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Lifestyle Medicine for Mental Health Guideline and ...
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So, I want to introduce you, and then we can get started. Is that okay? Mm-hmm. Okay, good. So, Dr. Sam Manger is here from, with, from us, oh gosh, let me try again, Dr. Sam Manger is here from James Cook University College of Medicine and Dentistry, where he's a general practitioner with a focus on lifestyle medicine and mental health, and he is the academic lead and senior lecturer of the post-graduate suite, which is basically the master graduate diploma and graduate certificate arm of the lifestyle medicine educational piece at the university. He's the immediate past president of the Australasian Society of Lifestyle Medicine, and he is an ambassador for Equally Well Australia, an advisory group member of Shaping a Healthy Australia Project, and hosts the GP Show podcast for health professionals. And he has been a keynote speaker many places and written many publications, which I will ask him to share with us after this meeting so that we can also get, catch up and get up to speed with what they're doing in Australia. I'm so excited that he agreed to join us here today, Sam, please. Well, thanks, Gia, for the introduction and the invitation. It is a great honour to be here today. I'm just talking, I'm in my clinic at the moment, so if there's noise in the background, that's why, so apologies about that, and that's why I was a little bit late today. So I'm just going to run through some of these slides, I won't obviously go through the introduction and just a few declarations. So the Australian Society of Lifestyle Medicine, which is sort of the equivalent of the American College of Lifestyle Medicine, that's a pro bono role, I'm the past president, I'm now the vice president, and the podcast is pro bono as well, obviously I'm employed as a GP, aka family physician at JCU as well. So I'm going to talk about what is lifestyle medicine, but I know that this is possibly people who are already kind of aware of this, so I'm going to, there's certain things I'm going to go over a bit quicker, and then some things I'll go into a little bit more detail. I've got quite a lot of slides, so I just always put this stop reality check, this is a little bit of a brain workout, this lecture, I've got 45 minutes, and I'm going to make the most of every single second. So good thing it's recorded, so you can listen back if needed. And also just I suppose the reality check is that I like to make it clear that I'm not a psychiatrist, I'm not a neuroscientist, I work with a lot of them, and I've done a lot of work with them. So I'm a family physician, I see this as sort of from a whole of person, whole of community point of view, a lot of what I do, and I also talk about what I think mechanisms, which I've found when I'm talking to patients and communities, what are the things that sort of sink in. So at the end of the day, there's a lot of information, it's a huge field, lifestyle psychiatry, and I'm going to try and condense it for you. So naturally, I will be neglecting certain things consciously. So what is lifestyle medicine? Well, lifestyle medicine is the medicine of the way we live our lives. So how we live our lives can either heal us or harm us. That includes mind, body practices like meditation, breath, work, mindfulness, and there are many other practices within that. It's a fascinating field in and of itself, nutrition and diet. And there's an emerging area called nutritional psychiatry, and there's an international organisation there now, which was, I believe, set up by Professor Fleece-Jacker, now headed by Dr. Wolfgang Marx. Physical activity and how we move, sleep quality and quantity, reducing harmful substances, and within that is screens as well, because we're seeing a lot of potential concerns arise from overuse of screen time, pathological screen use and connection, social connection, social prescribing and connection with the natural world. So they're the pillars of lifestyle medicine. And some people add a few other things onto there, like health equity and environmental things, and that's fine. But we really focus on those six main pillars. And then we've got what they call the drivers of lifestyle medicine. So they're the things that take those pillars and put them into action, put them into implementation. So it's the behaviour change approaches, the health coaching is crucially important, behavioral science and using that, whether it's in informing how we design our services, how we design our built environments and those modifiable aspects, the models of care and the services within that. And I'm going to cover a bunch of concepts that are used in Australia, New Zealand, UK and so on. But I've no doubt in America that the funding models are a little bit different. The delivery models are a little bit different. So acknowledging there's unique differences between countries. So take what I say with some context and clearly the digital aspect as well in the research component as well. There's a we have some good research in the last five to six years. We've had sort of really a rebirthing of this area of lifestyle psychiatry with some of the early randomized control trials. And I'll go through those with you. But the truth is, we have a lot more. We have a lot more research that is required. We have a lot longer to go. You know, we have some evidence for depression, anxiety and psychological stress more broadly. We are now, I think, the first randomized control trials for schizophrenia and severe mental illness, psychotic disorders are coming out or starting this year. And we're leading some of those at James Cook University. But we have we have a lot of work to do. So so this is an area of much interest, of much potential. And actually, philanthropy of all the funders are probably the most interested in this because of either their lived experience of family members or whomever with mental illness. And they're looking for other ways of managing their distress. And improving their recovery. So what lifestyle medicine is not, these are the things that have popped up to me over the years, so I thought I'd sort of shoot it early. So alternative medicine, I guess the important point is this is not me criticizing natural medicine or anything like that. This is not me being negative. I'm simply saying what lifestyle medicine is not. Lifestyle medicine is evidence based, foundational, common sense, mainstream, first line medicine. Is it herbs, oil supplements, homeopathy? No, not really. It's none of those things. Again, if there are certain food products, like if you take saffron, for example, which has quite a few randomized control trials in depression showing some benefit and it to be safe with other antipsychotropic medication. But so, you know, that's where does it where does it go? Is it saffron a food? Yes. Is it a supplement? Yes. And, you know, that gets where it gets a little bit gray. But but, you know, taking that into context, generally we're not talking about those alternative medicines. Is it medicine for wealthy people? And this is one of the things that I think is the nails on the chalkboard to me, the one that really grates me the most out of all of these comments I hear about lifestyle medicine. It's absolutely not. I mean, I've worked in psychiatric units for probably about seven years and as well as as well as being a GP for about 14 years. And I work with a lot of I bulk bill, which in Australia means we people don't get charged. They get it gets on the government scheme. So that's about 90 percent of my patients are bulk billed. And so I see a lot of people who are in the lower socioeconomic groups in society, people with chronic schizophrenia, often homeless or itinerant. And I've provided lifestyle medicine programs in psychiatric wards, in community programs and all different settings where the vast majority of people are absolutely not wealthy. They do not have access to resources. They do not have a lot of money. And I find it quite offensive to say that it's lifestyle medicine is only for wealthy people because this is actually the population cohort who benefit enormously. The evidence is quite clear that they want it as much, if not more than the average population. And they engage just as well on average. And of course, there are exceptions to that. And there's nuanced clinical nuance to all of that. But I suppose the point is, is that this is lifestyle medicine is about providing the best available care, full stop. It doesn't matter who the recipient is. It's also not one size fits all. And this is, I suppose, a big debate when it comes to nutrition. People say, no, there is one size fits all. I would say that there's not. I'm more on the personalized side of things, partly because of clinical and cultural context. I've got Aboriginal patients who would want to eat one way and I'll have other patients who want to go on another way. And my job is to be competent in all these different ways. But moving on from nutrition, I would say that there's no one movement that fits all. There's no one mind body practice that fits all people. There's no one. So some people are much more responsive to mindfulness. Some people are much more responsive to physical relaxation, progressive muscle relaxation, autogenic training and so on. So all of these things, whilst at the end of the day have commonalities between them, the way we deliver it has to be personalized. This is the lifestyle medicine model of disease that was sort of written into the textbooks back about six years ago by Professor Gary Agar here in Australia, who set up the Society of Lifestyle Medicine. And fundamentally, what we're talking about here is, you know, we identify syndromes and diagnostic labels like dementia and anxiety. But as we as all of us know here is that these are these are labels describing symptoms, the actual underlying disease process. There is overlap between them and there is so much overlap between these things that labels at some point come a little bit useless or