Look, thank you very much for inviting me to do this presentation today. So, my name is Professor David Forbes, I'm the Director of Phoenix, Australia, Centre for Post-Traumatic Mental Health, and we're affiliated with the Department of Psychiatry at the University of Melbourne. And what I've been asked to talk to you about today is evidence-based treatments for PTSD. Where are we and where do we need to go into the future? And what I was hoping to go through in relation to that was a little bit about, you know, what are the guidelines currently saying, what is the evidence as we have it at the moment? And I'm using as a reference point for that, the International Traumatic Stress Society guidelines, so the international guidelines, but recognising that there are a multiplicity of guidelines across the world, the USVADOD guidelines, the APA guidelines, the UK NICE guidelines. Here in Australia, we have our NHMRC guidelines, and that those guidelines share a lot in common, there's variations amongst them, but using the ISTSS guidelines initially as a first point of reference, just given the international nature of them. And so what I'll go through there is what are the psychological, what does the evidence tell us in relation to psychological recommendations, pharmacological recommendations, and what's the evidence telling us in relation to alternative approaches? And then kind of addressing the second part of the question, really, which is, you know, where do we need to go in relation, and the issues that I'm wanting to flag about where we need to go are really around the area of augmentation, what are some of the emerging and novel interventions we need to be thinking about? How do we deal with comorbidity in a multiplicity of ways? How do we better harness technology? And what is personalised, and raising the issue about personalised medicine going forward? I also recognise that where do we need to go from here also includes advances in relation to how do we use implementation science better? How do we advance the implementation of what we do? Probably important to say that's not going to be something I'm going to be addressing as part of this talk. That really is a talk in its own right, in relation to kind of what are the fundamental elements and components around implementation science that we're wanting to apply to the various types of interventions we're talking about today. So just to flag that early. I'm a clinical psychologist by training. I'm covering, as you can see, a lot of territory here. And I recognise that each of you that are listening, you're going to have your areas of interest, areas of speciality. And so for some of you, I may not be diving deeply enough into the areas of your speciality. Please forgive me for that. Trying to cover the territory as broadly as I can, as best as I can, recognising that there are some of the limits to the depth in which we can go in this initial keynote. But there is a panel in which we can discuss some of the details of interest or respond to questions down the track. Just before we start talking about what the guideline recommendations are, as a matter of course, I always kind of preface that by kind of citing that the comments of field and law going back to 1990, which is when we're talking about guidelines, remembering that we're talking about systematically developed statements to assist the practitioner and patient decisions about appropriate healthcare for specific clinical circumstances. And these are based on systematic reviews of the evidence, emphasis here on systematic reviews of the evidence, but also that absence of evidence is not evidence of absence. Which means that there's things that we don't recommend, not necessarily because we don't think that they're effective, we just don't have the evidence yet around them. So there's things that you're interested in if there are interventions that you think from your clinical experience are really gathering momentum, they're not mentioned here or mentioned lightly, it's really what we're saying is that the body of evidence around that hasn't accumulated to the point that we can make systematic recommendations about it. That's not a statement about its effectiveness or otherwise. Where we do have bodies of evidence to say that something doesn't work, we do make statements about that to say, to make recommendations about not doing something based on the body of evidence. And of course, these guidelines, international guidelines, national guidelines are always there to support or to recommend, and they're really not there to mandate. So that being said, as a highlight, what are the key recommendations of the International Society for Traumatic Stress Studies PTSD guidelines? So if we deal with the psychological recommendations in the first instance, and now what we're dealing with is an accumulated body of evidence where we've got over about 230 high quality RCTs that have gone into the mix, but upon which we then derive these recommendations. So we're really getting to the point where the body of evidence is really starting to build up quite significantly. And the strong recommendations are for trauma-focused cognitive behaviour therapy, prolonged exposure, cognitive processing therapy, trauma-focused cognitive therapy, so cognitive therapy a la