The Voices of War

80. Dr. Alex Lim - On Veterans’ Mental Health: The Good, The Bad And The Promising

VOW 80 | Veterans’ Mental Health

 

This a reminder that The Voices Of War will adopt a subscription model. You can hear the explainer here.

You can subscribe to the new channel here.

My guest today is Dr. Alexander YC Lim, who is an Adjunct Associate Professor of Medicine with the Queensland Brain Institute. He is a Psychiatrist in private practice, and now almost exclusively looks after members of the Australian Defence Force, the Australian Federal Police, and the veteran community more broadly.

 

In 2019, Dr. Lim set up Australia’s first integrated ketamine program for veterans, known as the ReVive Ketamine Program. Starting in February 2023, this program will become the subject of an ethics-approved clinical study into the long-term effectiveness and safety of ketamine for treatment-resistant depression and treatment-resistant PTSD.

 

Dr. Lim joined me today to discuss some of the mental health challenges faced by our veteran community and to shed light on some emerging treatments that could aid them on their path to wellness.

 

Some of the topics we covered are:

  • Lim’s entry into psychiatry and veteran mental health
  • The current state of veteran mental health support
  • Difference between civilian and military/emergency services stressors
  • Understanding the impact of stress, trauma, and PTSD
  • Post-Traumatic Stress Disorder as a multi-system dysfunction
  • Total and Permanent Impairment and associated challenges
  • Moral injury and what causes it
  • How stress affects our physiology, decision-making ability, and ethical frameworks
  • The need to indoctrinate appropriate ethical frameworks as early as possible
  • Importance of developing trust between the patient and their clinician
  • Treating suicidality
  • Drop-out rates in traditional psychotherapy treatment
  • Why medications are not the ‘silver bullet’ for mental health concerns
  • Synaptic Disconnection Syndrome and the effect of PTSD on the structure of the brain
  • The issue of treatment-resistant illness and the promise of ketamine
  • Preliminary findings and prospects of ketamine for treatment-resistant illness
  • How to access the ketamine program for those with treatment-resistant illness

As mentioned in the introduction, you can find Australian Defence Force personnel suicide statistics here.

Listen to the podcast here

 

Dr. Alex Lim – On Veterans’ Mental Health: The Good, The Bad And The Promising

Before we get to this important episode with a psychiatrist, Dr. Alex Lim, a reminder that the Voices of War will be transitioning to a subscription model. I published an explainer. In summary, from now until the end of January 2023, this channel will continue publishing full episodes to allow time for those who wish to subscribe to transition to the new channel.

However, from February 2023 onwards, this channel will publish only the first half of each episode, and each episode will be bookended with a notice and a link to the subscriber-only channel. Those who wish to subscribe can already do so via the link in the show notes. The subscription fee is $4 per month, which equates to roughly AU$6 or €3.75.

As you will read, I had a lengthy conversation with Dr. Lim about the state of mental health within our service and veteran communities. I hope this episode will be a timely reminder, especially as we enter the holiday season, that many of our brothers and sisters in arms and those working as first responders are suffering from a myriad of mental health challenges. If you can, please reach out to an at-risk mate and ask if they’re okay.

Importantly, as you will read in this discussion, there are new treatments on the horizon that bring much-needed hope and promise more effective results, especially for treatment-resistant illnesses. The successes of ongoing trials need to go mainstream. Taboos and stigmas surrounding alternate treatments need to be challenged. My hope is that this episode with Dr. Lim can be part of that process. One final point, Dr. Lim made reference to suicide rates in the veteran community is between 8% to 12%. However, as he shared with me, the number is 12 per 100,000 for the general population and much higher for ex-serving Australian Defence Force personnel. Let’s get to the episode now.

My guest is Dr. Alexander YC Lim, who is an Adjunct Associate Professor of Medicine with the Queensland Brain Institute. He is a psychiatrist in private practice and now almost exclusively looks after members of the Australian Defence Force, the Australian Federal Police, and the veteran community more broadly.

He is engaged in research in the areas of neuroscience and precision medicine. In 2019, Dr. Lim set up Australia’s first integrated ketamine program for veterans, known as the ReVive Ketamine Program, based in Canberra. It is now in Wagga Wagga and is expected to open in Adelaide in 2023. It will be the subject of an ethics-approved clinical study into the long-term effectiveness and safety of ketamine for treatment-resistant depression and treatment-resistant PTSD starting in February 2023.

Dr. Lim is also the Cofounder of the Zed3 Medical Group, where he is the Chief Medical Officer focusing on operational and strategic activities. He joins me to discuss some of the mental health challenges faced by a veteran community and to shed light on some emerging treatments that could aid on their path to wellness. Alex, thank you very much for joining me.

Thank you very much for the invite. It is a thrill to be here.

Before we get into the darker side of your life and work, maybe we can start with your own background. What motivated your journey into psychiatry first, and then how did you end up working with veterans, ADF people, and AFP?

Psychiatry was not on my card. I didn’t do well in psychiatry as a medical student. I hate psychiatry. It was this other thing that non-doctors did. I was gunning for paediatrics and orthopaedic surgery. I got out of medical school. I was doing lots of time up in Mackay as a non-accredited resident and did orthopaedic work. I love the time I spend on surgical and medical stuff.

The process was that you had to spend some time cooking after medical school. You are an intern and a resident for the first year. After two years, you can apply to a specialist school. I applied to surgical school and physician school, particularly paediatrics. It was a Wednesday. It was 11:00 AM, and I got a call from my former supervisor in Psychiatry. She goes, “Alex, you haven’t put in the application for Psychiatry. Do it now.” That particular individual is a wonderful human. No one messes with her.

I got into all of it. The thing that swayed me on the day was the interview panel was a bunch of people from Newcastle, and they looked like they were having fun being psychiatrists. I decided on the spot, “That is my pathway. I want to have fun doing what I’m doing and doing what I love doing. If that is what humans and individuals who have become psychiatrists are still doing, laughing and enjoying the space, let me do that.” The rest is history.

The only other factoid that is relevant is that medicine was not my first career. Medicine was my third career. I started off in politics after graduating from university. I wanted to become a lawyer. I started my legal education at City University. Midway through, I found medicine after doing a bit of time as an advisor for Philip Roddick.

I realised that I wanted to help people. I don’t want the policies, bureaucracies, and dilution of negotiations to change what I could do. My boss at the time said, “Off you go. We will still be in touch.” I was in medical school specialisation and doing what I do now. I’m passionate about what I’m doing now. We are still good mates. He attends my wedding. He has been part of baptisms. It is a continuity. It is good.

You are certainly not short of significant achievements in your life.

It is always a team effort. It takes a whole village to grow someone.

It's always a team effort. It takes a whole village to grow someone. Share on X

That is a good way to pivot toward our discussion. It takes a whole village to break someone and heal someone. I want to follow up on how you ended up working with veterans, ADF and AFP. What motivated that move?

