September 23, 2022
2 min read
OTTAWA — An expert told a special joint committee of the House of Commons and Senate that people with mental disorders can suffer for decades, and their distress is equally as valid as someone suffering physical pain.
People suffering solely from mental disorders are due to become eligible for assisted dying in March, and Dr. Justine Dembo, a psychiatrist and medical assistance in dying assessor, also cautioned the committee about perpetuating stigma about mental illness.
Mental health advocates warn it is harder to predict the outcomes and treatments of mental illnesses, and a wish to die is often a symptom, but an expert panel earlier this year said existing eligibility criteria and safeguards in medically assisted dying legislation would be adequate.
Both arguments were made today by a handful of witnesses appearing before the committee, which is deliberating what policies to recommend to lawmakers ahead of the March deadline.
Ellen Cohen, a coordinator advocate for the National Mental Health Inclusion Network, told committee members Canada needs laws to help patients, not hurt them.
“I don’t believe there were any safeguards recommended,” she said.
She resigned from the federal government’s expert panel on MAID and mental illness in December 2021. She said there was no space to identify how vulnerable people could be protected.
The panel released its report May 13, concluding that existing eligibility criteria and safeguards would be adequate “so long as those are interpreted appropriately to take into consideration the specificity of mental disorders.”
Dembo, who was one of the expert panel members, said following those guidelines for people with mental disorders “would ensure an extremely comprehensive, thorough and cautious approach.”
She told the committee people with mental disorders can suffer for decades.
“To say someone with mental illness just shouldn’t be eligible, with that big of a blanket statement, where people don’t even get the chance to be assessed as individuals unique in their circumstances, to me is very stigmatizing,” she said.
While the interim report released earlier this year stops short of making recommendations of its own, it concludes by urging the government to take steps to implement the recommendations of the expert panel “in a timely matter.”
A final report from the committee, complete with recommendations that address other areas including access for mature minors, advance requests, the state of palliative care and the protection of people with disabilities, is due on Oct. 17.
Cohen called the timeline for the legislation to be expanded by March unrealistic.
“I’d like to see this government push this deadline back,” she said.
But Dembo disagreed, telling MPs and senators that assessors are already gaining experience following the existing guidelines.
“Whether or not March 2023 is a realistic deadline depends on how committed and efficient various provincial bodies and local bodies can be in implementing guidelines based on the panel report. I’m hoping they can do that,” she said.
The committee’s review was mandated in the MAID legislation that required that a parliamentary review be initiated five years after the law came into effect in 2016. The committee began its work in 2021 before it was dissolved ahead of the federal election last fall.
The panel and the committee use the terminology “mental disorders,” rather than “mental illness,” stating in their reports that there is no standard definition for the latter and its use could cause confusion.
Conservative MPs on the committee offered a dissenting interim report earlier this year, saying it would be “problematic” to simply endorse the panel’s recommendations.
The MPs argued there are “far too many unanswered questions” on the subject, and nothing precludes the committee from revisiting whether assisted dying should be offered to this category of people at all.
“Legislation of this nature needs to be guided by science, and not ideology,” the Conservatives wrote in May, warning that an outcome that could “facilitate the deaths of Canadians who could have gotten better” would be completely unacceptable.
This report by The Canadian Press was first published Sept. 23, 2022
The Canadian Press
Every 22 minutes, a woman in Canada dies of a heart attack.
But the majority don’t have to, experts say, warning that more women will die unnecessarily if the medical community doesn’t tailor care to their needs.
“We have one of the best health-care systems in the world, and we’re not serving women,” said Dr. Paula Harvey, a cardiologist and head of the department of medicine at Women’s College Hospital in Toronto. “We have to do better.”
Heart disease is a top killer of women in Canada, and the push to change that is more urgent than ever. Harvey says more younger women are presenting with classic high risk factors for heart disease: high blood pressure, diabetes and obesity.
