• 12 Jul 2022
  • 43 min 33 sec
  • 12 Jul 2022
  • 43 min 33 sec

In this episode, NPS MedicineWise medical advisor Dr Caroline West speaks with Dr Nicola Holmes, an experienced GP who specialises in the mental health of young people. Dr Holmes gives her perspective and practical tips on what she feels makes a real difference to engagement and management.

Transcript

Hello and welcome. I'm Dr Caroline West and I'm a GP and Medical Advisor with NPS MedicineWise. Today we continue our podcast series on young people and mental health. In the latest Australian census, it's been revealed that our number one chronic health condition is mental health, and given that 75% of people with mental health issues experience them prior to the age of 25, it's never been more timely to address it. Whether a young person is engaged and empowered makes all the difference to how they track into the future.

Today, I'm talking with Dr Nicola Holmes, an experienced GP who specialises in the mental health of young people. I'm keen to get her perspective and practical tips on what she feels makes a real difference to engagement and management. How do you work together with someone to help them open up when they're depressed and withdrawn? How do you create time for mental health consults? From a consumer's point of view, it's tricky to get an appointment and from a health professional's point of view, your book might be overflowing with demand. How do you do safety planning and how do we foster strengths and a sense of hope? No conflicts of interest have been declared for this podcast. Thanks for being with us, Nicola.

Dr Nicola Holmes Thank you, Caroline. It's great to be here.

Dr Caroline West Thank you. Now can we just start off by, I guess, creating a sense of the big picture here? What's it been like for young people, in terms of their mental health, particularly during COVID?

Dr Nicola Holmes Look, Caroline, it's been a very challenging couple of years for young people and particularly during COVID. If you think of those complex tasks of adolescents, where they're developing their own identity, developing their sexuality, developing their financial independence from their parents, finishing their education, to be so disrupted by lockdowns, school closures, it's really had a big impact on their ability to navigate through that normal path of adolescence. And we are seeing more psychological distress, some of which is appropriate for the difficult times they've been through, but also then flowing over into more what we would label and qualify as mental illness in that group. So I think the isolation from their friends, they're having to spend a lot more time on technology, the sort of disruption to life as normal has certainly had an impact.

Dr Caroline West Yeah, the disruption factor has been enormous for that age group. And I think when we look at mental health across the board, today, of course, we're talking about young people in that 16 to 24 age bracket, but if we look at the bigger picture in Australia, it's young people in particular, who've really struggled with this period. There was already a tsunami, if you like, of mental health issues out there in young people, but COVID has certainly made it so much more intense.

Dr Nicola Holmes And I think that's correct around the importance of young people for finding their tribe and really interacting with their peers, is so important in identity development, and again, that has been disrupted. Lots of the places where young people would explore their identity, music festivals, parties with friends, all of that has been inaccessible over this time.

Dr Caroline West You're a GP and you're talking to young people all the time, do they actually come in and open up that conversation around mental health, or are they more likely to come in and present with something completely different?

Dr Nicola Holmes Look, I think they're getting better at identifying mental health and psychological distress, but overall I would say no. I would say it's still a difficult topic for young people to broach. You'll get scenarios where say a parent is dragging in a young person by the ear, who hasn't attended school for two months, saying, "Help us." But to be driven by themself, not as sort of confidently. In fact, I think every opportunity you see a young person is an opportunity to screen around their mental health. And you'll often find they'll come in with an infected toenail or they'll come in looking for help with their painful periods or whatever is the medical issue presenting, but behind that, if you explore, there's often you'll find the path into addressing psychological distress.

So just like if you see a 40-year-old guy, they don't come that often, you better take their blood pressure. I think if you see a young person, 16 to 25, you want to keep, as a clinician, in your mind, the greatest morbidity and mortality is going to come from mental health in this age group. And using something like the HEADSS screening tool, which is, tell us a little bit about who lives at home with you. What's home like? You can explore that more. What about education and employment? What activities do you enjoy? What sort of enlivens you and interests you? D is for depression and drugs. How's your mental health been? How's your mood been? Exploring around drug and alcohol use, because often young people will escalate drug and alcohol use when they've got more mental health issues they're dealing with.

And S is around sexuality, spirituality and suicidality. So using that as your little framework, normalizing it. I always see young people on their own, I always ask just general questions about life. That can be a way of hooking into those mental health conditions that are behind whatever they're presenting with.

