Mental Health Experiences and Service Use Among Veterinary Medical Students
Publication: Journal of Veterinary Medical Education
Volume 46, Number 4
Abstract
The mental health and wellness of veterinary students is an important contemporary focus of scholarship. Yet, to date, little empirical work has investigated mental health experiences and rates of mental health service use in large samples of veterinary students from multiple institutions. The purpose of this study is to explore the prevalence of mental health concerns among veterinary medical students, as well as rates of mental health service utilization, using validated measures and a large sample. Study participants were 573 veterinary medical students currently enrolled in accredited veterinary medical programs in the United States. Approximately one third of participants reported levels of depression or anxiety above the clinical cut-off, and a strong positive correlation was found between the two. Depression and anxiety were also associated with prior engagement in non-suicidal self-injury (NSSI), suicidal ideation, and prior suicide attempts. Nearly 80% of participants who scored above the clinical cut-off for depression or anxiety reported seeking some form of mental health services currently or in the past, and a majority reported having positive experiences with services. Results also indicated a higher than typical rate of NSSI among veterinary medical students. Implications for outreach, research, and education are discussed.
Over the past several years, mental health and wellness among veterinary students has become an important area of study.1 Veterinary medical students experience a variety of academic stressors, including concerns about maintaining high academic performance,2,3 managing a heavy workload,4–6 and navigating unclear expectations.3,5 They also face non-academic stressors, such as financial strain,4,7 transitional stress,3 and relationship problems.3,7 In light of these challenges, many studies have found that veterinary students experience high rates of depression,5,6,8,9 and they report moderate to high levels of anxiety across all four years of training.5
Furthermore, veterinary students may also experience problems with substance abuse. For example, Diulio et al.10 concluded that a large proportion of veterinary students engage in high-risk drinking behaviors. Although students may drink as a way of coping with stress,10,11 Kogan et al.7 found that many veterinary students reported experiencing negative consequences due to drinking, such as getting physically injured or having unprotected sex.
Some studies have found that veterinary students are also more likely than the general public to have had suicidal thoughts.8,12 Overall, research suggests that gender differences may exist regarding mental health concerns: while men tend to be at greater risk for substance abuse,10,13 women tend to experience higher levels of depression, anxiety, and academic stress.3,8,14,15
Research in community, general college student, and medical student samples suggests that many individuals may not seek professional support when they are in distress. For example, findings from community samples show that less than one third of individuals in distress sought services from a mental health professional.16 Furthermore, in a large sample of college students between the ages of 19 and 25 years, Blanco et al.17 found that only 18% of those who reported experiencing a mental health disorder in the past year had sought treatment, and rates of service use differed depending on the presenting issue. Specifically, the researchers found that approximately one third of college students with mood disorders had sought services, while only 5% of those with substance abuse disorders had sought help. Similarly, in a medical student sample, Tjia et al.18 found that slightly less than 27% of a sample of depressed medical students had sought treatment in the past, even when services were readily available. Despite the high prevalence rate of mental health concerns among veterinary students, these findings collectively suggest that many veterinary students may not seek professional mental health services when it is warranted.
Purpose of the Study
Promoting positive mental health among veterinary medical students is essential to ensuring their academic and professional success.4 Mental health concerns have been associated with impaired concentration, difficulty remembering information, and decreased executive functioning,19 as well as increased risk for dropping out of academic programs.20 Poor mental health among veterinary students may also negatively impact the quality of services they provide to clients and patients.21 Therefore, it is important for mental health professionals and veterinary educators to understand the mental health experiences of veterinary students and to identify whether students in need are getting appropriate support.
The main objectives of this study were to investigate the prevalence of mental health concerns among veterinary medical students as well as rates of mental health service use. We sought to address some limitations of previous studies by using validated measures, sampling from multiple institutions, and obtaining a large sample size. We also assessed rates of non-suicidal self-injury (NSSI), which has been notably absent in other studies involving veterinary students. NSSI refers to the “intentional destruction of body tissue without suicidal intent,”22(p.1045) such as cutting or burning, and it is most often performed in an attempt to reduce intense negative emotions. By definition, NSSI is a distinct behavior from making a suicide attempt,23 but it may also constitute a unique risk factor for suicidality.24 We explored several research questions, including the following:
1.