The first area of psychiatry for me was child psychiatry work. That is my love for paediatrics. I fell into the military and veterans. It was a referral back in 2015 from a patient who is a star-ranked member. ADF just transitioned out. The GP asked him to have a chat with me. I remember saying to the General, “Why are you seeing me? You could see anyone in Australia. I know nothing about this.”

Relevance and integrity are important. He said, “That GP sent me across to you. That is why I’m here.” That sparked the conversation. I fell into it. By the end of 2015, I realised that in this area of military medicine, military psychiatry, veteran psychiatry, and mental health, we were still in the dark ages. We had no form, structure, or framework. We had a few things by way of guidelines. We didn’t have a workforce. We had no planning for the workforce specific to the military and veterans. That is only for military veterans. This is the other corollary of first responders as well.

I fell into it. I found that it started tweaking that political stuff that I used to be interested in to say, “The medicine in front of me is limited back in 2015, but it seems straightforward. How can we still have this problem? Why is it that the General didn’t have a Rolodex immediately to refer to? What is that about? Why is the most junior inexperienced flunky in the whole of Australia seeing a general retired? Why did that happen?” That tweaked my political brain. I started asking questions, and I fell into it. It was good.

It sounds like an exceptional combination. It is not a surprise that you have become such a vocal and well-known advocate of the veterans’ community. Firstly, your psychiatric professional training, but your inclination or understanding of the political domain and your legal training or the beginnings of. I suspect that would have come in handy. You might have a fighter in you as in an argumentative side as much as you are smiling now.

It is quite a good combination. As a veteran and a serving member, I’m glad you are fighting this fight for us. We can now start diving into some of those issues. From where you are sitting and what you see now, several years into this particular domain, what is the state of mental health within our veteran community as you see it?

There are broad opportunities and strengths. We have a robust college of psychiatrists and a college of GPS and psychologists there. From a general workforce perspective, we have all of the elements that say, “This problem of mental health can be managed and dealt with by a system.” Systems in terms of GP, psychologists, and social workers are all in play. We need to dive down a little bit deeper.

Let’s consider the analogy here that if someone has a physical, medical, or surgical condition, and I like orthopaedics, let’s use that as an analogy. You crack a bone, whether it is an upper limb or a lower limb. Every GP, junior doctor, and intern will know what to do as the first step, second step, and third step. The surgeon leaves the patient to say, “Off you go to rehab.” Nearly everyone will say, “In an uncomplicated surgical procedure, you have a pathway that is six weeks upper limb, twelve weeks, lower limb, basic pathways that is accepted all the way through medicine in terms of management of this problem.”

We can see it. We can manage it. We know what to do with it. We need to know how to get that person back into function and back into living again. You take that analogy of medicine and medical specialisation workforce and pathway of treatment, and you overlay that across to military and veterans. The same thing doesn’t apply.

We don’t have the ability to be clear that what we have is something we can see, and we can definitively treat and return to function. We have a high rate of chronicity. In other words, we have a high rate of the problem, whether it is PTs, depression, anxiety, or alcohol. Having this long tail that says, “I still have this problem, doc. It has been 6 to 12 months, not 6 to 12 weeks.”

On top of that, we don’t have a clear entry point. If a member of the veteran’s community with bad depression, multiple tours of Iraq, Afghanistan, and even then earlier Somalia, anyone rocks up to the emergency department, is there a protocol that says, “I know what to do with this guy?” If you rock up to the GP, is there a protocol? If you rock up to the MO1 base anywhere in Australia, is there a protocol that says, “Service type, service category, the longevity of service, I know what to do with you from a mental health perspective?” There is no established guidance.

The Australian PTSD guidelines, as it stands, are far more relevant to civilians as it stands, rather than veterans and the military. When you look at the entire cascade, we start with early identification right the way through the management of chronic symptoms, and there is no clear pathway. On-ramping is an important feature that is missing.

VOW 80 | Veterans’ Mental Health
Veterans’ Mental Health: The Australian PTSD guidelines, as it stands, are far more relevant to civilians rather than veterans in the military.

 

You guys are all highly trained individuals. Whether you go through Cerberus, Edinburgh, 1RTU, 1RTB, or Duntroon, you are all highly trained in terms of problem-solving, and we are as well. If there is a problem that emerges, we have guidelines, whether it is bacteria or surgical. For mental health and in the population of military veterans, we need to establish that.

We have the workforce. We need to acculturate the workforce to make this an interesting, exciting, awesome sub-specialisation. We need to create paradigms of care. According to the service type category, the longevity of service, and where you have been, we need to say that PTSD military is different from PTSD civilian. We need to understand that depression that arises in the military is different from depression arises in civilians and know what to do about that stage 1, stage 2, and stage three.

Once we start doing that, we can articulate this other thing I hope to say, “I’m a veteran. I can walk up to the GP.” The veteran has access, and the GP has Rolodex access to a bunch of established experts in this field. Whether it is psychiatry or psychology, we are all working together. That is the end goal. Now, we don’t have that.

I have a number of my friends who are going through some significant mental health challenges. As we speak, the veteran’s experience varies. More often than not, it is not meeting the hopes and desires of the institution because the institution wants the best for our soldiers as much as institutionally. Sometimes, our hands are tied.

Perhaps that is the reason because we might have the workforce, but we don’t have a workforce or the people on hand that can have a look and respond immediately to what a veteran’s experience might be. I do want to ask an obvious question, but it might not be to all. Why is there a difference between what the civilian world experiences and what our emergency services, AFP, military, and veterans experience?

Let me give you an example. There is a condition called adjustment disorder. It is a consequence of stress. It is not a trauma but a stress. In ordinary life, things happen, whether it is a disagreement with a boss, my pet animal dying, or a relationship breakdown. We have a reaction to that. That reaction might be depressive symptoms, or anxiety symptoms, not coping symptoms.

When that happens in civilian land, we often say, “It is Mental Health Day. Let’s take a break, slow down, exercise, take a couple of days off, recuperate, and reengage the workforce.” In military first responders, you can’t take a day off. You will be AWOL. You can’t say, “Doc, can you give me a med cert, please?” It won’t happen because you are expected to turn up to work.

There’s a concept called high allostatic stress. It is a common scenario in Defence where whether you are in training, exercise, or the deployment cycle, you have to get up, go ahead, and do your work and multiple tasks at the same time. You are aware of the expectations your boss needs. You are aware of the rules of engagement. You can’t say, “Boss, orange card, I need to take five minutes or a day off, please.” You are barely sleeping. It is for a six-month deployment cycle.

That is the difference. The setting is different. Because the setting is different, the cumulation of traumatic experiences for PTSD, the accumulation of general life, experiential stress source, occupationally for you guys, place the conditions of PTSD, depression, anxiety, and alcohol in a different light. It makes it more likely and more prone to.

The consequence of that is secondary effects if you come back and you have been on six months, times two deployment tours of Iraq and Afghanistan. You are on Rockwell, or you have come back, and you have been told, “You are going to be posted to that place for the next two years, uplift down lift.” You have barely had two weeks with your loved ones and family, and you are back at it. Therefore, the ability to decompress is short and often not there. The duration of untreated illness gets longer.

