In this chapter, the impact of veterinary medical education on students’ personal wellbeing is presented, followed by a discussion of the steps undertaken by colleges to promote wellbeing and reduce maladaptive coping. Specific areas of concern include stress, depression, anxiety, substance use and abuse, suicide, relationships, and physical health.

Acknowledging the observed negative effects of veterinary medical training, colleges have implemented interventions. These interventions include mental health counseling services, support for career development, and some targeted programs designed to improve specific areas of concern.

Common sources of stress identified by students include academic, intrapersonal, and interpersonal challenges. Academic demands are, as would be expected, the most common student-identified stressor, given the requirements of veterinary medical training, and include the amount of material to study, feeling behind in studies, studying from exam to exam without taking time to learn material, relevance of material to be studied, and unclear instructor expectations (Kelman, 1978; Williams et al., 2005; McLennan and Sutton, 2005; Hafen et al., 2006; Siqueira-Drake et al., 2012; Reisbig et al., 2012).

The rich and challenging academic environment can also create intrapersonal challenges. For instance, Zenner and colleagues (2005) dubbed veterinary students “elite performers,” and discussed the challenges of transitioning into elite levels of training, such as veterinary medical training. Veterinary students are commonly a group of individuals who are high-achieving, academically gifted, accustomed to routinely outperforming peers and to having their self-worth heavily associated with performance-based positive social comparison (confidence equals outperforming others). The transition into veterinary training presents a new reality, where students become immersed in a group of academic equals or superiors. This experience is likely to confront their abilities to cope, and lead them to question their abilities and personal worth.

Some students may adjust expectations of themselves and of peers accordingly and cope appropriately when confronted with the transition to professional training. Another possible reaction is experiencing the “impostor phenomenon” (IP; Clance and Imes, 1978), or the internal experience of feeling an intellectual fraud (Bernard, Dollinger, and Ramaniah, 2002), chronically questioning one’s abilities (Henning, Ey, and Shaw, 1998), and believing that one’s accomplishments were the result of luck, manipulating impressions, or error (Longford and Clance, 1993). IP is associated with trait anxiety, constant fear that others will find out that the student is a fraud, and precarious self-esteem related to achievement, depression, and high neuroticism, and has been found to be common among individuals in professional training such as human medicine, veterinary medicine, dentistry, pharmacy, and nursing (Longford and Clance, 1993; Henning, Ey, and Shaw, 1998; Bernard, Dollinger, and Ramaniah, 2002). Clearly, students’ responses to the transition to professional training and the support that they have available can present opportunities for personal growth or for continued challenges.

Interpersonal challenges involve relationships within and outside academic training. As students transition into a professional training program, they also manage life transitions common to young adulthood. These include family stress such as illness, loss, or death of loved ones; relational stress, including personal relationship conflict (Hafen et al., 2013) and difficulty fitting in with peers (Hafen et al., 2006; Sutton, 2007); and transitional stress, such as homesickness (Hafen et al., 2008; Reisbig et al., 2012; Hafen, Ratcliffe, and Rush, 2013). Thus, as students pursue veterinary medical training, they are confronted with difficulties in managing both personal and professional interests. Outcomes will be dependent on students’ appraisal of these challenges, the resources they have available, and the coping strategies they use to manage the challenges.

Social science research, such as investigations regarding veterinary students’ wellbeing, is subject to ethical rules for research involving human subjects, including review by an Institutional Review Board (IRB) ensuring that the principles of voluntary participation, harmlessness, anonymity, and confidentiality are preserved (Bhattacherjee, 2012). Self-report surveys are the most common medium for information-gathering in social sciences, and include standardized assessments and/or researcher-constructed assessments. These are completed electronically or in paper–pencil format. In the context of social science research, four common challenges may arise: low response rates, nonselection bias, participants’ misrepresentation or omission of information, and timing of data collection.

