Thank you everybody for joining us tonight. We have had over 800 registrations for the webinar tonight We have an interdisciplinary panel discussion On a collaborative approach to supporting people with coronary heart disease and depression My name is Marco Murray. I'm a GP in town for with a special interest in wellness and psychological medicine and our panel tonight is Is eclectic and talented and covers many different disciplines and Rob Grenfell is a GP who practice near who practices near Horsham and Victoria He's a special interest in heart disease as well as being a rural doctor and he's well valued by the heart foundation for whom he consults David Calvoun is a cardiologist in Brisbane and he has also Has been for many years an associate professor at the University of Queensland. He also has a special interest in wellness and cardiology Dr. Rosemary Higgins is a psychologist. She practices at screening hospital in Melbourne She is a senior research fellow and at the heart of research foundation and lastly we have Nick Nick is a Practicers at the of all pH and Sydney he is associated with the brain and heart and mind Institute and in Sydney and he is a professor of psychiatry Now to ensure that everybody has an opportunity to participate to ask questions And we have a few ground rules be respectful about the participants and panelists behave as this would have faced the face activity Culture comments and questions for panels in the general chat box for help with technical issues post in the technical health chat box Be mindful that comments posted in the chat boxes can be seen by all participants and panelists Your feedback is very important So please complete the short exit survey which will appear as a pop-up when you exit the webinar We have some learning objectives for tonight So through an interdisciplinary panel discussion about Sheila you will have received the case study and read it If you haven't just picked back into NHPN and you'll be able to find it at the completion of the webinar Participants will better understand the mental health indicators in the context of coronary heart disease Identify the key principles of the featured disciplines approach in screening Diagnosing and supporting Sheila and lastly explore tips and strategies for interdisciplinary collaboration to support people like Sheila We are very grateful for your love to you tonight, and I trust that you have an enjoyable evening. We will now and Move on to our GP and Rob Grenfell and we will ask him to start his presentation. Thank you. Thanks so much Michael What we Have with Sheila is a patient that most of us in fact actually Know quite well in general practice someone who's been coming to see us for a good 20 or so years but the things that strikes me first about Sheila is how Stoic she is and in fact actually how she tends to be using her intellect as a cover and Sort of patients actually pretty resistant to Complaining about things and when they do complain about things the matter of Well, how sick are they and the question that I always ask with a patient coming to these types of problems at the beginning is what am I actually missing and the The thing behind that as we read through this case is that obviously from a general practice that Sometimes familiarity means that you actually do miss a lot of those cues because again patient like this is a real relief to see In most of your days because they're a big an intellectual conversation You'll have a lot of things to talk about and you may in fact actually be Outfoxed by them and not talk about the type of problems that she's really got or she may downplay those and be more Interested in talking about other things. Thank you Michael. We'll go to the next slide And and I guess as we move through there. We you know, thankfully saved her life around 56 by picking up some Occluded coronaries but That's reported by her husband. She just doesn't seem to be doing the best and You know why is it?  Let's face it And and how serious is this condition and what's Again the question comes to me about what's actually not being said because we've got a report here from her husband that she just doesn't seem to be How she is but You know she herself is not letting on with that so next slide. Thanks Michael Now the thing with some when you when you're looking at You know the whole patients you tend to be thinking about Well, I guess the patient directs you to where and what you're going to be talking about and They will Unless you question them They probably won't talk about some of the insecurities and some of the problems and this of course is a is a major Major problem, but again physical conditions deteriorate and as we age The condition itself would deteriorate and this is this is where With this particular patient it suddenly to work out the queues that were picked up in this case was she's not doing the best that she could and That was the the trigger for going back to the cardiologist and the insistence from the GP and again I think I can relate to this this issue with intelligent patient is not really telling you a bit You've got your radar up and you think hold on. This is a complaint from someone who doesn't complain. We need to deal with this So next slide. Thanks Michael And I guess the thing is again, she's young At 72 years of age, this is not an old patient by my standards So many of my rural patients were well in their 80s and still farming. So someone at 72 is talking about some shortness of breath or Digitally in fact actually doing physical activity or Something that the alarm bells are going off for me And and why is the therapy not working? My first thing I often think about is they're knowing that adherence is an extremely Poor thing for particularly people after that heart a heart attack unfortunately most people at least their medications by two years and I'd be asking is she actually taking a medication as she complies to these and probably the last question I've always got myself is my diagnosis wrong and I guess that's really the essence of medical practice That's why we call it practice because we're forever practicing it And I guess ultimately we retire when we think we've got it right Michael Thank you very much Rob and now we'll move on to David cousin that's important cardiologist David Yeah, well an important thing in patients with coron disease if we go to the first slide is that 30 to 40 percent around the time of their admission to hospital have At least mild depression Major depression may be around about 20 percent And it's usually missed. This is a slide that demonstrates Six years after the heart attack in the Australian lipid trial Which was a trial and best to go to cover satin versus to see both we use the beck depression inventory, which is commonly used in research studies and 27 percent of miles and 38 percent of females had a BDI to greater than 10 which is at least mild depression So this is very prevalent condition And had nothing to do With baseline character what your cholesterol is or whether you're on statins or not that they make this is the first trial That really showed statins don't cause depression. They can see this is a very prevalent risk factor And the heart foundation 2003 reviewed all the data and pointed out that depression is an independent risk factor of heart disease independent of You know cholesterol Hypertension, so it's a very prevalent risk factor Now if we move on to the next slide, how does it Back up to classic risk factors. It would see depression down the bottom there If you've got in just depressed mood, you don't fulfill the criteria for depression according to DSM 5 That's still influences prognosis as you can see Similar to the classic risk factors The thing is it took at least a decade After get doctors to be Measuring cholesterol and treating it. I think we'll take a lot longer here. So this is a very prevalent risk factor But there's stigma associated with it. There's a lot of people believe I look at just a reaction to illness But more importantly if we go to the next slide Even when we go to the first teaching hospital in the world the creme de la creme if you like, you know The Johns Hopkins just focused down on my first dot point 75% of cardiologists missed it even though they knew without the patients of being screened in the curry care unit there nurses much the same Consultants registrar's are all equally not good using our impressionistic medicine when we're doing rounds in the curry care unit And then in the ones we said had depression look about 24% Positive so we're not very good clearly. We need a tool to help us Measuring diabetes and ancient Egypt We tasted the urine and we said oh sugar in the urine that's diabetes. We need something better We've got blood tests. We got to move to the next one the heart foundation Following the example next slide the example of the American Heart Association We reformed our stretch working group and Nick is part of our group Nick Glossier And we've read with the Americans that our screening tools they get the ball rolling The phq to the patient health questionnaire These two questions here really simple when you're using the patient health questionnaire The two questions it's over the past month and anyone can remember this. Have you Often been bothered by feeling down happy for the press Yes, or no during the past month. Have you often been bothered by a little interest or pleasure in doing things? These two simple questions Are more than 90 percent sensitive to the development before the diagnosis of depression in other words They're mandatory questions now look it's self-fulfilling because if you look at DSM 5 and here we have the handbook here The first two questions were diagnosed of major depression You must have one or two of those questions that they have is over the next two weeks Um, and then you need four out of five of the other questions And what are these other questions go to the heart foundation website here? It is here. We can see on the camera This is on the heart foundation website and you can if you want to do look at all the other questions here and score if you like And our patient here poor old, um, Sheila she has Probably if we answer directly She says yes to probably both of the above and she's also got trouble sleeping Feeling tired and worn out and short of the breath is frequently a cause Is related to depression the next slide is a very simple screening tool which we all can remember Four questions rather than a tool It has prognostic information. This is from the san francisco Heart and soul study. We just go to the next slide just saying yes to either of those two questions As a major influence on prognosis Saying yes to either 55 percent greater cardiovascular events over the next six year follow-up That is very powerful prediction. Now a lot of the uh, uh depression is accounted for by Smoking non-exercise always other things in non-compliance But that's very important predictor that we need to do something now How can we do it next slide those two questions? We're introducing into our hospital Uh, the nurses put the stamp on Okay, so there rather than stamps is someone at risk of dbt. This is far more important the nurses love Uh, uh, this idea of doing the screening because they do it anyway. They do it when the patient's going to rehab Let's do it formally there and that highlights to the doctors and anyone else this patient Maybe at risk of depression needs to have further follow-up So I think I might stop there Michael because uh, mccardial's perspective Depression or my low mood is frequent Frequently missed and it has important prognostic information there and it's as important as diabetes type attention hypercostalemia Thank you very much. David. That's that's the That's the tone for the rest of the evening. I think Yeah, we'll just hear from our psychologist Rosemary Oh, yes, Rosemary. I just want to firstly thank the um cardiologist for measuring depression. That was