Dr Louise Newson: [01:00:00] Today on my podcast, I've got Dr Gareth Jarvis, who is a psychiatrist who prescribes hormones. There's not many of those around. He's learned a lot from his wife, Rachel, who actually works with us in the clinic. And he talks about how important it is to think about hormones and mental health. Think about how it important it is for us to be diagnosing properly in psychiatry and thinking about the important roles of hormones in our brains. So Gareth, thank you so much for coming today. It's always great having somebody who, like me, didn't really know about hormones at medical school and has just sort of seen the light almost. But you are a psychiatrist and I really enjoyed psychiatry. I did it in North Manchester, a very deprived area, but it was a really good unit, actually. Very cohesive. The doctors really worked together well. You know, my other students were really quite jealous that we were there at the time. We had eight weeks, which isn't long but it is quite a good chunk of time compared to like one week of ophthalmology I think that I did. But I've used a lot of my psychiatry training throughout, especially being a GP but I never thought about the association of hormones and mental health whereas every day I think about it now and you think about more now don't you?

Dr Gareth Jarvis: [01:01:28] I do, and I guess probably worth me saying full disclosure right up at the top of the the podcast that my wife, Rachel is a GP works for you for Newson Health and she's amazing. And and she's really helped bring me towards the evidence base around menopause because I'll admit Louise that I kept myself woefully poor, not up to date in this area for many years. It was a footnote at medical school. When I was up there in Edinburgh, we probably maybe had a day on it. I can't really, it's so much back in the midst of time now. And throughout my psychiatry training, again, at best a footnote at any point was menopause discussed.

Dr Louise Newson: [01:02:11] Terrible, isn't it?

Dr Gareth Jarvis: [01:02:12] And yet I look at it now and think, I can't believe that we haven't, how little attention was paid to it throughout that time. I mean, if I look back at medical school, that was around the time that the Women's Health Initiative study was out. And so that message just came through of, oh, hormones cause cancer and stay away from them. That HRT is dangerous was basically the only message I can remember receiving about it. I don't think I'd really updated my knowledge since then, because it wasn't my specialist area. It wasn't sort of specifically what I was focused on within my training. I didn't have a single supervisor who knew about it or wanted to talk about it. And that's such a key part of how we train as medical professionals.

Dr Louise Newson: [01:02:57] Of course it is, you learn on the job a lot, don't you? And also, what you read is dictated and shaped by your, like you say, your supervisors, your peers, any guidelines. So if it's not on your radar, it's really difficult, isn't it? And, and I mean, I trained before the WHI. So I graduated in 1994. And then I became a GP in 2000. So the WHI study came out in 2002. But I was writing evidence-based articles every week for GP Magazine, so it's a free magazine. It went to every GP, so I wrote key topics in various things that I could choose. And actually, I found them recently. So I wrote one in 2001 about HRT, and then I wrote another series, so I did four, because you'd only have, it was a small column, and there's a lot to talk about, obviously, with hormones in 2002. And actually it's interesting, because in 2002 I say, oh, there's this study that's come out, doesn't show us anything that we didn't know? Might be a slightly greater risk of breast cancer, but again, that's with older types of hormones, but it definitely helps with bone protection, helps people feel better, and we should continue, but obviously involve the patient in your decision-making. But I was in my little GP practice then, and I had no idea externally the rest of the world, HRT prescribing had just fallen off a cliff. And for the likes of you, a little bit younger, not having that anywhere in your radar. But when I was taught it was literally like you say a day or so but it or in a few hours really but it was more about a flushes, sweats oh there's something, it wasn't really, nothing about the mental health.  And also you know, as you know, well Rachel will seen a lot of our patients who have PMS and PMDD and for those women, actually so premenstrual dysphoric disorder is about one in 20 so it's really common. And, you know, patients say to me it's like night and day. You know, they say as the light goes out, their whole personality changes those days before their periods. And I must have seen it in general practice, in psychiatry, but if you don't ask about a change throughout the cycle, and you only see the women in their crisis, if you like, you don't build up the big picture, do you?

