An annual mental health fair, Mindfest raises awareness and battles stigma by encouraging discussions about mental illness. This year’s event focuses on mental health for students and young people. Speakers will include mental health experts, peer mentors, and individuals with lived experience. Workshops will offer attendees opportunities to engage in self-care activities such as yoga and guided meditation. Our exhibitor fair gives attendees an opportunity to explore the support and advocacy organizations that exist on and off campus.

Free event, no registration is necessary.

A free pizza lunch will be provided for attendees.

Location:

Hart House

7 Hart House Cir

Date and Time:

Wednesday, March 11, 2020

9:30 AM – 4:30 PM

Website:

www.mindfest.ca

Rural Canadians often experience disparities in health care which are unique to their environment, including a shortage of physicians in emergency room (ER) departments, and difficulty accessing specific health care services.

To better meet the health care needs of patients in rural settings, health care providers are establishing networks between urban academic emergency departments and their rural and regional counterparts.

A recent symposium paper, co-authored by researchers such as principal investigator Dr. Aaron Johnston, the Director of Distributed Learning and Rural Initiatives at the University of Calgary, and Dr. Yasmine Mawji, an assistant professor at U of T’s Faculty of Medicine, looked into ways to build and consolidate these relationships.

The co-authors identified some of the logistical benefits of a network between urban academic and rural communities, including more timely access to consultation, the facilitation of transfer of care, and opportunities for training medical students and residents in rural environments.

Strengthening relationships

The study surveyed health practitioners working in rural emergency departments and academic department leaders. A panel of leaders from both rural and urban settings convened over the course of eight months to propose seven recommendations on ways to consolidate and build these relationships.

According to the survey’s respondents, there seems to be a lapse in how urban practitioners understand and perceive the unique challenges of the rural environment. For example, rural physicians often have difficulties accessing specialists for advice by phone.

The study identified the significance of providing training opportunities for physicians, medical students, and residents in rural emergency departments in order to address the gaps in understanding. Both urban and rural physicians expressed interest in opportunities to shadow and work in the others’ environment.

The link between rural hospitals and universities

The relationship between the rural hospitals and universities must therefore be predicated on mutual understanding and learning, according to the co-authors. It is not recommended for universities to disseminate knowledge, which not only patronizes the rural constituency, but also fails to appreciate that the academic and operational approaches are two sides of the same coin.

“At the time of recruitment and admission to medical school, we need to provide opportunities… in the kind of areas we hope that people will work in,” said Johnston to The Varsity.

Training opportunities not only prepare individuals for rural communities through experiential learning, but this active involvement in medical education also stabilizes workforce communities. Communities involved in teaching medical trainees have more stable workforces over time, partly because some of these same trainees will be colleagues in the future.

There are challenges, however, to providing medical students with training opportunities. “We need to address issues of hidden bias or [the] hidden curriculum… that might dissuade people who are interested [in] or predisposed to a rural career from pursuing [it],” said Johnston.

The term ‘hidden curriculum’ refers to an implicit set of values that may impact care. To address this issue, he recommended providing exit surveys to graduate students which examine its impact on their educational and medical experiences.

Examples of the hidden curriculum include the idea that doctors may “never admit to not knowing something,” and the emphasis in many ERs to minimize wait times, which could lead to behaviours that reduce the quality of patient care.

What academic divisions can learn from rural departments

Engagement between rural departments and academic divisions also provides opportunities for mutual learning and teaching, and practitioners in rural settings can also teach other practitioners about the concepts and significance of generalism and clinical courage.

Clinical courage is the concept that practitioners are sometimes pushed to the limits of their training in order to meet the patient’s needs. Because of staff shortages and limited resources in rural environments, this concept is often applicable to everyday practice for rural physicians.

Johnston explained that it “is an idea that means working at the edge… [because] you’re really the only doctors there.” In a larger environment of health care, practitioners do not often consider this situation.

In fact, family physicians in rural communities across the country practice a broader scope of medicine, which even includes providing emergency care because of the shortage of ER physicians.

Rural physicians can also teach other environments and communities about resource stewardship, since these areas often have limited access to the labs and diagnostic testing that urban communities have, yet still manage to provide exceptional care.

