1 00:00:00,420 --> 00:00:05,230 I'm pretty. Thanks very much for staying on after the end of all the compulsory stuff. 2 00:00:05,630 --> 00:00:08,970 This is an optional extra, but we're delighted that you're here. 3 00:00:09,300 --> 00:00:13,470 I'd like to introduce, though, Sean Evans, who did the. 4 00:00:13,770 --> 00:00:17,249 When did you finish? When did I finish? 5 00:00:17,250 --> 00:00:20,470 When I graduate. Well, that was another story. 6 00:00:21,000 --> 00:00:24,630 You submitted 20 something. I'm 17, I guess five years ago. 7 00:00:24,990 --> 00:00:32,790 And I had the pleasure of supervising and it so I would let. 8 00:00:33,810 --> 00:00:40,620 So my life is quite about until. So, yes, I am sorry. 9 00:00:40,620 --> 00:00:43,739 I'm a serving member of Her Majesty's well Navy. 10 00:00:43,740 --> 00:00:49,610 I am back at the University of Oxford as a as an academic visitor. 11 00:00:49,620 --> 00:00:55,770 I think it's the technical term, but there is a there's the Guy Hudson Memorial Trust. 12 00:00:56,220 --> 00:01:08,100 He sponsored to several naval officers to come to Oxford on time to be members of the academic community and do research on a service related topic. 13 00:01:09,270 --> 00:01:15,870 This isn't it. So this is the research that I conducted on a while. 14 00:01:15,870 --> 00:01:18,989 I was kind of signing your chest in the massive evidence base. 15 00:01:18,990 --> 00:01:26,400 Hellcats vividly remember this module because that's where we came up with this idea because I didn't have it beforehand. 16 00:01:26,850 --> 00:01:30,660 So yeah, when I wrote them and I didn't have the idea by the Friday, 17 00:01:31,980 --> 00:01:39,840 we'd be so feisty right from the beginning we would work it out with more or less so this is what I was going to do. 18 00:01:41,220 --> 00:01:44,670 So little. So what are we going to do? 19 00:01:45,750 --> 00:01:52,530 I haven't got a clicker. I suppose I'm going to be so cool. 20 00:01:53,070 --> 00:01:56,309 So I'm going to talk to you about where the research idea came from. 21 00:01:56,310 --> 00:02:00,690 As you can probably hear, I did not arrive with a free design project. 22 00:02:01,110 --> 00:02:10,229 Talk about what we did to answer the research question, the somewhat tortuous process that was gaining approval to do the study, 23 00:02:10,230 --> 00:02:19,470 having had the good idea and what we what we found when we did the research, but then it was about what happens next. 24 00:02:19,890 --> 00:02:25,860 So I am a consultant, psychiatrist or a medical doctor who specialises in mental health. 25 00:02:26,520 --> 00:02:34,420 I was in my higher psychiatry training as a general adult psychiatrist when I started and started my masters. 26 00:02:35,090 --> 00:02:40,499 And I had one child and I was working full time. 27 00:02:40,500 --> 00:02:47,370 So I did my masters over three years alongside clinical work and shift work within the 28 00:02:47,370 --> 00:02:51,720 NHS and then subsequently working specifically for the well maybe that was watching my, 29 00:02:51,840 --> 00:02:54,990 my training and I've been in the Navy 20 years. 30 00:02:55,140 --> 00:03:03,180 Yeah. So, so I mean technology. 31 00:03:03,270 --> 00:03:05,280 So two big caveats. 32 00:03:05,970 --> 00:03:14,940 This research has not been published or exposed to robust peer review, but it has been through a relatively robust process to become a dissertation. 33 00:03:15,420 --> 00:03:23,880 To become a dissertation. One of the things that I here to do is actually write this study up for some kind of publication. 34 00:03:24,090 --> 00:03:30,600 And while I'm over the next well, now that way, now it's March or the next nine months. 35 00:03:30,600 --> 00:03:33,809 It was 12 months of everything I'm going to say. 36 00:03:33,810 --> 00:03:41,650 These are the opinions of me, as in Charlotte Evans, not the Royal Navy or the UK Ministry of Defence, which I to be. 37 00:03:45,040 --> 00:03:48,890 For example, the slides are not funded. So I. 38 00:03:48,970 --> 00:03:52,490 As I said, I'm a practising Royal Navy psychiatrist. 39 00:03:53,110 --> 00:03:59,350 I was actually doing clinical work until pretty much slightly overlapped with arriving here in January. 40 00:04:01,150 --> 00:04:06,850 I'm also happened to be married and have two children, and we live in the town of Portsmouth. 41 00:04:07,060 --> 00:04:18,700 So I've combined, you know, my clinical work in the NHS and the military along with the academic study back here again. 42 00:04:19,750 --> 00:04:26,930 So. So the research I do essentially is what my patients needed and I didn't know. 43 00:04:26,960 --> 00:04:37,190 And it came from two patients that had sat down with me independently of essentially these roughly tough military men had sat down, 44 00:04:37,700 --> 00:04:41,630 sat down sort of in my consulting room, and it probably burst into tears. 45 00:04:43,460 --> 00:04:47,600 And that's not something that is culturally acceptable, shall we say, in the world in which I work. 46 00:04:48,140 --> 00:04:53,690 And essentially for both of these individuals, there were only two outcomes from having sat down in a room with me, 47 00:04:53,690 --> 00:04:57,140 and this was before I could even introduce myself. So I try not to take it personally. 48 00:04:58,910 --> 00:05:05,720 If they had a mental health problem, either I had a padded cell and I was going to be throwing them in it in the next 10 minutes. 49 00:05:06,210 --> 00:05:09,500 You don't have a working community mental right? 50 00:05:10,370 --> 00:05:17,150 Or that was the end of that career. That was it. The fact that they have just sat down in the room with me, was it. 51 00:05:17,840 --> 00:05:23,600 Now, I cannot imagine to put myself in their shoes how bad things had to be for them 52 00:05:24,140 --> 00:05:28,970 for those two outcomes to two to make it worthwhile coming sitting down with me, 53 00:05:29,330 --> 00:05:35,870 you know, you've got to be pretty sick. You've got to be, you know, the amount that you struggle and the amount that the you know, 54 00:05:35,870 --> 00:05:42,680 the impact it's having on you and those around you to do that, to brave those outcomes is pretty significant. 55 00:05:43,880 --> 00:05:51,350 And the thing that I simply realised was that I had nothing to prove or disprove in terms of research, 56 00:05:51,350 --> 00:05:55,280 in terms of evidence, that assumptions that those are the only two things that could happen. 57 00:05:55,310 --> 00:05:59,960 Now, I've worked in military mental health for, you know, for a few years by this point. 58 00:06:00,230 --> 00:06:04,520 And instinctively, I knew that they were wrong. You know, I knew that we got people better. 59 00:06:04,550 --> 00:06:06,620 I knew that people's careers recovered. 60 00:06:06,920 --> 00:06:11,930 And I knew that we had a big problem, that people that recovered got on with their careers and never spoke about it again. 61 00:06:13,070 --> 00:06:21,160 We didn't have a we still don't really have some of the role models that we need within the armed forces who have been through that that, 62 00:06:21,170 --> 00:06:26,330 you know, who have mental health problems, been through the treatment process. And they on their careers have come out the other side. 63 00:06:27,890 --> 00:06:33,520 That is changing, unfortunately. It is not so much changing for officers. 