While the demands of veterinary medical training make stress an ever-present feature of training, not all students experience these challenges and stress in the same manner. Early studies on veterinary student wellbeing focused on documenting students’ reports of stressors and their intensity, with variable findings. For instance, three studies found that veterinary students were not under inordinate amounts of stress. Kelman (1978) surveyed over 200 veterinary students from Colorado State University College of Veterinary Medicine (CVM), and concluded that “most students did not appear to experience exorbitant strain” (p. 150). Powers (2002) surveyed over 800 first-year veterinary students from several US CVMs (response rate 38%), finding that only a small number of participants (4%) considered the academic requirements too demanding, and half of the sample indicated perceiving their first year as “not too stressful.” Finally, Moore and colleagues (2007) investigated the effects of a student leadership program and leadership activities on student stress and academic performance with a sample of over 200 students from the University of California–Davis CVM. Findings indicate that despite having greater time commitments due to their participation in leadership activities, students experienced fewer stressors (objective stress) and perceived themselves to be under less stress (subjective stress) than the general population. Conversely, a study examining 57 students in the fourth and fifth years of veterinary training at Murdoch University in Australia (response rate 41%) indicated that students experienced a moderate amount of stress: 40% agreed to feeling “overwhelmed” trying to balance study, work, and nonworking life, and two-thirds of the sample agreed or strongly agreed to feeling “panicked about assessments” (Williams et al., 2005). None of these studies reported whether the findings differed by gender.

Early studies investigating the prevalence of stress illustrate the variability of experiences within veterinary training, as well as the challenges in assessing student stress. Low response rates and different measures of stress utilized in studies hinder comparisons, generalizations to the population, and the reliability of findings. However, these studies’ findings likely describe the diversity in veterinary medical students’ experiences, ranging from “not too stressed” to “panicked” or “overwhelmed.”

While it is helpful to understand the prevalence and intensity of veterinary students’ stress, mixed findings likely reflect the variability in veterinary medical students’ experiences (see Box 43.2). It is safe to say that veterinary training is likely to bring a certain level of pressure and strain to students, but the way in which students perceive and cope with the stress varies. More recent studies, however, have shifted the focus from identifying stress to looking into student outcomes that may be associated with stress. For instance, there is a clear association between stressful life events and the onset of depressive symptomology (Kendler, 1999). While not all individuals who face stressful situations develop depression symptoms, it is likely that those who experience depression symptoms after a stressful life event have greater vulnerability to doing so. Current scholarship in mental health and risk factors for psychological distress indicate that stress is a common precursor to psychological distress, particularly depression, substance abuse (Fahlke et al., 2000) , suicide (Feskanitch et al., 2002), and, to a smaller extent, anxiety (Uliasek et al., 2010). Some authors argue that the chronic stress of a rigorous academic training such as medical training – or, possibly, veterinary medical training – may suffice in precipitating the development of psychological distress and psychopathology (Smith et al., 2007).

Depression is defined as experiencing a lack of interest or enjoyment in daily activities, and may include changes in appetite or weight, alterations in sleep patterns, decreased energy, feelings of worthlessness, difficulty concentrating, and suicidal thoughts (DSM V; APA, 2013). Individuals who are depressed often express feeling sad, hopeless, “down in the dumps,” or “blah.” In addition to an absence of or blunted feelings, individuals may also experience increased irritability. Anxiety is characterized by an “apprehensive anticipation of future danger or misfortune” that is accompanied by emotional disruption or physical tension (DSM V; APA, 2013). An example of this might be a student who fears failing an exam and experiences tension headaches, trouble sleeping, and racing thoughts of worry. Women are more likely to experience depression and anxiety, being one and a half to three times more likely to experience depression, and twice as likely to experience anxiety (DSM V; APA, 2013).

While previous findings regarding the severity of stress experienced by veterinary medical students are varied, often indicating that students’ stress is not too intense, studies investigating mental health outcomes associated with stress present a more concerning outlook. For instance, Strand, Zaparanick, and Brace (2005) surveyed a sample of almost 300 students from all four years of veterinary training from the University of Tennessee CVM (response rate 55%). Their findings partially support previous studies on student stress in that, objectively, veterinary students were not managing higher stress than the general population. However, Strand, Zaparanick, and Brace (2005) also found that students experienced greater time pressure and, most importantly, subjective stress and depression symptoms when compared to the general population. They also found that women were more likely to experience higher levels of perceived stress, time pressure, anxiety, and depression than men. While it is reassuring that veterinary students in this study did not experience more objective stress when compared with the general population, it is concerning that students’ subjective experience of stress was more pronounced; particularly as subjective stress can be a superior predictor of distress and psychopathology when compared to objective stress (Solomon, Mikulincer, and Hobfoll, 1987). However, this study’s most important contribution is the finding that students’ depression rates surpass those found in the general population. This concerning finding has been replicated by several studies since then.