What are the prevalence rates of depression, anxiety, alcohol abuse, NSSI, suicidal ideation, and suicide attempts among veterinary medical students?
2.
What are the relationships among depression, anxiety, alcohol abuse, NSSI, suicidal ideation, and suicide attempts among veterinary medical students?
3.
Are there gender differences with regard to depression, anxiety, alcohol abuse, NSSI, suicidal ideation, and suicide attempts among veterinary medical students?
4.
What proportion of veterinary medical students have used mental health services, what services do they use most frequently, how recently have they used services, and how positively do they rate their experiences?
5.
What proportion of students with elevated scores on measures of depression, anxiety, and alcohol use has used mental health services?
Methods
To recruit participants for the study, we emailed a request for research participation to the deans of each of the 30 Colleges of Veterinary Medicine (CVMs) in the United States accredited by the American Veterinary Medical Association Council on Education (AVMA COE); 16 CVMs agreed to participate in the study. We asked participating programs to distribute recruitment materials via email to current veterinary medical students in their colleges. This email contained an informed consent statement, including a summary of the study and information about procedures, time involvement, level of confidentiality, risks and benefits, and the voluntary nature of participation. The form also clearly explained that participants’ colleges would not have access to the research records, that participants would not be asked to identify their institutional affiliation, and that findings from the study would be presented in aggregate form. We included an electronic survey link, which directed participants to a password-protected Qualtrics account.a After acknowledging their understanding of the informed consent statement, participants completed the research survey online.
Participants
The participants in this study were 573 veterinary medical students currently enrolled in CVMs in the United States accredited by the AVMA COE. According to data provided in the Association of American Veterinary Medical College (AAVMC) 2016–2017 data report,25 this represents an approximate response rate of 8% among the 16 participating CVMs. Almost 5% of the total number of students currently enrolled in accredited programs are included in the study.
Participation in the study was entirely voluntary and confidential, and participants did not receive any financial compensation or other direct benefits for participating in the study. Most participants identified as white (541, 94.4%), female (498, 86.9%), and heterosexual (478, 83.4%). This suggests that students who identify as white were overrepresented in the sample, considering the proportion of students who identify as white among participating CVMs (86.5%) and at CVMs nationally (82.6%). Students who identify as female were also slightly over-represented in the sample, considering the proportion of students who identify as female among participating CVMs (80.5%) and at CVMs nationally (80.5%). The median age of the participants was 25, with ages ranging from 21 to 50. Approximately 17% (96) of the sample reported being married, over 35% (203) reported being single, and almost 46% (262) reported being in a serious dating or committed relationship. A minority of participants (32, 5.6%) indicated that they were parents, and most reported living with either roommates (256, 44.7%) or a partner or spouse (179, 31.2%). Students from all 4 years of training were fairly evenly represented in the sample. Participants reported a median grade point average (GPA) of 3.40 (range: 2.00–4.00).
Instruments
Participants responded to a 96-item electronic survey. The research survey included a demographic questionnaire and items pertaining to participants’ mental health symptoms and their history of mental health service use. The survey also included items related to participants’ attitudes toward seeking mental health services, mental health stigma, willingness to seek services, and perceived barriers to seeking mental health services; however, these items will not be discussed in the current article due to space constraints. We presented survey components in randomized order to reduce order effects.
Demographic Questionnaire
The demographic questionnaire asked participants to identify their age, gender identity, race/ethnicity, sexual orientation, relationship status, living situation, parent status, academic classification, and current GPA.
