JOHN A. MAJDA, M.D. MEMORIAL FUND UNIVERSITY OF CALIFORNIA, SAN DIEGO

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1 JOHN A. MAJDA, M.D. MEMORIAL FUND UNIVERSITY OF CALIFORNIA, SAN DIEGO 2017 PROGRESS REPORT Sidney Zisook, M.D. Distinguished Professor Director, Residency Training Department of Psychiatry

2 University California San Diego VA San Diego Healthcare Center UNIVERSITY OF CALIFORNIA, SAN DIEGO UCSD Berkeley Davis Irvine Los Angeles Merced Riverside San Diego San Francisco Santa Barbara Santa Cruz Sidney Zisook, M.D. Professor Director, Residency Training Department of Psychiatry School of Medicine Residency Training Program 9500 Gilman Drive, 9116A La Jolla, California Telephone: Fax: May 1, 2017 Dear Virginia, I am pleased to provide you with a progress report on this year s John A. Majda, MD Memorial Fund (the fund) activity. Formally established in July 2007, the MISSION of the Fund is: 1. To encourage, support and reward research in the areas of depression and suicide risk factors, with special consideration of physician depression and suicide. The scope of the project may also include physician wellness, the impact on families, and bereavement. 2. To provide seed money, if necessary, for beginning researchers, medical students and residents to carry out their research and modest financial awards for outstanding projects. Currently, the Fund has a balance of $26, Between April 2016 and April 2017, a total of $9, in donations was received. During this period, $8, was expended for research grants and administrative costs. The committee continued to review applications for funding, advise on decisions regarding the development and operation of the Fund, and judge projects for the end-of-the-year Majda Awards. The committee is comprised of the following members: Hagop Akiskal, MD, Emeritus Professor, UCSD; Lev Gertsik, MD, Director of Clinical Services, California Clinical Trials and Dr. Majda s personal physician; Bruce Hubbard, MD, Clinical Professor, Psychiatry, UCSD; Barry Lebowitz, PhD, Professor, Psychiatry, UCSD; Henry Powell, MD, Emeritus Professor, Pathology and President of the U.C. Academic Senate, UCSD; and Sidney Zisook, MD (Chair), Distinguished Professor and Chair of HEAR, UCSD. Greg Light, PhD, was added to the Committee this year. Dr. Light is a Professor and Deputy Vice Chair of Education and Training in the UCSD Department of Psychiatry and Director of the Mental Health Research Education and Clinical Center (MIRECC) at the VA San Diego Healthcare System

3 A. This past year we continued to make research funds available to all medical students, trainees, and researchers at UCSD and researchers all over the country. One can now find information about the John A. Majda Memorial Fund online on the UCSD Department of Psychiatry website and on the Healer Education Assessment and Referral (HEAR) Program website. The HEAR Program website shares the mission of the Fund, the application, the most recent progress report, and Virginia s personal and powerful cover letters ( ) in one document entitled Living with Physician Suicide. B. During the past year, the committee continued supporting several projects and provided new funding for others: 1) Kimberly Weingart, PhD (VA Medical Center, San Diego) Project name: The Mantram Repetition Study for Veterans with Depression (Awarded one-year grant in 2015) At this time, the study is complete. 40 participants were recruited and randomized to MRP or TAU. 17 Veterans were randomized to the MRP arm, with 16 completing the intervention trial. Preliminary data show that those in the MRP arm of the study showed significant reduction in depression as measured by the QIDS-C16. Further data analyses including treatment comparisons are ongoing. 2) Maryam Soltani, MD, PhD (Resident, Combined Psychiatry/Family Medicine, UCSD) and co-investigators Bradley Voytek, PhD and David Printz, MD Project Name: Neurostimulation, Depression and Suicide Risk Project (Awarded two-year grant in 2015) ECT remains one the most efficacious treatment for depression and is the treatment of choice for individuals who have failed numerous antidepressant trials and for patients who are severely ill and require rapid relief of symptoms (e.g., due to active suicidality, psychotic depression or depression associated with loss of appetite and severe weight loss). This project examines a novel proposal for how neurostimulation ameliorates depression and reduces suicide risk: that depression is a neurocommunication disorder arising from impaired communication within depression-related neural circuits and that the communication impairment can be unlearned via neurostimulation. If successful, the results of this project provide insights into a number of outstanding questions regarding the neurobiological basis of depression and suicide that may form testable hypotheses for future studies. 3) Joanne Harpel, MPhil, JD (Rethink the Conversation, Ltd.) and partners Franklin J. Cook, MA, CPC & John R. Jordan, PhD Project name: The Life Impact of Suicide Loss on Clinicians: An Experiential Retreat. A Care for The Caregiver Program (Awarded two-year grant in 2016) The John A. Majda, M.D. Memorial Fund has helped underwrite program development and two pilot offerings of Rethink The Conversation s Care for the Caregiver program, co-created with Jack Jordan, PhD and Franklin Cook, MA, CPC. This experiential workshop explores the impact of personal loss on clinicians