Dr Gareth Jarvis: [01:05:16] And that's the thing, so as psychiatrists, we're always trained to be really holistic in the way that we think about someone's health. And we've got the luxury of an hour to spend with someone, really trying to understand fully what's going on with their lives. Can we actually figure out what's gone through the life course. And that so often one of the distinguishing features we're looking for is actually at what point in their life cycle, did a change happen. But at no point was this sort of brought into my sort of thinking around actually focusing in on what happens on menopause. Yet you look at things that we know already about...we've known about for decades. When does suicide peak for women? And it's between 45 and 54. And what's happening around that age? And I kind of almost feel a little bit sort of shameful now. So looking back of like, why wouldn't I have paid that more attention to actually focus in on the changes that happened for women at that time?

Dr Louise Newson: [01:06:11] And I'm the same, but also when you read a stat, you don't always think what's behind it. And you might know that we funded a PhD student in suicide prevention with Liverpool John Moores University. And she's just got her PhD and she's going to come and work with us actually full time in research, which is wonderful. And we've had some really interesting publications already about that, but also one of the publications had a lot of quotes from women whose lives we have saved with hormones and one lady quoted to say, you know, if I had taken my life, I would just be another statistic and no-one would have known I was perimenopausal. And this is a problem, of course, isn't it? And for many centuries, really, women have been dismissed and gaslit and been told, well, it's their stress. It's their circumstances. And I don't know if you know but I was doing some volunteering in prisons. And a lot of people in prisons have a lot of mental health, all sorts of things that have gone on in the past. But they also, a lot of them, have early menopause because of their drug abuse, because of what's gone on in the past, and a lot of them are on heavy duty psychiatry drugs. So a lot of them are on quetiapine, a lot of them on pregabalin and gabapentin, some of them on lithium. A lot of them have implants for contraception. And the reason I'm saying all of these drugs is because they will not have their own natural hormones in their body. So a lot them have physical symptoms. So of them were having very itchy, dry skin, a lot cystitis, urinary tract symptoms, palpitations, and they weren't having periods. So I was going, just to educate about what hormones are and do, talking to some of the younger ones about PMDD. Because we've known for many years, people are more likely to commit a crime when they're angry and irritable in those days before their periods. And a lot of them, it was a lightbulb moment and they were like, oh my goodness, that's me, that me. But they couldn't get access hormones from their GPs or the doctors in prison. And I actually got reported to someone in the prison service because the doctors weren't happy I was there. And they reported me to my responsible officer who does my appraisal and they said that I was saying that all mental health was due to hormones. And like, it's just crazy because it's so many things that affect our mental health.

Dr Gareth Jarvis: [01:08:44] Absolutely.

Dr Louise Newson: [01:08:45] But if we ignore hormones the whole time, we're never going to get people completely well, I don't think.

Dr Gareth Jarvis: [01:08:51] That's it for me is that I'm not going to sort of turn around and say that HRT is some kind of silver bullet for all mental health problems. But, we cannot ignore it. It's such an integral part of a woman and making sure that she's optimised health. That, and it has such a big impact on mental state. Why on earth would we not be exploring that and being curious about it and and actually making sure we've got these incredibly low risk things that we can prescribe now for someone who's in their perimenopause or menopause, and they've got all these other massive health benefits. I mean, it's one of the things that really captured my imagination as I've been talking with Rachel about it, is that we've known for a very long time now this enormous mortality gap we have for people with severe mental illness. It's 20 years or younger that you will die if you have, on average, if you have a severe mental illness. And what are they dying from? They're dying from cardiovascular disease, they're dying from strokes, they die from dementia, they are dying from cancer. If we're looking around, what's in our armament to really try and push back about that holistically, as doctors working with people from whatever background you're coming from in medicine, to help close that mortality gap. This feels like such a potent tool to have in the box to actually support women with making sure that their bones stay strong and healthy, that their cardiovascular system is protected, that their brain is protected. Why wouldn't we be prescribing?