frustrating. And so in lifestyle medicine, what we're really talking about is understand talking about the determinants of health and illness, whether they are distal determinants like social and or proximal determinants like lifestyle factors. And how does that influence the cellular and molecular mechanisms of mental illness and health and recovery? And so what are we tweaking here? And by understanding those mechanisms, which, again, I will touch on very lightly. It allows us to justify lifestyle interventions as real interventions. They're not just sort of placebo, feel good, warm, cuddly things. They are actually real medicines and therefore deserve to be prescribed as an encouraged as real medicines. Now, in Australia, you know, after a bit of lobbying and a lot of papers, we in about two years ago or now three now to twenty four now got a sort of big change happen. I believe this is the first guideline in the world to to the first psychiatric college guideline in the world to really put lifestyle changes and formalize it right at the front of the guideline. So this is one of the images from the guideline. And the quote from it is lifestyle changes and psychological interventions are foundational and essentially non-negotiable for all mood disorders. And so because of the evidence that had been collating over the four years before that, and like I said, a little bit of lobbying, they recognize that actually this is a real medicine. Now, it's not just a sort of optional little additional extra that we can throw on when we when we have the time, but actually we should really start reorientating mental services to include these things. And and that that has been the result of this sort of lifestyle psychiatry. But so on the right here, you can see a meta review of lifestyle psychiatry, where this term really started to take off in twenty twenty and led by Joseph to was in Australia with us for a while, but it's now back in the UK. And a lot of these names you may recognize on the right there in the journal point, Brendan Stubbs and Felice Jacker and Scott Teasdale and many others being real leaders in this area. A lot of them in Australia, I'm pleased to say, Brendan being in the UK. And then on the left here, last year, beginning of last year, we myself and Wolfgang Marx and a number of others that you'll see from around the world, including America, James Blumenthal and others, Philippe in Brazil and so on, published this clinical guideline to really formalize that lifestyle interventions with, you know, with a with a respectable journal, as it were, can be considered a real intervention. Now, I will go through this in a little bit more detail. It's a bit painful, but I will go through it nonetheless. The point about the lifestyle psychiatry is one that we recognize it improves mental health, but also how much improved physical health. And that is no great surprise. But what may be more of a surprise, and this is a lot of work that's been done with equally well initiatives, is the life expectancy gap between those with the average population and severe mental illness. It's about 10 up to 20 years between those with schizophrenia. And that's largely due to chronic preventable disease like cardio metabolic disease. And studies have shown that about 80 percent of that is reversible or preventable. So why do we need these things? Well, I'm not I'm guess I'm talking to the preaching of converted to some degree here. But a hundred years ago, you know, the major diseases that we were dealt with were infections, child mortality, operations, mortality, maternal mortality during childbirth and so on. And we've done really well at last medicine did what it was supposed to do. It came up with public health measures, sanitation, anesthetics, operating better operations, antibiotics, vaccinations and so on. So we met the challenges of the time. And what part of my mission, you could say, is to encourage us to to not just rest on our laurels, but actually realize that there are new challenges that are in front of us now, which is chronic disease, chronic mental illness, chronic physical illness, and really address and re evolve medicine as we have continually been doing as an iterative process that we now need to change the way we deliver medicine to address the current challenges, which is a shame. It would be really nice if we dealt with the challenges 50, 60, 100 years ago, and that would have been it would have been stopped there. But sadly, that's not the way it's gone. And some of these diseases like type two diabetes, I know it's not a mental illness, are going up at alarming rates in Australia between 2000 and 2020. We had a tripling in the number of people with type two diabetes. This is a common trend around the world, worse in certain countries like Polynesia and Micronesia. And we now have about 25 percent of Australians with prediabetes or diabetes. The stats in America are not dissimilar, and that is very likely underdiagnosed. Now, when it comes to mental illness, again, these are stats from UK, Australia, so apologies, but I'm sure they're very similar for for America. As a GP, mental illnesses are now the number one sort of leading presentation that people present with because of the model. As it's built, the model is based on a infection disease model or on a trauma based model, whereas we know on a chronic disease model and we need to evolve that we respond as we kind of forced to respond with a pharmaceutical approach, which, of course, I'm not anti pharmaceuticals by any mean. I prescribe them. I've got scripts right in front of me right here. So it's not that I'm against them. It's just that it's about having more tools in the toolbox. That's simply the point that we're making. And because of the model, as it is over 60 percent of people leave a GP appointment with a script for psychotropics, despite the fact that that may well not be the best thing for them from a from a evidence point of view, from a recovery point of view and from a side effect point of view, because psychotropics, as we know, have significant side effects and that can be very hard to get off in stats around the world. So I show you here from New Zealand over the sort of 10, 20 years before Covid, we saw a increase of about 65 percent in adolescents, including a doubling of the anti psychotic prescriptions in young people in the UK, which is this table on the right. I'm not sure if my my image is in the way of my face is in the way there, but you can minimise all of that. And you can see that for the 10 years before Covid, there was a doubling in the number of antidepressant prescriptions prescribed by in the United Kingdom, despite the fact that we're really making no difference, the overall rates, it's similar rates in Australia and similar rates in other countries as well. So we've seen a sort of significant increase in our response to the psychological distress of our populations is has been largely to respond with the doubling of antidepressant prescriptions in Australia. Now, one in six Australians on antidepressants were actually the second highest in the OECD, which is frightening, quite frankly. And we don't have the island or Iceland at least has the excuse of seasonal affective disorder and no sunlight. We don't have that excuse in Australia. We have ample sunlight. So we have we have a real challenge on our hands. And what that's meant is an enormous increase in burden just for mental health concerns on the entire health care sector. And that means a lot more money is being spent on psychotropics and dealing with the side effects to that and mental health admissions and psychologists. And despite all of that, we've actually made no difference, despite the fact that we are pumping out antidepressants like they are Skittles, we have made no real difference to the rates. In fact, some of these stats, this is a paper that came out last year from the University of Melbourne, and they broke down mental health scores based on age. And on the left here, you can see the dark blue lines of the younger people and the fainter blue lines, the older people. And so in the older generations, their mental health seems to be fairly stable. But in the younger generations, we are seeing an absolute plummeting in the mental health of those younger generations for a number of reasons. But for sure, lifestyle and social factors, screens, social media, any number of things that fit into that. So my sort of message here is, as Lao Tzu said some thousands of years ago, if you do not change direction, you may end up where you're heading. And I'm pretty concerned about these statistics. So as part of the clinical guideline, we spent a couple of years reviewing the literature here, we reviewed the mixed literature, you could say, so the literature around psychological distress, and then we had to narrow it down because the I suppose the artificial nature of research is that we have to pick a population group, which we chose as major depression, given how common it is. But there were lots of papers on anxiety or psychological distress or dysthymia or other disorders, which we couldn't include because of the sort of very strict way of doing these systematic reviews and involving them. So I've decided to show you the evidence in a slightly different way. But we reviewed a good 10,000 papers here. We had a lot of meetings, we spoke to a lot of people. And so certainly it was a lot of work. And this is the author list that was there. So first, we looked at the observational studies, observational prospective studies looking at this, and we saw that there were a lot. So there's a lot of studies. And we're looking at 50 studies, physical activity, smoking, cessation, diet. So there was a lot of evidence in indicating to us from an epidemiological point of view, that lifestyle factors had a huge impact on mental health. We then looked at intervention studies in mixed populations, meaning things like mixed anxiety, depression, substance abuse, dysthymia, psychological distress, studies where they weren't very clear on who the actual or they weren't as refined in their population. And