Mental Health Meta-analytic Evaluation

Making significant improvements in public health predicaments often takes decades.  And when meaningful progress is made it is often piecemeal, very expensive and a matter of “trial and error”.  

A good case in point-  this meta-analytic evaluation of recent meta-analyses of psychotherapies and pharmacotherapies for mental health disorders. 102 meta-analyses are examined, covering depressive disorders, anxiety disorders, post-traumatic stress disorder, obsessive-compulsive disorder, somatoform disorders, eating disorders, attention-deficit/hyperactivity disorder, substance use disorders, insomnia, schizophrenia spectrum disorders, and bipolar disorder.  The conclusion it reaches:  “After more than half a century of research, thousands of RCTs and millions of invested funds, the effect sizes of psychotherapies and pharmacotherapies for mental disorders are limited, suggesting a ceiling effect for treatment research as presently conducted. A paradigm shift in research seems to be required to achieve further progress.”

Cheers, 
Colin

National Post Commentary on the Pandemic Response

I have an 1800 word opinion piece published in the National Post here titled "Divisive Mandatory Vaccines Further Erode Responsible Governance". 

This commentary captures my view on the lessons I think we need to learn from the past two years of our attempt to mitigate the threat posed by the virus.  

Cheers, 

Colin

New Paper on Framing Longevity Science

 

I am happy to share the news that my chapter submission titled "Framing Longevity Science and an “Aging Enhancement”" has been accepted for publication in The Routledge Handbook of the Ethics of Human Enhancement.  This essay was written during the prolonged lockdowns of the winter and spring of 2021, and helped me retain my sanity during it all.  The gist of my argument is that it is much more important to ask the right question than it is to provide answers to the wrong questions.  The abstract:

Advances in the biomedical sciences, like the potential development of an applied gerontological intervention (or “aging enhancement”), warrant serious ethical reflection and debate to help ensure scientific innovations are pursued in socially responsible ways.  This chapter critically assesses some of the ethical issues surrounding the “framing” of life extension and, more specifically, an aging enhancement. To frame an issue “is to select some aspects of a perceived reality and make them more salient in a communicating text, in such a way as to promote a particular problem definition, causal interpretation, moral evaluation, and/or treatment recommendation for the item described”.  Four different aging enhancement frames are assessed: (1) “Is extending life natural?” (2) “How long is enough life?” (3) “What about equality?” and (4) “Why promote public health?”.  I argue that the first three frames buttress support for the “aging status quo” by suggesting that something of significant moral value is compromised or threatened by altering the rate of biological aging, and little (if anything) of significance could be expected to be gained by slowing the rate of senescence.  This contrasts with question (4), the “Why promote public health?” question, which is framed to make vivid the actual harms of the “aging status quo”, as well as the benefits of slowing the aging process.  When it comes to ethical debates concerning an aging enhancement, it is much more important to ask the right questions than it is to try to provide answers to the wrong questions.  

Cheers, 

Colin    

A Deeper Dive Into Pandemic Reporting Issues

The catalyst for this lengthy blog post is the recent news that my province of Ontario is finally, two years later!, seriously considering distinguishing between causal and incidental COVID deaths and hospitalizations.  

This specific issue has been, for me, the single most significant and neglected issue throughout this whole pandemic.  Without transparency on this issue from day 1, the accuracy of the population health threat posed from the virus, which is then utilized to justify the stringent lockdown measures (e.g. school closures) of the past 2+ years, can be questioned.  Because most deaths and hospitalizations in general, and those actually caused by this virus, occur in older persons (age >70) it is absolutely essential to make a concerted effort to distinguish between causal and incidental deaths, ICUs and hospitalizations.  So I suppose it is better later than never, but this is long overdue.

To show why this is so vital I want to make an analogy with the way in which the province reports "Adverse Events Following Immunization", in particular deaths from the vaccine.  I draw attention to this issue not to arm anti-vaxxers with information to perpetuate vaccine hesitancy (the benefits of the vaccine far outweigh the risks, and the adverse events reported are within the normal range for other vaccines), but to show how important it is to distinguish between causal and incidental deaths from both COVID-19 and from vaccines. 

Firstly, imagine no serious attempt was made to make a distinction between causal and incidental vaccine deaths.  This would mean anyone who happened to die within a few weeks of getting the vaccine, regardless of whether they died in a car crash or of the underlying co-morbidities of advanced age, could be counted as an adverse event.  In justifying this odd public health approach health officials remarked "Out of an abundance of caution, we are reporting every conceivable adverse event so that we do not subject people to unsafe medical procedures".  If this approach was taken the whole process of immunizations would be undermined, and the population would be left at greater risk of COVID-19 mortality.  This approach would be folly because it conflates people who died with the vaccine with those who died from the vaccine.  There is a big difference between these two things.  And yet this lax approach in reporting deaths and hospitalizations with and from the virus has been taken. I think this was perhaps the biggest mistake of the world's pandemic response, because of the age profile of deaths and serious illnesses (i.e. mostly people over age 70).     