64 00:06:33,530 --> 00:06:40,970 It is changing for and particularly for senior NCOs and particularly interesting for those who've got deployment experience in. 65 00:06:42,140 --> 00:06:47,379 It is, it is much more acceptable for people to get to whom have deployed to be able to 66 00:06:47,380 --> 00:06:51,430 access mental health care because there is an automatic assumption that it is there. 67 00:06:52,440 --> 00:06:56,110 Warriors deployments for this. The reason why they need to seek mental health care. 68 00:06:56,770 --> 00:07:01,479 It is much more difficult, particularly those in the navy who probably didn't if they did go out to Iraq, 69 00:07:01,480 --> 00:07:06,580 Afghanistan, political it's traditional role that they closing in killing the enemy type role. 70 00:07:07,910 --> 00:07:13,280 See, that's for healthcare. So what did we do? 71 00:07:13,490 --> 00:07:21,890 Yes, I remember. And I remember very I had quite clear mind having decided that this was the research question I wanted to answer. 72 00:07:22,220 --> 00:07:31,730 What did happen to the careers of serving UK armed forces personnel after a period of mental health treatment? 73 00:07:31,940 --> 00:07:36,020 So after they had been, that person sat in the chair with a mental health professional. 74 00:07:36,320 --> 00:07:39,430 What happened to their career next? Okay. 75 00:07:39,440 --> 00:07:44,120 That's why that's what I wanted to find out. That's what my patients needed to know. 76 00:07:44,480 --> 00:07:51,770 Okay. So they could make that decision. Was it worth it? No, because I from my point of view, from my own experience, 77 00:07:52,130 --> 00:07:58,190 those assumptions that it was either a padded cell or, you know, different employment weren't right, 78 00:07:58,190 --> 00:08:08,090 that I didn't have the reason that I didn't have anything other than what I then came to know was called connected to a good start. 79 00:08:08,120 --> 00:08:10,670 So are you going to start somewhere? Unexpected is fine to start off with. 80 00:08:11,420 --> 00:08:24,080 So I knew that there was a, a national database of clinical records for military mental health patients, which could be accessed nationally. 81 00:08:25,370 --> 00:08:31,460 And so we already had the information recorded about what happened to these patients. 82 00:08:31,520 --> 00:08:35,930 We already was already you know, there wasn't necessarily new data. 83 00:08:36,470 --> 00:08:40,550 The question is, how did we legally and ethically access that? 84 00:08:41,220 --> 00:08:48,750 Right. And how do we do that in a meaningful way so that we could get something close to the answer that was looking out for the patients? 85 00:08:50,370 --> 00:08:58,200 So we came up with a closed cohort study so close because once you were in, you were in, and if you were out, you were coming in later. 86 00:08:58,560 --> 00:09:02,590 Okay. It was retrospectively incepted. 87 00:09:02,890 --> 00:09:11,770 So we looked back and the how far we looked back kept changing because the amount of time it took to go through the approvals. 88 00:09:12,070 --> 00:09:22,520 Okay, so we set a period of time and what we looked at is the all of the people who 89 00:09:22,520 --> 00:09:28,270 were assessed in three outpatient departments of community mental health, 90 00:09:28,270 --> 00:09:34,150 a military outpatient department of community mental health over a six month period to everyone who was assessed. 91 00:09:34,600 --> 00:09:38,940 The reason why we chose three different departments was because we've got three single services. 92 00:09:38,950 --> 00:09:41,140 So one obvious point of a navy, 93 00:09:41,500 --> 00:09:49,150 although all three of them see people from all three services say so the countries kind of carved up a geographical basis. 94 00:09:49,870 --> 00:09:53,320 But we know that, you know, most of the Navy were in the vicinity of Portsmouth. 95 00:09:53,620 --> 00:09:56,800 You know, if you were in the vicinity of Bristol, it's probably more relaxed. 96 00:09:57,190 --> 00:10:02,470 And then if it's somewhere near Salisbury Plain will be not only okay, but, 97 00:10:02,590 --> 00:10:06,310 you know, each of those three places will see people from all three services. 98 00:10:07,030 --> 00:10:11,329 So it was wrapped respectively incepted we weren't doing prospective recruits 99 00:10:11,330 --> 00:10:14,980 and we weren't starting at zero and then going right from this point onwards. 100 00:10:15,250 --> 00:10:21,309 We went back to a time that a point that already happened had included the patients then from that point. 101 00:10:21,310 --> 00:10:24,790 Sarah, that it already happens, but it was prospectively analysed. 102 00:10:24,790 --> 00:10:33,460 So we imagined that we had gone back in time and were looking at these patients and progress from the beginning, moving forwards. 103 00:10:33,790 --> 00:10:41,409 And as I say, no one extra came in, no one came out, although there were some people that went out back and again, if that makes sense. 104 00:10:41,410 --> 00:10:44,860 So they were assessed more than once over the time of the study. 105 00:10:44,920 --> 00:10:46,420 Not many, but you'll see that later. 106 00:10:46,720 --> 00:10:55,690 And it was multicentre and actually the initial study design wasn't intending to get a nationally representative sample. 107 00:10:55,690 --> 00:11:03,069 We wanted kind of a reasonable sample, but me being a singleton researcher, doing it on top of a clinical job, 108 00:11:03,070 --> 00:11:09,580 we looked we had to be slightly pragmatic about what was actually going to be capable within the time, within the resources available. 109 00:11:11,410 --> 00:11:17,740 But actually what we ended up with was nationally representative on basic demographics. 110 00:11:18,400 --> 00:11:25,300 We ended up sampling 10% of military mental health patients who were assessed in 2011. 111 00:11:27,430 --> 00:11:33,910 So pre-existing clinical records, three military departments of community mental health over six months, 112 00:11:34,480 --> 00:11:43,150 and we generated an anonymized research dataset from the electronic notes, but the scrutiny was done by clinicians within the departments. 113 00:11:43,420 --> 00:11:47,650 So these were people with a legitimate relationship with the care that had been given. 114 00:11:47,890 --> 00:11:51,520 It went outside researchers. They weren't anyone, anyone different. 115 00:11:52,090 --> 00:11:59,690 And in fact, we went backwards and forwards and forwards and backwards and to the university and to the everyday and somewhere else, I'm sure. 116 00:12:00,550 --> 00:12:07,800 And the Institute of Medicine and Background Round again, the Ministry of Defence, 117 00:12:08,470 --> 00:12:18,490 I hope quite rightly have learned some lessons from doing slightly cavalier research on the people within the UK armed forces and have very, 118 00:12:18,670 --> 00:12:27,790 very stringent rules about any research that is conducted on serving military personnel, both in terms of what is conducted, 119 00:12:27,790 --> 00:12:34,330 who does it, how it's consented, etc., etc. They therefore have three criteria of any studies. 