Results of largest trial of suicide intervention in emergency departments ever conducted in US

The NIMH issued a press release about the publication in JAMA Psychiatry of results of the ED-SAFE Study, the largest suicide intervention trial ever conducted in emergency departments (ED) in US.

NIMH

“We expect that EDs are capable of helping individuals at risk for suicide attempts. Earlier ED-SAFE study findings showed that brief universal screening could improve detection of more individuals at risk,”, said Jane Pearson, Ph.D., chair of the Suicide Research Consortium at the NIMH. “These recent findings show that if ED care also includes further assessment, safety planning, and telephone-based support after discharge, there is a significant reduction in later suicide attempts among adults.”

“We were happy that we were able to find these results,” said lead author Ivan Miller, Ph.D., Professor of Psychiatry and Human Behavior at Brown University, Providence, Rhode Island. “We would like to have had an even stronger effect, but the fact that we were able to impact attempts with this population and with a relatively limited intervention is encouraging.”

The report of the study in JAMA Psychiatry

Miller IW, Camargo CA, Arias SA, Sullivan AF, Allen MH, Goldstein AB, Manton AP, Espinola JA, Jones R, Hasegawa K, Boudreaux ED. Suicide prevention in an emergency department population: the ED-SAFE Study. JAMA Psychiatry. 2017 Apr 29.

The recently revamped website for the JAMA network of journals provided updated reports of the heavy traffic being drawn in by the article.

The new Key Points feature for important articles gave succinct, more quickly digestible summary of the study than the similarly spun abstract.

Key Points

Question  Do emergency department (ED)–initiated interventions reduce subsequent suicidal behavior among a sample of high-risk ED patients?

Findings  In this multicenter study of 1376 ED patients with recent suicide attempts or ideation, compared with treatment as usual, an intervention consisting of secondary suicide risk screening by the ED physician, discharge resources, and post-ED telephone calls focused on reducing suicide risk resulted in a 5% absolute decrease in the proportion of patients subsequently attempting suicide and a 30% decrease in the total number of suicide attempts over a 52-week follow-up period.

Meaning  For ED patients at risk for suicide, a multifaceted intervention can reduce future suicidal behavior.

The abstract elaborates:

Results  A total of 1376 participants were recruited, including 769 females (55.9%) with a median (interquartile range) age of 37 (26-47) years. A total of 288 participants (20.9%) made at least 1 suicide attempt, and there were 548 total suicide attempts among participants. There were no significant differences in risk reduction between the TAU and screening phases (23% vs 22%, respectively). However, compared with the TAU phase, patients in the intervention phase showed a 5% absolute reduction in suicide attempt risk (23% vs 18%), with a relative risk reduction of 20%. Participants in the intervention phase had 30% fewer total suicide attempts than participants in the TAU phase. Negative binomial regression analysis indicated that the participants in the intervention phase had significantly fewer total suicide attempts than participants in the TAU phase (incidence rate ratio, 0.72; 95% CI, 0.52-1.00; P = .05) but no differences between the TAU and screening phases (incidence rate ratio, 1.00; 95% CI, 0.71-1.41; P = .99).

I have the benefit of having read the entire article a number of times, but there are some notable statistics being reported in the abstract and some crucial things being left out.

The phase of the study that involved only introducing screening into treatment as usual (TAU) had no effect on suicide attempts (p= .99). The claim of an effect of the more extensive intervention on suicide attempts depends on multivariate analyses that include a confidence interval that includes 1.0. (incidence rate ratio, 0.72; 95% CI, 0.52-1.00; P = .05).

From JAMA Psychiatry

Results are quite weak, at best. Pairwise comparisons are being reporting, first the screening versus TAU, then the more extensive intervention versus TAU. Missing is any reporting of the overall ANOVA testing whether there is at least one significant pairwise difference between groups. Obtaining such a significant difference would justify a post hoc look at the specific pairs. Given what we have already been told in the abstract, it is safe to assume no overall effect. This is a null trial. If we stuck to a priori statistical plans, we would have to say that a phased-in, comprehensive intervention with suicidal patients presenting in an emergency room failed to impact subsequent suicide attempts.