Hafen and colleagues (2006) surveyed a sample of 93 first-year students at Kansas State University (response rate 90%) on their experience of stress, depression, and anxiety symptoms. Their findings were alarming: one-third of their sample of first-year veterinary students were experiencing clinical levels of depression symptoms, as well as elevated anxiety scores. Certain stressors that students identified as “slightly stressful” were more powerful predictors of distress than stressors that students considered “very stressful.” Conversely, stressors that students identified as “very stressful” were not necessarily predictive of distress (see Box 34.2). For instance, students endorsed financial concerns, academic performance, time spent studying, and heavy workload as their most important stressors. However, those who perceived their physical health to be poor, or experienced homesickness, unclear instructor expectations, feeling behind in studies, and worried about not being as smart as others, were statistically more likely to experience anxiety and depression symptoms, making these stressors superior predictors of distress. These findings were consistent regardless of gender. This study made two important contributions to the literature examining veterinary medical student wellbeing. First, it was the first time that a study with a representative sample provided prevalence rates for depression symptoms in a sample of veterinary students. Second, it established the difference between student-identified stressors and stressors that are predictive of student distress, based on statistical predictions.

Reisbig and colleagues (2012) utilized the same surveys and procedures as Hafen et al. (2006), surveying three cohorts of veterinary students from two CVMs during the first three semesters of training. They found remarkably high rates of depression symptoms: 49%, 65%, and 69% of the three cohorts surveyed reported depression symptoms reaching clinical levels. In this study, women were more likely to experience depression and anxiety symptoms, and those who experienced high academic stress and high transitional stress (transitioning to new area, homesickness, perceiving not to fit in with colleagues, transportation difficulties) were also more at risk of experiencing depression symptoms. Finally, academic stress also predicted students’ perceived physical health, with students who endorsed greater academic stress experiencing a greater decline in their perceived physical health. These numbers are particularly concerning when compared with depression rates among human medical students (23%; Rosal et al., 1997), undergraduate students (23.7%; Lin, Dean, and Ensel, 1986), and the general population (21.5%; Lin, Dean, and Ensel, 1986).

Student distress appears to persist throughout training. At least three studies have identified that students in their second and third years of training were the most distressed (Kelman, 1978; Hofmeister et al., 2010 Siqueira-Drake et al., 2012), with higher prevalence and intensity of depression and anxiety symptoms when compared to other cohorts. One study has documented that student distress persists throughout all four years of training, with second- and third-year students experiencing most distress (Siqueira-Drake et al., 2012).

However, not all students experience veterinary medical training as a chronic stress or experience clinically significant depression symptoms. Hafen and colleagues (2008) investigated the wellbeing of veterinary medical students throughout their first year of training, and identified two distinct groups, which they called “struggling” and “adaptive.” They found that 36% of students in their sample were considered to be “struggling”; that is, these students either became distressed at some point during the first year of training and the distress persisted for the remainder of the first year, or they began veterinary training already distressed and the distress persisted throughout the first year. Conversely, 64% of students in the sample were considered “adaptive,” not experiencing significant distress, or, if distress was present, it did not persist throughout their first year of training. This study also identified predictors for each group. For instance, students in their first semester of training who experienced concerns about academic performance and homesickness were, respectively, six and three times more likely to be struggling during their second semester. Additionally, students who were in the second semester of the first year of training and felt that they were less physically fit and had difficulty fitting in with peers were, respectively, five and four times more likely to be struggling during the second semester of training. These findings provide important directions for CVMs in their intervention efforts.

Studies increasingly indicate that veterinary students are at considerable risk of poor health outcomes, particularly experiencing depression at high rates. Studies also indicate that stressors are not all equal: certain stressors can have more weight in predicting student distress than others. Students commonly indicate financial worries, concerns about academic performance, time spent studying, work overload (Hafen et al., 2006), additional work/volunteer hours, and relationship concerns (Kogan, McConnell, and Schoenfeld-Tacher, 2005) as the most worrisome issues affecting their wellbeing. While this is helpful information in providing student support and resources, other stressors demonstrated to be important in predicting which students are likely to experience poor outcomes and interventions focused on these stressors may garner better outcomes. To date, studies on student wellbeing indicate that students who perceive their physical health to be poor, experience homesickness, have difficulty fitting in, and feel unclear about professors’ expectations are at greater risk for depression and anxiety (Hafen et al., 2006; Siqueira-Drake et al., 2012). As research efforts on veterinary medical student wellbeing have progressed, there has been more specific information to guide CVMs in better supporting students.