again, we saw a lot of studies here. You can see physical activity, 25 randomised control trials, smoking cessation, 12 randomised control trials, diet, 16 randomised control trials, sleep, 65 clinical trials, so actually a huge number of trials. Where the trials really fail, not fail, but where there's a massive gap in the literature is social connection. Interestingly, we all sort of intuitively understand how important social connection is, but yet there's been very little studies done on how do you actually improve social connection subjectively and objectively, and how do you personalise that? So that is a big gap in the literature, and we're getting, there are some studies now, and I can talk about that later. And then when we talk about, specifically people with depression, obviously the field starts to narrow now, because we're now focusing on those, and we've now got, say, take diet, for example, we've got four randomised control trials, looking two in adults, one in adolescents, and one in older adults. Sleep, we've got one meta-analysis, and so on and so forth. And then we're looking now at less quality evidence, say for green space and so on. And so these are the recommendations that we came out with. And in truth, some of our authors, including myself, were sort of not, almost not that happy with these, because we really wanted to see some grade A recommendations come through, especially for certain things which just seem so strong from the observational and mixed populations like physical activity, for example. Really, that should be a grade A, and so I would like to add two more columns to this if I was permitted. One is a common sense recommendation, and that would be an A, and one is based on the entirety of the evidence, not just on a specific disorder like major depression disorder, which would also be an A. Nonetheless, we have to stick to the rules of the guidelines and that is the way the system works, and I would throw that out as a slight challenge to the way we do guidelines and evidence, to be a little bit less reductionist, but nonetheless, this is where we're at at the moment. And that is based on their grading criteria where it sits. However, it's not to sort of underplay how much evidence there is in its entirety. And as you'll see here, most of them are grade B, which is, I think, a very high level of evidence. Loneliness, as I said, is the lowest because there just is very little evidence there. Now, a little bit of detail, and I've got about 25 minutes or so, so I'm gonna try and skim through this quite quickly. In particular, just to highlight a few points. Now, I've just highlighted a few of the studies, and there's lots of others that I could have chosen. Partly, just to highlight a few points. So I'm gonna stick with the mind-body to start with. Relaxation training being one. This was a meta-analysis published quite a while ago, but it's such a, it had some good learnings and lessons from it. Partly to highlight the importance of the repetitive nature of a lot of this sort of stuff, like the more we do it, the better we get at it. It's just like I explain to my patients, if I ask you to go to the gym now and bench press 40 kilos or 80 kilos, you probably couldn't do it. But if you train every day, then you'll be able to do it. Same with the mind-body practices. It's regular practice. If we look at it from a statistical analysis or effect size point of view, that's where the Cohen's d comes in. Now, Cohen's d is a size, a measure of effect size. So zero compared to control means no difference. So there's no real effect. 0.2 means mild, 0.5 means medium, and 0.8 means large. And to put it into context, antidepressants have on average a Cohen's d of about 0.3, give or take. It's more effective for severe depression and less effective for mild to moderate depression, but 0.3, 0.35 on average. So you see here that relaxation training for anxiety disorders, and there are mindfulness-based treatments as well, which I just didn't include for this presentation, but I could have, quite high at Cohen's d, 0.57. And if we understand why that is, then it makes a lot of sense. Now, I could go through this detail a lot. I could spend a whole hour on this slide alone, but simply to highlight the point that chronic biological, psychological, and social distress have these impacts on the brain that we are now truly really understanding how it is relevant to anxiety and depression. And we identified that these lifestyle factors, which address this biopsychosocial distress, does reverse and improve these central nervous system changes, and not just central nervous system, the microbiome and other aspects, which I'll touch on with the diet. One area in particular that I like to explain to patients is around the microglia. And microglia make up about 15% of our brain cells. They're our immune cells. They're derivatives of macrophages in our brain, and their job is to essentially clean the brain, clean the synapse, remove the amyloid plaques and the other sort of plaques that build up during the day and the damage that occurs. In a chronically inflammatory lifestyle, social background, these microglia switch to a pro-inflammatory phenotype, and that obviously begets, therefore, various other symptoms. And this paper here really highlighted the impact of this metabolic syndrome, obesity, chronic stress, which you can see at the bottom here, the dysbiosis and so on, the fancy sort of inflammasome and cascades that occur there, the impact on the microglia, and then the impact on the synapse itself, leading to a reduction in neurotransmitters and leading to a lot of these symptoms. So again, just highlighting that we're really understanding the mechanisms here. One of the programs we did in our hospital was what was called a PRN pilot. And we had, I assume you used the same terminology over there with PRN, but PRN means as needed medications. And as you would know, people in hospital often come along various acute distress or crisis for whatever reason, and they will present with requiring medication, usually some sort of sedative and antipsychotic. And about 80% of the time, the study showed that they are provided a sedative and antipsychotic. We set up a program where they had a choice. They could always have medication. We would never deny the medication if they needed it, but we would offer them instead to go into our room here, our sensory room, either do guided meditations or yoga or stretches or things like that that would be guided via an audio guiding or a video on the TV or something like that. And we actually found that about 70% of patients would prefer to do this than have medication. And what it did, it not only did this significantly reduce the amount of medication that we were dispensing, which is good because we're not creating dependence and side effects, but it actually led to the whole point of all of this, which is recovery. People learn how to respond to and have a better relationship with their emotional states through the actions of their way of life, which is fundamentally the goal. Now, movement, I don't really need to say because the evidence is so strong as I've already highlighted, but we know it's as effective as antidepressants and psychotherapy. We know it's effective for depression, anxiety and evidence is emerging for schizophrenia as well. This massive study that was done last year in Adelaide in Australia, it was an overview of systematic reviews. We love to, we used to think systematic reviews was the gold level of evidence and now we're doing systematic reviews of systematic reviews. So we've really like, we got to help ourselves. But this showed that the Cohen's D here was about 0.43, as I said, compared to pharmacotherapy at about 0.3, 0.35. So now that this is not a fair comparison because of varying statistical reasons, but all the same, it just goes to show that this is an intervention that deserves to be on the map. And I'd love to go again through this slide in an hour and I can't, but simply to say that exercise improves pretty much every single biological process in the body. Exercise improves it, whether it's peripheral, whether it's cardiovascular, whether it's mitochondrial, whether it's microbiome, whether it's synaptogenesis, it's good for everything. And the endocannabinoid system we're learning a lot more about too. This is the first trial. Many of you would have come across potentially the SMILES trial done here in Victoria, in Australia, looking at diet, modified Mediterranean diet. So predominantly whole food, plant-based diet with a little bit of fish, chicken, et cetera, showing that those who had a, those with moderate to severe depression who went, who had a modified Mediterranean diet, a third of those went into remission versus 8% in control. This is now being repeated three more times. And as I said, in mixed populations, which is the bottom here, the meta-analysis of RCTs confirms that. Why? Well, again, we're not just providing the substrates that we need for our body, the vitamins and the minerals, the omega-3s and so on, that our body needs to actually do its processes, aka convert tryptophan to serotonin to melatonin and so on. But we also, for all the other biological processes, the mitochondria need all these antioxidants and vitamin Bs and so on to operate so that they can run the neurons so that we can process information so that they can run the immune system so that we can clean up inflammation and we can reduce oxidative stress so we can make the hormones. The gut microbiome, enormously important. I'd love to touch on it, but can't. The tryptophan-carnurin pathway, again, super important. If we have, if we are providing our body with the right signals, then we will go ahead and make what we need to make out of our neurotransmitters. But if we don't, then we go on to make neurotoxic metabolites instead. This is a food program that uses me pre-beard some years ago with a psychiatrist, Dr. Luna Barron, where we were running essentially culinary nutrition programs within the ward itself and getting people to cook with the staff and the staff and