Healing One Woman at a Time by Educating Both Sides of the Doctor’s Desk
BY: Mikaeel Valli
Looking back within the last few decades, significant progress has been made in recognizing and improving women’s health. But this was certainly no easy feat. One aspect that positively influenced women’s health was advocacy for policy change to allow inclusion of women in clinical research, which was formally launched by the National Institutes of Health in the US in 1993, and soon after in Canada in 1997. This kind of policy pushed for researchers to educate the public and medical community on how medications, procedures, and diseases affected women differently than men. As a result of this policy change, an antidepressant drug known as nefazodone was taken off the Canadian market in 2003 after nine years, as it was discovered to cause serious liver damage especially in women, to an extent that some patients required a liver transplant to save their lives. Instrumental to this drug removal was Dr. Donna Stewart, one of Toronto’s clinician-scientists that has been playing a leading role in shaping a better future for women’s health. She is a psychiatrist at Toronto General Hospital and the Inaugural Chair of Women’s Health at the University Health Network and University of Toronto, whom the IMS Magazine had a pleasure of interviewing.
Dr. Stewart recalled back to the late 1960s, when she became intimately aware of how frequently women were experiencing sexual and physical violence. This was before she became a psychiatrist, when she was practicing family medicine in a small town in northern Ontario. “There was a lot of family violence and sexism,” Dr Stewart explained. “Women that worked at the local paper mill would come and tell me about terrible things that happened to them at work that included sexual abuse and harassment.” From that point, Dr. Stewart knew it was her calling to combat such unfairness towards women and their health. Five decades later, she has worked with many colleagues and stakeholders locally and internationally to push for reform in women’s health beyond psychiatry, into medical education and public health. She tackles the challenges of women’s health from both ends of the doctor’s desk: enhancing knowledge, knowledge translation, and access to both healthcare providers and patients.
On the doctor’s side of the desk, Dr. Stewart is working on enhancing healthcare providers’ knowledge and understanding of intimate partner violence (IPV) and sexual violence (SV), particularly against women. “Prevalence rates of such violence occurs from 15 to 71% across a lifetime or 4 to 54% within the last 12 months, based on a 10-country study by the World Health Organization” she explained. Furthermore, Dr. Stewart elaborated that these numbers are probably higher because women may feel guilty, ashamed, or face social stigma if they decide to speak out. These types of violence are pressing as they can result not only in physical injury, but also mental health complications including depression, anxiety, post-traumatic stress disorder, and an array of other mental challenges. It has been estimated that upwards of 30% of psychiatric patients have been exposed to IPV and SV.
Needs assessment has indicated that IPV and SV are key determinants of women’s mental health, however, “60% of mental health professionals report that they lack adequate knowledge and desire more education on this area,” Dr. Stewart said. Since these kinds of violence often do not get readily disclosed by patients or enquired about by psychiatrists or other physicians, this unfortunately takes a toll on women’s health as it impacts their diagnosis, treatment and outcome. “Healthcare physicians, including psychiatrists, must be familiar with the best evidence-based short- and long-term management of mental health sequalae as a result of these kinds of violence,” Dr. Stewart emphasized.
Therefore, Dr. Stewart led the World Psychiatry Association, along with the World Health Organization with other colleagues across the globe, to develop an Intimate Partner Violence and Sexual Violence (IPV/SV) competency-based curriculum for medical students, psychiatric trainees and practicing psychiatrists which has now been translated into 10 languages. This curriculum includes recommendations of how to assess an array of competencies including misconceptions, health sequalae and psychiatric management of mental health trauma. In addition, the curriculum includes recommendations for psychiatric management including the initiation and monitoring of first line methods needed to treat IPV/SV psychological trauma including cognitive behaviour therapy, pharmacology intervention, or rapid eye movement desensitization.
Dr. Stewart also played a role in shaping the new Canadian family violence curriculum-called VEGA-to be engaging and interactive for trainees because she has found, in her decades of teaching experience, medical students often become disengaged and uninterested with the traditional lecture format. “So, with Dr. Harriet MacMillan from McMaster University as lead, and other colleagues, the research team incorporated games and role-playing videos into the new curriculum. In the role-playing videos, for instance, the acting physician would say X, then the acting patient says Y, and then the trainee is to select from a choice of what the physician’s reply should be” Dr. Stewart explained. The advantage with this format is that it allows trainees to receive feedback and have a chance to correct their choices. “The students love it!” Dr. Stewart said, encouraged by their responses. “We are in the process of scientifically assessing student’s learning of the new curriculum to see how effective it is in making a meaningful impact on women suffering from IPV/SV and other victims of family violence. We essentially are aiming for enhanced knowledge, attitudinal change, and skill development which provide real life competencies.”
On the other end of the desk, Dr. Stewart with her colleagues helped develop a patient decision aid (PDA) for pregnant women affected with major depressive disorder (MDD). MDD is a common and serious complication associated with pregnancy. “If this condition goes untreated, it can lead to a seven-fold increased risk for postpartum depression and be detrimental to the maternal-infant attachment and child development,” Dr. Stewart cautioned. Treatment options are available to combat MDD during pregnancy, however, “treatment decisions must be guided not only by evidence, but also by how a woman values the potential benefits and drawbacks of the treatment options, which she prefers, and the extent to which she wants to be involved in the treatment,” she explained. Most women desire to play an active role in their treatment plan, but 50% of women have a decisional conflict—meaning they are having difficulty, discomfort and/or uncertainty about a medical decision. Decisional conflicts can increase the chances a person will delay an important decision or make a decision that will negatively impact their health.
Evidence shows that routine clinical care or existing informational resources appear to not be enough to reduce decisional conflict. Therefore, the research team that was led by Dr. Simone Vigod, and included Dr. Stewart, developed a PDA to specifically assist expectant mothers with MDD. The PDA is an online tool that aims to educate, enhance and supplement patient-provider consultation by providing detailed-specific, and personalized focus on options and potential outcomes. The PDA works to reduce decisional conflict by helping women identify the decision in question, presenting evidence-based information about benefits, risks and side effects of available options, and clarifying patient values related to the decision. “For example, they may feel that medication is not best for them and their babies, and that psychotherapy is better. Or if the depression is severe and they are experiencing suicide ideations, then psychotherapy is not enough. We give them information about the medication—what is known and unknown about it, and we help them choose the best course of action” Dr. Stewart explains.
The research team carried out a pilot clinical trial testing the utility of PDA for pregnant women with MDD. They were encouraged to find it was effective in reducing decisional conflicts, making this tool promisingly effective for women with otherwise minimal access to specialized reproductive psychiatric care. “The next stop going forward is to do a larger scale evaluation of the PDA for its impact on longer-term maternal and child outcomes, including maternal depression and anxiety symptoms during and after pregnancy, and understand the barriers and facilitators to allow PDA to be used in mainstream practice.”
When asked about her legacy, Dr. Stewart says she takes greatest pleasure in seeing her former trainees become the leading women’s health researchers in Canada and internationally. Reflecting on her career and research, Dr. Stewart ultimately hopes that her contributions to the advancement of knowledge and education will lead to meaningful changes in clinical practice locally, nationally and across the globe, to allow each woman to receive the best evidenced-based and equitable healthcare possible.