In the civil world, when someone says, “I’m a bit depressed. I got symptoms of bad depression,” your loved ones, family, or workplaces might say, “I need you to go see your EAP. I need you to see your GP.” Access is easier. I am tracking and treating it earlier. Even that aspect of getting on to treatment and getting that thing noticed, in Defence, you get downgraded. No one wants that.

It was certainly better than the last time I was in. I was out for some time. Since coming back in mid-2020, the stigma is no longer as prevalent, but it is undoubtedly still there.

Because you guys are a performance organisation and relevance is according to performance, corporals, sergeants, and woes get graded all the time against each other. You don’t want to be that person who says, “Doc, on my med file and purse docs, I had a period of time when I was unable.” That is a tough sell. From the MO’s perspective, they receive patients with symptoms. What do you do? Acknowledging they are on base in uniform and seeing people in uniform, MOs have a relationship with patients. What are their options? They want to maintain function. There is a deteriorating aspect of the patient, but the consequence of saying, “J34, J31, J32.” How do you rehab back from mental health?

For our non-Australian and non-military audiences, that is various gradings of your medical deployability and workplace ability to work.

The consequence of all that is that you have a system that says, “We want you to be able to work and remain relevant.” When you are not able, and if it is physical, we are going to rehab you because we know what to do. If it is mental health, the pathway to getting treatment and back from treatment into an employable and deployable status is less clear. The creation of stigma varies.

Another question that you have had to deal with and that is also the stigma that these mental health challenges only occur in frontline units. We are now seeing that is not necessarily the case, although one would suspect and expect that our most forward units, the ones under the greatest exposure to combat and war, suffer the most. Those in supporting and rear echelons are also suffering. Is that accurate?

Absolutely accurate. The entire Defence Force, in my appreciation understanding, is that recruitment retention is poor now. In many units, there are not enough staff members. Everyone left behind is doing multiple tasks within the same time period. That puts a high degree of stress on a prolonged period of time. Each unit member suffers a consequence of prolonged stress.

We know that physiologically and psychologically, stress leads to a deterioration of performance over time. If they start feeling that delta of performance, they might start taking some time off. If given that, and the moment you have that, that team’s capacity gets further degraded. In the non-frontline and non-operational sense, you have every unit under pressure and stress now. I got clerks who are doing five different jobs because no one else can do that.

In that case, can we say that that stress leads to something like post-traumatic stress disorder? Is there a different condition that one would end up with? It is a good chance to confirm for us what PTSD is or what we understand it to be now because it is also a misunderstood term, and it is thrown inaccurately at times.

According to the criteria, you have stress and trauma. Trauma, as it stands now, has to do with exposure to serious injury and life and death. People who are on deployment, particularly frontline troops inside the Y outside the Y, particularly with IEDs in Afghanistan and rockets, you expose to that environment, likewise, in particular high-level training. You are off-selection, whether it is East Coast or West Coast. A high level of exposure to serious injury is likely.

You have a range of traumatic experiences typical for those frontline troops, and likewise with the first responders. Even though we know that pre-deployment training is there for periods up to six months to acculturate the person and the human into the operational cycle and tempo, the mere accumulation of exposures to those traumatic events is what sets up PTSD in Defence. It is not a one-off. It is the multiples.

VOW 80 | Veterans’ Mental Health
Veterans’ Mental Health: The mere accumulation of exposure to those traumatic events is what sets up PTSD in defense.

 

Consequence symptoms of stress are clear, but stresses are different. Stresses are your everyday events of disagreements, lack of engagement, of difficulties where there is an expectation, and you don’t have the consequence of the expectations. Those are stressful. It is a gradient of stress. Accumulation of highly stressful environments causes a similar effect to what PTSD does. We can show that in rat studies. We have shown them rats’ degradation of neuronal circuitry.

Traumatic injuries have a particular characteristic. If we start talking about PTSD, I want to put aside whether or not we are talking about DSM criteria, which is the American volume of ICD, which is the European and Australian volume, but let’s say PTSD is a consolation of symptoms that we can say tie together. Once they tie together in a reliable fashion, we will call that a syndrome.

The syndrome of trauma, related events, and related symptoms are tied together. If you have a number of these things, you likely have PTSD. If you have a dysfunction in your personal or occupational relationship life, the D becomes invoked. It is D for the disorder. What is tricky here is establishing the D part for any stressful disorders, stress-related disorders, trauma-related disorders, or mood-related disorders because, in Defence, you are not allowed to cry sick. You are not allowed to take a sicky.

The criteria of occupational dysfunction are difficult to articulate because you guys rock up, turn up, put on a uniform, and crack on. The after-hours consequence is huge. Alcohol misuse, relationship stresses, and multiple divorces. Those become telltale signs of PTSD of adjustment disorder or major depressive disorder, even though the human still rocks up to work in uniform.

PTSD, coming back to that environment, is also a unique beast because whilst I say someone has PTSD and I’m a psychiatrist, I’m not talking about the person’s brain dysfunction. I’m talking about the whole human and the entire consequence of PTSD. It is not the brain state, but the downflow of that is endocrine hormone problems. Neuronal circuitry goes a little bit frazzled. I’m looking for signals of concentration problems. I’m looking for evidence of some cardiovascular, immunological, and even some signal of rheumatoid where you have the signal that the body is fighting against itself. All of those risk factors are elevated when you have PTSD.

We say that PTSD is an all-of-body or multi-system disorder. It is not a psychiatric disorder. It is a multi-system disorder. When that ties in to go, “I got a guy who has served several years in Defence. I don’t care which service or court they have served in. They have served several years in Defence.” The likelihood that they have musculoskeletal injuries is high.

PTSD is a multi-system disorder. It is not just a psychiatric disorder. Share on X

When you add musculoskeletal injuries and pain to PTSD, the likelihood of depression starts to come up. When you have PTSD, depressive disorder, and pain, the likelihood of anxiety disorder comes up. You have this cascade where psychiatrists have to be aware that you are now dealing with the entire system of the person and the person’s network of people because you will have relationship dysfunction and alcohol abuse.

Those systems are interplaying. If one is corrupted, chances are it is going to corrupt another one. It is the compounding effect of the breakdown in one area, which is why wellness is about the whole person. It is not about being fit or having your blood markers as healthy.

Employment is an awesome end state to reach for because getting employed and doing something meaningful is itself therapeutic. It was having structure, routine, and function. That is true for everyone. A key difficulty is when you get to the point where you can’t work. All the paperwork and assessment say that you are now TPI. DVA will accept that. I don’t entirely accept that forever. I say, “For now, I got a human who has TPI. I’m happy with that. I will work with that. I’m not yet satisfied that this is the case for the rest of their lives. I work hard to try to get some function back.”