Dr Louise Newson: [01:10:22] Well, it's so interesting and I'm very interested in the immune regulating effects of hormones because I don't know if you know, I've got a pathology degree as well and I spent the whole year focusing on the macrophage and inflammation. And the more we look at neuroinflammation, inflammation in the brain, it does seem to be closely associated with mental health, schizophrenia, depression, bipolar. We know that inflammation is associated with cardiovascular disease, osteoporosis, dementia. So there is a link as well, which we can't keep ignoring. But I'm also, I'm interested in pathology, but I'm also interested in history because I think that can shape a lot, actually, especially in medicine. So thinking about the power of hormones in our brain, we've known for many years. I mean, we're only known about hormones since the 1930s when they were discovered. But even in the Victorian times before that time, there were lots of people going to asylums, as we know. But there were some really great writers, of someone called Edward Tilt, who wrote a great book in 1888, which I've read, talking about the change of life. And he was talking about this time that was a real toll on mental health that seemed to improve with bleeding. So he didn't know about hormones, but he knew there was something that was going on. And he would talk about people going to prisons and committing crimes because of these symptoms. He talked or he wrote a lot about the toil of looking after children, the women, the mental health. And he was alluding to it being around the cycle. And I think then they didn't have the drugs that we have now. They weren't so short for time as we are often now. So he could really explore with patients and he was really associating the physical symptoms and the mental health symptoms. And then they discovered hormones, commercialised them and they went off down a different track. But then also the antidepressants and antipsychotics came out. And so a way of getting people out of the asylums was just giving them the antipsychotics, wasn't it? To clear the asylums and these people maybe got better temporarily. But then they realise the side effects of the antipsychotics.

Dr Gareth Jarvis: [01:12:43] And this is the thing is that I've always been someone within psychiatry who's cautious about the prescription of psychotropic medication. Now, they are really important, efficacious treatments that we have. However, they're potent, and they come with side effects. And so they have to be used judiciously and carefully and fit for the right situation and for the shortest period of time that we can for somebody. For me now, when I look at a woman coming to my clinic and we're going through the history, I do want to stop and think about, actually, number one, are you on HRT? If we're in that zone where we should be thinking about it, if you're already on HRT, have we optimised it? Because there's so much variation in the practice of its prescription. Because actually giving a woman back her own natural hormones, why wouldn't we go there first, before we start introducing a psychotropic medication into the system. It just feels like...

Dr Louise Newson: [01:13:50] Well, it's you, know, if I said to you, you've got an iron deficiency and you're quite tired, tiredness is a symptom of depression but I wouldn't give you an antidepressant, I would try you on iron first.

Dr Gareth Jarvis: [01:14:01] Yes, yes.

Dr Louise Newson: [01:14:02] It's all quite simplistic medicine, isn't it? And the same, you know, we know that progesterone, estradiol and testosterone are made in the brain, they're neurosteroids, so they have a role in the brain and, you know, there was even randomised controlled studies from the 1980s, women with severe mental illness who are in a psychiatric hospital, given either placebo or estradiol in conjunction with their other medication and the results are staggering.

Dr Louise Newson: [01:14:33] Thanks so much for listening to my podcasts. Did you know that if you prefer to watch rather than just listen, my podcasts are available on YouTube every week. You'll find full episodes and additional educational content on hormones, menopause and women's health, all grounded in science and real clinical experience. It's another way for me to share evidence-based information, challenge outdated thinking and make complex topics clearer and more accessible. So if you want to stay up to date, revisit episodes or share them with others who might benefit, make sure you subscribe to my YouTube.

Dr Louise Newson: [01:15:11] But the other thing about antipsychotics that I never realised, because I didn't think too broadly, but antipsychotics affect metabolism. So we know that people on them long term, there's an increased incidence of heart disease, diabetes. People usually have their blood tested for their cholesterol. They have their pressure, quite rightly, done. But we know they can increase prolactin. So if they increase prolactin, they can switch off or suppress FSH and LH, two hormones in our brain. So basically give people a chemical menopause. We've known for many years that people on these antipsychotics, long-term, have amenorrhea, so stopping of periods. But I've been trying to work out guidelines and I've in touch with your Royal College of Psychiatrists, in case I've missed them, but they've confirmed to me there aren't guidelines that we have to be testing or psychiatrists should test for hormones in women who are on psychiatric medication long-term and it doesn't make sense really.

Dr Gareth Jarvis: [01:16:09] Absolutely. I think this is where we get into some of the barriers that are there for psychiatrists in trying to sort of, their practice and  in stepping into thinking about perimenopause, menopause. I know as an NHS consultant that it can be really challenging to do blood testing as a psychiatrist. We're often not well set up within the average psychiatry clinic to actually just turn around and say, oh, hang on, I'll just take a blood test off you. And we're quite often having to ask our GP colleagues to help and assist us with that. Or we're having to try and book in through one of our depot clinics and it's complicated and challenging. So the systems just aren't really well set up for us doing blood testing on a regular basis. I know that's not meant to be an excuse, it's just a reality.

