Yes, sorry, Doctor. Thank you.
Evidence of meeting #108 for Health in the 44th Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was women.
A recording is available from Parliament.
Evidence of meeting #108 for Health in the 44th Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was women.
A recording is available from Parliament.
4:50 p.m.
Conservative
4:50 p.m.
Postdoctoral Research Fellow, BC Reproductive Mental Health Program, BC Women's Hospital and Health Centre, As an Individual
That's okay.
When that was released, it was actually consistent with the previous task force recommendation, which was focused more generally on depression in women or in adults, and it was still recommending against tool-based screening—so, using a questionnaire, basically, and suggesting that a conversation with your doctor would be better.
The change that we saw at the B.C. reproductive mental health program was that when the recommendation was released, we heard informally from OBGYN colleagues or family doctors who would say, “So I don't need to worry about screening anymore.” Even though that wasn't technically what the task force recommendation was, what was heard, generally speaking, by the maternity care community was that screening for perinatal depression was not recommended.
4:55 p.m.
Conservative
Stephen Ellis Conservative Cumberland—Colchester, NS
So in essence, Dr. Hippman, realistically.... I think we've heard very clearly from all of our witnesses today that this perinatal period is a unique time in life, obviously, for many reasons, but it also presents an opportunity to screen for mental illness and difficulties that can affect the pregnant woman and the child subsequently, of course, and the relationships there.
Just to be clear, for people listening, the unintended consequence of this recommendation was that screening is not being done. Am I clear on that?
4:55 p.m.
Postdoctoral Research Fellow, BC Reproductive Mental Health Program, BC Women's Hospital and Health Centre, As an Individual
Yes.
4:55 p.m.
Conservative
Stephen Ellis Conservative Cumberland—Colchester, NS
The recommendation now...what would you like to see differently? Do you want to return to tool-based screening? Often, medicine is about a relationship, of course. It makes it much easier if you've known the person, but as we know, many people don't have access to a family doctor. If you had all the money, the $4.5 billion of the untransferred Canada mental health money, what would you do differently?
4:55 p.m.
Postdoctoral Research Fellow, BC Reproductive Mental Health Program, BC Women's Hospital and Health Centre, As an Individual
What a dream.
Just on a very small scale, it would be great to have universal standardized screening recommended. What I mean by that is to have a clear message sent to all primary care providers that this is important and that there's nuance in how you do it. If you use the gold standard globally—that's called the Edinburgh postnatal depression scale—you can use it, but you can make it part of a conversation. It doesn't have to be handing someone a piece of paper, so you can incorporate that into your regular practice. However, the strong message is, “Ask people about their mental health to see whether there's depression there.”
Then, if I had the additional latitude and money, it would be wonderful to see some of these other recommendations you heard today, in terms of having more of a national strategy for perinatal mental health that would enable additional training and capacity for health care providers to know how to best support people and how to connect them to all of the amazing supports that are out there but that, as we heard, are not necessarily connected.
4:55 p.m.
Conservative
Stephen Ellis Conservative Cumberland—Colchester, NS
Thank you, Chair.
I guess the question that remains.... When we look at this, we know that 25% or maybe one-third of Canadians have issues with their mental health generally. I think today we heard very clearly that pregnant women have, perhaps, more issues, and almost half of people now have unmet health care needs.
Maybe I will give a shout-out to the Canadian Association of Occupational Therapists. I met with them today, and I think they would be ideally suited to provide part of this care. Is that a fair statement?
4:55 p.m.
Postdoctoral Research Fellow, BC Reproductive Mental Health Program, BC Women's Hospital and Health Centre, As an Individual
I think that would be great, yes. It would be fantastic.
I'd also love to see a role for psychiatric genetic counsellors to support that.
4:55 p.m.
Liberal
The Chair Liberal Sean Casey
Thank you, Dr. Hippman and Dr. Ellis.
Next we have Dr. Powlowski, please, for five minutes.
4:55 p.m.
Liberal
Marcus Powlowski Liberal Thunder Bay—Rainy River, ON
We're all a very sophisticated bunch here. I'm surprised no one has asked some really dumb questions, so leave it to me. I'm not a “common-sense Conservative” like the members over there, so I lack that.
4:55 p.m.
Voices
Oh, oh!
April 8th, 2024 / 4:55 p.m.
Liberal
Marcus Powlowski Liberal Thunder Bay—Rainy River, ON
I would have thought that, as I recall from medical school, the big issue around perinatal depression is that there is a societal expectation that people are happy. The husband, or whoever the father is, thinks that the mother should be happy. The siblings figure they should be happy. Their parents think they should be happy, and they're not. I would have thought it's part and parcel of the whole problem that there is this expectation. You're supposed to be happy, and perhaps there's some shame and unwillingness to talk about it because you're supposed to be happy.