Patient Health Questionnaire (PHQ-9)
The Patient Health Questionnaire (PHQ-9) is a 9-item scale developed to screen for depressive disorders; it has been shown to be a reliable and valid instrument for measuring depressive symptom severity.26 Each item reflects a symptom of depression (e.g., “Little interest or pleasure in doing things”), and participants are asked to select how frequently they have experienced each symptom in the past 2 weeks. Items are scored on a 4-point scale (0 = not at all; 3 = nearly every day), and item scores are summed to create a total score. Total scores can range from 0 to 27, with higher scores indicating greater severity of symptoms. Total scores of 5, 10, 15, and 20, respectively, reflect mild, moderate, moderately severe, and severe depression.26 The PHQ-9 also includes an additional unscored item to assess how the depressive symptoms participants endorse may impact their social, family, or vocational functioning (0 = not difficult at all; 3 = extremely difficult). Using a cut score of 10, the PHQ-9 has been shown to have a sensitivity of .88 and a specificity of .88 for detecting major depressive disorder.26,27 Previous studies have found that the PHQ-9 has good internal consistency (α = .86–.89),26 and it demonstrated similar internal consistency in the current sample (α = .88).
Generalized Anxiety Disorder 7-Item (GAD-7)
The Generalized Anxiety Disorder 7-Item (GAD-7) scale is a 7-item measure designed to assess symptoms of anxiety.28 Although it was originally designed to assess symptoms of generalized anxiety disorder, it has also been shown to be useful in detecting panic disorder, social anxiety disorder, and post-traumatic stress disorder.28 Each item reflects a symptom of anxiety (e.g., “Feeling nervous, anxious, or on edge”), and participants are asked to select how frequently they have experienced each symptom in the past 2 weeks. Items are scored on a 4-point scale (0 = not at all; 3 = nearly every day) and then summed to create a total score. Total scores can range from 0 to 21, with higher scores indicating higher levels of anxiety. Spitzer et al.28 reported that total scores of 5, 10, and 15 represent mild, moderate, and severe anxiety symptoms, respectively. The GAD-7 also includes an additional unscored item to assess how the anxiety symptoms participants endorse may impact their social, family, or vocational functioning (0 = not difficult at all; 3 = extremely difficult). Using a cut score of 10, the GAD-7 has been shown to have a sensitivity of .89 and a specificity of .82 for detecting generalized anxiety disorder.20 The GAD-7 has demonstrated good to excellent internal consistency in previous studies (α = .9228; α = .8629; α = 9530), and it showed excellent internal consistency in the current study (α = .91).
Alcohol Use Disorders Identification Test—Consumption (AUDIT-C)
We used the Alcohol Use Disorders Identification Test—Consumption (AUDIT-C) scale31 to evaluate alcohol use among participants. The AUDIT-C includes three items that assess the frequency (e.g., “How often did you have a drink containing alcohol in the past year?”) and quantity (e.g., “How many drinks did you have on a typical day when you were drinking in the past year?”) of participants’ alcohol consumption. Responses to each item are weighted from 0 to 4. Item scores are then summed to create a total score between 0 and 12, with higher total scores reflecting greater alcohol use. Dawson et al.32 found that using a cut score of 5, the AUDIT-C had a sensitivity of .83 and a specificity of .88 for detecting alcohol abuse in a sample of US adults.
NSSI and Suicidality
To assess participants’ history of NSSI and experiences with suicidal thoughts and suicide attempts, we asked them to respond yes or no regarding whether they had ever engaged in NSSI (e.g., cutting or burning), whether they had ever seriously thought about suicide, and whether they had ever made a suicide attempt.
Prior Use of Mental Health Services
To evaluate participants’ history of using mental health services, we asked them to respond yes or no in response to whether they had ever participated in or received individual counseling, family counseling, group counseling, crisis intervention services, or medication for mental health concerns. For those who reported having a history of using mental health services, we asked them how recently they participated in services (e.g., currently, within the last month, within the last year, within the last 1–5 years, or more than 5 years ago). We also asked them to rate how positively or negatively they perceived the experience on a 7-point Likert-type scale (1 = very negative; 7 = very positive).
Results
Prior to conducting statistical analyses, we screened the data to ensure that the underlying assumptions of each analysis were met. We used an alpha level of .05 for all analyses. The statistical procedures used to evaluate each research question are described below.