How is that perceived more broadly in the Department of Veteran Affairs, the entire process of treating a veteran, and particularly the permanent impairment because that in itself has a stigma? From my own personal experiences and the experiences of my close friends, the word permanent in it is a shock to the system and traumatic in a way. They don’t want to overplay it.

I can speak about members of our Special Forces community, who I know well, to say something like that to somebody who is operated at that level of capacity and competence and has achieved and was selected based on their ability to perform on duress, what is the impact of that?

When someone says, “You are down, and you are unable to function. This is not permanent.” Effectively, I have chopped someone’s legs off. That is a shock to the system. For that particular patient and their spouse and family, oftentimes, the TPI claim might be successful based on medical advice and medical evidence. What do you do with a guy who is now 42 years old? There are still decades in their lives. What are we expecting if we are not in this self-fulfilling prophecy way? We said that the patient had TPI. In ten years’ time, what are we expecting him to do?

If we are not putting forward items of relevance, structure, routine, and benefit to him, them, her, and the entire family, what are we expecting to happen? In medicine, in general, we are pathologists. We look for what is wrong. We often don’t look for strengths. One of the key bits that have been for the last several years has been this movement called The Recovery Movement. That is a more strength-based idea that says, “Even if you have schizophrenia, which is a horrible disease, even if you have bad depression and you need to have ECT multiple times a year, what are your strengths? What can you do? What can we force multiplier? What can we start doing to affect a greater effect?”

The human still has an identity. My story and narrative with every human and patient I see these days is to say, “What are you up to? Where are you up to?” I can see massive agitation, mood stuff, bad sleep, poor sleep, irritability, and a short fuse. I get that. We are going to work on that for the next several months. I want you to focus on all of the stuff that you can do. You can get out the door. You can go for a walk. You can say good day to the next-door neighbour.

The next step is my expectation. As you get better, what are you going to do differently with a new superpower? You are not SASI anymore. You are not in Holsworthy anymore. You are not training with a mission deployment briefing every day or every week. What are you going to do for yourself and for your new unit? That is your family, community, and friendship group. What can you do?

It might be something small. It might be something like, “I had coffee with my mate who is struggling. I spent time with my year four daughter for the first time in several years.” Hallelujah. That is a win. When you were back in SF, I said, “Your family member wants to have coffee and spend time with you developing this school-based assignment. How much time did you have? How guilty did you feel not being able to do that with her or him?” Now you can. Happy days. Let’s do that. Identity is key to the clinical journey. If we are not careful, we lose the person whilst treating PTSD and depression.

Identity is key to the clinical journey. If we're not careful, we lose the person who we’re treating for PTSD, depression, et cetera. Share on X

It warms me to hear it described as that because when we talk about PTSD, and it is through some of my own experiences and my friends, it is not necessarily discussed. The whole person and identity piece is heartwarming because Defence, any call, or any service, it doesn’t matter. There is an embodied identity that comes with it. For most of us, it becomes a significant part of our life with that identity. When it is under threat through illness, mental, or when one is leaving or discharged for medical reasons or otherwise, and that identity no longer plays a key part in our lives, that is a huge loss to one oneself.

Finding a new identity and reconnecting to your family, to a new sense of purpose in a new workplace, whether it is volunteering for your local surf lifesaving club, it doesn’t matter. It is something where you can feel like you are contributing because that is what service and Defence are. It is about contributing to a belief that you are part of something good and holy.

That takes me to my next question. That is moral injury. As we know, it is different from PTSD, but it is still a loosely defined term, and we haven’t come to terms with it, or at least there are competing definitions across moral psychology, moral ethics, and military ethics. It is still a competing term. What do you understand as moral injury? What are the causes, if you could attribute them to it, that lead to moral injury?

My reference for moral injury is to say, “Moral injury is an injury to the soul. Everyone rocked up to a job with a sense of ethics, purpose, fullness, and you bring yourself to the job.” When that is compromised, there is an injury to the integrity of yourself. It goes beyond the idea of self. It goes to a sense of, “Who am I? How was I formed as a human? How was I formed to tell the difference between right and wrong? I’m doing a job, but my decision points now might compete with the chain of command, the commander’s intent, and the mission’s success. I have to wear that in my own deliberations of right and wrong. In my soul, I know what I did was correct or what I was forced to do was not correct.”

Moral injury is an injury to the soul. Share on X

You have the elevations of attribution. I was the one entirely the cause and responsible for that. I was in a position where I was one of the people in a chain of events. There are various functions in Defence where the chain of command and the risk of oral injury are clear. Sometimes, the decision points at particularly higher levels are not translated at the moment to the people on the ground equally when expectations of doctrine don’t conform with the behaviours of others around you and a lack of ability to enforce a better standard that also sits with moral injury because it’s an injury to the soul.

The other bit that is wonderful at the same time as awful is there is a soul in Defence, and everyone shares this. It is like a church working in this organisation. There is a belief and integrity. When you hear and see your mates going through a particularly rough time because of a process or a person who’s either a peer or a senior, you think, “Why? That should never have happened.” The ability to affect change, even when you are one star, is difficult. When you are unable to see a change in the organisation you have signed on to service, it destroys.

I know that will resonate with many of my audience. It is something I discuss a lot on this show. When your expectations are dislocated, Defence, at its core, is meant to be a noble profession. You join to go and help people and do things. I’m sure that is what most of us will say, like, “I joined to help those who can’t help themselves to make the world a better place.” It is an idealised version of ourselves. That is an identity that we embrace, and hopefully, most of us embody as we go through our training because we are inculcated with certain values.

We are expected to uphold and assess throughout our careers. When your organisation doesn’t meet the expectations it expects of you, or you perceive it as such by going to a war that is not necessarily crystal clear that it is a moral and just war or that that war has a clear and easily understood purpose, I’m guessing the foundations that one has built on since joining start crumbling. These are discussions I have had with some of my peers, where many of us have asked ourselves, “Am I part of the problem or part of the solution by wearing the uniform?” Does that broadly sum up what potentially could lead to moral injury?

One of the joys of being a psychiatrist is I haven’t stepped foot on a map outside Dubai. I haven’t been part of operational theatres of conflict and war. I get to listen, understand and appreciate the journeys that my patients have been through, writ large and rid across multiple theatres. What is clear is that 100% of people who join up with Defence want to do good. They see themselves as being a part of a greater, nobler whole.

There are things that happen in organisations, including the ADF. It has been subject to royal commissions and inquiries where humans behave badly. Equally, participation in activities that may not be as clearly ethical as one’s thought starts to raise some questions. One of the many aspects of large organisations is how you keep the integrity and belief of the individuals in play. Sometimes, you are asking to do things that are difficult to do and on the fact of faith. It is a lawful order. You have to go ahead and do that.

Another example is that his wife had delivered a baby. There are some complications to that delivery, but your boss has said, “We are en route to Townsville to deploy. You are a critical asset. You need to attend to this rather than your own family.” How do you make a decision? There are other aspects involving sexual assaults that are soul-destroying, but it attacks the moral fabric of any organisation that doesn’t treat that with the respect that it needs to be given.