the patients all have a once a week lunch together. And there are many elements to this. Partly, again, it's about recovery, it's about teaching, it's about eating well, it's about hands-on experiential learning as opposed to theoretical didactic learning. But it was also about community building and changing the culture within the service, which if I could hand on any wisdom for what it's worth, it is about changing the culture of our services makes a huge difference. I highlight sleep because it's a core pillar. Sorry, it's just started raining and we have pretty significant tropical storms here where I live. So apologies if it gets quite noisy. But sleep disorders are so common in people with psychiatric illness, we essentially must screen for them. And they are a very common cause of treatment resistance. I've had many patients with severe depression or even psychotic disorders who've been resistant to clozapine and all the knobs of things. And then you treat their severe sleep apnea and then things change exponentially. This is a meta-analysis randomized control trials looking at non-pharmacological sleep interventions on depression symptoms. And this was a mixed population. So again, it couldn't really be included as strongly in our guideline because it was a mixed population, which is a shame, but it's a fantastic study nonetheless. And they showed that these various sort of paradoxical thinking and sleep restriction therapy and so on had an impact on depression symptoms. Now, this was such a big effect that I must admit, I am slightly skeptical that it's this positive, but nonetheless, this is still a great outcome. Now, I will say, again, I assume this is happening in America. It's certainly happening in Australia. One in four Australians are lonely. It's much higher in elderly people, in young people, in people with chronic disease and people with mental illness. It's up to one in two. We know that loneliness increases your risk of all cause mortality, even cancer specific mortality by about 30%, which is about as much as a pack of smokes a day. So I sort of encourage everyone to seriously consider just making sure, asking if your patients, how they feel in regards to their social support connection and loneliness, just make it a core part of your assessment. I mean, so many patients come and see me with depression, anxiety, whatever it is. And when we get down to the root of it, they are deeply lonely and they are struggling alone. And if they had a support, things would change. I'm not gonna go through the mechanisms of there, but this study was done in 2020, which was what's called a Mendelian randomization study. So it's a way of combining epidemiological data with some genetic data and other things to look at how we can derive causation from epidemiological data, which is a new thing. And what they looked at was all the modifiable factors for the prevention of depression. And they said the number one factor for protecting against depression was trusted social connection. So again, it just highlights the absolute crucialness, the crucial nature of us assessing and involving this. I can see little things coming from chat, but I'm not looking at them and I will at the Q and A. One of the questions that comes up always is which comes first, does people being depressed lead to loneliness or does loneliness lead to depression? And of course it's both, of course it's bi-directional, but a study in New Zealand looked at this about five years ago, and they found that actually social connectedness was found to be a stronger predictor of mental health, loneliness was more likely, was a stronger predictor of depression than the inverse. Now, social media is a big one. I think we can all recognise how big this is and how this is a generational and cultural struggle. And I think my hope is with time, we learn as humans to become more mature with our use of social media, but we shall see. This study here, meta-analysis, was the first study done to really look at all of the different aspects of social media use and mental health. And it showed that the associated depression symptoms and problematic social media use was moderate in its strength. So there's clearly a average trend that social media leads to depression on average. Now, of course, there's nuance here. There are good things about social media too. And the problematic social media use means are we checking it first thing in the morning? Are we checking it on the toilet? Are we checking it instead of attending to our life activities? Are we being interrupted by it? And I think if most of us are gonna be honest, most of us would struggle with some of that to some degree. Now, nature, there's not a lot of money to be made in nature. So the studies here are just not very strong. There's not a lot of randomised control trials here, but the few studies that we have, again, show the same thing. The more time we spend in nature, the better for our self-esteem, the better for our mood. This was a health economic study done and showed in UK. For every pound invested in people going into nature, we got seven pounds roughly in return on investment because of their wellbeing, return to work and so on. Smoking I bring up, because we all know smoking's bad, but there's been a sort of idea, partly based on experience, that when people quit smoking with mental illness, they get worse. And that's true in the sense that they feel crap for the first month. Most people who quit smoking feel pretty average for the first month or two. But the longer-term data, the sort of six to 12-month data, is actually that their mental health improves as much as if they were to start an antidepressant therapy. So that reducing those inflammatory compounds in the body is impressive. The same is true, systematic reviews have also, this is an old slide, apologies, I didn't upstate, there's actually a 2023 systematic review on this now, and I think a 2021 one on alcohol, showing the same results. And on top of that, and this is probably the biggest carrot to dangle for patients, is the fact that smoking increases the cytochrome, which is the liver enzyme metabolism of medication. So when we quit smoking, certain medications are not metabolised anymore, and therefore certain medications like olanzapine, plozapine, fluoxetine, you can reduce the dose of those by up to 50% in many patients once they stop smoking, purely because so much more of that medication is now getting into their system. So that can be a really good carrot to dangle. And of course, all of this is good for physical health as well. I don't really need to talk about that. We know that the majority of chronic disease is preventable. We've known this for some time. We've also known for some time, thanks to the work of people like Dr. Dean Ornish and other people in America, that these chronic lifestyle-related diseases like coronary artery disease, like type 2 diabetes, is also reversible with the same lifestyle measures. So we are having one or a series of interventions improving every domain of a person. So this is coronary artery disease on reversal. Whoops, I'm sorry, I've lost my slides here. This is one of my patients, and I don't know which one you use in America, percentages or millimoles or none of those for HbA1c's. But you can see here, my patient came in with a HbA1c of 11 with type 2 diabetes, and within three months, I got them down to 6.1. I stopped their medications and they were down to 5.8. So we can reverse disease. There is no reason we should be accepting chronic disease and just assuming that it's a lifelong thing that requires medication management. Yes, medication has its role. I'll say that again. And one thing that many people probably don't appreciate is this is the risk factors for suicide. And actually, chronic physical health disorders are the leading risk factor for suicide, and mood disorders are the second. So if we have a lifestyle interventions that improve both of those, we are also significantly addressing suicidal risk. So all of this adds up, not to be idealistic about it or naive about it. Of course, there are challenges implementation. Of course, the reality is that not everyone adopts these things, et cetera, et cetera. But I don't accept those as an excuse to not try, because the same analogy could be made for smoking cessation. We know that with the best nicotine replacement therapy and bupropion or Champix or whatever you're using and psychological support, we can take a average annual smoking cessation rate from say 3% with no support to 25% with the best support. I use that as analogous to lifestyle interventions in the sense that just because not 100% of people quit smoking, does that mean we don't even bother? Of course we try, because we know that we're gonna make a huge difference to a lot of people. It's the same with lifestyle interventions, though I would argue it's a lot better than 25%. So now in the last 10 minutes or so, I'm just gonna touch on models of care, because the reality is, as I said, we don't really do this. And the point of this picture is to say, do we need new models? Yes, a drill press is very effective. Yes, pharmaceuticals is very effective. Surgery is very effective. But sometimes it just gets a little bit silly to try and use a drill press for a small job. And it's kind of the same analogy. We just need to add tools to our toolbox, and that's what I'm suggesting. So this picture came from the guideline that we published, really to encourage us to zoom out and think about the way we deliver health more holistically. So we have our clinical care, our one-to-one clinical care, and that means embedding lifestyle interventions into that clinical care, as well as the way we communicate, our health coaching, behaviour change, terminology and techniques. But then to zoom out even further and think about the models of care and the implementation considerations, how do we work more effectively with disciplines? How do we work more effectively with peer support? How do we embed behaviour change science into the environment? How do we use digital technology? And then how do we address