the Ellison-Clark model, and eye movement desensitisation and reprocessing. So these are the treatments whereby we've got the strongest, we're able to make strong recommendations as to their effectiveness. And recognising that the trauma-focused CBT is kind of a broad brush approach, and then the others are more specific, if you like, branded and more specific variants of that. In relation to trauma-focused CBT, what does it involve? And there's an interesting chapter that I can draw your attention to, and I'll be referring to it a little bit. If I was face-to-face with you, I'd hold up a copy of it, but the Effective Treatments for PTSD third volume that we've just had published, that expands on the ISTSS guidelines, and there's a lot of detail about what these guidelines mean and how to apply them in clinical practice. There's a chapter in there that's kind of led by Miranda Rolfe, where we do talk about, you know, in terms of these trauma-focused CBT first-line recommended treatments, psychological treatments, what do they have in common? And really, its core elements are about assisting a person to confront or activating their memory in a gradual, safe and supported way, assisting the person to gradually confront the places and activities they've been avoiding in order to reclaim their lives, kind of addressing the experiential avoidance, and the third is assisting the person to address the thoughts or interpretations of what's happened and what it means about themselves, about others and about the world that's blocking their recovery. And whether through cognitive therapy, cognitive processing therapy, or post-exposure emotional processing, or things that come up through EMDR, all of these three elements find themselves in those key recommended treatments that I mentioned previously. In terms of the next level of evidence and what we call standard recommendations, here there's now an increasing body of evidence around guided internet-based trauma-focused CBT, PTSD, so MindSpot, for example, being an example of that. And these are guided or facilitated kind of internet-based interventions. There's the narrative exposure therapy, which takes a timeline approach for people who have been exposed to multiple traumas over a long period of time. Present-centered therapy, which was initially really introduced into a lot of the treatment trials as a potential active treatment control that's been found to be reasonably effective in its own right, which really looks to target the daily challenges that those people with PTSD experience and provide strategies to be able to address those daily challenges rather than targeting the core symptoms of PTSD itself. And some body of evidence around trauma-focused CBT on a group basis, and even for CBT more broadly. In terms of pharmacological interventions for adults with PTSD, we've now got approximately 50 high-quality studies across the range of agents that are out there, and where the international guidelines land, again, consistent with guidelines across the countries, is that we have recommended interventions, though they are stated as having a lower effect than the psychological interventions. And there, where we line up, is with the SSRIs, particularly paroxetine, fluoxetine, and sertraline, and also the SNRIs through Femlefaxine, as being the recommended interventions, although they're stated with lower effect than the psychological interventions. And the interventions with emerging evidence are quetiapine around that. Something I meant to say a fraction earlier in relation to the psychological treatment studies, but worthy of saying now, is even within the psychological treatment studies, we recognise also that many of those involved who are participating in those studies may have been on base levels of medication, whilst those medications are stabilised prior to entry into the study, and so that those trials are fairly rigorous in being able to say that the added impact of the trial is through the psychological therapy, we still haven't quite dismantled the degree to which entering into a trial on a base level of medication makes a difference to your capacity to benefit from the trial. It's an issue certainly worthy of further discussion, but not something that's been systematically addressed to the best of my knowledge, but something that is important for us to be considering. And so what are some of the other considerations around pharmacological interventions in relation to the psychological interventions? And these points are drawn from the Australian NHMRC PTSD guidelines, NHMRC standing for the National Health and Medical Research Council, effectively the kind of Australian equivalent of the NIH. And here in the Australian NHMRC guidelines, there are conditional recommendations for use to say, well, look, whilst the psychological treatments have a kind of a larger impact, there's a whole range of reasons why people might start on pharmacotherapy in the first instance. And those reasons are whether the person's unwilling or unable to engage in or access the recommended psychological therapy, whether the person's got a comorbid condition or associated symptoms, for example, very clinically significant depression, high levels of suicidality, high levels of dissociation, where the SSRIs might be indicated, whether