120 00:12:34,510 --> 00:12:41,950 One is research, okay, which is hypothesis testing, hypothesis generating and publishable. 121 00:12:42,820 --> 00:12:46,810 That's the kind of highest level. It's the highest standard. It's the highest level of scrutiny. 122 00:12:47,230 --> 00:12:51,940 The next level from that is service evaluation. 123 00:12:52,510 --> 00:12:56,740 Okay. So is looking at what is already being done, is it any good? 124 00:12:57,520 --> 00:13:04,960 And then the level below that is an audit accepted national standards and just a simple does it measure up or not? 125 00:13:05,320 --> 00:13:06,310 Does it matter or not? 126 00:13:07,900 --> 00:13:17,680 Now, what we were looking to do fell absolutely beautifully on the dividing line between service evaluation and ethics and research. 127 00:13:18,190 --> 00:13:25,690 Beautifully on the dividing line. Okay. Which is why we went back to school with same with that was round around the back and the 128 00:13:25,690 --> 00:13:30,750 university were very clear that this was service evaluation that had already been given. 129 00:13:31,030 --> 00:13:34,680 There was no interference with interference with the patient. 130 00:13:34,690 --> 00:13:40,750 The records already existed. This didn't need full university ethical approval. 131 00:13:41,020 --> 00:13:47,890 Myself as a military clinician had a legitimate relationship with the record to generate an anonymized dataset, 132 00:13:48,250 --> 00:13:55,960 which is what the research would be conducted on. The body wanted more reassurance than that. 133 00:13:56,260 --> 00:13:59,650 They wanted to know that they had a full legal and ethical framework. 134 00:14:00,130 --> 00:14:03,910 Because individual patient consent wasn't being sought. 135 00:14:04,660 --> 00:14:10,690 Now, that ultimately feels a bit kind of, you know, sort of is a bit of a jolt, isn't it? 136 00:14:10,840 --> 00:14:15,970 How many people's records of inspiration? I think, you know, 79. Who is doing what is being done? 137 00:14:17,170 --> 00:14:20,050 There are a number of factors that went into that decision. Okay. 138 00:14:20,350 --> 00:14:24,770 One of them was one of the things we wanted to do was include people who would like the other day. 139 00:14:25,560 --> 00:14:28,900 Would you like the. I moved the. Everybody don't know where you got it. 140 00:14:29,740 --> 00:14:36,640 Okay. So getting consent from these patients becomes essentially impossible unless you want to go by financial records. 141 00:14:36,820 --> 00:14:41,310 Seriously, the only people that people that know when they leave the military, if they want to be friends, that would be. 142 00:14:43,270 --> 00:14:47,860 That's that, you know, and that was to seriously skew the research. 143 00:14:47,860 --> 00:14:52,390 If we weren't able to look at the records of people who had left the military for whatever reason, 144 00:14:52,660 --> 00:14:55,510 that was going to seriously skew what we were looking at. 145 00:14:56,680 --> 00:15:01,720 The other one was there was potential harm from going and getting individual patient consent. 146 00:15:03,080 --> 00:15:06,500 Potential harm from doing that. We're talking about mental health care. 147 00:15:06,720 --> 00:15:09,860 But it finished some time. I'd finish sometimes. 148 00:15:09,860 --> 00:15:16,970 Previously it was ongoing. And so you got, you know, so there were risks of a skewed sample. 149 00:15:17,360 --> 00:15:26,300 There were risks of actually causing distress, causing harm by going back to ask for it, to ask for individual patient permission. 150 00:15:26,660 --> 00:15:34,010 And the only people accessing the record were clinicians who had a legitimate reason to access patient care records 151 00:15:34,010 --> 00:15:40,400 within their own departments to look at to look at the care that was being given within their departments to some extent. 152 00:15:40,670 --> 00:15:44,900 The only thing that I as a researcher got was an anonymous dataset. 153 00:15:45,110 --> 00:15:53,990 It was completely untraceable. Back to the record. There was no way I could link what I was given as a researcher back to any patient records. 154 00:15:54,410 --> 00:15:58,160 Even if I recognised, you know, even if as a patient, I looked after my record, 155 00:15:58,180 --> 00:16:03,140 I couldn't couldn't have done it completely in a completely anonymized. 156 00:16:07,340 --> 00:16:10,160 So that was one of the reasons why. 157 00:16:10,550 --> 00:16:21,350 And we had a particularly I don't know what adjective is actually about our experience of physically going to the A.G. Research Ethics Committee. 158 00:16:21,830 --> 00:16:30,920 And we had to go through, I think, the Ministry of Magic, and this is probably the best description and this is a little bit nerve wracking anyway. 159 00:16:31,940 --> 00:16:39,770 Having to get the Gershwin alert to the Ministry of Defence was absolutely terrifying 160 00:16:39,890 --> 00:16:43,820 in like all going through the airlocks to get into the boat like so literally like, 161 00:16:43,820 --> 00:16:48,049 you know, the Harry Potter kind of entrance over at the Ministry of Magic and they go through the 162 00:16:48,050 --> 00:16:52,310 five places we would go in three by looks that was very similar to that in this great big, 163 00:16:52,760 --> 00:17:01,670 great big room. And then once we got there, we would when we got into the committee room, big, very shiny table, 164 00:17:02,120 --> 00:17:15,560 all of the ethics committee at one end was at the exact other end this long table for away literally like a little clue. 165 00:17:17,480 --> 00:17:27,230 And I think unfortunately they weren't terribly supportive when we first sat there were though basically, which was slightly, 166 00:17:27,230 --> 00:17:31,070 as I think we've been through a considerable process with the Royal Navy's 167 00:17:31,520 --> 00:17:35,390 scientific advisory committee to even to be able to get to the Ethics Committee. 168 00:17:35,930 --> 00:17:42,110 So lots of scrutiny of the methodology, lots of scrutiny of the ethical considerations. 169 00:17:42,110 --> 00:17:48,350 And this this kind of again, this borderline of of research versus versus service motivation. 170 00:17:48,830 --> 00:17:54,950 And and we'd always been told, you know, if you get through all of that and this had taken a considerable period of time, 171 00:17:55,370 --> 00:17:58,600 get through all of that, you'll be fine. And Ethics Committee. And they literally sat down. 172 00:17:58,610 --> 00:18:02,200 What we're not sure what legal basis you have to do this that was that became 173 00:18:02,540 --> 00:18:10,740 literally the opening thing we just said sorry for you to fill in saying that. 174 00:18:11,750 --> 00:18:16,190 But actually the conversation that unfolds is and actually it was really 175 00:18:16,190 --> 00:18:20,570 interesting and the different people around the table had different takes on it. 176 00:18:21,050 --> 00:18:25,640 And their parting shot was, we think this is really important. We really want to make sure this happens. 