News & Analysis
Mann, MD, a psychiatrist at Columbia and the New York State Psychiatric Institute. “The chairman of medicine came back immediately from his vacation. We had meetings with all of the interns and residents. We had a massive, carefully organized set of initiatives, all geared to help people deal with their feelings about what happened.” The approach has been used in communities, corporations, and the military after a suicide prompts concerns over the potential for contagion or “copycat” suicides, Mann said. “You give people information, and you create the opportunity for people to ask questions.” One might wonder whether medicine attracts individuals who are more vulnerable to suicide. But a new study found that when students entered medical school, they actually had lower rates of burnout and depression symptoms and a higher quality of life than college graduates the same age who
weren’t enrolled in medical school (Brazeau CM et al. Acad Med. doi:10.1097/ACM .0000000000000482 [published online September 23, 2014]). The study, whose coauthors include Moutier and Dyrbye, surveyed entering students at 6 medical schools. But by the time they graduated, about half of medical students had burnout, a syndrome of depersonalization, emotional exhaustion, and a feeling of low personal accomplishment, Dyrbye found in a previous study (Dyrbye LN et al. Med Teach. 2011; 33[9]:756-758). Other research found that burnout was independently associated with recent suicidal ideation in practicing surgeons (Shanafelt TD et al. Arch Surg. 2011; 146[1]:54-62). Research shows that residents are depressed at a higher rate than people the same age who are not pursuing careers in medicine, Brigham said. “Is medical train-
ing doing some of the damage? What we’re finding is that there is an effect that medical education is having, and it’s not a positive one.” Some of the potential fixes are relatively simple, such as including a gym or a cafeteria when designing new medical school buildings, Zisook said. In a survey of first- and second-year students at 7 medical schools, Dyrbye and her coauthors found that how students were evaluated had a greater effect than other aspects of the curriculum structure on their well-being (Reed DA et al. Acad Med. 2011;86[11]:1367-1373). Students who were graded pass/fail were less likely to have burnout or consider dropping out of school than students who received letter grades. “I believe it is possible to reconstruct the medical curriculum to make it a more positive and humanistic experience,” the ACGME’s Baldwin said.
Rate of Suicide Increases in Middle Age Primary Care Key to Suicide Prevention Bridget M. Kuehn, MSJ
Eva Vagg/New York State Psychiatric Institute
T
he recent suicide death of comedian Robin Williams drew attention to a worrisome public health trend: a rising rate of suicide among middle-aged individuals. An analysis by the US Centers for Disease Control and Prevention found a 28.4% increase in suicides between 1999 and 2010 among people aged 35 to 64 years (Sullivan EM et al. MMWR Morb Mortal Wkly Rep. 2013;62[17]:321-325). During that period, suicide rates for men aged 50 to 59 years increased by about 50%, and the rate for women aged 60 to 64 years grew nearly 60%. The US National Strategy on Suicide Prevention highlights the risks facing this age group as well as other high-risk groups (such as Native Americans and youths who are lesbian, gay, bisexual, transgender, or questioning their sexual identity) and emphasizes that primary care physicians can help prevent suicide and its harmful effects on loved ones (Kuehn BM. JAMA. 2013;310[6]:570571). J. John Mann, MD, Paul Janssen Professor Translational Neuroscience in
Psychiatry and Radiology at Columbia University and the director of the division of molecular imaging and neuropathology at the New York State Psychiatric Institute, discussed suicide trends and the role of primary care physicians in preventing suicides with JAMA. JAMA: Do we know why the suicide rate has increased among middle-aged individuals? DR MANN: We are not entirely sure why the suicide rate is going up in middle-aged people. Suicide rates fluctuate. It’s linked to the level of alcohol consumption per capita. It has been linked to access to and quality of psychiatric care. But we don’t always know the reasons for increases and decreases in suicide rates. Some things to think about with men is how they deal with adversity like divorce or widowhood. The apparent effect of divorce on men, in terms of suicide, is greater than the effect seen in women even though women are often financially worse off after divorce. Since the increase in suicide rates also affects women, and the divorce rates have not changed that much since 1999, this may not play much of a role.
jama.com
Primary care physicians can help prevent suicides by asking patients about depression, said J. John Mann, MD, professor of psychiatry at Columbia University.
Another factor to think about since 2008 is the recession. There is a lot of debate about whether this has affected suicide rates because there is an imperfect match-up between the dates of the recession and the JAMA November 5, 2014 Volume 312, Number 17
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Georgia User on 05/28/2015
1727
News & Analysis
changes in suicide rates in different countries. Clearly, the recession starting in 2008 does not explain an increase in suicide rates that started well before that year. JAMA: What can primary care physicians look for to identify individuals at risk of suicide? DR MANN: We focus on what primary care physicians can do because we know that within 30 days of a suicide attempt a patient is twice as likely to see an internist than a mental health care professional. If we want to have an impact on suicide, you need to focus on that primary care contact. Depression is still undertreated and underdiagnosed. In part, this may be because patients may be presenting to their primary care physician with physical metaphors for their condition. They may describe somatic symptoms: feeling tired, sleeping poorly, poor concentration, losing weight. But when the laboratory results come back negative the patients are reassured everything is okay. Important questions are not being asked. Internists should not be railroaded into thinking it’s a somatic problem. They should ask if the patient is feeling depressed. For example, “Have you had any periods in the past 12 months where you felt depressed and weren’t able to do much?” That will open the door to a diagnosis of major depression. JAMA: What screening tools are currently available?