the person's circumstances aren't sufficiently stable to commence recommended psychological therapy, where the person hasn't gained significant benefit from the psychological therapy, they've tried it, or they've tried a number of variants of it and still not seem to have gained benefit, but also where there's a significant wait time before the psychological treatment's actually available. And as I mentioned earlier, it is noteworthy and unclear from the psychological treatment trials about how many folks are actually on stabilising medications prior to engagement in the psychological treatments. I am going to be focusing on PTSD. I'm not going to talk a lot about prevention here. And I think that the issue of prevention is emerging and certainly worthy of considerable attention in its own right, other than to say the guidelines currently do recommend against routine psychological debriefing. And what we mean by that really is that we're routinely and in almost a mandated way, the person's required in the aftermath of an event to go through their experience and talk about what their psychological, emotional, physiological responses were, what they've observed in detail, etc. And that this isn't recommended. That's not to say we discourage people from talking about it. Those who want to talk about it, by all means, speak about it and speak about it with whoever they feel most comfortable talking about it with. But the idea of actually mandating people to talk about it runs the risk of cutting across people's natural coping strategies. And also, it's really important that people choose who they feel comfortable with and whom they might want to talk about it with if that's what they do choose. So that's the basis for the recommendation about routine psychological debriefing not being recommended where it's mandated, irrespective of the wishes of the individual. And what is recommended is a kind of a lower level of evidence, really, which is better. The best approach is really after a potentially traumatic event, offer information, offering emotional support and offering practical assistance together with watchful waiting and being able to observe how the person progresses over time. And these actions are consistent with what we might think about as psychological first aid. The reason the guidelines haven't called it psychological first aid is that the packages of PFA can get presented in different ways in different contexts. And so we didn't want to kind of label it according to that, but really because it was more about the actions that were being recommended rather than the label itself. And it's from a pharmacological perspective, what's indicated interventions for the first for those within the first three months, there is emerging evidence around hydrocortisone. As I say, emerging evidence around hydrocortisone, again, this is taken from the ISTSS guidelines, but insufficient evidence to recommend a range of the other agents that are noted here in the slide. Interest in them, still some examination investigations into them, but yet insufficient evidence to be able to actually be recommending them. So the other issue is kind of non-psychological and non-pharmacological in treatments, you know, where are we at in terms of the evidence base in relation to a range of those others? And here we have over 30 RCTs, not in each of these areas specifically, but overall in relation to these types of treatments, we have an increasing body of evidence really around that. And the interventions that do seem to be showing emerging evidence with a focus being on emerging are acupuncture, neurofeedback, SKK, somatic experiencing, TMS, which we'll talk about variants of kind of TMS also a little bit down the track in this presentation, yoga. And as I say, we'll talk about some of these in more detail a little bit down the track. But these non-psychological, non-pharmacological treatments are gathering momentum and these are some interventions that are demonstrating some emerging evidence. In terms of what's our first line treatment and our first line, biggest effect size treatments, which is the psychological treatments, you know, what's the data telling us in that respect? And of course, how effective are they depends a little bit on the benchmark definitions of improvements. And I think there was a paper out by Mark Hinton just in the last six to 12 months really that was talking about when we talk about benchmarking, what do we mean? And this of course, this has been an area of study where there's been a range of papers trying to benchmark what do we mean by improvement? Currently, there's no single authoritative study to the best of my knowledge, but approximately, of course, this varies from study to study, some more, some less, but about, with the emphasis being on about, about one third of those who participate in those first line evidence-based treatments show dramatic improvement and no longer meeting criteria for the diagnosis. About a third showed significant and large, important kind of life-changing reductions, but they still have moderate symptoms. And about a third, you know, for a third of folks who are participating in those treatment trials, we find little or meaningful change. So the effectiveness of this, even these first line treatments kind of