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Dr. Alex Raben: [00:00:10] Welcome to PsychEd, the psychiatry podcast for medical learners by medical Learners. This episode covers medical assistance in dying and mental health or MAID and mental health. We're going to be covering this topic mostly from a Canadian perspective, although we hope our international listeners will gather some important general points that can apply to their jurisdictions as well. I'm Alex Raben. I'm a lecturer at the University of Toronto and a staff psychiatrist at the Centre for Addiction and Mental Health. I'll be the host for today's episode. This episode will be using a slightly different format than our general episodes, because today's episode is not just a podcast, it's also a grand rounds. It's Dr. Urvashi Prasad's Grand Rounds to be specific. For those who are not familiar with what Grand Rounds are, this is a time honoured tradition in medicine, not just in psychiatry, where a physician, a learner and allied health member will deliver a presentation to a live audience in a hospital on a medical topic. However, now, with the pandemic and with technology what it is, we're really happy that the PsychEd podcast is able to act as a platform for grand rounds. We'd also like to thank the University of Toronto for allowing this to be possible and to fulfil Dr. Prasad's Grand Rounds requirements. So let me introduce Dr. Urvashi Prasad, who is a PGY3 at the University of Toronto to the show. Hi, Urvashi. Welcome.
Dr. Urvashi Prasad: [00:01:46] Hi, Alex. Thank you for that introduction. As Alex mentioned, my name is Urvashi Prasad. I'm a third year psychiatry resident here at the University of Toronto. I am very excited to be here today and also super eager to share with you today's topic of discussion, which was one that piqued my interest not too long ago. Some months back, as a member of the American Psychiatric Association, Ontario branch, I remember sitting in on a brief discussion on Maid and Mental Health, which was led by Dr. Sonu Gaind. At the time, it was the first time I became formally aware of this topic. Fast forward a couple months from there, I was introduced to a patient during my SPMI block or Severe Persistent Mental Illness who had been requesting for made for primarily their psychiatric disorder. My appointments with her always left me with several questions on this topic, some practical as to what would be the eligibility criteria for MAiD for mental health. Is it legal to some of the more challenging questions around some of the ethical dilemmas around this topic? And so putting all of that together, this has brought me to here today where I decided to do my grand rounds topic on this on on made for mental health with the hopes of both educating myself and also perhaps educating others within the field. So to our listeners, whatever your reason might be for tuning in to our podcast today. Thanks for being here and we hope that we can make your time here with us worthwhile.
Dr. Alex Raben: [00:03:36] Well, thank you Urvashi for being here and for leading this episode today. We're really excited to learn more. You mentioned Dr. Sonu Gaind and he is actually our topic expert today who will be joining you in educating us on this important subject. And I'd like to just briefly introduce him as well. So Dr. Gaind is a professor at the University of Toronto, as well as the chief of psychiatry at Humber River Hospital and works clinically as a psycho-oncology consultant. He's been a past president of the Ontario Psychiatric Association, the Canadian Psychiatric Association and PARO. His experience in this topic is quite big. And I won't be able to, I think, list all of these things he's been involved with. And he can certainly add to this, but I'll mention just a few. He has testified, for instance, at the Federal External Panel on the options for a legislative response to legislation around this issue. He's also chaired the Time Limited Canadian Psychiatric Association Task Force on MAiD, and he has given talks both within Canada and internationally on the subject, as well as written papers on the subject. So, Dr. Gaind, we want to welcome you to the show as well. Thanks for joining us.
Dr. Sonu Gaind: [00:05:06] My pleasure to be here, and thank you for inviting me.
Dr. Alex Raben: [00:05:09] And then last but not least, we are also joined by David Eapen-John, who is a third year medical student at the University of Toronto who is eager to learn more and want to be part of the show as well in order to give the medical student perspective. So thank you, David, for being with us as well.
David Eapen-John: [00:05:30] Thank you so much, Dr. Raben. Very excited to be here.
Dr. Alex Raben: [00:05:34] Great. So I will briefly go through our learning objectives for this episode and then I will hand it over to Urvashi to take us through a background on the topic and to go through the topic with our expert guest. So by the end of this episode, you, the listener, should be able to, number one, briefly summarise the history of MAID in Canada. Number two, define the present policies of medical assistance in dying and mental health in this country and how that might apply in your jurisdiction. Number three, evaluate the arguments in support of and against the implementation of MAID in the mental health context. And number four, discuss the possible impacts of MAID both on the profession of psychiatry and on our patients. So without further ado, Urvashi, please take it away.
Dr. Urvashi Prasad: [00:06:36] Awesome. Thanks, Alex. Before we jump into the topic at hand and hearing from our expert guest speaker today, I'd like to take a few minutes to provide our listeners with some definitions and a bit of background on the history of MAID in Canada. This will hopefully help orient ourselves and help put things into a bit of context as we later focus our discussion on Maid and mental health specifically. So let's get started and maybe we can begin by some definitions. David, do you want to take this one on?
David Eapen-John: [00:07:11] Thanks so much, Dr. Prasad. So first to according to the government of Canada MAID itself describes the administering by a physician or nurse practitioner of a substance to a person at their request that causes their death or describes the prescribing or providing by a physician or nurse practitioner of a substance to a person at their request, so that they may self administer the substance and in doing so cause their own death.
Dr. Urvashi Prasad: [00:07:43] With that definition in mind, let's dive a little into the history of MAID in Canada, and this will hopefully also cover our first learning objective for today. So assisted suicide was illegal in Canada from 1892 to 2016 under section 241 B of the Criminal Code. During this time, anyone found guilty of counselling someone to take their own life or aiding someone to take their own life was guilty of culpable homicide and subject to imprisonment of up to 14 years. However, starting in the early 1900s, there were a series of court cases and legal proceedings which challenged the prohibition of assisted suicide as contrary to the Canadian Charter of Rights and Freedoms. Particularly, these cases argued that the law against assisted suicide violated Section seven and 15 of the Canadian Charter of Rights and Freedoms, which guarantees the right to life, liberty and security of person and equality. Some of you may be familiar with a few of these landmark cases, which include the Sue Rodrigues case in 1993, which was a case about a woman with ALS or amyotrophic lateral sclerosis requesting for physician assisted suicide. The Robert Latimer case in 1994, which was a case about a father ending the life of his severely disabled daughter. And the Carter versus Canada case in 2014, where Lee Carter assisted her 89 year old mother with degenerative spinal stenosis to assist her in planning her death in Switzerland.