On the flip side, physicians, trainees, and medical students can also gain additional skills from academic institutions in areas of palliative care, for example, or the ER, as there is an appreciation for adaptability or being able to meet the needs of the patient population by acquiring and updating an individual’s skills.

Looking outside Ontario

So, what does this mean for Ontario? The study recommended modelling future relationships between academic institutions and rural regions after successful models, like the British Columbia Emergency Medicine Network, which links the province’s emergency physicians and BC-relevant clinical resources initiated in September 2017.

The network encourages peers and colleagues to support one another and share knowledge and information in order to better serve patients. Its rural component is embodied in the network’s Rural Working Group, which provides a rural perspective on the clinical resources that the network offers. Where and when necessary, rural members review and update resources.

But there are challenges to building this kind of network, according to Johnston. Firstly, it takes time to build relationships, so the potential for successful results won’t be immediate or instant. Its infrastructure also requires significant amounts of money, resources, and manpower.

The BC Emergency Medicine Network works because it was intentionally built with specific goals in mind. Leaders travelled to rural communities to get a sense of what the community wanted and what the relationships between the community and the health care profession should look like.

By listening to the constituents, namely the physicians who use the resources, the BC Emergency Medicine Network has been successful, as it is equipped with knowledge of the needs of the health care communities.

Building a similar network elsewhere

To build a similar network elsewhere, Johnston recommends a web-like network rather than a “hub-and-spoke” model, in which the academic institution is in the middle and everything else is connected to it. While it may be more difficult to build a web-like network, Johnston noted it is important because it allows for the interconnection of nodes in different ways.

The Supplemental Emergency Medicine Experience (SEME) is a program that offers three months of clinical immersion in emergency medicine for physicians from rural environments, and was launched to address a staffing shortage of physicians working in ER departments in smaller and rural communities.

By providing family physicians with training, SEME hopes to aid in the acquisition of skills that are necessary for these physicians to practice emergency medicine in their rural communities. The program’s success is attributed to the collaborative network between U of T’s teaching hospital sites, the Rural Ontario Medical Program’s teaching sites, and many faculty members.

The program measures its success in the sustainability of family physicians in rural communities in emergency medicine. According to exit surveys, most respondents have still been providing care in emergency departments in rural communities one to five years after program completion.

“It’s rewarding to have them speak back to us [about] how much they feel the program has improved their confidence to practice emergency medicine and [their] interest to practice emergency medicine. We receive emails in terms of how they’ve been able to use the program in their day-to-day practice,” remarked Mawji, who is also SEME’s program director.

A great challenge for SEME, however, has been attracting physicians from northern Ontario, since it is difficult for some to leave their practice for such a long period of time. With the renewal of the program, Mawji hopes to create a satellite program in Thunder Bay. Hopefully, providing training opportunities closer to home may increase the recruitment of rural physicians into the program.

Physicians like Johnston and Mawji are taking action to improve the health care outcomes of rural communities, and the future seems promising for successive generations and how they can get involved with improving equitable health care for all.

An overlooked issue in medicine is the high rate of depression among people with other medical illnesses, according to a recent paper by U of T-affiliated co-authors including Dr. Joshua Rosenblat, a clinician-scientist at the Department of Psychiatry, and Dr. Paul Kurdyak, the director of Health Systems Research at the Centre for Addiction and Mental Health.

They reviewed articles related to depression among people with other medical illnesses, a condition which is twice as common for them than in otherwise healthy patients. The Varsity spoke with Rosenblat to learn more about the high rates of depression observed in patients with other medical illnesses, and how to best tackle the issue.

Causes of depression in patients with other medical illnesses

Rosenblat suggested three main sources of depression among people with other medical illnesses: biological, psychological, and social. Psychological and social triggers can include sadness driven by unfortunate circumstances, such as a serious medical diagnosis.

When considering biological sources, Rosenblat said, “A lot of things… can happen in your body biologically that can actually have a profound impact on the immune and cognitive systems.”