These findings contradict the statement of the NIMH Chair of the Suicide Research Consortium.

I know, it is arbitrary to make go/no go decisions based on an arbitrary level of significance, p< .05 or whatever. Yet, the implement/don’t implement and evidence-supported/not evidence-supported distinctions are binary. The best we can do is to set criteria based on a power analysis and avoid switching criteria when we don’t obtain the results that we would have liked.

We can stop here in our critique with the usual messages to avoid spinning of results in order to obtain politically expedient and socially satisfying, even if inaccurate conclusions.  Once again, results of a trial are being exaggerated to justify a conclusion to which the researchers and policy makers are already committed.

But there is a lot more to be learned from this report of a large and historically significant trial.

Who was enrolled and what treatments were offered?

1376 adult participants were selected from persons presenting to 8 emergency departments across 7 states with participants with a suicide attempt or ideation within the week prior to the ED visit. Patients under 18 were excluded.

In the TAU phase, participants were treated according to the usual and customary care at each site, serving as the control for the subsequent study phases.

In the screening phase, sites implemented clinical protocols with universal suicide risk screening (the Patient Safety Screener) for all ED patients.

In the intervention phase, in addition to universal screening, all sites implemented a 3-component intervention: (1) a secondary suicide risk screening designed for ED physicians to evaluate suicide risk following an initial positive screen, (2) the provision of a self-administered safety plan and information to patients by nursing staff, and (3) a series of telephone calls to the participant, with the optional involvement of their significant other (SO), for 52 weeks following the index ED visit.

The outcome

The outcome was the proportion of patients who made a suicide attempt and the total number of suicide attempts occurring during the 52-week follow-up period.

Overall, of 1376 participants, 288 (20.9%) made at least 1 suicide attempt during the 12-month period. In the TAU phase, 114 of 497 participants (22.9%) made a suicide attempt, compared with 81 of 377 participants (21.5%) in the screening phase and 92 of 502 participants (18.3%) in the intervention phase. Five attempts were fatal, with fatalities observed in the TAU phase (n = 2) and intervention phase (n = 3).

Suicide attempts can be interpreted as an outcome in itself or as a surrogate outcome for deaths by suicide. Despite the substantial sample size, there is no way that this study could have demonstrated a significant reduction in deaths by suicide. That reflects the infrequency of death by suicide, even in such a high risk population. The ratio of 57.6 suicide attempts per one death by suicide is much higher than what is typically observed (usually in the range of 100 or so per suicide. This probably reflects the high risk nature of this population, as well as the methodology for determining the serious of suicide attempts.

More evidence that screening for suicide doesn’t improve outcomes

This study adds to an accumulation of a lack of evidence that routine screening for suicide is either efficient or leads to less suicides.

Previously, I blogged about the SEYLE trial of a school-based intervention to prevent teen suicide. It was a large RCT, but failed to demonstrate that screening affected the likelihood of a suicide attempt.  The null findings for the Screening by Professionals programme (ProfScreen) of SEYLE are generally downplayed.

Another blog post Use of scales to assess risk for a suicide attempt wastes valuable clinical resources discussed a large UK study that found none of the commonly used screening scales were clinically useful in predicting subsequent suicide.

That study concluded

Risk scales following self-harm have limited clinical utility and may waste valuable resources. Most scales performed no better than clinician or patient ratings of risk. Some performed considerably worse. Positive predictive values were modest. In line with national guidelines, risk scales should not be used to determine patient management or predict self-harm.

Nonetheless there is:

The Joint Commission.  Detecting and treating suicide ideation in all settings.  Sentinel Event Alert. 2016;(56):1-7.

The Joint Commission is a United States-based nonprofit tax-exempt 501(c) organization[1] that accredits more than 21,000 health care organizations and programs in the United States. The Joint Commission recommends that hospitals routinely screen patients for risk of suicide.