Dr Caroline West And do you find that the area of drugs and alcohol is a bit of a tricky one, in that I found in my practice that often young people may be experimenting with recreational drugs, but sometimes they feel as though if they tell you about that, you're immediately going to tell somebody else and they might get into trouble, so they sometimes withhold stuff, or do you find in general that with the right environment and trust, they open up?

Dr Nicola Holmes I think that's often a sort of myth amongst young people, but again, as a clinician, you can really set the stage to make it comfortable for them to open up. So you'll say confidentiality statement, which is so important with young people, around ensuring that what they're talking about with you remains confidential. I always sort of frame that in the sense I say, I just want to let you know that what we talk about here is confidential. What does that mean to you? And then say, so what it means is that what we talk about here, can't be shared without your permission. And I say, I can't talk to your parents or your teachers or the police about things, because that's what they're worried, you'll tell their parents, the teachers or police, so I name that, without your permission. The only exception to that would be if I was concerned for the safety or life of you on the day, and that's very unusual.

So I have sort of a clause of exceptions, but it's the small part of it, the big part of it is getting them to realize that we have no desire or sort of obligation. And if it comes out in drug and alcohol, I will often reassure them, we're not obliged to tell the police that you're using these, if they are concerned about that, we have no obligation at all, in fact, we are mandated to keep conversations confidential.

Dr Caroline West And sometimes do you find that you also have explain that situation with confidentiality with family members or carers? I've found that sometimes you'll finish a consult with a young person and then a parent or a carer might contact you or bust in and go, "Oh, what did they say? You need to tell us exactly what they said." And it's like, well, actually, what happened in our consult room is confidential, and sometimes that's kind of challenging for people involved in the bigger picture.

Dr Nicola Holmes Yes, it is. I think what you can do in that situation, of course we need to maintain confidentiality, but what you're hearing often is an anxious parent who's really concerned that their young person is safe. And so I think as a clinician by restating, look, I'm afraid that what we talk about, me and your child, is confidential, but please rest assured that should I be really concerned for their safety, I'm legally obliged to break that. So again, the parent is anxious that is their child safe. So many parents say, "Do you think they're at risk of suicide?" The parent is anxious to know that their child is safe. So I think we need to give them a little bit of reassurance, it's not me and the child against you. And sometimes I'll say to parents, look, it's very important that the young person feels they have this confidential space so we can get the true story from them, that's why we do this.

Dr Caroline West I really like the way you put that, actually, that makes sense to really give the support team, the framework for reassurance. Because as you say, a lot of the time, they're really anxious that something terrible will happen to their family member and they want to make sure that that doesn't happen. And they often want to know about what are some of the signs to look out for? How will I know if they're getting worse? And I guess that brings me to my next area I'd like to explore, which is really this sense of how do you work out where someone's sitting in a severity scale, when mental health in young people is one of those things that can really fluctuate a lot from day to day, week to week?

Dr Nicola Holmes Yes. I think I've changed my approach to this over the years, I used to get more sort of anxious and concerned myself, when young people say, would disclose suicidal thinking, for example. Now I tend to look at the bigger picture to try and work out how severe is this episode that this young person is going through. So if a young person is generally functioning and by functioning, it's doing all the things that young people should be doing developmentally. So if they haven't been to school for three months, three years, then that's saying that there's a high level of severity. They should be interested in peer groups, finding their tribe, engaging with their friends. So if they're starting to withdraw and not go out with their friends, not want to have contact with people, family members, that's increasing the severity scale.

If they're increasing their drug and alcohol use, that's usually in response to psychological distress. Sometimes it's just normal risk-taking exploration of young people, but again, that can be a sign of more severity. And then again, similar to adults, the sort of melancholic symptoms, can't sleep, don't want to eat, weight changing, slowing down physically, they, of course, raise alarms that it's increasing severity.

Dr Caroline West And do you think some of the assessment tools that some of us have on our software, things like K-10, where do they sit in this picture, to help us determine whether somebody's moderately, mildly, severely depressed, for example?