Inflammation, often caused by infection, autoimmune disorders, and cardiovascular issues, can release inflammatory signals that lead to depression. This is likely an evolutionary adaptation meant to reduce the spread of disease disincentivizing socialization through depressive symptoms.

Additionally, neurological disorders can also make the brain more susceptible to depression. As an example, half of all stroke victims will develop depression.

Impacts of depression on treatment

It is important to note that while illness can cause depression, depression can also give rise to illness. For example, depression often leads to changes in appetite, resulting in malnourishment or complications related to overeating.

Additionally, just as inflammation can trigger depression, so too can depression trigger inflammation, leading to the development of autoimmune disorders among patients. Depression can also cause harmful changes in behaviour, such as alcohol or tobacco use disorders, which may lead to other illnesses such as cancer, and can worsen pre-existing medical conditions.

Depression can have serious impacts on disease recognition. According to Rosenblat, there is an increased risk of a false link between symptoms of neurological disorder or medical illness. For example, a patient with diagnosed anxiety may also have an undiagnosed stomach ulcer, but their stomach problems may be dismissed as a symptom of anxiety.

The opposite is also true: a patient being treated for cancer might struggle with low energy caused by undiagnosed depression, but this may be dismissed as a symptom of cancer.

Diagnosing and treating depression

Depression is often not properly diagnosed among people with other medical illnesses. It is difficult to measure how often depression is under diagnosed, but Rosenblat estimates at least 25 per cent of cases are not diagnosed.

There are a number of reasons for this discrepancy. Primarily, patients and medical providers may feel uncomfortable discussing depression. In addition, there may be problems with the systems used to diagnose depression. Screening tools that are too specific may overlook some patients who have depression, while screening tools that are too sensitive may overwhelm the mental health system with some patients who do not have depression.

An overwhelmed medical system can also mean that patients who have issues more serious than their depression might not have time to discuss depressive symptoms. Rosenblat suggested a number of solutions to these diagnosis problems, including reducing stigma, as well as pairing highly sensitive and highly specific screening tools.

An example of paired screening tools might be a doctor asking, “Do you feel depressed?” and “Do you feel less motivated?” as sensitive tools. If the responses are affirmative, they would follow up with a test that asks about symptoms of depression, which is a specific tool.

Unfortunately, screening improvements do not necessarily lead to improvements in depressive symptoms. Many hospitals do not have adequate resources to treat depression. More investment into the mental health system, as well as better treatment education for medical providers would help.

According to Rosenblat, the current recommended treatment includes starting with less intense interventions, such as community engagement and socialization, and if those do not work, trying antidepressants and psychotherapy.

Next steps for depression research

What’s on the horizon of depression research? A number of more radical treatments, such as psychedelics — Rosenblant’s current focus of research — and the dissociative anesthetic ketamine have shown interesting clinical trial results. More research is generally needed for biological treatments of depression.

Lastly, Rosenblat suggested that future clinical trials should begin with stronger predictions, such as the potential side effects of a drug and the ways in which it will improve depression. This is different from previous methods, which simply gave a drug to patients and considered side effects and biological pathways in hindsight.

Depression is difficult to both discuss and study. Numerous changes, such as reduced stigma, better funding, and additional research need to take place to improve the diagnosis and treatment of depression.

For now, the results of this study demonstrate the importance of considering depression among people with other medical illnesses and how to best go about diagnosing and treating the disease.

If you or someone you know is in distress, you can call:

• Canada Suicide Prevention Service phone available 24/7 at 1-833-456-4566
• Good 2 Talk Student Helpline at 1-866-925-5454
• Ontario Mental Health Helpline at 1-866-531-2600
• Gerstein Centre Crisis Line at 416-929-5200
• U of T Health & Wellness Centre at 416-978-8030.

“We are not fully human,” announced Dr. Shaiya Robinson, a research fellow at SickKids, last Saturday at the Go With Your Gut conference. “In fact, recent estimates place the ratio of bacterial cells and mammalian cells at something like one-to-one, which literally means you are just as much bacteria as you are human.”

Go With Your Gut, a conference hosted by the Laboratory Medicine and Pathobiology Student Union on January 11, explored the impact of gut microbiota on health and disease.

