Last spring everything changed for Denver resident Matt Larson.

“One day I was fine,” says Larson. “The next I was being rushed by ambulance to Denver Health following two very massive and violent seizures.”

The force of the seizures, from the sheer shaking, fractured and dislocated his shoulders and snapped two bones in his back. Soon his providers had life-altering test results.

“They came back and shut the door and said ‘you have mass on your brain,’ which was tough to hear,” says Larson.

The diagnosis, a malignant brain tumor called an anaplastic oligodendroglioma, rocked his world. Larson, 36, and his girlfriend, Kelly, decided to get married. He says a couple of days later, surgeons cracked open his skull and scooped out part of his brain. Since then he’s endured the tough road of radiation and chemo, with a sobering outlook.

“I have a 50/50 probability that I’m going to live,” says Larson. “I hope to beat the odds. I desperately want to live.”

But Larson has decided that if the brain cancer returns and is incurable, he’d like the option to end his life rather than face the possibility of an agonizing and painful death.

“It would just bring me a ton of peace and comfort now to know that I have this option,” Larson says.

He’s become an advocate for Colorado’s Proposition 106. It would give mentally competent adults the ability to end their lives with a doctor-prescribed drug, generally a sleeping medication called secobarbital.

“We need to help people diminish and assuage their suffering any way we can,” says Dr. David Grube, a family doctor in Oregon, one of five states to allow the practice.

Grube, who retired after practicing for 38 years, is also national medical director for the group Compassion & Choices. He became a proponent of what he calls “death with dignity” shortly before the law passed in Oregon in 1994. He was moved to the position after one of his patients, who was dying from bladder cancer, shot himself to death.

“If I can ever prevent such a violent and tragic end to a person’s life, I should be open to helping people,” Grube says.

Five states — Washington, Oregon, California and Vermont — currently allow the practice. Montana has effectively legalized it, due to a court ruling that protects doctors who help dying patients from prosecution.

Colorado’s proposal is modeled after Oregon’s law. In both, two doctors must determine a patient is mentally capable of making the choice and isn’t under undue influence or coercion. Grube says he has helped about 30 people end their lives, with about a third of those who requested medications deciding not to take them.

“Many more people just want to talk about it, just want to know if it’s a possible option,” says Grube. “Still, in all, it’s quite uncommon.”

According to the Oregon Public Health Division, during 2015, 218 people received prescriptions for lethal medications under the provisions of the state’s Death With Dignity Act. That was up from 155 the prior year. The division has received reports of 132 people who died in 2015 from taking the medications prescribed under the act, a rate of 38.6 per 10,000 patients.

More than 90 percent of those patients died at home and were enrolled in hospice care. Since the Oregon law was passed, 1,545 people have received legal prescriptions; 991 patients died ingesting the medications.

When patients were asked why they decided to consider ending their lives, the most common concerns were that they were less able to engage in activities that make life enjoyable, and that they were losing both autonomy and dignity. Further down the list was inadequate pain control and the financial impact of the treatment.

Doctors As Healers

But Denver physician Alan Rastrelli opposes the proposal. He worries it will erode the public’s trust in doctors as healers.

“Physicians will go towards this philosophy of assisting a patient in their death,” he says. “That will destroy, I think, the patient and physician relationship.”

Rastrelli, who practiced anesthesiology for 28 years, transitioned into hospice and palliative medicine 15 years ago. He says when doctors help patients end their lives it creates a societal and bioethical calamity.

Rastrelli worries about what the initiative doesn’t do, such as require a physician to be present when the person dies. He also said it’s difficult to know about common problems or mistakes are because reporting requirements in Oregon, and in Colorado’s proposal, are weak.

He advocates helping dying patients to use pain relievers and receive spiritual and psychological support to ease suffering.

“Woody Allen said, ‘I’m not afraid of dying, I just don’t want to be there when it happens,’ ” Rastrelli says. “We can help people be okay all the way through to the end.”

That makes a lot of sense to advocates with Not Dead Yet, a national group run by people with disabilities that opposes the proposal.

Anita Cameron, one of the groups board members, says doctors “are humans and they make mistakes.”

Cameron’s mother, Alice, was diagnosed with end-stage chronic lung disease seven years ago. She was given less than six months to live. Today, Cameron’s mother is still alive.

