Preventing Suicidal Ideation in Medical Interns.

In the first suchstudyof its kind, tomyknowledge,Guille and colleagues1 have shown that the use of web-based cognitive behavioral therapy (CBT) is effective in reducing suicidal ideation among medical interns. Relative to interns in an education and attentiononly control condition, those whoparticipated inweb-basedCBTwere60%less likely toendorse suicidal ideationduring the internship year. Buildingon the work of Christensen et al2 in developing electronic health interventions for suicide prevention, this study1 demonstrates thatyoungphysicianscanbe“inoculated”ataverycritical timeintheir lives, that is,providedwithknowledgeandskills that enable them to be resilient to the stresses of internship, depression, and suicidal ideation (a form of “selective” prevention in the Institute of Medicine’s taxonomy of mental illness prevention strategies). To place this study in context, we have long known that rates of suicide amongphysicians (particularly amongwomen physicians) are higher than in the general population.3While theproportionatemortality ratioofphysicianswhosmokehas declinedasphysicianeducationregarding thedangersof smokinghas increased, by contrast, theproportionatemortality ratio for suicide amongphysicianshas remainedhigh.3Risk factors for physician suicide aremainlyunipolar or bipolarmood disorders and substance use disorders.3 Physicians often do not recognize depression in themselves and/or have patterns of self-medication.Moreover, stigmaandconcerns about confidentiality are frequent barriers tomedical students andphysicians seeking help.4,5 Depression complicates the lives of young physicians.6 It disrupts sleep andbegets and amplifies cognitive disabilities. By exacerbating interpersonal difficulties, it undermines the ability to function effectively in caregiving teams and to find the support needed to cope with medical training. And, as Guille and colleagues1 emphasize, depression canbe aprecursor to suicide, with 1 doctor dying by suicide approximately every day. To date, somemedical schools and academic health centers have responded by curriculum reform (eg, includingmaterial on physician depression and suicide in lectures), use of depression-screening instruments to fill outprivatelyandconfidentially as a learning experience (eg, Patient Health Questionnaire–9), and education about stress and how to get help. Theseare important steps.Theyaddress theneedforearlyeducation about depression and can address stigma as a barrier to seeking help. However, many students and young physiciansdonotwant to take time for treatment, have limitedability to pay for care, and worry about issues of confidentiality, medical licensability, and clinical referrals.6 It iswithin thisbroader institutional context that theGuille et al1 study canbeunderstood. Specifically, it is a studyof prevention, not treatment—thereby showing how to circumvent many of the barriers to treatment including social, financial, and temporal issues.As aweb-based intervention, it offers access to mental health intervention to persons who might be unable or unwilling otherwise to access such services. The intervention is evidencebasedandefficientwith respect to time and money, 2 barriers that impede treatment of clinical depression. As a web-based intervention, it is also private, circumventing the concerns that could attend face-to-face treatment. Finally, it also has the potential for scalability, pending further research in other training programs, that is, for expanded use by the 24 000 medical trainees who begin their first postgraduate year annually. Finally, Guille et al,1 to my knowledge, have contributed the first controlled experimental observation about the efficacy of a learning-based approach to reducing the risk for suicidal ideation inphysicians—sadly,dataon thishavebeen lackingheretofore. Specifically, 12%of interns (12of 100) randomly assigned to CBT endorsed suicidal ideation vs 21.2% of interns (21 of 99) assigned to the attention-only control arm of the study. These data are broadly consistentwith the efficacy of brief behavioral and psychological interventions to reduce the incidenceof episodes ofmajor depression in at-risk adults (indicated and selective prevention).7 Going forward, one can anticipate that as issues of worklifebalanceandself-careareaddressedandasphysiciansadopt wellness strategies that promotewell-being, patient carewill also benefit.3,6