An editorial accompanying the JAMA Psychiatry report cited this recommendation as part of the rationale of the ED-SAFE  study and warned of implementing screening without resources:

Since the alert, many hospitals have implemented suicide risk screening without the benefit of evidence-based tools and clinical pathways, potentially increasing the risk of underdetection (ie, false-negatives) or overburdening limited mental health resources with false-positives.

Most patients in the ED-SAFE study were not recorded as receiving the intervention as intended.

Medical record review indicated that 449 of 502 participants (89.4%) had received a suicide risk assessment from their physician, but only 17 (3.9%) had documentation of the ED-SAFE standardized secondary screening was used.

And

Among those participants who completed the initial CLASP call, 114 (37.4%) reported having received a written safety plan in the ED.

You cannot fault these researchers for having failed to make a concerted effort to train personnel in the participating sites or to systematically implement the study protocol. See

Boudreaux ED, Camargo CA, Arias SA, Sullivan AF, Allen MH, Goldstein AB, Manton AP, Espinola JA, Miller IW. Improving suicide risk screening and detection in the emergency department. American Journal of Preventive Medicine. 2016 Apr 30;50(4):445-53.

A wealth of evidence suggests that is it is difficult to implement formal screening with self-report and interviewer-completed checklists in medical settings. Most medical personnel find such instruments intrusive and they are not efficient, anyway. Alex Mitchell and I documented this in our book, Screening for Depression in Clinical Practice: An Evidence-Based Guide

.In both the screening and intervention phase, it was difficult to get adherence to the protocol, in part  because patients entering EDs are not necessarily cooperative. But more importantly, EDs in this study were not well-connected to the specialty mental health services needed for timely follow up. The accompanying editorial notes:

Although EDs have been conceptualized as key sites to identify and treat individuals at high risk for suicide,8 the troubling reality is that mental health resources are not available in most American EDs, and few universally screen for suicide risk.9,10 Notably, participating ED-SAFE study sites did not have psychiatric services within or adjacent to the ED in order to increase generalizability. Although time constraints, inadequate training, and lack of proper screening instruments have been cited as reasons clinicians do not routinely screen for suicide risk,8,10,11 the absence of psychiatric services in most EDs reflects disproportionately low cultural expectations of the ED in addressing potentially life-threatening mental health crises.

The realignment and reallocation of resources needed to address this practical and structural problem are not easily obtained. Clinical instances in which quick referral and follow up of a seriously suicidal patient are relatively infrequent. It is difficult to maintain the personnel and resources unencumbered until they are needed, especially in the face of  other, pressing competing demands.

How will ED-SAFE be cited and entered into the accumulating literature concerning the difficulty getting reductions in lives lost to suicide?

The article reports the Number Needed to Treat (NNT) for patients receiving the comprehensive ED-SAFE intervention:

The NNT to prevent future suicidal behavior ranged between 13 and 22. This level of risk reduction compares favorably with other interventions to prevent major health issues, including statins to prevent heart attack (NNT = 104),23 antiplatelet therapy for acute ischemic stroke (NNT = 143),24 and vaccines to prevent influenza in elderly individuals (NNT = 20).25

But if the intervention is not effective, NNTs are misleading.

If the NIMH press release is taken as a sign, the ED-SAFE intervention will be interpreted as impressively effective. However, despite some spinning, the ED-SAFE researchers present the problems they encountered and the results they obtained in a way that the formidable obstacles to such a well-conceived effort succeeding are apparent. It would be unfortunate if the lessons to be learned are missed.

 

 

 

 

Remission of suicidal ideation by magnetic seizure therapy? Neuro-nonsense in JAMA: Psychiatry

A recent article in JAMA: Psychiatry:

Sun Y, Farzan F, Mulsant BH, Rajji TK, Fitzgerald PB, Barr MS, Downar J, Wong W, Blumberger DM, Daskalakis ZJ. Indicators for remission of suicidal ideation following magnetic seizure therapy in patients with treatment-resistant depression. JAMA Psychiatry. 2016 Mar 16.