varies considerably. Important to add though, that's when we talk about PTSD symptoms, and we do also see improvements in those first line treatments, not only in the PTSD treatments, which symptoms which they're targeting, but also in associated problems like depression and anxiety, and also moderate improvements in relationships and quality of life. So really important is that these first line treatments impact not only on PTSD symptoms, but on broader mental health and wellbeing and quality of life factors as well. So that's kind of the state of where are we now that now, I guess I wanted to just start to address the issue about where to from here. And in thinking about that, going across these issues of augmentation, about emerging and novel interventions, addressing co-morbidity, harsh harnessing technology and personalised medicine. And if we start off in the first instance with issues around augmentation, and again, in relation to these topics, there's a lot deeper we could be drilling into each of these topics. But for the sake of this initial presentation, really trying to get a sense of what in more or less where's the lay of the land. So from an augmentation perspective, again, we're talking about the potential benefit of an additional treatment, psychological, pharmacological or other, with the goal of improving outcomes of the first line treatment, or alternatively preparing an individual for a first line treatment. And in terms of augmentation, in terms of pharmacotherapy on pharmacotherapy agents with some evidence, and again, this is outlined by John Bisson and his colleagues in the effective treatments for PTSD book, where he's got a really helpful treatment algorithm, the agents with some evidence to symptom emerging, are kind of adding prazosin or risperidone as where it is an increasing evidence base around them being helpful as augmentation of first line pharmacological interventions. In terms of psychotherapy and pharmacotherapy, the additional benefits of those, certainly the current VA DOD guidelines, talk about insufficient evidence for the addition of medication for pharmacotherapy, for psychotherapy non-responders. So there doesn't seem to be at the moment a body of evidence to say for those who aren't responding to psychotherapy, if we add any particular pharmacological agent, we're able to see in a replicable way, evidence of improvement. That's not to say it's not there on a one-to-one clinical basis, but currently the evidence base more broadly isn't demonstrating that. And also a chapter in the effective treatments for PTSD book, which talks about combination therapy around pharmacotherapy with psychological therapy, identifies that there's no current compelling evidence for the addition of SSRIs to psychotherapy at this point. That's not to say that there isn't potential down the track, but at the moment we're not there where we can identify what are combination therapies that work best. In terms of pharmacotherapy and psychotherapy, there was a recently published systematic review of 34 augmentation RCTs by Olivia Metcalfe and colleagues that added an intervention to an existing first-line intervention. And they did find that paper did kind of report ceiling effects, which is that 86% of the studies reported no significant additional effects of the augmentation intervention on PTSD symptoms at post-treatment relative to the first-line treatment alone. There was, as I say, 86%, but there was promise in the other 14%. And the kinds of interventions that were showing benefit for being added, and in this case added to psychological interventions, were RTBS, acupuncture and exercise. So it didn't seem that adding another psychological treatment to a psychological treatment was making a difference. Some of the possible reasons that floated in that paper really were the advantage of why is it that these interventions like RTBS or acupuncture or exercise might provide some promise in augmentation to psychological interventions. So one is that they don't require additional or significant cognitive effort, which does matter when you're pairing it with something as cognitively taxing as PE or CPT, which is pretty cognitively demanding. You might more directly reduce some of the hyperarousal features, which also matters when the first-line treatment can be distressing to participate in. And also they're operating on completely different mechanisms to something like prolonged exposure, for example. So for these reasons, some of these augmentation methods might avoid the ceiling effects that were affecting the 86% of studies and showing some added benefit. Again, this is emerging. Where else do we need to go? And the next thing I wanted to talk about was emerging and novel interventions and some common themes that are amongst some of these emerging and novel interventions include focusing on non-talking therapies, experiential therapies and therapies that target somatic and hyperarousal symptoms more specifically. And as I mentioned earlier, we are now starting to see some emerging evidence around acupuncture, mantra-based meditation and mindfulness-focused interventions. With the mantra-based meditations, probably the one that has the strongest evidence base is around transcendental meditation. And there was a paper published by Nidhich