Dr Nicola Holmes Well, if I'm honest, I don't find them useful. So say a K-10, in my practice is more of a tick the box for auditing purposes, rather than I look at it and think, oh, I'm really worried about this young person or, oh, this person's okay. So they're not validated in this age group, for a start, a K-10. And the tools that I would use to try and assess severity and safety, is actually the clinical consultation. So I use a HEADSS screen, like I was saying before, to try and check, are there any strengths? Is there positives in that? Are they in the basketball team that they really enjoy? Is there something where we can draw strengths out of the HEADSS assessment? And then the patient engagement is very important and we know no matter what tool you use, if there's not engagement in the consultation, your risk assessment, which is never perfect, and we know we're not good at assessing risk, is sort of invalidated by lack of engagement.

So a young person who I can't engage with, I'm more concerned about their safety. And then the last thing is the part of the safety planning around what are we doing next? Whether that's just, how do we get back to school or how do we deal with suicidal thinking or our management plan, how well do they buy into that, and does that feel like it's kind of going to be followed and safe? And if there's a feeling that that's not working and they're not buying into it, then I'm more concerned about severity and risk.

Dr Caroline West I'd love to come back to that area of safety planning in a moment, but just going back to what you were saying about engagement, and that really being the central starting point for the consultation and making sure that you can actually assess someone involves engagement. What sort of strategies do you use when you sense somebody's not engaged? Like how do you increase that level of engagement?

Dr Nicola Holmes I've got a tool I call calling the elephant in the room, which is when you're sensing something like that, is to actually call it. So I might say to a young person, something like, oh, Jim, I can just feel that you're not really interested in being here. Is that right? Or, Tim, it seems like mum might have dragged you along here, is it her idea or your idea? Like sort of acknowledging the resistance and the reluctance to be there. And they're like, "Oh yeah. Okay. You can see it. Okay." And then it's like, how do we move forward? It's things like, well, what do you think mum would be worried about, that mum has dragged you here? Like from her point of view, if we asked her what would be her concerns. "Yeah. Oh, nothing. Nothing. No, I'm fine. I'm fine."

Okay. Well, if we're here, maybe we can just spend a little bit of time getting to know each other a bit. Wonder if you can tell me a bit about where you're up to, again, on a HEADSS style kind of assessment, you could use that as engagement. But also like if you get anything that they're interested in, any activities, anything that you see them spark up, you can watch their body language change as they talk to you about their game that they're playing on the internet, inquire about that, be curious, put them in the expert position. I don't know much about that game, can you tell me what sort of game is it? How do you play it? What's the goal? How long does it take? Do you play it with other people? Like just really curious, learning about you.

You can do that around their interests. If you get nothing from that, sometimes I say, do you take much photos of on your phone, have you got any good photos of things you've been doing lately, or anything you'd like to share off your phone? Sometimes they'll open up and show you some things and you get them talking. Again, if you can be beside them, rather than across a desk, so if you can be sitting beside them, looking at their phone, that also not too much eye contact, not too intense, that'll sometimes get people talking. Asking them about what music genres they like, because I can say, I don't know anything about that. Have you got any music you can play for me off your phone? What's that like? Is it heavy metal? So once you've got them teaching you, you're curious, they're now starting to feel more confident to tell you about what's important to them.

Dr Caroline West Yeah. I think that's a really good tip and most people always have their phone right by their side, and it's amazing how much of their history is stored on their phone or their music choices or photos of the music festival that they attended. And so going into their world, if they're happy to explore it a little with you, without us being too snoopy, I guess, that's the other thing is not wanting to be ...

Dr Nicola Holmes Yes, yes, it's a dance.

Dr Caroline West Yeah, it is a dance because you don't want to sort of overwhelm and flood them with so much that they feel as though they need to protect their privacy as well. So as you say, it's a dance, isn't it? And sometimes I've found it takes quite a few appointments to get the dance rhythm them happening because one appointment is often just flagging it.

Dr Nicola Holmes One appointment is sort of just getting across, I care about you and this is a safe space for you. If they come back to see you, you've succeeded in engagement. If they don't come back, then you failed. If they come back, then you can start to work more. I've got a couple of other little tips. I like having fiddle toys on the desk. So it's a bit like the phone, like fiddle toys can really, like a squeezy ball or Rubik's Cube, things in their hands, they talk better.

The other thing I will do occasionally is I'll walk and talk. I say to them, oh mate, gee, I haven't stretched my legs for a while, how about we just go for a walk? We've got a park near our surgery, let's just walk around the park for 10 minutes, I need a bit of sun. Come on, let's get out of here. And we walk beside each other and talk.