Dr. Urvashi Prasad: [00:09:19] Subsequently, in the year 2015, after decades of legal battles, the Supreme Court of Canada ruled unanimously to allow physician assisted suicide, which became legal in June 2016. According to the second Annual Report on Medical Assistance and Dying in Canada, published in the year 2020, the total number of medically assisted deaths reported in Canada since the enactment of federal legislation in mid 2016 to late 2020 was about 21,589 individuals. The average age at time of MAID being provided in 2020 was 75 years and cancer was the most commonly cited underlying medical condition, making up about 69.1% of the individuals who received MAID, followed by cardiovascular conditions, chronic respiratory conditions and neurological conditions. And these were similar trends that they saw in 2019 as well. So of course, all of that was in regards to Maid so far in Canada and some statistics to help sort of orient ourselves before we jump into MAID, specifically focusing on MAID for mental illness. Before we focus in on some of the questions with our expert guest speaker, what might be helpful is perhaps as a segue into our discussion is to introduce the patient case. And this is loosely based on the patient that I had alluded to a little bit earlier in my introduction as a means of perhaps anchoring some of our discussions around a topic around this topic.
Dr. Urvashi Prasad: [00:11:13] I should also mention importantly that all of this information here has been de-identified to ensure that we can preserve patient confidentiality. So let's talk about Anna. Anna is a 50 year old single female who lives in a supportive housing and is financially supported on government disability supports. She has around a ten year history of schizophrenia, during most of which unfortunately she had been untreated and I was previously a high functioning individual with a husband and two children. She had her her own house and a stable job after completing four years of an undergraduate degree since the onset of her illness, likely about ten years ago now, she gradually lost her family, her employment, her housing, and was only brought to medical attention when bystanders called 911 after seeing a homeless woman engaging in bizarre behaviour at the time. Anna spent three months in hospital on a psychiatric unit where she was started on Paliperidone, an antipsychotic medication, which is which she has shown fortunately some response to. She no longer hears voices, is able to organise her thoughts and is much less paranoid of others. Since discharged from hospital, she's able to maintain her supportive housing and has never failed to miss an outpatient psychiatric appointment.
Dr. Urvashi Prasad: [00:12:38] However, Anna still struggles with persistent delusions about being controlled by aliens, such that these aliens seem to dictate what food she eats. She also presents with prominent negative symptoms of schizophrenia, of being asocial, demonstrating a poverty of speech and a lack of motivation to do most things. She spends most of her time sleeping, waking intermittently for lunch and dinner, going on short walks and watching television. She has no interest in reconnecting with her family and has no desire to seek employment. From her perspective, Anna feels no change in medications would allow her to go back to her previous level of functioning prior to the onset of her illness. She does not feel that she is capable of leading a fulfilling life with her current illness and feels that the only answer to end her suffering is through Medical Assistance and Dying on the grounds of a mental illness. All right. Thank you all for patiently hearing me speak. I know it's a lot of talking on my end, but we are very excited and eager to hear Dr. Gaind's input on this discussion as well. So now that we've established the background of MAID as a whole in Canada, we can shift our focus on the topic of mental health. Maybe David can take this one on.
David Eapen-John: [00:14:04] For sure. So why don't we start with the probably the most important question in the forefront of our listeners minds: Is MAID for individuals with primarily mental illness legal in Canada right now?
Dr. Sonu Gaind: [00:14:19] So it's actually surprisingly complex answer because you would expect an answer to that question would either be a straightforward yes or no. But the history has been a bit more convoluted than that. Back in 2016, when MAID originally came about in Canada, there was no prohibition against MAID for sole mental illness conditions. However, there was a requirement. One of the safeguards that was in place in 2016 original legislation was that natural death needed to be reasonably foreseeable. And what that meant, for all intents and purposes, was that in the vast majority of cases, sole mental illness conditions wouldn't qualify because sole mental illness rarely, if ever, leads to natural death being reasonably foreseeable. And suicide was not considered a natural death that was reasonably foreseeable. Now, what's happened recently in 2021 with the new legislative changes is that initial safeguard of natural death being reasonably foreseeable is no longer there. That was removed. And in lieu of that, the government has put in what now is a temporary prohibition against made for sole mental illness, but they've attached a so called sunset clause to that, which means that within two years of that legislation being enacted, which was March 2021, that by March 2023 MAID for sole mental illness conditions is supposed to be permitted in Canada. So a somewhat convoluted answer to a fairly simple question.
Dr. Urvashi Prasad: [00:16:12] Thank you for that, Dr. Gaind. So to sort of put that into context with Anna, the patient that we talked about, it seems like at the moment made for mental health is currently not available for individuals with so mental illness. So she would not at present be eligible to apply. But it sounds like by March of 2023, as you mentioned, that starting from that time, there may be eligible for applying for MAID in individuals with primarily mental illness. Would that be correct?
Dr. Sonu Gaind: [00:17:05] That's correct. And part of what makes the area quite murky is that there are multiple eligibility criteria or safeguards that are in place, and you need to fulfil all of them in order to qualify for MAID in Canada. And so the question becomes that even once made for mental illness and I should clarify, by the way, that it does not mean that if you have a mental illness, you cannot apply for MAID, you can apply for MAID if you have a mental illness. However, some other condition needs to be the condition that's leading to reasonably foreseeable death or that is the basis of your application for it. So you're not precluded just by virtue of having a mental illness from getting MAID. Now, in 2023, what will change is that, as I mentioned, that sunset clause kicks in and so that temporary prohibition is removed. I should point out that when the original legislation that was passed in March 2021, Bill C-7, when that was drafted the previous year in 2020, the government had actually put in an exclusion of made for mental illness without a sunset clause. And so for that entire year from the draft legislation 2020 March to 2021 March or actually was February, the government had maintained that MAID for sole mental illness conditions would not actually be permitted pending further work and study. And then in a relatively short time, all of that changed in March where they put in this sunset clause to allow MAID for mental illness by March 2023. The question then shifts to are the other criteria able to be met for some mental illness conditions. And I'm sure that the discussion will lead into some of this. But the overarching criteria for any applicability for MAID is that somebody suffers from a grievous and irremediable medical condition. And then there are various ways that that's outlined in the legislation.
Dr. Urvashi Prasad: [00:19:31] Yeah. Thanks for bringing that up, Doctor Gaind, we'll certainly dive a little bit deeper into the criteria in just a little bit, hearing you share some of your thoughts around that has also got me thinking about one other one other aspect of this, which is upon the some of the history that we that we heard around how MAID in Canada was established at the time in 2016, it seemed to have been driven by real people stories that resulted in landmark Supreme Court cases when it comes to MAID for primarily mental illness. Has there been any such movement from patient experiences in terms of legal proceedings?