brilliant Now she was presenting with some worsening health issues She has that reluctance to bother the cardiologist that um, Rob was talking about as well with the gp fear of the emotional impact of further health issues some anxiety and panic Brief re loss of strength and aging some positive response to the depression screen And symptoms which you know depression symptoms cardiac symptoms other symptoms also sleep problems And low coping self efficacy. She's not sure if she'll be able to cope Then looking at it the precipitating factors for why now The husband has retired that retirement of a spouse can create quite a lot of pressure Canceled holiday there could be some guilt and tension regarding that Possible trauma and anxiety from the previous surgery in the infection She's an internalizer And person who seems to put her own needs last And there's been a large amount of threat to her role Pregnant if decline is possible and also what's the meaning of worn down? These are the sorts of things I'd like to know a little bit more about In terms of the perpetuating factors as we said, she's an internalizer We're not sure about her perceptions of the illness. You know what she thinks her illness is what it represents Um, we're not quite sure we know that she values strength and health And that's a big source of pride. So this is a major loss in terms of identity and perhaps these illnesses are weakness Her family relationship role She doesn't seem to be we don't have anything about her community or a friend So there's some concern that she might be isolated We don't know anything about her self management skills and capacity And it seems that she hasn't gone to cardiac rehabilitation In terms of the protective factors It would be really nice if she had an adult daughter That's a lovely thing to have as a patient Is her medical support her husband her own independence and resilience Whereas it gets in the way of her seeking help. It will also assist her in some ways A previous history of good coping But unsure at the moment better health behaviors or social support And really with with her I'd be wanting to work on values on what she values what her personal goals are Getting a physically active perhaps a bit of mindfulness Some cognitive behavior therapy But I'd really like to get her into the cardiac rehabilitation and get some group support going And possibly some sleep Intervention maybe self-management support or empowerment Thank you very much Rosemary. So that's really flashing it all out for us now Robert and David have set the scene from a medical point of view from a general practitioner's point of view Looking at things that can go wrong and looking at the possible and misdiagnosis of use time here rather than a suppress of episodes when somebody presents the heart disease And and Rosemary has looked at the factors the protective factors and these are the perpetuating factors and the perpetuating factors And now we're going to move on to our psychiatrist Nick And Okay, thank you very much So the role of a psychiatrist in this is I see very much really about Supporting the general practitioner in the primary sort of pivotal management of someone like this And potentially being there as part of a stepped or collaborative care approach To managing someone like this and also potentially helping The psychologist as well. These are the people I see very much as the first line and we really Psychiatrist role is very much for Information advice and potentially if things don't go well or there's a failure to improve So on one level, you know, people may like a diagnosis confirmed Certainly, of course, you've got the by the time someone actually agrees to come to see someone like me They have taken on board the idea that they may or They may have a A psychiatric or psychological condition Now in many of these cases many of her symptoms could be both anxiety or depression or the mixture of the two of them And I think that actually the difference is moved at the often at the at the initial level Um, I think what what we will probably be doing is looking at a initial one-off assessment to provide advice The kind of sort of 291 or 296 and actually examine what kind of treatment that Sheila and or Hugh Would prefer whether we can go to a sort of time limited treatment for Problem-solving CBT into personal therapy or medication or both as well as some other treatments. I'll talk about Interesting, although in this particular case, I would advocate taking a patient or couple centered approach Given the background some of the data shows that bringing the family and actually can be negative at times Potentially to do with stigma So if you can move on to the next slide, please so if we confirm that she's depressed or it's obviously and One of the areas we're looking at is actually extending the phq2 into the phq9 and those tools actually make Psychiatrists diagnosed better as well than when they're allowed to do things just off their own back Um, you can look at what kind of treatment recommendations And I think the one that actually has by far the most evidence behind it the best evidence is actually exercise So everyone's talking about behavioral activation and exercise and people might we might have to help address A how that happens and B potentially have fears about that of how one might start that and tailor that to her Then as I said, you've got to talk about the potential for sort of more focused Anti-depressant treatments be that both medication or time limited psychotherapy and access could be an issue for the psychotherapy beauty Interventions, I've got a trial actually showing that some of the internet-based psychotherapeutic interventions are not as effective But they are effective and they're free and they are readily available if people can't get to see a psychotherapist or other treating clinician in that way If you do go down to the medication route, then I think it'd be very important to actually Treat this in a very sort of standardized way keeping track of her symptoms Which are keeping track of the side effects particularly any of the more severe side effects and very much looking at adherence as rob said I think adherence compliance concordance Really really important people are depressed three times more likely to be non adherent than people are not depressed There's a really big issue And again, we can use other other parts of the health system as well So sessions with an exercise physiologist or dietician to help in addressing diet and other well-being factors Next slide, please There's another Symptoms and others have highlighted the idea of sleep disorder So one of the areas I'm particularly interested in is actually treating sleep disorder and evaluating whether it's an insomnia She has whether we're looking at some kind of phase advance i.e. people whose Phase system their body clock becomes out of kilter with their environment And actually treating this specifically and there are a range of things from the very sort of simple sleep hygiene To the more specific cbti approaches again both face-to-face or the internet which could be done Um, I wouldn't necessarily be going down the benzodiazepine route And if this is a problem one might consider some of the more sedating antidepressants if required We talked about the psychological impacts or her role change from coping care to what is she now? What does she see herself and all the aspects that have been brought up earlier on? I think the fatigue is an interesting issue people have flagged up the idea. Well, what is the cause? Is this some heart failure? Is this depression? Is there something else going on? Is there another is this a result of sleep disturbance of some cause? And again with someone who's expressing some health anxieties You've always got to balance those issues around how far do you investigate versus good history taking and Continual investigation can actually exacerbate people's health anxieties rather than Rather than actually making people more reassured, you know the classic I don't think there's anything wrong with you, but I'm just going to do a brain scan just in case Next slide please We've all talked about very much the family concerns and particularly the husband's concerns You know, what is what are his concerns about her illness and what the impact might be on there looking at diet Looking at enjoyable activities. This is someone who's been a coper and care all of her life What things does she want? What does she actually want out of treatment? What does she want to achieve in her life as ever and said she's still really quite young? Family involvement and one thing I'd be quite concerned about with with this woman is just checking her cognition I do a mini mental state exam or gets asked someone else to do that particularly early on There's quite likely if she is depressed and potentially with a cardiac history that she has some Cognitive impairment But I'd be interested to see whether this improves as her depression and cardiovascular risks are addressed Or whether there might be something underlying Her cognitive in some underlying cognitive dysfunction that may be driving some of her anxiety and concerns And the other area particularly if she's technically literate is we're using increasing amounts of the measured self You know sleep and moot diaries sleep applications sleep cognitive cognitive training through things like luminosity The use of pedometers so really getting her engaged in our own health management And that's it. I think for my my particular aspect. Thank you. Thank you very much, Nick So we've gone through the four panelists. We've had the setting of The general practice aspect the specialist aspect And We're now going to move on to the panel and conversation start discussions And I did note that there was a question from one of our attendees John Clark Where is the exercise physiologist and that leads me on to ask rosemary to You were concerned rosemary that then this patient Hadn't been for cardiac rehabilitation and you had some questions to ask around us Yes, um Many patients do miss out on cardiac rehabilitation and and that is a concern cardiac rehabilitation is very good for mobilizing patients And it also explains and talks about emotional health as well as physical health They can get access to all the health professionals and They um, there's enough evidence to say that it it does help it does assist And I think that Sheila had she gone to cardiac rehabilitation would have Early tackled the exercise and got a lot more confidence and maybe that would have helped her with her mood issues as well And rob from Europe from Europe consulting with the heart foundation What would be the main reason why somebody wouldn't be able to get into rehab? Uh, unfortunately, um, Michael in in today's climate only one in four Heart attack sufferers actually referred in the first place to cardiac rehab. So the problem begins at the hospital And some of our therapies of course are lasting You know two three four days at the maximum and sometimes they're padded on the shoulder and said you fix After a sense being put in and so they they're not even encouraged from the care team in the hospital That's something that from the heart foundation's perspective that we're we're trying to address from the health professional The the next challenge of course is when they turn up to you in your general practice and I used to play this sort of game How long will the discharge summary take to get to me? Um, and particularly the more rural you are and I was um isolated rural often You'd never see the discharge summary. So you you wouldn't have an idea about where the follow-up was the next is Is the patient's um, do they think that rehab is relevant? So a young patient versus an older patient group therapy if you've got a drive 50 or 100 kilometer round trip to go to cardiac rehab Are you going to go? How does this in fact actually fit into my life as to where it is? And probably