Dr Caroline West Yeah. Yeah. So it's just sort of finding that common ground. I guess a lot of GPs and consumers listening would go, oh look, they all sound like great suggestions, but all of those things take time. And time is often something that GPs are really struggling with. Let's face it, GPs are under enormous pressure to deliver services to people across the community and appointments are often brief. How do you actually create a bit more space for someone, and it needs space to really explore these areas and build trust, how do you create that when your appointment book is just completely gridlocked?

Dr Nicola Holmes Yes. Look, I think if I had a magic answer that, I'd be a millionaire, I think to acknowledge that it's a struggle is really important. So I've tried lots of different things over the time. I generally only book three people an hour, so three 15 minutes and a gap. And on top of that, I'll ask people that I know we're doing more significant mental health work, to book half an hour. So that might only be two people an hour, 15 minute and a half an hour. And in the afternoon you can have a slot where there's an hour of quick appointments for sore ears and urine infections, et cetera, and training your receptionist that this is a quick script time, and these are longer appointment times. It is constantly challenging to get the time right, but I don't think you can book 15-minute appointments and do mental health much justice, especially with youth that you're not already well engaged with. So that's a challenge for all of us. Yes.

Dr Caroline West Yeah. Yeah. Well, I mean, I think that's one of the key things, isn't it, to sort of create time so that when they return, they're not feeling time pressured. Because they can sense when you're in a rush, people are glancing at their computers, looking at their appointment book just overflowing in the waiting room. And so giving them their attention too, so you're not distracted.

Dr Nicola Holmes Yes. Again, that calling the elephant in the room, if someone springs on you and you really are totally pushed and have no time, just acknowledging, look, I really feel like this deserves a lot more of our time. So how about what we do today is X, Y, Z, a little bit of psychoeducation safety planning maybe. And then it'd be good if we could see each other, why don't we make some weekly appointments, just three or four in a row, and see how we go. So that gives them the space to know that they've got more opportunity to come back and you're the space to know that you don't have to do it all at once.

I guess my caveat for that is that when we get a chest pain walk into general practice, we don't say, sorry, you've only got a 15-minute appointment, you'll have to come back later. If they come in holding their chest with chest pain, we put them straight in the treatment room and we manage it as a chest pain, potentially an acute cardiac event. A young person with intense suicidal thinking is a chest pain, and you can't just say, sorry, I don't have time for it. So if there's high risk thoughts, you then have to respond to them and you blow out your waiting time. And whether you can get receptionist to shuffle people, tell people to come back later, move people to another day, if you're going to spend unexpected three quarters of an hour, an hour with someone who's in very high distress. So I treat them like chest pains.

Dr Caroline West Yeah. That's a really good way of looking at it, that really it's a total top priority. Because when we think about mental health issues in young people, you've mentioned it already with the anguish that everybody has around the risk of suicide. And that's fair enough because suicide is the leading cause of death in this young person age group, which is a tragedy, an absolute tragedy. And for every person that suicides, there are 100 to 200 attempts. And then beyond that, you've got the thousands more, who've been thinking about it. So it's the tip of the iceberg stuff, but it's one of those outcomes that everybody's trying to desperately avert. And so when it comes to actually doing safety planning, I guess a lot of health professionals and probably carers and people around this space, will think, oh, it's best not to talk about thoughts of suicide, because that's just going to make it worse. That's just going to increase somebody's risk. What's the evidence? Is that a big myth that we need to bust?

Dr Nicola Holmes Yeah, no, that's a total myth to be slammed out at the water quickly.

It's a bit like saying, don't ask anyone if they get any chest pain on exercise, just wait till they have their heart attack. So we have strong evidence that asking about suicidal thinking does not increase action on those thoughts. In fact, it decreases it and it lets the young person know that you are calm and comfortable and can hold this space of distress. You're not frightened of it. You can help them if they're having these thoughts. It's very important to get your language right around this too. You don't want to say, are you feeling suicidal? Remembering that's a very strong identity statement, I am a suicidal person. You actually want to separate out the thoughts from the person. So it's like, are you having any suicidal thoughts or people I know very well in a youth space, I'll say, how are your suicidal thoughts going, every single consult.

