Letters COMMENT & RESPONSE

Addressing Depression and Suicide Among Physician Trainees To the Editor In a JAMA Psychiatry Viewpoint, Goldman and colleagues1 addressed the current lack of concrete programs for the promotion of mental health among medical residents. Highlighting the success of programs implemented by the US Air Force and University of California, San Diego, they put forth a set of recommendations to educate, screen, and treat medical trainees. We agree that the similarities between the Air Force and medical residency programs would allow for an easy translation of such a model to the clinical setting. However, rather than waiting until residency to devote curricular time to mental health education, we believe that the proposed program would be most effective if implemented earlier and continued longitudinally throughout the entire course of medical training. Given the high burden of major depression among medical trainees of all levels,2,3 mental health and wellness education should begin as early as medical school orientation. A substantial proportion of incoming interns are already burned out and depressed prior to leaving medical school. Medical students should be educated on the risk factors and warning signs of burnout and depression and be equipped with resilience-promoting strategies that will empower them to successfully adapt to adversity.4 Incorporating these lessons into a mandatory undergraduate curriculum will help students become more comfortable with conversations about and eliminate the stigma surrounding mental health issues. The program we envision would be continued into residency. During orientation, trainees would fill out validated screening tools for burnout and depression. As the year goes on, they would engage with quarterly small-group sessions guided by a psychotherapist. Ensuring widespread participation means that no individual would feel singled out. In addition, if a trainee were to develop issues with depression in the future, they would already have an easily accessible, established, and familiar resource. Past research has shown the value of peer support and the active role it plays in professional growth and satisfaction.5 Group sessions would foster camaraderie; encourage honest, judgment-free discussions; and actively combat the feelings of isolation characteristic of depression. We hope that the Accreditation Council for Graduate Medical Education recognizes the gravity of this issue and addresses the need for immediate medical curriculum intervention. Early exposure in medical school will allow for information regarding resilience-based strategies to be disseminated to proactively address depression, and consistent 848

mental health screenings will facilitate early detection. As medical trainees ourselves, we commend Goldman and colleagues1 for addressing this important and understudied issue. Rida Khan, BS Jamie S. Lin, MD Douglas A. Mata, MD, MPH Author Affiliations: Department of Student Affairs, Baylor College of Medicine, Houston, Texas (Khan); Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia (Lin); Department of Pathology, Brigham and Women’s Hospital, Harvard University, Boston, Massachusetts (Mata). Corresponding Author: Douglas A. Mata, MD, MPH, Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02114 ([email protected]). Published Online: June 24, 2015. doi:10.1001/jamapsychiatry.2015.0643. Conflict of Interest Disclosures: None reported. 1. Goldman ML, Shah RN, Bernstein CA. Depression and suicide among physician trainees: recommendations for a national response. JAMA Psychiatry. 2015;72(5):411-412. 2. Schwenk TL, Davis L, Wimsatt LA. Depression, stigma, and suicidal ideation in medical students. JAMA. 2010;304(11):1181-1190. 3. Sen S, Kranzler HR, Krystal JH, et al. A prospective cohort study investigating factors associated with depression during medical internship. Arch Gen Psychiatry. 2010;67(6):557-565. 4. Wu G, Feder A, Cohen H, et al. Understanding resilience. Front Behav Neurosci. 2013;7:10. 5. Satterfield JM, Becerra C. Developmental challenges, stressors and coping strategies in medical residents: a qualitative analysis of support groups. Med Educ. 2010;44(9):908-916.

In Reply We agree with Khan and colleagues about the need to implement programs aimed at trainee wellness starting in medical school. Preclinical training offers an excellent opportunity for mandatory sessions to educate students on the issues of depression, suicide, and substance abuse among physicians. Use of screening tools for mental illness and substance abuse with corresponding group sessions may be offered both prior to and during the clinical rotations in medical school to promote resiliency early in a physician’s development. We believe that it is imperative to prioritize mental health throughout the entire course of a physician’s professional life, both before residency training and beyond. In addition to medical students and postgraduate trainees, attending physicians should receive ongoing education and have access to resources. The Depression Awareness and Suicide Prevention Program at the University of California, San Diego, was offered to students and physicians of all stages.1 A study at the Mayo Clinic developed a method for building resiliency skills among attending-level physicians.2 By broadly disseminating similar promising frameworks, physicians can become familiar with skills, screening proto-

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cols, and available treatment options that can be used to enhance wellness throughout one’s career. Matthew L. Goldman, MD, MS Ravi N. Shah, MD Carol A. Bernstein, MD Author Affiliations: Department of Psychiatry, Columbia University Medical Center, New York, New York (Goldman, Shah); New York State Psychiatric Institute, New York (Goldman, Shah); New York University School of Medicine, New York (Bernstein). Corresponding Author: Ravi N. Shah, MD, Columbia University Medical Center, New York State Psychiatric Institute, 1051 Riverside Dr, Box 103, New York, NY 10032 ([email protected]).

of OxyContin have decreased 53% and 38%, respectively, in the first 2 years after reformulation and have subsequently decreased further.5 Abuse-deterrent formulations of prescription opioids are one effective measure to reduce prescription drug abuse. They are not a panacea, but they offer the promise of discouraging individuals who decide to crush their medication for the purpose of abuse. Richard C. Dart, MD, PhD S. Geoff Severtson, PhD Jody L. Green, PhD

Conflict of Interest Disclosures: None reported.