the other pressing thing is denial. Another patient's factor is that um, I'm right now my symptoms are resolved I don't need to do this or I'm not going to deal with this and those are those are some of the Reasons why someone won't get rehab, but probably the main one is doctors. We're failing our patients by not referring them on David do you have any comments on this? Yeah, well at the two hospitals that I picked us at we agreed 25 years ago that all patients Can be approached the cardiologist can be approached by our liaison tactic rehabilitation this and every single patient is invited to join So you don't have to it's just silly to say you have to be referred. It's a routine thing So i'm at a private hospital everyone gets involved now I can't say that happens in our public hospitals That necessarily happens that way because then they don't necessarily have rehab units But with cost cutting and other things Honestly, there's no excuse for it But let me just say my colleagues are more interested in doing the high end doing balloons and stents and stuff And the patients are in and out very quickly as Rob points out and they're focused on this stuff Using the toys if you like rather than the long-term things that are very important The most important to have patients feel about themselves and what are they like? So it's partly the system But let me just say all you have to do is get your mates together and you have the meeting and the nurses love this They support the patients and everyone's approached in my part in my hospital for the last 20 something years Thanks very much Nick. Do you have any comments? Davidson and Robert leave it to us there on the the benefits of group therapies via cardiac rehab as against individual therapies The first comment I have in this particular area that I think we we heard it alluded to there is if you want to do things and get and get Good treatment across everybody one of the things we you know We we understand is that some people get stigmatized certain groups Either through their own denial or because of the way that doctors consider them Tend to not be invited to certain treatments We know that people with depression get fewer angioplasty and fewer stents despite being a high-risk group And in fact they have in a paper I've viewed recently a longer door to needle time in the emergency department as well So there's a whole bunch of system things And as they've alluded to I think something interesting is the idea if you ask doctors to do things Often things fall through for cracks really whereas when you actually set up systems And you use the professions allied to medicine and it becomes part of their systematic jobs things happen systems happen Patients get better care. So establishing those systems for cardiac rehab identification Really can work well when the systems are embedded and put in place Come go ahead. Sorry Uh in terms of actual the the cardiac rehabilitation The rehab areas is not my my specific area But I've certainly seen some really good results from group treatments there And the group can often sort of help break down some of the barriers about how people Feel about their illness the implications the perceptions and actually can lead to a kind of sort of group think about Treatment and particularly around behavioral modifications as well rather than necessarily adherence to medication You had a question that you wanted to ask In relation to the issues that that we noticed between the couples In relation to confidentiality care or family discord, etc. Could you expand on that please? the I think several of us have alluded to The issue that this is a couple they share the same gp There appear to be some imbalances. So for instance Sheila has been caring for Hugh for many many years care for the family She's taken on a specific role Um potentially enabled him to live his to live his life do other things He's retired wants to do wants to do something go on a trip that has failed because of her illness So looking at the different roles that the two of them are playing and how those may be changing could be really really important And particularly potentially some of Hugh's anxieties about what he's actually going on with his wife This sort of stoic solid supporting rock who's been with him for so many years and what his concerns might be And the flags have interesting confidentiality issues Don't will Sheila want her husband to know about her diagnosis Will Sheila want any communication about a potential psychological or psychiatric condition being given to someone like Hugh So the confidentiality and the boundaries will be a really important one to play out and This is where all those really really important gp management and sort of social skills come into it Anybody else have any thoughts on the concept how to how to broach the problem with the couple Oh Yeah, I I think that You know, there might well be some tensions there between With the holiday cancelled and Sheila feeling like she's led Hugh down Um, there's I would like them to just get them both in together and get Them to actually try and talk about the bit and for him to realize, you know What's going on with her in her mood that it might not be his fault or might not be anything He's done And but it also might not be something that he can fix because he is probably quite a practical man and likes to get things fixed and You know move on to the next problem So that's that's a bit of a challenge Yes David you've had a very good question For the rest of the panel in relation to how long we could wait before we see an improvement in depression Could you expand on that please? Well, first I'd just like to say rehabilitation literature has shown over the last 30 years improvement in cardiovascular outcomes and This is what nick said an exercise Only programs that have an exercise component is here to be associated with improved cardiovascular outcomes So we've had two major trials in the last 12 months that have shown Improvement not only depression But also improve cardiovascular outcomes with the exercise and it appears that exercise into most patients is mild depression is as good as a drug So it's it's what we've been saying for the last 30 years, but it's good to hear a psychiatrist saying get out and exercise I think it's fantastic, Nick But in terms of the response You know, I mean response to any therapy often we say take six great weeks with depression, but Honestly, in my experience a lot of people feel a lot better within a week or two when you've been able to You know, just say look what's troubling you is not a blocked artery. You know, you're not flibby not you're feeling down um, and it this is to do with you know, you move and um, people often respond much faster than they're meant to By simply unloading a little to their cardiologists like we actually pay attention I think paying attention makes a lot of A lot of sense and that's why so many placebo treatments work well because um, you know patients do heal themselves by just That's just paying attention to being nice to them Yeah, Michael, I'd have to agree is Talking to a patient's a good good idea And asking that question. I think this is where we've been remiss is Which we haven't posed that question about you know, how are you going and that's what's so good about the bq2 because it's really That's effectively you're asking that age old question how things going How are you feeling and and and then in fact actually allowing to listen because I think with this case Again the trust and I've been looking at some of the comments that have coming up there the the trust is the issue Is the GP over 20 odd years? You will have that trust and you will have a fair idea about how far you can go with regards to talking The two patients through the issues separately and then bringing them together Can I just come in on a comment by a david drummond talking about an mi survivor? And I think he's made a very interesting point about how Rehabilitation is often short term and many of the things we see post myocardial infarction post Stroke is really Looking at the impact About the polypharmacy the number of drugs and treatments that people are meant to be on. I wondered uh With david and robb how they deal with those kind of aspects I guess robb There are key drugs that improve survival need to be last term It's really the lipid lowering therapy and the aspirin After that Only if you have heart failure of some complications. So for the simple uncomplicated infarct It's the the statin possible minus the fire rate and the aspirin long term after the first year They actually can be quite simple. I must admit. I try and make it as simple as possible Because I'm only so much you can swallow in you know, honestly in a day Yes Right you have to agree with you there david that you're number one on your list in the long term, of course Is your is your statin as the you know the evidence has shown Uh on how it works. Um, uh the aspirin, of course, uh, again There's substantial evidence for that for preventing further events And I'd agree with you that uh, we we talk about in our guidelines the use of Ate inhibition and that really depends on where's the blood pressure setting but also what's the um cardiac muscle function like and You know ceasing that from a gps perspective is really something you talk to your cardiologist about if you if you're looking at that But it's fair in mind, you know, once you start to get over three tablets people stop taking them And you've got to wonder are they in fact actually on them or not? Um, but largely I would tend to say that secondary prevention which is taking the medications after a heart attack is for the rest of your life You don't have a Much of a say in those if you want to prevent that because the most likely person to have a heart attack in australia today someone who's already had one That can be Can I say something to pop in here? Yes, certainly. Yeah, uh that it can be quite confronting for patients to be put on on those drugs When when I it is so important for them to take it But there might be a lot of psychological work in there as well because they can it's really about confronting the fact that they have a chronic illness not an acute illness and um people may see this illness as something with episodes like Serious episodes like Sheila seems to have had a serious episode but not really been uh looking at this as a chronic long-term illness to manage for the rest of their life And that can be quite a challenge and part of that can be around confronting that death anxiety as well That knowing that you're mortal so there's there's quite a lot of um you know Ways to work with Sheila around that or any patient Yeah, right because I just come in here And I think we need to put the bed It's uh nonsense on catalyst the rob was on I explained to patients. It is fantastic what we can do now Whether you have quest ran to lower cholesterol or niacin or the statin for to the easiest Over 200 000 patients in randomized trials has shown the same thing for every one minimal reduction Of LDL cholesterol. There's 25 reduction of heart attack 20 percent reduction of stroke 10 percent reduction of mortality And in my patients and in all patients you honestly can get too many more reductions So we say look we are halving your risk of having a heart attack And this is incredible. We couldn't do this in the past And I I say to them the biggest side effect of taking these drugs is that you may well live longer So it's a great side effect. Yeah, and living with chronic illness isn't success. It's fantastic Not like there's business stuff here from health and this is always chronic illness It's fantastic in the past people died We live longer than any other country in the world and we are apparently the happiest apparently Outside it within the OECD, but that's a miserable group of people, right? What about Denmark? No, we're happier than them That's just you in brisbane Well, we are the most miserable city in the world is quite like this Oh, you're making this up now.  