The way through this amazing organisation has Latin phrases to explain some of the ethos. You have this amazing ability to form the individual, break them down, reform them into a unit, raise platoons and squadrons, and deploy in a coordinated fashion, either as Australian military Defence efforts and/or other international assets.

That is amazing. It speaks to the real traditions that everyone who wears the uniform understands and holds. Because of those expectations, the risk of oral injury is much higher. To maintain expectation at that higher level means that when there is a fall down from grace, you need to have clear mechanisms that apply to everyone regardless of rank, that an investigation happens without fear of bias that the outcome is good and just. When you have that, you have happy days. When you don’t have that, you erode the moral integrity of the organisation, not the individual.

VOW 80 | Veterans’ Mental Health
Veterans’ Mental Health: When there’s a fall down from grace, you need to have very clear mechanisms that apply to everyone regardless of rank. An investigation happens without fear of bias, and the outcome is good.

 

You are seeing this much better than I am, but as an observer from inside the organisation, we are seeing a little bit of that erosion happening now. One thing that spikes my interest is when we’re talking about stress and the impact of stress. Correct me if I’m wrong, but we know that when stress levels are elevated, our ability to make ethical decisions is also degraded. If that stress is continuous, over time, our ability to stick to our moral frameworks, compass, identity, and self becomes much harder to do.

This is something that I’m hoping to look at in some of my own research in the near future, but it is not often discussed when looking in relation to some of our soldiers and Special Forces members who are alleged to have done things we have since come to consider as war crimes. To what extent do you think this needs to be part of the equation? Are we paying enough attention to the science of what we know about stress?

The consequence of prolonged stress. Sustained stress is multiple. You are less able to think. You are less able to juggle multiple tasks. Your ability to recover and restore yourself in between tasks is less. The purpose of having it is to allow people to decompress and come back. Let’s say that stress management is key. In CASA, the airline accreditation standards and safety bureau fatigue are critical because it is stressful flying a commercial jet and becoming a pilot. It is stressful maintaining safety paradigms in your head while managing different vectoring.

By corollary, there are conversations and discussions about fatigue and fatigue management at the same time, whether or not a single pilot model of service is a safe idea or not. Let’s say there is a link between the ability of the human to think as clearly, and optimally as needed and prolonged and sustained stress degrades that capacity. There are a lot of physiological data to associate with that.

My input there is that moral frameworks need to be established at the earliest point in the formation of a Defence member. That becomes second nature. Moral training should be part of the fabric of every school because it starts from an early point, a lot like that several years ago, we started having a shift in behaviour with seat belts because we advertised to children to remind the adults in the car to click front and back.

Moral training should be part of the fabric of every school because it starts from a very early point. Share on X

That was about the time when I arrived in Australia. I remember that being a part of my indoctrination into the country, coming from a place like Bosnia where if you wear a seatbelt, that is embarrassing. You don’t know what wears a seatbelt.

Indoctrination is required. Indoctrination into moral frameworks of understanding is important. It should be the same for all levels of the hierarchy, whether or not you are a top-level general, a reminder of the ethical premises and foundations. From a medical training perspective, ethical training began when we were in the first year because we appreciated that our moral duties are multiple. When we are highly stressed working hard, there will be an invitation to do some unethical behaviours. From an early point, that was part of the training. It was a necessary part of the training.

Indoctrination into moral frameworks needs to happen at an early stage. When you are stressed out of your mind stressed, and you are task multiple things, you can reach back in and go, “It is part of the doctrine that I have a moral framework.” When a senior member says, “I want you to do something.” You could reach back into the doctrine of moral framework and say, “I wonder about something different here, sir, ma’am.” Have that conversation so that the risk of moral injury is lessened and the risk of moral engagement is heightened even when it is a split second. It could be a five-second convo about what is the right thing here to do. It elevates the conversations.

It forms a principal pillar of what it means to be a member of Defence is to have a sound and well-inculcated, well-developed, and well-self-reflected moral framework as you go forward. I couldn’t agree more that it is from the lowest level soldier to the highest general because we also expect those highest level generals to have the moral courage and their own moral frameworks intact to say back to the government, “I don’t think this is a war that is justifiable that is in accordance with our own war tradition.”

Notwithstanding the fact that if the government says you go, and we go, we need to develop the moral courage to speak up and be well-informed about the impacts a war like that might have on our workforce. That is what we are seeing. What is the issue? Given we are talking about the state of our workforce and what needs to be done, what are you seeing as the biggest problem now? Everybody knows it is quite well-established now that the suicide rates amongst veterans, particularly those of the younger demographic leaving the ADF, are elevated. Why do we not seem able to make headway in this?

Multiplex problem reference point. There is an increased suicide risk and rates of suicide in the general community with different hotspots and young people. The hotspot later on in life for men. There are deep and broad conversations happening around this. My input to that is this. We need to at least bring Defence and veterans’ mental health into a particular population where it is normal to be able to speak some veteran language.

Whether you are a GP, psychologist, psychiatrist, or social worker, we don’t even have the ability to speak and understand some common language with the people we are treating. Unless you have that bridge of language, how do you expect the human in front of you, my patient, to trust you implicitly if you have not bothered to understand the water they lived in?

VOW 80 | Veterans’ Mental Health
Veterans’ Mental Health: Unless you have that bridge of language, how do you expect the patient to trust you implicitly if you have not bothered to understand the water they lived in?

 

Trust is important. How many times have I said to someone from Defence, and they have given me the golden view to go, “I was fine, I was highly resilient, I have been through several years of service and been through all of these conflict theatres of conflict and war, but I’m fine? I sleep well. Nothing to see here.” It is because you start probing with a particular understanding of the culture that they have been through and going, “When you are downtime, what goes on?” They put their guard down and start speaking the truth.

We all know how to give you and psychs the smoke and mirrors. We have all done it. I have done it myself in post-deployment psychological interviews. I know what the answer is that the psych on the other end wants to tick that, “Fine. You can go and leave.” All of us do, and that is spot on.

Trust is born out of a common language but also a common understanding. Once upon a time, I understood that there were medical officers attached to teams. When that is the case, it is difficult to bullshit the guy who is there with you all the time. Therefore, trust and integrity lead to respect. When you are leading a troop, it is because you have gained their buy-in, and they accept your leadership.

When it is a medical environment, it is the same. Oftentimes you have gradients of trust. I have a guy who right now told me several months post started treating him that he is smoking. He is smoking, taking drugs, and taking cocaine. I was like, “I suspected it, but I’m glad you have brought it up. Let’s crack it and do some stuff.” Respecting the individual to hold back enough to go, “I’m not going to tell you everything about me, Doc, because not everything is relevant here.” Equally, enough trust to go, “I trust you. I’m going to tell you the stuff I need to get started to work on.”

