Letters
1. Knezevich SR, Barnhill RL, Elder DE, et al. Variability in mitotic figures in serial sections of thin melanomas. J Am Acad Dermatol. 2014;71(6):1204-1211. 2. Feinstein AR. A bibliography of publications on observer variability. J Chronic Dis. 1985;38(8):619-632. 3. Elmore JG, Feinstein AR. A bibliography of publications on observer variability (final installment). J Clin Epidemiol. 1992;45(6):567-580. 4. Khazai L, Middleton LP, Goktepe N, Liu BT, Sahin AA. Breast pathology second review identifies clinically significant discrepancies in over 10% of patients. J Surg Oncol. 2015;111(2):192-197.
Suicide Among US Military Personnel To the Editor Dr Friedman’s article highlighted the current research and risk factors associated with suicide among US Army personnel.1 However, I was surprised when the US Special Operations Command (USSOCOM), which includes members from all military branches, was discussed. Friedman suggested that the Command addresses the issue of suicide prevention “through a widespread emphasis on physical fitness” rather than focusing on identification and treatment of soldiers with disorders. His misperceptions of USSOCOM and their physical fitness program should be clarified. The Preservation of the Force and Family initiative was launched by USSOCOM over the past few years as an innovative and holistic means to enable human, psychological, and spiritual performance both on and off the battlefield for the Special Operations tactical athlete (Army Rangers, Army Special Forces, Navy SEALs, Air Force Special Tactics, Marine Corps Critical Skills Operators, etc) and their families.2 This initiative has ushered family- and psychological-embedded support into multiple USSOCOM units. This support system has included social workers, chaplains, and psychologists. The physical fitness aspect is simply one part of a larger holistic program. It has allowed USSOCOM members to receive strength and conditioning training along with physical therapy and rehabilitation on par with the collegiate and even the professional sports medicine model. Having served the past 3 years within one of these units as an embedded physician, I can attest to the benefits of this holistic and preventative approach. This team-based model allows the unit member (over time) to feel comfortable with a practitioner and seek help in a manner that would never be seen in a traditional mental health approach. Some of my most effective mental health sessions with members came about during physical fitness sessions. The average USSOCOM member has gone through extensive and rigorous assessments prior to entry into the Command, thus limiting many of the risk factors discussed in the article. Nevertheless, the threat of suicide remains. The care and treatment of USSOCOM warriors require innovative personal approaches coupled with data-driven guidelines. Philip M. Flatau, MD Author Affiliation: Air Force Special Operations, Hurlburt Field, Florida. Corresponding Author: Philip M. Flatau, MD, Air Force Special Operations, FAWM, 415 Independence Rd, Hurlburt Field, FL 32544 ([email protected]). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 84
Disclaimer: The views expressed in this letter are the authors’ own and do not necessarily represent the views of the US Air Force, USSOCOM, or the US Department of Defense. 1. Friedman MJ. Risk factors for suicides among army personnel. JAMA. 2015; 313(11):1154-1155. 2. US Special Operations Command. Preservation of the force and family. http: //www.socom.mil/POTFF/default.aspx. Accessed March 22, 2015.