There is evidence that substance use can be a concern among health professionals. Specifically, several studies have investigated substance use and abuse among human medical students and professionals (Baldwin et al., 1991; Newbury-Burch, White, and Kamali, 2000), and more recently attention has been given to veterinary medical professionals (Harling et al., 2009). Human medical students and professionals have been documented as utilizing alcohol at higher numbers than national, age-related comparison samples (Baldwin et al., 1991; Hughes et al., 1992). Studies investigating this issue among veterinarians are scarce. A 2009 study of German veterinarians (Harling et al., 2009) surveying over 1000 professionals (response rate 53%) indicated that psychosocial distress related to time pressure and difficulties balancing personal and professional demands was associated with high-risk alcohol consumption (more than 5 drinks on more than 5 days during a 30-day period), binge drinking (episodes of excessive drinking; that is, more than 5 drinks on one occasion), and higher likelihood of regular medical drug use (without a valid medical reason). In fact, more than 80% of the sample consumed alcohol, 30% of the sample engaged in high-risk alcohol consumption, 7% engaged in regular binge drinking, and 20% of veterinarians utilized medical drugs without prescription. These numbers indicated a higher prevalence of alcohol and substance use among veterinarians than in the general German population. No studies to date have documented veterinarians’ substance use prevalence in the United States.

Knowledge about veterinary students’ use of alcohol and illegal substances is limited. Only three studies to date have specifically surveyed veterinary medical students’ use of alcohol or illegal substances. However, given that concerns regarding substance use among health professionals and veterinary professionals have been discussed in the past (Baldwin et al., 1991; Hughes et al., 1992; Newbury-Burch, White, and Kamali, 2000; Harling et al., 2009), and that psychological distress is a common precursor to substance use (Hasin et al., 2005), it is appropriate to discuss this topic as relevant for veterinary medical student wellbeing.

Kogan et al. (2005), in an investigation of student stress, surveyed 189 veterinary medical students from a US CVM (response rate 35%) regarding their use of alcohol within a 30-day period, and found that 80% of the sample had consumed alcohol during the previous 30 days. Of those who affirmed that they had consumed alcohol, 25% noted doing something they regretted, including forgetting where they were or what they did, being physically injured, or having unprotected sex while under the influence. No information was provided about quantity consumed, so it is not possible to compare alcohol consumption among veterinary students with the prevalence of consumption in age-related samples. Hofmeister et al. (2010) focused on over-the-counter substance use among veterinary students, and inquired about the use of alcohol within the last month, as well as illegal drugs. Their sample comprised students from University of Georgia and Colorado State University CVMs; 80–85% of the sample had utilized alcohol within the last month, and 4–12% of the sample had utilized illegal drugs within the previous 30 days. The amount of alcohol or illegal substances used, as well as the frequency of use, was not reported. These researchers also found that approximately 35% of their sample utilized over-the-counter medications, and that 45% utilized energy drinks with the purpose of staying awake longer or over-the-counter medications as a sleep aid. Those who utilized these substances were more likely to be distressed, experiencing more stress and anxiety.

Finally, a recent study by Diulio and colleagues (2015) is the first investigation specifically focused on alcohol use among US veterinary medical students. They surveyed 210 students from Auburn University CVM, and found that the majority of students used alcohol regularly and approximately 50% of the sample engaged in episodes of binge drinking. As a comparison, the prevalence of binge drinking among US college students is 39% and among age-matched samples is 33% (NIAAA, 2015). Diulio et al. (2015) found that the primary motivation for those who utilized alcohol was managing internal states and rewards; that is, coping with difficult emotional states or out of mood-enhancing motives. Males were more likely to engage in heavy drinking and experience harm than females in that sample. These findings suggest that veterinary students in the study’s sample engage in binge drinking at much higher rates than nonveterinary students of similar age. More investigations are needed regarding this issue. However, limited but concerning findings suggest that veterinary students may be at high risk for problematic alcohol use.

Although only one study has specifically asked veterinary medical students about suicidal thoughts (Kogan, McConnell, and Schoenfeld-Tacher, 2005), suicide has been a concern among veterinary medical professionals in recent years. Additionally, as risk factors for suicide include depression, alcohol and drug use, certain personality traits, and environmental factors, such as chronic major difficulties and undesirable life events (Goldney, 2005; Bartram and Baldwin, 2010), it becomes clear that some veterinary students may be at risk.