Are you managing your suicidal thoughts, as a way of just do I need to spend more time on this? Where are we up to? So asking people, have you been ... and you need a way that feels comfortable for you. I've heard people do it many different ways in supervising registrars and they seem to work well, there's no correct way, other than being quite direct about the fact we're trying to work out are they having suicidal thoughts and normalizing that a little bit. Like when you're depressed, it's very normal and common to have these kind of thoughts. And what happens as you get better is we're expecting those thoughts are going to space out, be less intense and eventually completely go away. And when you're not feeling distressed like you are now, you don't experience those thoughts.

Dr Caroline West Yeah, yeah, no, that totally makes sense, and so separating it. And I guess also having a sense of a framework that's using a strengths-based model, with something like safety planning. Talk me through what you do in terms of safety planning with a young person.

Dr Nicola Holmes Yes. So I think any young person who gives you the feeling or agrees with you that they're "not coping," they're feeling overwhelmed, they're struggling to manage their emotions or their suicidal thinking, needs some kind of safety planning. So I have two strategies I use a lot with young people. The first is the Beyond Now app, which is put out by Beyond Blue. It's a free app you can get on your phone, and I would encourage everybody listening, just to download it so you've got it on your phone and you can look through it.

I'll often share that even with carers, that this is how we do some safety planning around this. So the Beyond Now app has some sections on it that I would ... so the way I use it is I ask, I say to the young person, would it be okay if we just did a little bit of safety planning around what to do when these suicidal thoughts are quite intense? You know how they come in waves, like you've seen them before, three weeks ago you were telling me about that time when they were really strong and it was really scary, but then they go away. So we've got a little app that's got some really good evidence for helping you sort of ride over that wave when those thoughts become intense. So would you be open to that?

And hopefully they say yes, if they say, no, I'll give you another plan for them. And actually, if they keep saying no, then I'm more concerned if they don't engage in some sort of safety planning. So I'll get them to download the app on their phone. Again, you sit sort of in parallel with them, if you can, looking at it. The first part of the safety plan is they talk through my warning signs, which are changes that let people know that at this time they're heading into a crisis. So it has suggestions, I try not to give the suggestions and get the young person to think hard and come up with their own observations of themself. But common things are they're not sleeping well, they're withdrawing from friends, et cetera. So you write those down in the app, it records them.

The second section they have is how to make the space safe from whatever their particular plan they may have. Very important, while we do ask about suicidal thoughts, we don't ever nominate plans. Like you wouldn't say, have you had any suicidal thoughts? Have you thought of hanging yourself or taking an overdose? We don't mention the method because there is evidence that mentioning method increases risk, but it's important if people have suicidal thoughts, to explore the strength of intent and how far they are along in their planning.

The next thing I love on this app is it's got my reasons to live and you can actually upload photos, which is fantastic.

It's hard to remember when you're feeling really distressed, that actually really love your pet dog or your best mate, or that holiday you're planning to go to wherever. So you can write down your reasons to live and they can upload photos. It has a section on things you can do to distract yourself and sensory activities are fantastic here. Again, try to get the young person to nominate sight, sound, taste, touch, smell. What kind of things are actually going to be soothing and calming and would they enjoy? It's got lots of suggestions if you can't come up with anything, but warm showers, take a walk, pat the dog, smell lavender, listen to your favourite special Spotify soundtrack you've made for distressing times.

The next part on the safety plan for Beyond Now is people and places I can connect with. And again, you can upload your contacts on there. And the next one is people that you can talk to. And it gives you the nice contacts for the suicide call-back service and emergency services that you can call in a crisis, but you can also put your own up there. And then it talks about professional support, other people that are in your team. And at the end of completing it, if you do it on your own computer at work, then you can actually print it off and you could scan it on a file with them. But if they do it on their phone, they can share that plan with other contacts.

So if they've got, and they would always need in a safety plan, some support person, might be aunt so and so, ideally it would be a parent, but in some cases, the parents are not able to provide that support. You can share the plan with people who are part of it, so they all know we're talking to the same hymn sheet. They know what you're going to find helpful when you're a bit overwhelmed with this kind of thinking. So that's a very, very useful, I think if it's the one thing people take away to use around safety planning, is the Beyond Now, suicide safety plan app, it's excellent.