In Reply Suicide is an urgent problem for all US military services, their components, and their commands as well as the United States. Because this is such a high priority, the US Army and the National Institute of Mental Health jointly funded the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) to identify “modifiable risk and resilience factors for suicidality that could be used to target effective preventative interventions for Army suicides … .”1 In my From The JAMA Network article regarding the first 3 Army STARRS articles, I concluded that these results provide sufficient information to suggest improvements in current suicide prevention and policy. The major finding was that a minority of soldiers, those with mental health problems before enlistment, after enlistment, or both, are responsible for a disproportionate amount of suicidal behavior. More granular analyses identified soldiers having frequent anger attacks (eg, meeting diagnostic criteria for intermittent explosive disorder) as the highestrisk group. I also identified peer and family support as important targets for intervention. These data hopefully will be translated into evidence-based policy and practice and save the lives of those who might otherwise kill themselves. Dr Flatau made 2 interesting statements based on his personal observations: that USSOCOM’s holistic approach promotes more comfortable mental health–seeking behavior than seen with traditional approaches and that his most effective mental health sessions with service members came during physical fitness. Scientific inquiry always begins with sophisticated observations such as these. Therefore, I urge Flatau and his USSOCOM colleagues to test these hypotheses concerning the utility of the holistic approach embodied within USSOCOM’s Preservation of the Force and Family initiative with respect to the prevention or early detection of suicidal behavior. It would be important for the field to have such data to help guide suicide prevention and intervention. Flatau also suggested that Army STARRS findings should not be generalized to USSOCOM because of differences between the military services. The USSOCOM should provide data showing that Army STARRS findings do not apply to their troops before setting suicide prevention policies that assume this to be the case. Until such data are gathered, however, the best scientific evidence available should be used to design preventative strategies. Right now, Army STARRS is the best available. The scientific data point toward a focus on mental health and early detection and treatment of mental illness to address suicide risk. Matthew J. Friedman, MD, PhD
JAMA July 7, 2015 Volume 314, Number 1 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a CAMBRIDGE UNIVERSITY LIBRARY User on 08/07/2015
jama.com
Letters
Author Affiliation: National Center for PTSD, US Department of Veterans Affairs, White River Junction, Vermont. Corresponding Author: Matthew J. Friedman, MD, PhD, Department of Veterans Affairs, National Center for PTSD, US Department of Veterans Affairs, 215 N Main St, White River Junction, VT 05009 ([email protected]).
Is ME/CFS a distinct syndrome or part of a spectrum? To answer that question, we need more research that complies with the basic rules on how to establish and validate diagnoses.
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported being a member of the Army STARRS scientific advisory board.
Per Fink, PhD, DMSc Andreas Schröder, MD, PhD
Disclaimer: The views expressed are entirely those of the author and do not represent positions of the US Department of Veterans Affairs or its National Center for PTSD.
Author Affiliations: Research Clinic for Functional Disorders, Aarhus University Hospital, Aarhus, Denmark.
1. Schoenbaum M, Kessler RC, Gilman SE, et al; Army STARRS Collaborators. Predictors of suicide and accident death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry. 2014;71(5):493-503.
Redefining Myalgic Encephalomyelitis/Chronic Fatigue Syndrome To the Editor The Institute of Medicine (IOM) proposed a new name (systemic exertion intolerance disease) and diagnostic criteria for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).1 The IOM panel aimed to “develop evidencebased clinical diagnostic criteria for ME/CFS for use by clinicians, using a consensus-building methodology.” We agree that more valid diagnostic criteria for ME/CFS are needed and welcome the panel’s effort to improve patient care through better diagnostic tools. However, we do not believe that a new consensus-driven proposal added to the many existing ones will help reach these important aims. The poor acceptance of ME/CFS in the scientific community is due to a lack of convincing evidence that ME/CFS is a distinct syndrome that can be delimited from other similar syndromes. Even though the panel’s comprehensive literature review revealed important data indicating the difficult experiences of patients with ME/CFS, the crucial question regarding the nosological status of ME/CFS remains unsolved2 and can be solved only through new scientific studies, not by consensus. To identify a distinct syndrome, 2 prerequisites need to be proved. First, studies need to show that symptoms cluster (ie, appear together more often than randomly), which can be done using a cluster or factor analysis.3 None of the reported analyses show that the suggested symptoms cluster (postexertion malaise, unrefreshing sleep, cognitive impairment, and orthostatic intolerance). Second, boundaries or points of rarity between the syndrome and related syndromes need to be identified, which can be achieved with latent class analysis or similar statistical techniques.3 This type of analysis is not reported. Because the suggested symptoms are common in numerous conditions, identifying these boundaries are of paramount importance. Patients with ME/CFS have multiple symptoms and many fulfill criteria for multiple syndromes.2-4 The new diagnostic proposal does not answer the important question of whether patients who have multisymptomatic ME/CFS have the same illness as patients with few symptoms. jama.com
Corresponding Author: Per Fink, PhD, DMSc, Research Clinic for Functional Disorders, Aarhus University Hospital, Noerrebrogade 44, Aarhus C, Denmark 8000 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Clayton EW. Beyond myalgic encephalomyelitis/chronic fatigue syndrome: an IOM report on redefining an illness. JAMA. 2015;313(11):1101-1102. 2. Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: one or many? Lancet. 1999;354(9182):936-939. 3. Kendell RE. Clinical validity. Psychol Med. 1989;19(1):45-55. 4. Fink P, Schröder A. One single diagnosis, bodily distress syndrome, succeeded to capture 10 diagnostic categories of functional somatic syndromes and somatoform disorders. J Psychosom Res. 2010;68(5):415-426.