177 00:18:25,640 --> 00:18:31,370 It's like you could have started with I know you're not finished with that. 178 00:18:32,930 --> 00:18:41,660 So so actually we took away we took away their concerns, which were mainly about the generation of the dataset. 179 00:18:42,710 --> 00:18:52,340 And rather than myself as a military clinician creating the dataset myself, we use clinicians within each of the individual care teams. 180 00:18:52,550 --> 00:18:58,300 So although we work as a national defence mental health service, they wanted to make sure that that, you know, 181 00:18:58,460 --> 00:19:05,540 it was robustly being, you know, the notes of being scrutinised firmly within the care teams when the care had been delivered. 182 00:19:06,020 --> 00:19:11,389 And so my, my Singleton research project, it wasn't going to bother anyone, it wasn't going to take too long. 183 00:19:11,390 --> 00:19:17,210 That was all, you know, within my experience. Grew arms and legs and mushroomed I think is probably the best one yet again. 184 00:19:19,850 --> 00:19:24,830 So these were the outcome measures that we came down to. 185 00:19:25,250 --> 00:19:37,129 There's a bit of jargon there, but basically it was either you were fully fit to go do your military job, pretty much fit to go do your military job. 186 00:19:37,130 --> 00:19:44,210 So what we call medical limited deploy ability or not fit to go and do your military job. 187 00:19:44,820 --> 00:19:48,979 Right. And we looked at that two years after assessment. 188 00:19:48,980 --> 00:19:55,250 We looked at that five years after assessment. And we also looked at it when you were discharged from care. 189 00:19:55,700 --> 00:20:01,040 And that sentence in itself was a massive lesson in the precision of language, 190 00:20:01,910 --> 00:20:11,480 because discharge was also discharged from the armed forces, as well as discharge from that period of mental health treatment. 191 00:20:12,170 --> 00:20:17,060 Sometimes the Venn diagram overlaps and sometimes it didn't. 192 00:20:17,570 --> 00:20:23,410 So we really had to realise that you lose people along the way to be there, like, well, when was the discharge from your ex? 193 00:20:23,430 --> 00:20:25,580 What was that discharge from? The armed forces were discharged. 194 00:20:26,690 --> 00:20:33,500 Discharged from Cath, discharged from the armed forces because we just took that discharge and switched it on, which won't work best. 195 00:20:34,610 --> 00:20:34,990 So what is it. 196 00:20:35,000 --> 00:20:42,559 That metric, demographic and treatment factors and we use univariate logistic regression as to their association with each of the outcomes. 197 00:20:42,560 --> 00:20:50,680 We had those three outcomes which was the medical capital medical deployed by the team as shown by the medical category that they were in an. 198 00:20:50,780 --> 00:20:56,480 All members of the UK armed forces are in a medical category at all times of the times. 199 00:20:56,750 --> 00:21:00,139 Okay, so that's nice and nice and clear. 200 00:21:00,140 --> 00:21:03,920 There wasn't anyone who we're not sure what category they're in there. 201 00:21:03,920 --> 00:21:08,110 In the last one they were given until someone changes it. That's it, basically. 202 00:21:09,760 --> 00:21:13,300 And then we did univariate logistic regression as the association with the outcomes. 203 00:21:15,190 --> 00:21:20,069 And then we also looked at discharge factors. 204 00:21:20,070 --> 00:21:21,310 So we also then look backwards. 205 00:21:21,380 --> 00:21:27,850 If someone had been discharged from care, we then looked back at what the point was at which they had been discharged from. 206 00:21:30,050 --> 00:21:35,660 All right. So we're looking at it this way. And then in the group that we knew had been discharged from the armed forces, 207 00:21:35,960 --> 00:21:39,950 we were then looking back at the timeline that that had happened and what makes sense, 208 00:21:40,160 --> 00:21:45,960 because we might have missed it if it was between the two and five years point as to exactly what time. 209 00:21:48,510 --> 00:21:57,930 Describing it where we found things were significantly associated with the outcomes that we were looking at. 210 00:21:58,200 --> 00:22:02,650 We then did. Statistics. 211 00:22:06,790 --> 00:22:12,380 But only on those things which we had already found for me for that. 212 00:22:13,360 --> 00:22:20,920 And univariate logistic regression. And we knew that there was something there that was something that that was worth looking more closely with. 213 00:22:21,280 --> 00:22:26,290 And what the multivariate analysis basically means is that you chase down, 214 00:22:26,620 --> 00:22:32,920 is it just the demographic or the treatment factor you're looking at that's making that difference? 215 00:22:33,250 --> 00:22:38,860 Or is it that actually everyone who has medication is that they had seen a doctor? 216 00:22:39,850 --> 00:22:44,440 So if you're looking at whether seeing a doctor impacts, whether you're discharged, 217 00:22:44,530 --> 00:22:49,689 you know, is associated with your body and having medication is associated, 218 00:22:49,690 --> 00:23:00,610 you know, actually the two of the same thing isn't the medication that's that's linked to you not being the services it to you is on its own. 219 00:23:00,730 --> 00:23:03,330 And it's not using a doctor that's linked. 220 00:23:03,880 --> 00:23:10,240 It's associated with you leaving the armed forces at two years because you can't do without without the other. 221 00:23:10,570 --> 00:23:12,820 Does that make sense? I would kind of just checking that. 222 00:23:13,060 --> 00:23:20,140 What we were looking at was the thing that was was the core was that it wasn't cause was associated. 223 00:23:20,680 --> 00:23:25,970 Or was it something else that happened as well at the same time? Does that make sense? 224 00:23:27,320 --> 00:23:29,540 Because it simply took me a long time to get my head around. 225 00:23:32,490 --> 00:23:43,940 So yeah, and we did that using SPSS, which is the software which was most familiar with for the type of research that was being. 226 00:23:45,290 --> 00:23:48,850 So I can't say there would be fancy sort of decisions around that. 227 00:23:48,860 --> 00:23:54,470 That was what was available on the research laptop that we had available to us. 228 00:23:55,730 --> 00:24:02,870 And what I should also say is the study that was done at this point was done jointly with King's College London, 229 00:24:02,870 --> 00:24:06,890 the Academic Department of Defence Mental Health, and he still. 230 00:24:10,240 --> 00:24:18,240 So the approvals process, which I've already spoken, spoken about, if I knew that, I mean, I had no concept this was going to be quite so involved. 231 00:24:18,250 --> 00:24:27,130 It has to be said, this seemed like a really simple idea and, you know, really patient focussed, aimed within my area of expertise. 232 00:24:27,910 --> 00:24:32,770 So the university process was actually really straightforward, really clear guidance, 233 00:24:32,770 --> 00:24:38,620 really clear guidelines and loads of support available within the within the department as to how to do it, 234 00:24:38,620 --> 00:24:42,670 what was required, what, what, what was needed. Loads of experience. 