Dr Caroline West Yeah. I found it a fantastic tool and people can update it themselves, bring it back into the next session, they've always got it with them. And you've talked a lot about sort of thinking about mental health as being like any other health condition. And with heart disease, you think about, well, what are the signs for chest pain, what do you do about it? We need to have the same sort of applied approach to mental health, with safety planning. And I've heard Dr. Mike Millard talk about it, he's a psychiatrist, and he talks about it being like a fire drill. And we all get fire drills, they keep us safe when there's a crisis and when we're overwhelmed with incoming inputs and challenges, and we've rehearsed what we're going to do in that that will keep us safe. And I think it's that idea of keeping us safe, keeping someone safe, and it's a simple thing that probably has a really powerful place in the management line up.

Dr Nicola Holmes Yes. And acknowledging, like in the fire drill, that when you're really distressed, you don't think as well. Your cognition is a bit offline if you're really in a heightened distressed state. And so even more so if they've ... I think it's particularly difficult with young people who use a lot of drugs and alcohol, because of course that disinhibits them further, their cognition is offline. But if you have this written plan about what you are actually going to do, when you're distressed, then it's easier to act on it.

Dr Caroline West And so just to recap, you've blown that myth out of the water, that talking about thoughts around suicide actually increases risk. It doesn't increase risk, it offsets risk, it keeps people safer. So you can take people through that and certainly making gentle inquiries, if there's any suggestion of risk, delving further and working out whether they've actually put any plans in place, without being specific about it and giving them ideas. You're actually just trying to get a sense of what they've actually done so far, if that's relevant.

Dr Nicola Holmes Yeah. Yeah.

Dr Caroline West And I guess that we've also got to think that in certain contexts, there are certain groups amongst young people, that are much higher risk. So I'm thinking rural and remote, for example, I'm thinking of Aboriginal young people, I'm thinking of people from LGBTQI backgrounds, who are all at increased risk of mental health issues and suicide, and that needs to be on our radar too. I guess that gets back to the HEADSS assessment, to try and ...

Dr Nicola Holmes It does. We know say our indigenous young people, have six times the chance of dying by suicide, which is just huge. It's about double the chance in our LGBTQI community. And 48% of transgender youth will attempt suicide. So these are high risk groups. And so when you see them, it's like men, you know they're a high-risk group. But I think the beauty about safety planning is it's working in the moment where the risk is higher at that time, to know what to do when the risk becomes relevant this week, this day. I mean, the fact that they're a young indigenous person, they have this background higher risk, but we're trying to teach them what do we do, like the fire drill, like the asthma plan, when the risk comes up this week, because of, I notice my warning signs.

Dr Caroline West Yeah. And so, I mean, you've talked about the strength-based approach. And in fact, this is anchoring people back to this strengths-based model, of these are the things to look forward to, these are the things you enjoy doing, reminding people of these elements of their life. And what sort of things, in terms of the lifestyle arena, do you find really make a difference? I'm thinking about whether you find interventions around sleep, for example, or exercise, nutrition.

Dr Nicola Holmes Definitely. There's no rocket science in that. Definitely. Definitely. And actually, it's interesting because in young people, I think these lifestyle things are often quite significantly disrupted. So young people are often up till 2:00 in the morning, on their devices or playing games. And they have already a natural tendency to shift their sleep cycle later to bed, later up. But once they get sleep deprived, it's much more challenging. So just psychoeducation around that and interventions around modem off, charge your phone outside your room, if you can, for a week, see if it helps. Good sleep hygiene, occasionally a bit of melatonin to just start that cycle going, has incredible impact on their mental health. Exercise, as powerful as antidepressants in this age group.

So again, if we're using something like exercise as an intervention, we have to really tailor it to the young person and make it easy and doable. And it's better that they walk five minutes, three houses down and three houses back every morning and do it as a routine, than we set them up to fail by joining the gym and doing an hour three times a week. So I think it's important when you're negotiating these things, you start small, get the routine in and gradually build up from it.

Dr Caroline West And finding areas that they're actually interested in. I think that with some lifestyle prescriptions, if we're not careful, it's easy to sort of rattle off a list of things, oh, you should do this, but actually that's never going to work because if it's not their idea, it's your idea, you may find that it falls flat. And that's one thing that I think is really worth the time, is to really explore what is it they're interested in? I mean, do you find that?