those social determinants from a micro level? And by micro level, I mean, community levels, schools, workplaces. And then, of course, at a policy level, but most of us have very little impact on policy. This is what we call the reverse Swiss cheese model, which we also published. And I'm a little bit proud of this because this was one of my babies. Both of these were. And the point was simply to, again, just to conceptually encourage us to think about that we'd like still medicine. It's not a single intervention. We are we are building in layers into a person's life. So that is so that we can capture and improve and prevent their well-being or prevent illness and capturing that early and encouraging well-being a lot sooner, if the more layers we have built, both from an individual point of view, but also from a health service point of view, the better we're going to have outcomes. Acknowledging that no one layer is perfect. And that's an important point, because that's probably where some of the criticism comes from. Now, we do need to fundamentally change education here. There's been systematic reviews showing that have looked at med school curriculars all around the world, showing that it's essentially inadequate in every curriculum around the world. That's the specialty training as well as medical school. And that's again, it sounds critical. I suppose it is critical, but it's not meant to be. We have a lot that we need to learn in med school. But it's simply to say that we also need to be a little bit humble and accept we don't know what we may not know. And actually, there may be a lot more evidence here than we than we originally were thought. I highlight this little slide just to simply say that industry, inverted commas, has been using behavior change science to make us buy things and want things that we haven't and don't really want and don't really want to buy. It's time to use this behavior change science, aka health coaching, for the betterment of our patients. And this area is, as you can see, is exponentially taking off in the last 10 to 15 years and how we actually help people change their behaviors in a ethical way. And that includes the built environment, as I said, how do we design waiting rooms? How do we design services? How do we use incentives and cues and nudging to better people's outcomes? And this is something we used a lot on the mental health wards, on the inpatient wards. We change the waiting rooms, we change the layouts, we change the rooms themselves, we change the common areas, etc, etc. And I'm just going to quickly go through this simply to say that whether it's tertiary hospital or primary care or community care, lifestyle interventions can be built in at every level. There is an opportunity at every point of contact within between us and the patients. This is one of the major programs that was led in first episode psychosis in New South Wales and Australia, which is really one of the first trials or programs done in the world. A lifestyle medicine program for those who came in with first episode psychosis who are admitted for it. We saw that with this lifestyle medicine program, we were able to attenuate the weight gain, which we know is a massive problem with antipsychotics, but we were able to, in a lot of patients, negate it completely. And in some patients, reduce it by sort of, in every other patient, reduce it by some degree of percentage, reduce smoking, improved diet quality and reduction of discretionary food. And most patients would recommend the program. So huge satisfaction. This program was then expanded to keeping the staff in mind because one of the major barriers was I've seen in this this cohort saw was actually the culture was a little bit anti lifestyle. See, it's not my job to do lifestyle. It's not my job to address this stuff or there's no evidence for this stuff. There's no point. So we ran well-being programs for the staff. And that changed the culture because people then started to have experienced experiences that actually this really improves my well-being and my mind and my body state. I can see now why it would be relevant to my patients. This is a study done in UK led by Matt Moore, a nurse over there in the psychiatric intensive care units. Again, a lifestyle medicine program. And one of my favorite parts here was that they had open feedback displayed in common areas. And here they saw a 43 percent reduction, the violent incidents in the ward and very high positive feedback from staff and users. And he's now rolling out safe gyms. So obviously, in a psychiatric intensive care unit, you're not going to provide a gym with weights because they might hurt themselves or someone. So there's a lot of adaptations here. You would use lightweights or bags and things of that nature. So he's now consulting a number of other psychiatric units on how to build gyms that are appropriate for the needs of that population. Shared medical appointments is something that's really taken off in America, but certainly around the world. There's hundreds of publications now, and we're doing these a lot more in patients. We're showing better outcomes, better satisfaction. Instead of me seeing one person with depression or anxiety at a time and spending 10 to 15 minutes with them, why don't I see six to nine people and spend an hour and a half and they can all learn from each other in a peer support facilitated professional way. We've applied this group methodology to Aboriginal people, and I know that we have Aboriginals here. You have your First Nations people in America. And I can't speak for America, but I can certainly speak for here that this group based approach is far more culturally appropriate. And we are seeing much, much better results and engagement with these new models of care to the point where we see increasing numbers over time of people attend, which is unheard of in one-to-one traditional, let's say, whatever you want to call it, Western or modern sort of medicine, traditional care. Some of the major paradigm shifts in primary care has been to expand the workforce. And some of this has been led by Patty Robinson, who you may be aware of in America. She's done a lot of work on behavior change consultants, done a lot of work with the Department of Defense and other aspects. And in New Zealand, we brought her over and to train a sort of new workforce in primary care, which is sort of health coaches, health well-being practitioners, social prescribers that have been added into mental health. In New Zealand, there are now 450 practices who have this model and they are seeing huge benefits, improvements in symptoms of physical mental health, improvement in access. Ninety percent of people are being seen within five days now. Very high levels of satisfaction and reduction in psychotropic prescribing. Similar models in UK, where they're bringing in volunteers and community people and peer support workers into primary care because they recognize that about 40 percent of what they do is psychosocial and this is not biomedical necessarily, although it has biomedical consequences. But how can we, if so much of mental distress is because of psychosocial determinants, how can we expand our workforce to accommodate that? And I'm happy to talk about that in more detail, but I just won't now. This is the Primrose study, which was published in The Lancet a couple of years ago, just to make a point that about this expanded workforce, that in this study, it was really about cardiovascular disease prevention. So they were looking at mental health, but it wasn't actually the primary aim of the study. But they found some interesting things with when they actually have nurses provide what is essentially lifestyle medicine, along with adherence to medications, which is health coaching, because health coaching is not just about adhering to a diet, but really adhering to any recommendation, a.k.a. medication. What they saw is a significant drop, 27 percent in the number of admissions. So that's a 63 percent or 73 percent drop and reduction in admissions to physical health and a significant reduction, almost a 40 percent reduction in the cost per person because of this more holistic approach to mental and physical health. And this is in people with severe mental illness, I should have said. Sorry. So this is not in the average population. This is a what people classify as a difficult to change population. But you can see here how much of a difference it made. And simply to say that there are many exciting ways that are emerging now, we can see that by using social media groups, by doing these sort of community based classes, by using group based programs, we're seeing completely different improvements on chronic disease management more broadly. I'd love to talk about rites of passage and Adelaide health outlets and health, but I can't because I'm over time. That's a beautiful video about rite of passages and mental health in Aboriginal people, if you're so interested in searching on YouTube. And then the digital program. So I will say this because this is relevant to America. You may have heard of Professor Darren Morton here from Australia. He's done a lot on positive psychology and he's got the lift program. And that's been shown in multiple randomized controlled trials now in various population groups to improve depression symptoms, anxiety symptoms. And what I love about Darren's work is he focuses on increasing vitality because it's so we so often focus on reducing negative symptoms, but so rarely focus on improving positive symptoms. And he's shown that we can actually get both. And for that, this is nothing to do with mental health, but I just make sure everyone's aware that if you've got patients with cardiovascular disease, that Dean Ornish program is now online, which is amazing. That happened quite recently. And the most common question I get is, OK, great. Thanks, Sam. But what do I do now? And I would just take them to the Rogers diffusion of innovation curve, which is how do we create change in a system? And we don't have to get 51 percent or 60 percent of people to change to create systemic