In Reply I concur with Drs Fink and Schröder that more research is needed to understand the etiology and refine the diagnosis of systemic exertion intolerance disease. I, however, cannot agree with their conclusion that the IOM Committee’s case definition fails because it was not based on a cluster or factor analysis or latent class analysis or by using similar statistical techniques. The Committee examined the existing literature that used these techniques 1(pp60-66) and found those studies inadequate for several reasons. The Committee also recognized that the framing of salient case definitions frequently relies on a variety of inputs, including expert consensus, input from patients and stakeholders, and evidence-based review of the literature that addresses etiology, pathophysiology, and discriminating clinical characteristics. The Committee cited 2 examples, the Jones criteria for rheumatic fever and the Diagnostic and Statistical Manual of Mental Disorders, in which case definitions had been made in the absence of clear understanding of etiology.1(p38) In its comprehensive literature review, which assessed the quality of available evidence, the Committee focused on identifying symptoms that are found in virtually every patient, with an emphasis on those that have objective findings on testing in cases of ambiguity. The criteria set forth in the report reflect that analysis. As directed by the statement of task, the criteria and the recommendations also reflect the voices of patients, advocates, and experts inside and outside the Committee who were eloquent in their statements about the seriousness, complexity, and chronicity of this disease, and the misunderstanding and dismissiveness of clinicians and others. I stand by the major contribution of the Committee’s work for these patients. Ellen Wright Clayton, MD, JD (Reprinted) JAMA July 7, 2015 Volume 314, Number 1
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a CAMBRIDGE UNIVERSITY LIBRARY User on 08/07/2015
85
1. Knezevich SR, Barnhill RL, Elder DE, et al. Variability in mitotic figures in serial sections of thin melanomas. J Am Acad Dermatol. 2014;71(6):1204-1211. 2. Feinstein AR. A bibliography of publications on observer variability. J Chronic Dis. 1985;38(8):619-632. 3. Elmore JG, Feinstein AR. A bibliography of publications on observer variability (final installment). J Clin Epidemiol. 1992;45(6):567-580. 4. Khazai L, Middleton LP, Goktepe N, Liu BT, Sahin AA. Breast pathology second review identifies clinically significant discrepancies in over 10% of patients. J Surg Oncol. 2015;111(2):192-197.
Suicide Among US Military Personnel To the Editor Dr Friedman’s article highlighted the current research and risk factors associated with suicide among US Army personnel.1 However, I was surprised when the US Special Operations Command (USSOCOM), which includes members from all military branches, was discussed. Friedman suggested that the Command addresses the issue of suicide prevention “through a widespread emphasis on physical fitness” rather than focusing on identification and treatment of soldiers with disorders. His misperceptions of USSOCOM and their physical fitness program should be clarified. The Preservation of the Force and Family initiative was launched by USSOCOM over the past few years as an innovative and holistic means to enable human, psychological, and spiritual performance both on and off the battlefield for the Special Operations tactical athlete (Army Rangers, Army Special Forces, Navy SEALs, Air Force Special Tactics, Marine Corps Critical Skills Operators, etc) and their families.2 This initiative has ushered family- and psychological-embedded support into multiple USSOCOM units. This support system has included social workers, chaplains, and psychologists. The physical fitness aspect is simply one part of a larger holistic program. It has allowed USSOCOM members to receive strength and conditioning training along with physical therapy and rehabilitation on par with the collegiate and even the professional sports medicine model. Having served the past 3 years within one of these units as an embedded physician, I can attest to the benefits of this holistic and preventative approach. This team-based model allows the unit member (over time) to feel comfortable with a practitioner and seek help in a manner that would never be seen in a traditional mental health approach. Some of my most effective mental health sessions with members came about during physical fitness sessions. The average USSOCOM member has gone through extensive and rigorous assessments prior to entry into the Command, thus limiting many of the risk factors discussed in the article. Nevertheless, the threat of suicide remains. The care and treatment of USSOCOM warriors require innovative personal approaches coupled with data-driven guidelines. Philip M. Flatau, MD Author Affiliation: Air Force Special Operations, Hurlburt Field, Florida. Corresponding Author: Philip M. Flatau, MD, Air Force Special Operations, FAWM, 415 Independence Rd, Hurlburt Field, FL 32544 ([email protected]). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 84
Disclaimer: The views expressed in this letter are the authors’ own and do not necessarily represent the views of the US Air Force, USSOCOM, or the US Department of Defense. 1. Friedman MJ. Risk factors for suicides among army personnel. JAMA. 2015; 313(11):1154-1155. 2. US Special Operations Command. Preservation of the force and family. http: //www.socom.mil/POTFF/default.aspx. Accessed March 22, 2015.