OK, so yes we must take great care to distinguish between causal and incidental deaths, whether the issue is death from COVID or from the vaccine.  But let us dig deeper.  In 2021 the province officially reports that there were 8 fatalities caused by the vaccines, but there are another 26 death cases that are currently listed as "persons under investigation" as they do not clearly meet the province's surveillance definition of death caused by the vaccine.  This definition of "death caused by the vaccine" rules out "individuals with multiple co-morbidities which may be related to the cause of death".  Here is the lengthy list of factors that rule out a death from being considered a death caused by the vaccine. 

1. Resident of a health-care institution with significant comorbidities. The cause of death was not attributed to the vaccine. 

2. Community dwelling senior with complex cardiovascular and renal conditions, wherein the AEFI may have contributed to but was not the underlying cause of death. 

3. Community dwelling senior with multiple comorbidities including heart disease and an autoimmune disorder. The cause of death was not attributed to the vaccine. 

4. An individual with VITT with death recorded in CCM (described above under Vaccine-Induced Immune Thrombotic Thrombocytopenia (VITT) and Thrombosis with Thrombocytopenia Syndrome (TTS) section). A Coroner’s investigation determined that the immediate causes of death included VITT. 

5. Individual with hypertension, wherein the cause of death was not clearly attributed to vaccine.

6. Community dwelling senior with a complex cardiovascular history. The AEFI may have contributed to but was not the underlying cause of death. 

7. Community dwelling senior with multiple comorbidities, wherein the AEFI may have contributed to but was not the underlying cause of death. 

8. Community dwelling senior with severe aortic stenosis. The AEFI may have contributed to but was not underlying cause of death.

Such scrutiny is certainly justified for without ruling such cases out it would skew our understanding of the safety of the vaccines.  However, we should apply a similar diligence to COVID deaths, ICUs and hospitalizations.  If we assume everyone who dies with a positive test result for COVID died from COVID, despite the fact that they already had serious underlying health problems, we will get a skewed picture of the pandemic. The same is true for COVID hospitalizations. And this is what has actually happened.

The COVID-19 pandemic has been a novel hybrid pandemic- the virus is both an novel infectious virus AND an emerging disease of aging. I believe the latter has been lost in both the media coverage and the public policy response to this pandemic.  And that neglect has meant we responded less effectively than we could have, imposing significant mental health burdens, educational deficits, economic burdens, etc. on younger persons (children and adults age < 50). 

I will add one last point to amplify the significance of this insight. At the moment the media headlines are dominated by COVID ICU and hospitalizations numbers.  These headlines suggest that it is the unvaccinated that are monopolizing most the hospital beds when it fact it is more accurate to say they are exacerbating the pressures placed on those resources from patients with non-COVID related health problems (the majority of which would be age-related causes- heart attacks, strokes, etc.).  

Let us unpack some of the data in Ontario's hospitals, as this goes into greater depth than the typical news story.  

The province has 2343 ICU (adult) beds, of which  1460 beds are for non-COVID patients.  I have yet to see a news headline in the past 2 years that discusses the causes, let alone ways to prevent, whatever it is that accounts for 62% of ICU beds for non-COVID patients.  At the moment there are 333 people in ICU beds with COVID.  This is 14% of the ICU beds, and of those 119 are unvaccinated.  So 5% of the ICU beds are being used by unvaccined persons, during the peak of our infection numbers.  550 ICU beds are still available, which means the total ICU bed capacity for adults is at 77% of its full capacity (23% of ICU beds remain available). [as an aside, ICU beds are not fixed and we have had two years to increase capacity vs opting for locking kids and society down as a response to pressures on healthcare resources].  Here is how Canada fares (a bit dated) among other OECD countries:

From my perspective, having studied the policy implications of the biology of aging for 15+ years, the popular narrative about the strains caused by the unvaccinated is simply a political distraction from the empirical reality.  The reality is that most ICU beds, so far in this pandemic, have been filled mostly with patients that were not hospitalized for COVID.  I could not find data on their ages but I would expect most cases are among the older age cohorts (age >60).  And of those that do have COVID in  (regardless of vaccination status) they are much more likely to be older.  This is just one symptom of the much larger health predicament we face with population aging.

This Lancet Public Health piece notes the tsunami of dementia that is coming by the year 2050.  Unless we alter our myopic fixation on the proximate causation of disease and death (which this pandemic has further entrenched in the medical sciences and media), we will not be able to meet the health challenges of today's aging world.

Cheers, 

Colin 

Mandating Vaccines for COVID-19? No.