This is someone who comes in she screams I'm interested with Robert. What do you feel his Colleagues what would happen in primary care? Would she immediately be referred on would you try an initial treatment? Would you actually do a watching and waiting for a couple of weeks? What would you do Robby with this person? Look, Nick with this with this patient. This depression has clearly been going on for some time and It's a lot more complicated than this rock standard one I mean, I guess somebody straight after a heart attack my my first thought is bring it to the floor talk about it Talk about this normalizing normalizing this but also understanding What they are and the changes that it's actually brought on in their life and Seriously following them up and working it. Is this a problem or is this just a transient thing? I think with Sheila. This is this is not transient the issue of medication is one that I I would think because there is Some significant issues with regards to life functioning and others Although I again I come back to your point about cognition testing because we all know that the brain is A heart that thinks really The blood vessels around your heart are no good the ones around your brain are probably no good either And we all know that dementia is one of the most rapid Diseases in Australia. So I'd be worried about cognition The the the thing about medication. I probably would be talking with the cardiologist first about Would I use this and is this the issue? But the the second part for either treatment Um The data now that if if someone like Sheila is amenable then cardiologists and gps Should with someone with a relatively severe depression be starting access our eyes pretty quickly I think that we you know that we can argue the pros and cons of whether or not We over prescribe I bought under prescribed I think it's more in Australia the targeting of prescription And I think the world you know after a heart attack or whatever it's right to feel depressed And certainly I think if you take an approach where they've had it for you've seen these people and you know What they're previously like and now they've changed and you've seen them took a couple of times You know multiple the tendencies with different symptoms aren't necessarily heart heart condition and again Multiple symptom complaints would be a real flag for depression. I think people should be starting SSRIs Probably quite quickly. We know that they are effective or you know, they're not magic bullets They're reasonably effective and we know that they're generally safe in people with heart conditions You don't have to consider what else she's thinking But I'm certainly being advocate that we should probably be using more of these in a targeted fashion and earlier and by non psychiatrists You are yes, go ahead. Yeah. Yeah. Oh, I would say it investigated in the sad heart trial post heart attack one of the two sites in Australia and that showed clearly the safety of surgery and the efficacy above placebo So it is certainly a safe safe There's only 300 pacers in that trial and we almost got statistical significant decrease cardiovascular events over six months so You know, it is there's no doubt about it being safe And if you know, you know, you can always stop later And the thing is we need to screen not just as a company in fact But you know from Sydney where you are now as you know Gordon Parker has demonstrated Prince of Wales in part patients if they develop depression a month afterwards That actually is worth prognosis at least some people in Sydney that people have at the time of the heart attack But yes, too many of my colleagues have dismissed Depression oh, it's just reaction the illness are going to get better. Well, that's you later 30% of them have got depression still We found the same at the heart research centre that it's the It's the later depression rather than the in-hospital distress that is predictive of mortality so it's really Not not just thinking about their distress in hospital, but looking at two months down the track and looking at the trajectory of depression where the Depression improves over time their distress improves over time Or it gets worse and we really worry about the ones to guess worse or that it doesn't change because for Many people it will improve because it's having distress early on is probably a natural normal response to a life-threatening or perceived life-threatening event sure think I mean Then you're playing up something interesting I just pop in there because there are a few other topics we need to cover before we finish It sounds as if everybody knows what should be done and everybody agrees on what should be done You had a question Sheila in relation to increasing the empowerment of Sheila and To improve self-management management. Could you expand on that? Sheila is that Rosemary? Sorry, sorry Rosemary. Yes, sorry Yeah, um Now her Her feelings about managing her illness knowledge of her illness and I think it'd be very important to To work very closely with her about her establishing her goals for You know for getting as well as she can in terms of whether it's physical fitness or mental health or You know social relationships what it is And getting her to set her goals and working with her to achieve her goals. That's where So we'll be talking about using a combination of cardio and psycho education I would say so. Yes Does anybody else have any thoughts about that about coordinating that pair? I just want to raise my hand before David here, don't you think? Um in navy or be she's scared to death of dropping dead And that's why we have units started up in the 60s and 70s by the Heart Foundation But they're absolutely scared. They're in bed for, you know, two or three months And the doctors everyone kept them in bed, you know, it may be very well other liners has raised me in as it before Scared to death of you know, catastrophe around the corner. And I guess that needs to be important But he's very competent lady. She's a retired professor of art. So she's no bill And it could be also that the husband scared to death of her Dropping dead and he's restricting her as well on doing we're not quite sure what's going on who's where the anxiety is I believe so yes, I think it's be very important to Get her to talk about, you know, what the values that she has and how she Thinks about her life what she's achieved what she's created What the meaning Is, you know, all of that I think is very important with the patient who's coming to terms of the fact that they're mortal Thanks very much. Nick, do you have any comments on that because you put up a A corner of therapy And, you know, going all the way from IPT down Yeah, I mean, I want to get across very much the idea that I think that the Sheila should be involved in the treatment modality And the evidence is that Both antidepressants and psychological therapies both work in this context And the evidence is that we can take problem-solving therapies And a lot of it really depends upon her preference for the approach Interestingly, we spend a lot of time talking about Matching treatments to particular characteristics of patients the reality from all of the studies is It's not so much whether the particular treatment modality Better or worse because we really can't show that it's how good the therapist is, you know, the reason why You know, the all blacks are better rugby players is not because they play a different type of rugby They just have different different players That's probably other teams So I put up those particular things because it really depends upon actually getting good therapists to do good therapy So if you're a CBT therapist, if you're an ITT therapist, if you're a problem-solving therapist You do that and you do that well Most therapists are actually eclectic when it comes down to them and use a bunch of different modalities That might be appropriate for the right kind of for the person who is involved And again, you know, so the better the therapist and we you know, we all know who are the good therapists The ones that we work with Quite consistently in those areas Whether or not the two are actually complimentary in this particular group of people We actually don't know we do know that that is true and that drugs and therapy are a little bit complementary Generally, you don't get an additive effect. You don't get the effect of the drugs and of the therapy together They're a little bit additive So I've bunged up a bunch of different things, but you can pick and choose I think the issue is about access about rurality is important And knowing that there are many of these interventions available over the net And more importantly that these interventions are much better than health information There is some good health information on the net. There's some rubbish health information on the net And these interventions delivered by I can give you a number of them. There's e-couch. There's beating the blues There's shut-eye for insomnia We know they are better than good health information and better than placebo So looking at those access issues, I think it can be really important in many areas of Australia Thanks, Nick. Rob, do you have any comments on how we should engage the patient? Yes, sorry, Michael. I just missed that last bit for this question Sorry, do you have any comments on how we should engage the patient? Assuming that you don't have any cognitive deficits, what's the best way to engage the patient? Well, again, this is to talk about how she doesn't seem to be making as much progress as she should be The position that she's in is that she's a young woman and that you'd expect that she would be able to enjoy her retirement far better than she is If you've got anything to think about or anything to say about in that perspective and then then opening up on Exploring what her thoughts and fears are about that because often the patient will say we've had a lot of Comments here about she's worried about dying and I think David sort of put that as well that These things need to be opened up and once you have opened those up This is a term of whether or not it's the GP I can deal with that and I really do like one of the comments there was absolutely good old-fashioned active listening and And that would be the start if you're isolated rural great idea Sit back and listen and then work out. Well, what resources have I gotten? I'd agree with what Nick said You can arrange in a number of rural areas contact through even it's just for yourself as a GP to be Discussing a case with a psychiatrist or even better still is increasing access to telemedicine services for that But the most important thing is trust that the patient's got trying to get involved with us we talked about with other family members definitely the partner and This person needs a care plan a chronic disease management care plan be effectively managed across range of activities and one of the interesting things that I've often found is that sometimes help comes in in some of the most unusual perspective some of my difficult chronic disease patients Would sometimes find with either say a nurse specialist in areas of rehabilitation The dain fact would actually break the veneer and Would develop a quite a deep before so it's a matter of really working with other people In in in having these patients come back to see you for a six-week check safe. Are there still the press in general? Well, it's the quick screen hospital But the real screen for me is the everyone who is under me in hospital sees me four to six weeks afterwards And we get an appointment before they leave And that's usually where where you know things really really move because Almost always it's with their spouse Now some feel a bit better some don't But you know, I usually do the ph q2 then And you know what the thing is a nickel. I'm sure and others will say