Dr Louise Newson: [01:16:53] It's practicalities, isn't it.

Dr Gareth Jarvis: [01:16:54] Because I know for my own practice I've been starting to try and sort of build up the way that I'm working here. And I read more into the evidence and read more of the guidelines around how you can practice in this area, I sort of realised, oh, it'd be really nice to actually know what the hormone levels are so I've got a sense of where we're at. And it certainly inhibits me from wanting to go above the licensed limits, even though I hear all the time from Rachel just how much success that she has within the Newson Health clinic of actually knowing for women who are poor absorbers of estradiol that actually if you've not had success on this sort of lower levels, it's probably because they're a poor absorber. There was a CPD module that I completed a couple of years ago, so I know you assisted in writing these, which was fantastic. I found that a really helpful module that's available on the Royal College website for our own CPD training. And that really got me over the line, actually, in feeling confident about prescribing, because it just really helps me understand exactly where... all It actually did was reconfirm everything that I'd heard from Rachel before and had all the papers put in front of me by her and we'd gone through and I'd read through a couple of the books, but actually then finally having the Royal College stamp on it helped get me over the line of feeling, okay, I feel comfortable and confident now that my practice is being backed.

Dr Louise Newson: [01:18:15] Yeah and I wrote that with some colleagues but it took me a good two years because I got a lot of pushback to say surely the evidence isn't this good, surely there's more harm, but fair play and actually I paid some of our money so that it would be free access because it was really important for me that it was free access and then I did get a prize because it was the most downloaded module. I went up to Edinburgh to receive it which was great and every psychiatrist I spoke said yes we realise this is a problem but most psychiatrists are not like you and they don't prescribe any hormones at all. And I find that really quite frustrating because as a GP, I'm expected to prescribe most things and hormones are safer than most other drugs, you know.

Dr Gareth Jarvis: [01:19:00] I guess the thing for me, I've always been really lucky, is that I've had Rachel on tap this whole time, who I can sit and debate cases with over the dinner table, and she'll say, you need to be prescribing that woman HRT. But also that, and Rachel, she's given me permission to talk about this openly, she's been going through her own perimenopause. So we've had our own personal experience of sort of going through that journey and we'd started to notice lots of changes with Rachel, that she was getting much more tired. She was, I mean, Rachel is just the most organised person you've ever met in your life. She's on top of everything all the time. And we just found that she wasn't just quite on top of things the way she used to be. And then we started to find that there was lots of mood swings started coming in and there'd be these moments of explosive anger that would come out of nowhere. And I'd be thinking, oh my God, what have I done now? And because I'm the kind of person who just internalises stuff straight away. And I was thinking, Oh, I'm a dreadful husband. I'm doing terrible things and it started to become this real sort of, it was a difficult point in our relationship where we were having these sort of flash points of argument. And then she started to really get into the world of understanding perimenopause and menopause and has been able to be prescribed. But she's a poor absorber.

Dr Louise Newson: [01:20:24] Yes.

Dr Gareth Jarvis: [01:20:24] And a 100mcg patch was not enough for her and she had to go up and she's on she's on 400mcg now. So she puts on four patches a day. And that's finally got to the point and it's a world of difference where she says I've got my energy back, my mood is great again, I'm able to function. And so having that personal experience and the confidence to see that that's made all the world of difference for her and for us. I think that's definitely made me want to go more women should have the chance to feel this good.