Prevalence of Mental Health Concerns
To examine the prevalence of depression, anxiety, alcohol abuse, NSSI, suicidal ideation, and suicide attempts among the sample, we produced and reported descriptive statistics for each concern. These results regarding depression and anxiety are shown in Table 1. Among participants who reported experiencing any of the depressive symptoms listed in the PHQ-9 items, 18% (103) indicated that these concerns made it very difficult or extremely difficult for them to do their work, take care of things at home, or get along with other people. Similarly, among participants who reported experiencing any of the anxiety symptoms listed in the GAD-7 items, 21% (120) indicated that these concerns made it very difficult or extremely difficult for them to do their work, take care of things at home, or get along with other people. With regard to alcohol use, the mean AUDIT-C total score was 3.19 (SD = 1.92, range: 0–10), and 25% (143) of the sample reported scores at or above the cut-off of 5 for detecting alcohol abuse. Over 24% (140) reported having a history of NSSI (e.g., cutting or burning). Over 30% (175) reported having seriously thought about suicide, and almost 5% (28) indicated that they had made a suicide attempt.
| Symptom severity n (%) | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Concern | n | M | SD | Range | Minimal | Mild | Moderate | Moderately severe | Severe |
| Depression | 564 | 8.19 | 5.82 | 0–27 | 183 (32.4) | 190 (33.7) | 107 (19.0) | 53 (9.4) | 31 (5.5) |
| Anxiety | 567 | 8.44 | 5.52 | 0–21 | 163 (28.4) | 199 (35.1) | 106 (18.7) | - | 99 (17.5) |
Notes: Depression scores are based on the Public Health Questionnaire (PHQ-9) total score.
Anxiety scores are based on the Generalized Anxiety Disorder 7-item (GAD-7) total score.
GAD-7 does not include a moderately severe scoring category.
Relationships Among Mental Health Concerns
We conducted Pearson product–moment correlations, point-biserial correlations, and chi-square tests to explore the relationships among the mental health concerns included in the study. Product–moment and point-biserial correlations are shown in Table 2. Depression scores on the PHQ-9 were highly positively correlated with anxiety scores on the GAD-7. Both depression and anxiety scores were positively related to prior engagement in NSSI, having seriously thought about suicide, and having made a suicide attempt.
| Concern | M | SD | 1. | 2. | 3. |
|---|---|---|---|---|---|
| 1. Depression | 8.19 | 5.82 | - | - | - |
| 2. Anxiety | 8.44 | 5.52 | .699*** | - | - |
| - | - | (559) | - | - | |
| 3. Alcohol use | 3.19 | 1.92 | −.046 | −.037 | - |
| - | - | (562) | (564) | - | |
| 4. NSSI† | 0.25 | 0.43 | .302*** | .205*** | −.006 |
| (560) | (563) | (565) | |||
| 5. Suicidal thoughts† | 0.31 | 0.46 | .414*** | .266*** | −.036 |
| (560) | (563) | (565) | |||
| 6. Suicide attempt† | 0.05 | 0.22 | .184*** | .088* | −.074 |
| (560) | (563) | (565) |
NSSI = non-suicidal self-injury
Notes: Depression scores are based on the Patient Health Questionnaire (PHQ-9) total score.
Anxiety scores are based on the Generalized Anxiety Disorder 7-item (GAD-7) total score.
Alcohol use scores are based on the Alcohol Use Disorders Identification Test—Consumption (AUDIT-C) total score.
NSSI scores are based on participants’ prior engagement in non-suicidal self-injury (0 = No; 1 = Yes).
Suicidal thoughts scores are based on whether participants had seriously thought about completing suicide (0 = No; 1 = Yes).
Suicide attempt scores are based on whether participants had made a suicide attempt (0 = No; 1 = Yes).
Degrees of freedom are noted in parentheses.