look, it's not important Which treatment used for depression as long as you use something and we've got long-term follow-up You know people feel better with obviously with the treatment of depression whatever you use go for a walk You know use your ssr i are cognitive therapy But that does lead on to increase compliance with everything else we like people to do And those who get better ill expect whether it's placebo or whatever. They have better cardiovascular outcomes. So It's uh, I haven't quite answered your question But it's just part of the routine asking questions. How are you going today? Look at the routine being able to last month since I saw you you're feeling Been bothered by feeling down. I hope or you know, and then I and then we ask about You know pleasure in doing things So it's just sort of rolls off. I know it's called formal ph q2, but it's only just to make sure that we think about it but You know, it is surprising how subtle it can be in mouth and Disagree and you see the wife saying rubbish, you know, like sometimes she doesn't want to talk about the mouth Thanks very much, david Now as usual with mhpn webinars, they fly by the time has sped we're coming towards the end of this webinar I'm now going to ask this excellent panel and to sum up their message In two and a half minutes each panel. I would start with you rope Great. Thanks, Michael again. I'd be first looking at Recognizing the problem and that really means looking at yourself as the practitioner and Using that. Well, I guess it's expense. Why aren't things getting better? Why are things getting worse and what else is going on behind the scenes? And if we don't ask the question, no one's in fact actually going to give us the answer And we may in fact just have a superficial patient off the patient relationship and not really get to the core of what's causing this person's problem I think we've brought up a number of key issues One is that we need to look at a chronic disease management situation and the team approach We need to look at what team members are available to us around there The value of physical activity, but also the idea of Cognition and an assessment of this patient in a broader perspective is going to be a lot of helping And Working with the patient herself. What does she want? What's her expectations and what does she in fact actually think and believe? And and trying to get to those so that we can make sure she's taking a medication and also complying with a lot of the lifestyle changes that are needed to make her better and If necessary, as Nick has put in Certainly considerations for someone who's got a longer standing depression. We need to give a trial of medication If nothing's happening with lifestyle intervention Thanks very much Rob. That was excellent excellent something else Rosemary Yeah, just really just really um focusing on what Sheila wants what her perception of her disease is what her thoughts about her future are How how she sees her role and whether she believes she'll be able to facilitate whether that Needs adjustment and really developing the trust with her and finding out what she values What what are these that um, she wants to do and achieve and how she wants to how she sees herself recovering That's fantastic so much in so few words That was lovely Nick would you like to To just summarize how you have used this case and what we talked about this evening Also, we've talked about loads a load of huge range of approaches. Um, we should really center upon one thing which is really about Identifying what Sheila wants to do and imparting the information to her to enable her to make informed decisions We've screened if we identify that there is a condition the most important thing is that we actually treat it In this country more depression is not treated than treated And we're often doing things that really have very little evidence to support them rather than actually doing the things that we do Know that work Conversely, and I've seen a few sort of slightly concerning comments in the general chat saying well Why wouldn't you be depressed if you were like this? Well conversely? Two thirds or more people are not depressed. So this is something that is different It's something that different for her if we identify it and identify with her What are the best ways of treating it and making sure that we do treat it adequately? Thanks very much Nick Davis Yeah, well, I can give you a little bit more time because the other speakers have been Summarized fairly very briefly and comprehensively your You're the guy who's seen these patients In ice the year. So I'll give you about five minutes to summarize how you see the situation Okay, well depression is called as the forgotten risk factor It's common. It's prevalent make people feel miserable And unless we seek it out and it's in at least 25 percent of our patients low mood Maybe higher than that Then we don't know about it and the influences whether the patients Do follow our lifestyle measures and do that take their medication. So it is common It's easy to screen for and I see in the comments how about some other tools and complex tools Yes, that'd be great. No problem. But at least get our practitioners asking two simple questions Which will help to identify patients at low mood It's a risk factor which is important as diabetes. It's more common than diabetes It's more important than smoking dare I say But many of our patients won't stop smoking because they do feel depressed and when they stop This is what happens actually it can get worse. It's easily missed Let's scream with the phq2 to start with the influences prognosis and look as nick pointed out another Look, there are many treatments. There are many roads to Rome. You don't have to use necessarily drugs But you know what we don't have to be afraid of drugs there because we know it is safe and effective And you know, it's the therapist that counts be positive. We do know Cardials and doctors who are depressed have or have low mood. I'm happy with their job Why don't I say go do something else? But patients are far more happier and adherent if You are happy and enjoying your job. And you know, we're in an incredible position here A privileged position. Look after patients and we have a duty to do the major thing in the quality of life Recognize that they may be depressed or anxious Acknowledge it and if you don't know how to initiate therapy, there are plenty of good people out there who can help So I think we need to be positive and positive emotions also associated with a better outcome as well Now it doesn't matter how you improve the depression if it improves Life improves people feel happier and they probably also have less further heart attacks. So Really, I think it's time to bring it out of the closet Should we should de-stigmatize and I try and do that and say to patients look, it's no big deal You know, this is a common phenomenon. Don't feel as if this is an embarrassment and you know, we've got help for that so Maybe that's enough the message is it's common. It's an important risk factor. It's forgotten It should de-stigmatize it and I think it's time to treat and treatment work As I said, we're talking to the converted here We can be positive while our cardiologists say leave it to me. We'll look after it to everyone out there in the web land Thank you very much Um, I feel a very humble um summing up here tonight and we've had four excellent speakers from different disciplines from general practice from Psychology from cardiology and psychiatry all playing the same tune and all of one mind So if I may just briefly sum up what we've heard tonight And the most important thing I feel is to recognize the problem Not to be afraid to ask the question and the questions are not are not Um Great. Do you have a low mood? Um, are you getting closer? Have you been getting closer out of life in the last month? So I think um That David has put the name on the head is that we really need to have a fast and brutal way of Assessing patients in the mail from that they meet when they go into a um a cardiac care unit There's no doubt From all the evidence and everybody is reiterated. It's tonight. That's improving depression improves at outcomes when people have cardiac events And that's between 25 and 30 33 percent of people are depressed following a myocardial infarction We need to recognize it and we need to be positive We need to engage with the patients We need to Do both cardiac education and psycho education simultaneously This is often only Possible to do, you know, in a large unit. It's often difficult for people in rural areas But in fact in rural areas or in inner city areas where people don't have the access as they do The private sphere they can all they can often have a good GP or a good psychologist or a good Social worker who can help to improve their life This activity is important Both for cardiac well-being And for depression and this has been brought out by many speakers The team approach, of course, is very important and that's what NHPN is all about Coordinating conversations between different team members and improving outcomes for all of our patients and clients through team activities Nick made the points very well that we need to screen And treat and recognize that our treatment does have positive outcomes And it's not that it isn't difficult and no matter what the therapy it often comes back down To you our attendees the therapist Who makes the biggest difference to our clients and patients? I thought that that rosemary's contribution was was fantastic and She talked about those real-time things that we all talk about with our patients and clients What their perception is of what's happened to them? What how they see the future? And how the patient or client sees their role in being engaging with the patient Finding out what their key values are and engendering a sense of trust And with the patient So all in all this has been a very valuable night. I would hope for all the attendees And certainly I have very much enjoyed the expertise that has been on show tonight I would ask all attendees and to please mature that you complete the exit survey before you log out It will appear on the screen after the session closes The typical of attendance for this webinar will be issued in four to five weeks Each participant will be sent a link to online resources associated with this webinar within one to two days This is our final webinar in 2013 We thank you very much. Many of you repeat attendees and I see the names coming up time and time again And for attending it is you who makes this These sessions good for our clients and patients And if you wish to keep up the date with upcoming webinars for 2014, please go to the upcoming webinars Hashtag slash after you log into MHPN.org Once again, I would like to thank everybody from MHPN. I would like to thank all our attendees and mostly I'm very important tonight for our very very talented presenters, David Colhoun, Nick Glowsier, Rob Grenfell and Rose McGinn. Thank you all and good night