The forum took place in the MacLeod Auditorium and featured talks by U of T researchers including Dr. Dana Philpott, Dr. Alberto Martin, and Dr. Susan Poutanen, who spoke on recent developments in understanding how intestinal microbes contribute to inflammatory bowel disease, colon cancer, obesity, and more.

The impact of gut microbiota on Crohn’s disease

The talk began with insights from Philpott, a professor at the Department of Immunology whose lab uses mouse models to study the interplay between genetics and bacteria in Crohn’s disease.

Philpott explained that the microbiota — the population of microorganisms living in the gut — of healthy individuals differs from that of patients with inflammatory bowel disease, and researchers can model the difference by treating newborn mice with antibiotics.

Her lab has explored whether a “short-term antibiotic regimen in the animal within the neonatal period” could have an impact on the animal’s gut microbiota. “There’s pretty good evidence now, in human studies, that repeated early-life exposure to antibiotics can increase the risk of Crohn’s disease development,” she noted.

Indeed, a recent study from her lab has shown that antibiotic treatment disturbs the intestinal bacteria of genetically susceptible mice, which makes them more vulnerable to inflammation.

The link between diet and gut microbiota

Martin, also a professor at the Department of Immunology, spoke about the interaction of genetic and environmental factors, particularly those of a person’s diet.

“There [are] two particular diets that have been linked to colon cancer, and one is the Western-style diet… and the other is a low-carb low-fibre diet,” he said.

He remarked on their work with a particular strain of E. coli that has been found to cause cancer in genetically susceptible mice, “So we want to ask whether that microbe interacts with these two different diets.”

He concluded that the “E. coli NC101 [strain] interacts specifically with a low-carb diet to enhance [tumour development].”

An audience member posed the question: “After all this research, what do you eat?” to which he answered, “I don’t want to really delve too far into this because [all this work is in] animal models, but I actually strongly think that it is probably applicable to the human condition.”

“A low-fibre diet is probably not very good… but really, this study is just beginning.”

Exploring fecal microbiota transplantation

Pivoting from causes of disease to treatment, Poutanen, a medical microbiologist, infectious diseases physician, and an associate professor at U of T, talked about fecal microbiota transplantation (FMT). FMT is the process of transporting gut bacteria from the stool of healthy donors into patients in order to recolonize their colons with healthy bacteria.

She discussed the positive results of this treatment — FMT is now recommended for treating recurrent C. difficile infection — but also the strange logistics of providing it.

“In terms of our donors, the big question at first is, ‘How do you collect the stool?’” she noted. She explained that they usually prefer to ask their donors to collect their sample in a provided container and place it in the fridge.

“And you may think that’s not very palatable — to put your stool in the fridge beside your food, but we have a very nice pack… [that looks like] an ice cream tub or a margarine tub.”

The promise of probiotics

Robinson closed the conference by discussing another emerging treatment: probiotics. She studies their utility in mouse models for preventing necrotizing enterocolitis, a serious gastrointestinal disorder which threatens the lives of preterm and low-birth-weight babies.

She also gave advice to young researchers, saying: “Always consider why you’re doing your research. Who does your research help, and how will it help them?” She further encouraged them to think “about [not only] how your study will drive the research field forward, but also how it drives society forward.”

Those not interested in performing research themselves can contribute by donating stool to the FMT trials, through projects such as the Microbiota Therapeutics Outcomes Program.

As Poutanen’s recruitment poster said: “Instead of flushing it down the drain, you could help someone in pain!”

Imagine running a marathon. Now, imagine running a marathon while carrying a backpack full of rocks. How much more difficult would it be to run? What if you had to jump over hurdles as well? Would you still be able to make it to the finish line?

Similarly, inequitable health care can make it much more difficult and sometimes impossible for disadvantaged groups to access the care that they need. This is where the Health Equity Impact Assessment (HEIA) tool comes into play. HEIA is a decision-making framework designed to assess the impacts of public health policy on marginalized and vulnerable groups.

In an interview with The Varsity, Dr. Branka Agic, Director of Knowledge Exchange at the Centre for Addiction and Mental Health (CAMH) and author of a recent review of the HEIA, provided an overview of how this tool is designed to reduce health care inequities.