“Had the law been in place, I’m pretty sure those doctors would have convinced my mom to take the pills,” Cameron said. “And she’d be dead.”

Cameron has several disabilities, including multiple sclerosis. She worries the ballot proposal will encourage people with disabilities to kill themselves. She also thinks that in some cases insurers will agree to pay for end-of-life medications, but not for measures to keep someone alive.

“When is it going to be a duty to die?” asks Cameron. “That’s what euthanasia is and when is it going to stop being a choice?”

Battle Draws Big Bucks

The ballot initiative is drawing passion — and plenty of money.

According to the latest filings with the Colorado Secretary of State’s office, backers have raised about $5.3 million, mostly from Compassion & Choices Action Network.

The “No Assisted Suicide Colorado” campaign has raised $1.8 million. That money is primarily coming from the Roman Catholic Archdiocese of Denver, which has donated $1.1 million, as well as other archdioceses around the country.

Both groups have also received numerous smaller donations.

The board of the Colorado Medical Society, the state’s largest physician group, voted to take a neutral position on the measure. President-elect Dr. Katie Lozano calls the proposal “the most personal of decisions that must be left to our patients” to decide.

A February poll of 618 Colorado physicians before the ballot measure was proposed found support within the group for physician-assisted death in general. Fifty-six percent of medical society members favored it; 35 percent opposed.

Among those who frequently treat patients in later stages of a terminal illness, the gap was smaller, with 50 percent backing physician-assisted death and 41 percent opposing it.

The medical society said there was a consensus that if the law were to pass, the medical society should focus on protecting patients and doctors, and increase awareness of end-of-life choices, emphasizing the importance of palliative and hospice care.

Election ballots will start being mailed next week.

This story is part of a reporting partnership with NPR, Colorado Public Radio and Kaiser Health News.

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Three doctors who have led a task force that evaluates preventive medical services say the group’s recommendations shouldn’t be tied by law to insurance coverage.

The former chairmen of the U.S. Preventive Services Task Force say the link between medical recommendations and insurance coverage leads to financial incentives that can corrupt the process and distort people’s health care decisions.

Under the Affordable Care Act, any preventive service that receives one of the USPSTF’s top two ratings must be covered by insurance without any out-of-pocket cost for the patient. The doctors advice to decouple the task force ratings from insurance coverage would require a change in the health law.

The authors of the commentary, which appears Monday in the Annals of Internal Medicine, point to heavy lobbying by the pharmaceutical company Mylan N.V. to get its anti-allergy device EpiPen deemed a preventive service. They say such lobbying can interfere with the task force’s mission to evaluate medical services to improve the health of the overall population.

“When people try to twist that mission for their own purposes, essentially what they’re doing is violating the integrity of the task force process, and it’s distracting from the mission,” says Dr. Virginia Moyer, the lead author of the commentary. Moyer, a former chairman of the task force, is now a vice president of the American Board of Pediatrics.

The USPSTF is an independent group of volunteer physicians who review the research on preventive medical services, such as vaccines and screenings tests, and recommend who should get them and how often.

Mylan has been lobbying the task force to have the EpiPen listed as a preventive device, even though it is used by people with diagnosed allergies. The EpiPen is an automatic injector that delivers a dose of epinephrine to stop dangerous allergic reactions. A two-pack costs more than $633, according to GoodRx.

The company has been under fire in recent months because it has raised the price of the device more than fivefold since 2007, even though the product has been on the market for decades. Mylan CEO Heather Bresch has blamed the uproar on trends in insurance coverage that leave patients responsible for a larger share of their medical costs.

If EpiPens were covered as preventive medications, patients could get them at no cost. The price increases Mylan has put in place would be invisible to consumers but would have to be borne by insurers.

“What Mylan has done, or what they’re attempting to do with this effort, is use a provision in law, which is intended to give people access to preventive services, and use it to their advantage for something that just plain is not a preventive service,” Moyer says.

That effort by Mylan, which was detailed in a story by The New York Times, spurred Moyer and her two colleagues, Dr. Michael LeFevre and Dr. Ned Calonge, who were also task force leaders, to write the opinion piece that questions the overall idea that insurance coverage should be tied by statute to the recommendations of the volunteer medical group.

The authors say the issues with the link go beyond the problem of lobbying. By putting prevention ahead of treatment of illness by making it free of cost, the system created by the ACA may be making treatment of illness more expensive and putting it out of reach of some patients.