Dr Louise Newson: [01:21:04] Yeah, I mean, it's the same. I mean I've been on HRT for 10 years, but I don't absorb well and I was on 100mcg, it did nothing and going up to 200 and I was perimenopausal then, so now I'm higher than that. But if I don't I get migraines really badly anyway and they just get a lot worse and I get joint pain, but my mood was terrible at times. But I have managed persuade a few psychiatrists to prescribe, there's one of my patients, It's really sad, actually. She was doing really well on HRT and then there was an HRT shortage a few years ago. So her GP said, well, you don't need it anymore so we'll stop everything. And her mental health deteriorated really quickly and her husband was doing some washing up and she jumped and so she fractured her spine and was in a psychiatric hospital and he reached out to me and I went to go and visit her actually one Sunday, I just turned up at the hospital and I hadn't been to a psychiatric hospital for many years and she was really agitated and she was absolutely mortified I was there and she was like a little sparrow you know she was she wasn't one of my patients so I didn't know what she was like before but she wasn't a clinic patient and I just felt really sad to see her so she had very dry hair very dry skin. She was ruminating a lot, she was fixating on the accident. She was so embarrassed that I was seeing her. So she had insight as well, which a lot of these people still do. And so I couldn't prescribe for her because she was under the NHS psychiatry unit. So the psychiatrist had done the module and recognised my name. So agreed to prescribe for her. And I saw her as a review last week, actually. And it's just amazing. She's like, she's so well. But it was the testosterone that made the biggest difference. And a lot of people who are that poorly, the estradiol and progesterone help, but it's the testosterone and it takes time. And physically she looks completely different, but mentally she's so different. And it's incredible, but having this rapport with a psychiatrist and actually giving them, telling them, or advising them what would be good to prescribe, looking at the blood results with them. It's been really good and it's happened to another couple of patients again who have been inpatients and that's really amazing. But I wouldn't have even thought about it years ago. That's what frustrates me. But now it's there it's so obvious and a lot of psychiatrists say, well, we need more evidence. But actually, there is really good evidence compared even to some of the other drugs. It's this sort of willful blindness, really, that they're using it as a reason maybe. But we need to change the conversations, don't we.

Dr Gareth Jarvis: [01:23:55] I find that a really tricky area to navigate, Louise, around that relationship with other doctors. And so even as I've sort of started making this a more regular part of my practice of prescribing HRT for women after we've gone through figuring out that that feels like a right fit for something to try. And then we've had some amazing results where women have just come back and said, I feel this has really helped. It's not solved my problem because by the time they come to see me as a psychiatrist, it's usually pretty severe and complex mental health problems, because actually the vast majority of mental health problems is managed by general practice.

Dr Louise Newson: [01:24:27] Yes, of course.

Dr Gareth Jarvis: [01:24:29] And so I'm seeing the most severe end. So it's not, as I say, not some silver bullet that's just taken away their problems. But they've said, this has helped. I'm sleeping better. I'm not drenched in sweats. My mood just feels that little bit calmer. And I'm just able, I've got that energy back to sort of start doing things again. So I'd really like, I say, great, let's get it continued. And I'll write back to the GP and say we've done this trial of HRT, please carry it on. I've had some very rude letters back from some GPs where they've actually come back and said, what do you think you're doing as a psychiatrist prescribing HRT. Another one I had was a woman who, she'd had a hysterectomy and she'd been given some HRT, but it was 50mcgs of estradiol and that was it. And I said, well, do you know what, actually, I think if we add in some Utrogestan, because she was really complaining that her sleep was really poor and she's very anxious. I said, I just, I'm interested to find out if this would be helpful. And this is common practice within psychiatry in terms of trying things out.

Dr Louise Newson: [01:25:28] We're very used to therapeutic trials.

Dr Gareth Jarvis: [01:25:31] Because the medications we prescribe normally in psychiatry that it's not like we're topping up your lack of sertraline or whatever it might be and we're adding in the agents that your body doesn't normally have because we're trying to see if the effects of it are helpful or not and give some space for helping. So that's just the normal way that we practice in psychiatry. I think if you can enter into HRT prescribing in that spirit of, let's try something and as again, just want to re-emphasise that very low risk, so why wouldn't we give it a go. Because you can always not prescribe it again if actually it turned out that did nothing or we can play with it a bit more and try and see if we can find even better fit. But yes, so back to that story, lady who had a hysterectomy, we introduced some Utrogestan and yes, after a few weeks, you know, she came back a few weeks later and said, do you know what, that's actually really helped. I'm sleeping a lot better. I feel a bit calmer. I'd like to continue that. I was like, great. So we wrote back to the GP and said that, you know, we've increased the estradiol. We've prescribed some Utrogestan. And she came back and said well, she doesn't need Utrogestan, she hasn't got a womb. And so I then entered a bit of a back and forth in the emails of saying, well, actually you know, she's benefiting from it. And we know that progesterone has an effect on the GABA system. Thanks to your module.

Dr Louise Newson: [01:26:51] Very good.