* p < .05
*** p < .001
† Point-biserial correlations
Correlations between participants’ AUDIT-C scores and scores on the PHQ-9 and GAD-7, as well as correlations between AUDIT-C scores and participants’ responses to whether they had ever engaged in NSSI, whether they had ever seriously thought about suicide, and whether they had ever made a suicide attempt were all nonsignificant (p > .05). Participants who reported engaging in NSSI were more likely to report having seriously thought about suicide (χ2 [1, N = 568] = 65.56, p < .01, ϕ = .38) or having made a suicide attempt (χ2 [1, N = 568] = 40.20, p < .001, ϕ = .26), and the effect sizes were moderately strong to very strong.
Gender Differences in Mental Health Concerns
To evaluate gender differences with regard to mental health concerns, we conducted a series of independent sample t-tests and chi-square tests. The results of the t-tests are shown in Table 3. Women reported marginally statistically significant higher levels of depressive symptoms on the PHQ-9 than men, as well as statistically significant higher levels of anxiety on the GAD-7. In both cases, the effect sizes were small. Differences in alcohol consumption scores on the AUDIT-C between women and men were nonsignificant.
| Women | Men | |||||||
|---|---|---|---|---|---|---|---|---|
| Concern | df | t | p | d | M | SD | M | SD |
| Depression | 553 | 8.27 | 5.78 | 6.77 | 5.84 | 1.92 | .056 | 0.16 |
| Anxiety | 556 | 8.64 | 5.56 | 6.54 | 4.94 | 2.82** | .005 | 0.24 |
| Alcohol use | 560 | 3.17 | 1.85 | 3.43 | 2.39 | −1.03 | .303 | 0.04 |
Notes: Depression scores are based on the Patient Health Questionnaire (PHQ-9) total score.
Anxiety scores are based on the Generalized Anxiety Disorder 7-item (GAD-7) total score.
Alcohol use scores are based on the Alcohol Use Disorders Identification Test—Consumption (AUDIT-C) total score.
** p < .01
In terms of NSSI and items related to suicidality, we found that women were more likely to report engaging in NSSI than men (χ2 [1, N = 559] = 7.97, p = .005, ϕ = −.12), while men were marginally significantly more likely to report having seriously thought about suicide than women (χ2 [1, N = 559] = 3.81, p = .051, ϕ = .08). However, the effect sizes for these differences were very small. The association between gender and having ever made a suicide attempt was nonsignificant (p > .05).
Mental Health Service Use
To evaluate facets of participants’ mental health service use, we produced and reported descriptive statistics. As shown in Table 4, almost 69% of participants reported a history of using some form of mental health service. Individual counseling and medication were the most commonly used services, while crisis intervention services were the least commonly used.
| Service use (overall) | Service use (elevated scores) % (n) | |||
|---|---|---|---|---|
| Service | n = 573 % (n) | PHQ-9 ≥ 10 n = 191 | GAD-7 ≥ 10 n = 205 | AUDIT-C ≥ 5 n = 143 |
| Individual counseling | 62.5 (358) | 74.9 (143) | 71.7 (147) | 58.0 (83) |
| Medication | 36.8 (211) | 49.7 (95) | 46.8 (96) | 33.6 (48) |
| Family counseling | 14.7 (84) | 17.3 (33) | 19.0 (39) | 13.3 (19) |
| Group counseling | 8.0 (46) | 12.0 (23) | 12.7 (26) | 7.0 (10) |
| Crisis intervention | 5.4 (31) | 11.5 (22) | 8.3 (17) | 4.9 (7) |
| Any service | 68.6 (393) | 78.5 (150) | 77.6 (159) | 65.7 (94) |
PHQ-9 = Patient Health Questionnaire (depression); GAD-7 = Generalized Anxiety Disorder 7-item (anxiety); AUDIT-C = Alcohol Use Disorders Identification Test—Consumption (alcohol use)
Notes: Figures shown indicate whether participants reported having a history of using each mental health service.
Importantly, participants who reported using mental health services generally indicated that their experiences were quite positive. For example, over 18% (72) described their experience as very positive, 35% (138) described it as positive, and almost 22% (85) described it as somewhat positive. Slightly more than 11% (44) of those who reported prior use of mental health services described it neutral, while only approximately 14% (54) described it as somewhat negative, negative, or very negative.