4 work and creates an opportunity for clinicians to have their own needs for emotional support met, explore where they are in their own journey of healing, examine how their losses have affected them personally and professionally, and connect with peers who have had similar experiences. The first opportunity to pilot the program was at the July 18, 2016 National Center for Death Education s Summer Institute in Thanatology at Mt. Ida College in Newton, MA a longstanding annual conference that attracts approximately 40 diverse professional caregivers including hospice and community clinicians. It was enthusiastically well-received, described by one attendee as the most enlightening and fulfilling program I ve ever attended. Having successfully debuted the program, support was renewed for the second of the two-year grant to enable the second pilot of this groundbreaking and impactful program. C Majda Awards: There were no student & trainee awards given this year. D. In addition to projects directly supported by the Fund, there are several programs, research projects and events directly or indirectly supported by the Fund that are worth mentioning: 1) The UCSD Committee on Physician Depression and Suicide Prevention (The HEAR Program) (Chaired by Dr. Zisook) has continued its educational outreach and web-based screening of all medical students, pharmacy students, residents, fellows and faculty members. Since its inception in 2009, 300 individuals have accepted mental health referrals, many of whom were considered to be at least moderately at risk and most of whom stated they otherwise would not have seen a mental health clinician. In July 2016, the HEAR Program received a one-year UCOP Risk Safety Grant to expand services to nurses and hospital staff at UC San Diego Health. In the first 10 months since the expansion, HEAR has: i. Assessed 592 completed questionnaires (High Risk: 289; Moderate Risk: 276.). ii. Of the 592 completed questionnaires: dialogued with the counselor online through our encrypted website engaged with the counselor over the phone met with a counselor in person for supportive assessment iii. 51 personalized referrals were made to vetted psychologists and psychiatrists in the community and/or within UCSD. In several cases, the HEAR Counselor/Psychiatrist meets with the employee before the first session with the provider to ensure adequate support and care is provided to our most vulnerable employees. iv. 10 referrals were made to the Compliance Hotline/Labor Relations/OPHD for reports related to workplace bullying, lateral violence, harassment and/or discrimination after other avenues of problem solving were unfruitful.

5 v. 12 process groups/debriefs were facilitated by HEAR to help staff cope with traumatic events, difficulties within units, the move to a new hospital, etc. vi. 28 HEAR presentations were given on resilience, burnout, depression, and suicide to students and staff at UCSD and at national conferences. vii. During the past year, HEAR Committee members have presented on Physician Burnout, Depression, and Suicide to several local hospitals, UCSD departments and programs, and pre-medical and medical students. They also have presented work on these topics and suicide prevention at several national and international conferences (see list of presentations below). In her role as Medical Director of the American Foundation for Suicide Prevention (AFSP), Dr. Christine Moutier, former co-director of HEAR and of the Majda Fund, has presented on suicide prevention around the world and has been instrumental in the initiation of the Zero-Suicide Initiative. viii. There have been four publications to date from this program, one of which was published during this past year (Martinez et al, Annals of Clinical Psychiatry, 2016) 2) 3 related Committee member research studies have been completed: i. HEAL Study, Complicated Grief Treatment for Suicide Bereaved Individuals (Principal Investigator, Dr. Zisook). This first project of AFSP's Survivor Research Initiative studied the treatment of complicated grief among survivors of suicide loss, complementing a major multi-site complicated grief study funded by the National Institutes of Health. The objective of this project was to compare the effectiveness of antidepressants alone or in combination with Complicated Grief Treatment (CGT) psychotherapy in survivors of suicide loss that have been bereaved at least 6 months and who meet criteria for complicated grief. Participants were randomly selected to receive one of four possible treatment combinations of either CGT therapy or no therapy and citalopram or placebo medication. Preliminary findings suggest that suicide survivors with CG may face unique challenges such as increased likelihood of cooccurring PTSD, lifetime MDD, suicidal ideation and maladaptive beliefs. Despite these differences, they appear to adhere to CGT and respond about equally well to treatment with CGT and those bereaved by other causes of death. ii. VA Cooperative Study #576, VA Augmentation and Switching Treatments for Improving Depression Outcomes (VAST-D) (National Co-Chair, Dr. Zisook). VAST-D was a 35-site national VA study designed to answer the question, what is the best pharmacological step for people who have been on an antidepressant and not responded or have only partially responded? Eligible Veterans were randomized to one of three treatments, all of which are frequently used by psychiatrists for treatment resistant depression: switch to bupropion, augment with bupropion, or augment with aripiprazole. This was the largest study of its

