November 15, 2013

 

 Finding calm amid the chaos

When it’s not the patient who needs a wellness check, but the veterinarian 





A University of Tennessee veterinary college graduate committed suicide in March 2011. At the time, he was pursuing a residency in laboratory animal medicine and a concurrent doctorate with the University of Missouri’s Comparative Medicine Program. A fourth-year veterinary student at the University of Montreal took her own life in May 2012, a day before she was to graduate. A second-year veterinary student at Mississippi State University did the same thing this past April. He had just earned his master’s in animal physiology from the University of Arkansas.   

It’s no secret that the veterinary profession can be rough on individuals. There’s the stress of getting into veterinary school, performing well, and standing out among peers, followed by years or decades of long hours, demanding clients, and heavy workloads.  

What isn’t discussed as freely is what happens when those stresses become overwhelming or when mental illness develops as a result. The good news is that more people are pushing for dialogue about this topic, in the hope of preventing these situations from developing or finding ways to help when they do.  

What’s the problem?

For many veterinarians, the stigma associated with mental illness is an important barrier not just to accessing mental health services but to even discussing the topic in the first place. According to the results of a 2012 study of U.K. veterinarians with a history of suicidal thoughts or behavior, half the participants had not talked with anyone about their problems, because they felt guilty or ashamed (Soc Psychiatry Psychiatr Epidemiol 2012;47:223-240).
 
Whether veterinarians are actually more prone to suicide and other mental health issues than the general population remains unclear. 
 
A fairly recent structured review by Dr. David J. Bartram and others (Veterinary Record 2010;166:388-397) found that the veterinary profession has around three to four times the rate of suicide that would be expected in the general population, and around twice that reported for other health care professionals. Although the review focused on the U.K. veterinary population, the study’s list of risk factors for suicide sounds familiar: characteristics of individuals entering the profession; negative effects during undergraduate training; work-related stressors; ready access to, and knowledge of, means; stigma associated with mental illness; professional and social isolation; and alcohol or drug misuse. Attitudes about death and euthanasia, and suicide contagion (due to direct or indirect exposure to suicide of peers) are other possible influences.
 
Dr. Bartram, in an interview with JAVMA News, expanded on how veterinarians’ personalities can sometimes be a liability. 
 
“They’re a self-selecting group of people for whom the frequency of people with personality traits such as neuroticism and conscientiousness and perfectionism are likely to be elevated. Populations of high achievers are likely to have a higher proportion of people with these personality traits, which we know can be risk factors for mental health problems,” said Dr. Bartram, who is on the board of the Veterinary Benevolent Fund. 
 
Yet, the study in Social Psychiatry and Psychiatric Epidemiology, titled “Suicidal behaviour and psychosocial problems in veterinary surgeons: a systematic review,” found little evidence that veterinarians have particularly poor mental health or suffer from an exceptionally high degree of stress.
 
That said, female veterinarians, young veterinarians, and those working alone were identified in the study as being more at risk for suicidal thoughts, mental health difficulties, and stress.  

Those findings mirror what is seen by the Veterinary Benevolent Fund, a U.K. charity that provides support to those in the profession who need mental health services. The VBF’s services include the Vet Helpline, an anonymous, confidential support service.
 
In 2012, 60 percent of calls to the Vet Helpline were from individuals age 30 or younger, said VBF director Dr. Rosie Allister, at the Veterinary Professional Wellness Summit, held Sept. 17 during the World Veterinary Congress in Prague. The summit was sponsored by the International Veterinary Officers Coalition. 
 
Citing additional results from the 2012 study, Allister also stated in her talk that veterinarians may be most likely to first experience suicidal thoughts during the transition from training to practice. Barriers to seeking help included concerns regarding the potential for adverse effects on career prospects, an inclination toward self-reliance, and a perception that support was of no value because it could not change circumstances, Dr. Allister said.
 
Dr. René A. Carlson, moderator of the wellness summit and AVMA director of international affairs, wasn’t surprised to hear that young practitioners seem to struggle more. 
 

“I often hear from the older half of our membership that when they went through veterinary school, they didn’t have such problems. But then, I was thinking of the list of things new veterinarians have to deal with: Their student debt is astronomical compared to when we went to school decades ago, there’s excess capacity in the supply of veterinary medical services, liability claims are more prevalent, the standard of care has gone way up, and there’s so much more competition for general practitioners from specialty practices, low-income spay/neuter clinics, and nonveterinary providers. Plus, there’s the Internet and social media bullying. You can lose your reputation in a matter of minutes,” she said. “The pressures are different, totally different.”   

People working in veterinary education have noticed changes with students, too. 
 

Kathleen Ruby, PhD, director of counseling and wellness at the Wash­ington State University College of Veterinary Medicine, recently met with fellow counselors and mental health professionals who work with veterinary students and reflected on what is different now from 25 years ago.  