With regard to the timeline of participants’ mental health service use, approximately 24% of the sample (135) reported currently engaging in some form of mental health services, over 5% (32) reported using services within the past month, and 13% (76) reported using services within the past year. Almost 15% (85) reported participating in mental health services within the past 1–5 years, and approximately 12% (66) reported engaging in services more than 5 years ago. Based on these data, we can infer that a substantial proportion of students accessed mental health services after starting veterinary medical school. For example, over 42% (243) of participants reported using mental health services sometime within the past year.
Symptom Severity and Mental Health Service Use
To explore whether participants with elevated scores on depression, anxiety, and alcohol use have accessed mental health services, we produced and reported descriptive statistics. As shown in Table 4, of the participants who scored at or above a clinical cut-off of 10 on the PHQ-9 (191, 33.9%), corresponding with moderate or higher depression severity, almost 79% reported having a history of using mental health services. Of the participants who scored at or above a clinical cut score of 10 on the GAD-7 (36.2%, 205), corresponding with moderate or higher anxiety, almost 78% reported using some form of mental health services currently or in the past. Last, among the participants who scored at or above a clinical cut-off of 5 on the AUDIT-C (143, 25%), almost 66% reported having a history of using some form of mental health service. Rates of use for specific mental health services are also shown in Table 4.
Discussion
Prevalence of Mental Health Concerns
In this study, we found that approximately one third of the participants reported symptoms of anxiety or depression that were above the clinical cut-off, which is similar to other veterinary student samples.5,8,9 These figures appear to be higher than prevalence rates in other non-veterinary samples. For example, in a study of third-year medical students, Mosley et al.33 found that 23% of respondents reported experiencing clinical levels of depression. Other researchers have found depression prevalence rates between 11%34 and 17%35 and anxiety prevalence rates between 4%34 and 12%17 in college student samples.
With regard to at-risk drinking, participants in the current sample reported drinking less than the practicing veterinarians included in Bartram et al.’s study,13 and their drinking behaviors were found to be similar to those of general college students. For instance, Slutske36 found that 18% of a college student sample experienced a clinically significant alcohol-related problem (mostly associated with binge drinking) in the past year. Blanco et al.17 found a 20% 12-month prevalence rate of alcohol use disorders among college students.
Almost one third of the sample reported that they had seriously thought about suicide at some point. This figure is similar to rates of suicidal ideation reported among medical school students,18 and it is higher than some figures reported among college students.35,37 However, in a study of 26,000 students from 70 colleges and universities, Drum et al.38 found that over half of the participants reported having at least one episode of suicidal thinking at some point in their lives, which is higher than in the current study. It is important to note that apparent differences in prevalence rates may be due to how the researchers operationalize the behavior and how recently it occurred. Approximately 5% of the veterinary students in the current study reported that they had attempted suicide, which is much higher than the 0.85% (undergraduate students) and 0.30% (graduate students) rates reported by Drum et al.38 This lends some support for concerns regarding suicidality among veterinarians.39,40
Furthermore, almost a quarter of the participants in the current study reported engaging in NSSI (e.g., cutting or burning) at some point. These figures appear to be higher than those found in some college student samples (12%)23 but consistent with others (20%).41 Research suggests that NSSI may serve an affect regulation function,42 and that adolescents and young adults tend to be at greatest risk for engaging in NSSI.22 Whitlock et al.43 reported that most people who engage in NSSI do so only once or a few times, and relatively few go on to self-injure regularly. Nonetheless, additional research on NSSI among veterinary medical students may be warranted, especially in light of its relationship with suicidality.
Relationships Among Mental Health Concerns
In this study, we found a strong relationship between anxiety and depressive symptoms, which is consistent with previous findings in both veterinary student3 and community samples.44 The high comorbidity between anxiety and depression warrants consideration, as it is relevant to treatment planning and understanding the ways in which symptoms of anxiety and depression may manifest among the veterinary student population. Although some studies have also found that depression is associated with increased alcohol use,10,45 the results of the current study are similar to those of Garlow et al.37 in that we did not find a significant association between depression and alcohol use.