In Reply Suicide is an urgent problem for all US military services, their components, and their commands as well as the United States. Because this is such a high priority, the US Army and the National Institute of Mental Health jointly funded the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) to identify “modifiable risk and resilience factors for suicidality that could be used to target effective preventative interventions for Army suicides … .”1 In my From The JAMA Network article regarding the first 3 Army STARRS articles, I concluded that these results provide sufficient information to suggest improvements in current suicide prevention and policy. The major finding was that a minority of soldiers, those with mental health problems before enlistment, after enlistment, or both, are responsible for a disproportionate amount of suicidal behavior. More granular analyses identified soldiers having frequent anger attacks (eg, meeting diagnostic criteria for intermittent explosive disorder) as the highestrisk group. I also identified peer and family support as important targets for intervention. These data hopefully will be translated into evidence-based policy and practice and save the lives of those who might otherwise kill themselves. Dr Flatau made 2 interesting statements based on his personal observations: that USSOCOM’s holistic approach promotes more comfortable mental health–seeking behavior than seen with traditional approaches and that his most effective mental health sessions with service members came during physical fitness. Scientific inquiry always begins with sophisticated observations such as these. Therefore, I urge Flatau and his USSOCOM colleagues to test these hypotheses concerning the utility of the holistic approach embodied within USSOCOM’s Preservation of the Force and Family initiative with respect to the prevention or early detection of suicidal behavior. It would be important for the field to have such data to help guide suicide prevention and intervention. Flatau also suggested that Army STARRS findings should not be generalized to USSOCOM because of differences between the military services. The USSOCOM should provide data showing that Army STARRS findings do not apply to their troops before setting suicide prevention policies that assume this to be the case. Until such data are gathered, however, the best scientific evidence available should be used to design preventative strategies. Right now, Army STARRS is the best available. The scientific data point toward a focus on mental health and early detection and treatment of mental illness to address suicide risk. Matthew J. Friedman, MD, PhD
JAMA July 7, 2015 Volume 314, Number 1 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a CAMBRIDGE UNIVERSITY LIBRARY User on 08/07/2015
jama.com
Letters
Author Affiliation: National Center for PTSD, US Department of Veterans Affairs, White River Junction, Vermont. Corresponding Author: Matthew J. Friedman, MD, PhD, Department of Veterans Affairs, National Center for PTSD, US Department of Veterans Affairs, 215 N Main St, White River Junction, VT 05009 ([email protected]).
Is ME/CFS a distinct syndrome or part of a spectrum? To answer that question, we need more research that complies with the basic rules on how to establish and validate diagnoses.
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported being a member of the Army STARRS scientific advisory board.
Per Fink, PhD, DMSc Andreas Schröder, MD, PhD
Disclaimer: The views expressed are entirely those of the author and do not represent positions of the US Department of Veterans Affairs or its National Center for PTSD.
Author Affiliations: Research Clinic for Functional Disorders, Aarhus University Hospital, Aarhus, Denmark.
1. Schoenbaum M, Kessler RC, Gilman SE, et al; Army STARRS Collaborators. Predictors of suicide and accident death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry. 2014;71(5):493-503.