Was accompanied by an editorial commentary:

Camprodon JA, Pascual-Leone A. Multimodal Applications of Transcranial Magnetic Stimulation for Circuit-Based Psychiatry. JAMA: Psychiatry. 2016 Mar 16.

Together both the article and commentary can be studied as:

  • An effort by the authors and the journal itself to promote prematurely a treatment for reducing suicide.
  • A pay back to sources of financial support for the authors. Both groups have industry ties that provide them with consulting fees, equipment, grants, and other unspecified rewards. One author has a patent that should increase in value as result of this article and commentary.
  • A bid for successful applications to new grant initiatives with a pledge of allegiance to the NIMH Research Domain Criteria (RDoC).

After considering just how bad the science and reporting:

We have sufficient reason to ask how did this promotional campaign come about? Why was this article accepted by JAMA:Psychiatry? Why was it deemed worthy of comment?

I think a skeptical look at this article would lead to a warning label:

exclamation pointWarning: Results reported in this article are neither robust nor trustworthy, but considerable effort has gone into promoting them as innovative and even breakthrough. Skepticism warranted.

As we will see, the article is seriously flawed as a contribution to neuroscience, identification of biomarkers, treatment development, and suicidology, but we can nonetheless learn a lot from it in terms of how to detect such flaws when they are more subtle. If nothing else, your skepticism will be raised about articles accompanied by commentaries in prestigious journals and you will learn tools for probing such pairs of articles.

 

This article involves intimidating technical details and awe-inspiring figures.

figure 1 picture onefigure 1 picture two

 

 

 

 

 

 

 

 

 

Yet, as in some past blog posts concerning neuroscience and the NIMH RDoC, we will gloss over some technical details, which would be readily interpreted by experts. I would welcome the comments and critiques from experts.

I nonetheless expect readers to agree when they have finished this blog post that I have demonstrated that you don’t have to be an expert to detect neurononsense and crass publishing of articles that fit vested interests.

The larger trial from which these patients is registered as:

ClinicalTrials.gov. Magnetic Seizure Therapy (MST) for Treatment Resistant Depression, Schizophrenia, and Obsessive Compulsive Disorder. NCT01596608.

Because this article is strikingly lacking in crucial details or details in places where we would expect to find them, it will be useful at times to refer to the trial registration.

The title and abstract of the article

As we will soon see, the title, Indicators for remission of suicidal ideation following MST in patients with treatment-resistant depression is misleading. The article has too small sample and too inappropriate a design to establish anything as a reproducible “indicator.”

That the article is going to fail to deliver is already apparent in the abstract.

The abstract states:

 Objective  To identify a biomarker that may serve as an indicator of remission of suicidal ideation following a course of MST by using cortical inhibition measures from interleaved transcranial magnetic stimulation and electroencephalography (TMS-EEG).

Design, Setting, and Participants  Thirty-three patients with TRD were part of an open-label clinical trial of MST treatment. Data from 27 patients (82%) were available for analysis in this study. Baseline TMS-EEG measures were assessed within 1 week before the initiation of MST treatment using the TMS-EEG measures of cortical inhibition (ie, N100 and long-interval cortical inhibition [LICI]) from the left dorsolateral prefrontal cortex and the left motor cortex, with the latter acting as a control site.

Interventions The MST treatments were administered under general anesthesia, and a stimulator coil consisting of 2 individual cone-shaped coils was used.

Main Outcomes and Measures Suicidal ideation was evaluated before initiation and after completion of MST using the Scale for Suicide Ideation (SSI). Measures of cortical inhibition (ie, N100 and LICI) from the left dorsolateral prefrontal cortex were selected. N100 was quantified as the amplitude of the negative peak around 100 milliseconds in the TMS-evoked potential (TEP) after a single TMS pulse. LICI was quantified as the amount of suppression in the double-pulse TEP relative to the single-pulse TEP.