First question is from fit as trucker Barbell rose supinated pronated dumbbell or penlay which one is better for building the bag all the above. Yeah, they all are all good Right, all right, let's break him down so that we kind of tell talk about like the I guess the differences between them, right? So let's start with that supinated barbell rose. That's just where the hands are facing up This is what supinated means now the difference between this and a traditional barbell row overhand is that you're gonna get a little bit more bicep Involvement and that rotating of the hands brings the elbows in closer to the body So I noticed when I go supinated I feel I can get more of a squeeze in my lats than when I use a bit You know when I use the overhand grip Dumbbell I get a little bit more mid-back with that because of the rotation at the top especially when it's one arm at a time Penlay is more of a power move and I don't Typically teach that to anyone unless They're strong and stable in all of the other you know traditional rows like I never had My like everyday average clients do a penlay row unless they were really consistent with me For a while, so that's kind of the breakdown of them. I thought they're all good I taught penlay rows pretty early do I mean, I think a bent over row is I mean It's not the easiest exercise to teach somebody and it does take some skills So it wouldn't be I would never start someone on a penlay. I'd go dumbbell first, right? Yeah, yeah No, I mean you would go through but I mean you once you understand how to do a bent over row pretty well And you can keep your your if you can keep your back in a you know neutral spine And and you can if you can load a regular row and keep good form Then you could probably teach a penlay row, which I love to stabilize and brace really good technique really down But yeah, really really good. Did you teach it? Would you teach it? I would I did Yeah, take a bit. I would teach it Eventually and not until they have a good prerequisite strength and stability Because of that fact is it's now we're moving it fast anything time We're moving it fast like as long as you have the stabilization and in the proper Mechanics involved like I think that's the next level to progress Yeah, yeah the the way that I like to do barbell if I had to pick one because I do them all is A pronated which is overhead grip and I don't go You know flat to the floor which I'll believe not a traditional barbell row You're supposed to be you know Horizontal the floor so your back is literally flat. That's a traditional row I like to do it where my upper body is more at a 45 degree angle And this is the way that like Doreen Yates used to barbell row back in the 90s And he made the exercise real popular because everybody loved how big his back was or whatever I feel it more that way now when I bend all the way over Obviously can't use as much weight. I feel a little bit more in the upper back and less of the lats So I'll do that 45 degree angle one and that's usually how I'll do my rows Yeah, I've noticed when you I row more almost all the way over Yeah, I just I feel like I get a lot of lower back involved in there because the erector spinae has to stabilize in that position And so I feel like I feel like a better overall back workout the further. I'm bent over but you're right You can't row very much, you know, but that's where the pin leg comes in like if you can do a pretty good You know, I don't know 225. Let's say of a bent over row all the way over Then you could shoot shooting up 275 plus with the pin lay if you can hold that position that that whole time So I kind of get both that way. Yeah, or if your lower back is, you know, feeling it quite a bit and is a bit fried I like to lean over the bench and get that kind of stabilized support so that way I can lift a bit heavier Too if it's been taxing like I did dead lifts, you know previous to that But yeah, I think they're all valid Well, and this is just a great way of just this is how you would they all belong in your arsenal, I think and I think you can Maybe except for a pen lay right because it's an explosive movement That's the only one that you know, you bring up the point that you should have pretty good mechanics with your other other row Exercises before you even consider doing pen lay. But if you have really good row form Then doing this explosive movement. I think is is totally fine If you do a row like a good row barbell row, I'd say probably one of the better ones are dumbbell row And a pull-up You're hitting almost everything. Um, you know the pull-up chin up or pull down. I prefer the chin up That's really lat heavy when you're doing the row You're getting more of that mid-back than you would with a pull-up and I think you develop a really nice balanced Back when you and of course you throw dead lifts and and you're pretty much covered With the whole deal, but I remember specifically there was a guy that worked out at Golds years ago. This is a golds I used to go to and he was like a pull-up machine That's actually all he did was a million and one different variations of pull-ups And he had these very well-developed lats but very weak mid-back and upper back development and you could tell All he did were pull-ups.  There's so many muscles You want to do rows? You want to do pull downs? You want scapular retraction? You want to do some kind of scapular elevation? You want to do all this stuff to develop all the different, you know muscles of that of that area? Well, and to answer the question, which is which one is better for building the back? It's And I think you guys would agree. It's the one that you're doing the least out of these, right?  So I think they all belong in the rotation And the best one that you should probably be doing right now is the one that you either never do or rarely do You like the information in this clip, you guys are going to love the information in this full episode Make sure you subscribe and check it out


Hi, my name's Charlotte, I'm 24, I'm Essex and one thing you should know about me is that I'm the biggest flirt you'll ever meet. The three best things about me are that I'm fun, loyal and I've got legs that go on for days. The three best things about me is that I am too trusting, I am sometimes too mouthy and on a night out I'll definitely get a little bit too drunk.  My longest relationship was five years, it ended just because we grew apart and it just wasn't for me anymore. After five days I get five day ick and I block them out, never talk to them again, call it quits, just get bored. My ideal first date would be somewhere that was nice, quiet, something that was really thoughtful and somewhere I could just kiss him. One thing you might not know about me is that I absolutely love Formula One, I love watching them go round and I like them all kitted up and I like them in a helmet.


What's up everyone? I am pumped to talk to you guys about Zen and the art of motorcycle maintenance by Robert Piercig I'm super grateful that one of my best friends Greg Harner had read the book and passed it along to me as a birthday gift recently and It was definitely one of the best books I've ever read. It's actually known as one of the best-selling philosophy books of all time Also as one of the most widely read philosophy books ever There have been millions and millions and millions of copies sold worldwide across 23 different languages And it's kind of funny because Robert after having a hundred and twenty one different rejections Ended up landing this as such a popular philosophy book I think one of the reasons why it ended up being so popular is Because he had a lot of breadth studying philosophy also he had an IQ of 170 which is One in about 50,000 people have that he graduated high school at age 14 And he was interested in science itself rather than any professional career path so basically in trying to understand what the essence of philosophy Science the nature of reality are Rather than following a career path in the actual economic machinery itself And I think that one of the reasons why he was so successful also was because that he follows a Rhythm in his writing that is of one of the highest cadences that I've ever kind of Took taken in it only took me about three days And he weaves together the biggest philosophical questions with within this 17-day motorcycle cross-country adventure to his son and in the first couple of days he was with his two other friends and so that's kind of One of the ways that he makes it relatable is that he's able to weave in these most complex philosophical questions in with something as Simple as a motorcycle cross-country adventure. It makes it more relatable So I would like to just pop things off and just start it off with this question. What is best? what is quality and a lot of what we have going on in our civilization is we have a A non focus on those questions if you think about it in school Did you ever have a time that a teacher or another student around you asked you those questions? What is best? Or what is quality? Because if we don't have our society pressing us to Figure out what those things are The likelihood that we just become cogs in the machinery increases. So that's why those questions are so important So maybe rather than asking one of your friends when you see them again, you know Hey, what's new instead of asking them that try asking them. Yo, what do you think is best? And just see where that conversation leads you So I'm gonna go ahead and wander into what is the most upstream issue so the downstream we have today's Church of Reason and economic machinery and things like that which have done good jobs in many ways But also have their own malevolence is that we'll talk about but I'm gonna head upstream for a moment. So if you think about Consciousness if you think about awareness if you think about perception These are the most fundamental characteristics of experience of phenomenology. There's nothing more fundamental than your consciousness than my Consciousness than our consciousness than this awareness Nothing is more fundamental than that And so because of that we are We are In deep need to understand what it is That's why it's basically this pinnacle of metaphysics It's this pinnacle of synthesis between science and spirituality is consciousness is awareness in the studying of that and understanding it What Robert did a good job of explaining was what happened with Immanuel Kant and what happened was that a Similar to what Nicholas Copernicus did when he Identified that it's not the earth. That's the center of the universe But that the earth orbits around the star that our son that There was this big sort of shift in perspective and consciousness that occurred slowly But it took a little bit of time and Kant did a similar thing where he said that it's not just this blank Slate that we're born with this blank slate But rather there is something called a priori and a priori can just simply be thought of as the 3.5 billion years of biological evolution that we went through before getting to this point So meaning from a single-celled organism Understanding sensing its environment right so that's where we had people like James Cook on our show That was talking about the the sort of internal consciousness understanding of keeping some sort of a ledger of an environment right and having that style of of Balance between that so it's sensing of an environment and making decisions based on that and so from that moment of the initial cell on the planet all the way up through the development of the Multicellular organism all of the Cambrian explosion and the different sea creatures all the way up to when they come on to land all the way up through the Reptilian era through the dinosaur era the asteroid collision the chimpanzee and then the human that there was this deep deep process of building up these biological a Priories and that's why when a mouse that has never seen a cat before and this is clear in scientific literature Gets even just the scent or the hair of a cat near it. It fear response and runs away So there is this lineage of epigenetics for mice that have been stacking up Over time and it's similar with us as well That's why when we think about this a priori we wonder is good built into it is Quality built into our a priori Do we inherently know what is good and what is not and then Then is it up to that free will to make the decision to head towards the good on an individual level on Manifesting our destiny into the world and our unique gift into the world and our highest moral potential and also on a collective level For us to as a civilization heads head towards what is the most? Benevolent future trajectory for us for all of us and rather than something that's more malevolent and so that sort of idea of unpacking what is our a priori Perceptual infrastructures that exist and another way of