235 00:24:44,200 --> 00:24:49,600 The Mod involved as we've said. I think actually was ultimately helpful. 236 00:24:49,870 --> 00:24:57,009 I can't say I felt that all the way through and I think a particular low point was having to calculate 237 00:24:57,010 --> 00:25:04,810 the sample size by hand because they didn't trust the electronic online calculator or any of them. 238 00:25:05,170 --> 00:25:06,430 Even though I said, Well, I've checked it for it. 239 00:25:06,490 --> 00:25:12,430 I think we've put it through like five in the end, just in case someone was using a different calculation and they were like, 240 00:25:12,430 --> 00:25:21,360 No, we want to see it, we want to see it works through my ordinary A-level maths is now coming in, coming out in full. 241 00:25:21,910 --> 00:25:26,410 That is not typical. That is not a typical experience at all. 242 00:25:27,850 --> 00:25:32,260 But I have to say one of the things that did come out of it was a [INAUDIBLE] of a network. 243 00:25:33,100 --> 00:25:37,839 Basically, the number of people that had to have contact with, the number of people that had to. 244 00:25:37,840 --> 00:25:45,040 Then I had said, you know, my elevator pitch for this research was homes only because of a number of people. 245 00:25:45,040 --> 00:25:54,370 I had to do a really quick explanation of so that I could get the very precise, you know, agreement and yes no out of them. 246 00:25:55,390 --> 00:26:00,880 And so that, you know, yeah, the soft skills definitely helped enormously with it with the Ethics Committee process. 247 00:26:02,080 --> 00:26:07,809 Definitely. And it did it did take longer than I thought. 248 00:26:07,810 --> 00:26:11,140 But the trouble is, at the beginning I didn't think I'd need it. So that's a difficult thing. 249 00:26:11,270 --> 00:26:16,140 It was a difficult thing to predict, to be honest with you. I am. 250 00:26:16,650 --> 00:26:23,680 I had the reason why I started matters in the first place was because I had a gaping hole. 251 00:26:23,680 --> 00:26:29,350 That was where research was supposed to be in my CV. And as I was approaching the end of my psychiatry training, 252 00:26:29,350 --> 00:26:34,809 this whole was getting more and more apparent and definitely needed something in it basically. 253 00:26:34,810 --> 00:26:42,970 So I'd got no background, you know, as an undergraduate or in the early days, my technical career as a researcher at. 254 00:26:43,890 --> 00:26:52,320 At all. So I think it's safe to say that the the Masters definitely feel the end. 255 00:26:52,470 --> 00:26:56,580 And the fact that I'm back here again probably says something about that as well. 256 00:26:58,020 --> 00:27:08,110 So for, you know, normal people that plan early, but also, you know, sort of expect the unexpected sometimes if it's just university stuff. 257 00:27:08,130 --> 00:27:15,330 Actually, I, you know, like kind of a bit jealous. It's like, you know, can they not say that it needs to go through that? 258 00:27:15,330 --> 00:27:20,100 But then, you know. So what do we actually find? 259 00:27:21,120 --> 00:27:24,490 So. Tick. 260 00:27:24,700 --> 00:27:31,910 Tick. This continues to haunt me. I spent hours, if not days, trying to get a out of this box. 261 00:27:33,170 --> 00:27:36,200 It does like this. It just. It. 262 00:27:36,430 --> 00:27:42,190 It doesn't exist when you go in anyway. So you become obsessed about things like this would be dissertation. 263 00:27:43,160 --> 00:27:46,520 Like trying to get the page numbers on the on the on the right side. 264 00:27:46,520 --> 00:27:51,890 They found it with the page numbers in the inside. And again, you know, things even, you know, this consumes your life. 265 00:27:52,600 --> 00:28:01,579 So. So the data is the defence analysis and statistics agencies that they were the ones who did the speaking 266 00:28:01,580 --> 00:28:06,760 of the electronics system to create the list of patients if you like but it wasn't a list of patients. 267 00:28:06,770 --> 00:28:13,549 It was an it was a coded list of patient identifying numbers which only exist within the electronic recordkeeping system. 268 00:28:13,550 --> 00:28:18,650 If you don't have access to the identity record system, the list means nothing to you at all. 269 00:28:18,890 --> 00:28:23,750 Leave them both not going to you know, not going to know about it. 270 00:28:25,490 --> 00:28:32,450 So these were two identified, the three departments for Community Mental Health, so that these match were all shopped, Brize Norton and Portsmouth. 271 00:28:34,670 --> 00:28:42,530 And they were two ways at the beginning of the period of research, which is again another complication. 272 00:28:42,990 --> 00:28:55,129 And the departments were asked to send in an Excel spreadsheet with the numbers of the patients that they'd seen at the beginning of the sort of time, 273 00:28:55,130 --> 00:29:01,130 at the beginning of the six months. But by the end of the six months it was all done by electronic searching. 274 00:29:01,910 --> 00:29:05,059 They were in a period of transition and that in itself we had to kind of paint. 275 00:29:05,060 --> 00:29:09,730 I was like, what? You know, where the you know, where the why, the numbers look so different. 276 00:29:09,770 --> 00:29:18,290 So we had to chase that down. 19 patients confinement or no idea where they were displayed on the site, how they how they ended up in here. 277 00:29:18,710 --> 00:29:24,380 So they were probably typos within the Excel spreadsheet that was generated probably. 278 00:29:24,470 --> 00:29:28,040 But we had absolutely no way of knowing what the number was on the system. 279 00:29:28,700 --> 00:29:37,520 Nothing that we could do. Nothing we could do about that. So we ended up with 670 and there were 45 patients who didn't meet the inclusion criteria. 280 00:29:37,940 --> 00:29:47,390 That was usually due to inputting error that a template had been completed about CAD had happened outside of the cohort inception period 281 00:29:47,840 --> 00:29:55,909 or patients had been coded as having a fresh case that hadn't actually happened either because they didn't attend or it was interrupted. 282 00:29:55,910 --> 00:30:03,980 Or there was some reason why that didn't happen, which left us with 572 patients who we knew definitely belonged within the cohort. 283 00:30:05,120 --> 00:30:09,290 One data collection form was just not that one patient number, 284 00:30:09,290 --> 00:30:16,010 just didn't have a data collection form, didn't arrive, don't think you got lost, just didn't exist. 285 00:30:17,090 --> 00:30:21,830 And on 20 forms weren't complete, they filled in. 286 00:30:24,330 --> 00:30:28,030 Nothing we can do, you know, nothing we can do about that, unfortunately. 287 00:30:29,310 --> 00:30:39,060 They were unfortunately from two of the three sites, but there was again, because there was no information on them, 288 00:30:39,270 --> 00:30:46,410 there's no way that we could tell whether this was skewing the data or whether they were specific or what have you. 289 00:30:47,220 --> 00:30:52,860 And because by this point, I was very much relying on the goodwill of colleagues, there was no way that I was going to be able to go back. 290 00:30:53,280 --> 00:30:56,750 Would you point out that you can't take all boxes but you months going back? 291 00:30:59,430 --> 00:31:06,650 So we ended up with 543 patients on which to base the study, the basis of the the research on. 292 00:31:07,530 --> 00:31:17,460 So what did we find? So I do have the numbers for this, but there is a painful little sliver of missing. 