Dr Gareth Jarvis: [01:26:52] And that's gonna reduce anxiety. It's going to help with the sleep so why on earth wouldn't we continue that. And she then came back again and, so I did have to send her quite a few more materials and papers to sort of try and reassure, because she was coming back saying it's going give her blood cots and I said, there is no evidence for that and it's amazing the amount of misinformation that's out there and I feel like there's no other area of medicine that has this degree of misinformation.

Dr Louise Newson: [01:27:21] No, it's absolutely maddening, isn't it because we're arguing over a natural hormone at the end of the day and the patient is central to that decision-making process. And actually we are reaching a stage often where the patients know more than the doctors and that can be difficult, but a lot of doctors are are waking up and realising because it is basic physiology as well. You know, we can have the psychiatric medication alongside. It's not a one or the other. And often, you know, people need both, that's fine as well. So there's lots we need to do. And I'm just really grateful that you're here talking about it. And hopefully we'll change the minds of others.

Dr Gareth Jarvis: [01:28:00] Well, that thing about changing minds. it preoccupies me a lot because as a psychiatrist, I'm really passionate about an approach to mental health care called open dialogue, which is really inclusive of family and trying to be transparent with the people that you're working with. So it's just got the, effectively at its heart, it's that. It's making sure that you have all the conversations you need to have about someone in front of them and that you include their social system around them or anyone who's important to them. I've been working on that for about 10 years now with various people in the UK. We did a big research trial around it called ODDESSI that we're publishing soon. And it's amazing the amount of resistance I've had over that time of trying to bring in a different way of working that there's just this huge degree of small c conservatism amongst the medical profession to anything that's new or different, this sort of level suspicion.

Dr Louise Newson: [01:28:57] Yes, it is suspicion, isn't it?

Dr Gareth Jarvis: [01:28:58] Of just, you know, it's amazing the sort of range of responses I'll get to it when I start trying to explain this sort of way of working to people. But first of all, they go, oh, that's no different to what I do already. And then the next response is, oh when they really get to understand they go that's too radically different from what we do already, then it's, oh no, it's too expensive and no, it'll take too much time. And every excuse in the book will come out and be thrown in the way of anything but trying to embrace change. I know we love our old stories of medicine and I often think about the story of Semmelweis.

Dr Louise Newson: [01:29:35] Oh yeah.

Dr Gareth Jarvis: [01:29:36] The Hungarian obstetrician who the medical students were coming in from the anatomy lab and they weren't washing their hands and they were going and helping out to deliver women's babies and he could see on the ward where the medical students were delivering babies rather than the ones where the midwives were, that they had much higher mortality rates. And presenting that data to his colleagues, he got utterly ostracised.

Dr Louise Newson: [01:29:59] He wasn't allowed to, well, he wasn't allowed to conferences, but the worst saddest thing about Simmelweis is that he ended up beaten to death in a straightjacket.

Dr Gareth Jarvis: [01:30:08] In an asylum.

Dr Louise Newson: [01:30:09] In an asylum. And don't get me wrong, I mean, there's many times that I've thought about Simmelweis and thought about my own mental health. But we need to end on a happy note. Things are changing and people are learning and we need to keep looking at the evidence. We need to keep looking at basic neurophysiology because that's often what we're talking about. So three things, Gareth. What three things do you think psychiatrists should just know about hormones? So I'm not talking about prescribing, but just know so they can ask the right questions for their patients.

Dr Gareth Jarvis: [01:30:46] So three things, the first thing I would say, I would really strongly recommend the CPD module on the Royal College website. It's really straightforward and you can get it complete within an hour or so and it will just bring you right up to speed really quickly. So I think go there. Secondly, I would think about how you can start having these conversations with your patients in your clinic, of actually just being curious, being curious about that life cycle and thinking about when did this change happen and is this woman in that sort of age range of sort of 35 to 55, somewhere in that range of actually what should I be thinking hormones? And the third one, don't be afraid to prescribe.

Dr Louise Newson: [01:31:36] Yes.

Dr Gareth Jarvis: [01:31:36] You've got you've got these really low risk natural products that you can prescribe to women their own hormones that you give back to them. It's going to be part of the solution, not just for their mental health, but you're going to be promoting their physical health as well, which is such a core issue for us to drive forward.

Dr Louise Newson: [01:31:54] Yes, so important. So thank you so much for sharing your wisdom and thoughts today. Thank you.

Dr Gareth Jarvis: [01:32:00] Thank you, Louise.