change. We actually only need about 18 to 20 percent of the cohort to change before that then gets the early majority kicks in and then people people just take it on board because it's now a norm. And so I encourage you just to connect, identify the people on this group today, the other people who you can connect with, who are the innovators and early adopters, strengthen each other, support each other, build your programs, build it. And they will come, as they say. And that's certainly been my experience in a lot of the work I've done. We've met resistance for various reasons, but we find our 20 percent who are the innovators and the early adopters. We make the programs, we make the change. And then eventually, after a year or two, pretty much everyone is on board. And if you're interested in my last slide, thank you for your patience, is we've just released this three week micro certificate on FutureLearn. It's an online training program for lifestyle medicine, mental services. So the first week is kind of what I've covered today. Second week is on communication skills, how to adjust psychotropic medications and using metformin and other things to offset some of those medication side effects. And then the third week is about implementation. So how do we implement services and some case studies? So Matt War, this nurse I mentioned is in there, the Keeping Body and Mind program, Simon Rosenbaum and others have done a video for us and they present on how they actually delivered these programs and did it. So we're still in early days fundamentally. I think that's it. Yeah. So we're still I'll just stop sharing my screen in early days in truth. And I don't want to make it sound like it's better than it really is. But I will say that there's a lot of hope. There's a lot of good evidence already. And the response from the population is enormous. Now, I'm going to just mute and go close my window because it's getting really loud out there. Okay, Sam, you can still hear us, I hope. But thank you so much for this presentation. This is phenomenal. And I think for this group, I just want to read. Were you done, Sam? Or did you have anything else you wanted to say? No. Okay. So I wanted to just give you a little orientation of this group. And I wanted to really Dr. Viz, our president elect is here of the American Psychiatric Association. So going to let him speak for a few minutes. But I wanted just to let you know that this Lifestyle Psychiatry Caucus for the American Psychiatric Association, as we've discussed before, is new. So this is our fourth month. And we're really excited about learning from what you've done in Australia, and being able to learn from you and implement some of these in and really create our 20% right here of the people that are that are interested and that are going to learn and do and move this forward. Many people in the room don't even know about the American College of Lifestyle Medicine. So you know, in orienting them to what's available, but also helping them as psychiatrists understand that what we have to offer is in concert with the physical aspects, right? That it is together and having you as a general practitioner bringing this information forward is very helpful for everyone in the room. Dr. Viz, are you available to talk right now? Yes. Thank you, Dr. Merlo for organizing this important presentation and keep the momentum going. And thank you, Dr. Manger for conveying, you know, this great work and being done in Australasia. And I'm the president elect of the American Psychiatric Association. I will become president in May of this year. And I'll have my term will be one year. And my annual meeting will be in Los Angeles in May of 2025. Guess what? You know, like every president chooses a team for his or her presidency. And the team I have chosen is a lifestyle for positive mental and physical health. So this talk is very timely. And as you said in the last slide, you know, what we are doing, you know, GIA forming the caucus and my having this team, you know, is kind of in the early period. And we hope with this, you know, enough people get mobilized. And also there's an interconnection with the Climate Psychiatry Alliance, you know, there's a lot of common interests. And so we, you know, hope to create enough awareness among our health care, you know, professionals, as well as the community, because this is quite important, both for mental and physical health, you know, both for us, as clinicians, as well as the people who we take care of. Beautiful. Thank you so much, Dr. Vaiz. So, Sam, did you want to address something? Or do you want to open it up for questions? No, no, I thank you very much. And it's wonderful to hear about the future intentions of the APA. It's very exciting. And now I'm happy to open it up for questions for the next 5-10 minutes or so. I'm just answering a couple in the chat there. Yeah, sure. So if anybody has wants to raise their hand, that may be an easy way. There's also a few questions that came up. I answered a few of them. But I don't know if you wanted to talk about some of them. So there was a there was a question about volunteerism and some of the some of the recent research on that. Are you aware of that, Sam? Or I talked? Yeah. Yeah. So so we did mention that. So in our guideline, we've broken it up into different sections and volunteering. Absolutely. It was mentioned in there and recommended as as a recommendation. So so I would say that from a common sense and from an other evidence point of view and is what you put in there and FMRI scans. So, again, this is where it gets a little bit artificial from a clinical guideline point of view, because clinical guidelines from a grading evidence say, no, but we want randomized control trial that's, you know, blinded and non-biased and all these sort of things in major depression specifically. So that's where we're a little bit life on a study. But when we look at psychological benefits broadly of volunteering, when we look at other chronic disease states, disability scales and so on, we absolutely see huge benefits there. And I think from a common sense point of view or from an anecdotal clinical experience point of view, many of us would have seen that. And I think there's a huge amount to be said, which is why I just quickly touched on that rite of passage work, which is the which is the rite of passage is the chain, the supported growth through very major changes of life. So adolescence to adulthood or adulthood to elder, for example. But there's a lot to be said for contributing to men's groups or women's groups or certain age groups and things like that. There's that social connection with your light can be very, very impactful. Beautiful. Thank you. There were quite a few questions about psychopharmacology and one really about do routinely began with metformin with every patient starting an antipsychotic or do you recommend lifestyle changes first? And then just a more general question. Can you discuss ways that you incorporate lifestyle medicine into your typical psychopharmacology or therapy visit? Yeah. So the metformin question I answered in the chat, but the evidence for metformin is much stronger on offsetting the weight gain and cardiometabolic side effects of many medications like the pains, the Lanspin, clozapine started early. So really, the best evidence is first episode psychosis or early. If you wait until people have already put on their 40 kilos, you're probably not going to get a lot. I mean, it's still have some benefit at improving insulin sensitivity and other aspects, but you're not going to have the major benefits that you would see otherwise. So we would often Dan Siskind, who's based here in Brisbane or near me in Brisbane has done a lot of work on his psychiatrist, done a lot of work on that. And that's kind of what it's showing. But I think a lot of people now in Australia would fairly early routinely start metformin with first episode or early psychosis. Whether they started later on is, I suppose, there's a side effect profile metformin like there is with everything gastrointestinal side effects, for example. So that's just part of the usual informed consent process. How do I incorporate it into my daily practice? Well, that depends on the setting. So if I'm right now, I'm here in my primary care. And so I have my standard 15 minute appointments, which is the bane of our existence, but nonetheless, the model we operate in. And so what I do in these appointments is I do my assessment and I do my risk like I would any good doctor in my risk approach. And then when I get to the point of management, I will always include a brief lifestyle assessment. So loneliness, diet, physical activity, sleep and screen use and substance use. That actually only takes me about three or four minutes. I have a tool which is in my drawer, which I could probably dig out in a moment, but which I call the LM10. Let me just see if I can find it while I'm talking. But it's that I use as an assessment. So essentially the LM 10. Oh, here it is. Okay, here. So this is the LM 10. So it is a zero on one, it's a scale of zero to 10. And we call them the vital signs. We call them the lifestyle medicine vital signs. Yeah, that's right. That's what it says. Just based this. So Dr. Wayne Dysinger, he did the lifestyle medicine for and I've expanded it to 10. So, so that includes green time and screen time and other things. And I will often get patients to subjectively rate it from zero to 10. And, and it's a great health coaching point because they'll say, Oh, my, you know, it's subjective. So they think their diets 10 out of 10. That's kind of not really the point. And then they'll go, you know, seven out of 10, seven out of 10, learn, and then they'll stop. And the one they almost always stop on is social connection. And they think about it. And then they go to and one, and they go, Oh, shit. So you're lonely. And they're like, Yeah, I'm actually I'm really lonely. And then so then you can you have your actionable points, you can see what what is most important to them, you can ask them. So why did you give it a seven and not