and colleagues in Lancet, where it was looking at a non-inferiority trial lined up against prolonged exposure. And so there is kind of an increasing body of evidence with at least one high quality RCT in these areas and in yoga as well. So again, this is showing promise, as I say, not yet to recommendation stage, but it's definitely showing promise and an area for us to be building, particularly if we're talking about, you know, where can we also augment first line intervention? So the potential for these to be standalone, but potentially also critically, as I said, as per the last point, how they might augment first line interventions. In terms of pharmacotherapy for PTSD, and again, I'm kind of declaring I'm a clinical psychologist by training. So pharmacology isn't my area of speciality, but I thought it was relevant to kind of review a consensus statement from PTSD pharmacology, psychopharmacology working group, published in Biological Psychiatry in 2017, which talked quite openly about, although the evidence based psychological treatments have come a fair way, there still remains a crisis really in pharmacotherapy in the treatment of PTSD, with really only the SSRIs and the SNRIs being approved in a reasonably consistent way internationally. And these reduce the symptoms, but don't really remit PTSD as we've spoken about. And there hadn't really been a novel pharmacological approach for some time. When the working group or the expert group were asked about what was the top therapeutic targets for PTSD, you know, table six listed here from the Biological Psychiatry paper, kind of identifies the NMDA receptor antagonists, cannabinoid receptor modulators, glucocorticoid receptor agonists, non-SRI antidepressants, opioid receptor agonists, as the most commonly scored or commonly reported potential future top therapeutic targets for future examination investigations into moving forward the pharmacological interventions for PTSD. The consensus statement also then made a series of recommendations about what needed to be done to move the area forward. And one was about an urgent need to find effective pharmacological treatments, that this was a national priority. And in fact, I would be saying an international priority. The need to increase the number of early phase clinical trials through novel collaborations around government, industry and academia. The need to develop new trial designs and methodologies, specifically in the area of PTSD pharmacology trials. Foundational studies to inform the optimal prescription, commonly prescribed medications with treatment of PTSD. The development of a psychopharmacology clinical trial workforce and infrastructure to advance the goal of increasing clinical trials in the area. Studies exploring the pathophysiology of PTSD being critical to the rational development of normal pharmacological intervention so that it was less haphazard and idiosyncratic. And there's a need to continue to invest in initiative in translational neuroscience to enhance the expansion of pipeline of new pharmacotherapeutics. So really, realise this is now a number of years old, but I think those statements still hold true today. Presentation on what's happening and where are we going in the area of the treatment of PTSD wouldn't be complete without some comment around the hallucinogens and novel agents. And probably, and this is something that's kind of, that is of high point of discussion across each of our, each country internationally. And there's merging evidence really around two classes of hallucinogens, phenomenally called that, in terms of mental health more broadly. And also to some degree in PTSD. And they are the psychedelics that are acting through the 5-HT system. So LSD, psilocybin. And the dissociative anesthetics that are acting through the glutamatergic system, for example, ketamine. And intactogens, for example, like MDMA. Cannabinoids also. And for these interventions being considered both as adjunctive to psychological treatments or potentially standalone. And we can, the paper published by Varka and colleagues just last year that kind of looked to say, well, amongst all of those, you know, what's the evidence base for PTSD? And it seemed that it was really MDMA as an adjunctive treatment to non-directive psychotherapy, which is kind of where the evidence base is at the time. The approach taken by Mithofer and colleagues had the strongest evidence of all of the above. And really they're kind of identifying the pro-social effects of the MDMA. Kind of promoting a stronger therapeutic alliance. Potential decrease in interpersonal alienation. Contributing to the survivor's, you know, which has been contributing to the survivor's sense of isolation. As I say, that those treatment trials were really as adjunctive with non-directive psychotherapy. But the question really that we need to be thinking about is testing it where it's adjunctive with what a first-line evidence-based treatment might be. Whether it's cognitive processing therapy, for example, or prolonged exposure therapy, is where MDMA showing promise with adjunctive co-occurring psychological non-directive therapy. Are those effects the same? Is it the non-directive effects that are important? Or alternatively, can we get better and more significant improvement if we line it