Results  Of the 27 patients included in the analyses, 15 (56%) were women; mean (SD) age of the sample was 46.0 (15.3) years. At baseline, patients had a mean SSI score of 9.0 (6.8), with 8 of 27 patients (30%) having a score of 0. After completion of MST, patients had a mean SSI score of 4.2 (6.3) (pre-post treatment mean difference, 4.8 [6.7]; paired t26 = 3.72; P = .001), and 18 of 27 individuals (67%) had a score of 0 for a remission rate of 53%. The N100 and LICI in the frontal cortex—but not in the motor cortex—were indicators of remission of suicidal ideation with 89% accuracy, 90% sensitivity, and 89% specificity (area under the curve, 0.90; P = .003).

Conclusions and Relevance  These results suggest that cortical inhibition may be used to identify patients with TRD who are most likely to experience remission of suicidal ideation following a course of MST. Stronger inhibitory neurotransmission at baseline may reflect the integrity of transsynaptic networks that are targeted by MST for optimal therapeutic response.

Even viewing the abstract alone, we can see this article is in trouble. It claims to identify a biomarker following a course of magnet seizure therapy (MST) ]. That is an extraordinary claim when a study only started with 33 patients of whom only 27 remain for analysis. Furthermore, at the initial assessment of suicidal ideation, eight of the 27 patients did not have any and so could show no benefit of treatment.

Any results could be substantially changed with any of the four excluded patients being recovered for analysis and any of the 27 included patients being dropped from analyses as an outlier. Statistical controls to control for potential confounds will produce spurious results because of overfit equations ] with even one confound. We also know well that in situation requiring control of possible confounding factors, control of only one is really sufficient and often produces worse results than leaving variables unadjusted.

Identification of any biomarkers is unlikely to be reproducible in larger more representative samples. Any claims of performance characteristics of the biomarkers (accuracy, sensitivity, specificity, area under the curve) are likely to capitalize on sampling and chance in ways that are unlikely to be reproducible.

Nonetheless, the accompanying figures are dazzling, even if not readily interpretable or representative of what would be found in another sample.

Comparison of the article to the trial registration.

According to the trial registration, the study started in February 2012 and the registration was received in May 2012. There were unspecified changes as recently as this month (March 2016), and the study is expected to and final collection of primary outcome data is in December 2016.

Primary outcome

The registration indicates that patients will have been diagnosed with severe major depression, schizophrenia or obsessive compulsive disorder. The primary outcome will depend on diagnosis. For depression it is the Hamilton Rating Scale for Depression.

There is no mention of suicidal ideation as either a primary or secondary outcome.

Secondary outcomes

According to the registration, outcomes include (1) cognitive functioning as measured by episodic memory and non-memory cognitive functions; (2) changes in neuroimaging measures of brain structure and activity derived from fMRI and MRI from baseline to 24th treatment or 12 weeks, whichever comes sooner.

Comparison to the article suggests some important neuroimaging assessment proposed in the registration were compromised. (1) only baseline measures were obtained and without MRI or fMRI; and (2) the article states

Although magnetic resonance imaging (MRI)–guided TMS-EEG is more accurate than non–MRI-guided methods, the added step of obtaining an MRI for every participant would have significantly slowed recruitment for this study owing to the pressing

need to begin treatment in acutely ill patients, many of whom were experiencing suicidal ideation. As such, we proceeded with non–MRI-guided TMS-EEG using EEG-guided methods according to a previously published study.

Treatment

magnetic seizure therapyThe article provides some details of the magnetic seizure treatment:

The MST treatments were administered under general anesthesia using a stimulator machine (MagPro MST; MagVenture) with a twin coil. Methohexital sodium (n = 14), methohexital with remifentanil hydrochloride (n = 18), and ketamine hydrochloride (n = 1) were used as the anesthetic agents. Succinylcholine chloride was used as the neuromuscular blocker. Patients had a mean (SD) seizure duration of 45.1 (21.4) seconds. The twin coil consists of 2 individual cone-shaped coils. Stimulation was delivered over the frontal cortex at the midline position directly over the electrode Fz according to the international 10-20 system.36 Placing the twin coil symmetrically over electrode Fz results in the centers of the 2 coils being over F3 and F4. Based on finite element modeling, this configuration produces a maximum induced electric field between the 2 coils, which is over electrode Fz in this case.37 Patients were treated for 24 sessions or until remission of depressive symptoms based on the 24-item Hamilton Rating Scale for Depression (HRSD) (defined as an HRSD-24 score ≤10 and 60% reduction in symptoms for at least 2 days after the last treatment).38 These remission criteria were standardized from previous ECT depression trials.39,40 Further details of the treatment protocol are available,30 and comprehensive clinical and neurophysiologic trial results will be reported separately.