In an article she published, Agic defined health inequity as “systematic, unfair and avoidable differences in health… between population groups deeply rooted in social determinants of health.”

The barriers to mental health care

Income, social status, employment, culture, education, gender, and sexual orientation are all examples of factors that can create barriers to accessing effective mental health care.

For example, in Ontario, members of the LGBTQ+ community experience higher rates of both depression and anxiety. Women in Ontario are also two times more likely to experience depression than men. Additionally, residents of lower-income neighbourhoods in Ontario report increased rates of depression in comparison to higher-income neighbourhoods.

Unfortunately, researchers have documented that despite increasing need for mental health services in disadvantaged groups, the service of care tends to decrease. This is a factor that causes mental health inequity.

How HEIA could lower barriers to health care

Agic described the HEIA as a framework for the development of effective policies to help mitigate or resolve health care challenges facing different communities. A working group composed of several important stakeholders developed the first HEIA with the Ministry of Health in 2011. In 2012, the tool was updated to incorporate feedback from more relevant parties.

As for how the HEIA works, the tool itself is set up to look like a spreadsheet, and plots out five steps for planners to take: identification of populations and causes of health inequity; consideration of unintended potential impacts; mitigation of potential negative impacts; monitoring of mitigation efforts; and dissemination of results.

Next steps for HEIA

While each step is vital for ensuring the successful implementation of the tool, the fifth step — dissemination — is especially important, because it allows developers to continue improving on the tool.

The types of evidence and information inputted into the HEIA are experiential in nature. What this means is that the tool’s impact assessment depends heavily on the experiences of both patient and practitioner, because health care is meant to serve everyone who needs it.

As a result, Agic cited feedback as integral to help the tool become more effective. There are many online platforms to support the community around the HEIA.

Mental health care itself is an ever-evolving conversation, and the HEIA is one evolving tool that could guide it toward a positive direction.

“It’s that time of the year again! BioSA is excited to announce our annual Students vs. Professors Basketball Game taking place on Thursday January 16th, from 6-8pm! Come out and support the student team while enjoying a half-time show with dance performances, giveaways, pizza, drinks, and more!!

The game will be held at the TPASC Courts, and the admission price is 1 canned good that will be donated to a food bank.

If you want to enjoy an evening of food and basketball while watching your fellow students dunk on your professors, mark your calendars because you won’t want to miss this event!”

Dr. Silvia Tenenbaum is a clinical psychologist and postdoctoral fellow at the Waakebiness-Bryce Institute for Indigenous Health, which is a part of U of T’s Dalla Lana School of Public Health.

She discussed her research in psychology, clinical practice, and challenging the gender status quo in an interview with The Varsity.

Intersectional research

Tenenbaum previously completed her PhD at the Ontario Institute for Studies in Education, where she studied applied psychology and human development. The focus of Tenenbaum’s research has been on the intersection of public health and Indigenous reconciliation.

For her doctoral thesis, she researched the experiences of Indigenous Latino border-gender youth with accessing mental health services, which she wrote was the “fastest growing refugee seeking population in Canada,” with a decolonizing approach.

Currently, Tenenbaum runs a private practice in clinical psychology as the chief psychologist.

“My passion,” she wrote, “is to advance a non-traditional approach to psychological treatment and healing, from a global viewpoint.”

Challenging the status quo

Tenenbaum wrote that she has “absolutely” faced challenges based on her identity.

“That is the white elephant in the room at U of T,” she wrote.

“If you speak with an accent, professors prefer to believe that you also probably think with an accent; if you are Queer but not part of the old visible club, you are the Other; if you don’t buy their justifications for using/abusing their privilege, and you claim your Otherness, you are met with a glass ceiling and are unlikely to be offered tenure in the long term, and are likely to encounter hostility in the short term.”

The advice she would give to students navigating sexism in academia is threefold: “To name the problems, to denounce them, and to generate community.”

Tenenbaum wrote that “challenging the status quo comes with a price, which I was willing to pay, and I did.”