293 00:31:19,320 --> 00:31:22,440 Very, very painful for me as a researcher, a little sliver of missing data. 294 00:31:24,600 --> 00:31:26,790 But so at two years after assessment, 295 00:31:27,630 --> 00:31:34,560 basically the easiest way of looking at it this is to work is to work your way round to bearing in mind that my patients assumed 296 00:31:34,890 --> 00:31:40,730 that their career was disappearing so back home that they were destined for essentially what it was leaving the padded cell. 297 00:31:40,740 --> 00:31:47,399 But, you know, so medical limited deploy ability, a medical full deploy ability. 298 00:31:47,400 --> 00:31:51,870 So this white [INAUDIBLE] isn't actually white. Okay? This is the full deploy abilities. 299 00:31:51,870 --> 00:31:57,330 These people who were who at two years after they were sexed were fully fit to do their job. 300 00:31:57,750 --> 00:32:04,260 And this and this coat was it. They were doing the job. They just might be some limitations on what to do. 301 00:32:04,260 --> 00:32:10,790 Now, that might be, for example, if they're in the Navy, their ship can't go they can't go on a ship that goes to say, 302 00:32:10,800 --> 00:32:14,430 but they can be on a ship that's alongside in the UK, for example. 303 00:32:15,520 --> 00:32:18,480 Or it might be that they can't do shift work. Okay. 304 00:32:18,990 --> 00:32:25,530 But what we don't know is whether that medical lack of deploy ability was actually due to their mental health. 305 00:32:26,340 --> 00:32:30,120 It could have been to sunk due to something else. It could have been a twisted ankle. 306 00:32:30,120 --> 00:32:33,920 It could have been a broken arm. Okay. Okay. 307 00:32:34,520 --> 00:32:42,650 And then in addition to that, we've got those people who are medically non deployable and then we've got these people who have left the armed forces, 308 00:32:42,800 --> 00:32:47,090 but not through medical discharge. They've gone because they've applied to leave. 309 00:32:47,900 --> 00:32:51,410 And then we've got this war which has left the services on medical grounds. 310 00:32:52,070 --> 00:32:57,590 So if we're looking for this for, you know, if the purpose of this research is looking at stigma and that. 311 00:32:57,590 --> 00:33:00,470 Right. That's it. You know, the end of my career. 312 00:33:00,980 --> 00:33:12,050 Well, you would expect if they were correct, that's the non deployable and the medically discharged would have been the majority of this growth. 313 00:33:12,860 --> 00:33:17,419 Right. And they're certainly not have got the numbers. 314 00:33:17,420 --> 00:33:24,230 But to be honest, giving them the numbers as meaningful as that is the big what is essentially on that on the graph. 315 00:33:24,560 --> 00:33:33,830 Okay. So we are certainly not saying, you know, setting clinical instinct, the kind of data that two years obsolete supported it. 316 00:33:34,280 --> 00:33:38,540 Now we can go on and probably talk for a long time about what? 317 00:33:38,540 --> 00:33:41,780 About this lack of services. Non-medical. Right. 318 00:33:42,260 --> 00:33:46,220 Was that really non-medical? Was there something else going on? 319 00:33:46,820 --> 00:33:54,650 And, you know, that that so that could have been the most of that would have been people who just let, you know, some responders left. 320 00:33:55,010 --> 00:33:58,970 Some may have failed drugs tests. Some may have been thrown out on disciplinary grounds. 321 00:33:59,270 --> 00:34:06,340 But that is never a huge number of people in the armed forces effort every year and is probably in the region of the list of them. 322 00:34:06,530 --> 00:34:12,890 And if we look at the whole armed forces. So in five years. 323 00:34:13,940 --> 00:34:19,310 So the left, the services, non-medical is looked even, is even bigger now. 324 00:34:19,820 --> 00:34:27,290 One of the big flaws of this is we don't know what you what the so-called natural wastage would you would expect in, 325 00:34:27,380 --> 00:34:30,200 you know, what's the turnover, if you like, 326 00:34:30,200 --> 00:34:38,420 the personnel, how many how many of these people would you expect to have left the armed forces and having an assessment individual to help, 327 00:34:38,990 --> 00:34:42,200 you know, kind of his thinking. Okay. 328 00:34:46,430 --> 00:34:55,850 But you can see that that the wedge of full deploy ability and limited deploy ability, it's time to go five years after assessment. 329 00:34:55,850 --> 00:34:59,080 But actually, these two still aren't looking massive. Right. 330 00:34:59,210 --> 00:35:06,470 People have left the game. They've not left because they've been medically discharged or or they're not hanging around, 331 00:35:06,470 --> 00:35:10,160 not able to do they're not able to do their job, said she. 332 00:35:10,160 --> 00:35:17,680 Under threat of this potentially, depending on what they, you know, what their skills, their expertise and think, you know, what they're doing. 333 00:35:19,810 --> 00:35:27,790 But this one, which is the point of discharge from care, I'd bear in mind again, this graph includes known mental health reasons. 334 00:35:28,770 --> 00:35:35,500 It is not mental health reasons, but this is at the point that we discharged them. 335 00:35:36,130 --> 00:35:39,130 Okay. This is the point at which they were discharged from clinical care. 336 00:35:39,460 --> 00:35:50,310 Something sorry, positive social and clinical care. So actually we've got full deploy ability, limited deploy ability. 337 00:35:51,240 --> 00:35:59,260 You've got a better chance of being in one of those two categories than you have in. And that in itself challenges the stigma. 338 00:36:00,320 --> 00:36:00,920 From the get go. 339 00:36:02,190 --> 00:36:15,060 And this has actually been essentially the most useful the the, you know, the most satisfying, for want of a better word statistic that we found. 340 00:36:16,470 --> 00:36:20,130 And we did also remember I said we looked at how long did that take? 341 00:36:20,340 --> 00:36:24,629 So we looked at two years, minutes at five years. But that's a nice kind of, you know, individual lives. 342 00:36:24,630 --> 00:36:32,850 How long did it take? And again, it pains me the fact that because it's up to 2000, the nought 200 bit, which is where it was, 343 00:36:33,090 --> 00:36:37,290 I never found a way of getting the computer to do this because it's done within SPSS. 344 00:36:38,970 --> 00:36:43,860 So but what you've basically got there is a very bad box and whisker plot. 345 00:36:44,490 --> 00:36:57,690 Okay. Where you've got the median, the most common time between the assessments and discharge from care is 83 days for everybody. 346 00:36:58,320 --> 00:37:02,670 If you're deployable at discharge, it's slightly shortening. 347 00:37:02,670 --> 00:37:08,580 It's shortened at 71 days. And if you're not too horrible at discharge, it's slightly longer. 