The article intended to refer the reader to the trial registration for further description of treatment, but the superscript citation in the article is inaccurate. Regardless, given other deviations from registration, readers can’t tell whether any deviations from what was proposed. In in the registration, seizure therapy was described as involving:

100% machine output at between 25 and 100 Hz, with coil directed over frontal brain regions, until adequate seizure achieved. Six treatment sessions, at a frequency of two or three times per week will be administered. If subjects fail to achieve the pre-defined criteria of remission at that point, the dose will be increased to the maximal stimulator output and 3 additional treatment sessions will be provided. This will be repeated a total of 5 times (i.e., maximum treatment number is 24). 24 treatments is typically longer that a conventional ECT treatment course.

One important implication is for this treatment being proposed as resolving suicidal ideation. It takes place over a considerable period of time. Patients who die by suicide notoriously break contact before doing so. It would seem that a required 24 treatments delivered on an outpatient basis would provide ample opportunities for breaks – including demoralization because so many treatments are needed in some cases – and therefore death by suicide

But a protocol that involves continuing treatment until a prespecified reduction in the Hamilton Depression Rating Scale is achieved assures that there will be a drop in suicidal ideation. The interview-based Hamilton depression rating scales and suicidal ideation are highly correlated.

eeg-electroencephalogrphy-250x250There is no randomization or even adequate description of patient accrual in terms of the population from which the patients came. There is no control group and therefore no control for nonspecific factors. The patients are being subject to an elaborate, intrusive ritual In terms of nonspecific effects. The treatment involves patients in an elaborate ritual, starting with electroencephalographic (EEG) assessment [http://www.mayoclinic.org/tests-procedures/eeg/basics/definition/prc-20014093].

The ritual will undoubtedly will undoubtedly have strong nonspecific factors associated with it – instilling a positive expectations and considerable personal attention.

The article’s discussion of results

The discussion opens with some strong claims, unjustified by the modesty of the study and the likelihood that its specific results are not reproducible:

We found that TMS-EEG measures of cortical inhibition (ie, the N100 and LICI) in the frontal cortex, but not in the motor cortex, were strongly correlated with changes in suicidal ideation in patients with TRD who were treated with MST. These findings suggest that patients who benefitted the most from MST demonstrated the greatest cortical inhibition at baseline. More important, when patients were divided into remitters and nonremitters based on their SSI score, our results show that these measures can indicate remission of suicidal ideation from a course of MST with 90% sensitivity and 89% specificity.

Pledge of AllegianceThe discussion contains a Pledge of Allegiance to the research domain criteria approach that is not actually a reflection of the results at hand. Among the many things that we knew before the study was done and that was not shown by the study, is to suicidal ideation is so hopelessly linked to hopelessness, negative affect, and attentional biases, that in such a situation is best seen as a surrogate measure of depression, rather than a marker for risk of suicidal acts or death by suicide.

 

 

Wave that RDoC flag and maybe you will attract money from NIMH.

Our results also support the research domain criteria approach, that is, that suicidal ideation represents a homogeneous symptom construct in TRD that is targeted by MST. Suicidal ideation has been shown to be linked to hopelessness, negative affect, and attentional biases. These maladaptive behaviors all fall under the domain of negative valence systems and are associated with the specific constructs of loss, sustained threat, and frustrative nonreward. Suicidal ideation may represent a better phenotype through which to understand the neurobiologic features of mental illnesses.In this case, variations in GABAergic-mediated inhibition before MST treatment explained much of the variance for improvements in suicidal ideation across individuals with TRD.