6 kind ever done in the VA Healthcare System. Over 1500 Veterans from VAs across the country were enrolled. Results are scheduled to be presented at the 2017 meeting of the American Psychiatric Association in May. iii. Presence of Symptomology and VA Service Seeking Among OEF/OIF/OND Veterans with Complicated Grief (Katherine Seay, PhD Dissertation; Zisook, Mentor). Combat-related emotional difficulties have been widely studied in Veterans Administration Hospitals across the country, particularly in relation to posttraumatic stress disorder (PTSD). However, little emphasis has been placed on loss-specific emotional difficulties, including Complicated Grief (CG). The goal of this study was to better understand CG in returning Veteran populations. Both CG and PTSD were associated with distress and impairment among OEF/OIF/OND Veterans. As expected, Veterans who screened positive for both CG and PTSD endorsed greater mental and physical health symptoms compared to all other groups. Results from this study highlight the importance of routinely screening for loss and CG in Veteran populations, and are relevant to better understanding and improving access to healthcare services for Veterans who screen positive for CG. 3) Virginia Majda and Dr. Lev Gertsik were interviewed by Dr. Michael Myer s for his recently published book "Why Physicians Die By Suicide: Lessons Learned From Their Families and Other Who Cared." The book is an informative and intimate collection of interviews with family members, colleagues, and friends of doctors who have taken their own life. 4) Dr. Christine Moutier, Chief Medical Officer of The American Foundation For Suicide Prevention (AFSP), will be visiting UCSD on May 18 th 2017 to give a Grand Rounds Presentation Healer s Mental Health: Preventing Suicide and Promoting Resilience and to meet with MAJDA & HEAR Committee members. 5) The UCSD Department of Psychiatry and the John A. Majda, M.D. Memorial Fund presents Tchaikovsky: Music & Melancholy with Dr. Richard Kogan, occurring on Monday, May 22 nd The subject of Dr. Kogan's performance is the mental illness and presumed suicide of the great Russian composer P.I. Tchaikovsky. Dr. Kogan, a professor of Clinical Psychiatry at New York University, was trained as a concert pianist at Juilliard School of Music before majoring in music and then attending medical school at Harvard University.

7 Related publications and presentations by committee members include: Publications 1. Baker, A.W., Keshaviah, A., Horenstein, A., Goetter, E.M., Mauro, C., et al (2016). The Role of Avoidance in Complicated Grief: A Detailed Examination of the Grief-Related Avoidance Questionnaire (GRAQ) in a Large Sample of Individuals with Complicated Grief. Journal of Loss and Trauma, Shear, M.K., Reynolds, C., Simon, N., Zisook, S. Complicated grief in adults: Epidemiology, clinical features, assessment, and diagnosis. In UpToDate, Roy-Byrne (ed). UpToDate, Waltham, MA. (Accessed on April 28, 2016) 3. Shear, M.K., Reynolds, C., Simon, N., Zisook, S. Complicated grief in adults: Treatment. In UpToDate, Roy-Byrne (ed). UpToDate, Waltham, MA. (Accessed on April 28, 2016) 4. Martinez, S., Tal, I., Norcross, W., Newton, I.G., Downs, N., Seay, K., McGuire, T. et al. (2016) Alcohol use in an academic medical school environment: A UC San Diego Healer Education Assessment and Regerral (HEAR) Report. Annals of Clinical Psychiatry, 28(2), Shear, M.K., Reynolds, C., Simon, N., Zisook, S., Wang, Y., Mauro, C., Duan, N. et al. (2016) Optimizing Treatment of Complicated Grief: A Multicenter Randomized Clinical Trial. JAMA Psychiatry, 73(7), Skritskaya, N.A., Mauro, C., Olonoff, M., Qiu, X., Duncan, S., Wang, Y. et al. (2016) Measuring Maladaptive Cognitions in Complicated Grief: Introducing the Typical Beliefs Questionnaire. American Journal of Geriatric Psychiatry, Epub ahead of print. 7. Baker, AW, Goetter, EM, Bui, E, Shah, R, Charney, ME, Mauro, C, Shear, MK, Simon, NM. (2016). The Influence of Anxiety Sensitivity on a Wish to Die in Complicated Grief. Journal of Nervous Mental Disease, 204 (4), p Zisook, S., Tal, I., Weingart, K., Hicks, P., Davis, L.L., Chen, P. et al. (2016) Characteristics of U.S. Veteran Patients with Major Depressive Disorder who Require Next-Step treatments: A VAST-D report. Journal of Affective Disorders, 206: Mauro, C., Shear, MK, Reynolds, C.F., Simon, N.M., Zisook, S., Skritskaya, N. et al. (2016) Performance Characteristics and Clinical Utility of Diagnostic Criteria Proposals in Bereaved Treatment-seeking Patients. Psychological Medicine, Tal, I., Mauro, C., Reynolds, C.F., Shear, M.K., Simon, N., Lebowitz. B. et al. (2016) Complicated Grief After Suicide Bereavement and Other Causes of Death. Death Stud, Epub ahead of print National Presentations 1. Zisook, S. "Grief and Bereavement Interactive Session Chair." Scientific Proceedings of the 169 th Annual Meeting of the American Psychiatric Association, Atlanta, Georgia, May 14, 2016.