“There’s this trend to cardiovascular risk factors starting to be a problem at an earlier age, and I find that disturbing,” said Harvey. “I never used to see a woman in her 40s with high blood pressure. I’m starting to see that, and that’s going to mean that we’ll have more premature heart disease.”
Some studies have already found the heart attack rate among women aged 35-54 has gone up.
Lifestyle factors play a role in the trend, but the threat itself is broader — the majority of Canadian women have at least one risk factor for cardiovascular disease. Women with diabetes and those who come from certain racial or ethnic backgrounds are at higher risk, but fluctuating hormones can wreak havoc with any woman’s heart health, especially as they enter menopause and levels of the heart-protecting hormone, estrogen, start to drop.
That transition starts when women are in their 40s and can catch many off guard, Harvey said.
“I do think that a lot of that comes from the fact that women are still not being educated, they’re not being counselled, they don’t understand the impact of our changing biology with age that puts them at cardiovascular risk.”
According to the Canadian Women’s Heart Health Centre, at the University of Ottawa Heart Institute, 24,000 Canadian women die of heart disease every year. That’s nearly five times more deaths than from breast cancer.
Yet when it comes to heart health, experts say it’s still largely a man’s world: Women remain underdiagnosed, undertreated and unaware.
“It is a glass ceiling. It’s a glass ceiling for awareness, it’s a glass ceiling for research and for how we provide care,” said Karin Humphries, an associate professor at the University of British Columbia whose has researched gender and sex differences in the diagnosis, treatment and outcomes of patients with cardiovascular disease.
The basic medical model is still male-dominated and contributes to a general lack of awareness among women and health-care providers, Humphries said. And while awareness is growing, it’s not growing fast enough, she said.
“Everything in our culture emphasizes that cardiovascular disease is a man’s disease. I mean, think of Hollywood. Every time you see a heart attack, it’s on the male, right? You’re not watching a woman in a Hollywood movie having a heart attack.”
Part of the problem is that women’s symptoms can be different than those of men and can be attributed by both doctors and women themselves to stress and busy lives. For example, months before a heart attack, women may experience unusual fatigue, trouble sleeping, indigestion and anxiety.
Even during a heart attack, the symptoms can be subtle. Women are more likely to have chest discomfort, shortness of breath and even neck, jaw or back pain.
“I was still, you know, two months after my event, still reeling from that shock,” said Risa Mallory, who had a heart attack four years ago at age 61.
Mallory had been experiencing discomfort in her chest for several days, she said, but it came and went and didn’t seem so bad — until it suddenly was.
“On the fourth day, I experienced chest pain. It had changed. It was much more severe. I was feeling nauseous and I had this sense of fight or flight,” she recalled. “I remember sitting in the car, rocking, and saying, ‘We gotta go, we gotta go, we gotta go.'”
Mallory ended up in the emergency room and got help in time. But it was a close call. Heart disease runs in her family, she was aware of her own risk, but she still almost missed the warning signs.
That’s something that happens often, according to a 2018 Heart and Stroke Foundation report. The report found that early signs of a heart attack were missed in 78 per cent of women.
“What it tells us is that there are still a lot of inequalities and biases at the community level and the health-care provider level,” said Dr. Thais Coutinho, a cardiologist and chair of the Canadian Women’s Heart Health Centre at the University of Ottawa Heart Institute.
Many women are in the dark, Coutinho said, in large part because much of the medical community is too.
Even now, the majority of heart disease research is conducted on men — despite important physiological differences, she said. Women’s hearts and arteries are smaller, and plaque builds in different ways. Standard diagnostic tests like angiograms and stress tests are often not sensitive enough to detect heart disease in women.
“That assumption still permeates through the cardiovascular research community that women are small men,” Coutinho said. “I do a lot of sex- and gender-based research, or women-specific cardiovascular research, and it’s amazing the differences that you find if you look. All of the gaps that we know exist from awareness, diagnosis, treatment, care, rehabilitation, education, everything — it starts with knowledge.