up with the interventions that actually already have a reasonably substantive evidence base as we've spoken about today? There is significant momentum investigations into ketamine and psilocybin across PTSD and other disorders. But in the PTSD space, the evidence for these are lower than around the MDMA. In terms of emerging evidence for the neuromodulation therapies, you know, there is increasing evidence around this being an area of investigation worth continuing to pursue. Whether it's through TMS, RTMS, theta burst stimulation, TDCS, and deep brain stimulation as well. The provision of these as adjunctive to psychological treatments or standalone is showing some promise and certainly worthy of attention on the watch list and to be able to progress treatment trials that are looking at advances in these areas. As I say, standalone treatments, but also potentially, as we identified in the Metcalfe study, as potentially potent adjunctive treatments to psychological or further first line interventions. In terms of where else we need to go in terms of the roadmap, there is the issue about addressing comorbidity. And here we're thinking about transdiagnostic interventions or issues of treatment sequencing. And as we know, really comorbidity is the rule rather than the exception in PTSD. The vast majority of individuals with PTSD report at least one comorbid disorder, with the average really being two additional diagnoses. And apart from even the additional conditions or diagnoses, we also know that there's a whole range of associated features of anger, guilt, shame, dissociation, suicidality that go with PTSD more commonly than not. And the current recommended treatments often insufficiently address some of this comorbidity, or alternatively, that the comorbidity itself seems to interfere with treatment effectiveness. So when addressing comorbidity directly, a question arises about what do we know about the evidence-based treatments for these associated disorders and problems? What do we know about the co-delivery of these EBTs with first-line EBTs for PTSD? So for example, thinking about Cath Mills and the work that her group has done in relation to EBT for substance use disorders co-occurring with EBTs for PTSD. And then what does it mean about the sequencing of these treatments to optimise the treatment effects? And here, in terms of what we know about the sleep and PTSD relationship, the anger and PTSD relationship, and the manner in which sequencing might make a difference for how to get better bang for buck out of therapy. And then there's also the issue of transdiagnostic interventions. So digging a little bit more deeply into that in relation to targeted treatment for associated constructs, anger, sleep, pain, shame, guilt, probably being amongst, and I'm sure many of you, nightmares, many of you will have issues that you identify as missing from that list, but just starting with that in the first instance. What we know is that some of these comorbidities limit treatment effectiveness, and probably the body of data that we've got the strongest evidence around is in veterans. A study by Phelps & Co published in Psychological Medicine identified a triad of dissociation, guilt, and depression as associated features, along with the PTSD, was associated with the poorest trajectory of recovery following a few thousand folks who had participated in PTSD treatment programs across Australia, and that it was really the combination of those that was associated with the poorest trajectory of outcomes. Also, there's a body of evidence that we've done, that our colleagues have done, really, that's looked at anger and aggression at the start of treatment and the degree to which it interferes with the impact or the benefits gained through first-line treatments, particularly in the veteran context as well, and here it kind of flags the potential, particularly in the context of anger and aggression, to intervene early in targeting risk-related aggressive behaviours to render the trauma-focused treatment as safe, and what's emerging out of that really is anxiety and fear from veteran participants with PTSD about accessing the traumatic memory, and what happens if they kind of lose control and act in a way that's kind of particularly risks and harms to those around them, based on the basis of their training of responding to fear and threat with kind of a mobilising pre-emptive aggressive response. And so, is there the potential to be able to intervene early, and briefly even, to kind of render, to address some of those behaviours to render the remainder of treatment as safe, to allow them to participate more comfortably? A paper also just recently published by Cartel and colleagues identified that following PTSD treatment, that residual insomnia actually was a predictor for those who might be more likely to return to baseline after even having initial improvements in PTSD treatment, kind of again just raising the issue about what are some things we're learning about, what are some of the, even where people might improve, for survivors, people with PTSD might improve as a result of treatment, what are the things that we're learning and around what are some of the residual symptoms that might be potentially stronger candidates for risks of reversion to baseline, and the paper