Regarding correlates of NSSI and suicidality, our findings that depressive symptoms were positively associated with NSSI are in line with previous literature,41,46–48 as are the findings pertaining to the relationship between anxiety symptoms and NSSI.41,47,49 Some studies have found that alcohol abuse is associated with NSSI,50,51 but the nonsignificant relationship we found between scores on the AUDIT-C and reported NSSI is similar to Gollust et al.’s findings.46
We also found that depression and anxiety were related to suicidal ideation and suicide attempts, which is consistent with other studies.37,49,52 This underscores the importance of attending to students’ mental health needs and offering accessible prevention and intervention services. Similar to Garlow et al.,37 we found that alcohol use was not related to suicidal ideation—although other studies have found that heavy alcohol use may increase suicide risk.53
Participants who reported engaging in NSSI at some point were also more likely to report having seriously thought about suicide or having made a suicide attempt, and the effect sizes were large. While NSSI is a distinct behavior from making a suicide attempt,23 research has shown that it may constitute a unique risk factor for suicidality.24 This suggests that it may be prudent for mental health professionals to assess for NSSI when evaluating risk.
Gender Differences in Mental Health Concerns
Our findings that women tended to report higher levels of anxiety and depression than men are consistent with previous research,1 although the nonsignificant gender differences we found regarding drinking behaviors are inconsistent with past studies that have found men to typically engage in more risky drinking behaviors than women.10,13 While women in the current study were more likely to report engaging in NSSI than men, men were more likely to report thinking about suicide. We did not find any significant gender differences in regard to previous suicide attempts.
Overall, data pertaining to gender differences in self-injury and suicidality are inconclusive.54 For example, while Whitlock et al.43 found that women engaged in self-injurious behaviors more often than men, other research has concluded that there are no significant gender differences with regard to the prevalence of NSSI among college student23 or community samples.55 However, gender differences may exist in the types of NSSI engaged in. For example, women may be more likely to engage in cutting, whereas men may be more likely to burn or hit themselves.56,57 Some researchers have found no significant gender differences with regard to suicidal thoughts,13,37 but additional research is needed. Collectively, the results of the current study suggest that mental health issues among veterinary students are not a gendered concern, especially considering the small effect sizes associated with several of the gender comparisons.
Mental Health Service Use
Overall, study participants reported high rates of mental health service use, with individual counseling and medication being the most commonly used interventions. Participants who reported having a history of using mental health services also generally indicated that their experiences were positive. This is something that may be beneficial to share in outreach programming to help address certain barriers to seeking mental health services, such as concerns about trust58 or the efficacy and utility of mental health services.59–61
Of particular importance is the finding that most students who scored above the clinical cut-off on measures of depression, anxiety, and alcohol use had accessed mental health treatment. This is in contrast with some previous research suggesting that undergraduate college students62,63 and medical students18 tend not to seek mental health services, even when they are in distress. Drum et al.38 found that almost half of the graduate students in their large sample had sought mental health services at some point in their lives, which suggests that college students may be using mental health services more frequently. It is possible that the high rates of service use reflected in this study are due, in part, to selection bias; however, it may also be due to improved accessibility to mental health services, as many CVMs have started employing mental health professionals.64
Strengths
Our careful study design is a strength of the present study that bolsters findings. We used validated instruments to measure symptoms of depression, anxiety, and substance use, which allows for meaningful comparisons across results. Further, we recruited students from multiple institutions to garner a larger, more representative sample. Although mental health and wellness among veterinary students is a contemporary focus of scholarship, few studies have used validated instruments and sampled from multiple institutions in their empirical investigations.
Among our findings, two areas are particularly important for their novel contributions to the literature. This investigation may be the first to evaluate help-seeking behaviors among veterinary medical students who report clinically significant symptoms of depression, anxiety, and substance use. We also assessed rates of NSSI and its correlates, which has been notably absent in other studies involving veterinary medical students. Although NSSI is a behavior distinct from making a suicide attempt, other scholarship has established a relationship between NSSI and suicidality, which raises serious concern for the high rate of NSSI and suicide attempts in our sample.