While I am not a fan of disclosing personal medical information on social media, tonight I will because I feel compelled to say something in response to our Minister of Health’s suggestions that mandatory COVID-19 vaccines should be on the table. So firstly… I am fully vaccinated, and I have also had the booster.

87.75% of Canadians over age 12 are fully vaccinated. According to Our World in Data, Canada ranks #6 in the world for vaccination against COVID-19. So well done!

Despite that good news, it was very disheartening, indeed shocking, to hear our Minister of Health suggest that mandatory COVID-19 vaccines should be on the table. Let’s start by noting some data from Health Canada’s database on vaccinations.

While it is a common term I will use in this post, referring to people as “unvaccinated” is not very helpful. It “others” people, and often implies that they are ill or diseased when that is not the case. Instead we should refer to these folks as people whose immune system has not been enhanced with vaccines to offer superior protection against COVID-19. Lest we forget, a year ago all of us were “unvaccinated”.

So who in Canada is unvaccinated? Here are a few details from Health Canada:

Provinces and territories: highest vaccination rate is Newfoundland and Labrador, and the lowest vaccination rate is Nunavut.

Sex: Females have a 3% higher vaccination rate than males.

Age: highest vaccinated age group is age > 80 at over 95% fully vaccinated, lowest is nearly 83% for ages 12-29 (young kids not counted).

But what is not listed are other important categories that could be morally relevant in assessing the pros and cons of mandating vaccines: such as race, education level, income, incarcerated or free, etc.

In my opinion, the vaccine passports already implemented in Ontario and elsewhere were deeply problematic- they were socially divisive and (mostly) ineffective (given the fact that we are where we are with lockdown again). And now that they didn’t achieve what the planners had hoped they are doubling down on this intimidation strategy, which I presume they simply hope will have popular support since it is not predicated upon empirical evidence and a proportionate weighting of the (long-term) pros and cons.

There is much more at stake with this issue than just getting out of this current pandemic. There is the kind of society that will be left standing post-pandemic. There is the potential distrust and damage we do to future vaccine compliance and public health more generally if we mandate people to take something that they are opposed to taking.

For me, taking the vaccine was a no brainer. I took it to protect the health of my community, my family and for my own health. But I am somewhat scientifically literate, am familiar with the cost/benefit reasoning that goes into public health decision-making, etc. I realize that not everyone sees this complex moral and empirical landscape in the same way as I do. And lastly, I am a male over age 50, so the risks to me are different than the risks to a 20 year old (especially a person that has already recovered from COVID-19).

The core moral conviction of the medical sciences, often (though inaccurately) attributed to the Hippocratic Oath, states “First do no harm”. Threatening fines and further isolation upon many of Canada’s most vulnerable populations is too hefty a price to pay for the speculative societal benefits its proponents are pandering. Let’s get out of this pandemic with a society and culture we can still be proud of. We have sacrificed too much already.

Cheers,

Colin

Positive Biology for the 21st century

As we enter year 3 of this pandemic, with media headlines consumed with yet more negative news about the spread of (new variants) of SARS-CoV-2, I thought I would share a few timely snippets from my book chapter titled "'Positive Biology' and Well-Ordered Science":

The philosophical question I would like to contemplate in this chapter is:  “What constitutes “well-ordered science”?”… I lay some preliminary foundations for addressing this question by elaborating briefly on the virtue epistemological construal of knowledge as “success from ability”.

….The world is a complex and constantly changing environment, and thus knowledge itself will be not fixed or static.  The normative value of different types of knowledge will be context-specific.  In one context certain empirical insights about the world might prove to be vital in helping us protect a population from disease and premature death.  But those same empirical insights might be, in a different context, of much more limited use and significance because the most pressing external threats to human populations are different. 

….Since the rise of epidemiology in the 19^th century, the central question which has been the primary focus of both clinical medicine and public health is- what causes disease?  In this chapter I argue that this fixation on disease-research (evident in oncology, cardiology, psychiatry, etc.) must now (i.e. in the 21^st century) be supplemented by a zeal to also invest in, and support, basic scientific research into the causation of exemplar positive phenotypes. 

…. I urge that the study of pathology be supplemented by the study of the determinates of exemplary positive phenotypes (e.g. healthy aging and happiness). 

…. Rather than fixating solely on the causation of pathology, positive biology encourages the study of the biology of centenarians, the emotional resilience of those who experience growth and development from adversity (vs those who become depressed or develop addiction), the genetic and environmental factors that contribute to self-esteem, healthy relationships and secure attachment, etc.  By transcending negative biology’s fixation on negative phenotypes, positive biology may be able to yield significant prescriptions that help the human populations of the 21^st century flourish in spite of the fact that we face a potentially precarious and uncertain future.  

Cheers 

Colin