Veterinary medical professionals are reportedly four times more likely to commit suicide when compared to the general population and twice as likely to commit suicide when compared to other health professionals. While absolute numbers for deaths by suicide in the veterinary profession do not surpass other professions, when examining the proportion of deaths by suicide among veterinarians and then comparing it to the proportion of deaths by suicide in the general population, we find that veterinary medicine is the profession with the highest proportional mortality ratio (PMR). These findings have been corroborated by studies in the United Kingdom, Australia, the United States, and Norway (for a review, see Platt et al., 2012). In a US survey of veterinary medical professionals, 66% admitted to having been clinically depressed, and more than 20% admitted to having considered suicide since starting veterinary school (Skipper and Williams, 2012).

Some of the factors reported to be associated with increased risk of suicide among veterinary medical professionals include work-related stress (work overload, isolation), financial stress, marital/familial stress (marital conflict, lacking spousal support), and factors related to the profession (attitudes toward death and euthanasia, accessibility to means to commit suicide) (Bartram and Baldwin, 2010).

In a study examining multiple facets of student wellbeing, Kogan, McConnell, and Schoenfeld-Tacher (2005) inquired among students from a US veterinary school, and found that 4.7% of their sample (n=233) endorsed feeling depressed to the point of seriously considering suicide more than once in the previous year. As a comparison, 3.7% of US adults (18 or older) claimed to have had suicidal thoughts or actions in 2008–2009 (Crosby et al., 2011).

The connection between physical and mental wellbeing is established in general literature (Dishman, Heath, and Lee, 2013). Improved physical health can act as a protective factor for numerous conditions, including mental health wellbeing (Cotman, Berchtold, and Christie, 2007). Likewise, increasing physical fitness can be used as an intervention to improve depressive symptoms (Bartholomew, Morrison, and Ciccolo, 2005), anxiety symptoms (Broman et al., 2004), and cognitive performance or learning information (Brisswalter, Collardeau, and Rene, 2002).

While little has been specifically investigated within this area for veterinary medical students, it is reasonable to expect a positive impact on mental and academic wellbeing from being engaged in a consistent fitness program. There are indications that physical health is connected to mental health (Hafen et al., 2006, 2008; Siqueira-Drake et al., 2012) and relational wellbeing (Hafen et al., 2013) for veterinary medical students. Poor physical health has been shown to be a significant predictor of elevated depression and anxiety (Hafen et al., 2006) and reduced relationship satisfaction (Hafen et al., 2013).

As already discussed, heavy workloads, demanding schedules, and intense expectations can take a toll on students’ individual wellbeing. Relationships during veterinary medical training can act as a contributor to stress or a mediator of stress (Sutton, 2007; Hafen et al., 2013).

Relationship challenges can contribute to stress. For instance, veterinary medical students acknowledged difficulty in balancing their school demands with their personal life (Sutton, 2007). When investigating common stressors for veterinary medical students, challenges experienced within personal relationships have been acknowledged (Collins and Foote, 2005). Specifically, a majority of veterinary medical students reported experiencing relational difficulties during their training program (Kogan, McConnell, and Schoenfeld-Tacher, 2005). Further, Nelsen (2006) reported that stress had a negative impact on relationship satisfaction for female veterinary medical students. Finally, challenges with classmates can significantly contribute to stress levels (Sutton, 2007).

Conversely, relationships can positively contribute to wellbeing. Developing close, collaborative, and supportive relationships with classmates can serve as a protective factor for stress (Sutton, 2007). Within romantic relationships, a potential safeguard against difficulties experienced by veterinary medical students is relationship satisfaction. Specifically, those veterinary medical students who experienced higher relationship satisfaction were less likely to report depressive symptomology, lower overall stress, and better physical health (Hafen et al., 2013).

Thus, many veterinary medical students experience stress, depression, and anxiety, among other challenges, while completing their training. Recently, students have indicated a desire to have access to a wide variety of support services, including mental health counseling, tutoring, and financial planning (Lord, Brandt, and Newhart, 2013). Many have advocated developing ways to support and improve veterinary medical student wellbeing (Kogan, Schoenfeld-Tacher, and Hathcock, 2012; Hafen et al., 2006; Gardner and Parkinson, 2011; Strand, 2006; Burns et al., 2006). As colleges become more aware of the need to support students, different ways of intervening are devised. Most colleges provide access to mental health counseling services. Some offer specific programs for personal development. Others organize career development activities for students. Many provide a combination of these support programs. A description of each area follows.