Dr. Sonu Gaind: [00:20:24] So for sole mental illness conditions, actually, this reflects one of the challenges we're facing that the legislation that's been drafted in response to court cases has all been drafted in response to court cases involving various degenerative or neurodegenerative medical conditions that are eminently predictable. And what has happened is that the policies have expanded to all sorts of other conditions, including now with the sunset clause, eventually mental illness conditions that were not examined by the courts. And that raises certain problems and questions, of course. There was one case back in 2016 prior to the original legislation being implemented, and this was at a time after the Carter ruling. The Carter ruling took place in 2015, and the country was given one year to come up with legislation to allow MAID in some circumstances. And during that time, prior to legislation being enacted in 2016, there were individual kind of applications to the courts that were allowed to be made. So there was one known case of a patient called EF in Alberta who did receive MAID at that time for sole mental illness conditions or a mental illness condition, I should say. And what that involved was a woman who was she was in her mid-fifties with conversion disorder and she suffered from intractable spasms, impaired mobility. And her family actually supported her application for MAID and she did receive MAID. Now, that case raised some concerns because it showed the potential problems or challenges when we don't have standards for what we're doing. In that case, the psychiatrist who opined on the case and on capacity based their entire assessment on chart review. They never saw the patient nor spoke with the patient. And they actually testified not just that they felt that the situation was irremediable, but also that the patient had capacity for the made request despite never speaking with the patient. And so it did raise eyebrows and concerns in some quarters about kind of the need for standards and what may happen when those don't exist.
Dr. Urvashi Prasad: [00:23:05] Wow. Yes, that sounds very controversial and potentially highly problematic. And also gets me wondering whether from now until March 2023, when MAID might be available for individuals with sole primary mental illness. What can we expect in terms of some of the the legislative changes and such from now until then?
Dr. Sonu Gaind: [00:23:34] So at this point, what's happened from the last legislative changes in March 2021 is that two pathways are now there in you could consider in a way in parallel for made one remains the pathway if death from some other medical condition is reasonably foreseeable. And in that pathway there's no longer a waiting period to receive MAID. There used to be a ten day waiting period that was required prior to getting MAID. But if death is deemed to be reasonably foreseeable under the current legislative changes, that waiting period is no longer there. But if death is not reasonably foreseeable. And so this was the big change in in March 2021 that Bill C-7 expanded MAID to eligibility for people who were not dying. And so if you have any disability. Other than a sole mental illness. But if you have any disability and you're not dying and you apply for MAID, you may qualify for it. If it can be shown that your illness is or you're suffering and condition is irremediable and you meet the other criteria and then you have a 90 day, three month waiting period. So looking forward to when to March 2023 once MAID for sole mental illness is supposed to be permitted. We don't know what the full legislative framework will be, but presumably there will be some pathway that has differences from some of the other pathways in terms of potentially waiting periods and other things like that. At this time, there is an expert panel that is deliberating on how to implement the processes for made for mental illness by 2023. I should point out that it's been made very clear that the expert panel is not deliberating about whether to provide MAID for mental illness or whether it is safe to or whether you can determine irremediably. They've been charged with essentially providing an instruction manual for how MAID for mental illness will be provided by 2023.
Dr. Urvashi Prasad: [00:25:42] Okay. Thank you for for clarifying some of that. I'm also wondering, at the time of legislation of Made in Canada in 2016, there were a few other countries at the time being Switzerland, the Netherlands, Belgium, Luxembourg and some US states, including Vermont, Oregon and Washington, which had already legalised assisted suicide in certain circumstances prior to Canada. When it comes to MAID for primarily mental illness reasons. Do we know if there are other countries that we could perhaps look to that may have already legalised assisted suicide and mental illness?
Dr. Sonu Gaind: [00:26:22] Yes, there are some of the European countries. So the jurisdictions that you mentioned in the states, they had and still have laws allowing assisted dying, but not for mental illness. So the ones in North America till now have all required in some way that death is either reasonably foreseeable as it had been previously in Canada or there's some element of terminality, etc. They don't allow MAID for sole mental illness conditions. The only jurisdictions that do allow that are in Europe and the Benelux countries. So the data we have is mostly from Belgium or Netherlands. We don't really have a lot of good data about the Swiss experience with this. And what we find from the data in Europe does, again, in many of us raised concerns because what it shows is that it's a different population that applies for MAID when it is sought for mental illness reasons. The data in North America till now when death needed to either be reasonably foreseeable or it was for some terminal condition, what that actually showed is that the people who would receive made here in North America under those circumstances tended to be better off. It was more affluent people who are better educated, higher socioeconomic status. And they actually had essentially, you could consider it, they had greater opportunity to live lives of autonomy. And the reason they're seeking MAID in those circumstances was to die with autonomy as well. And the dying with dignity, peace. In the European countries that allow MAID for mental illness, you actually lose that association. What you find is that when people apply for MAID outside of those conditions and for mental illness, they do have unresolved psychosocial suffering. They are not from the better off socioeconomic classes.
Dr. Sonu Gaind: [00:28:30] In fact, they have unresolved, as I was saying, psychosocial suffering and loneliness. One of the early works that showed the kind of all of the consecutive MAID requests in the Netherlands over a period of about two or three, I think it was about three years. What it also found and looked at all of the MAID requests in the Netherlands for mental illness and it found a 2 to 1 disproportionate gender gap or ratio of 70% women versus 30% men getting MAID for mental illness. And that contrasts to a 50-50 equal balance of MAID when it's for terminal conditions in North America. So that raises some concerns as well, because even in terms of demographics that then, as you know, parallels the 2 to 1 ratio of suicide attempts that we find women to men have. In terms of mental illness driven suicide attempts. And what it also found that data that the most common condition, as you would expect that people sought made for mental illness for Netherlands was depression. And that's paralleled in Belgium as well. And you also had some conditions, including psychosis, PTSD, somatoform disorders, but also prolonged grief and autism. It found that in over 10%, I think it was 11 or 12% of cases, there was no independent psychiatric input despite these being primary conditions of mental illness leading to MAID requests. And then fully one quarter in one quarter of the situations that people got MAID for mental illness, there was disagreement amongst consultants about whether the person should get it. But eventually some or sufficient consultants felt that the person should that they did end up receiving MAID. And all of these are differences from the other patient populations that we see seeking made.