Redefining Myalgic Encephalomyelitis/Chronic Fatigue Syndrome To the Editor The Institute of Medicine (IOM) proposed a new name (systemic exertion intolerance disease) and diagnostic criteria for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).1 The IOM panel aimed to “develop evidencebased clinical diagnostic criteria for ME/CFS for use by clinicians, using a consensus-building methodology.” We agree that more valid diagnostic criteria for ME/CFS are needed and welcome the panel’s effort to improve patient care through better diagnostic tools. However, we do not believe that a new consensus-driven proposal added to the many existing ones will help reach these important aims. The poor acceptance of ME/CFS in the scientific community is due to a lack of convincing evidence that ME/CFS is a distinct syndrome that can be delimited from other similar syndromes. Even though the panel’s comprehensive literature review revealed important data indicating the difficult experiences of patients with ME/CFS, the crucial question regarding the nosological status of ME/CFS remains unsolved2 and can be solved only through new scientific studies, not by consensus. To identify a distinct syndrome, 2 prerequisites need to be proved. First, studies need to show that symptoms cluster (ie, appear together more often than randomly), which can be done using a cluster or factor analysis.3 None of the reported analyses show that the suggested symptoms cluster (postexertion malaise, unrefreshing sleep, cognitive impairment, and orthostatic intolerance). Second, boundaries or points of rarity between the syndrome and related syndromes need to be identified, which can be achieved with latent class analysis or similar statistical techniques.3 This type of analysis is not reported. Because the suggested symptoms are common in numerous conditions, identifying these boundaries are of paramount importance. Patients with ME/CFS have multiple symptoms and many fulfill criteria for multiple syndromes.2-4 The new diagnostic proposal does not answer the important question of whether patients who have multisymptomatic ME/CFS have the same illness as patients with few symptoms. jama.com
Corresponding Author: Per Fink, PhD, DMSc, Research Clinic for Functional Disorders, Aarhus University Hospital, Noerrebrogade 44, Aarhus C, Denmark 8000 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Clayton EW. Beyond myalgic encephalomyelitis/chronic fatigue syndrome: an IOM report on redefining an illness. JAMA. 2015;313(11):1101-1102. 2. Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: one or many? Lancet. 1999;354(9182):936-939. 3. Kendell RE. Clinical validity. Psychol Med. 1989;19(1):45-55. 4. Fink P, Schröder A. One single diagnosis, bodily distress syndrome, succeeded to capture 10 diagnostic categories of functional somatic syndromes and somatoform disorders. J Psychosom Res. 2010;68(5):415-426.
In Reply I concur with Drs Fink and Schröder that more research is needed to understand the etiology and refine the diagnosis of systemic exertion intolerance disease. I, however, cannot agree with their conclusion that the IOM Committee’s case definition fails because it was not based on a cluster or factor analysis or latent class analysis or by using similar statistical techniques. The Committee examined the existing literature that used these techniques 1(pp60-66) and found those studies inadequate for several reasons. The Committee also recognized that the framing of salient case definitions frequently relies on a variety of inputs, including expert consensus, input from patients and stakeholders, and evidence-based review of the literature that addresses etiology, pathophysiology, and discriminating clinical characteristics. The Committee cited 2 examples, the Jones criteria for rheumatic fever and the Diagnostic and Statistical Manual of Mental Disorders, in which case definitions had been made in the absence of clear understanding of etiology.1(p38) In its comprehensive literature review, which assessed the quality of available evidence, the Committee focused on identifying symptoms that are found in virtually every patient, with an emphasis on those that have objective findings on testing in cases of ambiguity. The criteria set forth in the report reflect that analysis. As directed by the statement of task, the criteria and the recommendations also reflect the voices of patients, advocates, and experts inside and outside the Committee who were eloquent in their statements about the seriousness, complexity, and chronicity of this disease, and the misunderstanding and dismissiveness of clinicians and others. I stand by the major contribution of the Committee’s work for these patients. Ellen Wright Clayton, MD, JD (Reprinted) JAMA July 7, 2015 Volume 314, Number 1
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a CAMBRIDGE UNIVERSITY LIBRARY User on 08/07/2015
85