kind of understanding this is music, right? You hear these these beautiful tunes and rhythms and and melodies and harmonics and singing and orchestras and symphonies and That's why when you hear Bach or Beethoven or Mozart That your entire body gets chills sent through you and that's why they're known as the top Composers of all time and that's why you go there instead of listening to somebody just like scraping on a violin randomly, right and so This is the idea you have an inherent perceptual ability to sense good and to sense quality and that ability may even be ultimate reality, which will get to towards the end and And So just the unpacking of that is its own that's its own book and that's its own Documentary and that's its own and we're gonna be working on projects like that that really begin unpacking what that a priori Awareness infrastructure is that is then Basically Triangularly parsing our world for what the star is at all times And that's why right when you hear the music you can sense it But you it's not a logical reasoning thing you after you sense it then you break down logically Oh, well Mozart is incredible because of x y and z so it's an a priori snap to sensation of the good and to of quality and and not so much of The downstream is the reasoning part of it more so and that's why the Greek had the word arete for excellence and That the more that we sort of commune with what these ancient spiritual Wisdoms are the more we commune with those that are basically dead the more that we really begin to understand like What can I pull from like the ancient Egyptians and the and the Mesopotamians and the Indus Valley and and the Vedas and Zoroastrian and Judaism and Christianity and Islam and and Buddhism and Hinduism and and Taoism and Confucianism and the African Vodun traditions and the Native Americans and shamanism and plant medicines and that style of indigenous wisdom What can we basically begin pulling from them as a pattern of how they how they understood and embodied some sort of a metaphysical good or quality into their spirit in lives and how they basically leveraged that in order to live lives that were more Towards that good and quality as we saw in the Greek in many people say that the Greek Civilization was actually one of the peaks of Philosophy that we've ever had and I completely agree with that And there's some sort of a strange there was no division between good and truth is what we think It's a very interesting subject But then all of a sudden truth won over good And that's why we led to the world of reason and sort of the Aristotelian division of everything rather than that platonic sort of good one Ideology and there's a synthesis that needs to happen between the two where you can have truth and reason and science and Technology be synthesized with quality good values That style of thinking art and spirituality and that's basically one of the key essences of my life And it's a key essence of chapter 7 the sorting algorithm of high-level perception that would be published here in a couple weeks and that style of thinking of the synthesis of these two sort of dominating ways of perception and feeling and embodying and being and Catalyzing Advancements in the world is basically one of the most critical essences that we need to do in order to most properly move forward So that's basically what a big chunk of what Robert was writing about was it was that the reason lacks Values it lacks that quality and that that's causing all of these other downstream issues in our 20th century In the 20th century we experienced as Nietzsche said the death of God and we experienced 150 million or so deaths due to that secularization due to that nihilism due to the dropping of that Pinnacle star of the highest possible morality There was not so much of the embodiment of atlas and Buddha and Christ and there was more so the embodiment of some sort of a possession of of Secularization and it as Max Weber says a disenchantment and That sort of desacralization ended up catalyzing a lot of the malevolence downstream that happened with the Holocaust and with the the gulag and with the great leap forward and shine in with pulpa and with the Armenian Greek and Assyrian genocide that that these these types of Malevolences are very specifically honed from the from the most upstream issue of sort of reason not having a Heart and a value and a quality Or an understanding of the good and I think that's super-duper important for us to have Identified and today in the 21st century people feel like cogs in the economic machinery And this is a big problem with what we see in in places and in modernity like like China Is that they have a lot of? Communistic social fabric success with eradicating poverty and one not in giving people more But they also have the problem of people losing their individuality and feeling more like a cog in a machine As a replaceable cell in the organism of China And that that's also a big problem, but the United States also has their big problems with the over Individualization to such a point where the lack of sort of Social fabric Infrastructures become sort of secondary and thinking that that's actually not as important for actualizing the basic needs of every single person And so that's sort of an understanding as well in the sorting algorithm It's not just of science and spirituality that need to be sorted and uplifted But also of the left and the right domestically in the US of Nationally on an international level the US and China being able to sort these best practices into a synthesis at the That highest possible that that can be unleashed into the world getting rid of the disenchantments and maximizing the potential of a synthesis of Reason with quality so science also has a hierarchy of facts It was really interesting learning more about Jules Henry Poincaré. I actually Hadn't really come across his work too much But he's a massive massive influence on understanding that science actually has a hierarchy of facts itself And that's where there is you can begin seeing that actually science itself has a Has quality to it as well So there's a star in science as well and a good way to think about this is that it's it's more efficient for you to learn a very general truth in science than it is for you to learn some sort of like a Something way lower on the pyramid on the hierarchy like something that's only specific to the niche of one specific or species right So if I know the behavioral Drive of a single species in biology That's less important than if I know how a cell works and you can understand that the cell the general truths of a cell and of Proteins are way more important because they're applicable across the biological kingdom and spectrum then as the single behaviors of One species and so you can see there is beginning to be some sort of a hierarchy of facts in science as well So that's where you can kind of start beginning to see some sort of a synthesis And it's also very true. We talked about this before on the show as well is that in science if you don't have values and quality and spirituality that enter into science you have problems like the The the Robert Oppenheimer Edward Teller sort of atomic bomb hydrogen bomb era that became unleashed and Because of that death of God But then at the same time if you don't have science enter into the realm of spirituality Then you have people that are trying to peddle things like snake oil salesmen you have people that where there is we need the scientific test to be able to tell if that's sort of That claim that these things are energetically healing that we can scientifically verify those claims so Yeah, we've talked about this quite a bit We need to you know Robert talked about it as a classical the classical being the science and the technology and The reason and then the romantic being the arts and the quality and the spirituality and The values and we need a synthesis between those And that's going to maximize our potential and that every single Art our social fabric itself needs to be conducive maximally conducive incentive wise and inspiration wise to have every single person realize that They're gonna have the most meaning come into their lives by taking on the most burden on their back as in the more Responsibility like Jordan Peterson has been talking about the more you're like Atlas right in mythology the more you're like Christ the more you're like Buddha the more you eradicate the roots of your own suffering Through understanding the breath and understanding the consciousness and awareness and the more that you sort of take on the biggest moral burdens on yourself The more that you're gonna feel like you're achieving a higher level of existence in being and The more that you're gonna feel like you're heading towards a north star, right? We have to we have to head towards something. We have to future author our way So it's a balance between being here and in the now and being super present with also being super oriented towards the future And being honed in on that relentlessly and so it's that balance as well and you basically begin treating good as a noun rather than an Adjective and that this becomes the highest moral conduct of all and I think that's really profound and and Robert unpacked that more in his second book Lila Lila and Inquiry into morals that was written in 1991 whereas Sam Zen in the art of motorcycle maintenance and Inquiry into values was written in 1974 so I Also want to Remember just remember that last part that last part so crucial that you have to think about good as a noun rather than an adjective And the more that you think about that the more you realize that it really is like a sort of set of behaviors and principles and Objects and ideas and ideals that I have to sort of think about an embody and work with as Super frequently in order to have that highest moral conduct Another problem that happened in the book Well that I think was one of the biggest problems that super identifies to modern society is that We took this hundred and seventy IQ genius of Robert who was you know, phaedrus at that time and He was you know very brilliant as you know professing in English And he was he was recognizing that rather than teaching his students What quality was that he should be having them understand what quality is themselves? And so that was one of the profound realizations and then started building out this whole idea of a metaphysics of quality And then there was this sort of decision that oh well He's actually insane and then because of that decision and because of the time period that it was in that we could do things like do this electroconvulsive therapy onto him and basically Barbecue him and to await that personality into a new personality and that's a huge problem That's a huge problem. It's not you can't do that anymore today in a voluntary stuff like that I can't do that anymore today against the law, but It is something to think about is that level of neurodiversity if we have these people that are three standard deviations above the mean and IQ and more and their genius visionaries we need to we need to be highly conducive to helping them with storytellers and with and with teams and with further dissemination tools that allow them to actualize their technologies and their stories into the center of the bellicure of that then kind of move everybody up This is a big part of chapter four called portals and high-level perception And that that sort of essence is going to be critical rather than taking that neurodiversity And just throwing it off to the side like it's insanity and then we lose their gifts So that's so that was a very profound point for me as well There are these basically there's these patterns of the most uncommon 1 billion people that have ever lived out of the 100 billion people that have lived that we have the Civilizational inheritance from and the 99 billion common people that have lived Don't have as many of these patterns