With that, I have two questions. One is, why? How much of it is hormonal? I'm sure there are a large number of cases, because there's pre-existing depression, but how much of it is other things, like the situation the woman is in, if she is unhappy in the relationship or there's loss of freedom or lack of support? How much of it is situational? How much is hormonal? That's one question as to why. Then the second part of the question is, how much is that part and parcel of the whole problem of recognition and treatment, the fact that there is this expectation that you're supposed to be happy?
5 p.m.
Associate Professor and Scientist, Montreal Antenatal Well-Being Study, Québec Alliance for Perinatal Mental Health
We developed this program that I referred to before. It was inspired by mothers and babies and is evidence-based worldwide but stems from Palo Alto in the U.S. We adapted it to call it Toi, Moi, Bébé. One of the first couple of modules is really that. We made these kinds of cartoons, and we were addressing a lot of societal, universal golden rules of how people experience transition to parenthood.
It's not the same for everyone. I think a lot of the time there are these social standards that are sometimes perpetuated by what we see more actively in the media; therefore, I think this is very helpful. We've had people we've worked with test out the intervention at the very early stages in terms of feasibility and acceptability. That's one of the things they would point out. I felt so relieved to see a woman who was experiencing pregnancy in a positive light, where it was very challenging and it was not a joyful moment, but then there was also representation of me.
To get to your second question, until we know the why, there's nothing that prevents us from having these types of interventions available, because they do seem to help and they're easily accessible in our province, for example, online.
The other piece is that there are studies like ours, the Montreal antenatal well-being study, where we're looking for certain biomarkers, neural or endocrine. For sure there is something happening. We know that there are specific profiles of women who are more vulnerable; therefore, when we're talking here, it's more about women's health more generally. Preconception care, for example, brings about this opportunity, if we were to identify these biomarkers in combination with dialogue and picking up on certain things that are being mentioned by the pregnant people, to also have these more medical base biomarkers.
As a clinical psychologist, I see that people who are not expecting often neglect their well-being. We're all like that. We know what a healthy lifestyle is, but we don't necessarily live it.
Where pregnancy presents as an opportunity, for women but also men, is that, all of a sudden, I'm preparing to care not only for myself but also for my offspring. There's something that happens at the cognitive and motivational levels that people want to seek help for. Why not leverage this added motivation to get people to talk about mental health and how they can do a self-reflection at that moment to improve themselves, according to not a curative approach but a more preventative one?
We've already heard stats from Dr. Ryan Van Lieshout about the seven dollars for every dollar invested. This goes back to Dr. Heckman, who mentioned this in 2000. If we were to invest one dollar in prevention, it would save us seven dollars in terms of curative care later on.
This is what we need to keep in mind. There is an opportunity to use those motivational aspects to get people to want to get better.
5 p.m.
Postdoctoral Research Fellow, BC Reproductive Mental Health Program, BC Women's Hospital and Health Centre, As an Individual
I don't know if there's any time for me to add a little bit.
Even before we have the biomarkers or anything like that in a blood test, even right now, as a genetic counsellor, I take family histories. You can tell a lot about risk based on what's happened in somebody's family. You can work with them. Part of genetic counselling is identifying risk, but it's also talking to people about things they can do to protect their mental health. There are ways that we've seen improvement in mental health for people after they've come for genetic counselling. There's a mix in terms of genetic and environmental vulnerability.
5 p.m.
Liberal
The Chair Liberal Sean Casey
Thank you, Dr. Hippman.
Next we're going to Dr. Kitchen for five minutes.
5 p.m.
Conservative
Robert Gordon Kitchen Conservative Souris—Moose Mountain, SK
Thank you, Mr. Chair.
Thank you all for being here. It's greatly appreciated.
Ultimately, we're doing a study so we can hopefully ask Canadians how we are going to make it better for women. It's a challenge.
You all are researchers, and you've indicated that to us. I thank you for the research you do, because that helps practitioners. Some of us at this table have been practitioners, but at this point in our lives, we're politicians. Ultimately, how do we improve things for Canadians, especially when we're dealing with a health care system that is primarily a provincial issue? There's a huge challenge along those lines.
I know that throughout the conversation we've had today, in everything that has been talked about—postpartum and prepartum, etc.—it has been one year. I would argue that's not the case. I think people listening would say, “Oh, it's one year. I'm a year past giving birth, so I don't have to worry about it.”