“So if we don’t even know what the differences are, we don’t know how to manage them.”
Samia Janna was 48 when she first went to her doctor in 2018 because of shortness of breath. The Ottawa-area woman was prescribed anti-anxiety medication and told to take it easy. But the symptoms persisted.
Janna went back to her doctor twice more, only to be given the same advice.
“At that time, I said, ‘No, I know it’s not anxiety,'” Janna says. “I know myself. There’s something wrong with my heart.”
Blood tests didn’t flag anything, but Janna insisted on an ultrasound to check her heart. It revealed Janna’s heart was enlarged and causing damage to her heart valves. She ended up having two open heart surgeries.
Janna says it was hard to let go of her anger about the fact that her concerns were initially dismissed. She joined a cardiac rehabilitation program and says it helped her regain her physical and emotional strength. “If it wasn’t for them. I would have been in a different place now, in a very dark place.”
Research finds women are up to 50 per cent less likely than men to attend cardiac rehab programs, often because they don’t get referred to one or face other barriers to follow-up care, including a tendency to minimize their own needs.
It helps explain why women who have a heart attack are more likely to die or experience a second heart attack compared to men.
Harvey says research is beginning to uncover the biological, medical, and social reasons for this — and the hope is that new knowledge will lead to advances in tailoring prevention and treatment to women’s needs.
But she points out, 80 per cent of heart attacks can be prevented and women can decrease major risk factors by managing high blood pressure, not smoking and sticking to a healthy weight. Harvey says women should also urge their doctors to check their hearts.
“We need to be empowered,” she says. “Knowledge is power. Advocacy is power. And do what you can so that you are aware of cardiovascular risk.”
And though prevention is key, Humphries says women should not hesitate to get help if they feel something is wrong.
“Call 911 and ask for help. Don’t worry about, you know, taking up time for health-care providers. They’re there to help you. And if you find out there’s nothing wrong with you, that’s wonderful. But absolutely do not hesitate and call 911.”
The study by University of British Columbia researchers says that while reduced social interaction during the March-May 2020 lockdown worked to reduce HIV transmission, that may not have “outweighed” the increase caused by reduced access to services.
The study, published in Lancet Regional Health, found that fewer people started HIV antiretroviral therapy or undertook viral load testing under lockdown, while visits to overdose prevention services and safe consumption sites also decreased.
The overall number of new HIV diagnoses in B.C. continues a decades-long decline. But Dr. Jeffrey Joy, lead author of the report published on Friday, said he found a “surprising” spike in transmission among some drug users during lockdown.
Joy said transmission rates for such people had previously been fairly stable for about a decade.
“That’s because there’s been really good penetration of treatment and prevention services into those populations,” he said in an interview.
B.C. was a global leader in epidemic monitoring, which means the results are likely applicable elsewhere, Joy said.
“We are uniquely positioned to find these things,” he said. “The reason that I thought it was important to do this study and get it out there is (because) it’s probably happening everywhere, but other places don’t monitor their HIV epidemic in the same way that we do.”
Rachel Miller, a co-author of the report, said health authorities need to consider innovative solutions so the measures “put in place to address one health crisis don’t inadvertently exacerbate another.”
“These services are the front-line defence in the fight against HIV/AIDS. Many of them faced disruptions, closures, capacity limits and other challenges,” Miller said in a news release.
“Maintaining access and engagement with HIV services is absolutely essential to preventing regression in epidemic control and unnecessary harm.”
The Health Ministry did not immediately respond to requests for comment.
Researchers said the spike among “select groups” could be attributed to a combination of factors, including housing instability and diminished trust, increasing barriers for many people who normally receive HIV services.
British Columbia is set to become the first province in Canada to decriminalize the possession of small amounts of hard drugs in January, after receiving a temporary federal exemption in May.
Joy said this decision, alongside measures like safe supply and safe needle exchanges, will make a difference preventing similar issues in the future.
