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Original Investigation |

Web-Based Cognitive Behavioral Therapy Intervention for the Prevention of Suicidal Ideation in Medical Interns A Randomized Clinical Trial

Constance Guille, MD1; Zhuo Zhao, MS2; John Krystal, MD3; Breck Nichols, MD4; Kathleen Brady, MD, PhD1; Srijan Sen, MD, PhD2
[+] Author Affiliations
1Department of Psychiatry and Behavioral Science, Medical University of South Carolina, Charleston
2Department of Psychiatry, University of Michigan, Ann Arbor
3Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
4Department of Pediatrics, University of Southern California, Los Angeles
JAMA Psychiatry. 2015;72(12):1192-1198. doi:10.1001/jamapsychiatry.2015.1880.
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Importance  In the United States, approximately 1 physician dies by suicide every day. Training physicians are at particularly high risk, with suicidal ideation increasing more than 4-fold during the first 3 months of internship year. Despite this increase, to our knowledge, very few efforts have been made to prevent the escalation of suicidal thoughts among training physicians.

Objective  To assess the effectiveness of a web-based cognitive behavioral therapy (wCBT) program delivered prior to the start of internship year in the prevention of suicidal ideation in medical interns.

Design, Setting, and Participants  A randomized clinical trial conducted at 2 university hospitals with 199 interns from multiple specialties during academic years 2009-2010 or 2011-2012. The current study was conducted from May 2009 to June 2010 and May 2011 to June 2012, and data were analyzed using intent-to-treat principles, including last observation carried forward.

Interventions  Interns were randomly assigned to 2 study groups (wCBT and attention-control group [ACG]), and completed study activities lasting 30 minutes each week for 4 weeks prior to starting internship year. Participants assigned to wCBT completed online CBT modules and those assigned to ACG received emails with general information about depression, suicidal thinking, and local mental health professionals.

Main Outcomes and Measures  The Patient Health Questionnaire–9 was used to assess suicidal ideation (ie, “thoughts that you would be better off dead or hurting yourself in some way”) prior to the start of intern year and at 3-month intervals throughout the year.

Results  A total of 62.2% of interns (199 of 320) agreed to take part in the study; 100 were assigned to the wCBT group and 99 to the ACG. During at least 1 point over the course of internship year, 12% of interns (12 of 100) assigned to wCBT endorsed suicidal ideation compared with 21.2% of interns (21 of 99) assigned to ACG. After adjusting for covariates identified a priori that have previously shown to increase the risk for suicidal ideation, interns assigned to wCBT were less likely to endorse suicidal ideation during internship year (relative risk, 0.40; 95% CI, 0.17- 0.91; P = .03) compared with those assigned to ACG.

Conclusions and Relevance  This study demonstrates that a free, easily accessible, brief wCBT program is associated with reduced likelihood of suicidal ideation among medical interns. Prevention programs with these characteristics could be easily disseminated to medical training programs across the country.

Trial Registration  anzctr.org.au Identifier: ACTRN12610000628044

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Figure 1.
Study Flow of Participants From Recruitment to Data Analysis

CBT indicates cognitive behavioral therapy.

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Figure 2.
Study Timeline

ACG indicates attention-control group; wCBT, web-based cognitive behavioral therapy.

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Figure 3.
Number of Interns Endorsing Suicidal Ideation During Internship Year

wCBT indicates web-based cognitive behavioral therapy.

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