Is there any evidence to suggest how long it could be, Dr. Montreuil?
5:05 p.m.
Associate Professor and Scientist, Montreal Antenatal Well-Being Study, Québec Alliance for Perinatal Mental Health
That's a very good question.
I'd say that, more and more, we develop protocols to be able to follow that. That's one of the things. If we were to have a continuum of care from preconception going forward, we'd be able to establish very strong causal models to address the question that you have. Unfortunately, we have a lot of cross-sectional studies at different time points, and we can kind of put these studies together.
One thing we know for sure, from some of the studies that we're conducting at RI-MUHC, is that, for example, in the case of anxiety starting perinatally, there is some sort of linkage with conditions that are inflammatory, which can then.... Once we get these women at their first pregnancy, if we follow them into their second pregnancy, it seems that, if you were to look at these two pregnancies in more than just a year, there are connections. For example, the mental health that remains unaddressed will also affect—
5:05 p.m.
Conservative
Robert Gordon Kitchen Conservative Souris—Moose Mountain, SK
Thank you. I appreciate that. I apologize for cutting you off. There are a number of questions, and I have such a short period of time.
Dr. Van Lieshout, you talked a little about lactation and concerns about medications and issues. How do we educate Canadian women to truly...? I know that when I was in practice, Dr. Google came into my office every day and said, “This is what I have.” In today's world, Dr. Google seems to know a lot more about what goes on in lactation than practitioners supposedly do. I'm just wondering how we combat that.
5:05 p.m.
Associate Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster University, As an Individual
Yes, I'm familiar with Dr. Google and his credentials.
I think the first thing is that, when we put together these practice guidelines and we get the state-of-the-art and Canada together, and then we get that information out to the frontline practitioners so that they know this, when people seek a second opinion on Dr. Google and come and ask those questions, the practitioners will have that information handy and they can help those people make the best decisions possible. It's the same with midwives.
We look forward to doing that with the information we're pulling together now, and then I think we'll have to see how that goes. Maybe there's room for public health to get involved and start to talk about all of the real benefits and drawbacks of treatment versus not getting treatment. Unfortunately, Canada has a shortfall of psychotherapies; they're not available. Medicine is often a default option for a lot of people, and people just get no treatment as a result because of uncertainty about the safety.
5:05 p.m.
Conservative
Robert Gordon Kitchen Conservative Souris—Moose Mountain, SK
Thank you. I appreciate that as well.
Ultimately, I think that when we look at aspects of what we're dealing with, you brought up a point about.... I come from rural Saskatchewan. My colleague from the Bloc comes from rural Quebec, and my colleague from Nunavut comes from much farther. My riding, which I consider rural, is not even close to my colleague's from Nunavut. For my colleague beside me, who comes from a rural area in the London area, it's ultimately a half-hour drive, but it takes two or three hours for our constituents to get where they are going. Our female constituents are dealing with practitioners who come from various parts who have never lived in that area.
How do we educate those practitioners to make certain that that information for women is being put out during that time so that they know what to do? They drive three hours to go for a meeting and, as you said, Dr. Montreuil, the reality focuses on the baby as opposed to focusing on the mother. That is a big challenge, so how do we improve that?
5:05 p.m.
Professor, University of Toronto, and Head, Department of Psychiatry, Women’s College Hospital, As an Individual
Can I jump in? Is that okay?
5:05 p.m.
Conservative
5:05 p.m.
Professor, University of Toronto, and Head, Department of Psychiatry, Women’s College Hospital, As an Individual
If you go on PubMed and you type in “antidepressants in pregnancy”, you'll get like 80 articles a year. It is practically impossible for practitioners to go through that. Then, when patients type it into the Internet, it's the same.
A number of years ago, we created an online patient decision aid that talks to people about what their condition is and all the different treatments. It provides the potential benefits of the medication and the potential safety risks. When we tested it, we found that for somebody who talked to me in my clinic—because I'm a provider and I do this kind of counselling all the time—the decision didn't give much more to them, but when we tested it with people across Canada who, for example, lived in rural Saskatchewan and other places, they really had a big improvement in their decision-making difficulty and felt it was so much easier to make a decision about whether to use the medications or not. Then we were funded—and we've had about 500 people all across Canada—to see not only whether it helps their decisions, but whether it helps them have better outcomes and less likelihood of having depression in the long term.
If you can take a few specialists and have a trustable brand with the evidence, there are really neat ways of getting it out to people. The family doctor can download the tool, and the patient can look at it. We have really good technological ways of getting that stuff out, but I think it's about making sure that the information is branded in a trustable way.