Dr Nicola Holmes Definitely. And again, if you have some interest, that's where you'll often tailor your management plan around those lifestyle activities. For example, you have someone who's interested in music and singing, but isn't doing anything with that at the moment. Can we explore, is there anything through the school, through the Conservatorium, would they see themselves joining a choir group, which is very engaging and positive, or what could they do around their music? So, yes, definitely trying to find things they're already interested in. If they come up with nothing, then I'll often revert back to what is known as values work, which is finding the character traits that they really want to build up in themself. And there's lots of ways of doing this, but you can just get values lists off the internet and work through them with that.

Dr Caroline West Yeah. For those listening, we, on NPS MedicineWise, have a couple of other podcasts on young people in mental health. We've talked to two young people, Nic and Rebecca, about their lived experience with mental health issues, and they talk very eloquently about exactly what you're talking about. And I guess the other area that is worth flagging with our podcast, if people are interested in exploring the other areas of digital online therapies, we have a podcast on This Way Up, which is providing many people with access to evidence-based programs that assist with depression, anxiety, insomnia, for example.

Dr Nicola Holmes Yeah, they have a great insomnia and stress management, was quite good for young people, their stress management one and their insomnia one, and they have a student wellbeing as well.

Dr Caroline West My experience working in rural and remote areas, is often the GP is the port of call for many counselling opportunities, simply because there's a lack of psychological counselling staff in those parts of Australia. And I guess that's one of the frustrations for many people, that they're unable to obtain face to face counselling, or it's just too expensive. And so I guess that the digital options give us a chance to provide a choice there, if other services are not available. What's it like where you are?

Dr Nicola Holmes In Coffs Harbour, we have trouble accessing psychological services at a cost that young people can afford, so we have the same kind of issues. I would say there are a lot of psychologists in Coffs, but ones that will bulk young people are quite rare. Probably the most powerful sort of digital resource I would give to almost everyone I work with in mental health, is the Head to Health website. So Head to Health is a portal that has a lot of evidence based mental health resources on it, and a very good search engine. So again, if your listeners have a look at the Head to Health website and just search a couple of things within that, search anxiety, search suicidal thinking, see what comes up, you'll get a feel for that when you're sharing it with patients.

And I guess for the young people, there's also eheadspace. Now that's open to 1:00 AM, it's an online either chat or phone. It's not face to face, they don't need any referral, it's completely unlimited. And you're connecting with a mental health worker, psychologist, social worker, someone with training background. So it's quite different to ringing say a support line like Lifeline, where you haven't always got that high level of skill at the end of the phone, you have great compassion and absorbing and a bit of safety planning around, but not that same level of skill. So the eheadspace team will actually do kind of therapy with people, rather than just absorbing and listening and deescalating psychological distress. So that's open to 1:00 AM, so that's another resource for our young people.

Dr Caroline West Fantastic. And also just to put a plug in for NPS MedicineWise, we have a lot of resources on this topic in mental health issues, in young people, especially around engagement, empowerment. We've got videos, we've got a webinar on it, which certainly covers all of the management issues around interventions, first line therapy with psychology services or talk therapies, lifestyle interventions, and medication for people that are in the more severe category with their mental health condition. So if people would like to have a look at those, they can just go to the NPS MedicineWise website, and have a look at that. And I guess we've talked quite a bit today about this sense of having a strengths-based approach. And how important is it to sort of create a sense of hope or optimism here?

Dr Nicola Holmes Well, I think that's one of the greatest things we can offer young people actually, is with our experience of seeing many young people moving through this phase, I think we can really hold hope and share that hope with them. It's a very powerful sort of tool for people who are feeling really overwhelmed and distressed, is to have somebody almost calmly put their hand on their shoulder and say, it will be okay, with a true belief that it will be okay. And sort of sharing a bit, normalizing that it's not uncommon for young people in this find their feet, identity phase, to have ups and downs and experience times where their mental health is more sort of unwell and distressing, and that those phases will go.

And I have personally seen people go from 18 months inpatient over four years, haemoglobin 55 from self harm, every single piece of skin taken down to muscle, to well, thriving, studying aged care, living with partner, independent, moved out home in another city, and we've only got to see a couple of those to go, wow, anything's possible. And so you can kind of share, that's not what you tell them, but that's what's in your mind and your body as you're expressing hope, is I really think we've got this, it'll be okay.