Suicidality is a deeply personal reflection on life and death. The point of giving up hope about living to take on the path to death is a deeply personal one. Not every suicide is preceded by psychiatric or psychological intervention. Equally, not every suicide is preceded by a clear depressive syndrome or PTSD syndrome. Some people choose to end their lives.

The ones where we can say, “You got depression and PTSD. You are at much higher risk of suicide.” That is the population we need to increase our interventional integrity and interventional ability. Everyone coming out from Defence have social dislocation. You have a transition space where grief is happening. You are yearning for that relevance from before that you don’t have now. You have been a highly skilled weapon in Defence. You are not a highly skilled weapon in your family.

What happens to the conditions that you have already been diagnosed with? It gets worse. What interventions have you got? You got the people, clinicians delivering those interventions. The question now is, “Your doctor, psychologist, social worker, nurse, do they get it?” I go, “They give me scripts. I take twelve beds every day.” There is a missing link here.

The missing link and the treatments that are being proposed, I want all of that to get better. If we can affect a 30% delta to get people less wanting to suicide because they can see a better connection with the clinicians, a better treatment paradigm, and a way through it, out of their problems back into their community and families, I will take any day.

What is it about the more traditional treatments that we have found are simply not sufficient in treating the full spectrum or any spectrum of the conditions you are talking about?

Where we are talking now is the population of Defence personnel and the characteristics of the combat personnel. You have been exposed to a number of high allostatic stresses. It has been high kinetic and tempo for a long period of time. You have been physically injured and psychologically challenged and may be injured. Downstream, the constellation of everything comes together. You are unable to work anymore. You are exiting and are in transition toward a discharge date. Let’s talk about that population.

What do we have in conventional medicine? We have psychotherapy. We have specific psychotherapies to deal with traumas. In themselves, when they are studied and studied well, this has been replicated many times, and the ability of that psychotherapy to produce a good effect is high. It is awesome. Everyone in the world will say, “EMDR, prolonged exposure, cognitive processing therapy, and all these trauma psychotherapies have an amazing ability to get people better.”

Selection is key because the dropout rates of those psychotherapies are massively high. If you are able to get a psychologist who is trained in that stuff to deliver that stuff to you, it is happy days. It is step one. If that clinician is skilled with military members, it is step two. The dropout rate of clients attending those psychotherapies and finding it hard and dropping out is 30% to 50% for civilians.

There is a huge data study that got published in the States that showed that if you are a military member where the injuries and stressors are military-related, the rate of dropout is 1.6 times what it is for civilians. The ability to do that long-term will give you the stuff. If you stick with it, the dropout rate is massive. The issue is the preparedness of the human to undergo that treatment. We get better returns on investment and stickiness. The human, member, patient, and client get through the program to get to the end where you know there will be better.

The next bit is medications. Everyone will accept that medications, by themselves, SSRIs are the first line and don’t work all that well when it comes to treating the disorder. If I say to you, “Here is a tablet. It is an antibiotic. I want you to take this tablet because I can already see this medication is great for that particular bacteria that you got.” The ability of that treatment to affect the change and the cure is high, PTSD or depression.

If I gave someone an SSRI for bad PTSD, the amount of change I expect at a maximum is 30%. That 30% might be meaningful. They might be less irritable. Their spouses might say, “You are a better human. Keep taking this medication.” I haven’t taken away your PTSD, but I have resolved some of the intensity of the symptoms.

Medications from a psychiatric perspective for PTSD management are about symptom management, not about disorder management. Understand this. We have pain, PTSD, depression, anxiety, alcohol, relationship dysfunction, unemployability, and TPI. That is the constellation. Medications for themselves are delta 30% if you are lucky.

Medications, from a psychiatric perspective for PTSD management, are about symptom management, not about disorder management. Share on X

If I’m not taking the medication, but I’m self-medicating through alcohol, it is rounding out those edges that medication otherwise should perhaps do.

You are all good problem solvers. If the problem is at hand, you want to solve it. You don’t want to be a bad human. You don’t want to be arguing and being a ratbag at home with your young kids and spouse. You want to be a better human at home. You are going to do anything possible to stop that feeling and cycle of violence to yourself. Alcohol is everywhere in Defence and justice.

The next step is if medications writ large is not going to produce a better outcome, what about medications plus psychotherapy? For PTSD, there is some benefit, but it is not a massive benefit. It doesn’t matter which one comes first, psychotherapy or medications first, it doesn’t matter. The interesting is, within the house of psychotherapy, there are some good data that says, “If you do the short core psychotherapy to help your sleep, do that first, and you do the hard stuff later.” That produces better outcomes.

The importance of sleep can’t be overstated.

Once you have done the shorter course of psychotherapy, you understand what it is about and the psychologist trying to help you. It is hard, but you are going to get a benefit. If you get some early wins on the board, you are more likely to stick with it with the longer stuff. We are proposing that we have a shorter course of some stabilisation phase treatment before we start the longer course of the hard stuff.

For medications, we are now at a point where we are saying, “We understand from research the physical problems that happen with PTSD.” At the brain level, we know that it degrades the dendrites and axons. The signalling and integrity of the brain cells start to fall away. Medications such as SSRIs take far too long to have any beneficial impact on that aspect of PTSD.

Yale talked about this in terms of, “Let’s stop talking PTSD. We need to talk about this in terms of synaptic disconnection syndrome.” If you sign up to Defence, you know you are going to get injured, and you wear them with pride. You are like, “I got this shrapnel. I have broken my back. I got all these hip joints and backache problems.” You wear them with pride. What about PTSD? It is not carried with pride. What about traumatic brain injury? If we start saying synaptic disconnection syndrome, that is a little bit sexy.

It also removes it from, “You are going to be crazy. You can’t be trusted mentally. You weren’t strong enough.” All of those narratives are built around the stigma of mental health challenges or injuries.

This is not a failure of resilience. This is a consequence of your resilience in the operational tempo. Because of that, your brain gets affected. We can show you all of his amazing slides. One day, not too far into the future, in February 2024, we can start to spin some heads, particularly in Queensland. QBI has been amazing with this.

We can show you what has been happening. We can enter into the next phase of treatment that we have developed here in Canberra to show the new strands of signalling the new strands of brain cells that are occurring in real-time. We can do that. QBI has been able to do that for the past several years. It is cool tech. They were like, “We have been doing that for several years.”

It hasn’t gone mainstream in that sense. When we talked about your ketamine trial, was that part of it? This is a good way to pivot because this is an area of my interest or psychedelics in general because I have read the research myself. You had done the first trials of ketamine, which is different, but it still falls under the psychedelics broad umbrella. I was interested in talking to you about it. Maybe we can jump into that. What is this treatment? What is ketamine? Why do psychedelics do what they do? What do you see as the way forward?

My wheelhouse is ketamine. An interesting aspect is that we can all appreciate in psychiatry that for PTSD and particularly military PTSD, the ability for psychiatric drugs to take a meaningful effect is small. Therefore, the ongoing residual symptoms under PTSD and depression remain. The likelihood, therefore, of someone rocking up to my office on day one, I’m thinking, “I’m going to give you a couple of pills to take.” That person is coming back in six months, having tried many pills and still being affected by PSTD and depression pretty high.