Dr. Urvashi Prasad: [00:30:34] And just to clarify, Dr. Gaind, you mentioned that in these individuals with primarily psychiatric disorders, such as depression, that there was no psychiatric input. Just to clarify that for ourselves and our listeners, do you mean that there weren't any psychiatrists or mental health professionals that were involved in the MAID assessments and in the proceedings?
Dr. Sonu Gaind: [00:30:58] Yes. And about 11% of them, there wasn't any psychiatric input. The other point, bearing making here is that when you look at the demographics, they're not just of who gets made, but who does the made assessments. That also changes when MAID for mental illnesses provided versus other conditions. So in Netherlands, they have what are called end of life clinics, where people can go and get MAID assessment and get MAID provision. And those are clinics where the person hasn't received their ongoing medical or psychiatric care. And what we find is that at least 75% or more of the psychiatric MAID applications go through those clinics. So more than the vast majority, more than three quarters go through those clinics. And that contrasts to less than one in ten of the general medical assessments going through those clinics. So even the and what that seems to reflect is that in many of those cases, the mental health providers who had been involved in the person's care did not want to participate in the assessments or didn't agree with.
Dr. Urvashi Prasad: [00:32:12] Okay. That is certainly an interesting point. I'm also wondering, do these countries have specific regulations around MAID for primarily mental illness that perhaps would be helpful for our discussion?
Dr. Sonu Gaind: [00:32:25] It's a very good question. Whatever we're doing, we want to do as safely as we can and with as much evidence and evidence bases as we can. And what they tend to have and I'm actually going to rewind for a second to point out some of the differences from their regulations and Canada's because I think that people often don't realise that, in fact, with the Canadian law as it is and where it's heading, it's actually much more expansive than what the Benelux countries allow. People often think that because the Benelux countries were providing MAID earlier and because they allow it for mental illness, that other countries that follow will have more restrictive policies. In fact, Canada will have a much more open policy because in both Belgium and Netherlands, actually anywhere else in the world, that MAID is allowed. There is also a requirement that essentially means there is an assessment from the medical team that all reasonable options at treatment have been tried and exhausted and that there is no reasonable prospect of improvement. Canada is the only jurisdiction in the world that does not have that requirement. And the reason for that is that one of the pieces in legislation says that any treatment that may relieve suffering must be acceptable to the patient. And it's interesting because, of course, we don't want to be forcing treatments on people. People have autonomy and the right to make decisions when they have capacity. But what that does in the context of MAID legislation is it says that even if you haven't had treatments, you may qualify from it.
Dr. Sonu Gaind: [00:34:13] Now, think about what that means for someone with depression who has internalised a sense of hopelessness as part of the symptoms of depression. And I'm sure we've all had patients like this. I have one lady who, despite having been on low to moderate doses of citalopram, that each time she gets depressed actually help her relatively quickly. Every time she gets depressed, she is convinced nothing will ever help her and she doesn't want any help. And so the Canadian legislation, when you're asking about do those other jurisdictions have some frameworks that might help us, they do have some frameworks that might help us, but we don't have those in our legislation. Our legislation explicitly allows for people to get MAID despite not having received treatment. And when you have only one in three Canadians who need treatment for mental health having access to it, you can see that becomes an additional problem. And the one other piece that I think will hopefully have a chance to talk about is in terms of the safeguards and criterion, what it means to provide MAID for what purpose, meaning that if it's being provided for an irremediable medical condition, we need to be able to predict that a condition is irremediable. If it's being provided for other reasons, because we think someone has enough suffering in their lives, then that's a different criteria. But in Canada, it's supposed to be for irremediable medical conditions. And the whole question of whether you can actually predict that in mental illness, hopefully we have a chance to discuss.
Dr. Urvashi Prasad: [00:35:53] Why don't we take a look at the current eligibility criteria for MAID in Canada? I know we've been alluding to this for quite some time now, so let's take a moment here and we will go through the eligibility criteria. And then perhaps after we go through that, we can take a look at each one and discuss how this might if and if it might have to change and how that might look like when discussing the eligibility criteria for MAID in mental illness. So the current eligibility criteria for MAID, as defined in the Medical Assistance and Dying Act at present includes that an individual must be one eligible for publicly funded health care services in Canada to be 18 years of age or older. Three Be capable of making health care decisions. Four have a grievous and irremediable medical condition, which means A, the patient has a serious and incurable illness, disease or disability. And B, the patient is in an advanced state of irreversible decline and capabilities. And C, the patient is enduring physical or psychological suffering caused by the medical condition or the state of decline that is intolerable to the person and cannot be relieved under conditions that they consider acceptable.
Dr. Urvashi Prasad: [00:37:33] Five, Be making a voluntary request. Six, Provide informed consent to medical assistance in dying, which means one of two things; 1. For a person or a patient whose natural death is reasonably foreseeable, the patient provides consent after having been informed of the means that are available to relieve their suffering, including palliative care. And for a patient who's not or for a patient whose natural death is not reasonably foreseeable. The patient provides consent after having been informed of other means available to them, including counselling, mental health supports, disability supports, community services and palliative care. And after having been offered consultation with relevant professionals as available and applicable, and after having discussed these means with the medical or nurse practitioner and given serious consideration to these means. So maybe what we can do now is take a look at this criteria and perhaps discuss if and how some of these criteria might change or that we speculate might need to be changed or modified in order to fit the framework for MAID for individuals with primary mental illness.