Debunking ‘a better phenotype through which to understand the neurobiologic features of mental illnesses.’

  • Suicide is not a disorder or a symptom, but an infrequent, difficult to predict and complex act that varies greatly in nature and circumstances.
  • While some features of a brain or brain functioning may be correlated with eventual death by suicide, most identifications they provide of persons at risk to eventually die by suicide will be false positives.
  • In the United States, access to a firearm is a reliable proximal cause of suicide and is likely to be more so than anything in the brain. However, this basic observation is not consistent with American politics and can lead to grant applications not being funded.

In an important sense,

  • It’s not what’s going on in the brain, but what’s going in the interpersonal context of the brain, in terms of modifiable risk for death by suicide.

The editorial commentary

On the JAMA: Psychiatry website, both the article and the editorial commentary contain sidebar links to each other. Is only in the last two paragraphs of a 14 paragraph commentary that the target article is mentioned. However, the commentary ends with a resounding celebration of the innovation this article represents [emphasis added]:

Sun and colleagues10 report that 2 different EEG measures of cortical inhibition (a negative evoked potential in the EEG that happens approximately 100 milliseconds after a stimulus or event of interest and long-interval cortical inhibition) evoked by TMS to the left dorsolateral prefrontal cortex, but not to the left motor cortex, predicted remission of suicidal ideation with great sensitivity and specificity. This study10 illustrates the potential of multimodal TMS to study physiological properties of relevant circuits in neuropsychiatric populations. Significantly, it also highlights the anatomical specificity of these measures because the predictive value was exclusive to the inhibitory properties of prefrontal circuits but not motor systems.

Multimodal TMS applications allow us to study the physiology of human brain circuitry noninvasively and with causal resolution, expanding previous motor applications to cognitive, behavioral, and affective systems. These innovations can significantly affect psychiatry at multiple levels, by studying disease-relevant circuits to further develop systems for neuroscience models of disease and by developing tools that could be integrated into clinical practice, as they are in clinical neurophysiology clinics, to inform decision making, the differential diagnosis, or treatment planning.

Disclosures of conflicts of interest

The article’s disclosure of conflicts of interest statement is longer than the abstract.

conflict of interest disclosure

The disclosure for the conflicts of interest for the editorial commentary is much shorter but nonetheless impressive:

editorial commentary disclosures

How did this article get into JAMA: Psychiatry with an editorial comment?

Editorial commentaries are often provided by reviewers who either simply check the box on the reviewers’ form indicating their willingness to provide a comment. For reviewers who already have a conflict of interest, this provides an additional one: a non-peer-reviewed paper in which they can promote their interest.

Alternatively, commentators are simply picked by an editor who judges an article to be noteworthy of special recognition. It’s noteworthy that at least one of the associate editors of JAMA: Psychiatry is actively campaigning for a particular direction to suicide research funded by NIMH as seen in an editorial comment of his own that I recently discussed. One of the authors of this paper currently under discussion was until recently a senior member of this associate editor’s department, before departing to become Chair of the Department of Psychiatry at University of Toronto.

Essentially the authors of the paper and the authors of the commentary of providing carefully constructed advertisers for themselves and their agenda. The opportunity for them to do so is because of consistency with the agenda of at least one of the editors, if not the journal itself.

The Committee on Publication Ethics (COPE)   requires that non-peer-reviewed material in ostensibly peer reviewed journals be labeled as such. This requirement is seldom met.

The journal further promoted this article by providing 10 free continuing medical education credits for reading it.

I could go on much longer identifying other flaws in this paper and its editorial commentary. I could raise other objections to the article being published in JAMA:Psychiatry. But out of mercy for the authors, the editor, and my readers, I’ll stop here.

I would welcome comments about other flaws.

Special thanks to Bernard “Barney” Carroll for his helpful comments and encouragement, but all opinions expressed and all factual errors are my own responsibility.