“If such financial access comes at the cost of increased deductibles or copays for equally important services that are not preventive, then we must question whether the link inadvertently discourages other important care,” they write.

“Perhaps it is time for the USPSTF to inform, but not determine, coverage,” they conclude.

A recent survey by the Kaiser Family Foundation shows that more than half of people with insurance through their employer have policies with deductibles of more than $1,000.

Many advocates and economists agree that preventive services can cost more but also can improve the quality of health care. When the Affordable Care Act was being debated, advocates on both sides argued whether or not preventive services would save money in the long run.

“Preventive health services have become quite expensive over time,” says Joe Antos, a resident scholar at the American Enterprise Institute.

He says some preventive services such as vaccines are inexpensive and undoubtedly valuable. Others, such as mammograms, are also medically important but don’t necessarily save money.

When those services are provided free, the costs are spread across all policy holders through premiums and deductibles.

But Antos cautions against blaming rising deductibles and premiums only on preventive care.

“To what extent have preventive services been responsible for the big increase in deductibles and co-payments over the last decade or so?” he asks. “I would argue that they’ve contributed. But we’re really talking about rising health care costs, not just preventive services.”

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When the birth control pill debuted more than 50 years ago, women wanted to know: Is it safe? There wasn’t much evidence to answer that question, but women embraced the Pill as a revolutionary improvement in contraception.

Today, millions of women around the world use hormonal contraceptives that have expanded beyond the Pill to patches, implants, injections and uterine devices. Decades of research support their safety, and serious but very rare side effects such as blood clots are finally much better understood. But other areas of research lag, and we still don’t know as much as we’d like about how these medications affect women’s mental health.

So when a study came out linking hormonal birth control and depression, the headlines went wild. The stories made for good clicks, but not so great science reporting. Insufficient skepticism about a single study makes it easy to imply birth control definitely causes depression when the study shows nothing of the sort.

The study, which was conducted in Denmark and published in JAMA Psychiatry, analyzed 14 years’ worth of health data for more than 1 million women from national healthcare systems and databases not available in most other countries. It also measured depression two ways: diagnosis at a psychiatric hospital, which would be quite severe depression, or filling a prescription for antidepressants. Across the whole study, 2 percent of all women ages 15 to 34, were diagnosed with depression at a hospital and 13 percent began taking antidepressants.

Several news stories reported an 80 percent increase in risk of depression in some groups of women, but few noted that was relative risk, which is an expression of proportional increase. An 80 percent relative risk does not mean that 80 percent of women taking hormonal birth control develop depression. It means that if 10 women not taking hormonal birth control develop depression, then 18 women on the birth control will develop depression.

In this study, that 80 percent increase in relative risk referred specifically to the likelihood that those ages 15 to 19 taking combined oral contraceptives — the pill containing both progestin and estrogen — would begin taking antidepressants after going on birth control.

However, looking at absolute risks conveys a less dire interpretation. Among women not taking hormonal birth control, 1.7 percent took antidepressants and 0.28 percent received a depression diagnosis at a psychiatric hospital. By comparison, 2.2 percent of women who started birth control began taking antidepressants afterward, and 0.3 percent were diagnosed with depression at a hospital. Basically, about 0.5 percent of women who began hormonal contraception developed depression who might not have otherwise.

“Therefore for an individual woman, even one using a method of hormonal contraception, the overall probability of experiencing one of these outcomes in this study was still fairly low, particularly for diagnosis of depression,” explains Chelsea Polis, a senior research scientist at the Guttmacher Institute.

Rates of those filling antidepressant prescriptions were higher for other forms of hormonal birth control: 4.1 percent for the patch and 3.2 percent for the vaginal ring in the first year, for example. Psychiatric depression diagnoses occurred in 0.7 percent of patch users and 0.6 percent of vaginal ring users.

Even in terms of relative risk, though, many of the risk increases were modest: Among all women taking the combined pill, the increased risk was 10 percent for depression diagnosis and 20 percent for using antidepressants after statistically adjusting for women’s age, educational level, weight and history of endometriosis or polycystic ovary syndrome, all factors that could influence depression risk.

Other increased risks ranged from 20 to 70 percent for all women, depending on contraception type. The largest increases — up to triple the likelihood of starting antidepressants — occurred among teens using the ring or patch.