Dr. Sonu Gaind: [00:39:03] So thank you for that background and a comprehensive overview of what the current criteria are and in terms of how those may be modified. There are many different criteria there. I actually tend to consider many of those as safeguards in terms of we call them criteria. But the purpose of them also is to ensure that when people apply for made, they get it for the reasons that society thinks makes sense essentially and whatever normative and evidence based judgements we're making on that, that's the ostensible reason for the criteria. So I'm not going to comment on all of them because many of them I think are translatable. We my background is in psych-oncology and CL psychiatry and in any field in psychiatry and especially in CL, we make challenging decisions all the time, having to do with capacity, having to do with people wanting or not wanting treatment. And keep in mind that the vast majority of time our patients with mental illness has retained capacity. So it's not that they're formally incapable. They pass the criteria of capacity. But what I will do is point out a couple of challenges that that poses. And I'll end with the biggest one. But one is in terms of capacity. The vast majority of our patients can, should and do pass the capacity test when it comes to decisions about living and dying. Think about what or how mental illness can affect the person's wish to live while they still retain capacity. So the point I'm making is that capacity as a safeguard alone is a challenging one because you don't want people to not to be deemed incapable when they're capable. But we also do know that, again, for depression, the typical cognitive triad of what we get when we get clinical depression affects our view of the world, ourselves and the future in a way where we still retain capacity, but it might well influence our decision making nonetheless. And so that's one of the challenges. And how you sort that out in legal terms is really difficult because you're not going to say someone lacks capacity, but we need to be aware of those impacts. Another area is in terms and we tend not to weigh in to the motivation. Funds that people have for decisions because that's their autonomy about why they're making decisions. But when we're talking about life and death, the issue of suicidality also needs to be considered. And unlike any other medical conditions, suicidality is a symptom of some mental illnesses. It's not a diagnostic. We can have suicidality in the context of many things in life, but it's not a potential diagnostic criteria of any other medical conditions other than psychiatric ones. And so how we tease that apart also is challenging. And I don't have an answer for you for how we actually do that with criteria. And in fact, when you look at the data, you find that when people apply for MAID for medical conditions, you can see a difference between the populations that are traditionally suicidal versus those seeking made for other medical conditions. But when people are applying for a mate for mental illness, you see overlapping characteristics between the populations and shared characteristics of people with traditional suicidality for mental illness, including ambivalence, including despair about the future and other things. So those are two challenges that it's unclear to me how existing criteria would potentially address, but we'd be need to be mindful of those. But the biggest one that I said I would kind of lead to is the fundamental what I call the foot in the door safeguard, which is the need to have a grievous and irremediable medical condition. There's no doubt that mental illnesses can be grievous. They cause terrible suffering in people, and that suffering can be as bad or worse as any other suffering or medical condition. But the question of whether we can predict irremediably in mental illnesses is different. And there I would say that the evidence shows or suggests that we cannot. And people often, I think, mistakenly think that. Well. Does that mean that things that when someone has mental illness, it can never be irremediable? Remember that for assessments. That's not the question. The question is, can we predict that in this person the situation is irremediable.
Dr. Sonu Gaind: [00:43:51] And all the groups that have looked at this have concluded that you cannot make that prediction. And I'm just going to read the quote from Camh specifically on this point. And this is in their consultation advice, policy advice on MAID. And they conclude CAMH concludes that at any point in time it may appear that an individual is not responding to any interventions, that their illness is currently irremediable, but it is not possible to determine with any certainty the course of this individual's illness. There is simply not enough evidence available in the mental health field at this time for clinicians to ascertain whether a particular individual has an irremediable mental illness. And to me, this leads to the crux of the dilemma we're currently in. And I should preface my comments by saying I'm not a conscientious objector to MAID. You know, I'm not sure if I'd mentioned previously, but I actually am physician chair of our hospital MAID team. I certainly wouldn't do that if I was a conscientious objector to MAID and I see the value MAID can provide in certain circumstances. It's also sensitised me to the potential dangers if we proceed on safely. And the fundamental lack of ability to predict irremediable and mental illness, to me, that shows that the very first safeguard cannot be met. And so now we're in a dilemma where legislation is saying you have to allow it by March 2023.
Dr. Sonu Gaind: [00:45:26] All the science and evidence is saying we can't make predictions if irremediability. So it raises the question that if people end up getting MAID for mental illness but we can't predict irremediability; what are they actually getting it for? And so it does challenge our fundamental notion of what MAID might be provided for. And this is not to make a normative judgement even of whether it should or should not be provided. But I personally do think it is dangerous to provide MAID or death for one reason, when in fact we can't say that's the reason we're providing it for. And then it opens the door to all of the other reasons that people may be seeking death. And in fact, we've seen this. There are as we speak, there are people in Canada who have actually said with the MAID expansion that they will seek made when they run out of money. In other words, the worst case scenario that well, now what I want MAID when I have some other psychosocial suffering that society doesn't help me relieve. But if I can currently also have a mental illness, that might be my quote unquote foot in the door to apply. But if people can't even determine, my mental illness is truly irremediable, but I get MAID, what have I gotten MAID for? So a lot of things to consider and ponder.
Dr. Urvashi Prasad: [00:46:44] Certainly a lot there for us to consider and ponder. And I think it raises a whole bunch of questions in regards to the practicality of what the criteria, what and if the criteria may need to change, but also a whole slew of ethical and moral questions that also arise from that in terms of whether MAID would disproportionately affect a certain subset of our population versus others. Moving on to address our third objective for today is a discussion around some of the support for and against MAID for primarily mental illness. Perhaps prior to jumping into this, I believe there was a recent survey from conducted by the Ontario Medical Association. And Dr. Gaind, feel free to correct me if I'm wrong, which gathered the opinion of psychiatrists across Ontario on the topic of MAID. I'm aware that you were involved in this project and I'm hoping you could share with us some of the key results from the survey to help us get a sense of the opinion of our profession on this very highly controversial topic.
Dr. Sonu Gaind: [00:48:01] Thank you. And you're correct. It was conducted by the Ontario Medical Association section on psychiatry. So it was done just for or administered to psychiatrists in the province, and it was developed by the OMA section on psychiatry. I sit on the OMA section as an executive member, but it was developed by the entire executive, not just by one or two individuals. It was vetted by all of us. What the survey found, this was done in the fall of last year and the goal of the survey was both to ask questions, to solicit opinions of Ontario psychiatrists, but also to provide context of the expansion to mental illness, peace, and to get those specific questions of things that currently aren't in place but are predicted to be. And there were about 300 or so I think there were about 270 validated responses. So the OMA staff has a process of ensuring responses are validated, etc. and that's about how many ended up being validated. And what we found is that the overwhelming majority of psychiatrists support made about 86%. So actually let me give you the actual number. 86% said that they supported MAID in some medical situations, 11% did not support it and 3% preferred not to say. So that showed that the vast majority support MAID and are not conscientious objectors. When the question was shifted to "Do you believe MAID should be permitted for sole mental illness conditions", then it changed and there 56% did not support MAID for sole mental illness and 28% did.