a nine? What's not going great in your diet? Or why did you give it a seven and not a four? What is going really well, in your opinion in your diet. So that turns into a health coaching tool. The other thing which is American for the Australian American Academy of Family Physicians is the social needs assessment, which I've also let I laminate and use in my room. And that's a very good social determinants assessment. So I'll often do those as a very quick thing. I'm some I'm my nurses have these and I will get them to do them before new appointments and that sort of stuff. From a management point of view, I will simply give them a very I would say you've got options with your management, we've got lifestyle treatments, you've got natural supplements, you natural slash supplements, because they're not necessarily natural. You got pharmacological and you've got procedural, you know, transgenic, magnetic stimulation, etc. And so I will say these are your options. Where should we start with today and then it turns into a health coaching thing. So I bring the bring assessment and management into every consult. How much time I give that depends on how much time I've got. And then I will often say, Look, I'd love to see you for a longer appointment, 30 minutes to get into the nitty gritty and the depth about this, you know, assessing other things like trauma is always one that needs to be assessed from a medical point of view and takes longer, but I will at least identify that it is a relevant factor to that being and then follow up. So in a way, it's very similar to how we would do a lot of our other therapy. I hope that and then if it's a bigger appointment, like a tertiary centre, I've usually got a bit more time or I use peer support workers a lot or I use the nurses a lot. Again, just using your team. Beautiful, beautiful. Thank you. Dr. Viz, I know you've had your hand up for a while. The thing is, when people talk about exercise, they mostly talk about aerobic exercise. Many people neglect strength training. And I find, you know, I always, you know, basically there are two movements, which I stress upon with all my patients, and especially the older patients. One is squats and the other one is overhead press. And in fact, I make them even demonstrated in the sessions with them or even with telehealth. The reason being, I point out to the patients, you know, once you lose the ability to get up from the chair, then everything is downhill. And obviously, you know, overhead press, put some pressure on the axis and reduces risk for osteoporosis. And also, our functionality depends on that. And you, especially being a family physician, can you comment on that? Comment on strength training for our patients? In a minimum, we elaborate, but major muscle groups. Yeah. Yeah. So it is interesting, right? Because there's a number of things when you look at the literature and the science and the evidence here around movements. I mean, from a health coaching point of view, the movement you do is the movement that matters, right? So it doesn't, at any movement, the benefits of movement from a mental health and physical point of view, any movement is good. And then it just is sort of incremental benefits after that. And you're exactly right. The guidelines are what they are for a reason, aerobic exercise, 150 minutes a week, and strength training at least twice a week. And it's there for a reason. Oh, they do say that. Okay, that's good. Okay. Yeah. I didn't know the guidelines do mention strength training twice a week. That's all you need. You don't have to be doing it every day. Yeah. Yeah. And when you look at the evidence, there's two little nuances I'll add. The first thing is that the same exercise done outdoors is more beneficial to your mental health than done indoors. And so they've done they've done this, they've done parallel studies looking at this. The second thing is that intensity matters. And as but not, it's not everything consistency also matters. So I encourage patients to move in the way that they will and want to move. So did that mean putting on their favourite song for five minutes and dancing it out like a nut job in their kitchen? That's exactly what it means. Because I want them to push their comfort zone, I want them to get their heart up, I want to get a little bit of sweat going, and I want to get them a little bit challenged. Because it's within the challenge, as we know, with, you know, post traumatic growth, you know, that the right amount of stress, the right amount of stimulation to muscles is what stimulates hypertrophy, the right amount of stress in the brain is what stimulates this anti inflammatory, pro mitochondrial response. So yes, walking gently is nice. It's a feel good factor for an hour or two, but it's not going to make substantial changes. We got to get people challenged. But it doesn't have to be 60 minutes on the treadmill, it could be five minutes of being challenged in a cardio aerobic capacity, or five minutes or three minutes, not even 30 seconds on a wall squat will make most people's legs burn, you know, any sort of challenge is what we're aiming for. Yeah, and so the guidelines also include flexibility and balance. So there's actually four, four major components. And then they're very clear on, you know, especially as Robin had mentioned, as well on the chat, Dr. Cooper. So balance is also a component of that when the physical activity guidelines, at least in America's, I don't know what you have. Yeah, no, no, exactly the same here. And one of the things we incorporate, again, you asked me from a clinical point of view is I don't, I really try not to rely on just me. And so our nurses will often do health assessments. And within that, they will use what's called the short physical performance battery, which is a really nice, simple, very quick, but still sort of quantifiable, validated tool. And within that is, you know, your chair to stand, which is what you said, Dr. Viz, how many can you do in 30 seconds, your walking test, your balance test, just so I can quantify those, and I can see if they're improving over time. So absolutely, all those things can be assessed and improved over time. And the fifth one that's sort of emerging is myofascial release, which is interesting, we're seeing a lot more benefits around foam rolling and triggerpoint releases for chronic pain and releasing tissues, mobility, etc. So that that one is emerging. I've been an early adopter for that for the last 25 years. So I myofascial release is my thing. So yes, good. Good. There were a few other people that had their hands up, but they had to leave because of the top of the hour. I, you know, I actually talked a lot about this, and the connection, a lot of questions are coming up. Steve Sugden did the first webinar of this series. And he talked about substance use disorders, I talked about connectivity, and a lot of the emerging data that's coming out in the last few years around brain health. And then we had a general conversation. I think that I wanted to kind of end this conversation, if there weren't other questions. Really, I think there's there's one other question from Ari, which I'm happy to answer, please, please. Thank you. This was an excellent presentation. I noticed that many of the lifestyle issues are corrective ones. I wonder if you have a model of what is a healthy lifestyle that we would seek to have our patients aspire to? Do you mean corrective in the sense of? I'm not sure what you mean. Like, if smoking cessation, or enabling them to have more physical activity, or connecting with other people, all of those frequently, those are problems many patients have that they are smoking, or they're isolated, or they're not sleeping well. I'm wondering if there are any proactive to help people be just be healthier? Do we have a model of a healthy lifestyle? Yeah, well, I think I think the model of the healthy lifestyle is, you know, becoming and has been evident for some time from the sort of epidemiological things like the blue zones and other things like that point, certainly in the direction of what healthy communities look like. As far as the difference, I suppose the reason I talk about it from a corrective prescriptional, let's say disease point of view is because, like we're doctors, and most people come to us when they're sick, not when they're well. And so that's why my presentation is oriented the way it's oriented. Having said that from a primary prevention, or even secondary prevention with other disorders, like they've got diabetes, and then we can work on their mental health, even though they may not have a mental health illness. That, for sure, is part of it. And that's when we that's when I sort of did the onion ring model where we think about, and hopefully this is answering your question, apologies, but thinking about what are the micro environments? So instead of expecting a well person to come to me for advice as a GP, which they're unlikely to do, they're more likely to come to me when they're sick, which is a little late. We should be thinking as leaders in health, well, how can we be proactive in this? So what are the school programs? What are the community based programs? What are the workplace based wellbeing programs that we can start? Because the micro environments, the micro social determinants, we can impact quite a lot, we cannot affect the macro social policy things very often, very easily. But as an example, you know, so one of at our practice here, one thing we're establishing now is nighttime clinics, but the nighttime clinics are a little bit different. We have some doctors who do their usual thing, but we also have cooking classes, we have fires, fireside camp chats, we have movement classes, we have men's groups and women's groups, and things like that. So that people can just turn up, they don't have to be sick, they can turn up and they can start engaging in this conversation and what health means to them, because it does mean, that's why I say personalised, some people, it's a very spiritual thing, some people, it's a very practical thing. And so, but at the end of