For one thing, she said, all universities are noticing much higher usage of their health centers, as mental health care has become more accepted in the past 20 years. This has allowed more students to enter college, even though they might have a moderate condition.
 
“Some will certainly filter into veterinary medicine, so we have people who have higher needs coming in. Plus, in my 15 years, I’ve watched the curriculum and co-curriculum push toward things like business training, which I value highly, but I’ve also watched as they add to hours of the day of every student,” Dr. Ruby said.
 

“I think we’re helping them understand that business and professional skills are part of success, but now they have to learn those topics on top of everything they had to do before. Plus, they’re looking to distinguish themselves somehow from everyone else, and, because they’re all high-performing, it’s tough to do.” 

Lack of resources

Mental health care isn’t always readily available for U.S. veterinarians because of a spotty network of support services at the state and local levels.   
 
Many state VMAs, including those in Michigan, South Carolina, and Texas, rely on recovery programs that assist all health professionals with substance abuse and other issues. A few states have their own programs for veterinary professionals, such as Alabama’s Veterinary Professionals Wellness Program, which provides confidential evaluation and treatment for veterinarians, veterinary technicians, support staff, and families.
 
The American Society of Veterinary Medical Association Executives, dedicated to supporting and enhancing the efforts of organized veterinary medicine, has not been particularly involved in mental health and wellness issues for the profession, ASVMAE President David Foley said.
 
“I would imagine there have been some individual efforts in this regard from some of the VMAs within ASVMAE, and, perhaps (it) could be something ASVMAE could investigate as an organization in the form of resources for its members,” he said. 
 


Dr. Rosie Allister, a member of the U.K. Veterinary Benevolent Fund’s board of directors, speaks on the influences that might affect the mental well-being of veterinary students during the Veterinary Professional Wellness Summit, held Sept. 17 as part of the World Veterinary Congress in Prague and sponsored by the International Veterinary Officers Coalition. (Photo by Dr. René A. Carlson)
 
The AVMA formerly had a Committee on Wellness, which offered expertise on addiction and peer assistance. Yet, in 2004, the Executive Board voted to sunset the group, citing an AVMA Governance Performance Review Committee report that said “the wellness issues facing the profession have expanded in scope—taking in issues as varied as compassion fatigue and eating disorders—and that these issues are increasingly being addressed at the local level” (see JAVMA, June 1, 2004). Subsequently, the AVMA Member Services Committee took responsibility for the issue.   
 
Further, no dedicated rehabilitation facilities exist solely for veterinarians, although there are a handful of successful ones for health professionals. One of the first to be created was the Ridgeview Institute in Atlanta, after which many others are modeled. 
 

Dr. Jerome B. Williams, director of the Alabama veterinary wellness program and a speaker at the International Veterinary Officers Coalition wellness summit, told JAVMA News that some of the better facilities will be cost-prohibitive for veterinarians, charging up to $50,000 for treatment. By the time most veterinarians get to the point where they need treatment, they have exhausted all resources, he said.   

That goes hand in hand with another setback for troubled veterinarians. 

“One big problem in this country is the lack of a good health care system that takes care of everybody. Many countries provide support for veterinarians in treatment, but this country is way behind as far as having resources available,” Dr. Williams said. 

“The other thing we have to address is we’re not willing to pay what’s required to have a decent wellness program. It costs, but the benefits are enormous, because lives are saved and quality of care to patients and quality of life for their families is maintained.”
 
He advocates for state VMAs and state boards of veterinary medical examiners to provide more mental health resources. The way these boards are set up now, Dr. Williams said, “is their actions tend to be punitive rather than therapeutic, because most people don’t realize (mental illness, such as) addiction is a disease and it needs to be treated as such.” 
 
At the veterinary student level, a 2012 study showed that most U.S. veterinary colleges—22 of the 26 that participated—directed students to their university counseling centers for mental health services. Nine of these colleges had a designated counselor for veterinary students, but even those colleges typically had only a single individual available to provide services. The amount of time these counselors provided to veterinary programs varied greatly, from five hours per week to full time (JVME 2012;39:83-92).
 
At Washington State, Dr. Ruby works full time at the veterinary college. She teaches students about the human-animal bond, conducts bereavement training, coordinates the AVMA Veterinary Leadership Experience at the college, and, with another full-time employee, offers counseling. She estimates their office sees 10 to 15 percent of the veterinary student body for long-term counseling and maybe 40 percent total, including those who were dealing with stressful one-time situations such as a death in the family.
 
She hopes other veterinary schools adopt a model similar to WSU’s.
 
“It’s much better to hire a full-time person for a veterinary school who learns the personalities and systems and is a trusted member of the faculty and leadership team,” Dr. Ruby said.
 