8 2. Zisook, S. "Patient Suicide in Residency Training: The Ripple Effect." Scientific Proceedings of the 169 th Annual Meeting of the American Psychiatric Association, Atlanta, Georgia, May 17, Zisook, S. "Saving Lives: One Medical Center s Response to a Faculty Member s Suicide." Scientific Proceedings of the 169 th Annual Meeting of the American Psychiatric Association, Atlanta, Georgia, May 17, Zisook, S. Helping Our Residents Heal after Patient Suicide: Using the "Collateral Damage" DVD in Residency Education. 46 th Annual Meeting of the American Association of Directors of Psychiatry Residency Training, San Francisco, California, March 10, Zisook, S. The Zero Suicide Model: Bringing evidence- based suicide prevention practices to psychiatry clinical training. 46th Annual Meeting of the American Association of Directors of Psychiatry Residency Training, San Francisco, California, March 10, Zisook, S. Patient Suicide in Residency Training: The Ripple Effect. Annual Meeting of the American Psychiatric Association, San Diego, California, May 20, Zisook, S. Optimizing Treatment of Depression: The VAST-D Study. Annual Meeting of the American Psychiatric Association, San Diego, California, May 20, Zisook, S. Learning How to Guide Patients Through the Grief Process. Annual Meeting of the American Psychiatric Association, San Diego, California, May 21, Downs, N and Zisook, S. Inside College Mental Health Programs: Interviews From the APA Studio. Annual Meeting of the American Psychiatric Association, San Diego, California, May 23, Downs N, Alderman T, Swerdlow N. Implementing a New College Mental Health Program (CMHP) - An Overview of the First 12 Months. National Network of Depression Centers, Denver, Colorado, September Huang R, Young IT, Zisook S, Downs N, Lee KC. Comparing Suicidal Ideation Rates and Potential Risk Factors Among Pharmacy and Medical Students. College of Psychiatric and Neurologic Pharmacists Annual Meeting, Phoenix, Arizona, April Newton, I. On Burning Bright, Not Burning Out. AFSP Chapter Volunteer Leaders, January 22, Norcross, B. "Physician Burnout in the Era of Health Care Reform and the UC San Diego Healer Education Assessment and Referral (HEAR) Program." The 28th National Conference on Primary Health Care Access, New Orleans, Louisiana, Hyatt Regency New Orleans, April 10-12, Norcross, B. "Physician burnout, depression, and UC San Diego HEAR. The Medical Executive Leadership Retreat of the Childrens' Hospital of Orange County (CHOC), Dana Point, April 22, Norcross, B. "Physician burnout, depression, and UC San Diego HEAR. 29th Annual Western Regional Conference on Physician Wellbeing, May 24, 2017, Riverside, California.

9 We look forward to another productive year working together to help destigmatize depression and its treatment and to prevent suicide. Very Truly Yours, Sidney Zisook, MD (for the Committee)