1728
DR MANN: First, ask about depression and its severity. Then ask about suicidal thoughts and whether they involve methods and whether the person thinks they have intent, meaning the person believes he or she is likely to carry out the plan. Patients with intent need a prompt evaluation by a specialist. Have they attempted suicide in the past? Do they have a close relative who has committed suicide? Both are associated with a higher risk of suicide. JAMA: Are there other screening tools in development? DR MANN: Other methods for assessing suicide risk remain in the research domain. They include brain imaging. We have identified with positron emission tomography a neurotransmitter disorder in depressed patients who have committed suicide. This may reflect a predisposition to suicidal behavior. Another tool being studied is genetic markers for suicide. Epigenetic markers may also play a role. There is the possibility of creating blood tests for potential genetic and epigenetic markers of risk. JAMA: When physicians identify a patient at risk, what should they do? DR MANN: If the person has a family history of suicide or has suicidal ideation with a plan and intent, they must refer that person for psychiatric evaluation. The development of suicidal ideation with a plan and intent is an emergency. If the patient has
passive ideation, then the physician can make a referral to a psychiatrist or make a diagnosis of depression and start treatment. Most psychiatrists and internists will treat the patient with antidepressants. Cognitive behavioral therapy is another option for mild to moderate depression, but that’s not a form of therapy most clinicians are trained to deliver. Most suicides occur in those with untreated depression. So a potent way to reduce suicide is by treating depression. It’s very important for physicians to ask patients they are treating for depression how much they have improved, just like treating blood pressure. We are shooting for 80% or more improvement in symptoms. In adults, the degree of improvement in depression is proportional to the reduction in the risk of future suicidal ideation and behavior. JAMA: Are there other things physicians should be asking about? DR MANN: It’s important to ask about the use of alcohol. It shouldn’t be used at all by people with depression. When people drink, they can go from low risk to high risk very quickly. Alcohol can prevent an antidepressant from working. Also ask family to remove all guns from the house. Guns are the most common suicide method in the United States, which is different from most other countries. Availability of guns is a big factor in suicide risk. Restricting access to very lethal means is a very important part of suicide prevention.
JAMA November 5, 2014 Volume 312, Number 17
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Georgia User on 05/28/2015
jama.com
Mann, MD, a psychiatrist at Columbia and the New York State Psychiatric Institute. “The chairman of medicine came back immediately from his vacation. We had meetings with all of the interns and residents. We had a massive, carefully organized set of initiatives, all geared to help people deal with their feelings about what happened.” The approach has been used in communities, corporations, and the military after a suicide prompts concerns over the potential for contagion or “copycat” suicides, Mann said. “You give people information, and you create the opportunity for people to ask questions.” One might wonder whether medicine attracts individuals who are more vulnerable to suicide. But a new study found that when students entered medical school, they actually had lower rates of burnout and depression symptoms and a higher quality of life than college graduates the same age who
weren’t enrolled in medical school (Brazeau CM et al. Acad Med. doi:10.1097/ACM .0000000000000482 [published online September 23, 2014]). The study, whose coauthors include Moutier and Dyrbye, surveyed entering students at 6 medical schools. But by the time they graduated, about half of medical students had burnout, a syndrome of depersonalization, emotional exhaustion, and a feeling of low personal accomplishment, Dyrbye found in a previous study (Dyrbye LN et al. Med Teach. 2011; 33[9]:756-758). Other research found that burnout was independently associated with recent suicidal ideation in practicing surgeons (Shanafelt TD et al. Arch Surg. 2011; 146[1]:54-62). Research shows that residents are depressed at a higher rate than people the same age who are not pursuing careers in medicine, Brigham said. “Is medical train-
ing doing some of the damage? What we’re finding is that there is an effect that medical education is having, and it’s not a positive one.” Some of the potential fixes are relatively simple, such as including a gym or a cafeteria when designing new medical school buildings, Zisook said. In a survey of first- and second-year students at 7 medical schools, Dyrbye and her coauthors found that how students were evaluated had a greater effect than other aspects of the curriculum structure on their well-being (Reed DA et al. Acad Med. 2011;86[11]:1367-1373). Students who were graded pass/fail were less likely to have burnout or consider dropping out of school than students who received letter grades. “I believe it is possible to reconstruct the medical curriculum to make it a more positive and humanistic experience,” the ACGME’s Baldwin said.