that the 1 billion really uncommon people do that have basically made the world that we live in today And so we need to identify what those patterns are and amplify them more for everybody And that the sort of in the bucket of frogs example the center of this evolutionary pacer can't be Pulling down these genius level frogs that are trying to escape out of the bucket and help other people move forward And that's what we have with these like resentment and and and jealousy and envy that happens in that center of the of the bell curve so All right, I'll move into some of the last things here. So I think that one of the most profound things that Especially that joren peterson has been teaching about has been this idea that it's quite possible that A a metaphysics an understanding of how we got to where we are today is through an idea of that Uh, if you think about back to the age of chimpanzee slowly evolving into the sort of prehistoric humans what what happened was there was a moment of of sex sexual selection that occurred where It became more and more clear that that women had the choice of declining men in the hierarchy and so That made men more self-conscious. So basically it made men more Aware of their place in the hierarchy. It made them more aware of their behavioral patterns So women declining men in sexual selection Made men more self-conscious and so it made women more self-conscious and it made us together more aware So that was potentially this is an idea. It was potentially the birth of metacognition so sexual selection may have birthed metacognition And then metacognition may have given rise to what is good It may have given rise to values. It may have given rise to quality And so that idea of metacognition Sort of enabling the bifurcation of what is good and what is bad is another profound idea That it's possible that we then realize that I can use my free will In order to decide to make good moves to climb up this hierarchy of competence And then the higher I am on the hierarchy of competence the more likely I am to propagate my genes moving forward with a very high level female player A very profound idea and then even downstream from that is that these ideas So basically we took our metacognition and we took the ideas of values and quality and what is good And we put those into stories And so then those stories we put on you know, the big cave paintings from 30 000 years ago We put them into we wrote them on papyrus on stone And we began telling these stories orally through traditions over these tens of thousands of years And the idea is that those that were better returititions those that used the essences of persuasion of ethos logos Pathos the more that you can talk from a place of authority from a place of logic from a place of emotional persuasion When you tell stories the more your means will communicate Into the other persons of receiving genes And then that person will take their genes and be able to more successfully propagate them downstream So storytelling became one of the most critical aspects of our evolutionary history And it was really the ability to take quality what is good What is value and put it into like a compression algorithm into these stories And that's a big that's the that is the Old Testament basically And that the more that you realize that you know, able made that massive sacrifice And that kane made that horrible decision of killing Able in that resentment and jealousy that his sacrifice wasn't as good The more that you see that and embody that and realize that and understand that The more your genes are able to propagate at a higher level because you understand What is at the top of that sort of idea of values and quality and what is good And so we've been passing that down for tens of thousands of years now And it's a really interesting evolutionary story arc if it's true But at the same time there was this There was this really good, uh, there was this really good quote that was that was said by By robert in In the book as well That it was something along the lines of like that uh fagress Do we really need to know what is do we really need someone to tell us what is good and what is not And I think that that is also a really good Really good idea as well as that do you really need these So it's this balance between needing these sort of stories over tens of thousands of years And also understanding that you have this a priori infrastructure that enables you to sense What is good and of high quality so it's a balance between those two things And then Sort of you know, kind of rounding it off at the very end I'd like to say that I think that the idea of roberts metaphysics of quality is super duper interesting and it's very possible that As he says that it's possible that Quality is maybe Actually ultimate reality quality might be That sort of a priori filter that we have on our Awareness that sort of gives rise to those immediacies and consciousness the first ones that we sort of become aware of That that may in fact be ultimate reality that may be god it may be dao it may be the brahmin it may be It may be the essence of of ultimate reality and if that's true then It could imply it at a deeper Darwinian metaphysical level and not just at an individual level meaning that It's not only important that you with your individual decisions become christlike buddha like The highest level of morality possible through A synthesis of both your own a priori essences But also through understanding these deep literatures of tens of thousands of years But also that every single decision that you make actually has to do with the destiny of the cosmos at a deeper level so meaning that Your decisions butterfly effect out into civilization and then civilization's trajectory Goes towards that fork as well of if civilization's going to make it in our next big steps or if it's not And so that's the sort of darwinian metaphysical level is that in order for us to get to the next sort of Uh, we're potentially what I hypothesize in in chapter 10 called infinity in the book That it's possible that what we are as ultimate reality is that consciousness exploring infinity And that as robert pier success is that that quality a priori filter that we have on that is also ultimate reality In the sense that our free will decision making of going towards the good or going towards the bad that is A that's synthesized with the darwinian metaphysical level if we're going to make it to our Consciousness exploring infinity to the next recursion is very important And so every single decision that we make has to do with that trajectory if we're going to make it the snake eating its tail The oroboros symbol are we going to make it in the way? We do that as via john smart's Transition hypothesis meaning we actually go inward through the the vr the neuro prosthetics the ai age the agi age That it's a synthesis of all the simulation theory technologies that exist and that soon will have In an infinite amount of new universes that we'll be able to transcend into and that will be like this in the candy stores Just chocolate and that as donald hoffman says is that we're going into vanilla and strawberry and mango and cookies and cream And all the new flavors of consciousness ice cream that we'll be tasting that may not be these four-limbed two-eyed Carbon-based dna encoded creatures of consciousness, but rather different soul vehicles in those next recursion So we may be using different soul vehicles in the next recursions But in order to get there you need to think about this metaphysics of quality at your own moment-to-moment decision level chapter two is called seed theory In high-level perception and I talk a lot about the bifurcations that exist Every single one of those bifurcations you need to think about And really open up your heart to can I be good at this bifurcation? Instead of reacting to this stimulus that's trying to get me to be bad That's trying to get me to name call back at someone that's trying to get me to hit someone That's trying to get me to be violent or malevolent What if I instead take the moral burden on my back and make the good decision to stay calm And to stay loving and to stay compassionate and then to watch that anger and malevolence dissipate in that other person It we're triggered with these things all the time But it's up to us to have that high level of Metacognition and to realize that these things are happening to us and for us to aim in that direction Of the highest metaphysical good of that metaphysics of quality of values of what is good But also at the highest Darwinian level that we got to make it as a as a civilization You can think about it as one cellular organism that really wants to divide To undergo mitosis the whole planet But that our little cell cycle our our self checkpoint that we have to get to that checkpoint in order to divide And to go into the recursion But in order to get there all of the little organelles Inside of the cell all the different nations and all the different molecules like us individuals I need to have a high level of intracellular communication In order to be able to get to that cell checkpoint and to undergo mitosis and to go through the recursive process into the next Flavors in the infinite candy store that we're exploring So maybe that consciousness is exploring infinity And it's a big unbounded map and we're forever doing that And that your Metaphysics of quality your values your determining of what is good with your free will Determines how successful we are Achieving both you are individual goals and our collective destiny So every single decision you make has to do with the telos of the cosmos That's a big thing That's a big thing I love you very much Thank you for tuning in I'm super grateful for Robert Piercic. He passed about three years ago in in 2017 I highly recommend readings and in the art of motorcycle maintenance He's I think he's one of the best synthesis that has been around in a long time and Yeah, he was it's one of the best books. I mean, he really does a strong job at at Synthesizing all of the perennial philosophy But also at putting it in a really beautiful motorcycle adventure story at the same time And so I highly recommend reading it. I'll put a link in the bio to it so you guys can check it out And then his other book lila as well lila and inquiry into morals Check that out as well That kind of goes a little bit deeper on to his metaphysics of quality He has a there's a couple people online that are talking about it as well That you can find it's moq metaphysics of quality.org moq.org. I'll put that link in the bio too Check some stuff out again. Ask people what is best instead of what is new really start asking that question. What is best? Also, what is quality start asking people those big questions? Thanks, james appreciate the comment about awesome talk shout out to you shout out to you guys Thank you so much for tuning in. I'm super grateful for our audience that we have it's still at the early stages guys We have about 75k subs after about three years of going hard at this And still the early stages we're about to blow up. I'm about to publish this big synthesis. It's super explained like I'm five It's super visual. It's super beautiful and super short I'm pumped for you guys to all take that in and then for us to talk about our next chapter because The next chapter is huge and it's a big surprise for you and you'll see where that's going In about less than about less than a month You'll see where where we took the next chapter and how we're getting at the throat of the awakening and how we're Moving things forward at a at a bigger level. So I love you all very much big love to robert pierce Zen and the art of motorcycle maintenance check that out and godspeed to all of you as well on your north star journeys and Crush it crush it guys. We got this big love Comment subscribe share the video if you found it enriching you guys know what to do Bigest of love