Limitations
The non-probability sampling methods used in this study limits the generalizability of our findings. Participation was entirely voluntary, and participants did not receive any direct incentives for completing the survey. It is possible that veterinary students who chose to participate in the study had higher rates of mental health service use compared with students who opted not to participate.
In addition, the data set did not include students from programs not accredited by the AVMA COE or programs outside of the United States. The low number of participants who identified as nonwhite in the sample, compared with the number of racially and ethnically underrepresented students enrolled in participating CVMs and in CVMs nationally, may limit our ability to generalize the results.25 For example, Greenhill and Carmichael65 found that certain student sub-populations had different perceptions of their veterinary school experiences. In particular, sub-populations who reported distinctly different perceptions included students underrepresented in veterinary medicine, whose “advancement in the veterinary medical profession has historically been disproportionately impacted by six specific aspects of diversity (gender, race, ethnicity, geographic, socioeconomic, and educational disadvantage) due to legal, cultural, or social climate impediments.”25(p.16) Male students were also slightly underrepresented in the sample, considering the number of male students enrolled in participating CVMs and CVMs nationally.25
Although we asked students about the general timeline of their mental health service use, it may have been more informative to specifically evaluate students’ use of mental health services before and after starting veterinary medical school using more precise scaling. Similarly, it may have also been helpful to assess whether students who reported accessing mental health services after starting veterinary medical school used services provided through their CVM, the university counseling center, or other community resources.
Implications and Directions for Future Research
It is important for veterinary educators to understand the mental health experiences of veterinary students and identify whether students in need are getting appropriate support. When approaching students who are struggling academically, educators need to be aware that mental health concerns may be contributing to impaired concentration, difficulty remembering information, and problems planning or initiating tasks19; they are also associated with increased risk for dropping out of academic programs.20 With this in mind, educators should seek to understand the holistic concerns of students, in addition to inquiries about study habits. Participation in programming, such as campus events or AVMA-endorsed trainings,66 to develop comfort in engaging in difficult conversations about mental health and suicide risk is recommended.
There are several important directions for future research that can expand our understanding of mental health concerns and wellness among veterinary students and practitioners. First, elaboration of some of the many ways symptoms of anxiety and depression manifest, present, and affect members of this professional population is warranted. Inquiries that can attend to the complexities of the lived experience and nuanced difference of individuals could foster a richer understanding of these comorbidities. Next, the elevated prevalence of NSSI and prior suicide attempts in the sample was surprising. Additional inquiries of NSSI, suicidality, and the relationship between the two in veterinary students are needed. Also, though most students who reported depression or anxiety above the clinical cut-off also reported seeking help either currently or in the past, just over 20% of students with similar scores have not received or are not receiving mental health services to address these concerns. Further research is needed to better understand and address veterinary students’ barriers to seeking help.
Although the results of this study indicate that mental health concerns among veterinary medical students are not a gendered concern, other research suggests otherwise.1,3 Further, qualitative studies have illuminated the complexities of the gendered experiences of women in the veterinary profession.67 Additional research is necessary to further develop our understanding of these mixed results regarding the gendered dimensions in veterinary school or practice and how they contribute to mental health in general.
Conclusion
The results of this study are in accord with others, highlighting the prevalence of and relationship among mental health concerns in veterinary students. This study is significant in that it found that most students who scored above clinical cut-offs for anxiety, depression, and alcohol use were receiving metal health services and/or had sought services in the past. Most students reported positive experiences associated with mental health services, which is important for outreach efforts. The high prevalence of NSSI is surprising and concerning, and warrants further research.
Footnote
a
Qualtrics software. Provo, UT, USA. https://www.qualtrics.com/research-core/survey-software/
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Journal of Veterinary Medical Education
Volume 46 • Number 4 • Winter 2019
Pages: 449 - 458
PubMed: 30806561
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2019 AMMI Canada.
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Published online: 26 February 2019
Published in print: Winter 2019
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