Dr. Sonu Gaind: [00:49:46] When you looked at the end of range, strongest responses, in other words, comparing the people who strongly support to those who strongly don't support, then it was an even greater margin of 3 to 1, strongly disagreeing with MAID for sole mental illness to those who strongly agreed for it. And so that was the overall result. And we did have other nuanced questions that asked about things related to irremediability, whether stances should be based on evidence which most psychiatrists did agree with, did ask question on mature minors and advanced directives. I can go into any of those if you want more details, but the one that I do want to focus on, because this again points out a difference in Canadian law. Familiar to anyone, anywhere else in the world is whether psychiatrists thought a patient should be eligible for MAID for mental illness if standard best practice treatments have not been tried. Because again, as I mentioned, in Benelux countries and everywhere else, standard best practice treatment is a fundamental safeguard before applying for MAID, not in Canada. And here, as you'd probably expect, the overwhelming majority of psychiatrists thought that if standard best practice treatments have not been tried, then MAID should not be offered. And it was about over 90% felt that with.
Dr. Urvashi Prasad: [00:51:16] So if I were to apply that to or in other words, perhaps it sounds like the overwhelming majority of psychiatrists greater than 90%, as you point out, would likely not be in favour of MAID for mental illness as the legislation is currently laid out at present. Would that be a reasonable understanding of the statistics?
Dr. Sonu Gaind: [00:51:49] You know, I think it's a reasonable kind of conclusion from that, but with a caveat, because we don't know what additional potential safeguards might be coming into play. And so right now, based on the absence of that safeguard, I think that's a reasonable understanding because if it was simply MAID is allowed for mental illness, even if you haven't had standard, best practice standard, best practice treatment attempts or access. Right. It goes both ways then, yes, 90% of psychiatrists would think MAID should not be allowed in those circumstances.
Dr. Urvashi Prasad: [00:52:35] Okay. I'm also wondering what might we foresee as a field some of the challenges in supporting MAID for mental illness.
Dr. Sonu Gaind: [00:52:48] You know, it's something where there are different approaches to suicide prevention. But one of the commonalities is that in many of the approaches, we have tried to keep patients alive and think about our certification laws so somebody comes in to emerge. And if they're suffering from a mental illness and they say that they want to end their lives, in many cases they may end up being certified and hospitalised with MAID for mental illness on the horizon. How all of that plays out is unclear because then you may have somebody who comes in who is saying that and they end up being certified and they're beside someone in a stretcher who is saying something slightly different, who ends up then going down a MAID pathway. And so it does raise questions about what our role is, what will be our response to how we carry out other parts of our mandate as well. Is legislation aligned in a way that actually makes sense across the spectrum, not just MAID, but all of the other legislation do?
Dr. Urvashi Prasad: [00:53:57] And certainly, Dr. Gaind, you point a very vivid picture in my mind in terms of what as a resident where we frequently do work overnight on call, interfaced with some of these decisions around suicidality being in a scenario in the near future, perhaps of varying a suicide assessment based on whether a patient may be eligible for MAID or not does certainly seem to pose its challenges. I'm also wondering, for the sake of and for the sake of rounding out our conversation and also I think perhaps this might be important for us to touch up upon, is that what might be some of the reasons for supporting MAID for mental illness?
Dr. Sonu Gaind: [00:54:48] So, you know, I think that is not just an excellent question. I think that is the fundamental underlying issue we need to think about in terms of both how have we gotten to where we are and where do we think we should be going? Again, I'll present some that I think have led us to here and also provide some counterpoints, because I think some of them are based in a little bit of a myth, actually. But one of the fundamental ones in terms of mental illness is, look, we are the people who have advocated for those with mental illness. People with mental illness have been discriminated and stigmatised for decades, centuries. And so how can we now say that mental illness is treated, quote unquote, differently? So one of the fundamental arguments has been that it would be discrimination to treat mental illness differently. Now, my view on that is that mental illnesses are absolutely valid, as valid as any other illnesses, but it does not mean they're the same as everything else. No two illnesses are exactly the same. If they were, they'd be the same illness. And that applies whether it's mental illness or medical illnesses. And we just need to look at things like the issues of suicidality or how decision making is potentially affected, even while capacity is retained, to give some hints at that. And so I think we have to move away personally from the idea that, well, everything has to be treated the same or it's discrimination. We need to treat things for what they are. Equity is not the principle of everything being the same, but being treated properly for what it is.
Dr. Sonu Gaind: [00:56:35] The other is that it's autonomy, right? That it's an issue of autonomy. And the push for expansion has largely been about that. And there are some valid points to that, that what you do see is that in many of the situations where people seek MAID and these are probably the ones that you and I can picture. If I picture ahead about various life circumstances that might unfold, I want to have some autonomy over my life and death decisions. And so that's a valid point. However, we have to keep in mind that things need to be reasonable public policies, not just for me or for you, but for everyone that they're going to apply to. And so the autonomy, I actually think it's the autonomy myth that's largely fuelled this because people can easily see that argument that, well, I want autonomy to have a dignified death. But when we see the differences that data and evidence point out to how these issues play out differently for different populations, especially for marginalised populations and ones that suffer from mental illness that tend to be marginalised. So again, I'll take a segway here to the Aboriginal suicide rates. Nobody would say that Aboriginal suicide rates and it's not just Canada. First nations everywhere suffer this. Nobody would say that those suicide rates are because they just have a higher predisposition to mental illness. It's not that it's a social disenfranchisement that literally leads to that, and it may at times combine with mental illness. So the point I'm making there is that the drivers that lead people to wish to end their lives differ for different populations.
Dr. Sonu Gaind: [00:58:23] And so the autonomy myth that's fuelled the wide expansion suggests that MAID is safe. And what I would say is that MAID actually may be safe for many people. It's a little ironic to use the word safe in me, but I think you know what I mean, that it could be provided in an appropriate way that society thinks is being done for the right reasons. However, the broader we expand the criteria and eligibility, the more and more people potentially fall under it. And we're now at a point of expanding it so far that it's not just the people who've lived a life of dignity, who want to lie, who want to die with dignity. It's people who've never had a chance to live a life with dignity, who seek an escape from life suffering. And so there is a group that may get more autonomy as these things expand. And again, that gets back to your gets back to your question. What's one of the fundamental reasons for this expansion? I think that's one of the fundamental ones. But the problem is that when you expand that autonomy for me, you are also expanding the risk to a marginalised population. So it's actually not true autonomy, it's a privileged autonomy. It's more autonomy for the privileged at the expense of the marginalised. And that's where my concerns come into play. And they're fuelled by the fact that in my opinion, if. We are making determinations of irremediability that science and evidence tells us that we're not able to make and we're abandoning our role as medical experts as well.