Dr Caroline West And obviously working in this mental health field with young people, can be pretty exhausting and challenging. How do you look after your own mental health? Because I know that it's an area where GPs are experiencing high levels of burnout and exhaustion, and I guess it's about protecting ourselves with strategies just like we'd suggest the people that we see do the same. Okay, I'll cut to the chase, how do you look after yourself, Nicola?

Dr Nicola Holmes Yeah. It's taken me a long time to realize I'm not super woman and I have to invest in this. So it has actually taken me time to understand that, and I think that's what's preventing me burning out is realizing that I have a limit, I can't do it all, and how much I have to invest in myself. So personally, and this will be different for every clinician, but I quarantine walking on the beach time with the dog every morning at 6:00. There's nothing like 6:00, 6:30, seeing the sun come up and moving your body, listening to the waves, being in nature, and that provides some quiet head time while you're moving for reflection. So lots of people say that exercise is powerful in whatever way that you engage in it.

I've only very recently taken up meditating, in spite of it being a goal of mine for about 15 years, and good old James Clear, the writer of Atomic Habits, has started that with me. It's probably only been three or four months, so I can't tell you how ... that feels good, but it's not quite embedded in a habit yet. And possibly the most powerful thing I do is I seek psychological supervision. So every two to four weeks, I will spend an hour with an experienced psychologist, talking through difficult cases, things that trigger me, how to maybe work with a client that I'm feeling a bit stuck with. And that, I've been doing, we started at Headspace as a group supervision thing, probably about six, seven years ago, has totally transformed my wellbeing and mental health.

And I work in a general practice now and I've encouraged the practice manager there to employ a facilitator, and we do once a month, group supervision. It's only been going about a year and a half and it's just clicking along, it takes a while for a group to really bed down into a very deep sense of trust. But I would encourage people to look for supervision, everybody could do with a sort of reframe and work with an experienced psychological clinician every six months just for life, let alone if you're working with really complex clients.

Dr Caroline West Yeah, that's a really good suggestion, so thanks for sharing that. I know sometimes it's quite hard for clinicians to talk about what they do in their own personal life, but I think it makes sense for us to understand some of the strategies that other people have used successfully, to allow them to stay in their roles long term and continue to support the community.

Dr Nicola Holmes And a good break every now and then. We took a year off in 2004 and went sailing for a year, just step total sideways. I think taking a good break every now and then is really important as well, you need more than a week to really just let your mind, body chill out.

Dr Caroline West Yeah. That recharge time is really important. So hopefully more people will be able to travel again and get out and about and take that leave that they're owed and actually make time for themselves. So thank you so much, Nicola for sharing your strategies and tips.

Dr Nicola Holmes You're welcome, Caroline. Hopefully there's some tips in there somebody finds useful.

Dr Caroline West Look, there's so much that we could continue to talk about here, Nicola, it's such an interesting area and such an important one, given the majority of long-term health issues actually start prior to the age of 25. There's this fantastic opportunity to build engagement and a skill set that will really change the pathway for someone's future, and it's going to have positive outcomes in terms of their work, education, social life, it makes a huge difference.

Dr Nicola Holmes It does, physical health as well. If you can get this nailed in adolescence and get young people with some good coping strategies, some good self-care strategies, their physical health is going to be so much better in the future.

Dr Caroline West Their physical health and reducing the stigma so that if in the future, something arises where they need to seek help, that you've removed that barrier, so that they feel comfortable moving forward and asking for assistance and strategies. So there's so much that we obviously still need to provide to young people to help them with all of this complex area, because it has been an extremely challenging time, and will no doubt continue to be so, COVID certainly isn't over yet, and all the determinants that influence somebody's mental health are certainly there. And so it's a really important field for us to continue to focus on.

I appreciate your time today, Nicola, I've certainly learned a lot today and I'm sure our listeners have also. I've been with Dr Nicola Holmes, who's a GP who specializes in mental health issues in young people. Now, if you'd like any more resources on this area, you can go to NPS MedicineWise website and look up further videos, handouts, podcasts, it's all there for you to access. If you'd like CPD points, go to our website and we'll indicate on the website what you need to do to record those. So thank you so much again, Nicola, for being with us. And I'm Dr Caroline West, look forward to seeing you next time, being with you next time, bye for now.