. I suspect the winemaker is aiming more for a Chablis style of wine. This is not for those who like big buttery chardonnays. It has a gentleness that many will be attracted to. ($50)

The flagship wine of the estate. Coming from the highly acclaimed 2018 vintage. Classic cabernet nose; cedar, tobacco and cassis. Full flavoured and generous with fine fruit tannin balance. A fine effort. Drinkable now but will keep for many years. (Alcohol 14%. $65)

2020 Limited Release Tempranillo This has an exuberant bouquet of plums and cherries. Delicious and supple on the palate. Minimal oak evident but fine tannin support for the abundant fruitiness. Delicious now, but will definitely keep for a few years. (13.6% alcohol. $35) Although the cabernet scored the highest, my heart went for this delicious tempranillo.

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K C I P JUNE 2021 | 59

Take an armchair ride into space during a unique concert combining baroque music and spectacular images of the universe.

By Ara Jansen

It’s a tantalising idea to think that somewhere out there in the universe there are others like us or planets like ours.

theoretical than being a cosmologist. Geology is tangible; you can see and touch a planet’s surface and work out why it looks like it does.”

Astrophysicist and planetary geologist Dr Antony Brian is more interested in what we can see and potentially touch on the way to meeting those universal citizens.

In 1619, Johannes Kepler in Harmonices Mundi (The Harmony of the World) sought to explain the third law of planetary motion by recourse to the mathematics of scales and tuning systems. The so-called “harmony of the spheres” was a concept alive in the late Renaissance and early Baroque periods and was a potent creative catalyst amongst musicians and astronomers.

After doing a PhD on volcanoes and the resurfacing history of the planet Venus at University College London, Brian followed a mentor to California to continue his work, primarily researching and mapping Venus’s volcanoes covering areas around the size of Brazil. “I’ve always found space and the night sky fascinating,” says Brian, who is also quirkily known as a Venusian volcanologist. “When I was growing up, the NASA space shuttle era had just started. Becoming a planetary geologist allowed me to look at some amazing images of the planets. It also seemed a lot less

Now living in Perth, Brian is a business analyst and sometimes trumpet player who still marvels at space and continues to be inspired by the potential harmony between planets and music. The result is the creation of a multi-sensory performance called Space Music in which Brian guides the audience through the stars, planets, galaxies and nebula.

Winning ways Winners of the Republic of Fremantle spirits draw are Dr Yvonne Tan, Dr Richard Warne & Dr Sharon Smedley; Dr Jegajeeva Rao took home the Three Drops Doctors’ Dozen and Dr Claire Armanasco, Dr Megan Hardie and Dr Ben McGettigan won Kate Ceberano’s new album, Sweet Inspiration.

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Space Music has six movements and Brian will be sharing interesting and curious stories about our solar system, including how an error in translation hundreds of years ago led to the birth of the Martian and how an astronomer early last century fuelled speculation there were canals on Mars but was really seeing something else. Known for setting classical music in unexpected places, such as their Bach and beer events in a brewery and cakes and Corelli for high tea, Australian Baroque – in full baroque orchestra format – will create the musical backdrop to the curated images and space footage. They’ve been chosen from multiple sources including NASA’s Apollo, Mars Orbiter and Magellan missions and the Hubble Space Telescope. Brian says music has been chosen which mirrors or imitates character, for example Mars, considered the god of war, will be accompanied by Biber’s Battalia. “The baroque era has some fantastic music but you don’t need to know anything about it to enjoy Space Music.” ED: Space Music July 1-3 at Girls School in East Perth. The July 3 show is a 45-minute family special. Tickets from Eventbrite.

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Music of the spheres

Picture: European Southern Observatory

LIFESTYLE

Tales from the West Side A Broadway classic returns to Perth as West Side Story brings love and drama to the stage.

Picture: Jeff Busby

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LIFESTYLE

By Ara Jansen

When she thinks of classic musical theatre, Amba Fewster says West Side Story is always the production that first comes to mind. More than 60 years after it debuted on Broadway, its social, political and emotional themes are still highly relevant and numbers like the love ballad, Maria, and the undeniably catchy America are still much-loved. “The music gets you every time and I think that’s what makes people always want to come back,” says Fewster, a singer, dancer and actor appearing in the upcoming Perth production at Crown Theatre. Musical theatre changed forever when West Side Story first opened in 1957. Considered the most complex and challenging unity of music, dance, book and lyrics, it was the brainchild of a remarkable collaboration between Leonard Bernstein, Arthur Laurents, Stephen Sondheim and Jerome Robbins. A former pupil of Jerome Robbins, Joey McKneely’s vibrant new stage production comes to Perth after worldwide acclaim. Since the first world tour in 2003, there have been more than 1500 performances of this award-winning production. West Side Story is a modern retelling of Romeo and Juliet. It’s a tragic love story of two young people whose happiness is destroyed by MEDICAL FORUM | MENTAL HEALTH

the hate in New York City’s urban jungle. Two gangs are fighting for street dominance: The Jets are the sons of previous immigrants to America and the new Puerto Rican arrivals – the Sharks. Tony, a former Jets member falls in love with Maria, the sister of the Sharks leader.

muscle memory. Then you can let your body take over and build your character. “I feel like once you get the dancing and the stage movements into your body then you can let other things take over while the dancing almost becomes unconscious.”

Fewster, who hails from Perth, plays Francesca, a Shark girlfriend but also has the opportunity to regularly swap into other roles, including her favourite, Anita, who is the lead in the songs America and A Boy Like That.

Fewster’s profession requires a certain level of fitness and as a qualified Pilates instructor, she uses that to offset more aerobic training. She treats both her body and voice as instruments which both need to be nurtured and nourished.

“It certainly keeps you on your toes,” she says. “Playing both a Shark and a Jet, you have to be on the ball with everything and it can become pretty tricky. Equally, I also find it fun bringing something new to each of the roles as I move into a different position.

Fewster toured internationally with West Side Story in 2019 and is glad to be back with the production.

“There’s a lot of stage fighting so you have to be really aware of where everyone is standing and who is moving where.” In a musical where cast members are usually required to dance, sing and act, Fewster says first comes making the dancing part of your

“Whenever I’ve come back to the music, it gets me every time. Even with eight shows a week, it’s still powerful. There’s just something about how the music makes you feel. You just can’t help but feel every bit of emotion.” ED: West Side Story is at Crown Theatre from June 29-July 17. Tickets from Ticketmaster.

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