Author Affiliations: RADARS System, Denver Health and Hospital Authority, Denver, Colorado.

1. Moutier C, Norcross W, Jong P, et al. The suicide prevention and depression awareness program at the University of California, San Diego School of Medicine. Acad Med. 2012;87(3):320-326.

Corresponding Author: Richard C. Dart, MD, PhD, RADARS System, Denver Health and Hospital Authority, 777 Bannock St, Mail Code 0180, Denver, CO 80204 ([email protected]).

2. Sood A, Prasad K, Schroeder D, Varkey P. Stress management and resilience training among Department of Medicine faculty: a pilot randomized clinical trial. J Gen Intern Med. 2011;26(8):858-861.

Published Online: July 8, 2015. doi:10.1001/jamapsychiatry.2015.0723.

Published Online: June 24, 2015. doi:10.1001/jamapsychiatry.2015.0639.

Abuse-Deterrent Formulations of Prescription Opioids To the Editor Cicero and Ellis1 reported that 25% to 30% of individuals entering a group of substance abuse treatment centers endorse the reformulated OxyContin as a drug they had abused in the previous 30 days. Although Cicero and Ellis1 reported that the rate of endorsement of OxyContin fell from 46% to 25%, the popular press has portrayed the report as evidence that abuse-deterrent formulations are ineffective. The Survey of Key Informants’ Patients (SKIP) program on which Cicero and Ellis 1 reported is one part of the Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS) system, a national multicomponent surveillance system focusing specifically on the abuse and diversion of prescription drugs.2 The analysis omitted that the number of OxyContin endorsements by individuals in the SKIP program has fallen from an average of 0.273 abuse endorsements per 100 000 population 1 year prior the reformulation to 0.157 per 100 000 population in the second quarter of 2014, indicating a 42% decline. Another RADARS program, the Opioid Treatment Program (OTP), shares with SKIP identical questions regarding drugs the respondent has abused in the previous 30 days. The OTP represents a slightly different population—individuals entering substance abuse programs that use medical substitution therapy such as methadone or buprenorphine. In the OTP, the number of OxyContin endorsements has fallen from an average of 0.593 abuse endorsements per 100 000 population 1 year prior to the reformulation to 0.172 per 100 000 population, marking a 71% decline. We conclude that the abuse-deterrent formulations are indeed effective at reducing diversion and abuse. This conclusion is also supported by evidence from other research.3,4 Finally, the RADARS system also includes surveillance programs including drug diversion and poison centers.2 In these programs, diversion and intentional abuse jamapsychiatry.com

Conflict of Interest Disclosures: The Researched Abuse, Diversion and Addiction-Related Surveillance system is a department of the Denver Health and Hospital Authority. The system is supported financially by surveillance subscriptions from multiple pharmaceutical manufacturers. By contract, the subscriber does not have access to the data and is allowed no role in publication decisions. Thus, there are no sponsors for the study and no subscriber knew about the study nor participated in the development of the analysis, the analysis itself, or in any phase of writing. No other disclosures were reported. 1. Cicero TJ, Ellis MS. Abuse-deterrent formulations and the prescription opioid abuse epidemic in the United States: lessons learned from OxyContin. JAMA Psychiatry. 2015;72(5):424-430. 2. Dart RC, Surratt HL, Cicero TJ, et al. Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med. 2015;372(3):241-248. 3. Butler SF, Cassidy TA, Chilcoat H, et al. Abuse rates and routes of administration of reformulated extended-release oxycodone: initial findings from a sentinel surveillance sample of individuals assessed for substance abuse treatment. J Pain. 2013;14(4):351-358. 4. Sessler NE, Downing JM, Kale H, Chilcoat HD, Baumgartner TF, Coplan PM. Reductions in reported deaths following the introduction of extended-release oxycodone (OxyContin) with an abuse-deterrent formulation. Pharmacoepidemiol Drug Saf. 2014;23(12):1238-1246. 5. Severtson SG, Bartelson BB, Davis JM, et al. Reduced abuse, therapeutic errors, and diversion following reformulation of extended-release oxycodone in 2010. J Pain. 2013;14(10):1122-1130.

To the Editor It is with interest that we read the article “Abuse-Deterrent Formulations and the Prescription Opioid Abuse Epidemic in the United States: Lessons Learned From OxyContin” published in JAMA Psychiatry.1 Through their survey study, Cicero and Ellis 1 concluded that abusedeterrent formulations (ADFs) can have the intended purpose of curtailing abuse, but only with limited effectiveness, and efforts to reduce opioid supply alone with ADF technology will not mitigate the opioid abuse program in the United States. However, we would like to emphasize that increased use of heroin was predicted a few years ago by other experts2,3 when the newly formulated ADF OxyContin was introduced into the market. It was subsequently confirmed that prescription opioid abuse decreased by approximately 12% between 2010 and 2011, while heroin use increased. There were 119 000 total users in 2003 but 281 000 by 2011.4 Thus, the introduction of ADF opioids has, in part, driven a movement away from (Reprinted) JAMA Psychiatry August 2015 Volume 72, Number 8

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Addressing Depression and Suicide Among Physician Trainees--Reply.

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