When there has been a failure in multiple trials of treatment and still the ongoingness of symptoms, we call that condition Treatment Resistant PSTD and Treatment Resistant Depression. In conventional psychiatry for treatment-resistant depression, we have a series of other treatments. In particular, we have TMS, Transcranial Magnetic Stimulation, available through PBS since December 14th, 2021.

We also have ElectroConvulsive Therapy, ECT, that has been around for a long time. I want to be very coarse about this. ECT’s major side effect is a degradation of the memory circuit. People who undergo ECT might feel better, and they often do, 70% chance of feeling better. However, they often lose their memory. They might have ongoing memory loss as well as historical memory loss.

Is that why they feel better?

ECT in relation to PTSD. There is a guy called Professor Zachary Steel. He does lots of lecturing circuits at Richmond. One of the key bits I took away from one of his lectures was PTSD is a failure of the brain to learn something new. In other words, you are no longer unsafe. Stop pretending you are unsafe. The brain still thinks that you are in threatened danger. The learning circuits were compromised.

VOW 80 | Veterans’ Mental Health
Veterans’ Mental Health: PTSD is a failure of the brain to learn something new. In other words, you’re no longer unsafe. Stop pretending you are unsafe; the brain still thinks that you’re under threat and danger.

 

Lots of research data now say, “PTSD after treatment, the aspect that is the least able to be shifted through active treatment is that ability to concentrate, to attend potential circuits remain degraded.” If ECT compromises your learning and the problem of PSTD is a problem of learning, why would I want to do that? TMS is a newer therapy. The evidence for it in terms of PTSD is there, and it is growing but is not yet robust. We have this interesting dilemma of, “What do we do because I have this human who is suffering, and multiple pills are not cutting it.”

Back in 2019, up until the time that this ketamine program came up, I had patients who had been in and out of hospitals serially. They would be taking at least 8 to 10 medications a day. The side effects of all of those medications are quite disabling. It is standard because we are trying to keep this human alive. It is difficult for living and quality of life.

I reached out to Yale University. I went there for some training under the former chief of anaesthesiology training. I got trained in ketamine. I came across back here. I spoke with the Chief Health Officer, Jenny Furman. We went to some great lengths of what are the current solutions. What can we do for our veterans?

The interesting aspect is we don’t have any effective tools by way of medications that deal with treatment-resistant depression. We are still in the woods with treatment-resistant PTSD. We also have an additional problem of suicidality because that is still ringing high. We talked about ketamine. She agreed that, as a pilot program, we could start. She gave me a particular funding code to be able to do that. Because I was so concerned about the safety of my patients, I said to the hospital, “I wanted to do this. We must do this as if we are the Volvos of medicine.” A hundred percent safety first, airbags everywhere.

You don’t want to set a poor precedent, given the correct incipient and new nature of this.

We had to design this cautiously so that safety would be the number one priority. I reached out to my mates and anaesthesia land, and one of our good mates said, “She had a quick look at the literature around this.” Because ketamine is an anaesthetic medication, the real experts at this are anaesthetists. Because they are the experts, I reached out to them.

Thankfully, Dr. Val Quah, a good friend of ours, looked into this, reached out to her seniors, and a bunch of them had dinner. They came back to me after a couple of days and said, “There is no issue. We can deliver this.” I presented to the medical advisory committee across four different hospitals in Canberra. They rolled their eyes and said, “Alex, what you are asking us to do is low-level. The dose you are asking us to do is not anaesthetic level. You don’t need an anaesthetist. You need a CMO, a career medical officer, to deliver it. We will supervise.” I said, “No. You understand it is a psych program. I need real experts to guide and lead this.”

Calgary Hospital stood up and they were wonderful. The executive and nursing staff are wonderful. The post-recovery nursing staff is amazing. The anaesthetist, cohort, and group have taken it on. What we have now seen across the space of our past several years, we have now done more than 3,000 infusions. We have treated more than 160 veterans. We have had zero suicides.

These are treatment-resistant cases.

You come into this program. You tried meds and psychotherapy. Nothing is working.

Without the ketamine treatment control group, what would be the suicide rate of those who weren’t part of the trial? If it was the status quo, keep doing what you are doing. Do we have those nets?

We are tracking something in the order of 8% to 12%. Your modality is high. It is a completion rate. The issue becomes when we start looking at the population at risk because this is a population at high risk of suicidality. We say, “You have been a patient of mine for years. You have been to hospitals. You have been through a number of psychologists, psychiatrists, and GPs. No one has a solution for you.” What does that do to your soul? What does that do to your sense of, “Am I going to be like this for the rest of my life?”

We have been blessed. This program has been a huge success. We get feedback all of the time because we are continually looking at how to make our program better. The task in 2023 was to get ethics approval from Defence, DVA, and the human research ethics committee to study the program. We have been approved, and God loved them. They went to town. It was so awesome.

The feedback from the ethics application took several months to get through. The people who were involved went through every single line. They gave us feedback, A to Z, AA to ZZ, and a few AAA. We worked through the entire program. We received approval a couple of months back to study this program.

QBI at the University of Queensland is sending down two PhD students to undertake that study. I will be at arm’s length because I’m the clinician who runs the program. The research arm will be very arm’s length for me, and it will do a prospective study long term. With the data we already have, we will be putting in another ethics application to look at the past data of 3,000 cases because even then, I suspect we have the world’s longest longitudinal data set, and that is across all continents. The ability to say to our therapeutic goods administration, “We have the data. Can we start looking at normalising this for all Australians, not veterans?” It would be amazing.

Congratulations. The five minutes you spoke about could never capture the amount of work that is gone into getting that across the board. What is it about ketamine in particular? First, what does ketamine? What does it do to the mind? Why are we generally, as a society, still resistant? The ethics committee went through line by line because this is psychedelic. How do you view that problem?

It is an institutional and cultural problem. Ketamine is an anaesthetic medication. It was created in the 1970s for the purpose of having an anaesthetic that allowed the person to breathe freely. There was no respiratory compromise. As a consequence of that and how effective it was, it is now guaranteed supply by the World Health Organisation. If you are in a field hospital or a third-world country, a vial of ketamine costs nothing. It is maybe $10, whereas more expensive pain medications cost much more. Plus, you have opioid problems.

As an effective anaesthetic agent that can be deployed and used safely in the field, in third-world countries, and in the emergency department, this was created and used right the way through. If there were children presenting with burns or fractures that needed to be reset in the emergency department, ketamine is one of the go-to medications.

It came off patent for anaesthesia sometime in 2001 or 2002. Psychiatry picked it up because we were questioning, “We have been stuck with this paradigm of antidepressants based on a particular theory called the monoamine theory for the past several decades.” We haven’t moved on. All we have done is iterations of new medications with fewer supposed side effects and increase the tolerability of meds, but we haven’t changed the effectiveness of stuff that we are trying to achieve.