“The take-home message here is, in times of crisis and public health emergency or other crises, we need to support those really vulnerable populations more, not less,” he said.
“Minimally, we need to give them continuity and the access to their services that they depend on. Otherwise, it just leads to problems that can have long, long-term consequences.”
This report by The Canadian Press was first published Sept. 24, 2022.
© 2022 The Canadian Press
September 23, 2022
2 min read
One author reports receiving speaker and consultant fees from Bayer and Janssen for work unrelated to this study. Walli-Attaei and the other authors report no relevant financial disclosures.
The magnitude of associations with major CVD for most risk factors are similar in women and men, despite sex differences in risk factor levels, according to an analysis of the PURE study.
In a comprehensive overview of the prevalence of metabolic, behavioral and psychosocial risk factors for CVD in women and men globally, researchers also found that diet was more strongly associated with CVD in women than in men. However, high concentrations of non-HDL and related lipids and symptoms of depression were more strongly associated with risk for CVD in men than in women. Patterns remained consistent across countries regardless of income level.
“Existing studies, mostly from high-income countries, have reported that hypertension, diabetes, and smoking are more strongly associated with cardiovascular disease in women than in men,” Marjan Walli-Attaei, PhD, a research fellow at the Population Health Research Institute of McMaster University and Hamilton Health Sciences, and colleagues wrote in The Lancet. “Such findings would imply that women would benefit to a greater extent in reducing cardiovascular disease risk from control of these risk factors than would men. However, the burden of cardiovascular disease is greatest in low-income and middle-income countries, for which prospective data on the association of risk factors with cardiovascular disease are sparse, with a paucity of analysis by sex.”
Walli-Attaei and colleagues analyzed data from 155,724 adults aged 35 to 70 years at baseline without a history of CVD enrolled in the PURE study, which included participants from 21 high-, middle- and low-income countries, and followed them for approximately 10 years (58% women; mean baseline age, 50 years). Researchers recorded information on participants’ metabolic, behavioral and psychosocial risk factors; all participants had at least one follow-up visit. The primary outcome was a composite of major CV events, defined as CV death, MI, stroke and HF. Researchers reported the prevalence of each risk factor in women and men, HRs and population-attributable fractions associated with major CVD.
As of the data cutoff of Sept. 13, 2021, researchers observed 4,280 major CVD events in women (age-standardized incidence rate, 5 events per 1,000 person-years) and 4,911 in men (age-standardized incidence rate, 8.2 per 1,000 person-years).
Compared with men, women presented with a more favorable CV risk profile, especially at younger ages. HRs for metabolic risk factors were similar in women and men, except for non-HDL, for which high non-HDL was associated with an HR for major CVD of 1.11 in women (95% CI, 1.01-1.21) and 1.28 in men (95% CI, 1.19-1.39; P for interaction = .0037), with a consistent pattern for higher risk among men than women with other lipid markers.
Researchers also observed that maintaining a diet with a PURE score of 4 or lower (score range, 0-8) was more strongly associated with major CVD in women than in men, with HRs of 1.17 (95% CI, 1.08-1.26) and 1.07 (95% CI, 0.99-1.15; P for interaction = .0065), respectively.
In contrast, symptoms of depression were more strongly associated with CVD in men than in women, with the HRs for symptoms of depression being higher in men than in women (P for interaction = .0002). “The HRs of other behavioral and psychosocial risk factors, as well as grip strength and household air pollution, were similar among women and men,” the researchers wrote.
The total population-attributable fractions associated with behavioral and psychosocial risk factors were greater in men than in women (15.7% vs. 8.4%) mostly due to the larger contribution of smoking to population-attributable fractions in men (10.7%) vs. women (1.3%).
“Our results emphasize the importance of a similar strategy for the prevention of cardiovascular disease in both sexes,” the researchers wrote. “However, the increased risk of cardiovascular disease in men might be substantially attenuated with better reductions in tobacco use and lipid concentrations.”
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