“That goes a long way to convince students to seek help but also helps schools to make use of social workers  to reform the climate to be more hospitable to wellness.” 

Next steps

The topic of mental health and wellness seems to be gaining more attention in the profession following relevant presentations at veterinary conferences, including the 2012 Banfield Summit and the IVOC wellness summit this past September. In addition, The Ohio State University College of Veterinary Medicine recently hosted its first Health and Wellness Summit, Sept. 25-26. The event drew 60 attendees from 22 veterinary colleges in the U.S. and Canada, including deans, associate deans, and mental health professionals from these institutions. It was sponsored by the AVMA and Zoetis. The four speakers—Dr. Ruby; Elizabeth Strand, PhD; Jennifer Brandt, PhD; and Laurie Fonken—are counselors or mental health professionals who work at veterinary colleges.  
 
The summit came about after Dean Lonnie J. King of OSU’s veterinary college led a discussion on the topic at the Association of American Veterinary Medical Colleges’ Deans Conference this past January in Naples, Fla.  
 

Dr. King told JAVMA News, “Our concern was what we thought was potentially an increase in these kinds of issues around health and wellness (on our campuses). It’s not a crisis, but it’s concerning to us,” he said. “We need to know more about it and delve into it more deeply.”  

Dr. Linda Lord, associate dean for student affairs at OSU’s veterinary college, said the summit was intended to create an open forum where people could dialogue.
 
“I think the feeling amongst administrators is we are seeing more (mental health issues) now. Is this a millennial or generational issue? Is it because we’ve made strides in encouraging help-seeking behavior? I’m not sure we can answer those questions definitively,” Dr. Lord said. “Certainly, the feeling is it’s a good thing, a healthy thing, when you can create an environment where people are going to be comfortable talking about it.”
OSU summit attendees agreed that a task force of veterinary mental health professionals should be created to develop recommendations for veterinary colleges on best practices for mental health and wellness. These could be used not only by veterinary programs but also integrated into the curriculum or incorporated into state VMA programs.
 
A meeting is being considered for the AAVMC Annual Meeting in March, Dr. Ruby said. 

Better help, better data

The consensus from both the Ohio State and IVOC wellness summits, according to presenters and attendees, was that better resources are needed for veterinarians who require help, in addition to more research data on mental health issues in the profession.

Regarding such resources, Dr. Lord said, “The AVMA could be a key venue for this. We need something more comprehensive that can create common resources. The U.K. has done something like that with the Veterinary Benevolent Fund. There’s no sense in each state having to reproduce different things.”
 
Dr. Carlson agreed that the AVMA could make the topic of wellness and personal well-being a greater priority on some level.
 

“I’d like to highlight the fact that the AVMA, as part of IVOC, participated in promoting this topic on an international scale,” she said. “All of us in our careers have similar stresses, no matter where we work. We’re starting to recognize this as a health concern for our own profession.” 

Dr. Williams says credible research will help drive better debate and solutions. He encourages charities such as the American Veterinary Medical Foundation and drug companies such as Zoetis to sponsor studies or have public health students take on relevant projects.
 
Much of the existing data come from the U.K. and Australia. Currently, Dr. Allister of the VBF is working on a prospective cohort study investigating mental ill-health and mental well-being, job satisfaction, and job performance among newly qualified veterinary surgeons. And Dr. Bartram said the VBF is considering conducting a formal follow-up study of patients who have been through its Veterinary Surgeons Health Support Program, which is run by a mental health professional. The program has a current caseload of around 90 people. 

 

“We’d like to have data available of the long-term outcome for people, like if they return to work and whether they remain abstinent. If we could generate some accurate data on that rather than speculation, we could get information to patients with addiction problems, and, hopefully, that would encourage them to see positive outcomes,” he said, adding that the most frequently seen cases involved depression or anxiety followed by addiction.  

The VBF is also considering creating a veterinary mentoring program similar to those in Australia and The Netherlands. 
 
The Australian Veterinary Association’s Mentor Program pairs newly graduated member veterinarians with more experienced colleagues who help them negotiate their first years in practice as well as offer them general support and advice. 
 
Dr. Ruby says that, in her work, emphasizing wellness is just as important as treating mental health issues.

She coaches students to have self-awareness of the positive things they’re doing rather than worrying about a list of “must dos” or “have tos.” She also makes them aware of how often they criticize themselves.
 
“One thing highly driven people do is they have a hyperactive coach (in their head) condemning things and rethinking what it is they’re doing. That can cause anxiety and depression. I try to make them aware of the voice in their head. I have them count how many times a day it is critical and help them reframe that, rather than let it control them,” Dr. Ruby said.  “It’s not magic, but it’s a toolkit that, if applied, does work.”