Photo courtesy of Dr. Randall Nett

Dr. Randall Nett is a physician and epidemiologist at the Centers for Disease Control and Prevention.

Overall, however, most veterinarians are mentally healthy. 

Those findings, presented last month during the American Veterinary Medical Association convention in Boston, came out of a mental health survey conducted in 2014 by the U.S. Centers for Disease Control and Prevention. More than 12,707 participants responded between July and October to the anonymous, self-reporting survey, though roughly 1,100 of the respondents were disqualified because they practice outside of the United States or have never worked as a veterinarian. 

That left 11,627 veterinarians included in the final analysis.

Posted online, the electronic survey was conceived by Dr. Randall J. Nett, a physician with a master's in public health who works for the CDC as an epidemiology field officer. Nett's collaborator and the principal investigator in the study was Tracy Witte, a psychologist at Auburn University whose research emphasis is suicidal behavior. 

Nett, who's married to a veterinarian, was looking through his wife's Journal of the American Veterinary Association (JAVMA) in late 2013, when he came cross an article that suggested veterinarians commit suicide at about three to four times the rate of the general population. 

To figure out why, he decided to launch a survey. The questions asked focused on demographics, practice setting, experiences with depression and suicidal behaviors, mental health treatment, stressors related to practice and satisfaction in practicing. Most of the survey's respondents were female, married or in committed relationships and practicing small animal medicine. Of those who reported having suicidal thoughts, the demands of practice were cited as the most common stressor with financial struggles and educational indebtedness coming in second. 

The survey's results come on the heels of the high-profile suicides of Drs. Sophia Yin, Shirley Koshi and Clarissa Engstrom. They show that a significantly higher proportion of veterinarians suffer from psychological distress compared with adults in the general U.S. population, Nett said. 

"We found nearly one in 10 veterinarians had current serious psychological distress, and nearly one in six had considered suicide since leaving vet school," he said. 

It's unknown how many in the veterinary profession contemplate suicide compared with the U.S. population at large. The CDC does not track suicidal tendencies but reports that roughly 17 of every 100,000 American adults aged 22 and older died by suicide in 2013, the latest year for which statistics are available. That roughly translates to 54,000 suicides a year. 

According to Mental Health America, even more Americans make suicide attempts. The nonprofit dedicated to suicide prevention estimates that at least 500,000 people try to kill themselves each year, and nearly half of those who die had made previous attempts.

Substance abuse, the agency says, is involved in nearly half of all cases. 

It's also likely to be a contributing factor among depressed and/or suicidal veterinarians, said Dr. Jon Geller of the Fort Collins Veterinary Emergency and Rehabilitation Center in Colorado. Geller determined to study the topic last spring after two members of his practice died from drug overdoses. His online survey drew around 365 veterinarians who responded to questions about whether the practices they work for test employees for substance abuse. 

The survey results were released last month during the AVMA annual convenion in Boston, where Geller spoke of his deceased colleagues. "I don't know if they were intentional, what drugs they used or if they got them from our hospital, but I think it's likely they did," he reportedly said. "More scrutiny is needed from our profession about what might be happening." 

Geller's findings showed that despite well-recognized stressors and risk factors in the veterinary workplace (difficult cases, long hours, financial challenges, euthanasias, and access to many controlled and potentially addictive drugs), the incidence of drug screening and drug testing employees is low when compared with other workplaces. Just 30 percent of veterinary clinics perform employee drug testing of any type, compared with approximately 60 percent of all U.S. workplaces. 

Additionally, compliance with U.S. Drug Enforcement Agency regulations regarding storage and access to controlled drugs is highly variable among veterinary practices. For example, the survey showed that 35 percent of veterinary workplaces did not store controlled drugs in a location with limited access during normal working hours. 

Many who participated in Geller's survey described alarming circumstances of drug abuse and addiction in the workplace among veterinarians and other staff. Sixty-seven percent of the respondents indicated that they thought drug abuse and addiction in the veterinary workplace was at least as much of a problem or a bigger problem than it is in other workplaces, and 83 percent of respondents thought the AVMA and state veterinary medical associations should commit resources to addressing the topic. 

Nett, the CDC physician, says substance abuse plays a role in many veterinary suicide cases. Overall, his figures about suicide incidence in the profession are consistent with data from other self-reporting studies, particularly overseas. A 2010 British paper found that veterinarians are four times as likely to commit suicide as the average population. 