the day, we all sharing that commonality there. So is there a perfect ideal health? Probably not. I mean, I would, there's a great quote from, I think it's an Earl Nightingale, one of the philosophers of the early 20th century, he said, success is the progressive realisation of a worthy ideal. And so, you know, health is a worthy ideal, it's a perfect ideal, but we're not aiming for that. The success is the progressive realisation of that. So that's what I, that's what hopefully some of these more community proactive programs are about. I hope that answers your question. So I guess I want to, I want to just pivot for a second to a little bit more of a historical point of view. And I know the Liana Leonov and the Positive Psychology Group really spend a lot of time on well-being and making sure that we do that. But I wanted to really focus and just help us understand how long lifestyle medicine has been in the Australian sort of healthcare system, and when you started it, and when it was really adopted, so that we can understand where we are in our trajectory and how to and how to do that. You want me to answer that? Sam, we need to know from you when when you guys started this. Yeah. So the, sorry, I had a little message come up from one of my patients. So, okay, so the Australian, the Australian Society of Lifestyle Medicine, similar to the American College of Lifestyle Medicine was established sort of 2005, 2007, something like that, I lose the exact date in my mind. But so that was fairly early on. However, the, the movement around mental health and lifestyle psychiatry really didn't take off until I want to say about 2015, 2016. And then that first SMILES trials, 2017, and the Keeping Body and Mind programs, which are these first episodes, psychosis, lifestyle programs, the publication started to sort of roll out from there around the sort of similar around 2017, 2018 point in time. So then it was a case of, and this is why I share the tips I share, because around that diffusion of innovation, because we started that the few of us who existed in this field, informally, just started to catch up similar to what we're doing now. Australia is a smaller place. I mean, geographically, it's quite a huge, but the population is a lot smaller. And so we actually caught up quite a bit to actually start formulating similar to what you're doing here, you know, what are the practical steps to making this a prescription in a consult? And so we started, we started speaking to philanthropists and getting funding. So the SMILES trial, for example, was funded by philanthropy. And we then started to get some basic randomized control trials collating the people and collating the expertise together. So the esteemed professors and so on. We then started to talk to our colleges. And again, I know that everything's slightly different in America and Australia, but the colleges write the guidelines here, and, and deliver the training as well, as opposed to it being a decentralized training, which you've got in America, as far as I'm aware. And so we started to then speak with the colleges about what is the standard you need to reach when you're happy to start actually putting your stamp behind it and saying, this is real medicine, it's not just woo, alternative stuff. So we started that conversation as a united front, with the bits of evidence we had so far. And then we they told us and then you know, we worked towards that, they incorporated the guideline, which was a huge achievement. And now we're in the process of taking so then we made the clinical guideline for lifestyle interventions as an international movement, really, just to show that this isn't just an Australian thing that we need to think about this internationally in every country. And as I said, I acknowledge there are weaknesses to to the guideline in the sense of the restrictiveness of the disorder, but nonetheless, hopefully, it's still a good contribution. And now we're in the process of meeting with governments. So the federal government are now taking a significant interest into this. And now when we're mapping out how do you then from an implementation point of view, do this in primary and tertiary care. And this is where it's very hard to rely on the existing workforce, because we're already overloaded and kind of burnt out. So we think about it systematically. So training of the workforce that exists, but more likely adding on another tier of workforces, which I mentioned those sort of behaviour change consultants or health improvement or well being practitioners, or whatever you want to call them. And at the moment, we're going through a little bit of a change here because of a lot of this pressure, and the recommendations on the government to start thinking more holistically around people's well being. We're seeing funding models shift as well. So we're seeing we're looking at what we're moving away from fee for service, and we're moving more towards chronic disease payments, and so that we have a bit more flexibility in how we deliver care, aka some of those things I said before, I would have never been paid for a culinary medicine class at my clinic. But now we're getting these packages that we can start being offset and paid for that instead. So that's a slow burn. That's a long burn. But it's I suppose it's been part of the 10 year plan, as you said. It's so aspirational. Thank you so much. I know we've taken a lot of your time. There's some other questions. But I think, you know, maybe we can ask you to do that asynchronously. Unless you want to answer really quickly about are there guidelines for paediatric patients coming out by any chance, anytime soon? Not from us. But who knows, maybe at some point, I'm not sure. Sorry. It's like, I, oh, man, paediatrics. I mean, I don't know what you're seeing in America, but we are seeing a like epidemic of ADHD. And partly that's because people have had it for a long time. And now the awareness is high, and they want to be diagnosed with it. My the recent thing was international ADHD guideline, which was headed by, I can't remember his name, but in Melbourne here, and he was actually joining me on my podcast. And, you know, that's excellent, right? You know, I'm not against medication for people at ADHD as an example. But what disappointed me in that guideline, and I sort of expressed that to him is there was no mention of sleep. There's no mention of having breakfast in the morning, which we know improves child's attention spans. There's no mention of screens and screen use in an ADHD guideline. But you know, that's 210 pages, I think it was, and there's not one mention of it. And so I, you know, challenged him respectfully and professionally about that. And he will say, Okay, good point. We'll, we'll bring it up in the next guideline. But I think that so there's a number of cultural and structural changes that that need to be addressed here. But it's specific to your question, lifestyle interventions for pediatrics. I'm not aware of any guidelines, but it's certainly another area of need. Yeah, yeah. And you know, and I presented the Australian Mental Health Symposium, and I talked and I presented a pediatric patient that I treated an ADHD, ADHD patient with lifestyle, which was on, which was part of it was a little unheard of 30 years ago, but I've been doing that for a little while. So before we knew what lifestyle medicine was, so I want to end it here. Thank you so much for your time, your what you're doing, and what you have taken leadership on in Australia. It's just so inspirational for us. I'm going to I'm going to cry crack. It's just it's, it's really where we need to be. We are eight, nine, 10 years behind, but we are going to be able to move this faster because of what you've done. And because the literature that you've produced, so thank you for that. We owe you a ton for that. And we would love to have you again and continue this conversation in the future. And advise us as we start developing UME and GME and CME, and start developing our own guidelines within the Americas that works for us in North America. And that would be very, very helpful for us. Thank you all for joining. Come back next month where we will continue this conversation.
Video Summary
Dr. Sam Manger, a family physician from James Cook University with expertise in lifestyle medicine and mental health, shares insights into the growing field of lifestyle psychiatry. He describes lifestyle medicine as a holistic approach focusing on habits like nutrition, exercise, stress management, sleep, and social connection, emphasizing its relevance to both mental and physical health. Lifestyle medicine integrates interventions such as mindfulness, nutritional changes, and physical activity to promote well-being and manage mental disorders. Dr. Manger notes a significant lifespan gap between those with severe mental illness and the general population, largely due to preventable diseases. He outlines the importance of personalized care, dismissing the misconception that lifestyle medicine is a luxury for the wealthy. The talk elaborates on the history and trajectory of lifestyle medicine in Australia, pointing out that concerted efforts since around 2015 have led to formal integration into mental health guidelines. Dr. Manger highlights the importance of interdisciplinary and community approaches, supported by emerging evidence showing the improvement of mental health outcomes through lifestyle adjustments. The conversation emphasizes the necessity of evolving medical education to incorporate these holistic approaches. As part of a broader discussion on systemic change within healthcare, Dr. Manger advocates for a paradigm shift towards integrating these practices into routine care, supported by ongoing research demonstrating the efficacy of lifestyle interventions in treating mental health disorders.
Keywords
lifestyle psychiatry
lifestyle medicine
mental health
holistic approach
nutrition
exercise
stress management
personalized care
interdisciplinary approaches
mental health outcomes
healthcare paradigm shift
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