Nivedita Ravi-Caldwell 288

Photo by Kate Henschel

Dr. Nivedita Ravi-Caldwell, shown with a friend, Yoshi, writes that finding a sense of belonging with friends and family, along with changing workplace and school cultures, are keys to supporting well-being in the health professions.

A little over a decade ago, during veterinary school orientation, I was in a room full of bright-eyed go-getters, ready as anyone else to start an exciting professional journey. The issue of depression and suicide among veterinarians was presented briefly. We were urged to maintain a healthy school-life balance, make time for family and friends, and to not allow grades to become the sole focus of the next few years. I took in the message with distant curiosity and confident naiveté. I thought, "I am strong, I can handle this."

I was the only international student in the class at the time, away from my immediate family in India, and in a country where everything but the language was alien to me. Members of my extended family who lived in the United States were all out of reach in different ways. As the stress of veterinary school mounted, my health and ability to keep up declined. Unfortunately, after those few minutes during orientation, I never heard about mental health again from anyone at school. When my performance declined, I received a reprimanding letter from the school written with an apparent presumption that I was somehow enjoying my subpar performance.

In my experience, depression is a cumulative process that happens very slowly in real time. I assumed that it was absolutely normal for me to cry every single day for no other reason but sadness that couldn't be qualified. I felt isolated. I felt ashamed. When my grades suffered, I assumed I was incapable and stupid. When you feel depressed, it is almost impossible to reach out. If you're an introvert like me, you become hypersensitive to nonverbal cues like facial expressions and body language. So a stern letter from school was damaging, further pushing me into my own withdrawn world. It seemed truly impossible to reach out, let alone hope to feel understood.

In my final year of veterinary school, one night over dinner, a classmate and friend pointed out that I might be depressed. I will never forget that moment of bittersweet realization. The realization was sweet because there was finally an explanation for what I was going through. It was bitter because of the explanation itself, a mental health issue from which I had felt immune. Over time, however, I developed tremendous hope that I could manage my condition.

Writing this has been difficult. I went through a lot of self-doubt and some mild self-loathing. I had to relive some painful memories that were neatly tucked away in the far recesses of my brain. Most of all, I was fearful to write my story with the intention of publicizing it. I experienced fear of judgment from you, the reader.

What if my story doesn’t resonate with anyone? What if people think I sound silly? What if people misunderstand?

From experience, I have learned that it is exactly the time when I feel least connected and most isolated in my problems that I need to stop thinking and just reach out. I have learned to recognize fear-talk from rational-talk, and I know that none of the questions above bear weight. Sometimes, I simply turn to objective truth — after all, it is statistically impossible that not a single reader will relate to my story!

In 2015, the U.S. Centers for Disease Control and Prevention published findings from a study that evaluated the prevalence of suicide risk factors, attitudes toward mental illness, and practice-related stressors among veterinarians in the U.S. Of 11,627 respondents to a survey, 31% reported having experienced depressive episodes, 17% experienced suicidal ideation, and 9% reported current serious psychological distress.

A study by Brakke Consulting Inc. and collaborators, published in 2018 and titled Merck Animal Health Veterinary Wellbeing Study, found in a survey of 3,540 veterinarians that younger respondents (less than 45 years) were more likely to experience serious psychological distress than older ones, and the biggest contributors to this were high student debt and poor financial security.

Another CDC study, published this year, showed that veterinarians have been at an increased risk of suicide for the past three decades with a steady upward trend. This study also found that female veterinarians were 3.5 times as likely and male veterinarians 2.1 times as likely to die from suicide compared with the general population. The findings on female veterinarians are especially noteworthy because they make up more than 60% of the professional workforce.

Each study helps to deepen our understanding of the complex issue of mental health in the veterinary profession. The needs of underrepresented groups in the veterinary workforce also should not be overlooked. Veterinary students and professionals of all races, socioeconomic and cultural backgrounds, abilities, and gender identities should be considered while building a context around this issue. Further, simultaneous action at individual and organizational levels are necessary to help mitigate the unsettling trends in the profession.

• We must improve accessibility to mental health professionals in veterinary schools and require educators and staff to complete sensitivity training to be able to identify symptoms of mental health issues in students.
• We must require practice owners to complete cultural competency training, and offer time and avenues for employees to access mental health services.
• We must support and expand state veterinary medical associations’ emotional well-being programs for veterinarians.
• We must strive to be more honest about our limitations, and open and forgiving toward our coworkers.
• We must work to create an environment where our colleagues can feel comfortable to share their vulnerabilities and fears.

I believe that relatability can help elicit empathy, and empathy is a prerequisite for making change. I have been fortunate to find resources that have helped me improve my emotional resilience and build self-esteem. I have come to recognize my strengths as an empathetic introvert. I have known several similarly minded people who have encouraged me to be vocal about my experiences so that it may help other people.

Veterinary professionals are not alone in their predisposition to developing mental health issues. There are indications that other health professionals, including physicians, especially female physicians, have higher suicide rates than the overall population.

Today, I am involved in the American Public Health Association (APHA), serving as a section councilor for its Veterinary Public Health-Special Primary Interest Group (VPH-SPIG). In that role, I started a conversation with public-health colleagues to include veterinary professionals in discussions about mental health.

On Nov. 5, at the APHA annual meeting in Philadelphia, the VPH-SPIG, in collaboration with the Mental Health Section of APHA, will host a session on "Reducing Suicide Risk for All Health Professionals Through a One Health Approach to Mental Health: A Round Table for Action."

Following the theme of "Who cares for the caregivers?" the roundtable will explore the scope of mental health issues among health-care professionals, consider intrinsic and external contributing factors, seek helpful language for individual expression, and look at possible interventions using a One Health approach — an approach that recognizes the interconnections between people, other animals and their shared environment. Outcomes of the roundtable will inform the goals of the VPH-SPIG for the following year.

As much as external factors influence our circumstances, so, too, do personal factors. I urge readers to examine what and who brings them happiness and strength. It may be family, faith, therapy, physical activity or hobbies. I found a sense of belonging with my closest friends and family members, including my cat. I used spirituality and counseling to discover inner strength. Ultimately, even as we work on creating change in our environments, we will not find contentment and joy unless we believe ourselves to be valuable individuals, worthy of compassion and forgiveness.

About the author: Nivedita Ravi-Caldwell, DVM, MPH, is a veterinarian and a zoonotic disease epidemiologist at the District of Columbia Department of Health (DC Health). Originally from India, she moved to the U.S. for her higher education. Dr. Ravi-Caldwell lives in northern Virginia with her husband and cat. She enjoys a wide variety of music, movies, intellectual conversations, cooking, yoga and meditation, and likes to travel as often as possible.