Another thing to consider is that these numbers represent correlations — two things occurring at the same time that may or may not be linked.

“Depression is common. Contraception use is common. So both of those things are commonly going to occur together,” explains Jeffrey Jensen, a professor of reproductive & developmental sciences and director of the Women’s Health Research Unit at Oregon Health & Science University in Portland.

The study used several methods to reduce the possibility that other things could be causing depression. Jensen pointed out that women who are more likely to take hormones for contraception would probably also be more likely to take antidepressants for depression, but the authors did a separate analysis to compare women to themselves before and after beginning contraception and still found a depression risk.

None of this means that birth control does not cause depression, but it doesn’t mean it does, either. Since a half percent of millions of women taking birth control adds up, it’s important to know whether such a large number of women could be more susceptible to depression, which can be a very serious illness, after starting hormonal contraception.

But it’s complicated, and subtle.

For example, the study also found that depression risk peaked six months after women began using contraceptives, but then decreased to the point that women using hormonal contraception for four years actually had lower rates of depression than those not taking it. Though this likely resulted from many women with depression stopping their birth control, those findings match up with a previous large study finding a protective effect against depression with hormonal contraception. But the studies were done differently: The earlier study included only sexually active women, unlike the new study.

“Unfortunately, the analysis did not provide information on the frequency of depression diagnoses or antidepressant use among women using nonhormonal methods of contraception, such as copper IUDs,” says Polis. “Such a comparison would help to clarify whether the associations were related to other factors common to women choosing to use contraception, rather than being specifically related to the hormonal content of certain contraceptive methods.”

For example, those who become sexually active in adolescence have a higher risk for depression and anxiety, as previous research has shown. Even among women in their 20s and 30s, the decision to begin hormonal contraception may accompany various other circumstances in their lives that could potentially increase the risk of depression or anxiety — not a stretch when the study identifies just a half percent of women with the increased risk.

But the possibility that sexual initiation might come with mental health risks baffled study co-author Lidegaard. “Sexual relationships are a good experience for the majority of women, so I cannot see why women would get depressed by starting sexual relationships,” Lidegaard said in an interview. He pointed out that women not in relationships may experience loneliness, a risk factor for depression, but when asked about single women having sex, he said he believes “the majority feel more happy by realizing how wonderful sexual experiences can be. Why should women get depressed from that?”

What this study does do is suggest that women may respond differently to hormones and medical treatments.

“Doctors should perhaps be more careful when they prescribe hormonal contraception to young women and get a history of previous depression first,” Lidegaard says.

There’s no question that women are going to respond differently to hormonal contraception. But those differences are not well understood.

“We’re all very, very different, and we’re moving in the direction of precision medicine,” adds Catherine Monk, an associate professor of psychiatry and director of research at the Women’s Program at Columbia University Medical Center. “There are some women who are just much more sensitive to these hormone changes.”

The higher risk of depression found among teenage girls, both Monk and Lidegaard pointed out, might be biological, since teens may be more sensitive to the hormonal changes happening during puberty.

“You need to know yourself and be really informed,” Monk says. “If I were of an age and reading this article right now, I would want to be thinking, ‘Who am I? Am I sometimes who has moodiness around my periods?’ ” She notes the importance of each woman considering these findings in conjunction with what she knows about her own body and her own circumstances.

Philosophical differences about medicine may also influence how people interpret these findings in the absence of studies showing causation. Jensen, for example, pointed out that women in developed countries no longer see other women dying during childbirth, illegal, unsafe abortions or other devastating health effects of unplanned pregnancy, and have come to places less value the effectiveness of hormonal birth control.

“Women are more skeptical of using hormonal therapy than ever before,” Jensen says. “It’s a tragedy of the riches. If you really want to be depressed, have an unintended pregnancy.”

Toward the other end of the spectrum, Monk believes we may have gone too far in using hormones to control contraception. “Getting away from barrier methods of contraception is getting away from our bodies,” she says, and she would like to see a much larger range of options for contraception for men and women.

The fact that dissent rages over this issue points out a larger question about women’s health research.

“Understanding women’s health has been neglected, and there’s not enough research into understanding our hormones,” Monk says. “This is partially a story about women’s health research and how we need more of it.”

Tara Haelle is the co-author of The Informed Parent: A Science-Based Resource for Your Child’s First Four Years. She’s on Twitter: @tarahaelle

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