Dr. Urvashi Prasad: [00:59:57] Doctor, again, I think your answer tugs at some of the fundamental principles of that most of us perhaps have thought about in the field of medicine. And the topic of MAID and mental health perhaps is posing a challenge, which is the conversation around autonomy versus doing no harm. And I certainly do think that this conversation, it speaks to that largely. I know I'm just keeping an eye on the amount of time that we have together. And I do want to thank you for your time here today and in assisting with my grand rounds, helping facilitate it. I do really appreciate you being here as the other individuals on today's episode as well. I will pass it back to Alex to facilitate the Q&A period.
Dr. Alex Raben: [01:01:03] Thanks, Urvashi. And I echo your thanks to Dr. Gaind as well. Of course. So now we'll move to the Q&A period for you, Urvashi and Dr. Gaind, as mentioned before, you should feel free to add to this. But this is kind of a tradition of grand rounds, is that we do get a chance to ask some spontaneous questions towards the end. And so one thing I'm wondering, hearing this discussion and being a physician who doesn't come up against the MAID legislation very often in my practice, although that may be changing as we're hearing today. One kind of question that didn't quite get answered for me is we've talked about these criteria, but how is it implemented practically in the real world? Who is doing this assessment? Is it only would it be only psychiatrists? Would it be any physician you talked to? We heard about these clinics in Europe that are doing assessments. So how will this play out Dr. Prasad in Canada or what's the legislation currently?
Dr. Urvashi Prasad: [01:02:10] So based on my understanding, the legislative currently is not limited to just psychiatrists and it is open to other medical professionals or doctors specifically who are participating in doing these specific MAID assessments. And I believe it's more than one doctor, so it would be at least two doctors opinions in order to perform these assessments. And for somebody to be eligible to go ahead with MAID. I will certainly open up the space here for Dr. Gaind and as well to add his input on this.
Dr. Sonu Gaind: [01:02:58] Thanks, Urvashi. And you're correct, the current legislation requires two medical practitioners, but they don't have to be just physicians. It does allow for nurses, nurse practitioners or physicians. And one of the things that's changed so the original legislation, it's easy because they're the kind of, I guess one is half the other. So that's how you can remember the numbers. The original legislation was C-14 back in 2016, and that one is the one that required two medical practitioners but didn't have to be physicians, could be nurses, nurse practitioners, and it didn't define who you needed to be. With the change in C-7 in March 2021, as I mentioned, there are now the two pathways, one for if death is reasonably foreseeable and the other if it's not. So the non-dying disabled pathway you could say. And for that second pathway it is something where the requirement is supposed to be that at least one of the medical practitioners is expert in that particular area that the person is applying MAID for. And so presumably if that held true down the road, it would mean that a psychiatrist would need to be one of the people if the person's applying for MAID for mental illness. But again, that's all pending what happens in 2023 in terms of the specifics of the legislation.
Dr. Alex Raben: [01:04:24] All right. Thank you both for those answers. That's quite helpful. And David, I'm wondering if you had any questions. I've got one or two more myself, if there's time. But I wanted to make sure you had an opportunity as well.
David Eapen-John: [01:04:37] Yeah. Thanks so much, Dr. Raben. One question that I kind of wanted to talk about a bit, I think a really good point was brought up before about how these bioethical discussions can have different implications on different communities. And I really like the idea that MAID in the context of mental illness may mean more autonomy for the privileged and less autonomy for people who are more marginalised. And I think it also relates to kind of the data we have from other countries in Europe which may have a different population structure and makeup of their population compared to a more diverse place like Canada. And I was wondering if there are like ideas or ways that we can protect marginalised communities specifically by adjusting the kind of legislation that we already have in place, or will that involve like a major rewriting or redoing of the legislation altogether?
Dr. Urvashi Prasad: [01:05:36] I think, David, you bring up an excellent question and an excellent point. And you speak to the probably the biggest challenge that we currently are experiencing in regards to the the biggest sort of shortcoming of the current MAID criteria in regards to the way it is currently laid out and the fact that individuals from more marginalised communities, particularly lower socioeconomic parts of the community, might be disproportionately affected by the way the law is currently laid out. And I think this speaks to something that Dr. Gaind has had alluded to a little bit earlier in regards to safeguards. I think the legislation would certainly need to expand and or rather narrow down its eligibility criteria and perhaps be more specific to have some safeguards in place to protect individuals that might be more vulnerable and more disproportionately affected by the law. In terms of how we could possibly do that, I think we may have to take a closer look into the definition of what irremediable might be in regards to not just looking at it from a biological lens, but also from a psychosocial lens. So are there financial stressors that are contributing? Are there housing stressors that are contributing? Is there loneliness? Is there social isolation and ways in which to address some of these important struggles and challenges that many of our patients do face? Dr. Gaind, if you have anything else to add in here, we'll be great to hear your input on such an important question as well.
Dr. Sonu Gaind: [01:07:43] Thanks so much. I think you gave a very good answer to that. And David, that's really on point and insightful question because that's precisely part of what we need to be concerned about. And my kind of I liked your answer Urvashi, I'm just concerned that it may not be implementable. And I'll tell you why. I've been in policy discussions with and this was actually a psychiatrist who was saying that, look, when we see somebody who applies for MAID now, if they are applying for poverty and that's how they framed it, if they're applying for poverty, well, we wouldn't provide MAID. And I thought that's not a realistic actual reflection of what happens because suffering is cumulative. We don't compartmentalize our suffering and say that this amount of my suffering is from poverty, this is from my mental illness symptoms, and this is from my separation, from my family. It's all cumulative. And we've known this for many years in palliative care. There's a concept called Total Pain by Dame Cicely Saunders. And it's that idea that all of the suffering that we have kind of that's what we respond to. So in any practical implementation, if somebody is applying for MAID and they happen to also have poverty, how would we possibly rule that out? Because if we say that, oh, we're not going to let you get it because you are of lower socioeconomic status.
Dr. Sonu Gaind: [01:09:22] Imagine the discrimination charge is there because then you're actually saying we're not going to provide something to you because you have poverty. No one's going to come and say I want it for poverty, although some people are now actually saying that. But in practical terms, I don't know how you could actually separate it out. And this is why even the UN rapporteur on the Rights of Persons with Disabilities and in fact the UN,there were two UN reports that came out quite strongly against what Canada is doing with this expansion, because they essentially are saying that much of the expansion is based on ableism and that disability should never be a ground or justification to end someone's life directly or indirectly. And they add in the idea of the socioeconomic suffering that also fuels disability and the sense of being a burden to society. And so I really liked your answer. I just don't think it's in practical terms doable because when people come with that cumulative distress and apply for MAID, how do you separate it out?