by Cartel identifies sleep as one of those, where sleep and insomnia are still residual even after significant symptomatic reduction, potentially the importance of being able to target that more directly and more specifically in the aftermath of initial dose of PTSD treatment to change those recovery trajectories. And also PTSD and physical health comorbidity, we know in PTSD and pain are often co-occurring in the basis of particularly physical injury and the potential for them to have a bidirectional relationship, yet there isn't a strong evidence base at the moment around simultaneous or interventions for PTSD and pain. We might throw it into the area of comorbidity but just addressing the issue about moral injury, kind of recognising and certainly there's something that Brett Litz has made, it's been talked about and Jonathan Shea has been talking about this for many decades, Brett kind of bringing it back to our attention in 2012 which is, you know, in high-stakes situation where people are trauma-exposed, people are exposed also to events that may be perpetuated or where they're failing to prevent or bore witness to or learnt about acts that transgress deeply held moral beliefs and expectations and what the mental health fall out of that is. And whilst there's some investigations going as part of international consortium at the moment and a range of kind of outcome scales, that's the moral injury itself, you know, the kinds of constructs that we see in the mental health space that are outcomes around that, around shame, guilt, loss of trust, self-depreciation, anger, alcohol abuse, psychological functioning being impaired, relationship difficulty, suicidal ideation of the desire for harm self or others and often these, they can be but not necessarily addressed in traditional first-line treatments and Vicki Williamson and co just published a commentary in Lancet Psychiatry only two or three weeks back which kind of explores some of the broader psychosocial and spiritual interventions that might need to be considered in the context of addressing impacts of moral injury, it really not necessarily being the purview of mental health professionals alone. I mean talking about comorbidity, it does raise the issue about complex PTSD and its treatment and this presentation isn't about complex PTSD and again that would warrant a presentation in its own right but just if we're talking about PTSD and its associated morbidities we're thinking about complex PTSD just reminding ourselves while it hasn't found its way into DSM-5, it is now in ICD-11 as a recognised condition with the PTSD symptoms of re-experiencing avoidance and sense of current threat included but has the additional element of DSO or the disturbances of self-organisation which are kind of represented through kind of affective dysregulation, negative self-concept and the difficulty in forming and maintaining interpersonal relationships and we traditionally think about complex PTSD in the context of populations that have been exposed to sustained interpersonal trauma, childhood abuse, domestic violence, combat veterans, torture and genocide survivors and probably the most evaluated intervention is the STAIR program, the skills training and affect and interpersonal regulation is not the only one but probably the one that is there's most evidence around by Muriel and Cloyter, sometimes also co-occurring with a PTSD, a prolonged exposure element when a person has been given these precursive modules in emotional awareness, emotional regulation, distress tolerance, positive activities and the capacity to tolerate positive emotions and interpersonal skills training and certainly the data is very promising from the studies of populations who've been exposed to trauma consistent with that described above and there's a series of studies underway, currently recommendations haven't been put into either the Australian guidelines or the ISTSS guidelines because really these studies have been based on populations who have been exposed to the exposures we think about in relation to complex PTSD but weren't benchmarked by using the ICD criteria point of entry so there's a whole series of studies that are underway at the moment testing treatments using the ICD-11 criteria up front part of the assessment and these will be included in the findings of those will be included international guidelines as the data comes through from these trials hopefully over the course of the next 12 months or so. Coming back to our roadmap where do we need to go next and the issue is harnessing technology. Can we increase treatment delivery through options to make them more engaging, more accessible, more acceptable and certainly Barbara Rothbaum has done some terrific work in relation to virtual reality and it's really becoming increasingly a viable modality for exposure based therapies particularly as virtual reality has gone from something that was extremely technologically complex in relation to the particularly around the infrastructure and the equipment and now becoming something that is much more accessible and much more mobile. It certainly is becoming particularly for a gaming generation the evidence seems to be accruing there for it being as a valid and evidence-based intervention to make to increase the acceptability and