348 00:37:09,150 --> 00:37:16,420 Okay. Maximum time in care was 1728 days. 349 00:37:17,320 --> 00:37:20,940 We think that's probably an error, unfortunately, 350 00:37:20,950 --> 00:37:29,230 but it is possible at the time that was possible since then and towards the end of the time that the cohort was was followed up. 351 00:37:29,560 --> 00:37:39,130 There are now caps in the amount of time that patients are have care within military mental health services before discharge is considered. 352 00:37:39,210 --> 00:37:46,030 That wasn't the case at the time. It was then heart stop, if you like, and it's still not too hard for us to hold the hospital now. 353 00:37:46,030 --> 00:37:54,070 But there is more is greater scrutiny of people who need that level of care to continue that employment, which sounds really harsh, 354 00:37:54,850 --> 00:38:03,999 but also both as an employer, but also in terms of the job that you want people to do and people needing long term mental health care. 355 00:38:04,000 --> 00:38:08,440 That's not to say they don't need help. You know, they get better and then they need to. 356 00:38:08,440 --> 00:38:14,950 Again, that's not what we're talking about. We're talking about long term mental health care, continuing need that support. 357 00:38:15,790 --> 00:38:22,840 You have to question then whether their employment is why and whether they are best whether the individual is best served by continuing employment. 358 00:38:26,960 --> 00:38:30,890 And so we did that another way and we did it as a survival function. 359 00:38:32,890 --> 00:38:40,380 And basically what you see. So MFT is medically, fully deployable and instinctively this crap does look like vaguely what you think. 360 00:38:40,400 --> 00:38:48,770 So basically if you're going to be medically fully deployable when you leave care, you're probably going to be in care for a short amount of time. 361 00:38:49,400 --> 00:38:56,990 The graph here, which is your survival in treatment, as in the time you spent in treatment before you discharged, you going to leave? 362 00:38:56,990 --> 00:39:05,350 You're going to need less care or at least a shorter length of treatment compared to those who have got a lot left, 363 00:39:05,360 --> 00:39:08,710 who don't come out of treatment and just don't. 364 00:39:08,870 --> 00:39:11,989 So discharged from here, I don't know how it works in the military, 365 00:39:11,990 --> 00:39:19,880 but that you can be different for any number of reasons that you can just if you if you just never come back for like a therapeutic session, 366 00:39:20,240 --> 00:39:23,470 you're discharged after like three phone call. 367 00:39:23,570 --> 00:39:26,720 Like, you haven't come back. Yeah, you're discharged. Yeah. 368 00:39:27,050 --> 00:39:28,870 I don't know. Is that the same in the military? 369 00:39:28,880 --> 00:39:39,050 Like the discharge from care mean that therapeutic services were terminated because people had recurrently had like reduced symptoms and you are now. 370 00:39:39,170 --> 00:39:44,569 Well. So the fact that some of them are discharged medically, non deployable tells you that, you know, 371 00:39:44,570 --> 00:39:49,820 some people will still still have medical problems when they're discharged from care. 372 00:39:50,300 --> 00:39:54,530 The military do not compel people into mental health treatment. They can't be ordered. 373 00:39:54,650 --> 00:39:57,410 If it used to be, you could be ordered to attend your appointment, 374 00:39:57,410 --> 00:40:02,629 but you couldn't be ordered to do anything other than say to the receptionist on here, okay, that used to be the case. 375 00:40:02,630 --> 00:40:08,390 Once you done that, you reported to your place of duty and you know that you didn't. 376 00:40:08,750 --> 00:40:15,049 But if you didn't do that, you could be disciplined for not turning up and going on here, that even that now is no longer the case. 377 00:40:15,050 --> 00:40:19,940 You can't even be ordered to walk up to attend the appointment for mental health care. 378 00:40:20,030 --> 00:40:23,509 Now you are only there because you won't care. 379 00:40:23,510 --> 00:40:27,560 You have consented to care and you can withdraw that consent at any time. 380 00:40:28,220 --> 00:40:34,520 And we do have patients who just go I believe justify it about this isn't relevant to me bubble on on off you 381 00:40:34,520 --> 00:40:40,340 know staples house when there's like rubbish it's like nonsense or for people whose stigma levels are so high. 382 00:40:41,000 --> 00:40:44,960 All right, like, you know what? I'm fine now. You know, they have their assessment. 383 00:40:45,050 --> 00:40:49,040 You know, your wife's off my back. Yeah, because she's. Baby, come here. 384 00:40:49,880 --> 00:40:58,820 I'm fine. Thank you very much. You know, and, you know, we cannot compel them into you know, we will not compel them into treatment. 385 00:40:59,450 --> 00:41:05,210 But it doesn't get you a medically, fully deployable medical category, 386 00:41:05,330 --> 00:41:10,190 because if we're concerned your mental health is impacting your ability to do your job, 387 00:41:11,210 --> 00:41:14,900 we don't need your consent to restrict your duties, 388 00:41:15,360 --> 00:41:21,800 to stop you potentially causing a harm to yourself, but also to the other people who depend on you. 389 00:41:22,050 --> 00:41:26,120 We want to be that take it saying I'm fully deployable. 390 00:41:26,720 --> 00:41:36,140 You've got a treadmill, you're it's not impossible, but you are unlikely to be given a clean bill of health by a non mental health professional. 391 00:41:36,560 --> 00:41:41,300 If you haven't spoken to the mental health professional they referred you to, basically, 392 00:41:41,690 --> 00:41:46,940 you know who's you know who they thought you probably needed the cat awful things and Carol 393 00:41:47,270 --> 00:41:53,989 okay and I and and it's you know I certainly you know sometimes we just have some time. 394 00:41:53,990 --> 00:41:57,260 It's very interesting because clinicians want to help patients. 395 00:41:57,590 --> 00:42:03,260 You know, they like to know that there is someone who could benefit from their care who is choosing not to accept it. 396 00:42:06,000 --> 00:42:15,080 And but sometimes that's the right thing to do because it's the wrong time for the patient, particularly when you've got conditions such as PTSD. 397 00:42:15,120 --> 00:42:18,890 That avoidance is one of the cardinal symptoms of PTSD. 398 00:42:19,070 --> 00:42:25,550 They will do anything to not have to go and confront the reason why they've got PTSD. 399 00:42:28,560 --> 00:42:32,130 And it's part of the illness and so we have to recognise that, 400 00:42:32,580 --> 00:42:40,590 but also as responsible employers and this working for an organisation as well and diversos ethically practising doctor as well. 401 00:42:40,770 --> 00:42:47,850 You know, I have to do the best of my patient and sometimes the best of my patient isn't to agree that they can go back to the war zone. 402 00:42:49,890 --> 00:42:52,830 You know, sometimes that isn't you know, that isn't the case. 403 00:42:53,760 --> 00:42:59,399 And and then that's where the skill of my job comes in terms of reconciling patients expectations, 404 00:42:59,400 --> 00:43:03,870 organisational expectations and the care, you know, and delivering care. 405 00:43:03,870 --> 00:43:11,160 Because my duties of a doctor trump my military duties, basically, I report to the GMC first within the Navy. 406 00:43:11,940 --> 00:43:20,219 And that is that's very clear that the Navy recommends. Um, so, um, so yes, that's just another way of looking at it. 407 00:43:20,220 --> 00:43:26,420 Essentially. That was, it was a way to try and make that graph look a bit clearer, which I'm not sure it does, but that was it. 408 00:43:26,440 --> 00:43:33,340 That was the effort. But what's also interesting, I think, is these two are pretty entwined, that it's very different. 