She explained that that the “traditional view of an academically successful woman has been that of an upper class, straight, able-bodied, cis[gendered] woman that reflects a masculine model of competition, aggression, and individualistic aim.”

“This is the status quo, and [it] not only fails to represent today’s diverse society, but is not committed politically and ecologically to current pedagogical needs.”

As an example, she pointed to the misperception that women and non-binary people of color are in the minority.

“Minorities are majorities,” she wrote. The perpetuation of this misperception explains how those who are actually minorities silence those who are in the majority. According to Tenenbaum, these mischaracterizations are harmful because they solidify the status quo.

On mentorship and advice for students

Tenenbaum expressed that she has grown with the guidance of two woman mentors, but wrote that it is telling that she has only had two woman mentors in her two decades at U of T.

Her advice for undergraduate students is to “find your niche by searching for academics with similar ethical values.” Her advice for graduate students is to “make sure you still have a life.”

“Academia is not a life,” she wrote. “It is a preparation for achieving credentials, and perhaps a job after.”

Plastic pollution is a known ecological threat, but the scope of its impact is still largely a mystery. Macroplastics are undoubtedly responsible for many ecological effects. However, those of microplastics — pieces of plastic smaller than five millimetres in length — are much more complex.

A recent research review by Kennedy Bucci, Matthew Tulio, and Chelsea Rochman of U of T’s Department of Ecology & Evolutionary Biology analyzed the current literature concerning plastic pollution. Aiming to examine trends in detection of the effects of pollution and the environmental relevancy of lab experiments, they conclude that scientists may be approaching plastic pollution the wrong way.

“We suggest that it is time to ask more contextual questions and use more strategic experiments to begin to tease apart the complex effects of plastics on wildlife and ecosystem processes globally,” the co-authors wrote in the review.

What we know

Macroplastics, especially in marine environments, are the most obvious form of plastic pollution, and are where research on plastic pollution originally started, as Bucci explained in an interview with The Varsity.

As a result of this extended period of research on macroplastic pollution in marine ecosystems, there is subsequently a disproportionately large number of studies focusing on macroplastic pollution in marine ecosystems. Only recently have scientists began to examine the effects of macroplastics in freshwater and terrestrial environments.

In comparison to those of macroplastics, the effects of microplastic are much more subtle. The study of these effects is a relatively new field, which has gained a lot of recent attention due to our increased understanding of their prevalence and possible impacts on ecosystems.

It is difficult to study microplastics in field experiments and determine their effects. Of the lab experiments included in the meta-analysis, approximately half of them could not detect the effect they were testing for, and there is still no consensus on the impacts of microplastics, as the authors noted.

The co-authors recommend that researchers treat microplastics as a group of contaminants with many variations, rather than as a single class. By conducting more strategic investigations, they can gain a better understanding of the individual factors involved and how they contribute to the effects of microplastics.

Another important consideration is the ecological relevance of an experiment and how it relates to the natural world. Problems can arise when experiments fail to do so. For example, many laboratory experiments involving microplastics use concentrations that are not found in the natural world. The co-authors suggest that future researchers increase the number of field experiments and the use mesocosms — enclosed experimental ecosystems — to help predict future effects.

Finally, an overwhelming majority of studies are done in marine environments. With this imbalance in mind, the co-authors encourage researchers to apply what they have learned from marine environments and explore ecological effects in freshwater and terrestrial environments as well.

Impact of findings

Not only does this article present findings that can influence the way that scientists conduct future research on plastic pollution, but it also can serve as an important source for policymakers as well. The co-authors believe that the unbiased and meticulous nature of the article makes it an appealing reference, especially when considering that in recent years, science has been a major influence on the creation of new policies.

In the opinion of Alice (Xia) Zhu, a PhD student at the Rochman Lab involved in research-based policy, “Science should influence policy because we’re the ones who can communicate it the best.”

Zhu recalled that her own research has had an impact on policy. Dealing with plastic pollution in the San Francisco Bay and other urban bays in California, Zhu’s work has been involved with a legislative effort to ban styrofoam statewide.

“Plastic can seem like a big problem,” she said. “But if we all work together, we can make a big difference, especially right here in our community.”