accessibility of treatments. Telehealth modalities more broadly they really do have the potential to overcome a range of barriers like distance, travel time and cost, some of the privacy concerns, some of the lack of specialty of mental health providers might be occurring in regional areas that varies across the kind of our different respective countries but the tyranny of distance and kind of remote sites and access to treatment is not an uncommon issue and of course the perceived stigma that might be overcome we've got to address that in its own right but also telehealth modalities help us to overcome some of those stigma related problems and significant advances you know very significant advances in the notion of kind of passive data collection through wearables, through sensors, through smartphones and other passively kind of a low burden collected data that provides us with an opportunity really to get a rich amount of data for us to be thinking about that helps us think about what that data tells us in terms of the experience of PTSD across a range of indicators but also potentially provides us with a unique opportunity for intervention if we're gathering this data and using these signals to trigger whether in a self-directed or other directed fashion to trigger the seeking of assistance and that assistance coming potentially through those devices themselves or alternatively at least alerting the individual to be seeking assistance elsewhere so I think that the passive the forms of passive data collection and their capacity to report and provide signals and indicators around problems kind of provides us with a potentially rich source of data for further enhancing interventions and kind of this this kind of last area around personalised medicine again personalised medicine is potentially a presentation in its own right but for more than 50 years really we've been asking about which treatment and for whom what's the individual characteristics what are the treatment characteristics what are the circumstantial characteristics and how do we bring all of those together in order to be able to much better match what for whom in what context and when and the potential for using machine learning approaches to really refine and integrate what might be a reasonably complex and composite set of predictors that can help us make to enhance treatment responses by providing us with an algorithm for making some of these treatment decisions incorporating biological and physiological information psychology broader psychological information and more specific cognitive and effective information and making helping us make targeted decisions about what and it may well be that some of the issues we highlighted earlier in this presentation around a third a third a third so to speak part of it might just be getting better at being able to match up individuals to interventions in getting the timing of that right even not denying the need for novel interventions and adjunctive interventions but even with the interventions we have the potential to get better bang for buck when we can start to treatment match in this kind of way so conscious of time and just a few minutes left in this presentation but in conclusion really reinforcing the message that we do have effective treatments for PTSD and we end and with the issue of being able to think about how do we what does the future hold it really isn't about throwing the baby out with the bathwater we've got effective treatments which we need to make sure that at a minimum all of our constituencies have access to but it's also important to simultaneously recognize we don't currently have a silver bullet and we need to enhance the intervention effectiveness particularly for the 30 who aren't responding to augment what currently works to improve the effectiveness of that for those who aren't gaining full benefit so and addressing key mechanisms and barriers to recovery in that process thinking about also again what we've highlighted is trialling innovative approaches to the and using the advances in neuroscience and pharmacology and alternative approaches to be thinking about trialling these innovative approaches to really be thinking about how do we add to the stable of what works how do we get what works out there how do we make what works more effective but also how do we provide new and novel alternatives so we're genuinely adding to the stable how does technology help us both in terms of being able to signal when help is needed how help is needed add to the depth of the data that we have in relation to the experience of PTSD but also then act as a trigger for help seeking both passively directed through the technology or alternatively is guided through kind of other more traditional services and how do we improve the personalization and matching of treatment to be able to get more targeted over the course of time and of course while I haven't got into a great deal of detail advancing early intervention and engagement so look thank you very much for listening to this presentation and I look forward to talking to you in the panel thank you

evidence-based treatments

post-traumatic stress disorder

PTSD

international guidelines

psychological recommendations

pharmacological recommendations

emerging interventions

telehealth modalities