409 00:43:33,420 --> 00:43:36,670 You'd be very hard pressed to sort of look at two. 410 00:43:36,850 --> 00:43:40,420 You know, the plateau doesn't look much isn't that much different than. 411 00:43:42,410 --> 00:43:46,460 So any questions on the results? 412 00:43:49,400 --> 00:43:52,580 Okay. Good. Not sure. I'll go. More states. Well, think about it. 413 00:43:53,570 --> 00:44:00,770 So what came next? So for the research on this. 414 00:44:01,580 --> 00:44:08,780 So having having done the research, it was it was presented internally within the military. 415 00:44:09,200 --> 00:44:20,630 It was actually incorporated into non patient information materials about by seeking care but also around and destigmatizing mental health, 416 00:44:21,770 --> 00:44:26,180 including the Navy and commanding officers guide for mental health. 417 00:44:26,270 --> 00:44:30,349 So immediately, as soon as it was done, it hit the ground running. 418 00:44:30,350 --> 00:44:40,790 It did what it was supposed to do, which is very gratifying, and particularly when you've been through such a convoluted research process. 419 00:44:40,790 --> 00:44:44,150 To have it stock would have been quite painful. 420 00:44:44,210 --> 00:44:49,040 To be brutally honest with you. This was done with patients in mind and have felt it wasn't there. 421 00:44:49,580 --> 00:44:53,629 And I have to say that the Knowledge Interaction module was very, 422 00:44:53,630 --> 00:44:57,680 very helpful in terms of being able to look at the engagement and to look at how 423 00:44:57,680 --> 00:45:05,240 that research to be disseminated for the purpose that it was intended intended to. 424 00:45:06,350 --> 00:45:14,480 And I still got an email from one of my one nursing colleagues who basically emailed me to say, 425 00:45:14,840 --> 00:45:19,850 I just had a patient who saw the publication and is here because it changed their lives. 426 00:45:20,510 --> 00:45:28,700 Which that's it. That's it. You're done then. You know, all those years of blood, sweat and tears then become, you know, 427 00:45:28,790 --> 00:45:33,590 really do become become worth it, I think, you know, and it was it was a slog. 428 00:45:35,060 --> 00:45:36,080 It was a slog. 429 00:45:36,710 --> 00:45:46,560 I think the particular I think the particular low point was being given a direct order that I would not be finishing my masters on time. 430 00:45:46,580 --> 00:45:52,490 I'd had a patient suicides. And I was like, I've got a dissertation in the queue. 431 00:45:52,940 --> 00:45:59,989 And she was like, No, you need, you needs, you know, you've got other things to do. 432 00:45:59,990 --> 00:46:06,230 You've got other things that you need to concentrate on. Give it, give it what we thought under the terms before. 433 00:46:06,350 --> 00:46:12,080 So I've been processing and although we got an interim, they took it to make them go back anyway. 434 00:46:13,670 --> 00:46:17,149 So it's kind of like I'd had a baby in that time. 435 00:46:17,150 --> 00:46:21,080 Anyway, my, my attention had been gone even further away from my research. 436 00:46:22,250 --> 00:46:34,510 But yeah, it certainly but for me, I, you know, I had no concept whatsoever when I was in the, you know, this, you know, 437 00:46:34,520 --> 00:46:46,370 this module now and all those years ago, what I would be able to produce the difference that that in itself could potentially make for patients. 438 00:46:46,670 --> 00:46:52,819 But also then sort of what came what came next for me. So I qualified as a consultant psychiatrist. 439 00:46:52,820 --> 00:47:06,020 In February 20, 2017, I passed my Armed Forces consults written report in March, which I probably wouldn't have done without the researched it, 440 00:47:06,020 --> 00:47:09,430 and I probably wouldn't have passed the board without the officers, you know, 441 00:47:09,440 --> 00:47:14,120 that I could show that I'd produced and then had my son the following month. 442 00:47:14,720 --> 00:47:26,750 Tick, tick, tick. So and then after after some maternity leave came back as a case of came back from maternity leave and into a military job. 443 00:47:27,770 --> 00:47:31,560 And within six months, I was consultant adviser in psychiatry for the war. 444 00:47:34,240 --> 00:47:39,760 So which was a bit of a shocker to everyone, including me. 445 00:47:41,110 --> 00:47:45,330 I from that point. Okay. 446 00:47:45,340 --> 00:47:59,350 We we've completely, completely changed, but we very much put deployed and mental health treatment on the front foot because we couldn't use, 447 00:48:00,160 --> 00:48:08,440 you know, numbers like this to say to people, look, what you've you've got to you've got to think about what you think, what you think. 448 00:48:11,470 --> 00:48:17,860 And you may or may not have seen the documentary on HMS Queen Elizabeth. 449 00:48:18,670 --> 00:48:26,229 So I had a mental health team on board on this have been fortunate they took his life during that was not under the care but 450 00:48:26,230 --> 00:48:37,010 that was mental health and team embedded embedded within that and within that deployment and and and able to look after that. 451 00:48:37,560 --> 00:48:42,590 And the personnel out there. And that is something that, again, you know, 452 00:48:42,620 --> 00:48:49,349 the skills that I learned the and I see both in the study design and the the teaching 453 00:48:49,350 --> 00:48:55,500 evidence base health care until I did as well and the knowledge into action and augment 454 00:48:55,530 --> 00:49:01,559 that we could then really as a navy mental health service set things up using very much 455 00:49:01,560 --> 00:49:05,430 on the front foot so that we were getting mental health care where it was needed. 456 00:49:05,430 --> 00:49:09,150 But we could do it from an evidence base which showed where, 457 00:49:09,510 --> 00:49:16,950 where I was coming from and which has also then enabled me to come back here to Oxford again, 458 00:49:16,950 --> 00:49:23,610 which never, ever thought I would never, ever thought I would do. 459 00:49:24,840 --> 00:49:31,820 And I'm looking at two point to point mental health support and research in the maritime space. 460 00:49:33,930 --> 00:49:39,600 I'm trying to get people actually here to clinical research on here to look at policy and strategy. 461 00:49:39,990 --> 00:49:49,120 So this has enabled me to then build on that and to to hopefully go on certainly with my my psychiatric career. 462 00:49:50,530 --> 00:49:57,580 As well. So it's been you know, as I say, looking back, I cannot believe where I am now from where I started.