What was impressive was the National Institute for Mental Health in America. My appreciation of America is this wonderful place where innovation happens, but it is also the corporate heartland, and capitalism is everywhere. The dude who fronted up to a YouTube video, and he was the Head of the NIMH in America. He said clearly, “Stop investing in all of these new antidepressants. The vial of ketamine is what we need to investigate because it is available.”

America is this wonderful place where innovation happens, but it's also the corporate heartland and capitalism is everywhere. Share on X

In 2022, I was having a meeting with a group of people at TGA. When the meeting first happened, I was wearing a suit. I must have looked a little bit corporate. They looked a bit tense. The opening line was, “Dr. Lim, do you realise that you can’t make any money from this?” I said, “I know. That is the point. It costs nothing. It is already freely available and guaranteed supply by the World Health Organisation. You can rock up to the emergency department and get this for pain. If someone walks up with suicidality, they can’t get it because it has not been indicated for that.”

How does it work? We are not sure how it works. There are twenty different metabolites of this medication. A guy in Adelaide is investigating this. We think that it is 1 of the 2 metabolites of the twenty that is responsible for the biochemical changes in the brain. We know that one of the amazing things that it happens at a symptom level is within four hours, suicidality starts to drop down. In my group, within two sessions, suicidality is minimised.

We also know that within four hours, the brain restoration activity of growing new brain cells. You can see and watch new brain cells happening. That is amazing. When we start talking about psychiatric conditions, particularly PTSD in terms of synaptic disconnection syndrome, we say, “Here is a chemical compound, ketamine, that can reverse that.” We start talking like we are real doctors for the first time.

I don’t care where this medication comes from. I don’t care what it is associated with. It was a medication when it was first developed. It is the only one of the psychedelics that still is a medication in every hospital. In other words, we have clear clinical governance around how to use this effectively well and safely. We are going to intrude into the anaesthesia and land a lower dose, but safety is guaranteed and assured. How do we do that?

From my peace of mind, it is in the hospital because you have a bevy of specialists who know what to do with this. The area we don’t know is for psychiatric purposes. We know what happens within seven days because we have done this many times. I want to stretch it out and repeat the doses. What happens? We have that data now. We can’t talk about it. We can’t publish it yet. We will be able to talk about that in a long-term manner. We will be able to give an answer to, “Is it safe in the long-term?” We have the answer to be able to say and speak a clear truth about, “Is it effective long-term?” What factors can predict the effectiveness and safety of this medication long-term?

The first cool bit is the patients got better, and they stopped taking their usual medications. That wasn’t me. I didn’t encourage them. They stopped taking their meds. That has been a surprise. The other surprise is a double-edged sword, whereas my patients got better. Their thinking ability got better. They started picking on their spouse’s ball.

If they see more clearly and actively participate in their family lives, even if at the risk of conflict and resolving conflict, with a long-term view of becoming healthier as the multitude of systems is in play there, even conflict can be positive. It is an incredible thing that you have done and pushed that through in Australia. With ketamine, there is a stepping stone to some more innovative approaches.

I’m conscious that you can’t perhaps talk about it, but to put some words in your mouth, this is also happening. You are getting greater results for treatment-resistant depression and PTSD in the veteran community, but perhaps with far fewer side effects than we have seen or are seeing through the traditional methods, which don’t necessarily have anywhere near the effectiveness as far as success rates, but also come with the whole bag and a whole host of rather severe, in some cases, side effects. Is that accurate?

What we are seeing aligns with that. The opportunity now is to say, “Have we accidentally or purposefully discovered a pathway that is more effective with less side effects and has better benefit to the functionality of the human?” If we are able to articulate that and show that, can we start doing some predictor models to go for whom is to achieve? If this is achievable in 80% of people, that is stunning. That is spectacular. It 9is such a big shift from 30% to 80%.

For the last two questions, I will put it as one. Given the density of the subject we have talked about and we have jumped from various aspects of it, firstly, is there something that you wanted to say that I haven’t asked you or glanced over that you want to double-click on? My last question would be, what is your greatest fear and hope, given everything we have spoken about now?

Thank you for the opportunity because your platform clearly has a reach that is meaningful. What I want to establish is a sense of hope that it is not yet over. The guys who think that this is the end and I have nothing else, there are people and teams of people working hard to come up with paradigms of care that are more effective.

The end state that I would like to see is this whole area becoming completely normalised. A resident, intern, psychiatrist, or registrar can know about all of the treatment paradigms available and have no problems accessing it and being able to say to the patient or client in front of them, “I want you to start this pathway first. Cycle back and circle back later into this if we need to, and have it stepped gradient.” I would like that to happen within several years.

I have to ask one other question because I know it is going to come up when this goes out. Is there any way for people experiencing treatment-resistant depression and PTSD to join trials or get on board with some of these innovative or emerging forms of treatment?

I’m speaking my wheelhouse with ketamine. The program is available to everyone. We have people flying down from Queensland. We don’t have anyone yet from Northern Territory coming down. That could change sometime soon. We have one person in Tasmania, but DVA, if they approve, will transport and accommodate you, the veteran, for this program for as long as it is effective. We haven’t had a knockback yet.

We are looking at creating more sensors. If there is a hospital that is willing, able, and interested in creating this in partnership, it is happy days. Come on board. This is a following from a conversation with the Governor General. His comment to me was, “Why isn’t this everywhere around Australia?” We are now on track for that. We are opening up in Adelaide in 2023. We got one site.

I want to map this to where bases are, Melbourne, Townsville, and so forth. Once we get that, the only barrier is you have to go through the standard stock procedures of medications and psychotherapy. My only criterion is you need to have an ongoing psychologist to be working with you. With that psychologist, I want them to be able to work closely with the member. When the opportunity to do different, deeper, and better psychotherapy happens, the typical thing that happens in my program is they noted, grabbed it, and said, “We are going to work harder. Let’s go.” I get a phone call, and they go, “Do you know that Blackhawk thing that happened? We have cleared that. We are onto the next trauma.” That is brilliant when that happens.

Our criteria are open throughout Australia. DVA has facilitated. We have become a line item for DVA. We have clear entry points for all members. It doesn’t matter where you live. We can onboard you. We are on track for Adelaide. I am hoping for Brisbane, Perth, and Sydney in 2024. In Melbourne, if there is an opportunity, let’s have a look at it.

Dr. Lim, if I can give you a virtual standing ovation, please take it that you are getting one. That is amazing. Congratulations on everything you are doing. As a veteran, a service person, and as somebody who has got some of my best friends going through some hard times with this stuff, thank you for what you are doing. You are forging a new path.

Hopefully, on the other end, the treatment that is much more effective and the resultant lives that our veterans and other emergency services workers live far more wholesome, and they’re much closer to the original state of well-being. On that note, thank you for giving me so much of your time. I know you are a busy man. You’ve got multiple irons in the fire. Thank you, Doc.

Thank you.

 

Important Links