That's not to say Nett's research is infallible. The 11,627 respondents included in his study represent a small slice of the 100,000 or so veterinarians thought to be in the United States. What's more, self-reporting studies are inherently limited in that only those who choose to answer participate, and that group often is comprised of those who find the topic to be relevant. That means, Nett said, that the results of his survey can be skewed toward those who have been affected by suicide or have contemplated it. 

Even so, similar findings from other self-reporting studies add to the validity of his results, Nett said, pointing to near-identical outcomes from a survey of veterinarians in New Zealand. He knows that some people view self-reporting studies as inherently flawed but said there is a possibility for a non-response bias that becomes skewed toward reporting higher levels of illness. 

"However, there might be people out there who are depressed and lack initiative to answer surveys," Nett said. "We included in our calculations all respondents who did not answer a particular question. It makes it so that they answered in the negative." 

Veterinarians have died by suicide for decades. Yet something feels different different nowadays, said social worker Susan Cohen, who spent 28 years working at the Animal Medical Center in Manhattan, helping pet owners and improving veterinarians' communication skills. 

She believes there's more to the CDC's finding that veterinarians are more stressed by their work than financial or personal issues. The gender shift, Cohen said, might have something to do with it. Women use more health care than men and seem more willing to discuss concerns, she said, noting that twice as many women than men are diagnosed with depression, yet three times as many men die by suicide. 

In research Cohen has seen tracking suicide among professions, some studies show veterinarians near the top of the risk scale. Another report ranks the risk for veterinarians low, below accountants. She doesn't know what to make of discrepancies. 

"The question about the rate of suicide for vets changes from study-to-study," Cohen said. "In some, veterinarians are nowhere near the top." 

Cohen and Nett are aware that the stigma of mental health struggles looms large for veterinarians and physicians. Nett believes both professions are comprised of those who are driven, ambitious and competitive. He said the CDC survey shows that veterinarians, like physicians, often perceive a stigma towards mental illness, which is a barrier to getting help and a suicide risk factor. 

"The troubling part is that vets with serious mental illness had higher perceptions of stigma, and they're the ones who probably need help the most," Nett said. 

Cohen noted that airing someone's mental health issues could impact their job marketability. If an associate with anxiety tells the practice owner that due to her illness she can't work 60 hours a week or can't handle many emergencies, she could be penalized. 

Some state licensing boards can discipline veterinarians for not reporting depression, mental health issues or a suicide attempt. Such regulations can be found in a state's credentialing act that covers all professions or in a veterinary practice act. In some cases, suspension, probation or counseling can be mandated. 

"You are liable to lose your job if you can't maintain your performance, even if it makes you sick," Cohen said. "I know plenty of people who are terrified the (state) licensing board will know, that therapy will cost them their license, or worry because they had one attempt and their license was suspended for two years. We've gotten better about talking about the issues, but that doesn't mean that a vet's situation is any better. The practical reality is that if you've attempted suicide and you're going to be around lethal medication, maybe you ought to have a two-year break. That's a decision for patient and doctor." 

Cohen said there are online stress discussion groups for veterinarians that would have been unheard of even three years ago. The VIN Foundation, the charitable arm of the Veterinary Information Network (parent of VIN News Service), offers tools and initiatives to support veterinarians, including a live support group that Cohen facilitates. 

More and more, she said, it seems as though people reach a breaking point that leads to suicidal ideation. What's not new is a veterinarian feeling overwhelmed. 

In her work, Cohen hears veterinarians lament that they thought by the time they became a practice owner, they would be financially secure, working part time and able to attend their children's dance recitals. Instead, they are competing with numerous clinics, feed-store vaccines and adding hours instead of reducing them. General practitioners are not referring to specialists as often because they can't afford to lose business, adding pressure to perform difficult procedures. 

Will veterinary medicine ever be less stressful?

Nett wants to make that happen. He is discussing future analysis of the data he's collected and wants to improve the veterinary profession's response to mental health issues. Nett hopes organizations such as the AVMA will help create large, partnered efforts to shift perceptions, increase the use of prescription medicines and reduce barriers to getting treatment. 

He plans to survey his colleagues every five years to track changes. 

"I want to help reduce the percentage of vets who are suffering," he said, "maybe by improving the number who seek improvement, or lessen the stigma."