Rate of Suicide Increases in Middle Age Primary Care Key to Suicide Prevention Bridget M. Kuehn, MSJ
Eva Vagg/New York State Psychiatric Institute
T
he recent suicide death of comedian Robin Williams drew attention to a worrisome public health trend: a rising rate of suicide among middle-aged individuals. An analysis by the US Centers for Disease Control and Prevention found a 28.4% increase in suicides between 1999 and 2010 among people aged 35 to 64 years (Sullivan EM et al. MMWR Morb Mortal Wkly Rep. 2013;62[17]:321-325). During that period, suicide rates for men aged 50 to 59 years increased by about 50%, and the rate for women aged 60 to 64 years grew nearly 60%. The US National Strategy on Suicide Prevention highlights the risks facing this age group as well as other high-risk groups (such as Native Americans and youths who are lesbian, gay, bisexual, transgender, or questioning their sexual identity) and emphasizes that primary care physicians can help prevent suicide and its harmful effects on loved ones (Kuehn BM. JAMA. 2013;310[6]:570571). J. John Mann, MD, Paul Janssen Professor Translational Neuroscience in
Psychiatry and Radiology at Columbia University and the director of the division of molecular imaging and neuropathology at the New York State Psychiatric Institute, discussed suicide trends and the role of primary care physicians in preventing suicides with JAMA. JAMA: Do we know why the suicide rate has increased among middle-aged individuals? DR MANN: We are not entirely sure why the suicide rate is going up in middle-aged people. Suicide rates fluctuate. It’s linked to the level of alcohol consumption per capita. It has been linked to access to and quality of psychiatric care. But we don’t always know the reasons for increases and decreases in suicide rates. Some things to think about with men is how they deal with adversity like divorce or widowhood. The apparent effect of divorce on men, in terms of suicide, is greater than the effect seen in women even though women are often financially worse off after divorce. Since the increase in suicide rates also affects women, and the divorce rates have not changed that much since 1999, this may not play much of a role.
jama.com
Primary care physicians can help prevent suicides by asking patients about depression, said J. John Mann, MD, professor of psychiatry at Columbia University.
Another factor to think about since 2008 is the recession. There is a lot of debate about whether this has affected suicide rates because there is an imperfect match-up between the dates of the recession and the JAMA November 5, 2014 Volume 312, Number 17
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Georgia User on 05/28/2015
1727
News & Analysis
changes in suicide rates in different countries. Clearly, the recession starting in 2008 does not explain an increase in suicide rates that started well before that year. JAMA: What can primary care physicians look for to identify individuals at risk of suicide? DR MANN: We focus on what primary care physicians can do because we know that within 30 days of a suicide attempt a patient is twice as likely to see an internist than a mental health care professional. If we want to have an impact on suicide, you need to focus on that primary care contact. Depression is still undertreated and underdiagnosed. In part, this may be because patients may be presenting to their primary care physician with physical metaphors for their condition. They may describe somatic symptoms: feeling tired, sleeping poorly, poor concentration, losing weight. But when the laboratory results come back negative the patients are reassured everything is okay. Important questions are not being asked. Internists should not be railroaded into thinking it’s a somatic problem. They should ask if the patient is feeling depressed. For example, “Have you had any periods in the past 12 months where you felt depressed and weren’t able to do much?” That will open the door to a diagnosis of major depression. JAMA: What screening tools are currently available?
1728
DR MANN: First, ask about depression and its severity. Then ask about suicidal thoughts and whether they involve methods and whether the person thinks they have intent, meaning the person believes he or she is likely to carry out the plan. Patients with intent need a prompt evaluation by a specialist. Have they attempted suicide in the past? Do they have a close relative who has committed suicide? Both are associated with a higher risk of suicide. JAMA: Are there other screening tools in development? DR MANN: Other methods for assessing suicide risk remain in the research domain. They include brain imaging. We have identified with positron emission tomography a neurotransmitter disorder in depressed patients who have committed suicide. This may reflect a predisposition to suicidal behavior. Another tool being studied is genetic markers for suicide. Epigenetic markers may also play a role. There is the possibility of creating blood tests for potential genetic and epigenetic markers of risk. JAMA: When physicians identify a patient at risk, what should they do? DR MANN: If the person has a family history of suicide or has suicidal ideation with a plan and intent, they must refer that person for psychiatric evaluation. The development of suicidal ideation with a plan and intent is an emergency. If the patient has
passive ideation, then the physician can make a referral to a psychiatrist or make a diagnosis of depression and start treatment. Most psychiatrists and internists will treat the patient with antidepressants. Cognitive behavioral therapy is another option for mild to moderate depression, but that’s not a form of therapy most clinicians are trained to deliver. Most suicides occur in those with untreated depression. So a potent way to reduce suicide is by treating depression. It’s very important for physicians to ask patients they are treating for depression how much they have improved, just like treating blood pressure. We are shooting for 80% or more improvement in symptoms. In adults, the degree of improvement in depression is proportional to the reduction in the risk of future suicidal ideation and behavior. JAMA: Are there other things physicians should be asking about? DR MANN: It’s important to ask about the use of alcohol. It shouldn’t be used at all by people with depression. When people drink, they can go from low risk to high risk very quickly. Alcohol can prevent an antidepressant from working. Also ask family to remove all guns from the house. Guns are the most common suicide method in the United States, which is different from most other countries. Availability of guns is a big factor in suicide risk. Restricting access to very lethal means is a very important part of suicide prevention.
JAMA November 5, 2014 Volume 312, Number 17
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Georgia User on 05/28/2015
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