Dr. Alex Raben: [01:10:41] Thank you both for your answers there. Yeah, it sounds like quite a complex question and the complex answer that will be very difficult to tease out in a legislative, practical way because of these disparities that exist in our society. I'm sorry, Urvashi. I'm going to ask one last question, but it's kind of double-barrelled, but one I think will be a relatively faster answer. And that's just to bring it back to the case of Anna. I'm wondering if you think with the current legislation, if we fast forward to March 2023, do you think she could be eligible for MAID given her situation? And then my sort of final question is we've talked about feelings of hopelessness in the context of depression, possibly leading to someone applying for MAID. But I think just personally speaking, some feelings of hopelessness have come up for me in this discussion tonight that I'm wondering how we see, what we see, the future of this legislation being and if there is some potential for change here, because we've talked a lot about some problematic potential issues here in the future.
Dr. Urvashi Prasad: [01:11:57] Yeah. Alex, you ask a question that certainly been on my mind, especially with having some of my interactions with the patient that I alluded to a little bit earlier. So bringing this into Anna's case, particularly, I think if we were to fast forward to March 2023 and if I was faced with this question, the one criteria that I feel would be, possibly the most challenging and one that I would struggle with the most would be within the eligibility criteria. I'm just going to read this out loud just to bring everybody on the same page. So this the point being the patient is enduring physical or psychological suffering caused by the medical condition or the state of decline that is intolerable to the person and cannot be relieved under conditions that they consider acceptable. So given the way that that's worded, saying that it relies on the patient's level of acceptability, I do think that Anna would meet criteria for this and would likely meet criteria for being eligible for MAID. However to me if I were to be looking at that criteria and perhaps maybe even looping this back into David's question in terms of ways in which we could take a look at the current criteria and change it, I think one way of one way of perhaps revising this criteria would be to change it to both the physician and the patient, considering what might be acceptable versus what might not be acceptable treatment.
Dr. Urvashi Prasad: [01:13:54] So in Anna's case, she's only been on one trial of an antipsychotic medication that we know of. And from a physician perspective, I would consider that to be not acceptable in regards to knowing that there are other treatment options that we could pursue. So, from my regard, I would not find that to be acceptable. However, I think from a practical perspective, if we were just going by the criteria, I think she would meet criteria for MAID. And I'll get Dr. Gaind to weigh in on that in just a second. But I'm hoping to also answer the second part of your question, which is the question of hopelessness that some of our patients might be struggling with. And I do certainly think that in the case of Anna, that was something that was also very much evident.
Dr. Alex Raben: [01:14:54] Well, let me add to that Urvashi, because I was actually talking more about the provider feelings of hopelessness and where you see our role in this legislation or the role of Canadian Society in addressing some of the problematic issues we've talked about today. And I know it's very complicated, but do you see and it doesn't fall on any one of us. So it is a big question, certainly. And I don't expect you to know to have a single answer. Where do you see the hope in this?
Dr. Urvashi Prasad: [01:15:28] It's a big question. And to me, I think the first step really is raising awareness on this issue in regards to perhaps as health care providers feeling less isolated in our level of distress and hopelessness around such a complicated issue. And this also speaks to the reason why I was hoping to participate in a grand rounds on this and do a podcast, because I think, surprisingly, there isn't as much awareness on this very important issue. And I think a lot of us perhaps are dealing with the hopelessness around it in sort of silos independently. And I think the biggest step would be to increase awareness on this issue so that collectively, as a group, we could perhaps discuss some of our feelings around it and maybe even take that a step further to creating perhaps some expert panel groups or working with individuals that are working on improvising the policies for MAID in mental health so that there can be some movement driven by psychiatrists and mental health professionals to bring to light some of the challenges around the way the law is currently designed and to perhaps make some changes that would revise the eligibility criteria in a manner where we would not feel so disheartened when so many of our patients possibly maybe talking about or inquiring around MAID. Now how that might happen in terms of what sort of changes we would see in regards to the law would be difficult for me to answer to for all the reasons that Dr. Gaind mentioned a little bit earlier. But I think certainly being able to have being able to raise awareness and being able to discuss some of these emotions and then lead that into perhaps even pushing for changing policies might be the first couple of steps around this.
Dr. Alex Raben: [01:18:03] That's great Urvashi, I already feel more hopeful after hearing that from you. So thank you. Dr. Gaind, do you have any parting thoughts or thoughts on that? Last question there before we wrap up.
Dr. Sonu Gaind: [01:18:14] I would just echo actually what Urvashi said. I think you are absolutely right in what you're saying, that the answer to despair and hopelessness in this case is actually both us getting engaged. And by us, I mean all of us in the medical field and residents are the future of our medical field. So especially resonance and raising awareness, because what I can let you know is that although, you know, it's leading to a lot of challenges right now, this is something where as more people become aware of it, they're actually very surprised at the way things have proceeded. It is not something, you know, normally we have a sense of trust and confidence that by the time things come around to being said as national policy, they've gone through all the appropriate due diligence. And I can say to you that in this case, that has not happened. And although that's not a good thing, that it hasn't happened, but it also does really highlight, as more people learn about it, is, you know what, maybe we need to take another look at this. And it's not to say ideologically that something is or isn't right, but to understand what we're doing it for and to do it in at least what we can best try as an evidence-based way. And so, I do think that as people learn about this intermingled, I'd say, Alex, with that sense of "Oh, I'm feeling a bit hopeless" is also, you know what, this is actually a significant issue that's going to affect a lot of my patients and people that my patients know when the people were here trying to help, and that can be very motivated. And so I would say don't despair about it, but I think become aware and informed and also help others become aware and informed. And that can actually lead to positive policy changes and pressure.
Dr. Alex Raben: [01:20:11] What a wonderful note to end on that. There is there is hope here. And that as has been mentioned already, this episode itself serves as a platform for us to start or continue the discussion. And I hope that continues as well. Thank you again, Doctor Gaind for being our guest expert on this episode and to you, Urvashi and David. And of course, thank you to our listeners and we hope you enjoyed and we'll catch you on the next episode. Bye for now.
Dr. Alex Raben: [01:20:53] Psyched is a resident driven initiative led by residents at the University of Toronto, McGill and UBC. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced by Dr. Urvashi Prasad and Dr. Alex Raben. The episode was hosted by Alex Raben, Urvashi Prasad and David Eapen-John. The audio editing was done by Alex Raben. Our theme song is Working Solutions by All Live Music. A special thanks to our incredible guest, Dr. Sonu Gaind for serving as our expert on this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thank you so much for listening!